Journal of Nursing Management, 2015, 23, 1067–1075
Managers’ views on and experiences with moral case deliberation in nursing teams FROUKJE C. WEIDEMA WIDDERSHOVEN P r o f . 4
1 PhD ,
A. C. (BERT) MOLEWIJK
PhD
2
, FRANS KAMSTEEG
MA
3
and GUY A.M.
1
VUmc, Department of Medical Humanities, Amsterdam/GGNet Engelbert Kreijnck Centre, Warnsveld, 2VUmc, Department of Medical Humanities, Amsterdam, 3GGNet Engelbert Kreijnck Centre, Warnsveld and 4VUmc, Department of Medical Humanities, Amsterdam, The Netherlands
Correspondence Froukje C. Weidema GGNet EKC PO Box 2003 7230 GC Warnsveld The Netherlands E-mail: [email protected]
WEIDEMA F.C., MOLEWIJK A.C., KAMSTEEG F. & WIDDERSHOVEN G.A.M.
(2015) Journal of Nursing Management 23, 1067–1075. Managers’ views on and experiences with moral case deliberation in nursing teams Aims Providing management insights regarding moral case deliberation (MCD) from the experiential perspective of nursing managers. Background MCD concerns systematic group-wise reflection on ethical issues. Attention to implementing MCD in health care is increasing, and managers’ experiences regarding facilitating MCD’s implementation have not yet been studied. Method As part of an empirical qualitative study on implementing MCD in mental health care, a responsive evaluation design was used. Using former research findings (iterative procedures), a managers’ focus group was organised. Results Managers appreciated MCD, fostering nurses’ empowerment and critical reflection – according to managers, professional core competences. Managers found MCD a challenging intervention, resulting in dilemmas due to MCD’s confidential and egalitarian nature. Managers value MCD’s process-related outcomes, yet these are difficult to control/regulate. Conclusions MCD urges managers to reflect on their role and (hierarchical) position both within MCD and in the nursing team. Implications for nursing management MCD is in line with transformative and participatory management, fostering dialogical interaction between management and nursing team.
Keywords: dialogue, implementation, moral case deliberation, participatory management, responsive evaluation Accepted for publication: 17 June 2014
Introduction Clinical ethics support (CES) is currently under increased scrutiny in the international literature. Next to well-known approaches (i.e. ethics committees, ethics consultants), additive approaches have been introduced focusing on supporting health professionals in dealing with moral issues. Examples are: moral case deliberation (MCD) (Molewijk et al. 2008a, DOI: 10.1111/jonm.12253 ª 2015 John Wiley & Sons Ltd
Widdershoven et al. 2009, Dauwerse et al. 2011), skills laboratories (Vanlaere et al. 2010) and ethics rounds (Svantesson et al. 2008). These approaches foster deliberation rather than giving expert advice, showing attention to the context and experiences of health-care practitioners. This study focuses on MCD. In MCD, (multidisciplinary) groups of health-care professionals reflect on ethical issues they encounter during their work (Verkerk et al. 2004, Stolper et al. 1067
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2012). In contrast to supervision, MCD does not aim to help individuals to cope with technical/psychological issues, but invites all participants to reflect on values and moral concerns (Plantinga et al., 2012). Moral case deliberation is facilitated by a specifically trained facilitator. It is radically concrete, focusing on the participants’ experiences and reasoning (Irvine et al. 2004, Widdershoven et al. 2009), representing multiple perspectives (Van der Dam et al. 2011). The central aims of MCD are: advancing reflective dialogue (Weidema et al. 2011, Stolper et al. 2012), implying mutual equality, speaking frankly and sustaining an attitude of inquiry rather than convincing others (discussion, debate) (Weidema et al. 2011). Dialogue is the central notion in MCD, based on our theoretical and epistemological understanding of clinical ethics, inspired by pragmatic hermeneutics and dialogical ethics (Ruiz & Roche 2007, Widdershoven et al. 2009). Moral inquiry focuses on analytical, logical reasoning, but includes emotions and experiential learning (Kolb et al. 2002, Molewijk et al. 2011).
Literature overview Regarding the outcomes of MCD, one study showed that attention to day-to-day dilemmas influences the quality of care and job satisfaction (Erlen 2007). Another study reported that professionals improved their dealing with moral dilemmas with respect to knowledge, skills and attitude (Molewijk et al. 2008b). Open, straight, constructive communication and moral sensitivity increased; presuppositions, prejudices and automatic responses decreased (Molewijk et al. 2008c). A recent study found that managers initiate MCD in their teams to (1) increase nurses’ moral sensitivity/critical attitude; (2) improve (multidisciplinary) cooperation skills (Weidema et al. 2013). But how do nursing managers view MCD and how do they perceive their role in (implementing) this instrument for dialogue? It is unclear whether MCD can be positioned in relation to specific (management) goals, given its dialogical nature.
Research questions As part of a study on the implementation of MCD, we focused on the perception of managers from a Dutch mental health-care institution regarding their role in implementing MCD: ●
What perceptions do managers have of MCD?
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How do managers understand the process of implementing MCD? ● What role do managers see for themselves regarding their participation in MCD?
Research context This study was conducted in a large mental healthcare institution that is leading the field of MCD practice in Dutch health care, facilitating over 200 MCD sessions annually, covering 40 teams of professionals (caretakers, staff services, management teams etc.). An institutional MCD steering group, embedded in the institutional Expertise Centre and consisting of five people (including the MCD programme leader) from various organisational segments, coordinates, monitors and facilitates the quantity and quality of MCD. Alongside, co-ordinating and monitoring these activities, empirical research on implementing MCD was conducted. In 2004, MCD was introduced embedded in a project on the reduction of coercion and restraint. Once the project had ended, the teams involved decided to continue the sessions. Simultaneously, initiatives for MCD expanded organisation-wide. Current MCD initiatives are demand-driven; no team is obliged to do MCD (although the board encourages its use). Requests generally come from managers. When requiring six sessions or more, the MCD programme leader initiates a semi-structured conversation with the manager. Here, motivations, aims, expectations and end terms of MCD are agreed and documented. This agreement is used to streamline further evaluations of MCD.
