Children’s eating behavior does not necessarily align with dietary recommendations, and there is a need for better understanding the factors underlying their food choices. The aim of this study was to investigate children’s self-reported reasons for accepting and rejecting foods. A questionnaire was developed with reasons based on prior research and in-depth interviews. A set of various food stimuli covering different types was evaluated by 106 girls and 99 boys aged 10–13 years by checking all reasons that apply (CATA) for either accepting or rejecting them. Results showed gender differences among reasons for both food acceptance and rejection, but also in liking and willingness to re-taste the stimuli. The most common reason for food acceptance was good taste in boys and curiosity in girls; for food rejection they were bad taste, bad smell and dislike of appearance in boys and bad taste, bad smell, dislike of appearance and texture in girls. Overall, boys liked the food stimuli more than girls and were more willing to re-taste them. Future research should focus more on the role of sensory properties in both acceptance and rejection, and the potential of children’s curiosity as a driver in tasting foods should be further explored. Dietary variety has been linked to nutritional status and is therefore important for health . HoweverKoivisto and Sjödén 1996) investigated reasons for liking and disliking foods in 2–17-year-old children and discovered that distaste was the main reason for disliking and good taste the main reason for liking specific foods. Other important reasons children stated for dislike were “texture” and “negative consequences” or they were not able to indicate the reason and responded with “don’t know”. The importance of taste and texture has also been highlighted in other studies ,9, altho96 investCurrently, there is some inconsistency to which factors mostly determine children’s acceptance or rejection of food and there is also a lack of knowledge about children’s self-reported reasons. Most research in this field has examined children’s reasons indirectly, where factors influencing food choice were described by academic professionals or by asking parents ,16,17. IMoreover, there seem to be differences between genders in relation to children’s selection of food. It was detected that girls liked vegetables ,11,27,28Based on previous research we hypothesized that children base their food choices mainly on sensory attributes and that there are gender-specific differences in the reasons given for accepting or rejecting specific foods. Accordingly, the aim of the present study was to examine children’s self-reported reasons for accepting and rejecting food and to investigate possible gender differences related to these.The study comprised 106 girls and 99 boys aged 10–13 years and the average age was 11.0 ± 0.1 (mean ± standard error of the mean (SEM)) for both genders. Recruitment was done by sending invitation letters to public schools in Copenhagen, Denmark, whereof 10 school classes from five public secondary schools agreed to participate. Parents were asked to give written consent and to state if their child had any food allergies. It was voluntary for the children to participate. The procedures were in accordance with the Helsinki declaration. In Denmark this type of research does not require formal ethical approval, and it is thus not possible to obtain it.Previously, a pilot study was run to test the study procedure with 15 girls and 6 boys both aged 9–10 years attending a public school in Copenhagen that followed the same participation criteria as mentioned above.Palmaria palmata; Dietz Seaweed), physalis , caviar , herring , anchovy , blue cheese  and deer salami . Prior to study execution, the stimuli were cut into equal bite-sized pieces that were distributed and presented in tasting cups (30 mL).A broad spectrum of food groups was included, as previously conducted studies showed that boys and girls have different preferences for various food groups ,27 and cAnother part of the one-on-one interviews on the selection of food stimuli was also to interview the same children about their reasons for accepting or rejecting food based on their most liked and most disliked foods. The aim was to open a discussion about children’s most liked and disliked food stimuli and their reasons for them. First, children were asked to draw these foods on a provided sheet to make them feel at ease. All interviews were audio recorded and transcribed verbatim. The children reported 70 reasons for acceptance and 38 reasons for rejection. The reasons were categorized into themes following thematic analysis and summarized, if shown similar  , whereasThe databases Web of Science and PubMed were screened for relevant literature using the following key words: “children”, “food behavior”, “food choice”, “dietary choice”, “food acceptance”, “food rejection”, “food selection”, “food preferences”, “eating behavior”, “disliking”, “liking”, “reasons” and “factors”. The resulting literature was checked for relevance and references cited in each article, which were examined for further related studies. Only literature with full access and written in English were included, but no constraints were set in terms of date of publication. Studies that were considered eligible focused on factors and reasons in food choice in children and adults. A total of 52 articles were found to be eligible according to the above criteria, which were scanned for children’s reasons to accept or reject food see . As someA questionnaire was developed to gain insight into reasons for accepting or rejecting food stimuli in children. These reasons were collected via a check-all-that-apply (CATA), which has been previously shown to be an easy, quick and child-friendly tool to collect spontaneous responses to food preferences in pre-adolescents ,19,35. AAdditionally, familiarity of each stimulus was assessed by checking one of the response categories: I know it and tasted it before/I know it, but never tasted it before / I don’t know it. Children who tasted the food were asked to indicate their overall liking of the stimuli on a 7-point facial hedonic scale (response options: Super bad/Bad/Slightly bad/OK/Slightly good/Good/Super good)  and theiAt first, an instructor briefed the children that they were about to taste several food stimuli and that they would be asked about their self-reported reasons for accepting or rejecting these. It was emphasized that it was completely voluntary to participate. They were presented the questionnaire and asked to evaluate nine food stimuli by repeatedly going through the following steps: (a) tasting a sample (the children had the option not to taste the stimulus and had to note this accordingly); (b) giving reasons for accepting or rejecting it; (c) assessing the liking and willingness to re-taste, if tasted. The tasting sessions were conducted during school time at forenoon between 10:00–12:00 taking 45–60 min to complete. All necessary material was set up in the children’s habitual classrooms, where they normally eat. The children were allowed to sit at their ordinary seats and were not segregated by gender. The children were provided with a questionnaire, a plate, some forks and spoons, a napkin, a water cup for palate cleansing and a spitting cup. After tasting each food stimulus, children were asked to clean their palate with a water and dry bread crackers. The instructor guided the children through each stimulus assisted by two further assistants. The responsible teacher was present during the tasting session to keep the children as calm as possible. To minimize peer influence and stimulus boredom, two different serving orders were used (the other group received the same stimuli in the opposite serving order), so children sitting next to each other were served different foods ,39.The CATA questionnaire was analyzed by calculating the frequencies of reported reasons for acceptance of all food stimuli. The same procedure was done for food rejection. Reasons that were checked by ≥50% of children were regarded as an important reason to choose the food stimuli. Gender differences were analyzed via Fisher’s exact test for all food stimuli comparing the counts of girls and boys for each reason. Additional reasons for acceptance and rejection stated through the open-ended text format were analyzed via thematic analysis, which is appropriate for analyzing qualitative data in this context .t-test. The willingness to re-taste was expressed as the proportions of girls and boys who were willing to re-taste the stimuli using Fisher’s exact test. The familiarity of the stimuli was expressed as the frequency of children who had tasted and not tasted the stimuli previously/who did not know the stimuli. Food stimuli were regarded as familiar if tasted previously by ≥50% of children. χ2-test was used to test if there was a difference in serving order of the stimuli between the two groups comparing the frequencies of the totals of acceptance and rejection of the stimuli from each serving group. The comparison was conducted for each stimulus and conducted separately for acceptance and rejection. The level of significance was set to p ≤ 0.05.For analyzing liking data of the 7-point facial hedonic scale, the mean liking (±SEM) was calculated. Gender differences were obtained comparing the means for liking via two-sample Student’s ® Excel® (for Office 365 MSO (16.9.11); Version 1902, Redmond, WA 98052 USA).Statistical analyzes were conducted via XLSTAT  and visualized via Microsoftp = 0.72), so in the following all data are merged together.In total, boys gave 2270 reasons and girls gave 1832 reasons for accepting foods, while boys gave 704 reasons and girls gave 585 reasons for rejecting foods. There were 13 cases across several food stimuli with no responses arising from children with allergy and/or intolerances, who could not taste specific foods and were therefore excluded from the analyzes. There were no differences when comparing children with the two different serving orders (Most stimuli were rather unfamiliar as most of the food stimuli had been previously tasted by <50% of the children see . PumpkinChildren’s reasons for acceptance are given in p ≤ 0.01) and like of texture (p ≤ 0.05) were more important in boys, whereas curiosity (p ≤ 0.001) was more important in girls for accepting the food stimuli.There were gender differences for several of the reasons given. Good smell (p < 0.05), which was more important in girls when rejecting the food stimuli.Reasons for rejection are