Papers
Development of a theory of implementation and integration: Normalization Process Theory
May C, Mair FS, Finch T, MacFarlane A, Dowrick C, Treweek S, et al. Implementation Science. 2009;4(29).
This paper describes the processes by which we developed a theory of normalization processes that proposes a working model of implementation, embedding and integration in conditions marked by complexity and emergence. The paper shows how the theory was developed: (a) initially by synthesizing the results of qualitative studies of telemedicine systems in practice, (b) then by developing an applied theoretical model of the implementation of complex interventions in health care, (c) and finally through developing a formal middle range theory.
The aim of this work is to contribute to a 'whole systems' approach to understanding the ways that new technologies, ways of working, and organizing are implemented, embedded, and integrated in everyday practice. More fundamentally Normalization Process Theory is a tool that can be used to explore the *work* in processes of social construction.
This paper is published in an Open Access journal, and is free to readers.
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Implementing, Embedding, And Integrating Practices:
Carl May & Tracy Finch. Sociology 2009; 43(3): 535-554
ABSTRACT
Understanding the processes by which practices become routinely embedded in everyday life is a longstanding 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 paper 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.
My agreement with Sage is that this paper is available on an open access basis. It can be found at: http://soc.sagepub.com/cgi/content/abstract/43/3/535
Let me know if you can't access it and I'll send you a copy.
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Process evaluation for complex interventions in primary care: understanding trials using the normalization process model
Carl May, Frances Mair, Christopher Dowrick and Tracy Finch. Published in BMC Family Practice 2007, 8:42
This is an 'open access' paper available free to all on BioMedCentral. Click the link above.
Background
The Normalization Process Model is a conceptual tool intended to assist in understanding the factors that affect implementation processes in clinical trials and other evaluations of complex interventions. It focuses on the ways that the implementation of complex interventions is shaped by problems of workability and integration.
Method
In this paper the model is applied to two different complex trials: (i) the delivery of problem solving therapies for psychosocial distress, and (ii) the delivery of nurse-led clinics for heart failure treatment in primary care.
Results
Application of the model shows how process evaluations need to focus on more than the immediate contexts in which trial outcomes are generated. Problems relating to intervention workability and integration also need to be understood. The model may be used effectively to explain the implementation process in trials of complex interventions.
Conclusion
The model invites evaluators to attend equally to considering how a complex intervention interacts with existing patterns of service organization, professional practice, and professional-patient interaction. The justification for this may be found in the abundance of reports of clinical effectiveness for interventions that have little hope of being implemented in real healthcare settings.
The Clinical Encounter and the Problem of Context
Carl May. Sociology, 2007: 41(1: 29-45 DOI: 10.1177/0038038507072282
The encounter between professional and patient is one of the basic units of analysis in the field of ‘medical’ sociology. From the very beginnings of the sociological investigation of medical practice it has been conceived as a dyadic encounter, defined by asymmetries of power, the negotiation of rational and authoritative scientific knowledge, and private, proximal, relations. This article argues for a more dynamic theoretical vision of the clinical encounter: one that shifts attention away from a Parsonian ‘paradigm’ of professional–patient interaction towards a perspective that incorporates the systemic changes that late modernity brings to medicine.The clinical encounter is no longer the dyadic system envisaged by Parsons, and his theoretical perspective–which has played an important part in framing sociological accounts of the practice of medicine – now needs to be reframed in relation to the organizing impulses of contemporary corporate professional practice
(http://www.ncl.ac.uk/ihs/research/healthhuman/)
Understanding the implementation of complex interventions in health care: the normalization process model
Carl May, Tracy Finch, Frances Mair, Luciana Ballini, Christopher Dowrick, Martin Eccles, Linda Gask, Anne MacFarlane, Elizabeth Murray, Tim Rapley, Anne Rogers, Shaun Treweek, Paul Wallace, George Anderson, Jo Burns and Ben Heaven. Published in BMC Health Services Research 2007, 7:148
This is an 'open access' paper available free to all on BioMedCentral. Click the link above.
Background
The Normalization Process Model is a theoretical model that assists in explaining the processes by which complex interventions become routinely embedded in health care practice. It offers a framework for process evaluation and also for comparative studies of complex interventions. It focuses on the factors that promote or inhibit the routine embedding of complex interventions in health care practice.
Methods
A formal theory structure is used to define the model, and its internal causal relations and mechanisms. The model is broken down to show that it is consistent and adequate in generating accurate description, systematic explanation, and the production of rational knowledge claims about the workability and integration of complex interventions.
Results
The model explains the normalization of complex interventions by reference to four factors demonstrated to promote or inhibit the operationalization and embedding of complex interventions (interactional workability, relational integration, skill-set workability, and contextual integration).
