Original Manuscript
Evaluation and perceived results of moral case deliberation: A mixed methods study
Nursing Ethics 1–11 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014557115 nej.sagepub.com
Rien MJPA Janssens VU University Medical Center EMGOþ, The Netherlands
Ezra van Zadelhoff Zuyd University of Applied Sciences, The Netherlands
Ger van Loo Moral Case Deliberation Committee at Sevagram, Organisation for Elderly Care, The Netherlands
Guy AM Widdershoven VU University Medical Center EMGOþ, The Netherlands
Bert AC Molewijk VU University Medical Center EMGOþ, The Netherlands; University of Oslo, Centre for Medical Ethics, Norway
Abstract Background: Moral case deliberation is increasingly becoming part of various Dutch healthcare organizations. Although some evaluation studies of moral case deliberation have been carried out, research into the results of moral case deliberation within aged care is scarce. Research questions: How did participants evaluate moral case deliberation? What has moral case deliberation brought to them? What has moral case deliberation contributed to care practice? Should moral case deliberation be further implemented and, if so, how? Research design: Quantitative analysis of a questionnaire study among participants of moral case deliberation, both caregivers and team leaders. Qualitative analysis of written answers to open questions, interview study and focus group meetings among caregivers and team leaders. Participants and research context: Caregivers and team leaders in a large organization for aged care in the Netherlands. A total of 61 moral case deliberation sessions, carried out on 16 care locations belonging to the organization, were evaluated and perceived results were assessed. Ethical considerations: Participants gave informed consent and anonymity was guaranteed. In the Netherlands, the law does not prescribe independent ethical review by an Institutional Review Board for this kind of research among healthcare professionals. Findings: Moral case deliberation was evaluated positively by the participants. Content and atmosphere of moral case deliberation received high scores, while organizational issues regarding the moral case
Corresponding author: Rien MJPA Janssens, Department of Medical Humanities, EMGO, VU University Medical Centre, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands. Email: [email protected]
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deliberation sessions scored lower and merit further attention. Respondents indicated that moral case deliberation has the potential to contribute to care practice as relationships among team members improve, more openness is experienced and more understanding for different perspectives is fostered. If moral case deliberation is to be successfully implemented, top-down approaches should go hand in hand with bottom-up approaches. Conclusion: The relevance of moral case deliberation for care practice received wide acknowledgement from the respondents. It can contribute to the team’s cohesion as mutual understanding for one another’s views is fostered. If implemented well, moral case deliberation has the potential to improve care, according to the respondents. Keywords Clinical ethics, clinical ethics support, aged care, evaluation, moral case deliberation
Introduction Moral case deliberation (MCD) is a specific kind of clinical ethics support which can be understood as a structured and methodological deliberation on how MCD participants perceive morally good (organization of) care.1–4 MCD is part of a larger development in Dutch healthcare organizations where initiatives are being taken in order to (a) give structural attention to the moral dimension of determining good care and (b) support healthcare professionals when being confronted with moral dilemmas and questions.5 In MCD, caregivers and other professionals are invited to participate in a dialogue in order to articulate, clarify and scrutinize their own moral convictions and assumptions. The dialogue is facilitated by a trained facilitator, and often a specific conversation method is used.6 As such, MCD is different from everyday conversations or regular team meetings. MCD is concerned with the moral dimension of caregiving, that is, with the question what is right or wrong to do in a specific context. Not only the content of MCD (i.e. the caregiver’s moral concerns) distinguishes MCD from everyday interaction, it is also the process of MCD that is different. In MCD, it is expected from the participants that they have an open attitude to the moral convictions of others and to their own moral convictions. Respect for others, even if they hold other or opposite moral convictions, is required as well as the willingness to change or amend your own convictions if deemed necessary. Both process and content of the critical reflection within MCD are to increase caregivers’ awareness of the moral aspects of their daily work. Furthermore, evaluation studies on MCD report that MCD can contribute to the handling of difficult cases, professionals’ moral competency, multidisciplinary team cooperation and the development or adjustment of policy or guidelines.7 As such, MCD aims to improve care. Recently, various healthcare institutions in the Netherlands have started MCD implementation projects.5 Reflective studies on MCD have been published earlier.1,6,8,9 Although MCD receives increasing attention within Europe, empirical data on the evaluation and (perceived) results of MCD in aged care remain scarce. Recently, some research in this area has been conducted.7,10–12 Furthermore, in mental healthcare and aged care contexts, a limited number of evaluation studies have been published.13–15 These studies focus more on the evaluation of the MCD process than on the results of MCD. In this contribution, we report quantitative and qualitative results from a MCD evaluation and result study that was conducted among caregivers and team leaders who participated in MCD sessions at a Dutch institution for aged care. The aim of the study was to gain insight into what participants consider to be the value of MCD for themselves as professional caregivers and for their organization, with a specific focus on the contribution of MCD to care practice. Four research questions were formulated: (1) How did participants evaluate MCD? (2) What has MCD brought to 2
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them? (3) What has MCD contributed to their care practice? and (4) Should MCD be further implemented within the institution and, if so, in what way? In the section ‘Research setting’, we provide general information on the institutional context in which the MCD sessions took place and on how the MCD sessions were organized. Second, in the ‘Methods’ section, the qualitative and quantitative methods will be described. In the ‘Results’ section, the answers to the research questions will be presented. Finally, the ‘Discussion’ section contains an analysis of the practical relevance of MCD; it describes the study’s strengths and limitations and outlines lessons that can be learned from the study. The findings of this study, both positive and negative, can be of relevance to other aged care organizations which aim to implement and evaluate MCD. Furthermore, we hope that this article contributes to the future of MCD evaluation and result studies.
