Enacting ethics: bottom-up involvement in implementing moral case deliberation

Training nurses to facilitate and implement CURA in palliative care institutions: development and evaluation of a blended learning program

BACKGROUND

Healthcare professionals in palliative care are found to be confronted with moral challenges on a frequent basis. CURA is a low-threshold instrument for dialogical ethical reflection that was developed to deal with these challenges. A previous study identified the need of healthcare professionals to be trained to introduce CURA in their organization, initiate and facilitate reflections with CURA, and contribute to the implementation of CURA. The aim of this study was to develop and evaluate a training for professionals to become 'CURA-ambassadors'.

METHODS

The training was developed in a participatory way in two cycles. We trained 72 healthcare professionals. The training was evaluated by means of a questionnaire and six semi-structured interviews.

RESULTS

The study resulted in a blended learning training combining training sessions with an e-module and with practicing with organizing and facilitating CURA in daily healthcare practice. The main objectives of the training are to enable CURA-ambassadors to introduce CURA within their organization, initiate and facilitate ethical reflections using CURA, and contribute to the implementation of CURA. Participants were generally positive about the training program and the trainers. Technical difficulties related to the e-module were mentioned as main point of improvement.

DISCUSSION

The training program can generate ownership, responsibility, and competency among CURA-ambassadors, which are essential foundations for implementing complex interventions in healthcare practice. The training program received positive evaluations shortly after completing the program. This study adds to our understanding of what is needed for healthcare professionals to use CURA, in order to support them in dealing with moral challenges and to foster their moral resilience. Further research is needed to assess whether participants experience the training as sufficient and effective when using and implementing CURA structurally in their organizations over a longer period of time.

Descriptions of long-term impact from inter-professional ethics communication in groups

BACKGROUND

On a daily basis, healthcare professionals deal with various ethical issues and it can be difficult to determine how to act best. Clinical ethics support (CES) has been developed to provide support for healthcare professionals dealing with complex ethical issues. A long-term perspective of participating in inter-professional dialogue and reflective-based CES sessions is seemingly sparse in the literature.

RESEARCH AIM

The aim was to describe experiences of impact of Inter-professional Ethics Communication in groups (IEC) based on Habermas' theory of communicative actions, after 6 months from the perspective of an inter-professional team.

RESEARCH DESIGN

A qualitative inductive approach was chosen, and individual interviews (n = 13) were conducted. Interview data were analysed using qualitative content analysis.

PARTICIPANTS

The participants, 10 females and two males, represented assistant nurses, registered nurses, physicians, occupational therapists, physiotherapists, welfare officers and psychologists. Each had attended at least four IEC sessions.

ETHICAL CONSIDERATIONS

The study was approved by the Regional Ethical Review Board in Umeå, Sweden, and it has been undertaken in accordance with the Helsinki Declaration.

FINDINGS

Overall, the descriptions expressed a perceived achievement of a deepened and integrated ethical awareness that increased the participants' awareness of ethically difficult situations as well as their own ethical thinking, actions and approaches in daily work. Perspectives were shared and the team become more welded. They carried the memories of the reflections within them, which was perceived as supportive when encountered new ethically situations.

DISCUSSION

Putting words to unarticulated thoughts may stimulate repeated reflections, leading to new insights and alternative thoughts.

CONCLUSION

The outcome of IEC sessions 6 months following the last session can be described as an incorporated knowledge that enables actions in ethically difficult situations based on an ethical awareness both at a 'We-level' and an 'I-level'.

Bulgaria at the onset of clinical ethics consultation

BACKGROUND

Over the years, Bulgarian bioethics has been mainly an academic enterprise and fallen short of providing health professionals with skills for ethical decision-making. Clinical ethics support (CES) was piloted by the author through two bottom-up models - METAP (Modular, Ethical, Treatment, Allocation of resources, Process) and MCD (Moral Case Deliberation).

AIMS

This paper aims to present and analyse developments in the area of clinical ethics and the first experiences in CES in Bulgaria.

METHODOLOGY

The project reported here included a review of relevant literature on CES methods and evaluation and a documentary review of data from two CES pilot projects: METAP and MCD.

