Quality Characteristics for Clinical Ethics Support in the Netherlands

ABSTRACT

Background: This article presents a set of quality characteristics of clinical ethics support (CES) in the Netherlands.

Methods: The quality characteristics were developed with a large group of stakeholders working with CES, participating in the Dutch Network for Clinical Ethics Support (NEON).

Results: The quality characteristics concern the following domains: (1) goals of CES, (2) methods of CES, (3) competences of CES practitioners, and (4) implementation of CES.

Conclusions: We discuss suggestions for how to use the quality characteristics, discuss some aspects that stand out about these quality characteristics, and reflect on the method and the status of the quality characteristics. The quality characteristics are meant as a heuristic instrument, helping CES practitioners to explore and improve the quality of CES in a health care organization, but at the same time they can be improved based on experiences during their application to CES practices.

KEYWORDS:

• Health policy
• professional ethics
• clinical ethics
• medical ethics

Introduction

In a national survey from 2012 we learned that 69% of Dutch health care institutions provide some form of clinical ethics support (CES), including ethics committees, moral case deliberation, and ethics consultants (Dauwerse et al. 2014). Internationally, the presence of CES has increased within health care institutions over the last 30 years (Rasoal et al. 2017). CES shows variety regarding structure, function, model, and type of support (Doran et al. 2016). In the majority of countries, CES is encouraged as part of quality of care or support for health care professionals and/or patients. Accreditation agencies, such as NIAZ-Qmentum and JCI, stress the importance of CES as part of good health care (JCI 2018; Accreditation-Canada 2012).

Since CES can have a direct impact on patient care, the need to conceptualize, evaluate, and foster the quality of CES has been argued (Schildmann et al. 2013; Whitehead et al. 2009; Williamson, McLean, and Connell 2007; Pfafflin, Kobert, and Reiter-Theil 2009; Molewijk, Schildmann, and Slowther 2017; Pearlman et al. 2016). In order to foster the quality of CES in the United States, an American Society for Bioethics and Humanities (ASBH) task force developed an updated set of core competencies for and together with ethics consultants (ASBH 2011). Also, a tool was developed to assess the quality of ethics consultations based on written records (Pearlman et al. 2016) and an ethics code for ethics consultants was published (Tarzian and Wocial 2015).¹ Recently a certification program for health care ethics consultants was set up (ASBH 2020). In the United Kingdom, the UKCEN developed a set of core competencies for and together with members of clinical ethics committees in hospitals (Larcher, Slowther, and Watson 2010; Slowther 2008) and published a practical guide for clinical ethics committees (Slowther et al. 2004). Norway has also developed a manual for clinical ethics committees within the development of a network (Førde and Pedersen 2012). Finally, Canada has two national networks fostering the quality of CES, one concerning hospitals (CAPHE-ACCESS) and another concerning community care (CEN).²

In the Netherlands, there is little known and published about the quality of CES. There are no overviews, definitions, or goals of CES published.³ Up until now, standards, norms, or guidelines regulating the quality of CES, regarding the structure of CES, the quality of CES activities, and the quality of the CES practitioner, were absent. In order to foster the quality of CES and develop a set of quality characteristics, we decided to use a methodology inspired by a responsive evaluation on involving the relevant stakeholders in the evaluation process and, as such, strengthening ownership of these stakeholders in fostering quality improvement of local CES practices. As CES practices in the Netherlands are rather different from CES in the United Kingdom and the United States, for instance, with regard to the preferred method of CES (moral case deliberation instead of ethics consultants and clinical ethics committees), we decided to develop a set of quality characteristics specific for the Netherlands.

The main aim of this article is to present a set of quality characteristics on CES that has been developed with and for practitioners working in CES in the Netherlands. The findings in this article are about ethics programs generally (not individual consultants, but it does include work of individual consultants). The quality characteristics are part of an ongoing process of learning together with CES practitioners, instead of providing fixed quality norms on CES and then judging whether a certain CES activity meets these norms. We first describe the context of the study, the Dutch Network for Clinical Ethics Support (NEON), in more detail.⁴ Then we briefly describe the responsive evaluation methodology used to develop the set of quality characteristics.⁵ Next, we describe the quality characteristics, concerning the following domains: (1) goals of CES, (2) methods of CES, (3) competences of CES practitioners, and (4) implementation of CES. In the Discussion section, we elaborate upon suggestions for how to use the quality characteristics, discuss some aspects that stand out of these quality characteristics in comparison to UKCEN (United Kingdom) and the ASBH (United States), and reflect on the method and the status of the quality characteristics.

