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Table 2 NPT coding manual part B: secondary constructs—mechanisms

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

NPT construct Sub-construct Description and example
Coherence: How do people work together to understand and plan the activities that need to be accomplished to put an intervention and its components into practice? [11]. Differentiation [7] Description: How do people distinguish interventions and their components from their current ways of working? [40].
Example: ‘In order to invest in ERAS individuals needed to be able to differentiate its practices favourably with those enacted pre-implementation. This required coherence work in understanding the potential patient benefits allied to its introduction. Participants provided divergent accounts when they compared ERAS to previous practice. A number of participants asserted that the introduction of ERAS had brought about considerable changes to their day-to-day practice. These changes included positive adjustments in the management of patients and required patients to play a more active role in their own recovery’ [32].
Communal specification [7] Description: How do people collectively agree about the purpose of interventions and their components? [40].
Example: ‘Another barrier to coherence was lack of communal specification, since not everyone considered they had been informed about the study or understood its aims and processes. This caused implementation problems for the homes and the research team. For the homes, the researchers’ reasons for examining potential benefits from the intervention to have a positive impact on the culture of care had not been strongly reflected’ [41].
Individual specification [7] Description: How do people individually understand what interventions and their components require of them? [40].
Example: ‘One respondent felt discussing the new way to view the patients with the staff was a delicate issue. In the old care model, patients were usually only informed about the treatment whilst now, in the care model, patients were to be seen as partners. This was regarded as a shift in power and, at least for some physicians, it would be difficult to get used to’ [42].
Internalisation [7] Description: How do people construct potential value of interventions and their components for their work? [40].
Example: ‘At this stage (initial introductory meetings), the value of the intervention was purely based on individuals’ interpretation of the information given by the research team and the “fit” with their own interests. The GPs in General Practice 8 provided their views at the end of the introductory meeting, saying that they liked the structure and more systematic approach to caring for people with OA and concluded that “it is nice to be able to try something that may make a difference”’ [43].
Cognitive participation:
How do people work together to create networks of participation and communities of practice around interventions and their components? [11]
Initiation [7] Description: How do key individuals drive interventions and their components forward? [40]
Example: ‘Participants described the new SDM work as requiring leaders to define the work, and then enrolling others to contribute collectively to the process. Identifying leadership support for SDM was challenging: clinical teams are not simple hierarchical units, and substantial autonomy exists, especially for experienced clinicians’ [44].
Enrolment [7] Description: How do people join in with interventions and their components? [40].
Example: ‘Clinic participants also re-ported that the intervention provided a model for improved interprofessional team collaboration, resulting in a greater understanding of clinicians’ roles and skill sets. Huddles were viewed as worth creating and maintaining, both for interprofessional team and patient benefits. Participants identified that the majority of patients were satisfied with the interprofessional approach to primary care’ [45].
Legitimation [7] Description: How do people agree that interventions and their components are the right thing to do and should be part of their work? [40].
Example: ‘The respondents offered several explanations for resistance or lack of engagement: some staff felt that health promotion activities overstretched users’ resources and thus had a negative impact on their quality of life; others argued that health promotion activities did not respect personal preferences of users and staff (…) One of the important implementation ideas (…) was the concept of staff being role models for health promotion. As role models staff were[ expected to participate in different health promotion activities (like joining users for walks and meals) and to display a healthy lifestyle at work. In the four providers, such expectations were formulated and formalised by management or by key implementation staff to different extents. However, in all cases some staff did not buy into this idea; they felt that the elements of smoking cessation and healthier meals interfered with their usual lifestyle and personal preferences’ [46].
Activation [7] Description: How do people continue to support interventions and their components? [40].
Example: ‘While, overall, this system has worked well, many participants referenced instances of long wait times and rerouting of calls to reach the neonatologist. Based on the care teams' appraisal and experience with this process, they suggested modeling the teleneonatology service activation after the emergency department's response system, for immediate and direct connection. Other suggestions include making the technology simple enough for ease of use, and to mount a camera (which can be controlled by the remote neonatologist) to the baby warmer’ [47].
Collective action:
How do people work together to enact interventions and their components? [11].
Interactional workability [7] Description: How do people do the work required by interventions and their components? [40].
Example: ‘The rural allied health team indicated that telehealth technology provided ‘a whole range of other capabilities’, and considered it ‘safe and it’s appropriate and it’s an equivalent, if not better, sort of service that you can provide’. They were committed to the notion that telehealth could balance the unequal access to services across geographical locations, and were keen to pursue innovative ways of using telehealth technologies to allow them to provide complex distant therapy. In contrast to rural and experienced telehealth clinicians who were keen to utilise technology as part of their role and to deal with distance and isolation, urban clinicians with no exposure to telehealth reported more reservations about the safety and suitability of providing rehabilitation through telehealth. They generally felt that telehealth should be reserved for ‘people who are more autonomous and more capable and … straightforward’, rather than ‘real’ rehabilitation patients with complex issues. They felt that people who required rehabilitation often require a ‘hands on’ approach’ [48].
