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research-article2014

PED22110.1177/1757975914532505Original ArticleN. Sunderland et al.

Original Article Exploring health promotion practitioners’ experiences of moral distress in Canada and Australia Naomi Sunderland1, Paul Harris1, Kylie Johnstone1, Letitia Del Fabbro1 and Elizabeth Kendall1

Abstract: This article introduces moral distress – the experience of painful feelings due to institutional constraints on personal moral action – as a significant issue for the international health promotion workforce. Our exploratory study of practitioners’ experiences of health promotion in Australia and Canada during 2009–2010 indicated that practitioners who work in upstream policy- and systemslevel health promotion are affected by experiences of moral distress. Health promotion practitioners at all levels of the health promotion continuum also described themselves as being engaged in a minority practice within a larger dominant system that does not always value health promotion. We argue that health promotion practitioners are vulnerable to moral distress due to the values-driven and political nature of the practice, the emphasis on systems change and the inherent complexity and diversity of the practice. This vulnerability to moral distress poses significant challenges to both workers and organisations and the communities they seek to benefit. We propose that further research should be undertaken to fully identify the causes and symptoms of moral distress in health promotion. Extensive existing research on moral distress in nursing provides ample resources to conduct such research. (Global Health Promotion, 2015; 22(1): 32–45) Keywords: health promotion, moral distress, Australia, Canada, health promotion continuum

Introduction This article introduces the concept of moral distress in the context of health promotion practice and outlines its significance for future health promotion research and practice. Moral distress has been used for over a decade in nursing (1–3) and more recently in other health-related professions (4,5) to describe professionals’ experience of painful feelings when they cannot act according to their personal or professional moral values due to external constraints. We argue that a greater understanding of and response to moral distress is required in health promotion due to the degree that health promotion relies on individuals working to effect change within or upon broader institutions and

systems. Moral distress is a highly significant issue for the health promotion workforce because feelings of moral distress have been strongly linked with experiences of burnout, disillusionment, detachment and staff attrition (1,2). Our exploration of moral distress in health promotion emerged from an exploratory analysis of Canadian and Australian health promotion leaders’ experiences of health promotion practice conducted during 2009–2010. In order to introduce and explore the concept of moral distress in health promotion here, we first provide a background on existing literature that deals with moral distress and related experiences in health promotion. We next provide a brief summary of contemporary health

1. Griffith University, Meadowbrook, Australia. Correspondence to: Naomi Sunderland, Griffith University, Room 1.41 Level 1, Building L05, Meadowbrook, Queensland, 4131, Australia. Email: [email protected] (This manuscript was submitted on 3 January 2012. Following blind peer review, it was accepted for publication on 27 March 2014) Global Health Promotion 1757-9759; Vol 22(1): 32­ –45; 532505 Copyright © The Author(s) 2014, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975914532505 http://ghp.sagepub.com Downloaded from ped.sagepub.com at UNIV TORONTO on November 15, 2015

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promotion definitions and environments and an introduction to the concept of moral distress. We then provide detailed discussion of our exploratory research method and findings, which identified moral distress as a major theme across both Australian and Canadian participants. We conclude with a number of recommendations for future research, policy and practice relating to moral distress in health promotion.

Background Health promotion: a diverse and complex moral practice Since its inception, health promotion has been regarded as a highly complex, values-driven and political practice that is geared toward achieving significant health equity and social justice outcomes (6,7) across a range of contexts and populations (8,9). By all definitions, health promotion is an extremely comprehensive and ambitious practice in that it not only fosters actions directed at strengthening individuals’ skills and capabilities, but also actions directed toward changing social, environmental and economic conditions in order to alleviate their impact on public and individual health (10,11). As described in the Ottawa Charter (10), health promotion involves ‘enabling’ people to ‘increase control over’ the determinants of health and thereby improve their health (12). Hence, we argue that by its very nature, health promotion is a moral practice (13). The definition of a moral practice is such that the agreed purpose or teleology of the practice is targeted toward achieving a ‘good’ or moral outcome (13,14). Within the context of health promotion these moral outcomes include the fullest achievement of health potential, reduction of health inequalities and strengthening of communities. From its earliest articulation within the Alma Ata and the Ottawa Charter to modern policy definitions, health promotion is characterised by a commitment to health equity and the notion or value that health is a resource rightfully attainable for all people (15). Yet since the Ottawa Charter on Health Promotion (10) and the Jakarta Declaration Leading Health Promotion into the 21st Century (11) health promotion has taken a varied path. Contemporary health promotion is often conflated with terms such as ‘illness prevention’ and ‘health education’, though

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some health promotion theorists and practitioners reject these associations. In recent years health promotion has also become integrated with other practices as reflected in the concept of ‘integrated health promotion’ and ‘integrated public health practice’ (6,7). These integrated practices – at least theoretically – span continuums of health promotion activity across population (public) health, primary healthcare and early treatment services and link public health services with primary healthcare and hospital-based services (8,9). Health promotion has also been explicitly linked to continuums that map the social determinants of health from micro individual determinants (such as obesity and mental health) to macro-level systemic determinants (such as the distribution of wealth and public transport) (16). This micro-macro determinants’ view is reflected in the use of ‘upstreamdownstream’ metaphors (17) where ‘upstream’ refers to macro determinants while ‘downstream’ refers to micro-level determinants.