given in Children mentioned several other reasons for food acceptance and rejection. If children stated very similar reasons, these were merged into one category by the author. Other reasons for acceptance resulted in additional categories: grandparents, good association with other food, liking, challenge, good experience in childhood, ideals and price/value and other reasons for rejection resulted in processing of food, dislike and fear.p = 0.004), seaweed (p ≤ 0.001), caviar (p ≤ 0.001) and herring (p = 0.004).Food stimuli showed differences in mean liking, but differences between genders were shown see . In genep ≤ 0.05).Children’s willingness to re-taste the food stimuli was rather low, but it varied somewhat between stimuli see . In geneThe present study investigated children’s self-reported reasons for accepting and rejecting specific food stimuli and if there were gender differences for these. We could only partly confirm that sensory attributes are children’s main drivers in food acceptance and rejection, as hypothesized, but we were able to show some gender differences in reasons for accepting and rejecting specific food stimuli, which confirmed our hypothesis. The results will be discussed more in detail in the following sections.Curiosity was the most important reason in girls (66%) and was shown to be significantly more important in girls than boys. This suggests that girls may be more influenced by curiosity than boys when deciding to try rather novel food or they may just be more aware of this influence than boys may be. Although, curiosity was selected by 48% of boys, it was the second most important reason and a key contributing factor. Interestingly, the study showed a very high importance for curiosity for the food stimuli that were mainly unfamiliar in the current study. It seems like the children were very interested to taste the novel foods, which could result from their natural drive to explore and discover ,41,42. CGood taste was the most frequently stated reason in boys (61%) and the second most frequently stated reason among girls 45%). We could not show a direct difference between genders, suggesting good taste is almost equally important in girls and boys. The high frequency of good taste is in accordance with a study on 6–14-year-old children, where 41%–59% of the reasons for liking specific foods resulted to be good taste . Likewis5%. We coChildren selected appearance as the third most important reason (43% in boys and 32% in girls). The role of appearance in food choice has previously been demonstrated, where the serving style/shape of snack vegetables  and foodHealth and familiarity did not play a key role in this study, which aligns with previous findings, where familiarity was chosen less when choosing what to eat . This coIn the present study, food rejection was shown to be more dominant in girls than in boys, which was also demonstrated previously, where women rejected more foods than men . Women aThe reasons of unfamiliarity, inedible, disgust, unhealthy, bad experience and religion were not very important compared to the sensory properties in the rejection of the food stimuli. However, unfamiliarity was demonstrated to be the second most important reason after the sensory attributes, which conforms with findings that taste and familiarity affect children’s food choices greatly . ResearcThe same seems to apply to bad consequences in children’s rejection of foods. In addition to that, many children did not know and had not tried the stimuli before, which could be an explanation as to why this reason was not relevant for the children. Inappropriateness and disgust were only of very minor importance, which contrasts former research stating that these are one of the main reasons for food rejection in children and adults ,47. An eThe current study showed that boys liked most of the stimuli more than girls, which aligns with previous research, where men tended to give more likes than dislikes compared to women and vice versa . FurtherThe most liked food stimuli—like deer salami, physalis and kale—were also demonstrated to be the food stimuli the children would like to re-taste the most. This can be explained by the theory that positive food experiences can elevate its liking . The remThere was no significant gender difference in regard to re-tasting the food products, except for blue cheese, which boys were more willing to re-taste. These results propose that both genders may be similar in terms of re-tasting foods. Since boys generally liked the foods more than girls, it is remarkable that their absolute level of willingness to re-taste was almost the same. The food stimuli can be explained as rather unfamiliar to the children. Still, the number of accepted stimuli was very high, which contrasts research showing that familiar foods are more likely to be accepted compared to unfamiliar foods . One expAdditionally, the food stimuli covered several of foods groups including vegetables, fruits, fish and meat-based products and dairy. However, the food stimuli might be quite particular and therefore not reflect an entire food category, especially considering that both the products within a food category and their preparation methods can vary a lot. Therefore, the results of the current study may be unique to these foods as opposed to these types of foods or foods in general. Consequently, future research should focus on a broader range of stimuli to be able to generalize. The preparation of the stimuli (pre-cutting into bite-sized pieces) may have increased the number of accepted stimuli, as it was shown in a previous research ,66. HencAlthough it was a strength that the schools were located in various areas of Copenhagen, which represented children from different socio-economic backgrounds, the study might be limited to children living in the city as food choices of children from the city and rural areas can vary . AdditioPrevious studies showed that unfamiliar foods are often rejected ,24, whicAdditionally, the study provides support for the importance of sensory properties of foods in both acceptance and rejection. Previously conducted sensory education programs have shown positive effects on encouraging children to try novel foods and reducing food neophobia ,67. The In this respect, our findings provide suggestions for practical implications and a scope for further research on sensory education and food exposure programs, which have potential to motivate children to try new foods: children’s curiosity seems to be the optimal precondition to taste foods they have never tasted before. Exposure to novel healthy food products can help to increase children’s food acceptance and thereby broaden the variety of their diet . To promThe results suggest promising insights into children’s reasons to accept or reject foods and that gender differences should be considered when investigating children’s food choices and preferences. More focus should be on the role of sensory attributes in food acceptance and rejection and the importance of children’s curiosity as a driver to accept novel foods. This knowledge can be used to increase the dietary variety of healthy foods.


Interaction in educational environments might refer to a set of relationships between individuals in a school system. These links can be considered within a power-relations framework that includes the role of each of the subjects in a school and its community. This paper focuses on “transgressive” interactions involving adolescent students from diverse ethnic backgrounds in a Basque secondary school and relies on the concept of identity-in-interaction from a sociocultural approach, according to which, identity is constituted in a process of exchange between two or more parties. This research is drawn from the results of an ethnographic study conducted between July 2015 and June 2016 in a Basque secondary school attended by a high proportion of immigrant students, which shares characteristics with the broader Basque educational context. The methods used to collect data included documentary analysis, 9-months of participant observation, 36 in-depth interviews and four focus groups. Transgression in this context refers to the act of questioning socially established limits of behavior, which is considered typical during adolescent years. I categorize three types of student interaction as transgressive: personal, civic, and social limit transgressions, which involve challenges to peer-interpersonal, institutional, and community rules of interaction, respectively. In the Basque Country there are two official languages, Basque and Spanish, and students are instructed in both languages. They must daily face the particularities of a bilingual society where Basque is still a minority language. Community transgression is noteworthy, as immigrant students resisted the rule enforcing Basque instruction, leading to intercultural conflict with teachers. The study argues that identity can be constructed through transgression: immigrants’ refusing to learn Basque is a matter of rebellion that acts as an identity marker. This study contributes to the discussion of identity-in-interaction. Based on empirical data it uses the framework of transgression in multi-ethnic educational environments to consider community languages in a broader power-relations framework. This paper is part of a larger ethnographic study researching multi-ethnic student-to-student and teacher-to-student interactions in Basque secondary education. The Basque Country is located in the south of France and north of Spain and the school I refer to is located in the Basque Autonomous Community (BAC), one of the regions of the Basque Country in Spain where both Basque and Spanish have official status. Today, institutions in the BAC reinforce Basque language, but during Franco’s dictatorship between the late 1930s and mid 1970s speaking Basque was prohibited . Basque 1. In the Basque education system immigrant studentship is usually unevenly distributed between schools: in areas with a high immigrant population, immigrant students attend public schools, while most locals tend to enroll their children in privately funded schools which instruct their pupils almost entirely in Basque. Additionally, immigrant students in public schools tend to attend classes that are instructed mostly in Spanish, while locals enroll in classes predominantly instructed in Basque. This choice, which is ethnically guided, conflicts with one of the education system’s main objectives: to promote Basque language regardless of the ethnic, social, or linguistic