Methods

The process of jointly developing quality characteristics for CES took place within a larger project in which we developed the network NEON (Harman et al. 2020). In 2014, the NEON network was established. NEON aims to bring CES practitioners together in order to (1) learn from each other’s experiences on doing CES in health care organizations, (2) professionalize CES by stimulating knowledge exchange and reflection on the quality of their own CES activities, and (3) conceptualize the quality of CES by formulating a set of quality characteristics on CES. Participants in NEON include a large variety of professionals involved in CES (e.g., members of ethics committees, facilitators of moral case deliberation, ethics consultants, managers of CES, quality staff, and ethicists) in a variety of health care domains (e.g., hospital care, mental health care, care for the disabled, nursing care, youth care). As of early 2020, NEON had 261 individual participants and 15 ethics committees who present themselves on the NEON website,⁶ 1333 people receiving a quarterly newsletter from NEON, and a yearly national conference that attracts about 100 to 200 CES practitioners.

A responsive evaluation methodology (Abma, Molewijk, and Widdershoven 2009) shares several key objectives and presuppositions with our approach to CES. By means of a joint reflection process with involved stakeholders, allowing space for different perspectives, the objective is to achieve shared understanding and commitment to actions. Experiential knowledge is taken as a primary source of knowledge in this process, combined and refined by theoretical understanding (Hartman et al. 2020). Within a responsive evaluation methodology, stakeholders are encouraged to steer both the direction and the form of the evaluation process itself (Abma 2001; Abma, Nierse, and Widdershoven 2009). Inspired by this responsive evaluation methodology, the challenge of defining the quality of CES was used as an opportunity for mutual learning. Participants were active themselves in the process of fostering the quality of CES, and, at the same time, the framing of the quality objectives was also open to discussion. For instance, the term quality characteristics of CES was coined as a more open and appropriate term after a discussion at a NEON meeting; quality criteria was deemed too restrictive and with a risk of referring too much to standardized quality audits and therefore not suitable.

The process of developing the quality characteristics consisted of three phases. In the first phase (from December 2013 until December 2016) we conducted 24 semistructured interviews with CES practitioners and other stakeholders working in the field of CES, organized 3 expert meetings, and launched a website with inspiring practice examples of CES (see Table 1 for an overview).⁷ Based on the interviews, the first expert meetings, and the practice examples on the website, we developed the first draft of a working document on the quality of CES. This working document was sent back to the attendants of the first expert meeting and was continuously updated as the project unfolded.

Table 1. Overview of the methods by research phase and type of CES stakeholder.

Phase	Research activity	Date	CES stakeholder
I	24 Interviews with stakeholders in CES	4-2-2014 until 15-10-2014	4 members of Board of Directors, 4 CES program leaders, 7 CES practitioners, 6 academic ethicists, and 4 members of our research group, working in elderly care (4), mental health care (5), a hospital (2), a university (3), university medical centers (8), and other settings (2)
I	Expert meetings 1	22/23-05-2014,	1 member of board of directors, 4 CES program leaders, 6 CES practitioners, 3 academic ethicists, 5 members of our research group, and 7 other CES stakeholders (inspectorate, umbrella organizations, etc.), working in elderly care (2), mental health care (6), a hospital (2), a university (3), university medical centers (8), and other settings (7)
I	Expert meeting 2	17-10-2014	0 members of board of directors, 8 CES program leaders, 5 CES practitioners, 4 academic ethicists, 5 members of our research group, and 5 other CES stakeholders (inspectorate, umbrella organizations, etc.), working in elderly care (1), mental health care (7), a hospital (2), a university (2), university medical centers (9), and other settings (7)
I	Expert meeting 3	26/27-03-2015	0 members of board of directors, 5 CES program leaders, 6 CES practitioners, 1 academic ethicist, 5 members of our research group, and 6 other CES stakeholders (inspectorate, umbrella organizations, etc.), working in elderly care (1), mental health care (4), a hospital (3), a university (1), university medical centers (8), and other settings (7)
I	Website www.hetneon.nl with practice examples of CES	26-03-2015 (launch), ongoing
I	Writing handbook	26-03-2015 until 03-06-2016 (launch)	3 CES program leaders, 7 CES practitioners, 4 academic ethicists, and 4 other CES stakeholders (inspectorate, umbrella organizations, etc.), working in elderly care (2), mental health care (3), a hospital (2), a university (3), university medical center (4), and other settings (4)
I	Number of quality characteristics: 85
II	Training day for the responsive quality assessments	23-03-2017	21 CES practitioners working in mental health care (16), hospitals (3), and university hospitals (3).
II	10 quality assessments by 22 quality assessors in 10 health care organizations	23-03-2017 until 20-12-2017	See above
II	Meeting with the quality assessors to discuss the experiences and facilitate mutual learning	10-10-2017	See above
II	10 interviews with the quality assessors about the experiences during the responsive quality assessments	01-02-2018 until 30-4-2018	See above
II	Number of quality characteristics: 62
III	Research meeting about the quality characteristics and the evaluative remarks	22-08-2019	Authors LH, EvB, GW, and BM
III	A reformulation of the quality characteristics was sent out to 63 stakeholders in CES, and 18 stakeholders responded.	25-10-2019 until 5-12-2019	1 CES program leader, 10 CES practitioners, 3 academic ethicist, and 4 other CES stakeholders (inspectorate, umbrella organizations, etc.), working in mental health care (5), a hospital (2), a university (3), university medical center (3), and other settings (5)
III	The final set of quality characteristics is determined in two research meetings	18-12-2019 22-1-2020	Authors LH, EvB, GW, and BM
III	Number of quality characteristics: 60

