A qualitative systematic review of studies using the normalization process theory to research implementation processes

Background There is a well-recognized need for greater use of theory to address research translational gaps. Normalization Process Theory (NPT) provides a set of sociological tools to understand and explain the social processes through which new or modified practices of thinking, enacting, and organizing work are implemented, embedded, and integrated in healthcare and other organizational settings. This review of NPT offers readers the opportunity to observe how, and in what areas, a particular theoretical approach to implementation is being used. In this article we review the literature on NPT in order to understand what interventions NPT is being used to analyze, how NPT is being operationalized, and the reported benefits, if any, of using NPT. Methods Using a framework analysis approach, we conducted a qualitative systematic review of peer-reviewed literature using NPT. We searched 12 electronic databases and all citations linked to six key NPT development papers. Grey literature/unpublished studies were not sought. Limitations of English language, healthcare setting and year of publication 2006 to June 2012 were set. Results Twenty-nine articles met the inclusion criteria; in the main, NPT is being applied to qualitatively analyze a diverse range of complex interventions, many beyond its original field of e-health and telehealth. The NPT constructs have high stability across settings and, notwithstanding challenges in applying NPT in terms of managing overlaps between constructs, there is evidence that it is a beneficial heuristic device to explain and guide implementation processes. Conclusions NPT offers a generalizable framework that can be applied across contexts with opportunities for incremental knowledge gain over time and an explicit framework for analysis, which can explain and potentially shape implementation processes. This is the first review of NPT in use and it generates an impetus for further and extended use of NPT. We recommend that in future NPT research, authors should explicate their rationale for choosing NPT as their theoretical framework and, where possible, involve multiple stakeholders including service users to enable analysis of implementation from a range of perspectives.

Provider experiences of the implementation of a new tuberculosis treatment programme: A qualitative study using the normalisation process model.
All nurses (n=6) and adherence counsellors (n=6) working on the programme were asked to participate in interviews. All treatment supporters (approximately 85) were invited through adherence counsellors to participate in focus group discussions (FGDs).
A qualitative approach was used. Interviews and focus group discussions.
Using the NPM as an analytic framework, this study aims to explore staff perceptions of a new TB treatment programme modelled on the ART treatment programme.
Data were analysed initially using qualitative content analysis. The resulting categories were then organised under the constructs of the NPM.
Aims to explore staff perceptions of a new TB treatment programme modelled on the ART treatment programme.
The NPM assisted in categorising the challenges experienced during implementation of the TB Treatment Programme. The results suggest that issues remain that need to be resolved before the programme is implemented more widely. Considerable work is needed in order to embed the TB Treatment Programme in routine clinic practice.
Blakeman, T., Protheroe, J., Chew-Graham, C., Rogers,A. and Kennedy,A. [34] Understanding the management of early stage chronic kidney disease in primary care.
In total, 21 out of the 28 health professionals (75%) invited agreed to participate. The final sample was spread across 11 practices and comprised 11 GPs (six male, five female; median age 45 years [range 30-62 years]) and 10 nurses (all female; median age 47.5 years [range 39-60 years]). Eighteen out of the 21 participants were directly involved in the CLAHRC CKD collaborative A qualitative study using semi structured interviews.
Using NPT as a framework, the study constructs an understanding of how early-stage CKD is encountered and dealt with in general practice.
NPT was used to sensitise the analysis to the work being carried out in primary care. Initial coding of the data was undertaken independently by three of the authors and categories were identified by comparing these codes. Using the coding framework to help operationalise the theory, these constructs were applied to the sets of practices outlined above, concerning the management of CKD in primary care. The coding framework assisted comparative analysis of data from each individual account, matched interviews, and across the dataset out in primary care.
To explore processes underpinning the implementation of CKD management in primary care.
The study builds on previous findings concerning the disclosure of CKD in primary care. This study sought to understand the work undertaken by GPs and practice nurses in implementing a relatively new phenomenon into general practice. The findings highlight tensions experienced by professionals surrounding the management of individuals with early-stage CKD. These tensions need to be considered when developing interventions to improve the delivery of care for people with mild and moderately 'low kidney function', vascular conditions, or multimorbidity. . NPT provided a framework to explore in greater detail the interactional work that occurs in clinical encounters and within an organisation.