origin of each student.Today, this complex bilingual social and educational context faces another challenge, as the BAC has received a considerable immigrant population in recent yearsIn Mirebe , the town where the study took place, Spanish is the predominant language on the street while Basque is a minority language. In this paper we focus on Udabia, a secondary public school attended by a high proportion of immigrant students. More precisely, in the 2015/2016 school year the percentage of immigrant students at Udabia was 37%, while the average in Basque schools in that period was below 9%. In such an ethnically and linguistically diverse environment, teachers had to teach Basque to immigrant students, many of whom did not understand its importance within the Basque community. As illustrated in previously published results from this case study, some immigrant students bluntly refused to learn Basque, citing its lack of value to them, while their local counterparts did not show such resistance. In such cases, teachers often failed to manage the classroom effectively, as they were trying to teach Basque to an obviously unreceptive audience and the subsequent conflict seemed more significant to them than simple student misbehavior , 2019.In this paper, student misbehavior is designated as transgression. Transgression in this context makes reference to the act of questioning the socially accepted rules of interaction, which is typical behavior in adolescent years. Apart from transgressions related to their refusal to learn Basque, some students in this school also transgressed other rules, by not complying with teachers’ instructions or respecting their peers. These transgressions involved students in relation to their peers and teachers within a specific power-relations framework. Such interactions also marked differences between the subjects involved, which had consequences for the constitution of their identities. In other words, identity was performed and represented in each of these transgressive interactions. Focusing on this idea, the aims of this paper are (i) to analyze the kinds of transgressions-as-interactions that can be classified in such a context, and (ii) to show how the concept of teenage transgression, as a type of interaction, constitutes a specific kind of identity. In line with the aims, the hypotheses I propose are (1) transgressions are negative for classroom environment, and (2) transgressions constitute the main problem when Basque learning is involved, as student identity is constituted in acrimonious interaction.In this section, I will focus on two of the central elements of this paper: limits and transgression, the latter as a specific kind of interaction, and the concept of identity-in-interaction from a sociocultural perspective. The link between these two elements constitutes the main argument of this paper.I will define limits, according to A more recent contribution to transgression theory by Many authors have claimed that in adolescence limit transgressions happen through different practices, such as the enactment of risky and violent behaviors . In the In line with this idea, A sociocultural approach to the concept of identity-in-interaction by In line with this idea, This is a qualitative study using ethnographic methods. Ethnography is based on the long-term collection of discourses by and observation of people in the field . My roleThis investigation started in Spring 2015, when initial contact with Udabia was made. In July the Head of the School agreed to data collection beginning at the start of the next school year and preparatory documentary analysis began. For 2 months I collected data about the linguistic and social history of Mirebe, as well as the town’s immigrant population. In September 2015, participant observation started and lasted until June 2016. Participant observation is a technique designed to collect data about research participants in their natural environment and includes interaction with the ethnographer . At firsIn spring 2016, interviews with students and teachers took place. These were designed to find out more about participants’ discourse regarding their own behaviors . I askedAnalysis took place after all the data was collected. Notes and voice-recordings were transcribed and saved as an RTF document, which was codified using Atlas.ti software, and families of codes were created. Following the aims of this paper, the classification of the kinds of transgressions as observed during fieldwork are (1) personal limit transgressions, (2) civic limit transgressions, and (3) social limit transgressions. Personal limit transgression makes reference to the act of questioning the socially accepted rules of interaction between peers, that is, disrespecting each other. Civic limit transgression involves non-compliance with school rules, such as disrespecting school services, challenging teachers’ authority, or asking teachers inappropriate questions. Finally, social limit transgression is a kind of civic limit transgression referring to community rule-breaking. Social limit transgression is different from the former, as it involves the non-compliance with a community rule that is naturalized for locals. In other words, a local would not usually transgress such a limit because it is naturalized for them, while a non-local could more easily transgress as they are not implicitly aware of its cultural importance.N = 4) and students (N = 6) engaged in interactions, which are analyzed from the students’ perspective, as they are the primary focus. These participants were selected because their interactions are relevant and explanatory for the main purpose of this paper: to analyze transgressions as interactions and their consequences for student identity formation.As mentioned, this is part of a larger study, but the sample utilized in this paper differs from previous publications see , 2019. IThe students selected were enrolled in the 2nd year of secondary education and were studying in a classroom composed of 19 students, of which 14 were immigrants. The relevant characteristics of the six students selected are represented in Four of the students self-defined as Latino, more precisely, Ecuadorean (Amaia and Agustín), Bolivian (Juan), and Nicaraguan (Ana). Two of these students had always attended a Basque school (Amaia and Agustín) and had had previous contact with Basque, whereas two of them had arrived in the BAC later, when they were 7 (Juan) and 12 (Ana). These four students’ mother language was Spanish. The other two students were European-descended, from Portugal (David) and Bulgaria (Myriam), and both had arrived in the Basque Country the previous year; Spanish was their second language.Personal limits as observed in this case study refer to boundaries between peers in relation to respect, interpersonal distance, and dignity. One of the most typically transgressed personal limits was interpersonal distance: in the initial classroom hours students were calm, but after recess they returned to class much more active. In this activeness, transgressions of personal space were usual: they tended to excessively touch and hit each other. In this paper I will designate these as physical interactions. Other transgressions involved insulting or mistreating each other. In this section, I will introduce three examples of such personal limit transgressions between peers.In one of the early hours of class, a teacher started to organize students to work in pairs. He asked two of the students who were close to him to work together:Teacher 1: Amaia, pónte con David.Amaia, work with David.Amaia: ¿Qué?, ¿con esa chusma ingrata?What? Do I have to work with this ungrateful riffraff?The teacher probably did not hear Amaia’s comment, as he didn’t answer, and neither was there a reply from David, but he was obviously offended.In this excerpt we can see how a teacher ordered Amaia to work with David. David was usually a silent and shy student and Amaia was considered one of the popular girls in this class. Amaia scornfully answered to the teacher’s command by insulting David, transgressing an obvious personal limit. This had an impact on David, who did not feel comfortable with the comment although it did not have any repercussions for Amaia.Insults also occurred when teachers were not present. During a focus group some Latin American students, Agustín included, told me how local Roma students called them racist names. A popular disrespectful term used in Spain for the last decade or so to refer to some Latin American people has been Machu Picchu, the name of the ancient Peruvian city. In the case Agustín described, local Roma students designated Ecuadorean pupils as “machupino,” a corruption of “Machu Picchu,” which is even more disrespectful. When local Roma students at Udabia called Ecuadorean student “machupinos” they intended, and succeeded, in causing offense. I was not present for such interactions, but Agustín expressed his frustration thus, “si supieran que eso es un monte…” (if only they knew that Machu Picchu is a mountain…). When racist insults were involved in an interaction, a personal limit was transgressed and the consequence was offense taken by the party being insulted.Leave me alone, dude); or “Yo contigo no hablo” [Spanish] (I don’t speak to you). When questioned, he said his classmates behaved like children. Some of his peers felt very offended by Juan’s attitude toward them and decided not to interact with him anymore. In line with the previous two examples, Juan’s mistreatment of his peers transgressed personal limits.Juan was often particularly scornful and disrespectful to his peers, often refusing to talk to them. When they interacted with him, his response was often “Déjame en paz, tío” [Spanish]  (with their insulting comments). In this sense, Myriam described accurately how students felt after such transgression between peers had taken place. However, it should be noted that on a few occasions these interactions were taken with humor and students were not offended by them.Myriam, another student, showed great intuition interpreting attitudes such as the ones shown in examples 1, 2, and 3 and claimed that her classmates “…a veces… no se dan “de cuenta” de que… […] hacen daño (con sus insultos) [Spanish] . After his interruption, Juan looked around to see if anyone had heard him. The teacher on this occasion ignored his comment but I, as an ethnographer, had heard and could not hide my surprise. When he realized I had heard he told me “¡Que era una broma!” (That was a joke!). Following Juan’s lead, Agustín added “Es que quiero comida americanita” (I just want American food). None of these comments were remarked on by Teacher 2.In this example, Teacher 2 was speaking about the food students ate in the canteen and Juan, who was used to pushing limits with both his peers and teachers, said “es que la comida del comedor, ¡qué asco!