Building workforce capacity for ethical reflection in health promotion: a practitioner’s experience

Key words: codes of ethics, community health planning, ethical analysis, South Australia.

Embedding ethical reflection into routine health promotion practice continues to be a challenge internationally. In particular, there has yet to emerge a formal code of ethics that might consistently prompt and shape ethical reflection for health promotion practitioners. In 2007, Mittelmark invited progress towards precisely such ‘a serviceable ethic for daily work’, hoping also that a clearer professional identity for health promotion practitioners may emerge as a result.^1(p78) He observed the following:

Though we have the cornerstone of an ethic for health promotion, in the Ottawa Charter and in other principled documents that have followed, we have yet to build sufficiently on the cornerstone; an ethic for practice has yet to be codified.¹

Although this problem remains, it has not gone unnoticed and local attempts have at least been made to assist practitioners in their understanding and application of the sort of professional standards (or ‘competencies’) that have since been explicitly formulated in Australia.²

This article describes and analyses one such attempt at assisting practitioners in their ethical reflection, sustained from 2006 to 2014 in rural South Australia. In effect, the article describes an attempt at embedding ethical reflection into health promotion practice through capacity-building activities, which were informed by some principles of organisational change management.^3–7 Loosely speaking, those principles were: (1) involve all layers of the organisation; (2) create a sense of ownership over the change; (3) communicate the simple message; (4) implement system changes as a means of building a better culture; and, in particular (4) create ‘champions’, people who will promote change both actively and by example.^8–10 The attempt at capacity building is described to stimulate discussion towards fostering more routine and comprehensive ethical reflection in health promotion practice. The article presents a framework (largely comprising ethical questions) that may be useful to practitioners, especially in thinking through ethical considerations as part of formal applications for the ethical review of health promotion activities. The framework was developed to be as accessible as possible in light of the diverse educational backgrounds found in rural settings.

Anecdotal evidence suggests that ethical awareness and reflection is still limited in health promotion practice, at least in some parts of Australia: practitioners tend to veer away from the vagueness of ethics and, in this respect, are still in need of help. This article provides an example of how that help may be provided.

In 2006, South Australia’s health department undertook an internal audit of the health promotion capacity of its workforce in a particular rural region, using checklists developed for similar purposes in Canada.⁹ The audit made clear that limited capacity existed in two key areas.

First, the program planning and the evidence bases being used were poor. Allied health practitioners, administration staff and nurses usually worked as the project officers responsible for planning health promotion activities. These professionals tended to be proactive and practical (by nature, training or both), so they would sometimes replicate health promotion work they had seen presented at conferences without thorough examination of how that work may need tailoring to the local context.

Second, there was little consideration of the harm that health promotion activities could inadvertently cause and, even if the question of harm was considered, there was insufficient reflection on the sort of things that may constitute harm. For example, there was a lack of thinking about the sustainability of activities, especially about the community expectations that may be encouraged but then frustrated when program funding was discontinued. Furthermore, skills were lacking in identifying conflicts of interest, as demonstrated on one occasion when some health promotion practitioners partnered with a bank. The bank had requested access to the raw health data that would be collected as part of the health promotion activity. The bank would then have been in a position to share the health data of bank clients with internal insurance teams, violating clients’ privacy and potentially compromising their insurance coverage. The health promotion practitioners trusted the local bank staff, being acquainted with them personally, and they were overwhelmingly happy to have secured the bank’s support, especially in the form of funds. Nobody asked ‘Why would the bank want the raw health data?’ This example provides a reminder of one of the reasons why ethical reflection is important in health promotion: health promotion can cause harm.

The problem of limited workforce capacity, as revealed by the government’s internal audit, may have existed partly because of four complexities specific to the rural workforce.¹¹

First, the rural workforce is known for recruitment and retention problems.^12,13 There tend to be skills shortages, and the few people who have both the needed skills and the willingness to work in rural areas are in such demand that they can readily move on to new jobs.¹⁴ Second, if new staff come from metropolitan areas, they can fail to appreciate how, and how much, rural communities can differ from one another.¹¹ Third, geographical isolation means that many health promotion practitioners cannot engage in the face-to-face conversations that facilitate the in-depth exploration of issues such as ethical issues.¹¹