Methodology Responsive evaluation design A four-year responsive evaluation research project was conducted (2008–2012) to monitor, facilitate and evaluate the implementation of MCD. Responsive evaluation considers qualitative, transformative research, in which both the evaluation and development of programmes are studied and facilitated (Stake 2004). The active inclusion of stakeholders is essential, providing experiential knowledge, making embodied insiders’ perspectives explicit and stimulating the development of the subject under evaluation (Visse et al. 2012). Responsive evaluation develops via an emergent design, refining findings by insistently examining and ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1067–1075
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reflecting upon them in dialogue. Simultaneously, stakeholders learn about and develop their practice through research activities (Paulus et al. 2008). This cyclical process supports both practice and research, strengthening the collaboration between researcher and stakeholders, resulting in the co-production of both practice and research.
The evaluation process Responsive evaluation is in concordance with values that prevail in MCD, applying principles of hermeneutic ethics (Widdershoven et al. 2009), with comparable means and outcomes: (1) stakeholders’ active inclusion and participation; (2) sustaining meaningful dialogue; (3) mutual learning (Abma et al. 2009, Baur et al. 2010, Visse 2012). Insiders’ perspectives are brought in by multiple data collection methods i.e. interviews and focus groups (Morgan et al. 2008). Stakeholders’ issues, expectations and controversies are explored to obtain a rich understanding (Stake 2004, Ren & Langhout 2010). Research participants are information providers, advisors and active partners (Mertens 2009). Merging perspectives from all stakeholders results in a mutual learning environment and a vivid comprehension of practice (Greene 2001, Abma & Widdershoven 2006). Co-generating data, co-learning, cooperation and participation are important concepts.
Data collection For this study, a two-hour managers’ focus group was organised (October 2011). All the 20 managers who initiated at least six MCDs annually in the institution, were invited. Most managers responded that they were interested in the further organisational development of MCD. Eventually, eight managers attended, covering both enthusiastic and critical managers regarding MCD. The focus group, facilitated by the first and second author, was partly open, partly semi-structured. Table 1 shows the focus group agenda and the facilitators’ guide. The facilitators aimed to create an atmosphere of mutual openness, frank exploration of the personal/professional relation with MCD, reflections and doubts.
Data analysis With oral permission from the participants, the focus group was audio-taped and transcribed, using the transcript as data for this study. We conducted an ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1067–1075
inductive content analysis following a hermeneutic– dialectic interpretation process (Bernard 2000, Anderson 2012), applying steps of exact descriptions and abstracting, thereby meeting the criteria of credibility. From the transcript, the first and second author retrieved independently the issues and focuses of interest on managers’ perspectives on MCD. Next, discussions between all four authors were organised for credibility (investigator triangulation; Creswell & Miller 2000). The emerging topics were used to organise the data into subcategories and consequently clustered into three main categories: (1) managers’ perspectives on MCD; (2) managing MCD; (3) managers’ participation in MCD. Within the main categories, subcategories were maintained, sustaining authenticity and nuance. Throughout the analysing process, the categories were continuously compared and discussed by the author team, until the point of saturation (Morse 2001) and consensus. Data triangulation was realised by referring to empirical material and experiences from the focus group that were noted and checked during the meeting (Flick 2004).
Validity precautions Qualitative research has specific criteria to validate research outcomes: credibility, dependability, confirmability and transferability (Guba & Lincoln 1989). In transformative research, researchers are highly involved in the study context. This ‘prolonged engagement’ contributes to credibility. Further, we deliberately included critical managers in our study. Also, we applied iterative processes, using findings from earlier studies during the focus group. Dependability requires solid reflection on personal presuppositions to prevent bias. Therefore, all four authors cooperated in creating the interview guide and analysis procedure. The third and fourth authors were not directly involved in the institutional practice of MCD. All authors were involved in the analysing process. To increase trustworthiness, quotations were selected to support the presented findings. Confirmability refers to the plausibility of the data interpretation. Meetings with all authors, reflexive journals and discussions with participants helped to represent perceptions in a trustworthy way. With regard to transferability, the findings from responsive evaluation research count as particular and unique. Generalisation comes about when descriptions are used as learning material for understanding comparable practices (naturalistic generalisation; Hellstr€ om 2008, Denzin & 1069
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Table 1 Interview agenda and the focus group facilitators’ guide (October 2011) Interview agenda Introduction and exploratory question: What issues do you note in managing MCD in your team? Managers’ comments and evaluations on MCD: Presentation of predefined statements based on earlier research (iterative process)
Reflective discussion: Presentation of and discussion on managers’ aims and nurses’ harvest of MCD (iterative process) Closure
Focus group facilitators’ guide Researcher notes the issues from managers on a white-board Plenary discussion on overlap and differences between issues Noting hierarchy: which issues are most urgent? Discussion on issues Statement a: ‘Reaching pre-defined aims is no precondition to call an MCD-session ‘successful’ Statement b: ‘As a manager I have ownership of the ins and outs of an MCD-session in my team’ Statement c: MCD perfectly suits a management rationale of ‘plan–do–check–act’ Statement d: ‘I wish to have more of a grip on the content of an MCD-session in my team’ Participants individually write their response on sticky-notes. They put their sticky-notes on the white-board with the corresponding statement ‘Market’: individual reading of the separate reactions, noting differences in visions Plenary discussion of the differences and overlap The participants are handed out an overview of the outcomes of earlier research findings on aims and harvest of MCD Discussion on the findings Noting points of attention based on the discussions
Lincoln 2011). To enable readers to draw comparisons, thick descriptions were inserted.
Ethical considerations All participants gave their verbal consent for audiotaping the focus group. Ethical considerations, i.e. anonymity and confidentiality, were taken into account by removing the participants’ names, wards or any other detail and numbering the managers I– VIII. As no patients were included in this research, the study did not fall under Dutch law concerning medical research with human subjects. Approval from an IRB was not needed.
