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Table 3 Use of NPT in implementing 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: an NPT evaluation of robotic urological surgery
Coherence Is the intervention easy to describe? The intervention is easily distinguishable from current surgical techniques by the technology involved, new skills required, new operating theatre equipment needed and higher costs of the service.
  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? It is expected to improve the performance and the clinical outcomes of minimally invasive techniques.
  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 the intervention is a good idea? Professionals offered the technology are likely to be enthusiastic and prepared to invest their time and training in it.
(i.e., commitment and engagement by participants) Will they see the point easily?  
   Surgeons not offered the technology might not see it as advantageous and might discourage their patients from accessing the technology, particularly as this would mean the patient transferring to another centre.
  Will they be prepared to invest time, energy and work in it?  
Collective action How will the intervention affect the work of user groups? Surgeons working in centres not offering robotic surgery may hesitate to offer this treatment option which requires onward referral of the patient and may adversely affect the surgeon-patient relationship.
  Will it promote or impede their work?  
(i.e., the work participants do to make the trial function) What effect will it have on consultations?  
  Will staff require extensive training before they can use it? Most surgeons do not have the necessary skills and knowledge to use the new technology. New training programmes with defined content and assessment procedures will be needed to ensure accountability and confidence.
  How compatible is it with existing work practices? Establishing a highly specialized surgical network, where patients are referred from 'nondoers' to 'doers' and where surgical teams move between hospitals, will contribute to the development of a surgical elite, which will attract patients, resources, research resources and prestige. The impact of this will need to be monitored.
  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? Centres which are offered and choose to adopt the new service are likely to view it as having a positive impact on their goals, as it is likely to increase patient numbers. However, they will have to invest resources to achieve the structural and organizational changes required and take responsibility for accommodating the expected increased flow of patients, for training programmes and for specific risk management programmes.
Reflexive Monitoring How are users likely to perceive the intervention once it has been in use for a while? Systematic review evidence details the expected clinical impact of the new technology. Clinical audit will be undertaken to determine whether the expected benefits are being achieved in routine clinical practice.
(i.e., participants reflect on or appraise the trial)   
  Is it likely to be perceived as advantageous for patients or staff? Impact on equity of healthcare for patients and impact on development of the surgical network and surgical centres should be monitored through administrative data.
  Will it be clear what effects the intervention has had?  
  Can users/staff contribute feedback about the intervention once it is in use? Individual centres will be encouraged to ensure users have 'ownership' of the systems around the new surgical technique (training, accreditation, patient flow) and can adapt these as appropriate.
  Can the intervention be adapted/improved on the basis of experience?  
  1. Robotic urological surgery: a highly technological and costly form of minimally invasive surgery that introduces new skills and new patterns of action in healthcare with important repercussions on surgical services, patients' access to services, on the professional network of surgeons and on hospitals' budgets [36]. NPT analysis was undertaken from the point of view of a commissioning agency, responsible for healthcare provision across the whole local health economy, as part of implementation planning.
  2. The context for this implementation was secondary care across the administrative region of Emilia-Romagna, Italy. Surgical urological interventions were already widely available across the region, but access to minimally invasive surgical techniques varied widely between centres. These differences are likely to be increased and accentuated by the introduction of robotic urological surgery.