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Original Manuscript
Evaluation and perceived
results of moral case
deliberation: A mixed
methods study
Rien MJPA Janssens
VU University Medical Center EMGOþ, The Netherlands
Ezra van Zadelhoff
Zuyd University of Applied Sciences, The Netherlands
Ger van Loo
Moral Case Deliberation Committee at Sevagram, Organisation for Elderly Care, The Netherlands
Guy AM Widdershoven
VU University Medical Center EMGOþ, The Netherlands
Bert AC Molewijk
VU University Medical Center EMGOþ, The Netherlands; University of Oslo, Centre for Medical Ethics,
Norway
Abstract
Background: Moral case deliberation is increasingly becoming part of various Dutch healthcare
organizations. Although some evaluation studies of moral case deliberation have been carried out,
research into the results of moral case deliberation within aged care is scarce.
Research questions: How did participants evaluate moral case deliberation? What has moral case
deliberation brought to them? What has moral case deliberation contributed to care practice? Should
moral case deliberation be further implemented and, if so, how?
Research design: Quantitative analysis of a questionnaire study among participants of moral case
deliberation, both caregivers and team leaders. Qualitative analysis of written answers to open
questions, interview study and focus group meetings among caregivers and team leaders.
Participants and research context: Caregivers and team leaders in a large organization for aged care in
the Netherlands. A total of 61 moral case deliberation sessions, carried out on 16 care locations belonging
to the organization, were evaluated and perceived results were assessed.
Ethical considerations: Participants gave informed consent and anonymity was guaranteed. In the
Netherlands, the law does not prescribe independent ethical review by an Institutional Review Board for
this kind of research among healthcare professionals.
Findings: Moral case deliberation was evaluated positively by the participants. Content and atmosphere of
moral case deliberation received high scores, while organizational issues regarding the moral case
Corresponding author: Rien MJPA Janssens, Department of Medical Humanities, EMGO, VU University Medical Centre, P.O. Box
7057, 1007 MB Amsterdam, The Netherlands.
Email: mjpa.janssens@vumc.nl
Nursing Ethics
1–11
ªThe Author(s) 2014
Reprints and permission:
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10.1177/0969733014557115
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deliberation sessions scored lower and merit further attention. Respondents indicated that moral case
deliberation has the potential to contribute to care practice as relationships among team members
improve, more openness is experienced and more understanding for different perspectives is fostered. If
moral case deliberation is to be successfully implemented, top-down approaches should go hand in hand
with bottom-up approaches.
Conclusion: The relevance of moral case deliberation for care practice received wide acknowledgement
from the respondents. It can contribute to the team’s cohesion as mutual understanding for one another’s
views is fostered. If implemented well, moral case deliberation has the potential to improve care, according
to the respondents.
Keywords
Clinical ethics, clinical ethics support, aged care, evaluation, moral case deliberation
Introduction
Moral case deliberation (MCD) is a specific kind of clinical ethics support which can be understood as a
structured and methodological deliberation on how MCD participants perceive morally good (organization
of) care.
1–4
MCD is part of a larger development in Dutch healthcare organizations where initiatives are being
taken in order to (a) give structural attention to the moral dimension of determining good care and (b) support
healthcare professionals when being confronted with moraldilemmas and questions.
5
In MCD, caregivers and
other professionals are invited to participate in a dialogue in order to articulate, clarify and scrutinize their own
moral convictions and assumptions. The dialogue is facilitated by a trained facilitator, and often a specific
conversation method is used.