RESULTS

Most of the 69 METAP ethics meetings reviewed were first time meetings (88,4%); the average duration was 36 min and the average number of participants was four (44,9%). The meetings were organized in response to cases of severely or critically ill patients. The ethical dilemmas included choice of treatment (31,9%) and conflicts with the patient or their relatives (23,2%). Consensus was achieved in 34,8% of the cases. The situation was clarified with the patient (27,5%) and within the team (15,9%). The rights and obligations of both sides were discussed in 7,2% of the cases. The experience of the members of the Bulgarian Association of Bioethics and Clinical Ethics (BABCE) with MCD was also presented to justify the inference about the applicability of the two CES models in a Bulgarian context.

CONCLUSION

Among Eastern European countries Bulgaria has made progress in CES. Both METAP and MCD have been found to be useful methods.

Conceptualizing the impact of moral case deliberation: a multiple-case study in a health care institution for people with intellectual disabilities

Background

As moral case deliberations (MCDs) have increasingly been implemented in health care institutions as a form of ethics support, it is relevant to know whether and how MCDs actually contribute to positive changes in care. Insight is needed on what actually happens in daily care practice following MCD sessions. This study aimed at investigating the impact of MCD and exploring how ‘impact of MCD’ should be conceptualized for future research.

Methods

A multiple-case study was conducted in a care organization for people with intellectual disabilities and/or acquired brain injury, by observing MCD sessions as ‘cases’, followed by interviews with health care professionals concerning the follow-up to these cases, and a focus group with involved MCD facilitators. A conceptual scheme concerning the possible impact formed the basis for analysis: (1) individual moral awareness; (2) the actions of health care professionals; (3) collaboration among health care professionals; (4) the concrete situation of the client; (5) the client’s quality of care and life; (6) the organizational and policy level.

Results

According to interviewees, their moral awareness and their collaboration, both among colleagues and with clients’ relatives, improved after MCD. Perceived impact on client situation, quality of care/life and the organizational level varied among interviewees or was difficult to define or link to MCD. Three aspects were added to the conceptual scheme concerning the impact of MCD: (a) preparations and expectations prior to the MCD session; (b) a translational step between the conclusions of the MCD session and practical events in the following period, and (c) collaboration with clients’ relatives. A negative impact of MCD was also found on misunderstandings among participants and disappointment about lack of follow-up.

Conclusions

Concretizing and conceptualizing the ‘impact’ of MCD is complicated as many factors play a role either before or during the transition from MCD to practice. It is important to consider ‘impact’ in a broad sense and to relate it to the goals and context of the MCD in question. Future studies in this field should pay additional attention to the preparations, content and process involved in ethics support, including clients’ and relatives’ experiences.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-022-00747-2.

The Ethics Laboratory: A Dialogical Practice for Interdisciplinary Moral Deliberation

Recent advancements in therapeutic and diagnostic medicine, along with the creation of large biobanks and methods for monitoring health technologies, have improved the prospects for preventing, treating, and curing illness. These same advancements, however, give rise to a plethora of ethical questions concerning good decision-making and best action. These ethical questions engage policymakers, practitioners, scientists, and researchers from a variety of fields in different ways. Collaborations between professionals in the medical and health sciences and the social sciences and humanities often take an asymmetrical form, as when social scientists use ethnographic approaches to study the moral issues and practices of physicians. The ethics laboratory described in this article is a cross-sectoral and inter-disciplinary forum for collaborative investigation on important moral topics. It offers an experimental way of unpacking implied assumptions, underlying values, and comparable notions from different professional healthcare fields. The aim of this article is to present the ethics laboratory's methodology. The article offers a model and a hermeneutical framework that rests on a dialogical approach to ethical questions. The model and the framework derive from a Danish research project, Personalized Medicine in the Welfare State. This article uses personalized medicine as a point of reference, though it offers an argument for the applicability of the model more broadly.

Virtue-based ethics and integrity of research: train-the-trainer programme for upholding the principles and practices of the European Code of Conduct for Research Integrity (VIRT2UE)

Background: Recognising the importance of addressing ethics and research integrity (ERI) in Europe, in 2017, the All European Academies (ALLEA) published a revised and updated European Code of Conduct for Research Integrity (ECoC). Consistent application of the ECoC by researchers across Europe will require its widespread dissemination, as well as an innovative training programme and novel tools to enable researchers to truly uphold and internalise the principles and practices listed in the Code.

