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Until recently, moral case deliberation (MCD) sessions have mostly been facilitated by external experts, mainly professional ethicists. We have developed a train the facilitator programme for healthcare professionals aimed at providing them with the competences needed for being an MCD facilitator. In this paper, we present the first results of a study in which we evaluated the programme. We used a mixed methods design. One hundred and twenty trained healthcare professionals and five trainers from 16 training groups working in different healthcare organisations throughout the Netherlands were included. After completion of the programme, participants feel sufficiently confident and equipped to facilitate an MCD session. Feeling competent does not mean that participants have no doubts or questions left. Rather, they are aware of their limitations and see the need for continuous learning. According to the respondents, the actual exercise of facilitating MCD during and in between the training sessions contributed most to the development of competences necessary for being an MCD facilitator. Respondents without prior experience of participating in MCD sessions felt less competent after the training than those who had participated in MCD sessions before. Self-attributed competence varied between participants with different professional backgrounds. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The aim of this study is to investigate to which extent diversity is part of current healthcare practices and to explore opportunities and barriers in the implementation of diversity dimensions in healthcare practices. METHODS: Nine in-depth, semi-structured interviews and three focus groups were conducted in three healthcare settings (mental health, hospital, nursing home care). RESULTS: Results demonstrate that (the potential of) diversity is an ambiguous issue; diversity is said to be important, but this has not led to adjustments of the neutral, disease-oriented approach of patients. If recognized at all, diversity is reduced to one dimension (sex). Barriers in the implementation of diversity relate to: (a) lacking awareness and knowledge of diversity, (b) poor information and communication, and (c) organizational constraints. Opportunities to implement diversity in healthcare include: (d) an emerging sense of urgency to attend to diversity, (e) the development of good practices, and (f) the political climate. CONCLUSION: Various barriers and some opportunities for the implementation of diversity in healthcare practices have been identified. There is an ambiguity in how professionals deal with diversity. As a result, the neutral approach remains dominant in practice and policy. PRACTICE IMPLICATIONS: In order to raise the awareness and enhance the competence of professionals, educational programmes and learning networks are required. [ABSTRACT FROM AUTHOR]

Background: Clinical ethics support instruments aim to support healthcare professionals in dealing with moral challenges in clinical practice. CURA is a relatively new instrument tailored to the wishes and needs of healthcare professionals in palliative care, especially nurses. It aims to foster their moral resilience and moral competences. Aim: To investigate the effects of using CURA on healthcare professionals regarding their Moral Resilience and Moral Competences. Design: Single group pre-/post-test design with two questionnaires. Methods: Questionnaires used were the Rushton Moral Resilience Scale measuring Moral Resilience and the Euro-MCD, measuring Moral Competences. Respondents mainly consisted of nurses and nurse assistants who used CURA in daily practice. Forty-seven respondents contributed to both pre- and post-test with 18 months between both tests. Analysis was done using descriptive statistics and Wilcoxon signed rank tests. This study followed the SQUIRE checklist. Ethical considerations: This study was approved by the Institutional Review Board of Amsterdam UMC. Informed consent was obtained from all respondents. Results: The total Moral Resilience score and the scores of two subscales of the RMRS, that is, Responses to Moral Adversity and Relational Integrity, increased significantly. All subscales of the Euro-MCD increased significantly at posttest. Using CURA more often did not lead to significant higher scores on most (sub) scales. Conclusion: This study indicates that CURA can be used to foster moral resilience and moral competences of healthcare professionals. CURA therefore is a promising instrument to support healthcare professionals in dealing with moral challenges in everyday practice., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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.

So far, a recognizable pattern of clinical symptoms for child sexual abuse (CSA), especially in young male children, is lacking. To improve early recognition of CSA, we reviewed physical complaints, physical examination, and tests on sexually transmitted infections (STIs) in confirmed victims (predominantly preschool boys) of CSA from the Amsterdam sexual abuse case (ASAC). We retrospectively analyzed the outcomes of the primary assessment using mixed methods: descriptive analysis of physical complaints, physical exams, and STI tests from medical files and a qualitative analysis on expert's interpretations of physical complaints and children's behavior during physical examination. We included 54 confirmed CSA victims, median age 3.2 (0-6) years, 43 boys (80%), and 11 girls (20%). Physical complaints were reported in 50%, of which gastrointestinal and anogenital complaints were most common. None of the children showed CSA-specific genital signs at physical examination. Most prominent finding during physical examination was a deviant behavioral response (anxiety, withdrawal, too outgoing) in 15 children (28%), especially in children who experienced anal/vaginal penetration. Testing for STIs was negative., Conclusion: Physical complaints and physical signs at examinations were non-specific for CSA. Deviant behavioral reactions during physical examination were the most prominent finding. Precise observation of a child's behavior during physical examination is needed. What is known • Child sexual abuse (CSA) affects many children on both the short and the long term but remains unrecognized in most cases. • So far, there is a lack of studies on symptom patterns of CSA in male, preschool children. What is new • None of the children showed CSA-specific findings at physical and anogenital examination; STIs were not found in the confirmed victims of CSA. • The most prominent finding was the deviant behavioral response of the children examined, especially in children who experienced anal/vaginal penetration; therefore, precise observation of a child's behavior during physical examination is a crucial part of the evaluation of suspected CSA.

Health care professionals often face moral dilemmas. Not dealing constructively with moral dilemmas can cause moral distress and can negatively affect the quality of care. Little research has been documented with methodologies meant to support professionals in care for the homeless in dealing with their dilemmas. Moral case deliberation (MCD) is a method for systematic reflection on moral dilemmas and is increasingly being used as ethics support for professionals in various health-care domains. This study deals with the question: What is the contribution of MCD in helping professionals in an institution for care for the homeless to deal with their moral dilemmas? A mixed-methods responsive evaluation design was used to answer the research question. Five teams of professionals from a Dutch care institution for the homeless participated in MCD three times. Professionals in care for the homeless value MCD positively. They report that MCD helped them to identify the moral dilemma/question, and that they learned from other people's perspectives while reflecting and deliberating on the values at stake in the dilemma or moral question. They became aware of the moral dimension of moral dilemmas, of related norms and values, of other perspectives, and learned to formulate a moral standpoint. Some experienced the influence of MCD in the way they dealt with moral dilemmas in daily practice. Half of the professionals expect MCD will influence the way they deal with moral dilemmas in the future. Most of them were in favour of further implementation of MCD in their organization.