At the first expert meeting, a handbook of CES was mentioned as one of the desired outcomes of NEON. The structure of chapters and the content of each chapter were determined at the second NEON expert meeting. First drafts of each chapter were sent out to those people who had indicated a particular interest in contributing to a particular chapter. We collected and processed all comments we received. Multiple redrafting and feedback loops of CES practitioners resulted in the text of a handbook of CES in the Netherlands (Hartman et al. 2016). The handbook consisted of a general text about the quality of CES with contextual details and practice examples (resembling a thick description [Geertz 1973]), as well as tips, examples from CES practices, experiences from CES practitioners, useful CES formats, and so on. In the end, specific quality characteristics were formulated for each section as a succinct summary of a certain passage. Hence, the quality characteristics were derived from the rich descriptions of various Dutch CES practices by CES practitioners themselves. This resulted in 85 quality characteristics, all published in the CES handbook.

In the second phase of the project (January 2017 until August 2018), the published CES quality characteristics were applied by a group of 22 CES practitioners in 10 health care organizations.⁸ These CES practitioners responded to an open call. This group used the quality characteristics in order to assess the quality of CES practices in each other’s health care institution by means of a responsive quality assessment (Van Baarle et al. 2019). A training day was organized by the project team in order to develop and prepare for the responsive quality assessment. The quality characteristics were discussed in small groups, and feedback and suggestions for improvement of the characteristics were collected. Then the CES practitioners visited each other’s health care organizations for a responsive quality assessment of the CES using the quality characteristics as a starting point for a dialogue on quality of CES within each specific health care institution (Van Baarle et al. 2019). After the quality assessments, the process of applying the quality characteristics was evaluated. In 10 semistructured in-depth interviews the quality assessors were asked about their experiences during the assessment and the usefulness of the quality characteristics.

Building upon the evaluation of the second phase, in the third phase (August 2019 until November 2019) a final set of quality characteristics of CES was formulated. In several research meetings, authors LH, EvB, GW, and BM discussed the quality characteristics and the evaluative remarks of the quality assessors of the second phase and restructured and refined the quality characteristics. The resulting set of 61 quality characteristics was sent to all participants in both previous phases of the project (63 CES stakeholders in total). Of this group, 29% gave feedback (n = 18). Again, the remarks were collected, and in two final research meeting, authors LH, EB, GW, and BM discussed the feedback and reached consensus about the current set of quality characteristics, which are presented in the following. We made a report explicating our decision-making process regarding the final formulation of the quality characteristics, including the current set of quality characteristics, and sent this back to all respondents.

Research ethics

All participating CES practitioners gave their oral informed consent. All transcripts were summarized for the key points, and this summary was sent back to the respondent for a member check. At every meeting and interview, confidentiality was emphasized. Since the study does not include patients, an ethics approval is unnecessary, according to the Dutch Medical Research on Human Subjects Act (WMO) (CCMO).

Results

In this section, we present the quality characteristics of CES, categorized in the following domains: (1) goals of CES, (2) methods of CES, (3) competences of CES practitioners, and (4) implementation of CES.

Goals of CES

The first domain concerns the goals of CES. Having the goals of CES explicitly formulated provides direction for the CES staff and the quality staff of the health care organization to build the CES program. By making explicit the goals of CES, one may determine which CES activities are in line with the goals, and evaluate whether the goals are met and whether they are still appropriate in the health care organization (Table 2).

Table 2. Quality characteristics for goals of CES.

1. Quality characteristics concerning goals of CES
1.1.	Ensure that the goals of ethics support are explicitly phrased.
1.2.	In the interest of optimizing the implementation, quality, and acceptance of ethics support, regular evaluations of this support should be conducted in which all stakeholders are involved. If the evaluations reveal the need for adjustments, these should be made accordingly.