Bouamrane, M, Osbourne, J., Mair,F.S. [32] Understanding the implementation and integration of remote and telehealth services…an overview of NPT.
Review of NPT and supporting case studies. Case study 1: Qualitative approach using interviews; Case study 2: Qualitative approach using interviews; Case study 3: Qualitative approach using interviews.
The authors review the application of NPT to three selected case studies; teledermatology, tele-monitoring of patient with chronic lung disease a telepsychiatry.
The authors begin by describing issues with the continued sustainability of existing models of careand the potential opportunities for new technologies in addressing these challenges. This is followed in by a description of the NPM and the theory which subsequently developed from this model: the NPT. The authors review the application of NPT to 3 selected case-studies: tele-dermatology, telemonitoring of patient with chronic lung disease a tele-psychiatry. And conclude with a discussion and directions for future development of the theory.
Case studies that have normalisation of e-health services were successful when certain facilitating factors as per NPT were in place.
How does care coordination provided by registered nurses ''fit'' within the organisational processes and professional relationships in the general practice context?
Eleven general practices, who were members of a single division of general practice in South-East Queensland, Australia, were invited to participate. Six general practices met the selection criteria (that is, an experienced RN was involved, general practice managers supported the intervention, general practice management systems were organised and maintained, RNs had access to necessary resources, and the general practice could demonstrate capacity to meet the demands of the project). One general practice withdrew prior to commencement of the intervention. A total of nine RNs from five general practices participated in the study. Six participants were general practice RNs (one general practice was represented by two RNs), and three were RN GPLOs who provided pivotal support to general practice RNs.
A qualitative interpretive research design, which used focus group interviews with nurses using a semi-structured interview protocol.
To explore how registered nurse (RN)-provided care coordination could move beyond implementation to become embedded and integrated within the organisational processes and professional relationships of the general practice context.
Interpretive analysis of interview data was conducted using NPT, particularly NPM, to structure data analysis and interpretation.
The aim of this study was to develop understanding about how a registered nurse-provided care coordination model can ''fit'' within organisational processes and professional relationships in general practice.
Within teams of health care providers, interventions need to be workable and able to be integrated if they are to 'fit' within the context and become part of routine practice. Interventions such as RN-provided care coordination, which was piloted in this study, are more likely to become part of routine practice if they: (a) confer an interactional advantage, (b) equal or improve relational integration through accountability and confidence within networks, (c) improve skill-set workability by calibrating to an agreed skill-set at a recognizable location in the division of labour, and (d) support contextual integration by conferring an advantage on an organisation in flexibly executing and realizing work (May, 2006). Elwyn, G., Legare,F. et. al. [49] Ardous implementation: Does the Normalisation Process Model explain why it's so difficult to embed decision support technologies for patients in routine clinical practice?
Physicians, patients and managers.
The NPM was used as the basis of conceptual analysis of the outcomes of previous primary research and reviews. Using a virtual working environment the authors applied the model and its main concepts to examine: the 'workability' of DSTs in professional-patient interactions; how DSTs affect knowledge relations between their users; how DSTs impact on users' skills and performance; and the impact of DSTs on the allocation of organizational resources.
Through a conceptual analysis of the outcomes of previous primary research and reviews, authors aimed to decide whether the NPM was of value in understanding the difficulties encountered in getting DSTs embedded into practice.
NPM was used as the basis of conceptual analysis To test the conceptual adequacy of the model in understanding the difficulties encountered in getting DSTs embedded into practice.
One of the main insights gained by applying the NPM was the need to consider its propositions from the perspective of different actors, particularly when DSTs is an inherent component of interactions between the actors. The instrument was pre-tested in two health care settings in which e-health (electronic facilitation of healthcare decision-making and practice)was used by health care professionals.