Aim: VIRT2UE aims to develop a sustainable train-the-trainer blended learning programme enabling contextualised ERI teaching across Europe focusing on understanding and upholding the principles and practices of the ECoC.

Vision: The VIRT2UE project recognises that researchers not only need to have knowledge of the ECoC, but also to be able to truly uphold and internalise the principles underpinning the code. They need to learn how to integrate them into their everyday practice and understand how to act in concrete situations. VIRT2UE addresses this challenge by providing ERI trainers and researchers with an innovative blended (i.e. combined online and off-line approaches) learning programme that draws on a toolbox of educational resources and incorporates an e-learning course (including a YouTube channel) and face-to-face sessions designed to foster moral virtues. ERI trainers and researchers from academia and industry will have open access to online teaching material. Moreover, ERI trainers will learn how to facilitate face-to-face sessions of researchers, which focus on learning how to apply the content of the teaching material to concrete situations in daily practice.

Objectives: VIRT2UE’s work packages (WP) will: conduct a conceptual mapping amongst stakeholders to identify and rank the virtues which are essential for good scientific practice and their relationship to the principles and practices of the ECoC (WP1); identify and consult ERI trainers and the wider scientific community to understand existing capacity and deficiencies in ERI educational resources (WP2); develop the face-to-face component of the train-the-trainer programme which provides trainers with tools to foster researchers’ virtues and promote the ECoC and iteratively develop the programme based on evaluations (WP3); produce educational materials for online learning by researchers and trainers (WP4); implement and disseminate the train-the-trainer programme across Europe, ensuring the training of sufficient trainers for each country and build capacity and consistency by focusing on underdeveloped regions and unifying fragmented efforts (WP5); and develop the online training platform and user interface, which will be instrumental in evaluation of trainers’ and researchers’ needs and project sustainability (WP6).

Impact: The VIRT2UE training programme will promote consistent application of the ECoC across Europe. The programme will affect behaviour on the individual level of trainers and researchers – simultaneously developing an understanding of the ECoC and other ERI issues, whilst also developing scientific virtues, enabling the application of the acquired knowledge to concrete situations and complex moral dilemmas. Through a dedicated embedding strategy, the programme will also have an impact on an institutional level. The train-the-trainer approach multiplies the impact of the programme by reaching current and future European ERI trainers and, subsequently, the researchers they train.

A Qualitative Study on Experiences and Perspectives of Members of a Dutch Medical Research Ethics Committee

The aim of this research was to gain insight into the experiences and perspectives of individual members of a Medical Research Ethics Committee (MREC) regarding their individual roles and possible tensions within and between these roles. We conducted a qualitative interview study among members of a large MREC, supplemented by a focus group meeting. Respondents distinguish five roles: protector, facilitator, educator, advisor and assessor. Central to the role of protector is securing valid informed consent and a proper risk-benefit analysis. The role of facilitator implies that respondents want to think along with and assist researchers in order to help medical science progress. As educators, the respondents want to raise ethical and methodological awareness of researchers. The role of advisor implies that respondents bring in their own expertise. The role of assessor points to contributing to the overall evaluation of the research proposal. Various tensions were identified within and between roles. Within the role of protector, a tension is experienced between paternalism and autonomy. Between the role of protector and facilitator tensions occur when the value of a study is questioned while risks and burdens for the subjects are negligible. Within the role of assessor, a tension is felt between the implicit nature of judgments and the need for more explicit formulations. Awareness of various roles and responsibilities may prevent one-sided views on MREC work, not only by members themselves, but also by researchers. Tensions within and between the roles require reflection by MREC members.

Ethics reflection groups for school nurses

BACKGROUND

School nurses have great responsibilities as the connecting link between school, children/adolescents, parents, and other healthcare services. Being in this middle position, and handling complex situations and problems related to children in school, may be demanding and also lead to ethical challenges. Clinical ethics support, such as ethics reflection groups, may be of help when dealing with ethical challenges. However, there is little research on experiences with ethics reflection groups among school nurses.

