Arduous implementation: Does the Normalisation Process Model explain why it's so difficult to embed decision support technologies for patients in routine clinical practice

Department of Primary Care and Public Health, School of Medicine, Cardiff University, Heath Park, CF14 4YS, UK.
Implementation Science (Impact Factor: 3.47). 01/2009; 3:57. DOI: 10.1186/1748-5908-3-57
Source: PubMed

ABSTRACT Decision support technologies (DSTs, also known as decision aids) help patients and professionals take part in collaborative decision-making processes. Trials have shown favorable impacts on patient knowledge, satisfaction, decisional conflict and confidence. However, they have not become routinely embedded in health care settings. Few studies have approached this issue using a theoretical framework. We explained problems of implementing DSTs using the Normalization Process Model, a conceptual model that focuses attention on how complex interventions become routinely embedded in practice.
The Normalization Process Model was used as the basis of conceptual analysis of the outcomes of previous primary research and reviews. Using a virtual working environment we 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.
A conceptual analysis using the Normalization Process Model provided insight on implementation problems for DSTs in routine settings. Current research focuses mainly on the interactional workability of these technologies, but factors related to divisions of labor and health care, and the organizational contexts in which DSTs are used, are poorly described and understood.
The model successfully provided a framework for helping to identify factors that promote and inhibit the implementation of DSTs in healthcare and gave us insights into factors influencing the introduction of new technologies into contexts where negotiations are characterized by asymmetries of power and knowledge. Future research and development on the deployment of DSTs needs to take a more holistic approach and give emphasis to the structural conditions and social norms in which these technologies are enacted.

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Available from: Glyn Elwyn, Aug 09, 2015
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    • "Methods to improve health literacy and shared decision making [31] show some effectiveness, but are often difficult to implement in routine practice [39], where too much is often asked of patients [40]. Interventions designed to improve patient– provider communication [10] [23] are seen as essential to good patient-centered care, yet have not been routinely implemented into clinical care [41] [42]. 3.3. "
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    • "Our study was designed to fill this gap and aimed to identify salient sociotechnical influences on whether and how technologies entered use in the UK's NHS. As noted above, we approached the topic from a deliberately integrative theoretical perspective, combining STS, and specifically ANT, with structuration theory, and we were additionally informed by empirical studies and our own earlier work (Elwyn et al., 2008; Faulkner, 2009; Faulkner & Kent, 2001; Ulucanlar, 2011). "
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    • "In evaluations of teledermatology (Finch, 2008) and telecare of chronic obstructive airways disease (Mair et al., 2008), their normalization was limited by the actors' belief in the process and goals (interactional workability); the former by the incongruence of the patients needs and the latter by the nurses' concerns over the safety and efficiency of the process. By contrast, clinical governance in primary mental health (Gask et al., 2008) and the use of decision support technologies in patient– professional interactions (Elwyn et al., 2008) is limited by the context in which they operate (contextual integration), and it is this construct that is often under-researched and poorly under- stood. "
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