A 30-item instrument (Technology Adoption Readiness Scale (TARS)) for measuring normalisation processes in the context of e-health service interventions was developed on the basis on Normalization Process Theory (NPT). NPT focuses on how new practices become routinely embedded within social contexts. T This paper aimed to (1) describe the process and outcome of a project to develop a theory-based instrument for measuring implementation processes relating to e-health interventions; and (2) identify key issues and methodological challenges for advancing work in this field.
The practical output of this study was the development of the TARS instrument, which was intended to enable researchers and practitioners to quantify a range of processes proposed by the NPT to contribute to the successful normalisation of e-health, either as a 'diagnostic' tool or for evaluation purposes The Normalisation Process Model has provided a framework within the COSMOS trial to examine some of these issues prospectively, both through the evaluation research design (relating to the implementation of the model of care into practice) and analysis of findings. Organisations may use the evidence from the trial findings to guide implementation strategies, ensuring that constructs that have been identified as important for the protocols and guidelines as standard care. Case study 2: Recruitment of 2314 women to the trial took place from September 2007 to June 2010, with the last birth in December 2010 (primary outcomes reported elsewhere). Midwives already employed at the Women's were offered first preference to work in the caseload model, then external advertising was used to fill further vacancies (to a total of approximately 12 full time equivalent positions).
Melbourne, Australia, and consider how NPT can be used to understand the barriers and enablers to sustainability of new and complex models of care within maternity care settings.
understanding of issues related to implementation and sustainability can make a valuable contribution when researching complex interventions in complex settings such as hospitals.
complex interventions in complex settings such as hospitals.
model's sustainability are encompassed in implementation strategies. In addition, future trials of models of care may benefit from using the NPT not only to understand implementation, but to guide trial design and development of the intervention.
Franx, G. Oud, M., de Lange, J. Wensing, M. and Grol, R. [35] Implementing a stepped-care approach in primary care: results of a qualitative study Participants for the study were selected from thirteen multidisciplinary primary care teams participating in the depression Quality Improvement Collaborative (QIC). These thirteen QIC teams had been recruited throughout the country by a national QIC project team on the basis of the following criteria: the team had a multidisciplinary structure, there was sufficient motivation and time for all members to participate, and a local team coordinator was available. Although team members sometimes had worked together in another context, most of them had not worked together as a depression team prior to the QIC. At the start of the QIC, all teams were asked to participate in the intervention study and the process evaluation, alongside their implementation work. Five teams did not wish to spend extra time on research activities and declined. Eight teams consented, consisting of PCPs, primary care psychologists, social workers, mental health nurses, physiotherapists, consulting psychiatrists and psychotherapists, local An intervention study using a controlled before and after design was performed. Part of the study was a process evaluation utilizing a semi structured group interviews, to provide insight into the perceptions of the participating clinicians on the implementation of stepped care for depression into their daily routines.
Since 2004, 'steppedcare models' have been adopted in several international evidence-based clinical guidelines to guide clinicians in the organisation of depression care. To enhance the adoption of this new treatment approach, a Quality Improvement Collaborative (QIC) was initiated in the Netherlands. Alongside the QIC, an intervention study using a controlled before-and-after design was performed. Part of the study was a process evaluation, utilizing semistructured group interviews, to provide insight into the perceptions of the participating clinicians on the implementation of stepped care for depression into their daily routines.
Analysis was supported by NPT, with reference to Gunns NPT framework on depression.
The qualitative process analysis presented here aims to add to the quantitative findings as it documents the way in which the intervention was received and implemented by clinicians, and identifies the factors associated with reception and implementation.
By relating the findings to the NPT constructs, the authors were able to provide another layer to the findings. The constructs provide the authors with sensitizing concepts that could lead to a better understanding of the findings of this process evaluation, as well as guide additional recommendations on how to conduct implementation projects in depression care. managers, and team coordinator.
Furler, J., Spitzer, O., Young, D. and Best, J. [42] Insulin in general practice Barriers and enablers for timely initiation Ten general practitioners, four diabetes nurse educators and 12 patients were interviewed.
A qualitative study using semi structured, in-depth interviews.