AIM

The aim of this research was to explore how nurses in school healthcare experience their role, and how they experience participation in ethics reflection groups, using a model for systematic ethics reflection, the Centre for Medical Ethics model.

RESEARCH DESIGN

The project had a qualitative design, using focus group interviews and thematic analysis.

ETHICAL CONSIDERATIONS

The study was evaluated by the Data Protection Official at the Norwegian Centre for Research Data (project no. 57373). The participants were given oral and written information about the study and signed a written consent.

PARTICIPANTS AND CONTEXT

Twelve participants from school healthcare were recruited to the interviews.

FINDINGS

School nurses described their role as extremely challenging. How the school nurses experienced their role also influenced how they experienced participating in ethics reflection groups. The Centre for Medical Ethics model was experienced as both challenging and comprehensive. However, they also experienced that the model helped them to clarify their role and could also help them to find better solutions.

CONCLUSION

The role as school nurse is complex and demanding, with several ethical challenges. Ethics reflection groups may be of great help when dealing with these challenges. However, it is of great importance that the methods used are adjusted to the professionals' needs and context.

Impact of clinical ethics support on daily practice-First-line managers' experiences in the Euro-MCD project

AIM

To explore first-line managers' experiences of what Moral Case Deliberation has meant for daily practice, to describe perceptions of context influence and responsibility to manage ethically difficult situations.

BACKGROUND

In order to find measures to evaluate Moral Case Deliberation, the European Moral Case Deliberation Outcome instrument was developed and is now in the stage of revision. For this, there is a need of several perspectives, one of them being the managerial bird-eye perspective.

METHOD

Eleven first-line managers at workplaces, participating in the European Moral Case Deliberation Outcome instrument project, were interviewed and thematic analysis was applied.

RESULTS

Managers' experiences were interpreted as enhanced ethical climate: a closer-knit and more emotionally mature team, morally strengthened individuals, as well as ethics leaving its marks on everyday work and morally grounded actions. Despite organizational barriers, they felt inspired to continue ethics work.

CONCLUSION AND IMPLICATIONS

This study confirmed, but also added ethical climate aspects, such as morally grounded actions. Furthermore, adding ethical climate as a construct in the European Moral Case Deliberation Outcome instrument should be considered. First-line managers need clear directives from their managers that ethics work needs to be prioritized for the good of both the staff and the patients.

Communicative and organizational aspects of clinical ethics support

Studies show that healthcare professionals need inter-professional clinical ethics support (CES) in order to communicate and reflect on ethically difficult care situations that they experience in their clinical practice. Internationally, various CES interventions have been performed, but the communication processes and organisation of these interventions are rarely described in detail. The aim of this study was to explore communicative and organisational conditions of a CES intervention with the intention of promoting inter-professional communication about ethically difficult care situations. Eight audio- and video-recorded inter-professional CES sessions, inspired by Habermas' theory of communicative actions, were conducted. The observations were transcribed, sorted, and analysed using concept- and data-driven content analysis methods. The findings show three approaches to promoting communicative agreement, which include the CES facilitators' and participants' approaches to promoting a permissive communication, extended views, and mutual understanding. The CES sessions had organizational aspects for facilitating communicative agreement with both a given structure and openness for variation. The dynamic structure of the organization, promoted both safety and stability as well as a creativity and responsiveness, which in turn opened up for a free and dynamic inter-professional dialogue concerning ethically difficult care situations. The findings constitute a step towards a theory-based CES method inspired by Habermas' theory of communicative action. Further research is needed in order to fully develop the method and obtain increased knowledge about how to promote an inter-professional dialogue about ethically difficulties.

