Cited by 1,409Health Policy Implementation ScienceQualitative Research Methods and ApplicationsInformation Systems Theories and Implementation

The DOI matches its Crossref record; 61 of the 62 references it cites were found in a registry or an index; none of the 73 sources its claims cite is checked for support yet.

Development of a theory of implementation and integration: Normalization Process Theory

Open access

Abstract

BACKGROUND: Theories are important tools in the social and natural sciences. The methods by which they are derived are rarely described and discussed. Normalization Process Theory explains how new technologies, ways of acting, and ways of working become routinely embedded in everyday practice, and has applications in the study of implementation processes. This paper describes the process by which it was built. METHODS: Between 1998 and 2008, we developed a theory. We derived a set of empirical generalizations from analysis of data collected in qualitative studies of healthcare work and organization. We developed an applied theoretical model through analysis of empirical generalizations. Finally, we built a formal theory through a process of extension and implication analysis of the applied theoretical model. RESULTS: Each phase of theory development showed that the constructs of the theory did not conflict with each other, had explanatory power, and possessed sufficient robustness for formal testing. As the theory developed, its scope expanded from a set of observed regularities in data with procedural explanations, to an applied theoretical model, to a formal middle-range theory. CONCLUSION: Normalization Process Theory has been developed through procedures that were properly sceptical and critical, and which were opened to review at each stage of development. The theory has been shown to merit formal testing.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

This paper describes how Normalization Process Theory (NPT) was developed through three phases: empirical generalizations from qualitative healthcare studies, an applied Normalization Process Model (NPM), and a formal middle-range theory. NPT explains implementation, embedding, and integration through four generative mechanisms—coherence, cognitive participation, collective action, and reflexive monitoring—and is presented as meriting formal testing.

Key findings

  • NPT was built in three phases: empirical generalizations from secondary analyses of qualitative healthcare data (2001–2004), an applied NPM (2003–2007), and a formal middle-range theory (2006–2009).
  • The NPM’s four constructs—interactional workability, relational integration, skill-set workability, and contextual integration—became the collective action component of NPT; NPT adds coherence, cognitive participation, and reflexive monitoring as generative mechanisms.
  • Road testing included applying the NPM in three large qualitative studies and coding two datasets with both NPM and NPT; the authors report that the constructs did not conflict, had explanatory power, and were stable enough for formal testing.
  • NPT is presented as a middle-range sociological theory of implementation, embedding, and integration; formal testing was not conducted in this paper, and results are said to be forthcoming.

Methods

  • Design: a theory-building account using secondary analysis of qualitative data, grounded theory-building techniques, extension and implication analysis, analytical theorizing, and “road testing.”
  • Data/sample: qualitative studies of healthcare work and organization across four domains—telemedicine normalization, professional–patient interaction and chronic illness care, and the social production and operationalization of evidence in the clinical encounter—plus later applications in e-health, telecare, a randomized controlled trial, and shared decision-making.
  • Analysis: derived empirical generalizations, built the NPM, reformulated its constructs as generic mechanisms, mapped macro–micro links, and assessed construct stability and analytic advantage by applying NPM and NPT to data and research syntheses.

Limitations

  • The paper states that it did not formally test or falsify the NPM or NPT; “road testing” only assessed whether the theory was fit to be tested, and formal test results are forthcoming.
  • The authors state that procedural accounts of theory-building risk imposing an artificial order on processes that are highly contingent, opportunistic, and organic.
  • Evident from the text: no empirical outcomes, effect sizes, or formal validation results are reported; the claims rest on conceptual coherence, face validity, and practical application rather than definitive testing.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/1748-5908-4-29

Cites

61 of 61 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Verification

Claims the paper makes

42 Not checked yet · 21 Own interpretation · 21 No basis given · 7 Own method · 2 Own result

Verify all 73 references — free account

Show all 45 claims

  • Probably not a substantial claim. 38
  • It may state two separate claims as one. 20
48 of 48
  • The paper relies on this without support.

    It is important to show that a theory has been derived through rigorous methods, applied sceptically, and critically assessed.

    “It is important to show that the theory has been derived through processes that have involved the application of rigorous methods, that these methods have been applied in a properly sceptical way, and that the outcomes of their application have been critically assessed.”
  • The paper relies on this without support.

    The limited scope, conceptual range, and claims of middle-range theories make them practically workable in analysing practice.

