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Implementing, Embedding, and Integrating Practices: An Outline of Normalization Process Theory


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Understanding the processes by which practices become routinely embedded in everyday life is a long-standing concern of sociology and the other social sciences. It has important applied relevance in understanding and evaluating the implementation of material practices across a range of settings.This article sets out a theory of normalization processes that proposes a working model of implementation, embedding and integration in conditions marked by complexity and emergence. The theory focuses on the work of embedding and of sustaining practices within interaction chains, and helps in understanding why some processes seem to lead to a practice becoming normalized while others do not.
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DOI: 10.1177/0038038509103208
2009; 43; 535 Sociology
Carl May and Tracy Finch
Normalization Process Theory
Implementing, Embedding, and Integrating Practices: An Outline of
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Implementing, Embedding, and Integrating
Practices: An Outline of Normalization
Process Theory
Carl May
Newcastle University
Tracy Finch
Newcastle University
Understanding the processes by which practices become routinely embedded in
everyday life is a long-standing concern of sociology and the other social sciences.
It has important applied relevance in understanding and evaluating the implemen-
tation of material practices across a range of settings. This article sets out a theory
of normalization processes that proposes a working model of implementation,
embedding and integration in conditions marked by complexity and emergence.
The theory focuses on the work of embedding and of sustaining practices within
interaction chains, and helps in understanding why some processes seem to lead
to a practice becoming normalized while others do not.
diffusion of innovation / embedding / implementation / material practice /
normalization process theory / routinization
his is an article about how and why things become, or dont become, routine
and normal components of everyday work. This is an important question not
only for sociologists interested in the construction of the life-world, but for
those interested in understanding how particular material practices are rendered as
Copyright © 2009
BSA Publications Ltd®
Volume 43(3): 535–554
DOI: 10.1177/0038038509103208
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doable in specific institutional settings. As we shall see, this is a relevant general
problem in sociological research that focuses on social construction and organiza-
tion. There is also a practical use for explanations of such phenomena in applied
social research, in understanding how complex practices for example, business
processes or healthcare interventions are made workable and integrated in
context-dependent ways. A theoretical model that helps us to understand such
processes would also be a valuable tool in planning and evaluating the implemen-
tation of policy and practice. Our aim is therefore to sketch out the dimensions of
a middle range theory of Normalization Processes that provides an explanatory
framework for investigating the routine embedding of material practices in their
social contexts.
The article takes the following form. First, we discuss some existing ways
of theorizing the implementation, integration, and institutionalization of mate-
rial practices. Then we introduce Normalization Process Theory (henceforth
NPT), which helps us to understand how practices are embedded and integrated
into their social contexts. We then explore the question of the use of the theory
to investigate and anticipate the outcome of processes of implementation and
Institutionalization and Normalization
Institutionalization the routinization of practices of different kinds in everyday
social life was big news in sociology during the 1950s and 1960s. It is to be found
in functionalist (Merton, 1957; Parsons, 1951), interactionist (Blumer, 1969;
Goffman, 1974), and broadly phenomenological (Berger and Luckmann, 1966)
sociologies. After the 1970s, and in the face of the assault on functionalism and the
rise of post-structuralist and post-modern social theory, very concrete analytic con-
cepts like institutionalization declined in theoretical significance and were over-
taken by notions of the constructedness of social life and relativist notions of
‘reality’ itself (Rosenau, 1992).
While its analytic importance in general sociology has faded, the notion of
institutionalization runs through ‘social influence’ theories of organizational inno-
vation and change. In Rogers Diffusion of Innovations theory (Rogers, 1995;
Wejnert, 2002) it represents the final stage in a process of diffusion and adoption,
and research in this field has focused on the process of adopting and championing
innovations. In particular, it focuses on the ‘early adopters’ and ‘product champi-
ons’ who act entrepreneurially to engage with the ‘new’ (Strang and Meyer, 1993).
It has taken the form not simply of a theory that explains technological change –
mainly in retrospect, since prospective studies are few and far between, a fact
regretfully noted by Everett Rogers (2004) towards the end of his lifebut also as
a normative perspective that defines what needs to be done to engender organiza-
tional change, and which informs the perspectives of policy-makers (Greenhalgh
et al., 2004).
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At the same time, a concept analogous to institutionalization runs through the
very broad and more recent literature informed by ‘social shaping’ theories. Once
again, studies from these perspectives are almost never prospective. Whether we
are concerned with the positions and practices formed around thought collectives
(Fleck, 1979[1935]), the production of subjects and the constitution of objects
evinced in the writings of Michel Foucault (Gutting, 1989), or, most recently, with
Actor-Network Theory and the field of Science and Technology Studies (STS)
(Latour, 2005) and the social history of technology (Fox, 1996), the notion that
things become constructed and are stabilized is crucial. Researchers in the STS tra-
dition have offered both innumerable case studies and, in Donald MacKenzies
Inventing Accuracy (1993) and Mechanizing Proof (2001), two of the most
impressive theoretically informed empirical studies in any sociological tradition.
Institutionalization and stabilization are homomorphs, but in practice they
each mean something rather different. Institutionalization at least for Parsons
refers to the point where some practice has become generally habitualized, as the
product of socialization processes. Stabilization, on the other hand, seems to refer
to a moment of equilibrium in the relationships that flow through an Actor-
Network. Both raise a problem for students of ‘implementation’ processes how
are they brought about? This matters very much in the analysis and evaluation of
implementation processes in research on policy, organizations, and professional
knowledge and practice. For example, in structured evaluations of new technologies
in health care, the problem of implementation refers not only to embedding a new
treatment modality or other technology into service delivery, but also to embedding
the techniques and technologies required for its evaluation (Finch et al., 2003). The
notion of ‘implementation’ is politically loaded, and Henriette Langstrup (2008) has
observed that it is often employed in ways that assume the ‘organizational setting
and its actors as pre-givens, thus making the critical task the creation of a “fit”
between technology and organization’ (p. 118). Across the wider literature, such
problems are often understood in terms of the management of behaviours:
Implementation involves all activities that occur between making an adoption com-
mitment and the time that an innovation either becomes part of the organizational
routine, ceases to be new, or is abandoned (…) [and the] behavior of organizational
members over time evolves from avoidance or non-use, through unenthusiastic or
compliant use, to skilled or consistent use. (Linton, 2002: 65)
As Linton sets the problem out, implementation is about innovation, especially
technological innovation. It need not be. Implementation may be conservative
and focus on standardization and regulation of practices according to specific
criteria of adequacy, focusing on holding them in place; for example, the prob-
lem of implementing ‘evidence-based’ best practice so important in recent pro-
fessional change in medicine and health care. In the sense that it is used in the
management literature, ‘implementation’ is a highly purposive and directed set
of activities, but how practices become routinely embedded and integrated into
their social contexts – how they become normalized, or not needs to be under-
stood as a matter of more than external direction.
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Individual Action
Focusing on collective action is not unproblematic. After all, a number of strong
arguments have been advanced for believing that individuals’ intentions and pur-
poses should form the basic unit of analysis in sociology and that sociological
analysis should rest on methodological individualism. These arguments draw
on two different traditions, one which shifts sociology towards a psychological
perspective on volition (Homans, 1951; Simon, 1957), and one that draws on
behavioural economics (Becker, 1976) and sociological rational choice theory
(Coleman, 1990; Goldthorpe, 1998). These theoretical perspectives have tended
to focus on theoretical ideal-typical actors rather than real ones (Hechter and
Kanazawa, 1997), and population level phenomena (Hedström and Swedberg,
1996) rather than on context-dependent social processes.
In contrast, psychological theories of intention, and, in particular, the
Theory of Planned Behaviour (Ajzen, 1991; Ajzen and Fishbein, 1980), are
intended to explain the relation between intention and action in particular con-
texts and in relation to specific practices. Meta-analyses have suggested that
these theories can explain up to 25 per cent of variance in outcomes, in prospec-
tive studies of behaviour change (Gollwitzer and Sheeran, 2006; Webb and
Sheeran, 2006). However, these theories have been criticized by some psychol-
ogists for relying on analyses of correlation, rather than causes (Noar and
Zimmerman, 2005; Weinstein, 2007), and for assuming too much about the
instrumental relation between attitude and intention (Ogden, 2003).
