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Normalization process theory

Normalization Process Theory (NPT) is a middle-range sociological theory designed to explain the generative mechanisms that drive the implementation, embedding, and integration of complex healthcare interventions, new technologies, and organizational innovations into routine practice. Developed to address the challenges of translating research evidence into everyday clinical work, NPT focuses on the social dynamics of how such innovations become normalized—meaning they are operationalized as part of collective action, sustained through organizational structures, and appraised for ongoing viability.^[1] It emphasizes the agency of individuals and groups in healthcare settings, providing a practical toolkit for researchers, clinicians, and managers to evaluate and enhance implementation processes.^[2] NPT originated from qualitative empirical studies conducted between 2001 and 2004 on the implementation of telemedicine and chronic illness management in the UK National Health Service, using grounded theory methods to derive explanatory models. Led by Carl R. May and collaborators, including Frances Mair and Tracy Finch, the theory evolved in phases: initial empirical generalizations formed the basis for the Normalization Process Model (NPM) by 2007, which was then formalized as NPT in 2009 as a more robust, middle-range theory applicable beyond healthcare. This development was supported by funding from the UK National Institute for Health Research and the Economic and Social Research Council, building on sociological insights into work practices and organizational change. Key foundational publications include May et al.'s 2009 article in Implementation Science, which outlined the theory's structure, and a concurrent paper in Sociology that articulated its conceptual foundations.^[1] At its core, NPT is structured around four interconnected constructs that represent the key work required for normalization: coherence, which involves sense-making and defining the intervention's purpose and roles; cognitive participation, focusing on commitment, engagement, and relational work to initiate involvement; collective action, encompassing the operational efforts to enact the intervention through interactional and material resources; and reflexive monitoring, which includes formal and informal appraisals of the intervention's value and modification. These constructs are generative mechanisms that explain how practices are shaped by social interactions and organizational contexts, rather than deterministic factors. The theory's abstract formulation allows it to be operationalized through tools like the NoMAD instrument—a 23-item survey for assessing implementation barriers and facilitators—and qualitative coding manuals for data analysis.^[2]^[3] Since its formalization, NPT has been widely applied in implementation science to design, evaluate, and theorize complex interventions across healthcare domains, such as telehealth adoption, digital health records, and quality improvement initiatives. It has informed over 500 studies globally, with resources hosted by Northumbria University providing open-access toolkits and guidance for practical use. By prioritizing the "work" of implementation, NPT bridges gaps between efficacy trials and real-world integration, contributing to more effective health service innovations.^[3]^[4]

Overview

Definition and Scope

Normalization Process Theory (NPT) is a middle-range sociological theory that delineates the mechanisms through which new or modified practices—encompassing ways of thinking, acting, and organizing work—become routinely embedded in everyday social practices, thereby achieving normalization. Developed to address gaps in understanding implementation dynamics, NPT posits that normalization is not merely the adoption of innovations but the outcome of ongoing social processes that integrate these practices into routine operations. This theory provides analytical tools for examining how collective efforts sustain and reproduce such practices over time.^[1] The scope of NPT centers on implementation research, particularly in evaluating and facilitating the embedding of complex interventions within healthcare, social care, and broader organizational contexts. It emphasizes dynamic, interactive social processes that involve human agency and interaction, rather than focusing solely on static outcomes like uptake rates or fidelity. By highlighting the work required to operationalize and sustain innovations, NPT applies to settings where technologies, organizational changes, or service delivery models must integrate seamlessly into existing workflows.^[3]^[2] At its core, NPT asserts that normalization emerges from embedded practices shaped by collective action and reflexive adjustments among participants, distinguishing it from simpler diffusion or acceptance models. This premise underscores the theory's utility in explaining why some interventions normalize while others fail, without relying on deterministic factors.^[1]

Key Objectives

Normalization Process Theory (NPT) primarily aims to provide a robust framework for assessing the implementation potential of complex interventions in healthcare and other institutional settings, explaining the mechanisms through which new practices become routinely embedded in everyday work.^[1] By focusing on the social and organizational processes involved, NPT helps researchers and practitioners understand why certain interventions succeed in achieving normalization while others fail, thereby informing strategies to enhance integration into routine practice.^[1] This objective addresses the need for a theory that goes beyond mere adoption to examine sustained embedding, offering tools to predict and mitigate barriers to successful implementation.^[1] A core purpose of NPT is to bridge gaps in earlier implementation models, particularly those centered on diffusion and dissemination, which often overlook the ongoing social actions required for embedding and integration.^[1] Traditional diffusion-focused approaches, such as those emphasizing technology spread or knowledge transfer, fail to account for the dynamic work of operationalizing practices in real-world contexts, as evidenced by cases like the limited integration of telemedicine despite widespread adoption.^[1] NPT shifts emphasis to these human-centered processes, providing a sociological lens to analyze how interventions are enacted and sustained over time, thus enabling more effective design and evaluation of interventions.^[1] In practical terms, NPT supports qualitative and mixed-methods research for evaluating complex interventions by offering structured guidance for studying implementation dynamics across diverse settings.^[5] It facilitates the identification of key mechanisms that promote or inhibit normalization, aiding in the development of targeted strategies for healthcare innovations like e-health systems or shared decision-making tools.^[1] A notable tool derived from NPT is the Normalization Process Theory Measure (NoMAD), a validated instrument that quantifies implementation processes through surveys assessing coherence, engagement, action, and appraisal, thereby enabling empirical measurement and monitoring of normalization in research studies.^[6]

