. 2013 Apr 4;4(5):31. doi: 10.1177/2042533313476691

Table 3.

Model exploring reasons for non-use using normalization process theory

Endogenous (professional) factors	Exogenous (organizational) factors
Interactional workability	Skill-set workability
1. Congruence: normalization is likely if the actors have a shared belief in the process Lack of use by most practitioners suggests that there was doubt about the value of the tool: ‘I attended the training and thought (Isabel) would be quite useful but not to use on every patient. I didn't really get around to using it because you don't really see many of those patients in that time frame’ (1, Senior female GP) Doctor/patient relationship: ‘I'd be a bit concerned about the patients’ perception of entering information into a system that gives you an answer. You hear patients say, “Oh I went to see my GP and they looked at a book”’ (2, Junior female GP). 2. Disposal: normalization is likely if the actors have a shared belief in the goals Practitioners agreed that a decision support system could be useful, but not Isabel as it is currently configured. ‘[Isabel] comes up with the bizarre…not your common garden stuff you see in general practice’ (3, Senior nurse practitioner)	5. Allocation: normalization is likely if actors’ responsibilities are agreed within contexts Only the practice managers agreed to participate, not clinicians Use of the system was at the discretion of the practitioner Roles were not agreed ‘It would have been good for [the new trainee]….It is more placed as a learning tool…I don't think the GPs would have used it. They would have done it once and then thought…’ (3, Senior nurse practitioner) 6. Performance: normalization is likely if the level to which actors perform is agreed within contexts No agreement at a practice level: At practice G all GPs agreed that the practice nurse should be the sole person to trial the system.
Relational integration 3. Accountability: normalization is likely if actors have the necessary expertise Training provided was enough to use the system 4. Confidence: normalization is likely if actors believe it falls within their remit The system is not more knowledgeable than they are: ‘With Isabel you're putting data in and you're not giving the mind the exercise it needs. What you've been trained in medical school is going up against that.’ (4, Junior male GP)	Contextual integration 7. Execution: normalization is likely if resourcing issues are agreeable between/within contexts All practices had sufficient IT resources Time was not adequately resourced, e.g. no extra time was allotted for consultations 8. Realization: normalization is likely if organizational systems between/within contexts are minimally disrupted Searches took 4 minutes within a 10 minute period for consultations: ‘We have so many things thrown at us…the PCT telling us to do this and that you can get a little overwhelmed.’ (5, Senior male GP)

Endogenous (professional) factors

Exogenous (organizational) factors

Interactional workability

Skill-set workability

1. Congruence: normalization is likely if the actors have a shared belief in the process

Lack of use by most practitioners suggests that there was doubt about the value of the tool: ‘I attended the training and thought (Isabel) would be quite useful but not to use on every patient. I didn't really get around to using it because you don't really see many of those patients in that time frame’ (1, Senior female GP)
Doctor/patient relationship: ‘I'd be a bit concerned about the patients’ perception of entering information into a system that gives you an answer. You hear patients say, “Oh I went to see my GP and they looked at a book”’ (2, Junior female GP).

2. Disposal: normalization is likely if the actors have a shared belief in the goals

Practitioners agreed that a decision support system could be useful, but not Isabel as it is currently configured. ‘[Isabel] comes up with the bizarre…not your common garden stuff you see in general practice’ (3, Senior nurse practitioner)

5. Allocation: normalization is likely if actors’ responsibilities are agreed within contexts

Only the practice managers agreed to participate, not clinicians
Use of the system was at the discretion of the practitioner
Roles were not agreed ‘It would have been good for [the new trainee]….It is more placed as a learning tool…I don't think the GPs would have used it. They would have done it once and then thought…’ (3, Senior nurse practitioner)

6. Performance: normalization is likely if the level to which actors perform is agreed within contexts

No agreement at a practice level: At practice G all GPs agreed that the practice nurse should be the sole person to trial the system.

Relational integration
3. Accountability: normalization is likely if actors have the necessary expertise

Training provided was enough to use the system

4. Confidence: normalization is likely if actors believe it falls within their remit

The system is not more knowledgeable than they are: ‘With Isabel you're putting data in and you're not giving the mind the exercise it needs. What you've been trained in medical school is going up against that.’ (4, Junior male GP)

Contextual integration
7. Execution: normalization is likely if resourcing issues are agreeable between/within contexts

All practices had sufficient IT resources
Time was not adequately resourced, e.g. no extra time was allotted for consultations

8. Realization: normalization is likely if organizational systems between/within contexts are minimally disrupted

Searches took 4 minutes within a 10 minute period for consultations: ‘We have so many things thrown at us…the PCT telling us to do this and that you can get a little overwhelmed.’ (5, Senior male GP)