Background: Patients' preferences and expectations should be taken into account in treatment decision making in the last phase of life. Shared decision making (SDM) is regarded as a way to give the patient a central role in decision making. Little is known about how SDM is used in clinical practice in advanced cancer care., Objective: To examine whether and how the steps of SDM can be recognized in decision making about second- and third-line chemotherapy., Methods: Fourteen advanced cancer patients were followed over time using face-to-face in-depth interviews and observations of the patients' out-clinic visits. Interviews and outpatient clinic visits in which treatment options were discussed or decisions made were transcribed verbatim and analysed using open coding., Results: Patients were satisfied with the decision-making process, but the steps of SDM were barely seen in daily practice. The creation of awareness about available treatment options by physicians was limited and not discussed in an equal way. Patients' wishes and concerns were not explicitly assessed, which led to different expectations about improved survival from subsequent lines of chemotherapy., Conclusion: To reach SDM in daily practice, physicians should create awareness of all treatment options, including forgoing treatment, and communicate the risk of benefit and harm. Open and honest communication is needed in which patients' expectations and concerns are discussed. Through this, the difficult process of decision making in the last phase of life can be facilitated and the focus on the best care for the specific patient is strengthened., (© 2015 The Authors. Health Expectations Published by John Wiley & Sons Ltd.)

After a traumatic event like a stroke, people need to find meaning and control again. This study enhances knowledge on one of the driving principles behind meaning-making processes: global meaning. Global meaning refers to individuals' general orienting systems, comprising fundamental beliefs and life goals. Little is known about global meaning in people with stroke and whether global meaning changes after stroke. In this qualitative study, five aspects of global meaning were found: core values, relationships, worldview, identity and inner posture. Continuity in all aspects was reported, but worldview, identity and inner posture were also subjected to change., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Objective: In 2006, a goal of reducing seclusion in Dutch hospitals by at least 10% each year was set. More than 100 reduction projects in 55 hospitals have been conducted, with €35 million in funding. This study evaluated the results., Methods: Data (2008 to 2013) were from a national register. Multilevel logistic regression examined determinants of seclusion., Results: Hospital participation in the register ranged from eight in 2008 to 66 in 2013, and admissions ranged from 11,300 to 113,290. The average yearly nationwide reduction of secluded patients was about 9%. Reduction was achieved in half of the hospitals. Some hospitals saw increased rates. In some hospitals where seclusion decreased, use of forced medication increased. Higher seclusion rates were associated with psychotic and bipolar disorders, male gender, and several ward types., Conclusions: Seclusion decreased significantly, and forced medication increased. Rates varied widely between hospitals. For many hospitals, more efforts to reduce seclusion are needed.

Study Design: Qualitative study., Objectives: To explore whether aspects of global meaning (that is, fundamental beliefs and life goals concerning core values, relationships, worldview, identity and inner posture) are associated with processes and outcomes in rehabilitation, as experienced by people with spinal cord injury (SCI)., Setting: People living in the community receiving outpatient rehabilitation in a Dutch rehabilitation center., Methods: In-depth semi-structured interviews were conducted with 16 people with SCI. Interviews were analyzed using qualitative research methods: structural and provisional coding., Results: Core values, relationships, worldview, identity and inner posture (that is, the way in which people relate to the facts of life) were associated with various processes and outcomes of rehabilitation. Elements of the rehabilitation process included motivation, regulation of emotion, making decisions and handling stress. Elements of the outcome of rehabilitation included physical functioning, emotional functioning, social functioning and subjective sense of meaning. The influence was positive, with the exception of one case in which worldview and inner posture were negatively associated with motivation. Besides that, respondents emphasized the importance of rehabilitation professionals attuning to their global meaning., Conclusion: All aspects of global meaning were positively associated with various processes and outcomes of rehabilitation. It is recommended that rehabilitation professionals are aware of the importance of global meaning to people with SCI and that they take people's fundamental beliefs and life goals into account.

WHAT IS KNOWN ON THE SUBJECT?: Nurses play an important role in monitoring and supporting patients and their relatives at the end of life. To date, there is a lack of recent empirical research on the experiences of psychiatric nurses in providing palliative care to psychiatric patients who suffer from life-threatening physical co-morbidity. The limited literature available indicates that palliative care for psychiatric patients needs to be improved. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This explorative study is unique in offering an insight into current palliative care practice for psychiatric patients and showed that one in three nurses working in Dutch mental health facilities is involved in palliative care provision. Important elements of palliative care, i.e.: care domains, multidisciplinary approach, early recognition and family care are recognized by nurses. Moreover, in palliative care for psychiatric patients there is more attention for psychosocial and spiritual care compared to palliative care for patients without psychiatric disorders. Patient characteristics and little attention for palliative care within mental health facilities were found to hamper timely and adequate palliative care provision by nurses. WHAT ARE THE IMPLICATIONS FOR RESEARCH AND PRACTICE?: Educating psychiatric nurses about palliative care and close collaboration between physical and mental health care are crucial to address the palliative care needs of this vulnerable patient group. Since mental health care is increasingly provided ambulatory, the development of palliative care for psychiatric patients outside mental health facilities should be closely monitored., Abstract: Introduction Recent empirical research on palliative care for psychiatric patients is lacking. Aim The aim of this study was to explore nurses' experiences with and identify barriers to providing palliative care to psychiatric patients in Dutch mental health facilities. Methods Mixed-methods; 137 nurses working in Dutch mental health facilities completed a survey. Nine participated in in-depth interviews. Results Thirty-six percent of nurses had experience with providing palliative care to psychiatric patients with physical co-morbidity in the past 2 years. Of all patients, 63% received physical care before death, 46% psychosocial care and 33% spiritual care. In 91% of all cases, care was provided by multidisciplinary teams. Patient characteristics and little attention to palliative care were barriers for timely and adequate palliative care. Discussion In palliative care for psychiatric patients, there is more attention for psychosocial and spiritual care compared to palliative care for patients without psychiatric disorders. Yet there are barriers to adequate palliative care provision. Implications for practice Educating psychiatric nurses about palliative care and close collaboration between physical and mental health care are crucial to address the palliative care needs of psychiatric patients. Since mental health care is increasingly provided ambulatory, palliative care for psychiatric patients outside mental health facilities should be closely monitored., (© 2016 John Wiley & Sons Ltd.)