Historical Development

Origins and Early Formulations

Normalization Process Theory (NPT) emerged in the early 2000s as a framework to explain how new healthcare practices and technologies become embedded in routine clinical work. It was developed by Carl May and colleagues through a series of qualitative studies on the implementation of innovative health technologies in the UK. The foundational work began with a 2003 paper that examined the normalization of telemedicine services, focusing on telecare technologies for remote patient monitoring and consultation. This study highlighted barriers and facilitators to integrating such technologies into everyday practice, drawing on empirical data from healthcare providers and patients to identify patterns of adoption and resistance.^[7] The early formulations of NPT were articulated in subsequent publications, evolving from initial empirical observations into a structured model. In its nascent form, the theory conceptualized implementation around three core elements: "objects" referring to the technologies or practices being introduced, "agents" encompassing the individuals and groups enacting them, and "contexts" denoting the organizational and social settings in which they operate. This triad provided a lens to analyze how complex interventions interact with human behavior and institutional structures, emphasizing the dynamic processes of embedding rather than static outcomes. The model was first outlined in detail in 2006, building directly on the telemedicine research to propose mechanisms for successful normalization.^[1] These origins were rooted in influential empirical studies on UK healthcare innovations between 2000 and 2005, particularly e-health initiatives like telepsychiatry and chronic disease management systems. Conducted amid the National Health Service's push for digital health solutions, these investigations revealed common challenges in scaling up interventions, such as clinician skepticism and workflow disruptions, informing NPT's focus on practical integration. The initial model drew briefly from sociological influences, including actor-network theory for its emphasis on networks of actors and artifacts, and structuration theory for understanding agency within structures.^[1]

Evolution to Current Framework

The Normalization Process Model (NPM), introduced in 2006, provided an initial framework for understanding how complex interventions in healthcare become routinely embedded in practice, emphasizing factors that promote or inhibit collective action among practitioners. This model shifted attention from individual adoption to social processes of implementation, drawing on empirical studies of technology integration in clinical settings. By 2009, the framework evolved into Normalization Process Theory (NPT), formalized as a middle-range theory in sociological terms, which consolidated key elements into four generative mechanisms: coherence (sense-making), cognitive participation (engagement), collective action (enacting practices), and reflexive monitoring (appraisal).^[1] This refinement, further elaborated in 2010, marked a transition from static conceptualizations of objects and agents in implementation to dynamic processes that explain embedding and integration across diverse social contexts.^[2] A 2018 systematic review highlighted NPT's growing application in feasibility studies and process evaluations, particularly for explanatory modeling of late-stage implementation challenges, such as sustaining innovations beyond initial rollout in complex healthcare systems.^[5] To support empirical measurement, the NoMAD instrument was developed in 2013 as a validated tool for assessing NPT constructs in real-world settings, enabling quantitative evaluation of implementation dynamics.^[8] As of 2025, NPT has increasingly integrated with digital health tools, such as remote monitoring technologies, and complexity science principles to address adaptive implementation in multifaceted environments like telemedicine and AI-assisted care.^[9]

Theoretical Foundations

Sociological Roots

Normalization Process Theory (NPT) draws significant inspiration from Anthony Giddens' structuration theory, which emphasizes the duality of structure and agency in the ongoing reproduction of social systems. This duality underpins NPT's examination of how individual and collective actions enable the implementation and embedding of new practices within broader social structures, particularly in dynamic organizational contexts like healthcare. By integrating agency—the capacity for action—with structure—the rules and resources that constrain and enable it—NPT conceptualizes normalization as a recursive process where practices become routine through human interaction.^[10] Further roots lie in Bruno Latour's actor-network theory (ANT), which highlights the relational networks involving humans and non-human elements in social processes. It adopts relational thinking to analyze how technologies and practices are stabilized through interconnected social ties during implementation. Additionally, symbolic interactionism, as developed by Herbert Blumer, provides a foundation for understanding sense-making in social interactions, where individuals collectively interpret and negotiate the meaning of new practices to facilitate their integration into daily routines.^[11] Positioned as a middle-range theory, NPT bridges macro-sociological analyses of institutions and organizational change with micro-sociological insights into individual actions and interactions. This positioning allows NPT to offer testable explanations for implementation processes without the abstract generality of grand theories, focusing instead on empirical applicability in contexts of social innovation and routine formation.^[12]