Moral distress in the context of health promotion practice Although there is little literature relating to moral distress in health promotion, there is an abundance of applicable literature relating to nurses’ occupational moral distress (18). Jameton’s (19) original and widely cited description of moral distress in nursing refers to: painful feelings that occur when, because of institutional constraints, the [practitioner] cannot do what he or she perceives to be what is needed. Such feelings involve perception of moral responsibility and of the degree to which a person views herself or himself as individually responsible or as restricted by circumstances. (as cited in (1)) We agree with McCarthy and Deady (3), who suggested that moral distress is best viewed as an umbrella that captures the range of experiences of individuals who are morally constrained. Hanna (18) similarly argued for a broad conception of moral distress that encompasses a range of negative feelings associated with institutional and systemic constraints. IUHPE – Global Health Promotion Vol. 22, No. 1 2015

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The defining feature of moral distress is hence not the type of ‘painful feeling’ that occurs (for example frustration, anguish, or powerlessness) but rather that the painful feeling occurs because one cannot act in accordance with his or her personal or professional values due to external institutional or systemic constraints. Hanna (18) noted that moral distress is often associated with professional ‘anguish’ or ‘interior suffering’, disconnection from personal values and beliefs, and disenfranchised (socially unacknowledged) grief. Hanna (18) also found that while moral distress is often precipitated by a disjunction between personal core values and institutional values and practices, this does not always mean a separation between personal and professional values. In other words, professionals may believe that institutional and systemic constraints prevent them from exercising the ‘true’ nature and values of their profession. Table 1 provides examples of external constraints that have been found to produce values-oriented painful feelings for health practitioners (i.e. moral distress). Nursing researchers have identified significant negative outcomes associated with moral distress that are equally applicable to the health promotion workforce. Corley et al. (1,2) concluded that unresolved moral issues were associated with high staff turnover, reduced job satisfaction and burnout among nurses, particularly those located within an unresponsive organisational setting. Researchers have also linked moral distress to workforce shortages (20); negative health impacts on workers (3,20–22); feelings of anger and powerlessness (22); and isolation or withdrawal from other workers and clients (1,2). Despite these significant negative impacts, moral distress has also been identified as a potential motivator for positive learning, growth and change (3,18).

Method In this article, we posed the question: do health promotion practitioners report experiences of moral distress? We answered this question by analysing a series of interviews with Canadian and Australian health promotion practitioners. By bringing together these two datasets that had previously been collected as part of two distinct studies, this analysis has been able to identify and articulate a core theme that crosses international boundaries, namely moral distress.

Health promotion in Australia has been described as being deficient in several important areas, particularly workforce development (23). As a result, many health promotion practitioners in Australia continue to be influenced heavily by the Canadian leaders in this field. Canada is internationally recognised as being significant in the conceptualization and implementation of health promotion. Indeed, contemporary versions of health promotion are often traced back to the Lalonde Report (24) originating from Canada and its influence on the development of the World Health Organization Ottawa Charter (10). Canada and Australia are remarkably similar in terms of population, geography, government structure, constitutional history and public health system design (25,26), making comparison between the two countries even more useful. Although both countries have undergone significant structural reform in their health systems, they both continue to face challenges associated with rising costs, quality of care, access to health services and morale of the healthcare workforce (26). In addition, both countries continue to struggle with significant health discrepancies for marginalised groups, such as indigenous and rural citizens. However, Australia has historically spent less per capita on healthcare than Canada (25). Indeed, when broken down into expenditure categories, Australia spends more on inpatient treatment and less on outpatient and other health treatments (27), suggesting less emphasis on health promotion than in Canada.

Data collection The Canadian component of the research was funded by a small travel grant provided by Griffith University and in-kind support from the Griffith Health Institute and Queensland Health. The Australian component of the research drew on group interview data collected at the same time through an Australian Research Council study focused on local health promotion learning communities. The Griffith University human research ethics committee reviewed all aspects of data collection for the research prior to our commencing data collection. All participants reviewed and completed signed consent materials prior to participating in the research.

