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Ashcroft R, Menear M, Dahrouge S, Silveira J, Emode M, Booton J, Bahniwal R, Sheffield P, McKenzie K. Nurturing an organizational context that supports team-based primary mental health care: A grounded theory study. PLoS One 2024; 19:e0301796. [PMID: 38687719 PMCID: PMC11060570 DOI: 10.1371/journal.pone.0301796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 03/23/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND The expansion of the Patient-Centred Medical Home model presents a valuable opportunity to enhance the integration of team-based mental health services in primary care settings, thereby meeting the growing demand for such services. Understanding the organizational context of a Patient-Centred Medical Home is crucial for identifying the facilitators and barriers to integrating mental health care within primary care. The main objective of this paper is to present the findings related to the following research question: "What organizational features shape Family Health Teams' capacity to provide mental health services for depression and anxiety across Ontario, Canada?" METHODS Adopting a constructivist grounded theory approach, we conducted interviews with various mental health care providers, and administrators within Ontario's Family Health Teams, in addition to engaging provincial policy informants and community stakeholders. Data analysis involved a team-based approach, including code comparison and labelling, with a dedicated data analysis subcommittee convening monthly to explore coded concepts influencing contextual factors. RESULTS From the 96 interviews conducted, involving 82 participants, key insights emerged on the organizational contextual features considered vital in facilitating team-based mental health care in primary care settings. Five prominent themes were identified: i) mental health explicit in the organizational vision, ii) leadership driving mental health care, iii) developing a mature and stable team, iv) adequate physical space that facilitates team interaction, and v) electronic medical records to facilitate team communication. CONCLUSIONS This study underscores the often-neglected organizational elements that influence primary care teams' capacity to deliver quality mental health care services. It highlights the significance of strong leadership complemented by effective communication and collaboration within teams to enhance their ability to provide mental health care. Strengthening relationships within primary care teams lies at the core of effective healthcare delivery and should be leveraged to improve the integration of mental health care.
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Affiliation(s)
- Rachelle Ashcroft
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | - Matthew Menear
- Faculty of Medicine, Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, Quebec, Canada
| | - Simone Dahrouge
- Faculty of Medicine, Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jose Silveira
- Faculty of Medicine, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Monica Emode
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Jocelyn Booton
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | | | - Peter Sheffield
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | - Kwame McKenzie
- Faculty of Medicine, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Wellesley Institute, Toronto, Ontario, Canada
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Leather JZ, Keyworth C, Kapur N, Campbell SM, Armitage CJ. Examining drivers of self-harm guideline implementation by general practitioners: A qualitative analysis using the theoretical domains framework. Br J Health Psychol 2022; 27:1275-1295. [PMID: 35416355 PMCID: PMC9790562 DOI: 10.1111/bjhp.12598] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 03/29/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES This study aimed to (1) examine barriers and enablers to General Practitioners' (GP) use of National Institute for Health and Care Excellence (NICE) guidelines for self-harm and (2) recommend potential intervention strategies to improve implementation of them in primary care. DESIGN Qualitative interview study. METHODS Twenty-one telephone interviews, semi-structured around the capabilities, opportunities and motivations model of behaviour change (COM-B), were conducted with GPs in the United Kingdom. The Theoretical Domains Framework was employed as an analytical framework. Using the Behaviour Change Wheel, Behaviour Change Techniques (BCTs), intervention functions and exemplar interventions were identified. RESULTS GPs valued additional knowledge about self-harm risk assessments (knowledge), and communication skills were considered to be fundamental to high-pressure consultations (cognitive and interpersonal skills). GPs did not engage with the guidelines due to concerns that they would be a distraction from patient cues about risk during consultations (memory, attention and decision processes), and perceptions that following the guidance is difficult due to time pressures and lack of access to mental health referrals (environmental context and resources). Clinical uncertainty surrounding longer term care for people that self-harm, particularly patients that are waiting for or cannot access a referral, drives GPs to rely on their professional judgement over the guidance (beliefs about capabilities). CONCLUSIONS Three key drivers related to information and skill needs, guideline engagement and clinical uncertainty need to be addressed to support GPs to be able to assess and manage self-harm. Five intervention functions and ten BCT groups were identified as potential avenues for intervention design.
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Affiliation(s)
- Jessica Z. Leather
- NIHR Greater Manchester Patient Safety Translational Research CentreThe University of ManchesterManchester Academic Health Science CentreManchesterUK,Manchester Centre for Health PsychologyDivision of Psychology and Mental HealthSchool of Health SciencesUniversity of ManchesterManchesterUK
| | | | - Nav Kapur
- NIHR Greater Manchester Patient Safety Translational Research CentreThe University of ManchesterManchester Academic Health Science CentreManchesterUK,Centre for Mental Health and SafetyUniversity of ManchesterManchester Academic Health Science CentreManchesterUK,Greater Manchester Mental Health NHS Foundation TrustManchester Academic Health Science CentreManchesterUK
| | - Stephen M. Campbell
- NIHR Greater Manchester Patient Safety Translational Research CentreThe University of ManchesterManchester Academic Health Science CentreManchesterUK,Centre for Primary Care and Health Services ResearchSchool of Health SciencesUniversity of ManchesterManchesterUK
| | - Christopher J. Armitage
- NIHR Greater Manchester Patient Safety Translational Research CentreThe University of ManchesterManchester Academic Health Science CentreManchesterUK,Manchester Centre for Health PsychologyDivision of Psychology and Mental HealthSchool of Health SciencesUniversity of ManchesterManchesterUK,Manchester University NHS Foundation TrustManchester Academic Health Science CentreManchesterUK,NIHR Manchester Biomedical Research CentreManchester University NHS Foundation TrustManchester Academic Health Science CentreThe Nowgen CentreManchesterUK
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Ghavamabad LH, Vosoogh-Moghaddam A, Zaboli R, Aarabi M. Establishing clinical governance model in primary health care: A systematic review. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2021; 10:338. [PMID: 34761024 PMCID: PMC8552259 DOI: 10.4103/jehp.jehp_1299_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/12/2021] [Indexed: 06/13/2023]
Abstract
Clinical governance is a systematic approach to enhancing the quality of primary health care and ensuring high clinical standards, responsiveness to performance, and continuous improvement in service quality. The objective of the current study was to investigate the global experiences of clinical governance in primary health care. In the present systematic review, relevant articles from different countries were searched in various databases such as MD PubMed from Medline portal, Emerald Springer link, ProQuest, Cochrane, Scopus, Web of Science, and Consult until April 2019. The searched articles were checked through CASP and PRISMA checklists, and their results were extracted. Of the 17 selected studies, 16 belonged to developed countries, including England (13), Australia, Italy, and New Zealand, and one was from Turkey. The findings were divided into three general categories: (1) principles of effectiveness and risk management, (2) deployment requirements such as structural and organizational needs, resource and communication, and information management, and (3) barriers of clinical governance toward providing primary health care. it is recommended that a suitable framework or model be developed and designed adapted to the local culture and taking into account all effective dimensions for a proper establishment and implementation of clinical governance in primary health care.
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Affiliation(s)
| | - Abbas Vosoogh-Moghaddam
- Governance and Health Research Group, Neuroscience Research Institute, Tehran University of Medical Sciences and Health Services, Tehran, Iran
- Leadership and Governance Scientific Group, Health Managers Development Institute, Ministry of Health and Medical Education, Tehran, Iran
| | - Rouhollah Zaboli
- Healthcare Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mohsen Aarabi
- Department of Epidemiology and Biostatistics, Mazandaran University of Medical Sciences, Sari, Iran
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Clark M, Jolley D, Benbow SM, Greaves N, Greaves I. Exploring the scope for Normalisation Process Theory to help evaluate and understand the processes involved when scaling up integrated models of care: a case study of the scaling up of the Gnosall memory service. JOURNAL OF INTEGRATED CARE 2020. [DOI: 10.1108/jica-11-2018-0072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThe scaling up of promising, innovative integration projects presents challenges to social and health care systems. Evidence that a new service provides (cost) effective care in a (pilot) locality can often leave us some way from understanding how the innovation worked and what was crucial about the context to achieve the goals evidenced when applied to other localities. Even unpacking the “black box” of the innovation can still leave gaps in understanding with regard to scaling it up. Theory-led approaches are increasingly proposed as a means of helping to address this knowledge gap in understanding implementation. Our particular interest here is exploring the potential use of theory to help with understanding scaling up integration models across sites. The theory under consideration is Normalisation Process Theory (NPT).Design/methodology/approachThe article draws on a natural experiment providing a range of data from two sites working to scale up a well-thought-of, innovative integrated, primary care-based dementia service to other primary care sites. This provided an opportunity to use NPT as a means of framing understanding to explore what the theory adds to considering issues contributing to the success or failure of such a scaling up project.FindingsNPT offers a framework to potentially develop greater consistency in understanding the roll out of models of integrated care. The knowledge gained here and through further application of NPT could be applied to inform evaluation and planning of scaling-up programmes in the future.Research limitations/implicationsThe research was limited in the data collected from the case study; nevertheless, in the context of an exploration of the use of the theory, the observations provided a practical context in which to begin to examine the usefulness of NPT prior to embarking on its use in more expensive, larger-scale studies.Practical implicationsNPT provides a promising framework to better understand the detail of integrated service models from the point of view of what may contribute to their successful scaling up.Social implicationsNPT potentially provides a helpful framework to understand and manage efforts to have new integrated service models more widely adopted in practice and to help ensure that models which are effective in the small scale develop effectively when scaled up.Originality/valueThis paper examines the use of NPT as a theory to guide understanding of scaling up promising innovative integration service models.