Purpose: In response to the increased emphasis placed on older people's self-reliance in many welfare societies, we aimed to develop and validate a measurement instrument, assessing perceived control in health care among older adults with care needs. The target group consists of older people who live (semi-)independently and use professional health care, with or without informal care., Methods: Phase I (development) of the study consisted of the construction of the instrument based on the input from a variety of stakeholders. Phase II (validation) entailed a quantitative study in a sample of 247 respondents selected from the Longitudinal Aging Study Amsterdam, to assess the instrument's construct validity (structural validity and hypotheses testing) and reliability (internal consistency)., Results: The questionnaire consists of 29 items, related to organizing professional care, communication with care professionals, health management in the home situation, planning (more) complex care in the future, and perceived support from the social network. Based on a factor analysis, we identified three subscales: (I.) 'perceived personal control in health care'; (II.) 'anticipated personal control regarding future health care'; and (III.) 'perceived support from the social network,' with internal consistencies varying from Cronbach's α = .71 to .90. Factor I was associated with mastery, self-efficacy, self-esteem (r = .31-.35) and factor III with social loneliness (r = -.42). Factor II correlated less strongly with mastery, self-efficacy, and self-esteem (r < .30)., Conclusion: Our questionnaire revealed sufficient construct validity and internal consistency. The instrument provides a basis for further quantitative research regarding control, especially in relation to health care-related outcomes.

Patient competence, defined as the ability to reason, appreciate, understand, and express a choice is rarely discussed in patients with obsessive compulsive disorder (OCD), and coercive measures are seldom used. Nevertheless, a psychiatrist of psychologist may doubt whether OCD patients who refuse treatment understand their disease and the consequences of not being treated, which could result in tension between respecting the patient's autonomy and beneficence. The purpose of this article is to develop a notion of competence that is grounded in clinical practice and corresponds with the experiences of patients with obsessions and/or compulsions. We present a naturalistic case study giving both the patient's and the therapist's perspective based on in-depth interviews and a narrative analysis. The case study shows that competence is not merely an assessment by a therapist, but also a co-constructed reality shaped by the experiences and stories of patient and therapist. The patient, a medical student, initially told her story in a restitution narrative, focusing on cognitive rationality. Reconstructing the history of her disease, her story changed into a quest narrative where there was room for emotions, values and moral learning. This fitted well with the therapist's approach, who used motivational interventions with a view to appealing to the patient's responsibility to deal with her condition. We conclude that in practice both the patient and therapist used a quest narrative, approaching competence as the potential for practical reasoning to incorporate values and emotions.

Purpose: The study aims to describe mechanisms that contribute to the tendency towards continuing chemotherapy in patients with advanced cancer., Methods: The study conducted qualitative observations of outpatient clinic visits of 28 patients with advanced cancer (glioblastoma and metastatic colorectal cancer)., Results: We uncovered four mechanisms in daily oncology practice that can contribute to the tendency towards continuing chemotherapy in patients with advanced cancer: (1) "presenting the full therapy sets the standard"--patients seemed to base their justification for continuing chemotherapy on the "standard" therapy with the maximum number of cycles as presented by the physician at the start of the treatment; (2) "focus on standard evaluation moments hampers evaluation of care goals"--whether or not to continue the treatment was mostly only considered at standard evaluation moments; (3) "opening question guides towards focus on symptoms"--most patients gave an update of their physical symptoms in answer to the opening question of "How are you doing?" Physicians consequently discussed how to deal with this at length, which often took up most of the visit; (4) "treatment is perceived as the only option"--patients mostly wanted to continue with chemotherapy because they felt that they had to try every available option the physician offered. Physicians also often seemed to focus on treatment as the only option., Conclusion: Discussing care goals more regularly with the patient, facilitated for instance by implementing early palliative care, might help counter the mechanisms and enable a more well-considered decision. This could be either stopping or continuing chemotherapy.

Background: After spinal cord injury (SCI), people are confronted with abrupt discontinuity in almost all areas of life, leading to questions on how to live a meaningful life again. Global meaning refers to basic ideas and goals that guide people in giving meaning to their lives, in specific situations. Little is known about global meaning relating to SCI and whether global meaning changes after SCI., Purpose: The purpose of this study was twofold: (i) to explore the content of global meaning of people with SCI, and (ii) to explore whether or not global meaning changes after SCI., Methods: In-depth semi-structured interviews were conducted with 16 people with SCI. Interviews were analyzed according to the method of grounded theory., Results: (i) Five aspects of global meaning were found: core values, relationships, worldview, identity and inner posture. (ii) Overall, little change in the content of global meaning was found after SCI; specific aspects of global meaning were foregrounded after SCI., Conclusion: Five aspects of global meaning were found in people with SCI. Global meaning seems hardly subject to change.

Aims: Providing management insights regarding moral case deliberation (MCD) from the experiential perspective of nursing managers., Background: MCD concerns systematic group-wise reflection on ethical issues. Attention to implementing MCD in health care is increasing, and managers' experiences regarding facilitating MCD's implementation have not yet been studied., Method: As part of an empirical qualitative study on implementing MCD in mental health care, a responsive evaluation design was used. Using former research findings (iterative procedures), a managers' focus group was organised., Results: Managers appreciated MCD, fostering nurses' empowerment and critical reflection - according to managers, professional core competences. Managers found MCD a challenging intervention, resulting in dilemmas due to MCD's confidential and egalitarian nature. Managers value MCD's process-related outcomes, yet these are difficult to control/regulate., Conclusions: MCD urges managers to reflect on their role and (hierarchical) position both within MCD and in the nursing team., Implications for Nursing Management: MCD is in line with transformative and participatory management, fostering dialogical interaction between management and nursing team., (© 2015 John Wiley & Sons Ltd.)

Background: In cancer care, difficult decisions concerning advanced treatment need to be made, weighing possible life prolongation against harmful side effects. Treatment is frequently started, showing the need to explore how decisions are made. Little is known about the perspectives of physicians on sharing decision making with patients. This qualitative study aimed to describe the perspectives of medical specialists on the decision-making process with patients with glioblastoma concerning starting new treatment., Methods: Qualitative interviews were held with medical specialists. One focus group was organized with medical professionals. Their opinions about elements of shared decision making and the applicability in the context of patients with glioblastoma were assessed. The topic list for the focus group was based on the analysis of the interviews. Qualitative analysis of the transcripts was performed by three researchers independently., Results: Medical specialists considered shared decision making to be important; however, they did not adhere to its elements. Stopping treatment was not considered equal to continuing treatment. Exploration of the patients' wishes was done implicitly, and shared responsibility for the decision was not highly recognized. The main barriers to shared decision making were preferences of both patients and specialists for starting or continuing treatment and assumptions of physicians about knowing what patients want., Conclusion: Medical specialists recognized the importance of patient involvement but experienced difficulty in sharing decision making in practice. Elements of shared decision making are partly followed but do not guide decision making. To improve cancer care, education of medical specialists and adjustment to the elements are needed to involve patients., (©AlphaMed Press.)