Findings Managers’ perceptions Managers explored the meaning of MCD in general and for their nursing team in particular. Perspectives on the quality of MCD were shared, including ways to secure or strengthen this quality. Managers noted MCD as a tool for stimulating reflection, contributing to good care and communication. ‘[MCD implies reflection on] attitude to colleagues, to myself, how I should position myself in communication or cooperation. . . Yes, I believe ultimately that influences quality of care’. (Manager I) Leaving the comfort zone According to managers, MCD required leaving the comfort zone and entering critical thinking. In-depth 1070
reflection (rather than just a conversation) was preconditional to qualifying the session as ‘good’. Reflection was perceived as a necessity for improvement in care and cooperation. Yet, managers found it difficult to point out which factors supported the quality of MCD. ‘When I’m part of an MCD session in which I really discover the reason behind someone’s resistance (. . .), then I think: look how far we’ve got! We so much approached this issue from a different perspective, we left our comfort zone so bravely, that I truly discovered something new. And, we came to understand each other better’. (Manager IV) ‘I sometimes wish to have more of a grip on the quality of the sessions. About. . . did you really get to the punchline? Did you dare to, together?’. (Manager V) Reflection as professional competence Some managers were critical when it came to the team members’ capacity or willingness to reflect, as managers saw reflection as an essential professional competence. They pointed out that their responsibility to organise MCD was necessary because nurses felt no a priori need for reflection. ‘Some caregivers have been working in the same unit for 25 years. They may have had dilemmas at first, but they have become so hospitalised, they don’t experience any dilemma at all! I’d say that’s serious. At that point actually one cannot (Manager VII) properly function’.
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‘Nurses, they feel they have to be with the patients! In their opinion, MCD does not directly touch upon the heart of their work’. (Manager III)
Considerations on implementing moral deliberation Managers showed doubts regarding the extent to which s/he can regulate the organisation, content or outcomes of MCD. These doubts underlie the question of how to manage MCD. Differentiating moral deliberation from regular meetings Moral case deliberation was distinguished from regular ward meetings. Some managers facilitated MCD to keep regular ward meetings clear from moral issues, making regular meetings more efficient. ‘In regular ward meetings, I can postpone moral issues to the facilitated MCDs’. (Manager VII)
that this organisation deems it important that employees reflect on their work continuously’. (Manager III) Moral deliberation within plan–do–check–act? Most managers did not expect MCD to provide clear substantial outcomes. This ‘elusiveness’ was taken as a characteristic of MCD’s inherent free space, initiating processes that could not be grasped or steered. Many managers appreciated the process-oriented outcomes of MCD: openness, deliberation and joint critical reflection. A few managers considered the processrelated outcomes of MCD insufficient. ‘You cannot measure the outcomes. That makes it all the more difficult for me as a manager’. (Manager VII) ‘After two hours [of MCD] I often think: the togetherness and process that evolved in that session really are enough, without me thinking: oh my, now I do not have any concrete results’. (Manager IV) Another manager did suggest concrete outcomes:
Regulating frequency As for the nurses’ reflection, this was not as self-evident as managers would like and attending MCD had little priority in the heat of the moment, regulating MCD was necessary in terms of timing, presence and duration per session. This could include shuffling time-schedules or launching a mandate to join. ‘We as managers state: I want you all to join at least two sessions a year’. (Manager VI) ‘We did MCD for one hour a month. But in-depth reflection isn’t possible in one hour. So I worked towards four times a year for 1,5 hours per session. That really makes it more. . .special, incidental, extra. And from that, I do see the rewards’. (Manager I) Streamlining moral deliberation Three managers pleaded for a firm statement from the board, streamlining MCD organisation-wide as an obligatory part of professional practice. Also, they wished to attribute accreditation points to MCD. Top-down regulation could overcome the informal status of MCD, strengthening MCD as a part of regular work processes. ‘A BIG-registration [Dutch accreditation system] should be applied to MCD. (. . .) That would show ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1067–1075
‘For example, look at health-related absenteeism. On our ward, that rate is really low. So maybe that’s an effect: people are able to differentiate and ventilate their issues’. (Manager II) Managers hesitated to quantify MCD’s outcomes in terms of management tools, due to doubts on how to perceive or use MCD: as free space for nurses, exploring issues. These managers distinguished MCD from other meetings in terms of input, style and output expectations. ‘Communication, cooperation, attitude, bringing policy changes into practice. . . When I consider outcomes of MCD, I do not wonder: did this mean something for my policy?’. (Manager V)
Managers’ participation Managers had different views on joining the sessions or not. Some managers experienced dilemmas or precariousness. Considerations – pro and con – were related to the characteristics of MCD. Hierarchical relations Managers proved conscious of their hierarchical position, while MCD implies equality and frank 1071
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speaking. Participating in equal deliberation made the hierarchical differences explicit. Some managers stated that this evidently excluded them from participation. ‘I’d consider not joining the sessions. I’d feel that I would obstruct the process because of my position [as a manager] and I’d certainly observe people not speaking from the heart’. (Manager II) Interestingly, other managers referred to the same MCD characteristics, but in terms of diminishing hierarchical differences. They felt participating in MCD encouraged equality and shared decision-making. Joining MCD made them feel as partners involved from the inside. ‘I so much appreciate being present during the sessions. Because it creates togetherness, knowing: hey, we work together here, we focus on the same goal’. (Manager IV) ‘I strongly believe in my participation, showing my team: this also concerns me, and I’m learning here, too’. (Manager III)
Shared contexts For some managers, participating in MCD included them in relevant team processes, gaining insider’s views on issues and team dynamics. They felt they became a partner in the team; involved, interested, close-by. ‘What I hear during the sessions differs from what I hear in passing on the ward. And sincere dilemmas, for instance, when a client commits suicide, need my close attention and participation’. (Manager V)
Sharing vulnerability Managers participating in MCD wondered to what extent they should participate. MCD’s characteristics of equality and openness, thus requiring vulnerability, resulted in dilemmas of managers concerning their position in the team. ‘I’d not like to raise my own dilemmas in MCD. Because I’d then show vulnerability that might have consequences. It certainly has something to do with me being a manager’. (Manager II)
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Confidentiality Other managers mentioned moral concerns related to their participation in MCD, for example because of MCD’s confidential character. ‘I wonder: what may I do with the information that I’m hearing? Do I restrict this to the MCD, or can I use it later on?’. (Manager IV)
Responsibilities Negative aspects of participating in MCD were also related to creating shared responsibility: ‘I’m convinced that my participation in MCD would obstruct its aims. The responsibility of the nursing team would disappear as soon as I’d join. At that point the meeting would become. . .an instrument, part of business’. (Manager II) In Table 2, an overview and summary of the findings is presented.
