Lost in motivation? The case of a Norwegian community healthcare project on ethical reflection

Nilsen, Heidi Rapp; Ringholm, Toril Article Lost in motivation? The case of a Norwegian community healthcare project on ethical reflection Cogent Business & Management Provided in Cooperation with: Taylor & Francis Group Suggested Citation: Nilsen, Heidi Rapp; Ringholm, Toril (2019) : Lost in motivation? The case of a Norwegian community healthcare project on ethical reflection, Cogent Business & Management, ISSN 2331-1975, Taylor & Francis, Abingdon, Vol. 6, pp. 1-15, https://doi.org/10.1080/23311975.2019.1632045 This Version is available at: https://hdl.handle.net/10419/206198 Standard-Nutzungsbedingungen: Die Dokumente auf EconStor dürfen zu eigenen wissenschaftlichen Zwecken und zum Privatgebrauch gespeichert und kopiert werden. Sie dürfen die Dokumente nicht für öffentliche oder kommerzielle Zwecke vervielfältigen, öffentlich ausstellen, öffentlich zugänglich machen, vertreiben oder anderweitig nutzen. Sofern die Verfasser die Dokumente unter Open-Content-Lizenzen (insbesondere CC-Lizenzen) zur Verfügung gestellt haben sollten, gelten abweichend von diesen Nutzungsbedingungen die in der dort genannten Lizenz gewährten Nutzungsrechte. Terms of use: Documents in EconStor may be saved and copied for your personal and scholarly purposes. You are not to copy documents for public or commercial purposes, to exhibit the documents publicly, to make them publicly available on the internet, or to distribute or otherwise use the documents in public. If the documents have been made available under an Open Content Licence (especially Creative Commons Licences), you may exercise further usage rights as specified in the indicated licence. https://creativecommons.org/licenses/by/4.0/ MANAGEMENT | RESEARCH ARTICLE Lost in motivation? The case of a Norwegian community healthcare project on ethical reflection Heidi Rapp Nilsen 1 *and Toril Ringholm 2 Abstract: Innovations are needed to meet increasing challenges in public healthcare, and type of motivation has been identified as a pivotal factor for the success of an innovation. New public management crowd out the intrinsic motivation of employees which has resulted in a quest for more self-reliant service providers. This paper takes the opposite point of departure asking if intrinsic motivation can be at the cost of the public purpose of innovations. This paper is a case study of 180 municipalities whom chose to participate in the largest healthcare project on ethical reflection in Norway. Thousands of community health-care workers performed innovative activities by establishing ethical reflection on a regular basis. We have investigated if the municipalities’type of motivation is of importance for the type of results of the project, and how the results correspond with the policy signals on the very purpose of establishing ethical reflection in health care. We find that intrinsic motivation of enhanced competence crowds out the extrinsic motivation and public value of patient satisfaction. The link in the program theory between objective and purpose is too weak to induce a better fulfilment of the purpose. ABOUT THE AUTHORS Heidi Rapp Nilsen works as a postdoctoral researcher at NTNU, the Norwegian University of Science and Technology. She has a fractional appointment at the research institute NORCE, as a senior researcher, which this paper is part of. Heidi’s research interests are on the premises of our economic and social systems, as values, ethics and motivation. Her main contributions are on consequences of these, often, implicit values, and resulting practices on the global ecological foundation. Toril Ringholm is an Associate Professor at UiT The Arctic University of Norway. She specializes within the field of planning and regional research and has led several research projects focusing on public sector innovation, democracy and governance. A special attention has been paid to the level of municipalities, and she has contributed to this field in many books, research papers and as a lecturer at several universities. PUBLIC INTEREST STATEMENT The motivation of the employees that performs public sector innovation is important for the outcome of the innovation. Therefore, the public authorities and others that initiate innovation programs in order to enhance public value, needs to pay thorough attention to the balance between the intrinsic and extrinsic motivation that drives participation in such programs. These are the findings in a case study of 180 municipalities who participated in a large healthcare project on ethical reflection in Norway. We ask if the municipalities’type of motivation is important for the type of results, and how the results correspond with the policy ambitions on ethical reflection in health care. We find that intrinsic motivation of enhanced competence crowds out the extrinsic motivation and the public value of patient satisfaction. The objective and purpose of the program was too weakly connected to induce a better fulfilment of the purpose. Nilsen & Ringholm, Cogent Business & Management (2019), 6: 1632045 https://doi.org/10.1080/23311975.2019.1632045 © 2019 The Author(s). This open access article is distributed under a Creative Commons Attribution (CC-BY) 4.0 license. Received: 18 March 2019 Accepted: 10 June 2019 First Published: 16 June 2019 *Corresponding author: Heidi Rapp Nilsen, NORCE Norwegian Research Centre AS, P.O. 22 Nygårdstangen, Bergen 5838, Norway E-mail: [email protected] Reviewing editor: Andreea Molnar, Lancaster university, Lancaster, UK Additional