6
As such, MCD is different from everyday conversations or regular team
meetings. MCD is concerned with the moral dimension of caregiving, that is, with the question what is right
or wrong to do in a specific context. Not only the content of MCD (i.e. the caregiver’s moral concerns)
distinguishes MCD from everyday interaction, it is also the process of MCD that is different. In MCD, it is
expected from the participants that they have an open attitude to the moral convictions of others and to their
own moral convictions.Respect forothers, even if they holdother or opposite moral convictions, is required as
well as the willingness to change or amend your own convictions if deemed necessary. Both process and
content of the critical reflection within MCD are to increase caregivers’ awareness of the moral aspects of
their daily work. Furthermore, evaluation studies on MCD report that MCD can contribute to the handling
of difficult cases, professionals’ moral competency, multidisciplinary team cooperation and the development
or adjustment of policy or guidelines.
7
As such, MCD aims to improve care.
Recently, various healthcare institutions in the Netherlands have started MCD implementation projects.
5
Reflective studies on MCD have been published earlier.
1,6,8,9
Although MCD receives increasing attention
within Europe, empirical data on the evaluation and (perceived) results of MCD in aged care remain scarce.
Recently, some research in this area has been conducted.
7,10–12
Furthermore, in mental healthcare and aged
care contexts, a limited number of evaluation studies have been published.
13–15
These studies focus more on
the evaluation of the MCD process than on the results of MCD. In this contribution, we report quantitative
and qualitative results from a MCD evaluation and result study that was conducted among caregivers and
team leaders who participated in MCD sessions at a Dutch institution for aged care. The aim of the study
was to gain insight into what participants consider to be the value of MCD for themselves as professional
caregivers and for their organization, with a specific focus on the contribution of MCD to care practice. Four
research questions were formulated: (1) How did participants evaluate MCD? (2) What has MCD brought to
2Nursing Ethics
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them? (3) What has MCD contributed to their care practice? and (4) Should MCD be further implemented
within the institution and, if so, in what way?
In the section ‘Research setting’, we provide general information on the institutional context in which the
MCD sessions took place and on how the MCD sessions were organized. Second, in the ‘Methods’ section,
the qualitative and quantitative methods will be described. In the ‘Results’ section, the answers to the
research questions will be presented. Finally, the ‘Discussion’ section contains an analysis of the practical
relevance of MCD; it describes the study’s strengths and limitations and outlines lessons that can be learned
from the study. The findings of this study, both positive and negative, can be of relevance to other aged care
organizations which aim to implement and evaluate MCD. Furthermore, we hope that this article contri-
butes to the future of MCD evaluation and result studies.
Research setting
In 2007, MCD was introduced as a specific method during a small pilot project in a large organization for
aged care situated in the south of the Netherlands. The organization consists of 20 care centres where older
people can be admitted for various reasons. The care provided in the centres varies from specialist nursing
home care to more general support in daily activities. Terminal care is delivered in two hospices. The orga-
nization furthermore provides home care in the region and housing for older people who want to live close to
a care centre, in order to receive care when needed. A total of 2500 people are employed and 1100 volun-
teers are involved in the provision of care. At the time of the introduction of MCD in 2007, the Board of
Directors and the location managers suspected that attention for MCD would be congruent with the care
concept of the organization. Central notions in this concept of care are ‘human connection’, ‘authentic
understanding’ and ‘a warm, personal standard of care’. They decided to support the pilot project because
they assumed that MCD could (a) help raise the moral sensitivity of caregivers in their care delivery, (b)
contribute to a critical and learning organization and (c) promote transparent and effective cooperation and
decision-making. After positive experiences with the pilot project, it was decided in 2009 that MCD should
get structurally implemented in the whole organization. In order to facilitate this implementation process, an
MCD committee was installed consisting of a location manager (chair), two spiritual caregivers (of whom
one functions as the secretary of the committee) and two social workers. The members’ tasks were to collect
and disseminate knowledge on MCD and to monitor, steer and evaluate the implementation process of
MCD throughout the organization. Help was sought from an academic expertise group in clinical ethics sup-
port. This group developed an MCD facilitator training for 17 employees who were trained in order to
become facilitators of the MCD sessions.
