Volume 21, No. 1, Art. 7 – January 2020
In Search of a Research Strategy: Evaluation of an Ethics Program for Social Professionals Using Elements of the Most Significant Change Approach
Sabrina Keinemans, Mariӫl Kanne & Ed de Jonge
Abstract: In this article, we describe a study on the impact of an ethics program aimed at strengthening the ethical agency of 15 social workers of three welfare organizations. The goal of the study was to make an inventory of the impact of the program, and to evaluate the relevance of this impact with the help of several stakeholders. The most significant change (MSC) approach was used as a research strategy, though some changes to the approach were made with a view to our research goal. We explain the MSC approach and how we used it in our study design. Further, we describe the research process, answering the question whether our adaptation of the MSC was helpful to inventory the impact of our ethics program and the evaluation of its relevance. The implications of MSC's focus on "most significant" changes and the need for a thorough feedback of the results of the evaluation process in the participating organizations are discussed.
Key words: ethics; professionalization; moral case deliberation; ethics program; moral reflection; ethics work; most significant change approach; evaluation research
Table of Contents
2. The Ethics Program
3. The Most Significant Change (MSC) Approach
4. Research Design
4.2 Collection of stories
4.3 Selection of stories
4.5 Prudent data management
5.1 Selecting the most significant change stories: The process
5.2 Selecting the most significant change stories: The arguments
In 2008, our research group started a research program on social work ethics. This program was initiated following the observation that social workers in the Netherlands often deal with moral challenges in their professional practice, while a clear moral frame of reference is missing (TONKENS, 2009; VAN DOORN, 2008). Accordingly, in the past ten years our group has carried out extensive theoretical and empirical research on moral challenges and professional ethical agency in the field of social work (e.g., DE JONGE, 2014; KANNE, 2016; KEINEMANS, 2014; KEINEMANS, DE JONGE & KLOPPENBURG, 2014). 
Other Dutch researchers are conducting research on similar issues in the field of social work (e.g., KLAASE, 2017; SPIJKERBOER, 2018). Dutch scholars are therefore steadily working on a body of knowledge on professional ethics in social work, resulting in a better understanding of the moral challenges in the social domain but also producing practical tools for social workers such as methods for moral reflection, both as a group and individually. Some examples can be found on our Dutch website. 
Our research group noticed that social workers welcomed this body of knowledge, but were especially enthusiastic about the practical tools for moral reflection. As a participant in one of our research projects stated: "These meetings [aimed at moral reflection, our comment] were very useful and due to the meetings, I am more able to deal with the moral dimension of my work." 
This finding is substantiated by international research. In the past few years, several studies have demonstrated the relevance of ethical reflection, for example by means of "moral case deliberation" or "clinical ethics support sessions" in the field of care (GRÖNLUND, DAHLQVIST, ZINGMARK, SANDLUND & SÖDERBERG, 2016; HAAN, VAN GURP, NABER & GROENEWOUD, 2018; JANSSENS, VAN ZADELHOFF, VAN LOO, WIDDERSHOVEN & MOLEWIJK, 2015; MOLEWIJK, VAN ZADELHOFF, LENDEMEIJER & WIDDERSHOVEN, 2008; SVANTESSON et al., 2014; WEIDEMA, MOLEWIJK, KAMSTEEG & WIDDERSHOVEN, 2013) and social work (KANNE, 2016; SPIJKERBOER, 2018). The practice of moral case deliberation has a theoretical basis in pragmatics and hermeneutics (HARTMAN, METSELAAR, WIDDERSHOVEN & MOLEWIJK, 2019). Although findings differ to some extent, most studies demonstrate how professionals benefit from moral case deliberation. We provide a few examples1) from the field of social work: KANNE (2016) concludes, based on a literature review and empirical research, that moral case deliberation generates effects on four levels. On the level of a concrete case, participants learn to acknowledge that every situation can be seen from multiple perspectives. On the level of the professional, increased reflective competencies and awareness of the normative dimension of professional practices are mentioned as results. On the team level, respondents report an enhancement of mutual respect and understanding, as well as confidence and safety within teams. On the organizational level, inter- and multidisciplinary communication is improved. Similar effects—at least on the level of a case and the level of the professional—are mentioned by SPIJKERBOER (2018). SPIJKERBOER studied the ability of social work students and professionals to deal with moral dilemmas and concluded that—among other effects—they recognized moral dilemmas better and became more aware of alternative perspectives on a dilemma due to moral case deliberation. 
The cited studies involve the participants of moral case deliberation. Participants report how they are affected by the deliberation process or (progress in) their moral competence, which is studied by means of an assessment or reported by their manager. This research strategy is in itself an obvious choice: only participants can describe or demonstrate how the participation in moral case deliberation affected them. However, what remains unseen in this approach is whether and how these results matter according to several stakeholders in the field of social work. This issue is especially important, as the use of moral reflection tools presupposes that it yields "surplus value" for patient care (WEIDEMA et al., 2013, p.618). However, the perspective of patients and social service users is often lacking in evaluative studies on the impact of moral case deliberation, so that these studies often fail to address the relevance of intervention outcomes. 
Our research group therefore chose to perform an evaluation study of an ethics program, with the twofold purpose: 1., to describe the impact on the program participants and 2., to evaluate the relevance of this impact in the eyes of several stakeholders, such as social service providers, social service users, and operational managers. Consequently, our research is of a participative nature, although to a limited extent. In participatory research, people with lived experiences of the topic of study are co-creators of knowledge (LENETTE et al., 2019). Therefore, stakeholder involvement in all research phases, from planning to conducting a research process to data analysis, is generally seen as a prerequisite for participative research (BERGOLD & THOMAS, 2012). Our project involved several stakeholders from social work practice: it was collaborative but not user-led or user-controlled. The stakeholders who participated in our project were not actively involved in the formulation of the research goal and strategy and so one might question whether it was an authentic participatory research or just traditional research with an "add-on" of perspectives from service-users and service-providers (COOK, 2012). It can furthermore be questioned whether we succeeded in a true involvement of all stakeholders in the evaluation of the ethics program. There is a vast amount of literature on the difficulties of participatory research, for example because of hierarchical structures (LENETTE et al., 2019) but also because co-creation or participation does not necessarily lead to empowerment (KARA, 2017). As we worked with social service providers and very vulnerable service users, these issues were highly relevant for us. For example: including service users in research is very demanding and at certain points we decided not to engage service users because we did not want to wear them out (and we realize how patronizing that might sound). Yet another example: service providers were present during the stakeholder meeting with service users. Hence, power imbalances might have influenced the dialogue. On the other hand: we as researchers were not fully able to understand the (verbally impaired) service users. Consequently, the presence of mediators—such as service providers—was necessary in order to engage service users in the research. In sum: the participative nature of our research can be contested, but since there is no best way of doing participatory research, all we could do was to make deliberate choices with regard to the involvement of stakeholders. These will be described in more detail in Section 4.3. 