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Hogan-Murphy D, Stewart D, Tonna A, Strath A, Cunningham S. Use of Normalization Process Theory to explore key stakeholders' perceptions of the facilitators and barriers to implementing electronic systems for medicines management in hospital settings. Res Social Adm Pharm 2020; 17:398-405. [PMID: 32217059 DOI: 10.1016/j.sapharm.2020.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 03/10/2020] [Accepted: 03/14/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Limited data exist on the facilitators and barriers to implementing electronic systems for medicines management in hospitals. Whilst numerous studies advocate system use in improved patient safety and efficiency within the health service, their rate of adoption in practice has been slow. OBJECTIVE To explore the perceptions of key stakeholders towards the facilitators and barriers to implementing electronic prescribing systems, robotic pharmacy systems, and automated medication storage and retrieval systems in public hospital settings using Normalization Process Theory as a theoretical framework. METHODS Individual face-to-face semi-structured interviews were conducted in three public hospitals in Ireland with 23 consenting participants: nine nurses; four pharmacists; two pharmacy technicians; six doctors; and two Information Technology managers. RESULTS Enhanced patient safety and efficiency in healthcare delivery emerged as key facilitators to system implementation, as well as the need to have clinical champions and a multi-disciplinary implementation team to promote engagement and cognitive participation. Key barriers included inadequate training and organisational support, and the need for ease and confidence in system use to achieve collective action. CONCLUSIONS Many themes that are potentially transferable to other national settings have been identified and extend the evidence base. This will assist organisations around the world to better plan for implementation of medication-related eHealth systems.
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Affiliation(s)
| | | | - A Tonna
- Robert Gordon University, United Kingdom.
| | - A Strath
- Robert Gordon University, United Kingdom.
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Tierney E, Hannigan A, Kinneen L, May C, O'Sullivan M, King R, Kennedy N, MacFarlane A. Interdisciplinary team working in the Irish primary healthcare system: Analysis of 'invisible' bottom up innovations using Normalisation Process Theory. Health Policy 2019; 123:1083-1092. [PMID: 31575445 DOI: 10.1016/j.healthpol.2019.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/26/2019] [Accepted: 09/12/2019] [Indexed: 11/15/2022]
Abstract
Interdisciplinary team working in primary care is a key policy goal across healthcare jurisdictions. The National Primary Care Strategy (2001) in Ireland is a top down policy for primary healthcare reform, which prioritised the development and implementation of interdisciplinary Primary Care Teams. The number of Primary Care Teams and features of their clinical meetings have been the key metric in Ireland for appraising progress with the implementation of the strategy. However, these have been challenging to organise in practice. The aim of this paper is to analyse empirical evidence of other forms of interdisciplinary working in Irish primary care, using Normalisation Process Theory. Drawing on data from an on-line survey (71 GPs and 498 other healthcare professionals), and an interview study (37 participants; 8 GPs, 7 practice managers/admin support and 22 health care professionals) in three of the four Health Service Executive (HSE) regions in Ireland, we analyse the nature of these other forms of interdisciplinary working and describe innovations for service delivery that have been developed 'from the ground up' as a result. We examine levers and barriers to the implementation of these bottom up innovations. The levers are that these innovations make sense to professionals, are based on local needs and focus on preventive patient-centred care. They are driven forward by small groups of professionals from different backgrounds with complementary skills. The evaluations show positive impacts of the innovative services for patients, however, many have ceased to operate due to negative effects of the recent economic recession on the Irish healthcare system. These flexible and localised innovations were shaped in part by the reforms set out in the 2001 Primary Care Strategy but also represent unintended effects of that policy because they are the result of bottom up interdisciplinary working that occurs alongside, or instead of, Primary Care Team clinical meetings. Furthermore, as they not captured by existing metrics, the interdisciplinary work and resultant services have been 'invisible' to senior management and policy makers. If appropriately acknowledged and supported, they can shape primary care in the future.
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Affiliation(s)
| | - Ailish Hannigan
- Biomedical Statistics, Graduate Entry Medical School and Health Research Institute, University of Limerick, Ireland.
| | | | - Carl May
- Medical Sociology London School of Hygiene and Tropical Medicine, London, UK.
| | | | - Rachael King
- Graduate Entry Medical School, University of Limerick, Ireland.
| | - Norelee Kennedy
- Department of Clinical Therapies School of Allied Health, University of Limerick, Ireland.
| | - Anne MacFarlane
- Primary Healthcare Research, Graduate Entry Medical School and Health Research Institute University of Limerick, Ireland.
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Ziegler E, Valaitis R, Yost J, Carter N, Risdon C. "Primary care is primary care": Use of Normalization Process Theory to explore the implementation of primary care services for transgender individuals in Ontario. PLoS One 2019; 14:e0215873. [PMID: 31009508 PMCID: PMC6476519 DOI: 10.1371/journal.pone.0215873] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/09/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In Ontario, Canada, healthcare for transgender individuals is accessed through primary care; however, there are a limited number of practitioners providing transgender care, and patients are often on waiting lists and/or traveling great distances to receive care. Understanding how primary care is implemented and delivered to transgender individuals is key to improving access and eliminating healthcare barriers. The purpose of this study is to understand how the implementation of primary care services for transgender individuals compares across various models of primary care delivery in Ontario. METHODS A qualitative, exploratory, multiple-case study guided by Normalization Process Theory (NPT) was used to compare transgender care delivery and implementation across three primary care models. Three cases known to provide transgender primary care and represent different primary care models in Ontario, Canada (i.e., family health team, community health centre, fee-for service physician) were explored. The NoMAD survey, a tool to measure implementation processes, and qualitative interviews with primary care practitioners and allied healthcare staff were administered. RESULTS Using the NPT framework to guide analysis, key themes emerged about successful implementation of primary care services for transgender individuals. These themes include creating a safe space for patients, identifying gaps in services, understanding practitioners' roles, and the need for more training and education in transgender care for practitioners. CONCLUSIONS Primary care services for transgender individuals can and should be delivered in all models of primary care. Training and awareness for healthcare practitioners are needed to develop capacity in providing primary care to transgender individuals. A greater number of practitioners and organizations are needed to take on this work, embedding and normalizing transgender care into routine practice to address barriers to access and improve quality of care for transgender individuals.
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Affiliation(s)
- Erin Ziegler
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Ruta Valaitis
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Jennifer Yost
- M. Louise Fitzpatrick School of Nursing, Villanova University, Villanova, Pennsylvania, United States of America
| | - Nancy Carter
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Cathy Risdon
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
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Mirzaei S, Noorihekmat S, Oroomiei N, Vali L. Administrative challenges of clinical governance in military and university hospitals of Kerman/Iran. Int J Health Plann Manage 2019; 34:e1293-e1301. [PMID: 30924978 DOI: 10.1002/hpm.2774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/19/2019] [Accepted: 02/21/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Over the recent years, clinical governance model has been applied to improve the quality of university and private hospitals in Iran. In addition to university hospitals, military hospitals have an effective role in the preservation and promotion of public health. The challenges of clinical governance implementation have not been investigated in such settings. Hence, the present study objective is to identify the administrative challenges of clinical governance in military and university hospitals of Kerman/Iran METHODS: This qualitative study was carried out through phenomenology in 2017. A sample of managers and experts in the implementation and execution of clinical governance was purposefully selected from three university hospitals and three military hospitals in Kerman, Iran. A total of 39 managers and experts were interviewed, and data were gathered via semistructured interviews with open questions. For data analysis, conventional content analysis method was employed. RESULTS In this study, five main codes and 17 subcodes were obtained. Main codes were structural challenges, educational challenges, limitations, evaluation, and human resource challenges. CONCLUSIONS Clinical governance is being implemented hastily with no appropriate structural, financial, and training facilities, ensuing a waste of resources, more difficult work for staff and a negative view of personnel.
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Affiliation(s)
- Saeid Mirzaei
- Neuroscience Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Somayeh Noorihekmat
- Research Center for Health Services Management, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Nadia Oroomiei
- Department of Health Management, Policy and Economics, School of Public Health, Bam University of Medical Sciences, Bam, Iran
| | - Leila Vali
- Environmental Health Engineering Research center, Kerman University of Medical Sciences, Kerman, Iran
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Bracher M, Murphy J, Steward K, Wallis K, May CR. What factors promote or inhibit implementation of a new procedure for screening and treatment of malnutrition in community settings? A prospective process evaluation of the Implementing Nutrition Screening in Community Care for Older People (INSCCOPe) project (UK). BMJ Open 2019; 9:e023362. [PMID: 30804028 PMCID: PMC6443076 DOI: 10.1136/bmjopen-2018-023362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Malnutrition remains underdetected, undertreated and often overlooked by those working with older people in primary care in the UK. A new procedure for screening and treatment of malnutrition is currently being implemented by a large National Health Service (NHS) trust in England, incorporating a programme of training for staff working within Integrated Community Teams and Older People's Mental Health teams. Running in parallel, the Implementing Nutrition Screening in Community Care for Older People process evaluation study explores factors that may promote or inhibit its implementation and longer term embedding in routine care, with the aim of optimising sustainability and scalability. METHODS AND ANALYSIS Implementation will be assessed through observation of staff within a single area of the trust, in addition to the procedure development and delivery group (PDDG). Data collection will occur at three observation points: prior to implementation of training, baseline (T0); 2 months following training (T1); and 8 months following training (T2). Observation points will consist of a survey and follow-up semistructured telephone interview with staff. Investigation of the PDDG will involve: observations of discussions around development of the procedure; semistructured telephone interviews prior to implementation, and at 6 months following implementation. Quantitative data will be described using frequency tables reporting by team type, healthcare provider role group, and total study sample (Wilcoxon rank-sum and Wilcoxon signed-rank tests may also be conducted if appropriate. Audio and transcription data will be analysed using Nomarlization Process Theory as a framework for deductive thematic analysis (using the NVIVO CAQDAS software package). ETHICS AND DISSEMINATION Ethical approval for the study has been granted through institutional ethical review (Bournemouth University); NHS Research Ethics committee approval was not required. Dissemination will occur through presentations to academic and practitioner audiences and publication results in peer-reviewed academic journals.