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Table 1.  Examples of perceived institutional constraints identified in the existing literature. Examples of perceived institutional constraints identified in the existing literature

Context

Source

•• Lack of culturally and linguistically appropriate materials, services and resources; •• Lack of funding for creation and expansion of needed programs; •• Lack of understanding of the importance of relationships rather than simply measuring with numbers; •• Clashes between the agenda of funders and community; •• Highly asymmetrical relations of power with medical system; •• Inability to effect change in relation to the Ottawa Charter Action Area of ‘building healthy public policy’; •• Interventions focusing on individuals are ineffective if they do not consider the environments in which people live and can lead to a victim-blaming ideology; •• Health managers feeling obligated to ‘sell’ organisational decisions or policies with which he or she personally disagrees; •• Situations where scarce resources compel managers to place staff in situations where they meet with predictable and potentially avoidable risks; •• Futile care situations; •• Deception; •• Euthanasia; •• Inability or reluctance (due to fear of conflict or reprisal) to advocate effectively for their patients; •• Blurred boundaries between practitioners and participants in community-based participatory and action health research; •• Competing expectations between funders, institutions, and community participants.

Community care

De Jesus (34)

Part 1: Australian perspectives The Australian data were drawn from a current Australian Research Council research project designed to document Australian health promotion practitioners’ experiences and understandings of health promotion and was reanalyzed for the current study. Group interviews provided an economical option for data collection and exploratory analysis. The group interviews also allowed researchers to capture participants’ diverse experiences of health promotion and encourage

        Health promotion workforce

Godden (31)

Epidemiological research

Minkler (36) Haan, Kaplan & Camacho (37) Neubauer & Pratt (38)

Health service management

Mitton et al. (4)  

Acute care – medical and surgical nurses

Rice et al. (39)  

Acute care – nurses

Erlen (20)

Community-based health research

Sunderland et al. (21)  

mutual exploration of topics (28). The semistructured group interviews included questions regarding the following topics: •• What health promotion means to health professionals; •• The extent to which health professionals see health promotion as part of their role; and •• The characteristics of health promotion practice and experience in individuals’ current and, if relevant, previous working contexts. IUHPE – Global Health Promotion Vol. 22, No. 1 2015

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Table 2.  Group interview participants – Australia. Participant category

Number of participants recruited

100% ‘health promotion’ officers employed by the state health department Health education staff members from the regional general practitioners’ representative body Members of a government-funded place-based health promotion initiative Hospital-based nurse practitioner School-based health nurse Community health home care nurse Community health practitioner Hospital-based community hospital interface program nurses

The group interviews were conducted at venues in or near the participating health promotion practitioners’ workplaces. Six group interviews were conducted between September and November 2009. A representative sample of health professionals was recruited from a range of areas of specialization, including: •• •• •• •• •• •• •• •• ••

General Practice; Pharmacy; Optometry; Dentistry; Therapy/Psychology; Specialists; Emergency departments; Dedicated health promotion professionals; Allied Health Professions (including nurse practitioners, community health nurses and members of the Community Hospital Interface Program).

5 10 4 1 1 1 1 2

participants using a snowball selection process in which Australian health promotion professionals identified the Canadian health promotion ‘leaders’ who had influenced their practice. This process produced six potential participants of whom five subsequently participated in the research. A researcher conducted semi-structured face-to-face interviews with all five participants at their work venue or home during a visiting researcher tour of Canada between June and July 2009. Interview questions were provided before the interview and covered the following topics:

Part 2: Canadian perspectives

1. The professional life story of the participant; 2. Key personal values regarding health and wellbeing; 3. Definitions of health promotion and location on the health promotion continuum; 4. Strategies – how do conceptions of health promotion translate into concrete strategies for change? How are these implemented? 5. Evaluation – how are the outcomes of health promotion identified? 6. Politics and competing approaches to health promotion – how are these handled by the participant? 7. Difficulties and successes – what are the key difficulties and positive aspects of participants’ work in health promotion? 8. Other key issues identified by participants.

We conducted a series of in-depth interviews with five Canadian health promotion leaders between June and July 2009. We identified the Canadian

Three of the five Canadian participants reported that their current work involved national-level

These participants represented the full continuum of health promotion activity, from individual screening and health education and prevention to macro systems and policy-level change. A total of 25 individuals participated in the group interviews as outlined in Table 2.