Finally, the rural workforce features a diversity of education levels.¹⁵ For example, in the audited region of South Australia, some administrative staff had secondary school qualifications, whereas others had been specifically trained at a technical college. Some health professionals had been trained purely within the hospital setting (e.g. nurses trained some years ago), whereas others had attended university to complete Bachelor degrees and, in a minority of cases, Masters degrees.¹⁶ The frequent lack of university study may have reduced these health promotion practitioners’ exposure to ‘ethics’, considered as explicit and systematic ethical reflection informed by critically scrutinised concepts.¹⁷ In turn, this reduced exposure seemed to have resulted in practitioners not only lacking professional capacity, but also being intimidated about building such capacity. At the mere mention of ethics, some health promotion practitioners virtually threw their hands up in the air. This phenomenon, personally observed by the first author of this article, helped to clarify for her one of the key challenges in health promotion: in the academic literature, different frameworks offer multiple options for undertaking ethical reflection in the interests of improving practice,^17–26 but there is limited guidance for dealing with the diversity of understanding and education levels on the ground, especially in rural areas. Therefore, one of the main aims of this article is to present a framework developed to assist health promotion practitioners to engage in explicit and systematic ethical reflection with precisely this diversity in mind. This framework is introduced below.

From 2006 onward, medical, nursing and some allied health streams were moving to national registration and standards, including ethical practice standards.²⁷ However, such standards tended to be light on detail, and principles of organisational change management suggest that such standards tend to require appropriate supports to result in changes in practice. Competencies were formally introduced to the health promotion profession,² offering something of a framework for ethical practice but no real guidance as to how the competencies may be acquired, especially by rural practitioners, who suffered limited access to short-course education because of the cost and inconvenience of attending far away training. Moreover, the competencies were unaccompanied by any mechanism of enforcement or reward, such as formal accreditation. Therefore, practitioners needed other reasons to take them seriously.

From 2008 to 2011, an organised attempt was made by the South Australian health department to build the capacity of health promotion practitioners within one rural region to undertake ethical reflection as part of their routine practice. The attempt drew on principles of organisational change management,^3–7 especially in emphasising the role of ‘champions’ in effecting wider change.^8–10 Practitioners were encouraged to engage positively with the attempt, and to take seriously the new competencies with which it was intentionally aligned, through the offer of both Continuing Professional Development (CPD) points and formal qualifications through Australia’s Technical and Further Education (TAFE) system.

The attempt focused primarily on investing in people, namely the health promotion practitioners themselves. However, processes were also invested in because of the retention problems faced by the rural workforce. The attempt took the form of four interlinked components:

• Component 1: a framework for ethical reflection tailored to health promotion practice (the Health Promotion Ethics Framework)

• Component 2: an introductory session on ethics as it relates to health promotion

• Component 3: a short course spanning 6 months in which participants learned about program planning and evaluation, together with the role of ethical reflection

• Component 4: the addition of two prompts to a routinely used web-based program planning tool,²⁸ namely ‘Describe the steps that have been taken to ensure that this project is equitable and ethical’ and ‘Does this project require ethics approval?’

The framework for ethical reflection (Component 1) was imparted during both the introductory session (Component 2) and the short course (Component 3). It was also presented as a resource for answering the ethical questions added to the web-based planning tool (Component 4). During the short course (Component 3), participants were trained in the use of the web-based planning tool (Component 4) and given the opportunity to gain experience in conducting ethical reflection as part of using it.

Means for sharing past and future applications to Human Research Ethics Committees (HRECs) were also introduced. This aimed to address the problem of rural practitioners not always appreciating how rural communities could differ and thereby require different approaches. It also aimed to overcome the geographical isolation that impeded the collaborative exploration of ethical issues.

All components, especially Component 1, were made as accessible as possible in light of the educational diversity of the rural workforce. The aim of Component 1 was to provide practitioners with a resource that would help ensure a systematic and consistent approach to considering ethical issues as part of routine practice. The Health Promotion Ethics Framework that resulted comprised 10 headings, together with explanations of their meaning and relevance, along with questions under each heading that practitioners were encouraged to ask in relation to any proposed health promotion activity (see Appendix 1). This format was adopted to provide practitioners with greater clarity and precision regarding the kinds of ethical issues that could arise in the practice of health promotion. It was also adopted to make ethical reflection more approachable and less intimidating for practitioners, because anecdotal evidence had suggested that practitioners were tending to fear the word ‘ethics’, mistakenly thinking that if ethical issues were uncovered, then this was a bad thing and a horrific process awaited in needing to acquire formal approval from a review committee (e.g. an HREC).