Research setting In 2007, MCD was introduced as a specific method during a small pilot project in a large organization for aged care situated in the south of the Netherlands. The organization consists of 20 care centres where older people can be admitted for various reasons. The care provided in the centres varies from specialist nursing home care to more general support in daily activities. Terminal care is delivered in two hospices. The organization furthermore provides home care in the region and housing for older people who want to live close to a care centre, in order to receive care when needed. A total of 2500 people are employed and 1100 volunteers are involved in the provision of care. At the time of the introduction of MCD in 2007, the Board of Directors and the location managers suspected that attention for MCD would be congruent with the care concept of the organization. Central notions in this concept of care are ‘human connection’, ‘authentic understanding’ and ‘a warm, personal standard of care’. They decided to support the pilot project because they assumed that MCD could (a) help raise the moral sensitivity of caregivers in their care delivery, (b) contribute to a critical and learning organization and (c) promote transparent and effective cooperation and decision-making. After positive experiences with the pilot project, it was decided in 2009 that MCD should get structurally implemented in the whole organization. In order to facilitate this implementation process, an MCD committee was installed consisting of a location manager (chair), two spiritual caregivers (of whom one functions as the secretary of the committee) and two social workers. The members’ tasks were to collect and disseminate knowledge on MCD and to monitor, steer and evaluate the implementation process of MCD throughout the organization. Help was sought from an academic expertise group in clinical ethics support. This group developed an MCD facilitator training for 17 employees who were trained in order to become facilitators of the MCD sessions.16 As part of their training, the trainees practiced MCD sessions at the shop floor with their fellow trainees in between the training days. The MCD committee decided to start an evaluation and results study in order to assess how MCD participants had experienced the MCD sessions and what they perceived as results of the MCD sessions for the daily practice. The findings of the study were also used in order to reflect upon the quality of the MCD sessions as well as the quality of the new facilitators. Finally, results from the study could possibly also adjust the on-going MCD implementation project. It is on this study that we report here. A total of 61 MCD sessions were organized in 16 care centres. Participants were nursing caregivers of various educational levels, motivational therapists and dieticians as well as team leaders. The MCD sessions were chaired by the 17 newly trained facilitators. The facilitator requested the MCD participants to submit ‘a moral case’ 2 weeks before the sessions were scheduled. Case topics had to relate to a real-life experience of the case presenter and there had to be a genuine concern or uncertainty regarding what was morally right to do. In other words, the case had to really matter to the participant. Topics that were discussed included cooperation within the team, responsibility towards family members of the client, use of opioids, dealing with aggression, the use of coercion and freedom limitations. All deliberations were structured, using one 3
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Table 1. Rating of closed questions by caregivers. Mean score of caregivers (standard deviation within parentheses) (N ¼ 450)a
Evaluation of MCD Organization of MCD There was ample time/space in my working schedule for participating in MCD I was informed on MCD in time We have prepared this MCD meeting as a team Content of MCD I felt appealed to the case at hand in the MCD The discussion was relevant for our practice The way of discussing with one another was constructive Everyone had an equal share in the conversation In this MCD, I had enough opportunity to say what was on my mind It was good to analyse our reflections on the theme in an interrogative way The MCD facilitator The facilitator saw to it that everyone got his or her share during the MCD Atmosphere during MCD In the MCD, I could talk freely I felt safe during the MCD
3.71 (s1.23) 4.24 (s1.17) 4.41 (s1.06) 2.46 (s1.46) 4.44 (s0.91) 4.48 (s0.84) 4.58 (s0.80) 4.51 (s0.78) 4.25 (s1.04) 4.47 (s0.96) 4.36 (s0.98) 4.53 (s0.78) 4.62 (s0.77) 4.62 (s0.77) 4.62 (s0.76)
MCD: moral case deliberation. a Answers on 5-point Likert scale (1 ¼ totally disagree and 5 ¼ totally agree).
Table 2. List of open questions addressed to all MCD participants. How can this MCD be improved? What issues would you like to address in a future MCD? What has MCD brought to the team? What has MCD brought to you personally? What should, after this MCD, happen in practice? Do you have other general/supplemental remarks? MCD: moral case deliberation.
of two conversation methods for MCD: the dilemma method and the Socratic dialogue (for further reading on methods for MCD, see Steinkamp and Gordijn,6 Molewijk and Ahlzen17 and Kessels et al.18).
Methods Within this study, we made use of a combination of qualitative and quantitative research methods. All participants of every MCD session received a questionnaire containing statements that were to be scored on a 5-point Likert scale as well as a set of open questions. The statements focused on organization of MCD, content of MCD, quality of the facilitator and experiences of participants (see Table 1). The open questions addressed the perceived results of MCD for the individual participants and for care practice (see Table 2). Quantitative as well as qualitative data were analysed. Quantitative answers were calculated using descriptive analysis from Statistical Package for Social Sciences (SPSS). A total of 493 questionnaires were returned from the 61 MCDs (team leaders N ¼ 43, caregivers N ¼ 450). Participants were required to fill out the 4
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Table 3. List of open questions addressed to both interviewees (N ¼ 5) and focus groups (N ¼ 3). What is MCD according to you? What aim does MCD serve according to you? How did you experience MCD? What have been the results of MCD within the organization? What, to your opinion, went well and what went less well? Based on your experiences with MCD, how do you balance the costs versus the benefits of MCD? What do you think of the organization and planning of MCD within the organization? When is MCD successful in your opinion? What preconditions are necessary in order to further develop MCD within the organization? Is MCD the only means of reaching the set goals or are alternatives available? If so, which alternatives? What are the consequences of MCD in practice? What are good results of MCD within the organization? Do you see harmful results? What can be improved? Are the educational effects of MCD picked up sufficiently? How should MCD be continued and warranted in the organization? MCD: moral case deliberation.
questionnaires after the last MCD session, leading to an estimated response rate close to 100%. Answers to the open questions received open codes that were clustered into themes which were subsequently analysed. In addition to the questionnaires, five in-depth interviews and three focus group meetings were organized in order to gain further, in-depth, insight into participants’ experiences with MCD, the perceived results of MCD and their views on the MCD implementation process. This qualitative approach aimed at a more thorough understanding and explanation of the quantitative data. Table 3 lists the open questions that were addressed during both the interviews and the focus group meetings. All interviewees and participants of the focus group meetings had gathered experience with MCD in the course of this study. They were recruited from different locations and had different professional backgrounds (motivational therapist, team leader, facilitator, care assistant, nurse and dietician). Interviews and focus group meetings were audio-taped and transcribed. Interview summary reports were sent to all respondents for member check. Respondents’ amendments and additions were processed. Interview and focus group fragments received open codes which were compared and collected into categories. The code tree was again compared to the rough data. Interviewees and participants of the focus group meetings gave their Informed Consent and participated voluntary. Anonymity was guaranteed. In the evaluation report, only the professional background of the respondent was mentioned, as was promised in advance. In the Netherlands, the law does not prescribe independent ethical review by an Institutional Review Board (IRB) for this kind of research among healthcare professionals.
Results Below the research questions mentioned above will be answered consecutively, following the research questions.
