In this study, experienced MCD participants from a broad range of settings where MCD is practiced, explored possible MCD outcomes using the qualitative and quantitative method of concept mapping . The concept mapping focus group with 12 members provided a list of 85 possible outcomes. In the end, a clear categorization of 8 clusters that comprehends 85 possible outcomes was achieved: 1) Organisation and Policy; 2) Team development; 3) Personal development focused on the Other Person; 4) Personal development as Professional, focused on Skills; 5) Personal development as Professional, focused on Knowledge; 6) Personal development as an Individual; 7) Perception and Connection; and 8) Concrete action.
Reflection on focus group process
The focus group members came from a variety of professional backgrounds and had broad experiences with MCD participation in different settings (even outside healthcare). Due to this, they brought a large variety of statements into the brainstorm phase and at the same time were able to critically analyze the final list of statements. During the step in which they had to make piles of the statements, the number of piles differed. One focus group member distinguished only 2 thematic clusters covering all 85 outcomes while other distinguished up to 20 thematic clusters. A step for step dialogue in which they had the possibility to explain how they thought about the differentiation of clusters, relatively easily led to an agreement about how many clusters there should be. Furthermore, a surprising finding was that with regard to some clusters (Organisation and Policy, Team development, Personal development as an Individual and Perception and Connection), consensus was easily reached, possibly indicating that the cluster was recognizable as a specific theme and probably clearly enough constructed. However, the discussion about the other clusters took a while, and some focus group members did not contribute to the formulation of cluster names as they did not support the positioning of some clusters. Nevertheless, in the end, all focus group members agreed on the final naming and categorizing of the 8 clusters, despite the minor disagreements during the cluster discussions.
When exploratively reviewing literature, we found some (but not all) of these clusters as well. For instance, in the focus group study of Hem et al. , participants of ethics reflection groups (which is similar to MCD) described that they experienced an increased awareness of ethical issues, ‘professional development’ and better collaboration among their colleagues, in which we see a clear link with two clusters in our study, namely Team development and Personal development as a Professional. A better team collaboration and the impact on personal development have also been suggested by other studies [11, 13, 14]. Next, in the study of Seekles et al. , professionals working in the Dutch Health Care Inspectorate reported to feel more secure after participating in MCDs, which refers to several statements in the cluster Perception and Connection in our study. Furthermore, Lillemoen and Pedersen  reported how participation in ethics reflection groups contributed to ‘important changes in practice’, for example by improving their attitude towards and cooperation with patients and their relatives. This impact on concrete practice shows a link with the cluster Concrete Actions in our study. Thus, the clusters found in our study can to some extent be confirmed by other studies. However, all of these studies did not explicitly focus on the naming and meaning of the clusters and the mutual relationship between statements within clusters, which was systematically explored in the current study. Especially with regards developing tools to evaluate MCD outcomes, our findings are relevant to operationalize and concretely define what (categories of) MCD outcomes mean according to a heterogeneous group of experienced MCD participants.
Comparing focus group-clusters with euro-MCD domains
According to the second aim of this paper and the sixth step of concept mapping  and in light of the ultimate goal of the Euro-MCD field study, we would like to compare the outcomes and clusters as defined in the two concept mapping focus group sessions with outcomes from the Euro-MCD study [16, 17]. During the focus group, 15 out of the 26 items in the Euro-MCD Instrument were already spontaneously mentioned in the brainstorm phase, and 11 of these 26 items were added afterwards (i.e. when presented as possible outcomes, the focus group members approved these 11 Euro-MCD outcomes as relevant). As shown in Table 2, these 11 added outcomes came from different Euro-MCD domains, but it is remarkable that especially items from the domain of Collaboration were added at that moment; hence, they were not yet mentioned in the preceding brainstorm phase. The fact that almost no items from the domains of Concrete Results, Moral Reflexivity and Moral Attitude were added, means that these or similar outcomes were already brought up during the brainstorm phase, which might point to a tendency of the focus group members to think of outcomes linked to these domains.
When comparing the final cluster names with the names of the Euro-MCD domains, several links can be made: Concrete Action with Concrete Results; Organisation and Policy with Impact on Organisational Level; Team development with Collaboration. Furthermore, when looking at the Euro-MCD domain Emotional Support, we see a link with our cluster Perception and Connection, as both include feelings and emotions like ‘self-confidence’, ‘managing stress’ and ‘feeling secure’. Finally, the Euro-MCD domains Moral Reflexivity and Moral Attitude can be compared with the clusters about personal development (clusters 3–6), as they all include outcomes referring to self-reflection, like ‘I gain more clarity about my own responsibility in the ethically difficult situations’ and ‘Increases my awareness of the complexity of the situation’. Fortunately, we can therefore conclude that the original categorization of MCD outcomes by MCD experts in the Euro-MCD Instrument can be confirmed to some extent, despite the fact that their categorization was not yet based on empirical data at that time .