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Table 3.  Analysis matrices. Analysis matrix

Headings/Topics explored in matrix/wave of analysis

(one per wave of analysis) Matrix 1 Canadian interview data

Matrix 2 Australian focus group data

Matrix 3 Canadian and Australian interview and focus group data

  1.  Focus group name  2.  Themes   3.  Expressions and sources of distress   4.  Other (health promotion definitions, metaphors, other)   1.  Interviewee name   2.  How does interviewee define/talk about health promotion (HP)?   3.  What is the interviewee’s approach to HP?   4. Notable prelim features of interview (e.g. interviewee’s way of thinking, metaphor use, relationships with others, poignant experiences and turning points, wisdom, insights, ways the interviewee is different from others and the same)   5. Can you identify any themes (recurring patterns) in: (a) this interview; (b) the whole collection of interviews?    6.  How would you label the theme?    7.  Example of theme (quote or paraphrase from interview)   8. How does this interviewee’s experience in HP relate to your own experience in Australia?   1.  Data source   2.  Interpretive ranking of distress (low–high)   3. Reported or observed sources of distress (specific examples + intensity e.g. ‘issue’, ‘challenge’, ‘distressing’)   4. Level of HP activity (which determinants of health does the group or individual focus on?)   5.  HP concept analysis (‘HP is’ statements)   6.  HP description consistent with moral practice definition?   7.  Role of HP worker consistent with moral agent?   8.  Understanding of upstream HP values and practice?   9.  Personal link with HP values e.g. ‘personal commitment’ 10.  Personal link with other aspects of practice e.g. clients or community 11.  Contexts of practice 12.  Approx percentage of role committed to HP 13. Metaphors

health promotion initiatives, whereas the remaining two were involved in provincial or local-level initiatives. All five participants were employed in Canadian universities. Three of the five were current leaders of national or international health promotion networks.

Data analysis We conducted collaborative thematic analysis of the individual and group interview data in three consecutive waves. During the first wave five

researchers conducted an open (inductive) thematic analysis (29) using an analysis matrix (see Table 3) that included: (a) tentative descriptions of themes and expressions (quotations) of each theme; (b) a description of how the interviewee defined health promotion; (c) a description of where on the health promotion continuum he or she practised; and (d) any general comments about notable features of the interview content in the matrix. Each rater analysed a minimum of one Canadian interview. Two raters analysed all five of the Canadian interviews to provide consistency. All raters then met to present, IUHPE – Global Health Promotion Vol. 22, No. 1 2015

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discuss, and consolidate their preliminary themes. This discussion was audio taped. Through this process, the team identified moral distress as a key theme in the Canadian interview data. Our second wave of analysis identified indications of moral distress in the Australian group interview data. Two raters analysed the Australian group interview data using a shared qualitative analysis matrix (see Table 3). The matrix identified: (a) preliminary themes, expressions and sources of moral distress; and (b) other notable features of the data such as participants’ definitions of health promotion and use of metaphors. We then used a third analysis matrix to combine the results of the first and second waves of analysis in a third matrix. This matrix concentrated on the moral distress theme and allowed us to identify patterns across the different data sources and participants under the following headings: •• Level of reported health promotion activity (e.g. micro–macro); •• Concepts and definitions of health promotion; •• Is the participants’ description of health promotion consistent with a moral practice definition?; •• Does the worker see him or herself as a moral agent?; •• Does the worker exhibit understanding of upstream (macro) health promotion values and practice?; •• Approximate percentage of role committed to health promotion; and •• Metaphors used during the interview or group interview. In the third wave analysis we identified: (a) participants’ severity of moral distress relative to their location on the continuum; (b) if their distress appeared to relate to their definitions and contexts of health promotion practice; and (c) if there were any other notable patterns or aberrations in the data that would suggest useful categories and variables for future targeted research on moral distress in health promotion (see Table 3). A key limitation of our data and analysis was that we did not have the opportunity to ask participants to precisely define or communicate their own experiences of moral distress. Likewise, because moral distress was not the original focus of our

exploratory study but was, rather, an outcome of the thematic analysis across two discrete qualitative studies, we were not able to directly follow up on participants’ comments and narratives about moral distress at the time of the interview. Instead, we identified examples of moral distress in participants’ general descriptions of what it was like to work as health promotion practitioners in either Australia or Canada. As we will describe in the results and discussion sections, participants’ descriptions of their daily practice spontaneously (i.e. without provocation from research facilitators) included significant indications and examples of moral distress. It was notable that some participants gave spontaneous frequent and extended descriptions of negative experiences or painful feelings associated with external constraints, indicating that moral distress was a significant element of their daily lives.