information is available at the end of the article Page 1 of 15 Subjects: public & nonprofit management; critical management studies; organizational studies KEYWORDS: intrinsic motivation; extrinsic motivation; crowding out; program theory; innovation 1. Introduction The public sector in Norway, and many other industrialized countries, face growing challenges with giving good and adequate services in times of increasing demands, decreasing finances and the legacy of New Public Management-dominated logic. Innovation is therefore high on the public sector agenda these days, and local as well as central authorities strive to develop new and valuable solutions. Education and knowledge development is regarded as an important tool for better service performance, and for motivating the service producers to comply with the overall policy ambitions. We do, however, have little knowledge of the connection between different forms of motivation and the value compliance of the public servants. Community healthcare practice is a major public sector challenge. The number of people needing healthcare will rise, as will the complexity of their problems with dementia, psychical illness, and minority backgrounds. Ethical dilemmas are involved in many of these challenges, for example, patient protection in terms of autonomy and advocacy for vulnerable groups (Racher, 2007). Healthcare professionals need to recognize everyday ethical issues in their care work and have the confidence to face them in appropriate ways also when the manual or guidelines do not address the particular situation they are dealing with. This is the case even if the issues present themselves as rather banal (Söderhamn, Kjøstvedt, & Slettebø, 2015; Solum, Slettebø, & Hauge, 2008). Previous research has established that a certain degree of intrinsic motivation is necessary for innovative actions to take place. An intrinsic-motivated activity is defined to be valued for its own sake, in the absence of an external reward, as well as being self-sustained (Calder & Staw, 1975; Deci & Ryan, 1985). Intrinsic motivation is an inner force driven by the challenges the work itself gives and is realized independent of extrinsic consequences. On the other hand, extrinsic motivation occurs when there is an obvious instrumental connection between behavior or activity, and a form of reward. The reward can range from money and fringe benefits to praise, reputation and customer satisfaction. The combinations of these two types of motives often involve the risk of the extrinsic motivation crowding out the intrinsic motivation. The activity is then only performed to receive the award, and the activity itself loses its inherent value (Cooper & Jayatilaka, 2006; Roberts, Hann, & Slaughter, 2006). This has been one of the prominent critiques against NPM- based reward systems. However, the overall question of this paper is put the other way around; does intrinsic motivation crowd out extrinsic motivation, and consequently crowd out the positive extrinsic consequences for the recipients of public service? The question is timely, because the research on ethical reflection has not, so far, critically questioned the difference between effect for the employee and effect for the patient or her/his next of kin. The focus has primarily been on results and effect for the employees, typically reporting results as enhanced competence, better handling of ethical challenges and better employee cooperation (Magelssen, Gjerberg, Lillemoen, Førde, & Pedersen, 2016b; Magelssen, Gjerberg, Pedersen, Førde, & Lillemoen, 2016a; Tønnessen, Lillemoen, & Gjerberg, 2016). These are of course positive internal results and some results, as enhanced competence in systematic ethical reflection among employees, can indeed be a premise for patients experiencing a positive change in healthcare service. Is it, however, possible that the positive effects of this innovative activity primarily are found internally in the organization, and not among the recipients of the public healthcare service? And, do the concepts of intrinsic and extrinsic motivation offer an explanatory platform to answer this question? Nilsen & Ringholm, Cogent Business & Management (2019), 6: 1632045 https://doi.org/10.1080/23311975.2019.1632045 Page 2 of 15 2. The ethics project and the research questions We pursue this question by analyzing a large national project in Norway carried out by the Norwegian Association of Local and Regional Authorities (KS): “Cooperation for enhancing ethical competence”, hereafter the Ethics project. It lasted from 2007–2015, and all 428 municipalities in Norway were invited to participate for a two-year period. The purpose of the Ethics project was to enhance healthcare patients’experience of integrity and dignity. This was to be achieved through strengthening ethical competence among community health-care personnel in Norway, through establishing ethical reflection on a structured and regular basis (KS, 2014; Nilsen, Antonsen, Normann, Kirkhaug, & Tønnessen, 2015). Altogether 243 municipalities chose to participate in the Ethics project. The project involved more than 2000 community health-care workers. 