The Health Promotion Ethics Framework was developed primarily by adapting the framework that, internationally, the youth sector had developed for prompting and guiding ethical reflection on professional practice.²⁹ Other points of reference used during the development of the Health Promotion Ethics Framework included: national healthcare standards;³⁰ Australia’s National Statement on Ethical Conduct in Human Research;³¹ the Aboriginal Health Impact Statement, the use of which is mandated by the South Australian health department;³² broader research policies of the South Australian health department;^33,34 and Patton’s ‘ethical issues checklist’ for conducting qualitative research.^35(p408) The Health Promotion Ethics Framework was also developed with an understanding of three dominant theories within the field of public health ethics as those theories are elaborated and situated by Holland: utilitarianism, liberalism and communitarianism.¹⁸ Participants in the introductory session and the short course (Components 2 and 3) were introduced to these theories in terms of their potential relevance for analysing the ethical acceptability of health promotion activities. The theories were discussed in terms of the importance of securing positive outcomes for people’s welfare, respecting individuals’ rights, and upholding a community’s identity and ethos, especially in relation to Indigenous communities. Participants were invited to consider how these considerations often had to be balanced against one another.

Evidence of the feasibility and effectiveness of the capacity-building attempt that comprised Components 1–4 is limited and mostly anecdotal. Early attendees (n = 56) at the introductory session on ethics (Component 2) provided written feedback: 90% confirmed that the session would change their practice, with 5% confirming that it would not and 5% being unsure. Informal feedback was also positive, as were peer review evaluations of the short course (Component 3). Local employers were persuaded to list in relevant job descriptions attendance at the short course as a ‘highly desirable’ selection criterion, and 49 short-course participants went on to earn a Certificate III or IV,³⁶ or a Diploma, in Population Health. Equipped with the Health Promotion Ethics Framework (Component 1), staff stated that they now felt ready to query ethical issues with a view to improving practice and that ‘ethics’ is not merely about HREC approval. Moreover, the number of HREC applications and approvals rose in the region: the number rose from zero applications in 2007 to two to four approved applications per year now. Finally, some of the region’s health promotion work is now award winning, and Components 1–4 may have played some role in this.

Carter et al. interviewed health promotion practitioners to identify their guiding values.³⁷ Interviewees held that:

…health promotion strategies should be developed over time in respectful relationships, that practitioners should be flexible and responsive to communities, that interventions should build capabilities in communities, and that health promotion work should be sustainable.

Considered together as an attempt at capacity building, Components 1–4 reflected these values, precisely while acting to foster them in health promotion practitioners.

Component 1 (the Health Promotion Ethics Framework that was developed) mainly takes the form of what Carter termed ‘questions to sensitise the user to ethical concerns’.^38(p20) It is consistent with the Ottawa Charter in at least three important respects. First, it evinces a clear emphasis on community consultation and partnership, implicitly envisaging ‘citizens as active contributors to their own health and the health of the public’.^38(p24) Second, it evinces a ‘socioecological approach to health’,³⁹ whereby health is ‘the product of social, environmental and economic living conditions’.^38(p20) Finally, it evinces a concern for well being and not simply health in a narrower sense.

Within the Health Promotion Ethics Framework, under the heading of ‘Duty of Care’, one can clearly discern an emphasis on two of the principles of biomedical ethics: beneficence and non-maleficence:⁴⁰ ‘Workers will act in the best interests of people, avoid exposing them to physical, psychological or emotional harm or injury, and always uphold the principle of ‘do no harm’.’ The principle of non-maleficence (‘do no harm’) is given particular emphasis, and this emphasis is consistent with the emphasis that a liberal society such as Australia places on some fundamental rights of the individual. Meanwhile, repeated use of the word ‘community’ throughout the Framework also indicates a communitarian perspective. This perspective, commonly associated with health promotion, challenges the adequacy of liberalism in its foregrounding individuals, rather than communities, as the primary locus of moral concern. In the Health Promotion Ethics Framework, this communitarian perspective does seem supplementary to the liberal perspective, with individual rights, especially negative rights regarding the avoidance of harm, being implicitly deemed to be more important than the identity and strength of a community. Again, this emphasis mirrors Australia’s liberalism and, more widely, the prominence of human rights in global political discourse.

The Health Promotion Ethics Framework does not reflect a single ethical theory, but rather an occasion for ethical reasoning based on principles. As Carter has observed, ‘[r]easoning from principles is a common approach in bioethics, because it provides heuristics to support practical problem solving under time pressure’.^38(p20) Compared with theories, principles also tend to be simpler and thus more readily understandable, which helps to keep the Health Promotion Ethics Framework accessible and thereby useful to the diversity of health promotion practitioners for which it was designed. The Framework is also fairly pragmatic and inclusive of a wide range of potential ethical issues, and in this respect it resembles Hoffman’s checklist for canvassing potential ethical issues as part of assessing a health technology.⁴¹