Question 1: How did participants evaluate MCD? Qualitative as well as quantitative results showed that MCD was regarded as (very) useful. Quantitative results focused on the evaluative part of this study and are listed in Table 1. All statements together were rated by the caregivers with an average score of 4.32 on a 5-point Likert scale. Caregivers indicate that the sessions and the topics of deliberation were considered relevant to their daily work, and the relevance of 5
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MCD for care practice was rated with 4.58 points. Content of MCD received an average score of 4.44. Most participants felt free and safe to say what was on their minds (opportunity to say what is on your mind receives a score of 4.47). The atmosphere during the sessions was considered to be open and respectful (ability to speak freely and feel safe received scores of 4.62). Caregivers report relatively low scores on the organization of the MCD sessions (average 3.71). The statements addressed to the team leaders received an average score of 4.52. Team leaders were relatively more positive about the content of MCD (4.58 caregivers, 4.84 team leaders) and the organization of the MCD sessions (3.71 caregivers, 4.33 team leaders). With regard to the other questions, no notable differences between the answers of team leaders and caregivers were seen. Table 2 lists the open questions that were directed to all respondents. The answers to the open questions can explain some of the quantitative data reported above. With regard to the organization of the MCD meetings, participants often reported that the case was not always submitted (2 weeks) before the session. Some did not know what to expect from MCD and report that they would have appreciated a more general introduction into MCD. Thus, respondents felt not always adequately prepared for the sessions. Participants regularly mentioned that being given time for preparing and participating in the MCD sessions is crucial in this respect. Other answers indicate that topics for future MCD should not only relate to difficult situations with patients and loved ones. Also, the functioning of the team and communication between caregivers are mentioned as possible future topics for MCD. The open questionnaire made clear that many appreciated the role of the facilitator. In this respect, team leaders as well as caregivers see surplus value in the structured conversation method within MCD. One caregiver, however, writes that she or he would prefer to get more freedom (i.e. a less structured conversation method) during the MCD sessions. In some sessions, not every participant had the feeling that she or he was given equal opportunity to articulate his or her opinion. One team leader underscores this as she or he writes, the opinions of the participants should get more equal attention. (Team leader in evaluation questionnaire)
Various respondents indicate they experienced openness, understanding and respect: MCD stimulates growth, understanding and insight of the professional and the team. (Team leader in evaluation questionnaire)
Some caregivers stated that it was not always easy to see the team leader as an equal participant. Some caregivers reported that MCD has made it easier to contact the team leader in the future with possible problems or ideas. Respondents, caregivers as well as team leaders, felt sorry that not all members of the team were always present. Various respondents favour obligatory presence for all because they see MCD as a group happening, whereas others mention that unwilling participants may hamper the (quality of the) dialogue.
Question 2: What has MCD brought to the participants? The rest of this section focuses on the answers to the open questions and the interviews and focus groups. These qualitative data highlight the results of MCD as perceived by the MCD participants and can be used to draw lessons and point out directions for the future of MCD within the organization. Table 3 lists the open questions addressed to interviewees and focus group members. Respondents mentioned that MCD can contribute to a gradual process in which feelings of trust and safety are fostered. In this respect, the facilitator needs to have an eye for the hierarchy in the team, especially since team leaders are present. Respondents note that mutual understanding among colleagues is 6
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enhanced and respect for other people’s views and care practice is increased. Respondents got to know one another better. A team leader notes that MCD paves the way to open communication. (Team leader in interview)
A caregiver states, You get to know other peoples’ feelings of powerlessness and what’s bothering them. (Team member in evaluation questionnaire)
Interviewees not only acknowledge but also appreciate the fact that participants in MCD have different perspectives. They see the value of getting acquainted with the other opinions and ideas of colleagues because it can help explain their everyday care practice. An interviewee states, Because we discussed the case, relationships with colleagues change. There is more understanding. When difficult situations occur, I say: ‘Guys, can I go out for a minute?’ They now know my story, emotions and ideas behind it. (Team member in interview)
For the caregivers personally, MCD has increased awareness as well as empathy with other colleagues. Respondents indicate that participants become more conscious of their own views and ways of acting: To me, this MCD has brought the awareness that my behaviour/practice affects others. (Team member in evaluation questionnaire) You get to appreciate one another’s views. I have learnt to think broader and to judge differently. (Team member in evaluation questionnaire) I now see that you should not deal with questions and impossibilities on your own . . . and instead seek for solutions together. (Team member in evaluation questionnaire)
Question 3: What has MCD contributed to care practice? The answers regarding the impact of MCD on everyday care practice seem to be closely related to the perceived impact of MCD on the participants (question 2). For instance, experiences of safety mentioned above are considered relevant for everyday care practice as understanding for colleagues is increased and dialogue is fostered: After MCD you share more with other team members. Everyone listens better now to what others have to say . . . There is more negotiation and understanding. You also approach colleagues quicker and that may happen more often, in my view. (Team member in interview) I also notice that at other moments (other than MCD, authors) there is recognition of the moral weight of an issue, leading to dialogue. (Team member in interview) You often presuppose that others think likewise but after hearing different points of view, you realise that that is not the case . . . Now, you negotiate more often and look at a case together. (Team member in interview)
MCD makes participants feel better as they experience that their views and stories are taken seriously. This improves care, according to the following respondent: 7
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The impact of MCD on the way caregivers work together is illustrated by a team member who says, In MCD, people working in care practice experience the amount of force, information and knowledge they possess. This is not the case in normal conversations . . . The old way of working was passive . . . now, people learn to take more initiative and that means that they think, work and act differently. (Team member in interview)
MCD thus seems to raise awareness and understanding, not only on an individual level (Research Question 2) but also on an interpersonal level and at the team level.
Question 4: Should MCD be further implemented and, if so, how? In the light of the positive experiences described above, most respondents indicate that MCD should be continued, in separate sessions but also as an integral part of everyday care. Open dialogue should become part of regular team meetings. The interviewees and focus group members also indicate that the atmosphere and method of conversation in MCD should become part of the team meetings: You can organise team meetings in a way that people really talk and share with one another. (Team member in interview)
Apart from integrating the lessons from MCD in everyday practice, separate MCD sessions can also count on support. Most respondents agree that MCD is the best way to come to a structured dialogue on difficult matters. A minimum of two MCDs a year for every ward is deemed appropriate but respondents indicate that if there is a need for an MCD, for instance due to an acute problem, extra ad hoc MCDs may be organized. Finally, respondents indicate that they need time, not only to participate in an MCD but also to prepare an MCD session (cf. Research Question 1): Time should be made available to discuss dilemmas at ease, since everyday concerns may easily swallow you up. The necessity of MCD is acknowledged in high and low levels of the organisation. Location manager and team leader need to stimulate the caregivers. (Team member in interview)
Thus, respondents advocate a two-way trajectory: (1) The lessons learnt from MCD related to dialogue and questioning should become part of everyday practice and team meetings and (2) separate MCD sessions should be organized at least twice a year and if possible more often. In order to guarantee continuity, it is vital that the topics that are discussed during MCD lead to actions, respondents say. This may imply contact with other levels within the organization. Some matters should be dealt with by the board of directors, while other matters are best dealt with by care managers: It is of importance that something is done with the issues discussed during MCD. If certain issues are regularly discussed, for instance safety policy or work environment, contact should be sought with other levels of the organisation. Some issues can for instance be dealt with at the management level. The (MCD, authors) committee can submit issues and cases but team members can also submit issues to team leaders or care managers. (Team member in interview) 8
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Thus, MCD is seen not only in connection to care practice but also in connection to the policy of the organization. Warranting continuity of MCD is a matter of top-down as well as bottom-up approaches. In the end, the management of the several locations is considered responsible for the coordination of future MCD sessions.
