Thesis

Moral Case Deliberation with prison staff Moral themes, evaluation and impact on moral craftsmanship Anne Ilse Schaap

MORAL CASE DELIBERATION WITH PRISON STAFF Moral themes, evaluation and impact on moral craftsmanship Anne Ilse Schaap

Colophon Moral Case Deliberation with prison staff Painted by: Merel Schröder Designed by: Wiebke Keck, persoonlijkproefschrift.nl Printed by: Ipskamp printing ISBN/EAN: 978-94-6473-171-2 Copyright © 2023, Anne Schaap All rights reserved. No part of this book may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written consent of the author.

VRIJE UNIVERSITEIT MORAL CASE DELIBERATION WITH PRISON STAFF Moral themes, evaluation and impact on moral craftsmanship ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad Doctor of Philosophy aan de Vrije Universiteit Amsterdam, op gezag van de rector magnificus prof.dr. J.J.G. Geurts, in het openbaar te verdedigen ten overstaan van de promotiecommissie van de Faculteit der Geneeskunde op dinsdag 3 oktober 2023 om 11.45 uur in een bijeenkomst van de universiteit, De Boelelaan 1105 door Anne Ilse Schaap geboren te Breukelen

promotoren: copromotor: promotiecommissie: prof.dr. A.C. Molewijk prof.dr.ir. H.C.W. de Vet dr. M.M. Stolper prof.dr. M.A. van den Hoven prof.dr. R. Porz dr. M.L. Gerrek prof.dr. R.W.J.G. Ostelo dr. T. Molleman

CONTENTS CHAPTER 1 General introduction 9 PART A THEMES AND EVALUATION OF MCD CHAPTER 2 Moral dilemmas of Dutch prison staff: a thematic overview from all professional disciplines 37 CHAPTER 3 Empirical research on an ethics support service for prison staff: evaluation of Moral Case Deliberation sessions 63 PART B MEANING AND MEASUREMENT OF MORAL CRAFTSMANSHIP CHAPTER 4 Defining and measuring the concept of moral craftsmanship: developing a questionnaire for the Dutch prison context 89 CHAPTER 5 Contribution of Moral Case Deliberation to the moral craftsmanship of prison staff: a quantitative analysis 113 PART C EXPERIENCED OUTCOMES AND MORAL LEARNING CHAPTER 6 Experienced outcomes of Moral Case Deliberation sessions: the moral learning of Dutch prison staff 139 CHAPTER 7 General discussion 163 English summary 199 Nederlandse samenvatting 207 Appendices 217 ‘Eén is geen’ 247 Dankwoord 249 About the author 255

General introduction 1

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11 General introduction INTRODUCTION ‘A prisoner asks you to do something you’re not allowed to do, for example, taking a postcard out of the facility and putting it in a mailbox. Of course, we have a code of conduct, but there is also a large gray area in our practice. How do you deal with that? I think people always have to make up their own minds. [..] Of course, there are also working agreements, but there is a whole world behind them: how easily do you confront each other about behavior? What do you report to your manager, and when do you turn a blind eye?’ – a prison director (Ledegang, 2015) Working in prison involves being confronted with gray areas and difficult situations, as mentioned by this prison director. What types of moral challenges do prison staff encounter in their practice, how can prison staff be facilitated to deal with these challenges and what impact will an ethics support intervention – that aims to help dealing with moral challenges – have on prison staff? Challenges of prison work The work of prison staff is tough and demanding, as staff is ‘charged with the central task of supervising and securing unwilling and potentially violent populations’ (Armstrong & Griffin, 2004; Auerbach et al., 2003). In literature, the security and rehabilitation aims of prison work have been placed at the core of prison practice (Bruhn et al., 2010). A recent study in the Netherlands shows that prison staff themselves state the following values should play a central role: humanity, security, and reintegration (Paanakker, 2020, p. 48). As DCIA states, it is their goal to ‘ensure a safe and humane detention and work with our adjacent organizations and the prisoner, toward reintegration’ (DCIA, 2009). However, prison staff are shown to be frequently unsure about which of these aspects should take precedence (Liebling et al., 2011, p. 64). In general, prison staff suffer high levels of stress (Finney et al., 2013; Huckabee, 1992; Schaufeli & Peeters, 2000), e.g., due to the volatile environment and based on the conflict of values they experience in their practice (Liebling et al., 2011, pp. 63–64). However, research about prison staff’s experiences and needs is lacking. A recent literature review showed no articles are available on the support and supervision needs of prison officers (Forsyth et al., 2022). The review highlights a significant gap in research about our understanding of prison staff’s needs and needs for support. While, for good performance, correctional institutions rely heavily on their staff (Lambert et al., 2005); hence, ‘satisfied prison staff 1