Background: We studied preferences on continuing or forgoing different types of treatments at the end of life in two groups: the general public and people with an advance directive (AD). Furthermore, we studied factors associated with these preferences and whether people's preferences concurred with the content of their AD., Methods: A representative sample of the Dutch population (n=1402) and a cohort of people who own an AD, consisting of members of Right to Die-NL (NVVE, n=5661) and the Christian-orientated Nederlandse Patiënten Vereniging (NPV, n=1059), answered written questionnaires in 2005 or 2007. We used two hypothetical scenarios, about cancer and dementia, and asked questions about continuing or forgoing four medical treatments., Results: A majority of the Dutch public (62-87%) and NVVE members (88-99%) wanted to forgo the different treatments in both scenarios, while members of the NPV generally wanted to continue treatment (46-73%). In all three groups, in both scenarios, a substantial group (13-38%) had different preferences for the different treatments. People were more explicit in their preferences in case of dementia than in case of cancer. Being female, over 55 years of age, having had a higher education and having no (significant) religion increased the odds to refuse treatment. ADs that gave the direction to refuse treatment generally concurred with the preference of their owners (85-98% wanting to refuse treatments)., Discussion: The fact that people with and without ADs have different preferences concerning different treatments and diseases stresses the importance of communication surrounding decision making at the end of life., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Decision-making in the acute phase after a severe stroke is complex and may involve life-and-death decisions. Apart from the medical condition and prognosis, quality of life and the deliberation of palliative care should be part of the decision-making process. Relatives play an important role by informing physicians about the patient's values and preferences. However, little is known about how the patients' relatives experience the decision-making process., Aim: To elicit the perspective of relatives of severe stroke patients with regard to the decision-making process in the acute phase in order to understand how they participate in treatment decisions., Design: An exploratory qualitative interview approach guided by the principles of grounded theory., Settings/participants: Relatives of severe stroke patients (n = 15) were interviewed about their experiences in the decision-making process in the acute phase., Results: Four categories reflecting relatives' experiences were identified: (1) making decisions under time pressure, (2) the feeling of 'who am I' to decide, (3) reluctance in saying 'let her die' and (4) coping with unexpected changes. Following the treatment proposal of the physician was found to be the prevailing tendency of relatives in the decision-making process., Conclusion: A better understanding of the latent world of experiences of relatives that influence the decision-making process may help physicians and other health-care providers to better involve relatives in decision-making and enhance the care, including palliative care, for patients with severe stroke in line with their values and preferences. Communication between physician and relatives seems vital in this process., (© The Author(s) 2015.)

Purpose: The purpose of this study is to provide a critical analysis of contemporary Lean leadership in the context of a healthcare practice. The Lean leadership model supports professionals with a leading role in implementing Lean. This article presents a case study focusing specifically on leadership behaviours and issues that were experienced, observed and reported in a Dutch university medical centre., Design/methodology/approach: This ethnographic case study provides auto-ethnographic accounts based on experiences, participant observation, interviews and document analysis., Findings: Characteristics of Lean leadership were identified to establish an understanding of how to achieve successful Lean transformation. This study emphasizes the importance for Lean leaders to go to the gemba, to see the situation for one's own self, empower health-care employees and be modest. All of these are critical attributes in defining the Lean leadership mindset., Originality/value: In this case study, Lean leadership is specifically related to healthcare, but certain common leadership characteristics are relevant across all fields. This article shows the value of an auto-ethnographic view on management learning for the analysis of Lean leadership. The knowledge acquired through this research is based on the first author's experiences in fulfilling his role as a health-care leader. This may help the reader examining his/her own role and reflecting on what matters most in the field of Lean leadership.

Frail older adults are increasingly encouraged to be in control of their health care, in Western societies. However, little is known about how they themselves perceive control in health care. Therefore, this study aims to investigate the concept of health care-related perceived control from the viewpoint of frail older adults. A qualitative interview study was conducted following a Grounded Theory approach. Thirty-two Dutch frail older adults, aged 65 and over, participated in 20 in-depth interviews (n=20) and three focus group discussions (n=12). Data were analysed according to techniques of coding and constant comparison. From this analysis constituting factors of perceived control emerged, providing elements of a conceptual model. Perceived control reflects the feeling or belief that health care is under control, which is constituted by five, either internal or external, factors: (I) self-confidence in organising professional and/or informal care, (II) self-confidence in health management in the home setting, (III) perceived support from people in the social network, (IV) perceived support from health care professionals and organisations, and (V) perceived support from (health care) infrastructure and services. Therefore, the concept does not only consist of people's own perceived efforts, but also includes the influence of external sources. Our conceptual model points out what external factors should be taken into consideration by health care professionals and policy makers when enhancing older people's perceived control. Moreover, it can serve as the basis for the development of a measurement instrument, to enable future quantitative research on health care-related perceived control among older adults., (Copyright © 2014 Elsevier Inc. All rights reserved.)

In this article, an intervention aimed at improving quality of care to prevent seclusion in psychiatry by focusing on the first five minutes at admission is analyzed from a care ethics perspective. Two cases are presented from an evaluation study in a psychiatric hospital. In both cases, the nurses follow the intervention protocol, but the outcome is different. In the first case, the patient ends up in the seclusion room. In the second case, this does not happen. Analyzing the cases from a care ethics perspective, we conclude that applying the intervention in the right way implies more than following the steps laid down in the protocol. It requires a new way of thinking and acting, resulting in new relationships between nurses and patients. Care ethics theory can help clarify what good care is actually about and keep in mind what is needed to apply the intervention. Thus, care ethics theory can be highly practical and helpful in changing and improving healthcare practice., (© The Author(s) 2013.)

