http://repub.eur.nl/res/aut/29325/ List of Publications en http://repub.eur.nl/static-eur/img/logo.png http://repub.eur.nl http://repub.eur.nl/res/pub/31132/ 2012-01-26T00:00:00Z 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. http://repub.eur.nl/res/pub/37274/ 2012-01-01T00:00:00Z We investigated the role of power in public governance using a Foucauldian conceptualization of power, i.e., power is produced by a range of techniques as diverse as language and measuring. We draw on an evaluation study of a quality improvement collaborative, in which different mental health care organizations were encouraged to improve their care in a structured way. We analyzed how the different actors involved in the collaborative were governed and came to govern themselves differently. Measurement instruments were an example of a dominant mechanism by which actors at different levels of the collaborative were governed: by accounting for improvements, introducing or strengthening a certain way of thinking about health care clients, and changing how clients thought about and acted upon themselves. We argue that the focus on consequences of governing techniques is fruitful for studying governmentality and leads to new research questions in the context of public policy analyses. http://repub.eur.nl/res/pub/30721/ 2011-10-06T00:00:00Z Accessible summary: Overall, the four collaboratives lead to significant improvement in most objective outcomes, such as health, loneliness, and clients' problem areas. With respect to perceived effectiveness significant differences between the four collaboratives were found. Team members participating in the Social Psychiatric Care collaborative scored significantly lower than team members in the other three collaboratives. The Recovery-Oriented Care collaborative scored weakly higher. Multilevel regression analyses indicated that innovation attributes, appropriate measures, usable data collection tools, and an innovative team culture could explain variation in perceived effectiveness. The results supported the notion that a layered approach is necessary to achieve improvements in quality of care. This multiple case study evaluates four quality improvement collaboratives (QICs) in long-term mental health care focusing on social psychiatric care, recovery oriented care, social participation and somatic co-morbidity of psychiatric patients. The aim is to explore (1) effectiveness in terms of objective outcome indicators and impact of changes as perceived by team members; and (2) associations between collaborative-, organizational- and team-level factors and perceived effectiveness. Most objective outcomes, such as health, loneliness and clients' problem areas, showed significant improvement. Because of the diversity in content no single measure for objective effectiveness could be computed across the four collaboratives. Perceived effectiveness of team members was used as an indicator of the overall impact. In all, 55 of the 94 participating team leaders and 117 remaining team members completed a written survey at the end of each quality improvement collaborative. Multilevel regression analyses indicated that innovation attributes, appropriate measures, usable data collection tools and an innovative team culture could explain variation in perceived effectiveness. In conclusion, overall positive changes for clients were realized as demonstrated by objective outcomes and team members' perceptions of improvements in care processes. The results supported the notion that a layered approach is necessary to achieve improvements in quality of care. http://repub.eur.nl/res/pub/23892/ 2011-05-01T00:00:00Z This paper reports on an evaluation of a 'social participation' improvement project in a mental health care and care for the intellectually disabled setting. The main research question is how sociality (i.e. clients' social lives) was constructed and what consequences this had for the project and for the clients. We undertook a dual approach: investigating the predefined outcomes and analysing the improvement processes in terms of how these processes construct sociality. As to the predefined outcomes, clients' social networks were not widened, but clients felt significantly less lonely at the end of the project. In a bottom-up analysis of data gathered on the improvement processes, we articulated two ways of constructing sociality: individualization, in which clients had to verbalize their wishes (verbalization) and to act upon them more actively (enterprising); and normalization, in which a good social life was one embedded in 'normal' community. We argue that this (explorative) way of conceptualizing change corresponds with some of the quantitative findings but also brings to light aspects that would have gone unnoticed by using only the predefined outcomes. Therefore, a mixed methods approach in studying effectiveness is a fruitful addition to the quality improvement literature. http://repub.eur.nl/res/pub/39093/ 2010-12-01T00:00:00Z The objective of the present study was to explore how mental health-care professionals initiate, improve, and maintain client autonomy while improving other aspects of quality of care. We studied the different ways in which they approach autonomy and the dilemmas associated with them. As a methodology, we used the insights of actor-network theory, where concepts cannot be predefined, but are formed within specific situations, and therefore, should be studied by addressing the actors involved. Data were gathered by conducting ethnographic observations of national conferences of a quality-improvement collaborative and by interviewing actors involved in the improvement practices. In a bottom-up analysis, four approaches to autonomy emerged: (i) professionals removed constraints to autonomy and passed initiative to clients; (ii) professionals made an active effort to learn and support client preferences; (iii) clients were given opportunities towards independent lifestyles; and (iv) professionals tried to 'normalize' their relationship with clients to encourage roles other than those of client. The study showed that autonomy is an important issue throughout the process of quality improvement. Articulating the different approaches to autonomy and the dilemmas in these approaches contributed to reflection on the concept and highlighted the limits of the concept within a mental health-care setting.