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Examining Interprofessional teams structures and processes in the implementation of a primary care intervention (Health TAPESTRY) for older adults using normalization process theory.

ABSTRACT: BACKGROUND:Many countries are engaged in primary care reforms to support older adults who are living longer in the community. Health Teams Advancing Patient Experience: Strengthening Quality [Health TAPESTRY] is a primary care intervention aimed at supporting older adults that involves trained volunteers, interprofessional teams, technology, and system navigation. This paper examines implementation of Health TAPESTRY in relation to interprofessional teamwork including volunteers. METHODS:This study applied Normalization Process Theory (NPT) and used a descriptive qualitative approach [1] embedded in a mixed-methods, pragmatic randomized controlled trial. It was situated in two primary care practice sites in a large urban setting in Ontario, Canada. Focus groups and interviews were conducted with primary care providers, clinical managers, administrative assistants, volunteers, and a volunteer coordinator. Data was collected at 4?months (June-July 2015) and 12?months (February-March 2016) after intervention start-up. Patients were interviewed at the end of the six-month intervention. Field notes were taken at weekly huddle meetings. RESULTS:Overall, 84 participants were included in 17 focus groups and 13 interviews; 24 field notes were collected. Themes were organized under four NPT constructs of implementation: 1) Coherence- (making sense/understanding of the program's purpose/value) generating comprehensive assessments of older adults; strengthening health promotion, disease prevention, and self-management; enhancing patient-focused care; strengthening interprofessional care delivery; improving coordination of health and community services. 2) Cognitive Participation- (enrolment/buy-in) tackling new ways of working; attaining role clarity. 3) Collective Action- (enactment/operationalizing) changing team processes; reconfiguring resources. 4) Reflective Monitoring- (appraisal) improving teamwork and collaboration; reconfiguring roles and processes. CONCLUSIONS:This study contributes key strategies for effective implementation of interventions involving interprofessional primary care teams. Findings indicate that regular communication among all team members, the development of procedures and/or protocols to support team processes, and ongoing review and feedback are critical to implementation of innovations involving primary care teams. TRIAL REGISTRATION:ClinicalTrials.gov, no. NCT02283723 November 5, 2014. Prospectively registered.

SUBMITTER: Valaitis R

PROVIDER: S-EPMC7160930 | biostudies-literature | 2020 Apr

REPOSITORIES: biostudies-literature

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Examining Interprofessional teams structures and processes in the implementation of a primary care intervention (Health TAPESTRY) for older adults using normalization process theory.

Valaitis Ruta R Cleghorn Laura L Dolovich Lisa L Agarwal Gina G Gaber Jessica J Mangin Derelie D Oliver Doug D Parascandalo Fiona F Ploeg Jenny J Risdon Cathy C

BMC family practice 20200415 1

<h4>Background</h4>Many countries are engaged in primary care reforms to support older adults who are living longer in the community. Health Teams Advancing Patient Experience: Strengthening Quality [Health TAPESTRY] is a primary care intervention aimed at supporting older adults that involves trained volunteers, interprofessional teams, technology, and system navigation. This paper examines implementation of Health TAPESTRY in relation to interprofessional teamwork including volunteers.<h4>Meth ...[more]

PMID: 32295524

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Project description: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.

Project description:IntroductionSuccessful implementation and embedding of new health care practices relies on co-ordinated, collective behaviour of individuals working within the constraints of health care settings. Normalization Process Theory (NPT) provides a theory of implementation that emphasises collective action in explaining, and shaping, the embedding of new practices. To extend the practical utility of NPT for improving implementation success, an instrument (NoMAD) was developed and validated.MethodsDescriptive analysis and psychometric testing of an instrument developed by the authors, through an iterative process that included item generation, consensus methods, item appraisal, and cognitive testing. A 46 item questionnaire was tested in 6 sites implementing health related interventions, using paper and online completion. Participants were staff directly involved in working with the interventions. Descriptive analysis and consensus methods were used to remove redundancy, reducing the final tool to 23 items. Data were subject to confirmatory factor analysis which sought to confirm the theoretical structure within the sample.ResultsWe obtained 831 completed questionnaires, an average response rate of 39% (range: 22-77%). Full completion of items was 50% (n?=?413). The confirmatory factor analysis showed the model achieved acceptable fit (CFI?=?0.95, TLI?=?0.93, RMSEA?=?0.08, SRMR?=?0.03). Construct validity of the four theoretical constructs of NPT was supported, and internal consistency (Cronbach's alpha) were as follows: Coherence (4 items, ??=?0.71); Collective Action (7 items, ??=?0.78); Cognitive Participation (4 items, ??=?0.81); Reflexive Monitoring (5 items, ??=?0.65). The normalisation scale overall, was highly reliable (20 items, ??=?0.89).ConclusionsThe NoMAD instrument has good face validity, construct validity and internal consistency, for assessing staff perceptions of factors relevant to embedding interventions that change their work practices. Uses in evaluating and guiding implementation are proposed.

