Improving the normalization of complex interventions: part 2 - validation of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT)

Abstract

IntroductionSuccessful implementation and embedding of new health care practices relies on co-ordinated, collective behaviour of individuals working within the constraints of health care settings. Normalization Process Theory (NPT) provides a theory of implementation that emphasises collective action in explaining, and shaping, the embedding of new practices. To extend the practical utility of NPT for improving implementation success, an instrument (NoMAD) was developed and validated.MethodsDescriptive analysis and psychometric testing of an instrument developed by the authors, through an iterative process that included item generation, consensus methods, item appraisal, and cognitive testing. A 46 item questionnaire was tested in 6 sites implementing health related interventions, using paper and online completion. Participants were staff directly involved in working with the interventions. Descriptive analysis and consensus methods were used to remove redundancy, reducing the final tool to 23 items. Data were subject to confirmatory factor analysis which sought to confirm the theoretical structure within the sample.ResultsWe obtained 831 completed questionnaires, an average response rate of 39% (range: 22–77%). Full completion of items was 50% (n = 413). The confirmatory factor analysis showed the model achieved acceptable fit (CFI = 0.95, TLI = 0.93, RMSEA = 0.08, SRMR = 0.03). Construct validity of the four theoretical constructs of NPT was supported, and internal consistency (Cronbach’s alpha) were as follows: Coherence (4 items, α = 0.71); Collective Action (7 items, α = 0.78); Cognitive Participation (4 items, α = 0.81); Reflexive Monitoring (5 items, α = 0.65). The normalisation scale overall, was highly reliable (20 items, α = 0.89).ConclusionsThe NoMAD instrument has good face validity, construct validity and internal consistency, for assessing staff perceptions of factors relevant to embedding interventions that change their work practices. Uses in evaluating and guiding implementation are proposed.Electronic supplementary materialThe online version of this article (10.1186/s12874-018-0591-x) contains supplementary material, which is available to authorized users.

Implementation of the Identification and Referral to Improve Safety programme for patients with experience of domestic violence and abuse: A theory‐based mixed‐method process evaluation

“…The questionnaire included a socio‐demographic section, a standardised validated instrument (NoMAD) and space for free‐text comments. The NPT‐based instrument NoMAD (Finch et al, ; Rapley et al, ) measured individual's opinions on the levels of IRIS embeddedness in daily work. The NoMAD instrument consists of two sections: (a) three general questions about normalisation of the practice (a 10‐point scale from 0 ‘Not at all’ to 10 ‘Completely’) and (b) 23 items reflecting the four NPT constructs (Finch et al, ) (a 5‐point scale from 1 ‘Strongly disagree’ to 5 ‘Strongly agree’ with 0 for ‘Not relevant to me’).…”

“…Survey responses were downloaded from the Online Surveys platform (Jisc, ), cleaned and imported into Stata 15. Counts and frequencies were used to describe the sample and summarise NoMAD responses (Finch et al, ; Rapley et al, ). The customised 23‐item NoMAD instrument demonstrated a very good reliability of the whole scale (Cronbach α = 0.94) and the four NPT constructs (coherence α = 0.86, cognitive participation α = 0.86, collective action α = 0.80, reflexive monitoring α = 0.83) (DeVellis, ; Tavakol & Dennick, ).…”

Developing oral health risk assessment as routine practice during early stages of clinical careers: A cross‐sectional study of dental students using the NoMAD questionnaire

“…Respondents completed the NoMAD questionnaire. 27,32 NoMAD provides a tool based on NPT, for the assessment of the work of implementation from the perspective of those involved in working with the practice innovation. For analyses reported in this paper, the questionnaire comprised 4-7 items for each of the four generative processes associated with normalisation: coherence, cognitive participation, collective action and reflexive monitoring (20 items in total).…”

Protocol for the Process Evaluation of a Complex Intervention Delivered in Schools to Prevent Adolescent Depression: The Future Proofing Study

“…Items are rated on a 5point Likert scale from 1 (strongly agree) to 5 (strongly disagree). Initial validation demonstrated that the NoMAD has good face validity, construct validity, and internal consistency (39).…”