A practical tool for ethical reflection needs to be accessible to the profession for which it is designed. Therefore, efforts need to be made to cater for different education levels and casts of mind as they exist within that profession. The Health Promotion Ethics Framework reflects one such effort. Keeping things accessible does not automatically mean dumbing things down, although it does mean trying very hard to make things clear and direct. Conversely, one risk of pursing clarity and directness above all is to promote simplistic approaches to ethical reflection. Gaita argues that there are ‘pressures to simplification’ within our culture, including even the charitable impulse ‘in a morally diverse and multi-cultural community to seek a common moral and political language – a kind of moral Esperanto’.^{42(pp252–3)} The importance placed on government transparency and accountability may function as another pressure to simplification. Pressures to simplify things ‘make consequentialism – the doctrine that teaches that only the consequences of our actions matter morally, an almost irresistibly attractive political philosophy’.^42(p253) This is problematic to the degree that consequentialism can commend actions that we intuit to be immoral, and to the degree that consequentialism can ‘make most of our appreciative moral vocabulary redundant’.^43(p81) In other words, consequentialism can diminish our ways of speaking about important matters, and therein it can diminish us. Therefore, in putting together a set of questions to promote and guide serious ethical reflection within a profession, one needs to achieve accessibility but avoid over-simplification. Making the questions clear and direct, but also quite numerous, may be one means of achieving this. The Health Promotion Ethics Framework seems to take this approach.

It is strange that the word ‘ethics’ should come to provoke exasperation of the kind marked by throwing one’s hands in the air. The word ‘ethics’ may excite this response for three reasons.

First, the word may strike people as utterly ambiguous, because it is too often used without context, just being dumped on the front door, as it were. The headings in the Health Promotion Ethics Framework go some way to providing a context in which the word ‘ethics’ can make more sense to people in their professional role.

Second, the word ‘ethics’, at least in some contexts, may have become a weasel word, a word that is used in ways that have become painfully routine and almost meaningless. Watson characterised such words (or, more precisely, tired uses of words) in terms of ‘clichéd, impenetrable, lifeless sludge’.⁴⁴ Again, it is strange that the word ‘ethics’ should have come to this, but perhaps it has in some circles because it was being used without sufficient context and because of the final reason why it may provoke exasperation.

The word ‘ethics’ can intimidate people because it is too often presented as delineating a field of scholarship that is impenetrably complex and, partly for that reason, the proper concern of others (in short, experts who aren’t you). But ethics are lived as well as studied, and there is a diversity of opinion as to precisely what the people paid to study ethics bring. The perception that ‘ethics’ is the proper concern of experts is not helped by sentiments such as the following: ‘lists of principles alone cannot be detailed enough to support thorough ethical reasoning about a situation: to fully understand the principles requires familiarity with the complex concepts that underpin them’.^38(p20) Moral philosophers debate whether such statements are true, namely whether theory is really needed to reason well when it comes to ethical matters. How thorough-going must one’s thinking be to quality as a justifying account of some action? In seeking to justify one’s action, can one appeal to a simple principle or must one delve deeper to some theory that underpins and ultimately unifies principles? Gaita⁴³ and other moral philosophers⁴⁵ who apply insights made by Wittgenstein⁴⁹ argue that general ethical theory is often redundant, if not downright misleading in its reductionism.

The professionalisation of ethical reflection is a double-edged sword. Its merits continue to be debated among bioethicists, for instance.^46,47 On the one hand, it can foster meaningful ethical reflection; on the other hand, it threatens to shoulder out of serious and important discussions every non-professional, namely most of us. Moreover, it threatens to lighten the burden of ethical reflection that historically comes with being a practitioner in so many fields of endeavour. Why worry too much about what is right to do when other people are paid to worry for you? Why go into all that confusing business when other people are paid to become experts for you? These sentiments are important to discourage, therefore people who are paid to undertake ethical reflection do well to bring others along with them by doing two things: by creating accessible prompts and guides to reflection, such as the Health Promotion Ethics Framework presented in this article, and by not insisting on an expertise that makes genuine dialogue impossible.⁴⁸

Anecdotal evidence suggests that, in rural South Australia, ethical reflection is now more embedded in routine health promotion practice, with workforce capacity having been built. Moreover, transferable materials, such as the Health Promotion Ethics Framework, now exist to help practitioners elsewhere. This article has described and analysed one attempt at capacity building in order to foster broader discussion within the field of health promotion on how to increase the frequency and quality of ethical reflection undertaken by practitioners. The article has provided a framework that could serve as a useful tool for practitioners, especially those with diverse educational backgrounds, as found in rural settings. It has also highlighted some philosophical dimensions to the framework and provided some observations in defence of its role in prompting and guiding practitioners to undertake ethical reflection: ethical reflection is integral to good practice, and never simply the province of theorists.