Results In both the Canadian and Australian data, participants described elevated levels of moral distress within the profession generally. An example is provided in the following statement, ‘I know a lot of people that have [had the misfortune of being a sole practitioner working in a hostile environment] and I know what it’s done to them’. There was a general awareness that they worked within challenging institutional environments and that this produces painful feelings (i.e. moral distress). More importantly, distress appeared to be a common pattern and, therefore, a potentially ‘taken for granted’ element of health promotion practice. Canadian and Australian participants all indicated that they had held strong value-based expectations about how they would practise as health promotion professionals when entering the profession. However, these expectations did not match the reality of the institutional environments in which they eventually worked. Participants did not appear to ‘brush off’ or ‘get over’ this mismatch between personal expectations and working environments but, rather, regarded it as further indication of how much systemic and institutional change was actually required if health promotion as defined by the Ottawa Charter was to ‘truly’ achieve its aims. Three main themes were evident in the data that assisted in clarifying the experience of moral distress. First, there were intensity differences in the experience of

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moral distress between those who worked in ‘upstream’ versus ‘downstream’ health promotion. Second, all health promotion practitioners reported a sense of being marginalised within a broader system. Finally, there was a sense of movement between demoralisation and remoralisation that occurred continuously, even for practitioners who had been practising for many years. This theme indicated that practitioners drew strength from supportive environments and initiatives.

Upstream versus downstream practitioners The Canadian and Australian data indicated significant moral distress in health promotion leaders who sought to practice ‘upstream’ health promotion: that is, macro-level policy and systems change to promote health and remove health inequalities. Although minor accounts of institutional constraints were reported by interviewees who worked at other levels of the health promotion continuum – for example implementing screening tools with general practitioners – the strongest accounts were from upstream practitioners. Upstream practitioners reported significant frustration regarding the amount of health promotion activity that was targeted toward lifestyle factors as opposed to health inequalities and systemic-level change. One interviewee who strongly advocated for upstream health promotion indicated that much health promotion being practised in Canada ‘is a perversion of what we should be doing’ and that health promotion had therefore become ‘irrelevant’. Another interviewee who worked on large national upstream health promotion collaborations argued that a lot of ‘lip service’ was paid to upstream health determinants but very little concrete action occurred. She argued that Canadian health promotion ‘looks good from the outside but [there is] not a lot behind it’ despite health promotion being the ‘flavour of the day’. This interviewee observed that the government did not appear to be interested in ‘a broader approach’ and needed to ‘shift to a higher level’ if health promotion was to be effective. Another interviewee indicated that there was little political leadership for systemic change, with governments preferring to focus on ‘health risk management’ rather than health promotion. This same interviewee observed that health promotion

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researchers ‘have to buy into short-term health solutions because it’s the only game in town’. The tension between individual practitioners and their institutional environments was equally clear in the Australian upstream health promotion participants. In particular, as reflected in the quotation below, moral distress was evident in participants’ descriptions of painful feelings such as powerlessness and demoralisation that resulted from their daily interactions with broader systems that were the focus of their health promotion work (that is, systems that they were trying to influence in the course of their health promotion practice); So it’s that really high-level stuff [health policy] that you’ve got no control over. There’s nothing that we can do to stem that flow. If that happens up there, the implications are just massive. So my two big projects are the Healthy Regions project, which was the really high-level statewide one; and then my more local regional Pathways to Action, which was around developing research at the regional level, what we can do to impact on those determinants here… Both of those projects, all of our staff got taken and in the last few months – not just the restructure, this is because of swine flu as well. It’s the stuff that’s outside of your control. So the two big projects that I invested in, just gone, you know, just like that. So that’s the negative stuff. That’s why you have to stay so strong in your practice and with your colleagues. They become so important to ground you, you know, because otherwise you’re just like a leaf blowing in the wind. You’ve got to have strong foundations because the political environment is difficult, to say the least. In addition to working within and upon challenging institutional and systemic environments, upstream Australian health promotion professionals reported that they often did not get to work on the things that they felt were ‘truly’ health promotion and that this caused moral distress. In particular, many upstream participants reported frustration regarding what they saw to be an over-emphasis on clinical health education and lifestyle factors by governments. As one Australian participant employed in a state health department described: IUHPE – Global Health Promotion Vol. 22, No. 1 2015

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It’s [health promotion] about the equitable distribution of resources for health… all [of] that stuff happens upstream. So I knew I wanted to move into that, and that’s why I moved into population health because I thought I’d be able to do that. Of course, the reality is that we don’t get to do that very often. Where are the resources? We’ve got about 200 health promotion staff at the moment all focusing on what people put in their mouths and whether they’re [physically] active or not. All very clever people who could be looking in the policy domain. Another Australian participant reported frustration regarding the divide between the ‘known’ social determinants of health and health promotion policy as indicated in this quotation: We know that the single most important factor for an indigenous child’s health is how far their mother got with education. Why aren’t we investing there? In addition to providing verbal examples of external constraints that caused moral distress, participants in the Australian upstream group interview became observably affected by the discussion of the frustrations they experienced in their day-to-day work. This was evident in the heightened volume in the discussion and the strong language and metaphors participants used to describe their experiences. Examples of metaphors participants used to describe their experiences include: •• •• •• •• •• ••

wanting to ‘throw up’ (vomit); ‘wreaking havoc’; ‘destroying us as a profession’; being ‘drawn and quartered’; ‘walking away from that level of advocacy’; and trying to ‘stick it out’.