Conclusion
The model is consistent and adequate. Repeated calls for theoretically sound process evaluations in randomized controlled trials of complex interventions, and policy-makers who call for a proper understanding of implementation processes, emphasize the value of conceptual tools like the Normalization Process Model.
Mobilising modern facts: Health technology assessment and the politics of evidence
Carl May Sociology of Health and Illness. 2006: 28 (5); 513-532 DOI: 10.1111/j.1467-9566.2006.00505.x
Conventional models of 'evidence' for clinical practice focus on the role of randomised controlled clinical trials and systematic reviews as technologies that promote a specific model of rigour and analytic accountability. The assumption that runs through the disciplinary field of health technology assessment (HTA), for example, is that the quantification of evidence about cost and clinical effectiveness is central to rational policy-making and healthcare provision. But what are the conditions in which such knowledge is mediated into decision-making contexts, and how is it understood and used when it gets there? This paper addresses these questions by examining a series of meetings and seminars attended by senior clinical researchers, social care and health service managers in the UK between 1998-2004, and sessions of the House of Commons Health Committee held in 2001 and 2005. These provide contexts in which questions about the value and utility of evidence produced within the frame of HTA were explored in relation to parallel questions about the design, evaluation and implementation of telemedicine and telecare systems. The paper points to the ways that evidence generated in the normative frame of HTA was increasingly seen as one-dimensional and medicalised knowledge that failed to respond to the contingencies of everyday practice in health and social care settings.
Understanding the Normalization of Telemedicine Services through Qualitative Evaluation
Carl May, Robert Harrison, Tracy Finch, Anne MacFarlane, Frances Mair, Paul Wallace
Objective:
Qualitative studies can help us understand the "successes" and "failures" of telemedicine to normalize within clinical service provision. This report presents the development of a robust conceptual model of normalization processes in the implementation and development of telemedicine services.
Design:
Retrospective and cumulative analysis of longitudinal qualitative data from three studies was undertaken between 1997 and 2002. Observation and semistructured interviews produced a substantial body of data relating to approximately 582 discrete data collection episodes. Data were analyzed separately in each of three studies. Cumulative analysis was conducted by constant comparison.
Results:
(1)Implementation of telemedicine services depends on a positive link with a (local or national) policy level sponsor.
(2) Adoption of telemedicine systems in service depends on successful structural integration so that development of organizational structures takes place.
(3) Translation of telemedicine technologies into clinical practice depends on the enrollment of cohesive, cooperative groups.
(4) Stabilization of telemedicine systems in practice depends on integration at the level of professional knowledge and practice, where clinicians are able to accommodate telemedicine through the development of new procedures and protocols.
Conclusion:
A rationalized linear diffusion model of "telehealthcare" is inadequate in assessing the potential for normalization, and the political, organizational, and "ownership" problems that govern the process of development, implementation, and normalization need to be accounted for. This report presents a model for assessing the potential for successful implementation of telehealthcare services. This model defines the requirements for the successful normalization of telemedicine systems in clinical practice.
Framing the doctor-patient relationship in chronic illness: A comparative study of general practitioners' accounts
Carl May, Gayle Allison, Alison Chapple, Carolyn Chew-Graham, Clare Dixon, Linda Gask, Ruth Graham, Anne Rogers, Martin Roland. Sociology of Health and Illness. 2004: 26 (2);135-158 DOI: 10.1111/j.1467-9566.2004.00384.x
Abstract
How family doctors conceptualise chronic illness in the consultation has important implications for both the delivery of medical care, and its experience by patients. In this paper, we present the results of a re-analysis of qualitative data collected in a series of studies of British family doctors between 1995 and 2001, to explore the ways in which the legitimacy and authority of medical knowledge and practice are organised and worked out in relation to three kinds of chronic illness (menorrhagia; depression; and chronic low back pain/medically unexplained symptoms). We present a comparative analysis of (a) the moral evaluation of the patient (and judgements about the legitimacy of symptom presentation); (b) the possibilities of disposal; and (c) doctors' empathic responses to the patient, in each of these clinical cases. Our analysis defines some of the fundamental conditions through which general practitioners frame their relationships with patients presenting complex but sometimes diffuse combinations of 'social', 'psychological' and 'medical' symptoms. These are fundamental to, yet barely touched by, the increasingly voluminous literature on how doctors should interact with patients. Moving beyond the individual studies from which our data are drawn, we have outlined some of the highly complex and demanding features of what is often seen as routine and unrewarding medical work, and some of the key requirements for the local negotiation of patients' problems and their meanings (for both patients and doctors) in everyday general practice.
A rational model for assessing and evaluating complex interventions in health care
Carl May, BMC Health Services Research 2006, 6:86
This is an 'open access' paper available free to all on BioMedCentral. Click the link above.