Clinical Ethics Support for Healthcare Personnel: An Integrative Literature Review

This study describes which clinical ethics approaches are available to support healthcare personnel in clinical practice in terms of their construction, functions and goals. Healthcare personnel frequently face ethically difficult situations in the course of their work and these issues cover a wide range of areas from prenatal care to end-of-life care. Although various forms of clinical ethics support have been developed, to our knowledge there is a lack of review studies describing which ethics support approaches are available, how they are constructed and their goals in supporting healthcare personnel in clinical practice. This study engages in an integrative literature review. We searched for peer-reviewed academic articles written in English between 2000 and 2016 using specific Mesh terms and manual keywords in CINAHL, MEDLINE and Psych INFO databases. In total, 54 articles worldwide described clinical ethics support approaches that include clinical ethics consultation, clinical ethics committees, moral case deliberation, ethics rounds, ethics discussion groups, and ethics reflection groups. Clinical ethics consultation and clinical ethics committees have various roles and functions in different countries. They can provide healthcare personnel with advice and recommendations regarding the best course of action. Moral case deliberation, ethics rounds, ethics discussion groups and ethics reflection groups support the idea that group reflection increases insight into ethical issues. Clinical ethics support in the form of a "bottom-up" perspective might give healthcare personnel opportunities to think and reflect more than a "top-down" perspective. A "bottom-up" approach leaves the healthcare personnel with the moral responsibility for their choice of action in clinical practice, while a "top-down" approach risks removing such moral responsibility.

Moral competency: meta-competence of nursing care

Introduction

To follow the progress of technology and increasing domain of nurses’ duties, ethical challenges can be observed more than ever. Therefore, the growing and dynamic system of nursing requires nurses with professional and ethical competence who can provide optimal care. The aim of the present study was to define and explain dimensions of moral competency among the clinical nurses of Iran.

Methods

This qualitative content analysis study was carried out in the years 2014 and 2015 in Iran. Data were collected through in-depth semistructured interviews and field notes. The resulting data were analyzed by Graneheim and Lundman’s method of conventional content analysis. The participants were 12 clinical nurses who were selected using purposive convenient sampling and continued interviews until data saturation.

Results

Themes obtained in the present study were posited in three main categories of “moral character,” with subcategories of altruism, search for meaning, be pioneering, perfectionism, self-control, honesty, and forgiveness; “moral care” with subcategories of dignified care, safe care, fair care, and holistic care; and “moral decision-making” with subcategories of moral sensitivity, moral thinking, moral reasoning, and moral courage.

Conclusions

Findings of the present study suggest that nurses’ moral competency is an adorable character with a wide range that includes moral virtues and character, moral decision-making, and ultimately providing moral care; therefore, moral competency is a meta-competence in the field of nursing. Because there are many competencies in different fields.

Does Moral Case Deliberation Help Professionals in Care for the Homeless in Dealing with Their Dilemmas? A Mixed-Methods Responsive Study

Health care professionals often face moral dilemmas. Not dealing constructively with moral dilemmas can cause moral distress and can negatively affect the quality of care. Little research has been documented with methodologies meant to support professionals in care for the homeless in dealing with their dilemmas. Moral case deliberation (MCD) is a method for systematic reflection on moral dilemmas and is increasingly being used as ethics support for professionals in various health-care domains. This study deals with the question: What is the contribution of MCD in helping professionals in an institution for care for the homeless to deal with their moral dilemmas? A mixed-methods responsive evaluation design was used to answer the research question. Five teams of professionals from a Dutch care institution for the homeless participated in MCD three times. Professionals in care for the homeless value MCD positively. They report that MCD helped them to identify the moral dilemma/question, and that they learned from other people's perspectives while reflecting and deliberating on the values at stake in the dilemma or moral question. They became aware of the moral dimension of moral dilemmas, of related norms and values, of other perspectives, and learned to formulate a moral standpoint. Some experienced the influence of MCD in the way they dealt with moral dilemmas in daily practice. Half of the professionals expect MCD will influence the way they deal with moral dilemmas in the future. Most of them were in favour of further implementation of MCD in their organization.

Developing organisational ethics in palliative care

BACKGROUND

Palliative carers constantly face ethical problems. There is lack of organised support for the carers to handle these ethical problems in a consistent way. Within organisational ethics, we find models for moral deliberation and for developing organisational culture; however, they are not combined in a structured way to support carers' everyday work.

RESEARCH OBJECTIVE

The aim of this study was to describe ethical problems faced by palliative carers and develop an adapted organisational set of values to support the handling of these problems.

