The result of the revision process is the revised Euro-MCD Instrument: the Euro-MCD 2.0. This will be presented and explained in part I, including comparisons with the Euro-MCD Instrument from 2014. In part II, we elaborate on the revision process and our arguments for revision as developed throughout the iterative revision process.
Table 2 – The Euro-MCD 2.0 - Revised Instrument
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Link to former Euro-MCD item (if any)
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(Sub)Category
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Item #
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Moral Competence
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Moral sensitivity
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1. I recognize a situation as being ethically difficult
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Increases my awareness of the complexity of ethically difficult situations (no. 12)
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2. I am aware of others’ perspectives in ethically difficult situations
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I see the ethically difficult situations from different perspectives (no. 14)
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Analytical skills
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3. I can identify the different values at stake in ethically difficult situations
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Develops my ability to identify the core ethical question in the difficult situations (no. 13)
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4. I can formulate arguments in favor of and against different courses of actions in ethically difficult situations
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Find more courses of actions to manage the ethically difficult situations (no. 24)
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Virtuous attitude
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5. I listen with an open mind to others when discussing an ethically difficult situation
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I listen more seriously to others’ opinions (no. 18)
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6. I speak up in ethically difficult situations
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Strengthens my self-confidence when managing ethically difficult situations (no. 2)
& Gives me more courage to express my ethical standpoint (no. 19)
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Moral Teamwork
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Open dialogue
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7. We openly express our viewpoints in ethically difficult situations
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More open communication among co-workers (no. 10)
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8. We all have opportunities to express our viewpoint on ethically difficult situations
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Greater opportunity for everyone to have their say (no. 6)
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9.We respect different viewpoints when discussing ethically difficult situations
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Enhanced mutual respect amongst co-workers (no. 8)
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Supportive relationships
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10. We feel secure to share emotions in ethically difficult situations
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Enhances possibility to share difficult emotions and thoughts with co-workers (no. 1)
& I feel more secure to express doubts or uncertainty (no. 5)
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11. We support each other when dealing with ethically difficult situations
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Moral Action
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Moral decision-making
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12. We make decisions on how to act in ethically difficult situations
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Find more courses of actions to manage the ethically difficult situations (no. 24) & Enables me and my co-workers to decide on concrete actions in order to manage the ethically difficult situations (no. 26)
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13. We base our decisions on moral considerations in ethically difficult situations
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Responsible care
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14. We are responsive to the values and needs of patients and their families when interacting with them in ethically difficult situations
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15. We are able to explain and justify our care towards patients and their families
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Part I: presenting and explaining the revised Euro-MCD Instrument: Euro-MCD 2.0
The Euro-MCD 2.0 consists of 15 items covered by three domains: 1) Moral Competence; 2) Moral Teamwork and 3) Moral Action, as presented in Table 2. This table also shows the link with previous Euro-MCD items. In the Appendix (part II), the complete Euro-MCD 2.0 including instructions and answer options is presented.
1. Moral Competence
The first domain of Moral Competence includes ‘moral awareness’, ‘analytical skills’ and a ‘virtuous attitude’ when experiencing and dealing with an ethically difficult situation. In the field studies, outcomes referring to moral competences were valued and experienced by participants and associated with each other. Due to MCD, participants might develop awareness to recognize a situation as being ethically difficult (item #1) and become aware of others’ perspectives (items #2). Furthermore, participants might grow in analytical skills to identify values and formulate arguments when encountering an ethically difficult situation (items #3 and #4). Besides, a virtuous attitude can become more apparent by openness when listening to others (item #5) and courage to speak up in ethically difficult situations (item #6).
