Publications
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Kuhumba, Shija Kevin; Sævareid, Trygve Johannes Lereim; Mhando, Nandera Ernest & Molewijk, Albert Christiaan
(2025).
Responding to Moral Challenges in Clinical Practice: A Qualitative Assessment of Clinical Ethics Support Needs at Three Tanzanian Hospitals.
HEC Forum.
ISSN 0956-2737.
38,
p. 1–23.
doi:
10.1007/s10730-025-09547-8.
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Jakobsen, Lena M; Molewijk, Albert Christiaan; Snoo-Trimp, Janine de; Svantesson, Mia & Ursin, Gøril
(2024).
What is a High-Quality Moral Case Deliberation?-Facilitators’ Perspectives in the Euro-MCD Project.
HEC Forum.
ISSN 0956-2737.
doi:
10.1007/s10730-023-09519-w.
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The evaluation of the European Moral Case Deliberation Outcomes project (EuroMCD) has resulted in a revised evaluation instrument, knowledge about the content of MCD (moral case deliberation), and the perspectives of those involved. In this paper, we report on a perspective that has been overlooked, the facilitators’. We aim to describe facilitators’ perceptions of high-quality moral case deliberation and their Euro-MCD sessions. The research took place in Norway, Sweden, and the Netherlands using a survey combined with interviews with 41 facilitators. Facilitators’ perceived that attaining a high-quality MCD implies fostering a safe and respectful atmosphere, creating a wondering mode, being an attentive authority, developing moral refective skills, reaching a common understanding, and ensuring organisational prerequisites for the MCD sessions. Our central conclusion is that eforts at three levels are required to attain a high-quality MCD: trained and virtuous facilitator; committed, respectful participants; and organizational space. Furthermore, managers have a responsibility to prepare MCD participants for what it means to take part in MCD.
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Kuhumba, Shija Kevin; Molewijk, Albert Christiaan; Solbakk, Jan Helge; Mhando, Nandera Ernest & Sævareid, Trygve Johannes Lereim
(2024).
Moral challenges and understanding of clinical ethics in
Tanzanian hospitals: Perspectives of healthcare professionals.
Developing World Bioethics.
ISSN 1471-8731.
doi:
10.1111/dewb.12467.
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Healthcare professionals encounter many moral challenges in their daily clinical practice. However, there have been few studies on the subject matter in Tanzania. This study aims to provide an account of moral challenges faced by healthcare professionals in Tanzanian hospitals, their understanding of clinical ethics, and the ethics education they have received. Many participants reported receiving some kind of ethics training through formal education and on-the-job training. Some participants understood ethics in healthcare settings as adherence to established laws, regulations, guidelines, procedures, norms, and rules essential in clinical practice. Analysis of the data identified four themes of moral challenges. These challenges are related to 1) decision-making and communication in clinical practice, 2) scarcity of medical resources and prioritization in clinical practice, 3) withdrawal of curative treatment, and 4) conflicts between professional judgment, religious convictions and adherence to alternative
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Spijkers, Amber S.; Snoek, Anke; Molewijk, Albert Christiaan & Baarle, Eva van
(2024).
Complexities and Possibilities of Strengthening the Social Inclusion of Military Women in the Netherlands Armed Forces: Findings From an Action Research Project.
Armed forces and society.
ISSN 0095-327X.
doi:
10.1177/0095327X241279184.
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Kröger, Charlotte; Molewijk, Albert Christiaan; Muntinga, Maaike & Metselaar, Suzanne
(2024).
The Diversity Compass: a clinical ethics support instrument for dialogues on diversity in healthcare organizations.
BMC Medical Ethics.
25(1),
p. 1–14.
doi:
10.1186/s12910-023-00992-z.
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Background Increasing social pluralism adds to the already existing variety of heterogeneous moral perspectives on good care, health, and quality of life. Pluralism in social identities is also connected to health and care disparities for minoritized patient (i.e. care receiver) populations, and to specific diversity-related moral challenges of healthcare professionals and organizations that aim to deliver diversity-responsive care in an inclusive work environment. Clinical ethics support (CES) services and instruments may help with adequately responding to these diversity-related moral challenges. However, although various CES instruments exist to support healthcare professionals with dealing well with morally challenging situations in healthcare, current tools do not address challenges specifically related to moral pluralism and intersectional aspects of diversity and social justice issues. This article describes the content and developmental process of a novel CES instrument called the Diversity Compass. This instrument was designed with and for healthcare professionals to dialogically address and reflect on moral challenges related to intersectional aspects of diversity and social justice issues that they experience in daily practice. Methods We used a participatory development design to develop the Diversity Compass at a large long-term care organization in a major city in the Netherlands. Over a period of thirteen months, we conducted seven focus groups with healthcare professionals and peer-experts, carried out five expert interviews, and facilitated four meetings with a community of practice consisting of various healthcare professionals who developed and tested preliminary versions of the instrument throughout three cycles of iterative co-creation. Results The Diversity Compass is a practical, dialogical CES instrument that is designed as a small booklet and includes an eight-step deliberation method, as well as a guideline with seven recommendations to support professionals with engaging in dialogue when they are confronted with diversity-related moral challenges. The seven recommendations are key components in working toward creating an inclusive and safe space for dialogue to occur. Conclusions The Diversity Compass seeks to support healthcare professionals and organizations in their efforts to facilitate awareness, moral learning and joint reflection on moral challenges related to diversity and social justice issues. It is the first dialogical CES instrument that specifically acknowledges the role of social location in shaping moral perspectives or experiences with systemic injustices. However, to make healthcare more just, an instrument like the Diversity Compass is not enough on its own. In addition to the Diversity Compass, a systemic and structural approach to social justice issues in healthcare organizations is needed in order to foster a more inclusive, safe and diversity-responsive care and work environment in health care organizations.
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Pergert, Pernilla; Molewijk, Albert Christiaan & Bartholdson, Cecilia
(2024).
Positioning Ethics When Direct Patient Care is Prioritized: Experiences from Implementing Ethics Case Reflection Rounds in Childhood Cancer Care.
HEC Forum.
ISSN 0956-2737.
doi:
10.1007/s10730-024-09541-6.
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Weiner, Charlotte; Pergert, Pernilla; Castor, Anders; Molewijk, Albert Christiaan & Bartholdson, Cecilia
(2024).
Children’s voices on their values and moral dilemmas when being cared and treated for cancer– a qualitative interview study.
BMC Medical Ethics.
25(1).
doi:
10.1186/s12910-024-01075-3.
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Background Childhood cancers affect about 350 children every year in Sweden and are life-threatening diseases. During the treatment period, situations arise that can become morally challenging for the child. When knowing children’s values and morally challenging situations in childhood cancer care, targeted ethics support could be developed and used in care. Aim To explore children’s values and moral dilemmas when undergoing cancer treatment. Methods This is a qualitative study based on empirical data. The data collection was conducted through three focus group interviews and six individual interviews with children between 10 and 18 years (n = 16). A content analysis methodology was used to generate themes. Children who were/have been treated for cancer at three childhood cancer centres in Sweden were invited to participate. The study was approved by the Swedish Ethical Review Authority. The children’s participation was based on voluntariness and consent/assent. Findings During the analysis, five themes of values emerged: Personal relationships, Bodily ease and identity, Feeling in control and being involved, Positive distractions and Right care that is needed. Their moral dilemmas were thematized into: Should I consider others or not? Should I rest or not? and Should I refuse treatment or not? Conclusion Children undergoing cancer treatment want to have personal relationships with healthcare professionals. Their moral dilemmas were about questioning their own physical and psychological well-being against their expectations, the values of others and the treatment required. Further research is needed to understand how to deal with moral dilemmas in children undergoing cancer treatment.
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Huysentruyt, Marie; Schaap, Anne; Stolper, Margreet; Snijdewind, Marianne; Vet, Riekie de & Molewijk, Albert Christiaan
(2023).
Contribution of moral case deliberations to the Moral Craftmanship of prison staff: A quantitative analysis.
International Journal of Ethics Education.
ISSN 2363-9997.
doi:
10.1007/s40889-023-00165-x.
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This study explores the impact of participation in a series of moral case deliberations (MCD) on the moral craftsmanship (MCS) of Dutch prison staff. Between 2017–2020, ten MCDs per team were implemented in three prisons (i.e., intervention group). In three other prisons (i.e., control group) no MCDs were implemented. We compared the intervention and control group using a self-developed questionnaire, administered before (pre-measurement) and after the series of MCDs (post-measurement). Results After the MCDs, participants scored significantly higher on 7 of the 70 items related to MCS. On some items there were significant impact differences between the various professional disciplines. Discussion Possible explanations for a relatively low impact are discussed. A shorter and validated questionnaire is needed in order to further study the MCS of professionals and the impact of Ethics Support Services (ESS). Conclusions There was a positive development on some elements of MCS after participation in a series of MCDs.