16
As part of their training, the trainees practiced MCD sessions
at the shop floor with their fellow trainees in between the training days. The MCD committee decided to
start an evaluation and results study in order to assess how MCD participants had experienced the MCD
sessions and what they perceived as results of the MCD sessions for the daily practice. The findings of the
study were also used in order to reflect upon the quality of the MCD sessions as well as the quality of the
new facilitators. Finally, results from the study could possibly also adjust the on-going MCD implementa-
tion project. It is on this study that we report here.
A total of 61 MCD sessions were organized in 16 care centres. Participants were nursing caregivers of
various educational levels, motivational therapists and dieticians as well as team leaders. The MCD sessions
were chaired by the 17 newly trained facilitators. The facilitator requested the MCD participants to submit
‘a moral case’ 2 weeks before the sessions were scheduled. Case topics had to relate to a real-life experience
of the case presenter and there had to be a genuine concern or uncertainty regarding what was morally right
to do. In other words, the case had to really matter to the participant. Topics that were discussed included
cooperation within the team, responsibility towards family members of the client, use of opioids, dealing
with aggression, the use of coercion and freedom limitations. All deliberations were structured, using one
Janssens et al. 3
3
of two conversation methods for MCD: the dilemma method and the Socratic dialogue (for further reading
on methods for MCD, see Steinkamp and Gordijn,
6
Molewijk and Ahlzen
17
and Kessels et al.
18
).
Methods
Within this study, we made use of a combination of qualitative and quantitative research methods. All
participants of every MCD session received a questionnaire containing statements that were to be scored
on a 5-point Likert scale as well as a set of open questions. The statements focused on organization of MCD,
content of MCD, quality of the facilitator and experiences of participants (see Table 1). The open questions
addressed the perceived results of MCD for the individual participants and for care practice (see Table 2).
Quantitative as well as qualitative data were analysed. Quantitative answers were calculated using descrip-
tive analysis from Statistical Package for Social Sciences (SPSS). A total of 493 questionnaires were returned
from the 61 MCDs (team leaders N ¼43, caregivers N ¼450). Participants were required to fill out the
Table 1. Rating of closed questions by caregivers.
Evaluation of MCD
Mean score of caregivers
(standard deviation
within parentheses)
(N ¼450)
a
Organization of MCD 3.71 (s1.23)
There was ample time/space in my working schedule for participating in MCD 4.24 (s1.17)
I was informed on MCD in time 4.41 (s1.06)
We have prepared this MCD meeting as a team 2.46 (s1.46)
Content of MCD 4.44 (s0.91)
I felt appealed to the case at hand in the MCD 4.48 (s0.84)
The discussion was relevant for our practice 4.58 (s0.80)
The way of discussing with one another was constructive 4.51 (s0.78)
Everyone had an equal share in the conversation 4.25 (s1.04)
In this MCD, I had enough opportunity to say what was on my mind 4.47 (s0.96)
It was good to analyse our reflections on the theme in an interrogative way 4.36 (s0.98)
The MCD facilitator
The facilitator saw to it that everyone got his or her share during the MCD 4.53 (s0.78)
Atmosphere during MCD 4.62 (s0.77)
In the MCD, I could talk freely 4.62 (s0.77)
I felt safe during the MCD 4.62 (s0.76)
MCD: moral case deliberation.
a
Answers on 5-point Likert scale (1 ¼totally disagree and 5 ¼totally agree).
Table 2. List of open questions addressed to all MCD participants.
How can this MCD be improved?
What issues would you like to address in a future MCD?
What has MCD brought to the team?
What has MCD brought to you personally?
What should, after this MCD, happen in practice?
Do you have other general/supplemental remarks?
MCD: moral case deliberation.
4Nursing Ethics
4
questionnaires after the last MCD session, leading to an estimated response rate close to 100%. Answers to the
open questions received open codes that were clustered into themes which were subsequently analysed.