Clinical ethics support mechanisms in healthcare are increasing but little is known about the specific developments in elderly care. The aim of this paper is to present a systematic literature review on the characteristics of existing ethics support mechanisms in institutional elderly care. A review was performed in three electronic databases (Pubmed, CINAHL/PsycINFO, Ethxweb). Sixty papers were included in the review. The ethics support mechanisms are classified in four categories: 'institutional bodies' (ethics committee and consultation team); 'frameworks' (analytical tools to assist care professionals); 'educational programmes and moral case deliberation'; and 'written documents and policies'. For each category the goals, methods and ways of organising are described. Ethics support often serves several goals and can be targeted at various levels: case, professional or organisation. Over the past decades a number of changes have taken place in the development of ethics support in elderly care. Considering the goals, ethics support has become more outreaching and proactive, aiming to qualify professionals to integrate ethics in daily care processes. The approaches in clinical ethics support have become more diverse, more focused on everyday ethical issues and better adapted to the concrete learning style of the nursing staff. Ethics support has become less centrally organised and more connected to local contexts and primary process within the organisation., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Involving patients in decisions on primary prevention can be questioned from an ethical perspective, due to a tension between health promotion activities and patient autonomy. A nurse-led intervention for prevention of cardiovascular diseases, including counselling (risk communication, and elements of shared decision-making and motivational interviewing) and supportive tools such as a decision aid, was implemented in primary care. The aim of this study was to evaluate the nurse-led intervention from an ethical perspective by exploring in detail the experiences of patients with the intervention, and their views on the role of both the nurse and patient. The study had a qualitative design. 18 patients who had received the intervention participated. Data were gathered by in-depth interviews. The interviews were analysed using directed content analysis. The findings revealed that patients perceived the consultations not as an infringement on their autonomy, but as supportive to risk reduction efforts they tried but found hard to realise. They specifically emphasised the role of the nurse, and appreciated the nurse's realistic advice, encouragement, and help in understanding. Patients' views on and experiences with risk management are in line with notions of relational autonomy, caring cooperation and communicative action found in the literature. We conclude that patients define the relationship with the nurse as shared work in the process of developing a healthier lifestyle., (© The Author(s) 2013.)

Issue: Research has often stressed the significance of reducing door movement during surgery for preventing surgical site infections. This study investigated the possible effect of a lean A3 intervention on the reduction of door movement during surgery in a university medical center in the Netherlands., Initial Assessment: A digital counter recorded door movement during 8009 surgical procedures during 8 months. The number of door movements per surgical procedure ranged from 0 to 555, with a mean of 24 door movements per hour across 26 specialisms., Choice of Solution: We aimed to reduce door movement in one operating room for orthopedic surgery by a lean A3 intervention. This intervention was executed by means of an A3 report that promotes structured problem solving based on a Plan-Do-Check-Act cycle., Implementation: The steps of the A3 report was followed and completed one-by-one by a multidisciplinary team. The effect of the changes was monitored over the course of 12 months., Evaluation: The use of a lean A3 intervention resulted in a sustainable decrease of door movements by 78%, from a mean of 24 to a mean of 4 door movements per hour during orthopedic surgery at one OR., Lessons Learned: This paper shows the relevance of and the possibility for a reduction of door movement during surgery by lean management methods in general and an A3 intervention in particular. This intervention stimulated dialogue and encouraged knowledge-sharing and collaboration between specialized healthcare professionals and this resulted in a thorough root-cause analysis that provided synergy in the countermeasures-with, according to respondents, a sustainable result., (© The Author 2014. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.)

Purpose: Patients are often encouraged to participate in treatment decision-making. Most studies on this subject focus on choosing between different curative treatment types. In the last phase of life treatment decisions differ as they often put more emphasis on weighing quantity against quality of life, such as whether or not to start treatment aimed at life prolongation but with the possibility of side effects. This study aimed to obtain insight into cancer patients' preferences and the reasons for patients' preferred role in treatment decision-making at the end of life., Methods: 28 advanced cancer patients were included at the start of their first line treatment. In-depth interviews were held prior to upcoming treatment decisions whether or not to start a life prolonging treatment. The Control Preference Scale was used to start discussing the extent and type of influence patients wanted to have concerning upcoming treatment decision-making. Interviews were audio taped and transcribed., Results: All patients wanted their physician to participate in the treatment decision-making process. The extent to which patients themselves preferred to participate seemed to depend on how patients saw their own role or assessed their own capabilities for participating in treatment decision-making. Patients foresaw a shift in the preferred level of participation to a more active role depending in the later phase of illness when life prolongation would become more limited and quality of life would become more important., Conclusion: Patients vary in how much involvement they would like to have in upcoming treatment decision-making. Individual patients' preferences may change in the course of the illness, with a shift to more active participation in the later phases. Communication about patients' expectations, wishes and preferences for participation in upcoming treatment decisions is of great importance. An approach in which these topics are openly discussed would be beneficial.

Objective: What are motivations of owners of an advance directive (AD) to draft an AD, what do they aim for with their AD and do they communicate about their AD?, Methods: Written questionnaires were sent to a cohort of people owning different types of ADs (n=5768). A purposive sample of people suffering from an illness was selected from the cohort for an in-depth interview (n=29)., Results: About half of our population had no direct motivation to draft their AD. Most mentioned motivation for the other half was an illness of a family member or friend. Many different and specific aims for drafting an AD were mentioned. An often mentioned more general aim in people with different ADs was to prevent unnecessary lengthening of life or treatment (14-16%). Most respondents communicated about having an AD with close-ones (63-88%) and with their GP (65-79%). In the interviews people gave vivid examples of experiences of what they hoped to prevent at the end of life. Some mentioned difficulties foreseeing the future and gave examples of response shift., Conclusion: ADs can give directions to caregivers about what people want at the end of life., Practice Implications: ADs have to be discussed in detail by their owners and caregivers, since owners often have specific aims with their AD., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Patients are increasingly expected and asked to be involved in health care decisions. In this decision-making process, preferences for participation are important. In this systematic review we aim to provide an overview the literature related to the congruence between patients' preferences and their perceived participation in medical decision-making. We also explore the direction of mismatched and outline factors associated with congruence., Methods: A systematic review was performed on patient participation in medical decision-making. Medline, PsycINFO, CINAHL, EMBASE and the Cochrane Library databases up to September 2012, were searched and all studies were rigorously critically appraised. In total 44 papers were included, they sampled contained 52 different patient samples., Results: Mean of congruence between preference for and perceived participation in decision-making was 60% (49 and 70 representing 25th and 75th percentiles). If no congruence was found, of 36 patient samples most patients preferred more involvement and of 9 patient samples most patients preferred less involvement. Factors associated with preferences the most investigated were age and educational level. Younger patients preferred more often an active or shared role as did higher educated patients., Conclusion: This review suggests that a similar approach to all patients is not likely to meet patients' wishes, since preferences for participation vary among patients. Health care professionals should be sensitive to patients individual preferences and communicate about patients' participation wishes on a regular basis during their illness trajectory.