Insulin in general practice: Barriers and enablers for timely initiation
Data analysis drew on the NPM in developing initial coding categories.
This study explores barriers and enablers to insulin initiation in general practice.
Normalisation process theory provides a framework for analysis of the findings through focusing on how the 'work' of diabetes care is understood, given meaning, undertaken and supported. Gallacher, K., May, C. et al.
[18] Understanding Patient's Experiences of Treatment Burden in Chronic Heart Failure Using Normalization Process Theory Participants were 47 patients with chronic heart failure managed in primary care in the United Kingdom who had participated in an earlier qualitative study about living with this condition.
Secondary analysis of qualitative interview data.
To assess the burden associated with treatment among patients living with chronic heart failure and to determine whether NPT is a useful framework to help describe the components of treatment burden in these patients Framework analysis, informed by NPT To use NPT to identify, describe, and understand the components of treatment burden experienced by patients with chronic heart failure.
Suggests that NPT is a useful theoretical framework for understanding patients experiences of illness and health care services, and their active contribution to their overall care and self care.
A convenience sample of stakeholders was recruited from primary care organizations (PCOs) in the north of the UK. Primary Care Physicians (PCPs) and practice nurses were recruited from practices in PCOs that had agreed to participate in the trial. Other participants were recruited from teams and specialist care providers that provided primary and secondary mental healthcare to the PCOs. Patients were recruited by four participating PCPs who each mailed a letter to 20 of their patients who were receiving treatment for depression in primary care. No participants had had any experience of this method of organizing care and none been involved in the trial design. The authors interviewed 49 participants. All 38 professionals who were asked to participate in the study agreed to do so: 12 PCPs, four psychiatrists, four clinical psychologists, four practice nurses and 14 mental health workers (seven mental health nurses, two Application of the NPM to qualitative data collected in both focus groups and one to one interviews before and after an exploratory randomised controlled trial of a collaborative model of care for depression. This study utilises the Normalisation Process Model (NPM) to inform the process of implementation of collaborative care in both a future fullscale trial, and the wider health economy.
Framework analysis, based on the NPM.
Aim to apply the NPM to the process data in order to consider what can be learnt about the additional or 'hidden' work (i.e., that which is not immediately apparent at conception of the project or not usually included in publication of results of a trial) that needs to be done to make a collaborative care intervention for depression in primary care both workable and integrated into routine practice in both our forthcoming full-scale trial of collaborative care for depression in the UK and the wider healthcare settings following the trial. In initiating this task, the authors were particularly interested in the value of application of the NPM to process data in order to aid in the further development and evaluation of this intervention in the UK.
The NPM provided a neat and conceptually rich framework to guide analysis and our thinking about a range of key issues in the implementation of collaborative care for depression in both research trials and routine practice. It provided a novel way of evaluating and interpreting process data that added value to the analysis. Using the model, it was possible to observe that certain predictions about work that would need to be done that could be made from analysis of the pre-trial data relating to the four different factors of the NPM were borne out in the post-trial data.
counsellors, three graduate mental health workers, one social worker, and one unqualified support worker). Most interviews were conducted individually apart from two focus groups with 11 of the 14 mental health staff. From the 80 letters posted to patients, 17 consented to participate of which 11 were interviewed, five subsequently declined or could not be contacted, and one became so distressed that the interview was abandoned on ethical grounds and the patient was encouraged to contact the PCP. Gask, L. Rogers,A. et al. [48] Beyond the limits of clinical governance? The case of mental health in English primary care.
Interviews with clinical governance leads and managers (12 interviews carried out with 17 informants), audit leads (3 interviews) and mental health leads (11 interviews with 18 informants-one site could not identify a lead) to explore how implementation of clinical governance had progressed. Additionally the authors interviewed informants identified as by PCT informants as 'primary care' leads at the local Mental Health provider trust. For three of the sites, as the Trust was an integrated provider of primary care and mental health, there was no need to conduct a further interview. A further site arranged a single group interview with four representatives from both primary care and mental health. Four interim interviews with mental health leads in both PCTs and mental health trusts were carried out at two sites during 2001, selected on the basis of the case study profiles because they might provide contrasting views of the development of primary A longitudinal qualitative multiple case-study approach in a purpose sample of 12 PCTs To explore the quality of primary care for people with mental health problems through the new institutional processes of 'clinical governance'.