In addition to the questionnaires, five in-depth interviews and three focus group meetings were organized
in order to gain further, in-depth, insight into participants’ experiences with MCD, the perceived results of
MCD and their views on the MCD implementation process. This qualitative approach aimed at a more thor-
ough understanding and explanation of the quantitative data. Table 3 lists the open questions that were
addressed during both the interviews and the focus group meetings. All interviewees and participants of the
focus group meetings had gathered experience with MCD in the course of this study. They were recruited
from different locations and had different professional backgrounds (motivational therapist, team leader,
facilitator, care assistant, nurse and dietician). Interviews and focus group meetings were audio-taped and
transcribed. Interview summary reports were sent to all respondents for member check. Respondents’
amendments and additions were processed. Interview and focus group fragments received open codes
which were compared and collected into categories. The code tree was again compared to the rough data.
Interviewees and participants of the focus group meetings gave their Informed Consent and participated
voluntary. Anonymity was guaranteed. In the evaluation report, only the professional background of the
respondent was mentioned, as was promised in advance. In the Netherlands, the law does not prescribe inde-
pendent ethical review by an Institutional Review Board (IRB) for this kind of research among healthcare
professionals.
Results
Below the research questions mentioned above will be answered consecutively, following the research
questions.
Question 1: How did participants evaluate MCD?
Qualitative as well as quantitative results showed that MCD was regarded as (very) useful. Quantitative
results focused on the evaluative part of this study and are listed in Table 1. All statements together were
rated by the caregivers with an average score of 4.32 on a 5-point Likert scale. Caregivers indicate that the
sessions and the topics of deliberation were considered relevant to their daily work, and the relevance of
Table 3. List of open questions addressed to both interviewees (N ¼5) and focus groups (N ¼3).
What is MCD according to you?
What aim does MCD serve according to you?
How did you experience MCD?
What have been the results of MCD within the organization?
What, to your opinion, went well and what went less well?
Based on your experiences with MCD, how do you balance the costs versus the benefits of MCD?
What do you think of the organization and planning of MCD within the organization?
When is MCD successful in your opinion?
What preconditions are necessary in order to further develop MCD within the organization?
Is MCD the only means of reaching the set goals or are alternatives available? If so, which alternatives?
What are the consequences of MCD in practice?
What are good results of MCD within the organization? Do you see harmful results? What can be improved?
Are the educational effects of MCD picked up sufficiently?
How should MCD be continued and warranted in the organization?
MCD: moral case deliberation.
Janssens et al. 5
5
MCD for care practice was rated with 4.58 points. Content of MCD received an average score of 4.44. Most
participants felt free and safe to say what was on their minds (opportunity to say what is on your mind
receives a score of 4.47). The atmosphere during the sessions was considered to be open and respectful
(ability to speak freely and feel safe received scores of 4.62). Caregivers report relatively low scores on the
organization of the MCD sessions (average 3.71).
The statements addressed to the team leaders received an average score of 4.52. Team leaders were rel-
atively more positive about the content of MCD (4.58 caregivers, 4.84 team leaders) and the organization of
the MCD sessions (3.71 caregivers, 4.33 team leaders). With regard to the other questions, no notable dif-
ferences between the answers of team leaders and caregivers were seen. Table 2 lists the open questions that
were directed to all respondents.
The answers to the open questions can explain some of the quantitative data reported above. With regard
to the organization of the MCD meetings, participants often reported that the case was not always submitted
(2 weeks) before the session. Some did not know what to expect from MCD and report that they would have
appreciated a more general introduction into MCD. Thus, respondents felt not always adequately prepared
for the sessions. Participants regularly mentioned that being given time for preparing and participating in the
MCD sessions is crucial in this respect.
Other answers indicate that topics for future MCD should not only relate to difficult situations with
patients and loved ones. Also, the functioning of the team and communication between caregivers are men-
tioned as possible future topics for MCD. The open questionnaire made clear that many appreciated the role
of the facilitator. In this respect, team leaders as well as caregivers see surplus value in the structured con-
versation method within MCD. One caregiver, however, writes that she or he would prefer to get more free-
dom (i.e. a less structured conversation method) during the MCD sessions.