RESEARCH DESIGN

Ethical problems were mapped out using focus groups and content analysis. The organisational culture were developed using normative analysis and focus group methodology within a participatory action research approach. Main participants and research context: A total of 15 registered nurses and 10 assistant nurses at a palliative unit (with 19 patient beds) at a major University Hospital in Sweden. Ethical considerations: The study followed standard ethics guidelines concerning informed consent and confidentiality.

FINDINGS

We found six categories of ethical problems (with the main focus on problems relating to the patient's loved ones) and five categories of organisational obstacles. Based on these findings, we developed a set of values in three levels: a general level, an explanatory level and a level of action strategies.

DISCUSSION

The ethical problems found corresponded to problems in other studies with a notable exception, the large focus on patient loved ones. The three-level set of values is a way to handle risks of formulating abstract values not providing guidance in concrete care voiced in other studies.

CONCLUSION

Developing a three-level set of values adapted to the specific ethical problems in a concrete care setting is a first step towards a better handling of ethical problems.

Evaluation and perceived results of moral case deliberation

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 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.

Evaluating clinical ethics support in mental healthcare: a systematic literature review

A systematic literature review on evaluation of clinical ethics support services in mental healthcare is presented and discussed. The focus was on (a) forms of clinical ethics support services, (b) evaluation of clinical ethics support services, (c) contexts and participants and (d) results. Five studies were included. The ethics support activities described were moral case deliberations and ethics rounds. Different qualitative and quantitative research methods were utilized. The results show that (a) participants felt that they gained an increased insight into moral issues through systematic reflection; (b) there was improved cooperation among multidisciplinary team members; (c) it was uncertain whether clinical ethics support services led to better patient care; (d) the issue of patient and client participation is complex; and (e) the implementation process is challenging. Clinical ethics support services have mainly been studied through the experiences of the participating facilitators and healthcare professionals. Hence, there is limited knowledge of whether and how various types of clinical ethics support services influence the quality of care and how patients and relatives may evaluate clinical ethics support services. Based on the six excluded 'grey zone articles', in which there was an implicit focus on ethics reflection, other ways of working with ethical reflection in practice are discussed. Implementing and evaluating clinical ethics support services as approaches to clinical ethics support that are more integrated into the development of good practice are in focus. In order to meet some of the shortcomings of the field of clinical ethics support services, a research project that aims to strengthen ethics support in the mental health services, including patients' and caregivers' views on ethical challenges, is presented.

Prevalence and characteristics of moral case deliberation in Dutch health care

The attention for Moral case deliberation (MCD) has increased over the past years. Previous research on MCD is often written from the perspective of MCD experts or MCD participants and we lack a more distant view to the role of MCD in Dutch health care institutions in general. The purpose of this paper is to provide an overview of the state of the art concerning MCD in the Netherlands. As part of a larger national study on clinical ethics support in the Netherlands, we will focus on the prevalence and characteristics of MCD in Dutch health. A mixed methods design was used in which we combined two survey questionnaires (sent to all health care institutions), two focus groups and 17 individual interviews with top managers or ethics support staff. The findings demonstrate that the prevalence of MCD is relatively high in Dutch health care (44 % has MCD), especially in mental health care (in which MCD is mentioned as present in the organization by 62 % of the respondents). Institutions with MCD differ from institutions without MCD concerning size, kind of problems and importance of ideological background. Characteristic of MCD is that it often exists for 3 years or more, has a high participation of health professionals and middle managers and is both organized scheduled as unscheduled. As well integration in existing policy as key persons emerge as important issues in relation to the positioning of MCD. We conclude that MCD is a part of an integrated ethics policy and serves as a (bottom up) catalyst for such an integrated ethics policy.

Outcomes of moral case deliberation--the development of an evaluation instrument for clinical ethics support (the Euro-MCD)

BACKGROUND

Clinical ethics support, in particular Moral Case Deliberation, aims to support health care providers to manage ethically difficult situations. However, there is a lack of evaluation instruments regarding outcomes of clinical ethics support in general and regarding Moral Case Deliberation (MCD) in particular. There also is a lack of clarity and consensuses regarding which MCD outcomes are beneficial. In addition, MCD outcomes might be context-sensitive. Against this background, there is a need for a standardised but flexible outcome evaluation instrument. The aim of this study was to develop a multi-contextual evaluation instrument measuring health care providers' experiences and perceived importance of outcomes of Moral Case Deliberation.