12 Chapter 1 is important for the successful operation of a prison’ (Cheeseman et al., 2011). Prison staff – in their role as a part of the ‘executive authority’ of our government institutions – hold responsibility for the well-being of prisoners (Enggist et al., 2014). Prison staff can even function as role models for prisoners (DCIA Educational Institute, 2014; Liebling et al., 2011, pp. 48–49, 55). However, literature shows how persistent priority is given to the control of prisoners (Craig, 2004) and this prioritization of security can be at the expense of other goals of imprisonment (Dilulio, 1987). Many work processes in prison show to be established in regulations and protocols. In Dutch prisons, an increasing number of regulations seem to be developed and enforced in response to incidents (Van Houwelingen et al., 2015, p. 109). DCIA is described as an incident- and solution-oriented organization in which staff members rely on automatisms in their practice. Additionally, the presence of hierarchical structures in the DCIA organization can limit the staff’s own initiative (Van Houwelingen et al., 2015, p. 20). Within the DCIA organization there is a risk that these tendencies could lead to ‘a lack of moral awareness’ among prison staff and that staff would mostly base judgements and action on their intuitions and emotions instead of well-considered reflections (Van Houwelingen et al., 2015, p. 81). The mentioned prison director observes his staff struggling with the morality of their daily practice since ‘there is often a need to act quickly [..] The assessment and discussions on moral dilemmas have to occur between all operations’ (Ledegang, 2015). Moral dilemmas occur when two or more conflicting values raise doubts regarding the right action (Maclagan, 2003). It is indeed known that the context of working in prison can lead to many challenging situations (Schmalleger & Smykla, 2014), often these are situations with moral components (White et al., 2014). However, the prison context does not immediately provoke a reflective working style on what ‘good’ or ‘successful’ practice means. Prison staff are known to develop a ‘closed culture’ among colleagues with a tendency to function based on ‘this is the way things are done around here’ (Liebling, 2000). There is a need to change this, as a WHO report stated: ‘Prisons can, by reputation and experience, be hazardous and stressful places for staff. However, it need not be this way. Leadership and staff training is fundamental to ensure that employees can work productively, act as role models for prisoners, be healthy and be confident of support.’ (Enggist et al., 2014)

13 General introduction To stimulate prison staff’s awareness and ability to reflect upon what is good in practice, DCIA initiated a new training program in 2016/2017 for their staff called craftsmanship1. The overall aim of this program by DCIA was to facilitate support and further professional development of their staff (DCIA, 2016a). Together with the above-mentioned challenges of prison work, DCIA wished to address the increased complexity of the practice of prison staff. Specifically, in the Dutch setting, DCIA noticed – in the years before the training program – an increase in reported incidents in the organizations, a change in the population of prisoners (e.g., more psychological problems in non-specialist institutions), and an experienced high work pressure by staff (DCIA, 2016c, 2022; FNV Overheid, 2017, 2020). According to DCIA, the craftsmanship they wish to foster in staff entails an ongoing deliberation between colleagues, discussing doubts and complex considerations encountered in practice. In this way, prison staff can arrive at balanced decisions that can be explained to colleagues and prisoners. The related DCIA report states: ‘The underlying principle is that doubts may be expressed about all daily choices on how to deal with prisoners and colleagues; it is considered to be a quality if staff discuss their doubts’ (DCIA, 2016a). Fostering the moral craftsmanship of prison staff Van Houwelingen et al. (2015, p. 81) reported the absence of ‘moral learning consultations’ for prison staff. Hence, they advised DCIA to implement a method that can strengthen the moral awareness of prison staff. DCIA included an additional aim to their newly developed training program: to develop further the so-called moral craftsmanship of staff (DCIA, 2016a). Moral craftsmanship would entail more transparent and well-considered decision-making processes, which could prevent challenging moral decisions or cases from causing distress to staff and prisoners. According to a group of experts, particularly at DCIA, moral craftsmanship is important because prison staff is expected to set an example and behave responsibly toward prisoners (DCIA Educational Institute, 2014). With the training program, DCIA wanted to stimulate and facilitate a moral learning process for prison staff. Ideally, ‘moral judgment is a central part of prison work’ (DCIA, 2016a). DCIA wanted a new training method to address the why of actions. This could increase staff’s ability to ‘be open and constructive about differences in viewpoints’ (DCIA, 2016a) when discussing the question of ‘how to best act in everchanging situations’ (DCIA, 2016b). The program devoted explicit attention to reflections 1 During this project, research, and in the whole thesis: whenever the term ‘craftsmanship’ is used, please keep in mind that the concept is directed at all genders, not just men. 1

14 Chapter 1 on work since, as DCIA stated, reflection is seen as a precondition for a learning process. Overall, the training program on craftsmanship included many types of training; for example, directed at reflection in general, such as their instrument called ‘Talking about your profession’ (in Dutch: ‘Praten over je vak’) (DCIA Educational Institute, 2017). One instrument was introduced with an explicit focus on the development of moral awareness and reflection of staff: Moral Case Deliberation (MCD) (DCIA Education Institute, 2017). This thesis focuses specifically on the use of MCD within the general craftsmanship training program. MORAL CASE DELIBERATION Reflection, in general, is the process of getting insights into the rationale for, and implementation of, actions within (professional) situations (Groen, 2006, p. 60). The instrument of MCD implemented by DCIA is focused on the reflection on situations with moral components, where conflicting values raise doubts regarding the right action (Maclagan, 2003). Moral reflection can be seen as studying the reasons behind our moral decisions (Larmore, 2010). MCD can help professionals to reflect on and deal with moral dilemmas, doubts, and challenges they encounter (De Bree & Veening, 2012). MCD focuses on reflective group learning; by following a stepwise procedure and by means of a dialogue (Van den Hoven & Kole, 2015). MCD offers several optional conversation methods (Steinkamp & Gordijn, 2003), of which the dilemma method is used at DCIA. A short version of the steps of this conversation method is shown in Figure 1, a more detailed version in Appendix 2. As the name implies, this conversation method contains specific steps that strongly focus on identifying and discussing moral dilemmas. Moral dilemmas show situations in which possible courses of action will always have adverse consequences and the options are not feasible to apply simultaneously (Stolper et al., 2016). The facilitator of an MCD session (Stolper et al., 2015) does not give content-driven advice during MCD; instead, they foster the dialogue between participants and stimulate moral reasoning and the learning process of participants (Stolper et al., 2016). During MCD, the facilitator helps participants resist the appeal of moving toward ‘quick fixes’ and ‘rushed solutions’ based on less thoughtful interpretations of the situation at hand. Instead, during MCD, ‘slow thinking’ is promoted, entailing a conscious slowing down and an invitation to reflect extensively on the topic, also called ‘suspended judgment’. Intuitive judgments or presuppositions are thus critically examined, allowing more systematic reflection than most participants are accustomed to in daily practice (Van den