Projects within the Dutch National Program for Elderly Care (NPO) have been experimenting since 2008 to increase coherence in care for the frail elderly. Invest-NPO explored the problems and solutions to secure the financing of these innovative projects. Problems were expected with coordination because there was not yet a structural reimbursement for such an activity for the frail elderly. There where doubts about the adequacy of reimbursement for multidisciplinary consultation and certain structural conditions. The existing fragmentation across multiple domains and reimbursement rules made it difficult to achieve an integrated approach and creativeness in care. The principles of bundled payment can be helpful in problems concerning multidisciplinary consultation, structural conditions and coordination because joint agreements are needed. According to many, capitation is even a better solution if properly applied, because there are fewer boundaries in deciding how care is organized. Initiatives from entrepreneurs may represent first steps in the right direction. The findings of Invest-NPO may contribute to the development of further steps.

According to the Dutch euthanasia law, the current wishes of the patient can be replaced by an advance directive if the patient is unable to give consent. However, Dutch physicians say they have difficulty responding to advance directives in people with dementia. A crucial issue is how to establish whether the patient actually suffers in a specific situation. We argue that the patient's wishes, views and decisions should be discussed in a timely manner, and laid down both in patient directives and in the doctor's files. We also ask for regular discussion, updating and reaffirmation of the advance directive so that the patient can trust the doctor knowing the patient's wishes and what constitutes unbearable suffering for that patient. Through frequent discussion and reaffirmation, the advance directive can play the role intended by the law on euthanasia.

Objectives: To date, experiences of leaders in the implementation of Lean after a Lean Training Programme have not been systematically investigated within teaching hospitals. Existing studies have identified barriers and facilitators only from an improvement programme perspective and have not considered the experiences of leaders themselves. This study aims to bridge this gap., Design: Semistructured, indepth interviews., Setting: One of largest teaching hospitals in the Netherlands., Participants: 31 medical, surgical and nursing professionals with an average of 19.2 years of supervisory experience. All professionals were appointed to a Lean Training Programme and were directly involved in the implementation of Lean., Results: The evidence obtained in this study shows that, from the perspectives of participants, leadership management support, a continuous learning environment and cross-departmental cooperation play a significant role in successful Lean implementation. The results suggest that a Lean Training Programme contributed to positive outcomes in personal and professional skills that were evident during the first 4 months after programme completion., Conclusions: Implementing Lean in a teaching hospital setting is a challenge because of the ambiguous and complex environment of a highly professionalised organisation. The study found that leadership management support and a continuous learning environment are important facilitators of Lean implementation. To increase the successful outcomes of leadership actions, training should be supplemented with actions to remove perceived barriers. This requires the involvement of all professionals, the crossing of departmental boundaries and a focus on meaning-making processes rather than simply 'implementing' facts. Therefore, this research suggests that programme participants, such as staff members and leaders, can mutually explore the meanings of Lean thinking and working for their own contexts. By entering this shared learning process (eg, learning on the job) the ownership of Lean implementation could also increase.

Deliberative ways of dealing with ethical issues in health care are expanding. Moral case deliberation is an example, providing group-wise, structured reflection on dilemmas from practice. Although moral case deliberation is well described in literature, aims and results of moral case deliberation sessions are unknown. This research shows (a) why managers introduce moral case deliberation and (b) what moral case deliberation participants experience as moral case deliberation results. A responsive evaluation was conducted, explicating moral case deliberation experiences by analysing aims (N = 78) and harvest (N = 255). A naturalistic data collection included interviews with managers and evaluation questionnaires of moral case deliberation participants (nurses). From the analysis, moral case deliberation appeals for cooperation, team bonding, critical attitude towards routines and nurses' empowerment. Differences are that managers aim to foster identity of the nursing profession, whereas nurses emphasize learning processes and understanding perspectives. We conclude that moral case deliberation influences team cooperation that cannot be controlled with traditional management tools, but requires time and dialogue. Exchanging aims and harvest between manager and team could result in co-creating (moral) practice in which improvements for daily cooperation result from bringing together perspectives of managers and team members.

Objective: The crisis card is a specific form of psychiatric advance directive, documenting mental clients' treatment preferences in advance of a potential psychiatric crisis. In this paper, we aim to provide insight into implementation issues surrounding the crisis card., Method: A Dutch crisis-card project formed the scope of this study. Data were collected through interviews with 15 participants from six stakeholder groups., Results: Identified implementation issues are: (a) The role of the crisis-card counselor, (b) lack of distribution and familiarity, (c) care professionals' routines, and (d) client readiness., Conclusions and Implications for Practice: The crisis-card counselor appears to play a key role in fostering benefits of the crisis card by supporting clients' perspectives. More structural integration of the crisis card in care processes may enhance its impact, but should be carefully explored., ((PsycINFO Database Record (c) 2013 APA, all rights reserved).)

In the field of bioethics a trend can be noticed toward deliberative and collective forms of moral reflection among practitioners. Moral Case Deliberation (MCD) is an example of this development and currently introduced in an increasing number of health care organizations in the Netherlands, including elderly care. The purpose of this article is to evaluate the process of implementation of MCD focusing on the learning experiences of practitioners over time. The article is grounded in a naturalistic evaluation of the implementation of MCD in two elderly care institutions between 2006 and 2012. Methods included interviews, participant observations and focus groups. The results indicate that gaining experience with MCD brought about a learning process in which both the learning of competence for reflection and deliberation (e.g. an exploratory attitude) and experiencing the benefits (e.g. relief of moral distress) were key elements. We conclude that doing ethics is the best way to motivate practitioners to engage in moral deliberations on the work floor. Gaining practical experience should be explicitly stimulated bottom-up and facilitated top-down., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Comparison of seclusion figures between wards in Dutch psychiatric hospitals showed substantial differences in number and duration of seclusions. In the opinion of nurses and ward managers, these differences may predominantly be explained by differences in patient characteristics, as these are expected to have a large impact on these seclusion rates. Nurses assume more admissions of severely ill patients are related to higher seclusion rates. In order to test this hypothesis, we investigated differences in patient and background characteristics of 718 secluded patients over 5,097 admissions on 29 different admission wards over seven Dutch psychiatric hospitals. We performed an extreme group analysis to explore the relationship between patient and ward characteristics and the wards' number of seclusion hours per 1,000 admission hours. In a multivariate and a multilevel analysis, various characteristics turned out to be related to the number of seclusion hours per 1,000 admission hours as well as to the likelihood of a patient being secluded, confirming the nurses assumptions. The extreme group analysis showed that seclusion rates depended on both patient and ward characteristics. A multivariate and multilevel analyses revealed that differences in seclusion hours between wards could partially be explained by ward size next to patient characteristics. However, the largest deal of the difference between wards in seclusion rates could not be explained by characteristics measured in this study. We concluded ward policy and adequate staffing may, in particular on smaller wards, be key issues in reduction of seclusion.