Project description:BACKGROUND:Smoking in pregnancy causes harm to mother and baby. Despite evidence from trials of what helps women quit, implementation in the real world has been hard to achieve. An evidence-based intervention, babyClear©, involving staff training, universal carbon monoxide monitoring, opt-out referral to smoking cessation services, enhanced follow-up protocols and a risk perception tool was introduced across North East England. This paper presents the results of the qualitative analyses, reporting acceptability of the system changes to staff, as well as aids and hindrances to implementation and normalization of this complex intervention. METHODS:Process evaluation was used to complement an effectiveness study. Interviews with maternity and smoking cessation services staff and observations of training were undertaken. Normalization Process Theory (NPT) was used to frame the interview guides and analysis. NPT is an empirically-derived theory, developed by sociologists, that uses four concepts to understand the process of routinising new practices. RESULTS:Staff interviews took place across eight National Health Service trusts at a time of widespread restructuring in smoking cessation services. Principally interviewees worked in maternity (n = 63) and smoking cessation services (n = 35). Five main themes, identified inductively, influenced the implementation: 1) initial preparedness of the organisations; 2) staff training; 3) managing partnership working; 4) resources; 5) review and planning for sustainability. CONCLUSIONS:NPT was used to show that the babyClear© package was acceptable to staff in a range of organisations. Illustrated in Themes 1, 2 & 3, staff welcomed ways to approach pregnant women about their smoking, without damaging their professional relationship with them. Predicated on producing individual behaviour change in women, the intervention does this largely through reorganising and standardising healthcare systems that are required to implement best practice guidelines. Changing organisational systems requires belief and commitment from staff, so that they set up and maintain practical adjustments to their practice and are reflective about adapting themselves and the work context as new challenges are encountered. The ongoing challenge is to identify and maintain the elements of the intervention package which are essential for its effectiveness and how to tailor them to local circumstances and resources without compromising its core ingredients.

Project description:BackgroundSuicide rates continue to rise across the United States, galvanizing the need for increased suicide prevention and intervention efforts. The Zero Suicide (ZS) model was developed in response to this need and highlights four key clinical functions of high-quality health care for patients at risk of suicide. The goal of this quality improvement study was to understand how six large health care systems operationalized practices to support these functions-identification, engagement, treatment and care transitions.MethodsUsing a key informant interview guide and data collection template, researchers who were embedded in each health care system cataloged and summarized current and future practices supporting ZS, including, (1) the function addressed; (2) a description of practice intent and mechanism of intervention; (3) the target patient population and service setting; (4) when/how the practice was (or will be) implemented; and (5) whether/how the practice was documented and/or measured. Normalization process theory (NPT), an implementation evaluation framework, was applied to help understand how ZS had been operationalized in routine clinical practices and, specifically, what ZS practices were described by key informants (coherence), the current state of norms/conventions supporting these practices (cognitive participation), how health care teams performed these practices (collective action), and whether/how practices were measured when they occurred (reflexive monitoring).ResultsThe most well-defined and consistently measured ZS practices (current and future) focused on the identification of patients at high risk of suicide. Stakeholders also described numerous engagement and treatment practices, and some practices intended to support care transitions. However, few engagement and transition practices were systematically measured, and few treatment practices were designed specifically for patients at risk of suicide.ConclusionsThe findings from this study will support large-scale evaluation of the effectiveness of ZS implementation and inform recommendations for implementation of high-quality suicide-related care in health care systems nationwide.