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Affiliation(s)
- Mike Bracher
- School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK
- Visiting Fellow, Bournemouth University, Bournemouth, UK
| | - Jane Murphy
- Ageing and Dementia Research Centre, Bournemouth University, Bournemouth, UK
| | | | - Kathy Wallis
- Wessex Academic Health Science Network (AHSN), Southampton, UK
| | - Carl R May
- London School of Hygiene and Tropical Medicine, London, UK
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Meurk C, Harris M, Wright E, Reavley N, Scheurer R, Bassilios B, Salom C, Pirkis J. Systems levers for commissioning primary mental healthcare: a rapid review. Aust J Prim Health 2019; 24:29-53. [PMID: 29338836 DOI: 10.1071/py17030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 09/23/2017] [Indexed: 11/23/2022]
Abstract
Primary Health Networks (PHNs) are a new institution for health systems management in the Australian healthcare system. PHNs will play a key role in mental health reform through planning and commissioning primary mental health services at a regional level, specifically adopting a stepped care approach. Selected PHNs are also trialling a healthcare homes approach. Little is known about the systems levers that could be applied by PHNs to achieve these aims. A rapid review of academic and grey literature published between 2006 and 2016 was undertaken to describe the use of systems levers in commissioning primary care services. Fifty-six documents met the inclusion criteria, including twelve specific to primary mental healthcare. Twenty-six levers were identified. Referral management, contracts and tendering processes, and health information systems were identified as useful levers for implementing stepped care approaches. Location, enrolment, capitation and health information systems were identified as useful in implementing a healthcare homes approach. Other levers were relevant to overall health system functioning. Further work is needed to develop a robust evidence-base for systems levers. PHNs can facilitate this by documenting and evaluating the levers that they deploy, and making their findings available to researchers and other commissioning bodies.
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Affiliation(s)
- Carla Meurk
- The University of Queensland, School of Public Health, Corner Herston Road and Wyndham Street, Herston, Qld 4006, Australia
| | - Meredith Harris
- The University of Queensland, School of Public Health, Corner Herston Road and Wyndham Street, Herston, Qld 4006, Australia
| | - Eryn Wright
- The University of Queensland, School of Public Health, Corner Herston Road and Wyndham Street, Herston, Qld 4006, Australia
| | - Nicola Reavley
- The University of Melbourne, Melbourne School of Population and Global Health, Vic. 3010, Australia
| | - Roman Scheurer
- The University of Queensland, School of Public Health, Corner Herston Road and Wyndham Street, Herston, Qld 4006, Australia
| | - Bridget Bassilios
- The University of Melbourne, Melbourne School of Population and Global Health, Vic. 3010, Australia
| | - Caroline Salom
- Policy and Epidemiology Group, Queensland Centre for Mental Health Research, Locked Bag 500, Archerfield, Qld 4108, Australia
| | - Jane Pirkis
- The University of Melbourne, Melbourne School of Population and Global Health, Vic. 3010, Australia
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Rapley T, Girling M, Mair FS, Murray E, Treweek S, McColl E, Steen IN, May CR, Finch TL. Improving the normalization of complex interventions: part 1 - development of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT). BMC Med Res Methodol 2018; 18:133. [PMID: 30442093 PMCID: PMC6238361 DOI: 10.1186/s12874-018-0590-y] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 10/29/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Understanding and measuring implementation processes is a key challenge for implementation researchers. This study draws on Normalization Process Theory (NPT) to develop an instrument that can be applied to assess, monitor or measure factors likely to affect normalization from the perspective of implementation participants. METHODS An iterative process of instrument development was undertaken using the following methods: theoretical elaboration, item generation and item reduction (team workshops); item appraisal (QAS-99); cognitive testing with complex intervention teams; theory re-validation with NPT experts; and pilot testing of instrument. RESULTS We initially generated 112 potential questionnaire items; these were then reduced to 47 through team workshops and item appraisal. No concerns about item wording and construction were raised through the item appraisal process. We undertook three rounds of cognitive interviews with professionals (n = 30) involved in the development, evaluation, delivery or reception of complex interventions. We identified minor issues around wording of some items; universal issues around how to engage with people at different time points in an intervention; and conceptual issues around the types of people for whom the instrument should be designed. We managed these by adding extra items (n = 6) and including a new set of option responses: 'not relevant at this stage', 'not relevant to my role' and 'not relevant to this intervention' and decided to design an instrument explicitly for those people either delivering or receiving an intervention. This version of the instrument had 53 items. Twenty-three people with a good working knowledge of NPT reviewed the items for theoretical drift. Items that displayed a poor alignment with NPT sub-constructs were removed (n = 8) and others revised or combined (n = 6). The final instrument, with 43 items, was successfully piloted with five people, with a 100% completion rate of items. CONCLUSION The process of moving through cycles of theoretical translation, item generation, cognitive testing, and theoretical (re)validation was essential for maintaining a balance between the theoretical integrity of the NPT concepts and the ease with which intended respondents could answer the questions. The final instrument could be easily understood and completed, while retaining theoretical validity. NoMAD represents a measure that can be used to understand implementation participants' experiences. It is intended as a measure that can be used alongside instruments that measure other dimensions of implementation activity, such as implementation fidelity, adoption, and readiness.
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Affiliation(s)
- Tim Rapley
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Coach Lane Campus West, Newcastle upon Tyne, NE7 7XA UK
| | - Melissa Girling
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle-upon-Tyne, NE2 4AX UK
| | - Frances S. Mair
- Institute of Health and Wellbeing, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX UK
| | - Elizabeth Murray
- Research Department of Primary Care and Population Health, University College London, Upper Floor 3, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF UK
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, 3rd Floor, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Elaine McColl
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle-upon-Tyne, NE2 4AX UK
| | - Ian Nicholas Steen
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle-upon-Tyne, NE2 4AX UK
| | - Carl R. May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Tracy L. Finch
- Department of Nursing, Midwifery and Health, Northumbria University, Coach Lane Campus West, Newcastle upon Tyne, NE7 7XA UK
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May CR, Cummings A, Girling M, Bracher M, Mair FS, May CM, Murray E, Myall M, Rapley T, Finch T. Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review. Implement Sci 2018; 13:80. [PMID: 29879986 PMCID: PMC5992634 DOI: 10.1186/s13012-018-0758-1] [Citation(s) in RCA: 316] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 04/24/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Normalization 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. A large body of literature that employs NPT to inform feasibility studies and process evaluations of complex healthcare interventions has now emerged. The aims of this review were to review this literature; to identify and characterise the uses and limits of NPT in research on the implementation and integration of healthcare interventions; and to explore NPT's contribution to understanding the dynamics of these processes. METHODS A qualitative systematic review was conducted. We searched Web of Science, Scopus and Google Scholar for articles with empirical data in peer-reviewed journals that cited either key papers presenting and developing NPT, or the NPT Online Toolkit ( www.normalizationprocess.org ). We included in the review only articles that used NPT as the primary approach to collection, analysis or reporting of data in studies of the implementation of healthcare techniques, technologies or other interventions. A structured data extraction instrument was used, and data were analysed qualitatively. RESULTS Searches revealed 3322 citations. We show that after eliminating 2337 duplicates and broken or junk URLs, 985 were screened as titles and abstracts. Of these, 101 were excluded because they did not fit the inclusion criteria for the review. This left 884 articles for full-text screening. Of these, 754 did not fit the inclusion criteria for the review. This left 130 papers presenting results from 108 identifiable studies to be included in the review. NPT appears to provide researchers and practitioners with a conceptual vocabulary for rigorous studies of implementation processes. It identifies, characterises and explains empirically identifiable mechanisms that motivate and shape implementation processes. Taken together, these mean that analyses using NPT can effectively assist in the explanation of the success or failure of specific implementation projects. Ten percent of papers included critiques of some aspect of NPT, with those that did mainly focusing on its terminology. However, two studies critiqued NPT emphasis on agency, and one study critiqued NPT for its normative focus. CONCLUSIONS This review demonstrates that researchers found NPT useful and applied it across a wide range of interventions. It has been effectively used to aid intervention development and implementation planning as well as evaluating and understanding implementation processes themselves. In particular, NPT appears to have offered a valuable set of conceptual tools to aid understanding of implementation as a dynamic process.
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Affiliation(s)
- Carl R. May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Amanda Cummings
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Melissa Girling
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Mike Bracher
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Frances S. Mair
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Christine M. May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Elizabeth Murray
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Michelle Myall
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Tim Rapley
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Tracy Finch
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Goodridge D, Rana M, Harrison EL, Rotter T, Dobson R, Groot G, Udod S, Lloyd J. Assessing the implementation processes of a large-scale, multi-year quality improvement initiative: survey of health care providers. BMC Health Serv Res 2018; 18:237. [PMID: 29615014 PMCID: PMC5883256 DOI: 10.1186/s12913-018-3045-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 03/20/2018] [Indexed: 11/29/2022] Open
Abstract
Background Beginning in 2012, Lean was introduced to improve health care quality and promote patient-centredness throughout the province of Saskatchewan, Canada with the aim of producing coordinated, system-wide change. Significant investments have been made in training and implementation, although limited evaluation of the outcomes have been reported. In order to better understand the complex influences that make innovations such as Lean “workable” in practice, Normalization Process Theory guided this study. The objectives of the study were to: a) evaluate the implementation processes associated with Lean implementation in the Saskatchewan health care system from the perspectives of health care professionals; and b) identify demographic, training and role variables associated with normalization of Lean. Methods Licensed health care professionals were invited through their professional associations to complete a cross-sectional, modified, online version of the NoMAD questionnaire in March, 2016. Analysis was based on 1032 completed surveys. Descriptive and univariate analyses were conducted. Multivariate multinomial regressions were used to quantify the associations between five NoMAD items representing the four Normalization Process Theory constructs (coherence, cognitive participation, collective action and reflexive monitoring). Results More than 75% of respondents indicated that neither sufficient training nor resources (collective action) had been made available to them for the implementation of Lean. Compared to other providers, nurses were more likely to report that Lean increased their workload. Significant differences in responses were evident between: leaders vs. direct care providers; nurses vs. other health professionals; and providers who reported increased workload as a result of Lean vs. those who did not. There were no associations between responses to normalization construct proxy items and: completion of introductory Lean training; participation in Lean activities; age group; years of professional experience; or employment status (full-time or part-time). Lean leader training was positively associated with proxy items reflecting coherence, cognitive participation and reflexive monitoring. Conclusions From the perspectives of the cross-section of health care professionals responding to this survey, major gaps remain in embedding Lean into healthcare. Strategies that address the challenges faced by nurses and direct care providers, in particular, are needed if intended goals are to be achieved. Electronic supplementary material The online version of this article (10.1186/s12913-018-3045-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Donna Goodridge
- College of Medicine, University of Saskatchewan, Saskatoon, Canada.