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Molewijk, Albert Christiaan; Pedersen, Reidar; Kok, Almar; Førde, Reidun & Aasland, Olaf Gjerløw
(2023).
Two years of ethics reflection groups about coercion in psychiatry. Measuring variation within employees’ normative attitudes, user involvement and the handling of disagreement.
BMC Medical Ethics.
24.
doi:
10.1186/s12910-023-00909-w.
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Background Research on the impact of ethics reflection groups (ERG) (also called moral case deliberations (MCD)) is complex and scarce. Within a larger study, two years of ERG sessions have been used as an intervention to stimulate ethical reflection about the use of coercive measures. We studied changes in: employees’ attitudes regarding the use of coercion, team competence, user involvement, team cooperation and the handling of disagreement in teams. Methods We used panel data in a longitudinal design study to measure variation in survey scores from multidisciplinary employees from seven departments within three Norwegian mental health care institutions at three time points (T0–T1–T2). Mixed models were used to account for dependence of data in persons who participated more than once. Results In total, 1068 surveys (from 817 employees who did and did not participate in ERG) were included in the analyses. Of these, 7.6% (N = 62) responded at three points in time, 15.5% (N = 127) at two points, and 76.8% (N = 628) once. On average, over time, respondents who participated in ERG viewed coercion more strongly as offending (p < 0.05). Those who presented a case in the ERG sessions showed lower scores on User Involvement (p < 0.001), Team Cooperation (p < 0.01) and Constructive Disagreement (p < 0.01). We observed significant differences in outcomes between individuals from different departments, as well as between different professions. Initial significant changes due to frequency of participation in ERG and case presentation in ERG did not remain statistically significant after adjustment for Departments and Professions. Differences were generally small in absolute terms, possibly due to the low amount of longitudinal data. Conclusions This study measured specific intervention-related outcome parameters for describing the impact of clinical ethics support (CES). Structural implementation of ERGs or MCDs seems to contribute to employees reporting a more critical attitude towards coercion. Ethics support is a complex intervention and studying changes over time is complex in itself. Several recommendations for strengthening the outcomes of future CES evaluation studies are discussed. CES evaluation studies are important, since—despite the intrinsic value of participating in ERG or MCD—CES inherently aims, and should aim, at improving clinical practices.
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Zuylen, Mark L. van; Snoo-Trimp, Janine C. de; Metselaar, Suzanne; Dongelmans, Dave A. & Molewijk, Albert Christiaan
(2023).
Moral distress and positive experiences of ICU staff during the COVID-19 pandemic: lessons learned.
BMC Medical Ethics.
24.
doi:
10.1186/s12910-023-00919-8.
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Background The COVID-19 pandemic causes moral challenges and moral distress for healthcare professionals and, due to an increased work load, reduces time and opportunities for clinical ethics support services. Nevertheless, healthcare professionals could also identify essential elements to maintain or change in the future, as moral distress and moral challenges can indicate opportunities to strengthen moral resilience of healthcare professionals and organisations. This study describes 1) the experienced moral distress, challenges and ethical climate concerning end-of-life care of Intensive Care Unit staff during the first wave of the COVID-19 pandemic and 2) their positive experiences and lessons learned, which function as directions for future forms of ethics support. Methods A cross-sectional survey combining quantitative and qualitative elements was sent to all healthcare professionals who worked at the Intensive Care Unit of the Amsterdam UMC - Location AMC during the first wave of the COVID-19 pandemic. The survey consisted of 36 items about moral distress (concerning quality of care and emotional stress), team cooperation, ethical climate and (ways of dealing with) end-of-life decisions, and two open questions about positive experiences and suggestions for work improvement. Results All 178 respondents (response rate: 25–32%) showed signs of moral distress, and experienced moral dilemmas in end-of-life decisions, whereas they experienced a relatively positive ethical climate. Nurses scored significantly higher than physicians on most items. Positive experiences were mostly related to ‘team cooperation’, ‘team solidarity’ and ‘work ethic’. Lessons learned were mostly related to ‘quality of care’ and ‘professional qualities’. Conclusions Despite the crisis, positive experiences related to ethical climate, team members and overall work ethic were reported by Intensive Care Unit staff and quality and organisation of care lessons were learned. Ethics support services can be tailored to reflect on morally challenging situations, restore moral resilience, create space for self-care and strengthen team spirit. This can improve healthcare professionals’ dealing of inherent moral challenges and moral distress in order to strengthen both individual and organisational moral resilience. Trial registration The trial was registered on The Netherlands Trial Register, number NL9177.
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Evans, Natalie; Schmolmueller, Armin; Stolper, Margreet; Inguaggiato, Giulia; Hooghiemstra, Astrid & Tokalic, Ruzica
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(2023).
VIRT<sup>2</sup>UE: A European train-the-trainer programme for teaching research integrity.
Research Ethics.
ISSN 1747-0161.
doi:
10.1177/17470161231161267.
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Universities and other research institutions are increasingly providing additional training in research integrity to improve the quality and reliability of research. Various training courses have been developed, with diverse learning goals and content. Despite the importance of training that focuses on moral character and professional virtues, there remains a lack of training that adopts a virtue ethics approach. To address this, we, a European Commission-funded consortium, have designed a train-the-trainer programme for research integrity. The programme is based on (1) virtue ethics, (2) the ethos of science, (3) learning by doing and (4) learner-centred teaching. The blended learning programme combines e-learning modules with participatory group sessions. Trainers are taught how to guide researchers through a series of structured exercises for fostering reflection on scientific virtues, and how to promote understanding and application of the European Code of Conduct for Research Integrity. Trainers are provided with adaptable tools and resources that can be used and combined in different ways. The programme implementation began in Spring 2020 and 470 trainers have participated to date. When trainers were asked to grade – between 0 (very bad) and 10 (excellent) – the e-learning modules and the participatory exercises, 60% scored a grade 8 or higher (median = 8, IQR = 2) for the e-learning modules, whereas 80% scored a grade 8 or higher (median = 9, IQR = 1) for the participatory exercises. A majority felt that the training helped them as a trainer to learn about ways to organise and teach a research integrity course (82%) and would recommend the interactive exercises to others (92%). Trainers have educated over 3300 researchers in Europe using our virtue-based approach. The VIRT 2 UE train-the-trainer programme fosters research integrity by providing trainers with exercises and tools which enable them to stimulate the development of good researchers across Europe.
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Kröger, Charlotte; Molewijk, Albert Christiaan & Metselaar, Suzanne
(2023).
Developing Organizational Diversity Statements Through Dialogical Clinical Ethics Support: The Role of the Clinical Ethicist.
Journal of Bioethical Inquiry.
ISSN 1176-7529.
doi:
10.1007/s11673-023-10258-3.
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Abstract In pluralist societies, stakeholders in healthcare may have different experiences of and moral perspectives on health, well-being, and good care. Increasing cultural, religious, sexual, and gender diversity among both patients and healthcare professionals requires healthcare organizations to address these differences. Addressing diversity, however, comes with inherent moral challenges; for example, regarding how to deal with healthcare disparities between minoritized and majoritized patients or how to accommodate different healthcare needs and values. Diversity statements are an important strategy for healthcare organizations to define their normative ideas with respect to diversity and to establish a point of departure for concrete diversity approaches. We argue that healthcare organizations ought to develop diversity statements in a participatory and inclusive way in order to promote social justice. Furthermore, we maintain that clinical ethicists can support healthcare organizations in developing diversity statements in a more participatory way by fostering reflective dialogues through clinical ethics support. We will use a case example from our own practice to explore what such a developmental process may look like. We will critically reflect on the procedural strengths and challenges as well as on the role of the clinical ethicist in this example.
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Weiner, Charlotte; Pergert, Pernilla; Castor, Anders; Molewijk, Albert Christiaan & Bartholdson, Cecilia
(2023).
Sheltering in chaos: parents’ experiences when facing moral challenges in childhood cancer care.
Ethics & behavior.
ISSN 1050-8422.
doi:
10.1080/10508422.2023.2267708.
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Childhood cancers are life-threatening diseases that affect the whole family. During the treatment moral situations might arise. Research on how parents perceive moral challenges in childhood cancer care is sparse. The aim was to explore parents’ main concern, and how they deal with their main concern, when facing moral challenges in childhood cancer care. Data collection included focus group interviews with parents. The data analysis was carried out according to a classical theory and revealed the core category “Sheltering in chaos”. The strategies to handle the main concern included “To bring the child through a life-saving trajectory” by “Balancing control” and “Deliberating of suffering. The consequences included feelings of being “Torn between roles”. “Familiarity” emerged as a facilitating factor to handle moral challenges. The results indicate that parents are torn between different roles, and that the care experience is improved through familiarity with the healthcare professionals. The following findings may inspire new ways of offering moral support to families in childhood cancer care.