METHODS

A multi-item instrument for assessing outcomes of Moral Case Deliberation (MCD) was constructed through an iterative process, founded on a literature review and modified through a multistep review by ethicists and health care providers. The instrument measures perceived importance of outcomes before and after MCD, as well as experienced outcomes during MCD and in daily work. A purposeful sample of 86 European participants contributed to a Delphi panel and content validity testing. The Delphi panel (n = 13), consisting of ethicists and ethics researchers, participated in three Delphi-rounds. Health care providers (n = 73) participated in the content validity testing through 'think-aloud' interviews and a method using Content Validity Index.

RESULTS

The development process resulted in the European Moral Case Deliberation Outcomes Instrument (Euro-MCD), which consists of two sections, one to be completed before a participant's first MCD and the other after completing multiple MCDs. The instrument contains a few open-ended questions and 26 specific items with a corresponding rating/response scale representing various MCD outcomes. The items were categorised into the following six domains: Enhanced emotional support, Enhanced collaboration, Improved moral reflexivity, Improved moral attitude, Improvement on organizational level and Concrete results.

CONCLUSIONS

A tentative instrument has been developed that seems to cover main outcomes of Moral Case Deliberation. The next step will be to test the Euro-MCD in a field study.

Evaluation of clinical ethics support services and its normativity

Evaluation of clinical ethics support services (CESS) has attracted considerable interest in recent decades. However, few evaluation studies are explicit about normative presuppositions which underlie the goals and the research design of CESS evaluation. In this paper, we provide an account of normative premises of different approaches to CESS evaluation and argue that normativity should be a focus of considerations when designing and conducting evaluation research of CESS. In a first step, we present three different approaches to CESS evaluation from published literature. Next to a brief sketch of the well-established approaches of 'descriptive evaluation' and 'evaluation of outcomes', we will give a more detailed description of a third approach to evaluation-'reconstructing quality norms of CESS'-which is explicit about the normative presuppositions of its research (design). In the subsequent section, we will analyse the normative premises of each of the three approaches to CESS evaluation. We will conclude with a brief argument for more sensitivity towards the normativity of CESS and its evaluation research.

Pioneering partnerships: Resident involvement from multiple perspectives

Resident involvement in residential care homes is a challenge due to shortcomings of consumerist and formal approaches such as resident councils. The PARTNER approach aims to involve residents through collective action to improve their community life and wellbeing. The purpose of this article is to provide insights into the process of resident involvement by the PARTNER approach from the perspectives of multiple stakeholders, including residents, volunteers and staff members. A responsive evaluation was conducted, using participant observations, semi-structured interviews with residents, volunteers and professionals (n=16), and three focus groups. The findings show that critical elements in this process of resident involvement were the agenda-setting by residents, the formation of a cohesive resident group, the sharing of experiences and stories, the development of collective action, and the development of partnerships between residents and professionals and other stakeholder groups. Residents developed actions (gallery parties and a buddy project) to strengthen social interactions and realized these with the help of volunteers and professionals. We conclude that bringing residents together around a shared topic creates room for activism and leads to empowerment, feelings of social belonging and learning processes. We argue that it is a worthwhile enterprise to further develop structural partnership relations between residents, volunteers and staff in residential care homes.

Preventing seclusion in psychiatry: a care ethics perspective on the first five minutes at admission

In this article, an intervention aimed at improving quality of care to prevent seclusion in psychiatry by focusing on the first five minutes at admission is analyzed from a care ethics perspective. Two cases are presented from an evaluation study in a psychiatric hospital. In both cases, the nurses follow the intervention protocol, but the outcome is different. In the first case, the patient ends up in the seclusion room. In the second case, this does not happen. Analyzing the cases from a care ethics perspective, we conclude that applying the intervention in the right way implies more than following the steps laid down in the protocol. It requires a new way of thinking and acting, resulting in new relationships between nurses and patients. Care ethics theory can help clarify what good care is actually about and keep in mind what is needed to apply the intervention. Thus, care ethics theory can be highly practical and helpful in changing and improving healthcare practice.

