Understanding the Implementation of a Complex Intervention Aiming to Change a Health Professional Role: A Conceptual Framework for Implementation Evaluation


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 is evolved. Each system is operationalized by four dimensions (values, methods, actors 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.

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Abou-Malham, S. , Hatem, M. & Leduc, N. (2013). Understanding the Implementation of a Complex Intervention Aiming to Change a Health Professional Role: A Conceptual Framework for Implementation Evaluation. Open Journal of Philosophy, 3, 491-501. doi: 10.4236/ojpp.2013.34071.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Abric, J.-C. (1994). Pratiques sociales et représentations. Paris: Presses Universitaires de France.
[2] Banathy, B. H. (1996). Designing social systems in a changing world. New York: Plenum Press.
[3] Banathy, B. H., & Jenlink, P. M. (2004). Systems inquiry and its application in education. In D. H. E. Jonassen (Ed.), Handbook of research for educational communications and technology (2nd ed., pp. 37-58). Mahwah, NJ: Lawrence Erlbaum Associates.
[4] Bertrand, Y., & Valois, P. (1982). Les options en éducation. Québec: Gouvernement du Québec, Ministère de l’éducation, Direction de la recherche.
[5] Blais, R., & Joubert, P. (2000). Evaluation of the midwifery pilot projects in Quebec: An overview. L’equipe d’evaluation des projets-pilotes sages-femmes. [Comparative study multicenter study research support, Non-U.S. Gov’t]. Canadian Journal of Public Health, 91, I1-I4.
[6] Brodie, P. (2002). Addressing the barriers to midwifery—Australian midwives speaking out. The Australian Journal of Midwifery, 15, 514. http://dx.doi.org/10.1016/S1031-170X(02)80003-4
[7] Champagne, F., Brousselle, A., Hartz, Z., Contandriopoulos, A.-P., & Denis, J.-L. (2011). L’analyse de l’implantation. In A. Brousselle, F. Champagne, A.-P. Contandriopoulos, & Z. Hartz (Eds.), L’évaluation: Concepts et méthodes (2 mise à jour ed., pp. 238-273). Montréal: Les Presses de l’Université de Montréal.
[8] Checkland, P. (1999). Systems thinking, systems practice. Chichester: John Wiley.
[9] Collin, J., Blais, R., White, D., Demers, A., Desbiens, F., & L’équipe d’évaluation des projets-pilotes sages-femmes (2000). Integration of midwives into the Quebec Health Care System. Canadian Journal of Public Health, 91, 1-17.
[10] Damschroder, L. J., & Hagedorn, H. J. (2011). A guiding framework and approach for implementation research in substance use disorders treatment. Psychology of Addictive Behaviors, 25, 194-205.
[11] Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, 50.
[12] Dubois, C.-A., & Singh, D. (2009). From staff-mix to skill-mix and beyond: Towards a systemic approach to health workforce management. Human Resources for Health, 7, 87.
[13] Foster-Fishman, P., Nowell, B., & Yang, H. (2007). Putting the system back into systems change: A framework for understanding and changing organizational and community systems. American Journal of Community Psychology, 39, 197-215.
[14] Freidson, E. (1970). Profession of medicine: A study of the sociology of applied knowledge. New York: Harper & Row.
[15] French, S., Green, S., O’Connor, D., McKenzie, J., Francis, J., Michie, S., & Grimshaw, J. (2012). Developing theory-informed behaviour change interventions to implement evidence into practice: A systematic approach using the theoretical domains framework. Implementation Science, 7, 38. http://dx.doi.org/10.1186/1748-5908-7-38
[16] Gash, D. C., & Orlikowski, W. J. (1991). Changing frames: Towards an understanding of information technology and organizational change.
[17] Grol, R. (1997). Personal paper. Beliefs and evidence in changing clinical practice. BMJ, 315, 418-421.
[18] Hargreaves, M. B. (2010). Evaluating system change: A planning guide.
[19] Hatem, M. (2008). Rapport de fin de mission: Assistance technique pour la révision du programme de formation des sages-femmes dans le Royaume du Maroc. Rapport inédit.
[20] Hatem-Asmar, M. (1997). Choix éducationnels pour la formation des professionnels de la santé: Le cas de la profession de sage-femme au Québec. Thèse de doctorat inédite, Québec: Université de Montréal.