| | - Masud Rana
- Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Elizabeth L Harrison
- School of Physical Therapy, College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Thomas Rotter
- Health Quality Programs, Queen's University, Kingston, Canada
| | - Roy Dobson
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada
| | - Gary Groot
- College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Sonia Udod
- Faculty of Nursing, University of Manitoba, Winnipeg, Canada
| | - Joshua Lloyd
- College of Medicine, University of Saskatchewan, Saskatoon, Canada
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Burau V, Carstensen K, Fredens M, Kousgaard MB. Exploring drivers and challenges in implementation of health promotion in community mental health services: a qualitative multi-site case study using Normalization Process Theory. BMC Health Serv Res 2018; 18:36. [PMID: 29361935 PMCID: PMC5781336 DOI: 10.1186/s12913-018-2850-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 01/16/2018] [Indexed: 01/23/2023] Open
Abstract
Background There is an increased interest in improving the physical health of people with mental illness. Little is known about implementing health promotion interventions in adult mental health organisations where many users also have physical health problems. The literature suggests that contextual factors are important for implementation in community settings. This study focused on the change process and analysed the implementation of a structural health promotion intervention in community mental health organisations in different contexts in Denmark. Methods The study was based on a qualitative multiple-case design and included two municipal and two regional provider organisations. Data were various written sources and 13 semi-structured interviews with 22 key managers and frontline staff. The analysis was organised around the four main constructs of Normalization Process Theory: Coherence, Cognitive Participation, Collective Action, and Reflexive Monitoring. Results Coherence: Most respondents found the intervention to be meaningful in that the intervention fitted well into existing goals, practices and treatment approaches. Cognitive Participation: Management engagement varied across providers and low engagement impeded implementation. Engaging all staff was a general problem although some of the initial resistance was apparently overcome. Collective Action: Daily enactment depended on staff being attentive and flexible enough to manage the complex needs and varying capacities of users. Reflexive Monitoring: During implementation, staff evaluations of the progress and impact of the intervention were mostly informal and ad hoc and staff used these to make on-going adjustments to activities. Overall, characteristics of context common to all providers (work force and user groups) seemed to be more important for implementation than differences in the external political-administrative context. Conclusions In terms of research, future studies should adopt a more bottom-up, grounded description of context and pay closer attention to the interplay between different dimensions of implementation. In terms of practice, future interventions need to better facilitate the translation of the initial sense of general meaning into daily practice by active local management support that occurs throughout the implementation process and that systematically connects the intervention to existing practices.
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Affiliation(s)
- Viola Burau
- DEFACTUM - Public Health and Health Services Research, Central Denmark Region, Aarhus, Denmark. .,Department of Public Health, University of Aarhus, Aarhus, Denmark.
| | - Kathrine Carstensen
- DEFACTUM - Public Health and Health Services Research, Central Denmark Region, Aarhus, Denmark
| | - Mia Fredens
- DEFACTUM - Public Health and Health Services Research, Central Denmark Region, Aarhus, Denmark
| | - Marius Brostrøm Kousgaard
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Herbert G, Sutton E, Burden S, Lewis S, Thomas S, Ness A, Atkinson C. Healthcare professionals' views of the enhanced recovery after surgery programme: a qualitative investigation. BMC Health Serv Res 2017; 17:617. [PMID: 28859687 PMCID: PMC5580205 DOI: 10.1186/s12913-017-2547-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 08/15/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The Enhanced Recovery After Surgery (ERAS) programme is an approach to the perioperative care of patients which aims to improve outcomes and speed up recovery after surgery. Although the evidence base appears strong for this programme, the implementation of ERAS has been slow. This study aimed to gain an understanding of the facilitating factors and challenges of implementing the programme with a view to providing additional contextual information to aid implementation. The study had a particular focus on the nutritional elements as these have been highlighted as important. METHODS The study employed qualitative research methods, guided by the Normalisation Process Theory (NPT) to explore the experiences and opinions of 26 healthcare professionals from a range of disciplines implementing the programme. RESULTS This study identified facilitating factors to the implementation of ERAS: alignment with evidence based practice, standardising practice, drawing on the evidence base of other specialties, leadership, teamwork, ERAS meetings, patient involvement and education, a pre-operative assessment unit, staff education, resources attached to obtaining The Commissioning for Quality and Innovation (CQUIN) money, the ward layout, data collection and feedback, and adapting the care pathway. A number of implementation challenges were also identified: resistance to change, standardisation affecting personalised patient care, the buy-in of relevant stakeholders, keeping ERAS visible, information provision to patients, resources, palatability of nutritional drinks, aligning different ward cultures, patients going to non-ERAS departments, spreading the programme within the hospital, differences in health issue, and utilising a segmental approach. CONCLUSIONS: The findings presented here provide useful contextual information from diverse surgical specialties to inform healthcare providers when implementing ERAS in practice. Addressing the challenges and utilising the facilitating factors identified in this study, could speed up the rate at which ERAS is adopted, implemented and embedded.
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Affiliation(s)
- Georgia Herbert
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK.
| | - Eileen Sutton
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK
| | - Sorrel Burden
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK.,School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Stephen Lewis
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK.,Derriford Hospital, Plymouth, UK
| | - Steve Thomas
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK.,Oral and Maxillofacial Surgery, University of Bristol, Bristol, UK
| | - Andy Ness
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK
| | - Charlotte Atkinson
- The NIHR Biomedical Research Unit at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol in Nutrition, Diet and Lifestyle, Bristol, UK
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16
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Hazell CM, Strauss C, Hayward M, Cavanagh K. Understanding clinician attitudes towards implementation of guided self-help cognitive behaviour therapy for those who hear distressing voices: using factor analysis to test normalisation process theory. BMC Health Serv Res 2017; 17:507. [PMID: 28738854 PMCID: PMC5525252 DOI: 10.1186/s12913-017-2449-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 07/16/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The Normalisation Process Theory (NPT) has been used to understand the implementation of physical health care interventions. The current study aims to apply the NPT model to a secondary mental health context, and test the model using exploratory factor analysis. This study will consider the implementation of a brief cognitive behaviour therapy for psychosis (CBTp) intervention. METHODS Mental health clinicians were asked to complete a NPT-based questionnaire on the implementation of a brief CBTp intervention. All clinicians had experience of either working with the target client group or were able to deliver psychological therapies. In total, 201 clinicians completed the questionnaire. RESULTS The results of the exploratory factor analysis found partial support for the NPT model, as three of the NPT factors were extracted: (1) coherence, (2) cognitive participation, and (3) reflexive monitoring. We did not find support for the fourth NPT factor (collective action). All scales showed strong internal consistency. Secondary analysis of these factors showed clinicians to generally support the implementation of the brief CBTp intervention. CONCLUSIONS This study provides strong evidence for the validity of the three NPT factors extracted. Further research is needed to determine whether participants' level of seniority moderates factor extraction, whether this factor structure can be generalised to other healthcare settings, and whether pre-implementation attitudes predict actual implementation outcomes.
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Affiliation(s)
- Cassie M. Hazell
- School of Psychology, University of Sussex, Falmer, Brighton, BN1 9QJ UK
| | - Clara Strauss
- School of Psychology, University of Sussex, Falmer, Brighton, BN1 9QJ UK
- R&D Department, Sussex Partnership NHS Foundation Trust, Sussex Education Centre, Hove, BN3 7HZ UK
| | - Mark Hayward
- School of Psychology, University of Sussex, Falmer, Brighton, BN1 9QJ UK
- R&D Department, Sussex Partnership NHS Foundation Trust, Sussex Education Centre, Hove, BN3 7HZ UK
| | - Kate Cavanagh
- School of Psychology, University of Sussex, Falmer, Brighton, BN1 9QJ UK
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17
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Upadhaya N, Jordans MJD, Pokhrel R, Gurung D, Adhikari RP, Petersen I, Komproe IH. Current situations and future directions for mental health system governance in Nepal: findings from a qualitative study. Int J Ment Health Syst 2017; 11:37. [PMID: 28603549 PMCID: PMC5465682 DOI: 10.1186/s13033-017-0145-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 05/24/2017] [Indexed: 12/05/2022] Open
Abstract
Background Assessing and understanding health systems governance is crucial to ensure accountability and transparency, and to improve the performance of mental health systems. There is a lack of systematic procedures to assess governance in mental health systems at a country level. The aim of this study was to appraise mental health systems governance in Nepal, with the view to making recommendations for improvements. Methods In-depth individual interviews were conducted with national-level policymakers (n = 17) and district-level planners (n = 11). The interview checklist was developed using an existing health systems governance framework developed by Siddiqi and colleagues as a guide. Data analysis was done with NVivo 10, using the procedure of framework analysis. Results The mental health systems governance assessment reveals a few enabling factors and many barriers. Factors enabling good governance include availability of mental health policy, inclusion of mental health in other general health policies and plans, increasing presence of Non-Governmental Organizations (NGOs) and service user organizations in policy forums, and implementation of a few mental health projects through government-NGO collaborations. Legal and policy barriers include the failure to officially revise or fully implement the mental health policy of 1996, the existence of legislation and several laws that have discriminatory provisions for people with mental illness, and lack of a mental health act and associated regulations to protect against this. Other barriers include lack of a mental health unit within the Ministry of Health, absence of district-level mental health planning, inadequate mental health record-keeping systems, inequitable allocation of funding for mental health, very few health workers trained in mental health, and the lack of availability of psychotropic drugs at the primary health care level. Conclusions In the last few years, some positive developments have emerged in terms of policy recognition for mental health, as well as the increased presence of NGOs, increased presence of service users or caregivers in mental health governance, albeit restricted to only some of its domains. However, the improvements at the policy level have not been translated into implementation due to lack of strong leadership and governance mechanisms.
