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Diversity and normalisation in the narrative of 'Fragments of Him': a practical workshop

Steering in complex education systems

In the wake of neo-liberal informed global trends to set performance standards and intensify accountability, the Dutch government aimed for ‘raising standards for basic skills’. While the implementation of literacy standards was hardly noticed, the introduction of numeracy standards caused a major backlash in secondary schools, which ended in a failed introduction of a high stakes test. How can these major differences be explained? Inspired by Foucault’s governmentality concept a theoretical framework is developed to allow for detailed empirical research on steering processes in complex systems in which many actors are involved in educational decision-making. A mixed-methods multiple embedded case-study was conducted comprising nine school boards and fifteen secondary schools. Analyses unveil processes of responsibilisation, normalisation and emerging dividing practices. Literacy standards reinforced responsibilities of Dutch language teachers; for numeracy, school leadership created entirely new roles and responsibilities for teachers. Literacy standards were incorporated in an already used instrument which made implementation both subtle and inevitable. For numeracy, schools distinguished students by risk of not passing the new test affirming the disciplinary nature of schools in the process. While little changed to address teachers main concerns about students’ literacy skills, the failed introduction of the numeracy test usurped most resources.

Developing a Smoking Cessation Intervention for People With Severe Mental Illness Treated by Flexible Assertive Community Treatment Teams in the Netherlands

Background: There is still limited evidence on the effectiveness and implementation of smoking cessation interventions for people with severe mental illness (SMI) in Dutch outpatient psychiatric settings. The present study aimed to establish expert consensus on the core components and strategies to optimise practical implementation of a smoking cessation intervention for people treated by Flexible Assertive Community Treatment (FACT) teams in the Netherlands. Design: A modified Delphi method was applied to reach consensus on three core components (behavioural counselling, pharmacological treatment and peer support) of the intervention. The Delphi panel comprised five experts with different professional backgrounds. We proposed a first intervention concept. The panel critically examined the evolving concept in three iterative rounds of 90 min each. Responses were recorded, transcribed verbatim and thematically analysed. Results: Overall, results yielded that behavioural counselling should focus on preparation for smoking cessation, guidance, relapse prevention and normalisation. Pharmacological treatment consisting of nicotine replacement therapy (NRT), Varenicline or Bupropion, under supervision of a psychiatrist, was recommended. The panel agreed on integrating peer support as a regular part of the intervention, thus fostering emotional and practical support among patients. Treatment of a co-morbid cannabis use disorder needs to be integrated into the intervention if indicated. Regarding implementation, staff’s motivation to support smoking cessation was considered essential. For each ambulatory team, two mental health care professionals will have a central role in delivering the intervention. Conclusions: This study provides insight into expert consensus on the core components of a smoking cessation intervention for people with SMI. The results of this study were used for the development of a comprehensive smoking cessation program.

Fostering executive functions the Montessori way

Identification of promising strategies to sustain improvements in hospital practice

Background: A quality improvement collaborative is an intensive project involving a combination of implementation strategies applied in a limited “breakthrough” time window. After an implementation project, it is generally difficult to sustain its success. In the current study, sustainability was described as maintaining an implemented innovation and its benefits over a longer period of time after the implementation project has ended. The aim of the study was to explore potentially promising strategies for sustaining the Enhanced Recovery After Surgery (ERAS) programme in colonic surgery as perceived by professionals, three to six years after the hospital had successfully finished a quality improvement collaborative. Methods: A qualitative case study was performed to identify promising strategies to sustain key outcome variables related to the ERAS programme in terms of adherence, time needed for functional recovery and hospital length of stay (LOS), as achieved immediately after implementation. Ten hospitals were selected which had successfully implemented the ERAS programme in colonic surgery (2006–2009), with success defined as a median LOS of 6 days or less and protocol adherence rates above 70%. Fourteen semi-structured interviews were held with eighteen key participants of the care process three to six years after implementation, starting with the project leader in every hospital. The interviews started by confronting them with the level of sustained implementation results. A direct content analysis with an inductive coding approach was used to identify promising strategies. The mean duration of the interviews was 37 minutes (min 26 minutes – max 51 minutes). Results: The current study revealed strategies targeting professionals and the organisation. They comprised internal audit and feedback on outcomes, small-scale educational booster meetings, reminders, changing the physical structure of the organisation, changing the care process, making work agreements and delegating responsibility, and involving a coordinator. A multifaceted self-driven promising strategy was applied in most hospitals, and in most hospitals promising strategies were suggested to sustain the ERAS programme. Conclusions: Joining a quality improvement collaborative may not be enough to achieve long-term normalisation of transformed care, and additional investments may be needed. The findings suggest that certain post-implementation strategies are valuable in sustaining implementation successes achieved after joining a quality improvement collaborative.

Awor nan ta yama nos criminal! (and now they can call us criminals!)

In this article, the author will question the seemingly obvious boundary between civil disobedience, as conceptualised by Rawls and Arendt, and several examples of criminal, or simply annoying, activities which don't meet their criteria, such as the case of the ‘Top 50'. The ‘Top 50' are multi-problem Dutch-Caribbean men, who refuse to adapt to predominant norms in Dutch society. IThe author argues that political aspects of their behaviour should be acknowledged, even if they engage in criminal behaviour and don't present explicit political goals. Firstly, she questions the way in which Rawls based his definition on a centralistic conception of governmental power and contrast it with Foucault's conception of normalising power, in which power is diffuse and cannot be restricted to the enactment of formal laws. Secondly, she discusses what the minimum requirements are to be able to classifyacts as civil disobedience. Rawls and Arendt draw a clear line between criminal behaviour and civil disobedience, but their requirements may be too strict. We might miss signals of injustice if actions that do not meet these criteria are excluded from the political discourse. The conclusion is that comparing Arendt's and Rawls' conception of civil disobedience with the behaviour of a marginal migrant group may be useful in questioning the boundaries of this concept and in making it more inclusive. A wider conception of civil disobedience may help to explain the meaning of deviant behaviour in terms of social critique and to challenge the traditional understanding of civil disobedience.