… quiero una pizza con su Coca-Colita” , which was almost fully funded in an educational institution.I already told you! I couldn’t get up). After this outburst, the two teachers and I remained silent, as we were shocked by her reaction. This teacher felt her authority being questioned by Myriam’s comment but did not react to it. It was obvious that Myriam had transgressed a civic limit by speaking in an inappropriate way to a teacher. As in Example 5, Myriam was probably expecting some reaction from the teacher but did not get any, at least directly.This example took place in the first hour of class on a Tuesday. On Tuesdays, two teachers (Teacher 2 and Teacher 3) taught these students and they noticed that certain were missing, which was usual. Indeed, some students often missed the first hours of class because they claimed to be too tired. When the school bell rang and classes were supposed to change, the teachers and I remained to speak about the classroom dynamic for a while. Suddenly, Myriam, a student who had been missing for the first hour, arrived and after a look from Teacher 2 said: ¡Es que ya te lo he dicho! No me podía levantar  330, seguís hasta el final, si no (lo) habéis hecho, hacéis (también) hasta el final.If you have completed exercise 330, keep going until the end, and if you have not finished it, you keep going until the end too.Juan: ¿Me estás vacilando?Are you kidding me?After a brief and tense silence, Juan and the teacher ended up laughing. Later on, during the same lesson, Juan interacted with the teacher again:Juan: ¿Tienes hijos?Do you have children?Teacher 2: Se me están quitando las ganas.All of you are taking away the desire for it.(Both Juan and the teacher laugh).In this example two civic limit transgressions can be observed, both of them initiated by Juan. The first one takes place when Juan questioned her instruction, but the teacher did not take offense and laughed about it, letting the classroom dynamic flow. After a few minutes, Juan transgressed another civic limit by asking a personal question, transgressing an obvious boundary. By reacting with humor the teacher deflected conflict and maintained a positive classroom dynamic.In examples 4, 5, and 6 good management of the classroom dynamic took place, as students transgressing a limit did not perceive that they provoked a negative reaction from teachers. Example 6 was especially remarkable, as the teacher humorously managed the limit transgression and the classroom environment remained positive.Social limits are a kind of civic limits with particular characteristics. They are institutional rules that facilitate the harmonious functioning of school and as such, they are explicit norms. But at the same time, these norms are embedded and naturalized for most local students. As social limits are imbricated in community life, locals do not usually violate them, while for non-locals, these rules are not so obvious. Hence, under specific circumstances, non-locals transgress them. In this case study, these rules relate to Basque society and its education system, where both local and immigrant students were supposed to be integrated. One explicit rule is that Basque is the basic language in the public education system, and it is compulsory to study it. As such, it is also an implicit rule according to which students are classified and distributed, as classes are organized in terms of the level of Basque instruction. However, it is important to note that students (and their parents) choose the level of Basque they are instructed in. The six immigrant students who form the basis of these observations were enrolled in a classroom with a low Basque instruction and transgressed this social limit when they opposed Basque language learning, while local students involved in the larger ethnographic study did not. The latter also chose a higher level of Basque instruction.Commonly, interactions where teachers tried to teach students words in Basque elicited blunt responses, such as “I don’t like the Basque language,” or “Why do we have to learn Basque?” In the following examples I will show indirect ways students tried to avoid speaking Basque or questioned its validity.During a Basque lesson, Teacher 4 tried to motivate students in various ways. Basque was especially difficult to teach, as students did not understand its importance in Basque schools and the community. It is also a difficult language to learn as it does not have many common elements with other languages. In this example, the teacher started the session by asking students about their ethnic origins:Teacher 4: Nongoa zara? [Basque]Where are you from?Many students answered in Spanish and most seemed to be happy about the classroom dynamic. However, when the teacher started an explanation about Basque grammar the tone of students’ interventions changed.Ana: ¿Qué?, Profesora, no entiendo. [Spanish]What? Miss, I don’t understand.Myriam: Jo, ¿qué? (? [Spanish])Really, what?In these interventions no specific question was posed and they were aimed at interrupting the explanation. They also led to a small boycott of the classroom dynamic and constitute transgressions in the sense that they aimed to prevent the Basque lesson from advancing. Although this type of behavior was occasionally observed in other subjects, it was most common during Basque lessons.This example also took place in a Basque class after some students had bluntly expressed their dislike of Basque. Teacher 4 felt offended and decided to ask one by one whether students liked Basque or not.Teacher 4: Y a ti, te gusta (el euskera)?Do you like Basque?Ana: A mi antes no me gustaba lo del euskera y eso, pero ahora bien.Before I didn’t like Basque and all that, but now it’s okay.David: Me da igual.I don’t care about it.María: NormalNormalAfter these interactions, the teacher felt disappointed to see a lack of student investment in Basque. In contrast to the previous example, students demonstrated passivity, which frustrated their teacher. The limit transgression was initiated by students claim to dislike Basque, continued when the teacher felt the questioning of its validity and reacted to it, culminating in the students’ negative response. This transgression and teacher reaction led to a negative classroom environment.This example involves a complex history of interactions between Teacher 2 and Juan. Juan had observed many interactions between Teacher 2 and other students where the teacher reacted defensively toward complaints about learning Basque. In this case, in principle, Basque learning was not involved, but the teacher was unhappy with the results these students had obtained in an exam. After a tense interaction between the teacher and students, Juan, again testing limits, suddenly asked:Juan: ¿A ti te gusta tu lengua (euskera)?Do you like your language (Basque)?Teacher: A ver, Juan, no se trata de que te guste o no te guste. Es mi lengua.Juan, it is not about liking it or not. It is my language.In this case, Basque learning was not directly involved but had been a matter of tension on other occasions, which Juan exploited. After the teacher showed irritation at the students’ low marks, Juan decided to bring up Basque language, out of the blue, probably to provoke the teacher even more. His interaction was aimed at bringing up a matter of conflict in the classroom. This indirect way of questioning the validity of Basque transgressed a social limit.This paper has analyzed interactions in a multi-ethnic school setting. More precisely, it focused on the kinds of adolescent interactions between six adolescent students and four teachers in a highly ethnically diverse Basque school setting. Data shows that there are three kinds of interactions performed as transgressions. Transgression in this paper has referred to the act of using language or physical interactions to transgress a limit, which separated deviant from appropriate behavior. According to Adolescent limit transgression, as observed in this case study, showed a need to mark difference and elicited a self-determined response from individuals in each of the examples presented. Following the concept of identity-in-interaction by This paper has contributed to the theory of identity-in-interaction by introducing the concept of transgression to a Basque case study. More precisely, by analyzing transgressions of personal, civic, and social limits by six immigrant students in a Basque school, it concludes that transgressions constitute identities-in-opposition to the main rules of social interaction. Social limit transgressions were the most salient interactions in performing an identity, by resisting one of the main rules in Basque schools: learning Basque. These students represent common attitudes among immigrant students in this and other schools in the BAC more broadly, in contrast to local students who do not tend to transgress the rule of learning Basque. In fact, social limits for local students were naturalized and often unnoticed, making them unlikely to be transgressed. Social limit transgressions were noteworthy in this case study, as immigrant students refused or complained about learning Basque, the minority language that acts as an identity marker for a large part of the Basque community. This sometimes led to intercultural conflict, as teachers felt their work as promoters of Basque identity was undervalued or misunderstood. Hence, the second hypothesis is confirmed, as immigrant student identity was performed in transgression, which was an acrimonious intercultural interaction, and this constituted an obvious problem when Basque learning was involved.A limitation of this study is that it does not analyze the social class disparities between immigrant and local students. Such a comparison could comprise the analysis of ethnic inequalities in relation to limit transgressions in academic contexts. Finally, this study contributes to the literature of second and third language acquisition in the case of immigrant students and the management of intercultural conflict in educational settings. Based on the results, I suggest that how teachers express sensitive personal responses to student transgressions related to the learning of Basque can improve classroom management and student learning. Finally, this