Exploring implementation and sustainability of models of care: can theory help?

Abstract

ObjectiveResearch on new models of care in health service provision is complex, as is the introduction and embedding of such models, and positive research findings are only one factor in whether a new model of care will be implemented. In order to understand why this is the case, research design must not only take account of proposed changes in the clinical encounter, but the organisational context that must sustain and normalise any changed practices. We use two case studies where new models of maternity care were implemented and evaluated via randomised controlled trials (RCTs) to discuss how (or whether) the use of theory might inform implementation and sustainability strategies. The Normalisation Process Model is proposed as a suitable theoretical framework, and a comparison made using the two case studies – one where a theoretical framework was used, the other where it was not.Context and approachIn the maternity sector there is considerable debate about which model of care provides the best outcomes for women, while being sustainable in the organisational setting. We explore why a model of maternity care – team midwifery (where women have a small group of midwives providing their care) – that was implemented and tested in an RCT was not continued after the RCT’s conclusion, despite showing the same or better outcomes for women in the intervention group compared with women allocated to usual care. We then discuss the conceptualisation and rationale leading to the use of the ‘Normalisation Process Model' as an aid to exploring aspects of implementation of a caseload midwifery model (where women are allocated a primary midwife for their care) that has recently been evaluated by RCT.DiscussionWe demonstrate how the Normalisation Process Model was applied in planning of the evaluation phases of the RCT as a means of exploring the implementation of the caseload model of care. We argue that a theoretical understanding of issues related to implementation and sustainability can make a valuable contribution when researching complex interventions in complex settings such as hospitals.Conclusion and implicationsApplication of a theoretical model in the research of a complex intervention enables a greater understanding of the organisational context into which new models of care are introduced and identification of factors that promote or challenge implementation of these models of care.

What women want: qualitative analysis of consumer evaluations of maternity care in Queensland, Australia

“…Over the past two decades, studies and advisory reports [4,10-12] have used both quantitative and qualitative methods [13] to explore discrete components of maternity care (e.g. antenatal or postnatal care [14]).…”

Reducing dementia risk by targeting modifiable risk factors in mid-life: study protocol for the Innovative Midlife Intervention for Dementia Deterrence (In-MINDD) randomised controlled feasibility trial

“…Theory can provide a framework that is generalizable across settings and individuals; it provides the opportunity for the incremental generation of knowledge and provides a framework to guide analysis [43, 44]. It can also highlight and enhance our understanding of the barriers to implementation and alert us to the context into which new interventions and services are placed [39, 45–47]. …”

From theory to 'measurement' in complex interventions: Methodological lessons from the development of an e-health normalisation instrument

“…In attempting to address such problems of implementation, the application of theory to designing health care interventions [7], planning and evaluating them [8][9,10], and developing effective strategies for their implementation [11] offers much potential.…”

“…This evidence spans diverse settings in which new technologies and practices have been the focus of its application, such as telecare [23], e-health [24,25], clinical decision support systems [26], teledermatology [27], infertility management [28], maternity services [10]and the management and treatment of depression [29,30]. …”

“…Considerable work has been undertaken to critique NPT in terms of its potential for describing key processes that underpin the success or otherwise of implementation, and to ensure that NPT’s core constructs can be operationalised in a stable and consistent way by multiple user constituencies, including testing out NPT in qualitative studies of a variety of practices and in a diverse range of contexts [10,23-30]. Recent work has also extended the practical utility of NPT for a wide range of academic and non-academic users.…”