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Affiliation(s)
| | - Mark J D Jordans
- Department of Research and Development, HealthNet TPO, Amsterdam, The Netherlands.,Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ruja Pokhrel
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
| | - Dristy Gurung
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
| | | | - Inge Petersen
- School of Nursing and Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Ivan H Komproe
- Department of Research and Development, HealthNet TPO, Amsterdam, The Netherlands.,Utrecht University, Utrecht, The Netherlands
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18
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Díaz-Castro L, Arredondo A, Pelcastre-Villafuerte BE, Hufty M. Governance and mental health: contributions for public policy approach. Rev Saude Publica 2017; 51:4. [PMID: 28146159 PMCID: PMC5286910 DOI: 10.1590/s1518-8787.2017051006991] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 07/19/2016] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To analyze the conceptualization of the term governance on public mental health programs. METHODS In this systematic review, we analyzed the scientific literature published in the international scenario during 15 years (from 2000 to 2015). The databases analyzed were: Medline, CINAHL, PsycINFO and PubMed. Governance and mental health were the descriptors. We included relevant articles according to our subject of study and levels of analysis: (i) the concept of governance in mental health; (ii) process and decision spaces; (iii) strategic and pertinent actors who operate in the functioning of the health system, and (iv) social regulations. We excluded letters to the editor, news articles, comments and case reports, incomplete articles and articles whose approach did not include the object of study of this review. RESULTS We have found five conceptualizations of the term governance on mental health in the area of provision policies and service organization. The agents were both those who offer and those who receive the services: we identified several social norms. CONCLUSIONS The concept of governance in mental health includes standards of quality and attention centered on the patient, and incorporates the consumers of mental healthcare in the decision-making process. OBJETIVO Analizar la conceptualización del término gobernanza en las políticas de salud mental. MÉTODOS En esta revisión sistemática se analizó literatura científica publicada en el ámbito internacional durante 15 años (de 2000 hasta 2015). Las bases de datos analizadas fueron: Medline, CINAHL, PsycINFO y PubMed. Los descriptores fueron gobernanza y salud mental. Fueron incluidos artículos relevantes de acuerdo a nuestro objeto de estudio y niveles de análisis: (i) concepto de gobernanza en salud mental; (ii) proceso y espacios de decisión; (iii) actores estratégicos y de interés que intervienen en el funcionamiento del sistema de salud, y (iv) normas sociales. Se excluyeron cartas al editor, noticias, comentarios y reporte de caso, artículos incompletos y artículos que no incluyeran en su abordaje el objeto de estudio de esta revisión. RESULTADOS Se reportaron cinco conceptualizaciones del término gobernanza en salud mental en el ámbito de políticas de provisión y organización de servicios. Los actores fueron desde proveedores a usuarios de servicios; se identificaron diversas normas sociales. CONCLUSIONES El concepto de gobernanza en salud mental incorpora estándares de calidad y atención centrada en el paciente, e incluye a los usuarios en la toma de decisiones.
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Affiliation(s)
- Lina Díaz-Castro
- Servicios de Atención Psiquiátrica. Secretaría de Salud. Ciudad de México, México
| | | | | | - Marc Hufty
- Graduate Institute of International and Development Studies. Geneva, Switzerland
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Thomas LH, French B, Sutton CJ, Forshaw D, Leathley MJ, Burton CR, Roe B, Cheater FM, Booth J, McColl E, Carter B, Walker A, Brittain K, Whiteley G, Rodgers H, Barrett J, Watkins CL. Identifying Continence OptioNs after Stroke (ICONS): an evidence synthesis, case study and exploratory cluster randomised controlled trial of the introduction of a systematic voiding programme for patients with urinary incontinence after stroke in secondary care. PROGRAMME GRANTS FOR APPLIED RESEARCH 2015. [DOI: 10.3310/pgfar03010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BackgroundUrinary incontinence (UI) following acute stroke is common, affecting between 40% and 60% of people in hospital, but is often poorly managed.AimTo develop, implement and evaluate the preliminary effectiveness and potential cost-effectiveness of a systematic voiding programme (SVP), with or without supported implementation, for the management of UI after stroke in secondary care.DesignStructured in line with the Medical Research Council framework for the evaluation of complex interventions, the programme comprised two phases: Phase I, evidence synthesis of combined approaches to manage UI post stroke, case study of the introduction of the SVP in one stroke service; Phase II, cluster randomised controlled exploratory trial incorporating a process evaluation and testing of health economic data collection methods.SettingOne English stroke service (case study) and 12 stroke services in England and Wales (randomised trial).ParticipantsCase study, 43 patients; randomised trial, 413 patients admitted to hospital with stroke and UI.InterventionsA SVP comprising assessment, individualised conservative interventions and weekly review. In the supported implementation trial arm, facilitation was used as an implementation strategy to support and enable people to change their practice.Main outcome measuresParticipant incontinence (presence/absence) at 12 weeks post stroke. Secondary outcomes were quality of life, frequency and severity of incontinence, urinary symptoms, activities of daily living and death, at discharge, 6, 12 and 52 weeks post stroke.ResultsThere was no suggestion of a beneficial effect on outcome at 12 weeks post stroke [intervention vs. usual care: odds ratio (OR) 1.02, 95% confidence interval (CI) 0.54 to 1.93; supported implementation vs. usual care: OR 1.06, 95% CI 0.54 to 2.09]. There was weak evidence of better outcomes on the Incontinence Impact Questionnaire in supported implementation (OR 1.22, 95% CI 0.72 to 2.08) but the CI is wide and includes both clinically relevant benefit and harm. Both intervention arms had a higher estimated odds of continence for patients with urge incontinence than usual care (intervention: OR 1.58, 95% CI 0.83 to 2.99; supported implementation: OR 1.73, 95% CI 0.88 to 3.43). The process evaluation showed that the SVP increased the visibility of continence management through greater evaluation of patients’ trajectories and outcomes, and closer attention to workload. In-hospital resource use had to be based on estimates provided by staff. The response rates for the postal questionnaires were 73% and 56% of eligible patients at 12 and 52 weeks respectively. Completion of individual data items varied between 67% and 100%.ConclusionsThe trial was exploratory and did not set out to establish effectiveness; however, there are indications the intervention may be effective in patients with urge and stress incontinence. A definitive trial is now warranted.Study registrationThis study is registered as ISRCTN08609907.Funding detailsThe National Institute for Health Research Programme Grants for Applied Research programme. Excess treatment costs and research support costs were funded by participating NHS trusts and health boards, Lancashire and Cumbria and East Anglia Comprehensive Local Research Networks and the Welsh National Institute for Social Care and Health Research.
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Affiliation(s)
- Lois H Thomas
- School of Health, University of Central Lancashire, Preston, UK
| | - Beverley French
- School of Health, University of Central Lancashire, Preston, UK
| | | | - Denise Forshaw
- School of Health, University of Central Lancashire, Preston, UK
| | | | | | - Brenda Roe
- Evidence-Based Practice Research Centre, Edge Hill University, Ormskirk, UK
| | - Francine M Cheater
- School of Health Science, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Jo Booth
- Department of Nursing and Community Health, Glasgow Caledonian University, Glasgow, UK
| | - Elaine McColl
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | | | - Andrew Walker
- Robertson Centre for Biostatistics, Glasgow University, Glasgow, UK
| | - Katie Brittain
- Institute of Health and Society and Institute for Ageing and Health, Newcastle University, Newcastle upon Tyne, UK
| | - Gemma Whiteley
- Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Preston, UK
| | - Helen Rodgers
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - James Barrett
- Wirral University Teaching Hospitals NHS Foundation Trust, Arrowe Park Hospital, Wirral, Merseyside, UK
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Hooshmand E, Tourani S, Ravaghi H, Ebrahimipour H. Challenges in evaluating clinical governance systems in iran: a qualitative study. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e13421. [PMID: 24910799 PMCID: PMC4028772 DOI: 10.5812/ircmj.13421] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Revised: 07/31/2013] [Accepted: 09/03/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND In spite of the pivotal role of clinical governance in enhancing quality of services provided by hospitals across the country, a scientific framework with specific criteria for evaluating hospitals has not been developed so far. OBJECTIVES This study was conducted with the aim to identify the challenges involved in evaluating systems of clinical governance in Iran. MATERIALS AND METHODS For the purposes of this qualitative study, 15 semi-structured interviews with experts in the field were conducted in 2011 and the data were analyzed using framework analysis method. RESULTS Five major challenges in evaluating clinical governance include managing human resources, improving clinical quality, managing development, organizing clinical governance, and providing patient-oriented healthcare system. CONCLUSIONS Healthcare system in Iran requires a clinical governance program which has a patient-oriented approach in philosophy, operation, and effectiveness in order to meet the challenges ahead.
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Affiliation(s)
- Elaheh Hooshmand
- Health Sciences Research Center, Department of Health and Management, School of Health, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Sogand Tourani
- Hospital Management Research Center, Iran University of Medical Sciences, Tehran, IR Iran
- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, IR Iran
- Corresponding Author: Sogand Tourani, , School of Health Management and Information Sciences, Iran University of Medical Sciences, P.O. Box: 1995614111, Tehran, IR Iran. Tel: +98-9123458077, Fax: +98-2188883334, E-mail:
| | - Hamid Ravaghi
- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, IR Iran
| | - Hossein Ebrahimipour
- Health Sciences Research Center, Department of Health and Management, School of Health, Mashhad University of Medical Sciences, Mashhad, IR Iran
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Thomas LH, French B, Burton CR, Sutton C, Forshaw D, Dickinson H, Leathley MJ, Britt D, Roe B, Cheater FM, Booth J, Watkins CL. Evaluating a systematic voiding programme for patients with urinary incontinence after stroke in secondary care using soft systems analysis and Normalisation Process Theory: findings from the ICONS case study phase. Int J Nurs Stud 2014; 51:1308-20. [PMID: 24656435 DOI: 10.1016/j.ijnurstu.2014.02.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 02/06/2014] [Accepted: 02/09/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Urinary incontinence (UI) affects between 40 and 60% of people in hospital after stroke, but is often poorly managed in stroke units. OBJECTIVES To inform an exploratory trial by three methods: identifying the organisational context for embedding the SVP; exploring health professionals' views around embedding the SVP and measuring presence/absence of UI and frequency of UI episodes at baseline and six weeks post-stroke. DESIGN A mixed methods single case study included analysis of organisational context using interviews with clinical leaders analysed with soft systems methodology, a process evaluation using interviews with staff delivering the intervention and analysed with Normalisation Process Theory, and outcome evaluation using data from patients receiving the SVP and analysed using descriptive statistics. SETTING An 18 bed acute stroke unit in a large Foundation Trust (a 'not for profit' privately controlled entity not accountable to the UK Department of Health) serving a population of 370,000. PARTICIPANTS Health professionals and clinical leaders with a role in either delivering the SVP or linking with it in any capacity were recruited following informed consent. Patients were recruited meeting the following inclusion criteria: aged 18 or over with a diagnosis of stroke; urinary incontinence (UI) as defined by the International Continence Society; conscious; medically stable as judged by the clinical team and with incontinence classified as stress, urge, mixed or 'functional'. All patients admitted to the unit during the intervention period were screened for eligibility; informed consent to collect baseline and outcome data was sought from all eligible patients. RESULTS Organisational context: 18 health professionals took part in four group interviews. Findings suggest an environment not conducive to therapeutic continence management and a focus on containment of UI. Embedding the SVP into practice: 21 nursing staff took part in six group interviews. Initial confusion gave way to embedding of processes facilitated by new routines and procedures. Patient outcome: 43 patients were recruited; 28 of these commenced the SVP. Of these, 6/28 (21%) were continent at six weeks post-stroke or discharge. CONCLUSION It was possible to embed the SVP into practice despite an organisational context not conducive to therapeutic continence care. Recommendations are made for introducing the SVP in a trial context.
