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Normalisation in a nutshell

Fri. 05. Oct 2018 09:00

ImpleMentAll’s aim is to make the normalisation process easier and more effective for healthcare innovations in the future. Thus, normalisation is a key part of our work with this project, and therefore crucial to understand in order to understand ImpleMentAll.

Normalisation is easier said than done. The following definitions might seem quite straight forward, but the elaboration makes it clear that there is a lot more to the term and the process than the definition leads one to think. With this blog post, we will try to break down the normalisation process and make it easier to understand in order to provide insight into the core of ImpleMentAll.

Normalisation refers to the things people do to embed and integrate an innovation in routine practice. Thus, normalisation is the process of creating new routines based on an innovation. In ImpleMentAll, we realise that most health innovations, regardless of how good or beneficial they might be, rarely find their way to routine practice simply because the normalisation process is too complex. Therefore, we work with the Normalisation Process Theory (NPT).

NPT explains the work of implementation, embedding, and integration with a focus on the contribution of individuals and groups. It is an action theory, meaning that it explains actions rather than attitudes. NPT features four constructs explaining the work that people might do when implementing an innovation; coherence, cognitive participation, collective action, and reflexive monitoring.

Coherence is the sense-making work done in order to operationalise the innovation. People must distinguish how the innovation differs from the current routine practice. Furthermore, they must work together to agree on the aims, objectives, and expected benefits of the innovation, while working individually to detect the tasks and responsibilities they themselves have in relation to the innovation. Finally, they must understand the benefits and values of the innovation.

Cognitive participation is the relational work done to build and sustain new practices related to the innovation. First, the new set of practices must be initiated in order to be driven forward, then the participants may need to organise or reorganise themselves to collectively contribute to the work involved in new practices. It must be ensured that other participants believe that it is important to be involved in the integration, and lastly, the actions and procedures to sustain the innovation must be collectively defined.

Collective action is the operational work done in order to adopt the innovation. The participants should work with artefacts and symbols related to the innovation. Moreover, they must do knowledge work in order to build accountability and maintain confidence in the innovation. The work done in relation to the innovation must be divided between the participants, making it clear who does what. Finally, the resources must be allocated.

Reflexive monitoring is the appraisal work done in order for the participants to assess and understand how the innovation affects them and others. The participants must determine how effective or useful the innovation is, as well as what it is worth in order to detect whether redefinitions and modifications of practices are needed.

Thus, in order to successfully turn an innovation into routine practice it is important for the participants to fully understand the innovation at various levels, as well as prepare themselves for the innovation and actively ensure to drive forward the new set of practices. Moreover, the participants must collectively define and carry out work with the innovation, and lastly, evaluate and perhaps adjust the innovation.

The ImpleMentAll trial is using a 23-item self-report questionnaire that taps into the four core constructs of the NPT to measure organisational readiness for implementing change. The Normalisation MeAsure Development questionnaire (NoMAD) is an instrument designed for measuring implementation processes and predicting their outcomes. NoMAD comprises three sections; Part A assesses respondent background information, Part B assesses global normalisation (3 items), and Part C assesses the four central implementation processes of NPT discussed in the above (20 items).

As has been made clear, normalisation is an extremely complex process, and changing it, or optimising it, is a very difficult task to take on. Nonetheless, that’s exactly what we have done in ImpleMentAll. If you would like to dig deeper into normalisation and learn more about it, please comment any question you may have below and we will have our experts answer it, or follow the links to read more about NoMAD and NPT.