1 These municipalities performed innovative activities by establishing an ethical reflection on a regular basis. They did not receive extra funding for bygone time for this activity. In this paper, we investigate the motivation for the municipalities to participate in the Ethics project. More specifically, we ask if their partaking was intrinsically or extrinsically motivated. The overall question of the analysis is: Was the Ethics project an appropriate tool for giving better services by strengthening the skills of the employees? We address this issue by a set of research questions. Firstly, we ask how the balance between intrinsic and extrinsic motivation was among the municipalities that participated. To answer this question, we look into the motivation that the municipalities had for implementing the Ethics project. One form of intrinsic motivation could, for instance, be a primary need of competence, while an aspect of extrinsic motivation could be a customer or patient satisfaction. We will assume that most of the municipalities will display a combination of motivations. However, the overall pattern of expressed motivating factors will be a strong indication of the relative weight of the two forms. Secondly, we ask how the municipalities’motivations correspond with the policy signals on the very purpose of these innovative activities. The purpose of strengthening competence and practice in ethical reflection is to provide better health-care services to patients or to the next of kin (Eide & Aadland, 2012). The purpose of the Ethics project was specified even more with regard to how the services were to be improved: by enhancing health-care patients’experience of integrity and dignity. As the municipalities can be motivated by several factors, the way that these ideas are implemented, does not necessarily comply with the centrally defined policy signals. Thirdly, we pose the question whether the results that the municipalities achieved during the project were in accordance with their primary motivations. The answer to this will help us to illuminate Figure 1, whether the motivation is of importance for the results that are being achieved, or if it is in fact of lesser importance. This paper generates valuable information with regard to policies, planning, and implementation of future innovative practices in the public sector. The analysis shows that it is necessary to critically question why an innovation is to be implemented, to differ between objective and Intrinsic motivation for participation in the Ethics project Municipality Extrinsic motivation for participation in the Ethics project Results from the Ethics project Results from the Ethics project Figure 1. Analytical approach. Nilsen & Ringholm, Cogent Business & Management (2019), 6: 1632045 https://doi.org/10.1080/23311975.2019.1632045 Page 3 of 15 purpose, and to not assume that the program theory automatically leads to the purpose. In particular, this paper enhances our knowledge on the motivation for strengthening ethical competence and practices in health-care services. The next chapter presents the theoretical background and introduces the analytical framework of this paper, followed by a short description with more facts and figures on the Ethics project. The chapter on methodology describes the chosen case-study method and the qualitative data to answer the research questions, as well as limitations on data and method. The last chapters present the results, analysis and concluding remarks. 3. Theoretical background The motivational bases for public services have been a research theme for a while (Perry & Wise, 1990; Le Grand, 2010). It has, however, not to a great degree been investigated explicitly with regard to public innovation. A recent paper shows that the initial motivation of a public innovation is a very strong driving force for having the motivation carried out (Ringholm, 2017). Innovation can have different connotations. Our understanding is based on the classical definition given by Schumpeter in 1934 that defines innovation as novelties that are new to the context, both products and organization (Schumpeter, 1934/1975). More refined classifications have been introduced later, and can be summed up as process innovation, administrative process innovation, technological process innovation, product and service innovation, governance innovation and conceptual innovation (De Vries, Bekkers, & Tummers, 2015). The systematic use of ethical reflection is a process innovation that also carries the ambition of leading to service innovation. If the ambition is fulfilled, is a question that can only be answered in the long run. However, the alloy of extrinsic and intrinsic motivation can be an important indicator of whether the municipalities areon trackin this regard.In a wider perspective,the knowledge is also suited to shed light on the dynamics, possibilities and obstacles, involved in enhancing the operational capacity for creating public value. One strand of the critique against New Public Management is developed in the line of thought that led to the concept of service-dominant logic (Vargo & Lusch, 2008), a concept that seems to be gaining interest in both practice and research on public sector service. The service-dominant logic asks for service providers of a more self-reliant character than the logic of NPM does, also in questions that has to do with the ethics of the service-giving situation. This is closely coupled to the issue of public value (Benington & Moore, 2011; Hartley, Alford, Huges, & Yates, 2015; Moore, 1995, 2013). The concept was developed in order to draw attention to the role of public managers in actually shaping the values that public services and development convey, and not only as valuefree clerks for the policy that was being outlined by the political bodies (Moore, 1995). In recent literature, the concept is increasingly being drawn into the discussion of innovation and renewal of the public sector, based on a recognition of the importance of the public organization