Iris Wallenburg

Between Trust and Accountability: Different Perspectives on the Modernization of Postgraduate Medical Training in the Netherlands

Purpose Postgraduate medical training was reformed to be more responsive to changing societal needs. In the Netherlands, as in various other Western countries, a competency-based curriculum was introduced reflecting the clinical and nonclinical roles a modern doctor should fulfill. It is still unclear, however, what this modernization process exactly comprises and what its consequences might be for clinical practice and medical work. Method The authors conducted a Q methodological study to investigate which different perspectives exist on the modernization of postgraduate medical training among actors involved. Results The authors found four distinct perspectives, reflecting the different features of medical training. The accountability perspective stresses the importance of formal regulations within medical training and the monitoring of results in order to be more transparent and accountable to society. According to the educational perspective, medical training should be more formalized and directed at the educational process. The work–life balance perspective stresses the balance between a working life and a private life, as well as the changing professional relationship between staff members and residents. The trust-based perspective reflects the classic view of medical training in which role modeling and trust are considered most important. Conclusions The four perspectives on the modernization of postgraduate medical training show that various aspects of the modernization process are valued differently by stakeholders, highlighting important sources of agreement and disagreement between them. An important source of disagreement is diverging expectations of the role of physicians in modern medical practice.

Costs and effects of new professional roles: Evidence from a literature review.

One way in which governments are seeking to improve the efficiency of the health care sector is by redesigning health services to contain labour costs. The aim of this study was to investigate the impact of new professional roles on a wide range of health service outcomes and costs. A systematic literature review was performed by searching in different databases for evaluation papers of new professional roles (published 1985-2013). The PRISMA checklist was used to conduct and report the systematic literature review and the EPHPP-Quality Assessment Tool to assess the quality of the studies. Forty-one studies of specialist nurses (SNs) and advanced nurse practitioners (ANPs) were selected for data extraction and analysis. The 25 SN studies evaluated most often quality of life (10 studies), clinical outcomes (8), and costs (8). Significant advantages were seen most frequently regarding health care utilization (in 3 of 3 studies), patient information (5 of 6), and patient satisfaction (4 of 6). The 16 ANP studies evaluated most often patient satisfaction (8), clinical outcomes (5), and costs (5). Significant advantages were seen most frequently regarding clinical outcomes (5 of 5), patient information (3 of 4), and patient satisfaction (5 of 8). Promoting new professional roles may help improve health care delivery and possibly contain costs. Exploring the optimal skill-mix deserves further attention from health care professionals, researchers and policy makers.

Negotiating authority: A comparative study of reform in medical training regimes

Recently the medical profession has faced increased outside pressure to reform postgraduate medical training programs to better equip young doctors for changing health care needs and public expectations. In this article we explore the impact of reform on professional self-governance by conducting a comparative historical-institutional analysis of postgraduate medical training reform in the United Kingdom and the Netherlands. In both countries the medical training regime has shifted from professional self-regulation to coregulation. Yet there are notable differences in each country that cannot be explained solely by diverging institutional contexts. They also result from the strategic actions by the actors involved. Based on an assessment of the recent literature on institutional transformation, this article shows how strategic actions set negotiating authority processes into motion, producing new and sometimes surprising institutional arrangements that can have profound effects on the distribution and allocation of authority in the medical training regime. It stresses the need to study the interactions among political context, the properties of institutions, and negotiating authority processes, as they are crucially important to understanding institutional transformation.

Reconfiguring health workforce: a case-based comparative study explaining the increasingly diverse professional roles in Europe

BackgroundOver the past decade the healthcare workforce has diversified in several directions with formalised roles for health care assistants, specialised roles for nurses and technicians, advanced roles for physician associates and nurse practitioners and new professions for new services, such as case managers. Hence the composition of health care teams has become increasingly diverse. The exact extent of this diversity is unknown across the different countries of Europe, as are the drivers of this change.The research questions guiding this study were: What extended professional roles are emerging on health care teams? How are extended professional roles created? What main drivers explain the observed differences, if any, in extended roles in and between countries?MethodsWe performed a case-based comparison of the extended roles in care pathways for breast cancer, heart disease and type 2 diabetes. We conducted 16 case studies in eight European countries, including in total 160 interviews with physicians, nurses and other health care professionals in new roles and 600+ hours of observation in health care clinics.ResultsThe results show a relatively diverse composition of roles in the three care pathways. We identified specialised roles for physicians, extended roles for nurses and technicians, and independent roles for advanced nurse practitioners and physician associates. The development of extended roles depends upon the willingness of physicians to delegate tasks, developments in medical technology and service (re)design. Academic training and setting a formal scope of practice for new roles have less impact upon the development of new roles. While specialised roles focus particularly on a well-specified technical or clinical domain, the generic roles concentrate on organising and integrating care and cure.ConclusionThere are considerable differences in the number and kind of extended roles between both countries and care pathways. The main drivers for new roles reside in the technological development of medical treatment and the need for more generic competencies. Extended roles develop in two directions: 1) specialised roles and 2) generic roles.