During our deliberations on this domain, literature on moral competence helped us to further reflect upon the name of this domain and refine the formulation of its items. Moral competence is a rather broad concept in literature, most often used in business ethics and theories on moral development. The three subdomains of awareness, skills and attitude have been described in several studies close to ours as possible outcomes of ethics education or ethics support. First, the three elements of awareness, skills and attitude are reflected in the focus on perception and reflection by Kälvemark Sporrong et al. [27], who argue that ethical competence ‘entails the ability to integrate perception, reflection and action, and to understand oneself as being responsible for one’s own actions’. Furthermore, Eriksson et al. [28] argued that ethical competence should include ‘being’ (i.e. virtues), ‘doing’ (i.e. acting according to ethical guidelines and rules): and ‘knowing’ (i.e. reflecting on relevant virtues and guidelines). More recently, in their development of ethics education aimed to foster moral competence, Van Baarle and colleagues [29] operationalized moral competence as follows: ‘moral competence entails the ability to be aware of one’s personal moral values and the values of others, the ability to recognize the moral dimension of situations, the ability to judge adequately a moral dilemma, to communicate this judgment, the willingness and ability to act in accordance with this judgment in a morally responsible manner, and the willingness and ability to be accountable to yourself and to others’. In this definition, the focus on awareness can clearly be recognized, and the repeated use of the words ‘willingness and ability’ reflect similar attitudes and skills as we propose in this domain.
In this domain Moral Competence, items of the original Euro-MCD domains of Moral Reflexivity (no. 11, 12, 14 and 15), Moral Attitude (no. 16-20) and (to some extent) Emotional Support (no. 2 and 4) were reformulated and integrated. This was due to the factor analyses (studies III, IV) not supporting a distinction between them, hence, we merged them. The field studies (I-IV), both regarding perceived importance as well as experience, did nevertheless show the value of the items from these domains.
2. Moral Teamwork
The second domain is Moral Teamwork and involves two subdomains: ‘open dialogue’ and ‘supportive relationships’ among healthcare professionals. As MCD inherently is a group exercise in interaction, the MCD meetings might have an impact on how the involved healthcare professionals as a group talk and work together when facing an ethically difficult situation, also beyond the MCD sessions in their daily practice. The field studies clearly showed that outcomes about teamwork were highly valued and experienced by MCD participants. ‘Moral teamwork’ was chosen as a name for this domain. This name was considered to cover the content as closely and clearly as possible: it is not only about communication but rather about their joint way of working together, their teamwork, related to ethically difficult situations. And it is not about the practical content of this teamwork but about its moral aspects. The items in the subdomain of ‘an open dialogue’ involve whether team members talk openly and honestly with each other (item #7), discuss ethical issues on an equal level (item #8) and in a respectful way (item #9). The subdomain of ‘supportive relationships’ is about whether the team members feel secure amongst each other to share emotions (item #10) and motivated to support each other when dealing with ethically difficult situations (item #11).
In order to define this domain and (re)formulate its items, we used aspects from existing literature on teamwork. Literature on teamwork is extensive and terms like ‘team effectiveness’ or ‘interprofessional teamwork’ have been studied across various research areas (e.g. business, sociology, medicine) [30-32]. For instance, Schmutz et al. [32] recently examined the link between effective teams and clinical performance because they saw that ‘researchers and practitioners often lack a common conceptual foundation for investigating teams and teamwork in healthcare’. In their meta-analytical review, they defined teams as ‘identifiable social work units consisting of two or more people with several unique characteristics’. Next, they operationalized teamwork as follows: ‘teamwork is a process that describes interactions among team members who combine collective resources to resolve task demands (e.g. giving clear orders)’ [32]. They further made a distinction between ‘teamwork’ and ‘taskwork’. The latter concerns ‘what a team is doing whereas teamwork is how the members of a team are doing something with each other’. This distinction is helpful for us since our domain Moral Teamwork is about how the team members work together in ethical matters, not primarily about what they – in the end – do to manage the ethical situation. Furthermore, this definition is focused on the interaction between team members, which resembles our focus on dialogue in this domain. The focus on dialogue also appears in the definition by Babiker et al. [31] of team effectiveness: ‘an effective team is a one where the team members, including the patients, communicate with each other, as well as merging their observations, expertise and decision-making responsibilities to optimize patients’ care’. They described several characteristics of an effective team, including some with a clear link to our domain, like ‘honesty’ and ‘effective communication’ referring to open and equal interaction possibilities for team members. In addition, a literature review by Mickan & Rodger [30] revealed eighteen characteristics for ‘effective teamwork’ in healthcare, categorized into an organizational domain, a domain for the contributions of individual team members and a domain for ‘team processes’. In this latter domain, the notions of ‘communication’ ‘cohesion’, and ‘social relationships’ are relevant. These notions are reflected in our subdomains dialogue and relationships.