To realize our research goal —describing the impact of an ethics program and evaluating its relevance with the help of several stakeholders—we used a modification of the most significant change (MSC) approach by DAVIES and DART (2005). In this article, we do not aim to describe the findings (that is, the impact and relevance of our ethics program); rather, the purpose of the article is to describe our research and critically reflect on the usefulness of elements of the MSC approach in such a participative evaluation of an ethics program. It is important to note that the goal is not to evaluate the MSC as a research strategy in itself. Instead, we analyze whether elements of MSC could be useful in evaluation research with an explicit ethical dimension. 
In Section 2, we describe the ethics program that was studied in our research and provide clarification on some ethical assumptions at the heart of this program. The basic premises and phases of the MSC are described in Section 3. As we adjusted the MSC approach to fit our purpose, we will also provide a detailed account of our proceedings in the research process (Section 4), as well as our experiences with the approach and the hurdles that had to be overcome (Section 5). 
2. The Ethics Program
Our research team consists of two persons with a background in ethics (author two and three) and one with a background in social sciences (corresponding author), and we are socialized in various traditions (e.g., virtue ethics, critical theory, feminist theory, ethics of care). We share the phenomenological assumption that all (especially social and moral) knowledge is mediated through experience, hence that all (social and moral) research deliberately should start with experience and our research group prefers research strategies that do justice to "lived experience." This filters through our ethics program, which leans on authors such as GADAMER (1975 ), RICOEUR (1992 ), TAYLOR (1989), and TRONTO (1993, 2013). Most prominently however, our research program on ethics work is based on the concepts of "normative professionalization" (KUNNEMAN, 2005, 2013; VAN EWIJK & KUNNEMAN, 2013) and "ethics work" (BANKS, 2016, 2013). At the heart of these concepts lies the assumption that permanent thinking and reflecting on ethical, ideological, and political aspects of social work is necessary in order for professionals to provide not only effective and efficient, but also ethically good care for social service users. In order to do this, social work professionals need to constantly perform ethics work: "Ethics work is the effort people put into seeing ethical aspects of situations, developing themselves as good practitioners, working out the right course of action, and justifying who they are and what they have done" (BANKS, 2013, p.601). 
The practical tools—that is, the methods for moral reflection at an individual or group level—we developed in our research program aim to support social workers in their ethics work, and address six dimensions of their ethical agency, which are described with the help of the well-known iceberg metaphor (McCLELLAND, 1993):
ethical capability: the ability to act in an ethically careful way (above the water);
ethical motivation: the willingness to do ethically good work (waterline);
ethical frames of reference: ethical theories, ideologies and professional codes of conduct which influence professional thinking and acting (just below the surface);
ethical sensibility: the awareness of the moral dimension of social work, and the ability to be aware of ethical differences between stakeholders (under water);
ethical identity: the personal and professional "being" of the social worker (under water);
ethical context: the political dimension of social care that is apparent in the societal and organizational context in which the professional operates (the surrounding water) (KEINEMANS et al., 2014). 
To provide some examples: our research group developed a moral dilemma questionnaire which helps professionals to understand their professional stance toward common moral challenges in social work practice, and to relate this stance to ethical frames of reference. Also, our group uses moral case deliberations—structured and democratic forms of deliberating on moral questions and dilemmas, starting from an experienced concrete case (SPIJKERBOER, 2018) —to find a way out of a concrete dilemma. Further, conversation tools inspired by Socratic dialogue as well as individual reflective assignments are used to reflect on the core values of the social worker as a person and as a professional. 
These tools are sometimes used in once-only meetings, for example when social work organizations invited our research group to organize a lecture or workshop on moral challenges in social work. However, we usually organize series of meetings and one of these series was the object of the study as described in this article, hence the term ethics program. 
The overall purpose of the program was to stimulate social workers to be actively involved in ethics work and to develop their ethical agency. Six meetings were organized, arranged in two modules: the first addressed ethics work with regard to motivation, sensibility, and identity; the second module addressed ethics work in relation to the context of the social workers, but also discussed whether participants felt able—or enabled—to translate their ethical attitude into action. 
Because we tried to align the program as much as possible with the needs and questions of the participants, no detailed learning objectives were formulated, nor did we plan beforehand which reflection tools would be used in the program. The program was guided by the overall goal to contribute to the ethics work and ethical agency of social workers along the six dimensions we described above, and every meeting was evaluated before the agenda for the next meeting was set. All of this was done by the three researchers who were present during the meetings, although one of them (Mariӫl KANNE) took the lead as the chair of the meetings. To analyze the impact of the ethics program on the professional thinking and acting of the participants, and to discuss the relevance of this impact with stakeholders, we used a modified version of the MSC approach. 