15 General introduction Hoven & Kole, 2015, p. 20). For over two decades MCD has been implemented, primarily, in health care institutions (Bartholdson et al., 2014; Dauwerse et al., 2014; Lillemoen & Pedersen, 2015), but in recent years it has increasingly received attention in other contexts, such as in the military (Van Baarle, 2018) or counterterrorism (Kowalski, 2020). Introduction Case presentation Formulation of the dilemma Clarifying the case through elucidating questions Collecting of involved perspectives, values and norms Brainstorm of alternative courses of action Individually argued considerations Examining similarities and differences Conclusions and plan for follow-up actions Wrap-up and evaluation Figure 1. The steps of the dilemma method for MCD at DCIA (Stolper et al., 2016) Theoretical viewpoints of MCD MCD is inspired by hermeneutic, dialogical, and pragmatic approaches to ethics (support). These approaches focus on learning from experiences, achieved through a joint dialogue in which different perspectives and insights are integrated (Molewijk, Abma, et al., 2008). Based on a hermeneutic approach, MCD emerged from the view that understanding in general and especially in moral learning starts from a focus on concrete situations and emerges from experiences in practical contexts (Widdershoven & Molewijk, 2010). The hermeneutic approach presupposes that there is no objective truth or universal answer to what constitutes right courses of action. Instead, we experience and interpret situations in a context-specific way, and we can learn from each other’s perspectives on situations. Viewpoints are based on time, location, the people involved, and the previous experiences of the person interpreting the situation. In the effort to make the best out of challenging conditions, an essential element is understanding that one 1

16 Chapter 1 cannot learn from experiences without the art of asking questions. Gadamer mentions the value of knowing what you do not know since you lack insights or experiences that others might have (Gadamer, 2014, p. 345). MCD builds on this, since dialogue and asking questions – while postponing judgment – are crucial elements to learn from each other’s perspectives during MCD. Participants speak without there being a hierarchy during MCD; all participants and their views are considered worthwhile to listen to (Hartman et al., 2016, pp. 79–80). Not surprisingly, MCD is based on dialogical ethics. In this approach, establishing what is good cannot be done in advance or in general terms. Rudnick (2002, 2007) states that using general principles would not work sufficiently for professional ethics. Instead, determining what is good should be done through ‘a procedure enacted by the parties involved’, and this procedure is necessarily in the form of a dialogue (Rudnick, 2002). During MCD, professionals deliberate with peers based on their experiences with moral doubts or disagreements instead of leaving the moral judgments to experts or committees (Abma et al., 2009). The facilitators foster the dialogical process of participants and thereby stimulate a learning process and the moral reflection of participants (Stolper et al., 2016). A dialogue between stakeholders is ‘key to sound moral decision-making’ (Rudnick, 2007). Dialogical ethics does not provide a framework for deciding; instead, it provides guidelines for conducting dialogue (Koehn, 1998). The purpose of a joint dialogue is to expand the perspective of the participants by confronting them with the insights of others (Molewijk et al., 2008; Weidema, 2014). This can only be of value if all involved are willing to be anti-dogmatic (Inguaggiato, Porz, et al., 2019) and to be critical of themselves and others (Widdershoven et al., 2009). MCD embodies also a pragmatist approach since it: a) focuses on facts, actions, and considerations within the specific situation in order to understand why a situation is morally troublesome, b) facilitates participants to share their values and beliefs and stimulates them to share and explore considerations in an anti-dogmatic way, c) urges them to explore the value of those considerations and values in a particular context, and d) fosters a shared process of moral inquiry focused on what actually works in practice for the involved stakeholders (Inguaggiato, Porz, et al., 2019). The dilemma method for MCD focuses on moral experiences concerning a concrete dilemma in practice. During MCD sessions with the use of the dilemma method, participants not only develop knowledge, but also skills, attitude and character (Stolper et al., 2016). This learning process concerning in-depth insights regarding practices, works best in a context where

17 General introduction diversity is the starting point; hence, where initial ideas or beliefs clash (Inguaggiato, Porz, et al., 2019). That creates a context to explore together, when all participants are willing to investigate the case and the perspectives. ‘Being anti-dogmatic and ready to revise given theories and practices sets moral reasoning in motion and is the driving force behind moral progress’ (Inguaggiato, Porz, et al., 2019). Because of the focus on concrete situations in MCD, the newly developed insights, skills or attitude can be more easily translated to work practice. Furthermore, during the dilemma method there is attention to potential harmful aspects of situations or decisions, and possible ways to minimalize such ‘moral damage’ (Stolper et al., 2016). Hence, the dilemma method aims to help participants make the translation from the dialogue toward how to act in practice. Research on MCD as an Ethics Support Service MCD is introduced at DCIA as an intervention to develop the prison staff’s moral craftsmanship. In general, MCD is stated to be a ‘quality-enhancing tool’ (De Bree & Veening, 2012, p. 13). Health care organizations consider it a good employment practice2 to offer ethics support to their staff (Hartman et al., 2016, p. 34). Positive statements about the outcomes of MCD are not always substantiated with empirical data. So far, for example, no positive impact of MCD was found on reducing moral distress (Kälvemark Sporrong et al., 2007) or improving the work climate (Forsgärde, 2000). A literature review on the evaluation of the significance of MCD in health care did show how systematic moral reflection improves participants’ understanding of moral challenges, but whether it led to better care practices was not certain (Hem et al., 2015). Another literature review on various MCD evaluation studies shows that MCD does indeed increase insight into moral issues, and that MCD improves the constructive handling of different viewpoints and helps develop team cooperation (Haan et al., 2018). Also new research questions arise. Can instruments such as MCD help decrease moral (dis)stress levels or increase the moral resilience of professionals (Hartman et al., 2016, p. 40)? Can MCD help professionals by addressing the inherent tragic dimension of (potential) harmful situations and experiences (Spronk et al., 2020)? More in general, MCD is said to be able to help develop participants ‘moral learning process’ (Metselaar et al., 2015). Yet research on the exact meaning of moral learning for professionals is relatively underdeveloped (Railton, 2017). Most articles that state MCD fosters a moral learning process, do not accompany the statement with related empirical data (as seen in e.g., Inguaggiato et al., 2 For the accreditation of health care institutions these institutions are increasingly required to have ethics support structures for their employees (Hartman et al., 2022; JCI, 2018). 1