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Hem, Marit Helene; Molewijk, Albert Christiaan; Weimand, Bente Margrethe & Pedersen, Reidar
(2023).
Patients with severe mental illness and the ethical challenges related to confidentiality during family involvement: a scoping review.
Frontiers in Public Health.
10,
p. 1–14.
doi:
10.3389/fpubh.2022.960815.
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Background: Despite evidence on the significant potential value of family involvement during the treatment of patients with severe mental illness, research has shown that family involvement is largely underused. The duty of confidentiality is reported to be a key barrier to family involvement. To develop more insight into this barrier, this scoping review focuses on the following question: What are the reported ethical challenges related to confidentiality when involving family in the treatment of patients with severe mental illness?
Methods: A systematic search into primary studies was conducted using the following databases: Medline (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), and Web of Science core collection (Clarivate). The PICO (Population, Intervention, Comparison, Outcome) scheme and qualitative content analysis were used to make the ethical challenges more explicit.
Results: Twelve studies—both qualitative and quantitative—were included. We identified the following main categories of ethical challenges: (1) the best interest of family members vs. confidentiality, (2) the patient's best interest vs. the right to confidentiality, (3) patient trust and alliance as a reason not to involve the relatives or not to share information, and (4) using confidentiality as a smokescreen. We also identified several subcategories and illustrative and concrete examples of ethical challenges.
Conclusions: Through a systematic examination, we discovered various types of ethical challenges related to confidentiality when involving the family in the treatment of patients with severe mental illness. However, research on these ethical challenges and the constituents of these challenges remains limited and often implicit. An ethical analysis will create knowledge which may facilitate a more balanced and nuanced approach to respecting the principle of confidentiality while also considering other moral principles. The duty of confidentiality does not always have to be a major barrier to family involvement; this insight and using this ethical analysis in the training of healthcare professionals may benefit the patient, the family, and the services.
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Haven, Tamarinde L; Molewijk, Albert Christiaan; Bouter, Lex; Widdershoven, Guy; Blom, Fenneke & Tijdink, Joeri
(2023).
Can moral case deliberation in research groups help to navigate research integrity dilemmas? A pilot study.
Research Ethics.
ISSN 1747-0161.
doi:
10.1177/17470161231198402.
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There is an increased focus on fostering integrity in research by through creating an open culture where research integrity dilemmas can be discussed. We describe a pilot intervention study that used Moral Case Deliberation (MCD), a method that originated in clinical ethics support, to discuss research integrity dilemmas with researchers. Our research question was: can moral case deliberation in research groups help to navigate research integrity dilemmas? We performed 10 MCDs with 19 researchers who worked in three different research groups from three different disciplinary fields at a university in the Netherlands. We analyzed the dilemmas and values discussed, sent out a survey questionnaire to assess self-perceived moral competencies, and conducted in-depth interviews. We found research integrity dilemmas pertained to authorship disputes, supervision of junior co-workers, and questionable handling of data. Participants perceived the majority of moral competencies to a higher degree during the MCD when compared to perceiving them in daily practice afterward. Interviewees told us that they felt most comfortable discussing dilemmas among peers with whom they were not closely affiliated. We conclude that MCD sessions could be relevant in navigating research integrity dilemmas, but that revisions to ensure commitment and safety are required.
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Snoo-Trimp, Janine de; Vries, Annelou de; Molewijk, Albert Christiaan & Hein, Irma
(2022).
How to deal with moral challenges around the decision-making competence in transgender adolescent care? Development of an ethics support tool.
BMC Medical Ethics.
23(1).
doi:
10.1186/s12910-022-00837-1.
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Background Decision-making competence is a complex concept in the care for transgender and gender diverse adolescents, since this type of care concerns one’s developing gender identity and involves treatment options that often lack international consensus. Even despite competence assessments, moral challenges arise in the decision-making process. Here, traditional forms of clinical ethics support such as moral case deliberation might not fit as these do not provide thematic guidance. This study therefore aimed to develop a practice-oriented ethics support tool to assist care providers when dealing with moral challenges around decision-making competence in transgender adolescent care. Methods The study followed a participatory design to develop a tool in close collaboration with care providers; they had a say in all phases of development and dissemination. Firstly, nine care providers were interviewed about experienced moral challenges and needs for ethics support. Based on this, the structure and content of the tool was constructed and discussed in two focus group meetings, after which four care providers tested the tool and additional feedback was collected from the team and an advisory board. The final tool was presented to all Dutch care providers in transgender adolescent care. Results Care providers expressed a need for guidance in defining and assessing decision-making competence. Main moral challenges concerned discussing fertility options with young clients, dealing with co-occurring mental health difficulties and the decision-making role of parents. The final tool, named the Competence Consultant, is an interactive pdf containing four parts: (1) Clarify information; (2) Identify doubts and moral questions; (3) Guidance for conversations and (4) Overview and Conclusions. Discussion Developing an ethics support tool in a controversial care setting is highly relevant as it aims to help individual care providers in defining, discussing and dealing with their moral challenges in actual practice. The ‘Competence Consultant’ for transgender care providers contributes to their moral sensitivity and moral competence. It is an example of the development of innovative and integrative forms of thematic ethics support.
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Snoo-Trimp, Snoo-Trimp de; Gurp, Gurp van & Molewijk, Albert Christiaan
(2022).
Conceptualizing the impact of moral case deliberation: a multiple-case study in a health care institution for people with intellectual disabilities.
BMC Medical Ethics.
23(1).
doi:
10.1186/s12910-022-00747-2.
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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.
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Weiner, C.; Pergert, P.; Castor, A.; Molewijk, Albert Christiaan & Bartholdson, C.
(2022).
Difficult situations and moral questions raised during moral case deliberations in Swedish childhood cancer care – A qualitative nationwide study.
European Journal of Oncology Nursing.
ISSN 1462-3889.
60.
doi:
10.1016/j.ejon.2022.102189.
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Schaik, Malene Vera van; Pasman, H. Roeline; Widdershoven, Guy; Molewijk, Albert Christiaan & Metselaar, Suzanne
(2021).
CURA—An Ethics Support Instrument for Nurses in Palliative Care. Feasibility and First Perceived Outcomes.
HEC Forum.
ISSN 0956-2737.
doi:
10.1007/s10730-021-09456-6.
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Gerritse, Karl; Hartman, Laura A.; Bremmer, Marijke A.; Kreukels, Baudewijntje P.C. & Molewijk, Albert Christiaan
(2021).
Decision-making approaches in transgender healthcare: conceptual analysis and ethical implications.
Medicine, Health care and Philosophy.
ISSN 1386-7423.
24(4),
p. 687–699.
doi:
10.1007/s11019-021-10023-6.
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Bartholdson, Cecilia; Sandeberg, Margareta af; Molewijk, Albert Christiaan & Pergert, Pernilla
(2021).
Does participation in ethics discussions have an impact on ethics decision-making? A cross-sectional study among healthcare professionals in paediatric oncology.
European Journal of Oncology Nursing.
ISSN 1462-3889.
52.
doi:
10.1016/j.ejon.2021.101950.
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Hartman, L; Widdershoven, Guy; Baarle, Eva van; Weidema, Froukje & Molewijk, Albert Christiaan
(2021).
Conceptualizing and Fostering the Quality of CES Through a Dutch National Network on CES (NEON).
HEC Forum.
ISSN 0956-2737.
doi:
10.1007/s10730-020-09432-6.
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Weiner, Charlotte; Pergert, Pernilla; Molewijk, Albert Christiaan; Castor, Anders & Bartholdson, Cecilia
(2021).
Perceptions of important outcomes of moral case deliberations: a qualitative study among healthcare professionals in childhood cancer care.
BMC Medical Ethics.
22(1),
p. 1–11.
doi:
10.1186/s12910-021-00597-4.
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Background In childhood cancer care, healthcare professionals must deal with several difficult moral situations in clinical practice. Previous studies show that morally difficult challenges are related to decisions on treatment limitations, infringing on the child's integrity and growing autonomy, and interprofessional conflicts. Research also shows that healthcare professionals have expressed a need for clinical ethics support to help them deal with morally difficult situations. Moral case deliberations (MCDs) are one example of ethics support. The aim of this study was to describe the MCD-related outcomes that healthcare professionals in childhood cancer care considered important, before MCDs were implemented, in order to facilitate the implementation of MCDs in childhood cancer care in Sweden. Methods This study is based on qualitative data. Healthcare professionals, mostly representing registered nurses, nursing assistants and physicians, working at childhood cancer care centres in Sweden, were invited to respond to the translated and content validated European MCD Outcomes Instrument, before participating in regular MCDs. Answers to the main open-ended question, included in the questionnaire, was analysed according to systematic text condensation. Results Data was collected from 161 responses from the healthcare professionals. The responses included healthcare professionals’ perceptions of which MCD-related outcomes they found important for handling moral challenges. Three different themes of important outcomes from the analysis of the data are presented as follows: Interprofessional well-being in team interactions on a team level; Professional comfort when dealing with moral challenges on a personal level; and Improved quality of care for the child and the family on a care level. Conclusions Healthcare professionals in childhood cancer care considered it important that ethics support could enhance the well-being of interprofessional teams, support healthcare professionals on an individual level and improve quality of care. The results of this study can be used in current and future training for MCD-facilitators. When knowing the context specific important MCD-outcomes, the sessions could be adapted. Managers in childhood cancer care would benefit from knowing about the specific important outcomes for their target group because they could then create relevant working conditions for clinical ethics support.