Methods of CES

The domain “methods for CES” describes and ­categorizes the methods of CES practitioners. The methods are categorized as follows: First, two general characteristics that apply to all methods are ­formulated (2.1.1 and 2.1.2). The first quality characteristic states it is important to start with clear agreements about procedure and time frame (2.1.1). The second quality characteristic concerns documentation of the CES activities. This is important for the visibility of CES in the organization and evaluation and improvement, but it should not become an administrative goal in itself. Therefore, the second quality characteristic emphasized that a balance is important (2.1.2)

Then, quality characteristics for various methods are described: giving advice or consultation on a moral case (2.2); moral counseling (2.3); moral case deliberation (2.4); ethics support activities in which the moral dimension of daily affairs is articulated and investigated (2.5); meetings on a moral issue (2.6); ethics education (2.7); and for policy advice on ethical issues and ethical aspects of policy (2.8). See Table 3 and later Table 10 for an overview of all quality characteristics concerning methods of CES. The first characteristic of each method tries to capture the essence of the specific method. Then a number of more specific quality characteristics are formulated for each method.

Table 3. Quality characteristics for methods of CES.

2.1. Quality characteristics concerning methods of CES
2.1.1	Start by agreeing on and setting a clear procedure and time frame for the ethics support process.
2.1.2	Take care to document the process, while maintaining a balance between the time and energy required for documentation on the one hand, and its benefits—with regard to ethics support’s visibility in the organization and the quality of ethics support evaluations—on the other hand.

With regard to giving advice or consultation about a moral case (2.2), taking enough time to clarify what the involved stakeholders perceive as the moral issue is emphasized by characteristic 2.2.1. Also, striving to include many relevant perspectives and stakeholders (2.2.2) and taking into account what is not possible based on the advice (2.2.3) are formulated as part of the quality of this method. Finally, a balance is emphasized between making sure that the outcome of the method fits with the practice, expectations of the stakeholders, and the independence of the advice (2.2.5) (Table 4).

Table 4. Quality characteristics for advice or consultation on a moral case.

2.2. Quality characteristics for advice or consultation on a moral case
2.2.1	Advice or consultation is sound if it provides an overview of relevant considerations regarding the moral case, explicit weighing of moral factors, and substantiated conclusions or advice.
2.2.2	Ensure that there is enough time to clarify what everyone involved perceives as the moral issue.
2.2.3	Strive to involve as many relevant perspectives and stakeholders as possible in the process of weighing moral factors.
2.2.4	Take into account the potential moral harm of what is not possible on the basis of the conclusions or advice.
2.2.5	See to it that the advice is appropriate given the actual situation, motives, and expectations of the person(s) seeking advice, while at the same time ensuring that the advice remains independent.

Moral counseling consists of an individual conversation (or a series of conversations) with a patient or health care professional about a morally troublesome issue. Moral counseling is mainly facilitated by pastoral care in the Netherlands. For moral counseling the importance of a judgment-free space (2.3.1) and assisting the interlocutor to weigh their own arguments (2.3.2) are emphasized as central parts of its quality. Also the importance that the interlocutor have time and space to make her own choice (2.3.3) and the use of an appropriate conversation method (2.3.4) are defined as parts of qualitatively good moral counseling (Table 5).

Table 5. Quality characteristics for moral counseling.

2.3. Quality characteristics for moral counseling
2.3.1	Create a judgment-free space in which interlocutors can articulate and explore their moral convictions, norms and values in their own words.
2.3.2	Ensure that interlocutors are assisted in ordering their moral judgments according to the relative weight, as assigned to them from the interlocutors’ perspective.
2.3.3	Provide sufficient time and space for interlocutors to make their own decisions following moral counseling.
2.3.4	Make use of an appropriate conversation method.

A sound moral case deliberation (2.4) is characterized as facilitating an ethical consideration in dialogue between the participants while keeping the focus on the moral issue (2.4.1). Similar to moral counseling, the quality characteristics for moral case deliberation emphasize the importance of a relevant conversation method (2.4.2), an open and free investigation (2.4.4), and that all participants can have an equal input (2.4.5). This quality characteristic emphasizes that all participants should at least have the possibility to equally contribute. A noteworthy difference for moral counseling is the emphasis on follow-up of the insights within the organization (2.4.6). This characteristic points toward the fact that moral case deliberation can be part of quality-of-care improvement mechanisms in the organization (Table 6).

Table 6. Quality characteristics for moral case deliberation.

2.4. Quality characteristics for moral case deliberation
2.4.1	A moral case deliberation is sound if it focuses on the moral question at stake and facilitates ethical consideration in a dialogue between the participants.
2.4.2	Make use of a relevant conversation method for moral case deliberation.
2.4.3	Make sure the conversation is led by a trained MCD facilitator.
2.4.4	Foster open and free exploration of various aspects of the moral issue.
2.4.5	Foster equal input by all participants and constructive exploration of any differences of opinion.
2.4.6	Ensure a follow up on the conclusions of the moral case deliberation throughout the organization.

