Using the Normalization Process Theory to qualitatively explore sense-making in implementation of the Enhanced Recovery After Surgery programme: "It's not rocket science"

Abstract

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.

Making change last? Exploring the value of sustainability approaches in healthcare: a scoping review

“…Stolldorf et al [ 99 ] Level of Institutionalisation Scale To determine the level of sustainability of rapid response teams (RRTs) among a group of hospitals that participated in a state-wide collaborative to implement and sustain RRTs United States Secondary Care 57. Sutton et al [ 100 ] Normalisation Process Theory To explore the utility of NPT as a methodological framework to aid exploration of Enhanced Recovery After Surgery (ERAS) programme implementation United Kingdom Tertiary Care 58. Thomas, L.H.…”

“…The most common benefit reported from the use of sustainability approaches was the improved understanding of sustainability and sustainability constructs. Twenty-five articles stated they were able to improve conceptualisation of sustainability of interventions [ 47 , 48 , 50 , 53 , 54 , 58 , 61 , 71 – 73 , 75 , 78 – 80 , 86 , 88 , 92 , 95 , 96 , 100 , 101 , 103 , 104 , 110 ]. For example, Deconinck et al applied Atun’s Conceptual Framework for Analysing Integration of Targeted Health Interventions, and found that the approach provided a systems lens that increased understanding of pathways for integration to help sustain coverage of effective interventions [ 58 , 120 ].…”

Evaluating the CYP-IAPT transformation of child and adolescent mental health services in Cambridgeshire, UK: a qualitative implementation study

“…Our findings showed there was lack of clarity among local stakeholders regarding the scope of the programme, which is a crucial element for achieving successful implementation [46]. There was consensus that the programme was predominantly about embedding outcome measures and EBP into practice.…”

Investigating the nutritional status and care of older (≥65 years) general surgical patients: a multiphase, action research study

“…As previously identified, implementation science in the perioperative care setting is in its infancy Gramlich et al, 2017;Herbert et al, 2017;Lyon et al, 2014;. Barriers relevant to the intervention itself also exist, such as failure to adapt the guideline to the local context, degree of fit to an often diverse patient group and adoption of a segmental approach or 'over tailoring' of the intervention (Gramlich et al, 2017;Herbert et al, 2017;Lyon et al, 2014;Sutton et al, 2018), as well as a reported tension between standardised versus individualised care (Lyon et al, 2014). Cohesive, visible leadership and adequate ongoing multidisciplinary staff education are identified as enablers at the micro-level.…”

“…At the meso-level (i.e. local and organisational context), lack of formal leadership support, unsupportive culture, limited stakeholder buy-in, complex systems and processes, and failure to establish ongoing audit and feedback processes were identified as barriers to implementation (Gotlib Conn et al, 2015;Gramlich et al, 2017;Herbert et al, 2017;Pearsall et al, 2015;Sutton et al, 2018), whereas embedding the change into existing systems and processes was an enabler (Herbert et al, 2017).…”