One major topic of discussion in the project team was whether we should call this domain ‘ethical climate’, which also focuses on dialogue and relationships [25, 33-36]. Ethical climate is mainly characterized as ‘shared perceptions’ of values and supportive relationships among healthcare professionals and the presence of possibilities to reflect, decide and act in an ethical way [33-36]. It is comparable to what MCD envisions in facilitating dialogue, mutual understanding and common grounds when dealing with ethical challenges. The project team therefore considered that MCD outcomes in the domain of Moral Teamwork show similarities with aspects of ethical climate. At the same time, ethical climate has been described to cover more than only team collaboration and is used as a rather broad concept involving both possibilities for ethical reflection (e.g. ethics consultants or MCD) as well as relationships, beliefs and behavior of individuals. This is for instance described by Silén and Svantesson [25] in their recent study on manager’s experiences with clinical ethics support, where they extensively elaborated on the concept of ethical climate. They argued that ethical climate might involve both group dynamics as well as ‘morally grounded actions and morally strengthened individuals’. In the end, we came to consensus on using ‘moral teamwork’ as a more pragmatic term, meaningful with regards to the content and at the same abstraction level as the other domain names.
The domain Moral Teamwork includes some adapted items from the former domains of Enhanced Collaboration (no. 6,8 and 10) and Emotional Support (no. 1 and 5). Since this domain is about how participants work together, all items are formulated as ‘We…’. A new item (#11) is added: ‘We support each other when dealing with an ethically difficult situation’ as this mutual support was considered to be an essential element of moral teamwork and suggested by respondents in open answers of both our field studies (I-III) and our focus group study (study V).
3. Moral Action
Lastly, the domain of Moral Action involves the subdomains ‘moral decision-making’ and ‘responsible care’. The project team considered it important to include items referring to concrete decisions and actual caring practice, as was also suggested in the closed and open responses of respondents in the field studies. The deliberation in MCD might not only change the participants in their individual moral competences (the first domain) and their teamwork (the second domain), but also, and maybe even through the first and second domain, the actual situation itself.
Firstly, in the subdomain ‘moral decision-making’, we want to assess whether MCD participants report to make a decision on how to deal with the situation at all (item #12) and if they base these decisions on moral considerations (item #13). Making a decision on moral grounds refers to how participants perceived the deliberation: did they consider the moral aspects of the situations, and not only the medical facts or psychosocial worries? In line with the theoretical background of MCD, the deliberation ideally results in a plan of action. According to hermeneutic pragmatic philosophy and dialogical ethics, one may start to experience and understand things in a new way and come to new or adapted plans of action [10,37]. In one of our field studies, managers of workplaces where MCD took place told that ‘ethics was more marked in written documents, such as the operational plan, in notes regarding breakpoint dialogues and care goals as well as in reasons for changing decisions’ [25]. As such, MCD seems to impact the actual daily practice and in particular how concrete decisions are made or changed.
Secondly, we built the subdomain ‘responsible care’ to indicate the relationship with patients (and their families) and to explicitly show our operationalization of ‘good’ care: depended on the context and clarified by the responsible healthcare professional. We considered that a core element of providing good care concerns a responsiveness to the values and needs of patients and their family when interacting with them (item #14). Experiencing and valuing good interactions with patients and family can be seen as a crucial element of good care, as most general ethics approaches plea for patient-centered approaches in healthcare [38]. In particular, the care ethics approach emphasizes the interdependency and equal relationships between care-givers and care-receivers [39,40]. A care ethics approach fits well to the daily practice of healthcare – the setting where MCD takes place. Here, healthcare professionals may have complex interactions with various stakeholders, confronting them with fundamental questions challenging their own presuppositions. In addition, the patient being the most important stakeholder is often a vulnerable person, hence, the healthcare professional should establish a responsible relationship with him or her [41]. Next, we previously described that a definition on good care would not fit in the Euro-MCD Instrument, as good care is exactly what MCD participants deliberate on in the MCD session (as is the case in CES in general). Yet, the result of this deliberation should (at least) be that responsible healthcare professionals are able to explain their view on good care to patients and their families. Therefore, assessing whether good care has been reached should be focused on the process instead of the content, and on the perceptions of participants. Therefore, we could ask MCD participants whether they think they are able to explain and justify their care towards patients and their families, which we assess in our last new item (#15).