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Hartman, Laura; Inguaggiato, Giulia; Widdershoven, Guy; Wensing-Kruger, Annelijn & Molewijk, Albert Christiaan
(2020).
Theory and practice of integrative clinical ethics support: a joint experience within gender affirmative care.
BMC Medical Ethics.
21(1).
doi:
10.1186/s12910-020-00520-3.
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Snoo-Trimp, Janine de; Vet, Riekie de; Widdershoven, Guy; Molewijk, Albert Christiaan & Svantesson, Mia
(2020).
Moral competence, moral teamwork and moral action - The European Moral Case Deliberation Outcomes (Euro-MCD) Instrument 2.0 and its revision process.
BMC Medical Ethics.
21(1).
doi:
10.1186/s12910-020-00493-3.
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Background
Clinical Ethics Support (CES) services are offered to support healthcare professionals in dealing with ethically difficult situations. Evaluation of CES is important to understand if it is indeed a supportive service in order to inform and improve future implementation of CES. Yet, methods to measure outcomes of CES are scarce. In 2014, the European Moral Case Deliberation Outcomes Instrument (Euro-MCD) was developed to measure outcomes of Moral Case Deliberation (MCD). To further validate the instrument, we tested it in field studies and revised it. This paper presents the Euro-MCD 2.0 and describes the revision process. Methods
The revision process comprised an iterative dialogue among the authors as Euro-MCD-project team, including empirical findings from six Euro-MCD field-studies and input from European experts in CES and theory. Empirical findings contained perceptions and experiences of MCD outcomes among healthcare professionals who participated in MCDs in various settings in Norway, Sweden and the Netherlands. Theoretical viewpoints on CES, literature on goals of CES and MCD and ethics theory guided the interpretation of the empirical findings and final selection of MCD outcomes. Results
The Euro-MCD 2.0 Instrument includes three domains: Moral Competence, Moral Teamwork and Moral Action. Moral Competence consists of items about moral sensitivity, analytical skills and virtuous attitude. Moral Teamwork includes open dialogue and supportive relationships and Moral Action refers to moral decision-making and responsible care. During the revision process, we made decisions about adding and reformulating items as well as decreasing the number from 26 to 15 items. We also altered the sentence structure of items to assess the current status of outcomes (e.g. ‘now’) instead of an assumed improvement over time (e.g. ‘better’) and we omitted the question about perceived importance. Conclusions
The Euro-MCD 2.0 is shorter, less complex and more strongly substantiated by an integration of empirical findings, theoretical reflections and dialogues with participants and experts. Use of the Euro-MCD 2.0 will facilitate evaluation of MCD and can thereby monitor and foster implementation and quality of MCD. The Euro-MCD 2.0 will strengthen future research on evaluation of outcomes of MCD.
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Widdershoven, Guy; Stolper, Margreet; Molewijk, Albert Christiaan & Metselaar, Suzanne
(2020).
How to Support Patient and Family in Dealing with Ethical Issues? The Relevance of Moral Case Deliberation.
AJOB Empirical Bioethics.
ISSN 2329-4515.
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Weiner, Charlotte; Pergert, Pernilla; Molewijk, Albert Christiaan; Castor, Anders & Bartholdson, Cecilia
(2020).
What Outcomes of Ethics Case Reflection Rounds does Healthcare Professionals Find Important in Paediatric Oncology? - A National Cross-Sectional Survey.
Pediatric Blood & Cancer.
ISSN 1545-5009.
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Stolper, Margreet; Pedersen, Reidar & Molewijk, Albert Christiaan
(2020).
Examining the Doing of Ethics Support Staff. A Dialogical Approach Toward Assessing the Quality of Facilitators of Moral Case Deliberation.
AJOB Empirical Bioethics.
ISSN 2329-4515.
doi:
10.1080/15265161.2020.1714805.
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Vrouenraets, Lieke; Hartman, Laura; Hein, Irma; Vries, Annelou de; Vries, Martine De & Molewijk, Albert Christiaan
(2020).
Dealing with moral challenges in the treatment of transgender children and adolescents: Evaluating the role of Moral Case Deliberation.
Archives of Sexual Behavior.
ISSN 0004-0002.
doi:
10.1007/s10508-020-01762.
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Snoo-Trimp, Janine de; Molewijk, Albert Christiaan; Svantesson, Mia; Widdershoven, Guy & Vet, Riekie de
(2020).
Field-Testing the Euro-MCD Instrument: Important Outcomes According to Participants Before and After Moral Case Deliberation.
HEC Forum.
ISSN 0956-2737.
34(1).
doi:
10.1007/s10730-020-09421-9.
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Metselaar, Suzanne; Voskes, Yolande; Molewijk, Albert Christiaan & Widdershoven, Guy
(2020).
Implementation in Bioethics: A Plea for a Participatory and Dialogical Approach.
AJOB Empirical Bioethics.
ISSN 2329-4515.
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Hartman, Laura; Metselaar, Suzanne; Widdershoven, Guy & Molewijk, Albert Christiaan
(2019).
Developing a ‘moral compass tool’ based on moral case deliberations: A pragmatic hermeneutic approach to clinical ethics.
Bioethics.
ISSN 0269-9702.
p. 1–10.
doi:
10.1111/bioe.12617.
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Svantesson, Mia; Snoo-Trimp, Janine de; Ursin, Gøril; Vet, Henrica CW De; Brinchmann, Berit Støre & Molewijk, Albert Christiaan
(2019).
Important outcomes of moral case deliberation: A Euro-MCD field survey of healthcare professionals' priorities.
Journal of Medical Ethics.
ISSN 0306-6800.
doi:
10.1136/medethics-2018-104745.
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Show summary
Background There is a lack of empirical research
regarding the outcomes of such clinical ethics support
methods as moral case deliberation (MCD). Empirical
research in how healthcare professionals perceive
potential outcomes is needed in order to evaluate the
value and effectiveness of ethics support; and help to
design future outcomes research. The aim was to use the
European Moral Case Deliberation Outcome Instrument
(Euro-MCD) instrument to examine the importance
of various MCD outcomes, according to healthcare
professionals, prior to participation.
Methods A North European field survey among
healthcare professionals drawn from 73 workplaces in a
variety of healthcare settings in the Netherlands, Norway
and Sweden. The Euro-MCD instrument was used.
Results All outcomes regarding the domains of
moral reflexivity, moral attitude, emotional support,
collaboration, impact at organisational level and concrete
results, were perceived as very or quite important by
76%–97% of the 703 respondents. Outcomes regarding
collaboration and concrete results were perceived as
most important. Outcomes assessed as least important
were mostly about moral attitude. ’Better interactions
with patient/family’ emerged as a new domain from
the qualitative analysis. Dutch respondents perceived
most of the outcomes as significantly less important
than the Scandinavians, especially regarding emotional
support. Furthermore, men, those who were younger, and
physician-respondents scored most of the outcomes as
statistically significantly less important compared with
the other respondents.
Conclusions The findings indicate a need for a broad
instrument such as the Euro-MCD. Outcomes related to
better interactions between professionals and patients
must also be included in the future. The empirical
findings raise the normative question of whether
outcomes that were perceived as less important, such
as moral reflexivity and moral attitude outcomes, should
still be included. In the future, a combination of empirical findings (practice) and normative reflection (theories) will contribute to the revision of the instrument.
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Snoo-Trimp, Janine C. de; Molewijk, Albert Christiaan; Ursin, Gøril; Brinchmann, Berit Støre; Widdershoven, G. A. M. & Vet, Henrica CW de
[Show all 7 contributors for this article]
(2019).
Field-testing the Euro-MCD Instrument: Experienced outcomes of moral case deliberation.
Nursing Ethics.
ISSN 0969-7330.
p. 1–17.
doi:
10.1177/0969733019849454.
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Show summary
Abstract
Background:
Moral case deliberation is a form of clinical ethics support to help healthcare professionals in dealing with ethically difficult situations. There is a lack of evidence about what outcomes healthcare professionals experience in daily practice after moral case deliberations. The Euro-MCD Instrument was developed to measure outcomes, based on the literature, a Delphi panel, and content validity testing. To examine relevance of items and adequateness of domains, a field study is needed.