Framework analysis, based on the NPM.
To examine the extent to which clinical governance of mental health care has been normalised within NHS primary care.
The NPM predicts that in order to become normalised, new working practices such as clinical governance activities have to satisfy four (sets of) conditions. The contested nature and status of 'mental health' within primary medical care makes it particularly difficult to change clinical working practices and the ways in which patients and professionals themselves interact, i.e. to satisfy the interactional workability and relational integration, insofar as they apply to clinical governance activities. It also compounds the (more substantial) skill-set and contextual problems and uncertainties faced by those who seek to 'improve the quality of primary mental health care'. The data show a lack of clear conceptualisation about what primary mental health care is or ought to be, under defined roles and wide professional discretion, especially for GPs. They also suggest that clinical governance and the mental health NSF only weakly satisfy the NPM's contextual integration conditions. This is not for want of willingness on senior managers' or clinicians' parts but more due to lack of knowledge about what (material and human) resources are required and how they can be used to integrate clinical governance activity, including NSF implementation, more centrally into mental health care; and how to start bridging the service gaps noted above. these sites were unchanged from the previous year, however by 2003-4 the PCT mental health leads had changed in all but 3 of the 11 sites for which they could identify a lead person. A total of 41 interviews carried out with 49 informants form the main empirical material for the analysis. Godden,D. and King,G. [29] Rational development of telehealth to support primary care respiratory medicine: patient distribution and organisational factors.
Semi-structured interviews (n=20) were conducted with health professionals and managers likely to be involved in implementation of telehealth. These key informantsincluding GPs, consultants, nurses, and others involved in respiratory carehad responsibilities across the region (including urban, rural and remote areas) and they were recruited purposively.
Qualitative interviews with health professionals (n=20) focussing on the potential for telehealth in respiratory medicine were analysed using the NPM.
The potential for telehealth in respiratory medicine.

Analysis was supported by NPM
The study examined the potential for applying telehealth in a region of the UK by exploring the distribution of patients and examining attitudes to implementation of telehealth.
The main perceived barriers to implementation in the study were in skill set workabilitymainly training issuesand contextual integrationmainly about costs. Interestingly, realisationan element of contextual integration which refers to moving responsibilities between professional groupswas not a prominent concern, perhaps reflecting the extent to which this is already happening in rural communities as, for example, nurses and paramedics take on roles previously delivered by doctors. However there is evidence that actual implementation of telecare services can face major problems of interactional workability where nurses lack confidence in the technological approach adopted.
Gunn, J. Palmer, V. et al. [45] Embedding effective depression care: using theory for primary care organisational and systems change.
Seven eligible primary care organisations were identified. Each had from two up to ten or more GPs working within them plus other professionals (receptionists, practice nurses, dieticians, diabetic nurse educators, psychologists, and social workers). Five organisations were privately owned by principal GPs, one was a corporate owned health centre, and one was a publicly funded community health centre.
Authors used a mixed method, observational approach to gather data about routine depression care in a range of primary care settings via: audit of electronic health records; observation of routine clinical care; and structured, facilitated whole of organisation meetings.
To identify the components of an effective model of depression care.
NPT identified as an analytical theory to guide the conceptual framework development To identify the components of an effective model of depression care. Work is presented as a conceptual framework to guide how to implement organisational and systems change in mental health care reform in primary care.
Identifies NPT as suitable for the task of providing an analytical theory to develop a conceptual framework to guide the implementation of an effective model and system of depression care.

James, D.M. [39]
The Applicability of Normalisation Process Theory to Speech and Language Therapy: A review of qualitative research on a speech and language intervention.
