Open Journal of Philosophy
2013. Vol.3, No.4, 491-501
Published Online November 2013 in SciRes (http://www.scirp.org/journal/ojpp) http://dx.doi.org/10.4236/ojpp.2013.34071
Open Access 491
Understanding the Implementation of a Complex Intervention
Aiming to Change a Health Professional Role: A Conceptual
Framework for Implementation Evaluation
Sabina Abou-Malham1, Marie Hatem1, Nicole Leduc2
1Department of Social and Preventive Medicine , School of Public Heath, Université d e Montréal, Montreal, Canada
2Department of Health Admini stration, School of Public Health, Université de Montréal, Montreal, Canada
Email: email@example.com, firstname.lastname@example.org, email@example.com
Received August 5th, 2013; re vis ed Se ptember 5th, 2013; accepted September 12th, 2013
Copyright © 2013 Sabina Abou-Malham et al. This is an open access article distributed under the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
This paper proposes a conceptual framework for understanding the implementation process of a complex
intervention concerned with professional role change. The proposed framework holds that the intervention
must address three interacting systems (socio-cultural, educational and disciplinary) through which a
health professional role evolves. Each system is operationalized by four dimensions (values, methods, ac-
tors and targets). As for the implementation, the framework posits that it can be analyzed, by depicting
the barriers and facilitators located within the dimensions of the three interacting systems and within the
intervention involved in the process through using the “menu of constructs” approach suggested by the
Consolidated Framework for Implementation Research (CFIR). The implications of this framework, on
theoretical research and practical levels, are reviewed.
Keywords: Evaluation; Implementation; Framework; Change; Health Professional Role; Midwifery
Professional role change has been the focus of many policy
initiatives in a context of rising social pressures, new technolo-
gies, higher demands of care and health needs. It has been con-
sidered as a viable strategy to address health resource shortages,
and to support the move from fragmented care provision to
models that provide continuity of care and accessibility to op-
timal health care (Laurant et al., 2010; McKenna, Keeney, &
Hasson, 2009). Many types of changes in professional roles
have been put forward such as enhancement, substitution, dele-
gation, and introducing a ne w type of professional (Laurant et al.,
2010; Sibbald, Shen, & McBride, 2004). Thus, enhancing roles
and proliferation of new roles in many disciplines (e.g. nursing,
midwifery) are occurring in health care systems throughout the
world (Kislov, Nelson, de Normanville, Kelly, & Payne, 2012;
McKenna et al., 2008). For instance, we are witnessing lately
considerable growth in implementing initiatives for expanding
professional roles such as nurse practitioner role and even cre-
ating new roles such as consultant midwifery roles a cross many
countries (UK, Australia, Quebec) (Sangster-Gormley, Martin-
Misener, Downe-Wamboldt, & DiCenso, 2011).
Professional role does not operate in a vacuum, but in
systems that modulate this role (Dubois & Singh, 2009; Hatem-
Asmar, Fraser, & Blais, 2002; Laurant et al., 2010). Thus,
changing a health professional role refers to a complex process
involving interdependent changes occurring within a variety of
systems (Hatem-Asmar, 1997; Laurant et al., 2010; Nancarrow,
Moran, Wiseman, Pighills, & Murphy, 2012). For instance,
professional education has to be enhanced and training pro-
grams have to be reviewed. With regard to society, public ac-
ceptance of professional authority, and cultural credibility of
the new role have to be gained and client support has to be
mobilized. Concerning the organization of the profession, legal
and regulatory actions, professional associations have to be
adapted to accommodate role change (Hatem, 2008; Kronus,
1987; Laurant et al., 2010; Turner, 1990).
Given that issues surrounding health professions are con-
ceived as being fundamentally systemic in nature, this requires
accordingly that interventions aiming to change a health pro-
fessional role need to address the relevant systems. Neverthe-
less, successful implementation of such interventions depends
upon whether contextual conditions are favorable for change.
Given the complexity of the implementation process, research-
ers are called upon to conduct implementation focused-evalua-
tion, measure the extent of real-time implementation and iden-
tify potential influences of contextual factors on the progress of
implementation efforts (Champagne, Brousselle, Hartz, Contan-
driopoulos, & Denis, 2011; Damschroder et al., 2009).
Therefore, understanding the implementation process re-
quires a comprehensive evaluative framework adapted to the
context in which the intervention is being introduced, and in
our case the systems concerned with professional role change.
Such framework helps to better understand the challenges that
come into play for facilitating or impeding the implementation
The present paper argues and justifies the relevance of a
comprehensive conceptual framework to analyze the imple-
S. ABOU-MALHAM ET AL.
mentation of a complex intervention aiming to change a health
professional role. It is organized as follows: first, we begin by
explaining how we conceptualize a health professional role
change; we then, present implications of our conceptual think-
ing for designing interventions aiming to change a health pro-
fessional role. This is followed by presenting the relevance of
using implementation focused-evaluation and by describing our
proposed conceptual framework laying the two theoretical per-
spectives that guided the development of the framework:
1) Hatem-Asmar conceptual model to identify the context in
which the implementation takes place; 2) and the meta-theo-
retical Consolidated Framework for Implementation Research
(CFIR) of Damschroder et al. (2009) as an analytical tool for
understanding implementation success or failure. Next, we
illustrate the use of the framework through an example in the
field of midwifery professional role; and lastly we discuss its
implications in the domain of evaluation and the organization
Conceptualizing a Health Professional
We advance systems approach as a basis capable of support-
ing health professional role change. Therefore, in this section,
we will explore the following themes: 1) the role of systems
approach in addressing the issues that affect a health profes-
sional role change; 2) the nature of systems concerned with the
professional role change; 3) a conceptual model for health pro-
fessional role; and the 4) applicability of the model to mid-
wifery role change.