Aim:
To describe experienced outcomes after participating in a series of moral case deliberations, both during sessions and in daily practice, and to explore correlations between items to further validate the Euro-MCD Instrument.
Methods:
In Sweden, the Netherlands, and Norway, healthcare institutions that planned a series of moral case deliberations were invited. Closed responses were quantitatively analyzed. The factor structure of the instrument was tested using exploratory factor analyses.
Ethical considerations:
The study was approved in Sweden by a review board. In Norway and the Netherlands, data services and review boards were informed about the study.
Results:
The Euro-MCD Instrument was completed by 443 and 247 healthcare professionals after four and eight moral case deliberations, respectively. They experienced especially outcomes related to a better collaboration with co-workers and outcomes about individual moral reflexivity and attitude, both during sessions and in daily practice. Outcomes were experienced to a higher extent during sessions than in daily practice. The factor structure revealed four domains of outcomes, which did not confirm the six Euro-MCD domains.
Conclusion:
Field-testing the Euro-MCD Instrument showed the most frequently experienced outcomes and which outcomes correlated with each other. When revising the instrument, domains should be reconsidered, combined with theory about underlying concepts. In the future, a feasible and valid instrument will be presented to get insight into how moral case deliberation supports and improves healthcare.
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Baarle, Eva van; Potma, Marieke C; Hoek, Maria E C Van; Hartman, Laura; Molewijk, Albert Christiaan & Gurp, Jelle L P Van
(2019).
Lessons learned from implementing a responsive quality assessment of clinical ethics support.
BMC Medical Ethics.
20(1),
p. 1–11.
doi:
10.1186/s12910-019-0418-2.
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Background Various forms of Clinical Ethics Support (CES) have been developed in health care organizations. Over the past years, increasing attention has been paid to the question of how to foster the quality of ethics support. In the Netherlands, a CES quality assessment project based on a responsive evaluation design has been implemented. CES practitioners themselves reflected upon the quality of ethics support within each other’s health care organizations. This study presents a qualitative evaluation of this Responsive Quality Assessment (RQA) project. Methods CES practitioners’ experiences with and perspectives on the RQA project were collected by means of ten semi-structured interviews. Both the data collection and the qualitative data analysis followed a stepwise approach, including continuous peer review and careful documentation of the decisions. Results The main findings illustrate the relevance of the RQA with regard to fostering the quality of CES by connecting to context specific issues, such as gaining support from upper management and to solidify CES services within health care organizations. Based on their participation in the RQA, CES practitioners perceived a number of changes regarding CES in Dutch health care organizations after the RQA: acknowledgement of the relevance of CES for the quality of care; CES practices being more formalized; inspiration for developing new CES-related activities and more self-reflection on existing CES practices. Conclusions The evaluation of the RQA shows that this method facilitates an open learning process by actively involving CES practitioners and their concrete practices. Lessons learned include that “servant leadership” and more intensive guidance of RQA participants may help to further enhance both the critical dimension and the learning process within RQA.
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Hem, Marit Helene; Molewijk, Albert Christiaan; Gjerberg, Elisabeth; Lillemoen, Lillian & Pedersen, Reidar
(2018).
The significance of ethics reflection groups in mental health care: a focus group study among health care professionals.
BMC Medical Ethics.
19(54).
doi:
10.1186/s12910-018-0297-y.
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Background: Professionals within the mental health services face many ethical dilemmas and challenging situations regarding the use of coercion. The purpose of this study was to evaluate the significance of participating in systematic ethics reflection groups focusing on ethical challenges related to coercion.
Methods: In 2013 and 2014, 20 focus group interviews with 127 participants were conducted. The interviews were tape recorded and transcribed verbatim. The analysis is inspired by the concept of ‘bricolage’ which means our approach was inductive.
Results: Most participants report positive experiences with participating in ethics reflection groups: A systematic and well-structured approach to discuss ethical challenges, increased consciousness of formal and informal coercion, a possibility to challenge problematic concepts, attitudes and practices, improved professional competence and confidence, greater trust within the team, more constructive disagreement and room for internal critique, less judgmental reactions and more reasoned approaches, and identification of potential for improvement and alternative courses of action. On several wards, the participation of psychiatrists and psychologists in the reflection groups was missing. The impact of the perceived lack of safety in reflection groups should not be underestimated. Sometimes the method for ethics reflection was utilised in a rigid way. Direct involvement of patients and family was missing.
Conclusion: This focus group study indicates the potential of ethics reflection groups to create a moral space in the workplace that promotes critical, reflective and collaborative moral deliberations. Future research, with other designs and methodologies, is needed to further investigate the impact of ethics reflection groups on improving health care practices.
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Gerritse, Karl; Hartman, L; Antonides, Marte Fleur; Wensing-Kruger, Annelijn; de, Annelou Vries, & Molewijk, Albert Christiaan
(2018).
Moral Challenges in Transgender Care: A Thematic Analysis Based on a Focused Ethnography.
Archives of Sexual Behavior.
ISSN 0004-0002.
47(8),
p. 2319–2333.
doi:
10.1007/s10508-018-1287-3.
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Treatment teams providing transgender-affirming medical care are inherently faced with various kinds of moral and ethical dilemmas and questions, which are becoming even more pressing due to increasing treatment numbers and public attention for transgender care. Little is known about what kinds of moral and ethical challenges manifest in clinical practice. The aim of the present research was to map the moral and ethical challenges of healthcare professionals working in a specialized multidisciplinary transgender care center. Over a period of 7 months, during a focused ethnographic study, data were collected through participant observation of multidisciplinary team meetings, observation of individual psychodiagnostic assessment sessions with clients, and analysis of transcripts and reports of a series of moral case deliberations. A thematic content analysis of the data identified various implicit and explicit moral and ethical challenges around the following six themes: (1) assessing eligibility; (2) content of treatment; (3) sequential order of the treatment steps; (4) role of the clinical guidelines; (5) differing notions regarding gender identity, and (6) decision-making process. Our research provides a detailed insight into the way healthcare professionals experience these moral and ethical challenges and how they are related to (local) guidelines, the multidisciplinary character of GD care, and its inherent implicit and explicit gender norms. Our findings suggest that good transgender care may profit from continuous multidisciplinary deliberation of and sensitivity toward the normative dimension of transgender care. The paper ends with recommendations for ethics support mechanisms in transgender care.
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Baarle, Eva van; Braak, Ineke van de; Verweij, Desiree; Widdershoven, Guy & Molewijk, Albert Christiaan
(2018).
The safety paradox in ethics training: a case study on safety dynamics within a military ethics train-the-trainer course.
Medicine, Health care and Philosophy.
ISSN 1386-7423.
22(1),
p. 107–117.
doi:
10.1007/s11019-018-9847-9.
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There is considerable support for the idea that an atmosphere of safety can foster learning in groups, especially during ethics training courses. However, the question how safety dynamics works during ethics courses is still understudied. This article aims to investigate safety dynamics by examining a critical incident during a military ethics train-the trainer course during which safety was threatened. We examine this incident by means of a four-factor analysis model from the field of Theme-Centered Interaction (TCI). We show that during ethics training courses a safety paradox can occur, involving a tension between honesty and openness to other perspectives and values. Finally, we discuss how trainers can foster safety during ethics training.
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Widdershoven, Guy; Molewijk, Albert Christiaan & Metselaar, Suzanne
(2018).
Peer review and beyond. Towards a dialogical approach of quality of ethics support.
In Finder, Stuart & Bliton, Mark (Ed.),
Peer Review, Peer Education and Modeling in the Practice of Clinical Ethics Consultation: The Zadeh Project..
Springer.
ISSN 9783319909554.
p. 193–203.
doi:
10.1007/978-3-319-90955-4.
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Bartholdson, Cecilia; Molewijk, Albert Christiaan; Lützén, Kim; Blomgren, Klas & Pergert, Pernilla
(2018).
Ethics case reflection sessions: Enablers and barriers.
Nursing Ethics.
ISSN 0969-7330.
25(2),
p. 199–211.
doi:
10.1177/0969733017693471.
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Snoo-Trimp, Janine De; Molewijk, Albert Christiaan & Vet, Henrika C.W. de
(2018).
Defining and categorizing outcomes of Moral Case Deliberation (MCD): Concept mapping with experienced MCD participants.
BMC Medical Ethics.
19(1),
p. 1–14.
doi:
10.1186/s12910-018-0324-z.
