Agency and implementation: Understanding the embedding of healthcare innovations in practice

An innovation is almost never a thing-in-itself. To be sure, there is often what looks like a thing – a newly invented or modified way of thinking or acting, or an artifact, or a system – that is identified in everyday talk as something new. In healthcare, as in almost every other area of human organization, innovations often involve highly organized, institutionally sanctioned, and systematically regulated changes in the structure and delivery of services. This paper presents a theory of implementation and embedding of innovations – Normalization Process Theory – and explores its application to a highly complex ensemble of socio-technical practices, clinical shared decision making. The theoretical analysis presented here shows how implementation as a process and embedding as a state can be conceptualized in terms of social mechanisms that effect changes in the ways that agents' contribute to normative restructuring, the reworking of relational conventions and group processes, the enacting of practices, and their projection into the future.