In some sessions, not every participant had the feeling that she or he was given equal opportunity to
articulate his or her opinion. One team leader underscores this as she or he writes,
the opinions of the participants should get more equal attention. (Team leader in evaluation questionnaire)
Various respondents indicate they experienced openness, understanding and respect:
MCD stimulates growth, understanding and insight of the professional and the team. (Team leader in evaluation
questionnaire)
Some caregivers stated that it was not always easy to see the team leader as an equal participant. Some
caregivers reported that MCD has made it easier to contact the team leader in the future with possible prob-
lems or ideas.
Respondents, caregivers as well as team leaders, felt sorry that not all members of the team were always
present. Various respondents favour obligatory presence for all because they see MCD as a group happen-
ing, whereas others mention that unwilling participants may hamper the (quality of the) dialogue.
Question 2: What has MCD brought to the participants?
The rest of this section focuses on the answers to the open questions and the interviews and focus groups.
These qualitative data highlight the results of MCD as perceived by the MCD participants and can be used to
draw lessons and point out directions for the future of MCD within the organization. Table 3 lists the open
questions addressed to interviewees and focus group members.
Respondents mentioned that MCD can contribute to a gradual process in which feelings of trust and
safety are fostered. In this respect, the facilitator needs to have an eye for the hierarchy in the team, espe-
cially since team leaders are present. Respondents note that mutual understanding among colleagues is
6Nursing Ethics
6
enhanced and respect for other people’s views and care practice is increased. Respondents got to know one
another better. A team leader notes that
MCD paves the way to open communication. (Team leader in interview)
A caregiver states,
You get to know other peoples’ feelings of powerlessness and what’s bothering them. (Team member in evalua-
tion questionnaire)
Interviewees not only acknowledge but also appreciate the fact that participants in MCD have different
perspectives. They see the value of getting acquainted with the other opinions and ideas of colleagues
because it can help explain their everyday care practice. An interviewee states,
Because we discussed the case, relationships with colleagues change. There is more understanding. When dif-
ficult situations occur, I say: ‘Guys, can I go out for a minute?’ They now know my story, emotions and ideas
behind it. (Team member in interview)
For the caregivers personally, MCD has increased awareness as well as empathy with other colleagues.
Respondents indicate that participants become more conscious of their own views and ways of acting:
To me, this MCD has brought the awareness that my behaviour/practice affects others. (Team member in eva-
luation questionnaire)
You get to appreciate one another’s views. I have learnt to think broader and to judge differently. (Team member
in evaluation questionnaire)
I now see that you should not deal with questions and impossibilities on your own ... and instead seek for solu-
tions together. (Team member in evaluation questionnaire)
Question 3: What has MCD contributed to care practice?
The answers regarding the impact of MCD on everyday care practice seem to be closely related to the per-
ceived impact of MCD on the participants (question 2). For instance, experiences of safety mentioned above
are considered relevant for everyday care practice as understanding for colleagues is increased and dialogue
is fostered:
After MCD you share more with other team members. Everyone listens better now to what others have to say ...
There is more negotiation and understanding. You also approach colleagues quicker and that may happen more
often, in my view. (Team member in interview)
I also notice that at other moments (other than MCD, authors) there is recognition of the moral weight of an issue,
leading to dialogue. (Team member in interview)
You often presuppose that others think likewise but after hearing different points of view, you realise that that is
not the case ... Now, you negotiate more often and look at a case together. (Team member in interview)
MCD makes participants feel better as they experience that their views and stories are taken seriously.
