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

Tracy L. Finch (Corresponding Author), Melissa Girling, Carl R. May, Frances Mair, Elizabeth Murray, Shaun Treweek, Elaine McColl, Ian Nicholas Steen, Clare Cook, Christopher Vernazza, Nicola Mackintosh, Samridh Sharma, Gaery Barbery, Jimmy Steele, Tim Rapley

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Successful 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.

Descriptive 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.

We 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).

The 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.
Original languageEnglish
Article number135
JournalBMC Medical Research Methodology
Publication statusPublished - 15 Nov 2018

Bibliographical note

This study is funded by the Economic and Social Research Council Study [Grant Number RES-062-23-3274] which is gratefully acknowledged. This work was also partially supported by funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 733025, ImpleMentAll project. This content reflects only the author’s view and the European Commission is not responsible for any use that may be made of the information it contains.The Health Services Research Unit, University of Aberdeen, receives core funding from the Chief Scientist Office of the Scottish Government Health Directorates. CRV was funded by a Clinician Scientist award supported by the National Institute for Health Research during this independent research.

Availability of data and materials
The datasets generated and/or analysed during the current study are deposited on UK Datashare (record 852,387). Further information is available from the corresponding author on reasonable request.


  • normalization process theory
  • NPT
  • NoMAD
  • implementation process
  • questionnaire
  • instrument development
  • complex interventions


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