3. The Most Significant Change (MSC) Approach
The MSC approach was developed in order to study the impact of complex interventions, for example development projects in third-world countries. Contrary to traditional effect studies, MSC does not focus on the measurement of output or the outcome of interventions. Instead, MSC is interested in the personal experiences of the participants in a specific intervention program and uses a narrative approach to collect these experiences. Participants of an intervention program are invited to establish the impact of an intervention by writing a story about the most significant change (SC stories) they noticed, due to a specific intervention or intervention program. Consequently, a broad range of possible changes may come up and thus, unexpected returns of an intervention may be revealed (DAVIES & DART, 2005; OMLO, 2014). However, not all of these returns are equally relevant with regard to the intervention and the practices which it tries to improve. As a result, the next step in the MSC approach is to assign value to all the SC stories. Put more precisely, several stakeholders in the organization read the "stories of change" and select the most significant stories within the domain of change. In MSC these stakeholders are usually managers at different levels of the organization, and the selection process follows the managerial hierarchy of organizations or intervention programs. They analyze the stories and make a selection of "most significant" stories, which are—accompanied by the arguments for the selection—filtered up through the levels of authority typically found within an organization or program. These two steps—the writing and selection of SC stories—are at the heart of the MSC (DAVIES & DART, 2005). Although these steps can be preceded or succeeded by several other steps—such as the selection of domains of change and the verification of stories, see Figure 1—they are not as characteristic of the MSC as the writing and selection of the stories.
Figure 1: Overview of what a "full" implementation of MSC might look like (DAVIES & DART, p.10) 
These two stages raised our interest in the MSC. There are multiple reasons for this choice, but two considerations are especially relevant. The first is that the narrative approach of MSC fits our research and educational orientation, which is not focused on a set of predefined learning outcomes but uses the lived experiences of participants in an intervention as a starting point to study the impact of an intervention. The second reason is that MSC combines descriptive and evaluative analysis. The method is used to describe the experienced changes due to a certain intervention but also explicitly invites stakeholders to value these changes, in turn enabling a discussion about the values that are at stake in an organization or intervention program and adding more depth to an evaluation. In the words of DAVIES and DART: "It [MSC] is a good way to clearly identify the values that prevail in an organization and to have a practical discussion about which of those values are the most important" (p.12). 
Clearly, this is especially of interest for our research question on the impact and relevance of an ethics program. Our research was designed according to the principles of the MSC, but especially paid attention to the collection and selection of most significant change stories. Consequently, not all of the stages mentioned in Figure 1 are discussed in this article. Activities like "how to start and raise interest" and "defining a reporting period" are addressed in most studies and the same applies for this project. Hence, they are not as characteristic for MSC as the stages which are at the heart of the approach: the collection and selection of the most significant change stories, and they will not be discussed in this article. However, we did explicitly decide to skip stages 2 and 7, 8, 9. 10. As we described in Section 2, our intervention (an ethics program) had no specific predefined goals, besides the general goal of strengthening ethical agency, and we explicitly chose to not formulate learning goals. In line with this choice, we also did not want to "define domains of change" (DAVIES & DART, 2005, Figure 1) as this would possibly shape our view on the impact of the ethics program and, ultimately, possibly the program itself. Further, we were especially interested in the lived impact of our program and ethical evaluation of the SC stories, hence analytic procedures like quantification and meta-monitoring fell beyond the scope of our project (not to mention time and financial constraints). 
4. Research Design
In September 2016 we started our ethics program for social workers. The research was not funded, so there was no financial compensation for the participating social service providers, other than the participation in the "free" ethics program. As we had to rely on the commitment and willingness of organizations to participate, convenience sampling was used as a strategy to select participating organizations and participants in the program (SAUMURE & GIVEN, 2008). First, we approached spokespersons of four organizations, which were already involved in our research group and were familiar with the researchers, to participate in the study. Three of them agreed:
one organization (A) for community care (buurtteam), providing services in neighborhoods of one of the four largest cities of the Netherlands;
two organizations (B & C) for residential and ambulatory care for people with a mental disability, in more of a countryside location. 
Next, these spokespersons wrote a call for their employees to participate in the study, and this resulted in an overload of applications. Consequently, a selection had to be made, which was done by the managers. Only one methodological criterion was used in the selection process: if social service providers had already joined an ethics program, they were excluded as this would probably influence the impact. A total of 17 participants were selected to participate in the ethics program and were present at the start-up meeting. However, one of them became ill and had to leave the program, one of them left without explanation, and one of the initial participants had participated in a comparable program before. She was replaced by a colleague, so 15 participants finished the ethics program, five from each participating organization (Table 1).
Table 1: Participants 
4.2 Collection of stories
After each module of the ethics program, we asked the participants to write their individual SC story, answering two questions: 1. What is, according to you, the most significant change in your work routine since the start of the ethics program? 2. Why is this change significant to you? Participants were instructed to focus on the change itself, and not to worry about their use of language or the "attractiveness" of the story. A total of 13 stories were written after the first module, 12 stories were written after the second module, which resulted in a total of 25 stories. Several participants from Organization A wrote their story together after the second module, as they noticed that they were all going through similar (major) changes and because they wanted to use this story as an incentive to stimulate ethical reflection within their organization. 
As we did not know beforehand how easy or difficult it would be to write a story about the impact of an ethics program and because we wanted to give all participants an equal chance to express their thoughts (we were aware of the fact that our participants had different social backgrounds and education levels), we provided the opportunity to add information to the stories. Therefore, all stories were discussed with the participants in two separate meetings, which took place shortly after finishing each separate module. These meetings were recorded and transcribed, and based on these transcriptions information was added to the original story (if necessary) without changing anything in the initial text. Next, each story was sent to the author, asking: 1. Is this text your story and is it complete? 2. Are we allowed to send it to stakeholders in order to start the selection of "most significant" change stories? Every participant agreed to this. 
At the end of the study we organized a concluding meeting, inviting all participants (of the ethics program and stakeholder meetings) as well as other managers, service providers and service users of the participating organization, to feed back the results of the research process in general (Phase 6 of the MSC). We discussed the content of the SC stories as well as their relevance as discussed in the stakeholder meetings. 
4.3 Selection of stories
For the selection of the stories, we opted for a different approach than MSC. The selection of stories in MSC is a fairly vertical process, as managers (lower and upper level) perform the selection process. In our study, our aim was to gain insight into the ethical relevance of our ethics program. This program does not only (and certainly not primarily) have an impact on managers, but first of all on service providers and service users. Therefore, we wanted to know their thoughts and opinions about the SC stories. Hence, we decided to include social service users and social service providers as partners in the selection process and organized a more horizontal selection process, which used a two-step approach. 