Discussion and implications for nursing management Although managers generally appreciated moral case deliberation for its contribution to the professional functioning of nurses, our study showed that managers could not easily integrate MCD in standard management approaches, as outcomes were difficult to measure, although some managers connected measurable outcomes to MCD (reduction of health-related absenteeism). Most managers expected that MCD would positively influence team cooperation and reflection on good care, and experienced that it did so. Managers also stated that MCD provided a platform for different ways of communicating: open, explorative, not primarily appealing to decision-making. They agreed that the quality of MCD lies in the process. Given this process-related character, regulating the quality of sessions or outcomes appeared impossible. Moral case deliberation required a different attitude from managers, resulting in managers searching how to relate to MCD. The findings showed that managers thought MCD did not fully fit the traditional linear plan–do–check– act structures (Christensen et al. 2007). Except for one, managers did not perceive this as problematic: the findings showed that managers did not search for managerial utility in MCD.
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Table 2 Main- and subcategories of managers’ experiences with moral case deliberation Main categories Managers’ perceptions of moral case deliberation
Managers’ considerations on the implementation process of moral case deliberation
Subcategories Leaving the comfort zone Reflection as professional competence Differentiation from regular meetings Regulating frequency Streamlining MCD
Managers’ participation in moral case deliberation sessions
MCD within or outside the plan–do– check–act cycle? Hierarchical relations
Shared contexts Sharing vulnerability Confidentiality Responsibilities
The current literature on change management, points out that a broadening of the concept of utility is necessary to optimise the commitment and involvement of employees (Martin 2000). This requires space for (moral) orientation on personal ideals and values. It is therefore suggested that the concept of utility be expanded with that of meaningfulness (Carr & Oreszczyn 2003, Karssing & Spoor 2010), referring to understanding personal and contextual values, their mutual relationship (Martin 2000), and their embodiment in professionalism (Flynn & Anderson 2012). To trace the intertwining of values and their relations, reflection is required (Loughran 2010). MCD explicates these processes through focusing on values and norms, supporting professionals in articulating and understanding their relation with their institutional context (Grill et al. 2011). Regarding their participation in MCD, managers had various views. The characteristics of MCD – equality, confidentiality, frankness of speaking, and therefore vulnerability – raised questions and dilemmas concerning the managers’ professional identity. Some managers saw opportunities for mutual openness and shared learning. They deemed togetherness – by sharing reflection, uncertainties and concerns – as valuable, referring to collaborative practices and shared responsibility (Robinson 2009) known from theories on value-driven transformational leadership (BamfordWade & Moss 2010, Newman 2011, Tomlinson 2012). Transformational leadership implies that managers should work towards three-dimensional relationships with employees: not only informing or communicating, but actively sharing processes (Atkinson et al. 2003), ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1067–1075
Examples given by the managers Courage to start in-depth reflection as part of critical thinking and nursing team functioning MCD facilitates and stimulates reflection skills Moral issues in regular ward meetings are postponed to MCD Search for right time and duration MCD as an organisation-wide, top-down obligation for professionals? Process-related outcomes of MCD result in inappropriateness of steering MCD MCD’s characteristics result in search or dilemmas considering the managers’ professional identity Being part of nursing team dynamics Suitability of managers sharing their vulnerability Dilemmas regarding the use of confidential information from MCD sessions MCD should not lead up to a transfer of responsibilities to the manager
managing expectations and sharing responsibilities (Ott & Ross 2014). Nevertheless, managers wondered to what extent they should/could be equal partners and what their participation would mean for other MCD participants. Also, MCD’s confidentiality raised dilemmas on how to deal with information from MCD. In contrast, other managers thought participation would compromise MCD, suggesting that their hierarchical position would disturb frank deliberation, responsibility issues and require an inappropriate appeal to the managers’ vulnerability. From conceptual frameworks of transformational management, leadership means focusing on, valuing and strengthening the potential resources of employees (Bamford-Wade & Moss 2010). Environmental, relational and hierarchical aspects are part of an ongoing learning process, nourished by experiences and sharing (Caldwell et al. 2008, Gustafsson et al. 2010). Participatory management not only includes active managers’ partnership in team-related processes but also refers to self-governance of the team. Research on participatory management showed nursing managers may function as a moral compass, enabling nurses to enforce and sustain ethical practice (c.f. Storch et al. 2002). This includes enforcement of nursing empowerment by stimulating self-reliant decision-making and taking up responsibilities (Bamford-Wade & Moss 2010). The absence of the manager during MCD could then be perceived as a sign of trust: facilitating space for making responsible choices (‘semi-autonomous space’, Karssing & Spoor 2010). Yet, managers not participating in MCD miss out on an opportunity 1073
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to share learning processes with the team, essential from the perspective of shared governance (McGuire & Kennerly 2006, Bass 2010).
Limitations of the study Only eight of the 20 invited managers joined the focus group. Furthermore, the researchers may have been regarded as being in favour of MCD, risking a positive bias on the side of the respondents. Finally, situated in mental health care, the transferability of findings may be limited.
Conclusions In terms of nursing management, implementing MCD requires being open to cooperation with the nursing team, focusing on process-related outcomes. MCD fosters a contribution to nurses’ professionalism and competence. The core features of MCD (i.e. openness, vulnerability, equality) are relevant for managers at a practical level, in terms of organising MCD and regarding the managers’ identity. Firstly, managers should create room for systematic reflection by providing time and place for MCD. Secondly, the implementation of MCD requires dealing with process-oriented outcomes and complex issues of utility and value. Managers cannot anticipate straightforward working towards predefined goals, because the outcomes of MCD depend on the experiences of the participants. Finally, fostering MCD requires reflection on whether or not to participate. Whichever choice is made, these reflections refer to identity-issues regarding the managers’ role and position towards the team, and issues concerning hierarchy. The role of managers in implementing MCD can be perceived as exemplary for participatory management. Fostering MCD may pave the way for transformative management, particularly when managers join MCD. MCD can contribute to establishing a dialogical interaction between nursing management and nursing teams, resulting in a mutual encounter and further shared meaning-making in relation to ethical issues in health care.
Acknowledgements This research was possible due to the inspiring ongoing cooperation between GGNet and VUmc. We wish to thank all GGNet participants for their active and well-appreciated involvement in this research, in particular the managers of the MCD sessions. 1074
Sources of funding This research received no formal financial grant. However, it received institutional support from GGNet and VUmc as the first author is an employee at both GGNet and VUmc.
