Health Care Analysis

, Volume 20, Issue 3, pp 281–296 | Cite as

Moral Learning in an Integrated Social and Healthcare Service Network

  • Merel Visse
  • Guy A. M. Widdershoven
  • Tineke A. Abma
Original Article


The traditional organizational boundaries between healthcare, social work, police and other non-profit organizations are fading and being replaced by new relational patterns among a variety of disciplines. Professionals work from their own history, role, values and relationships. It is often unclear who is responsible for what because this new network structure requires rules and procedures to be re-interpreted and re-negotiated. A new moral climate needs to be developed, particularly in the early stages of integrated services. Who should do what, with whom and why? Departing from a relational and hermeneutic perspective, this article shows that professionals in integrated service networks embark upon a moral learning process when starting to work together for the client’s benefit. In this context, instrumental ways of thinking about responsibilities are actually counterproductive. Instead, professionals need to find out who they are in relation to other professionals, what core values they share and what responsibilities derive from these aspects. This article demonstrates moral learning by examining the case of an integrated social service network. The network’s development and implementation were supported by responsive evaluation, enriched by insights of care ethics and hermeneutic ethics.


Integrated service Social service Care ethics Hermeneutic ethics Moral ecology 


  1. 1.
    Abma, T. A. (2003). Learning by telling. Storytelling workshops as an organizational learning intervention. Management Learning, 34(2), 221–240.CrossRefGoogle Scholar
  2. 2.
    Abma, T. A., de Bruijn, A., Schols, J., Kardol, T., & Widdershoven, G. A. M. (2011). Responsibilities in elderly care. Mr Powell’s narrative of duty and relations. Bioethics (in press).Google Scholar
  3. 3.
    Abma, T. A., Molewijk, B., & Widdershoven, G. A. M. (2009). Good care in ongoing dialogues. Responsive evaluation and moral deliberation. Health Care Analysis, 17(3), 217–235.PubMedCrossRefGoogle Scholar
  4. 4.
    Abma, T. A., & Noordegraaf, M. (2003). Public managers amidst ambiguity: Towards a typology of evaluative practices in public management. Evaluation, 9, 285–305.CrossRefGoogle Scholar
  5. 5.
    Abma, T. A., Oeseburg, B., Goldsteen, M., Widdershoven, G. A. M., & Verkerk, M. (2005). Two women with multiple sclerosis. Conflicting normative expectations between patients and their caregivers. Nursing Ethics, 12(5), 479–492.PubMedCrossRefGoogle Scholar
  6. 6.
    Abma, T. A., & Widdershoven, G. A. M. (2008). Evaluation as social relation. Evaluation, 2(14), 209–225.CrossRefGoogle Scholar
  7. 7.
    Abma, T. A., & Widdershoven, G. A. M. (2010). Evaluation as relationally responsible practice. In N. Denzin & Y. Lincoln (Eds.), Chapter for the handbook for qualitative inquiry (in press).Google Scholar
  8. 8.
    Ahgren, B. (2001). Chains of care: A counterbalance to fragmented health care. Journal of Integrated Care Pathways, 5, 126–132.Google Scholar
  9. 9.
    Benaroyo, L., & Widdershoven, G. A. M. (2004). Competence in mental health care: A hermeneutic perspective. Health Care Analysis, 12(4), 295–306.PubMedCrossRefGoogle Scholar
  10. 10.
    Bernstein, R. J. (1983). Beyond objectivism and relativism. Science, hermeneutics, and praxis. University of Pennsylvania Press.Google Scholar
  11. 11.
    Czarniawska, B. (2008). A theory of organizing. Cheltenham, UK: Edward Elgar.Google Scholar
  12. 12.
    Farmakopoulou, N. (2002). What lies underneath? An inter-organizational analysis of collaboration between education and social work. British Association of Social Workers, 32, 1051–1066.Google Scholar
  13. 13.
    Gadamer, H. G. (1975). Truth and method. New York: Seabury Press.Google Scholar
  14. 14.
    Goldsteen, M., Abma, T. A., Oeseburg, B., Verkerk, M., & Widdershoven, G. A. M. (2007). What it is to be a daughter? Identities under pressure in dementia care. Bioethics, 21(1), 1–12.PubMedCrossRefGoogle Scholar
  15. 15.
