Exploring the implementation of an electronic record into a maternity unit: a qualitative study using Normalisation Process Theory

Abstract

BackgroundTo explore the benefits, barriers and disadvantages of implementing an electronic record system (ERS). The extent that the system has become ‘normalised’ into routine practice was also explored.MethodsQualitative semi-structured interviews were conducted with 19 members of NHS staff who represented a variety of staff groups (doctors, midwives of different grades, health care assistants) and wards within a maternity unit at a NHS teaching hospital. Interviews were conducted during the first year of the phased implementation of ERS and were analysed thematically. The four mechanisms of Normalisation Process Theory (NPT) (coherence, cognitive participation, collective action and reflexive monitoring) were adapted for use within the study and provided a theoretical framework to interpret the study’s findings.ResultsCoherence (participants’ understanding of why the ERS has been implemented) was mixed – whilst those involved in ERS implementation anticipated advantages such as improved access to information; the majority were unclear why the ERS was introduced. Participants’ willingness to engage with and invest time into the ERS (cognitive participation) depended on the amount of training and support they received and their willingness to change from paper to electronic records. Collective action (the extent the ERS was used) may be influenced by whether participants perceived there to be benefits associated with the system. Whilst some individuals reported benefits such as improved legibility of records, others felt benefits were yet to emerge. The parallel use of paper and the lack of integration of electronic systems within and between the trust and other healthcare organisations hindered ERS use. When appraising the ERS (reflexive monitoring) participants perceived the system to negatively impact the patient-clinician relationship, time and patient safety.ConclusionsDespite expectations that the ERS would have a number of advantages, its implementation was perceived to have a range of disadvantages and only a limited number of ‘clinical benefits’. The study highlights the complexity of implementing electronic systems and the associated longevity before they can become ‘embedded’ into routine practice. Through the identification of barriers to the employment of electronic systems this process could be streamlined with the avoidance of any potential detriment to clinical services.Electronic supplementary materialThe online version of this article (doi:10.1186/s12911-016-0406-0) contains supplementary material, which is available to authorized users.

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“…The fourth construct, reflective appraisal, was not considered useful at this stage given that the intervention was not yet implemented. We used these three constructs to create the following broad working definitions so that normalization process theory could be usefully applied within our study: 23 These three constructs of normalization process theory were used to shape the questions within the discussion guides for focus groups (see Appendix 2 for care home staff and Appendix 3 for family members) and individual interviews (see Appendix 4) that were devised and agreed by members of the research team. For example, both guides included questions about usual practice when a resident was suspected to have an infection.…”

“…21,22 This is a sociological theory that aims to explain the social processes that can lead to the routine embedding, or normalization, of a new health organisational practice, focusing on the work that individuals and groups do to enable an intervention to become normalised. Normalization process theory has previously been used to explore the implementation of complex interventions, such as electronic records in maternity units, 23 medical…”

Medizinische Datenhaltung – Ansatz, Konzepte, strategische und operative Implikationen

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Staff expectations for the implementation of an electronic health record system: A qualitative study using Normalisation Process Theory

“…NPT proposes that implementing technology can be achieved through 'energising' four mechanisms: coherence (understanding of reasons for implementation and potential value of the technology), cognitive participation (preparedness to engage and commit to use the technology), collective action (ability to do the work to use the technology) and reflexive monitoring (how staff appraise the technology) (45,47,49). It is generally accepted that NPT provides a consistent framework that can be used to describe, assess and enhance implementation potential (49)(50)(51)(52)(53)(54)(55)(56)(57). The mechanisms have high stability across settings and, notwithstanding challenges in applying NPT in terms of managing overlaps between constructs, there is evidence that it is a beneficial heuristic device to explain and guide implementation processes (58).…”