Items from the former Euro-MCD domain of Concrete Results (no. 24 and 26) are merged in in the subdomain of moral decision-making: ‘We make decisions on how to act in ethically difficult situations’ (item #12). In this subdomain, a new item (#13) is added: ‘We base our decisions on moral considerations in ethically difficult situations’. The items in the subdomain ‘responsible care’ are also new: ‘We are responsive to the values and needs of patients and their family when interacting with them in ethically difficult situations’ (#14) and ‘We are able to explain and justify our care towards patients and their families’ (#15).
Part II: The revision process in detail
We will now describe how our decisions for revision were based on the empirical findings and developed throughout our revision process. First, a brief summary of the empirical findings is given, followed by a description of how these findings indicate points for revision and reflection.
Summary of the six field studies
In short, the following conclusions regarding the Euro-MCD Instrument (2014-version) could be drawn based on the empirical field studies:
- The majority of respondents rated all MCD outcomes as quite or very important, both before and after MCD participation, without a considerable difference between these moments (Studies I-III, Table 1).
- Outcomes referring to the domain ‘Enhanced Collaboration’ were particularly valued (Studies I-III) and experienced by the majority of respondents (Study IV)
- Outcomes regarding the domain ‘Concrete Results’ were perceived as quite or very important before MCD participation (studies I-II)
- Outcomes regarding the domain ‘Moral Attitude’ were experienced in a quite or very high degree during the sessions and in daily practice (Study IV)
- Outcomes referring to quality of care and the interaction with patients and their family members were suggested as new outcomes by respondents who were about to participate in MCD (Studies I-II)
- Factor analyses of the outcomes did not confirm the six originally proposed domains but revealed three or four domains of outcomes, indicating a possible distinction between virtues, skills, sharing feelings and actions (Study III-IV)
- Twelve outcomes of the 26 (no. 1,3,5,9,13,15,17,19,22-25 in Table 3) should be reconsidered regarding importance or clarity of formulation as these had low associations with other items in the factor analyses (Studies III-IV)
- Experienced MCD participants listed 85 possible outcomes of MCD into eight categories of which four categories referred to personal development (as professional and individual, focused on the other, knowledge and skills), two concerned the team (with regards to its development and connection), one referred to organization and policy and one referred to concrete actions (Study V)
- Outcomes reported by managers were categorized as an enhanced ethical climate, including a closer-knit team, morally strengthened professionals, morally grounded actions and ethics leaving its marks on everyday work (Study VI)
A detailed overview of the results and considerations per Euro-MCD item is presented in Table 3.
Table 3 - Euro-MCD domains and items (2014) – Arguments for adaptation, reformulation or deletion
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Domain and Item
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Consideration project team
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Decision
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Enhanced Emotional Support
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- Enhances possibility to share difficult emotions and thoughts with co-workers
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Needs reconsideration, was important for respondents but might have been misinterpreted by respondents as it does not correlate with other items from the domain Emotional Support.
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Rewritten as item #10 in revised domain ‘Moral Teamwork’: We feel secure to share emotions in ethically difficult situations
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- Strengthens my self-confidence when managing ethically difficult situations
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Good item but seems to belong to Moral Attitude rather than to Emotional Support
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Included in item #6 in revised domain ‘Moral Competence’: I speak up in ethically difficult situations
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- Enables me to better manage the stress caused by ethically difficult situations
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Needs adaptation or deletion, too vague, might have been misinterpreted by respondents and managing stress might not be a necessary outcome of MCD at all
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Deleted
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- Increased awareness of my own emotions regarding ethically difficult situations
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Good item but seems to belong to Moral Attitude rather than to Emotional Support
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Not included because of item reduction, as other items in revised domain ‘Moral Competence’ were determined as being closely related concept
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- I feel more secure to express doubts or uncertainty regarding ethically difficult situations
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Needs reconsideration as it does not seem to be important according to respondents and does not seem to correlate with other items from Emotional Support and it might be too similar to items 2 and 5.