as a whole working in the same direction in order to create service innovation (Moore & Benington, 2011; Hartley et al., 2016). Creating public value, thus, is seen as distinctively different from creating private value (Benington & Moore, 2011,p.4–11). As public value is what we want from public funding, and as we normally find ambitions of public value embedded in public innovation initiatives, it is certainly relevant to ask the question of whether this is actually the output. The importance of intrinsic motivation for innovation has been well documented within organizational behavior research and the field of social psychology (Amabile, 1988; Frese, Teng, & Wijnen, 1999; West, 1987) whereas the role of extrinsic motivators for innovation is less clear (Harrison, Neff, Schwall, & Zhao, 2006). It has been suggested that intrinsic and extrinsic motivation might serve different functions; intrinsic motivation might be linked to work on a specific task and the desire for this intellectual challenge, whereas extrinsic motivation might affect the choice of task or implementation strategy (Mumford, 2003; Sauermann & Cohen, 2008). Moreover, it has been suggested that people in public organizations are more altruistic than people in private sector but as Chen and Hsieh (2015) shows, certain types of extrinsic motivation is also prevalent among public sector employees, like job security. Nilsen & Ringholm, Cogent Business & Management (2019), 6: 1632045 https://doi.org/10.1080/23311975.2019.1632045 Page 4 of 15 The debate on intrinsic versus extrinsic motivation also constitutes an important part of the debate between the long-lasting regime of neoclassical economics, also known as mainstream economics, and other heterodox schools of economics. Mainstream economics have had to come a long way from characterizing people and employees as homo economicus, which are only extrinsically motivated and dependent on rewards, to recognizing other human values and motivations (Nilsen, 2010). The existence of intrinsic motivation is now recognized also within mainstream economics and research, but it is often left aside because it is difficult to analyze and control (Osterloh & Frey, 2000; Williamson, 1985). Other economic schools with imperative contributions especially from psychology but also from feminist perspectives in social sciences, have managed to integrate intrinsic motivation in their analysis as well as identifying different combinations and premises for intrinsic and extrinsic motivation (Folbre & Nelson, 2000; Gilg & Barr, 2006; Sutinen & Kuperan, 1999). This development is also a critique of seeing humans as only utility-maximizing models of homo economicus, whereas other existing human ethical characteristics as deeds and duty are ignored (Daly & Cobb, 1989; Nilsen, 2010). There is now an interdisciplinary understanding that combinations of and correlations between intrinsic and extrinsic motivation often involve the concepts of crowding-in and crowding-out. A positive effect on the intrinsic motivation of an external intervention or institution is called crowding-in. A negative effect on intrinsic motivation is called crowding-out, an effect which has been particularly challenging for the mainstream economic regime. “When intrinsic motivation is present, pecuniary sources of utility might crowd out its nonpecuniary sources”(Valentinov, 2007, p. 53). If achieving a task is at the same time extrinsically and intrinsically motivated, the more devalued the attribution of a self-determined action is, the more strongly the individuals believe themselves to be subject to outside control. When one goal is taken to be instrumental for reaching another goal, the first goal loses its value (Kruglanski, 1975). Moynihan (2010) also criticizes a too strong focus on extrinsic incentives, adding a claim that agency theories from market models, applied on public service employees have created opportunities for moral hazard. In this paper, we look into the opposite possibility, which is hardly studied before, that intrinsic motivation crowd out extrinsic motivation, and, thereby have a negative effect on the purpose of an innovative activity in the public sector. 3.1. Analytical approach Intrinsic motivation in working life is rooted in the primary need of competence for the task (Deci & Ryan, 1985). Thus, one potential intrinsic motivation for participating in the Ethics project is to enhance competence in ethical reflection, which is also the objective of the project. Moreover, as systematic ethical reflection is an innovative activity in these municipalities (Nilsen et al., 2015), this activity may also be seen as an intellectual challenge which does not need any reward beyond this activity (Sauermann & Cohen, 2008). The purpose of the Ethics project is to contribute to enhance patients’experience of integrity and dignity. This is an instrumental goal derived from the objective, with satisfied patients as the reward. The purpose of the Ethics project can therefore also be seen as an extrinsic motivation for participating in the project. In Figure 1we illustrate the links which we will investigate between the municipalities’motivation to participate, and the results of the project. The program theory of the Ethics project is that doing an ethical reflection on a regular basis will enhance the employee’s competence in ethics, which will lead to patients experiencing enhanced feeling of integrity and dignity (KS, 2014). In short, a program theory is the theory or model of how an intervention—such as a project of policy—contribute to a chain of intermediate results and finally to the intended outcome (Funnell & Rogers, 2011). The interest and use of program theory or program logic, and also program theory evaluation as a method, has grown considerably since the early start in the 1960’s (Rogers, Petrosino, Huebner, & Hacsi, 2000; Suchman, 1967; Weiss, 1972). This paper is not an evaluation of a program theory as such, but takes a critical look into the Nilsen & Ringholm, Cogent Business & Management (2019), 6: 1632045 https://doi.org/10.1080/23311975.2019.1632045 Page 5 of 15 program logic of the Ethics project. In particular, we focus on the link between objective and purpose as a possible explanatory factor in interpreting the data and results of this paper. 