Qualitative research is becoming a key tool in identifying, describing and understanding implementation processes.  It is now very common to use qualitative research in process evaluations for trials of complex interventions. Given its focus on detailed empirical accounts of individual, collective and organisational processes, practices and ways of reasoning, qualitative research can enable rich insights into the day-to-day work of how new technologies and ways of working become implemented, embedded and integrated in health care contexts.  The key constructs and components of Normalization Process Theory initially emerged from a large cohort of studies that drew on a range of qualitative methods and methodologies, over an array of health and social care contexts.

What role can NPT play in a qualitative research project? Centrally, NPT is a middle-range theory.  There are four main ways in which NPT could be used to inform implementation research that uses qualitative research:

1. It can help inform, guide or structure your initial research focus and questions.  You could think of it in a similar way to Bury's (1) empirical concept of biographical disruption in chronic illness, or Davison, Smith & Frankel's (2) empirical concept of candidacy, in that NPT might inspire or initiate a set of issues and problems that you want to research further.
2. It can help inform, guide or structure your initial research design, sampling and data collection.  You could think of it in a similar way to one of Glaser and Strauss' (3) middle-range theories like 'Awareness Contexts', in that NPT may inform the range of situations or people you may want collect data from.
3. It can help inform, guide or structure the way you code and analyse your data.  You could think of it in a similar way to one of Glaser's (4, 5, 6) coding families, or Strauss and Corbin's (7) single coding approach, in that all the data can be coded against NPTs core constructs and the specific components
4. It can help inform, guide or structure your emerging interpretations, conclusions and recommendations. You could think of it in a similar way to how ideas, insights or concepts from any theory - be it some aspect of Foucauldian scholarship, or Goffman's canon or writings about Actor-Network Theory -  are used to help make sense of and situate your analytic findings.  In this way, NPT may act as a source for inspiration to enable you to further conceptualise your empirical work.

Each of these potential uses of NPT in relation to qualitative research is discussed in its own section.  Click on the links above to navigate to the issue you are interested in.

As you consider the various uses of the NPT in qualitative research about implementation processes, it is also important to note that NPT can be used at different points in the life cycle of a qualitative research project. You can use it:

• throughout the life of an ongoing research project - to inspire initial research questions, inform data collection, coding and analysis and then further to inform your interpretation and conclusions.
• at only one of the stages in the lifecycle of an ongoing qualitative research project, say, to inform the project design.  So, for example, given NPTs focus on the practical hands-on work involved in implementing a specific technology or way of working, you may be inspired to engage in some form of observation, to focus on what people practically do.
• use it to re-analyse qualitative data from a completed research project that you've already collected and/or to re-think your interpretation of prior results.

AN EXAMPLE OF THE USING NPT IN A RESEARCH PROJECT

Q: At what point in the lifecycle of your research did you use it?

A: We used it at the study design stage to inform thinking about what participant groups should be involved (e.g. practice administrative staff were involved prompted by NPT thinking), we used it to formulate questions for our interviews (e.g. we were not likely to have asked questions about practices local policies if we had not been thinking about/following NPT), we used it to provide 'higher order' category analysis of data generated from an initial thematic analysis.

Q: Did you initially use NPM/NPT very prescriptively? How did you loosen-up your usage?

A: I would say we used it lightly in the early stages of the work and in a more significant way as the study progressed. I don't feel we followed it prescriptively - it shaped our thinking along the way.

Q: How scary, odd, hard, weird, was it to first try and use it?

A: The scariest part was being confident that we understood the intended meaning of the NPT constructs and our concern that we would operationalise them in an appropriate and meaningful way

Whatever use you may make of NPT and whenever you draw on it in your research it is very important to remember that NPT is not a protocol about how to do research, it is not a recipe.  It is not prescriptive or rigid and should be used in a flexible and dynamic way.

We also need to consider what NPT is not, in relation to the qualitative research paradigm.

• it is not a grand theoretical perspective, like positivism, post-positivism, interpretivism, social constructionism etcetera, or an epistemology or ontology. It does not seek to offer a trans-contextual approach to how we act in the world, or how we come to know the world, or how the world is.
• it is not a 'methodology'. It does not offer you a theory of method, or logic of practice (which is what methodology means), in the sense of a set of defined procedures, loosely structured norms, ideal and ways of working through and analysing the data you collected.  Typical examples of methodologies that are often cited in the health and social care literature are things like case study, ethnography, framework analysis, grounded theory, interpretative phenomenological analysis, phenomenology, thematic analysis.
• it is not a 'method'.  Open-ended interviews, non-participant observation, focus groups, audio-recording interactions etcetera are all examples of method, as in, they are specific practices, ways of collecting data in the field.

NPT is a middle-range theory and it can be used with and alongside the epistemological and theoretical perspectives, methodologies and methods that qualitative researchers currently draw on in health and social care research.

The key point is that NPT is, above all, a theoretical device that enables you to think creatively about your qualitative research about implementation processes, that it can both direct and sensitise the practical and analytic trajectory of your research project.

Things to consider

• Good qualitative research is very time-consuming and involves a high degree of skills and expertise.  If you are new to qualitative research, before embarking on any qualitative research, speak to as many people as possible about how they undertake qualitative research. Read a broad range of 'how-to' books and articles on how to undertake a specific  method alongside a range of empirical articles that show you how others have used as specific method.  Also try and undertake qualitative research as part of a team.
• NPT can be used at any stage of the qualitative research lifecycle.  Use it flexibly that is, try and adapt to your research needs.  It is not theory-of-everything, a panacea to all your research issues or questions.

References

1. Bury, M. (1982) Chronic illness as biographical disruption. Sociology of Health and Illness, 4, 167-182.  Back to text
2. Davison, C., Smith, G.D., Frankel, S. (1991) Lay epidemiology and the prevention paradox. Sociology of Health and Illness, 13, 1-19 Back to text
3. Glaser, B.G. & Strauss, A.L. (1965) Awareness of dying. Chicago: Aldine.  Back to text
4. Glaser BG. (1978) Theoretical Sensitivity: Advances in the methodology of Grounded Theory. Sociology Press. Back to text
5. Glaser, B.G. (1998) Doing Grounded Theory - Issues and Discussions. Mill Valley, CA: Sociology Press.  Back to text
6. Glaser, B.G. (2005) The Grounded Theory Perspective III: Theoretical coding. Mill Valley, CA: Sociology Press.  Back to text
7. Strauss, A. & Corbin, J.M. (1990) Basics of qualitative research: Grounded theory procedures and techniques. Thousand Oaks, CA: Sage.  Back to text