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Managers’ views on and experiences with moral case deliberation in nursing teams FROUKJE C. WEIDEMA WIDDERSHOVEN P r o f . 4
1 PhD ,
A. C. (BERT) MOLEWIJK
PhD
2
, FRANS KAMSTEEG
MA
3
and GUY A.M.
1
VUmc, Department of Medical Humanities, Amsterdam/GGNet Engelbert Kreijnck Centre, Warnsveld, 2VUmc, Department of Medical Humanities, Amsterdam, 3GGNet Engelbert Kreijnck Centre, Warnsveld and 4VUmc, Department of Medical Humanities, Amsterdam, The Netherlands
Correspondence Froukje C. Weidema GGNet EKC PO Box 2003 7230 GC Warnsveld The Netherlands E-mail: [email protected]
WEIDEMA F.C., MOLEWIJK A.C., KAMSTEEG F. & WIDDERSHOVEN G.A.M.
(2015) Journal of Nursing Management 23, 1067–1075. Managers’ views on and experiences with moral case deliberation in nursing teams Aims Providing management insights regarding moral case deliberation (MCD) from the experiential perspective of nursing managers. Background MCD concerns systematic group-wise reflection on ethical issues. Attention to implementing MCD in health care is increasing, and managers’ experiences regarding facilitating MCD’s implementation have not yet been studied. Method As part of an empirical qualitative study on implementing MCD in mental health care, a responsive evaluation design was used. Using former research findings (iterative procedures), a managers’ focus group was organised. Results Managers appreciated MCD, fostering nurses’ empowerment and critical reflection – according to managers, professional core competences. Managers found MCD a challenging intervention, resulting in dilemmas due to MCD’s confidential and egalitarian nature. Managers value MCD’s process-related outcomes, yet these are difficult to control/regulate. Conclusions MCD urges managers to reflect on their role and (hierarchical) position both within MCD and in the nursing team. Implications for nursing management MCD is in line with transformative and participatory management, fostering dialogical interaction between management and nursing team.
Keywords: dialogue, implementation, moral case deliberation, participatory management, responsive evaluation Accepted for publication: 17 June 2014
Introduction Clinical ethics support (CES) is currently under increased scrutiny in the international literature. Next to well-known approaches (i.e. ethics committees, ethics consultants), additive approaches have been introduced focusing on supporting health professionals in dealing with moral issues. Examples are: moral case deliberation (MCD) (Molewijk et al. 2008a, DOI: 10.1111/jonm.12253 ª 2015 John Wiley & Sons Ltd
Widdershoven et al. 2009, Dauwerse et al. 2011), skills laboratories (Vanlaere et al. 2010) and ethics rounds (Svantesson et al. 2008). These approaches foster deliberation rather than giving expert advice, showing attention to the context and experiences of health-care practitioners. This study focuses on MCD. In MCD, (multidisciplinary) groups of health-care professionals reflect on ethical issues they encounter during their work (Verkerk et al. 2004, Stolper et al. 1067
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2012). In contrast to supervision, MCD does not aim to help individuals to cope with technical/psychological issues, but invites all participants to reflect on values and moral concerns (Plantinga et al., 2012). Moral case deliberation is facilitated by a specifically trained facilitator. It is radically concrete, focusing on the participants’ experiences and reasoning (Irvine et al. 2004, Widdershoven et al. 2009), representing multiple perspectives (Van der Dam et al. 2011). The central aims of MCD are: advancing reflective dialogue (Weidema et al. 2011, Stolper et al. 2012), implying mutual equality, speaking frankly and sustaining an attitude of inquiry rather than convincing others (discussion, debate) (Weidema et al. 2011). Dialogue is the central notion in MCD, based on our theoretical and epistemological understanding of clinical ethics, inspired by pragmatic hermeneutics and dialogical ethics (Ruiz & Roche 2007, Widdershoven et al. 2009). Moral inquiry focuses on analytical, logical reasoning, but includes emotions and experiential learning (Kolb et al. 2002, Molewijk et al. 2011).
Literature overview Regarding the outcomes of MCD, one study showed that attention to day-to-day dilemmas influences the quality of care and job satisfaction (Erlen 2007). Another study reported that professionals improved their dealing with moral dilemmas with respect to knowledge, skills and attitude (Molewijk et al. 2008b). Open, straight, constructive communication and moral sensitivity increased; presuppositions, prejudices and automatic responses decreased (Molewijk et al. 2008c). A recent study found that managers initiate MCD in their teams to (1) increase nurses’ moral sensitivity/critical attitude; (2) improve (multidisciplinary) cooperation skills (Weidema et al. 2013). But how do nursing managers view MCD and how do they perceive their role in (implementing) this instrument for dialogue? It is unclear whether MCD can be positioned in relation to specific (management) goals, given its dialogical nature.
Research questions As part of a study on the implementation of MCD, we focused on the perception of managers from a Dutch mental health-care institution regarding their role in implementing MCD: ●
What perceptions do managers have of MCD?
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How do managers understand the process of implementing MCD? ● What role do managers see for themselves regarding their participation in MCD?
Research context This study was conducted in a large mental healthcare institution that is leading the field of MCD practice in Dutch health care, facilitating over 200 MCD sessions annually, covering 40 teams of professionals (caretakers, staff services, management teams etc.). An institutional MCD steering group, embedded in the institutional Expertise Centre and consisting of five people (including the MCD programme leader) from various organisational segments, coordinates, monitors and facilitates the quantity and quality of MCD. Alongside, co-ordinating and monitoring these activities, empirical research on implementing MCD was conducted. In 2004, MCD was introduced embedded in a project on the reduction of coercion and restraint. Once the project had ended, the teams involved decided to continue the sessions. Simultaneously, initiatives for MCD expanded organisation-wide. Current MCD initiatives are demand-driven; no team is obliged to do MCD (although the board encourages its use). Requests generally come from managers. When requiring six sessions or more, the MCD programme leader initiates a semi-structured conversation with the manager. Here, motivations, aims, expectations and end terms of MCD are agreed and documented. This agreement is used to streamline further evaluations of MCD.