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Background: To support healthcare professionals in dealing with ethically difficult situations, Clinical Ethics Support (CES) services like Moral Case Deliberation (MCD) are increasingly implemented. To assess the impact of CES, it is important to evaluate outcomes. Despite general claims about outcomes from MCD experts and some qualitative research, there exists no conceptual analysis of outcomes yet. Therefore, the aim of this study was to systematically define and categorize MCD outcomes. An additional aim was to compare these outcomes with the outcomes in the Euro-MCD Instrument from 2014, to further validate this Instrument. Methods: The concept mapping method was used and involves qualitative and quantitative steps including brainstorming, individual structuring, computation of concept maps (by principal component analysis and cluster analysis), group interpretation and utilization. In total, 12 experienced MCD participants from a variety of professional backgrounds participated in two sessions. Results: The focus group brainstorm resulted in a list of 85 possible MCD outcomes, of which a point map and concept maps were constructed. After a thorough discussion of each cluster, final consensus was reached on the names and position of 8 clusters of MCD outcomes: 1) Organisation and Policy; 2) Team development; 3) Personal development focused on the Other Person; 4) Personal development as Professional, focused on Skills; 5) Personal development as Professional, focused on Knowledge; 6) Personal development as an Individual; 7) Perception and Connection; and 8) Concrete action. Conclusions: This study explored and categorized MCD outcomes in a concept mapping focus group. When comparing the results with the Euro-MCD Instrument, our study confirms that outcomes of MCD can be categorized in clusters referring to the organisational level, team development, personal development (both as an individual and a professional) and the concrete case-level. In developing CES evaluation tools, it is important to be explicit if an outcome refers to the individual or the team, to knowledge or skills, to the organisation or the specific case. The findings will be used in the further validation of the Euro-MCD Instrument. The current study further contributes to the field of evaluating CES in general and defining outcomes of MCD in particular.
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Hartman, L; Metselaar, Suzanne; Molewijk, Albert Christiaan; Edelbroek, Hannah & Widdershoven, Guy
(2018).
Developing an ethics support tool for dealing with dilemmas around client autonomy based on moral case deliberations.
BMC Medical Ethics.
19(197),
p. 1–11.
doi:
10.1186/s12910-018-0335-9.
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Background Moral Case Deliberations (MCDs) are reflective dialogues with a group of participants on their own moral dilemmas. Although MCD is successful as clinical ethics support (CES), it also has limitations. 1. Lessons learned from individual MCDs are not shared in order to be used in other contexts 2. Moral learning stays limited to the participants of the MCD; 3. MCD requires quite some organisational effort, 4. MCD deals with one individual concrete case. It does not address other, similar cases (it is case based). These limitations warrant research into complementary ways of providing CES to healthcare professionals. Our research objective was therefore to develop a low threshold CES tool based on a series of MCDs on autonomy in long-term care. Methods We used a qualitative research design in which we analyzed the process and content of a series of MCDs, combined with reflections on the theoretical background of MCD. In total 28 MCDs (10 transcripts and 18 summary reports) were analyzed by means of a thematic content analysis. In various rounds of development, the results of the analysis were combined with theoretical reflections on CES. Consequently, the tool was evaluated in three focus groups and adjusted. Results The CES tool, called ‘moral compass’, guides the users through a series of six subsequent questions in order to methodically reflect on their concrete moral dilemma, in the form of a booklet of 23 pages. It combines a methodical element that encourages and structures a reflection process with a substantive element, including norms, values, options, strategies, and insights regarding dealing with client autonomy. Conclusion By using data from a series of MCDs, combined with theoretical reflections on MCD, ethics support and moral learning, we developed a thematic, low-threshold CES tool that supports healthcare professionals in daily practice in dealing with moral questions regarding client autonomy. It integrates examples and insights from earlier MCDs on the same topic. The moral compass is not a replacement of, but can be used complementary to MCD. The feasibility and impact of the moral compass need to be investigated in an evaluative follow-up study. The methodology presented in this paper may be used to develop moral compasses on different topics in various healthcare organizations.
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Baarle, Eva van; verweij, desiree; Molewijk, Albert Christiaan & Widdershoven, Guy
(2018).
The relevance of Foucauldian art-of-living for ethics education in a military context: Theory and practice.
Journal of Moral Education.
ISSN 0305-7240.
47(1),
p. 126–143.
doi:
10.1080/03057240.2017.1389703.
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How can ethical decision-making in organizations be further reinforced? This article explores the relevance of Michel Foucault’s ideas on art-of-living for ethics education in organizations. First, we present a theoretical analysis of art-of-living in the work of Foucault as well as in the work of two philosophers who greatly influenced his work, Friedrich Nietzsche and Pierre Hadot. Next, we illustrate how art-of-living can be applied in ethics education. In order to examine some of the benefits and challenges of applying the art-of-living in the practice of ethics education, we discuss an example of how the art-of-living concept has been used in a train-the-trainer course on military ethics. We suggest that Foucauldian art-of-living may foster awareness of power dynamics which are in play when military personnel face moral dilemmas.
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Molewijk, Albert Christiaan; Kok, Almar; Husum, Tonje Lossius; Pedersen, Reidar & Aasland, Olaf Gjerløw
(2017).
Staff’s normative attitudes towards
coercion: the role of moral doubt and
professional context—a cross-sectional
survey study.
BMC Medical Ethics.
18(37),
p. 1–14.
doi:
10.1186/s12910-017-0190-0.
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Background The use of coercion is morally problematic and requires an ongoing critical reflection. We wondered if not knowing or being uncertain whether coercion is morally right or justified (i.e. experiencing moral doubt) is related to professionals’ normative attitudes regarding the use of coercion. Methods This paper describes an explorative statistical analysis based on a cross-sectional survey across seven wards in three Norwegian mental health care institutions. Results Descriptive analyses showed that in general the 379 respondents a) were not so sure whether coercion should be seen as offending, b) agreed with the viewpoint that coercion is needed for care and security, and c) slightly disagreed that coercion could be seen as treatment. Staff did not report high rates of moral doubt related to the use of coercion, although most of them agreed there will never be a single answer to the question ‘What is the right thing to do?’. Bivariate analyses showed that the more they experienced general moral doubt and relative doubt, the more one thought that coercion is offending. Especially psychologists were critical towards coercion. We found significant differences among ward types. Respondents with decisional responsibility for coercion and leadership responsibility saw coercion less as treatment. Frequent experience with coercion was related to seeing coercion more as care and security. Conclusions This study showed that experiencing moral doubt is related to some one’s normative attitude towards coercion. Future research could investigate whether moral case deliberation increases professionals’ experience of moral doubt and whether this will evoke more critical thinking and increase staff’s curiosity for alternatives to coercion.
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Snoo-Trimp, Janine De; Widdershoven, Guy; Svantesson, Mia; Vet, Henrica de & Molewijk, Albert Christiaan
(2017).
WHAT OUTCOMES DO DUTCH HEALTHCARE PROFESSIONALS
PERCEIVE AS IMPORTANT BEFORE PARTICIPATION IN MORAL CASE
DELIBERATION?
Bioethics.
ISSN 0269-9702.
doi:
10.1111/bioe.12354.
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Metselaar, Suzanne; Widdershoven, Guy; Porz, Rouven & Molewijk, Albert Christiaan
(2017).
Evaluating clinical ethics support: A participatory approach.
Bioethics.
ISSN 0269-9702.
31(4),
p. 258–266.
doi:
10.1111/bioe.12348.
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Jellema, Hylke; Kremer, Swanny; Mackor, Anne Ruth & Molewijk, Albert Christiaan
(2017).
EVALUATING THE QUALITY OF THE DELIBERATION IN MORAL CASE
DELIBERATIONS: A CODING SCHEME.
Bioethics.
ISSN 0269-9702.
doi:
10.1111/bioe.12346.
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Molewijk, Albert Christiaan
(2017).
Moral Case Deliberation: Facilitating a Structured Dialogue with Involved Stakeholders.
MID-ATLANTIC ETHICS COMMITTEE.
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Landeweer, Elisabeth Geke Marjan; Molewijk, Albert Christiaan; Hem, Marit Helene & Pedersen, Reidar
(2017).
Worlds apart? A scoping review addressing different stakeholder perspectives on barriers to family involvement in the care for persons with severe mental illness.
BMC Health Services Research.
17(349),
p. 1–10.
doi:
10.1186/s12913-017-2213-4.