study opens new avenues for research in multi-ethnic and multilingual environments when minority language learning is involved.The datasets for this study will not be made publicly available because according to the Ethics Committee that approved this research, data must remain confidential in all cases. This means that the author cannot share data with anyone .Ethics Committee that approved the study: Comisión Ética de Investigación con Seres Humanos de la Universidad del País Vasco . Ethics Committee for Research with Humans of the University of the Basque Country. Consent procedure: Research participants were informed of the research project. The school agreed to data collection and participants were given and signed an informed consent in order to take part in this study. Please note that confidentiality of participants is kept throughout all the article and these remain anonymous (pseudonyms are used).The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Since 2011, the Government of Ontario, Canada, has phased in hospital funding reforms hoping to encourage standardised, evidence-based clinical care processes to both improve patient outcomes and reduce system costs. One aspect of the reform – quality-based procedures (QBPs) – replaced some of each hospital’s global budget with a pre-set price per episode of care for patients with specific diagnoses or procedures. The QBP initiative included publication and dissemination of a handbook for each of these diagnoses or procedures, developed by an expert technical group. Each handbook was intended to guide hospitals in reducing inappropriate variation in patient care and cost by specifying an evidence-based episode of care pathway. We explored whether, how and why hospitals implemented these episode of care pathways in response to this initiative.We interviewed key informants at three levels in the healthcare system, namely individuals who conceived and designed the QBP policy, individuals and organisations supporting QBP adoption, and leaders in five case-study hospitals responsible for QBP implementation. Analysis involved an inductive approach, incorporating framework analysis to generate descriptive and explanatory themes from data.The 46 key informants described variable implementation of best practice episode of care pathways across QBPs and across hospitals. Handbooks outlining evidence-based clinical pathways did not address specific barriers to change for different QBPs nor differences in hospitals’ capacity to manage change. Hospitals sometimes found it easier to focus on containing and standardising costs of care than on implementing standardised care processes that adhered to best clinical practices.Implementation of QBPs in Ontario’s hospitals depended on the interplay between three factors, namely complexity of changes required, internal capacity for organisational change, and availability and appropriateness of targeted external facilitators and supports to manage change. Variation in these factors across QBPs and hospitals suggests the need for more tailored and flexible implementation supports designed to fit all elements of the policy, rather than one-size-fits-all handbooks alone. Without such supports, hospitals may enact quick fixes aimed mainly at preserving budgets, rather than pursue evidence- and value-based changes in care management. Overestimating hospitals’ change management capacity increases the risk of implementation failure.The online version of this article (10.1186/s12961-018-0353-6) contains supplementary material, which is available to authorized users. Health systems around the world are responding to pressures to achieve the Triple Aim  by testiIn 2011, the Government of Ontario, Canada, began a multi-year implementation of hospital funding reforms. These reforms included replacing some of each hospital’s global budget with procedure- or diagnosis-specific funding based on a pre-set price per episode of care, a variant of activity-based funding . This asTo support the implementation of QBPs, the provincial government, in collaboration with Health Quality Ontario  and/or relevant disease-oriented agencies, developed and published a series of handbooks – one for each QBP – outlining best practice episode of care pathways for managing patients with particular diagnoses or undergoing particular procedures. These handbooks and the episode of care pathways contained therein –developed in partnership with technical expert advisory panels including leading clinicians, scientists and patients – serve as a compendium of evidence and clinical consensus for each QBP. Each QBP clinical handbook defines a target patient cohort for a particular diagnosis or procedure and recommends an evidence-based episode of care pathway for that cohort. This includes the critical decision points and phases of treatment for implementation in a particular care setting . Each handbook also suggests quality indicators to monitor the impact of changes made to implement the episode of care pathway for the targeted cohort. During the period covered by our study 2012–2017), 15 handbooks were produced and published  and adoption supporters (Level 2), we reviewed public documents about the hospital funding reform and consulted with research team members familiar with the reform to generate a list of potential key informants. One team member (AB) directly emailed these individuals to request their participation and to facilitate communication between them and the interviewer (KP).® online survey software. First, we surveyed executives in 14 Local Health Integration Networks , the Ontario Hospital Association and Cancer Care Ontario , we selected hospitals through a multiple-stage, stratified, purposeful, sampling approach, aided by Qualtricsservices , 13). WeOne research team member (AB) then contacted each representative hospital’s Chief Executive Officer (CEO) to seek permission to include their facility in our research. If they agreed, we then asked the CEO to connect our team with leaders or their delegates. We sought interviews within each of the following four groups: (1) chief executive (e.g. CEO); (2) financial/decision support ; (3) clinical ; and (4) medical . If initial informants nominated other participants, we pursued snowball sampling to achieve saturation.One research team member (KP) conducted all interviews by telephone, following a semi-structured interview guide. We pre-tested the interview guide and continued to refine it iteratively based on regular discussion with the research team regarding emerging findings of interest. We sought further information at all three levels and within each case-study hospital until saturation was reached. Interviews were audio recorded, professionally transcribed and de-identified. The interviewer made summary case notes immediately after each interview.® qualitative data analysis software, to facilitate coding, analysis and data management. Each member of the research team independently identified key themes for discussion; upon consensus, data were curated accordingly. Finally, we organised key themes by level of respondent  and by case-study hospital to facilitate comparisons. One research team member (KP) identified an initial set of representative quotations from the transcripts for each key theme. From these quotes, we collaboratively and iteratively sought meaning from the data by building a logical chain of evidence that was conceptually and theoretically coherent  numbers have gone up in the last couple of weeks so I'm challenging my teams to do something about that. R: That seems to be the thing that you're spending most of your attention on. It’s not QBPs so much… P: Definitely, no. R: Yeah, okay, I understand. P: If I can solve that…QBPs is the least of my worries at this time.”“P: Source: Senior Executive, Hospital, Level 3 – 026… in terms of the systems of data analytics that are required to really do it well… we don’t have some of the key enablers that will be necessary to really get us to perfection or a lot closer to perfection than we are today.”“Source: Senior Executive, Hospital, Level 3 – 024Then there are two other QBP things that we’re wrestling with. One is heart failure, and the other one is pneumonia. We’ve had a lot of trouble in this hospital, getting people to put patients into those QBPs. R: What do you mean by, put patients into those QBPs? P: Enrol them into the pathway. R: Okay, so follow the pathway? P: Yeah, because people come in, and they don’t say, I’ve got heart failure, they come in and say, I’ve got shortness of breath, so we need a shortness of breath pathway. Then blood work is done, an x-ray is done, we figure out, oh, it was actually an infarct that caused the shortness of breath, or it was pneumonia, or it was heart failure, or it was a chest infection that produced a bit of heart failure, so where do you put that patient? When you get away from a very well-described thing like renal failure, a hip replacement, we’ve had a lot of difficulty, and I know other places have had a lot of difficulty with these medical ones.”“Source: Senior Executive, Hospital, Level 3 – 028The extent to which episode of care pathways were implemented varied not only across hospitals, but also across QBPs. Medically complex, unplanned QBPs were inherently more difficult to implement than planned, procedurally oriented, QBPs. Medically complex QBPs with a high degree of clinical uncertainty required more sophisticated and clinically nuanced adoption supports to initiate the recommended pathway, but these were not available.When you have the nice, neatly defined episode of care, it’s pretty easy, like hip fractures, knees, and surgical things. They lend themselves very well to QBPs. It works well. The medical ones are more of a challenge, like CHF [congestive heart failure], COPD [chronic obstructive pulmonary disease]. The hospital is only a small component of that person’s healthcare journey… the way our system is designed and organised, we have precious little influence or control over probably 90% of their healthcare experience.”“Source: Senior Executive, Hospital, Level 3 – 022I think a key enabler is having some sort of an agency or focus where you know that you’ve already got traction in the system. For example, for our cardiac and vascular QBPs, we already work with those end users and stakeholders. And so, when it came time for us to go out and do some dissemination and some road shows to each of the hospitals, we already had those connections.”