[21] Hatem-Asmar, M., & Fraser, W. (2004). La sage-femme du Québec: De la renaissance à la reconnaissance. Santé, Société et Solidarité, 3, 105-115. http://dx.doi.org/10.3406/oss.2004.1231
[22] Hatem-Asmar, M., Fraser, W., & Blais, R. (2002). Trois paradigmes pour développer un programme de formation des professionnels de la santé: Le cas de la formation des sages-femmes au Québec. Ruptures, Revue Transdisciplinaire en Santé, 9, 86-102.
[23] Ho, L.-A., & Schwen, T. M. (2006). Evaluation in the design of complex systems. Performance Improvement Quarterly, 19, 135-154.
[24] Homer, C. S., Passant, L., Brodie, P. M., Kildea, S., Leap, N., Pincombe, J., & Thorogood, C. (2009). The role of the midwife in Australia: views of women and midwives. [Research Support, Non-U.S. Gov’t]. Midwifery, 25, 673-681.
[25] Hummelbrunner, R. (2011). Systems thinking and evaluation. Evaluation, 17, 395-403. http://dx.doi.org/10.1177/1356389011421935
[26] Ilott, I., Gerrish, K., Booth, A., & Field, B. (2012). Testing the consolidated framework for implementation research on health care innovations from South Yorkshire. Journal of Evaluation in Clinical Practice. http://dx.doi.org/10.1111/j.1365-2753.2012.01876.x
[27] Ison, R. L., Maiteny, P. T., & Carr, S. (1997). Systems methodologies for sustainable natural resources research and development. Agricultural Systems, 55, 257-272.
[28] Kislov, R., Nelson, A., de Normanville, C., Kelly, P. M., & Payne, K. (2012). Work redesign and health promotion in healthcare organisations: A review of the literature. Sheffield Hallam University.
[29] Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice: A conceptual framework. Quality in Health Care, 7, 149-158.
[30] Klein, M. C. (2002). Working symposium on midwifery, building our contribution to maternity care. Paper presented at the A Family Physician’s Observations, Vancouver, British Columbia, Canada.
[31] Kronus, C. L. (1987). The evolution of occupational power: An historical study of task boundaries between physicians and pharmacists. Sociology of Work and Occupations, 3, 3-37.
[32] Laszlo, A., & Krippner, S. (1998). Systems theories: Their origins, foundations, and development. In J. S. Jordan (Ed.), Systems theories and a priori aspects of perception (pp. 47-74). Amsterdam: Elsevier Science. http://dx.doi.org/10.1016/S0166-4115(98)80017-4
[33] Laurant, M., Harmsen, M., Faber, M., Wollersheim, H., Sibbald, B., & Grol, R. (2010). Revision of professional roles and quality improvement: A review of the evidence. London: The Health Foundation.
[34] Love, A. (2004). Implementation evaluation. In J. S. Wholey, H. P. Hatry, & K. E. Newcomer (Eds.), Handbook of practical program evaluation (2nd ed., pp. 63-97). San Francisco, CA: Jossey-Bass.
[35] MacFarlane, A., & O’Reilly-de Brún, M. (2012). Using a theory-driven conceptual framework in qualitative health research. Qualitative Health Research, 22, 607-618.
[36] May, C., Finch, T., Mair, F., Ballini, L., Dowrick, C., Eccles, M., & Heaven, B. (2007). Understanding the implementation of complex interventions in health care: The normalization process model. BMC Health Services Research, 7, 148.
[37] McKenna, H., Keeney, S., & Hasson, F. (2009). Health care managers’ perspectives on new nursing and midwifery roles: Perceived impact on patient care and cost effectiveness. Journal of Nursing Management, 17, 627-635.
[38] McKenna, M., Richey, R., Keeney, S., Hasson, F., Poulton, B., & Sinclair, M. (2008). The managerial and development issues of nurses and midwives in new roles. Scandinavian Journal of Caring Sciences, 22, 227-235. http://dx.doi.org/10.1111/j.1471-6712.2007.00519.x
[39] Nancarrow, S., Moran, A., Wiseman, L., Pighills, A. C., & Murphy, K. (2012). Assessing the implementation process and outcomes of newly introduced assistant roles: A qualitative study to examine the utility of the Calderdale Framework as an appraisal tool. Journal of Multidisciplinary Healthcare, 5, 307-317.
[40] Parsons, B. (2007). The state of methods and tools for social systems change. American Journal of Community Psychology, 39, 405-409.
[41] Patton, M. Q. (1997). Utilization-focused evaluation: The new century text (3rd ed.). Thousand Oaks, CA: Sage Publications.
