This paper, authored by Carl May and titled “Agency and implementation: Understanding the embedding of healthcare innovations in practice,” was published in Social Science & Medicine in 2013. It provides a theoretical analysis of how innovations are implemented and embedded, specifically focusing on complex socio-technical practices within healthcare.
The article emphasizes that an innovation is rarely an isolated “thing-in-itself”. Instead, it is typically an “invented or modified way of thinking or acting, or an artifact, or a system” that involves “highly organized, institutionally sanctioned, and systematically regulated changes in the structure and delivery of services”. These innovations are profoundly influenced by and, in turn, shape their social, technical, and spatial contexts, including associated beliefs, behaviors, and activities. A key challenge for social sciences, as highlighted in the paper, is to understand how these innovations become routinely incorporated or “embedded” in daily practice.
To address this, May introduces and explores the application of Normalization Process Theory (NPT). NPT is characterized as a “middle range theory” that centers on the “agentic contributions” of individuals and groups to the social processes by which innovations are implemented, embedded, and integrated into their social contexts. It conceptualizes implementation as a process and embedding as a state, explained through social mechanisms that alter how agents contribute to normative restructuring, the reworking of relational conventions and group processes, the enactment of practices, and their projection into the future.
The core assumptions of NPT, as detailed in the paper, include:
- Innovations become embedded because agents, both individually and collectively, actively work to enact them.
- The embedding of innovations is achieved through generative mechanisms, which are the result of human agency. These mechanisms manifest as agentic contributions in processes of coherence, cognitive participation, collective action, and reflexive monitoring.
- The operation of these generative mechanisms is influenced by organizing structures and social norms that define roles, rules, group processes, and interactional conventions.
- The ongoing reproduction of an innovation necessitates continued investments by agents in actions that carry the innovation forward in time and space.
The article uses clinical Shared Decision-Making (SDM) as a detailed example to discuss the application of NPT. SDM is presented as a valuable case because it is a “highly complex ensemble of socio-technical practices” that involves significant reorganization of care, negotiation of relationships, and the integration of new techniques and technologies into existing practices. Implementing and embedding SDM requires normative changes that reframe professional and patient roles and rules within the clinical encounter.
The paper extends NPT by proposing a set of analytic propositions that link the theory’s mechanisms to the agentic contributions made by individuals and groups as they embed healthcare innovations. These propositions articulate how embedding depends on agents investing in various practices, which are categorized under four social mechanisms:
- Sense-making and Coherence: Involve practices like differentiation (making the innovation distinct and meaningful) and legitimation (securing agreement on its validity).
- Reworking Conventions and Group Processes: Include practices such as communal specification (producing shared knowledge about purpose), enrolment (persuading others to participate), and relational integration (securing accountability and confidence in evidence).
- Enacting Practices: Focus on individual specification (personalizing knowledge), initiation (bringing the innovation into being), and interactional workability (operationalizing practices and artifacts).
- Projecting Practices into the Future: Encompass internalization (linking to personal norms and values), activation (sustaining commitment), skill-set workability (allocating tasks and sharing knowledge), and reconfiguration (informing changes in participation and action). The paper also discusses systematization (collecting information about effects) and communal/individual appraisal (assessing utility and value) as part of reflexive monitoring.
Ultimately, the paper argues that the embedding of an innovation is a state achieved when these agentic contributions lead to appropriate normative restructuring, the reworking of relational conventions and group processes, the enacting of practices, and their projection into the future. It highlights that implementation and embedding are not merely instrumental but are significant sociological phenomena worthy of sustained attention.
Reference for this article:
May, C. (2013). Agency and implementation: Understanding the embedding of healthcare innovations in practice. Social Science & Medicine, 78, 26–33.