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Rewritten as a group-related outcome, item #10 in revised domain ‘Moral Teamwork’: We feel secure to share emotions in ethically difficult situations
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Enhanced Collaboration
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- Greater opportunity for everyone to have their say
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Good and important item
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Included as item #8 in revised domain ‘Moral Teamwork’:
We all have opportunities to express our viewpoint on ethically difficult situations
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- Better mutual understanding of each other’s reasoning and acting
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Good and important item, but might need reconsideration as it correlates with both individual items (5 and 19) and group items (6,8 and 10) indicating various possible interpretations.
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Deleted because of item reduction as it was considered to be covered by other items
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- Enhanced mutual respect amongst co-workers
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Good item but might need reconsideration as it also seems to correlate with items from Moral Attitude.
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Rewritten as item #9 in revised domain ‘Moral Teamwork’: We respect different viewpoints when discussing ethically difficult situations
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- I and my co-workers manage disagreements more constructively
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Needs reconsideration or deletion as it does not seem to be important or experienced according to respondents indicating that it might not be an outcome of MCD at all.
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Deletion
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- More open communication among co-workers
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Good and important item
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Included as item #7 in revised domain ‘Moral Teamwork’: We openly express our viewpoints in ethically difficult situations
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Improved Moral Reflexivity
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- Develops my skills to analyse ethically difficult situations
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Needs reconsideration – might be too general and already covered by other items
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Deleted because of item reduction as it was considered to be covered by other items
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- Increases my awareness of the complexity of ethically difficult situations
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Good and important item
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Rewritten as item #1 in revised domain ‘Moral Competence’: I recognize a situation as being ethically difficult
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- Develops my ability to identify the core ethical question in the difficult situations
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Needs reconsideration or deletion as it does not seem to be important according to respondents and it might be too similar to other items from Moral Reflexivity.
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Changed and rewritten as item #3 in revised domain ‘Moral Competence’: I can identify the different values at stake in ethically difficult situations
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- I see the ethically difficult situations from different perspectives
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Good and important item
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Included as item #2 in revised domain ‘Moral Competence’: I am aware of others’ perspectives in ethically difficult situations
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- Enhances my understanding of ethical theories (ethical principles, values and norms)
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Needs adaptation or deletion, as it might not be an outcome of MCD at all
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Deleted as it was not considered to be relevant/intended outcome of MCD
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Improved Moral Attitude
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- I become more aware of my preconceived notions
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Good item but might be too general considering the correlations with many other items and possible social desirability in its formulation
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Deleted because of item reduction, not considered to be a clear outcome of MCD.
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- I gain more clarity about my own responsibility in the ethically difficult situations
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Needs reconsideration or deletion as it might have been misinterpreted as shown by the lack of correlations with other items in the perceived importance-data.
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Deleted as it was not considered to be a clear outcome of MCD
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- I listen more seriously to others’ opinions
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Good item but might need reconsideration as it seems to become important for respondents only after participation in MCD.
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Rewritten as item #7 in revised domain ‘Moral Competence’: I listen with an open mind to others when discussing an ethically difficult situation
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- Gives me more courage to express my ethical standpoint
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Needs reconsideration as it does not seem to be important according to respondents and it might be too similar to items 2 and 5.
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Deleted because item about self-confidence was considered as same outcome, item #6 in revised domain ‘Moral Competence’: I speak up in ethically difficult situations
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- I understand better what it means to be a good professional
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Good item but might be too general considering the correlations with many other items and possible social desirability in its formulation
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Deleted because of item reduction, too vague and general formulation
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Impact on Organizational Level
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|
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- I and my co-workers become more aware of recurring ethically difficult situations
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Needs reconsideration since the item seems to be about moral reflexivity than the organizational level regarding the correlations with items from the Moral Reflexivity domain.
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Deleted because of item reduction and too vague to apply to experience before MCD participation.
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- Contributes to the development of practice/policy in the workplace
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Needs adaptation or deletion, might have been misinterpreted by respondents or developing policies might not be an outcome of MCD at all
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Deleted, not necessarily an outcome of MCD
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- I and my co-workers examine more critically the existing practice/policies in the workplace/organization
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Needs reconsideration or deletion as it does not seem to be important or experienced according to respondents indicating that it might not be an outcome of MCD at all.
