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Table 1 NPT coding manual part A: primary constructs—contexts, mechanisms, and outcomes

From: Translational framework for implementation evaluation and research: a normalisation process theory coding manual for qualitative research and instrument development

CMO domain NPT construct Description and example
Implementation contexts:
Contexts are patterns of social relations and structures that unfold over time and across settings. They make up the implementation environment.
Strategic intentions [11] Description: How do contexts shape the formulation and planning of interventions and their components? [11].
Example: ‘The analysis centres on English primary care and in particular on the issue of how healthcare professions are affected by, and in turn affect, the interpretation and adoption of new services. We use the case of the implementation of evidence-based approaches for managing patients with osteoarthritis. This musculoskeletal problem occurs in a high proportion of GP consultations, and is projected to increase due to a rapidly ageing population in the western world’ [29].
Adaptive execution [10] Description: How do contexts affect the ways in which users can find and enact workarounds that make an intervention and its components a workable proposition in practice? [11].
Example: ‘Huge effort was expended and continues to be required to implement and keep this technology in use. This innovation must be understood both as a computer technology and as a set of practices related to that technology, kept in place by a network of actors in particular contexts. While technologies can be ‘made to work’ in different settings, successful implementation has been achieved, and will only be maintained, through the efforts of those involved in the specific settings and if the wider context continues to support the coherence, cognitive participation, and reflective monitoring processes that surround this collective action. Implementation is more than simply putting technologies in place – it requires new resources and considerable effort, perhaps on an on-going basis’ [30].
Negotiating capacity [10] Description: How do contexts affect the extent that an intervention and its components can fit, or be integrated, into existing ways of working by their users? [11].
Example: ‘Aligning IPC guidelines with local clinical context is an essential means to reduce the sense of dissonance and represents a critical step forward towards successful implementation. Some strategies described in the literature to promote alignment include: integration of IPC recommendations within other established programmes; and education and audit interventions acknowledging the positive and negative beliefs of staff on IPC practices [31].
Reframing organisational logics [10] Description: How do existing social structural and social cognitive resources shape the implementation environment? [11].
Example: ‘The external and internal partnership building were key and also strategic, so as not to impose ERAS but to co-create it from the ground up. This relational work, as framed in the NPT, is deceptively complex as it involves convincing others that this is a legitimate improvement programme worth participating in without devaluing their current practice and beliefs. The interprofessional and interdepartmental relationships the champion teams established appeared to lay an important foundation for accepting changes and the data reports as meaningful and embedding ERAS into everyday practice’ [32].
Implementation mechanisms:
Mechanisms are revealed through purposive social action—collaborative work—that involves the investment of personal and group resources to achieve goals
Coherence building [7] Description: How do people work together in everyday settings to understand and plan the activities that need to be accomplished to put an intervention and its components into practice? [11].
Example: ‘Coherence was achieved around the CDSS despite local context variation. Across all three sites there was agreement that the CDSS was suitable for the (varied) tasks and that appropriate resources were in place to enable effective implementation, although these varied between settings. There were differences between settings where the CDSS replaced an established system with existing staff and where the service and/or the staff were new and the work of establishing coherence had to be altered to reflect this. It was clear that knowledge, experience and work identities built through doing call-handling work influenced the coherence of the CDSS for staff in the different settings. What is especially interesting in the wider policy context – where this same CDSS is now being used to support a national ‘111’ urgent care service (...) is that coherence was not just a local ‘problem’, it was necessarily underpinned by wider understandings and discourses for example about the necessity of rationing and the need to modify caller/patient behaviour and beyond that the very legitimacy of evidence based medicine and the kinds of expert knowledge which underpinned the CDSS’ [30].
Cognitive participation [7] Description: How do people work together to create networks of participation and communities of practice around interventions and their components? [11]
Example: ‘Cognitive participation relates to the work that participants undertake to build up and sustain a community of practice around an intervention. In terms of CST, participants identified training as an important factor in generating their own and their colleagues’ interest in CST and thus ensuring all stakeholders were involved. Staff were further motivated to continue running the groups within their service through observing the direct beneficial effects of CST on clients’ [33].