“Source: Senior Executive, QBP Adoption Supporter, Level 2 – 021Pre-existing, external QI and change management supports facilitated implementation of some disease-specific QBPs, but not all. In almost every case, these pre-existing, external QI supports were associated with provincial organisations experienced in supporting change management processes. These included established disease-specific agencies, pre-existing communities of practice, and/or established performance monitoring and evaluation mechanisms. QBPs for which there were no pre-existing, external QI supports were more challenging to implement.We know that the first wave of QBPs that were created, which were, of course, closely linked to the original wait times activity, that those are in very advanced stages of adoption. But, subsequent QBPs, subsequent batteries of QBPs, at a minimum we know are implemented in a highly non-standardised manner across the province, and we know that in some parts of the province they’re not implemented at all.”“Source: Senior Executive QBP Adoption Supporter, Level 2 – 020Having some of those provincial organisations out there assisting hospitals with less internal capacity is a good thing, and I think the OHA [Ontario Hospital Association] has also started to do some more analytics support for its organisations, especially small hospitals. So, I think all those are good strategies at the provincial level, to ensure people don’t get left behind.”“Source: Senior Executive, QBP Adoption Supporter, Level 1 – 014All of the things that the Ontario Stroke Network has been able to do around the stroke QBP are just totally the sorts of things that have contributed to success in terms of adopting clinical best practices. One of the things to remember is that there’s nothing magical about the stroke handbook. Pretty much all the recommendations from that were taken from the existing Heart & Stroke guideline. But, I think the Stroke Network was very adept in terms of capitalising on the QBP introduction, to sort of make this case for clinical practice change, and so they did very well as a result whereas, if you look at COPD, there was much less of that going on. And, I think pneumonia was…a perfect example in that there’s no Ontario pneumonia network. There wasn’t much activity going on in that area, there’s no pneumonia scorecard, any of this stuff brought in feedback. And, so there’s actually probably been very little impact of that pneumonia QBP handbook in terms of clinical practice change.”“Source: Source: Senior Executive, QBP Adoption Supporter, Level 1 – 014My guess is most clinicians have never read a QBP clinical handbook. So, they can’t make change if people don’t read them.”“Source: Senior Executive, QBP Adoption Supporter, Level 2 – 018Regardless of hospitals’ internal capacity for change, and irrespective of whether external QI and change management supports were available, supports were lacking to facilitate physician engagement and collaboration with clinical care teams in the implementation of standardised episode of care pathways. The extent to which clinical leaders and hospital administrators were able to engage physicians to collaboratively implement pathways varied by QBP and by hospital.I’m guessing I wouldn’t have to walk very far down the hall before I could find a doctor who would be grumpy about this or that in terms of what is in there. But I don’t think that is the big problem. The big problem is, what mechanisms and what tools do we have in place to relentlessly drive towards compliance standardisation? And it’s very difficult because these guys, they don’t work for me. R: The physicians? P: Yes. R: (Laughs.) Right, I suppose. P: It’s the truth. They don’t. R: They are not employees, in that sense, you mean? P: Not only are they not employees, they are essentially tenured. So, not only is it very difficult to give them direction, it’s very difficult to do anything when they don’t comply with it.”“P: Source: Senior Executive, Hospital, Level 3 – 024And so, that is our challenge, and we want to do better. We want to do well. We’re struggling. We keep going back and we meet with one group of docs, another group of docs, our Emergency docs. And to date, we have not found the magic to trigger it because it seems so complex, like I said, with other systems involved. So, we’re going to continue trying because we want to do well, but it is very difficult.”“Source: Senior Executive, Hospital, Level 3 – 042I think what I originally was hoping for, looking at the QBPs, I think there was hope to have a little stronger clinical engagement and how do you engage clinicians better and use existing infrastructures in the province to help create communities of practice. I don’t think that really materialised. And I think that is what we’re seeing now. It’s great that you throw a best practice at me. It’s great that you show me the baseline results. It’s great that you pay me an average price. But I have no idea how to move this forward.”“Source: QBP Designer, Ministry of Health, Level 1 – 005If you pull back the camera lens, health system funding reform, including quality-based procedures, was entirely designed and primarily implemented by the Ministry in a command-and-control function with virtually no genuine engagement and collaboration with the very sector that is supposed to implement the change. There was a very wide range of meetings and groups that came together under Ministry sponsorship from time to time, but they were inauthentic and simply masquerading as mechanisms of, again, consultation, collection of evidence and guidance, and refinement of tactic and strategy. It’s in the last year the Ministry has come to genuinely appreciate that the trajectory of HSFR [Health System Funding Reform] in general is no longer viable, and that a fundamental recalibration is needed. And, so they’ve abandoned the old committee structure, which was representational only, it had no other real authentic function, and we’ve reconvened a new governance collaborative.”“Source: Senior Executive, QBP Adoption Supporter, Level 2 – 020Insufficient stakeholder input in planning for the implementation of QBPs led to development of adoption supports that were not effective for all involved. Stakeholders perceived incomplete, inadequate and/or inauthentic consultation and collaboration between the key groups involved  about how best to implement QBPs. This impeded design of effective adoption supports to enable implementation and change management, which was exacerbated by a lack of funding for change management initiatives affecting the work of both adoption support agencies and individual hospitals.You can’t just write a handbook, throw the brick over the fence and assume your job is done. And, there are pockets of change management support for different kinds of QBPs in the province. The OHA [Ontario Hospital Association], for instance, partnered with the OMA [Ontario Medical Association] and did regional programming for clinicians on one type of QBP last year. But, the scale of change management supports that are required on a sustained and system basis are enormous. The Ministry deserves full criticism of this. They paid no attention to the change management requirements of QBP implementation.”“Source: Senior Executive, QBP Adoption Supporter, Level 2 – 020But to some degree there has not been change management dollars behind change. And fundamentally at the end of the day, I think most people understand that change actually costs to implement and then you get the benefits down the line.”“Source: Senior Executive, Hospital, Level 3 – 023I think the hospitals are pushing back and saying, slow down, because this is tougher to manage than we thought and it’s got all kinds of complication in the implementation. And even if they are done very, very well, the capacity of hospitals to really get their arms around what they should be doing with them is a process. There is quite variable capacity in hospitals to deal with that, I think. So, I think hospitals are pushing back and saying, slow down. I think the execution needs to be improved for the whole QBP and health system funding reform process.”“Source: Senior Executive, QBP Adoption Supporter, Level 2 – 013Adoption support handbooks focused on clinical care rather than on financial operations. However, hospital finance administrators, typically responsible for the pressing task of ensuring that costs for QBPs did not exceed the set prices, required, but lacked, analytical and decision support to inform financial operations. Without these supports, and given the time pressure to implement QBPs, hospital leadership struggled to prioritise whether (and which) changes were required for each of the QBPs. Hospital administrators responsible for finances felt there was no systematic approach to support them in their role in the change management process, or to facilitate interaction between the clinical and financial sides of hospitals.The pushback we’re getting is largely from administrators, right? This is too much, too soon, too fast. I think I’m hearing it largely from the administrative side of the house where they’re seeing the risks of not being able to predict the volumes, not being able to plan, having to change processes, all this kind of thing.”“Source: QBP Designer, Ministry of Health, Level 1 – 006Although nobody would ever say it this way, I think what it really means is, if you want us to figure out how to use these new funding formulas to maximise our revenue, we need time. And they’re really complicated and these incentives sometimes act in confusing and conflicting ways, particularly because we didn’t shift to just the straight up rate by volume funding mechanism. If we had, it would have been very clear, you’ve got to identify your admissions, or your costs are greater than your revenues, and work to reduce costs on those, and maybe reduce volumes there.”“Source: Senior Executive, Adoption Supporter, Level 2 – 018No one has shown me any information that would say, you know what, we’ve mapped out and costed the perfect care pathway for the CMG [case mix group], and when you do that, this is what you should have. You should have a length of stay at this. You should have nursing coverage at that. You should have this and that. In a perfect world, this would be a cost structure. It’s still based on average performance across the province, so it’s a bit of an anomaly to think that we’ve actually tried to provide all the appropriate operational guidance, clinical guidance, to hit the mark that was, I think, fully intended at the outset.”