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Normalisation process theory predicts that for any new way of working to become fully embedded into everyday practice needs continuous work in four areas (domains) of activity:11 Domain Description of work involved Sense making The new intervention must make sense to the people responsible for implementing it, including that they recognise it as a distinct and different way of working. Engagement People must choose to engage with the new way of working, including those who lead or pioneer the introduction, along with the majority choosing to join. Action People need the resources to implement the new way of working, whether that be skills, time, or other. Monitoring People must get feedback on the new approach; feedback which encourages them to keep going. Observation of PACT delivery Shadowing members of the PACT team at each location for half a day, including mini interviews with staff and patients. Interview data 6 individual GP interviews, and a focus group with 6 members of a local PACT team. Online survey using a study modified version of the NoMAD tool The qualitative data were used to support the development of a bespoke version of the NOMAD evaluation tool (a survey tool developed from normalisation process theory to assess the implementation of new initiatives in practice). The survey was sent to all staff in the five sites, with 90 responding (45% response rate) including 39 GPs, 11 PACT nurses, 12 other primary care nurses (including district and practice nurses), 2 care home practitioners, and 22 practice managers, team managers, or administrators. NPT themes Themes emerging from the data Why this matters Examples from dataset Sense making Valued and of value Core to professional values and patient values (driver that keeps things going in face of adversity). 52% see potential value of PACT to their professional role (NoMAD)
‘I think you know, we've come as a practice … to recognise the value I think, let's put it that way.’ (GP interview)Lacks clarity Lack of clarity in aim and purpose led to differing implementation across the location. 21% do not believe staff in their organisation share understanding of the purpose of PACT (NoMAD)
‘The problem is, because they’re working across different practices, everybody had different ideas of what they wanted them to do.’ (GP interview)Engagement Need champions To drive the initiative forward and to adapt working practices. 51% agree there are key people driving PACT (NoMAD).
88% agree that they are open to working with colleagues in a new way to make PACT work (NoMAD).
'I am desperate to try and improve the [usual] service … I cannot agree with the service continuing in its current form. I feel I am serving a bureaucratic service which only benefits some of the patients some of the time.' (PACT nurse)
‘I’m a big believer that it depends on the person doing the role from the PACT team, and what they are doing.’ (GP interview)Action Redesign required, not plug-in of evidence-based frailty tools. Necessary because of variability in need; variation in understanding; to overcome disruption and fragmentation; and to establish new, or add missing, infrastructure. ‘ ... people will acknowledge that the tools available haven't been that good.’ (PACT GP) Unanticipated resistance Recognising additional, unanticipated patient resistance that required work. Families also have to be included in that work. 33% of staff had confidence in patients’ ability to use PACT (NoMAD).
‘We’ve had the odd patient who doesn’t want it, who is a bit like, they don’t want it … "Oh no, I’ve always had the doctor, I want the doctor to come and do that." ' (PACT GP)Monitoring Service-focused outcomes Monitored outcomes differed from the reported motivators and drivers for doing the work (professional and patient-centred values). 33% agree that they have received feedback about PACT (NoMAD).
‘What we should be doing is saying, "Well we're just going to put all the money into this, get a good service up and running because we know it's the right thing to do" [but] … the outcome measure really is a reduction of inappropriate admissions, but you will never be able to measure that because of the context of A&E demands and all the rest of it.’ (PACT GP)Generating new knowledge Vital to making the implementation work. Mechanism to generate practice-based evidence. Help healthcare professionals recognise and trust quality that is beyond guideline. 90% agree that feedback about PACT could be used to make future improvements (NoMAD).
‘… it was all a bit on the back of an envelope to be honest. But essentially … we all had a list of maybe five or six people we knew who were frail. We combined that with the top 2% and then the people who were going into hospital frequently and we've got a list, essentially.’ (PACT GP)
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Implementing change in primary care practice: lessons from a mixed-methods evaluation of a frailty initiative
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