Governing Ideals of Good Care: Quality improvement in mental health care

In the spring of 2008 I attended a conference on the use of coercion in mental health care. A healthcare worker who was also a “practicing patient”, as the program told us, held an impressive lecture that captured the audience from the moment the woman walked to the front. She referred to herself as “difficult patient” and questioned certain care practices in her lecture, mainly those on the use of coercion within psychiatry. “How free are you actually?” she asked the audience. “Your life is made up of constraints.” But the difference is, she said, that in normal life constraints agreed upon by partners or created institutionally lead to bonds, whereas in care they often lead to marginalization. The conference also featured some interactive workshops. One of the workshops was on the subject of how to deal (differently) with situations in which coercion is needed. It was mainly professionals who engaged in the discussion and one of them told about a client who maintained she would be able to live independently. Her care givers, however, were less convinced. “To what extent can we force her to live in the institution?” the care professional brought up. Eventually someone remarked: “if we continue with coercion [in this case] we win the war but loose the peace”. It became clear that coercion would endanger the (caring) relationship with this client. This conference taught me how difficult it can be to provide and to receive mental health care. There are no easy solutions. At the end of this coercion workshop one of the organizers concluded that the discussion had rendered no tips that would help provide care in a better or less difficult way. Attending conferences like these therefore made me wonder: how do professionals go about providing good care? What is good care? What values are deemed important? How are these values defined and enacted? How do different actors decipher what is ‘best’ in a given situation? What do they see as (moral) problems in providing and improving care? These are the questions I explore in this thesis

(Low) Expectations, Legitimization, and the Contingent Uses of Scientific Knowledge: Engagements with Neuroscience in Scottish Social Policy and Services

Neuroscientific research increasingly sparks the imaginations and hopes of policymakers. Whilst the diversity of assertive statements being made on the basis of neuroscience has been well documented, less frequently explored are more contingent discourses regarding studies of the brain. In this paper, we analyze how social policy and service actors discuss their engagements with neuroscientific terms, concepts and findings. These are mobilized, for one, to substantiate and enlarge the focus of existing policy—for example to attract funding for different target groups (such as babies, people who just retired, etc.)—as well as to help develop (new) policies and services. We show how, in so doing, invocation of the neurosciences can act to align “mutual imagined understandings” among policy actors, practitioners and parents. Tentativeness and ambivalence also figured within our respondents’ accounts of the use of the neurosciences. They argued that research had to be simplified in order to make it relevant for wider stakeholders (including politicians), whilst simultaneously considering simplification problematic in some cases. Our analysis foregrounds the different complexities, ambivalences, reductions and instrumentalizations involved in policy and service engagements with the neurosciences, rendering challengeable any notion that (ideas about) neuroscientific research “determines” policy in a linear sense

Mutual powerlessness in client participation practices in mental health care

Background Client participation has become a dominant policy goal in many countries including the Netherlands and is a topic much discussed in the literature. The success of client participation is usually measured in terms of the extent to which clients have a say in the participation process. Many articles have concluded that client participation is limited; professionals often still control the participation process and outcomes. Objective The objective of this study is to gain insight into (i) the practice of client participation within a quality improvement collaborative in mental health care and (ii) the consequences of a Foucauldian conceptualization of power in analysing practices of client participation. Design We used an ethnographic design consisting of observations of national events and improvement team meetings and interviews with the collaborative's team members and programme managers. Results Contrary to many studies on client participation, we found both clients and service providers frequently felt powerless in its practice. Professionals and clients alike struggled with the contributions clients could make to the improvement processes and what functions they should fulfil. Moreover, professionals did not want to exert power upon clients, but ironically just for that reason sometimes struggled with shaping practices of client participation. This mutual powerlessness (partly) disappeared when clients helped to determine and execute specific improvement actions instead of participating in improvement teams. Conclusion Recognizing that power is inescapable might allow for a more substantive discussion concerning the consequences that power arrangements produce, rather than looking at who is exerting how much power

Laboratory Practices, Potentiality, and Material Patienthood in Genomic Cancer Medicine

Laboratory practitioners working in oncology are increasingly involved in implementing genomic medicine, operating at the intersection of the laboratory and the clinic. This includes molecular diagnostic work and molecular testing to direct entry into molecular-based clinical trials and treatment decision-making based on molecular profiling. In this article, we draw on qualitative interviews with laboratory practitioners in the United Kingdom to explore the role of laboratory work in genomic cancer medicine, focusing on the handling of patient tissue and making of potentiality to guide patients’ present and future care. With an increase in molecular testing to inform standard care and clinical trial participation, we show how practitioners “potentialized” the tissue by carefully negotiating what to test, how to test, and when. This included maximizing and managing small amounts of tissue in anticipation of possible future patient care. Tissue archives also took on new meaning, and potentiality, which practitioners negotiated alongside patient care. Potentiality was key to generating the “big” future of genomic medicine and also involved care work where the tissue emerged as an extension of the patient, as a form of “material patienthood,” to secure present and future care for patients through their involvement in genomic medicine

Neuroscience, Policy and Family Life

Background: Research on the brain is increasingly drawn upon in policy-making and family services, with consequences for parenting advice and parenting practices. Especially in the early years of children's lives, infant brains are said to grow rapidly, and this option has informed policies around parent and service for parents

De weg naar duurzame kwaliteit in de langdurige zorg?

__Abstract__ Als we iets over het resultaat van Zorg voor Beter zouden kunnen zeggen dan is het wel het uitdijende karakter. Qua opzet, doel en grootschaligheid is Zorg voor Beter een uniek programma en heeft het de kwaliteit van de langdurige zorg onmiskenbaar op de agenda heeft gezet. Een jaar na de start van Zorg voor Beter werd in opdracht van ZonMw een evaluatietraject in gang gezet door het instituut voor Beleid en Management Gezondheidszorg (iBMG). Het evaluatieonderzoek is gericht op onderzoeksvragen zoals: Wat zijn de resultaten van de projecten? Hoe kunnen we het succes (of falen) van de verschillende trajecten verklaren? Wat is de invloed van contextuele factoren en financiering? Hoe worden thema’s als autonomie, keuzevrijheid van cliënten en betrokkenheid van het management vormgegeven in het programma (Strating e.a. 2008)? Wij maakten gebruik van zowel kwantitatieve (vragenlijsten voor cliënten, medewerkers en teamleiders) als kwalitatieve onderzoeksmethoden zoals observaties van conferenties en case studies in de deelnemende organisaties. In dit hoofdstuk reflecteren wij op thema’s zoals de resultaten (voor zowel cliënten als deelnemende organisaties), de koppeling met ontwikkelingen in de sector, de functie van het meten en het vasthouden en verspreiden van verbeteringen en nieuwe werkmethoden. In de laatste paragrafen beschrijven wij hoe in het programma en in de deelnemende teams aandacht is besteed aan de thema’s cliëntenparticipatie en managementbetrokkenheid