We interpreted the strong language and metaphor use to be a further indication of the degree to which participants felt personally affected by the professional experiences they were describing. This level of personal commitment and distress is a further defining characteristic of moral distress related to perceptions of moral agency or responsibility.

Minority practice within a dominant system Although moral distress was not evident in the group interview of Australian health educators working in general practice, they did describe significant frustration relating to their perceived status as an ‘add on’ feature in their contexts of practice. Several of these participants emphasised that health promotion was seen as a ‘luxury’ amid other tasks that were funded and charged to clients under the federal Medicare funding mechanism. They felt the need to ‘defend’ their health promotion practice which was seen as an ‘add on’ in the context of general practice. They agreed that ‘there isn’t enough emphasis on preventative medicine… it’s all about in the door and straight back out again’. They attributed this situation to the predominance of Medicare billing systems in general practice ‘because Medicare won’t pay for long consults’. The experiences of these practitioners point to a wider pattern across both the Canadian and Australian data: all health promotion practitioners who participated in this research uniformly described their practice as a minority practice within a larger dominant system that did not value their work. This situation made them vulnerable to experiences that appeared to be related to moral distress. One Canadian interviewee described several examples of health promoters feeling intensely marginalised for adopting or attempting to adopt the Ottawa Charter principles for health promotion. They reported a view that their careers or organisations would be in jeopardy if they sought to practise health promotion as it was described in the Ottawa Charter: So there’s been this real – again whether it’s accurate or not is another question, but – there are all kinds of anecdotes and stories that suggest that in these very conservative times the basic principles of the Ottawa Charter are not something to be trifled with. In other words… there’s an actual perception that it could be threatening to raise these [Ottawa Charter] issues. So what you find is that [you’ll] be at a workshop on ‘moving upstream’ and [you’ll] be sitting around a table and people introduce themselves and a woman will say ‘I’m the community coordinator for a hospital in this region and I’m sitting here today

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because I want to know how I could raise these [Ottawa Charter] issues… in a way that’s not a career threatening move’. So there’s this actual real perception and I think it’s held by many public health medical officers of health as well. The interviewee commented further that: Even when there is some attempt to talk about broader determinants of health and health promotion and prerequisites of health and healthy public policy the discourse is so unsupported that it gets lost in the background of all of the healthy living and healthy lifestyles stuff. Another interviewee who worked primarily in screening and prevention within general practice clinics identified resistance to organisational change within clinics and lack of funding as substantial barriers. However, this interviewee did not report high levels of frustration or distress as a result of these barriers, indicating individual differences in the way constraints are evaluated.

Dynamics of remoralisation and demoralisation There was evidence that participants experienced a complex process of remoralisation (hope) and demoralisation (hopelessness) in relation to their external environments. Health promotion practitioners from both Australia and Canada described themselves as moving between being ‘naïve’ or idealistic in relation to their health promotion practice to being disappointed, frustrated, or disillusioned, suggesting a continual process of demoralisation and remoralisation. One Canadian participant remarked that: I was naïve and I basically believed that most people working in HP took the Ottawa Charter seriously. As I was reading about what HP was supposed to be which was WHO, Ottawa Charter, achieving health for all kind of stuff it seemed a natural tie in with not only what I knew about developmental psychology and health but also into the general views I had about politics and the nature of society. And that was again the early 1990s and the concept of democratic participation,

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prerequisites of health, Ottawa Charter stuff was basically consistent with my political views about the nature of society which I held since I was a little boy. The participant proceeded to outline how his initial ‘naïve’ impressions of health promotion were completely eroded over time by various political and economic shifts in Canada. Another Canadian participant described his/her personal journey from conducting research in chronic illness to becoming actively involved in health promotion at the policy level: I was very interested in lifestyle adaptation and this kind of thing and social support processes… for people with chronic illness and disability… doing that work I became very interested in the broader policy environment. We were generating a lot of research but in fact a lot of things weren’t changing where they needed to whether that was at a clinical level or a broader community level, you just still saw people suffering. These examples illustrate how health promotion workers have often made personal investments in their work and, in turn, how they operate as moral agents engaged in the moral practice of health promotion. This crossover between personal and professional values heightens the likelihood of distress when not able to pursue those values due to external constraints. Other participants from both Australia and Canada described the same narrative progression which involved moving from a state of inspired or ‘remoralised’ understanding and expectation of health promotion into a more painful or challenging state of feeling demoralised or upset by the ongoing ‘suffering’ of people they were trying to support. Interviewees identified several initiatives that provided a source of hope or remoralisation for them. These were typically described as initiatives that attempted to implement health promotion as it was defined in the Ottawa Charter or that tackled the ‘social determinants of health’ or environments that valued health promotion. For instance, three Canadian participants spoke about the Act Now BCi place-based health promotion initiative as a positive example of health promotion in Canada at IUHPE – Global Health Promotion Vol. 22, No. 1 2015