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Deleted because of item reduction and too vague to apply to experience before MCD participation.
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Concrete Results
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- Find more courses of actions to manage the ethically difficult situations
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Needs reconsideration, seems to be important for respondents but might have been misinterpreted by respondents as it does not seem to correlate with other items from the domain Concrete Results.
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Included as item #4 in revised domain of ‘Moral Competence’: I can formulate arguments in favor of and against different courses of action in ethically difficult situations
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- Consensus is gained amongst co-workers in how to manage the ethically difficult situations
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Needs adaptation or deletion, too vague as it does not seem to belong to domain of concrete results
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Deleted due to item reduction and being too vague
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- Enables me and my co-workers to decide on concrete actions in order to manage the ethically difficult situations
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Good and important item
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Included as item #12 in revised domain of ‘Moral Action’: ‘We make decisions on how to act in ethically difficult situations’
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Based on the field studies, the following decisions for revising the Euro-MCD Instrument were made: 1) reformulating items and changing all items into assessing the current status of MCD related outcomes (e.g. ‘now’) instead of change over time (e.g. ‘better’); 2) changing the original domains; 3) adding items about quality of care and interacting with patients and family; 4) omitting the question about perceived importance; and 5) deleting items not sufficiently relevant to or associated with MCD.
1) Reformulating items to assess current instead of changed practice
Firstly, the formulation of items turned out to be problematic in the field studies. All outcomes were formulated in a comparative manner including words like ‘more’ or ‘better’, for instance: ‘More open communication among co-workers’ or ‘I understand better what it means to be a good professional’. This could have made it rather straightforward for respondents to agree on their importance and difficult to disagree with them. Moreover, potential bias might have occurred here as respondents might be directed towards desirable answer options regarding their practice. It could also have made it hard for respondents to discriminate between items regarding both importance as well as experience. Therefore, the decision was made to reformulate outcomes more neutrally and about the current practice instead of a transition or indication of an improvement, like ‘We openly express our viewpoints in ethically difficult situations’ (#7). As a result of this reformulation, we changed the answer options as well, from a degree of importance or experience towards an agreement on the item, on a four point Likert scale from ‘strongly agree’ to ‘strongly disagree’.
2) Changing the original domains
A second point for revision that emerged from the empirical findings concerned the categorization of outcomes. As described before, the original Euro-MCD Instrument consisted of 6 domains. These domains were not confirmed in the factor structures of the data, as factor analyses revealed 3 and 4 domains for the perceived-importance and experience question respectively. In particular, the domains Impact on the Organizational Level and Concrete Results needed reconsideration since their items were not associated with each other and did thus not convincingly form distinct domains. Therefore, we left these six domains and made a new categorization in the revised instrument, in which elements of these former domains can still be recognized. Initially, consensus was reached on a general division of items on the individual, group and case level. This division was indicated by the factor analyses. The first level referred to individual development and changes due to participation in MCD, including awareness, skills and attitude. The second level comprised the impact on dialogue and relationships among healthcare professionals as a group or team and the third level was linked to actual care practices and decisions made about the concrete quality of care. The next step was to go from abstract levels to definite domains including items. We have described this in the previous part.
3) Adding items about quality of care and interaction with patients and family
Furthermore, a point for revision was the consideration of new items, like quality of care (as suggested in study I) and better interaction with patient and family (as suggested in study II). With regards to quality of care: we considered that contributing to quality of care is the ultimate and overarching goal of clinical ethics support. In the end, MCD should support healthcare professionals to pursue high quality of patient care. At the same time, it has been described to be complicated to give concrete and universal definitions of quality of care in general, and more specific as outcome of CES since CES inherently concerns a reflection upon how we define quality of care [3,43]. Subsequently, it is difficult or maybe impossible to directly define the impact of ethics support on quality of care [6,13,15]. Therefore, a predefined outcome regarding what quality of care should look like does not fit here.
This does however not mean that it is not at all possible to link MCD to quality of care, as it is at least possible to assess how healthcare professionals themselves think about the process to arrive at good decisions, or how they think about preconditions to deliver good care. As MCD is mostly intended to be a service supporting healthcare professionals in defining good care, it is important that outcome measures stay close to how professionals define good care. In the end, outcomes referring to quality of care, like all outcomes in the Euro-MCD Instrument, should only be included if healthcare professionals are able to recognize and experience them. Support for this could be found in the focus group study (study V), in which items referring to the procedure to arrive at good care were suggested, such as ‘Clarify what good care entails’ and ‘Better quality of work’. We further reflected on these suggestions when defining items in the new domain of ‘Moral Action’, see part I.