However, several differences can be found as well when comparing the Euro-MCD domains with the clusters of the concept map. Firstly, the Euro-MCD domains Emotional Support and Collaboration seem to be reflected in more than 2 focus group-clusters, namely Team development, Personal development focused on the Other Person and Perception and Connection. Secondly, the Euro-MCD domains Moral Reflexivity and Moral Attitude cannot be recognized easily in the focus group-clusters, since terms like ‘reflexivity’ or ‘attitude’ were not used. These domains are about analytic skills, awareness and understanding of ethically difficult situations. Yet, the focus group members made a distinction between skills and knowledge in their separate clusters about personal development as a professional (4 and 5). To conclude, we can say that the focus group members defined additional and more detailed categories of outcomes that match with outcomes from the Euro-MCD domains Moral Reflexivity and Moral Attitude, namely based on whether the outcome was about personal or professional development, about oneself or directed to the other, and about skills or about knowledge. This resulted in 4 separate clusters (3–6) for personal and professional development, and skills and knowledge. This difference in nuances might be explained by the fact that the definition of the Euro-MCD domains of Moral Reflexivity and Moral Attitude was based on theory, literature and the opinion of MCD experts , while the naming of the 4 focus group clusters about personal development in the current study was only based on the practical experience of actual MCD participants. In our opinion, this might show the added value of both using the method of concept mapping and giving voice to the concrete users of MCD focusing on their experiences with participating in MCD sessions.
Negative outcomes of MCD
An interesting difference between this study and the Euro-MCD Instrument is the formulation and position of possible negative outcomes (‘Disappointment about outcome’ and ‘Sense of wasting time’) in the focus group cluster Perceiving and Connecting, while the Euro-MCD domains only contain positively formulated outcomes. The formulation of these two negative outcomes was a surprising finding in our study, although the number of two might be a quite low number. We think and literature shows that MCD might cause negative outcomes as well, like frustrations about the lack of solutions  or not experiencing changes in daily work [10, 14]. A reason for this could be that defining possible outcomes of MCD is closely linked to how participants experienced the MCDs they participated in. The focus group members in our study all had extensive experience with MCD and did thus not base their thoughts on only one positive (or negative) MCD. It is important for future research on outcomes of MCD to make sure if outcomes of MCD really involve outcomes and not the process of MCDs themselves. Future qualitative studies should investigate what kind of negative outcomes MCD participants report, whether they refer to literally negative or harmful outcomes or a lack of expected positive outcomes, and in which way they are related to MCD as such. This is important in order to avoid a bias in presenting (only positive) MCD evaluation results. Furthermore, negative MCD outcomes could be helpful in improving, adjusting or not using MCD as ethics support mechanism. Furthermore, we should reflect upon the question whether we should pay attention to negative MCD outcomes in the further validation of the Euro-MCD Instrument.
One of the strengths of this study was the fact that the concept mapping procedure consisted of structured and systematic conceptual-analytical steps in which qualitative and quantitative measures were integrated within a reflective open dialogue. A main strength of our study was the composition of the focus group: members came from various professional backgrounds, in diverse settings of MCD, both inside and outside healthcare, and were all very experienced as participants in MCD. As such, they were no specific ‘experts’ in evaluation research, instrument development, but people from a broad range of settings were MCD is practiced. They were all present and actively involved in both sessions of the focus group, and they all had a critical and analytical yet constructive contribution. This might be caused by the fact that they were experienced MCD participants and thus were used to group sessions with equal participation, a critical dialogue, being open towards different perspectives and letting others express their thoughts. The final concept map with named clusters is a product of the participants themselves, as it was based on statements that they generated in their own words, with extra input from the original Euro-MCD. Furthermore, a methodological strength was that we were able to complement the brainstorm among the focus group members with data from the large Euro-MCD field study as well, in order to get as rich data as possible. Lastly, the focus group members achieved a relatively strong agreement on the final names and categorization of the clusters, resulting in an experience- and consensus-based categorization of MCD outcomes.
Yet, our study has limitations as well. The study contained only one focus group consisting of two sessions in only one country, due to limited time and financial resources. Since we needed experienced MCD participants, the Netherlands was a good candidate for performing this study as MCD is implemented in this country for a long time . It is important to know whether MCD participants from other countries might come up with similar MCD outcomes, not only because of cultural differences but also because of possible differences in how MCD is seen and performed. Thus, in developing instruments to measure outcomes of CES interventions like MCD, data from other countries should also serve as an important basis.