Project description:BackgroundNormalisation Process Theory (NPT) provides a framework to understand how interventions are implemented, embedded, and integrated in healthcare settings. Previous reviews of published literature have examined the application of NPT across international healthcare and reports its benefits. However, given the distinctive clinical function, organisational arrangements and the increasing management of people with a wide variety of conditions in primary care settings in the United Kingdom, it is important to understand how and why authors utilise and reflect on NPT in such settings to inform and evaluate implementation processes.MethodsA systematic review of peer-reviewed literature using NPT in primary care settings in the United Kingdom (UK) was conducted. Eight electronic databases were searched using replicable methods to identify articles published between January 2012 and April 2018. Data were analysed using a framework approach.ResultsThirty-one articles met the inclusion criteria. Researchers utilised NPT to explore the implementation of interventions, targeting a wide range of health services and conditions, within primary care settings in the UK. NPT was mostly applied qualitatively; however, a small number of researchers have moved towards mixed and quantitative methods. Some variation was observed in the use of NPT constructs and sub-constructs, and whether and how researchers undertook modification to make them more relevant to the implementation process and multiple stakeholder perspectives.ConclusionNPT provides a flexible framework for the development and evaluation of complex healthcare interventions in UK primary care settings. This review updates the literature on NPT use and indicates that its application is well suited to these environments, particularly in supporting patients with long-term conditions and co-morbidities. We recommend future research explores the receipt of interventions by multiple stakeholders and suggest that authors reflect on justifications for using NPT in their reporting.

Project description:BACKGROUND:'Cascade training' or 'train-the-trainers' has been widely utilised in the dissemination of information and expertise in health and social care, but with little examination of the work required for optimal delivery. National suicide prevention strategies commonly include such training initiatives. METHODS:A qualitative study to characterise the work, according to the concepts of Normalization Process Theory, required to disseminate STORM, a model of suicide prevention training across Scotland, and then implement it within organisations. This utilised a cascade style 'train-the trainers' intervention delivered as part of the Choose Life suicide prevention strategy in Scotland during 2008-11. Semi-structured interviews were carried out with 19 training facilitators, 30 of their group participants within organisations and 11 local managers within health boards in Scotland. RESULTS:Crucial to the process of a cascade training approach to implementing suicide prevention within an organisation was the multi-layered activity of constructing coherence of the intervention at every level in order to prevent dilution of the training. This necessitated collaborative work within and between groups of actors- managers, facilitators and participants. Where facilitators were effectively engaged in their role, confident in their ability to train, supported by supervision and possessed the leadership skills to engage both with participants and their local context to deliver training, there was evidence of both successful delivery and embedding within the organisation. However, there was little systematic evidence of institutional level appraisal- crucial to truly implementing a novel intervention within the system - despite efforts at local managerial engagement. CONCLUSIONS:Successful cascade or train-the-trainer implementation of an intervention requires extensive collaborative work to take place between and within groups of actors at all levels of an organization from those working at policy level to the 'coalface'. A priori application of Normalization Process Theory, to specify aims and goals for the necessary work to be carried out between different groups of actors, would assist in embedding a novel working practice at all levels. Future national training strategies for suicide prevention should address what is required to establish a flourishing culture of high-quality skills acquisition and development within healthcare organisations.

Project description:BackgroundSpecific factors that facilitate or prevent the implementation of enhanced recovery protocols for colorectal cancer surgery have been described in previous qualitative studies. This study aims to perform a concurrent qualitative and quantitative evaluation of factors associated with successful implementation of a care pathway (CP) for patients undergoing surgery for colorectal cancer.MethodsThis comparative mixed methods multiple case study was based on a sample of 10 hospitals in 4 European countries that implemented a specific CP and performed pre- and post-implementation measurements. In-depth post-implementation interviews were conducted with healthcare professionals who were directly involved. Primary outcomes included protocol adherence and improvement rate. Secondary outcomes included length of stay (LOS) and self-rated protocol adherence. The hospitals were ranked based on these quantitative findings, and those with the highest and lowest scores were included in this study. Qualitative data were summarized on a per-case basis using extended Normalization Process Theory (eNPT) as theoretical framework. The data were then combined and analyzed using joint display methodology.ResultsData from 381 patients and 30 healthcare professionals were included. Mean protocol adherence rate increased from 56 to 62% and mean LOS decreased by 2.1?days. Both measures varied greatly between hospitals. The two highest-ranking hospitals and the three lowest-ranking hospitals were included as cases. Factors which could explain the differences in pre- and post-implementation performance included the degree to which the CP was integrated into daily practice, the level of experience and support for CP methodology provided to the improvement team, the intrinsic motivation of the team, shared goals and the degree of management support, alignment of CP development and hospital strategy, and participation of relevant disciplines, most notably, physicians.ConclusionsOverall improvement was achieved but was highly variable among the 5 hospitals evaluated. Specific factors involved in the implementation process that may be contributing to these differences were conceptualized using eNPT. Multidisciplinary teams intending to implement a CP should invest in shared goals and teamwork and focus on integration of the CP into daily processes. Support from hospital management directed specifically at quality improvement including audit may likewise facilitate the implementation process.Trial registrationNCT02965794 . US National Library of Medicine, ClinicalTrials.gov . Registered 4 August 2014.