In the first phase of the selection process, all of the (anonymized) 25 stories were sent to two groups of stakeholders in each organization: operational managers and social service providers. We asked them to read the stories and rate their relevance on a 1-10 scale, answering the question, "what impact (as described in the SC stories) do you consider to be the most important and relevant for your organization?" This ranking was not meant to discuss ethical issues from daily care practice, but it was meant as a means to start a dialogue about the impact of the ethics program and its relevance according to the several stakeholders. 
A meeting with each separate stakeholder group (in accordance with Table 2) was organized to discuss this relevance of the SC stories. We started the meeting by explaining the purpose of the dialogue, elaborating on both the ethics program and our research plan. Further, we explained that we wanted to discuss whether the impact of the ethics program as described in the SC stories was ethically relevant for the social services as delivered by the participating organizations. We started the dialogue by making an inventory of the ratings, and especially those stories which were considered to be highly relevant were discussed, as well as stories which caused disagreement. The purpose of the meeting was to collect and discuss the arguments for the evaluations of the SC stories. Consequently, the ratings were not the focus, but the starting point for the dialogue in the stakeholder meetings. 
In the second phase of the selection process, we discussed the "most significant" stories—that is the stories which were valued most by managers and service providers—with service users from organizations A and B. We opted for this different approach, as we did not want to lay a burden on service users by sending them all the SC stories. At this point, we saw a trade-off between our aim to engage service users without harming them. 
As we wanted to include service users with an intellectual disability in our study (service users from Organization B), some adjustments were made in our research design. When we started our research project in 2016, our university of applied sciences did not yet have an internal research ethics review board (a research ethics committee was installed in 2018, with one of the researchers as a member). As our research did not fall under the strict definition of medical scientific research and did not interfere drastically with the lives of the respondents, it was not subjected to the rules of the Wet Medisch-wetenschappelijk Onderzoek [Medical Research Involving Human Subjects Act] (WMO)2). If we had to submit our proposal to include persons labeled with intellectual disabilities in our research for approval to a research ethics committee, we might not have been able to work with these service users as co-researchers, because people with intellectual disabilities are often seen as "too vulnerable" or "too naïve" to be able to participate in research. In this way, although well-intentioned, "practices of ethical governance through university research ethics committees can contribute to the silencing of people labeled with intellectual disabilities" (MARTINO & SCHORMANS, 2018, §3). But to find out more about the impact of our ethics program for professionals who care for them, we had to hear their voices. Of course, as we mentioned in Section 1, we wanted to be careful not to "overask" these service users with mental disabilities. As researchers from a university of applied sciences we work according to a professional code; being careful and responsible is a core value in this code3) and engagement of service users (and other stakeholders) should be thoughtfully carried out and should not make them feel burdened or insecure. This is why we took some extra measures. First, we made sure to use a "concrete frame of reference" (HOLLOMOTZ, 2018, p.158) in the communication with service users, which means that metaphors and abstract and ambiguous language were avoided as much as possible. We did this with the help of service providers from Organization B. They helped us to rewrite the two selected stories, using language as concrete as possible. The rewritten stories were not sent to the service users prior to the stakeholder meeting, but we—the researchers—read them out loud during the meeting. This is important to note, as it means that this stakeholder group was not enabled to take account of the total range of SC stories and did not see the original words and language which were used by the participants in the ethics program. 
During the stakeholder meeting, we used picture cards displaying basic emotions. One of the service providers, who was highly trusted by the service users, was present during the meeting and this presence proved to be very valuable. As this service provider knew the people who attended, she was more sensible to their verbal and especially nonverbal communication and helped the researchers to adequately deal with issues of acquiescence, unresponsiveness, and recency (HOLLOMOTZ, 2018). 
As service users of Organization A do not have an intellectual disability, we did not have to make this effort for their stakeholder meeting. Here we discussed five "most significant" stories with two service users. Unfortunately, we were not able to arrange stakeholder meetings with employees and service users from Organization C. The participants of the stakeholder meetings were distributed as displayed in Table 2.
Table 2: Stakeholders 
All stakeholder meetings were recorded and fully transcribed. Further, we kept a log throughout the entire research project in which we described the proceedings and explained possible changes in the research process. 
Although the title of the approach might suggest otherwise, our primary goal was not to select the one or two stories that demonstrated the most significant impact of our ethics program. In the MSC approach, the criteria and arguments in the selection process are as important as the selected stories. Discussing and sharing these arguments enables a practical discussion about those values which are the most important in an organization (DAVIES & DART, 2005, p.12). In the end, we were especially interested in this practical discussion. We used the MSC as a means to start a value-based dialogue with stakeholders about the relevance of the ethics program. These findings of the study—that is, the impact which is revealed in the SC stories and its relevance according to stakeholders—are described elsewhere (DE JONGE et al., 2019, submitted). However, we also wanted to reflect on the question of whether our adjusted version of the MSC was helpful to start this participative, value-based dialogue about the impact and relevance of our ethics program. In order to do this, we analyzed the stakeholder meetings, paying attention to:
The process of the meetings: were we successful in how we organized the stakeholder meetings and were participants able to voice their views and opinions on the relevance of the SC stories?
The content of the meetings: did the multi-stakeholder perspective add value to a shared understanding of the relevance of the ethics program? 
With regard to the latter, we were especially interested in the type of arguments used by stakeholders to value a story. Therefore, a conventional content analysis (HSIEH & SHANNON, 2005) or induktive Kategorienbildung [inductive development of categories] (MAYRING, 2019) was used to analyze: We inductively searched—through a systematic classification process of coding—for themes or patterns in the arguments that were exchanged in the multiple stakeholder meetings. The adjective "conventional" refers to the fact that our themes were not derived from prefixed categories but from data (HSIEH & SHANNON, 2005). Two researchers analyzed the transcriptions of the stakeholder meetings using MAXQDA, and started their analysis with an individual "open coding" of the data, staying as close to the words of the participants as possible. This resulted in codes like "Argument: the change contributes to good care" or "Argument: the change which is described is too shallow" which resulted in a long list of over 50 arguments. Next, both researchers discussed their encoding and interpretations to acquire an intersubjective understanding of the data and to search for themes or categories in the encoding, which are described in sections 5.2.1 and 5.2.2. This joint analysis of the open coding process resulted in a stable "code tree," which we used to analyze all the data for a second time. The full code tree is described (in Dutch) in an extensive research report (KEINEMANS, KANNE & DE JONGE, 2018). 