Discussion This study in a Dutch organization for aged care has provided insight into how participants of MCD evaluated the MCD sessions and what kind of results of MCD they perceived. MCD was evaluated well by the respondents. The atmosphere and the role of the facilitator received scores above 4.50 on a 5-point Likert scale. Apparently, the facilitators managed to foster a safe environment during the sessions in which the majority of participants felt free to say what was on their minds. At the same time, a few respondents felt they did not have an equal share in the conversation. The variety of opinions that were articulated during the sessions was appreciated. Participants tried to empathize with views which were not necessarily their own. In spite of the good evaluation of the facilitator, some participants experienced difficulties in experiencing equality since also team leaders were present in the MCD sessions. One of the recurring problems during the sessions was that not all team members were present. Some respondents argued for an obligatory presence in this respect, while others object to having an MCD session with unwilling participants. Other problems regarding the organization of the MCD sessions relate to the lack of instructive information and time to prepare well for an MCD session. With regard to the results of MCD, interesting findings came to the surface. Results mentioned were among others increased openness, increased mutual understanding and increased respect for different perspectives and opinions. Respondents report that MCD increased the team’s cohesion even though this notion was not explicitly mentioned in the questionnaire or interview study. Respondents reported that they experience the impact of MCD in their daily practice. They feel free to address one another more often and earlier, including team leaders. The MCD participants reported that they experienced that MCD improves the quality of care (e.g. in the way patients are approached). The impact of MCD on dealing with difficult problems and on everyday care was one of the interesting findings of this study on the evaluation and perceived results of MCD. For this impact of MCD, proper implementation, taking into account the specific characteristics of the organization, is a prerequisite. In this organization, there has been a long-term and gradual increasing investment in MCD. MCD could count on support from the management and Board of Directors. The installation of an MCD committee, specifically designed to develop and organize MCD throughout the organization, was illustrative in this respect. Furthermore, much time and effort were invested in the training of 17 employees as MCD facilitators. In times of scarcity in which organizations are more and more focusing on effectiveness and cost-efficiency, management support cannot be taken for granted.8 Apart from the role of the management, bottom-up enactment of MCD is also essential.10,13
Strengths and limitations of this study A strength of our study was the combination of qualitative and quantitative methods which made that the results could be deepened and enriched. This helped to broaden the scope of the data, and a rich image was thus revealed on the promises and pitfalls of the implementation of MCD in this institution for aged care. Another strength was the relatively high response rate and the high number of MCD sessions that were evaluated. However, our study has some limitations too. The number of interviews and focus groups was limited. Furthermore, the results of our study cannot easily be generalized and applied to other care settings 9
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because the implementation and evaluation of MCD is context depended.19 This study does not answer the question whether the results could also be reached through other measures than MCD (in other words, how typical are the results for MCD as ‘intervention’?). However, the findings are often related to the specific characteristics of MCD (e.g. focusing on dialogue, listening, learning from differences and the constructive handling of disagreement). Finally, this study only presented perceived results according to the MCD participants. Although these findings are important, this study and the research design of this study do not inform us about what factually changed and whether this was caused by the MCD sessions. Future research studies could focus on observational results of MCD sessions.
Recommendations Investment in the quality of the MCD sessions is an important recommendation for those institutions that want to start with or implement MCD. The MCD facilitators play a key role in creating and fostering safety and dialogue among the participants. Therefore, ample time should be invested in the professional training of the MCD facilitators and some follow-up sessions as well.20 Furthermore, if MCD is to get implemented well, management support is required as well as bottom-up support. Top-down and bottom-up approaches should go hand in hand. Successful MCD implementation requires additional preparation, time and a wellfunctioning MCD committee. Members of this MCD committee were in touch with the MCD facilitators, the MCD participants as well as with the management and Board of Directors. Training of MCD facilitators is just a first step of the implementation process. Another recommendation regarding the implementation of MCD is the fact that the evaluation of MCD not only monitors the progress and pitfalls of the implementation process but also facilitates the implementation itself. Through the evaluation study, many stakeholders were given a voice regarding how they relate to MCD and what their interest of MCD is. Evaluation research can, when performed and designed in an appropriate way, stimulate employees’ ownership and the practical usefulness of MCD. Our final recommendation relates to future research in (implementation of) MCD. While a limited number of MCD evaluation studies have been conducted, future studies could also focus on the concrete impact of MCD for the quality of care.9,21 Even though MCD has a clear value in itself, as clearly demonstrated by different MCD evaluation studies with MCD participants, it is important to explore the actual contribution to the quality of care via other research designs such as observational and control-group studies. Acknowledgements We would like to thank all respondents for their contribution to this study. Furthermore, we would like to thank the organization, including the management team, the Board of the Directors and last but not least the MCD Committee for their on-going investment and cooperation. Conflict of interest The authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. References 1. Abma T and Widdershoven GA. Moral deliberation in psychiatric nursing practice. Nurs Ethics 2006; 13(5): 546–557. 10
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2. Molewijk B, Abma T, Stolper M, et al. Teaching ethics in the clinic. The theory and practice of moral case deliberation. J Med Ethics 2008; 34: 120–124. 3. Van der Dam S, Abma T, Molewijk B, et al. Organizing moral case deliberation experiences in two Dutch nursing homes. Nurs Ethics 2011; 18(3): 327–340. 4. Van der Dam S, Molewijk B and Widdershoven G. Ethics support in institutional elderly care. A review of the literature. J Med Ethics 2014. DOI: 10.1136/medethics-2012-101295. 5. Dauwerse L, Stolper M, Widdershoven GA, et al. Prevalence and characteristics of moral case deliberation in Dutch health care. Med Health Care Philos 2014; 17: 365–375. 6. Steinkamp N and Gordijn B. Ethical case deliberation on the ward. A comparison of four methods. Med Health Care Philos 2003; 6(3): 235–246. 7. Molewijk B, van Zadelhoff E, Lendemeijer B, et al. Implementing moral case deliberation in Dutch health care. Improving moral competency of professionals and the quality of care. Bioethica Forum 2008; 1(1): 57–65. 8. Abma T, Molewijk B and Widdershoven GA. Good care in ongoing dialogue. Improving the quality of care through moral deliberation and responsive evaluation. Health Care Anal 2009; 17: 217–235. 9. Porz R, Landeweer E and Widdershoven GA. Theory and practice of clinical ethics support services: narrative and hermeneutical perspectives. Bioethics 2011; 25(7): 354–360. 10. Weidema FC, Molewijk B, Kamsteeg F, et al. Aims and harvest of moral case deliberation. Nurs Ethics 2013; 20(6): 617–631. 11. Weidema FC, Molewijk B, Widdershoven GA, et al. Enacting ethics: bottom-up involvement in implementing moral case deliberation. Health Care Anal 2011; 20: 1–19. 12. Van der Dam S, Abma T, Kardol M, et al. Here’s my dilemma. Moral case deliberation as a platform for discussing everyday ethics in elderly care. Health Care Anal 2012; 20: 250–267. 13. Molewijk B, Verkerk M, Milius H, et al. Implementing moral case deliberation in a psychiatric hospital: process and outcome. Med Health Care Philos 2008; 11: 43–56. 14. Van der Dam S. Ethics support in elderly care. PhD Thesis, Maastricht University, Maastricht, 2012. 15. Landeweer E, Abma T and Widdershoven GA. Moral margins concerning the use of coercion in psychiatry. Nurs Ethics 2011; 18(3): 304–316. 16. Plantinga M, Molewijk B, De Bree M, et al. Training health care professionals as moral case deliberation facilitators: evaluation of a Dutch training programme. J Med Ethics 2012; 38: 630–635. 17. Molewijk B and Ahlzen R. Clinical Ethics Committee Case 13: should the school doctor contact the mother of a 17-year-old girl who has expressed suicidal thoughts? Clin Ethics 2011; 6: 5–10. 18. Kessels J, Mostert P and Broers E. Free space: philosophy in organisations. Amsterdam: Boom, 2006. 19. Dauwerse L, van der Dam S and Abma T. Morality in the mundane: specific needs for ethics support in elderly care. Nurs Ethics 2012; 19: 91–103. 20. Stolper M, Molewijk B and Widdershoven G. Learning by doing. Training health care professionals to become facilitator of Moral Case Deliberation. HEC Forum 2014. DOI: 10.1007/s10730-014-9251-7. 21. Svantesson M, Karlsson J, Boitte P, et al. Outcomes of Moral Case Deliberation. The development of an evaluation instrument for clinical ethics support (the Euro-MCD). BMC Medical Ethics 2014; 15: 30.