Role of Systems Approach in Addressing the Issues
That Affect a Health Professional Role Change
The concept of systems approach consists of comprehending
the whole (system) instead of the parts. It concerns examining
the linkages and interrelationships between the parts (subsys-
tems) and the whole, and the relation of the whole with its con-
text (Hargreaves, 2010; Parsons, 2007; Trochim, Cabrera,
Milstein, Gallagher, & Leischow, 2006). Exploring the change
process thru a systemic lens requires focusing on the interac-
tions between system parts and with external environment as
well as on coherence and alignment of the system’s compo-
nents with the desired impact (Foster-Fishman, Nowell, &
Yang, 2007; Supovitz & Taylor, 2005). Systems approach
places emphasis on problem solving and can be seen as a sec-
ond order change (Ison, Maiteny, & Carr, 1997) which requires
attention to the underlying root causes of a problem and in-
volves radical changes (Gash & Orlikowski, 1991). Shifting the
focus from parts to wholes is a fundamental issue and this is
why systems approaches appear so relevant to changing a
health professional role.
A systems approach moving away from silo thinking and
analyzing the multiple facets of a health profession situation
has been advocated by a number of sociologists. Freidson
(1970) has emphasized that redesigning a formal curriculum of
training and supporting the profession by licensure and legal
exclusive right to work, will not assure its survival unless con-
sidering “the profession service orientation which is a public
imputation by which leaders have persuaded society to grant
and support its autonomy” (Friedson, 1970: p. 82). According
to the author, conditions which are causal in producing profes-
sional autonomy are the societal, political, legal, educational
and inter occupational which set the general limits of the work
and grant an occupation the professional status of self-regula-
tive autonomy. This is also echoed in Turner’s view (Turner,
1990) who suggests that conditions necessary to complete the
change process involve a more generalized public acceptance of
professional authority. Similarly, Kronus (1987) points out that
conditions conducive to the successful expansion of role
boundaries depend not only on the development of training
facilities but upon mobilized client support and role’s credibil-
ity among the society at large. To summarize briefly, a health
professional role’s change is deeply grounded, not just in the
education system, but within the current position of the profes-
sion in the society at large and also as regards to the discipli-
nary characteristics of the profession mainly its organization
thru regulation which defines the scope of practice and also
shapes inter-professional relationships.
Nature of Systems Concerned with the Professional
Understanding the type of system and its general characteris-
tics in which the addressed problem is embedded is crucial for
choosing the frame of reference that is appropriate for system
investigation. In this context, systems refer to Human Social
Activity Systems (HSAS) exhibiting the following characteris-
tics: being open systems, depending on their external interac-
tion (with their environment) as well as on their internal inter-
actions (within-system), and governed by balancing and rein-
forcing feedback mechanisms (Banathy & Jenlink, 2004; Senge,
1990). They are composed of subsystems capable of making
transformations of inputs to produce outputs for use by other
subsystems, and characterized by alignment (Hummelbrunner,
2011). For example, systemic change efforts in midwifery role
have been the focus of attention of many international organi-
zations calling for a fundamental change in reinforcing profes-
sional role as a key to quality health services. These calls seek
not only a change in the educational activities but a deep
change in many systems such as political system, society, and
the organization of the discipline itself through establishing
regulation, midwifery models of care, etc. (Brodie, 2002;
Homer et al., 2009; United Nations Population Fund, 2010).
Consequently, it is presumed that such perspective has tremens-
dous implications on improving maternal health according to
the strategies aiming to attain Millennium Development Goals
4 & 51 (World Health Organization, 2002). As a result, profes-
sional role change in the health sphere cannot be examined
without considering the systems that modulate the role. As we
seek to understand the systems view to professional role change,
it will be helpful to introduce a conceptual framework which
explains the underpinnings of this view.
Paradigmati c Conceptual Model for Health
Professional Ro le
The nature of instigations to role change fit into the triadic
conceptual model of paradigms developed by Hatem-Asmar
(1997, 2002). The authors highlight the importance of taking
into account three systems (socio-cultural, educational, disci-
plinary) as a whole system for addressing a health professional
role change. The authors consider those three systems, includ-
1MDG4: to reduce child mortality ; M DG5 : t o improve maternal health.
S. ABOU-MALHAM ET AL.
ing their dimensions, to have an interactional relationship
within which a professional role evolves, acknowledging the
complex nature of developing an educational program for
health professionals. The authors adopted Bertrand and Valois
(1982) model who demonstrated the need to consider the mutu-
ally reinforcing links between educational and socio-cultural
paradigms, based on their systemic nature, while developing an
educational program intended for school students and for tech-
nicians; choosing an educational paradigm depends on the
dominant socio-cultural paradigm and its corresponding type of
society. As stated by these authors, education in any society is a
reflection of the collective beliefs, values and needs of that
society which are manifested in terms of the educational goals;
these goals shape the content of the educational program and
make it relevant to the aspirations of the society. Thus, society
and education are considered as open social systems, repre-
senting one for the other the external energy used to regenerate
the system (Rousseau, Desmet, & Paradis, 1989). The charac-
teristics of these systems embrace: i) the environment within
which this system operates; ii) the relevant structures so called
elements within a system to bring about the desired change; iii)
the operator that represents numerous actors whose functions
relate to handling the variables of action; iv) the variables of
action allowing the operator to process the transformation from
input to output (methods); and finally; v) the essential variables
which consist of criteria for measuring the success of the mis-
sion assigned to the educational institution (goals). Bertrand
and Valois (1982) also demonstrated that the relation between
the socio-cultural paradigms and the educational institutions,
through various logics—the cybernetic logic of causality, the
logic of systemic approach and the self-determination of the
socio-cultural systems, is bidirectional. Relying on this relation,
they stipulated that the socio-cultural paradigm guides the edu-
cational one. However, despite the dominance of the socio-
cultural paradigm, the educational institution has the capacity to
be self-determinate, to choose an educational paradigm differ-
ent from that imposed by the dominant socio-cultural paradigm
and thus to produce changes through fulfilling three main func-
tions: creation, adaptation and reproduction.
