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Sociology
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
■
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Carl May
Newcastle University
■
■
Tracy Finch
Newcastle University
AB S TRACT
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.
KE Y WOR DS
diffusion of innovation / embedding / implementation / material practice /
normalization process theory / routinization
Introduction
T
his is an article about how and why things become, or don’t 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
535
Sociology
Copyright © 2009
BSA Publications Ltd®
Volume 43(3): 535–554
DOI: 10.1177/0038038509103208
SAGE Publications
Los Angeles, London,
New Delhi and Singapore
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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
integration.
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 life – but 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 MacKenzie’s
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
(integration).
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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).
Definitions
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
monitoring).
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
Cognitive
Participation
(enrolment and
engagement of
individuals and
groups)
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
meaningful
qualities of a
practice)
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, actors’ investments 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
Coherence
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
mechanism.
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
Mechanisms
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
Workability
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?
Conclusion
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
investments
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.
Acknowledgements
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).
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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.
E-mail: c.r.may@ncl.ac.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.
E-mail: tracy.finch@newcastle.ac.uk
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