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the time of the research. Although all interviewees were positive about the initiative, one interviewee indicated significant disappointment saying that ‘it [Act Now BC] has probably disappeared’, ‘there was no money’ and ‘it [Act Now BC] was sexy for a while’. In contrast, another interviewee remarked that she remained ‘very opportunistic and driven’ regarding the future of comprehensive initiatives such as Act Now BC. This same interviewee raised a significant further issue in relation to moral distress in the health promotion workforce: she remarked that ‘cynicism’ in the health promotion workforce was ‘suffocating’ and ‘not helpful for practitioners’. This remark regarding cynicism indicated that ways of seeing within the profession may also be a source of distress for practitioners: that is, practitioners may have cynical expectations regarding institutional and political conditions that shape their experiences of demoralisation and remoralisation. Australian participants emphasised the importance and benefit they experienced when surrounded by a supportive work environment where employers were ‘actually interested in me’, ‘understand health promotion’ and are ‘very supportive’. They described workplaces that had provided these supportive environments as ‘havens’ for health promotion and a source of remoralisation: from an individual practitioner perspective, having a supportive environment, managers and colleagues, peers around you. I don’t think I’ve ever had the misfortune of being a sole practitioner working in a hostile environment. I know a lot of people that have and I know what it’s done to them.

Discussion Our research revealed that Australian and Canadian participants working across the health promotion continuum experienced moral distress and feelings of marginality in relation to larger dominant systems that do not uphold the values of health promotion. Upstream health promotion practitioners in both countries gave the most intense descriptions of moral distress. Participants who practised downstream health education, screening, and service integration also reported institutional

and systemic constraints on their work, but did not indicate the same level of painful feelings and anguish associated with those constraints. Hence we interpreted that these downstream practitioners did not experience the same level of moral distress as that experienced by upstream participants. The strongest source of moral distress in our analysis was that health promotion practice is highly political and is dominated by downstream lifestyle and risk factor approaches with very little attention being given to upstream health determinants, health equity, and policy change. Significantly, Canadian participants indicated that they or their colleagues had felt that their jobs or program funding were in jeopardy due to differences in values between practitioners and the institutions or systems within which they worked. Both Australian and Canadian participants referred to the lack of upstream health promotion principles and values in government-level policy and funding decisions despite growing evidence that individual lifestyle approaches to health promotion served to increase population health disparities and lead to stigmatisation of ‘offending’ population groups (30). Upstream participants emphasised that their daily work experiences did not reflect either their personal or the objectively documented (e.g. via the Ottawa Charter) theoretical underpinnings and values of their profession. This mismatch was particularly evident when participants described their expectations of the profession when they began their career. Consonant with Godden’s (31) survey of Australian health promotion practitioners, Australian and Canadian participants reported that their workplaces and work settings required them to focus on the Ottawa Action Area of ‘developing personal skills’ at the cost of upstream action targeting policy and systems change. Canadian and Australian participants also expressed frustration that chronic disease had become the new banner for health promotion. Upstream participants were cynical that government initiatives were merely giving ‘lip service’ to the underlying social determinants of health and health inequalities, instead focusing on lifestyle health determinants. In support of this conclusion, Lin and Fawkes (32) found that social determinants are often recognised but are rarely translated into concrete strategies, funding, and policy action.

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The level of moral distress that was evident among the sample of Canadian and Australian ‘upstream’ practitioners is perhaps not surprising given the increasingly narrow focus on specific diseases and risk factors following the neoliberal reforms in the 1990s (32). As Foley (33) suggests, health promoters know (or at least are told) that rather than being ‘neoliberal subjects’ behaving as rational economic actors, humans are social beings embedded in fields of power characterised by highly stratified social relations. The Canadian and Australian upstream participants clearly frame this [mis]direction of health promotion effort and funding as a ‘moral issue’ that inhibits the wellbeing of disadvantaged members of the community. The intensity of distress described by upstream participants is also perhaps not surprising given the inherent complexity and high ambitions of the health promotion profession and associated theory. Systems change, such as that advocated by health promotion, is not easy to achieve because the social systems that health promoters seek to transform are highly complex socio-historical and political–economic phenomena that have emerged from centuries of social and political activity. In seeking to transform policy, institutional and systemic social structures, upstream health promoters are effectively seeking to transform intensely powerful and deeply embedded, socio-historically constituted ways of seeing, being, and acting. Although we in no way question the worthiness of seeking this transformation, we do emphasise the inherent complexity and precariousness of a profession that by nature and definition seeks to effect such fundamental social and moral change. It is precisely for these reasons that we see health promotion as a profession that is acutely vulnerable to experiences of moral distress.

