Table 1
Core Constructs and Contextual Features of Normalization Process Theory.
| CONTEXT FEATURES | |
|---|---|
| |
| CORE CONSTRUCTS | EXPLANATION AND SUBCONSTRUCTS |
| Coherence refers to the extent to which a new practice can be understood and made meaningful by individuals and groups. It reflects how stakeholders differentiate it from existing practices, understand its purpose, and internalize its value. Subconstructs are:
|
| Cognitive Participation refers to the relational work of building and sustaining commitment to a new practice. It is a property of individuals and groups, and includes activating leadership, enrolling others, legitimizing roles, and sustaining engagement. Subconstructs are:
|
| Collective Action describes the concerted effort to integrate a new practice into existing workflows and is a property of the community and the system. It reflects whether people are capable, supported, and organized to implement the change. Subconstructs are:
|
| Reflexive Monitoring refers to how people assess and reflect on the effects of the new practice and adjust over time. It includes both individual and collective forms of evaluation. Subconstructs are:
|
Figure 1
The Implementation Core of Normalization Process Theory (from May et al 2020).
Table 2
Cross-context synthesis of EPA implementation using NPT.
| NPT CORE CONSTRUCT | CROSS-CONTEXT PATTERNS AND EXAMPLES |
|---|---|
| Coherence (the apparent qualities of a proposed new practice: does it make sense?) | Latin America: EPAs provided an accessible entry point where “competence” was ideologically resisted, improving initial coherence despite lack of a CBME foundation, supporting early uptake but with limited conceptual depth. Singapore: Strong coherence via a shared national vision and mental model, supported by dual top-down and bottom-up strategies, facilitating aligned implementation and sustained engagement. Taiwan: EPA adoption was advanced through specialty-led initiatives and visible tools (e.g., EMYWAY). However, alignment regarding the formative and summative purposes of EPA use remained variable across settings, contributing to ongoing conceptual and operational challenges. Canada: Reflexive monitoring revealed limited coherence in practice despite initial conceptual clarity, prompting recalibration, highlighting the need for ongoing alignment to support implementation fidelity. Switzerland: Weak coherence; EPAs often misperceived as mere assessment tools, leading to conceptual confusion and resistance undermining engagement and slowing implementation. |
| Cognitive Participation (the engagement of individuals and groups) | Latin America: CP supported through regional EPA courses and community building, despite lack of formal mandates, enabling initial engagement but with variable sustainability. Singapore: Strong CP via national faculty development, EPA champions, and high-level stakeholder coordination, supporting broad engagement and role legitimation. Taiwan: Partial CP; faculty and residents engaged locally, but national coordination and clear role legitimation were insufficient, limiting broader sustained collective commitment. USA: CP occurred at specialty and institutional levels; absence of national mandate limited broad engagement, resulting in fragmented implementation efforts. Switzerland: CP hampered by weak value proposition; clinicians questioned relevance and legitimacy of the reform, limiting buy-in and engagement. |
| Collective Action (the actual agency in context) | Latin America: CA largely informal and partial; absence of integrated tech or shared infrastructure, limiting workflow integration and alignment. Singapore: Strong CA via coordinated leadership, tech platforms, and alignment with service needs (e.g., stackable EPAs), facilitating integration into routine practice. Taiwan: CA was facilitated by digital tools such as EMYWAY. Nevertheless, variation in CCC processes, supervisory practices, and role clarity limited interactional workability and consistency across implementation settings. Canada: CA challenged by residents’ responsibility to initiate assessments and program variability; potential misalignment of assessment burden, leading to misalignment with workflow and assessment burden concerns. Switzerland: Some tools available, but weak engagement and misalignment with local workflows limited enactment, constraining effective implementation. |
| Reflexive Monitoring (appraisal of a new practice and reconfiguration if needed) | Latin America: Incremental reforms and faculty reflection led to tangible shifts (e.g., longer rotations, more feedback), despite lack of systematization, supporting gradual adaptation but limiting scalability. Singapore: Ongoing refinement, informed by feedback from pilots and service needs; RM was explicitly embedded, supporting continuous improvement and sustainability. Taiwan: Early digital dashboards enabled feedback loops (e.g., EMYWAY), though summative vs formative tensions persisted, shaping adaptation but maintaining conceptual challenges. Canada: National monitoring by RCPSC triggered course correction, including specialty-specific adaptations, supporting system-level recalibration. Switzerland: Some macro-level RM (e.g., questioning whether EPAs alone can shift educational culture), but limited evidence of structured evaluation systems, constraining feedback loops and adaptation. |