Although it is undoubtedly the case that actors do have preferences and
intentions that they seek to express, there are always social factors that promote
or constrain particular expressions of agency. These do not automatically rest
on individual cognition and volition and include extant vocabularies and reper-
toires of interaction, normative frameworks and belief systems, symbolic and
material resources, power relations and legitimating authority the key pro -
perties of collective action in social networks. Individual intention and prefer-
ences are thus necessary, but not sufficient, explanations for collective action.
We argue that sociological problems of accounting for ‘institutionalization’
and ‘stabilization’ and the policy problem of accounting for ‘implementation’
all revolve around the ways in which these involve participants in work that has
contingent outcomes. NPT helps us to explore the social production and orga-
nization of this work, to understand these contingencies, and to consider their
effects. It begins with the question, what is the work?
Normalization Process Theory
Normalization Process Theory is concerned with the social organization of the
work (implementation), of making practices routine elements of everyday life
(embedding), and of sustaining embedded practices in their social contexts
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Focusing on factors that promote or inhibit routine embedding, the first
iteration of the Normalization Process Model (May, 2006b; May et al., 2007)
sought to explain the operationalization of complex interventions in health care
settings. It was derived from secondary analyses of multiple qualitative studies
in health care settings, and both these studies and the method by which it was
formulated have been described in detail elsewhere (May, 2006b; May et al.,
2007). Empirical application of the model to experimental (Wilkes, 2007),
qualitative (Gask et al., 2008; Mair et al., 2008), and review (Elwyn et al.,
2008) data showed that the model had utility in explaining factors that pro-
moted and inhibited collective action in operationalizing practices.
In its first iteration, the model was limited in scope and did not explain
how complex interventions were formed in ways that held together, how actors
were enrolled into them, or how they were appraised. In this article, we seek to
fill this gap, and extend the explanatory model to a middle range theory. This
means that we are no longer specifically concerned with complex interventions
in health care, but now focus on general processes by which material practices
come to be embedded in their social contexts. In what follows, we therefore
outline the key components of the theory by exploring new domains of coher-
ence, cognitive participation, and reflexive monitoring. The relationship
between these core concepts is mapped out in Figure 1, (with reference to the
conditions that pertain to collective action); all of the theory’s components are
summarized in Table 1; and their application is sketched out in Table 2. As we
do this, we use as exemplars ethnographic and other studies of the develop-
ment, implementation, and evaluation of a teledermatology service that sought
to replace in-person diagnoses of skin conditions with remote diagnosis using
digital images. We describe in detail elsewhere the methods by which the theory
was built (May and Finch, forthcoming).
There is a good deal of debate in the social sciences about what ‘theory’ is, and
what it might be good for (Hechter and Horne, 2003; Manicas, 1988). Our
starting point is that a theory is a coherent conceptual arrangement that, when
it is operationalized, makes possible a rational description and taxonomy of
phenomena and constructs by which their systematic explanation is possible.
From these stem a set of knowledge claims that, in turn, offer the potential for
hypotheses or propositions that might be open to further investigation. As we
discuss later, these lead to questions about the prediction of outcomes or results
of social processes.
The theory rests on apprehending the work that people do, and by work
we mean purposive social action that involves the investment of personal and
group resources to achieve goals. When we refer to a ‘practice’, we are specifi-
cally concerned with material practices: that is, the things that people do to per-
form certain acts and meet specific goals. Further, we are concerned with
material practices that are produced, reproduced, and transformed, in relatively
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formal settings within an institutional or organizational framework which
are consciously composed and purposively directed. Following others in this
field, we refer to such purposive direction as implementation although we rec-
ognize that this is a politically loaded term. This work takes place in what we
call interaction chains, socially patterned points in time and space which are
connected by the flow of social processes.
By normalization, we mean the work that actors do as they engage with
some ensemble of activities (that may include new or changed ways of thinking,
acting, and organizing) and by which means it becomes routinely embedded in
the matrices of already existing, socially patterned, knowledge and practices. For
these reasons, the scope of the theory includes only the products of deliberate
social action in formal organizational settings, and excludes the products of ‘evo-
lutionary’ or ‘traditional’ historical processes of habituation or of the informal
practices that produce cultural forms and fashions (Camic, 1986). Within the
frame of the theory, human action is not assumed to be reducible to individual
factors or to the emergent patterns of corporate direction, and it is further
assumed that the contribution of both individuals and groups to the processes
that lead to implementation, embedding, and integration are interdependent.
Summary Statement of the Theory
NPT provides a set of sociological tools to understand and explain the social
processes that frame the implementation of material practices. The theory pro-
poses that:
a) Material practices become routinely embedded in social contexts as the
result of people working, individually and collectively, to implement them.
Implementation processes are therefore organized and organizing expressions of
human agency that involve patterns of dynamic and contingent interactions within
a specific context, over time. A general and symbolic map of this process is given
at Figure 1. So, to understand the embedding of a practice we must look at what
people actually do and how they work. In this context, the theory proposes that:
b) The work of implementation is operationalized through four generative
mechanisms (coherence; cognitive participation; collective action; reflexive
These are affected by factors that promote or inhibit the routine embedding, or
normalization, of a practice in its social contexts – the immediate and organizing
components outlined in Table 1. The embedding of a practice is thus dependent
on organized and organizing agency, and the theory therefore proposes that:
c) The production and reproduction of a material practice requires continu-
ous investment by agents in ensembles of action that carry forward in time
and space.
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541Implementing, embedding and integrating practices May & Finch
(enrolment and
engagement of
individuals and
Reflexive monitoring
(how a practice is
understood and assessed
by actors implicated in it)
Organizing structures and social norms – how a
social context normatively accommodates a practice
Organizing factors
Skill set workability
Contextual Integration
Collective Action
Interaction with already
existing practices
Immediate factors
Interactional workability
Relational Integration
Group processes and conventions – how a
practice is produced and reproduced in actual
patterns of interpersonal behaviour
Coherence (the
qualities of a
Figure 1 Model of the components of normalization process theory
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This continued investment sustains the integration of a practice in its social
contexts, outlined in Table 2. Through all of this, actorsinvestments and the
work that flows from these are themselves affected by the play of power and by
changing social contexts (Clegg, 2002). These processes are dynamic and con-
tingent, activities in all four domains may occur concurrently, and their produc-
tion and reproduction over time is emergent. Figure1 is therefore a map of the
relations between the core concepts of the theory rather than an empirical map
of normalization processes, and relations between these core concepts are not
linear. Even so, they focus our attention down on how the work gets done – the
everyday business of getting on with the job in hand.
Components of the Theory
The starting point for our account of NPT is the notion of coherence. This
draws into view work that defines and organizes the objects of a material prac-
tice. We begin with the proposition that:
Embedding is dependent on work that defines and organizes a practice as a cogni-
tive and behavioural ensemble. (1.1)
Coherence means that a practice an ensemble of beliefs, behaviours, and acts
that manipulate or organize objects and others is made possible by a
set of ideas about its meaning, uses, and utility; and by socially defined and
organized competencies. These meanings and competencies hold the practice
together, and make it possible to share and enact it. This leads to a second
proposition that:
Embedding work is shaped by factors that promote or inhibit actors’ apprehension
of a practice as meaningful. (1.2)
It stands to reason that a practice is defined by its differences from other prac-
tices, but the nature of this differentiation is often in doubt. One of us (Finch,
2008) has explored the coherence of attempts to replace the in-person diagnosis
of skin disease in clinics with remote diagnosis using digital images. In this case
differentiation was conceived of by practitioners as that of the image.
