Journal Sharing

Veronica I. Baptista

Organizing moral case deliberation Experiences in two Dutch nursing homes

S van der Dam TA Abma AC Molewijk MJM Kardol JMGA Schols GAM Widdershoven

 Moral case deliberation (MCD) is a specific form of clinical ethics, aiming to stimulate ethical reflection in daily practice in order to improve the quality of care. This article focuses on the implementation of MCD in nursing homes and the questions how and where to organize MCD. The purpose of this study was to evaluate one way of organizing MCD in two Dutch nursing homes.

 Moral dilemmas are part of the dayto-day care in nursing homes. Ethics in nursing homes is not restricted to life and death issues. There are many moral issues concerning the quality of life and care. The bigger ethical questions related to life and death (euthanasia, sedation, resuscitation) are often tackled by ethical committees or ethical consultants. The focus is then on the assistance in ethical decision making by experts.

 A large proportion of nursing homes in the Netherlands do not provide these services, however. The more common moral questions in nursing homes are the subject of structural, ethical reflection. Nurses and other health care professionals are not always aware of the ethical dimensions in their work, and may overlook certain moral dilemmas or experience pressure to avoid issues and to adjust to working routines. At the same time there appears to be a need among health care professionals to reflect on everyday ethics.

 In the Netherlands a growing number of health care organizations have started implementing MCD in order to support health care professionals in dealing with moral issues and communicating on these issues in a more reflective and dialogical way.

 In MCD, health care professionals sit down together to systematically reflect on one of the moral questions from their practice. MCD can have several goals: a) to reflect on the case and improve the quality of care within that case, b) to reflect on what it means to be a good professional and to enhance professionals moral competencies, and c) to reflect on institutional or organizational issues and improve the moral quality of care at that level

 The task of the MCDfacilitator, an ethicist or health care professional trained in ethics, is to foster a sincere and constructive dialogue among the participants, to keep the focus on the moral dimension of the case, to support the joint reasoning process, and to help the group in planning actions in order to improve the quality of care. The facilitator chooses the conversation method that matches with the specific goal of an MCD session, which may vary from Socratic conversations to a dilemma method.

 Who should participate in the MCD sessions? With respect to the composition of the MCD groups, it matters whether groups are homogeneous (converging professional background and interests) or heterogeneous (diverging background and interests). The literature on organizational and professional learning indicates that while homogeneity may serve to create an atmosphere of openness and safety, that fosters mutual learning, such homogeneity may also create blind spots and group think. Heterogeneity may help participants to place their own viewpoints in perspective and add new experiences to their own repertoire.

 Where to embed MCD? Innovations often start in niches apart from the formal organization where they can flourish without the ballast of the dominant culture. Yet, after some time the innovation, if successful, should be integrated within the institution, becoming part of the formal organization and communication structure. This is called mainstreaming. It is unknown how this works out for MCD within nursing homes.

 Study purpose The purpose of this study was to evaluate one way of implementing and organizing MCD in two Dutch nursing homes and to consider alternative ways. This article reports on participants positive and negative experiences with a mixed group and on their expectations of alternatives.

 Setting: MCD in two nursing homes Nursing home A consisted of eight wards, where approximately 270 residents lived and about 150 staff members worked

Nursing home B consisted of seven wards,where 180 residents lived and 75 staff members were employed

 As is common in Dutch nursing homes,25 to ensure that the complex multi-disciplinary care that the residents require are adequately met, each of these nursing homes employed their own paramedical and psychosocial staff as well as nursing staff and a specially trained nursing home physician. The communication structure in nursing homes features multidisciplinary meetings, evaluating the residents care plan, as well as disciplinary meetings, in the disciplinary teams and on the wards.

 MCD Groups In the first year of the project, in both nursing homes a project team with members of the university and the institution was installed and a mixed MCD group was composed with internally motivated participants that had different professional backgrounds and came from various wards. This was a deliberate choice. It was expected that this would facilitate the creative and protective environment that innovations need. Besides, representation of as many teams as possible in the MCD groups was considered to foster the dissemination of MCD into the institution. All participants of the MCD groups were involved in the primary care process.

 Semi-structured interviews with middle managers, directors and keyfigures of the institutions. Conversation topics included the following: types of ethical issues, organization of MCD and goals of MCD. The interviews lasted for approximately 45 minutes and were transcribed by the interviewer Observations Group sessions

 Results Positive experiences: broadening of horizons Greater awareness of each others moral issues More informal communication about moral issues Enriched moral inquiry

 Results Negative experiences: different levels of involvement and moral competence Lack of involvement Differences in moral competence

 Organizing MCD apart from existing structures Positive experiences: safety and openness Safe atmosphere and openness A way to unburden

 Organizing MCD apart from existing structures Negative experiences: distance from practice Lack of direct impact A gap with the rest of the team.

 Conclusion

We conclude that there is not one best way and place where ethical reflection should be organized. Each implementation strategy serves different goals and the use of a specific implementation strategy also depends on the phase of the MCD project in the specific health care institution. In the end, a combination of strategies, combining the positive aspects of a mixed group apart from existing structures and in time utilizing the opportunities for moral reflection becoming an integrated part of existing communication structures, seems promising for enhancing the ethical milieu in elderly care.

There are certain qualities fundamental to an organizer. He should have the right attitude for organizing work and should have basic organizing skills. Although one may not have them in the beginning, it is possible to acquire them through training. Training uncovers, develops and sharpens skills and other qualities so that the organizer uses them more consciously. The following section discusses these basic qualities and skills essential to organizational work and can be used as recruiting criteria.