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Evaluation and perceived results of moral case deliberation: A mixed methods study
Nursing Ethics 1–11 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014557115 nej.sagepub.com
Rien MJPA Janssens VU University Medical Center EMGOþ, The Netherlands
Ezra van Zadelhoff Zuyd University of Applied Sciences, The Netherlands
Ger van Loo Moral Case Deliberation Committee at Sevagram, Organisation for Elderly Care, The Netherlands
Guy AM Widdershoven VU University Medical Center EMGOþ, The Netherlands
Bert AC Molewijk VU University Medical Center EMGOþ, The Netherlands; University of Oslo, Centre for Medical Ethics, Norway
Abstract Background: Moral case deliberation is increasingly becoming part of various Dutch healthcare organizations. Although some evaluation studies of moral case deliberation have been carried out, research into the results of moral case deliberation within aged care is scarce. Research questions: How did participants evaluate moral case deliberation? What has moral case deliberation brought to them? What has moral case deliberation contributed to care practice? Should moral case deliberation be further implemented and, if so, how? Research design: Quantitative analysis of a questionnaire study among participants of moral case deliberation, both caregivers and team leaders. Qualitative analysis of written answers to open questions, interview study and focus group meetings among caregivers and team leaders. Participants and research context: Caregivers and team leaders in a large organization for aged care in the Netherlands. A total of 61 moral case deliberation sessions, carried out on 16 care locations belonging to the organization, were evaluated and perceived results were assessed. Ethical considerations: Participants gave informed consent and anonymity was guaranteed. In the Netherlands, the law does not prescribe independent ethical review by an Institutional Review Board for this kind of research among healthcare professionals. Findings: Moral case deliberation was evaluated positively by the participants. Content and atmosphere of moral case deliberation received high scores, while organizational issues regarding the moral case
Corresponding author: Rien MJPA Janssens, Department of Medical Humanities, EMGO, VU University Medical Centre, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands. Email: [email protected]
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deliberation sessions scored lower and merit further attention. Respondents indicated that moral case deliberation has the potential to contribute to care practice as relationships among team members improve, more openness is experienced and more understanding for different perspectives is fostered. If moral case deliberation is to be successfully implemented, top-down approaches should go hand in hand with bottom-up approaches. Conclusion: The relevance of moral case deliberation for care practice received wide acknowledgement from the respondents. It can contribute to the team’s cohesion as mutual understanding for one another’s views is fostered. If implemented well, moral case deliberation has the potential to improve care, according to the respondents. Keywords Clinical ethics, clinical ethics support, aged care, evaluation, moral case deliberation
Introduction Moral case deliberation (MCD) is a specific kind of clinical ethics support which can be understood as a structured and methodological deliberation on how MCD participants perceive morally good (organization of) care.1–4 MCD is part of a larger development in Dutch healthcare organizations where initiatives are being taken in order to (a) give structural attention to the moral dimension of determining good care and (b) support healthcare professionals when being confronted with moral dilemmas and questions.5 In MCD, caregivers and other professionals are invited to participate in a dialogue in order to articulate, clarify and scrutinize their own moral convictions and assumptions. The dialogue is facilitated by a trained facilitator, and often a specific conversation method is used.6 As such, MCD is different from everyday conversations or regular team meetings. MCD is concerned with the moral dimension of caregiving, that is, with the question what is right or wrong to do in a specific context. Not only the content of MCD (i.e. the caregiver’s moral concerns) distinguishes MCD from everyday interaction, it is also the process of MCD that is different. In MCD, it is expected from the participants that they have an open attitude to the moral convictions of others and to their own moral convictions. Respect for others, even if they hold other or opposite moral convictions, is required as well as the willingness to change or amend your own convictions if deemed necessary. Both process and content of the critical reflection within MCD are to increase caregivers’ awareness of the moral aspects of their daily work. Furthermore, evaluation studies on MCD report that MCD can contribute to the handling of difficult cases, professionals’ moral competency, multidisciplinary team cooperation and the development or adjustment of policy or guidelines.7 As such, MCD aims to improve care. Recently, various healthcare institutions in the Netherlands have started MCD implementation projects.5 Reflective studies on MCD have been published earlier.1,6,8,9 Although MCD receives increasing attention within Europe, empirical data on the evaluation and (perceived) results of MCD in aged care remain scarce. Recently, some research in this area has been conducted.7,10–12 Furthermore, in mental healthcare and aged care contexts, a limited number of evaluation studies have been published.13–15 These studies focus more on the evaluation of the MCD process than on the results of MCD. In this contribution, we report quantitative and qualitative results from a MCD evaluation and result study that was conducted among caregivers and team leaders who participated in MCD sessions at a Dutch institution for aged care. The aim of the study was to gain insight into what participants consider to be the value of MCD for themselves as professional caregivers and for their organization, with a specific focus on the contribution of MCD to care practice. Four research questions were formulated: (1) How did participants evaluate MCD? (2) What has MCD brought to 2
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them? (3) What has MCD contributed to their care practice? and (4) Should MCD be further implemented within the institution and, if so, in what way? In the section ‘Research setting’, we provide general information on the institutional context in which the MCD sessions took place and on how the MCD sessions were organized. Second, in the ‘Methods’ section, the qualitative and quantitative methods will be described. In the ‘Results’ section, the answers to the research questions will be presented. Finally, the ‘Discussion’ section contains an analysis of the practical relevance of MCD; it describes the study’s strengths and limitations and outlines lessons that can be learned from the study. The findings of this study, both positive and negative, can be of relevance to other aged care organizations which aim to implement and evaluate MCD. Furthermore, we hope that this article contributes to the future of MCD evaluation and result studies.
