title: Applying normalization process theory to understand implementation of a family violence screening and care model in maternal and child health nursing practice: a mixed method process evaluation of a randomised controlled trial.
abstract: BACKGROUND
  In Victoria, Australia, Maternal and Child Health (MCH) services deliver primary health care to families with children 0-6 years, focusing on health promotion, parenting support and early intervention. Family violence (FV) has been identified as a major public health concern, with increased prevalence in the child-bearing years. Victorian Government policy recommends routine FV screening of all women attending MCH services. Using Normalization Process Theory (NPT), we aimed to understand the barriers and facilitators of implementing an enhanced screening model into MCH nurse clinical practice.
  
  
  METHODS
  NPT informed the process evaluation of a pragmatic, cluster randomised controlled trial in eight MCH nurse teams in metropolitan Melbourne, Victoria, Australia. Using mixed methods (surveys and interviews), we explored the views of MCH nurses, MCH nurse team leaders, FV liaison workers and FV managers on implementation of the model. Quantitative data were analysed by comparing proportionate group differences and change within trial arm over time between interim and impact nurse surveys. Qualitative data were inductively coded, thematically analysed and mapped to NPT constructs (coherence, cognitive participation, collective action and reflexive monitoring) to enhance our understanding of the outcome evaluation.
  
  
  RESULTS
  MCH nurse participation rates for interim and impact surveys were 79% (127/160) and 71% (114/160), respectively. Twenty-three key stakeholder interviews were completed. FV screening work was meaningful and valued by participants; however, the implementation coincided with a significant (government directed) change in clinical practice which impacted on full engagement with the model (coherence and cognitive participation). The use of MCH nurse-designed FV screening/management tools in focussed women's health consultations and links with FV services enhanced the participants' work (collective action). Monitoring of FV work (reflexive monitoring) was limited.
  
  
  CONCLUSIONS
  The use of theory-based process evaluation helped identify both what inhibited and enhanced intervention effectiveness. Successful implementation of an enhanced FV screening model for MCH nurses occurred in the context of focussed women's health consultations, with the use of a maternal health and wellbeing checklist and greater collaboration with FV services. Improving links with these services and the ongoing appraisal of nurse work would overcome the barriers identified in this study.
authors.affiliation: Judith Lumley Centre, La Trobe University, Melbourne, Australia. l.hooker@latrobe.edu.au.
authors.forename: Leesa
authors.initials: L
authors.lastname: Hooker
authors.affiliation: Judith Lumley Centre, La Trobe University, Melbourne, Australia. r.small@latrobe.edu.au.
authors.forename: Rhonda
authors.initials: R
authors.lastname: Small
authors.affiliation: School of Social Work, University of Melbourne, Melbourne, Australia. cathy.humphreys@unimelb.edu.au.
authors.forename: Cathy
authors.initials: C
authors.lastname: Humphreys
authors.affiliation: Department of General Practice, Primary Care Research Unit, University of Melbourne, Melbourne, Australia. k.hegarty@unimelb.edu.au.
authors.forename: Kelsey
authors.initials: K
authors.lastname: Hegarty
authors.affiliation: Judith Lumley Centre, La Trobe University, Melbourne, Australia. a.taft@latrobe.edu.au.
authors.forename: Angela
authors.initials: A
authors.lastname: Taft
mesh_terms: D002648:Child; D002662:Child Health Services / Q000458:organization & administration; D002675:Child, Preschool; D017579:Domestic Violence / Q000517:prevention & control*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008427:Maternal Health Services / Q000458:organization & administration; D016389:Maternal-Child Nursing / Q000379:methods; D010371:Pediatric Nursing / Q000379:methods; D016730:Program Development; D014739:Victoria