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Background Empirical evidence shows that family involvement (FI) can play a pivotal role in the coping and recovery of persons with severe mental illness (SMI). Nevertheless, various studies demonstrate that FI in mental healthcare services is often not (sufficiently) realized. In order to develop more insights, this scoping review gives an overview of how various stakeholders conceptualize, perceive and experience barriers to FI. Central questions are: 1) What are the main barriers to FI reported by the different key stakeholders (i.e. the persons with SMI, their families and the professionals, and 2) What are the differences and similarities between the various stakeholders’ perspectives on these barriers. Methods A systematic search into primary studies regarding FI was conducted in four databases: Medline/Pubmed, Cinahl, PsychInfo and Web of Knowledge with the use of a PICO scheme. Thematic analysis focused on stakeholder perspectives (i.e. which stakeholder group reports the barrier) and types of barriers (i.e. which types of barriers are addressed). Results Thirty three studies were included. The main barriers reported by the stakeholder groups reveal important similarities and differences between the stakeholder groups and were related to: 1) the person with SMI, 2) the family, 3) the professionals, 4) the organization of care and 5) the culture-paradigm. Discussion Our stakeholder approach elicits the different stakeholders’ concepts, presuppositions and experiences of barriers to FI, and gives fundamental insights on how to deal with barriers to FI. The stakeholders differing interpretations and perceptions of the barriers related to FI is closely related to the inherent complexity involved in FI in itself. In order to deal better with these barriers, openly discussing and reflecting upon each other’s normative understandings of barriers is needed. Conclusions Differences in perceptions of barriers to FI can itself be a barrier. To deal with barriers to FI, a dialogical approach on how the different stakeholders perceive and value FI and its barriers is required. Methods such as moral case deliberation or systematic ethics reflections can be useful.
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Baarle, Eva van; Hartman, Laura; Verweij, Desiree; Molewijk, Albert Christiaan & Widdershoven, Guy
(2017).
What Sticks? The Evaluation of a Train-the-Trainer Course in Military Ethics and its Perceived Outcomes.
Journal of Military Ethics.
ISSN 1502-7570.
16(1-2),
p. 56–77.
doi:
10.1080/15027570.2017.1355182.
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Seekles, Wike; Widdershoven, Guy; Robben, Paul; Dalfsen, Gonny Van & Molewijk, Albert Christiaan
(2017).
Inspectors’ ethical challenges in health care regulation: a pilot study.
Medicine, Health care and Philosophy.
ISSN 1386-7423.
20(3),
p. 311–320.
doi:
10.1007/s11019-016-9736-z.
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Stolper, Margreet; Molewijk, Albert Christiaan & Widdershoven, Guy
(2016).
Bioethics education in clinical settings: Theory and practice of the dilemma method of moral case deliberation.
BMC Medical Ethics.
17:45.
doi:
10.1186/s12910-016-0125-1.
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Molewijk, Albert Christiaan; Stokke, Ingvild & Pedersen, Reidar
(2016).
Two years of moral case deliberations on the use of coercion in mental health care: Which ethical challenges are being discussed by health care professionals?
Clinical Ethics.
ISSN 1477-7509.
11(2-3),
p. 87–96.
doi:
10.1177/1477750915622034.
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Spijkerboer, R. P.; Stel, J. C. van der; Widdershoven, G. A. M. & Molewijk, Albert Christiaan
(2016).
Does moral case deliberation help professionals in care for the homeless in dealing with their dilemmas? A mixed-methods responsive study.
HEC Forum.
ISSN 0956-2737.
29(1),
p. 21–41.
doi:
10.1007/s10730-016-9310-3.
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Weidema, Frouk; Dartel, Hans van & Molewijk, Albert Christiaan
(2016).
Working towards implementing moral case deliberation in mental healthcare: Ongoing dialogue and shared ownership as strategy.
Clinical Ethics.
ISSN 1477-7509.
11(2-3),
p. 54–62.
doi:
10.1177/1477750916644932.
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Seekles, Wike; Widdershoven, Guy; Robben, Paul; Dalfsen, Gonny Van & Molewijk, Albert Christiaan
(2016).
Evaluation of moral case deliberation at the Dutch Health Care Inspectorate: A pilot study.
BMC Medical Ethics.
17:31,
p. 1–11.
doi:
10.1186/s12910-016-0114-4.
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roo, karin pasman-de; Stolper, Margreet; Widdershoven, Guy & Molewijk, Albert Christiaan
(2016).
Training facilitators of Moral Case Deliberation: a successful experience with external health care professionals in the sessions and in feedback to the trainees.
Bioethica Forum.
ISSN 1662-6001.
9(2),
p. 71–75.
Full text in Research Archive
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Stokke, Ingvild; Molewijk, Albert Christiaan & Pedersen, Reidar
(2016).
Etiske utfordringer ved bruk av tvang i psykisk helsevern : når lovverk møter praksis.
Tidsskrift for Norsk psykologforening (Psykologtidsskriftet).
ISSN 0332-6470.
53(2),
p. 103–110.
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Spijkerboer, R. P.; Stel, J. C. van der; Widdershoven, G. A. M. & Molewijk, Albert Christiaan
(2016).
Social work students dealing with moral dilemmas in the care for children and young people: an evaluation of moral case deliberation as an educational tool.
Social Work Education.
ISSN 0261-5479.
35(7),
p. 794–808.
doi:
10.1080/02615479.2016.1201468.
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Spijkerboer, R. P.; Widdershoven, Guy; stel, Jaap van der & Molewijk, Albert Christiaan
(2016).
Moral Dilemmas in Care for the Homeless: What Issues Do Professionals Face, How Do They Deal With Them, and Do They Need Ethics Support?
The Journal of Social Work Values and Ethics.
13(2),
p. 22–34.
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Molewijk, Albert Christiaan; Slowther, Anne* & Schildmann, Jan
(2016).
The European Clinical Ethics Network (ECEN): the professional development of clinical ethics support in Europe and the importance of quality assessment through evaluation research.
Bioethica Forum.
ISSN 1662-6001.
9(2),
p. 86–89.
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Molewijk, Albert Christiaan; Hem, Marit Helene & Pedersen, Reidar
(2015).
Dealing with ethical challenges: A focus group study with professionals in mental health care.
BMC Medical Ethics.
16(1).
doi:
10.1186/1472-6939-16-4.
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Background Little is known about how health care professionals deal with ethical challenges in mental health care, especially when not making use of a formal ethics support service. Understanding this is important in order to be able to support the professionals, to improve the quality of care, and to know in which way future ethics support services might be helpful. Methods Within a project on ethics, coercion and psychiatry, we executed a focus group interview study at seven departments with 65 health care professionals and managers. We performed a systematic and open qualitative analysis focusing on the question: ‘How do health care professionals deal with ethical challenges?’ We deliberately did not present a fixed definition or theory of ethical challenge. Results We categorized relevant topics into three subthemes: 1) Identification and presence of ethical challenges; 2) What do the participants actually do when dealing with an ethical challenge?; and 3) The significance of facing ethical challenges. Results varied from dealing with ethical challenges every day and appreciating it as a positive part of working in mental health care, to experiencing ethical challenges as paralyzing burdens that cause a lot of stress and hinder constructive team cooperation. Some participants reported that they do not have the time and that they lack a specific methodology. Quite often, informal and retrospective ad-hoc meetings in small teams were organized. Participants struggled with what makes a challenge an ethical challenge and whether it differs from a professional challenge. When dealing with ethical challenges, a number of participants experienced difficulties handling disagreement in a constructive way. Furthermore, some participants plead for more attention for underlying intentions and justifications of treatment decisions. Conclusions The interviewed health care professionals dealt with ethical challenges in many different ways, often in an informal, implicit and reactive manner. This study revealed nine different categories of what health care professionals implicitly or explicitly conceive as ‘ethical challenges’. Future research should focus on how ethics support services, such as ethics reflection groups or moral case deliberation, can be of help with respect to dealing with ethical challenges and value disagreements in a constructive way.
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Stolper, Margreet; Molewijk, Albert Christiaan & Widdershoven, Guy
(2015).
Learning by doing. Training health care professionals to become facilitators of moral case deliberation.
HEC Forum.
ISSN 0956-2737.
27(1),
p. 47–59.
doi:
10.1007/s10730-014-9251-7.
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Lorem, Geir F; Hem, Marit Helene & Molewijk, Albert Christiaan
(2015).
Good coercion: Patients' moral evaluation of coercion in mental health care.
International Journal of Mental Health Nursing.
ISSN 1445-8330.
24(3),
p. 231–240.
doi:
10.1111/inm.12106.
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Weidema, Frouk; Molewijk, Albert Christiaan; Kamsteeg, Frans & Widdershoven, Guy
(2015).
Managers' views on and experiences with moral case deliberation in nursing teams.
Journal of Nursing Management.
ISSN 0966-0429.
doi:
10.1111/jonm.12253.
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Hem, Marit Helene; Pedersen, Reidar; Norvoll, Reidun & Molewijk, Albert Christiaan
(2015).
Evaluating clinical ethics support in mental healthcare: A systematic literature review.
Nursing Ethics.
ISSN 0969-7330.
22(4),
p. 452–466.
doi:
10.1177/0969733014539783.
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Janssens, Rien; Zadelhoff, Ezra van; Loo, Ger van; Widdershoven, Guy & Molewijk, Albert Christiaan
(2015).