Research setting In 2007, MCD was introduced as a specific method during a small pilot project in a large organization for aged care situated in the south of the Netherlands. The organization consists of 20 care centres where older people can be admitted for various reasons. The care provided in the centres varies from specialist nursing home care to more general support in daily activities. Terminal care is delivered in two hospices. The organization furthermore provides home care in the region and housing for older people who want to live close to a care centre, in order to receive care when needed. A total of 2500 people are employed and 1100 volunteers are involved in the provision of care. At the time of the introduction of MCD in 2007, the Board of Directors and the location managers suspected that attention for MCD would be congruent with the care concept of the organization. Central notions in this concept of care are ‘human connection’, ‘authentic understanding’ and ‘a warm, personal standard of care’. They decided to support the pilot project because they assumed that MCD could (a) help raise the moral sensitivity of caregivers in their care delivery, (b) contribute to a critical and learning organization and (c) promote transparent and effective cooperation and decision-making. After positive experiences with the pilot project, it was decided in 2009 that MCD should get structurally implemented in the whole organization. In order to facilitate this implementation process, an MCD committee was installed consisting of a location manager (chair), two spiritual caregivers (of whom one functions as the secretary of the committee) and two social workers. The members’ tasks were to collect and disseminate knowledge on MCD and to monitor, steer and evaluate the implementation process of MCD throughout the organization. Help was sought from an academic expertise group in clinical ethics support. This group developed an MCD facilitator training for 17 employees who were trained in order to become facilitators of the MCD sessions.16 As part of their training, the trainees practiced MCD sessions at the shop floor with their fellow trainees in between the training days. The MCD committee decided to start an evaluation and results study in order to assess how MCD participants had experienced the MCD sessions and what they perceived as results of the MCD sessions for the daily practice. The findings of the study were also used in order to reflect upon the quality of the MCD sessions as well as the quality of the new facilitators. Finally, results from the study could possibly also adjust the on-going MCD implementation project. It is on this study that we report here. A total of 61 MCD sessions were organized in 16 care centres. Participants were nursing caregivers of various educational levels, motivational therapists and dieticians as well as team leaders. The MCD sessions were chaired by the 17 newly trained facilitators. The facilitator requested the MCD participants to submit ‘a moral case’ 2 weeks before the sessions were scheduled. Case topics had to relate to a real-life experience of the case presenter and there had to be a genuine concern or uncertainty regarding what was morally right to do. In other words, the case had to really matter to the participant. Topics that were discussed included cooperation within the team, responsibility towards family members of the client, use of opioids, dealing with aggression, the use of coercion and freedom limitations. All deliberations were structured, using one 3
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Table 1. Rating of closed questions by caregivers. Mean score of caregivers (standard deviation within parentheses) (N ¼ 450)a
Evaluation of MCD Organization of MCD There was ample time/space in my working schedule for participating in MCD I was informed on MCD in time We have prepared this MCD meeting as a team Content of MCD I felt appealed to the case at hand in the MCD The discussion was relevant for our practice The way of discussing with one another was constructive Everyone had an equal share in the conversation In this MCD, I had enough opportunity to say what was on my mind It was good to analyse our reflections on the theme in an interrogative way The MCD facilitator The facilitator saw to it that everyone got his or her share during the MCD Atmosphere during MCD In the MCD, I could talk freely I felt safe during the MCD
3.71 (s1.23) 4.24 (s1.17) 4.41 (s1.06) 2.46 (s1.46) 4.44 (s0.91) 4.48 (s0.84) 4.58 (s0.80) 4.51 (s0.78) 4.25 (s1.04) 4.47 (s0.96) 4.36 (s0.98) 4.53 (s0.78) 4.62 (s0.77) 4.62 (s0.77) 4.62 (s0.76)
MCD: moral case deliberation. a Answers on 5-point Likert scale (1 ¼ totally disagree and 5 ¼ totally agree).
Table 2. List of open questions addressed to all MCD participants. How can this MCD be improved? What issues would you like to address in a future MCD? What has MCD brought to the team? What has MCD brought to you personally? What should, after this MCD, happen in practice? Do you have other general/supplemental remarks? MCD: moral case deliberation.
of two conversation methods for MCD: the dilemma method and the Socratic dialogue (for further reading on methods for MCD, see Steinkamp and Gordijn,6 Molewijk and Ahlzen17 and Kessels et al.18).
Methods Within this study, we made use of a combination of qualitative and quantitative research methods. All participants of every MCD session received a questionnaire containing statements that were to be scored on a 5-point Likert scale as well as a set of open questions. The statements focused on organization of MCD, content of MCD, quality of the facilitator and experiences of participants (see Table 1). The open questions addressed the perceived results of MCD for the individual participants and for care practice (see Table 2). Quantitative as well as qualitative data were analysed. Quantitative answers were calculated using descriptive analysis from Statistical Package for Social Sciences (SPSS). A total of 493 questionnaires were returned from the 61 MCDs (team leaders N ¼ 43, caregivers N ¼ 450). Participants were required to fill out the 4
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Table 3. List of open questions addressed to both interviewees (N ¼ 5) and focus groups (N ¼ 3). What is MCD according to you? What aim does MCD serve according to you? How did you experience MCD? What have been the results of MCD within the organization? What, to your opinion, went well and what went less well? Based on your experiences with MCD, how do you balance the costs versus the benefits of MCD? What do you think of the organization and planning of MCD within the organization? When is MCD successful in your opinion? What preconditions are necessary in order to further develop MCD within the organization? Is MCD the only means of reaching the set goals or are alternatives available? If so, which alternatives? What are the consequences of MCD in practice? What are good results of MCD within the organization? Do you see harmful results? What can be improved? Are the educational effects of MCD picked up sufficiently? How should MCD be continued and warranted in the organization? MCD: moral case deliberation.
questionnaires after the last MCD session, leading to an estimated response rate close to 100%. Answers to the open questions received open codes that were clustered into themes which were subsequently analysed. In addition to the questionnaires, five in-depth interviews and three focus group meetings were organized in order to gain further, in-depth, insight into participants’ experiences with MCD, the perceived results of MCD and their views on the MCD implementation process. This qualitative approach aimed at a more thorough understanding and explanation of the quantitative data. Table 3 lists the open questions that were addressed during both the interviews and the focus group meetings. All interviewees and participants of the focus group meetings had gathered experience with MCD in the course of this study. They were recruited from different locations and had different professional backgrounds (motivational therapist, team leader, facilitator, care assistant, nurse and dietician). Interviews and focus group meetings were audio-taped and transcribed. Interview summary reports were sent to all respondents for member check. Respondents’ amendments and additions were processed. Interview and focus group fragments received open codes which were compared and collected into categories. The code tree was again compared to the rough data. Interviewees and participants of the focus group meetings gave their Informed Consent and participated voluntary. Anonymity was guaranteed. In the evaluation report, only the professional background of the respondent was mentioned, as was promised in advance. In the Netherlands, the law does not prescribe independent ethical review by an Institutional Review Board (IRB) for this kind of research among healthcare professionals.