Collective action [7] Description: How do people work together to enact interventions and their components? [11].
Example: ‘The daily tasks involved in carrying out Point of Care (POC) testing were deciding which tests (if any) to take for each patient when they arrived; communicating this to others; taking the blood; running the tests; examining the results; communicating the results to others; and deciding what action to take accordingly. This work was allocated to different staff according to their skills and availability. Close teamwork appeared key to ensuring that each task was performed by an appropriate person at the necessary time’ [34].
Reflexive monitoring [7] Description: How do people work together to appraise interventions and their components? [11].
Example: ‘Data provision by the laboratories proved to be difficult despite the standardized format. The database manager at the central level reported he had to put much effort in getting the data from the system administrator from the laboratories because they did not prioritize data delivery. It was reported by them that saving the data extraction queries, as the research group suggested, for use in the next time period was increasingly helpful in the course of the implementation period. By fine-tuning these queries after each extraction, the quality of the delivered data improved’ [35].
Implementation outcomes:
The practical effects of implementation mechanisms at work
Intervention performance [6] Description: What practices have changed as the result of interventions and their components being operationalized, enacted, reproduced, over time and across settings? [11]
Example: ‘The bed-monitoring technologies were felt to be useful in helping staff identify patterns in resident behaviour and explore reasons for these behaviours. The bed sensors at Sycamore Lane were capable of recording clinical data such as heart rate, but the manager reported that “it’s not something that we use readily”, and this functionality was never observed in use during the present study. The location-based system at Conifer Gardens was similarly able to record data, including information about resident mobility activity. This functionality had initially been anticipated as potentially useful for enhancing clinical understanding, however, the Occupational Therapist reflected that the time needed to analyze and interpret these data had been “a job in itself” and thus has been difficult to integrate into daily practice. There were questions about the clinical utility of some of the data, which appeared to become more pronounced when considering the financial expense of the technology’ [36].
Relational restructuring [10] Description: How have working with interventions and their components changed the ways people are organized and relate to each other? [11].
Example: ‘The CMs became “everyday representatives” for the secondary sector and were responsible for acting as bridge- builders between hospital psychiatry and general practice. Previous research on Nurse Practitioners/ Advanced Nurse Practitioners in general practice (...) has shown that if the clinics are not involved at an early stage and prepared thoroughly for the Nurse Practitioner's arrival, their integration in general practice is hampered. Preparation involves practical issues, a clearly defined role for the nurse practitioner, and organizational leadership, meaning that the managers of the responsible organization must be involved in the process of defining and supporting the role (...) The challenges also pointed towards a lack of managerial co-ordination of, and responsibility for, the practical issues associated with the CM's role in general practice. (...) This meant that on many occasions, the CMs had to take on the role of implementation ambassadors assuming responsibility for maintenance of the collaborative care model’ [37].
Normative restructuring [10] Description: How have working with interventions and their components changed the norms, rules and resources that govern action? [11].
Example: ‘The first theme, trusting and embedding new relationships, is a reminder that while locally-led innovation is designed to address local problems, convincing others of its value is core work. This is particularly so when the innovation challenges professional norms and involves changes to traditional delivery models and renegotiation of professional roles (...). In this case, the findings are consistent with previous research which has indicated that the success of such innovations is dependent on the trust of all involved and the credibility of clinicians (...)’ [38].
Sustainment (normalisation) [6] Description: How have interventions and their components become incorporated in practice? [11].
Example: ‘At the end of the project period, the pathway was integrated in daily practice in two of the six municipalities. In these municipalities the care pathway was found to have the potential of structuring the provision of home care services and collaboration with the GPs, and serving as a management tool to effect change and improve knowledge and skills. (...) The generic care pathway for elderly patients has a potential of improving follow-up in primary care by meeting professional and managerial needs for improved quality of care, as well as more efficient organization of home care services. However, implementation of this complex intervention in full-time running organizations was demanding and required’ [39].