title: Arduous implementation: does the Normalisation Process Model explain why it's so difficult to embed decision support technologies for patients in routine clinical practice.
abstract: BACKGROUND
  Decision support technologies (DSTs, also known as decision aids) help patients and professionals take part in collaborative decision-making processes. Trials have shown favorable impacts on patient knowledge, satisfaction, decisional conflict and confidence. However, they have not become routinely embedded in health care settings. Few studies have approached this issue using a theoretical framework. We explained problems of implementing DSTs using the Normalization Process Model, a conceptual model that focuses attention on how complex interventions become routinely embedded in practice.
  
  
  METHODS
  The Normalization Process Model was used as the basis of conceptual analysis of the outcomes of previous primary research and reviews. Using a virtual working environment we applied the model and its main concepts to examine: the 'workability' of DSTs in professional-patient interactions; how DSTs affect knowledge relations between their users; how DSTs impact on users' skills and performance; and the impact of DSTs on the allocation of organizational resources.
  
  
  RESULTS
  A conceptual analysis using the Normalization Process Model provided insight on implementation problems for DSTs in routine settings. Current research focuses mainly on the interactional workability of these technologies, but factors related to divisions of labor and health care, and the organizational contexts in which DSTs are used, are poorly described and understood.
  
  
  CONCLUSIONS
  The model successfully provided a framework for helping to identify factors that promote and inhibit the implementation of DSTs in healthcare and gave us insights into factors influencing the introduction of new technologies into contexts where negotiations are characterized by asymmetries of power and knowledge. Future research and development on the deployment of DSTs needs to take a more holistic approach and give emphasis to the structural conditions and social norms in which these technologies are enacted.
authors.affiliation: Department of Primary Care and Public Health, School of Medicine, Cardiff University, Heath Park, CF14 4YS, UK. elwyng@cardiff.ac.uk
authors.forename: Glyn
authors.initials: G
authors.lastname: Elwyn
authors.forename: France
authors.initials: F
authors.lastname: Légaré
authors.forename: Trudy
authors.initials: T
authors.lastname: van der Weijden
authors.forename: Adrian
authors.initials: A
authors.lastname: Edwards
authors.forename: Carl
authors.initials: C
authors.lastname: May