    Guba, E. G., & Lincoln, Y. (1989). Fourth generation evaluation. Sage: Newbury Park.Google Scholar
  16. 16.
    Harker, R. M., Dobel-Ober, D., Berridge, D., & Sinclair, R. (2004). More than the sum of its parts? Inter-professional working in the education of looked after children. Children & Society, 18, 179–193.CrossRefGoogle Scholar
  17. 17.
    Hosking, D. M., & McNamee, S. (2006). The social construction of organization. Malmö: Liber & Copenhagen Business School Press.Google Scholar
  18. 18.
    Kunneman, H. (2009). Het belang van normatieve professionalisering in de sociale sector. The Netherlands: Lecture NVMW-conference.Google Scholar
  19. 19.
    Landeweer, E. G. M., Abma, T. A., & Widdershoven, G. A. M. (2010). The essence of psychiatric nursing: redefining nurses’ identity through moral dialogue about reducing the use of coercion and restraint. Advances in Nursing Science, 33(4), E31–E42.PubMedGoogle Scholar
  20. 20.
    Letiche, H. (2010). Polyphony and its Other. Organization Studies, 31, 261. doi: 10.1177/0170840609357386.CrossRefGoogle Scholar
  21. 21.
    Mandell, M. P. (2001). Getting results through collaboration: Networks and network structures for public policy and management. Quorum Books.Google Scholar
  22. 22.
    Marston, G. (2000). Metaphor, morality and myth: a critical discourse analysis of public housing policy in Queensland. Critical Social Policy, 20, 349–372.CrossRefGoogle Scholar
  23. 23.
    Molewijk, B., Abma, T., Stolper, M., & Widdershoven, G. (2008). Teaching ethics in the clinic. The theory and practice of moral case deliberation. Journal of Medical Ethics, 34, 120–124.PubMedCrossRefGoogle Scholar
  24. 24.
    Mooney, G. (2010). Review: What’s wrong with social policy and how to fix it bill Jordan polity. Critical social policy. doi: 10.1177/02610183100300040705.
  25. 25.
    O’Toole, L. J., & Meier, K. (2003). Desperately seeking Selznick: Cooptation and the dark side of public management in networks. Paper prepared for the 7th National Public Management Research Association Conference, Georgetown University.Google Scholar
  26. 26.
    Schwandt, T. A. (1995). Thoughts on the moral career of the interpretive inquirer. Studies in Symbolic Interaction, 19, 131–140.Google Scholar
  27. 27.
    Sievers, B. (1993). Work, death and life itself: Essays on management and organization. Berlin: Walter de Guyter & Co.Google Scholar
  28. 28.
    Stein, K. V., & Rieder, A. (2009). Integrated care at the crossroads—defining the way forward. International Journal of Integrated Care, 9, 1–5.Google Scholar
  29. 29.
    Tronto, J. C. (2009). Consent as a grant of authority. A care ethics reading of informed consent. In H. Lindeman, M. Verkerk, & M. U. Walker (Eds.), Naturalized bioethics: Toward responsible knowing, practice. New York: Cambridge University Press.Google Scholar
  30. 30.
    van Dongen, H., De Laat, W. A. M., & Maas, A. J. J. A. (1996). Een kwestie van verschil: Conficthantering en onderhandeling in een configuratieve integratietheorie (A matter of difference: Management of conflicts and negotiation in a configuration theory). Delft: Eburon.Google Scholar
  31. 31.
    Visse, M. A., Teunissen, T., Peters, A., Widdershoven, G. A. M., & Abma, T. A. (2010). Dialogue for air, air for dialogue: Toward shared responsibilities in COPD practice. Health Care Analysis, 18(4), 358–373.PubMedCrossRefGoogle Scholar
  32. 32.
    Walker, M. (2007). Moral understandings: A feminist study in ethics. New York: Oxford University Press.Google Scholar
  33. 33.
    Weick, K. E. (1995). Sensemaking in organizations. California, Sage: Thousand Oaks.Google Scholar
  34. 34.
    Widdershoven, G. A. M., Abma, T. A., & Molewijk, B. (2009). Improving care and ethics: A plea for interactive empirical ethics. The American Journal of Bioethics, 9(6 & 7), 99–101.PubMedCrossRefGoogle Scholar
  35. 35.
    Wuthnow, R. (1987). Meaning and moral order. California: University of California Press.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Merel Visse
    • 1
  • Guy A. M. Widdershoven
    • 1
  • Tineke A. Abma
    • 1
  1. 1.Department of Medical Humanities, EMGO+ Institute for Health and Care ResearchVU University Medical CenterAmsterdamThe Netherlands

Personalised recommendations