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Affiliation(s)
- L H Thomas
- School of Health, University of Central Lancashire (UCLan), Preston PR1 2HE, UK.
| | - B French
- School of Health, University of Central Lancashire (UCLan), Preston PR1 2HE, UK
| | - C R Burton
- School of Health Care Sciences, Bangor University, Gwynedd LL57 2EF, UK
| | - C Sutton
- School of Health, University of Central Lancashire (UCLan), Preston PR1 2HE, UK
| | - D Forshaw
- School of Health, University of Central Lancashire (UCLan), Preston PR1 2HE, UK
| | - H Dickinson
- School of Health, University of Central Lancashire (UCLan), Preston PR1 2HE, UK
| | - M J Leathley
- School of Health, University of Central Lancashire (UCLan), Preston PR1 2HE, UK
| | - D Britt
- Division of Primary Care, University of Liverpool, Brownlow Street, Liverpool L69 3GL, UK
| | - B Roe
- Evidence-Based Practice Research Centre, Edge Hill University, St Helens Road, Ormskirk L39 4QP, UK
| | - F M Cheater
- School of Nursing Sciences, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK
| | - J Booth
- School of Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA, UK
| | - C L Watkins
- School of Health, University of Central Lancashire (UCLan), Preston PR1 2HE, UK
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McEvoy R, Ballini L, Maltoni S, O’Donnell CA, Mair FS, MacFarlane A. A qualitative systematic review of studies using the normalization process theory to research implementation processes. Implement Sci 2014; 9:2. [PMID: 24383661 PMCID: PMC3905960 DOI: 10.1186/1748-5908-9-2] [Citation(s) in RCA: 226] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 12/03/2013] [Indexed: 12/31/2023] Open
Abstract
BACKGROUND There is a well-recognized need for greater use of theory to address research translational gaps. Normalization Process Theory (NPT) provides a set of sociological tools to understand and explain the social processes through which new or modified practices of thinking, enacting, and organizing work are implemented, embedded, and integrated in healthcare and other organizational settings. This review of NPT offers readers the opportunity to observe how, and in what areas, a particular theoretical approach to implementation is being used. In this article we review the literature on NPT in order to understand what interventions NPT is being used to analyze, how NPT is being operationalized, and the reported benefits, if any, of using NPT. METHODS Using a framework analysis approach, we conducted a qualitative systematic review of peer-reviewed literature using NPT. We searched 12 electronic databases and all citations linked to six key NPT development papers. Grey literature/unpublished studies were not sought. Limitations of English language, healthcare setting and year of publication 2006 to June 2012 were set. RESULTS Twenty-nine articles met the inclusion criteria; in the main, NPT is being applied to qualitatively analyze a diverse range of complex interventions, many beyond its original field of e-health and telehealth. The NPT constructs have high stability across settings and, notwithstanding challenges in applying NPT in terms of managing overlaps between constructs, there is evidence that it is a beneficial heuristic device to explain and guide implementation processes. CONCLUSIONS NPT offers a generalizable framework that can be applied across contexts with opportunities for incremental knowledge gain over time and an explicit framework for analysis, which can explain and potentially shape implementation processes. This is the first review of NPT in use and it generates an impetus for further and extended use of NPT. We recommend that in future NPT research, authors should explicate their rationale for choosing NPT as their theoretical framework and, where possible, involve multiple stakeholders including service users to enable analysis of implementation from a range of perspectives.
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Affiliation(s)
- Rachel McEvoy
- Graduate Entry Medical School, 4i Research Center, University of Limerick, Limerick, Ireland
| | - Luciana Ballini
- Responsabile di Area, Osservatorio Regionale per l’Innovazione (ORI), Agenzia sanitaria e sociale regionale, viale Aldo Moro 21-40127, Bologna, Italy
| | - Susanna Maltoni
- Responsabile di Area, Osservatorio Regionale per l’Innovazione (ORI), Agenzia sanitaria e sociale regionale, viale Aldo Moro 21-40127, Bologna, Italy
| | - Catherine A O’Donnell
- General Practice and Primary Care, Institute of Health and Wellbeing, MVLS. University of Glasgow, 1 Horselethill Road, G12 9LX, Glasgow, Scotland
| | - Frances S Mair
- General Practice and Primary Care, Institute of Health and Wellbeing, MVLS. University of Glasgow, 1 Horselethill Road, G12 9LX, Glasgow, Scotland
| | - Anne MacFarlane
- Graduate Entry Medical School, 4i Research Center, University of Limerick, Limerick, Ireland
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Hoberg AA, Vickers KS, Ericksen J, Bauer G, Kung S, Stone R, Williams M, Moore MJ, Frye MA. Feasibility evaluation of an interpersonal and social rhythm therapy group delivery model. Arch Psychiatr Nurs 2013; 27:271-7. [PMID: 24238006 PMCID: PMC4020708 DOI: 10.1016/j.apnu.2013.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 07/13/2013] [Accepted: 08/01/2013] [Indexed: 11/24/2022]
Abstract
The effectiveness of psychotherapies, such as interpersonal and social rhythm therapy (IPSRT), is supported by randomized controlled trials. These trials provide minimal direction regarding feasibility of psychotherapy delivery models. The study purpose was to identify factors facilitating implementation and sustainability of an IPRST group for patients with bipolar disorder. Qualitative data were assessed by the normalization process model (NPM). The results demonstrate feasibility of implementation with experienced clinicians, program coordination, and leadership support. Sustainability challenges include aftercare groups, space, and clinician time. The NPM provides a useful framework for evaluation of factors influencing the feasibility of psychotherapy delivery models.
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Affiliation(s)
- Astrid A Hoberg
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN.
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Finch TL, Rapley T, Girling M, Mair FS, Murray E, Treweek S, McColl E, Steen IN, May CR. Improving the normalization of complex interventions: measure development based on normalization process theory (NoMAD): study protocol. Implement Sci 2013; 8:43. [PMID: 23578304 PMCID: PMC3637119 DOI: 10.1186/1748-5908-8-43] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 04/08/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Understanding implementation processes is key to ensuring that complex interventions in healthcare are taken up in practice and thus maximize intended benefits for service provision and (ultimately) care to patients. Normalization Process Theory (NPT) provides a framework for understanding how a new intervention becomes part of normal practice. This study aims to develop and validate simple generic tools derived from NPT, to be used to improve the implementation of complex healthcare interventions. OBJECTIVES The objectives of this study are to: develop a set of NPT-based measures and formatively evaluate their use for identifying implementation problems and monitoring progress; conduct preliminary evaluation of these measures across a range of interventions and contexts, and identify factors that affect this process; explore the utility of these measures for predicting outcomes; and develop an online users' manual for the measures. METHODS A combination of qualitative (workshops, item development, user feedback, cognitive interviews) and quantitative (survey) methods will be used to develop NPT measures, and test the utility of the measures in six healthcare intervention settings. DISCUSSION The measures developed in the study will be available for use by those involved in planning, implementing, and evaluating complex interventions in healthcare and have the potential to enhance the chances of their implementation, leading to sustained changes in working practices.
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Affiliation(s)
- Tracy L Finch
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle-upon-Tyne NE2 4AX, UK.
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Fleury MJ, Imboua A, Aubé D, Farand L. Collaboration between general practitioners (GPs) and mental healthcare professionals within the context of reforms in Quebec. MENTAL HEALTH IN FAMILY MEDICINE 2012; 9:77-90. [PMID: 23730332 PMCID: PMC3513700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Background In the context of the high prevalence and impact of mental disorders worldwide, and less than optimal utilisation of services and adequacy of care, strengthening primary mental healthcare should be a leading priority. This article assesses the state of collaboration among general practitioners (GPs), psychiatrists and psychosocial mental healthcare professionals, factors that enable and hinder shared care, and GPs' perceptions of best practices in the management of mental disorders. A collaboration model is also developed. Methods The study employs a mixed-method approach, with emphasis on qualitative investigation. Drawing from a previous survey representative of the Quebec GP population, 60 GPs were selected for further investigation. Results Globally, GPs managed mental healthcare patients in solo practice in parallel or sequential follow-up with mental healthcare professionals. GPs cited psychologists and psychiatrists as their main partners. Numerous hindering factors associated with shared care were found: lack of resources (either professionals or services); long waiting times; lack of training, time and incentives for collaboration; and inappropriate GP payment modes. The ideal practice model includes GPs working in multidisciplinary group practice in their own settings. GPs recommended expanding psychosocial services and shared care to increase overall access and quality of care for these patients. Conclusion As increasing attention is devoted worldwide to the development of optimal integrated primary care, this article contributes to the discussion on mental healthcare service planning. A culture of collaboration has to be encouraged as comprehensive services and continuity of care are key recovery factors of patients with mental disorders.