Hatem-Asmar et al. (2002) shed light on the limitations of
this thinking when applied to a health profession and emphasize
the need for a third paradigm called the disciplinary paradigm
which considers the characteristics pertaining to the profession
itself. Similarly, they demonstrate the systemic nature of a
health profession to make explicit its interaction with the other
two systems (socio-cultural and educational) by referring to the
characteristics of a system. As a result, they hypothesized that a
health profession presents the following main characteristics of
a system: i) the environment that is the context in which the
professional as part of the system operates; ii) the system that
comprises the structures to make the desired change (e.g. the
governmental bodies concerned by the legalization of the pro-
fession and its subsequent implementation); iii) the operator
whose function relates to handling the variables of action (e.g.
practitioners, educators); iv) the variables of action (means)
consisting of the health care services provided by health profes-
sionals to patients and their families; and finally v) the key
variables corresponding to the targets considered as the ex-
pected impact of the professional practice on population’s
health. Based on this rationale which demonstrates the linkages
between these three paradigms that have the systemic charac-
teristics, this conceptual approach considers three systems to
have an interactional relationship explained by the fact that any
change in a single system does not remain isolated but can in-
fluence the two other systems.
The model further acknowledges the four inter-dimensions
relationships within each system which means between: 1) the
axiology/values (beliefs, legal, moral grounding); 2) the meth-
odology (organizational procedures used to represent a problem
and its solutions); 3) the ontology/actors (persons or entities
physically and mentally involved in the process); and finally, 4)
the teleology/targets (intentions, ultimate goals and solutions)
(Hatem-Asmar et al., 2002).
As a conclusion, changing a health professional role involves
profound changes in the socio-cultural and disciplinary systems
that interact with the educational one.
Applying the Conceptual Model to Midwifery Role
We seek to demonstrate how this model can be applied em-
pirically in the field of midwifery professional role change.
According to the systems change approach, leveraging change
in a single system will not lead to the desired outcome unless
coupled with changes occurring in other parts of the system;
what counts are the properties that emerge from a whole rather
than the parts (Checkland, 1999). Consequently, a broader view
allows one to see the evolution of a health professional role as
an emergent property of the synergistic relationships among the
socio-cultural, educational, and disciplinary systems and among
each system’s dimensions which constitutes “a functioning
whole” (Laszlo & Krippner, 1998; Trochim et al., 2006: p. 539).
Therefore, producing a fully qualified midwife fit to practice,
according to the needs of society in an enabling environment, is
determined by a multi-conceptual faceted systems interacting in
synergy where no single system’s influence dominates. It is
considered as a second order change involving a radical rupture
with past frames (Gash & Orlikowski, 1991). In the case of
midwifery, such a change has been triggered by various inter-
national calls to develop an autonomous, self-regulated mid-
wifery workforce capable of fulfilling the woman-centered
philosophical midwifery mandate which promotes a human
rights-based approach to reduce maternal mortality (United
Nations Population Fund, 2011; World Health Organization,
Relying on Hatem-Asmar model, we will illustrate in the
following section how the characteristics of human social activ-
ity systems (HSAS) under investigation can be applied to the
midwifery domain. The following characteristics are discussed:
transformation, alignment and feedback.
Transformation: Systems transform inputs, flowing from
the external environment and from subsystems, into outputs, in
order to sustain the life of the system (Banathy & Jenlink, 2004;
Hummelbrunner, 2011). In the case of midwifery, the educa-
tional system processes inputs coming from the larger society,
represented for instance by the potential candidate who is seek-
ing to be enrolled in the midwifery education program, who
enters the educational system and then undergoes the educa-
tional transformation process (e.g. methods of learning) to be-
come a qualified midwife. Thereafter, she enters again in the
disciplinary system in which her professional qualifications are
put into practice under the specific regulatory conditions in
order to perform properly and autonomously. Those services
are considered as inputs for the socio-cultural system that is, if
Open Access 493
S. ABOU-MALHAM ET AL.
used adequately, contribute to improving the performance of
health systems (e.g. continuity of maternal ca re) and ultimately
women’s health. Quality reproductive health services will aid to
increase the demand of midwifery services which in turn will
help to enhance awareness of the importance of these services
and consequently, improve the midwifery image and gain wide-
spread legitimacy from the public. This will have a potential
appealing effect on pursuing a career in midwifery and on en-
rollment of new candidates in th e midwifery education.
Alignment: Contribution to improving maternal outcomes
thru strengthening midwifery professional role will not occur
unless improvement is set up concurrently in the socio-cultural,
educational and disciplinary systems. For the intervention to
succeed, it must align each of these three systems: indeed, the
midwifery educational program should reflect the values of the
society and be consistent with the social needs. Those values
should then be incorporated into the language of the legislation,
regulation, and standards of practice governing the redesigned
professional role (World Health Organization, 2011b). Deliv-
ering health services must also be grounded in the philosophy
underpinning the educational foundation for practice (a phi-
losophy that promotes a non-interventionist approach) (United
Nations Population Fund, 2011).
A case example outlining the re-emergence of midwifery
profession in Quebec can serve for giving further insight into
analysis of systems alignment. In the late 1980’s, the social
feminism movement, demanding for control over natural child-
birth and the political commitment to promote maternal health,
have led to the legalization and the implementation of the mid-
wifery profession following the favorable results of the evalua-
tion of midwifery practice in Quebec (Blais & Joubert, 2000).
