This article is part of a series of articles on research.
General practice research is diverse in both the topics under exploration and the methods that are used. One branch of general practice research is health services research that explores access to and the use and quality of healthcare.1 Health services research also covers the implementation of innovations and explorations of usual practice, and usually involves a multidisciplinary team.2 Here we explore one theoretical framework, Normalisation Process Theory (NPT), to better understand how it can be used in general practice research.3 NPT is increasingly used as a theoretical foundation for understanding, developing and evaluating complex interventions because it brings explanatory power to implementation and can be applied to a great variety of research methods.
What is NPT?
NPT is a theoretical framework that describes how new ways of working can become part of everyday practice (‘normalisation’). It is an established theory built on the social and behavioural sciences and is an example of a mid-level (also known as mesolevel) theory because it deals with organisations, social movement and communities.4 NPT enables reflection on how different participants integrate new work into everyday practice, including their roles, actions and interactions with different participants (Box 1).
| Box 1. The four categories of Normalisation Process Theory |
There are four categories in the Normalisation Process Theory framework that break the process into smaller parts, allowing a better understanding of how and why processes may be working, or not:
- Coherence: includes participants’ understanding of the new program, whether they believe it is beneficial and has a clear purpose and the value that they place on the benefits of the program
- Cognitive participation: includes whether participants believe that the program is part of their work duties, how invested they are in the program and how willing they are to spend their time and energy on the program
- Collective action: covers how well the program fits into organisational practices and everyone’s usual ways of working together
- Reflexive monitoring: relates to how participants reflect on the program and how it is working, whether participants are able to see the effect of the program and whether participants are able to adapt the program for ongoing use
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When is NPT useful?
NPT provides a valuable set of conceptual tools to use when developing new complex interventions. Often in general practice we are trying out new ways of working as a clinical team or attempting to establish new clinical practices. NPT includes factors that may help or hinder the establishment of the new way of working, especially if the research team is interested in the role of different participants and how they are working together towards a common aim, in the real world.
NPT is also commonly used to guide research about implementing new programs, especially those focused on the role of different actors and their interactions with each other (Box 2). A systematic review of studies using NPT found seven topics of research, namely healthcare service organisation and delivery; implementation of diagnostic and therapeutic interventions; e-health and telemedicine; screening and surveillance; decision support, including shared decision-making; new changes in professional roles; and guideline implementation.5
| Box 2. Examples of general practice research that uses Normalisation Process Theory |
- Supporting insulin initiation in type 2 diabetes in primary care: Results of the Stepping Up pragmatic cluster randomised controlled clinical trial: A new model of diabetes care used Normalisation Process Theory (NPT) to inform the development of the intervention by informing the implementation of new behaviours in health professionals.9
- Feasibility and acceptability of a physician-delivered weight management program: NPT was used in the data collection and analysis processes to assess the implementation of a new weight management program using both qualitative data (interviews) and the NoMAD tool.10
- Embedding effective depression care: Using theory for primary care organisational and systems change: This research developed a conceptual framework for how depression is best managed in primary care and used NPT as an analytical theory.11
- A missed opportunity: Lessons learnt from a chlamydia testing observation study in general practice: NPT was used in the discussion in this paper to better understand why there was no change in the testing for chlamydia.12
- Implementing a QCancer risk tool into general practice consultations: An exploratory study using simulated consultations with Australian general practitioners: NPT was used to direct the development of the interview guide to understand how a new cancer risk model was used in practice.13
- Increasing the uptake of alcohol brief interventions in general practice: NPT was used to inform the design of the intervention.14
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If the research focuses on factors that are external to the general practice itself, it may be better to use a framework that has a wider focus; for example, Consolidated Framework for Implementation Research (CFIR), which has more focus on policy and external factors than NPT.6 CFIR can be used in conjunction with NPT to retain the more granular detail about participant and team performance that NPT brings.7
How to use NPT when planning your research design
The use of mid-level theories like NPT is particularly valuable for conceptualising how variables relate to one another, to help explain or predict phenomena that occur in the world and to provide rationales or explanations for observed and hypothesised processes. Mid-level theories have been described as ‘conceptual toolkits that can be used flexibly to deal with practical problems’.5 It is recommended that you work with GP research experts to choose the most appropriate framework for your research.
Adopting NPT as a theoretical underpinning encourages researchers to consider implementation issues during the design of complex interventions, as well as the context in which they will be deployed. In implementation studies, users of NPT have described having additional explanatory power for better understanding implementation.7 NPT provides a set of sociological tools to understand and explain the social processes, through which innovations are adopted and become routine within real-world settings, which is particularly valuable for research and evaluation in primary care.
NPT can inform both qualitative and quantitative methods
Often NPT is used to guide the collection of qualitative data (eg interviews, focus groups, long-answer surveys), but it also has a quantitative tool that was developed in 2018. The Normalization MeAsure Development (NoMAD) tool asks participants to rate their agreement with different statements on a five-point Likert scale.8 The 23 survey questions relate to the different categories of the NPT framework, and this allows for quantification of participants’ perspectives on how well things are working in relation to the parts of the NPT framework. The NoMAD survey can be repeated over time to track changes in the normalisation process. It can also be used in a mixed-methods project to compare and contrast the results of the survey, which can then be deepened with data from qualitative sources.
Summary
NPT is a useful framework for general practice research that can be used to explore the implementation of new programs or to gain a deeper understanding of current practice. NPT can be used to guide intervention development, data collection and analysis, as well as data interpretation. An understanding of NPT is useful for any researcher who is interested in health services research.