Methodology Responsive evaluation design A four-year responsive evaluation research project was conducted (2008–2012) to monitor, facilitate and evaluate the implementation of MCD. Responsive evaluation considers qualitative, transformative research, in which both the evaluation and development of programmes are studied and facilitated (Stake 2004). The active inclusion of stakeholders is essential, providing experiential knowledge, making embodied insiders’ perspectives explicit and stimulating the development of the subject under evaluation (Visse et al. 2012). Responsive evaluation develops via an emergent design, refining findings by insistently examining and ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1067–1075
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reflecting upon them in dialogue. Simultaneously, stakeholders learn about and develop their practice through research activities (Paulus et al. 2008). This cyclical process supports both practice and research, strengthening the collaboration between researcher and stakeholders, resulting in the co-production of both practice and research.
The evaluation process Responsive evaluation is in concordance with values that prevail in MCD, applying principles of hermeneutic ethics (Widdershoven et al. 2009), with comparable means and outcomes: (1) stakeholders’ active inclusion and participation; (2) sustaining meaningful dialogue; (3) mutual learning (Abma et al. 2009, Baur et al. 2010, Visse 2012). Insiders’ perspectives are brought in by multiple data collection methods i.e. interviews and focus groups (Morgan et al. 2008). Stakeholders’ issues, expectations and controversies are explored to obtain a rich understanding (Stake 2004, Ren & Langhout 2010). Research participants are information providers, advisors and active partners (Mertens 2009). Merging perspectives from all stakeholders results in a mutual learning environment and a vivid comprehension of practice (Greene 2001, Abma & Widdershoven 2006). Co-generating data, co-learning, cooperation and participation are important concepts.
Data collection For this study, a two-hour managers’ focus group was organised (October 2011). All the 20 managers who initiated at least six MCDs annually in the institution, were invited. Most managers responded that they were interested in the further organisational development of MCD. Eventually, eight managers attended, covering both enthusiastic and critical managers regarding MCD. The focus group, facilitated by the first and second author, was partly open, partly semi-structured. Table 1 shows the focus group agenda and the facilitators’ guide. The facilitators aimed to create an atmosphere of mutual openness, frank exploration of the personal/professional relation with MCD, reflections and doubts.
Data analysis With oral permission from the participants, the focus group was audio-taped and transcribed, using the transcript as data for this study. We conducted an ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1067–1075
inductive content analysis following a hermeneutic– dialectic interpretation process (Bernard 2000, Anderson 2012), applying steps of exact descriptions and abstracting, thereby meeting the criteria of credibility. From the transcript, the first and second author retrieved independently the issues and focuses of interest on managers’ perspectives on MCD. Next, discussions between all four authors were organised for credibility (investigator triangulation; Creswell & Miller 2000). The emerging topics were used to organise the data into subcategories and consequently clustered into three main categories: (1) managers’ perspectives on MCD; (2) managing MCD; (3) managers’ participation in MCD. Within the main categories, subcategories were maintained, sustaining authenticity and nuance. Throughout the analysing process, the categories were continuously compared and discussed by the author team, until the point of saturation (Morse 2001) and consensus. Data triangulation was realised by referring to empirical material and experiences from the focus group that were noted and checked during the meeting (Flick 2004).
Validity precautions Qualitative research has specific criteria to validate research outcomes: credibility, dependability, confirmability and transferability (Guba & Lincoln 1989). In transformative research, researchers are highly involved in the study context. This ‘prolonged engagement’ contributes to credibility. Further, we deliberately included critical managers in our study. Also, we applied iterative processes, using findings from earlier studies during the focus group. Dependability requires solid reflection on personal presuppositions to prevent bias. Therefore, all four authors cooperated in creating the interview guide and analysis procedure. The third and fourth authors were not directly involved in the institutional practice of MCD. All authors were involved in the analysing process. To increase trustworthiness, quotations were selected to support the presented findings. Confirmability refers to the plausibility of the data interpretation. Meetings with all authors, reflexive journals and discussions with participants helped to represent perceptions in a trustworthy way. With regard to transferability, the findings from responsive evaluation research count as particular and unique. Generalisation comes about when descriptions are used as learning material for understanding comparable practices (naturalistic generalisation; Hellstr€ om 2008, Denzin & 1069
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Table 1 Interview agenda and the focus group facilitators’ guide (October 2011) Interview agenda Introduction and exploratory question: What issues do you note in managing MCD in your team? Managers’ comments and evaluations on MCD: Presentation of predefined statements based on earlier research (iterative process)
Reflective discussion: Presentation of and discussion on managers’ aims and nurses’ harvest of MCD (iterative process) Closure
Focus group facilitators’ guide Researcher notes the issues from managers on a white-board Plenary discussion on overlap and differences between issues Noting hierarchy: which issues are most urgent? Discussion on issues Statement a: ‘Reaching pre-defined aims is no precondition to call an MCD-session ‘successful’ Statement b: ‘As a manager I have ownership of the ins and outs of an MCD-session in my team’ Statement c: MCD perfectly suits a management rationale of ‘plan–do–check–act’ Statement d: ‘I wish to have more of a grip on the content of an MCD-session in my team’ Participants individually write their response on sticky-notes. They put their sticky-notes on the white-board with the corresponding statement ‘Market’: individual reading of the separate reactions, noting differences in visions Plenary discussion of the differences and overlap The participants are handed out an overview of the outcomes of earlier research findings on aims and harvest of MCD Discussion on the findings Noting points of attention based on the discussions
Lincoln 2011). To enable readers to draw comparisons, thick descriptions were inserted.
Ethical considerations All participants gave their verbal consent for audiotaping the focus group. Ethical considerations, i.e. anonymity and confidentiality, were taken into account by removing the participants’ names, wards or any other detail and numbering the managers I– VIII. As no patients were included in this research, the study did not fall under Dutch law concerning medical research with human subjects. Approval from an IRB was not needed.
