This presentation outlines Normalisation Process Theory (NPT). It was developed for use with the FP7 funded RESTORE project (REsearch into implementation STrategies to support patients of different ORigins and language background in a variety of European primary care settings). This focused on the the implementation of guidances and training initiatives designed to support cross-cultural communication in primary care. The study protocol is available at MacFarlane et al Implementation Science 2012; 7:111 (http://www.implementationscience.com/content/pdf/1748-5908-7-111.pdf).

1. Unpicking NPT
Professor Kate O’Donnell
For the RESTORE team NPT
training November 2011.

2. What is NPT?
 A mid-level sociological theory.
 Derived from empirical work on the implementation of ehealth
initiatives.
 Further tested on a range of complex interventions, involving
practitioners, implementors and patients.

3. • NPT focuses on the work that individuals and groups
have to do for a new technology/practice/way of working
to become embedded and sustained in routine practice.
• It is about both implementation and routinisation.

4. “Helps us to identify and understand factors which promote
and inhibit the routine incorporation of complex interventions
in everyday practice.”
Murray et al. BMC Medicine 2010.

5. A few definitions …….
“It” or “the intervention”: Generally a complex intervention.
e.g. Telehealth care system.
New way of providing care for a group of patients.
Provision of interpreters.
Participants: However are involved in the above.
e.g. Practitioners.
Implementors.
Policy makers.
Patients.

6. NPT Constructs.
Coherence
Cognitive
Participation
Collection Action
Reflexive Monitoring
Making sense of it.
Getting people involved in it.
What has to be done to make
it work.
Evaluating it.

7. Coherence.
About: How participants make sense of the intervention.
What does it mean to them.
Key questions:
Is the intervention easy to describe?
Is it different/distinct from other, established, ways of working?
Does it have a clear purpose for all the relevant participants?
Do participants have a shared understanding of the intervention – its purpose and
aim?
What are the benefits; and for whom?
Will these benefits be valued by potential participants?

8. Cognitive Participation.
About: How much participants commit to and engage with the intervention.
How much they are able to get others to buy-into the intervention. (Often
referred to as enrolment).
Key questions:
Do relevant participants see the point of the intervention?
Do they think it is a good idea?
Are they prepared to invest time, energy and work in it?
Are they prepared to define the activities and work needed to sustain the
intervention?
Are they prepared to get others involved in the intervention?

9. Collective Action.
About: The work participants do to make the intervention happen.
Key questions:
What do participants have to do to make the intervention work in practice?
How does the intervention affect the work of participants?
Has existing work changed at all e.g. are new staff required?
Does it make existing work easier or harder?
Do staff have confidence in the intervention? Do staff need training before delivering/using
the intervention?
Is it compatible with existing work practices?
Does it impact on division of labour, responsibility etc?
Does it fit with organisational goals and activity?

10. Reflexive Monitoring.
About: How participants reflect on, evaluate or appraise the intervention.
Key questions:
How are users likely to perceive the intervention once it has been in use for a
while?
Is it likely to be thought of as advantageous e.g .for staff, for patients?
Will the effects of the intervention be easily identifiable?
Can relevant participants contribute to feedback about the intervention, once it is in
use?
Can the intervention be adapted/improved on the basis of feedback and
experience?

11. Each construct then has its own sub-constructs …….

12. Coherence Cognitive
Participation
Collective Action Reflexive
Monitoring
Differentiation Initiation Interactional
workability
Systematisation
Communal
specification
Legitimation Relational
integration
Communal
appraisal
Individual
specification
Enrolment Skill set workability Individual appraisal
Internalisation Activation Contextual
integration
Reconfiguration

13. Coherence.
About: How participants make sense of the intervention.
What does it mean to them.
Key questions:
Is the intervention easy to describe? (Differentiation)
Is it different/distinct from other, established, ways of working? (Differentiation)
Do participants have a shared understanding of the intervention – its purpose and aim?
(Communal specification)
Do participants understand what is expected of them? (Individual specification)
What are the benefits; and for whom? (Internalisation)
Will these benefits be valued by potential participants? (Internalisation)

14. Cognitive Participation.
About: How much participants commit to and engage with the intervention.
How much they are able to get others to buy-into the intervention. (Often
referred to as enrolment).
Key questions:
Do relevant participants see the point of the intervention? (Legitimation)
Do they think it is a good idea? (Legitimation)
Are they prepared to invest time, energy and work in it? (Enrolment)
Are they prepared to define the activities and work needed to sustain the intervention?
(Activation)
Are they prepared to drive the implementation forward? (Initiation)
Are they prepared to get others involved in the intervention? (Initiation)

15. Collective Action.
About: The work participants do to make the intervention happen.
Key questions:
What do participants have to do to make the intervention work in practice? (Interactional workability)
How does the intervention affect the work of participants? (Interactional workability)
Has existing work changed at all e.g. are new staff required? (Interactional workability)
Does it make existing work easier or harder? (Relational integration)
Do staff have confidence in the intervention? (Relational integration)
Do staff need training before delivering/using the intervention? (Skill set workability)
Is it compatible with existing work practices? (Skill set workability)
Does it impact on division of labour, responsibility etc? (Contextual integration)
Does it fit with organisational goals and activity? (Contextual integration)

16. Reflexive Monitoring.
About: How participants reflect on, evaluate or appraise the intervention.
Key questions:
How are users likely to perceive the intervention once it has been in use for a while?
(Systemisation)
Is it likely to be thought of as advantageous e.g .for staff, for patients? (Communal/Individual
appraisal)
Will the effects of the intervention be easily identifiable? (Systemisation)
Can relevant participants contribute to feedback about the intervention, once it is in use?
(Communal/Individual appraisal)
Can the intervention be adapted/improved on the basis of feedback and experience?
(Reconfiguration)

17. Acknowledgements.
RESTORE was funded by the European Union’s FP7 Health Programme, contract
number 257258.
The work was led by Professor Anne MacFarlane, University of Limerick, Eire.
This presentation was delivered to the RESTORE team in November 2011.
http://www.fp7restore.eu/

18. NPT Training for the RESTORE project.
This presentation was designed and delivered by:
Professors Kate O’Donnell and Frances Mair, University of Glasgow, Scotland.
Professor Christopher Dowrick, University of Liverpool, England.
Professor Anne MacFarlane, University of Limerick, Eire.
For further information, contact: Kate.O’Donnell@glasgow.ac.uk