There were five papers that presented data on the parents' or therapists' views. Three of these papers used semi-structured interviews or focus groups to elicit participants' views on the intervention. Two of the papers presented data from questionnaires that were used to elicit parental views of speech and language therapy. These studies were included because they explored parental views on direct (traditional) versus indirect (such as the HPP) approaches with children and families. Girolametto, Tannock and Siegel (1993); Mothers who had taken part in a HPP N = 32. Glogowska and Campbell (2000) Parents who had taken part in a RCT to evaluate traditional SLT intervention in pre-school children N = 16 selected respondents according to the logic of maximum variation. The primary aim of this study was to test the applicability of the propositions on the role of collaborative work laid out in the NPM and NPT to the context of speech and language therapy so that, if found to be applicable, the NPT could be used to inform the design of new intervention research in the field.
The analysis based on the NPM uncovered interpersonal processes between the practitioners and parents that were likely to have given rise to successful implementation of the intervention. In previous qualitative research on this intervention where the Medical Research Council's guidance on developing a design for a complex intervention had been used as a framework, the interpersonal work within the intervention had emerged as a barrier to implementation of the intervention. It is suggested that the design of services for children and families needs to extend beyond the consideration of benefits and barriers to embrace the social processes that appear to afford success in embedding innovation in healthcare.
Kennedy, A. Chew- Graham,C. et al. [44] Delivering the WISE Training Package in Primary Care: Learning from formative evaluation.
Practices with more than two GPs were identified within a Primary Care Trust (PCT). The practices who agreed to take part in the study were asked to select two training dates where all staff (GPs, nurses, practice managers, and clerical and reception staff) could be present for a three-hour training session.
Observation, audio recordings, and face to face semi structured interviews were conducted.
Using the NPM as an analytic framework, this study aims to learn from the formative evalution of the Whole System Informing Selfmanagement Engagement (WISE) approach which encompasses creating, finding, and implementing appropriate self-care support for people with long-term conditions. Framework analysis informed by NPT.
Aimed to refine the patient, practitioner, and patient level components of the WISE approach and translate the principles of WISE into an operational intervention deliverable through NHS training methods The formative evaluation approach and attention to normalisation process theory allowed the training team to make adjustments to content and delivery and ensure appropriate staff attended each session.

MacFarlane, A. and Oreilly De Brun, M. [40]
A reflexive account of using a theory-driven conceptual framework in qualitative health research.
18 General practitioners; 4 General practice administrators; 2 Independent interpreters; 2 Service user representatives; 14 Service user representatives; 1 Company manager. The emphasis for sampling and recruitment was on identifying information-rich cases, participants who were understood to have knowledge and experiences relevant to the phenomenon under investigation (Patton, 1990). The funders of the study had a particular interest in the experiences and views of general practitioners, and the original study remit included general practitioners as the sole participant group. However, the authors encouraged inclusion of a broader group of participants so that experiences and views of implementation and normalization could be examined across stakeholder groups. This was prompted by our experience of using a multiperspectival approach in qualitative research.
The authors present a reflective paper on their decisions about whether or not to use the NPM, and describe their actual use of it to inform research questions, sampling, coding, and data analysis.
A reflexive account of using a theorydriven conceptual framework in qualitative health research.
NPM was used as the basis of conceptual analysis.
The authors provide a reflexive account of Their experience of using a theory-driven conceptual framework, the NPM, in a qualitative evaluation of general practitioners' uptake of a free, pilot, language interpreting service in the Republic of Ireland.
The added value of the NPM analysis was that the authors understanding of individual themes became more insightful and advanced, and the interpretation of themes was enhanced. The NPM offered an organizing principle to "think with our data" in a very specific way; i.e., to think about the layered meanings of individual themes in relation to predescribed macro-and micro-level issues, and the mediating relations between these, and thus to be more alert to the complex processes of implementation and conditions for normalization. In a sense, it provided an element of the researcher analyst role in that it offered an outline of analytic and theoretical categories to advance the descriptive analysis (Gibbs, 2007). Mair,F.,Hiscock,J. and Beaton,S. [50] Understanding factors that inhibit or promote the utilization of telecare in chronic lung disease.
Patients (n=9) and specialist respiratory nurses (n=11) providing the telecare service in chronic lung disease.