Results Below the research questions mentioned above will be answered consecutively, following the research questions.
Question 1: How did participants evaluate MCD? Qualitative as well as quantitative results showed that MCD was regarded as (very) useful. Quantitative results focused on the evaluative part of this study and are listed in Table 1. All statements together were rated by the caregivers with an average score of 4.32 on a 5-point Likert scale. Caregivers indicate that the sessions and the topics of deliberation were considered relevant to their daily work, and the relevance of 5
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MCD for care practice was rated with 4.58 points. Content of MCD received an average score of 4.44. Most participants felt free and safe to say what was on their minds (opportunity to say what is on your mind receives a score of 4.47). The atmosphere during the sessions was considered to be open and respectful (ability to speak freely and feel safe received scores of 4.62). Caregivers report relatively low scores on the organization of the MCD sessions (average 3.71). The statements addressed to the team leaders received an average score of 4.52. Team leaders were relatively more positive about the content of MCD (4.58 caregivers, 4.84 team leaders) and the organization of the MCD sessions (3.71 caregivers, 4.33 team leaders). With regard to the other questions, no notable differences between the answers of team leaders and caregivers were seen. Table 2 lists the open questions that were directed to all respondents. The answers to the open questions can explain some of the quantitative data reported above. With regard to the organization of the MCD meetings, participants often reported that the case was not always submitted (2 weeks) before the session. Some did not know what to expect from MCD and report that they would have appreciated a more general introduction into MCD. Thus, respondents felt not always adequately prepared for the sessions. Participants regularly mentioned that being given time for preparing and participating in the MCD sessions is crucial in this respect. Other answers indicate that topics for future MCD should not only relate to difficult situations with patients and loved ones. Also, the functioning of the team and communication between caregivers are mentioned as possible future topics for MCD. The open questionnaire made clear that many appreciated the role of the facilitator. In this respect, team leaders as well as caregivers see surplus value in the structured conversation method within MCD. One caregiver, however, writes that she or he would prefer to get more freedom (i.e. a less structured conversation method) during the MCD sessions. In some sessions, not every participant had the feeling that she or he was given equal opportunity to articulate his or her opinion. One team leader underscores this as she or he writes, the opinions of the participants should get more equal attention. (Team leader in evaluation questionnaire)
Various respondents indicate they experienced openness, understanding and respect: MCD stimulates growth, understanding and insight of the professional and the team. (Team leader in evaluation questionnaire)
Some caregivers stated that it was not always easy to see the team leader as an equal participant. Some caregivers reported that MCD has made it easier to contact the team leader in the future with possible problems or ideas. Respondents, caregivers as well as team leaders, felt sorry that not all members of the team were always present. Various respondents favour obligatory presence for all because they see MCD as a group happening, whereas others mention that unwilling participants may hamper the (quality of the) dialogue.
Question 2: What has MCD brought to the participants? The rest of this section focuses on the answers to the open questions and the interviews and focus groups. These qualitative data highlight the results of MCD as perceived by the MCD participants and can be used to draw lessons and point out directions for the future of MCD within the organization. Table 3 lists the open questions addressed to interviewees and focus group members. Respondents mentioned that MCD can contribute to a gradual process in which feelings of trust and safety are fostered. In this respect, the facilitator needs to have an eye for the hierarchy in the team, especially since team leaders are present. Respondents note that mutual understanding among colleagues is 6
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enhanced and respect for other people’s views and care practice is increased. Respondents got to know one another better. A team leader notes that MCD paves the way to open communication. (Team leader in interview)
A caregiver states, You get to know other peoples’ feelings of powerlessness and what’s bothering them. (Team member in evaluation questionnaire)
Interviewees not only acknowledge but also appreciate the fact that participants in MCD have different perspectives. They see the value of getting acquainted with the other opinions and ideas of colleagues because it can help explain their everyday care practice. An interviewee states, Because we discussed the case, relationships with colleagues change. There is more understanding. When difficult situations occur, I say: ‘Guys, can I go out for a minute?’ They now know my story, emotions and ideas behind it. (Team member in interview)
For the caregivers personally, MCD has increased awareness as well as empathy with other colleagues. Respondents indicate that participants become more conscious of their own views and ways of acting: To me, this MCD has brought the awareness that my behaviour/practice affects others. (Team member in evaluation questionnaire) You get to appreciate one another’s views. I have learnt to think broader and to judge differently. (Team member in evaluation questionnaire) I now see that you should not deal with questions and impossibilities on your own . . . and instead seek for solutions together. (Team member in evaluation questionnaire)
Question 3: What has MCD contributed to care practice? The answers regarding the impact of MCD on everyday care practice seem to be closely related to the perceived impact of MCD on the participants (question 2). For instance, experiences of safety mentioned above are considered relevant for everyday care practice as understanding for colleagues is increased and dialogue is fostered: After MCD you share more with other team members. Everyone listens better now to what others have to say . . . There is more negotiation and understanding. You also approach colleagues quicker and that may happen more often, in my view. (Team member in interview) I also notice that at other moments (other than MCD, authors) there is recognition of the moral weight of an issue, leading to dialogue. (Team member in interview) You often presuppose that others think likewise but after hearing different points of view, you realise that that is not the case . . . Now, you negotiate more often and look at a case together. (Team member in interview)
MCD makes participants feel better as they experience that their views and stories are taken seriously. This improves care, according to the following respondent: 7
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The impact of MCD on the way caregivers work together is illustrated by a team member who says, In MCD, people working in care practice experience the amount of force, information and knowledge they possess. This is not the case in normal conversations . . . The old way of working was passive . . . now, people learn to take more initiative and that means that they think, work and act differently. (Team member in interview)
MCD thus seems to raise awareness and understanding, not only on an individual level (Research Question 2) but also on an interpersonal level and at the team level.