This improves care, according to the following respondent:
Janssens et al. 7
7
You feel better if you get advice on how to handle difficult situations. If you feel better, than you also have,
unconsciously, another way in which you deal with clients. If you feel more relaxed, you can also make another
person feel better. The quality of care thus improves. (Team member in interview)
The impact of MCD on the way caregivers work together is illustrated by a team member who says,
In MCD, people working in care practice experience the amount of force, information and knowledge they
possess. This is not the case in normal conversations ... The old way of working was passive ... now,
people learn to take more initiative and that means that they think, work and act differently. (Team mem-
ber in interview)
MCD thus seems to raise awareness and understanding, not only on an individual level (Research Ques-
tion 2) but also on an interpersonal level and at the team level.
Question 4: Should MCD be further implemented and, if so, how?
In the light of the positive experiences described above, most respondents indicate that MCD should be con-
tinued, in separate sessions but also as an integral part of everyday care. Open dialogue should become part
of regular team meetings. The interviewees and focus group members also indicate that the atmosphere and
method of conversation in MCD should become part of the team meetings:
You can organise team meetings in a way that people really talk and share with one another. (Team member in
interview)
Apart from integrating the lessons from MCD in everyday practice, separate MCD sessions can also
count on support. Most respondents agree that MCD is the best way to come to a structured dialogue on
difficult matters. A minimum of two MCDs a year for every ward is deemed appropriate but respondents
indicate that if there is a need for an MCD, for instance due to an acute problem, extra ad hoc MCDs may be
organized. Finally, respondents indicate that they need time, not only to participate in an MCD but also to
prepare an MCD session (cf. Research Question 1):
Time should be made available to discuss dilemmas at ease, since everyday concerns may easily swallow you up.
The necessity of MCD is acknowledged in high and low levels of the organisation. Location manager and team
leader need to stimulate the caregivers. (Team member in interview)
Thus, respondents advocate a two-way trajectory: (1) The lessons learnt from MCD related to dialogue
and questioning should become part of everyday practice and team meetings and (2) separate MCD sessions
should be organized at least twice a year and if possible more often.
In order to guarantee continuity, it is vital that the topics that are discussed during MCD lead to actions,
respondents say. This may imply contact with other levels within the organization. Some matters should be
dealt with by the board of directors, while other matters are best dealt with by care managers:
It is of importance that something is done with the issues discussed during MCD. If certain issues are regularly
discussed, for instance safety policy or work environment, contact should be sought with other levels of the orga-
nisation. Some issues can for instance be dealt with at the management level. The (MCD, authors) committee can
submit issues and cases but team members can also submit issues to team leaders or care managers. (Team mem-
ber in interview)
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8
Thus, MCD is seen not only in connection to care practice but also in connection to the policy of
the organization. Warranting continuity of MCD is a matter of top-down as well as bottom-up
approaches.
In the end, the management of the several locations is considered responsible for the coordination of
future MCD sessions.
Discussion
This study in a Dutch organization for aged care has provided insight into how participants of MCD eval-
uated the MCD sessions and what kind of results of MCD they perceived. MCD was evaluated well by the
respondents. The atmosphere and the role of the facilitator received scores above 4.50 on a 5-point Likert
scale. Apparently, the facilitators managed to foster a safe environment during the sessions in which the
majority of participants felt free to say what was on their minds. At the same time, a few respondents felt
they did not have an equal share in the conversation. The variety of opinions that were articulated during the
sessions was appreciated. Participants tried to empathize with views which were not necessarily their own.
In spite of the good evaluation of the facilitator, some participants experienced difficulties in experiencing
equality since also team leaders were present in the MCD sessions. One of the recurring problems during the
sessions was that not all team members were present. Some respondents argued for an obligatory presence
in this respect, while others object to having an MCD session with unwilling participants. Other problems
regarding the organization of the MCD sessions relate to the lack of instructive information and time to pre-
pare well for an MCD session.