18 Chapter 1 2019; Metselaar et al., 2015) or do not include a detailed description of what the general concept of moral learning entails (as seen in e.g., Stolper et al., 2012). In general, measuring effects of a complex intervention on ESS shows to be highly difficult (Schildmann et al., 2019; Svantesson et al., 2014). A challenge within the current empirical research on MCD is that there are many variable conditions. For example, the group of participants are different at each MCD session during research of series of MCD sessions (see, e.g., Janssens et al., 2015) or different conversation methods of MCD and different MCD facilitators with different amount of training are used in MCD evaluation research (see, e.g., De Snoo-Trimp et al., 2020). Furthermore, the involved prison staff did not have experience with explicit, joint and facilitated moral reflections regarding their practice, whereas previous studies on the impact of MCD are often based on sessions with participants who have had prior experience with moral reflection or even with the instrument of MCD. This is shown in the MCD outcomes study EURO-MCD as developed and used in the studies of Svantesson et al. (2014) and De Snoo-Trimp et al. (2020). RESEARCH AIMS AND RESEARCH QUESTIONS This thesis aims to assess the value of MCD in the specific context of working in prisons. Overall, empirical research on the ethics of working in prisons is not yet common as research is often hindered by the ‘difficult-to-access prison environment’ (Shaw et al., 2014). Professional ethics is an understudied topic in the context of prisons, unfortunately. Even more uncommon is research that takes the perspectives of prison staff themselves into account. There is as no literature on the moral dilemmas occurring while working in prison based on the perspectives and experiences of prison staff of different disciplines. In line with the earlier mentioned aims of DCIA, we want to give a voice to prison staff by collecting and analyzing self-perceived moral dilemmas from their practice. Next, we aim to evaluate how prison staff and the MCD facilitators experience the MCD sessions to gain insights about aspects that possibly influence MCD experiences, both positively and negatively. Unlike most current studies on MCD, as mentioned above, we aim to have regulated conditions of the MCD sessions in our research and to enhance insights on the evaluations of single sessions and a series of MCD sessions. Internationally, this is the first time MCD has been structurally implemented and researched with prison staff.

19 General introduction Based on the overall aim of DCIA – to further stimulate the moral craftsmanship of their staff – we aim to research whether MCD sessions influence the moral craftsmanship of prison staff. We wish to add insights about the value of MCD to present literature, since quantitative data about the impact of MCD are not yet common. Furthermore, the concept of moral craftsmanship is not well-studied and defined yet. We therefore wanted to describe the concept of moral craftsmanship in order to better understand what moral craftsmanship in the context of prison work means and which components it entails when measuring moral craftsmanship. With the description of the concept of moral craftsmanship, we aimed at developing a first questionnaire to measure components of moral craftsmanship. By this, we wish to operationalize the concept of moral craftsmanship in the context of prison work. To improve insights on what the MCD sessions offer prison staff, lastly, we aim to analyze what prison staff themselves mention as experienced outcomes of MCD sessions. In addition, we want to know in which way these experienced MCD outcomes are related to a potential moral learning process of prison staff. The overall aim of this thesis is to assess the value of MCD in the context of working in prisons. The aims mentioned above resulted in the following research questions (RQ): 1. Content of MCD: What are the themes of the moral dilemmas discussed during MCD sessions with prison staff? 2. Evaluation of MCD: How do prison staff and their MCD facilitators experience single MCD sessions and the series of MCD sessions? 3. Meaning and measurement of Moral Craftsmanship: What does the concept of moral craftsmanship entail in prison work, and how is this to be operationalized into a questionnaire? 4. Impact of MCD on Moral Craftsmanship: What is the impact of participating in a series of MCD sessions on the moral craftsmanship of prison staff? 5. Outcomes of MCD: What are the outcomes of MCD as mentioned by participating prison staff and their facilitators, and how does this relate to a moral learning process of participants by MCD? 1

20 Chapter 1 PILOT STUDY MCD sessions at DCIA before starting the main study Before presenting the research design of the main study of this thesis, we first present the pilot study we performed with MCD at DCIA. We will elaborate briefly about the lessons learned from that pilot, since it helped us decide on what conditions and design to aim for in the main study of this thesis. Prior to the research from this thesis, a series of MCD sessions was implemented at one DCIA location. The aim was that all staff participated in at least 3 MCD sessions within several months. DCIA and we, as researchers, explored staff experiences with MCD. We wished to learn more about how to implement MCD at DCIA, before actually starting the main study in other DCIA locations. Between March and July of 2017, evaluative data via nine interviews with prison staff, one focus group session with seven MCD facilitators, and four observations of MCD sessions were collected. The data from this pilot was presented in my Dutch master’s thesis (Schaap, 2019). The pilot showed, besides positive evaluations, some resistance of staff to MCD. Four types of reasons for resistance were distinguished: 1) concerns about broader organizational changes that influenced the general learning attitude of staff, 2) a wish for more focus on actions in practice than on reflection, 3) a lack of familiarity with ethics and moral dilemmas, and 4) the experienced vulnerability hindered the cultivation of an open and dialogical attitude during MCD (Schaap, 2019). Such resistance can hinder participation in reflection because learning is ‘not possible without the recognition of disruptive aspects that are present’ (Bosch, 2009, p. 478). Lessons learned from this pilot – about the implementation of MCD in the context of DCIA – were taken into account when MCD was initiated at the locations that are part of the main study as described in this thesis. During the pilot, the intention was to begin with discussing personal moral dilemmas. This start caused unease among participants partly due to a lack of basic knowledge of ethics and moral dilemmas, for example, they did not recognize which situations include moral components and which do not. Therefore, some participants did not understand when a facilitator addressed a case as unsuitable for MCD, for example, when it addressed a practical instead of a moral dilemma. We learned that to create a good start of the learning process during an MCD series, at new locations in our research we needed to start with an introductory meeting. In this meeting, participants and facilitators were introduced to each other. Furthermore,