Limitations and where to from here The primary limitations of this research relate to the limited selection of health promotion workers and academics interviewed in each country and the exploratory nature of the research. Although the results were developed through a multi-phase interpretive thematic analysis of two discrete qualitative studies using multiple raters, neither of the two studies were initially designed to research moral distress in health promotion. The two data collection methods were different and, although we

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overcame this by using the interpretive thematic analysis, the nature of experiences reported in each study may have differed from those that might have emerged in response to targeted research questions. In the case of the Australian group interviews, we acknowledge the potential influence of group dynamics. In the Canadian data, theoretical values may have dominated, given that all participants were employed in Canadian universities. Finally, it was an unexpected outcome that moral distress emerged as a significant theme in the inductive analysis across both projects. This finding communicates the degree to which distress was strongly and spontaneously reported in the data from both countries. However, it also has implications for the degree to which our conclusions can reflect deliberate, considered responses by participants regarding their own experiences of moral distress. Beyond this exploratory qualitative study, we need to determine the actual extent of moral distress in the workforce and its effects on job satisfaction and productivity, learning, development, burnout, and career progression (1,6,31). Future research would benefit from mixed methods research that seeks to further articulate the qualitative experience of moral distress, to quantify its presence in the current workforce and determine the extent to which productivity is affected. Future applied and participatory research could evaluate potential solutions and responses to moral distress in health promotion. Existing literature and our findings suggests some strategies that may be useful in counteracting the ill effects of moral distress. De Jesus (34), for example, suggested resourcing and organising health promotion functions across the health promotion continuum (i.e. from downstream micro functions to upstream macro functions) and providing opportunities to create supportive environments for the health promotion workforce (8,20). Ewing and Carter (35) also explored ways to address major stressors such as disenfranchised grief for neonatal intensive care nurses and found education programs that promoted peer bonding and sharing of experiences to be beneficial. Similarly, Erlan (20) found that a support group of one’s peers provided a forum for discussing issues of moral distress, promoted sharing of common experiences and bolstered members of the group. Other strategies have IUHPE – Global Health Promotion Vol. 22, No. 1 2015

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included networking, collaborating, negotiating and adjusting, compromising, being flexible, having honest discussions with administrators, education, creative action, having an open mind, and promoting understanding of health promotion as a mission and not as a job (34). Ironically, however, strategies designed to address moral distress are subject to the same flaws as those that created the problem in the first instance. Specifically, it is easiest to focus only on identifying moral distress in individual practitioners and provide ‘downstream’ solutions. However, by doing so, we are not addressing the root causes of distress, namely the mismatch between the values of the profession and the reality of practice in constrained settings. The response to moral distress requires a continuum of activity ranging from individual-level education and support for those who experience moral distress to systemic institutional and policylevel change to prevent or minimise the impact of moral distress in the longer term. We recognise that this challenge must be taken up collaboratively by researchers, policymakers, and practitioners alike.

is to effect complex social, political, and moral transformation. We also acknowledge that feelings of moral distress are not always negative and may, in fact, be productive for some practitioners. The present challenge is, however, to unveil moral distress as a significant phenomenon and experience in health promotion and take bold steps toward alleviating the condition within this vital and morally significant profession.i Acknowledgements The authors would like to acknowledge Garth Henniker and Peter McKeown for their contributions to the first wave collaborative analysis of Canadian interview data for this project. We acknowledge and thank all participants for their valuable input into the project. We also thank Courtney Wright for valuable editorial support.

Funding Collection of data included in this research was partially funded by the Australian Research Council and Griffith University.

Note

Conclusion

i. See http://www.actnowbc.ca/

This article has reported the outcomes of an exploratory analysis of the experiences of Australian and Canadian health promotion practitioners. An unexpected finding related to experiences of moral distress in health promotion practitioners, particularly those who focused on ‘upstream’ health promotion. However, all participants experienced significant marginality in relation to their health promotion work, which may be a precursor to moral distress. We have argued that the lofty aims and values of health promotion, namely to affect systems-level change and promote health equity, provide fertile ground for moral distress. This situation is exacerbated by the intense diversity, complexity, and stratification of the profession. Further research is required to more accurately measure and describe the extent, causes, and impact of moral distress in the health promotion workforce. This research needs to be paralleled with holistic evidence-based strategies and investments to alleviate and prevent moral distress in health promotion. We acknowledge that moral distress may be an intractable problem for a profession whose purpose

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Exploring health promotion practitioners' experiences of moral distress in Canada and Australia.

This article introduces moral distress - the experience of painful feelings due to institutional constraints on personal moral action - as a significa...
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