Conceptualization of the image was the result of a process of communal specifi-
cation in which the practice of remote diagnosis was rendered in terms that were
understandable to, and shared by, the people who work with it in relation to its
distinctive features and perceived suitability for the task in hand. They attributed
an identity to the practice (teledermatology), as a thing that held together well
enough that it could be operationalized. In this sense, users established its coher-
ence by defining the components of a practice, and its differences from other –
already established practices. But as they explored their contributions to
remote diagnosis they found that these were not consistent with those previously
communally specified. In fact, they found that they lost knowledge of the patient
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gained through other diagnostic practices of face-to-face interaction. This lack
of fit between the work of communal and individual specification revealed the
ways that remote diagnosis failed to cohere with other clinical work. The prac-
tices of diagnosis are more than a set of acts that are externally defined and
normatively constrained. They have a meaning that is learned, shared, and expe-
rienced by actors in specific social contexts, as they work the practice through.
This meaning is internalized and contributes to embedding by anchoring the
practice in the lived experiences of individuals. This leads to a further proposi-
tion that:
The production and reproduction of coherence in a practice requires that actors col-
lectively invest meaning in it. (1.3)
Cognitive participation
Within the purposive interaction chains that make up an implementation pro-
cess, a practice is framed through cognitive participation, the symbolic and
real enrolments and engagements of human actors that position them for the
interactional and material work of collective action. From this stems the
proposition that:
Embedding is dependent on work that defines and organizes the actors implicated
in a practice. (2.1)
Here, work that defines and organizes human engagement with a material prac-
tice runs through long interaction chains. Such chains can involve highly
focused work (in enacting a routine laboratory experiment, for example), or
more diffuse patterns of activity (in operationalizing a policy decision in a large
organization). Such chains are organized through socially patterned cognitive
participation, and this leads to the proposition that:
Embedding work is shaped by factors that promote or inhibit actors’ participation. (2.2)
Staying with teledermatology as an example, we can see that actors initiate a
practice. That is, they possessed powers of invention and agency and were both
able and prepared to exercise them. Initiation involves work that brings a prac-
tice forth. It requires that actors are enrolled across social and socio-technical
networks. Having defined a mode of teledermatology that seemed to suit their
circumstances, its clinical proponents then sought to enrol others into the new
system of practice (May et al., 2004). Enrolment involves actors working
together and organizing themselves to participate in a new practice. In this case,
enrolment was sometimes mandatory (since not all participants especially
nurses possessed powers of negotiation or resistance) but sometimes highly
negotiable, as high status and autonomous consultant dermatologists worked
through the possible implications of remote diagnosis for their clinical practice.
Enrolment involves work that brings about and organizes a community of
practice. Legitimation, on the other hand, requires the work of interpreting and
‘buying in’ to that practice in relation to institutionally shared beliefs about the
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propriety and value of knowledge and other existing practices. In this case,
legitimation was secured by proponents of the teledermatology service by appeals
to the technological ambitions of some participants (who wanted to be ‘first’ to
demonstrate the utility of the system), and to the moral ambitions of others (who
wanted better and more rapid access to specialist services for patients).
Legitimation is essential for a practice to be generally activated in contexts where
actors work together to decide the procedures by which it is to be enacted, and
how engagement with it is defined. This decision-making work leads to the acti-
vation of a practice, bringing forth the materials and means by which in this
case, teledermatology – could be effectively operationalized in a clinical setting.
The question of cognitive participation is therefore closely bound to the
norms (Therborn, 2003) and conventions (Biggart and Beamish, 2003) that cir-
culate within the social matrices in which actors find themselves working out a
material practice. This leads to a further proposition, that:
The production and reproduction of a practice requires that actors collectively
invest commitment in it. (2.3)
Collective action
The chains of interactions in which we can trace the cognitive participation of
actors are, in NPT, understood to be the site of mental and material work that is
about organizing and enacting a practice. From this stems the proposition that:
Embedding is dependent on work that defines and operationalizes a practice. (3.1)
This work may be to reshape behaviours or actions, to employ objects or arte-
facts, or it may be to reorganize relationships and contexts – but it involves col-
lective purposive action aimed at some goal. Goal-orientation, in this context,
may include resistance, subversion or reinvention, as well as affirmation and
compliance, but it always involves some investment of effort around the prac-
tice in play. This leads to a further proposition.
Embedding work is shaped by factors that promote or inhibit actors’ enacting it. (3.2)
The work of enacting a practice is located in the operant conditions of encoun-
ters between actors, and the conditions that organize these. In these immediate
conditions, two important qualities of a practice can be observed to come into
play. First, the interactional workability of a practice refers to how actors opera-
tionalize it. In the teledermatology service we use as an exemplar how the focus
of professional–patient interaction shifted from the lesion to the digital image and
the computer-driven protocol that governed its use (Mort et al., 2003). A mate-
rial practice will affect cooperative interactions over work, and the normal pat-
tern of outcomes of this work.
Second, relational integration refers to the way that a practice is mediated
and understood within the networks of people around it. A material practice
will also affect not only the knowledge required by its users, but also the ways
that they understand the actions of people around them. Trust relations
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between dermatologists, nurses, and patients using the teledermatology service
were maintained, yet doctors’ confidence in the practice of remote diagnosis
declined as they struggled to make sense of the digital images that were trans-
mitted to them. This loss of confidence increased over time, as they took a pro-
gressively more evidential approach to diagnostic decisions (Mort et al., 2003).
In organizing conditions, two further qualities are important. First, skill-set
workability describes the distribution and conduct of work that distributes a
practice in a division of labour. A material practice will affect the ways that work
is allocated, and the ways skills are defined. Teledermatology was appropriate to
the skills of nurses administering it, and they felt it enhanced these. It led to spe-
cialist nurses operationalizing high level clinical knowledge that overlapped
with, but was accepted by, medical specialists (May et al., 2004), even though
this threatened the strict demarcation of diagnostic boundaries between
medicine and nursing. Second, contextual integration refers to the incorporation
of a practice within a social context. A material practice will also affect the
mechanisms that link work to existing structures and procedures, and for real-
izing material and symbolic resources for them. Here the teledermatology service
added complexity and workload to specialist services, it never achieved real inte-
gration with the existing set of practices that ran through the clinical encounter
with patients with skin diseases, and it added complexity to the funding and
organization of the clinics in which these practices were activated. The operation
of the factors that frame collective action lead us to the proposition that:
The production and reproduction of a practice requires that actors collectively
invest effort in it. (3.3)
Reflexive monitoring
Patterns of collective action and their outcomes are continuously evaluated, both
formally and informally, by participants in implementation processes, and the
formality and intensity of this monitoring work reflects the nature of their cog-
nitive participation and collective action. From this stems the proposition that:
Embedding is dependent on work that defines and organizes the everyday under-
standing of a practice. (4.1)
Formal patterns of monitoring focus attention on normative elements of imple-
mentation. These frame how things ought to be, rather than the conventions
that frame how things are worked out in practice. The shift from explicit to
tacit appraisal by participants is an important signal of the routine embedding
of a practice (Finch et al., 2007). This leads to a further proposition:
Embedding work is shaped by factors that promote or inhibit appraisal. (4.2)
Reflexive monitoring may involve judgements about the utility and effective-
ness of a new practice, and these are made with reference to socially patterned
and institutionally shared beliefs. Systematization is central to this process,
and it refers to the methodological formality of these judgements and the
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rationalities that underpin them. Keeping teledermatology in mind, we can see
that relatively informal modes of evaluation – characterized by participants as
clinical experience seem to be associated with embedding services (Finch
et al., 2007), while highly formal and strictly defined modes of evaluation
such as randomized controlled trials – seem to be associated with real problems
in integrating experiential knowledge and abstract information (May, 2006a).