With regard to the results of MCD, interesting findings came to the surface. Results mentioned were
among others increased openness, increased mutual understanding and increased respect for different per-
spectives and opinions. Respondents report that MCD increased the team’s cohesion even though this
notion was not explicitly mentioned in the questionnaire or interview study. Respondents reported that they
experience the impact of MCD in their daily practice. They feel free to address one another more often and
earlier, including team leaders. The MCD participants reported that they experienced that MCD improves
the quality of care (e.g. in the way patients are approached). The impact of MCD on dealing with difficult
problems and on everyday care was one of the interesting findings of this study on the evaluation and per-
ceived results of MCD.
For this impact of MCD, proper implementation, taking into account the specific characteristics of the
organization, is a prerequisite. In this organization, there has been a long-term and gradual increasing
investment in MCD. MCD could count on support from the management and Board of Directors. The instal-
lation of an MCD committee, specifically designed to develop and organize MCD throughout the organi-
zation, was illustrative in this respect. Furthermore, much time and effort were invested in the training of 17
employees as MCD facilitators. In times of scarcity in which organizations are more and more focusing on
effectiveness and cost-efficiency, management support cannot be taken for granted.
8
Apart from the role of
the management, bottom-up enactment of MCD is also essential.
10,13
Strengths and limitations of this study
A strength of our study was the combination of qualitative and quantitative methods which made that the
results could be deepened and enriched. This helped to broaden the scope of the data, and a rich image was
thus revealed on the promises and pitfalls of the implementation of MCD in this institution for aged care.
Another strength was the relatively high response rate and the high number of MCD sessions that were eval-
uated. However, our study has some limitations too. The number of interviews and focus groups was lim-
ited. Furthermore, the results of our study cannot easily be generalized and applied to other care settings
Janssens et al. 9
9
because the implementation and evaluation of MCD is context depended.
19
This study does not answer the
question whether the results could also be reached through other measures than MCD (in other words, how
typical are the results for MCD as ‘intervention’?). However, the findings are often related to the specific
characteristics of MCD (e.g. focusing on dialogue, listening, learning from differences and the constructive
handling of disagreement). Finally, this study only presented perceived results according to the MCD par-
ticipants. Although these findings are important, this study and the research design of this study do not
inform us about what factually changed and whether this was caused by the MCD sessions. Future research
studies could focus on observational results of MCD sessions.
Recommendations
Investment in the quality of the MCD sessions is an important recommendation for those institutions that
want to start with or implement MCD. The MCD facilitators play a key role in creating and fostering safety
and dialogue among the participants. Therefore, ample time should be invested in the professional training
of the MCD facilitators and some follow-up sessions as well.
20
Furthermore, if MCD is to get implemented
well, management support is required as well as bottom-up support. Top-down and bottom-up approaches
should go hand in hand. Successful MCD implementation requires additional preparation, time and a well-
functioning MCD committee. Members of this MCD committee were in touch with the MCD facilitators,
the MCD participants as well as with the management and Board of Directors. Training of MCD facilitators
is just a first step of the implementation process.
Another recommendation regarding the implementation of MCD is the fact that the evaluation of MCD
not only monitors the progress and pitfalls of the implementation process but also facilitates the implemen-
tation itself. Through the evaluation study, many stakeholders were given a voice regarding how they relate
to MCD and what their interest of MCD is. Evaluation research can, when performed and designed in an
appropriate way, stimulate employees’ ownership and the practical usefulness of MCD.
Our final recommendation relates to future research in (implementation of) MCD. While a limited num-
ber of MCD evaluation studies have been conducted, future studies could also focus on the concrete impact
of MCD for the quality of care.
9,21
Even though MCD has a clear value in itself, as clearly demonstrated by
different MCD evaluation studies with MCD participants, it is important to explore the actual contribution
to the quality of care via other research designs such as observational and control-group studies.
Acknowledgements
We would like to thank all respondents for their contribution to this study. Furthermore, we would like to
thank the organization, including the management team, the Board of the Directors and last but not least the
MCD Committee for their on-going investment and cooperation.
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit
sectors.
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