Table 2 Describing complex interventions and Normalisation Process Theory

Normalisation Process Theory (NPT) [26] predicts that successful implementation of a complex intervention needs continuous work in four areas which, for the purposes of discussion with our stakeholders, we described as: Sense making, Engagement, Action and Monitoring

SENSE MAKING: people must individually and collectively understand what the new way of working is; how it is different from what went before; and why it matters.

ENGAGEMENT: people must agree to start doing the new model of care, and continue working at it.

ACTION: people need to have the resources to work in the new way.

MONITORING: people need to get feedback that reinforces the new way of working.

The NPT toolkit [26] is designed to support the implementation of complex interventions by helping practitioners examine the nature and extent of the implementation work being undertaken in each of the four domains. Questions explored include [27]:

Sense making: How is a practice understood by participants, and compared with others? Engagement: How do participants come to take part in a practice, and stay motivated?

Actions: How do participants make it work? How are their activities organised and structured?

Monitoring: How do participants evaluate a practice? How does this change over time and what are its effects?