A comparison of arguments between the different stakeholders was made to find out whether different perspectives provide new insight into the relevance of the ethics program. The several argumentative categories were color coded, and document portraits were made for several stakeholders, displaying which type or argument dominated the dialogue. Also, we looked into the narrative structure of the several stakeholder meetings to acquire a deeper understanding of the differences in perspectives, as described in Section 5.2.3. This comparison only applies to Organization B, as no (or hardly any) stakeholders were involved in the selection process of stories in organizations A and C. Hence, these findings should be interpreted with some caution: we gathered data from a small selection of stakeholders, from organizations with a specific organizational structure and culture. Finally, in addition to the stakeholder meetings, we also analyzed the content of the SC stories. The results of this sub-study, and subsequently the process of data analysis are described elsewhere (DE JONGE et al., 2019, submitted). 
4.5 Prudent data management
Before the start of the ethics program, a start-up meeting was arranged for participants in order to explain the goal and methods of the program and the study. Participants were told that all meetings would be recorded, and that we would use the material during the selection process of the study, but also for our own analysis and publications. All participants were asked to fill out a questionnaire asking for general background information (age, education, experience) and to sign an informed consent form, stating that they agreed that the data of the study would be used in the analysis, which could result in publication. However, after the SC stories were written we noticed that several participants felt uncomfortable in sharing their stories with the stakeholder groups. Therefore, we created an extra opportunity to adjust their story and asked for explicit consent for every single story before using them in the selection process. 
Participants in the stakeholder meetings did not provide any personal background information (age, job, professional experience, care needs, etc.) as we did not consider this information relevant for the selection process: we were merely interested in an evaluative judgment of the stakeholders with regard to the SC stories. At the start of every stakeholder meeting, information was provided on the goal and method of our research, the purpose of the stakeholder meeting and the use of data. Permission was also requested orally (and given) to record the meetings and to make use of these recordings for research purposes. 
5.1 Selecting the most significant change stories: The process
5.1.1 Involving all the stakeholders
Our research design was organized horizontally: we wanted to involve representatives of various organizational levels and made the deliberate choice to invite not only operational managers but also social service providers and users in the selection process of SC stories. Also, we considered all stakeholders as equal co-researchers. However, it was not easy to live up to that ideal, for several reasons. It was easy to plan a meeting with managers, but with social service providers and especially service users it was quite a different story. The efforts made by those involved were crucial: some organizations were very committed to hearing the arguments of all stakeholders and were persistent in their efforts to involve them in the selection process. Nevertheless, not all stakeholders were equally interested in participating in the study. Organization A, for example, went the extra mile to organize a meeting with service users by (re)scheduling the meeting to a convenient time and place, making sure that lunch would be served in addition to the meeting. Despite this effort, only two service users wanted to participate. 
During the process, between the various meetings, we as researchers also reflected on 1, the ethical significance of these differences between organizations and what this means for "us" when we engage in collaborative research with stakeholders in different practices and 2, how the different "forms of friendship" that develop during the research process influence the co-production of knowledge (SIRY, ALI-KHAN, & ZUSS, 2011). 
5.1.2 Discussing the relevance of the SC stories
Even when we did manage to organize a stakeholder meeting, it took some effort to create a fruitful dialogue. Managers and professionals had to read and evaluate 25 single or two-page stories, and during the stakeholder meetings it became evident that some of the participants were not quite as prepared as we had hoped. We tried to solve this problem by creating space and time for reading during the meetings, but this is not quite a satisfying solution, as the time pressure does not offer participants the opportunity to rethink the stories. Consequently, their evaluation of the stories and their arguments were sometimes based on a first impression. 
Further, we noticed that some participants found it difficult to evaluate the relevance of the SC stories for several reasons:
Stakeholders explicitly mentioned difficulties in interpreting the stories.
They also felt troubled and burdened in valuing something as personal as a learning experience and hesitated to judge that experience as more or less relevant. The fact that we asked stakeholders to rate the stories, which was meant to be helpful, might actually have contributed to this uncomfortable feeling: "Yes, that is difficult. To rate that ... Then I think: 'Well, it's great what this ethics program has brought to you'" (Manager, Organization A).
Participants sometimes mentioned, and we noticed repeatedly, that they needed some kind of guidance to value the relevance of the stories. They4) were not used to the "ethics talk" which was obviously part of the ethics program, and which filtered through the SC stories. This issue was not overtly present in the meeting with service users from Organization B, probably because we used a very concrete frame of reference in this meeting, but in the other meetings we noticed that some stakeholders not only discussed the SC stories, but also (the general meaning of) ethics and morality, the core values in their work, moral dilemmas, etc. Although this did not always help to get a clear idea about the relevance of the SC stories, it demonstrated that the research strategy does work to enable a practical discussion about those values which are the most important in an organization. 
Reading the SC stories sometimes turned out to be an educational or reflective experience for participants in the stakeholder meetings: "Well, I started to reflect on my professional actions, how I do things and why I do these things and how I feel when colleagues act in a different way. [...] It made me think ..." (Service provider, Organization B). 
All this illustrates that organizing stakeholder meetings in order to discuss the value and relevance of the impact of an ethics program is not very easy, and that several hurdles have to be overcome before an evaluative dialogue with stakeholders can take place. It truly requires time and effort to really involve all of the stakeholders. Moreover, some stakeholders experienced difficulty in valuing stories, whereas we as researchers had simply assumed that they could understand and use the ethics talk of the program. It could be helpful to offer more preparation for stakeholders to understand such ethics talk and to understand what the ethics program is about, before organizing a meeting. 