Regular and organized procedures for monitoring and ongoing assessment
of the process and impact of the new practice within an organizational context
may involve highly structured and formal mechanisms of institutional knowl-
edge production and interpretation – patterns of communal appraisal. Of
course, communal appraisal co-exists with individual appraisal that relies on
experiential and unsystematic practices of judging the value and outcomes of a
practice, and from which stem individual commitments to its conduct and per-
formance. More immediately, both communal and individual appraisal may
lead to attempts at reconfiguration in which ideas about the use and utility of
a practice are subverted, modified, or reconstructed. These play an important
part in feeding back into notions of the coherence and meaningfulness of a
practice. This leads us to a final proposition:
The production and reproduction of a practice requires that actors collectively
invest in its understanding. (4.3)
The Status of Propositions in Normalization Process Theory
NPT is structured around a propositional scheme. Such schemes play an impor-
tant part in the development of theory (Turner, 1987), and are especially impor-
tant in considering the problem of mechanisms. In this context, a theory must
do more than propose a link between a process and its effects (Hechter and
Horne, 2003), but must also propose a mechanism by which these effects are
produced (Hedström, 2005). We follow Bunge (2004) in understanding a mech-
anism to be a process that ‘brings about or prevents some change in a concrete
system’ (2004: 193). In NPT, three kinds of proposition specify elements of a
1 Propositions (e.g. 1.1 above) that define a mechanism (i.e. embedding is
dependent on socially patterned implementation work).
2 Propositions (e.g. 3.2) that define components of the mechanism (i.e. fac-
tors that shape socially patterned implementation work).
3 Propositions (e.g. 4.3) that define actors’ investments in a mechanism (i.e. how
the mechanism is energized).
Propositions beg empirical verification, but it is important to be clear that
the purpose of those outlined here is also to give structure to theory and to pro-
vide analytical leverage. This scheme allows us to conceptualize the general
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structure of an implementation process, and it thus sensitizes us to a set of activ-
ities, mechanisms, and investments that are crucial to its outcomes. In Table 1
we set these mechanisms, components, and investments out in tabular form, but
there is a caveat to this. Setting out the components of a theory in propositional
and tabular form implies a degree of rigidity that is completely alien to the phe-
nomena with which NPT is concerned. We emphasize that ‘implementation’ is
a dynamic and fluid process. Moreover, the operation and importance of par-
ticular mechanisms and components will vary within and between particular
empirical contexts. This raises the question of the application of Normalization
Process Theory to understanding and forecasting the trajectory and outcomes
of implementation processes. It is to these problems that we turn to next.
Prediction and Potential
Normalization processes are found everywhere that people work to implement
specific practices and to integrate them in their social worlds. They are impor-
tant sources of contextual change in organizational settings; for example, as
‘business processes’ in firms, or ‘complex interventions’ in health care organi-
zations. These are also two areas where ‘implementation’ is seen to be highly
important. The question is, can the outcomes of such processes be predicted?
Almost all social theories provide a point of departure for retrospective
explanation of some social relationship or process. The goal of many theories,
however, is to move beyond post-hoc explanations to predict outcomes. This
really is a significant methodological and theoretical challenge, and one that
many theories in the social sciences have been poor at meeting (Gorski, 2004). It
is worth asking why this is so. One reason is the problem of accounting for cau-
sation, in the context of complex relations between elements of a social process
547Implementing, embedding and integrating practices May & Finch
Table 1 Mechanisms, components and investments
Components Coherence Cognitive Collective Reflexive
Participation Action Monitoring
Components (1) Differentiation Initiation Interactional Systematization
Immediate work Workability
Individual Legitimation Relational Individual
Specification Integration Appraisal
Components (2) Communal Enrolment Contextual Communal
Organizing work Specification Integration Appraisal
Internalization Activation Skill Set Reconfiguration
Investments Meaning Commitment Effort Comprehension
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(Kern, 2004). All social processes are complex and emergent (Sawyer, 2005).
They can be transformed by the proximity of, or interaction with, some other
process or event. Implementation processes are no different. In real-world stud-
ies, predictions about outcomes are complicated by multiple confounders that
include the sheer number of actors in a process, the weight of numbers and effects
of confounding variables, and the intervention of chance as an actor in a social
system under observation rather than a statistical problem that needs to be solved
by an external observer. Crucially, these processes are also the foci of contests,
and mechanisms of the theory map out sites of resistance and conflict. This means
that predictions of the outcome of a complex and emergent process are a prob-
lem. After all, social processes transform as they are produced and reproduced.
Although implementation processes are complex and emergent, they are
rarely arbitrary. In practice, emergence is often characterized by a relatively nar-
row range of possibilities that are held in place by normative frameworks
(which include shared beliefs about action, rules about appropriate forms of
behaviour, and so forth) and structural constraints (which include the permis-
sive actions of others, the availability of social spaces for action, and material
and symbolic resources). Normative and structural constraints thus have a
powerful effect on implementation processes at work, and reflect actors’
propensities to work within already normalized frames of knowledge and prac-
tice. So, although we make no claim of absolute predictive power for the the-
ory, we do argue below that the trajectory of a practice can be anticipated
within certain limits. Probabilistic assessments of the potential of a practice to
embed and of the readiness of actors to accept it in a specific context ought to
be possible. To assess potential, we need to consider the structure of NPT and
the variables that it suggests. In doing so we must bear in mind that variable
driven theoretical models in social science possess certain problems. In this con-
text, we need to avoid the situation remarked by Hedström where:
Theoretical statements have become synonymous with hypotheses about the rela-
tionships between variables, and variables have replaced actors as the active subjects
with causal powers. (2005: 105)
Drawing on the work of Coleman (1986), Hedström goes on to reject a model
of theory building that relies on studies, ‘where behaviour is explained by refer-
ence to whatever individual or environmental variables can be measured’ (2005:
105). We also take this view. In this context, we emphasize that NPT expresses
an empirically observable set of social processes that can be modelled. Even
though such a forecast is subject to a range of unknowable contingencies, and
emergence and complexity are significant constraints on predicting the outcomes
of social processes, the theory’s constructs may be used to construct a
statistical model of a process and forecast its outcome in probabilistic terms. To
assess the normalization potential of a practice, for example, requires that val-
ues can be reliably assigned to variables derived from the theory.
Whether we choose to use NPT as the foundation for hypothesis testing inves-
tigations that use quasi-experimental or other quantitative methods, or for analytic
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investigations using ethnographic or other qualitative methods, operationalizing the
theory requires that its abstract core constructs (set out in Figure 1 and Table 1) are
translated into a working model with real-world correlates. These form a basis for
the conceptual work of describing, explaining, making, and testing claims about
observed phenomena. In Table 2 we set these elements out in a simple summary
table, always beginning with the question, what is the work?
Normalization Process Theory provides a robust and replicable ecological
framework for analysing the dynamic collective work and relationships involved
in the implementation and social shaping of practices. It is a theory for empiri-
cal application rather than abstract critique. It focuses attention on organized
and organizing agency in the production and reproduction of the implementa-
tion, embedding (or not), and continuing integration of material practices.
There is a hierarchy of scope in sociological theory, and throughout this
article we have been clear that NPT is an example of what Merton (1957) called
a ‘middle range’ theory, which addresses a discrete sociological question how
549Implementing, embedding and integrating practices May & Finch
Table 2 Framework for operationalizing normalization process theory
Coherence Cognitive Collective Reflexive
What is the work? Participation Action Monitoring
Who does How does the How is the work
the work? work get done? understood?
Systematic Factors that Factors that Factors that Factors that
explanation of promote or promote or promote or promote or inhibit
mechanisms and inhibit the inhibit participation inhibit enacting the appraisal of a
components at mobilization of in a practice a practice practice
work a practice
Knowledge Beliefs and Beliefs and Beliefs and Beliefs and
about the behaviours that behaviours that behaviours that behaviours that
sources and define and define and define and define and organize
operation of organize objects organize actors organize work understanding
at work
Investigation of How is a practice How do How do How do participants
core questions conceptualized participants come participants appraise a practice
that could by participants? to engage with a enact a practice? What are its effects
include… How does it hold practice? How do How are their of appraisal? How
together in action? they decide on activities are they mediated?
engagement and structured and
the purposes that constrained?
it serves?