There are different work forms described for ethics support activities in which the moral dimension of daily affairs is articulated and investigated (2.5). There is one quality characteristic described per work form. “Mirror meetings”⁹ and “immersion sessions”¹⁰ stimulate awareness of the perspective of patients and clients on good care, and as such contribute to normative insights from a patient perspective and reflection by health care professionals about how their actions are experienced by recipients of care. Regarding a mirror meeting, active listening and understanding different perspectives (2.5.1) are emphasized; for immersion sessions, the experience of those who receive care from care staff is defined as part of its quality (2.5.2). Concerning observations by CES practitioners, the importance of focusing both on explicit as well as implicit (moral issues that may be unrecognized as such by care workers) is emphasized as part of the quality of this work form (2.5.3). This combination is again emphasized by participation in regular meetings, including encouraging the care workers to reflect on and weigh the relevant moral factors (2.5.4) (Table 7).

Table 7. Quality characteristics for ethics support activities in which the moral dimension of daily affairs is articulated and investigated.

2.5. Quality characteristics for ethics support activities in which the moral dimension of daily affairs is articulated and investigated
Work form		Quality characteristic
2.5.1	Mirror meeting	A mirror meeting is sound if it encourages open and active listening and understanding of different perspectives on the question of what is a morally right course of action.
2.5.2	Immersion session	An immersion session is sound if it allows care staff to (physically) experience a situation from the care recipient’s perspective.
2.5.3	Observation	An observation of moral topics in daily care practice is sound if it focuses on both explicit and implicit moral issues.
2.5.4	Participating in a regular meeting	For an ethics support practitioner, participating in a regular meeting means addressing the explicit and implicit moral aspects that come up in the meeting and encouraging care providers to reflect on and explicitly weigh moral factors during the meeting and in the report.

Organizing meetings with a moral theme and providing ethics education were also categorized as methods of CES. With regard to theme meetings (2.6), making ethical theory accessible (2.6.1) and stimulating reflection (2.6.2) are emphasized. Sound ethics education (2.7) is focused on the development of the moral competencies (2.7.1), in line with the level and experience of those who are educated (2.7.2), and pays attention to the application of the knowledge and skills within practices (2.7.3) (Tables 8 and 9).

Table 8. Quality characteristics for meetings on a moral issue.

2.6. Quality characteristics for meetings on a moral issue
2.6.1	A meeting on a moral issue is sound if it makes ethical theories, moral concepts, other viewpoints and experiential knowledge accessible to its participants.
2.6.2	Encourage attendees to reflect on their own, and others’, assumptions and preconceptions.

Table 9. Quality characteristics for ethics education.

2.7. Quality characteristics for ethics education
2.7.1	Ethics education is sound if it fosters the development of moral competence, integrating knowledge (ethical theory), skills (such as recognizing a moral issue, reflecting on one’s own values and beliefs, and recognizing and acknowledging other perspectives), and an open, inquisitive attitude.
2.7.2	Ensure that the education you offer is in line with the level and experience of the course participants who run up against moral issues in practice.
2.7.3	Focus on the application of knowledge and skills in daily care practice.

Table 10. Quality characteristics for policy advice on ethical issues and ethical aspects of policy.

2.8. Quality characteristics for policy advice on ethical issues and ethical aspects of policy
2.8.1	Provide an analysis focusing on the normative aspects of policy.
2.8.2	Provide methodically sound and substantiated recommendations.
2.8.3	Ensure that the policy advice is formulated independently.
2.8.4	Take into account different perspectives from within the organization on a specific policy or policy issue.
2.8.5	Ensure that the advice given contributes to the development of a concrete result, such as a new or adjusted guideline, which is relevant to practical issues and can be applied in practice.

Finally, “policy advice on ethical issues and ethical aspects of policy” (2.8) encompasses both policy development regarding an ethical theme, for instance palliative care or advanced care planning, and contribution to other kinds of policy from an ethics perspective. Examples include a contribution to the institution’s human resources (HR) policy or the purchasing strategy regarding contracts with pharmacy companies of the health care organization. For qualitatively good policy advice, it is emphasized that recommendations are methodical and substantiated (2.8.2). Also, this requires an independent position (2.8.3), takes into account different perspectives (2.8.4), and is practically applicable within care practices (2.8.5) (Table 10).

Competencies of CES practitioners

A third domain regards the competencies of CES practitioners. The competencies are divided into 3.1, knowledge, 3.2, skills, and 3.3, attitude. Making the competencies explicit allows for the development of training programs and further training of CES practitioners. Also, the list may help to recruit CES staff members who have certain skills of knowledge that are underrepresented in the current CES team.