5.2 Selecting the most significant change stories: The arguments
5.2.1 A value-based dialogue about the relevance of the SC stories
Despite the difficulties in the organization of the stakeholder meetings, we spoke with three groups of managers, two groups of professionals, and two groups of service users (though one was very small). Although time was spent on reading stories, we managed to discuss one or more of the most valued stories in each stakeholder meeting, which gives us an insight into the arguments for the relevance of the stories. We categorized these arguments in five clusters. 
Some participants value a story because the style of writing or metaphors in the story appeals to them. We categorize this type of argument under the name of rhetoric. One of the stakeholders mentions for example: "Yes, I really liked that! That was catchy. I thought: 'well, that makes it clear.' Because that story also describes the trip to the location of the meetings" (Manager, Organization B). This trip is used in the story as a metaphor for a trip to tranquility and reflection. 
Although this type of argument is not used very frequently, it is important to mention it as it illustrates that evaluations of SC stories are not always based on the actual impact of the ethics program, described in the stories. We have to be aware of the fact that stories might appeal to readers for other reasons than their impact. 
A second type of argument, categorized as professional development, valued stories because of the knowledge, skills, or attitude a participant developed during the ethics program. What counts in these arguments is not so much what participants learn in the program, but that they have learned something.
Chair: "Why do you consider it to be important for employees to grow as a team?"
Stakeholder: "Then you continue learning. That's what I think. Everybody continues to learn from each other. And continues to ask questions. I just consider that to be important" (Manager, Organization A). 
A third type of argument relates to the positioning of service providers with regard to the organizational vision and mission statement: stories are valued because they demonstrate that participants in the program have (re-)positioned themselves with regard to this statement. Stakeholders are ambiguous with respect to the direction of this repositioning. Some stakeholders prefer to see "normative alignment" among service providers in the organization, whereas others explicitly value diversity in the ideals and value orientations of service providers. At the heart of this matter are various ideas about a just distribution of care: the idea that the same care should be applied to every client versus the idea that tailored care should be provided, attuned to the value orientation of the client. 
Stakeholders mention that they consider a story to be more relevant when its impact reaches beyond the personal experience of the participants in the ethics program. In other words, the impact should be noticeable for others, and preferably very clearly so. The normative rationale behind this type of argument sometimes seems to be of a utilitarian kind: "the greatest impact for the greatest number." This type of argument is categorized under the fourth heading of size and beneficiaries. 
The final category of arguments is more explicitly normative, which means that the stories are evaluated by the specific content of the lessons learned. Three subcategories can be discerned, which can be classified as three perspectives on good work: the perspective of the service user, the perspective of the service provider as employee, and the perspective which takes actually delivered care as starting point for evaluation. Stakeholders appreciate stories in which service providers demonstrate that they have become less judgmental toward service users, that they recognize and stimulate the strengths and possibilities of service users, and listen to their concerns: "What I read is: putting the client in the center of attention. That is what is written down in the story. To teach the client to stand up for himself" (Manager, Organization A). 
Further, stakeholders consider it important for social service providers to enjoy their work and to work in a supportive team where you can talk to each other. For example: stories that reveal that the team spirit changed for the better due to the program were appreciated from this point of view, although arguments are interrelated at this point, as it is also assumed that team spirit influences caring practices and—therefore—the client. Finally, stakeholders value stories in which the author stated that they are able to deliver better care due to the ethics program. It remains unclear, however, what "better" means in this respect, as is demonstrated in the following quote. "It is all a matter of: Are you able to connect to the client? Are you providing good care for a client? Are you able to stay attuned in that process?" (Manager, Organization B) 
In light of the research goal—to evaluate the relevance of the impact of an ethics program with help of several stakeholders—we can state that the stakeholder meetings actually did provide insight into which elements of the SC stories seemed to matter. After all, some clear arguments and considerations were discussed, which also shed some light on the value-base of the practice under study: for example, stakeholders discussed their views on a just distribution of care, the relevance of professionalization, and three perspectives on good work (service user, service provider, the actually delivered care). 
5.2.2 Surface and depth structure
As already mentioned in the previous section, arguments are sometimes interrelated or connected. For example, in one excerpt, one of the stakeholders of Organization B states that a story is of specific interest because the author displays that the professional has learned to "slow down," that is to reflect before acting, and the stakeholder adds, "that is good." Other stakeholders and the chair dive into the matter: "Why and how is slowing down good? Does it not sometimes hinder a rapid response to a care need?" The conversation that unfolds also reveals the normative ground on which the argument rests. Slowing down creates the necessary space to weigh up several solutions and actions, but it is not because more options become available that slowing down is considered to be important. Instead, stakeholders point out that they work with vulnerable people who can easily be overshadowed or intimidated by care professionals: slowing down gives them the opportunity to tune in to the caring process. On top of that, this aligns with the organizational vision which stresses the need to situate care in the triangle professional-client-relatives. Here, we see how several types of arguments are actually tied up, offering a better view on the normative grounds for the evaluation of a story. Hence, this interrelatedness of arguments reveals that a specific argumentative structure is at work in some parts of the conversation, demonstrating that arguments have "surface and depth structure." When asked to value a story, stakeholders quite often cite organizational or professional norms, with a certain ease, without referring to the foundations of such norms. It seems as if they are not aware of the fundamental ethical orientation of these norms (RICOEUR, 1992 ). In what follows, other stakeholders and the chair of the meeting "dig in" to the argument by adding new but related arguments (often from different categories). 
The depth structure of the arguments sheds light especially on the relevance of some SC stories, as they seem to refer to core values of the care practice in which several stakeholders are involved. However, this depth structure was difficult to uncover. The conversations during the meeting as well as the probing by the chair were needed to arrive at a comprehensive understanding of the arguments, and we did not always succeed in this. In fact, we sometimes got the impression that stakeholders did not really understand what we were looking for when we asked them to explain their arguments (Section 5.1.2). Perhaps, when using stakeholder dialogues in ethics-related research, more preparation time for the stakeholder meetings is needed in order to get a better grip on the MS stories and the purpose of the meetings. 