21 General introduction participants can be informed about ethics in general and MCD in particular, and they learned more about morality, dialogue, and moral dilemma. Another lesson from the pilot was that staff often mentioned they felt little connection to the discussed dilemma since it did not play a role in their practice. MCD sessions were multidisciplinary, and group composition would change every session during the pilot. Interviews showed how staff felt the need to first experience MCD with their team, and a multidisciplinary group would potentially be appreciated at a later moment in the process. The staff also mentioned they would be more willing to open up about their considerations and thoughts if the MCD sessions did not have so many participants they did not work with on a daily basis. Another lesson we learned is to better instruct the MCD facilitators to create enough room during MCD for the last steps of the conversation method, in which participants jointly reflect on how to transfer the insights to practice. Based on the unfamiliarity with MCD, many sessions seemed to not have enough time left for these important last steps during MCD. Furthermore, we learned that during the start of an MCD session the facilitators need to help staff translate their (organizational) struggles into the formulation of the related moral dilemmas, which could then be discussed during MCD. We also learned that for prison staff to open up more, it would be best to not always include the team manager in the MCD session, unless a team explicitly requests it. Another lesson we learned was about the vocabulary used by prison staff and we used these insights to better instruct MCD facilitators. For example, we constructed a list of typical DCIA abbreviations for the MCD facilitators. Prison staff initially stated they never experienced doubts in practice, so reflections on situations of doubt would be unnecessary. When we eliminated the word doubt and asked them about their challenging experiences from practice, a dilemma would come forward more organically. We also learned from a lack of regulations concerning the planning and implementation of MCD. We noticed some staff members had never experienced MCD; by contrast, others in the pilot participated more than ten times. Additionally, the composition of the multidisciplinary groups and their facilitators differed each session. A more structured and regulated approach seemed to be best for all involved; to create calmer conditions for fruitful MCD sessions and a preset number of sessions more suitable for our research. These lessons from this pilot helped us to shape the research design and the implementation and organization of the MCD sessions in the DCIA locations of the main study. 1

22 Chapter 1 RESEARCH DESIGN Creating intervention- and control locations For our research questions we needed prison locations willing to start implementing MCD: the intervention locations in our study. The DCIA program of craftsmanship ensured money and time were available within the organization (DCIA, 2022) to pay attention to proper implementation of MCD. Overall, the organization and implementation of the MCD sessions was the responsibility of the DCIA Educational Institute. MCD can be facilitated in many different settings and with various conversation methods (Steinkamp & Gordijn, 2003). For our research aims, the intervention groups involved in MCD needed regulated conditions. Such regulations would benefit the comparability and validity of our data. To prevent having different conditions at each session during the series of MCD at DCIA, the following regulations in the setting of MCD at the intervention locations were chosen: having one introductory meeting before starting with MCD, having set prison locations that would start implementing MCD with five to six selected teams per location that we could follow during the implementation, they would participate in team-based MCD sessions, using only one type of conversation method for all sessions (i.e., the dilemma method, see Figure 1 and Appendix 2, Stolper et al., 2016), each team would have a fixed pair of MCD facilitators, and all participating teams aimed to have 10 MCD sessions within one to one-and-a-half years. During these MCD sessions the manager or superior of the team would only participate at the request of the team. MCD sessions were scheduled for two to two-and-a-half hours each. All involved teams appointed one team member who would help a local coordinator and the Educational Institute with the organizational aspects of MCD. This person, together with their team and the local coordinator, decided upon a scheduled time for MCD sessions. Most teams opted for periods during their regular work routines, for example, a time they would otherwise use for sports. The MCD sessions were guided by a total of 18 trained MCD facilitators deployed as freelancers by the DCIA Educational Institute. The facilitators were professionally trained, most of them by the ‘MCD facilitator training program’ of the Department of Ethics, Law and Humanities of the Amsterdam UMC (Stolper et al., 2015). Furthermore, to be able to analyze the impact of MCD, we selected locations of prisons that would serve as control locations. These locations neither had the experience nor the intention to start implementing MCD during the period of our data collection. As a condition for our research, no similar training (such as: ‘Talking about your profession’, in Dutch: ‘Praten over je vak’) could take place during our research period. Their staff