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Affiliation(s)
- Marie-Josée Fleury
- Associate Professor, Department of Psychiatry, McGill University, Douglas Mental Health University Institute Research Centre, Montreal, Canada
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26
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Macfarlane A, O'Reilly-de Brún M. Using a theory-driven conceptual framework in qualitative health research. QUALITATIVE HEALTH RESEARCH 2012; 22:607-618. [PMID: 22203386 DOI: 10.1177/1049732311431898] [Citation(s) in RCA: 121] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The role and merits of highly inductive research designs in qualitative health research are well established, and there has been a powerful proliferation of grounded theory method in the field. However, tight qualitative research designs informed by social theory can be useful to sensitize researchers to concepts and processes that they might not necessarily identify through inductive processes. In this article, we provide a reflexive account of our experience of using a theory-driven conceptual framework, the Normalization Process Model, in a qualitative evaluation of general practitioners' uptake of a free, pilot, language interpreting service in the Republic of Ireland. We reflect on our decisions about whether or not to use the Model, and describe our actual use of it to inform research questions, sampling, coding, and data analysis. We conclude with reflections on the added value that the Model and tight design brought to our research.
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Affiliation(s)
- Anne Macfarlane
- University of Limerick, Castletroy, Limerick, Republic of Ireland.
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Franx G, Oud M, de Lange J, Wensing M, Grol R. Implementing a stepped-care approach in primary care: results of a qualitative study. Implement Sci 2012; 7:8. [PMID: 22293362 PMCID: PMC3292960 DOI: 10.1186/1748-5908-7-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Accepted: 01/31/2012] [Indexed: 11/10/2022] Open
Abstract
Background Since 2004, 'stepped-care models' have been adopted in several international evidence-based clinical guidelines to guide clinicians in the organisation of depression care. To enhance the adoption of this new treatment approach, a Quality Improvement Collaborative (QIC) was initiated in the Netherlands. Methods Alongside the QIC, an intervention study using a controlled before-and-after design was performed. Part of the study was a process evaluation, utilizing semi-structured group interviews, to provide insight into the perceptions of the participating clinicians on the implementation of stepped care for depression into their daily routines. Participants were primary care clinicians, specialist clinicians, and other healthcare staff from eight regions in the Netherlands. Analysis was supported by the Normalisation Process Theory (NPT). Results The introduction of a stepped-care model for depression to primary care teams within the context of a depression QIC was generally well received by participating clinicians. All three elements of the proposed stepped-care model (patient differentiation, stepped-care treatment, and outcome monitoring), were translated and introduced locally. Clinicians reported changes in terms of learning how to differentiate between patient groups and different levels of care, changing antidepressant prescribing routines as a consequence of having a broader treatment package to offer to their patients, and better working relationships with patients and colleagues. A complex range of factors influenced the implementation process. Facilitating factors were the stepped-care model itself, the structured team meetings (part of the QIC method), and the positive reaction from patients to stepped care. The differing views of depression and depression care within multidisciplinary health teams, lack of resources, and poor information systems hindered the rapid introduction of the stepped-care model. The NPT constructs 'coherence' and 'cognitive participation' appeared to be crucial drivers in the initial stage of the process. Conclusions Stepped care for depression is received positively in primary care. While it is difficult for the implementation of a full stepped-care approach to occur within a short time frame, clinicians can make progress towards achieving a stepped-care approach, particularly within the context of a QIC. Creating a shared understanding within multidisciplinary teams of what constitutes depression, reaching a consensus about the content of depression care, and the division of tasks are important when addressing the implementation process.
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Affiliation(s)
- Gerdien Franx
- Trimbos-institute, Netherlands Institute of Mental Health and Addiction, PO Box 725, 3500 AS Utrecht, the Netherlands.
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Brooks H, Pilgrim D, Rogers A. Innovation in mental health services: what are the key components of success? Implement Sci 2011; 6:120. [PMID: 22029930 PMCID: PMC3214129 DOI: 10.1186/1748-5908-6-120] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 10/26/2011] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Service development innovation in health technology and practice is viewed as a pressing need within the field of mental health yet is relatively poorly understood. Macro-level theories have been criticised for their limited explanatory power and they may not be appropriate for understanding local and fine-grained uncertainties of services and barriers to the sustainability of change. This study aimed to identify contextual influences inhibiting or promoting the acceptance and integration of innovations in mental health services in both National Health Service (NHS) and community settings. METHODS A comparative study using qualitative and case study data collection methods, including semi-structured interviews with key stakeholders and follow-up telephone interviews over a one-year period. The analysis was informed by learning organisation theory. Drawn from 11 mental health innovation projects within community, voluntary and NHS settings, 65 participants were recruited including service users, commissioners, health and non-health professionals, managers, and caregivers. The methods deployed in this evaluation focused on process-outcome links within and between the 11 projects. RESULTS Key barriers to innovation included resistance from corporate departments and middle management, complexity of the innovation, and the availability and access to resources on a prospective basis within the host organisation. The results informed the construction of a proposed model of innovation implementation within mental health services. The main components of which are context, process, and outcomes. CONCLUSIONS The study produced a model of conducive and impeding factors drawn from the composite picture of 11 innovative mental health projects, and this is discussed in light of relevant literature. The model provides a rich agenda to consider for services wanting to innovate or adopt innovations from elsewhere. The evaluation suggested the importance of studying innovation with a focus on context, process, and outcomes.
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Affiliation(s)
- Helen Brooks
- Health Sciences, Primary Care, Community Based Medicine, University of Manchester, Manchester, UK
| | - David Pilgrim
- School of Social Work, University of Central Lancashire, Preston, UK
| | - Anne Rogers
- National Institute for Health Research, School for Primary Care Research, Community Based Medicine, University of Manchester, Manchester, UK
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May CR, Finch T, Ballini L, MacFarlane A, Mair F, Murray E, Treweek S, Rapley T. Evaluating complex interventions and health technologies using normalization process theory: development of a simplified approach and web-enabled toolkit. BMC Health Serv Res 2011; 11:245. [PMID: 21961827 PMCID: PMC3205031 DOI: 10.1186/1472-6963-11-245] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Accepted: 09/30/2011] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Normalization Process Theory (NPT) can be used to explain implementation processes in health care relating to new technologies and complex interventions. This paper describes the processes by which we developed a simplified version of NPT for use by clinicians, managers, and policy makers, and which could be embedded in a web-enabled toolkit and on-line users manual. METHODS Between 2006 and 2010 we undertook four tasks. (i) We presented NPT to potential and actual users in multiple workshops, seminars, and presentations. (ii) Using what we discovered from these meetings, we decided to create a simplified set of statements and explanations expressing core constructs of the theory (iii) We circulated these statements to a criterion sample of 60 researchers, clinicians and others, using SurveyMonkey to collect qualitative textual data about their criticisms of the statements. (iv) We then reconstructed the statements and explanations to meet users' criticisms, embedded them in a web-enabled toolkit, and beta tested this 'in the wild'. RESULTS On-line data collection was effective: over a four week period 50/60 participants responded using SurveyMonkey (40/60) or direct phone and email contact (10/60). An additional nine responses were received from people who had been sent the SurveyMonkey form by other respondents. Beta testing of the web enabled toolkit produced 13 responses, from 327 visits to http://www.normalizationprocess.org. Qualitative analysis of both sets of responses showed a high level of support for the statements but also showed that some statements poorly expressed their underlying constructs or overlapped with others. These were rewritten to take account of users' criticisms and then embedded in a web-enabled toolkit. As a result we were able translate the core constructs into a simplified set of statements that could be utilized by non-experts. CONCLUSION Normalization Process Theory has been developed through transparent procedures at each stage of its life. The theory has been shown to be sufficiently robust to merit formal testing. This project has provided a user friendly version of NPT that can be embedded in a web-enabled toolkit and used as a heuristic device to think through implementation and integration problems.
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Affiliation(s)
- Carl R May
- Faculty of Health Sciences, University of Southampton, UK
| | - Tracy Finch
- Institute of Health and Society, Newcastle University, UK
| | | | - Anne MacFarlane
- Discipline of General Practice, National University of Ireland, Galway, Ireland
| | - Frances Mair
- Academic Unit of General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, UK
| | - Elizabeth Murray
- Research Department of Primary Care and Population Health, University College London, UK
| | - Shaun Treweek
- Quality, Safety & Informatics Research Group, University of Dundee, UK
| | - Tim Rapley
- Institute of Health and Society, Newcastle University, UK
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Gunn JM, Palmer VJ, Dowrick CF, Herrman HE, Griffiths FE, Kokanovic R, Blashki GA, Hegarty KL, Johnson CL, Potiriadis M, May CR. Embedding effective depression care: using theory for primary care organisational and systems change. Implement Sci 2010; 5:62. [PMID: 20687962 PMCID: PMC2925331 DOI: 10.1186/1748-5908-5-62] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 08/06/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Depression and related disorders represent a significant part of general practitioners (GPs) daily work. Implementing the evidence about what works for depression care into routine practice presents a challenge for researchers and service designers. The emerging consensus is that the transfer of efficacious interventions into routine practice is strongly linked to how well the interventions are based upon theory and take into account the contextual factors of the setting into which they are to be transferred. We set out to develop a conceptual framework to guide change and the implementation of best practice depression care in the primary care setting. METHODS We used a mixed method, observational approach to gather data about routine depression care in a range of primary care settings via: audit of electronic health records; observation of routine clinical care; and structured, facilitated whole of organisation meetings. Audit data were summarised using simple descriptive statistics. Observational data were collected using field notes. Organisational meetings were audio taped and transcribed. All the data sets were grouped, by organisation, and considered as a whole case. Normalisation Process Theory (NPT) was identified as an analytical theory to guide the conceptual framework development. RESULTS Five privately owned primary care organisations (general practices) and one community health centre took part over the course of 18 months. We successfully developed a conceptual framework for implementing an effective model of depression care based on the four constructs of NPT: coherence, which proposes that depression work requires the conceptualisation of boundaries of who is depressed and who is not depressed and techniques for dealing with diffuseness; cognitive participation, which proposes that depression work requires engagement with a shared set of techniques that deal with depression as a health problem; collective action, which proposes that agreement is reached about how care is organised; and reflexive monitoring, which proposes that depression work requires agreement about how depression work will be monitored at the patient and practice level. We describe how these constructs can be used to guide the design and implementation of effective depression care in a way that can take account of contextual differences. CONCLUSIONS Ideas about what is required for an effective model and system of depression care in primary care need to be accompanied by theoretically informed frameworks that consider how these can be implemented. The conceptual framework we have presented can be used to guide organisational and system change to develop common language around each construct between policy makers, service users, professionals, and researchers. This shared understanding across groups is fundamental to the effective implementation of change in primary care for depression.