Findings Managers’ perceptions Managers explored the meaning of MCD in general and for their nursing team in particular. Perspectives on the quality of MCD were shared, including ways to secure or strengthen this quality. Managers noted MCD as a tool for stimulating reflection, contributing to good care and communication. ‘[MCD implies reflection on] attitude to colleagues, to myself, how I should position myself in communication or cooperation. . . Yes, I believe ultimately that influences quality of care’. (Manager I) Leaving the comfort zone According to managers, MCD required leaving the comfort zone and entering critical thinking. In-depth 1070
reflection (rather than just a conversation) was preconditional to qualifying the session as ‘good’. Reflection was perceived as a necessity for improvement in care and cooperation. Yet, managers found it difficult to point out which factors supported the quality of MCD. ‘When I’m part of an MCD session in which I really discover the reason behind someone’s resistance (. . .), then I think: look how far we’ve got! We so much approached this issue from a different perspective, we left our comfort zone so bravely, that I truly discovered something new. And, we came to understand each other better’. (Manager IV) ‘I sometimes wish to have more of a grip on the quality of the sessions. About. . . did you really get to the punchline? Did you dare to, together?’. (Manager V) Reflection as professional competence Some managers were critical when it came to the team members’ capacity or willingness to reflect, as managers saw reflection as an essential professional competence. They pointed out that their responsibility to organise MCD was necessary because nurses felt no a priori need for reflection. ‘Some caregivers have been working in the same unit for 25 years. They may have had dilemmas at first, but they have become so hospitalised, they don’t experience any dilemma at all! I’d say that’s serious. At that point actually one cannot (Manager VII) properly function’.
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‘Nurses, they feel they have to be with the patients! In their opinion, MCD does not directly touch upon the heart of their work’. (Manager III)
Considerations on implementing moral deliberation Managers showed doubts regarding the extent to which s/he can regulate the organisation, content or outcomes of MCD. These doubts underlie the question of how to manage MCD. Differentiating moral deliberation from regular meetings Moral case deliberation was distinguished from regular ward meetings. Some managers facilitated MCD to keep regular ward meetings clear from moral issues, making regular meetings more efficient. ‘In regular ward meetings, I can postpone moral issues to the facilitated MCDs’. (Manager VII)
that this organisation deems it important that employees reflect on their work continuously’. (Manager III) Moral deliberation within plan–do–check–act? Most managers did not expect MCD to provide clear substantial outcomes. This ‘elusiveness’ was taken as a characteristic of MCD’s inherent free space, initiating processes that could not be grasped or steered. Many managers appreciated the process-oriented outcomes of MCD: openness, deliberation and joint critical reflection. A few managers considered the processrelated outcomes of MCD insufficient. ‘You cannot measure the outcomes. That makes it all the more difficult for me as a manager’. (Manager VII) ‘After two hours [of MCD] I often think: the togetherness and process that evolved in that session really are enough, without me thinking: oh my, now I do not have any concrete results’. (Manager IV) Another manager did suggest concrete outcomes:
Regulating frequency As for the nurses’ reflection, this was not as self-evident as managers would like and attending MCD had little priority in the heat of the moment, regulating MCD was necessary in terms of timing, presence and duration per session. This could include shuffling time-schedules or launching a mandate to join. ‘We as managers state: I want you all to join at least two sessions a year’. (Manager VI) ‘We did MCD for one hour a month. But in-depth reflection isn’t possible in one hour. So I worked towards four times a year for 1,5 hours per session. That really makes it more. . .special, incidental, extra. And from that, I do see the rewards’. (Manager I) Streamlining moral deliberation Three managers pleaded for a firm statement from the board, streamlining MCD organisation-wide as an obligatory part of professional practice. Also, they wished to attribute accreditation points to MCD. Top-down regulation could overcome the informal status of MCD, strengthening MCD as a part of regular work processes. ‘A BIG-registration [Dutch accreditation system] should be applied to MCD. (. . .) That would show ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1067–1075
‘For example, look at health-related absenteeism. On our ward, that rate is really low. So maybe that’s an effect: people are able to differentiate and ventilate their issues’. (Manager II) Managers hesitated to quantify MCD’s outcomes in terms of management tools, due to doubts on how to perceive or use MCD: as free space for nurses, exploring issues. These managers distinguished MCD from other meetings in terms of input, style and output expectations. ‘Communication, cooperation, attitude, bringing policy changes into practice. . . When I consider outcomes of MCD, I do not wonder: did this mean something for my policy?’. (Manager V)
Managers’ participation Managers had different views on joining the sessions or not. Some managers experienced dilemmas or precariousness. Considerations – pro and con – were related to the characteristics of MCD. Hierarchical relations Managers proved conscious of their hierarchical position, while MCD implies equality and frank 1071
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speaking. Participating in equal deliberation made the hierarchical differences explicit. Some managers stated that this evidently excluded them from participation. ‘I’d consider not joining the sessions. I’d feel that I would obstruct the process because of my position [as a manager] and I’d certainly observe people not speaking from the heart’. (Manager II) Interestingly, other managers referred to the same MCD characteristics, but in terms of diminishing hierarchical differences. They felt participating in MCD encouraged equality and shared decision-making. Joining MCD made them feel as partners involved from the inside. ‘I so much appreciate being present during the sessions. Because it creates togetherness, knowing: hey, we work together here, we focus on the same goal’. (Manager IV) ‘I strongly believe in my participation, showing my team: this also concerns me, and I’m learning here, too’. (Manager III)
Shared contexts For some managers, participating in MCD included them in relevant team processes, gaining insider’s views on issues and team dynamics. They felt they became a partner in the team; involved, interested, close-by. ‘What I hear during the sessions differs from what I hear in passing on the ward. And sincere dilemmas, for instance, when a client commits suicide, need my close attention and participation’. (Manager V)
Sharing vulnerability Managers participating in MCD wondered to what extent they should participate. MCD’s characteristics of equality and openness, thus requiring vulnerability, resulted in dilemmas of managers concerning their position in the team. ‘I’d not like to raise my own dilemmas in MCD. Because I’d then show vulnerability that might have consequences. It certainly has something to do with me being a manager’. (Manager II)
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Confidentiality Other managers mentioned moral concerns related to their participation in MCD, for example because of MCD’s confidential character. ‘I wonder: what may I do with the information that I’m hearing? Do I restrict this to the MCD, or can I use it later on?’. (Manager IV)
Responsibilities Negative aspects of participating in MCD were also related to creating shared responsibility: ‘I’m convinced that my participation in MCD would obstruct its aims. The responsibility of the nursing team would disappear as soon as I’d join. At that point the meeting would become. . .an instrument, part of business’. (Manager II) In Table 2, an overview and summary of the findings is presented.