23 General introduction members function as a control group to compare their situation with those involved as participants in the implementation of MCD at DCIA. To select prison locations that were willing to introduce MCD and those that would serve as a control location, we collaborated with the DCIA Educational Institute and the management teams of the prisons. MCD sessions were also held at some other DCIA locations, e.g., in Zwolle, but they were not part of this study. Ultimately 5 Dutch prison locations took part in this research: Leeuwarden, Vught, Almere, Nieuwegein, and Zwaag. In the prison locations ready to implement MCD, various teams were approached to participate in order to create a broad representation of the professional disciplines of the organization. Table 1 shows the disciplines of the involved teams. Table 1. Professional disciplines of the selected teams at the intervention locations Labour instructors Health care professionals Security guards Correctional officers Correctionals officers for repeated offenders Middle management Management team Case-managers re-integration services Backoffice re-integration services Prison locations serving as the control locations for the impact study were selected in a similar manner from institutions that were not willing to introduce MCD yet. We selected locations that would be comparable to the intervention groups based on confidential information from DCIA., with regard to the size of the prison or the type of prison (only correctional institutes, and no other types such as Penitentiary Psychiatric Centers). Additionally, more specific details were looked at per location, e.g., scores from their employee satisfaction survey. Eventually, together with local management we selected teams comparable to the ones in the intervention locations, based on their professional disciplines and the sizes of teams. 1

24 Chapter 1 A responsive evaluation approach For the research on the intervention of MCD, we were inspired by responsive evaluation research (Abma, 2005). This approach aims to support active involvement of and interaction between all parties during the implementation and evaluation of MCD. To a certain degree, responsive evaluation allows adjustment during the implementation of MCD. Key in responsive evaluations is the direct involvement of all stakeholders whose interests are at stake, to evaluate how to reach the joint goal (Abma, 2005). This approach fits with the hermeneutic viewpoint on MCD since interpretation and understanding take place during the process (Freeman, 2011). Additionally, the approach fits since it is the first time MCD is evaluated based on experiences with MCD in the prison context. Hence, lessons along the way based on this specific context need to be translated into adjustments in the implementation of MCD. An implementation process of MCD benefits from the possibility of changing circumstances along the way (Weidema et al., 2016). Current literature often mentions the need for ‘shared ownership’ of MCD; meaning that all involved work together to realize a shared aim of the MCD sessions (Hartman, 2020; Hartman et al., 2016; Weidema, 2014). A proper implementation process of MCD needs commitment from managers, as well as involvement from staff members. Moreover, ‘the evaluator’ of the process should create conditions for interactions between stakeholders (Abma, 2005) to be able to move toward an experience of joint learning and improvements of the learning process. By all stakeholders being equally involved, and feeling equal during dialogues about the process, all can learn from each other. Responsive research aims to facilitate or stimulate improvements in practices via reflection and ongoing dialogue between all parties (Abma et al., 2009). Steering committees and peer meetings To create such interactions between all involved for a responsive approach, to elicit ‘shared ownership’ and an ongoing dialogue in the implementation of MCD, hence, to keep learning from each other’s experiences and perspectives, we advised locations starting to implement MCD to install local MCD steering committees. At the intervention locations, these Committees consisted of some members from the participating teams, the local management team including one or two director(s), a coordinator from the Educational Institute, and two of the involved researchers per location. The aim was to facilitate and monitor the implementation process of the MCD sessions and make adjustments when necessary. The research team was actively involved in the implementation process of MCD to understand the insights of participants and facilitators and to foster the improvement of practice (Widdershoven et al., 2009). Furthermore, the

25 General introduction researchers shared relevant findings from the ongoing research to highlight experiences that could potentially improve the implementation process. Since several locations were involved, an additional national steering committee was formed during the research. This group consisted of the research team, stakeholders of DCIA concerning this part of the craftsmanship program, and the involved coordinator and director of the DCIA Educational Institute. Every three months, this group discussed the progress of the project with MCD and of the research to enhance the collaboration between all involved and gain more understanding of each other’s work. Furthermore, to foster mid-term learning of MCD facilitators and jointly search for possible improvements in their role, peer meetings were organized for MCD facilitators working at DCIA. We organized this together with the DCIA Educational Institute and within the craftsmanship program. These meetings give facilitators the opportunity to continue to develop themselves (Stolper et al., 2014, p. 256) and improve their connection with the participants in this specific context. Most MCD facilitators had no prior experience with working in the prison context. Both the steering committees and these peer meetings created an environment that enabled the responsive approach; researchers shared anonymized research data – based on the interviews with participants, focus groups with facilitators, and data from the evaluation forms – to start a dialogue and collaborative learning process about the results. Adaptations in our design due to the closing of prisons Initially, two institutions were selected as the intervention group: the prisons of Nieuwegein and Zwaag. At these two locations, 11 teams started with MCD and were part of the research. Two comparable locations were selected as a control group: the prisons of Almere and Leeuwarden. This original set-up changed during the research period because in the summer of 2018, one location from the intervention group (Zwaag) and one from the control locations (Almere) were closed by the Ministry of Justice and Security. To collect enough reliable data for our analyses, we started the project at two ‘new’ intervention- and control locations from 2019 onwards. When the data collection of the control location Leeuwarden was completed, they wished to start implementing MCD. Therefore, after the research on the control group Leeuwarden had ended, they started as an intervention group. We selected one new location to be the control group for this phase: the prison of Vught. Eventually, these five prison locations were part of this research project. Figure 2 shows the data collection period for the intervention and control groups. 1