The first category, knowledge (3.1), specifies basic knowledge of ethical concepts (3.1.1), basic knowledge of methods for clinical ethics support (3.1.2), and basic knowledge of the health care sector the CES practitioners work in (3.1.3). The second category, skills (3.2), is comprised of analytical skills (3.2.1), skills to facilitate a dialogue (3.2.4), and the competency to adjust the communication style to the level of the interlocutors, since CES practitioners function through the whole organization (3.2.5). Also, the skill to recognize moral argument in practice (3.2.2) and an ability to distinguish moral from nonmoral arguments are formulated (3.2.3). Finally, the category skills entail the ability to reflect on the influence of one’s own normative preferences, both regarding ethical issues and regarding CES itself, in providing CES (3.2.6). For instance, when a CES practitioner has a preference for facilitating moral case deliberation, it is important that she is aware of this and is also able to reflect on the strengths and limitations of this CES method and take into account other CES methods as well.

The third category, attitude (3.3), describes independence and the ability to discuss moral themes in a constructive manner (3.3.1). Respecting confidentiality (3.3.2) and a learning attitude are also categorized under the category of a qualitative good attitude of CES practitioners (Table 11).

Table 11. Competencies of CES practitioners.

3. Competencies of CES practitioners
3.1. Knowledge
Ethics support practitioners:
3.1.1	can recognize and explain ethical concepts, such as “value,” “norm,” “virtue,” “principle,” and “dilemma”;
3.1.2	are versed in multiple ethics support methods, and know the advantages and disadvantages of various methods depending on the goals and context of a specific case;
3.1.3	have a basic understanding of the relevant health care sector and the prevailing ethical and legal frameworks, protocols, and guidelines.
3.2. Skills
Ethics support practitioners:
3.2.1	have analytical skills;
3.2.2	can distinguish between moral and nonmoral questions;
3.2.3	recognize moral arguments in practice;
3.2.4	have a variety of skills related to initiating and encouraging dialogue—these are: listening and knowing how to encourage good listening; recognizing, postponing and articulating judgments; asking good questions; recognizing emotions and relating them to reflections on a moral theme; teaching others to critically yet respectfully question each other’s perspectives;
3.2.5	are able to attune to the level of understanding and experience of those involved;
3.2.6	are able to reflect, within the practice of ethics support, on their own normative views, beliefs, and presuppositions and their mutual interferences.
3.3. Attitude
Ethics support practitioners:
3.3.1	act independently of existing hierarchies, address people respectfully, ask critical questions; are not afraid to articulate and discuss moral issues in a constructive manner/discussion;
3.3.2	respect confidentiality;
3.3.3	have a learning attitude, reflect on their own actions, and further develop their competencies through training.

Implementation of CES

Within the process of developing the NEON quality characteristics, it became clear that the organization and implementation of CES make up an important aspect of the quality of CES. This is why a separate domain of the quality characteristics was dedicated to implementation of CES.

With regard to a qualitatively good implementation of CES, a balance between top-down processes, in the sense of support from the board of directors and adequate financing (4.6 and 4.8), and bottom-up processes, for instance, spontaneous activities meeting a certain need at the work floor, is important (4.1). Also, qualitatively good implementation of CES includes that the organization’s management and board of directors make use of CES as well (4.3). Good implementation of CES requires a certain flexibility and the ability to connect to new and existing projects in the organization (4.2). Sometimes large projects on a certain theme or hot topic within a health care organization can benefit from input from CES or can, viewed the other way around, provide an excellent way of demonstrating the value of CES in a very practical and visible way. The visibility and accessibility of CES (4.5) are important for the practical usefulness of CES in a health care organization. Some health care organizations have an elaborate CES program, but the program is invisible to and not used by health care workers.

Keeping a register of CES activities in an annual report (4.7) and aiming to position ethics support as one of the organization’s quality instruments (4.4) can be important mechanisms to maintain and foster the quality of the CES activities. Finally, an independent (4.8) and recognizable (4.9) position of CES within the organizational structure is emphasized as part of qualitatively good CES (Table 12).

Table 12. Quality characteristics for implementation of CES.

4. Quality characteristics for implementation of CES
4.1.	Good implementation of ethics support is achieved by organizing a coherent body of both bottom-up and top-down processes.
4.2.	Make use of potential points of reference with new and existing projects in the organization.
4.3.	Provide an opportunity for the organization’s management and board of directors to experience ethics support in one form or another.
4.4.	Aim to position ethics support as one of the organization’s quality instruments and to integrate it into the organization’s project plans or strategic choices.
4.5.	Promote the visibility of ethics support within the organization through various media and communication channels.
4.6.	Ensure that ethics support activities are budgeted and included in annual policy plans (financing, human resources, other resources) for both programs and projects.
4.7.	Keeping track of and reporting on ethics support activities in annual reports and elsewhere can help widen institutional acceptance of ethics support and strengthen the basis for the evaluation and improvement of this support. It is important to maintain a balance between the time investment and the benefits of this tracking and documentation.
4.8.	Ensure that the organization’s management and board of directors guarantee the independence of ethics support and ensure ethics support practitioners are given the room to ask critical questions of all parties in the care organization.
4.9.	Make sure ethics support is integrated into the organizational structure and has its own recognizable position within it.