The main premise of the Royal Dutch Medical Association's (RDMA) guideline on palliative sedation is that palliative sedation, contrary to euthanasia, is normal medical practice. Although we do not deny the ethical distinctions between euthanasia and palliative sedation, we will critically analyse the guideline's argumentation strategy with which euthanasia is demarcated from palliative sedation. First, we will analyse the guideline's main premise, which entails that palliative sedation is normal medical treatment. After this, we will critically discuss three crucial propositions of the guideline that are used to support this premise: (1) the patient's life expectancy should not exceed 2 weeks; (2) the aim of the physician should be to relieve suffering and (3) expert consultation is optional. We will conclude that, if inherent problematic aspects of palliative sedation are taken seriously, palliative sedation is less normal than it is now depicted in the guideline.

Health-care professionals in end-of-life care are frequently confronted with patients who seem to be 'ambivalent' about treatment decisions, especially if they express a wish to die. This article investigates this phenomenon by analysing two case stories based on narrative interviews with two patients and their caregivers. First, we argue that a respectful approach to patients requires acknowledging that coexistence of opposing wishes can be part of authentic, multi-layered experiences and moral understandings at the end of life. Second, caregivers need to understand when contradictory statements point to tensions in a patient's moral experience that require support. Third, caregivers should be careful not to negatively label or even pathologize seemingly contradictory patient statements.

The traditional organizational boundaries between healthcare, social work, police and other non-profit organizations are fading and being replaced by new relational patterns among a variety of disciplines. Professionals work from their own history, role, values and relationships. It is often unclear who is responsible for what because this new network structure requires rules and procedures to be re-interpreted and re-negotiated. A new moral climate needs to be developed, particularly in the early stages of integrated services. Who should do what, with whom and why? Departing from a relational and hermeneutic perspective, this article shows that professionals in integrated service networks embark upon a moral learning process when starting to work together for the client's benefit. In this context, instrumental ways of thinking about responsibilities are actually counterproductive. Instead, professionals need to find out who they are in relation to other professionals, what core values they share and what responsibilities derive from these aspects. This article demonstrates moral learning by examining the case of an integrated social service network. The network's development and implementation were supported by responsive evaluation, enriched by insights of care ethics and hermeneutic ethics.

Our study presents an overview of the issues that were brought forward by participants of a moral case deliberation (MCD) project in two elderly care organizations. The overview was inductively derived from all case descriptions (N = 202) provided by participants of seven mixed MCD groups, consisting of care providers from various professional backgrounds, from nursing assistant to physician. The MCD groups were part of a larger MCD project within two care institutions (residential homes and nursing homes). Care providers are confronted with a wide variety of largely everyday ethical issues. We distinguished three main categories: 'resident's behavior', 'divergent perspectives on good care' and 'organizational context'. The overview can be used for agendasetting when institutions wish to stimulate reflection and deliberation. It is important that an agenda is constructed from the bottom-up and open to a variety of issues. In addition, organizing reflection and deliberation requires effort to identify moral questions in practice whilst at the same time maintaining the connection with the organizational context and existing communication structures. Once care providers are used to dealing with divergent perspectives, inviting different perspectives (e.g. family members) to take part in the deliberation, might help to identify and address ethical 'blind spots'.

Introduction: With an ageing population, end-of-life care is increasing in importance. The present work investigated characteristics and time trends of older peoples' attitudes towards euthanasia and an end-of-life pill., Methods: Three samples aged 64 years or older from the Longitudinal Ageing Study Amsterdam (N=1284 (2001), N=1303 (2005) and N=1245 (2008)) were studied. Respondents were asked whether they could imagine requesting their physician to end their life (euthanasia), or imagine asking for a pill to end their life if they became tired of living in the absence of a severe disease (end-of-life pill). Using logistic multivariable techniques, changes of attitudes over time and their association with demographic and health characteristics were assessed., Results: The proportion of respondents with a positive attitude somewhat increased over time, but significantly only among the 64-74 age group. For euthanasia, these percentages were 58% (2001), 64% (2005) and 70% (2008) (OR of most recent versus earliest period (95% CI): 1.30 (1.17 to 1.44)). For an end-of-life pill, these percentages were 31% (2001), 33% (2005) and 45% (2008) (OR (95% CI): 1.37 (1.23 to 1.52)). For the end-of-life pill, interaction between the most recent time period and age group was significant., Conclusions: An increasing proportion of older people reported that they could imagine desiring euthanasia or an end-of-life pill. This may imply an increased interest in deciding about your own life and stresses the importance to take older peoples' wishes seriously.

In moral case deliberation (MCD), healthcare professionals meet to reflect upon their moral questions supported by a structured conversation method and non-directive conversation facilitator. An increasing number of Dutch healthcare institutions work with MCD to (1) deal with moral questions, (2) improve reflection skills, interdisciplinary cooperation and decision-making, and (3) develop policy. Despite positive evaluations of MCD, organization and implementation of MCD appears difficult, depending on individuals or external experts. Studies on MCD implementation processes have not yet been published. The aim of this study is to describe MCD implementation processes from the perspective of nurses who co-organize MCD meetings, so called 'local coordinators'. Various qualitative methods were used within the framework of a responsive evaluation research design. The results demonstrate that local coordinators work hard on the pragmatic implementation of MCD. They do not emphasize the ethical and normative underpinnings of MCD, but create organizational conditions to foster a learning process, engagement and continuity. Local coordinators indicate MCD needs firm back-up from management regulations. These pragmatic action-oriented implementation strategies are as important as ideological reasons for MCD implementation. Advocates of clinical ethics support should pro-actively facilitate these strategies for both practical and ethical reasons.