Aims and harvest of moral case deliberation

Deliberative ways of dealing with ethical issues in health care are expanding. Moral case deliberation is an example, providing group-wise, structured reflection on dilemmas from practice. Although moral case deliberation is well described in literature, aims and results of moral case deliberation sessions are unknown. This research shows (a) why managers introduce moral case deliberation and (b) what moral case deliberation participants experience as moral case deliberation results. A responsive evaluation was conducted, explicating moral case deliberation experiences by analysing aims (N = 78) and harvest (N = 255). A naturalistic data collection included interviews with managers and evaluation questionnaires of moral case deliberation participants (nurses). From the analysis, moral case deliberation appeals for cooperation, team bonding, critical attitude towards routines and nurses' empowerment. Differences are that managers aim to foster identity of the nursing profession, whereas nurses emphasize learning processes and understanding perspectives. We conclude that moral case deliberation influences team cooperation that cannot be controlled with traditional management tools, but requires time and dialogue. Exchanging aims and harvest between manager and team could result in co-creating (moral) practice in which improvements for daily cooperation result from bringing together perspectives of managers and team members.

The discovery of deliberation. From ambiguity to appreciation through the learning process of doing Moral Case Deliberation in Dutch elderly care

In the field of bioethics a trend can be noticed toward deliberative and collective forms of moral reflection among practitioners. Moral Case Deliberation (MCD) is an example of this development and currently introduced in an increasing number of health care organizations in the Netherlands, including elderly care. The purpose of this article is to evaluate the process of implementation of MCD focusing on the learning experiences of practitioners over time. The article is grounded in a naturalistic evaluation of the implementation of MCD in two elderly care institutions between 2006 and 2012. Methods included interviews, participant observations and focus groups. The results indicate that gaining experience with MCD brought about a learning process in which both the learning of competence for reflection and deliberation (e.g. an exploratory attitude) and experiencing the benefits (e.g. relief of moral distress) were key elements. We conclude that doing ethics is the best way to motivate practitioners to engage in moral deliberations on the work floor. Gaining practical experience should be explicitly stimulated bottom-up and facilitated top-down.

How can one be both a philosophical ethicist and a democrat?

How can one be both a philosophical ethicist and a democrat? In this article I conclude that it can be difficult to reconcile the two roles. One involves understanding, and reconciling, the conflicting views of citizens, and the other requires the pursuit of truth through reason. Nevertheless, an important function of philosophy and ethics is to inform and improve policy. If done effectively, we could expect better, and more just, laws and policies, thereby benefiting many lives. So applying philosophical thinking to policy is an important job. However, it comes with substantial difficulties, not least in reconciling, or choosing between, competing philosophical theories. Despite the importance of the task, and the apparent obstacles, there is relatively little literature on how to apply ethics to real-world policy-making. Democracies need ethicists who can engage in democratic debate and bridge the gap between philosophy and public policy. I offer some tactics here.

Client participation in moral case deliberation: a precarious relational balance

Moral case deliberation (MCD) is a form of clinical ethics support in which the ethicist as facilitator aims at supporting professionals with a structured moral inquiry into their moral issues from practice. Cases often affect clients, however, their inclusion in MCD is not common. Client participation often raises questions concerning conditions for equal collaboration and good dialogue. Despite these questions, there is little empirical research regarding client participation in clinical ethics support in general and in MCD in particular. This article aims at describing the experiences and processes of two MCD groups with client participation in a mental healthcare institution. A responsive evaluation was conducted examining stakeholders’ issues concerning client participation. Findings demonstrate that participation initially creates uneasiness. As routine builds up and client participants meet certain criteria, both clients and professionals start thinking beyond ‘us-them’ distinctions, and become more equal partners in dialogue. Still, sentiments of distrust and feelings of not being safe may reoccur. Client participation in MCD thus requires continuous reflection and alertness on relational dynamics and the quality of and conditions for dialogue. Participation puts the essentials of MCD (i.e., dialogue) to the test. Yet, the methodology and features of MCD offer an appropriate platform to introduce client participation in healthcare institutions.