Box 3.

Factors influencing the achievement of Normalisation Process Theory (NPT) constructs^a

NPT construct	Description	Barriers to achievement
Coherence (Sense-making work)	The work of understanding ways of working or new practices	Lack of clear understanding and differentiation of HFpEF Professional scepticism Lack of visibility of HFpEF Variability in referral pathways and specialist input Diagnostic process not attuned to identifying HFpEF Lack of shared knowledge of specific tasks for HFpEF management, for example, clinical inertia/lack of evidence-based practice Uncertain roles and responsibilities in HFpEF care Lack of clear understanding of the implications of practices involved in HFpEF care
Cognitive participation (Relational work)	The work of engaging individuals/groups to engage in ways of working or new practices	Uncertainty about who to engage in HFpEF work, stemming from a lack of coherence Uncertainty about what constitutes the right set of practices and the validity of these practices for HFpEF Lack of collective definition of the procedures required for optimal HFpEF care
Collective action (Operational work)	The work of implementing ways of working or new practices and providing the necessary resources and training to operationalise these	Failure to initiate work around managing HFpEF owing to lack of coherence Unclear undifferentiated treatment due to lack of coherence Educational need around HFpEF Missed opportunities for self-management, specialist review, or cardiac rehabilitation/activity programmes Unclear division of labour for HFpEF work Systems more attuned to practices for HFrEF, for example, QOF, referral pathways, and echocardiogram reports Inequitable and variable division of resources for HFpEF
Reflexive monitoring (Appraisal work)	The work of evaluating and monitoring ways of working or new practices	Variability/uncertainty about best practice and roles/responsibilities in long-term follow-up due to lack of coherence and inequitable HF provision Communication problems across primary and secondary interface Access and capacity limitations Systems more attuned to monitoring HFrEF or associated comorbid conditions

^aNPT framework by May et al has been used to inform findings.²⁶ HF = heart failure. HFpEF = heart failure with preserved ejection fraction. HFrEF = heart failure with reduced ejection fraction. QOF = Quality and Outcomes Framework.