Background
Understanding how new clinical techniques, technologies and other complex interventions become normalized in practice is important to researchers, clinicians, health service managers and policy-makers. This paper presents a model of the normalization of complex interventions.
Methods
Between 1995 and 2005 multiple qualitative studies were undertaken. These examined: professional-patient relationships; changing patterns of care; the development, evaluation and implementation of telemedicine and related informatics systems; and the production and utilization of evidence for practice. Data from these studies were subjected to (i) formative re-analysis, leading to sets of analytic propositions; and to (ii) a summative analysis that aimed to build a robust conceptual model of the normalization of complex interventions in health care.
Results
A normalization process model that enables analysis of the conditions necessary to support the introduction of complex interventions is presented. The model is defined by four constructs: interactional workability; relational integration; skill set workability and contextual integration. This model can be used to understand the normalization potential of new techniques and technologies in healthcare settings
Conclusion
The normalization process model has face validity in (i) assessing the potential for complex interventions to become routinely embedded in everyday clinical work, and (ii) evaluating the factors that promote or inhibit their success and failure in practice.
(http://www.ncl.ac.uk/ihs/research/healthhuman/)
Towards a wireless patient: Chronic illness, scarce care and technological innovation in the United Kingdom
Carl May, Tracy Finch, Frances Mair, Maggie Mort Social Science and Medicine. 2005: 61 (7) 1485-1494 DOI: 10.1016/j.socscimed.2005.03.008
'Modernization' is a key health policy objective in the UK. It extends across a range of public service delivery and organizational contexts, and also means there are radical changes in perspective on professional behaviour and practice. New information and communications technologies have been seen as one of the key mechanisms by which these changes can be engendered. In particular, massive investment in information technologies promises the rapid distribution and deployment of patient-centred information across internal organizational boundaries. While the National Health Service (NHS) sits on the edge of a £6billion investment in electronic patient records, other technologies find their status as innovative vehicles for professional behaviour change and service delivery in question. In this paper, we consider the ways that telemedicine and telehealthcare systems have been constructed first as a field of technological innovation, and more recently, as management solutions to problems around the distribution of health care. We use NHS responses to chronic illness as a medium for understanding these shifts. In particular, we draw attention to the shifting definitions of 'innovation' and to the ways that these shifts define a move away from notions of technological advance towards management control. © 2005 Elsevier Ltd. All rights reserved.
(http://www.ncl.ac.uk/ihs/research/healthhuman/)
Protocol: Normalizing new health technologies - building a web-enabled toolkit for implementation practitioners. Economic and Social Research Council, ‘Follow-on’ Funding Programme (Grant 189-25-0003)
Co-Investigators: Carl May [Chief Investigator (1)], Elizabeth Murray (2), Tracy Finch (1), Frances Mair (3), Shaun Treweek (4), Tim Rapley. Associate Investigators: Luciana Ballini, Anne Macfarlane, Jane Gunn, France Legare, Mary Ellen Purkis, Victor Montori
Normalization Process Theory enables clinicians and managers to understand the dynamics of embedding new healthcare techniques and organizational changes in context. In the UK, the Economic and Social Research Council has funded the further development of an on-line users manual and web-based tools that will assist researchers, clinicians, and managers in employing NPT.
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We Need Minimally Disruptive Medicine
May C, Montori VM, Mair FS. We need minimally disruptive medicine. BMJ 2009;339:b2803
We have proposed that we need Minimally Disruptive Medicine. The aim here is to accept that the burden of work transferred from the clinic to the home is growing steadily greater, and that the burden of illness plus the burden of treatment may be too great for some people to bear. This is especially the case as a growing population of older people suffer an increasing number of co-morbidities. This view stems from the ways that we are using Normalization Process Theory to think about the new kinds of healthcare work that are implemented, embedded, and integrated, in everyday life - and which are crossing the boundaries between the clinic and the home.
Illness is a plural: homecare, governmentality, and reframing the work of patienthood
To be published in 'In Sickness and in Health: Government of the Self in the Clinic and the Community' edited by Mary Ellen Purkis and Christine Ceci
This is the draft of a short ntroductory chapter for the Proceedings collection of ISIH 2009, held in Victoria, British Columbia (April 2009). Critical comments are welcome.
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Retheorizing the Clinical Encounter:
For publication in ‘Assaults on the Lifeworld: New Directions in the Sociology of Chronic and Disabling Conditions’ Edited by Graham Scambler and Sasha Scambler, (London: Routledge)
This book chapter sets out the application of Normalization Process Theory to the analysis of individual experiences of sickness. In particular, it revisits the idea of the sickness career, and uses this as a basis for considering a series of theory drive hypotheses about that nature of clinical encounters and the relationship between people with chronic illness and multiple comorbidities and healthcare systems.
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