26 Chapter 1 Figure 2. Data collection per location, of the pre- and post-measurements with the MCSQ *These locations closed down in the summer of 2018, hence, our research stopped earlier than originally planned RESEARCH METHODS This study used various research methods. Table 2 shows an overview per Chapter. More detailed explanations of the methods can be found in the related Chapters. In the article concerning the moral dilemmas of prison staff (RQ 1, Chapter 2) we aimed to give a voice to the prison staff. Therefore, we stayed as close as possible to the respondents’ words; hence, we used ‘conventional content analysis’ approach (Hsieh & Shannon, 2005). Additionally, to summarize the variation and regularities in the data found, we used a thematic content analysis (Green & Thorogood, 2013). For the evaluation of MCD (RQ 2, Ch.3) and the experienced outcomes (RQ 5, CH.6) we used embedded mixed methods (Creswell, 2014, p. 44). The combined data of quantitative and qualitative analyses enrich each other and provide an insightful understanding of the data. This is needed for the responsive approach we aim to use during the implementation of MCD (Abma, 2005). For our explorative approach on RQ 3 (Ch.4) an iterative process was performed by all authors actively looking for consensus on the definition and elements of MCS. The conceptual elements found were categorized by a thematic content analysis (Green & Thorogood, 2013). We tested our developed questionnaire via think-aloud interviews (Mcdonald et al., 2012), to improve its usability and content validity. Our self-developed questionnaire was used to address RQ 4 (Ch.5) about the impact of MCD on moral craftsmanship. We performed many types of quantitative analyses: multivariate analyses, ANOVA tests, exploratory factor analysis, Chi-squared test, independent sample t-test, and a multiple regression. Additionally, we conducted mid-term interviews, varying in duration between 30-60 minutes, with participants (n=19) and local managers or directors (n=12), representing all involved teams and locations of the intervention group.

27 General introduction We conducted three focus group meetings with facilitators. The interviews and focus group meetings were audiotaped and transcribed, and mainly used as a monitoring instrument for the implementation process, generating input for the local steering committees and facilitators’ peer meetings. Table 2. Overview of methodologies and included data per chapter Chapters Methods Single sessions or series of MCD Included data 2: Moral themes of Dutch prison staff Qualitative: thematic content analysis Per single MCD 148 MCD sessions 1065 evaluation forms by participants 171 evaluation forms by facilitators 154 cases of moral dilemmas 3: Evaluation of MCD at DCIA Embedded mixed methods, e.g., multilevel analyses and open coding Per single MCD and after the MCD series 131 MCD sessions 871 evaluation forms by participants 122 evaluation forms by facilitators 167 surveys after the series by participants 4: What is moral craftsmanship, and how to measure it? Conceptual: document, literature study and thematic content analysis - DCIA documents Literature 7 think-aloud interviews 5: Impact of MCD on moral craftsmanship Quantitative: e.g., multilevel analyses and ANOVA tests Before and after the MCD series 459 premeasurement surveys and 456 postmeasurement surveys by intervention- and control groups 6: Experienced outcomes and moral learning through MCD Embedded mixed methods: e.g., multilevel analyses and thematic content analysis Per single MCD and after the series 131 MCD sessions 871 evaluation forms by participants 122 evaluation forms by facilitators 167 surveys after the series by participants 1

28 Chapter 1 OUTLINE OF THE THESIS Part A: Themes and evaluation of moral case deliberation Chapter 2 describes the moral themes of prison work as categorized based on a thematic content analysis of the self-perceived moral dilemmas as they were mentioned during MCD sessions (RQ 1). Chapter 3 shows how the MCD participants and the MCD facilitators evaluated the MCD sessions at DCIA based on single and a series of sessions (RQ 2). Part B: Meaning and measurement of moral craftsmanship Chapter 4 focuses on exploring the definition and conceptual elements of moral craftsmanship for prison staff and developing a measurement tool for moral craftsmanship (RQ 3). Chapter 5 shows a quantitative study on the influence of a series of MCD sessions on the moral craftsmanship of prison staff, with pre-and post-measurements and intervention and control groups (RQ 4). Part C: Experienced outcomes and moral learning Chapter 6 presents the experienced outcomes for MCD participants based on single sessions and a series of sessions and reflects on the moral learning process of prison staff through MCD (RQ 5). In the closing Chapter 7, the general discussion of this thesis, I will provide an overview of the research results and then reflect on three broader observations from our research, focusing on a) learning from resistance, 2) the particularities of the DCIA context and related challenges when implementing MCD, and 3) methodological challenges when researching the impact of MCD. Finally, based on the research in this thesis, I will give some recommendations for ethics support in prisons and specifically to the continuation of strengthening moral craftsmanship in the context of DCIA. Finally, I will provide directions for future research on MCD and Ethics Support Services (ESS).