Relational integration [7] Description: How does using interventions and their components affect the confidence that people have in each other? [40].
Example: ‘Enhanced collegial discussion about FV and adherence to the safety measures, such as the home visiting policy and procedures introduced in (…) model, were important for nurses to feel safe and undertake the FV work. As implementation progressed, intervention nurses felt safer than comparison nurses when attending home visits (…). Relationships within teams and with FV services varied across the MCH intervention teams. High workloads, time constraints and a lack of nursing staff or relievers in some centres impacted on the organisation of the FV work at times. The nurse mentor role to provide secondary consultation, linkage to FV services and support for other MCH nurses had varied success. Due to time constraints and the often solo nature of MCH practice, most nurses preferred to discuss clinical issues with a nurse friend or co-worker at the time rather than try to contact the designated MOVE nurse mentor, with only 38% of nurses using the nurse mentor role early in the trial. This increased to 52% as time went on. If the nurse was not comfortable speaking and had insufficient time or access to the nurse mentor, then this aspect of the model was lost’ [49].
Skill-set workability [7] Description: How is the work of interventions and their components appropriately allocated to people? [40].
Example: ‘A key theme identified in the literature and through this study is the need for more training for practitioners. This includes training both in professional education and continuing educational opportunities for all practitioners. Medical, nursing and allied health education programs need to improve LGBT curriculum content (…). Providing education on general terminology, healthcare needs specific to the transgender population, and practitioners’ role in providing healthcare for this population will better prepare new practitioners for serving this community. Increased access to continuing education with LGBT content will help to increase the knowledge and skill of current practitioners. Embedding LGBT content within current programs of continuing education may increase awareness more than having specific LGBT courses (…). Embedding it in current programs may bring awareness to the concepts and highlight the need for practitioners to seek out more specific training to address their learning gaps’ [50].
Contextual integration [7] Description: How is the work of interventions and their components supported by host organizations? [40].
Example: ‘Since POs were able to self-select into the pilot, the alignment of PO priorities with participation in a pilot on care management was a good fit. The leadership in all POs voiced interest in providing care management to patients within their PO as a means of improving patient outcomes, easing burden on providers of handling complex patients, and to meet health care standards and reimbursement policies such as patient-centred medical home recognition, accountable care, and meaningful use. Therefore, in this study overall organizational support was not found to be variant. Where organizational support emerged as an issue related more to resources and support for the care management program relative to the needs and goals of the program. The most common issue here was not having either enough care managers or enough care manager protected time to do care management for the number of patients needing it. So in well-normalized programs, there was a sense of “rationing” of the care manager. Because the program was being used so much more and there was a capacity constraint at the practice level with the practice-based care manager structure, the practices in these POs voiced more concern about lack of care manager capacity. Lack of resources was evident in other ways such as lack of space for patient visits or access to phone lines to make longer calls’ [51].
Reflexive monitoring
Description: How do people work together to appraise interventions and their components? [11].
Systematisation [7] Description: How do people access information about the effects of interventions and their components? [40].
Example: Feedback was never provided to staff on the effect of the AKI e-alert “I haven’t had any feedback since the new version (of the AKI e-alert) went in actually(...) I don’t know whether there is a formal mechanism for that getting to anyone”’ [52].
Communal appraisal [7] Description: How do people collectively assess interventions and their components as worthwhile? [40].
Example: ‘The e-alert was rarely (if ever) discussed among clinicians, but participants often stated they felt that others would find it worthwhile. “The e-alert was rarely (if ever) discussed among clinicians, but participants often stated they felt that others would find it worthwhile. “Most people I'm sure would know it's a good idea having them. That's what I'd say to someone about these alerts”’ [52].
Individual appraisal [7] Description: How do people individually assess interventions and their components as worthwhile? [40].
Example: ‘A key barrier which has not previously been identified concerned the ability of case managers to identify, and act on, emerging patient and carer needs; we identified examples of missed and unmet needs for all three case managers. One case manager explicitly attributed this to the timing of the intervention; a study of case management for people with early symptoms of dementia and their carers similarly found that case managers did not feel the intervention was needed at this point’ [53].
Reconfiguration [7] Description: How do people modify their work in response to their appraisal of interventions and their components? [40].
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].