4. Facts and figures on the ethics project The Ethics project lasted from 2007 till 2015 and was a cooperation between the Ministry of Health and Care Services, the Norwegian Directorate of Health, trade unions with members from healthcare professions, Centre for Medical Ethics, and the Norwegian Association of Local and Regional Authorities. These organizations also constituted the board, headed by the Ministry. This project was part of an agreement between the Norwegian Government and the Norwegian Association of Local and Regional Authorities (Ministry of Health and Care services, 2006). In 2016 the Ministry of Health and Care service decided to prolong the main features of the Ethics project. This paper does not look into this prolonged part. Moreover, the web sites of the Norwegian Association of Local and Regional Authorities primarily refer to activities starting from 2016 (KS, 2017). All the Norwegian municipalities are a member of KS, which advocates the interests of its members towards central government, the Parliament, labor organizations and other organizations. Their vision is an independent and innovative local government sector and one of their main objectives is to strengthen the members as competent and reliable employers (KS, 2018). The municipalities did decide themselves if they wanted to join the Ethics project, and which year to start. The project management sent letters of invitation to all municipalities, prior to the start of each new group of municipalities, totaling 10 groups—as illustrated in Figure 2. The project management’s main tasks was to recruit municipalities, to arrange seminars for them on ethical reflection, to make tools on ethical reflection available both on the projects web page as well as in printed versions, and to collect end-of-project reports from the participating municipalities. 2–4 persons from each municipality took part in mandatory seminars on ethical reflection. These persons were mostly health-care personnel from nursing homes, home-based care, and sheltered housing, but also administrators from different levels of the municipality participated. After the seminars on ethical reflection, the health-care personnel arranged and guided ethics reflection groups for their colleagues at their work-place. The person leading this activity is called ethics facilitators and chose the specific tool for the exercise on ethical reflection based on factors like the size of the group, the time available for the activity, and how often they did it; which varied from weekly to monthly, or more seldom (Nilsen et al., 2015). Different methods on ethical reflection have been developed before and independent of the Ethics project (Racher, 2007). Through the Ethics project, existing tools were modified to fit the project, and several new tools were developed as well (KS, 2015, p. 30). The new tools were developed both by the participating Board of the Ethics project Group 1 of municipalities (2007) Groups 2-9 of municipalities (2008-2013) Group 10 of municipalities (2014) Project management Figure 2. The organizational structure of the Ethics project. Nilsen & Ringholm, Cogent Business & Management (2019), 6: 1632045 https://doi.org/10.1080/23311975.2019.1632045 Page 6 of 15 municipalities on their own initiative, and by academics on ethical reflection—after a request from the project management (Eide & Aadland, 2012; KS, 2015). Common tools in the Ethics project are known as the pedagogic sun, the fishbowl-method and reflection cards. To exemplify one of these, the pedagogic sun has a question or statement in the middle regarding a difficult situation in patient care, and each participant is assigned a sunbeam to fill in a reflection on the statement. Summing up all the different reflections is to give attention to different perspectives and thereby different values involved in the situation. The group is then to discuss priorities, what is at stake, which values are more important, and why, in each case (Tveiten, 2002). The municipalities participated in the Ethics project on average 2 years each, which was also according to the overall project plan (Nilsen et al., 2015). This paper does not look into what happened in the municipalities after this project period was over. 5. Methodology The empirical case of this paper is by far the biggest project in Norway to enhance ethical competence in community health-care services, with regard to a number of persons and municipalities involved as well as the time span of 9 years (Magelssen et al., 2016a). The scale of this case makes it suitable to shed light on the important factor of motivation for innovative ethical practices in community health-care services, and how motivation corresponds with the results from the Ethics project as well as policy signals on the purpose of this national project. This is our primary reason for using this case to