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Normalisation Process Model Process evaluation in a multi-method study Scott Wilkes Hilton Hotel

Normalisation Process Model Process evaluation in a multi-method study Scott Wilkes Hilton Hotel Gateshead 9 th May 2007. scott.wilkes@sunderland.ac.uk. Evaluation of open access hysterosalpingography (HSG) for the initial management of infertility in primary care : O A T S trial.

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Normalisation Process Model Process evaluation in a multi-method study Scott Wilkes Hilton Hotel

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  1. Normalisation Process Model Process evaluation in a multi-method study Scott Wilkes Hilton Hotel Gateshead 9th May 2007 scott.wilkes@sunderland.ac.uk

  2. Evaluation of open access hysterosalpingography (HSG) for the initial management of infertility in primary care: OATS trial. • Dr. Scott Wilkes, GP/Clinical Research Fellow* • Prof. Greg Rubin, Professor of Primary Care * • Prof. Alison Murdoch, Professor of Reproductive Medicine ** • Dr Anne Crosland, Professor of Nursing* • Nicola Hall. Researcher * • Dr John Wilsdon, Radiologist *** • * Centre for Primary & Community Care, University of Sunderland. • ** International Centre for Life, Newcastle Upon Tyne • *** Royal Victoria Infirmary, Newcastle Upon Tyne

  3. Normalisation Process Model and the OATS Trial • Contextualise • My interpretation of the NPM • Mapping my work onto the model • Present the results from applying the model • Observations on the development of the model.

  4. Background • Causes of infertility • NICE guidelines

  5. Introduction • Focus Group study • Pilot survey • Pragmatic Cluster Randomised Controlled Trial • Patient and professional interviews

  6. Focus Group Study • The findings • Perceived responsibilities/who should carry out the initial management of the infertile couple? • Uncertainty and lack of knowledge • Consistency of approach • Access to infertility services Scott Wilkes, Nicola Hall, Ann Crosland, Alison Murdoch, Greg Rubin. General practitioners’ perceptions and attitudes to infertility management in primary care: focus group study. Journal of Evaluation in Clinical Practice. 2007. online ISSN 1356-1294.

  7. Pilot Survey • 6 couples had open access HSG (15%) • 12 couples had hospital initiated HSG • Half of the GP performed recommended investigations which rose to almost 100% with use of the open access HSG service • Time from presentation to management plan OA HSG 14.4 weeks (SD 3.6) Hospital 18.4 weeks (SD 8.0) Diff between means 4 weeks, 95CI -8.8 to 0.4, p=0.07 Scott Wilkes, Alison Murdoch, Greg Rubin, David Chinn, John Wilsdon. Investigation of infertility management in primary care with open access hysterosalpingography (HSG): a pilot study. Human Fertility, March 2006; 9(1): 47-51.

  8. CRCT • Uptake of open access HSG: 10% • Reached primary outcome measure sooner • Better quality of information recorded in the referral letter • More appropriate referral pattern

  9. Patient and professional interviews • Organisational factors within the practice • Performance monitoring • Practice expertise • Workload • Organisational factors outside the practice • Guidelines • Access • Commissioning • NHS capacity Professional factors personal to the GP • Uncertainty and lack of knowledge • Interest • Confidence, competence, education Professional factors specific to the role of a GP • Perceived responsibilities • Safety/Risk • Infrequent presentation • Professional values

  10. Normalisation Process Model Agents Objects Collectives • ENDOGENOUS FACTORS • Interactional workability: Normalisation is likely if it confers an advantage to the agents • Congruence: Normalisation is likely if the agents have a shared belief in the process • Disposal: Normalisation is likely if the agents have a shared belief in the goals • Relational Integration: Normalisation is likely if it fits the agents’ role • Accountability: Normalisation is likely if agents have the necessary expertise • Confidence: Normalisation is likely if agents believe it falls within their remit • EXOGENOUS FACTORS • Skill-set workability: Normalisation is likely if collectives agree agent skill-set requirements • Allocation: Normalisation is likely if collectives agree which agents are responsible • Performance: Normalisation is likely if collectives at what level agents perform • Contextual integration: Normalisation is likely if it confers an advantage to collectives • Execution: Normalisation is likely if collectives agree on resourcing issues • Realisation: Normalisation is likely if collectives’ organisational systems are minimally disrupted.