“Source: Senior Executive, Hospital, Level 3 – 023Yes, the handbooks are useful, but what you really need is having strong clinical champions, having a network, having timely data on quality performance that you can provide to hospitals.” Source: QBP Designer, Adoption Support Agency, Level 1 – 014“The mismatch in adoption supports was evident not only at the level of hospital financial operations, but also in the area of clinician leadership within and between hospital systems. There were no formal supports to put clinical leaders in place as champions and change agents. Although the QBP handbooks specified ideal episode of care pathways, and although the process of developing these pathways and handbooks brought together clinical leaders from around the province to participate in the technical expert advisory panels, there was no mechanism that leveraged the credibility and expertise of those leaders to encourage implementation of the care pathways in their own hospitals and across the whole hospital system.I think they vary by QBP to the extent that there are different levels of clinical engagement and support in these different service areas in Ontario. And in some areas like cancer we have a really mature and robust clinical champion and a formalised network of clinical leads that are able to do knowledge transfer really effectively through Cancer Care Ontario. That’s an outlier. And then we have less formalised clinical leadership networks, not only paid physicians, clinical leads, and then in some areas we really don’t have any infrastructure like that at all in the province. To that extent it varies because of the way that we’ve supported clinicians in being champions and engaging with their peers in knowledge transfer and exchange. And that’s just really varied by clinical area in the province. I guess I would say again I don’t know that it’s about personalities as much as to what degree we’ve supported that clinical peer knowledge translation function in the province.”“Source: QBP Designer, Ministry of Health, Level 1 – 006How long does it take, or did it take, to implement a new QBP from when it’s announced? P: Oh. Some of them were really... R: That was a big groan. P: Yeah, some of them were lickety-split easy and some of them hard, hard, hard, hard, hard. R: Can you differentiate between the easy and the hard and why some were easier and some were hard? P: Uh, yeah, yeah, yeah, I think it generally had to do with how much clinical engagement and clinical consensus you could generate and where you had the strongest physician champions. The physician champions were critical because… I mean, at the end of the day, we would have the support of the whole team, absolutely, but they don’t admit, discharge, or order.”“R: Source: Senior Executive, Hospital, Level 3 – 043In terms of the systems of data analytics that are required to really do it well, and that hospitals and healthcare are lacking…we don’t have some of the key enablers that will be necessary to really get us to perfection or a lot closer to perfection than we are today.”“Source: Senior Executive, Hospital, Level 3 – 024Additional adoption supports aimed at hospital administrators or clinicians, such as data analytics tools and standardised clinical order sets, were envisioned and well-intentioned, but not fully implemented in time to be useful to hospitals. Hospitals in which additional supports were pursued, but which lacked stakeholder buy-in, experienced implementation failure.They would rather hand-write all the orders, and for the life of me, I can’t figure out why. They would rather scrawl and write exactly what they want, rather than go through this lovely pre-printed thing, check, check, yes, no, this is how it should be, and I don’t understand it. We have put them out over and over again. R: The pathway? P: We have launched... the pathways, yes R: The order sets? P: The order sets. We have launched them. We have re-launched them. We have gone around and we have talked to our internal medicine specialists, our hospitalists, our cardiologists and everybody and say, they are right here in Emerg. Oh, you know, when I go there and open the door, they are never there. And we go back to Emerg and we put them in red, and then we put up big signs, flashing light bulbs, like the blue light special. We do everything we can, and they won’t get used.”“Source: Senior Executive, Hospital, Level 3 – 042You’re in the process of already creating standardised order sets for those. So, much of what drives the care that the patient gets is based on what the physician orders and so these order sets are the tool that really enhances the success of the QBP.”“Source: Senior Executive, Hospital, Level 3 – 030There is virtually no provincial understanding about spread and scale of QBP adoption but for some heat maps that have been sponsored by Local Health Integration Networks. That’s the only mechanism that allows us to evaluate the scale of QBP adoption in the province.”“Source: Senior Executive, Adoption Supporter, Level 2 – 020Although there has been some evaluation of the extent to which QBPs are implemented, it has been neither systematic nor comprehensive. Instead, it focused on hospital self-reports of QBP implementation. Indicators are lacking to enable comprehensive and ongoing evaluation of (1) the scale of QBP adoption, (2) the degree to which clinicians adhered to episode of care pathways, or (3) the effect of such adherence on patient outcomes.I don’t know the measures that are out there to even tell me that some of them have been implemented, other than a process measure that says someone wrote a handbook. Nobody is measuring the quality of delivery according to best practice, so how would we know?”“Source: Senior Executive, Adoption Supporter, Level 2 – 021There are some indicators, yes, absolutely, but there are many indicators that don’t exist. And, then this gets to a more kind of systemic issue, which is there’s a sense that the sector is overwhelmed in that it’s asked to conduct so much performance measurement, and all of it is given equal importance, that the sector simply doesn’t know which priority the government feels is more significant over the other. Some indicators are publicly reported, others are for boards only. Others are for management teams only. But, it’s not just QBP indicators, but there are hundreds and hundreds of indicators for completely different quality improvement, quality assurance initiatives that compete with QBP, and so you have a confounding situation on your hands.” Source: Senior Executive, Adoption Supporter, Level 2 – 020“I’m not sure that anybody really has told us what the desired effect is. I don’t mean to be flippant but I just think it’s assumed all these wonderful things will happen. I think it’s early days to tell, to tell you the truth. I’m not sure they’re going to be measured locally. I think it’s almost at the system level. I would say to you at the gross system level for a primary unilateral hip or unilateral knee, are your costs stable, has your length of stay come down, and what are your outcomes? R: Do you collect those data, the ones you just mentioned? P: There’s very little outcome data available to us for anything that we do with patients. That's one of the things I think the whole system grapples with. We have lots of process indicators. We don’t have a lot of outcome indicators.”“Source: Senior Executive, Hospital, Level 3 – 022People are saying oh, it’s just too complex, too complicated, I’ll leave it to the finance people to deal with. And, so, I think you kind of lose that emphasis on quality once you begin to disengage, I think, for people that are in that quality side of the house.”“Senior Executive, Hospital, Level 1 – 008When QBPs were implemented, their stated goal was to address unwarranted variation. They were both a funding reform aimed at standardising costs and a quality of care initiative aimed at standardising clinical processes. Many hospitals struggled to simultaneously address these twin goals, perceiving them as conflicting or creating tension, rather than as complementary or aligned. Consequently, some hospitals focused more on one aspect of the reform (standardising cost) than on the other (standardising care). The immediate route to addressing cost-pressures of QBPs was not often perceived as flowing through the complete implementation of care pathways. Rather, quick fixes to address shortfalls instead included reducing length of stay when possible or shifting funds from other streams.We use this network of physicians, and clinical leadership, and stuff like that, and we use them helping us guide the strategy of all this, but the ministry uses the CFOs [Chief Financial Officers] to help guide all the strategy. They’re more interested in, make it simple, make sure my hospital doesn’t get hosed somehow, and I get way more money than I used to have.”“Source: Senior Executive, Adoption Supporter, Level 2 – 017… one of those key things this has done has been a catalyst for conversations between the clinical and administrative sides of the hospital. But having said that, they’re not necessarily seeing eye to-eye, right? (Laughter) So, I think it surfaces as some tensions as well.”“Source: QBP Designer, Ministry of Health, Level 1 – 006So, we got a reduction in volume of cases, but the math would say that they were less complex cases so they should cost you less and we’re going to give you less funding. But the reality is a hip patient still went into a bed, there was still a nurse, there was still a meal delivered, there were still all these things. The length of stay didn’t drop the bottom out. So, it was a very mathematical thing to suggest that it cost us less to do the same number of hips the next year that we did last year, and yet funding went down, right?”“Source: Senior Executive, Hospital, Level 3 – 023There’s lots of change, for sure, right? And, layoffs and closure of… winding down of, FTE [full-term employment] positions is absolutely one of them, and so is hiring new positions and new people. So, it’s never fair to think that… it might be a cut in and of itself in that moment in time, but at an organisational basis and on a regional basis and on a provincial basis, there’s still continued growth overall. So, there’s change happening, but to the employees who it affects, yeah, it’s pretty darned important.”“Source: Senior Executive, Adoption Supporter, Level 2 – 020Typically what happens is there’s a QBP handbook comes out and the folks start to take a run at it, and they go, ‘our length of stay is a little high’ and things like that, and they do go to work on that and they bring it in line.”