Participant observation of activities involved in the implementation and delivery of the home telecare service. Semi-structured interviews were carried out with patients (n = 9) and nurses (n = 11) participating in a RCT.
A process evaluation of a randomized controlled trial (RCT) of home telecare for the management of acute exacerbations of chronic obstructive pulmonary disease (COPD), using the NPM as an explanatory framework.
A framework approach to data analysis was used.
The telecare service did not provide an interactional advantage for the nurses providing this service and did not fit with the nurses' views of the most appropriate or preferred use of their skills. The telecare service seemed unlikely to become normalized as part of routine healthcare delivery, because the nursing team lacked confidence that it was a safe way to provide healthcare in this context and it was not perceived as improving efficiency. The telecare intervention failed to satisfy three of the four constructs of the NPM, namely interactional workability, relational integration, and skill-set workability.
The NPM effectively mapped onto the study findings and explained those factors that inhibited the routine delivery of COPD services by telecare.

Murray, E. [28]
A systematic review of reviews of e-health implementation studies, focusing on implementation processes rather than outcomes.
From 8206 unique citations screened, the authors excluded 7973 on the basis of the title or abstract and retrieved 233 full-text articles. Of these, 37 met the inclusion criteria. Of note, 20 of these reviews were published between 1995 and 2007 and 17 were published in the following two years.
An explanatory systematic review.
A systematic review of reviews of e-health implementation studies, focusing on implementation processes rather than outcomes.
The authors have interpreted the results in the light of an explanatory framework -NPT, that specifies mechanisms of importance in implementation processes.
This review not only collates and summarizes data but also analyses it and interprets it within a theoretical framework, NPT. The authors approach has allowed them to explore the factors that facilitate and hinder implementation, identify gaps in the literature and highlight directions for future research. In particular, this work highlights a continued focus on organizational issues, which, despite their importance, are only one among a range of factors that need to be considered when implementing ehealth systems.
Content analysis of the 37 reviews identified 801 attributive statements about implementation processes that could be interpreted using NPT as an explanatory framework.
May, C. Finch, T. et. al. [30] Integrating telecare for chronic disease management in the community: What needs to be done?
Drawn from telecare services in community and domestic settings in England and Scotland, 221 participants were included, consisting of health professionals and managers (n=22); patients and carers (n=31); social care professionals and managers (n=90); and service suppliers (n=11) and manufacturers (n=67).
Large scale comparative study employing qualitative data collection techniques: semi-structured interviews with key informants, taskgroups, and workshops.
To identify factors inhibiting the implementation and integration of telecare systems for chronic disease management in the community.

Framework analysis informed by NPT
To identify the policy and practice factors that affect the routine incorporation of telecare into everyday practice, and to explore the ways that these factors promoted or inhibited the implementation and integration of telecare systems.
The study revealed the ways that multiple cycles of uncertainty run through implementation processes, and inhibit the embedding and integration of new ways of delivering care. The authors present a model of the analysed data that shows how uncertainties were derived from problems of coherence and participation as per NPT. This follows the key storylines that ran through participants accounts. Along each storyline are a series of nodes that identifies a factor that inhibits the normalization of telecare systems in practice and which appeared in respondents accounts.
Treweek, S. and Rapley, T. [32] Evaluating complex interventions and health technologies using NPT: development of a simplified approach and web enabled tool kit.
Multiple potential users, researchers and practitioners, of NPT (n=60).
Presented NPT to potiential and actual users. (ii) created a simplified set of statement and explanations expressing core constructs of the theory (iii) circulated statements of a criterion sample of 60 researchers, clinicians and others to collect qualitative data about their criticisms of the statements (iv) reconstructed statements and explanations to meet users criticisms.
Development of a simplified version of NPT for use by clinicians, managers, and policy makers, and which could be embedded in a webenabled toolkit and on-line users manual.
The authors treated the comments about the value and limits of the NPT toolkit as attributive statements and analysed them using a simple and descriptive thematic analysis.
The paper describes the processes by which the authors developed a simplified version of NPT for use by clinicians, managers and policy makers and which could be embedded in a web enabled toolkit and online users manual.
