How to use NoMAD?
The NoMAD instrument may be used in different ways to suit your needs, but it needs to be adapted to ‘make sense’ for your participants. Here we provide guidance on how to do this.
What are you using it for?
We hope that the NoMAD instrument will be used for a wide range of purposes and across different settings. It could be used simply to describe participants’ views about how an intervention impacts on their work, and their expectations about whether it could become a routine part of their work. It could be used at different time points, to see if perceptions have changed after a period time. It also could be used as a way of improving implementation by identifying areas needing further work to progress an implementation project. For example, the responses may indicate that the intervention ‘makes sense’ to participants (Coherence), but that specific aspects of engagement (Cognitive Participation) appear low, suggesting that further effort could be targeted at broadening participation or working on participants’ commitment to making the intervention work.
These are just examples though of how NoMAD might be used. We look forward to hearing about the different ways that others use NoMAD in future.
Whatever way you wish to use the NoMAD instrument, this will determine how you approach the task of customising your survey.
Customising NoMAD for use
The NoMAD instrument items need to be embedded in a survey that you develop yourself so that it is appropriate for your target respondents. This includes having a specific introduction about the intervention you are asking about, adding relevant questions about the respondents’ roles, and potentially including additional general questions about the intervention that you are also interested in.
Determine who should complete the survey. You may be interested in the perceptions of a single group of professionals, or multiple groups. In deciding who should complete it, a key consideration is how involved they are with the implementation. It is likely that some groups will be more familiar with engaging with the target intervention than are others, but this is okay if all groups are familiar enough to be able to answer most questions. The item response options allow for people to indicate if and why they cannot rate a particular item.
Deciding how to conduct the survey. It is possible to create your survey electronically (eg using online survey software) or on paper. This will depend on how you can best access respondents. In our study we used both approaches.
Customising the instructions. In the instrument accessible on this website, we provide an example of how to introduce the survey. This just needs to be adapted to fit your own purpose.
Determine your role questions. We have provided examples of these, but just as a guide. These questions should reflect your participant groups, and any other information you might want to collect for comparing responses. For example, if you are surveying people from different sites or geographical regions and want to explore any site differences, then you will include a question about this.
Customising the wording of the items. We recommend that throughout the survey, the term [intervention] is replaced with an intervention ‘name’ that will be most familiar to the respondents. This includes using your own intervention name in the ‘option B’ response labels.
Customising and/or adding general questions. In addition to the 20 items reflecting the NPT constructs, we provide 3 items intended to provide a more general assessment of participants’ experience and expectations of the implementation process. These items should be adapted as appropriate, and you may wish to add extra questions that you are interested in. These extra questions may be about any practice related outcomes of interest rather than the implementation process. For example, if an objective of the intervention is to make it easier for staff to support patients to self manage, you may want to add a question such as ‘the [intervention] makes it easier for me to support patients in managing their own care’.
Analysing your survey data. How you approach this will depend on the questions you wish to explore, and the expertise you have available for analysis. However, we suggest that this does not need to be complicated. For example, tables summarising the frequency of responses to items can indicate where participants are providing more positive or negative responses. We will update this website with examples of analysis from use of the NoMAD instrument in due course.
- Linking responses of individuals at different survey points. If you are interested in how individuals' perceptions change over time, you may wish to track responses. If you are using electronic survey software, you may be able to do this in various ways, for example by using unique survey entry links for individual participants generated by the software. It is also possible to do this in paper surveys, without compromising anonymity, for example by requesting participants to use a formula to develop a unique identifier code based on selected characters of name, birthdate etc that would lead to the same identifier code if completed at a later time. This is unlikely to be foolproof - but may be a solution for smaller paper-based surveys.
Other things to consider:
NPT is all about understanding the complexity of the work involved in implementation, and we acknowledge that specific approaches to using the NoMAD instrument will need to vary. We have addressed this as far as possible within the NoMAD instrument by including guidance on framing the survey instructions, and by the use of the ‘Option B’ response categories for respondents to indicate if an item is not relevant to their role, to the intervention or to the present time when surveyed. We feel these options are important as they make it easier for participants to respond, and they help enhance the validity of the instrument by ensuring that item responses are genuine.
Despite this, you may need to think about adapting the wording of the NoMAD items more than just adding the target intervention name. For example, if you are using it very early on during an implementation process, the wording of the NoMAD items may make more sense to respondents if they are framed about their expectations rather than experiences For example, ‘I can see how [the intervention] would differ from usual ways of working’ rather than ‘I can see how [the intervention] differs from usual ways of working’. If you need to adapt the items we would advise sticking to the original wording of the items as far as possible, while ensuring they make sense to the respondents and to the timing of the survey.
It is also possible that only particular sets of items (from the four construct sections) may be of interest or appropriate at the time of your survey. This is fine if it makes sense for your use of the NoMAD instrument.
At this time, we do not provide specific instruction on how to generate scale or construct scores for the NoMAD instrument. Further guidance on this will be provided in due course.
How to cite the NoMAD instrument:
Finch, T.L., Girling, M., May, C.R., Mair, F.S., Murray, E., Treweek, S., Steen, I.N., McColl, E.M., Dickinson, C., Rapley, T. (2015). Nomad: Implementation measure based on Normalization Process Theory. [Measurement instrument]. Retrieved from http://www.normalizationprocess.org.