    “The limited scope, conceptual range, and claims of middle-range theories are important because they are what make them practically workable in analysing practice.”
2 of 2

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Citations

Cites

Show all 62 references

Research works printed but not linked: 8

  1. Ashford AJ: Behavioural change in professional practice: supporting the development of effective implementation strategies. 2002, Newcastle upon Tyne: Centre for Health Services Research
  2. May C, Finch T: Implementation, embedding, and integration: an outline of Normalization Process Theory. Sociology. 2009,
  3. Glaser BG, Strauss A: The discovery of grounded theory. 1967, Chicago: Aldine
  4. Goldthorpe JH: On Sociology: Critique and Program. 2006, Stanford: Stanford University Press
  5. Hechter M, Horne C: Theory is explanation. Theories of social order. Edited by: Hechter M, Horne C. 2003, Stanford CA: Stanford University Press
  6. May C: Mundane Medicine, Therapeutic Relationships, and the Clinical Encounter.'. Handbook of the Sociology of Health, Illness, and Healing: A Blueprint for the 21st Century. Edited by: Pescosolido B, Martin JA, Rogers A. New York: Springer
  7. Mair F, May C, Murray E, Finch T, Anderson G, O'Donnell C, Wallace P, Sullivan F: Understanding the Implementation and Integration of E-Health Services. 2009, London: National Co-ordinating Centre for the National Institute for Health Research Service Delivery and Organisation Programme (NCCSDO)
  8. Wilkes S: Evaluation of open access hysterosalpingography in the initial management of infertility in primary care. 2007, Unpublished PhD Thesis, University of Sunderland

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Metadata

Authors
May, C. R., Mair, F., Finch, T., MacFarlane, A., Dowrick, C., Treweek, S., Rapley, T., Ballini, L., Ong, B. N., Rogers, A., Murray, E., Elwyn, G., Légaré, F., Gunn, J., & Montori, V. M.
Affiliations
  • Newcastle University (GB)
  • University of Glasgow (GB)
  • Ollscoil na Gaillimhe – University of Galway (IE)
  • University of Liverpool (GB)
  • University of Dundee (GB)
  • Agenzia Sanitaria e Sociale Regionale (IT)
  • Keele University (GB)
  • University of Manchester (GB)
  • University College London (GB)
  • Cardiff University (GB)
  • Université Laval (CA)
  • The University of Melbourne (AU)
Corresponding author
May, Carl R
Venue
Implementation Science
Published
2009-05-21
Volume
4
Issue
1
Pages
29-29
ISSN
1748-5908 (ISSN-L)
OpenAlex
W2124199620
Cited by
1,409
References
62
Citations by year
2026: 113 · 2025: 133 · 2024: 156 · 2023: 112 · 2022: 124 · 2021: 143 · 2020: 164 · 2019: 63 · 2018: 79 · 2017: 68 · 2016: 63 · 2015: 52 · 2014: 52 · 2013: 23 · 2012: 25
FWCI
37.64
Type
journal article
Language
en
Open access
Locations
  • Implementation Science (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Discovery Research Portal (University of Dundee) (publishedVersion, cc-by)
  • ORCA Online Research @Cardiff (Cardiff University) (acceptedVersion)
  • Northumbria Research Link (Northumbria University) (acceptedVersion, other-oa)
  • Arrow@dit (Dublin Institute of Technology) (acceptedVersion)
  • BIBSYS Brage (BIBSYS (Norway)) (acceptedVersion, cc-by)
  • LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
  • Arrow@dit (Dublin Institute of Technology) (submittedVersion)
  • ARAN (University of Galway Research Repository) (Ollscoil na Gaillimhe – University of Galway) (submittedVersion, cc-by-nc-nd)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
  • ePrints Soton (University of Southampton) (submittedVersion)
  • UCL Discovery (University College London) (submittedVersion)
  • Minerva Access (University of Melbourne) (submittedVersion, cc-by)
  • NORA - Norwegian Open Research Archives (submittedVersion, cc-by)
  • Radboud Repository (Radboud University) (submittedVersion)
  • University of Limerick Institutional Repository (University of Limerick) (submittedVersion, cc-by-nc-sa)
  • Radboud Repository (Radboud University) (submittedVersion, other-oa)
  • Newcastle University ePrints (Newcastle Univesity)
Funders
National Institute for Health and Care Research (RP-PG-0407-10386)
Topics
  • Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
  • Social Sciences › Education › Qualitative Research Methods and Applications
  • Social Sciences › Business, Management and Accounting › Management Information Systems › Information Systems Theories and Implementation
Keywords
Normalization Process Theory, theory development, implementation theory, middle-range theory, empirical generalization, theory testing

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