Evaluation and perceived results of moral case deliberation in a Dutch organization for elderly care.
Nursing Ethics.
ISSN 0969-7330.
doi:
10.1177/0969733014557115.
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Svantesson, Mia; Karlsson, Jan; Boitte, Pierre; Schildman, Jan; Dauwerse, Linda & Widdershoven, Guy
[Show all 9 contributors for this article]
(2014).
Outcomes of Moral Case Deliberation - The development of an evaluation instrument for clinical ethics support (the Euro-MCD).
BMC Medical Ethics.
15(1).
doi:
10.1186/1472-6939-15-30.
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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.
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Janssen, Rien; Zadelhoff, E van; Loo, Ger van; Widdershoven, Guy & Molewijk, Albert Christiaan
(2014).
Evaluation and perceived results of moral case deliberation in a Dutch organisation for elderly care. A quantitative and qualitative study.
Nursing Ethics.
ISSN 0969-7330.
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Hem, Marit Helene; Molewijk, Albert Christiaan & Pedersen, Reidar
(2014).
Ethical challenges in connection with the use of coercion: a focus group study of health care personnel in mental health care.
BMC Medical Ethics.
15(82).
doi:
10.1186/1472-6939-15-82.
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Background: In recent years, the attention on the use of coercion in mental health care has increased. The use of coercion is common and controversial, and involves many complex ethical challenges. The research question in this study was: What kind of ethical challenges related to the use of coercion do health care practitioners face in their daily clinical work? Methods: We conducted seven focus group interviews in three mental health care institutions involving 65 multidisciplinary participants from different clinical fields. The interviews were recorded and transcribed verbatim. We analysed the material applying a ‘bricolage’ approach. Basic ethical principles for research ethics were followed. We received permission from the hospitals’ administrations and all health care professionals who participated in the focus group interviews. Results: Health care practitioners describe ethical dilemmas they face concerning formal, informal and perceived coercion. They provide a complex picture. They have to handle various ethical challenges, not seldom concerning questions of life and death. In every situation, the dignity of the patient is at stake when coercion is considered as morally right, as well as when coercion is not the preferred intervention. The work of the mental health professional is a complicated “moral enterprise”. The ethical challenges deserve to be identified and handled in a systematic way. This is important for developing the quality of health care, and it is relevant to the current focus on reducing the use of coercion and increasing patient participation. Precise knowledge about ethical challenges is necessary for those who want to develop ethics support in mental health care. Better communication skills among health care professionals and improved therapeutic relationships seem to be vital. Conclusions: A systematic focus on ethical challenges when dealing with coercion is an important step forward in order to improve health care in the mental health field.
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Dauwerse, Linda; Weidema, Frouk; Abma, T. A.; Molewijk, Albert Christian & Widdershoven, Guy
(2014).
Implicit and Explicit Clinical Ethics Support in The Netherlands: A Mixed Methods Overview Study.
HEC Forum.
ISSN 0956-2737.
26(2),
p. 95–109.
doi:
10.1007/s10730-013-9224-2.
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Dauwerse, Linda; Stolper, Margreet; Widdershoven, Guy & Molewijk, Albert Christian
(2014).
Prevalence and characteristics of moral case deliberation in Dutch health care.
Medicine, Health care and Philosophy.
ISSN 1386-7423.
17(3),
p. 365–375.
doi:
10.1007/s11019-013-9537-6.
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Schildmann, Jan; Molewijk, Albert Christiaan; Benaroyo, Lazare; Førde, Reidun & Neitzke, Gerald
(2013).
Evaluation of clinical ethics support services and its normativity.
Journal of Medical Ethics.
ISSN 0306-6800.
39(11),
p. 681–685.
doi:
10.1136/medethics-2012-100697.
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Widdershoven, Guy; Molewijk, Albert Christiaan & Metselaar, Suzanne
(2018).
Peer Review, Peer Education and Modeling in the Practice of Clinical Ethics Consultation: The Zadeh Project.
Springer.
ISBN 9783319909530.
228 p.
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Hem, Marit Helene; Molewijk, Albert Christiaan & Pedersen, Reidar
(2017).
Systematisk etikkrefleksjon gjør en forskjell. Et ressurshefte for etikkrefleksjonsgrupper i psykisk helsevern.
Universitetet i Oslo.
ISBN 9788293544043.
97 p.
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Dette ressursheftet er utviklet av forskere ved Senter for medisinsk etikk (SME) ved Universitetet i Oslo. SME har gjennom en årrekke arbeidet med etikk i helsetjenesten. To viktige satsinger har vært utviklingen av Kliniske etikk-komitéer (KEK) som nå alle helseforetak er pålagt å ha,1 samt Etikk i kommunehelsetjenesten (EIK).2 På bakgrunn av at vi så behovet for en etikksatsing i psykisk helsevern, fikk vi – takket være økonomisk støtte fra Helsedirektoratet i en lengre periode (2011-2016) – muligheten til å sette fokus på etiske problemstillinger i de psykiske helsetjenestene. Prosjektet fikk navnet Psykiske helsetjenester, etikk og tvang (PET), og det har blitt ledet av Reidar Pedersen. Øvrige medarbeidere i prosjektet har vært Reidun Norvoll, Bert Molewijk, Marit Helene Hem, Tonje Lossius Husum, Reidun Førde, Olaf Gjerløw Aasland, Elisabeth Gjerberg, Lillian Lillemoen, Elin Håkonsen Martinsen, Bente Weimand, Irene Syse og Anders Tvedt.
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Hem, Marit Helene; Molewijk, Albert Christiaan; Husum, Tonje Lossius & Pedersen, Reidar
(2017).
Tvang og etikk i de psykiske helsetjenestene.
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Hem, Marit Helene; Molewijk, Albert Christiaan; Gjerberg, Elisabeth; Lillemoen, Lillian & Pedersen, Reidar
(2017).
Etisk refleksjon om bruk av tvang. En fokusgruppestudie av helsepersonell.
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Molewijk, Albert Christiaan; Widdershoven, Guy; Schildmann, Jan & Vollmann, Jochen
(2016).
What quality is actually assessed within written records?
16(9),
p. 34–36.
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Molewijk, Albert Christiaan & Reiter-Theil, Stella
(2016).
The particular relevance of clinical ethics support in psychiatry: Concepts, research, and experiences.
Clinical Ethics.
ISSN 1477-7509.
11(2-3),
p. 43–44.
doi:
10.1177/1477750916660854.
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Molewijk, Albert Christiaan & Reiter-Theil, Stella
(2016).
The particular relevance of clinical ethics support in psychiatry. Concepts, research, and experiences.
Clinical Ethics.
ISSN 1477-7509.
11(2-3),
p. 43–44.
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Rørvik, Jorunn Marie; Carlsen, Liv Berit; Støverud, Siri; Haukland-Haugen, Lene; Lorentzen, Bernhard & Molewijk, Albert Christiaan
(2015).
Implementing ethics reflection groups in a department of Geriatric Psychiatry in Norway.
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Hem, Marit Helene; Molewijk, Albert Christiaan; Lillemoen, Lillian; Gjerberg, Elisabeth & Pedersen, Reidar
(2015).
Mental health care, ethics and coercion. Experience with ethics reflection groups. Preliminary findings from a focus group study.
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Molewijk, Albert Christiaan; Slowther, Anne* & Aulisio, Mark
(2015).
Clinical Ethics: Support.
In Have, Henk ten (Eds.),
Encyclopedia of Global Bioethics.
Springer.
ISSN 9783319055442.
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Hem, Marit Helene; Molewijk, Albert Christiaan; Husum, Tonje Lossius; Aasland, Olaf Gjerløw; Engerdahl, Ingvild Stokke & Pedersen, Reidar
(2015).
Ansattes etiske dilemma.
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Molewijk, Albert Christiaan; Hem, Marit Helene & Pedersen, Reidar
(2015).
Hvordan starte opp med etikk refleksjonsgrupper i de psykiske helsetjenester?
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Molewijk, Albert Christiaan; Hem, Marit Helene & Pedersen, Reidar
(2014).
How do employees in mental health care deal with ethical challenges?
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Hem, Marit Helene; Molewijk, Albert Christiaan & Pedersen, Reidar
(2014).
When the patient's voice is overrruled. Ethical challenges and coercion in mental health care. A qualitative study of health care personnel.
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Pedersen, Reidar; Hem, Marit Helene & Molewijk, Albert Christiaan
(2013).
Psykiske helsetjenester, etikk og tvang – foreløpige erfaringer fra en intervensjonsstudie med refleksjonsgrupper.
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Hem, Marit Helene; Molewijk, Albert Christian & Pedersen, Reidar
(2013).
Bruk av etisk refleksjon og dialog for å kvalitetssikre og redusere bruk av tvang.
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Published
Oct. 25, 2011 12:32 PM