Integration with Implementation Science

Normalization Process Theory (NPT) serves as a key theoretical tool within implementation science, providing a process-oriented lens to examine the embedding and integration of complex interventions into everyday practice. It elucidates the social dynamics through which new technologies, practices, or ways of working become normalized, focusing on mechanisms such as sense-making, engagement, enactment, and appraisal rather than solely on outcomes. This approach complements outcome-oriented frameworks like RE-AIM, which prioritize dimensions such as reach, effectiveness, adoption, implementation, and maintenance, by addressing the "how" of sustained change through collective action. For instance, studies have combined NPT with RE-AIM to evaluate referral of patients to diabetes prevention programmes from community campaigns and general practices, highlighting NPT's role in unpacking process barriers alongside RE-AIM's assessment of broader impacts.^[1]^[13] NPT contributes substantially to implementation science by guiding trial design, process evaluations, and the scaling of interventions. It supports the identification of factors that promote or inhibit normalization, enabling researchers to refine interventions prospectively and retrospectively. In particular, NPT facilitates mixed-methods approaches for understanding implementation dynamics, as evidenced in its application to e-health and telecare initiatives where it has provided stable explanations for varying degrees of success. NPT integrates seamlessly with the Medical Research Council (MRC) framework for developing and evaluating complex interventions, originally outlined in 2008 and updated in 2021, by offering structured constructs to assess coherence, feasibility, and stakeholder engagement during intervention modeling, optimization, and appraisal phases. Recent syntheses have further demonstrated its utility in aligning with the 2021 MRC emphasis on contextual interactions and iterative refinement.^[1]^[2]^[14] Through its interdisciplinary orientation, NPT bridges sociological theory with health services research, emphasizing social and organizational mechanisms over individualistic models of behavior change. Originating from sociological inquiries into technology adoption, it adapts these insights to implementation contexts, fostering a nuanced view of how collective efforts drive the routine incorporation of innovations. This linkage has enriched implementation science by promoting theory-driven strategies that account for relational and structural influences on practice integration.^[1]

Core Constructs

Coherence: Sense-Making

Coherence, also known as sense-making, is the first core construct of Normalization Process Theory (NPT), representing the collective process through which individuals and groups develop an understanding of a new practice or intervention, distinguishing it as meaningful and workable within their context.^[2] This stage emphasizes the cognitive work required to comprehend the intervention's purpose, components, and potential benefits, ensuring that participants can articulate its value before proceeding to engagement or action.^[15] The construct encompasses four interrelated sub-constructs that facilitate this sense-making. Differentiation involves participants identifying and distinguishing the key components of the intervention from existing routines, allowing them to perceive it as a distinct and separable entity rather than an undifferentiated addition to current work.^[2] Communal specification refers to the development of a shared understanding among group members about the intervention's overall aims, objectives, and expected outcomes, fostering collective agreement on its purpose.^[15] Individual specification occurs when participants clarify their personal roles and responsibilities within the intervention, aligning it with their specific tasks and goals.^[2] Finally, internalization entails the cognitive integration of the intervention's value, where participants assess and buy into its benefits, making it psychologically salient and motivating.^[15] Through these sub-constructs, coherence builds shared cognitive resources that underpin the normalization of practices by reducing uncertainty and promoting a common mental model.^[2] For instance, unresolved ambiguity in sense-making, such as when general practitioners in a back pain management study viewed the intervention as irrelevant to their broader workload, led to non-normalization, with tools like decision-support aids being ignored or underutilized.^[2] This mechanism highlights how effective coherence work is essential for subsequent implementation success, as it transforms abstract ideas into actionable, valued elements of everyday practice.^[15]

Cognitive Participation: Engagement

Cognitive participation in Normalization Process Theory (NPT) refers to the relational work that individuals and groups undertake to build and sustain a community of practice around a new practice or intervention, fostering commitment and engagement to drive its implementation. This construct emphasizes the transition from individual understanding to collective buy-in, where participants invest effort in relating to the intervention and each other. As outlined in the foundational NPT framework, cognitive participation is essential for embedding practices into routine work, as it positions actors within interaction chains that frame and support the intervention's adoption. The construct comprises four interrelated sub-constructs that detail the phases of engagement. Initiation involves key influencers or enthusiasts who drive the uptake of the intervention by identifying opportunities and mobilizing early support, often setting the direction for its introduction within a group or organization. Legitimation follows, where participants build collective confidence in the intervention's value and appropriateness, legitimizing it through shared meaning and alignment with existing roles and goals. Enrolment entails recruiting and organizing participants to contribute collectively, often by defining roles and rethinking relationships to build commitment. Finally, activation focuses on the ongoing effort to sustain involvement, where participants monitor their commitment and adjust actions to maintain momentum. These sub-constructs collectively enable the relational dynamics needed for successful normalization.^[16] Mechanisms within cognitive participation include enrolling others into the practice and countering resistance to participation, which are critical for shifting from preparatory sense-making to active implementation. Enrolling involves recruiting and organizing participants to contribute collectively, often by rethinking relationships and responsibilities to accommodate the intervention. Countering resistance addresses potential barriers, such as skepticism or competing priorities, through persuasion and reinforcement of the intervention's benefits. Building on sense-making foundations from the coherence construct, cognitive participation ensures that understanding translates into relational investment and community initiation. For instance, in healthcare implementations, opinion leaders often initiate engagement by enrolling colleagues, legitimizing new protocols through demonstrated value, and activating sustained participation to overcome initial pushback.^[2]