Discussion and implications for nursing management Although managers generally appreciated moral case deliberation for its contribution to the professional functioning of nurses, our study showed that managers could not easily integrate MCD in standard management approaches, as outcomes were difficult to measure, although some managers connected measurable outcomes to MCD (reduction of health-related absenteeism). Most managers expected that MCD would positively influence team cooperation and reflection on good care, and experienced that it did so. Managers also stated that MCD provided a platform for different ways of communicating: open, explorative, not primarily appealing to decision-making. They agreed that the quality of MCD lies in the process. Given this process-related character, regulating the quality of sessions or outcomes appeared impossible. Moral case deliberation required a different attitude from managers, resulting in managers searching how to relate to MCD. The findings showed that managers thought MCD did not fully fit the traditional linear plan–do–check– act structures (Christensen et al. 2007). Except for one, managers did not perceive this as problematic: the findings showed that managers did not search for managerial utility in MCD.
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Table 2 Main- and subcategories of managers’ experiences with moral case deliberation Main categories Managers’ perceptions of moral case deliberation
Managers’ considerations on the implementation process of moral case deliberation
Subcategories Leaving the comfort zone Reflection as professional competence Differentiation from regular meetings Regulating frequency Streamlining MCD
Managers’ participation in moral case deliberation sessions
MCD within or outside the plan–do– check–act cycle? Hierarchical relations
Shared contexts Sharing vulnerability Confidentiality Responsibilities
The current literature on change management, points out that a broadening of the concept of utility is necessary to optimise the commitment and involvement of employees (Martin 2000). This requires space for (moral) orientation on personal ideals and values. It is therefore suggested that the concept of utility be expanded with that of meaningfulness (Carr & Oreszczyn 2003, Karssing & Spoor 2010), referring to understanding personal and contextual values, their mutual relationship (Martin 2000), and their embodiment in professionalism (Flynn & Anderson 2012). To trace the intertwining of values and their relations, reflection is required (Loughran 2010). MCD explicates these processes through focusing on values and norms, supporting professionals in articulating and understanding their relation with their institutional context (Grill et al. 2011). Regarding their participation in MCD, managers had various views. The characteristics of MCD – equality, confidentiality, frankness of speaking, and therefore vulnerability – raised questions and dilemmas concerning the managers’ professional identity. Some managers saw opportunities for mutual openness and shared learning. They deemed togetherness – by sharing reflection, uncertainties and concerns – as valuable, referring to collaborative practices and shared responsibility (Robinson 2009) known from theories on value-driven transformational leadership (BamfordWade & Moss 2010, Newman 2011, Tomlinson 2012). Transformational leadership implies that managers should work towards three-dimensional relationships with employees: not only informing or communicating, but actively sharing processes (Atkinson et al. 2003), ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1067–1075
Examples given by the managers Courage to start in-depth reflection as part of critical thinking and nursing team functioning MCD facilitates and stimulates reflection skills Moral issues in regular ward meetings are postponed to MCD Search for right time and duration MCD as an organisation-wide, top-down obligation for professionals? Process-related outcomes of MCD result in inappropriateness of steering MCD MCD’s characteristics result in search or dilemmas considering the managers’ professional identity Being part of nursing team dynamics Suitability of managers sharing their vulnerability Dilemmas regarding the use of confidential information from MCD sessions MCD should not lead up to a transfer of responsibilities to the manager
managing expectations and sharing responsibilities (Ott & Ross 2014). Nevertheless, managers wondered to what extent they should/could be equal partners and what their participation would mean for other MCD participants. Also, MCD’s confidentiality raised dilemmas on how to deal with information from MCD. In contrast, other managers thought participation would compromise MCD, suggesting that their hierarchical position would disturb frank deliberation, responsibility issues and require an inappropriate appeal to the managers’ vulnerability. From conceptual frameworks of transformational management, leadership means focusing on, valuing and strengthening the potential resources of employees (Bamford-Wade & Moss 2010). Environmental, relational and hierarchical aspects are part of an ongoing learning process, nourished by experiences and sharing (Caldwell et al. 2008, Gustafsson et al. 2010). Participatory management not only includes active managers’ partnership in team-related processes but also refers to self-governance of the team. Research on participatory management showed nursing managers may function as a moral compass, enabling nurses to enforce and sustain ethical practice (c.f. Storch et al. 2002). This includes enforcement of nursing empowerment by stimulating self-reliant decision-making and taking up responsibilities (Bamford-Wade & Moss 2010). The absence of the manager during MCD could then be perceived as a sign of trust: facilitating space for making responsible choices (‘semi-autonomous space’, Karssing & Spoor 2010). Yet, managers not participating in MCD miss out on an opportunity 1073
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to share learning processes with the team, essential from the perspective of shared governance (McGuire & Kennerly 2006, Bass 2010).
Limitations of the study Only eight of the 20 invited managers joined the focus group. Furthermore, the researchers may have been regarded as being in favour of MCD, risking a positive bias on the side of the respondents. Finally, situated in mental health care, the transferability of findings may be limited.
Conclusions In terms of nursing management, implementing MCD requires being open to cooperation with the nursing team, focusing on process-related outcomes. MCD fosters a contribution to nurses’ professionalism and competence. The core features of MCD (i.e. openness, vulnerability, equality) are relevant for managers at a practical level, in terms of organising MCD and regarding the managers’ identity. Firstly, managers should create room for systematic reflection by providing time and place for MCD. Secondly, the implementation of MCD requires dealing with process-oriented outcomes and complex issues of utility and value. Managers cannot anticipate straightforward working towards predefined goals, because the outcomes of MCD depend on the experiences of the participants. Finally, fostering MCD requires reflection on whether or not to participate. Whichever choice is made, these reflections refer to identity-issues regarding the managers’ role and position towards the team, and issues concerning hierarchy. The role of managers in implementing MCD can be perceived as exemplary for participatory management. Fostering MCD may pave the way for transformative management, particularly when managers join MCD. MCD can contribute to establishing a dialogical interaction between nursing management and nursing teams, resulting in a mutual encounter and further shared meaning-making in relation to ethical issues in health care.
Acknowledgements This research was possible due to the inspiring ongoing cooperation between GGNet and VUmc. We wish to thank all GGNet participants for their active and well-appreciated involvement in this research, in particular the managers of the MCD sessions. 1074
Sources of funding This research received no formal financial grant. However, it received institutional support from GGNet and VUmc as the first author is an employee at both GGNet and VUmc.
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