[42] Patton, M. Q. (2002). Qualitative research & evaluation methods (3rd ed.). Thousand Oaks, CA: Sage Publications.
[43] Patton, M. Q. (2008). Utilization-focused evaluation (4th ed.). Thousand Oaks, CA: Sage Publications.
[44] Pettigrew, A. M., Woodman, R. W., & Cameron, K. S. (2001). Studying organizational change and development: Challenges for future research. The Academy of Management Journal, 44, 697-713.
[45] Rousseau, S., Desmet, R., & Paradis, L. (1989). L’organisation selon Edgard Morin: Application à la communication et à l’éducation. Revue des sciences de l’éducation, 15, 433-447.
[46] Sangster-Gormley, E., Martin-Misener, R., Downe-Wamboldt, B., & DiCenso, A. (2011). Factors affecting nurse practitioner role implementation in Canadian practice settings: An integrative review. Journal of Advanced Nursing, 67, 1178-1190.
[47] Seidman, E. (1988). Back to the future, community psychology: Unfolding a theory of social intervention. American Journal of Community Psychology, 16, 3-24. http://dx.doi.org/10.1007/BF00906069
[48] Senge, P. (1990). The fifth discipline. New York: Currency Doubleday.
[49] Shaban, I., & Leap, N. (2011). A review of midwifery education curriculum documents in Jordan. Women and Birth.
[50] Shaban, I., Barclay, L., Lock, L., & Homer, C. (2012). Barriers to developing midwifery as a primary health-care strategy: A Jordanian study. Midwifery, 28, 106-111.
[51] Sibbald, B., Shen, J., & McBride, A. (2004). Changing the skill-mix of the health care workforce. [Research Support, Non-U.S. Gov’t Review]. Journal of Health Services Research & Policy, 9, 28-38.
[52] Stetler, C., Legro, M., Wallace, C., Bowman, C., Guihan, M., Hagedorn, H., & Smith, J. (2006). The role of formative evaluation in implementation research and the QUERI experience. Journal of General Internal Medicine, 21, S1-S8.
[53] Supovitz, J. A., & Taylor, B. S. (2005). Systemic education evaluation. American Journal of Evaluation, 26, 204-230.
[54] Thompson, J. B., Fullerton, J. T., & Sawyer, A. J. (2011). The international confederation of midwives: Global standards for midwifery education (2010) with companion guidelines. Midwifery, 27, 409416. http://dx.doi.org/10.1016/j.midw.2011.04.001
[55] Trochim, W. M., Cabrera, D. A., Milstein, B., Gallagher, R. S., & Leischow, S. J. (2006). Practical challenges of systems thinking and modeling in public health. American Journal of Public Health, 96, 538-546. http://dx.doi.org/10.2105/AJPH.2005.066001
[56] Tseng, V., & Seidman, E. (2007). A systems framework for understanding social settings. American Journal of Community Psychology, 39, 217-228. http://dx.doi.org/10.1007/s10464-007-9101-8
[57] Turner, R. H. (1990). Role change. Annual Review of Sociology, 16, 87110. http://dx.doi.org/10.1146/annurev.so.16.080190.000511
[58] United Nations Population Fund (2010). Global call to action: Strengthen midwifery to save lives and promote health of women and newborns.
[59] United Nations Population Fund (2011). The state of the world’s midwifery report 2011: Delivering health, saving lives.
[60] Varkey, P., Horne, A., & Bennet, K. E. (2008). Innovation in health care: A primer. American Journal of Medical Quality, 23, 382-388.
[61] Wilkinson, E. (1998). Characteristics of a profession.
[62] World Health Organization (2002). Nursing and midwifery services: Strategic directions 2002-2008. www.searo.who.int
[63] World Health Organization (2003). Nursing and midwifery workforce management: Conceptual framework.
[64] World Health Organization (2009). Systems thinking for health systems strengthening. In D. D. Savigny, & T. Adam (Eds.), Alliance for health policyand systems research. France.
[65] World Health Organization (2011a). Strenghtening midwifery toolkit: Module 1—Strenghtening midwifery: A background paper.
[66] World Health Organization (2011b). Strengthening midwifery toolkit: Module 2—Legislation and regulation of midwifery—Making safe motherhood possible.
[67] World Health Organization (2011c). Strengthening midwifery toolkit: Module 5—Developing a midwifery curriculum for safe motherhood: Guidelines for midwifery eduaction programmes.

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