Collective Action: Enacting Practices

Collective action in Normalization Process Theory (NPT) refers to the operational work undertaken by individuals and groups to enact and sustain new practices or interventions within everyday routines, emphasizing the collective performance required for their integration into ongoing activities.^[1] This construct highlights how practices are enacted through coordinated efforts that address practical challenges in implementation, ensuring they become embedded without disrupting core workflows.^[2] Unlike initial engagement, which builds commitment, collective action focuses on the hands-on execution that makes practices viable in real-world settings.^[17] The construct comprises four interrelated sub-constructs that detail the dimensions of this enactment process. Interactional workability assesses how well a practice fits into interactions among users, artifacts, and existing routines, enabling flexible task accomplishment without straining social relations—for instance, in telemedicine implementations where negotiation of patient-provider interactions can either streamline or complicate delivery.^[1] Skill-set workability evaluates the alignment of the practice with participants' capabilities and the division of labor, ensuring tasks are allocated to those with appropriate skills to avoid overburdening individuals or teams.^[2] Contextual integration examines the embedding of the practice within organizational structures, including adaptations to the broader setting through protocols and resource management.^[17] Finally, relational integration involves building trust and accountability among actors, fostering confidence in the practice's reliability and supporting cooperative dynamics essential for sustained use.^[1] These sub-constructs operate through mechanisms that tackle implementation barriers, such as resource constraints and workflow disruptions, by promoting adaptive strategies that normalize practices over time. For example, effective resource allocation under contextual integration helps mitigate disruptions by aligning the practice with available infrastructure, while relational integration counters skepticism through demonstrated reliability in team interactions.^[2] Overall, collective action underscores that normalization depends on overcoming these practical hurdles to achieve seamless enactment, transforming potential innovations into routine elements of collective performance.^[17]

Reflexive Monitoring: Appraisal

Reflexive monitoring in Normalization Process Theory (NPT) refers to the ongoing processes through which individuals and groups appraise the value, progress, and impacts of an intervention or new practice, enabling assessment of its benefits, costs, and overall effectiveness in everyday work. This construct emphasizes the reflexive work of evaluation that occurs during and after implementation, distinguishing it from pre-implementation sense-making or engagement activities. By focusing on appraisal, reflexive monitoring supports the normalization of practices by identifying what works, what does not, and how adjustments can be made to enhance embedding.^[1] The construct comprises four interrelated sub-constructs that capture different dimensions of this appraisal work. Communal appraisal involves shared evaluations within groups, where collective discussions and experiential data are used to assess the intervention's outcomes and resolve differing interpretations of its value. For instance, healthcare teams might collectively review patient feedback to gauge a new protocol's impact on care delivery. Individual appraisal, in contrast, pertains to personal judgments by actors about how the practice affects their own roles, workloads, or routines, such as a clinician reflecting on whether a digital tool reduces administrative burden.^[2]^[18] Systematisation addresses the formal and informal collection of data to monitor progress, ranging from structured audits or trials to anecdotal observations that inform evaluations of usefulness and effectiveness. This sub-construct ensures that appraisals are grounded in evidence, whether through quantitative metrics like outcome measures or qualitative insights from daily interactions. Reconfiguration involves adapting the practice based on these appraisals, tailoring it to specific contexts to address identified issues, such as modifying a workflow to better fit organizational constraints.^[2] These sub-constructs collectively drive iterative refinement by creating feedback loops that allow for continuous adjustment, promoting the sustained integration of practices. Disruptions in reflexive monitoring, such as inadequate data collection or conflicting appraisals, can impede normalization by preventing necessary adaptations and leading to abandonment of the intervention. In this way, reflexive monitoring not only evaluates but also actively shapes the trajectory of implementation toward routine embedding.^[1]^[2]

Applications and Empirical Use

In Healthcare Settings

Normalization Process Theory (NPT) has been extensively applied in healthcare to evaluate the implementation of electronic health records (EHRs) within the UK National Health Service (NHS) during the 2010s. In a qualitative study of a large academic acute NHS hospital procuring a commercial EHR system, NPT constructs revealed staff expectations around coherence and collective action, highlighting how shared understanding and operational work influenced integration into routine practice.^[19] Similarly, research on EHR implementation in primary care settings used NPT to identify barriers such as fragmented data systems and data security concerns, which impeded normalization across multidisciplinary teams.^[20] During the COVID-19 pandemic from 2020 to 2025, NPT guided evaluations of telehealth adoption, particularly in emergency and primary care contexts. A study on integrating a virtual emergency department (ED) alongside in-person operations in the US found that NPT's cognitive participation and reflexive monitoring constructs explained rapid embedding, with physicians normalizing telehealth through iterative feedback despite initial technological hurdles.^[21] In the UK, NPT analyzed the implementation of digital health interventions for long COVID management in community and secondary care, underscoring how collective action facilitated sustained use of telehealth platforms amid heightened demand.^[22] These applications demonstrated telehealth's normalization as a response to crisis-driven service disruptions. Empirical insights from NPT applications show that the coherence construct aids adoption of tools for chronic disease management by fostering shared sense-making among patients and providers. For instance, in primary care management of early-stage chronic kidney disease, coherence-building activities, such as educational workshops, enhanced differentiation of the intervention from existing practices, promoting sustained engagement.^[23] Regarding collective action, barriers in multidisciplinary teams often arise from conflicting professional roles and resource allocation, as seen in primary care interdisciplinary working where NPT identified insufficient collaborative labor as a key inhibitor to embedding integrated care models.^[24] In pharmacist integration within teams, collective action challenges included unclear accountability, which NPT helped mitigate through targeted workflow adjustments.^[25] Outcomes from NPT-guided studies in healthcare are supported by systematic reviews, which indicate that NPT effectively explains implementation processes and predicts success in complex interventions. A 2018 systematic review included 108 studies that used NPT in feasibility studies (n=25) and process evaluations (n=73) of complex healthcare interventions, linking its constructs to mechanisms influencing embedding outcomes across diverse healthcare settings.^[5]