Provides a user friendly version of NPT that can be embedded in a web enabled toolkit and used as a heuristic device to think through implementation and integration problems. To critically review the evidence concerning the implementation of clinical guidelines for bipolar disorder. May's normalization process model can be used to predict how easily a guideline recommendation will be to implement, so that it becomes embedded in routine clinical practice. Furthermore, it can also be used to identify the nature of the barrier to its implementation into practice.
Without a detailed local understanding of the barriers to implementation as per NPM and the resources and will to overcome them, there is likely to be a considerable local variation in the implementation of guidelines for bipolar disorder.
Murray, E,. May,C and Mair,F. [33] Development and formative evaluation of the e-Health Implementation Toolkit (e-HIT).
In the first stage of the evaluation, those interviewed included senior clinicians, managers and academics each of whom had extensive experience of e-health implementations within the NHS (n = 13). In the second stage of the formative evaluation, the revised toolkit was circulated by email to the implementers who had been interviewed in the qualitative study (n = 23).
A two stage formative evaluation of the e-HIT was undertaken. For the first stage, the prototype e-HIT was circulated to a group of e-Health experts. These experts were asked to complete the e-HIT for an e-Health initiative they had personal experience of, and on the basis of this experience, to comment critically on the e-HIT. In the second stage of the formative evaluation, the revised toolkit was circulated by e-mail to the implementers who had been interviewed in the qualitative study (n = 23).
Participants were asked to comment on the likely usefulness of the e-HIT, make suggestions for improvement, and whether it adequately reflected their own experience.
The development and formative evaluation of an e-Health Implementation Toolkit (e-HIT) which aims to summarise and synthesise new and existing research on implementation of e-Health initiatives, and present it to senior managers in a user-friendly format.
Data derived from interviews were summarised, synthesised and combined with the constructs from the NPM.
The aim of the e-HIT was to summarise and synthesise research evidence on factors that impede or facilitate implementation of e-Health initiatives and present this evidence in a format that could be easily digested and used by staff considering or planning an e-Health implementation. The aim of this paper is to describe the process of development and formative evaluation of e-HIT, and describe the final toolkit, in line with recent calls for more detailed descriptions of the processes and content of complex interventions.
The e-HIT shows potential as a tool for enhancing future e-Health implementations. Further work is needed to make it fully web-enabled, and to determine its predictive potential for future implementations.
subgrouping for targeted treatment system. All papers were coded using a framework analysis which evaluated the data in two ways using the 10 transition categories and four elements of Normalization Process Theory that are important for successful implementation and integration of healthcare interventions.
To identify models of transitional care from child to adult health services for CP, ASD and diabetes, using a broad range of literature including peer reviewed publications (1980( -April 2010; To seek evidence to inform 'best practice' about transitional care for children with CHNs; To investigate whether the identified models of transitional care have been evaluated; To use Normalization Process Theory to evaluate whether aspects of service sustainability had been considered.
The scoping review identified no models of transitional care for young people with ASDs, either from electronic database searches or from UK professionals working in the field. Services lacked evaluation, with only a minority reporting consideration of sustainability of the service. NPT provided a structure to assess key elements required for successful implementation and integration of new practice into everyday healthcare.
descriptions of specific services, papers focussing on other conditions and service recommendations. No models of transitional care for young people with ASD were identified from database searches or expert recommendations.
and transition literature was also undertaken; 10 common summary categories for the components of high quality services were identified. Nineteen papers were selected for review. To map the results of four empirical quantitative studies to the NPM to explain why open access hysterosalpingography (HSG) for the initial management of infertile couples has or has not normalized in primary care The NPM has given an explanation why open access HSG has been adopted but not normalized into everyday general practice. The challenge, now, is to define and address the constructs within the model that are limiting normalization and propose methods to address these barriers. Modeling a complex intervention and mapping the barriers is currently a process seldom undertaken in complex intervention trials (Bosch et al., 2007). The NPM has been a useful tool to describe the likely normalization of open access HSG for the initial management of infertility in primary care..