5.2.3 Stakeholder perspectives
Our goal in this research project was to involve several stakeholder perspectives in the evaluation of an ethics program. Consequently, we were interested in whether the different stakeholder meetings shed a different light on the SC stories. Unfortunately, we did not manage to speak with many service users, and our findings are based on a small group (especially from Organization B). However, we noticed that stakeholders in this specific organization did mention different arguments in the meetings. 
To start with, we gave every argumentative category a separate color in MAXQDA, which enabled the creation of "document portraits." These portraits clearly demonstrate that service users mention less diverse arguments: they hardly refer to arguments in the category "positioning with regard to organizational vision," for example (yellow), and more often use arguments that are explicitly of a normative nature (green).
Figure 2: Document portraits 
Whereas managers and service providers sometimes experience difficulty in getting to the depth structure of their arguments, service users addressed this matter quite easily. For instance, all of the stakeholders stressed the relevance of listening to service users and considered it relevant when this was mentioned in SC stories. However, the stakeholder meetings with service users illuminated precisely the relevance of this "listening to clients" by providing examples from everyday experience. One service user mentioned how cookies were banned at the coffee table at a support group on account of health considerations, and another service user mentioned how another client was forced to wear painful orthopedic shoes, presumably to stimulate this client's mobility. In both instances, social service professionals were trying to enhance the health and mobility of service users, but were doing harm in the process. Therefore, the stakeholder meetings with service users revealed that care practices should not merely revolve around realizing values like health and mobility but are also about furthering "a good life," like enjoying company with tasty food and living comfortably without pain. 
The abovementioned examples demonstrate how service users always find themselves in an unequal and dependent relation with social professionals. Some have difficulty to express themselves due to a disability, for example, which makes it difficult for one service user to explain why the new orthopedic shoes bothered her so much. Still, service users want to be heard in care practices, and want to be enabled to be heard. Therefore, they value stories where authors say that they "listen more to service users." Consequently, the "listening to client concerns" which is expressed in the SC stories is not only relevant in order to further a good life (the existential dimension of care), but also because it helps to acknowledge the dissymmetry in caring relations (the political dimension of care). 
All the stakeholders highlighted the importance of listening to service users; the experiences of service users especially substantiated this point. Their experiences provided a more comprehensive understanding of the arguments, which were also mentioned in the other stakeholder meetings. Hence, we consider our effort to involve service users of utmost importance in our study and in our use of the MSC. 
One issue that we need to discuss is our double role as researchers and trainers of the ethics program. This role was due to financial constraints: we were unable to acquire funding for the study and therefore performed it on a very limited budget. Nevertheless, the findings of the study might be influenced by the fact that participants knew that we, as trainers, were going to analyze their stories. Perhaps they exaggerated the impact of the training, or did not disclose any negative experiences in order not to offend us. This is a serious risk, which we tried to mitigate by investing in an open and trusting working relationship, which was also needed for the training. Further, we made adjustments to some of the SC stories in order to discuss them with service users. In our view, this change was necessary: otherwise it would not have been possible to include these service users in the evaluation process. In hindsight, it would have been better if we—as trainer-researchers—had not been involved in this adjustment process. 
Another major limitation of our study is that we did not manage to include quite as many stakeholders as we had hoped to. As the study included a very small sample and service users are especially underrepresented, conclusions with regard to the usefulness of our adaptation of the MSC in the evaluation of our ethics program need to be interpreted with some caution. However, our findings do suggest that including the service user perspective is very important for our understanding of the relevance of the ethics program. Hence, we should do our best to reach more service users in subsequent studies and should rethink our strategies to reach that goal. The chances of success will probably improve when service providers are involved in this effort. 
Further, although we obtained an overview of the arguments which were used to evaluate the relevance of the stories, it remained unclear which impact of our ethics program mattered most, and which impact mattered less. This might be due to the fact that we used a horizontal approach in our study. Also, the fact that our stakeholder meetings were focused on discussing the most significant stories might be a relevant element in this finding. Consequently, the least relevant stories might have been overlooked. A few things can be said about this issue. 
First, it might be helpful if MSC were to be less focused on the most significant stories, to also discuss the less significant stories. This is especially because there is always the hurdle of different interpretations; our meetings showed that talking about the significance of a story often changes a stakeholder's opinion. On the other hand, we expect this will make it all the more difficult for stakeholders to engage in a fruitful dialogue, as they already felt burdened in the process of selecting the most significant stories (Section 5.1.2). 
Second, another way to get a better picture of the relevance of the SC stories and the impact of our ethics program might be to make a more thorough and participative analysis of the arguments and dialogues in the stakeholder meetings. Although we did compare the arguments of the different stakeholders, we did not truly confront their perspectives face to face and hence one might ask whether we obtained a good enough understanding of the relevance of the impact of our program. Managerial considerations to value a story might have changed when confronted with the service user perspective, for example. We could have used the phase of feeding back the results, a crucial element in the MSC to contribute to a more thorough analysis of the stakeholder evaluations. In fact, we did try to feed some of our understandings into the evaluation process by organizing a feedback meeting after the research, where all the stakeholders could meet and discuss the SC stories and the arguments of the stakeholder meetings. Not many stakeholders attended this meeting, however (no service users were present, for example), and visitors were not so much interested in looking back at the evaluation process as in discussing the next steps to develop their ethical agency. Further, in fear of a diminishing commitment by the stakeholders, we wanted to organize the feedback meeting shortly after the last stakeholder meeting was held. Therefore, our analysis was still a work in progress. As a result, the feedback meeting did not actually contribute to a better understanding of the evaluative comments in the diverse stakeholder meetings. In a future study we could profit from this lesson and consider this feedback meeting not so much as a closing session but as an actual part of the research process. This process would enable stakeholders to discuss and confront their arguments, to relate them again to the SC stories, and decide which type of impact is more or less relevant. This would also prevent the reintroduction of a more vertical selection process and contribute to the participative and dialogical goal of our research. 