This was the drive for establishing a student-centered education
program that aimed to develop the necessary competencies to
provide women-centered care and also to align midwifery edu-
cation with the philosophy of the profession (Hatem-Asmar,
1997; Hatem-Asmar & Fraser, 2004). It also led to setting up a
supportive legislative and regulatory environment governing
midwifery education and practice. Nevertheless, many chal-
lenges to the integration of midwives into the health care sys-
tem were documented during the evaluation phase such as: i)
lack of knowledge about the practice of midwifery on the part
of other health care providers; ii) deficiencies in the legal and
organizational structure of the pilot-projects; iii) competition
over professional territories; and iv) gaps between the mid-
wives’ and other providers’ professional cultures (Collin et al.,
2000). Till date, integration of midwives into the Quebec’s
healthcare system remains difficult to achieve, due to deficient
interdisciplinary collaboration with other maternity care pro-
viders resulting from the medical profession’s opposition to
midwifery care in some cases. In this example, a mismatch is
evident between the educa ti onal system on the one hand and the
socio-cultural and disciplinary systems on the other hand.
Negative interaction and misalignment between the three sys-
tems remain as midwives are currently being educated accord-
ing to the midwifery philosophy of care (values) but are still
experiencing in the practice settings difficult collaborative rela-
tionships (methods) with physicians and nurses which restrain
them from putting their competencies into practice in hospitals
settings limiting therefore their practice to birthing homes
(Collin et al., 2000). Challenges to successful integration is still
giving rise to adverse consequences for outcomes, thus affect-
ing the continuity of care, and putting mothers and babies at
risk (outcomes) (Klein, 2002).
Feedback: It is considered as the positive or negative re-
sponse that may facilitate or constrain the intervention from
attaining the expected outcomes (World Health Organization,
2009). One example is the humanistic philosophy of care im-
plying new collaborative models of care between care providers
in the disciplinary system. If this new vision encounters resis-
tance from physicians, it will then require a reaction in other
systems such as making adjustment in the socio-cultural system
and establishing new maternal policy initiatives and mecha-
nisms of care in clinical settings for successfully attaining the
In conclusion, reviewing the type of systems in which the
addressed problem is embedded, has implications for the way
interventions are designed to solve the problem, implemented
Designing an Intervention Concerned with Health
Professional Ro le
Through the application of the conceptual framework to the
case of midwifery profession in Quebec, an attempt has been
made to validate it empirically and to demonstrate the theoreti-
cal foundations for designing an intervention aiming to change
a health professional role. French et al. (2012) among other
researchers, advance that the use of theory along with the re-
sults of empirical methods research, will allow to assess the
barriers of and facilitators for implementation problem and
decide upon intervention components in order to build a sound
theoretically informed solutions. Therefore, we consider that
the model provides a strong theoretical rationale for the design
of the intervention, that allows analyzing the multiple facets of
the health profession situation (Hatem, 2008).
Consequently, we advance that the intervention will have to
consider introducing sets of complementary changes in three
systems with the intention of consolidating the whole system as
a central unit of change for broad scale improvement of a health
professional role in order to maximize the probability of suc-
cess. Nevertheless, it is important to note that the different com-
ponents of the intervention will be situationally determined by
the problem being addressed and empirically investigated
within the local context. Depending on the situation, it should
target either solely or conjointly education, the current position
and image of the health profession in the society, the legislative
framework that governs the profession, the human resources
management framework (e.g. working conditions), etc. (World
Health Organization, 2003).
Our Experience of Designing a Theory-Based
Intervention in the Midwifery Field
Following the international trend to effectively reduce ma-
ternal mortality, a multi-systems Action Plan concerning the
midwifery professional role has been recently developed in
Morocco (Hatem, 2008). The aim of the intervention was to
provide fully qualified midwives trained according to the In-
ternational Confederation of Midwives (ICM) Essential Com-
petencies for Basic Midwifery Practice (Thompson, Fullerton,
& Sawyer, 2011) to assist every woman through the reproduc-
tive life (United Nations Population Fund, 2010; World Health
To develop the midwifery intervention, the conceptual model
of Hatem-Asmar et al. (2002) was adopted using a three-step
approach translating thus theory into intervention design:
S. ABOU-MALHAM ET AL.
1) Assessing the current problem concerning the midwifery
profession by identifying the barriers and facilitators to the
professional role (target of change) that need to be addressed in
order to guide the choice of intervention components.
Barriers to, and facilitators of, the profession were identified
during the diagnostic phase and linked to each of the three-
system’s dimensions (values, methods, actors, targets) in an
empirical qualitative study conducted through focus group in-
terviews with many stakeholders in Morocco. The results re-
vealed that the midwifery profession’s problem is deeply
grounded, not just in education, but within the current image
and visibility of the profession in the society and in the profes-
sional community, and is related also to the legal framework, to
the professional scope of practice and conditions of work
(Hatem, 2008). It showed clearly that the midwife is trained in
a technocratic educational system, which prepares her to prac-
tice according to a biomedical disciplinary system in a socio-
cultural system that does not consider nor value the human
being (Hatem, 2008). In sum, the existing of such midwifery
workforce in Morocco was not an appropriate mechanism to the
full realization of the potential of the midwife as a key con-
tributor to a safe motherhood process, to advocate the position
of women in society and their reproductive health rights, and
subsequently to reduce MM (World Health Organization,
2) Designing an Action Plan consisting of components in-
tended to overcome the local barriers identified based on the
expertise of the consultant but mainly on the potential solutions
suggested by the key informants from the Moroccan field
(health professionals, midwifery educators, policy decision
makers, health programmer, etc.). Selection of components was
informed by the list of barriers and facilitators established. For
example: within the socio-cultural system, to address the barrier
related to the values dimension (midwifery image and lack of
visibility in the society), social marketing activities were cho-
sen to promote the professional role of the midwife; within the
educational system: as regards to barrier related to the tradi-
tional educational methods for delivering knowledge, increas-
ing material educational resources (anatomic models) to fit with
the new competency-based approach were selected.