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Affiliation(s)
- Jane M Gunn
- Primary Care Research Unit, The Department of General Practice, School of Medicine, The University of Melbourne, Australia
| | - Victoria J Palmer
- Primary Care Research Unit, The Department of General Practice, School of Medicine, The University of Melbourne, Australia
| | - Christopher F Dowrick
- Department of Primary Care, School of Population, Community and Behavioural Sciences, University of Liverpool, Liverpool, UK
| | - Helen E Herrman
- Centre for Youth Mental Health, The University of Melbourne, Australia
| | - Frances E Griffiths
- Centre for Primary Health Care Studies, Warwick Medical School, University of Warwick, UK
| | - Renata Kokanovic
- Department of Sociology, School of Political and Social Enquiry, Monash University, Australia
| | - Grant A Blashki
- Nossal Institute for Global Health, The University of Melbourne, Australia
| | - Kelsey L Hegarty
- Primary Care Research Unit, The Department of General Practice, School of Medicine, The University of Melbourne, Australia
| | - Caroline L Johnson
- Primary Care Research Unit, The Department of General Practice, School of Medicine, The University of Melbourne, Australia
| | - Maria Potiriadis
- Primary Care Research Unit, The Department of General Practice, School of Medicine, The University of Melbourne, Australia
| | - Carl R May
- Institute of Health and Society, Newcastle University, UK
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Process evaluation of infertility management in primary care: has open access HSG been normalized? Prim Health Care Res Dev 2009. [DOI: 10.1017/s1463423609990168] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Fleury MJ, Bamvita JM, Tremblay J. Variables associated with general practitioners taking on serious mental disorder patients. BMC FAMILY PRACTICE 2009; 10:41. [PMID: 19515248 PMCID: PMC2706225 DOI: 10.1186/1471-2296-10-41] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/13/2008] [Accepted: 06/10/2009] [Indexed: 11/10/2022]
Abstract
BACKGROUND As part of community-based initiatives to strengthen integrated care and promote patient recovery, GPs are asked to play a greater part in treating serious mental disorder (SMD) patients. All current healthcare reforms favour the reinforcement of primary care. More information on enhancing the role of GPs in mental health would benefit policymakers, especially as regards SMD patients, where little research has been published as yet. This article assesses variables associated with GPs taking on SMD patients. METHODS The study, encompassing multiple sites, is based on a sample of 398 GPs, representative of the GP population in the Canadian province of Quebec. GPs were asked to answer a 143-item questionnaire on their socio-demographic and clinical practice profiles, patient characteristics, perceived inter-professional relationships and quality of care. Descriptive, bivariate and multivariate analyses were performed. RESULTS Our data highlighted that GPs currently followed up only a minority of SMD patients on a continuous basis and far fewer for both physical and mental health problems. A linear regression model that accounts for 43% of the variance was generated. The best variables associated positively with GPs taking on SMD patients were: frequency of referrals for joint follow-up with other resources, and involvement in post-hospitalization follow-up. Conversely, lack of expertise in mental health (related in our model to frequency of mental disorder patient transfer due to insufficient mental health training) is associated with a lower incidence of GPs taking on patients. CONCLUSION As advocated in current healthcare reforms, our study confirms the need to promote greater GP involvement in integrated care models and enhance their training in mental health--thereby helping to reverse the trend among GPs of transferring SMD patients to specialized care. Patients with stable SMDs ought to have the same care access as the general population.
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Affiliation(s)
- Marie-Josée Fleury
- Department of Psychiatry, McGill University, Douglas Mental Health University Institute Research Centre (DMHUIRC), Quebec, Canada
| | | | - Jacques Tremblay
- Department of Psychiatry, McGill University, Douglas Mental Health University Institute Research Centre (DMHUIRC), Quebec, Canada
- DMHUIRC, Montreal, Quebec, Canada
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May CR, Mair F, Finch T, MacFarlane A, Dowrick C, Treweek S, Rapley T, Ballini L, Ong BN, Rogers A, Murray E, Elwyn G, Légaré F, Gunn J, Montori VM. Development of a theory of implementation and integration: Normalization Process Theory. Implement Sci 2009; 4:29. [PMID: 19460163 PMCID: PMC2693517 DOI: 10.1186/1748-5908-4-29] [Citation(s) in RCA: 654] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Accepted: 05/21/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Theories are important tools in the social and natural sciences. The methods by which they are derived are rarely described and discussed. Normalization Process Theory explains how new technologies, ways of acting, and ways of working become routinely embedded in everyday practice, and has applications in the study of implementation processes. This paper describes the process by which it was built. METHODS Between 1998 and 2008, we developed a theory. We derived a set of empirical generalizations from analysis of data collected in qualitative studies of healthcare work and organization. We developed an applied theoretical model through analysis of empirical generalizations. Finally, we built a formal theory through a process of extension and implication analysis of the applied theoretical model. RESULTS Each phase of theory development showed that the constructs of the theory did not conflict with each other, had explanatory power, and possessed sufficient robustness for formal testing. As the theory developed, its scope expanded from a set of observed regularities in data with procedural explanations, to an applied theoretical model, to a formal middle-range theory. CONCLUSION Normalization Process Theory has been developed through procedures that were properly sceptical and critical, and which were opened to review at each stage of development. The theory has been shown to merit formal testing.
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Affiliation(s)
- Carl R May
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Frances Mair
- Division of General Practice, Glasgow University, Glasgow, UK
| | - Tracy Finch
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Anne MacFarlane
- Department of General Practice, National University of Ireland, Galway, Ireland
| | - Christopher Dowrick
- School of Population and Behavioural Sciences, University of Liverpool, Liverpool, UK
| | - Shaun Treweek
- Centre for Primary Care and Population Research, University of Dundee, Dundee, UK
| | - Tim Rapley
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | | | - Bie Nio Ong
- Arthritis Research Campaign National Primary Care Centre, Keele University, Keele, UK
| | - Anne Rogers
- National Primary Care Research and Development Centre, University of Manchester, Manchester, UK
| | - Elizabeth Murray
- Department of Primary Care, University College London, London, UK
| | - Glyn Elwyn
- Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - France Légaré
- Department of Family Medicine, Université Laval, Québec, Québec, Canada
| | - Jane Gunn
- Department of General Practice, University of Melbourne, Melbourne, Australia
| | - Victor M Montori
- Knowledge and Encounter Research Unit, Mayo Clinic, Rochester MN, USA
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Elwyn G, Légaré F, Weijden TVD, Edwards A, May C. Arduous implementation: does the Normalisation Process Model explain why it's so difficult to embed decision support technologies for patients in routine clinical practice. Implement Sci 2008; 3:57. [PMID: 19117509 PMCID: PMC2631595 DOI: 10.1186/1748-5908-3-57] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Accepted: 12/31/2008] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Decision support technologies (DSTs, also known as decision aids) help patients and professionals take part in collaborative decision-making processes. Trials have shown favorable impacts on patient knowledge, satisfaction, decisional conflict and confidence. However, they have not become routinely embedded in health care settings. Few studies have approached this issue using a theoretical framework. We explained problems of implementing DSTs using the Normalization Process Model, a conceptual model that focuses attention on how complex interventions become routinely embedded in practice. METHODS The Normalization Process Model was used as the basis of conceptual analysis of the outcomes of previous primary research and reviews. Using a virtual working environment we applied the model and its main concepts to examine: the 'workability' of DSTs in professional-patient interactions; how DSTs affect knowledge relations between their users; how DSTs impact on users' skills and performance; and the impact of DSTs on the allocation of organizational resources. RESULTS A conceptual analysis using the Normalization Process Model provided insight on implementation problems for DSTs in routine settings. Current research focuses mainly on the interactional workability of these technologies, but factors related to divisions of labor and health care, and the organizational contexts in which DSTs are used, are poorly described and understood. CONCLUSION The model successfully provided a framework for helping to identify factors that promote and inhibit the implementation of DSTs in healthcare and gave us insights into factors influencing the introduction of new technologies into contexts where negotiations are characterized by asymmetries of power and knowledge. Future research and development on the deployment of DSTs needs to take a more holistic approach and give emphasis to the structural conditions and social norms in which these technologies are enacted.
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Affiliation(s)
- Glyn Elwyn
- Department of Primary Care and Public Health, School of Medicine, Cardiff University, Heath Park, CF14 4YS, UK
| | - France Légaré
- Department of Family Medicine, Université Laval, Centre Hospitalier Universitaire de Québec, Hôpital St-François d'Assise10 Rue Espinay, Québec, G1L 3L5, Canada
| | - Trudy van der Weijden
- Department of General Practice, School for Primary Care and Public Health (Caphri), Maastricht University, PO Box 616, 6200 MD Maastricht, Netherlands
| | - Adrian Edwards
- Department of Primary Care and Public Health, School of Medicine, Cardiff University, Heath Park, CF14 4YS, UK
| | - Carl May
- Institute of Health and Society, Newcastle University, 21 Claremont Place, Newcastle upon Tyne, NE2 4AA, UK
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Abstract
OBJECTIVE To explore the importance of ;coherence' in the normalization of treatment interventions by examining teledermatology for skin disease management from the perspectives of patients and their advocates. METHODS Twelve teledermatology services were studied using semi-structured interviews. Participants were patients (n = 20) and health professionals, managers and patient advocates (n = 68). RESULTS Teledermatology lacked coherence for patients and advocates. It was seen to be different from standard dermatology care, but the objectives of it -- what it is for -- were neither clear nor understandable to participants. Teledermatology 'fitting in' with the patient's own lifeworld appeared to be unlikely for patients suffering a range of skin diseases, as features of teledermatology (e.g. absence of talk with consultant, and diagnostic uncertainty) were incongruent with the wide-ranging needs of patients and limited their participation in management. DISCUSSION Healthcare technology may facilitate greater self-management of chronic disease. However, successful normalization of technology for this purpose will require greater understanding of what it means to patients in the context of their experiences of disease and the parameters of their lives.
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Affiliation(s)
- Tracy Finch
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.
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