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Frameworks for Understanding Implementation

The last few years have seen an important shift in thinking about implementation. Researchers and practitioners have shifted the focus of their work way from implementation as the outcome of a linear process (beliefs –> intentions –> behaviours), and instead have started to explore a much more complex set of interactions between different mechanisms. Understanding the nature and operation of these mechanisms is of fundamental importance. There are now many different approaches to this problem, informed by sociology, psychology, and behavioural economics, but all of them attempt to map – in one way or another – the complexities of individual and collective action and the mechanisms that drive them. This presentation explores the value of one such theoretical model, Normalization Process Theory (NPT). NPT identifies, characterizes and explains key mechanisms that can be empirically demonstrated to shape implementation processes and to affect their outcomes. NPT is an ecological model of innovation, implementation and improvement processes in healthcare. It characterizes the components of these processes and explains their significance; it is grounded in empirical observation of complex and emergent features of healthcare systems; and it focuses on the things that participants in implementation processes do, rather than one their beliefs, attitudes and intentions. NPT thus offers a way to understand factors that promote and inhibit not only implementation processes, but also the embedding and integration of new health techniques, technologies, and other complex interventions. The presentation draws on preliminary results from a systematic review of 79 reports of studies informed by NPT in healthcare setting. It will show how the work of implementation is expressed in feedback loops rather than linear processes. Within these feedback loops, proponents of new healthcare practices and organizational innovations must successfully compete with already normalized practices; mobilize resources; inspire collective action; manage negotiations between participants and their contexts; and secure workability and integration of their innovations in everyday work.

Carl May is Professor of Healthcare Innovation at the University of Southampton, UK. Carl’s work has focuses on developing a richer understanding of the development and implementation of innovative healthcare technologies, and other complex healthcare interventions. His work in this field includes leading the project to develop Normalization Process Theory (NPT). NPT has informed more than 150 published implementation studies with any more currently in progress.