In sum, the Action Plan was designed to be implemented in
the three systems (socio-cultural, educational, disciplinary). It
focused on the values, methods, actors and targets of the three
systems as a whole. The whole being the interaction of the in-
tervention with the dimensions of the three systems in which
the midwife operates.
3) Validation of the proposed intervention through a work-
shop involving several key persons belonging to the education,
political and clinical field. The objective was to explain the
theoretical underpinnings of the adopted pathways to change, to
check the relevance of the intervention and to readjust it ac-
cording to the views expressed.
In conclusion, the growth of change efforts in health profes-
sional role leads naturally to evaluative attempts of such initia-
tives which will be covered in the following sections.
The Relevance of an Implementation-Focused
Evaluation approaches serve a number of purposes which can
be developmental, formative, summative, or focused on moni-
toring and accountability. Evaluation designs, adopting forma-
tive approaches, are more likely to be of greater value at the
early phase of an innovation cycle (Patton, 2002, 2008). Im-
plementation of interventions has been reported to present
many challenges: it does not occur in a vacuum, it is sensitive
to local context and it can fail because of unforeseen contextual
barriers. There is general agreement among researchers that
interventions cannot be treated as black boxes independent of
their social, political, educational and professional contexts
(Champagne et al., 2011; Love, 2004). As such, a good under-
standing of the potential interactions between the intervention
and the context in which the intervention is implemented
proves to be crucial.
Process evaluation is particularly well suited for understand-
ing how the intervention outspreads under the specific context
conditions, for capturing information in real time and for keep-
ing consequently the iterative developmental process (Ho &
Schwen, 2006; Hummelbrunner, 2011; Pettigrew, Woodman, &
Cameron, 2001). It allows to generate lessons in order to fine-
tune the intervention to make effective adjustments as imple-
mentation progresses, and increases thus the likelihood of
changing a factor from a barrier to a driver (Champagne et al.,
2011; Love, 2004; Patton, 1997; Varkey, Horne, & Bennet,
2008). Besides, implementation information plays a critical role
in the accurate interpretation of evaluation outcomes, since it
can help in understanding how those outcomes are reached
(Damschroder et al., 2009; May et al., 2007). As such it pro-
vides many advantages to implementation success and long-
term sustainability (Stetler et al., 2006).
The Conceptual Framework: A Comprehensive
Evaluation Framework for Health
Professional Role Change
Theory Basis for the Proposed Framework
Understanding the implementation of an intervention aiming
to change a health professional role requires a framework that
examines the congruence of the intervention with the context,
and how the salient components of the intervention are unfold-
ing within the boundaries of three complex human activity
systems: 1) socio-cultural; 2) educational; and 3) disciplinary
We propose a conceptual framework that incorporates in-
sights from Hatem-Asmar et al. (2002) model discussed earlier,
and from the meta-theoretical framework developed by Dam-
schroder et al. (2009) to carry out implementation analysis. In
the following, we provide our rationale for choosing these
models and outline the theoretical principles supporting our
Hatem-Asmar Model: Hatem-Asmar (1997) argue that it is
unlikely that problems related to the health professional role be
correctly diagnosed and addressed without adopting the inter-
acting three systems approach, precisely because problems
often lie in the three systems in which evolves a health profes-
sional role. In our case, the context, defined according to im-
plementation research as the “environment or setting in which
the proposed change is to be implemented” (Kitson, Harvey, &
McCormack, 1998), is a multiple systems environment. It
serves as the basis of our Evaluation Framework which is more
suitable for illustrating what a professional role’s intervention
should target and how it should be evaluated. Therefore, our
framework builds on the work of Hatem-Asmar et al. (2002) to
identify the context through which the intervention proceeds
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S. ABOU-MALHAM ET AL.
which is represented by the three interacting systems (the
socio-cultural, educational, disciplinary systems). The added
value to using the three systems is: i) mapping the broad-based
change; ii) providing a structure to examine the context of im-
plementing the intervention to change a health professional role;
iii) and considering relationships within, between dimensions
across the systems and the intervention to be evaluated captur-
ing thus the dynamic nature of the implementation process.
To track the implementation process and the interaction of
the systems with the intervention involved in the change proc-
ess through the lens of implementation theories, we used the
meta-theoretical framework developed by Damschroder et al.
(2009) which can provide the analytical lens needed to explore
the phenomenon under study.
The Consolidated Framework for Implementation Re-
search (CFIR) (Damschroder et al., 2009): The CFIR is
grounded in implementation theories and can be applied for
exploring a wide variety of interventions in the health care set-
tings across multiple contexts (Ilott, Gerrish, Booth, & Field,
2012). It provides a comprehensive taxonomy of orienting con-
structs that have been drawn from a synthesis of nineteen theo-
ries (e.g. dissemination, innovation, organizational change) and
can be used to guide formative evaluation and to understand the
complexity of implementation. The CFIR offers a typology of
constructs classified in five key domains, without specifying
causal relationships between them, that are critical to successful
implementation. These domains are identified as:
1) The characteristics of individuals involved with the im-
plementation process represented by five constructs (e.g.,
knowledge, self-efficacy, stage of change, personal attributes,
identification with organization, etc.);
2) The outer setting which refers to the broad environment in
which implementation occurs, and includes the political, social
and economic context, involving four constructs (e.g., external
policy and incentives, patient needs and resources);
3) The inner setting comprises five constructs concerned with
features of the organization (e.g., structural characteristics, cul-
ture, networks and communication, readiness for implementa-
4) The characteristics of the intervention influencing imple-
mentation which consider eight constructs that must be taken
into account (e.g., intervention source, evidence strength and
quality, relative advantage, adaptability, complexity); and fi-
5) The process of implementation which is the active change
process embracing four essential constructs (planning, engaging,
executing, reflecting, evaluating).
