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What is Normalization Process Theory for?
Understanding how new clinical techniques, technologies and other complex interventions become routinely embedded in practice is important to researchers, clinicians, health service managers and policy-makers. Normalization Process Theory provides a conceptual framework for understanding and evaluating the processes (implementation) by which new health technologies and other complex interventions are routinely operationalized in everyday work (embedding), and sustained in practice (integration). It has practical value - helping us understand how new ways of thinking, acting and organizing become embedded in healthcare systems. And it offers a conceptual map for the process evaluation of complex interventions and for the organization of implementation processes.
NPT proposes that implementation and integration should be understood by reference to the work that people do. To investigate this we need to consider four further questions. In relation to any complex intervention, we need to ask:
- What is the work? In particular, we are interested in work that defines and organizes the components of a complex intervention, and its relationship with the contexts in which it is set (we call this coherence).
- Who gets to do the work? In particular, we are interested in work that defines and organizes the people involved in a complex intervention (we call this cognitive participation)
- How does the work get done? In particular, we are interested in work that defines and organizes the enacting of a complex intervention (we call this collective action)
- How is the work understood? In particular, we are interested in work that defines and organizes assessment of the outcomes of a complex intervention (we call this reflexive monitoring)
We recognise that how a complex intervention is diffused and adopted by an organization is an important source of its coherence, and that peoples’ attitudes and intentions are important elements of their cognitive participation in a complex intervention, but NPT focuses on their collective and individual work – sometimes very creative, sometimes very reluctant – to achieve a set of collective goals. This means that NPT focuses mainly on the observable collective action of enacting a complex intervention in practice. It leads us to four further questions about collective action:
- How does a complex intervention affect interactions between people and practices? In particular, we are interested in how a complex intervention is operationalized in practice by the people using it (we call this interactional workability)
- How does a complex intervention relate to existing patterns of knowledge and relationships? In particular, we are interested in how knowledge and practice about a complex intervention is mediated and understood within networks, (we call this relational integration)
- How is the allocation and performance of work affected by a complex intervention? In particular, we are interested in how work associated with a complex intervention is distributed and performed in a division of labour, (we call this skill-set workability).
- How does a complex intervention relate to the organisation in which it is set? In particular, we are interested in how a complex intervention is linked to, and resourced through, organizational structures, (we call this contextual integration).
These are important questions in any intervention design or process evaluation. Importantly, like the rest of NPT, they are drawn from empirical studies of real world complex interventions, and they are highly flexible in their application.
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