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are material practices implemented and routinely embedded in everyday life
through analysis and explanation of a specific set of concrete behaviours and
relations. Boudon (1991) has argued that such theories are not simply powerful
in their own right, but that they are also ‘efficient’ because they can ‘federate
and consolidate empirical and theoretical observations across disciplines.
If there is a hierarchy of scope in sociological theories, there is also the prob-
lem of the role of theories themselves. NPT is intended to explicate the condi-
tions of social action in a specific, and limited, arena. It holds out the hope of
prospectively assessing the potential of practices to normalize by reference to a
set of constructs that define the work that actors do in such circumstances, and
thus also provides a sociological framework for comparative implementation
studies. The theory is formal, in that it proposes a set of generative statements
that may be expressed as an abstract model, and that lead to hypotheses about
specific relationships between its elements. The theory is verifiable because these
hypotheses are amenable to experimental investigation and concurrent qualita-
tive inquiry. Beyond this, the theory provides a sociological basis for explanatory
and comparative studies of the work of social construction, by reference to a set
of mechanisms that permit the dynamic, creative, and complex work evident in
the ‘normalization’ of what often seem to be very simple things.
Christine May read and commented on an unreasonable number of drafts of this
article. We thank her, and Glyn Elwyn, Jane Gunn, France Legaré, Frances Mair,
Elizabeth Murray, Victor Montori, Tiago Moreira, Catherine Pope, Tim Rapley,
Anne Rogers, Peter Salmon and Karen Willis for difficult questions and detailed
comments on the arguments presented here at various stages in their evolution.
This article also benefited from discussion with participants at a symposium of
the COMPASS Collaboration of Melbourne and La Trobe Universities,
(Melbourne, 21 April 2008); at Research Grand Rounds of the Mayo Clinic,
(Rochester, Minnesota, 27 August 2008); and at Ehealth 2008 (London, 9
September 2008).
Ajzen, I. (1991) ‘The Theory of Planned Behavior’, Organizational Behavior and
Human Decision Processes 50: 179–211.
Ajzen, I. and M. Fishbein (1980) Understanding Attitudes and Predicting Social
Behaviour. Englewood Cliffs, NJ: Prentice-Hall.
Becker, G.C. (1976) The Economic Approach to Human Behavior. Chicago, IL:
University of Chicago Press.
Berger, P.L. and T. Luckmann (1966) The Social Construction of Reality.
Harmondsworth: Penguin.
550 Sociology Volume 43
Number 3
June 2009
at UNIV OF NEWCASTLE UPON TYNE on October 15, 2009 http://soc.sagepub.comDownloaded from
Biggart, N.W. and T.D. Beamish (2003) ‘The Economic Sociology of Conventions:
Habit, Custom, Practice, and Routine in Market Order’, Annual Review of
Sociology 29: 443–64.
Blumer, H. (1969) Symbolic Interactionism – Perspective and Method. Los Angeles,
CA: University of California Press.
Boudon, R. (1991) ‘What Middle-Range Theories Are’, Contemporary Sociology
20(4): 519–22.
Bunge, M. (2004) ‘How Does it Work? The Search for Explanatory Mechanisms’,
Philosophy of the Social Sciences 34(2): 182–210.
Camic, C. (1986) ‘The Matter of Habit’, American Journal of Sociology 91(5): 1039–87.
Clegg, S.R. (2002) Frameworks of Power. London: SAGE.
Coleman, J.S. (ed.) (1986) Individual Interests and Collective Action: Selected
Essays. Cambridge: Cambridge University Press.
Coleman, J.S. (1990) Foundations of Social Theory. Cambridge, MA: Harvard
University Press.
Elwyn, G., F. Legare, A. Edwards, T. van der Weijden and C. May (2008) ‘Arduous
Implementation: Does the Normalisation Process Model Explain Why It’s so
Difficult to Embed Decision Support Technologies in Routine Clinical Practice’,
Implementation Science 3: 57.
Finch, T. (2008) ‘Teledermatology for Chronic Disease Management: Coherence
and Normalization’, Chronic Illness 4(2): 127–34.
Finch, T.L., F.S. Mair and C.R. May (2007) ‘Teledermatology in the UK: Lessons in
Service Innovation’, British Journal of Dermatology 156(3): 521–7.
Finch, T., C. May, F. Mair, M. Mort and L. Gask (2003) ‘Integrating Service
Development with Evaluation in Telehealthcare: An Ethnographic Study’,
British Medical Journal 327(7425): 1205–9.
Fleck, L. (1979[1935]) The Genesis and Development of a Scientific Fact. Chicago,
IL: Chicago University Press.
Fox, R. (1996) ‘Methods and Themes in the History of Technology’, in R. Fox (ed.)
Technological Change, pp. 1–16. Amsterdam: Harwood.
Gask, L., A. Rogers, S. Campbell and R. Sheaff (2008) ‘Beyond the Limits of Clinical
Governance: The Case of Mental Health in Primary Care’, BMC Health Services
Research 8(63).
Goffman, E. (1974) Frame Analysis: An Essay on the Organisation of Experience.
Boston, MA: Northeastern University Press.
Goldthorpe, J.H. (1998) ‘Rational Action Theory for Sociology’, British Journal of
Sociology 49(2): 167–92.
Gollwitzer, P.M. and P. Sheeran (2006) ‘Implementation Intentions and Goal
Achievement: A Meta-Analysis of Effects and Processes’, Advances in
Experimental Social Psychology 38: 69–119.
Gorski, P.S. (2004) ‘The Poverty of Deductivism: A Constructive Realist Model of
Sociological Explanation’, Sociological Methodology 34(1): 1–33.
Greenhalgh, T., G. Robert, F. Macfarlane, P. Bate and O. Kyriakidou (2004)
‘Diffusion of Innovations in Service Organizations: Systematic Review and
Recommendations’, Milbank Quarterly 82(4): 581–629.
Gutting, G. (1989) Michel Foucault’s Archaeology of Scientific Reason. Cambridge:
Cambridge University Press.
551Implementing, embedding and integrating practices May & Finch
at UNIV OF NEWCASTLE UPON TYNE on October 15, 2009 http://soc.sagepub.comDownloaded from
Hechter, M. and C. Horne (2003) ‘Theory is Explanation’, in M. Hechter and C.
Horne (eds) Theories of Social Order, pp. 3–8. Stanford, CA: Stanford University
Hechter, M. and S. Kanazawa (1997) ‘Sociological Rational Choice Theory’,
Annual Review of Sociology 23: 191–214.
Hedström, P. (2005) Dissecting the Social: On the Principles of Analytical Sociology.
Cambridge: Cambridge University Press.
Hedström, P. and R. Swedberg (1996) ‘Rational Choice, Empirical Research, and
the Sociological Tradition’, European Sociological Review 12(2): 127–46.
Homans, G.C. (1951) The Human Group. London: Routledge & Kegan Paul.
Kern, S. (2004) A Cultural History of Causality: Science, Murder Novels and
Systems of Thought. Princeton, NJ: Princeton University Press.
Langstrup, H. (2008) ‘Making Connections through Online Asthma Monitoring’,
Chronic Illness 4(2): 118–26.
Latour, B. (2005) Reassembling the Social: An Introduction to Actor Network Theory.
Oxford: Oxford University Press.
Linton, J.D. (2002) ‘Implementation Research: State of the Art and Future
Directions’, Technovation 22(2): 65–79.
MacKenzie, D. (1993) Inventing Accuracy: A Historical Sociology of Nuclear
Missile Guidance. Cambridge, MA: MIT Press.
MacKenzie, D. (2001) Mechanizing Proof: Computing, Risk and Trust. London:
MIT Press.
Mair, F.S., J. Hiscock and S.C. Beaton (2008) ‘Understanding Factors that Inhibit or
Promote the Utilization of Telecare in Chronic Lung Disease’, Chronic Illness
4(2): 110–17.