Making Hospitals Governable Performativity and Institutional Work in Ranking Practices

Rankings have become ubiquitous in public service settings. Although there are high hopes that comparative analysis leads to improved processes and outcomes, there is also a growing criticism of rankings as creating perverse effects. In this article, we analyze how public service governance is affected by rankings with a special focus on how, in what ways, and to what extent organizations are made into governable entities as a response to rankings. The article is based on a detailed ethnographic study in three Dutch hospitals, using insights from actor–network theory and institutional work, combining the concepts of performativity and institutional work.

Care in place: A case study of assembling a carescape

In this article we analyse the process of the multiple ways place and care shape each other and are co-produced and co-functioning. The resulting emerging assemblage of this co-constituent process we call a carescape. Focusing on a case study of a nursing home on a Dutch island, we use place as a theoretical construct for analysing how current changes in healthcare governance interact with mundane practices of care. In order to make the patterns of care in our case explicit, we use actor-network theory (ANT) sensibilities and especially the concept of assemblage. Our goal is to show - by zooming in on a particular case - how to study the co-constituent processes of place- and care-shaping, revealing the ontological diversity of place and care. Through this, we contribute a perspective of the heterogeneity and multiplicity of care in its dynamic relationship of co-production with place.

To vaccinate or not to vaccinate? Perspectives on HPV vaccination among girls, boys, and parents in the Netherlands: a Q-methodological study

BackgroundDespite the introduction of Human papillomavirus (HPV) vaccination in national immunization programs (NIPs), vaccination rates in most countries remain relatively low. An understanding of the reasons underlying decisions about whether to vaccinate is essential in order to promote wider spread of HPV vaccination. This is particularly important in relation to policies seeking to address shortfalls in current HPV campaigns. The aim of this study was to explore prevailing perspectives concerning HPV vaccination among girls, boys, and parents, and so to identify potential determinants of HPV vaccination decisions in these groups.MethodPerspectives were explored using Q-methodology. Forty-seven girls, 39 boys, and 107 parents in the Netherlands were asked to rank a comprehensive set of 35 statements, assembled based on the health belief model (HBM), according to their agreement with them. By-person factor analysis was used to identify common patterns in these rankings, which were interpreted as perspectives on HPV vaccination. These perspectives were further interpreted and described using data collected with interviews and open-ended questions.ResultsThe analysis revealed four perspectives: “prevention is better than cure,” “fear of unknown side effects,” “lack of information and awareness,” and “my body, my choice.” The first two perspectives and corresponding determinants of HPV vaccination decisions were coherent and distinct; the third and fourth perspectives were more ambiguous and, to some extent, incoherent, involving doubt and lack of awareness and information (perspective 3), and overconfidence (perspective 4).ConclusionsGiven the aim of publically funded vaccination programs to minimize the spread of HPV infection and HPV-related disease and the concerns about current uptake levels, our results indicate that focus should be placed on increasing awareness and knowledge, in particular among those in a modifiable phase.

Onderwijsvernieuwing als beleidsinstrument. Over de modernisering van de medische vervolgopleidingen.

Inleiding: Onderwijsvernieuwing wordt meer en meer gezien als een beleidsinstrument. Dit artikel gaat over de vraag hoe dit instrument werkt, dat wil zeggen we zijn op zoek gegaan naar de betekenis van het project Modernisering van de Medische Vervolgopleidingen (MMV) voor de modernisering van de zorg.

The gaming healthcare practitioner: How practices of datafication and gamification reconfigure care

This article explores how datafication, as an increasing use of quantified performance data (e.g. performance indicators, rating sites), and social media are enacted in everyday healthcare practice. Drawing on the literature about the quantified self, this article shows that datafication evokes practices of gamification: the application of frames of play and rewards to the healthcare setting. We discern three (intermingling) practices of gamification: adapting, ignoring and changing. ‘Adapting’ refers to the incorporation of quantifying features in healthcare, while ‘ignoring’ sheds light on how practitioners seek to circumvent quantifying mechanisms. Change refers to how practitioners actually embrace quantifying mechanisms in order to extend (and improve) their work and to highlight their quantified professional self. We elucidate how datafication of healthcare ‘opens up’ and reconfigures established practices of organizing care and caring – not only for the patient but also to (re)craft the professional clinical identity.

We moeten anders gaan denken over innovatie

SamenvattingHoe kom je tot goede innovatie in de zorg? In elk geval moet daartoe meer aandacht komen voor het proces van innoveren in de praktijk: bij beleidsmakers, managers én professionals. Dit kan de innovatiekracht van zorgorganisaties versterken. En het kan de bijdrage van innovaties vergroten: aan de betaalbaarheid, toegankelijkheid en de kwaliteit van de zorg.