29 General introduction REFERENCES Abma, T. (2005). Responsive evaluation in health promotion: Its value for ambiguous contexts. Health Promotion International, 20(4), 391–397. https:// doi.org/10.1093/heapro/dai013 Abma, T., Molewijk, B., & Widdershoven, G. (2009). Good care in ongoing dialogue. Improving the quality of care through moral deliberation and responsive evaluation. Health Care Analysis: HCA: Journal of Health Philosophy and Policy, 17(3), 217–235. https://doi.org/10.1007/ s10728-008-0102-z Armstrong, G. S., & Griffin, M. L. (2004). Does the job matter? Comparing correlates of stress among treatment and correctional staff in prisons. Journal of Criminal Justice, 32(6), 577–592. https:// doi.org/10.1016/j.jcrimjus.2004.08.007 Auerbach, S., Quick, B., & Pegg, P. (2003). General job stress and job-specific stress in juvenile correctional officers. Journal of Criminal Justice, 31, 25–36. https://doi.org/10.1016/S00472352(02)00197-6 Bartholdson, C., Pergert, P., & Helgesson, G. (2014). Procedures for clinical ethics case reflections: An example from childhood cancer care. Clinical Ethics, 9(2–3), 87–95. https://doi. org/10.1177/1477750914546758 Bosch, J., & Wortel, E. M. (2009). Versterking van de morele competentie. De verdiepingscursus militaire ethiek. Militaire Spectator, 178(9), 471–486. Bruhn, A., Nylander, P., & Lindberg, O. (2010). The Prison Officer’s Dilemma: Professional Representations among Swedish Prison Officers. Les Dossiers Des Sciences de l’éducation, 23(1), 77–93. https://doi.org/10.13140/2.1.1154.1122 Cheeseman, K. A., Kim, B., Lambert, E. G., & Hogan, N. L. (2011). Correctional officer perceptions of inmates and overall job satisfaction. Journal of Crime and Justice, 34(2), 81–102. https://doi.org/10.1080/0 735648X.2011.580515 Craig, S. C. (2004). Rehabilitation versus Control: An Organizational Theory of Prison Management. The Prison Journal, 84(4_suppl), 92S-114S. https://doi. org/10.1177/0032885504269394 Creswell, J. W. (2014). Research design: Qualitative, quantitative, and mixed methods approaches (4th ed). SAGE Publications. Dauwerse, L., Stolper, M., Widdershoven, G., & Molewijk, B. (2014). Prevalence and characteristics of moral case deliberation in Dutch health care. Medicine, Health Care, and Philosophy, 17(3), 365–375. https://doi.org/10.1007/ s11019-013-9537-6 DCIA. (2009). Strategisch kader modernisering gevangeniswezen [Strategic framework modernization prison system]. Dutch Correctional Institutions Agency. DCIA. (2016a). Vakmanschap en de vakmanschapsladder—Divisie GW/VB [Craftsmanship and its developmental steps—Division prisons and detention centres] [DCIA internal document]. DCIA. (2016b). Programma Vakmanschap GW/ VB [Craftsmanship program—Division prisons and detention centres] [DCIA internal document]. DCIA. (2016c). Jaarplan DJI 2017 [Yearplans DCIA 2017]. DCIA. (2022). Evaluatie convenant DJI 20182021 [Evaluation report agreements DCIA 2018-2021]. Ministerie van Algemene Zaken. https://www. rijksoverheid.nl/documenten/ rapporten/2022/07/08/tk-bijlagerapport-evaluatie-convenant-dji-20182021-definitief 1

30 Chapter 1 DCIA Education Institute. (2017). Moreel Beraad. Methodisch reflecteren op een dilemma [Moral Case Deliberation. Methodological reflection on a dilemma]. Opleidingsinstituut DJI. DCIA Educational Institute. (2014). Kenniskring Moreel Vakmanschap [Expertise committee Moral Craftsmanshp]. Opleidingsinstituut DJI. DCIA Educational Institute. (2017). Opleidingsgids [Training guide]. De Bree, M., & Veening, E. (2012). Handleiding Moreel Beraad. Praktische gids voor zorgprofessionals. Van Gorcum. De Snoo-Trimp, J. C., Molewijk, B., & de Vet, H. C. W. (2018). Defining and categorizing outcomes of Moral Case Deliberation (MCD): Concept mapping with experienced MCD participants. BMC Medical Ethics, 19(1), 88. https://doi. org/10.1186/s12910-018-0324-z De Snoo-Trimp, J., Molewijk, B., Ursin, G., Store Brinchmann, B., Widdershoven, G., De Vet, R., & Svantesson, M. (2020). Field-testing the Euro MCD instrument: Experienced outcomes of moral case deliberation. Nursing Ethics, 27(2), 390–406. Dilulio, J. J. (1987). Governing Prisons. Free Press. Enggist, S., Møller, L., Galea, G., & Udesen, C. (2014). Prisons and health. World Health Organization. Regional Office for Europe. Finney, C., Stergiopoulos, E., Hensel, J., Bonato, S., & Dewa, C. S. (2013). Organizational stressors associated with job stress and burnout in correctional officers: A systematic review. BMC Public Health, 13, 82. https://doi.org/10.1186/14712458-13-82 FNV Overheid. (2017). Onderzoek werkdruk bij DJI—’Op te veel plekken te weinig ogen’ [Analyses of work pressure at DCIA - ’In too many places not enough eyes’]. FNV Overheid. (2020). Code Rood. Werkdruk bij Dienst Justitiele Inrichtingen [Code Red. Work pressure at DCIA]. Forsgärde, B. W., Lennart Nygren, Marianne. (2000). Ethical discussion groups as an intervention to improve the climate in interprofessional work with the elderly and disabled. Journal of Interprofessional Care, 14(4), 351–361. https://doi. org/10.1080/13561820020003900 Forsyth, J., Shaw, J., & Shepherd, A. (2022). The support and supervision needs of prison officers working within prison environments. An empty systematic review. The Journal of Forensic Psychiatry & Psychology, 33(4), 475–490. https://doi.org/10.1080/14789949.2022 .2085150 Freeman, M. (2011). Validity in Dialogic Encounters With Hermeneutic Truths. Qualitative Inquiry, 17(6), 543–551. https://doi. org/10.1177/1077800411409887 Gadamer, H. G. (2014). Waarheid en Methode. Hoofdlijnen van een filosofische hermeneutiek [Truth and method]. Vantilt. Green, J., & Thorogood, N. (2013). Beginning Data Analysis. In Qualitative methods for health research (Vol. 3, pp. 209–217). Sage Publications. Groen, M. (2006). Reflecteren: de basis. Op weg naar bewust en bekwaam handelen. Wolters-Noordhoff. Haan, M. M., van Gurp, J. L. P., Naber, S. M., & Groenewoud, A. S. (2018). Impact of moral case deliberation in healthcare settings: A literature review. BMC Medical Ethics, 19(1), 85. https://doi. org/10.1186/s12910-018-0325-y Hartman, L. (2020). Innovations in Clinical Ethics Support. Vrije Universiteit [PhD Thesis]. Hartman, L., Van Baarle, E., Diepeveen, M., Widdershoven, G., & Molewijk, B. (2022). Quality Characteristics for Clinical Ethics Support in the Netherlands. AJOB Empirical Bioethics, 13(1), 22–32. https://doi.org/10.1080/23 294515.2021.1925776

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