Extensions to Other Domains

Normalization Process Theory (NPT) has been extended beyond its primary healthcare applications to diverse sectors, demonstrating its versatility in analyzing the implementation and embedding of complex practices in non-clinical environments. In these adaptations, NPT's core constructs—coherence, cognitive participation, collective action, and reflexive monitoring—are applied to understand how innovations become routine amid varying organizational dynamics and stakeholder needs.^[26] In education, NPT has informed studies on the integration of digital learning platforms, particularly from 2015 to 2023. For instance, a qualitative analysis in Swedish schools examined the implementation of digital technologies using NPT alongside the Job Demand-Resources model, revealing that while teachers engaged through self-organization and collegial support, challenges in shared sense-making and insufficient time for learning hindered full normalization.^[27] Similarly, in a Ghanaian higher education context, NPT was used to evaluate the shift to online course and lecturer evaluations, where coherence was achieved through perceived efficiency gains, but cognitive participation faltered due to low student engagement and technical barriers, leading to partial embedding.^[28] These applications highlight NPT's utility in addressing resource constraints and fostering collective action in educational settings.^[29] Extensions to social care have focused on normalizing person-centered planning and related interventions. In Swedish coordinated individual care planning (CIP), NPT guided an exploration of shared decision-making (SDM) implementation, identifying that staff coherence around SDM's value for person-centered care was strong, yet cognitive participation required cross-organizational training to overcome power imbalances and territorial barriers.^[30] Another study applied NPT to a peer-delivered intervention for homelessness and substance use in third-sector services, where reflexive monitoring enabled adaptations to a harm reduction approach, though initial role confusion among staff delayed collective action; this demonstrated NPT's role in embedding flexible, community-based practices.^[31] In organizational contexts, such as business process reengineering, NPT has been employed to dissect agile methodology adoption in tech and finance firms during the 2020s. A case study of a global financial organization's large-scale transformation using the Spotify model showed that inadequate coherence in communicating the agile vision led to resistance, while overemphasis on productivity metrics undermined reflexive monitoring and long-term sustainability, resulting in abandonment after 18 months.^[32] NPT's framework revealed that cognitive participation was particularly critical, as sustained stakeholder buy-in—through clear role definitions and balanced autonomy—distinguished successful embeddings from superficial adoptions in scaled agile frameworks like SAFe and LeSS.^[33] Adaptations of NPT for non-clinical contexts, including policy implementation, involve tailoring its constructs to emphasize collective processes over individual behaviors. A 2025 taxonomy derived from NPT synthesized 24 implementation strategies across leadership, information, empowerment, and service user involvement, applicable to policy rollouts by addressing contextual barriers like resource allocation in diverse organizations.^[34] In restorative justice policy, NPT has been adjusted to focus on cognitive participation for engaging stakeholders in dynamic social norms, enabling the translation of strategic intentions into routine practices while accounting for local structures.^[26] These modifications underscore NPT's flexibility in promoting sustained change outside clinical domains.