Project description:IntroductionThe Enhanced Recovery After Surgery programme (ERAS) is an approach to the perioperative care of patients encompassing multiple interventions and involving a wide range of different actors. It can thus be defined as a complex intervention. Despite the strength of the evidence-base in its support, the implementation of ERAS has been slow. This paper specifically explores the utility of Normalization Process Theory (NPT) as a methodological framework to aid exploration of ERAS implementation, with a focus on the core NPT construct coherence.Methods and materialsThe study employed qualitative methods guided by NPT. Semi-structured interviews were conducted with twenty-six healthcare professionals working in three specialities (thoracic, colorectal, head and neck) in a UK hospital. Data were analysed using an adapted Framework Approach.ResultsCoherence, or sense-making work, was key to successful implementation and demonstrated in the importance of participants believing in ERAS both as an individual and as a team. In order to invest in ERAS individuals needed to be able to differentiate its practices favourably with those enacted pre-implementation (differentiation). Participants also needed to understand their specific tasks and responsibilities (individual specification) and build a shared understanding (communal specification), resolving differences in planning meetings. Belief in the worth of ERAS was often aligned to evidence for its effectiveness or benefit to patients (internalization), so implementing ERAS therefore 'made sense'. Sense-making work had strong links with aspects of implementation related to other NPT constructs including resource issues such as funding for data collection and feedback (reflexive monitoring: systemization) and failure to replace key staff members (collective action: skill set workability).ConclusionsNPT was found to be a valuable heuristic device to employ in the exploration of ERAS implementation processes. NPT was useful in facilitating recognition of the importance of coherence work to successful implementation. However despite participants' strong beliefs in the worth of ERAS, it was in translating these beliefs into action that barriers were encountered, highlighting the interconnectedness of NPT constructs and the complicated nature of implementing complex interventions.

Project description:AimThe aim of the study was to describe practices that support collaboration in interprofessional primary health care teams, and identify performance indicators perceived to measure the impact of this collaboration from the perspective of interprofessional health providers.BackgroundDespite the surge of interprofessional primary health care models implemented across Canada, there is little evidence as to whether or not the intended outcomes of primary health care teams have been achieved. Part of the challenge is determining the most appropriate measures that can demonstrate the value of collaborative care. To date, little remains known about performance measurement from the providers contributing to the collaborative care process in interprofessional primary care teams. Having providers from a range of disciplinary backgrounds assist in the development of performance measures can help identify measures most relevant to demonstrate the value of collaborative care on the intended outcomes of interprofessional primary care models.MethodsA qualitative study; part of a larger mixed methods developmental evaluation to examine performance measurement in interprofessional primary health care teams. A stakeholder workshop was conducted at an annual association meeting of interprofessional primary health care teams in the province of Ontario, Canada. Six questions guided the workshop groups and participant responses were documented on worksheets and flip charts. All responses were collected and entered verbatim into a word document. Qualitative analytic strategies were applied to each question.FindingsA total of 283 primary health care providers from 14 health professions working in interprofessional primary health care teams participated. Top three elements of interprofessional collaboration (total n = 628) were communication (n = 146), co-treatment (n = 112) and patient-based conferences (n = 81). Top three performance indicators currently used to demonstrate the value of interprofessional collaboration (total n = 241) were patient experience (n = 71), patient health status (n = 35) and within team referrals (n = 30).

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Examining Interprofessional teams structures and processes in the implementation of a primary care intervention (Health TAPESTRY) for older adults using normalization process theory.

Publications

Examining Interprofessional teams structures and processes in the implementation of a primary care intervention (Health TAPESTRY) for older adults using normalization process theory.

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