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Table 1 Use of NPT in developing complex interventions

From: Normalisation process theory: a framework for developing, evaluating and implementing complex interventions

NPT Components Questions to consider within the NPT framework Example: NPT evaluation of the ImPACT back pain study
Coherence Is the intervention easy to describe? Participating GPs did not differentiate the new intervention from current practice and were unable to perceive the projected benefits to patients, primary care teams and physiotherapists.
  Is it clearly distinct from other interventions?  
(i.e., meaning and sense making by participants) Does it have a clear purpose for all relevant participants?  
  Do participants have a shared sense of its purpose?  
  What benefits will the intervention bring and to whom?  
  Are these benefits likely to be valued by potential participants?  
  Will it fit with the overall goals and activity of the organisation?  
Cognitive participation Are target user groups likely to think it is a good idea? Participating GPs saw it as research (i.e., recruiting patients to the study), and peripheral to their main task of delivering patient care. Projected benefits were not obvious to the GPs so they were insufficiently motivated to invest thought and energy into changing their practice.
(i.e., commitment and engagement by participants) Will they see the point of the intervention easily?  
  Will they be prepared to invest time, energy and work in it?  
Collective action How will the intervention affect the work of user groups? Participating GPs were expected to use a computer-based decision-support tool during consultations. Many GPs did not access the computer until after the consultation was completed. GPs were unconvinced that such a brief tool could form an appropriate basis for decisions about referral.
  Will it promote or impede their work?  
(i.e., the work participants do to make the intervention function) What effect will it have on consultations?  
  Will staff require extensive training before they can use it? GPs were not fully aware of the additional training received by participating physiotherapists, and did not therefore realise that the physios were well equipped to deal with emotional or psychological components of back pain.
  How compatible is it with existing work practices? GPs already felt under pressure of time in consultations, and felt that using the decision-support tool was an unjustified additional use of time.
  What impact will it have on division of labour, resources, power, and responsibility between different professional groups?  
  Will it fit with the overall goals and activity of the organisation?  
Reflexive Monitoring How are users likely to perceive the intervention once it has been in use for a while? Despite regular feedback from the research team GPs did not perceive benefits to the new system as they did not use it enough.
(i.e., participants reflect on or appraise the intervention) Is it likely to be perceived as advantageous for patients or staff?  
  Will it be clear what effects the intervention has had?  
  Can users/staff contribute feedback about the intervention once it is in use?  
  Can the intervention be adapted or improved on the basis of experience?  
  1. The UK ImPACT back study aims to promote evidence-based care of patients with back pain in primary care[23]. Physiotherapists were trained to provide psychological support to patients with low back pain, and GPs were asked to use paper-based or computer-based decision-support tools to assess patients with back pain and refer those at risk of developing chronic low back pain to these specialised physiotherapists. As a result of the analysis presented here, the intervention could be modified to provide greater coherence to the GPs, and hence greater cognitive participation as well as modifications which enabled better fit with existing GP consultation practices.
  2. The context for this intervention was UK primary care. GPs were a potential rate-limiting factor as they had to use the intervention to refer patients to the specialised physiotherapists. GPs main concerns were providing high quality care under extreme pressure of time while responding to multiple other changes in primary care. Many UK GPs reported feeling under pressure and suffering from "change fatigue", leading to a concentration on "core business" rather than "optional extras" such as research or teaching.