Position Within Broader Scholarship

Relation to Science and Technology Studies

Normalization Process Theory (NPT) aligns closely with the principles of science and technology studies (STS) by emphasizing the co-construction of technology and society in processes of sociotechnical change. Developed within a sociological framework informed by STS, NPT examines how new technologies and practices are embedded into social systems through ongoing interactions and negotiations among human and non-human actors. This perspective draws on actor-network theory (ANT), particularly Bruno Latour's concept of translation, which describes how innovations are enrolled into networks of relations to achieve stability and routine use. NPT contributes to STS by providing a practical explanatory model for the normalization of sociotechnical interventions, bridging theoretical insights from STS with empirical implementation in real-world settings. While STS literature, such as that critiquing the interplay between health technologies and societal structures, highlights the mutual shaping of artifacts and users, NPT operationalizes these ideas to analyze the work required for embedding innovations into everyday practices. For instance, in studies of telemedicine, NPT has been used to trace how remote care technologies co-evolve with clinical routines, revealing barriers like relational disruptions in doctor-patient interactions. This approach extends STS's focus on innovation trajectories by detailing the mechanisms—such as communal specification and interactional workability—that facilitate or hinder the integration of technologies into social contexts. Key overlaps between NPT and STS are evident in their shared emphasis on relationality and embedding, particularly in analyses of digital health technologies during the 2010s. NPT's constructs of collective action and reflexive monitoring underscore the relational dynamics through which technologies become normalized, aligning with STS examinations of how digital tools, like patient decision support systems, are inscribed into healthcare ecosystems. For example, research on e-health interventions has applied NPT to demonstrate how embedding occurs through iterative appraisals and adjustments, ensuring technologies align with existing social and material relations rather than imposing top-down changes. This relational lens has informed STS scholarship on digital health by highlighting the distributed agency in sociotechnical assemblages, such as in the implementation of web-based diabetes management programs.^[35]^[36] Normalization Process Theory (NPT) differs from Everett Rogers' Diffusion of Innovations (DOI) theory in its emphasis on the post-adoption embedding of complex interventions into everyday practice, rather than solely on the initial spread and adoption of innovations across social systems.^[37] While DOI focuses on system-level attributes like relative advantage, compatibility, and communication channels to explain diffusion rates, NPT examines the actionable work involved in coherence-building, engagement, enactment, and appraisal to sustain normalization. This actor-centered approach in NPT addresses the collective and organizational processes required for integration, contrasting with DOI's broader, less granular view of whole-system transmission without detailing component interactions. In comparison to the Theoretical Domains Framework (TDF), which identifies 14 behavioral determinants such as knowledge, skills, and environmental context to inform individual-level interventions for behavior change, NPT adopts a processual perspective on how social and collective mechanisms drive the normalization of practices over time. TDF serves primarily as a diagnostic tool for pinpointing barriers and enablers in professional behaviors, often linked to psychological theories like the Theory of Planned Behavior, whereas NPT explains the dynamic, generative processes through which innovations become routinely embedded, emphasizing interactional work among actors. Thus, while TDF is static and individual-focused, NPT highlights ongoing collective action and reflexive monitoring as key to implementation success.^[38] NPT also contrasts with the Consolidated Framework for Implementation Research (CFIR), a multi-level determinant framework that organizes influences on implementation across five domains—intervention characteristics, outer setting, inner setting, individual characteristics, and process—without specifying causal mechanisms for change.^[39] CFIR excels in assessing contextual factors like readiness and complexity but remains descriptive of barriers and facilitators, whereas NPT's four generative constructs provide explanatory power for the social dynamics and work required to operationalize implementation, offering practical guidance for embedding practices. This makes NPT particularly suited for evaluating processual aspects, complementing CFIR's static taxonomy by illuminating how actors enact and appraise changes in real-time settings.^[39] Overall, NPT's unique strength lies in its dynamic, actor-centered orientation, which prioritizes the explanatory mechanisms of normalization as an active, collective process, distinguishing it from more static or outcome-oriented models like DOI, TDF, and CFIR that focus on diffusion, behavior, or determinants without equivalent emphasis on ongoing enactment.^[37]

Criticisms and Future Directions

Identified Limitations

One key critique of Normalization Process Theory (NPT) is its overemphasis on social and agency-based processes, which may undervalue broader structural barriers such as policy constraints and funding limitations. For instance, reviewers have noted that NPT prioritizes individual and collective actions among practitioners while insufficiently addressing how organizational contexts or systemic factors influence implementation outcomes. This agency-centric focus can limit the theory's explanatory power in settings where external structures, like resource allocation or regulatory environments, dominate. Such concerns were highlighted in systematic analyses of NPT applications, where the theory's constructs were seen as placing "undue emphasis on individual and collective agency without explicitly locating this within... organisational and relational context."^[5] NPT also offers limited guidance on power dynamics within implementation processes, often overlooking how hierarchical relationships or inequities among stakeholders affect embedding practices. Critics argue that the theory's mechanisms, such as cognitive participation and collective action, do not adequately account for power imbalances that can hinder or skew normalization efforts, particularly in multidisciplinary teams. Methodologically, NPT relies heavily on qualitative data to explore implementation dynamics, which presents challenges in quantifying its constructs for broader comparative or evaluative purposes. Although tools like the Normalization Process Theory Measure (NPT-M) and NoMAD instrument have been developed to operationalize NPT for surveys, researchers report difficulties with overlapping constructs and technical terminology that complicate consistent coding and interpretation in qualitative analyses. These issues can lead to variability in how NPT is applied across studies, reducing its reliability for rigorous measurement. For example, the intensity of "translation work" required to adapt constructs to specific contexts has been cited as a barrier to precise application.^[40] Significant gaps exist in NPT's attention to de-implementation—the process of discontinuing ineffective or outdated practices—and failure modes in normalization. The theory primarily explains successful embedding and integration, with less emphasis on mechanisms for reversal or the factors leading to sustained non-normalization, limiting its utility in scenarios involving practice abandonment. Studies from 2020 onward have applied NPT to failed implementations but highlight this as an underdeveloped area.^[41] Recent critiques from 2020 to 2025 also point to challenges in NPT's cultural adaptability, particularly in non-Western contexts where social norms, healthcare systems, and relational dynamics differ markedly from the theory's origins in Western settings. Applications in diverse regions reveal difficulties in aligning constructs like reflexive monitoring with local cultural values, potentially reducing the theory's relevance and effectiveness outside high-income environments.