Patients' health and health needs are influenced by categories of difference like sex, gender, ethnic origin and socioeconomic status (SES). To enhance awareness of this diversity among patients and to provide holistic care for them, health professionals should first be aware of the relation between dimensions of diversity and patients' health and health demands. This paper presents a formative process evaluation of a diversity sensitivity training programme for healthcare professionals. The training was implemented in three healthcare settings (mental healthcare, nursing home and hospital care). Mixed methods were used to monitor the implementation of the training and its effects after three years. Findings demonstrate that the training stimulated participants' awareness, knowledge and critical attitudes towards diversity. Their motivation and willingness to take action regarding diversity was also enhanced. Yet these developments were less apparent among nursing home participants who felt less satisfied and did not develop a critical perspective on this issue. Qualitative data were helpful to explain differences between the settings. By means of the combination of quantitative and qualitative data, we can conclude that individual learning was not enough to guarantee a sensitive approach to diversity at the organizational level., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

This article explores how we can enhance our understanding of the moral responsibilities in daily, plural practices of responsive evaluation. It introduces an interpretive framework for understanding the moral aspects of evaluation practice. The framework supports responsive evaluators to better understand and handle their moral responsibilities. A case is introduced to illustrate our argument. Responsive evaluation contributes to the design and implementation of policy by working with stakeholders and coordinating the evaluation process as a relationally responsible practice. Responsive evaluation entails a democratic process in which the evaluator fosters and enters a partnership with stakeholders. The responsibilities of an evaluator generally involve issues such as 'confidentiality', 'accountability' and 'privacy'. The responsive evaluator has specific responsibilities, for example to include stakeholders and vulnerable groups and to foster an ongoing dialogue. In addition, responsive evaluation involves a relational responsibility, which becomes present in daily situations in which stakeholders express expectations and voice demands. In our everyday work as evaluators, it is difficult to respond to all these demands at the same time. In addition, this article demonstrates that novice evaluators experience challenges concerning over- and underidenfitication with stakeholders. Guidelines and quality criteria on how to act are helpful, but need interpretation and application to the unique situation at hand., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective:   Formally, incompetence implies that a patient cannot meet the legal requirements for informed consent. Our aim was to review the scientific literature on the relationship between competence and insight in patients with psychiatric disorders, how competence and insight are connected in these patients and whether there are differences in competence and insight among patients with different disorders., Method:   A search in PubMed/Medline was performed. Articles were assessed on relevance criteria by two independent reviewers. Study design, population, variables, and outcomes were extracted., Results:   Seven articles were included on studies of psychiatric inpatients and outpatients and of psychotic and non-psychotic patients. All studies used the MacArthur Competence Assessment Tool (MacCAT). All studies but one found a strong correlation between poor insight and incompetence. Psychotic patients with poor insight are very likely to be incompetent, and psychotic patients with adequate insight are generally competent. One well-executed study showed that in non-psychotic disorders, however, another relationship emerges; competence and insight do not completely overlap in these patients., Conclusion:   Most incompetent psychotic patients have poor insight, but non-psychotic patients with adequate insight were incompetent in a substantial number of cases. In sum: non-psychotic patients with adequate insight can be incompetent., (© 2011 John Wiley & Sons A/S.)

Aim: This article is a report of a study on how participation in photo groups influenced the perception of the impact of sickness on daily life., Background: Living with severe mental illness can have a strong impact on daily life and the experience of self. In combination with self-stigmatization, this can lead to a sense of being no more than a patient., Method: A mixed-methods design was used to measure the perception of sickness impact. Consumers of psychiatric services participated in photography groups that aimed at integration of illness and developing new goals in life. These groups were conducted by nurses and data were collected between the years 2005 and 2009. The Sickness Impact Profile (SIP) questionnaires were completed by the respondents before and after intervention. The SIP was used to differentiate between respondents who perceived less impact of illness on their daily lives after following a photogroup and those who did not perceive so or remained the same. A sample of these three groups was used to complement the quantitative findings with in-depth interviews with consumers and mentor nurses., Results: Findings indicated absence of important changes in the sickness impact scores except in the domain of mobility. Consumers did, however, show signs of progress in terms of increasing openness, understanding of their feelings and situation and abilities to cope with them., Conclusion: Participating in photo groups can help patients get along with their life and make it more bearable. No signs of demoralization and self-stigmatization were found., (© 2011 The Authors. Journal of Advanced Nursing © 2011 Blackwell Publishing Ltd.)

Moral case deliberation (MCD) is a form of clinical ethics support in which the ethicist as facilitator aims at supporting professionals with a structured moral inquiry into their moral issues from practice. Cases often affect clients, however, their inclusion in MCD is not common. Client participation often raises questions concerning conditions for equal collaboration and good dialogue. Despite these questions, there is little empirical research regarding client participation in clinical ethics support in general and in MCD in particular. This article aims at describing the experiences and processes of two MCD groups with client participation in a mental healthcare institution. A responsive evaluation was conducted examining stakeholders' issues concerning client participation. Findings demonstrate that participation initially creates uneasiness. As routine builds up and client participants meet certain criteria, both clients and professionals start thinking beyond 'us-them' distinctions, and become more equal partners in dialogue. Still, sentiments of distrust and feelings of not being safe may reoccur. Client participation in MCD thus requires continuous reflection and alertness on relational dynamics and the quality of and conditions for dialogue. Participation puts the essentials of MCD (i.e., dialogue) to the test. Yet, the methodology and features of MCD offer an appropriate platform to introduce client participation in healthcare institutions.

The purpose of this article is to illustrate moral learning in persons with a psychiatric disability who participated in a nursing intervention, called the photo-instrument. This intervention is a form of hermeneutic photography. The findings are based on a multiple case study of 42 patients and additional interviews with eight of them. Photo groups were organized within three settings of psychiatric services: ambulatory as well as clinical, all situated in the Netherlands. Data were analysed according to hermeneutic and semiotic principles. Two cases are presented. Findings show that voice and face are concepts that help to identify elements of moral learning in the rehabilitation process of persons with a psychiatric disability. During the process patients become more aware of their responsibilities towards themselves and others.