Article

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.

Download full-text

Full-text

Available from: Glyn Elwyn, Aug 09, 2015
0 Followers
 · 
234 Views
  • Source
    • "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. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Objective Examine existing reviews of patient engagement methods to propose a model where the focus is on engaging patients in clinical workflows, and to assess the feasibility of advocated patient engagement methods. Methods A literature search of reviews of patient engagement methods was conducted. Included reviews were peer-reviewed, written in English, and focused on methods that targeted patients or patient-provider dyads. Methods were categorized to propose a conceptual model. The feasibility of methods was assessed using an adapted rating system. Results We observed that we could categorize patient engagement methods based on information provision, patient activation, and patient-provider collaboration. Methods could be divided by high and low feasibility, predicated on the extent of extra work required by the patient or clinical system. Methods that have good fit with existing workflows and that require proportional amounts of work by patients are likely to be the most feasible. Conclusions Implementation of patient engagement methods is likely to depend on finding a “sweet-spot” where demands required by patients generate improved knowledge and motivate active participation. Practice implications Attention should be given to those interventions and methods that advocate feasibility with patients, providers, and organizational workflows.
    Patient Education and Counseling 05/2014; 95(2). DOI:10.1016/j.pec.2014.01.016 · 2.60 Impact Factor
  • Source
    • "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). "
    [Show abstract] [Hide abstract]
    ABSTRACT: This study explored the sociotechnical influences shaping the naturally-occurring adoption and non-adoption of device technologies in the UK's National Health Service (NHS), amid increasing policy interest in this area. The study was informed by Science and Technology Studies and structuration and Actor Network Theory perspectives, drawing attention to the performative capacities of the technology alongside human agentic forces such as agendas and expectations, in the context of structural and macro conditions. Eight technologies were studied using a comparative ethnographic case study design and purposive and snowball sampling to identify relevant NHS, academic and industry participants. Data were collected between May 2009 and February 2012, included in-depth interviews, conference observations and printed and web-based documents and were analysed using constructivist grounded theory methods. The study suggests that while adoption decisions are made within the jurisdiction of healthcare organisations, they are shaped within a dynamic and fluid ‘adoption space’ that transcends organisational and geographic boundaries. Diverse influences from the industry, health care organisation and practice, health technology assessment and policy interact to produce ‘technology identities.’ Technology identities are composite and contested attributes that encompass different aspects of the technology (novelty, effectiveness, utility, risks, requirements) and that give a distinctive character to each. We argue that it is these socially constructed and contingent heuristic identities that shape the desirability, acceptability, feasibility and adoptability of each technology, a perspective that policy must acknowledge in seeking to intervene in health care technology adoption.
    Social Science [?] Medicine 12/2013; 98:95–105. DOI:10.1016/j.socscimed.2013.09.008 · 2.56 Impact Factor
  • Source
    • "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. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Aim To map the results of four empirical quantitative and qualitative studies to the Normalization Process Model (NPM) to explain why open access hysterosalpingography (HSG) for the initial management of infertile couples has or has not normalized in primary care.Background The NPM is an applied theoretical model to help understand the factors that lead to the routine embedding of a complex intervention in everyday practice. Open access HSG has recently become available for the initial assessment of infertility in primary care.Methods The results of two qualitative studies (a focus group study and an in-depth interview study with patients and professionals) and two quantitative studies (a pilot survey and a pragmatic cluster-randomized controlled trial) evaluating open access HSG are interpreted by mapping the results to the NPM.Findings Application of the model shows that open access HSG would confer an advantage to all agencies if they could be sure that the expertise was present and supported within primary care.Conclusions Open access HSG was adopted but not normalized into everyday practice. Despite demonstration of modest workability, it has been counteracted by limited integration. Further evaluation of integration within contexts is required.
    Primary Health Care Research & Development 09/2009; 10(04):290 - 298. DOI:10.1017/S1463423609990168
Show more