Ongoing Developments

Recent research has advanced the application of Normalization Process Theory (NPT) through its integration with AI-driven interventions in healthcare settings. A 2025 qualitative study in Swedish primary care examined the implementation of AI-based triage tools using NPT, revealing that ongoing sense-making, collective engagement, and operational work among healthcare professionals were crucial for embedding these technologies into routine practice, despite challenges in reflexive monitoring.^[42] This work demonstrates NPT's utility in addressing the dynamic embedding of AI systems, where coherence-building around AI's role enhances adoption.^[43] Hybrid models combining NPT with complexity theory have emerged as a key development, particularly for understanding the nonlinear dynamics of complex interventions. Recent studies, such as a 2025 analysis of peer-delivered programs for substance use, applied NPT within complexity-informed frameworks to evaluate implementation in multifaceted social care environments, emphasizing how emergent interactions influence collective action and appraisal.^[31] Similarly, a 2025 taxonomy of implementation strategies grounded in NPT incorporates complexity perspectives to classify actions that promote embedding across diverse contexts, offering a structured approach to navigate unpredictable implementation pathways.^[34] Future directions for NPT emphasize expansion into global health equity and the creation of digital toolkits for real-time monitoring. Emerging applications in diverse healthcare systems, including discharge planning across international settings, highlight NPT's potential to address equity by tailoring implementation to cultural and resource variations.^[44]