Discussion

We presented quality characteristics of CES developed through a method inspired by a responsive evaluation approach by CES stakeholders who were involved in a Dutch network for ethics support (NEON). The aim of formulating the quality characteristics of CES was to work together toward a threefold goal; to stimulate reflection on the quality of CES activities, to inspire CES practitioners, and to give concrete suggestions for improvement of ES activities in health care organizations. Hence, inspired by a responsive evaluation methodology, not only the outcome of this process (the quality characteristics) but also the process of formulating the quality characteristics were meant to stimulate reflection on the quality of CES (Abma, Molewijk, and Widdershoven 2009). We described quality characteristics regarding (1) goals of CES, (2) methods of CES, (3) competences of CES practitioners, and (4) implementation of CES. In the following we first discuss some suggestions for how to use the quality characteristics, then discuss some notable aspects of our quality characteristics, and finally reflect on the method and the status of the quality characteristics.

The quality characteristics are intended for inspiration in various national and international contexts. Ideally, the characteristics function as a starting point for a conversation about the quality of CES with fellow CES staff, management, the board of directors, quality staff in the organization, or fellow CES staff outside the organization. Suggestions to use the quality features include: (1) for each characteristic check whether it is present and/or desirable and discuss this with a CES colleague or the entire CES team, (2) elaborate on the concretization of particular characteristics that are relevant for the specific CES context, (3) discuss the presence and desirability of the quality characteristics with the management or the board of directors in the organization in order to improve CES, (4) use the quality features for a training day for CES staff, (5) use the quality characteristics to prepare for a responsive quality exchange visit between CES staff from two or more organizations (see Van Baarle et al. 2019), and (6) use (a selection of) the quality characteristics for a regional or national survey among CES teams (e.g., by asking whether each characteristic is present, important, and substantive enough).

What stands out about the described quality characteristics is their broadness, applying to all health care sectors. The quality characteristics of NEON also encompass more aspects then the core competencies of ethics committees and individual consultants as published by the network UKCEN in the United Kingdom (Larcher, Slowther, and Watson 2010) and the ASBH in the United States (ASBH 2011). In that sense, the described quality characteristics of CES and the specific way of both developing and applying them function quite well as a program evaluation for clinical ethics support programs (Mertens and Wilson 2018). An example of this is the attention for to overall goals of the CES being present, the quality of the implementation of CES, and the quality of particular methods of CES. However, these societies or networks have published other documents, like an ethics code for ethics consultants (Tarzian and Wocial 2015; Baker 2005; Kipnis 2005), an education guide (ASBH 2009), and a “practical guide to clinical ethics support” (Slowther et al. 2004) that also cover aspects of our quality characteristics. Also, different from the ASBH (ASBH 2020), NEON has explicitly distanced itself from a certification program (the quality characteristics are meant as heuristic instruments). Finally, the quality characteristics are used differently: We focus on an ongoing process of learning together with NEON participants, instead of first formulating norms and then assessing whether a certain CES program meets those norms. Another relevant aspect of the quality characteristics we have developed is the emphasis on general requirements, with the absence of concrete directions. For instance, with regard to goals of CES, it is stated that it is important to have goals explicitly formulated and evaluated, but without mentioning what kind of goals are appropriate for CES. This is in line with quality-of-care characteristics.¹¹ An advantage of this approach is that the quality characteristics leave room for adaptation of CES to the local context of a health care organization. A disadvantage may be that general quality characteristics do not capture the essence of the quality of CES and may not provide enough concreteness and guidance.

A reason for this emphasis on general requirements and lack of concrete normative description of what quality of CES looks like could have to do with our chosen research method. Our commitment to include as many stakeholders as possible may have led to less concrete quality characteristics. Furthermore, the relative newness of the field of CES may have contributed to this. In the absence of overviews, definitions, standards, or norms for CES, the quality characteristics also function as conceptual clarifications. For instance, the Methods section provides an overview of different CES activities a CES practitioner can undertake. Clarity and consensus about possible CES methods, demarcation lines and terminology may provide a first step toward more normative quality characteristics of the CES methods.

Defining and fostering the quality of CES are approached from different angles and through a variety of methodologies (Magill 2013). The method we used focused on an open learning process by actively involving CES practitioners and their concrete practices, similar to the approach in Canada (Kirby and Simpson 2012). Other initiatives, although using responsive elements as well (such as the ASBH code of practice standards), seem to depart more from pregiven values and focus more on a normative set of criteria for CES (Tarzian and Wocial 2015). Simultaneously to the updated version of the Core Competencies, the National Center for Ethics in Health Care in the U.S. government’s Department of Veteran Affairs (VA) developed the so-called “Integrated Ethics” program (Fox et al. 2010). The ASBH focuses on developing knowledge and skills for health care ethics consultants; the VA provides a comprehensive approach that describes a way to organize CES in a health care organization such that CES is integrated throughout the whole health care organization.