Third, we wish to emphasize (again) that we were not particularly interested in the "most significant" story as such; rather, we wanted to know if and why the impact of our ethics program matters to stakeholders. The stakeholder meetings did give us a better understanding in this respect. For example, it became clear why the ability to look at your work from another perspective, such as the service users' perspective, is so important in care practices. 
Finally, in doing research on the impact of an ethics program as ethicists who also developed and implemented this program, we realize that thorough reflection on our own normativity is necessary to be able to do "good" research. We want our research to contribute to good care and quality of life of service users; we want to take the intersubjective nature of knowledge production into account; we want to preserve the dignity of stakeholders and respect the differences between them, and we want to be attentive to power relations within and outside of the research endeavor. With GUISHARD, HALKOVIC, GALETTA and LI (2018) we notice that these elements are lacking in ethics codes for researchers, but they are indispensable for researchers who view themselves as "normative professionals" (KUNNEMAN, 2013) engaged in doing "ethics work" (BANKS, 2016, see also Section 2). This is why we organized many moments for collective reflection during the period of this research project, where we questioned our own and each other's ethical principles and sought to relate our opinions to theoretical positions from a philosophical and social science perspective. However, we kept many of the results of these reflections to ourselves. We chose not to mention our own normative positions and did not elaborate on various theoretical notions in the stakeholder dialogues because we did not want to influence the results. In retrospect, however, we wonder whether bringing in our own ethical reflections would not have contributed to obtaining a better view on the depth structure of arguments (Section 5.2.2). 
The question which remains at the end of this paper is: Did our version of the MSC prove to be a useful approach in the evaluation of an ethics program for social professionals? Multiple difficulties arose during the stakeholder meetings, as participants did not always prepare for the meetings and found it difficult to evaluate the MSC stories. Moreover, our analysis suggests that it takes some effort to get to the "depth" structure of the arguments for the evaluation and that a confrontation of stakeholder arguments might have contributed to a more thorough understanding of the relevance of our ethics program. 
That being said, we consider the collection of SC stories and the involvement of stakeholders in ethical evaluation processes a promising research strategy in our research program on ethics work. Some of the difficulties we experienced, like the active engagement of stakeholders, are not specific for this strategy but are common in other types of participatory research as well. Besides, despite the abovementioned troubles, the stakeholder meetings did provide some insight into the relevance of our ethics program. Especially the client perspective illuminated the relevance of some SC stories. Therefore, we consider the adaptation of the vertical selection process of MSC to a horizontal selection process to be valuable. Finally, our research never aimed for a "normative conclusion." We were not searching for "the most relevant story." Rather, we strived for a comprehensive understanding of the relevance of moral reflection tools and ethics programs in order to help stakeholders deliver "good care." We feel that our project succeeded in this respect, but realize that MSC could be more fruitful as a strategy for our research program when a more thorough dialogue between stakeholders is stimulated after the separate meetings. Hence, the next step in our ongoing quest will be to enrich our horizontal adaptation of the MSC with strategies to optimize the involvement of all stakeholders who are willing to participate in a value-based dialogue with specific attention for the ethical dimension of the care practices in their organization. 
We wish to thank all the participating social service providers, service users and managers for their time and effort to share and read stories, and for their commitment to our joint search for good work in health and social care.
1) More evaluation results from ethics research in the social sector are discussed elsewhere (DE JONGE, KEINEMANS & KANNE, 2019, submitted). <back>
2) If a study is subject to the WMO, it must undergo a review by an accredited ethics committee or the central committee of research on human beings. Research is subject to the WMO if it concerns medical scientific research in the field of illness and health and if participants are subject to procedures that infringe on their physical and/or psychological integrity. <back>
3) When we started in 2016 we worked according to the Code of Conduct for the Preparation and Execution of Applied Research in Higher Professional Education in the Netherlands (ANDRIESSEN, ONSTENK, DELNOOZ, SMEIJSTERS & PEIJ, 2010). This Code is based on five core values: 1. Serving professional and societal interests, 2. being respectful, 3. being careful, 4. having integrity, 5. justifying choices and behaviour. Since October 2018 there is a new Code (Netherlands Code of Conduct for Research Integrity), which is more elaborate. This code is based on five principles (honesty, scrupulousness, transparency, independence and responsibility) and provides standards for good research practices, e.g. concerning research design, conduct, and reporting results. <back>
4) All citations are translated from Dutch by us. <back>
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Dr. Sabrina KEINEMANS is professor of applied sciences at Zuyd Hogeschool. Her research program focuses on precariousness and the politico-ethical nature of social work, using predominantly qualitative research strategies rooted in hermeneutical/phenomenological tradition. Sabrina is a member of the research network Critical Ethics of Care.
Zuyd University of Applied Sciences, Division Social Studies
Ligne 1, 6131 MT Sittard | P.O. Box 69, 6130 AB Sittard, the Netherlands
Tel.: 31 (0)6 8274 3484
Dr. Mariӫl KANNE is lecturer in ethics in the master advanced nursing practice and post doc researcher in the Innovation of Social Work research group at the Utrecht University of Applied Sciences in the Netherlands. Her work focuses on the moral dimension of caring practices in social as well as health care.
HU University of Applied Sciences Utrecht, Research Centre for Social Innovation
Padualaan 101, 3584CH, Utrecht, the Netherlands
Tel.: +31 (0)6 4164 0439
Dr. Ed DE JONGE is associate professor professionalization of social work at Utrecht University of Applied Sciences. His work focuses on practice-based research and curriculum development. His main interests are (the intersections of) professionalism, ethics, and complexity.
Ed de Jonge
HU University of Applied Sciences Utrecht, Research Centre for Social Innovation
Padualaan 101, 3584CH, Utrecht, the Netherlands
Tel.: +31 (0)6 1296 6538
Keinemans, Sabrina; Kanne, Mariӫl & de Jonge, Ed (2020). In Search of a Research Strategy: Evaluation of an Ethics Program for Social Professionals Using Elements of the Most Significant Change Approach [66 paragraphs]. Forum Qualitative Sozialforschung / Forum: Qualitative Social Research, 21(1), Art. 7, http://dx.doi.org/10.17169/fqs-21.1.3282.