Question 4: Should MCD be further implemented and, if so, how? In the light of the positive experiences described above, most respondents indicate that MCD should be continued, in separate sessions but also as an integral part of everyday care. Open dialogue should become part of regular team meetings. The interviewees and focus group members also indicate that the atmosphere and method of conversation in MCD should become part of the team meetings: You can organise team meetings in a way that people really talk and share with one another. (Team member in interview)
Apart from integrating the lessons from MCD in everyday practice, separate MCD sessions can also count on support. Most respondents agree that MCD is the best way to come to a structured dialogue on difficult matters. A minimum of two MCDs a year for every ward is deemed appropriate but respondents indicate that if there is a need for an MCD, for instance due to an acute problem, extra ad hoc MCDs may be organized. Finally, respondents indicate that they need time, not only to participate in an MCD but also to prepare an MCD session (cf. Research Question 1): Time should be made available to discuss dilemmas at ease, since everyday concerns may easily swallow you up. The necessity of MCD is acknowledged in high and low levels of the organisation. Location manager and team leader need to stimulate the caregivers. (Team member in interview)
Thus, respondents advocate a two-way trajectory: (1) The lessons learnt from MCD related to dialogue and questioning should become part of everyday practice and team meetings and (2) separate MCD sessions should be organized at least twice a year and if possible more often. In order to guarantee continuity, it is vital that the topics that are discussed during MCD lead to actions, respondents say. This may imply contact with other levels within the organization. Some matters should be dealt with by the board of directors, while other matters are best dealt with by care managers: It is of importance that something is done with the issues discussed during MCD. If certain issues are regularly discussed, for instance safety policy or work environment, contact should be sought with other levels of the organisation. Some issues can for instance be dealt with at the management level. The (MCD, authors) committee can submit issues and cases but team members can also submit issues to team leaders or care managers. (Team member in interview) 8
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Thus, MCD is seen not only in connection to care practice but also in connection to the policy of the organization. Warranting continuity of MCD is a matter of top-down as well as bottom-up approaches. In the end, the management of the several locations is considered responsible for the coordination of future MCD sessions.
Discussion This study in a Dutch organization for aged care has provided insight into how participants of MCD evaluated the MCD sessions and what kind of results of MCD they perceived. MCD was evaluated well by the respondents. The atmosphere and the role of the facilitator received scores above 4.50 on a 5-point Likert scale. Apparently, the facilitators managed to foster a safe environment during the sessions in which the majority of participants felt free to say what was on their minds. At the same time, a few respondents felt they did not have an equal share in the conversation. The variety of opinions that were articulated during the sessions was appreciated. Participants tried to empathize with views which were not necessarily their own. In spite of the good evaluation of the facilitator, some participants experienced difficulties in experiencing equality since also team leaders were present in the MCD sessions. One of the recurring problems during the sessions was that not all team members were present. Some respondents argued for an obligatory presence in this respect, while others object to having an MCD session with unwilling participants. Other problems regarding the organization of the MCD sessions relate to the lack of instructive information and time to prepare well for an MCD session. With regard to the results of MCD, interesting findings came to the surface. Results mentioned were among others increased openness, increased mutual understanding and increased respect for different perspectives and opinions. Respondents report that MCD increased the team’s cohesion even though this notion was not explicitly mentioned in the questionnaire or interview study. Respondents reported that they experience the impact of MCD in their daily practice. They feel free to address one another more often and earlier, including team leaders. The MCD participants reported that they experienced that MCD improves the quality of care (e.g. in the way patients are approached). The impact of MCD on dealing with difficult problems and on everyday care was one of the interesting findings of this study on the evaluation and perceived results of MCD. For this impact of MCD, proper implementation, taking into account the specific characteristics of the organization, is a prerequisite. In this organization, there has been a long-term and gradual increasing investment in MCD. MCD could count on support from the management and Board of Directors. The installation of an MCD committee, specifically designed to develop and organize MCD throughout the organization, was illustrative in this respect. Furthermore, much time and effort were invested in the training of 17 employees as MCD facilitators. In times of scarcity in which organizations are more and more focusing on effectiveness and cost-efficiency, management support cannot be taken for granted.8 Apart from the role of the management, bottom-up enactment of MCD is also essential.10,13
Strengths and limitations of this study A strength of our study was the combination of qualitative and quantitative methods which made that the results could be deepened and enriched. This helped to broaden the scope of the data, and a rich image was thus revealed on the promises and pitfalls of the implementation of MCD in this institution for aged care. Another strength was the relatively high response rate and the high number of MCD sessions that were evaluated. However, our study has some limitations too. The number of interviews and focus groups was limited. Furthermore, the results of our study cannot easily be generalized and applied to other care settings 9
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because the implementation and evaluation of MCD is context depended.19 This study does not answer the question whether the results could also be reached through other measures than MCD (in other words, how typical are the results for MCD as ‘intervention’?). However, the findings are often related to the specific characteristics of MCD (e.g. focusing on dialogue, listening, learning from differences and the constructive handling of disagreement). Finally, this study only presented perceived results according to the MCD participants. Although these findings are important, this study and the research design of this study do not inform us about what factually changed and whether this was caused by the MCD sessions. Future research studies could focus on observational results of MCD sessions.
Recommendations Investment in the quality of the MCD sessions is an important recommendation for those institutions that want to start with or implement MCD. The MCD facilitators play a key role in creating and fostering safety and dialogue among the participants. Therefore, ample time should be invested in the professional training of the MCD facilitators and some follow-up sessions as well.20 Furthermore, if MCD is to get implemented well, management support is required as well as bottom-up support. Top-down and bottom-up approaches should go hand in hand. Successful MCD implementation requires additional preparation, time and a wellfunctioning MCD committee. Members of this MCD committee were in touch with the MCD facilitators, the MCD participants as well as with the management and Board of Directors. Training of MCD facilitators is just a first step of the implementation process. Another recommendation regarding the implementation of MCD is the fact that the evaluation of MCD not only monitors the progress and pitfalls of the implementation process but also facilitates the implementation itself. Through the evaluation study, many stakeholders were given a voice regarding how they relate to MCD and what their interest of MCD is. Evaluation research can, when performed and designed in an appropriate way, stimulate employees’ ownership and the practical usefulness of MCD. Our final recommendation relates to future research in (implementation of) MCD. While a limited number of MCD evaluation studies have been conducted, future studies could also focus on the concrete impact of MCD for the quality of care.9,21 Even though MCD has a clear value in itself, as clearly demonstrated by different MCD evaluation studies with MCD participants, it is important to explore the actual contribution to the quality of care via other research designs such as observational and control-group studies. Acknowledgements We would like to thank all respondents for their contribution to this study. Furthermore, we would like to thank the organization, including the management team, the Board of the Directors and last but not least the MCD Committee for their on-going investment and cooperation. Conflict of interest The authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. References 1. Abma T and Widdershoven GA. Moral deliberation in psychiatric nursing practice. Nurs Ethics 2006; 13(5): 546–557. 10
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