The five domains offer a comprehensive view that considers
importantly both the intervention and the implementation
(Damschroder & Hagedorn, 2011; Ilott et al., 2012).
The CFIR can serve as a foundational framework to organize
qualitative findings related to the influencing context (Dam-
schroder & Hagedorn, 2011). Consequently, the CFIR will not
be applied as a predetermined conceptual framework. It will be
used as an analytical tool to frame the observed barriers and
facilitators through its menu of constructs, along the four di-
mensions of each of the three systems framework, and how
they interact to influence implementation across the systems.
Using an inductive approach, the CFIR will help us to:
“map” the emergent themes from the synthesized data to con-
structs in the CFIR without forcing data into predetermined
codes; and to clarify the constructs at play in facilitating or
hampering the implementation.
Applying themes at the construct/sub-construct level will be
done for all domains. Nevertheless, constructs of two domains
(Inner and Outer Settings) will be applied to the dimensions of
the three systems and will not be classified under Inner and
Outer Settings domains as in our case there is no single set
Inner Setting versus Outer Setting due to the complex nature of
the interrelated systems under study.
This approach mapping the data to a theory-driven concep-
tual framework has been advocated by MacFarlane and
O’Reilly-de Brún (2011) to qualitatively evaluate general prac-
titioners’ uptake of the language interpreting service in the
Republic of Ireland.
We consider that these two models are well positioned to
understand the context at play for successfully implementing
and reaching the outcomes of an intervention, to synthesize our
findings and to draw conclusions from our analysis.
Nevertheless, designing a framework requires steps such as:
1) defining the phenomenon of interest (the context of imple-
mentation represented by the interaction of the three systems
with the intervention) that are the domain of the investigation;
and 2) suggesting possible ways to operationalize it (Seidman,
1988: p. 5) to illuminate t h u s the scope of the evaluation.
We have already demonstrated that the three systems are
considered as human social activity system (HSAS) made of
dimensions that interact effectively and efficiently internally
and externally. Referring to Checkland (1981), “HSAS are
structured sets of people who make up the system, coupled with
a collection of activities such as processing information, mak-
ing plans”, etc. (as cited in Banathy, 1996: p. 14). Ackoff and
Emery (1972) also characterized HSAS as purposeful systems
and goal-oriented that select goals as well as the means to pur-
sue them (as cited in Banathy, 1996: p. 14). Actions are carried
out according to the values, and in case of misalignment be-
tween system components, significant challenges emerge. As
well, Banathy defines a HSAS as: “An assembly of people who
select and carry out activities-individually and collectively—
that will enable them to attain a collectively identified purpose”
(Banathy, 1996). Through focusing on the three systems, such
framework widens the scope of analysis by emphasizing the
whole context within which the intervention is supposed to
work thus, to change a health professional role.
Description of the Conceptual Framework
The framework depicted in Figure 1 highlights three spheres:
The first sphere corresponds to the context of the interven-
tion comprising three lozenges that represent the three systems
(with their four interrelated dimensions) that are interacting
with each other’s and with the intervention which lies at the
centre of the three systems to bring about the desired change.
These systems serve as a foundation for understanding the im-
plementation process from a holistic perspective.
Implementing the intervention is influenced by the interre-
lated dimensions of the three interacting systems and by the
characteristics of the intervention itself. These systems repre-
sented by a lozenge are: I) the socio-cultural system; II) the
educational system; and III) the disciplinary system.
As for the middle sphere, it corresponds to the extent of co-
herence, degree of alignment (synergy) or misalignment (an
tagonism), among the various dimensions of systems, and the
intervention which form the ceus of the evaluative ntral foc
S. ABOU-MALHAM ET AL.
Open Access 497
Proposed conceptual framework to evaluate the implementation of a complex intervention aiming to
change a health professional role.
Those two spheres are surrounded by an external one which
represents the analytical conceptual lens through which we can
map the themes, using an inductive approach, on to the CIFR
constructs of the five domains : 1) characteristics of the inter-
vention, 2) the outer setting; 3) the inner setting; and, 4) the
characteristics of individuals.
The fifth (5) domain passes across the centre of the three
spheres and corresponds to the process by which implementa-
tion is executed.
Bi-directional arrows express the inter-relatedness of the
three systems and symbolize their interaction with the interven-
tion. Each lozenge includes interrelated dimensions derived
from the system conceptualization of Hatem-Asmar within
which potential facilitators or barriers to the implementation
process could lie.
The development of a framework requires that we: 1) present
the three systems; and 2) define and describe their dimensions.
Systems and Core Dimensions: Drawing on Hatem-Asmar
model, each empirical HSAS is conceptualized as made of a set
of four interrelated dimensions: values, system methods, actors,
and targets. The three lozenges representing the three systems
are the following:
I) Socio-cultural lozenge. It represents the larger societal
system, encompassing political (governmental bodies—e.g. the
ministry of he alth), and social s ystems at large (civ il society, e.g.
women). It concerns the values and expectations of society, laws
and regulations (Hatem-Asmar et al., 2002). It may include in-
fluencing factors exerting the broadest level of influence on the
implementation process (e.g. the social and political setting)
(Damschroder et al., 2009).
II) Educational lozenge. According to Hatem-Asmar et al.
