Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review

May, Carl, Cummings, Amanda, Girling, Melissa, Bracher, Mike, Mair, Frances, May, Christine, Murray, Elizabeth, Myall, Michelle, Rapley, Tim and Finch, Tracy (2018) Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review. Implementation Science, 13 (1). p. 80. ISSN 1748-5908

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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.

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 ( 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.

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.

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.

Item Type: Article
Additional Information: Funding information: CRM, MB, AC and MM were supported by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Wessex, which is a partnership between Wessex NHS organisations and partners and the University of Southampton. TLF, MG, FSM, EM, and TR were supported by the Economic and Social Research Council, Grant ES-062-23-3274. EM is also supported by the NIHR School of Primary Care Research. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health or the Economic and Social Research Council. Funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. CMM’s contribution was supported in part by Macmillan Cancer Support through core funding of the Macmillan Survivorship Research Group at the University of Southampton.
Uncontrolled Keywords: Normalization Process Theory, Complex interventions, Implementation research, Process evaluation, Systematic review
Subjects: B900 Others in Subjects allied to Medicine
L500 Social Work
Department: Faculties > Health and Life Sciences > Nursing, Midwifery and Health
Faculties > Health and Life Sciences > Social Work, Education and Community Wellbeing
Depositing User: Becky Skoyles
Date Deposited: 29 Nov 2018 15:15
Last Modified: 31 Jul 2021 15:49

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