We think both attempts to foster quality of CES can reinforce each other. Our approach can be viewed as more collaborative and participative and more capable of generating change during the process (Abma et al. 2010), while guidelines or specific sets of values may give more clarity and guidance.

Finally, the method we chose to develop the quality characteristics has implications for the status of the quality characteristics. Our set of quality characteristics is meant to function as an inspiration and to stimulate reflection and dialogue about the quality of CES in concrete CES practices. The set of quality characteristics is never fully ready or complete, but needs to be regularly updated by continuous experiences within CES practices, involving new stakeholders or acknowledging new research evidence. The NEON network for ethics support staff is currently proposing both institutional workshops and shortened programs for responsive quality assessments exchange visits among CES staff teams. This will contribute to the further development of both the quality characteristics and ways to use them in the practice of ethics support. The quality characteristics are meant as a heuristic instrument, helping CES practitioners to explore and improve the quality of CES in a health care organization, but at the same time they can be improved based on experiences during their application to CES practice.

Conclusion

This article presents a set of quality characteristics of clinical ethics support (CES), developed in the Netherlands. The quality characteristics were developed in dialogue with stakeholders working on CES within the Network Ethics Support in the Netherlands (NEON) following a method inspired by a responsive evaluation methodology. The 60 quality characteristics concern the following domains: (1) goals of CES, (2) methods of CES, (3) competencies of CES practitioners, and (4) implementation of CES. The broadness, variety, and scope of the quality characteristics and of the health care sectors involved stand out in comparison to the core competencies and standards published by the ASBH in the United States and by UKCEN in the United Kingdom. Another relevant aspect of the NEON quality characteristics is the emphasis on general requirements. The quality characteristics are meant as a heuristic instrument, helping CES practitioners to explore and improve the quality of CES in a health care organization, but at the same time they can be improved based on experiences during their application to CES practice. The quality characteristics themselves and the use of them within CES practices need to be evaluated and refined regularly, based on new practical experiences within CES practices, in an ongoing learning process.

Acknowledgments

We acknowledge Froukje Weidema, Jelle van Gurp, Yolande Voskes Marieke Potma, Marline van Hoek, and Emy Kool for working with us in different stages of the NEON project. Also, we thank all NEON participants for their input, constructive criticism, and involvement in this project. We thank the Ministry of Health for the funding of this project.

Disclosure statement

We have no conflicts of interest to disclose and all authors have approved the article for submission.

Notes

1 These core competencies have been accompanied by an education guide (ASBH 2009).

2 CAPHE-ACESS stands for Canadian Association of Practicing Healthcare Ethicists—Association canadienne des éthiciens en soins de santé. CEN stands for Community Ethics Network.

3 One exception is a Dutch document about the quality of the moral case deliberation facilitator, developed by the working group of the former Dutch Platform for Moral Case deliberation (Platform Moreel Beraad 2010).

4 NEON is an acronym for Netwerk Ethiek Ondersteuning Nederland (Dutch). NEON was founded in the context of a 4-year research project at Amsterdam UMC (location VUmc) funded by the Ministry of Health of the Netherlands that started December 1, 2013. When the funding ended (August 1, 2018), the network continued as an independent foundation.

5 A more extensive description of this responsive evaluation methodology process and how this process itself has been evaluated by the CES staff that worked with this methodology has been published elsewhere (respectively, Hartman et al. 2021 and Van Baarle et al. 2019).

6 http://www.hetneon.nl

7 We also organized other activities through NEON, such as the annual NEON conferences, NEON workshops, and NEON master classes, but since these activities do not directly relate to the development of the quality characteristics of CES, we have not listed them in this table.

8 The project originally consisted of 11 participating health care organizations. One health care organization withdrew, so 10 health care organizations completed this phase.

9 In Dutch: “Spiegelbijeenkomsten.” “Spiegelbijeenkomsten” is a common method in Dutch health care in which patients talk in a closed circle about their experiences with receiving the care at a certain unit/ward or department, while the health care professionals sit around the circle, listen, and can only ask questions for clarification (i.e., they may not go into discussion about the experiences).

10 In Dutch: “Inleefsessies.” Inleefsessies are experiences in which the care provider assumes the role of the care recipient. Such a session revolves around the question: What is it like to need care? Each participant chooses a role in advance—for example, a wheelchair-dependent person with dementia, a partially sighted person with Parkinson’s, or a deaf and depressed person with aphasia. To mimic the experience, participants use aids such as wheelchairs, walkers, earplugs, blurred glasses, or splints.

11 For instance, a norm of quality of care prescribes that a treatment plan should be updated yearly, but the content of the treatment plan is dependent on the local context.