illustrate our research questions. The large scale, and the sizable amount of data described in the following sections, also serves the purpose of giving validity to this research design. All available data received from KS including 180 reports from the participating municipalities are analyzed, and not only well-chosen examples. We thereby avoid anecdotalism, a weakness in many qualitative studies, and instead entail a“comprehensive data treatment”(Silverman, 2005, p.211–215). To further strengthen the validity, we have used what is called a constant comparative method which implies to constantly inspect and compare all the data that arise in the case (Glaser & Strauss, 1967). Three researchers started out by analysing a few of the 180 reports and, based on these, generating a set of categories. “Then, having generated a set of categories, you can test out emerging hypotheses by steadily expanding your data corpus”(Silverman, 2005, p. 214). By expanding the dataset, it is necessary to have a constant back and forth between the different data and eventually ending up with the final categories which we describe below and present in Tables 1and 2. This back and forth process was done by three researchers, separately, whom thereafter met to discuss adjustments of the categories. After all the data were discussed within the group of three researchers, the data and the categories were presented for two more researcher, acting as expert advisors (Nilsen et al., 2015). Finally, and enhancing the reliability of this method, the results were approved by the board of the Ethics project (see Figure 2). 5.1. Data The data for our analysis were gathered by two different qualitative methods; a broad document analysis, and interviews with the project management and members of the board of the Ethics project. 5.2. Document analysis The main bulk of documents which we analyzed were the 180 reports requested by the project management from municipalities participating in the Ethics project, from the start in 2007 till the end in 2015. These reports did not follow the same standard, for several reasons; 1) the project management revised the form of these reports as the project proceeded, based on their own need of information in the daily running of the project, 2) some municipalities made their own report format answering the same questions in a more expansive way, 3) some municipalities added separate attachments not asked for by the project management, but made for other purposes Nilsen & Ringholm, Cogent Business & Management (2019), 6: 1632045 https://doi.org/10.1080/23311975.2019.1632045 Page 7 of 15 such as local or regional politicians, describing their project in a more official way. Still, most reports were 2 pages of A4 long, whereas 50% of this space was the questions from the project management. Reports from 63 municipalities were lacking to make up the total of 243 participants in the Ethics project. The project management made efforts to get these missing reports from municipalities, but did not succeed. The reports present the results from the departments where the ethical reflection had taken place. The form of the reports, developed by the project management, was an encouragement to write in a story-telling style, and most reports from the municipalities were consequently in that form. Hence, the results presented in the following chapters are based on a thorough qualitative interpretation of all answers from each municipality. The motivation for participating in the Ethics project was in most of the reports found as an answer to this question: “What did you want to achieve by participating in this project, and why? Specify the goal and background for your participation.”(Our translation from Norwegian) The results reported by the municipalities were in most of the reports found as an answer to the following question: “What have you achieved so far? What has been decisive to achieve this—success criteria?”(Our translation from Norwegian) For other and more detailed questions in the reports on a specific outcome, kindly see the first paragraph in the chapter on Results as well as Table 1in the same chapter. Other documents which we analyzed were the mandate of the board and other internal management systems papers, as well as the letters of invitation from the project management to the municipalities. 5.3. Interviews The interviews were conducted in 2014 and 2015 and served two purposes. Firstly, to gather the information that was not provided by the document studies, secondly, to dig deeper into questions Table 1. Results of the Ethics project in municipalities Reported results from 180 municipalities Number of municipalities* A Enhanced employee competence 145 B Enhanced quality in the healthcare service 38 C Better communication between colleagues, interdisciplinary understanding 33 D Better working environment 47 E Reduced sick leave 15 F Enhanced user satisfaction 18 *The figures in this row cannot be summed up, as many municipalities describe more than one type of result. Table 2. Link between motivation for participating and enhanced user satisfaction Motivation Number of municipalities Number of municipalities with results in row F, Table 1 Enhanced competence in ethical reflection 140 0 Enhanced user satisfaction including experience of integrity and dignity 10 5 Both enhanced competence and user satisfaction 30 13 Nilsen & Ringholm, Cogent Business & Management (2019), 6: 1632045 https://doi.org/10.1080/23311975.2019.1632045 Page 8 of 15 Sutinen, J. G., & Kuperan, K. (1999). 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