(2002), it corresponds to the underlying approaches and princi-
ple prevailing in this system ; educational m ethods for optimi zing
the preparation of health professionals and attain the training
III) Disciplinary loze nge. I t repre sent s th e d iscip li nar y s ystem
which is inherent to the characteristics pertaining to the profes-
sion. It outlin es the v alues of its m embers, methods and p ractical
approaches used; the organisation of health professions includ-
ing relationships with other professional groups; and finally the
goals of developing their role.
Since the three systems are made of set of dimensions that
work together and with the intervention for the overall objec-
tive (change of a health professional role), we need to define
the underlying dimensions at play. An empirical human social
activity system can be described as having values that guide
activities in which actors are involved, to attain goals—that are
directly or indirectly perceived to have influence on the imple-
mentation process. Within each system, influences among di-
mensions are bi-directional. We will address those concepts for
gaining insight into empirical systems in practice.
1) Values. Refer to the rules and legal grounding of each sys-
tem that steer their methods. Values drive the behaviour of the
system actors; According to Senge (1990), mental models re-
flect the beliefs , values that w e p ersonally hold, and underlie our
reasons for doing things the way we do.
2) Methods. This dimension refers to organizational proce-
dures used to represent a problem and its solutions. Systems
enact different methods to attain their targets such as commu-
nication and coordination activities within and across systems,
organization and distribution of resources across institutions
involved in the implementation process (Tseng & Seidman,
2007). Methods must be congruent with the values prevailing in
the system in order to attain the target (Hatem-Asmar et al.,
3) Actors. They refer to the heterogeneous groups of actors
intervening at multiple levels and involved in the process. Ac-
tors are characterized by their attitudes, skills, motivation
needed to facilitate or constrain the change (Damschroder et al.,
S. ABOU-MALHAM ET AL.
2009; Grol, 1997). For example, policymakers, women are key
contributors to the functioning of the socio-cultural system
whereas academic directors and students play a crucial role in
the educational system. Actors in the disciplinary system are
the health professionals from various disciplines.
4) Targets. It’s about the intentions, purposes, and ultimate
goals of a system.
The Intervention: Given the contribution of intervention
characteristics to implementation success, we will consider in
our framework the perceptions of the different participants to
identify the key attributes of the intervention that might facili-
tate or impede its implementation. In order to do so, an induc-
tive investigative approach is adopted and analysis is guided by
the framework developed by Damschroder et al. (2009).
In sum, we propose a comprehensive framework that in-
cludes a holistic view of the three systems interacting with the
intervention, that can assist in understanding the numerous
potentially relevant factors influencing the implementation
through the “menu of constructs” approach identified in the
Interactions between the Systems and the Intervention:
Centre Piece of the Framework: The theory underpinning our
framework would allow to conduct an evaluation and to search
for the extent of coherence, degree of alignment (synergy) or
misalignment (antagonism), among the various dimensions of
each system, and the intervention (e.g. between the values,
methods, etc. of the educational institutions, the clinical settings
and the intervention). Building upon these interactions, it is
possible to identify the barriers and facilitators associated with
the intervention’s success and challenges. We consider that the
greatest contribution to enhancing implementation may lie in
these interactions which form the central focus of the evaluative
Such results could inform the development of activities that
are tailored to address these barriers for more effective imple-
mentation and moreover to realize the full benefits of role
A Pattern for Understanding the Evaluation
Conceptual Framework: Review of a Jordanian
Study on Barriers to Developing Midwifery as a
Primary Healthcare Strategy
To further explain our framework, we will use as an example
a study on barriers to and facilitators for developing midwifery
primary healthcare practice and will lay out an explanation of
how the findings can be looked at using our framework. We
will draw also a hypothetical situation (implementing an inter-
vention such as a competency-based education program) in
order to exemplify how the dimensions within these three sys-
tems and the intervention through the lens of the CFIR frame-
work might facilitate or impede the implementation process.
The case example concerns the results of an action research led
by Shaban, Barclay, Lock, and Homer (2012) across three re-
gions of Jordan to identify the barriers to developing midwifery
as a primary healthcare strategy. Five main barriers were re-
ported: 1) a lack of professional recognition; 2) a lack of recog-
nition and status for midwifery within society; 3) high levels of
stress and workload; 4) medical domination of health services;
and 5) problems with the quality of midwifery education. Re-
ferring to our framework, we can explain how these findings
can be looked at in terms of the systems dimensions of the in-
ternal sphere. For example, the findings, regarding the poor
image and lack of recognition of midwifery within society,
pertain within our framework to social representations defined
by key elements (beliefs, opinions) (Abric, 1994) which are
related to the values dimension of the socio-cultural system.
High levels of stress and workload are classified as part of the
methodology of the disciplinary system, because they reflect
that practicing midwives are working in stressful environments.
As for the medical domination of health services, these reflect
the prevailing interactions between the disciplines which con-
cerns the methodology dimension of the disciplinary system.
Concerning midwifery education, major issues related to the
quality of clinical placements, the competency of educators and
the level of supervision of midwifery students were highlighted.