References

[1]
Development of a theory of implementation and integration: Normalization Process Theory - Implementation Science
### Summary of Normalization Process Theory Development (2009 Paper)
[2]
Normalisation process theory: a framework for developing ...
Oct 20, 2010 · The NPT is a new theory which offers trialists a consistent framework that can be used to describe, assess and enhance implementation potential.
[3]
Normalization Process Theory
Normalization Process Theory (NPT) is a set of conceptual tools and explanatory models used to support the implementation and evaluation of complex ...Theory behind NPT · What is NPT? · NPT Toolkit · NoMAD Study
[4]
a normalisation process theory coding manual for qualitative ...
Feb 22, 2022 · Normalisation Process Theory (NPT) is frequently used to inform qualitative research that aims to explain and evaluate processes that shape late ...
[5]
Using Normalization Process Theory in feasibility studies and ...
Jun 7, 2018 · Normalization Process Theory (NPT) identifies, characterises and explains key mechanisms that promote and inhibit the implementation, ...
[6]
Improving the normalization of complex interventions: measure ...
Apr 11, 2013 · Normalization Process Theory (NPT) provides a framework for understanding how a new intervention becomes part of normal practice. This study ...
[7]
Understanding the Normalization of Telemedicine Services through ...
The study aimed to identify and explore those factors that promote or inhibit the effective evaluation of telemedicine systems and was specifically concerned ...
[8]
Staff expectations for the implementation of digital remote monitoring ...
Jul 9, 2025 · Using Normalisation Process Theory (NPT), this study identified key barriers to DRM implementation, including role ambiguity, data concerns, and ...
[9]
Towards a general theory of implementation
Feb 13, 2013 · This paper sets out core constituents of a general theory of implementation, building on Normalization Process Theory and linking it to key constructs from ...Background · Implementation Theory · Constructs Of The General...
[10]
[PDF] Normalization and Discipline - PhilArchive
Foucault regarded normalization as a central—if not the central—strategy of biopower's management of “life”. Foucault claimed that, beginning in the eighteenth ...
[11]
An Outline of Normalization Process Theory - Carl May, Tracy Finch ...
Abstract. Understanding the processes by which practices become routinely embedded in everyday life is a long-standing concern of sociology and the other social ...
[12]
Development of a theory of implementation and integration
May 21, 2009 · Normalization Process Theory explains how new technologies, ways of acting, and ways of working become routinely embedded in everyday practice.
[13]
Referral of patients to diabetes prevention programmes from ...
May 22, 2019 · A review of diabetes self-management education interventions which employed the RE-AIM framework recommended more formal evaluation of the ...
[14]
Using normalisation process theory for intervention development ...
Sep 18, 2023 · This review demonstrates NPT's utility in supporting intervention implementation for orthopaedic and musculoskeletal conditions.
[15]
NPT Toolkit - Normalization Process Theory
1. Participants distinguish the intervention from current ways of working. · 2. Participants collectively agree about the purpose of the intervention. · 3.
[16]
Cognitive Participation - Normalization Process Theory
and Finch, T.L. (2015) Normalization Process Theory On-line Users' Manual, Toolkit and NoMAD instrument. Available from http://www.normalizationprocess.org.
[17]
Normalization Process Theory | Collective Action
### Summary of Collective Action Construct
[18]
Reflexive Monitoring - Normalization Process Theory
The NPT construct of reflexive monitoring describes the work that people do to appraise the effects of an implementation.Missing: primary sources
[19]
A Qualitative Study using Normalisation Process Theory
This study explored staff expectations for change and outcome following procurement of a commercial EHR system by a large academic acute NHS hospital in the UK.
[20]
Using normalisation process theory to evaluate the implementation ...
The DHI was judged to have demonstrated the potential to affect long-established patterns and organisational structures of engagement between healthcare ...
[21]
Qualitative Study Using the Normalization Process Theory
Sep 12, 2022 · Normalization Process Theory ... Normalization is defined as the embedding of a technology as a routine and taken-for-granted element of clinical ...
[22]
Using normalisation process theory to evaluate the implementation ...
Nov 27, 2024 · Using normalisation process theory to evaluate the implementation of a digital health intervention in community and secondary care long COVID ...Missing: Normalization telehealth
[23]
Use of Normalization Process Theory to explore the implementation ...
Apr 22, 2019 · The reflexive monitoring construct was normally distributed and there was no statistically significant difference was identified between the ...
[24]
Assessing the facilitators and barriers of interdisciplinary team ...
We have employed Normalisation Process Theory (NPT) as a heuristic device to “think through” descriptions of health care practices from a variety of primary ...
[25]
a qualitative interview study based on the normalization process ...
May 2, 2024 · Our aim was to identify barriers and facilitators to optimal utilization of pharmacist services within a multidisciplinary team. Methods. Semi- ...
[26]
(PDF) The implementation and validation of the NoMAD during a ...
Jun 8, 2022 · Background Normalization process theory (NPT) has been widely used ... This study aimed to determine sustainment of practice and what predicts ...
[27]
(PDF) Normalization Process Theory - ResearchGate
Jul 5, 2025 · This study uses Normalization Process Theory (NPT) to identify how restorative justice has been implemented (May et al., 2020) . NPT is ...
[28]
Full article: Implementing digital technologies in the school setting
Jul 25, 2024 · In this study, we want to understand the link between the process of digitalising work and the work environment using the Normalisation Process ...
[29]
[PDF] Normalisation of Technology Use in a Developing Country Higher ...
The purpose of this paper is to understand how the use of an online course and lecturer evaluation process becomes normalised evaluation process in a higher ...Missing: digital | Show results with:digital
[30]
[PDF] Towards normalization in e-learning for collaborative work ... - HAL
Jul 1, 2016 · This paper presents an exploration of digital documents in the educational field and its implications within common problematic such as ...<|separator|>
[31]
Conditions for implementing shared decision making (SDM) in coordinated individual care planning (CIP) in Sweden through the lens of normalization process theory: a prospective study
### Summary of NPT Use in Social Care for Shared Decision Making (SDM) or Person-Centered Processes
[32]
Applying Normalisation Process Theory to a peer-delivered complex ...
Jan 10, 2025 · Application of normalisation process theory in understanding implementation processes in primary care settings in the UK: a systematic review.
[33]
An exploratory study of a large-scale agile transformation
Normalisation process theory examines the adoption of a new practice. As outlined in Table 2, NPT provides a rich theoretical lens to develop novel insights on ...
[34]
Applying Normalization Process Theory to Explain Large-Scale ...
Apr 29, 2020 · In this article, we focus on the challenge of normalizing large scale agile transformations and apply Normalization Process Theory (NPT) to ...
[35]
implementation strategies derived from normalization process theory
Jul 27, 2025 · This study develops a taxonomy of implementation strategies grounded in Normalization Process Theory (NPT), an implementation theory that ...
[36]
https://doi.org/10.1186/s12913-018-3615-7
[37]
https://doi.org/10.1186/1741-7015-8-63
[38]
https://pubmed.ncbi.nlm.nih.gov/40600301/
[39]
From theory to practice: using the Normalization Process ... - PubMed
Jun 4, 2025 · This study's objective is to map and compare the application of the Normalization Process Theory (NPT) and Theoretical Domains Framework (TDF) in understanding ...
[40]
https://doi.org/10.1177/1049732319863420
[41]
https://onlinelibrary.wiley.com/doi/abs/10.1111/jan.16261
[42]
https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-025-03057-9
[43]
Failed implementation of a nursing intervention to support family ...
Jun 17, 2024 · This framework emphasizes that successful implementation of an intervention relies on its 'normalization', consisting of four constructs: ...
[44]
Factors influencing general practice nurse's implementation ... - PMC
Jul 14, 2024 · To explore levers and barriers to providing culturally responsive care for general practice nurses (GPNs) using normalization process theory.<|control11|><|separator|>
[45]
Integrating AI-based triage in primary care: a qualitative study of ...
Nov 4, 2025 · According to normalization process theory (NPT), these processes include continuous sense-making, collective engagement, the operationalization ...
[46]
https://www.researchgate.net/publication/397261356_Integrating_AI-based_triage_in_primary_care_a_qualitative_study_of_Swedish_healthcare_professionals%27_experiences_applying_normalization_process_theory
[47]
Application of Normalization Process Theory in Discharge Planning
May 30, 2025 · This review aimed to explore the use of Normalization Process Theory (NPT) in patient discharge planning and how this theory is applied in various healthcare ...Missing: variance | Show results with:variance
[48]
Using Normalisation Process Theory to explore the contribution of ...
Sep 2, 2024 · Normalisation Process Theory (NPT) [8] was developed to understand and overcome difficulties encountered when implementing complex behavioural ...