  11. Mapping my themes onto the model (professional interview study) • Professional factors maps onto endogenous factors • Personal factors maps onto interactional workability • In the role of a GP maps onto relational integration • Organisational factors maps onto exogenous factors • Within the practice maps onto skill-set workability • Outside the practice maps onto contextual integration

  12. NPM framework and open access HSG • Interactional workability (personal factors) • Congruence • Cooperation Do patients, fertility specialists and GPs believe that tubal assessment of the infertile couple with HSG is the right thing to do in general practice? • Conduct Do patients, fertility specialists and GPs believe it fits into the everyday practice of the GP? • Disposal • Goals Do patients and GPs share the same expectations of what Open access HSG can do? • Meaning Do patients and GPs share the same meanings and anticipated consequences of performing open access HSG?

  13. NPM framework and open access HSG • Relational integration (role of being a GP) • Accountability • Validity Do patients, fertility specialists and GPs see open access HSG as the right thing to do? • Expertise Do patients, fertility specialists and GPs believe that GPs have the necessary expertise to perform open access HSG? • Confidence • Credibility Do authoritative sources of knowledge acknowledge that this role for GPs? • Utility Does this really fit within the role of the GP?

  14. NPM framework and open access HSG • Skill-set workability (within the practice) • Allocation • Distribution Is there agreement on who should deliver the service, resource it and the rewards? • Definition Is there practice agreement on the level of skills required? • Performance • Boundaries Is there agreement on the level at which a GP can work when using open access HSG? • Autonomy Can it be adopted and owned by the GP rather than being seen as doing it on behalf of the specialist?

  15. NPM framework and open access HSG • Contextual integration (outside the practice) • Execution • Resourcing Can this be resourced without disruption to the PCT and NHS? • Power Can open access HSG happen without disruption to current allocation of responsibilities with regard to fertility management in the NHS? • Realisation • Risk Does open access HSG carry any additional risks for the patient, the practice, the PCT or the NHS? • Action Can open access HSG happen without disruption to current allocation of resources?

  16. How the NPM was populated

  17. Normalisation, adoption or rejection Adopted

  18. Model results: adoption Congruence: The agents (patients, GPs and fertility specialists) have differing beliefs in the process both within and between groups. Disposal: The agents have differing beliefs in the goals both within and between groups. Unsure if there is an advantageous outcome for the agents. Accountability: Agents believe GPs should perform open access HSG and have the necessary expertise to do it. Confidence: Most agents believe it falls within their remit although this is new and not supported by authoritative sources of knowledge. Allocation: Some agents believe it’s the GPs responsibility and others believe it’s the responsibility of the fertility specialist. Performance: Agents disagree at what level GPs should perform.. Execution: This would require a change in policy and resource allocation. Realisation: Organisational systems would have to change ? Minimally.

  19. Model development • Complex 4 tier model • Exogenous/endogenous n=2 • Constructs n=4 • Propositions n=8 • Sub-propositions n=16

  20. Model development • Mostly populated by the qualitative studies • Partly populated by published/policy documents • Sparsely populated by quantitative studies

  21. Model development • Is there a need to weight propositions or constructs when applying the model? • Normalisation is described by many sub-propositions but is limited by a few.

  22. Evaluation of open access hysterosalpingography (HSG) for the initial management of infertility in primary care: OATS trial. • Dr. Scott Wilkes, GP/Clinical Research Fellow* • Prof. Greg Rubin, Professor of Primary Care * • Prof. Alison Murdoch, Professor of Reproductive Medicine ** • Dr Anne Crosland, Professor of Nursing* • Nicola Hall. Researcher * • Dr John Wilsdon, Radiologist *** • * Centre for Primary & Community Care, University of Sunderland. • ** International Centre for Life, Newcastle Upon Tyne • *** Royal Victoria Infirmary, Newcastle Upon Tyne

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