Manicas, P.T. (1988) A History and Philosophy of the Social Sciences. Oxford:
May, C. (2006a) ‘Mobilizing Modern Facts: Health Technology Assessment and the
Politics of Evidence’, Sociology of Health & Illness 28(5): 513–32.
May, C. (2006b) ‘A Rational Model for Assessing and Evaluating Complex
Interventions in Health Care’, BMC Health Services Research 6, article 86.
May, C. and T.L. Finch (forthcoming) Normalizing Health Technologies. London:
May, C., M. Mort, T. Finch and F. Mair (2004) ‘The Anatomy of Failure?
Teledermatology in an English City’, in P.S. Whitten and D.J. Cook (eds)
Understanding Health Communications Technologies: A Case Study Approach,
pp. 80–91. San Francisco, CA: Jossey-Bass.
May, C., T. Finch, F.S. Mair, L. Ballini, C. Dowrick, M. Eccles, L. Gask, A. MacFarlane,
E. Murray, T. Rapley, A. Rogers, S. Treweek and P. Wallace (2007) ‘Understanding
the Implementation of Complex Interventions in Health Care: The Normalization
Process Model’, BMC Health Services Research 7, article 148.
Merton, R.K. (1957) Social Theory and Social Structure. New York: The Free Press.
Mort, M., C.R. May and T. Williams (2003) ‘Remote Doctors and Absent Patients:
Acting at a Distance in Telemedicine?’ Science, Technology and Human Values
28(2): 274–95.
Noar, S.M. and R.S. Zimmerman (2005) ‘Health Behavior Theory and Cumulative
Knowledge Regarding Health Behaviors: Are We Moving in the Right Direction?’,
Health Education Research 20(3): 275–90.
Ogden, J. (2003) ‘Some Problems with Social Cognition Models: A Pragmatic and
Conceptual Analysis’, Health Psychology 22(4): 424–8.
552 Sociology Volume 43
Number 3
June 2009
at UNIV OF NEWCASTLE UPON TYNE on October 15, 2009 http://soc.sagepub.comDownloaded from
Parsons, T. (1951) The Social System. London: Routledge & Kegan Paul.
Rogers, E.M. (1995) The Diffusion of Innovations, 4th edn. New York: Free Press.
Rogers, E.M. (2004) ‘A Prospective and Retrospective Look at the Diffusion Model’,
Journal of Health Communication 9(9): 13–19.
Rosenau, P. (1992) Postmodernism and the Social Sciences: Insights, Inroads and
Intrusions. Princeton, NJ: Princeton University Press.
Sawyer, R.K. (2005) Social Emergence: Societies as Complex Systems. Cambridge:
Cambridge University Press.
Simon, H. (1957) Models of Man. New York: Wiley.
Strang, D. and J.W. Meyer (1993) ‘Institutional Conditions for Diffusion’, Theory
and Society 22(4): 487–511.
Therborn, G. (2003) ‘Back to Norms! On the Scope and Dynamics of Norms and
Normative Action’, Current Sociology 50(6): 863–80.
Turner, J.H. (1987) ‘Analytical Theorizing’, in A. Giddens and J. Turner (eds) Social
Theory Today, pp. 156–94. Cambridge: Polity.
Webb, T.L. and P. Sheeran (2006) ‘Does Changing Behavioral Intentions Engender
Behaviour Change? A Meta-Analysis of the Experimental Evidence’,
Psychological Bulletin 132(2): 249–68.
Weinstein, N.D. (2007) ‘Misleading Tests of Health Behavior Theories’, Annals of
Behavioral Medicine 33(1): 1–10.
Wejnert, B. (2002) ‘Integrating Models of Diffusion of Innovations: A Conceptual
Framework’, Annual Review of Sociology 28: 297–326.
Wilkes, S. (2007) ‘Evaluation of Open Access Hysterosalpingography in the Initial
Management of Infertility in Primary Care’, Unpublished PhD Thesis,
University of Sunderland.
Carl May
Is Professor of medical sociology and leads the Health Technologies and Human Relations
research programme in the Institute of Health and Society at Newcastle University. He
has researched and published widely on professional–patient interaction in the manage-
ment of chronic illness; the design, evaluation and implementation of innovative health
technologies; and the sociology of the randomized controlled trial. With Tracy Finch, he
is the author of Normalizing Health Technologies to be published by Palgrave in 2010.
Address: Institute of Health and Society, Newcastle University, 21 Claremont Place,
Newcastle upon Tyne, NE2 4AA, UK.
553Implementing, embedding and integrating practices May & Finch
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Tracy Finch
Is Senior Lecturer in health psychology in the Health Technologies and Human Relations
research group at Newcastle University. She has interests in the social and psychological
aspects of health technology assessment and technology use in practice. Her research
programme includes studies of attitudes and behaviour in relation to the adoption and
normalization of new technologies, particularly telemedicine, telecare and ehealth.
Address: Institute of Health and Society, Newcastle University, 21 Claremont Place,
Newcastle upon Tyne, NE2 4AA, UK.
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... Normalisation Process Theory (NPT) identifies, characterises, and explains key mechanisms that promote and inhibit the implementation, embedding and integration of new health techniques, technologies, and other complex interventions [26]. NPT defines implementation, embedding, and integration as a process that occurs when participants deliberately initiate and seek to sustain a sequence of events that bring it into operation. ...
... NPT defines implementation, embedding, and integration as a process that occurs when participants deliberately initiate and seek to sustain a sequence of events that bring it into operation. The dynamics of implementation processes are complex, but normalisation process theory facilitates understanding by focusing attention on the mechanisms through which participants invest and contribute to them [26]. We believe that, in accordance with NPT [26], new interventions have the best chance of succeeding if they are based on an awareness and active engagement with existing organisational culture and practices therefore NPT influenced data collection methods, topic guide and data analysis. ...
... The dynamics of implementation processes are complex, but normalisation process theory facilitates understanding by focusing attention on the mechanisms through which participants invest and contribute to them [26]. We believe that, in accordance with NPT [26], new interventions have the best chance of succeeding if they are based on an awareness and active engagement with existing organisational culture and practices therefore NPT influenced data collection methods, topic guide and data analysis. This study was developed in accordance with the Medical Research Council framework for developing complex interventions which specifies that before an intervention is piloted (as is the case for multiagency hoarding services in the UK), evidence-based modelling of the condition, its determinants and points for intervention should be specified [27]. ...
Full-text available
Hoarding disorder is characterised by the acquisition of, and failure to discard large numbers of items regardless of their actual value, a perceived need to save the items and distress associated with discarding them, significant clutter in living spaces that render the activities associated with those spaces very difficult causing significant distress or impairment in functioning. To aid development of an intervention for hoarding disorder we aimed to identify current practice by investigating key stakeholders existing practice regarding identification, assessment and intervention associated with people with hoarding disorder. Two focus groups with a purposive sample of 17 (eight male, nine female) stakeholders representing a range of services from housing, health, and social care were audio recorded, transcribed verbatim and analysed thematically. There was a lack of consensus regarding how hoarding disorder was understood and of the number of cases of hoarding disorder however all stakeholders agreed hoarding disorder appeared to be increasing. The clutter image rating scale was most used to identify people who needed help for hoarding disorder, in addition to other assessments relevant to the stakeholder. People with hoarding disorder were commonly identified in social housing where regular access to property was required. Stakeholders reported that symptoms of hoarding disorder were often tackled by enforced cleaning, eviction, or other legal action however these approaches were extremely traumatic for the person with hoarding disorder and failed to address the root cause of the disorder. While stakeholders reported there was no established services or treatment pathways specifically for people with hoarding disorder, stakeholders were unanimous in their support for a multi-agency approach. The absence of an established multiagency service that would offer an appropriate and effective pathway when working with a hoarding disorder presentation led stakeholders to work together to suggest a psychology led multiagency model for people who present with hoarding disorder. There is currently a need to examine the acceptability of such a model.