The competency of educators is one of the characteristics of
actors in the educational system. As for the clinical placements
and the level of supervision of midwifery students, these pertain
to the methodology as they are about the resources and the ac-
tions taken in the educational system to improve midwives’
To illustrate the interaction of the three systems, we stipulate
that any undertaking for the dimensions of the socio-cultural
system provides a feedback to the dimensions of the educa-
tional or and disciplinary systems and vice versa. According to
the results of a study conducted by the same authors on mid-
wifery education in Jordan (Shaban & Leap, 2011), the mid-
wifery education curriculum reflects a medical model, with an
emphasis on illness and intervention rather than preparation for
the internationally defined full role of the midwife. Based on
the results of the two Jordanian studies, we can stipulate that
values in the socio-cultural system (social representations
about midwifery’s image) and in the educational (prevailing
philosophy of medical model) and methods in the disciplinary
systems (medical domination of health services) are viewed as
dimensions that interact negatively constraining thereby mid-
wives in Jordan to be positioned as primary maternal providers
We can draw a hypothetical situation and try to explore what
would be the barriers or facilitators according to the constructs
of the CFIR (the external sphere of our framework) across the
three interacting systems and the intervention if we attempt to
implement an intervention such as a competency-based educa-
tion (CBE) program. We stipulate that a midwifery program
must be based on a “humanistic” philosophy in order to prepare
a competent midwife capable of empowering women and pro-
moting health reproductive care (World Health Organization,
2011c). Nevertheless, implementation might be constrained by
the existing socio-cultural and disciplinary systems that are not
aligned with the intervention focusing only on the educational
system. Transferring the new midwifery competencies accord-
ing to the humanistic educational philosophy into practice field
(disciplinary system) would be constrained by the prevailing
biomedical culture of the professional groups in this system
(values-culture) that support functioning within professional
hierarchies; and also the ongoing hierarchical medical work
relationships instead of collaborative teamwork (methods-net-
works) in the clinical settings among professionals. Moreover,
we argue that actors (actors-attitudes) might be source of resis-
tance as they are not trained to practice according to the new
philosophy, and also due to issues of territoriality. In sum,
practicing within the fractured maternity care which operates
under the medical system might not allow midwives to apply
S. ABOU-MALHAM ET AL.
the skills acquired during the training, to their job settings.
Regarding the barriers related to the CBE program, if new
competencies are introduced (e.g. newborn life saving skills)
according to the international guidelines without approval of
the medical profession (Intervention source), attitudes of resis-
tance will result in rejecting the new program as it might be not
congruent with their beliefs.
Based on the forgoing discussion, we can refer to the middle
sphere of our framework and state that values in the educational
system are misali gned with the values, methods and character-
istics of actors and targets within the disciplinary system; and
the intervention is not aligned with the values of the profes-
sional groups in the disciplinary system. Therefore, misalign-
ment between the two systems and the intervention might con-
strain the implementation process of an intervention focusing
on one system and not considering the whole change and might
be an impediment to providing a fully qualified midwife fit to
practice as a primary care provider.
We also stipulate that if there is a strong political will to en-
hance the midwife’s autonomy in Jordan in order to promote
primary health care, compatible change across the three sys-
tems in order to align them towards reaching the outcome must
be initiated. Therefore, we assume that an “existential” socio-
cultural system based on perspective that values the women-
centered approach should be enhanced in Jordan. The current
“technocratic” educational system and “biomedical-based” dis-
ciplinary system promoting risk-pregnancy practices should
also be replaced by a “humanistic” educational system and a
“health-based” disciplinary system in order to be aligned with
the “existential” socio-cultural system (Hatem-Asmar et al.,
2002). Therefore, any intervention focusing exclusively on one
system only provides a part of the equation as each system is a
vital dimension to enable the entire system to attain the goal.
Based on this example, we have demonstrated the utility of
our framework to depict the barriers and or facilitators within
and across the three interacting systems with the intervention to
facilitate the change process.
The present article makes valuable contributions to the field
of the evaluation of professions and is innovative in three ways:
Firstly, the model is the first to adopt holistic perspective to
analyze the implementation of a health profession intervention
acknowledging i) the complexity of the process needed to
change a health professional role; ii) the requisite to take into
account the interaction between the three systems and the in-
tervention if an intervention is to be fruitful in improving a
health profession and achieving better health outcomes.
Secondly, the model aims to provide a conceptual tool for
research design, analysis and interpretation for studies related
to workforce innovation’s implementation. Indeed, with the aim
of meeting health needs of countries, we propose our frame-
work as a conceptual map to gain a rich understanding to
analysis of changes to a health professional role. We speculate
that it might also apply to a professional role in general.
Our assumption is rooted in the statements made by Abbott
(1988), that educational institution provides only recognition of
the knowledge and competencies relevant to the profession
without guaranteeing its right to practice or its position in soci-
ety. In the light of these assumptions, we presume that the ulti-
mate goals of any occupational group that strives to achieve are
to: i) obtain public recognition and acceptance of the profes-
sional status; ii) gain a legislative and regulatory authority for
the role; iii) establish codes of ethics and high standards of
practice; iv) receive an education centered on evidence-based
competencies to improve the individual performance; and fi-
nally, v) carry on activities in a motivating practice setting ac-
cording to a well delineate code of practice. Relying on these
professional needs, we stipulate that our framework might have
potentially profound implications for professions across a range
of disciplines. It offers a useful frame reference to: guide diag-
nostic assessment, design and implement interventions and
finally evaluate implementation progress of interventions aim-
ing to change a professional role.
Thirdly, a final insight of relevance is that the information
gathered from an evaluation is crucial for evaluators, pol-
icy-makers, health professionals, educators to identify where
difficulties in implementation lie so that it can be alleviated in
order to make prompt adjustments. The framework can also
serve to judge the appropriateness of an intervention designed
to change a health professional role.
This paper has provided an innovative-evaluative framework
for investigating an intervention aiming to change a health pro-
fessional role. We argued that the evaluation must focus on
examining the coherence of the intervention with the three in-
teracting systems (socio-cultural, educational, and disciplinary)
within which it unfolds in order to provide valuable information
and to avoid failures in further implementation efforts. Most
importantly, the framework is a resource for program planners
seeking to roll out an intervention throughout many countries
facing high demands for role change and also researchers un-
dertaking evaluations of such interventions.
The main author of this study benefited from financial sup-
port in the form of a QTNPR scholarship (CIHR—Quebec
Training Network in Perinatal Research) and a scholarship
granted by The Research Institute in Public Health at the Uni-
versité de Montreal (IRSPUM).The main author acknowledges
the financial support for this research received from Professor
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