“Source: Senior Executive, Hospital, Level 3 – 023I think there’s probably some indicators we’re getting better outcomes. My only point is, nobody has that conversation. When you’re actually a hospital [executive]… when we get our numbers, I don’t hear everybody rushing into my office saying, oh my God, we did so well on QBPs this year, we had such better outcomes of patient experience. I hear from my colleagues, oh, how did you do on QBPs, did you lose or did you gain money. Then, it’s not a quality indicator.”“Source: Senior Executive, Hospital, Level 3 – 031If you don’t deliver the QBPs, you have to give the money back. If you deliver more than what you are funded for, you are not paid for it. So, for planned care, yes, we can cap at that. For unplanned care, we have no ability to cap. R: So, what do you do? Where do you get the money? P: Well, it has to come from the hospital. We have to balance the bottom line. R: So, you take it out of the globe? P: We take it out of the globe.”“Source: Senior Executive, Hospital, Level 3 – 025We found substantial variation in how hospitals responded to the QBP hospital funding reform. Our findings suggest that three factors affected the degree to which the QBP initiative was successfully implemented, namely complexity of the changes required, internal capacity for organisational change, and availability and appropriateness of targeted external facilitators and supports to manage change.disparate groups of physicians and directors”, as compared to surgical QBPs with their “neatly defined” episodes of care and smaller uni-disciplinary clinical teams.Regarding complexity of changes required, as highlighted in sub-findings 1a and 1b, surgical QBPs were easier to implement than medical QBPs. This was partly because medical QBPs involve a higher degree of clinical uncertainty and larger multi-disciplinary clinical teams with “The role of internal change capacity is illustrated in main finding 1, and sub-findings 2a, 2b, and 2c. Successful implementation was affected by whether there was sufficient internal capacity for managing change, such as local QI supports and/or informatics infrastructure  and whether there is a receptive context , 22 and Targeted external supports provided by condition-specific agencies and provincial networks, such as for cancer and stroke, as described in sub-finding 1b, helped to facilitate implementation by leveraging existing relationships across the health system to identify and enable best practices, whereas other QBPs, such as pneumonia, lack networks.As depicted in Table One interpretation arising from the interplay between these factors is that policy-makers might consider restricting QBPs to areas where the changes required are less complex, and where there are known resources existing within hospitals, or in the broader system, to facilitate the necessary change management processes to achieve the desired patient care and outcomes. Policy-makers might also consider discontinuance  of thoseThe challenges of standardising care within different clinical groups that involve fundamentally different microsystems do not seem to have been adequately considered in the design of the QBP adoption supports. Policy designers and adoption supporters appeared to over-estimate the capacity of some hospitals to manage change, including the receptive context for change, resulting in incomplete implementation efforts in a number of hospitals. Many hospitals were under-resourced to manage this type of change, especially without involvement of relevant external agencies with established capacity to engage clinicians and provide useful supports. It is possible to conceive of a situation where healthcare systems already have the full range of analytic decision support and change management enablers in place. However, it is often challenging to justify extensive investment in supports without the motivation of a major policy reform like QBPs. Given this dynamic, system-wide interventions are likely to limp along, unless there is substantial investment up front in the change management infrastructure to support implementation and to assess its effect on outcomes of interest. However, this means that policy designers and implementers will need to make the case for these supports, which will inevitably reduce the attractiveness of the policy change itself as its overall costs increase.Our research found no qualitative evidence that the episode of care pathways described in QBP handbooks are being consistently used across hospitals. This would be expected given that there was neither an expectation that hospitals report the degree to which they are using the pathways nor a mechanism by which to do so. Since patient outcomes were not directly connected to payment , QBPs inAnother possible interpretation for our results arises from the effect of policy drift on implementation. As described elsewhere , prior tWe know of only two published studies specific to QBPs, one evaluating healthcare leaders’ early responses to implementing QBPs , and theA key debate in the policy implementation literature is the top-down versus bottom-up approach to policy-making , 27. Ourfocus attention on policy implementers who are capable of re-shaping policy during its implementation, with consequences for policy outcomes” [Prior research establishes the importance of the implementation process itself – including the utility of appropriate adoption supports – in achieving intended policy goals , 28–30. utcomes” . A systeutcomes” . Our resOur work revealed subtleties and complexities about the research topic that may have been missed by more positivistic enquiries . AcknowlWe highlight the importance of designing appropriate and targeted adoption supports as part of a fully fleshed out policy design to enable implementation, ensuring that supports are timely, account for internal change management capacity, and are appropriate to the complexity of the change. Our results also indicate the need to adjust supports if policies change due to drift, layering or other reasons.Going forward, how can this work inform future funding reforms under consideration, such as bundled payments and other mechanisms, so that they not only achieve their cost objectives but also achieve their intended goals related to patient care? First, to avoid conflicted success , precarSecond, policy-makers ought to carefully assess the key success factors, identified in Table Consult with stakeholders to carefully assess adoption support needs. Before deciding what adoption supports are needed, policy designers ought to consult with stakeholders to assess their needs with regard to implementing desired changes. Attempts by policy designers, alone, to build new adoption supports may be constrained by a preference for one-size-fits-all approaches. Such strategies, even within one jurisdiction, are likely to fail. This highlights the importance of grounding what may seem to be a technically simple policy in a fine-grained understanding of the healthcare system.Benefit from existing prêt-a porter adoption tools and communities of practice. From the outset, policy-makers would benefit from collaborating with external adoption support groups that have already built tools and communities of practice and, where such groups do not exist, take pains to accelerate their creation. Nimble and/or focused organisations  are likely more able to engage directly with the field, so as to create more bespoke adoption supports.Develop novel made-to-measure adoption supports in collaboration with people in the field. If new adoption supports are needed, they are best developed through extensive engagement with people working in the field so as to understand both the clinical problems and change management resources available within the healthcare system. Broad engagement with stakeholders is ideal, and the use of technical experts alone can be problematic. The ability to implement policy interventions is heavily grounded in history and context, which, by definition, varies across hospitals and jurisdictions. As such, new tools ought to be calibrated to the specific problems and to the unique needs of each microsystem.Consistent with the key success factors identified, we offer three observations about implementing change:Our findings suggest that the QBP policy appears to have been developed at a high level, with the consequence that attention to implementation supports may not have been grounded in a clearly articulated and consistent programme theory. This led to a profound mismatch between the adoption supports that were likely needed, and those that were developed. Supports were focused on tools (i.e. handbooks and a toolkit) aimed at one group , but responsibility in hospitals was shared with another group  for whom there were no customised external supports. Hospitals generally lacked capacity to standardise both costs and clinical aspects of the episode of care pathways on their own, which may have affected achievement of some policy goals. Hospital managers might have been expected to respond in a more effective and reliable manner if the policy designers and funder had made the programme theory more clear and consistent. Even still, some hospitals with less internal capacity to manage change could have benefitted from tailored external supports to ensure the policy would achieve its aims.While the urge of policy-makers to use a financial lever to incentivise action is understandable, it is important to always be cognisant of the attendant risks, especially when the changes that are easiest to implement to earn those incentives are not the changes desired. The purpose of adoption supports developed alongside a hospital funding reform is to facilitate implementation of best-practice episode of care pathways that result in the best possible patient outcomes, rather than other changes that are merely quick fixes to address short-term budgetary concerns. If internal capacity of hospital and/or external adoption supports cannot be leveraged to meet this goal for certain QBPs, policy-makers should reconsider the approach to funding for those types of care-episodes or conditions. Additionally, if policy-makers are considering bundled payments, or other funding reforms, it is important to specifically define the clinical goals of such initiatives, reflect on whether monetary incentives are needed to encourage the necessary changes to achieve those goals, and identify the additional supports needed.Additional file 1:Handbooks for Quality-Based Procedures implemented between 2012 and 2017 . (DOCX 1