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Table 5 Author-reported reflections on using NPT in primary care setting

From: Application of normalisation process theory in understanding implementation processes in primary care settings in the UK: a systematic review

Author reflection Example quotation
Identification of where the intervention addressed potential implementation issues [31, 37, 41, 49, 50, 53]. “NPT helped to illuminate the context and localised systems approach that may need to be adopted to work with local stakeholders to implement sick day guidance” [49].
Identification of acceptability, variations in implementation, and barriers to and feasibility of completing the intervention work in specific contexts [31, 34, 36, 38, 44, 47, 48, 55,56,57, 59, 60]. “It is essential to understand the dynamic process of adaptation as an integral part of implementation and routinization, and to assess its contribution to eventual longer term outcomes (positive and negative)” [48].
Useful way of understanding the experience of the implementation of innovation, from multiple perspectives [33, 38, 42, 45, 51, 57, 59, 60]. Perception that NPT facilitated appreciation of “beliefs and opinions of people with different sociocultural status and educational background” [60].
Provides a uniform interpretation scheme for the different views and beliefs of a diverse group of stakeholders [60].
Refinement of intervention ahead of full trial [37, 53]. “We have highlighted the use of Normalisation Process Theory to support development, and not just implementation, of a complex intervention” [48].
Ability to complement other theories and frameworks [31, 40, 43]. In adopting this approach, the intervention was grounded “in an in-depth understanding of the barriers and facilitators most relevant to this specific intervention and user population” [31].
Disagreement over the operationalisation of NPT constructs [33, 38, 52, 58]. Whilst NPT is presented as a temporal process, analysis showed that many participants experience the constructs of NPT simultaneously” [28].
Requires prior awareness of stakeholders and context in order to sensitise to the constructs [59]. We acknowledge that research teams found it difficult to answer some of the 16 sensitizing questions without knowing which stakeholders or sites were going to be involved with the implementation work” [53].
Lacks consideration of the patient perspective on and/or role in implementation [40, 44]. There is a need for greater consideration in implementation theory of the importance of the patient role and the implementation work they need to do” [43].
Places insufficient emphasis on those who receive complex interventions [43].
Risk of artificially imposing (“shoehorning”) constructs onto data collection and analysis [48]. One tension in utilising such an approach is that it can influence the focus of the data collected, subsequent analysis, and the findings. But as detailed in the methods section we took steps to ensure themes, issues and topics which sat outside of the scope of NPT could be explored and accounted for” [48].
Potential for cross-over of NPT constructs, differentiation of the four elements of the NPT framework [27, 32, 46, 55]. “…understanding of the obstacles and drivers associated with embedding real-time feedback in general practices has been enhanced by organising qualitative data according to NPT constructs. … it is important to note that all four NPT constructs operated and were experienced concurrently” [38].