4) Omitting the question about perceived importance
Fourthly, the question on perceived importance of the presented MCD outcomes needed reconsideration. Since respondents perceived all outcomes as quite or very important, without a meaningful change over time, there was no clear emphasis on or discrimination between certain outcomes. The reason for these high rates is not clear. Perhaps MCD might have been very welcome as opportunity to sit and talk, – in particular – for Scandinavian nurse assistants, which might partly explain why outcomes were rated so high in the Scandinavian countries (study II). In the end, we concluded that the question on perceived importance would not have any value in the revised version because the field study respondents confirmed their assumed relevance and did not discriminate between items to allow for tailoring or weighing outcomes. It is however important to note that the question has been of great value in the revision process as it showed the perceptions of end-users regarding the relevance and importance of items.
5) Deleting items not sufficiently relevant to or associated with MCD
Some items of the Euro-MCD Instrument were omitted (see Table 3), due to a lack of correlations with other items or low experience-rates in the empirical data, implying to be insufficiently relevant or associated with MCD. The item ‘Enables me to better manage stress caused by ethical difficult situations’(no. 3), was believed to have a vague formulation. Also, we concluded that some items with low scores or low correlations (no. 9, 13,22 and 25) did not appear to be clear outcomes of MCD. Firstly, we decided to delete the item ‘I and my co-workers manage disagreements more constructively’ (no. 9). Although we considered it as a relevant outcome that participants might learn to deal with disagreements during and after MCD, it might have been too ambitious to learn this after a few MCD sessions. It might also have been too difficult to answer as it requires thinking about both disagreement itself as well as with how disagreement is dealt. Next, we considered learning about ethical theory (no. 13) not as a characteristic for the process of MCD as MCD is not a theoretical course but a reflective dialogue focusing on participants’ perspectives. The item about developing practice and policy (no. 22) was not considered as basically relevant for healthcare professionals and might have been a too ambitious goal of participating in some MCD sessions. Lastly, gaining consensus (no. 25) did not seem to be interpreted as a ‘Concrete Results’-outcome by respondents. We concluded that the term ‘consensus’ is confusing: does it mean that everyone agrees on the decision? Does it relate to shared decision-making, in the sense that all relevant parties should be involved in the decision-making process? In the end, MCD is not per se about decision-making or a joint agreement, and important parties for decision-making like patients or family might be absent. Therefore, we decided to delete this item. Nevertheless, aspects from these outcomes on how healthcare professionals jointly discuss about and decide on ethically difficult situations are resembled in the revised instrument (see part I).
Finalizing the instrument
In the last phase of the revision process, the draft version was discussed with four native English speakers in think aloud interviews, resulting in clarifications and adjustments on detailed item level. (See the Appendix I, Table 2 for their characteristics.) One of the suggestions was to divide the experience in the MCD sessions from the experience in daily practice, by making two separate questionnaires for each setting, with the same items. We accepted this suggestion as it was considered to enhance the readability and feasibility for future users of the Euro-MCD Instrument. As a consequence, respondents now have to rate their experience for only one setting (MCD sessions or daily practice). We decided that the Euro-MCD 2.0 can be completed at three moments: 1) at baseline, so before MCD participation, to assess experience of the listed outcomes in current daily practice; 2) directly after (a series of) MCD, to assess experience of outcomes during these MCD(s) and 3) at a later moment after (a series of) MCD, to assess experience of outcomes in daily practice. In the introduction of the questionnaire, respondents are instructed which setting they should consider when rating the items. As such, the context in which the respondent completes the instrument determines the particular question for the 15 items: if we want to know the outcomes with regard to the sessions, we ask about their experience when thinking about the sessions. If we want to know the outcomes with regard to daily practice (either before or after MCD participation), we ask respondents to complete the questionnaire with their daily practice in mind. In finalizing the instrument, we checked whether items were applicable for all these moments.