... The HealthCall team and LA Commissioner also highlighted these benefits. 42 43 While the residents interviewed did not appear to be fully aware of the intervention, one resident, 44 ...
... Conclusion 43 The HealthCall Digital Care Homes app appears to be a feasible, appropriate and legitimate 44 intervention to support improved referral, triage and health care support for non-urgent health care 45 needs of care home residents. The comprehensive implementation process that welcomed feedback 46 to support improvements to the intervention and implementation is the core of this intervention's 47 success. ...
Recent years have seen a rise in digital interventions to improve coordination between care homes and NHS services, supporting remote sharing of data on the health of care home residents. Such interventions were key components in the response to the COVID-19 pandemic. This paper presents findings from the qualitative component of an evaluation of an implementation of the HealthCall Digital Care Homes application, across sites in northern England. The implementation commenced prior to the pandemic and continued throughout. Semi-structured, qualitative interviews were held with stakeholders. Interviews were conducted remotely (October 2020 -June 2021). Data were analysed via a reflexive thematic analysis then mapped against Normalization Process Theory (NPT) constructs (coherence, collective action, cognitive participation, and reflexive monitoring) providing a framework to assess implementation success. Thirty-five participants were recruited: 16 care home staff, six NHS community nurses, five relatives of care home residents, four HealthCall team members, three care home residents, and one local authority commissioner. Despite facing challenges such as apprehension towards digital technology among care home staff, the application was viewed positively across stakeholder groups. The HealthCall team maintained formal and informal feedback loop with stakeholders. This resulted in revisions to the intervention and implementation. Appropriate training and problem solving from the HealthCall team and buy-in from care home and NHS staff were key to achieving success across NPT constructs. While this implementation appears broadly successful, establishing rapport and maintaining ongoing support requires significant time, financial backing, and the right individuals in place across stakeholder groups to drive implementation and intervention evolution. The digital literacy of care home staff requires encouragement to enhance their readiness for digital interventions. The COVID-19 pandemic has pushed this agenda forward. Problems with stability across the workforce within care homes need to be addressed to avoid skill loss and support embeddedness of digital interventions. What is known about this topic? Improving healthcare delivery in UK care homes is a health policy priority. Digital interventions designed to enhance the referral process between care homes and NHS services and improve the healthcare delivery in care homes have become increasingly common in the UK. The HealthCall Digital Care Homes application is one such intervention. These interventions and their implementations require evaluation to ensure that they operate as intended, function coherently and are considered appropriate and legitimate to the care home setting. What this paper adds? The HealthCall Digital Care Homes app is a feasible, appropriate and legitimate intervention for referral, triage and health care support for non-urgent health care needs of care home residents. The ongoing involvement of end users in further developing the intervention, and the level of monitoring and support provided by the implementation team appears to be key to the implementation’s success. The digital preparedness of UK care homes is limited. Ensuring that care homes are digitally enabled, with a digitally literate workforce, should be a policy and research priority.
... For the same intervention, Putnam's (2000) classic theory of bonding and bridging social capital was used to explain the mechanisms that facilitate engagement in interventions. For SUPRANET in the Netherlands, the process evaluation was guided by the Normalisation Process Theory (NPT) (May and Finch, 2009) and proposed to be used to understand factors influencing the adoption and delivery of the intervention, fidelity in a real-life setting, and context related barriers and facilitators. The NPT was also used in an implementation evaluation of the Zero Suicide Framework. ...
... For example, a process evaluation was used to better understand intervention outcomes, understand the transferability of an intervention, to document and describe processes, the context, and the experience of being a part of the trial. The Normalisation Process Theory (May and Finch, 2009) was used to understand how practices are operationalised and routinised within health care systems. The Precede-Proceed framework (Green and Kreuter, 2005) was proposed to be used to understand intervention consistency, adherence, and integration into practice. ...
Full-text available
Objectives: Little is known about how complex, multilevel, and multicomponent suicide prevention interventions work in real life settings. Understanding the methods used to systematically adopt, deliver, and sustain these interventions could ensure that they have the best chance of unfolding their full effect. This systematic review aimed to examine the application and extent of utilisation of implementation science in understanding and evaluating complex suicide prevention interventions. Methods: The review adhered to updated PRISMA guidelines and was prospectively registered with PROSPERO (CRD42021247950). PubMed, CINAHL, PsycINFO, ProQuest, SCOPUS and CENTRAL were searched. All English-language records (1990-2022) with suicide and/or self-harm as the primary aims or targets of intervention were eligible. A forward citation search and a reference search further bolstered the search strategy. Interventions were considered complex if they consisted of three or more components and were implemented across two or more levels of socio-ecology or levels of prevention. Results: One hundred thirty-nine records describing 19 complex interventions were identified. In 13 interventions, use of implementation science approaches, primarily process evaluations, was explicitly stated. However, extent of utilisation of implementation science approaches was found to be inconsistent and incomprehensive. Limitations: The inclusion criteria, along with a narrow definition of complex interventions may have limited our findings. Conclusion: Understanding the implementation of complex interventions is crucial for unlocking key questions about theory-practice knowledge translation. Inconsistent reporting and inadequate understanding of implementation processes can lead to loss of critical, experiential knowledge related to what works to prevent suicide in real world settings.
... Our analysis aims not to generalize or compare across different geo-political ideologies, but to use Yurchak's key insights into hypernormalization in the Soviet Union to understand contemporary social practices and how their manifestations in work and workplaces that can be perceived as absurd. Hypernormalization concerns the normalization of the absurd, and thus the process by which the absurd is taken for granted, perpetuated, and projected upon people as the norm (May and Finch, 2009). It is a process that may be orchestrated and deliberately managed, but also unfolds spontaneously. ...
Full-text available
This paper examines absurdities in contemporary society and workplaces. Absurdity arises from the absence of rationality, where observed human practices paradoxically veer away from official discourse and institutional rhetoric. Absurdity does not exist in a vacuum but is penetrated by and hypernormalized through internalized societal ideologies. Hypernormalization, or the normalization of absurdity, was originally coined by Russian-born anthropologist Yurchak (2003, 2005) to understand the split between ideological, authoritative discourse and practice in the last decades of the Soviet Union. We extend the understanding of hypernormalization to describe how contemporary absurdities are normalized both in society and organizations. Moreover, we explain how hypernormalization unfolds at collective and individual levels through ideological fantasy and internalization. Fantasmatic investment and internalization enable individuals to manage the absurdities arising from the perpetual gap between authoritative discourse (e.g., companies' commitment to climate action) and actual day-today practices (e.g., companies' continued investment in fossil fuels). We finish by presenting three interrelated steps through which resistance, as a mechanism to deal with hypernormalization, emerges: problematization, resistance and imagination. We contribute to the literature by showing how these three ways may offer a way out of hypernormalization in society and workplaces.
... Our study contributes methodologically to the literature on PLS-SEM by analysing the relationship of theoretically pre-defined latent NPT variables [81,82] to the normalization of SD. PLS-SEM can model latent variables under the conditions of non-normality for small to medium sample sizes [83], amplifying the clarified variation in endogenous constructs and forecast measures for the latent constructs through multiple regressions [84]. ...
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This study, based on the normalization process theory (NPT), explores the implementation of nonpharmaceutical interventions (NPIs)—specifically social distancing (SD)—in the professional lives of healthcare workers in three Pakistani hospitals. We collected and analysed health workers’ data using partial least squares structural equation modelling (PLS-SEM) and assessed the policy implications of the results. Violations of normality assumptions in the quantitative data and the need for scores of independent variables for follow-up analysis guided the researchers to adopt a structural equation modelling process that involved a stepwise evaluation process for convergent validity, individual item validity, discriminant validity, the structural model relationship, and overall model fitness. Theoretical constructs coherence, cognitive participation, collective action, and reflexive monitoring were found to influence the normalization of SD. The results show that SD was normalized in the professional lives of healthcare workers through strong collective action (resources required) and reflexive monitoring (appraisal) but weak cognitive participation (actors’ engagement) and coherence (sense-making). Low and middle-income countries (LMICs) should work more on actors’ sense-making and engagement in dealing with healthcare crises that require SD. The research findings can aid policy institutions in better understanding the loopholes in the implementation process and making better policies.
