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Improving the normalization of complex interventions: measure development based on normalization process theory (NoMAD): study protocol

Tracy L Finch1*, Tim Rapley1, Melissa Girling1, Frances S Mair2, Elizabeth Murray3, Shaun Treweek4, Elaine McColl1, Ian Nicholas Steen1 and Carl R May5

Author Affiliations

1 Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle-upon-Tyne NE2 4AX, UK

2 Institute of Health and WellBeing, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK

3 Research Department of Primary Care and Population Health, University College London, Upper Floor 3, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK

4 Health Services Research Unit, University of Aberdeen, 3rd Floor, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK

5 Faculty of Health Sciences, Building 67, University of Southampton, Highfield, Southampton, SO17 1BJ, UK

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Implementation Science 2013, 8:43  doi:10.1186/1748-5908-8-43

Published: 11 April 2013



Understanding implementation processes is key to ensuring that complex interventions in healthcare are taken up in practice and thus maximize intended benefits for service provision and (ultimately) care to patients. Normalization Process Theory (NPT) provides a framework for understanding how a new intervention becomes part of normal practice. This study aims to develop and validate simple generic tools derived from NPT, to be used to improve the implementation of complex healthcare interventions.


The objectives of this study are to: develop a set of NPT-based measures and formatively evaluate their use for identifying implementation problems and monitoring progress; conduct preliminary evaluation of these measures across a range of interventions and contexts, and identify factors that affect this process; explore the utility of these measures for predicting outcomes; and develop an online users’ manual for the measures.


A combination of qualitative (workshops, item development, user feedback, cognitive interviews) and quantitative (survey) methods will be used to develop NPT measures, and test the utility of the measures in six healthcare intervention settings.


The measures developed in the study will be available for use by those involved in planning, implementing, and evaluating complex interventions in healthcare and have the potential to enhance the chances of their implementation, leading to sustained changes in working practices.

Normalization process theory; NPT; Implementation process; Survey; Instrument development; Complex interventions