Validation of the German Normalization Process Theory Measure G-NoMAD: Translation, Adaptation, and Pilot Testing
Authors: Freund Johanna , Piotrowski Alexandra , Bührmann Leah , Oehler Caroline , Titzler Ingrid , Netter Anna-Lena , Potthoff Sebastian , Ebert David Daniel , Finch Tracy , Köberlein-Neu Juliane , Etzelmüller Anne 
Published: June 2023

Abstract
Background
Implementation of evidence-based healthcare practices (EBPs) is a complex endeavour and is often lagging behind research-informed decision processes. Understanding and systematically improving implementation using implementation theory can help bridge the gap between research findings and practice. This study aims to translate, pilot and validate the German version of the NoMAD questionnaire (G-NoMAD), an instrument derived from Normalization Process Theory, to be used to explore the implementation of EBPs.
Methods
Survey data has been collected in four German research projects and subsequently combined into a validation data set. Two versions of the G-NoMAD existed, independently translated from the original English version by two research groups. A measurement invariance analysis was conducted comparing latent scale structures between groups of respondents to both versions. After determining the baseline model, the questionnaire was tested for different degrees of invariance (configural, metric, scalar, and uniqueness) across samples. A confirmatory factor analysis for three models (a four factor, a unidimensional, and a hierarchical model) was used to examine the theoretical structure of the G-NoMAD. Finally, psychometric results were discussed in a consensus meeting and the final instructions, items, and scale format were agreed.
Results
A total of 539 health care professionals completed the questionnaire. The results of the measurement invariance analysis showed configural, partial metric and partial scalar invariance indicating that the questionnaire versions are comparable. Internal consistency ranged from acceptable to good (0.79 ≤ α ≤ 0.85) per subscale. Both the four factor and the hierarchical model achieved a better fit than the unidimensional model, with indices from acceptable (SRMR = 0.08) to good (CFI = 0.97; TLI = 0.96). However, the RMSEA values were only close to acceptable (four-factor model: χ2164 = 1029.84, RMSEA = 0.10; hierarchical model: χ2166 = 1073.43, RMSEA = 0.10).
Conclusions
The G-NoMAD provides a reliable and promising tool to measure the degree of normalization among individuals involved in implementation activities. Since the fit was similar in both the four factor and the hierarchical model, priority should be given to the practical relevance of the hierarchical model which includes a total score and four subscale scores. The findings of this study support the further usage of the G-NoMAD in German implementation settings.
Trial registration
Both the AdAM project (No. NCT03430336, 06/02/2018) and the EU-project ImpleMentAll (No. NCT03652883, 29/08/2018) were registered on ClinicalTrials.gov. The ImplementIT study was registered at the German Clinical Trial Registration (No. DRKS00017078, 18/04/2019). The G-NoMAD validation study was registered at the Open Science Framework (No7u9ab, 17/04/2023).