As the cohort of People Living with HIV (PLHIV) ages, so does the spectrum and burden of non-AIDS define HIV-associated conditions (NARC). PLHIV are likely to need different and increased healthcare services. It requires health systems to adapt to this disease trend and conform to a chronic care model, which respects the distinct needs of the ageing population. In this article, we explore the lived experiences of PLHIV and their healthcare providers in managing the challenges of dealing with NARC in Arba Minch, Southern Ethiopia. This study utilises interpretative substantive methods, encompassing qualitative interviews and Focus Group Discussions. The Normalisation Practice Theory (NPT) guided the semi-structured questions concerning routine screenings and current models of HIV care for ageing individuals. The main structural challenges in providing adequate geriatric care included: (i) the lack of awareness of the risk of NARCs; (ii) the absence of blended care; (iii) an HIV-centred approach exclusive of multidisciplinary care; and (iv) financial constraints. In an era with increasing NARCs, traditional HIV care models must adapt to the emerging challenges of a 'greying' and growing population.
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Introduction With 65 million cases globally, chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death and imposes a heavy burden on patients’ lives and healthcare resources worldwide. Around half of all patients with COPD have frequent (≥2 per year) acute exacerbations of COPD (AECOPD). Rapid readmissions are also common. Exacerbations impact significantly on COPD outcomes, causing significant lung function decline. Prompt exacerbation management optimises recovery and delays the time to the next acute episode. Methods/analysis The Predict & Prevent AECOPD trial is a phase III, two arm, multi-centre, open label, parallel-group individually randomised clinical trial investigating the use of a personalised early warning decision support system (COPDPredict) to predict and prevent AECOPD. We aim to recruit 384 participants and randomise each individual in a 1:1 ratio to either standard self-management plans with rescue medication (RM) (control arm) or COPDPredict with RM (intervention arm). The trial will inform the future standard of care regarding management of exacerbations in COPD patients. The main outcome measure is to provide further validation, as compared with usual care, for the clinical effectiveness of COPDPredict to help guide and support COPD patients and their respective clinical teams in identifying exacerbations early, with an aim to reduce the total number of AECOPD-induced hospital admissions in the 12 months following each patient’s randomisation. Ethics and dissemination This study protocol is reported in accordance with the guidance set out in the Standard Protocol Items: Recommendations for Interventional Trials statement. Predict & Prevent AECOPD has obtained ethical approval in England (19/LO/1939). On completion of the trial and publication of results a lay findings summary will be disseminated to trial participants. Trial registration number NCT04136418 .
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The effectiveness of the aid enterprise is a matter of much debate with some scholars arguing that even interventions that are successfully implemented seldom last beyond the withdrawal of the donor. This failure is often attributed to a lack of ownership and studies of aid effectiveness often call for greater local ownership. But what does local ownership mean, how does it manifest on individual interventions and does greater ownership translate into greater sustainability in practice? This research investigates how donor rules affect local ownership and how local ownership in turn influences programme institutionalisation. The research uses two programmes as illustrative case studies: the Area Based Management Programme (ABM) within the eThekwini Municipal Authority (EMA) and the Gijima KZN LED Support Programme (Gijima) within the provincial Department of Economic Development and Tourism (DEDT). The research hypothesises that the ABM, which was funded through the sector based support (SBS) modality, would enjoy greater levels of local ownership that would lead to better institutionalisation outcomes than Gijima, which was funded through the project based support (PBS) modality.
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Background: The concept of biopsychosocial care is one of the approaches recommended in the health system by the WHO. Although efforts are being made on the provider side to implement it, community involvement is needed to enable its integration into the health sector. For this to happen, the community must first have an understanding of the approach, as a stakeholder and direct beneficiary. The objective of this study is to understand the community's views on the concept of integrated health care according to the biopsychosocial approach (BPS) at the Health Center of a Health District. Methods: We conducted a qualitative study based on individual semi-directive interviews with members of the Health Development Committees of six Health Areas belonging to four Health Districts as well as with some patients met in health facilities. A total of 15 interviews were conducted. The adapted NoMAD tool, derived from the Theory of the Normalization Process of Complex Interventions, allowed us to collect data from November 2017 to February 2018, and then from November 2018 to February 2019. After data extraction and synthesis, we conducted a thematic analysis using the NoMAD tool to build a thematic framework. Results: Initially, community perceptions were diverse in relation to the BPS approach of integrated care in the Health Centre; but later, the concept became clearer with the implementation of the approach, even for the providers with the change in their way of working (interprofessional collaboration, sharing of responsibilities...). Certain practices were encouraged to help the approach, notably the development of financial autonomy and mutual support. According to the community, the BPS model has further strengthened the performance of health workers and should be expanded and sustained. Stakeholders throughout the country were called upon to support the BPS concept in its implementation. Conclusions: The results of our study should encourage the involvement of community participation in any process of integrating the biopsychosocial model of person-centred health care, even at higher levels of care. However, the barriers and enablers to the BPS mechanism identified in our study should be taken into consideration.
This pioneering work is the first to trace how our understanding of the causes of human behavior has changed radically over the course of European and American cultural history since 1830. Focusing on the act of murder, as documented vividly by more than a hundred novels including Crime and Punishment, An American Tragedy, The Trial, and Lolita, Stephen Kern devotes each chapter of A Cultural History of Causality to examining a specific causal factor or motive for murder--ancestry, childhood, language, sexuality, emotion, mind, society, and ideology. In addition to drawing on particular novels, each chapter considers the sciences (genetics, endocrinology, physiology, neuroscience) and systems of thought (psychoanalysis, linguistics, sociology, forensic psychiatry, and existential philosophy) most germane to each causal factor or motive. Kern identifies five shifts in thinking about causality, shifts toward increasing specificity, multiplicity, complexity, probability, and uncertainty. He argues that the more researchers learned about the causes of human behavior, the more they realized how much more there was to know and how little they knew about what they thought they knew. The book closes by considering the revolutionary impact of quantum theory, which, though it influenced novelists only marginally, shattered the model of causal understanding that had dominated Western thought since the seventeenth century. Others have addressed changing ideas about causality in specific areas, but no one has tackled a broad cultural history of this concept as does Stephen Kern in this engagingly written and lucidly argued book.
Sociologists have long believed that psychology alone can't explain what happens when people work together in complex modern societies. In contrast, most psychologists and economists believe that we can explain much about social life with an accurate theory of how individuals make choices and act on them. R. Keith Sawyer argues, however, that societies are complex dynamical systems, and that the best way to resolve these debates is by developing the concept of emergence, paying attention to multiple levels of analysis--individuals, interactions, and groups--with a dynamic focus on how social group phenomena emerge from communication processes among individual members.
Over the past few decades serious reservations have been expressed about the explanatory power of sociological theory and research. In this important book, leading social theorist Peter Hedström outlines the foundations of an analytically oriented sociology that seeks to address this criticism. Building on his earlier influential contributions to contemporary debates, Professor Hedström argues for a systematic development of sociological theory so that it has the explanatory power and precision to inform sociological research and understanding. He discusses various mechanisms of action and interaction and shows how strong links can be forged between the micro and the macro, and between theory and empirical research. Combining approaches to theory and methodology and using extensive examples to illustrate how they might be applied, this clear, concise and original book will appeal to a broad range of social scientists.
Rational action theory (RAT) is not a highly unified intellectual entity. In the first part of the paper, varieties of RAT are distinguished in terms of three criteria: i.e. according to whether they (i) have strong rather than weak rationality requirements; (ii) focus on situational rather than procedural rationality; (iii) claim to provide a general rather than a special theory of action. In the second part, these same criteria are applied in a consideration of which version of RAT holds out most promise for use in sociology.