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   Article Healthcare professionals’perspectives on environmentalsustainability  Jillian L Dunphy Charles Sturt University, Australia AbstractBackground:  Human health is dependent upon environmental sustainability. Many have argued thatenvironmental sustainability advocacy and environmentally responsible healthcare practice are imperativehealthcare actions. Research questions:  What are the key obstacles to healthcare professionals supporting environmentalsustainability? How may these obstacles be overcome? Research design:  Data-driven thematic qualitative analysis of semi-structured interviews identified com-mon and pertinent themes, and differences between specific healthcare disciplines. Participants:  A total of 64 healthcare professionals and academics from all states and territories of Australia, and multiple healthcare disciplines were recruited. Ethical considerations:  Institutional ethics approval was obtained for data collection. Participants gaveinformed consent. All data were de-identified to protect participant anonymity. Findings:  Qualitative analysis indicated that Australian healthcare professionals often take more action intheir personal than professional lives to protect the environment, particularly those with strongprofessional identities. The healthcare sector’s focus on economic rationalism was a substantial barrierto environmentally responsible behaviour. Professionals also feared conflict and professional ostracism,and often did not feel qualified to take action. This led to healthcare professionals making inconsistentmoral judgements, and feeling silenced and powerless. Constraints on non-clinical employees within andbeyond the sector exacerbated these difficulties. Discussion:  The findings are consistent with the literature reporting that organisational constraints, andstrong social identification, can inhibit actions that align with personal values. This disparity can causemoral distress and residue, leading to feelings of powerlessness, resulting in less ethical behaviour. Conclusion:  The data highlight a disparity between personal and professional actions to addressenvironmental sustainability. Given the constraints Australian healthcare professionals encounter, theyare unlikely to shift to environmentally responsible practice without support from institutions andprofessional associations. Professional development is required to support this endeavour. The poortransference of pro-ecological behaviour from one setting to another is likely to have internationalimplications for healthcare practice. Keywords Environmental sustainability, healthcare ethics, professional paradigms, social identification Corresponding author:  Jillian L Dunphy, School of Community Health, Charles Sturt University, PO Box 789, Albury, NSW 2640,Australia.Email: jidunphy@csu.edu.au Nursing Ethics2014, Vol. 21(4) 414–425 ª The Author(s) 2013Reprints and permission:sagepub.co.uk/journalsPermissions.nav10.1177/0969733013502802nej.sagepub.com  Introduction There is an intrinsic and interdependent relationship between the social and natural environments. 1–3 Thehealth of humans is dependent upon ecological and social sustainability, yet healthcare has significant neg-ative impacts on the environment. 4–6 In addition to being resource intensive and consuming large amountsof clean water, materials and energy, healthcare uses, produces and inadvertently disseminates toxic and carcinogenic materials which contaminate waterways and food chains. 4,5 It also relies heavily upon non- biodegradable and carcinogenic plastics, and leads to the contamination of waterways with pharmaceuticalresiduesthatmayaffectaquaticspeciesandcontaminate humandrinkingwater. 4–6 Actionhasbeentakentoaddress these issues, such as a decrease in the use of mercury, but they remain substantial. 5 In Australia, there is considerable public concern regarding environmental sustainability, and Australianhealthcare professionals are reported to be gravely concerned. 3,7,8 Many have argued that it is a moralimperative that healthcare professionals address environmental sustainability and ensure that they practisein an environmentally responsible way. 3,9–11 However, the qualitative data used in this article and in two previous papers suggest that most Australian healthcare professionals do not see addressing environmentalsustainability as a core responsibility of their disciplines. 12,13 Through qualitative analysis, the author iden-tifies factors resulting in a disconnection between personal and professional ethics and responsibilities,which inhibits change of healthcare practice to support environmental sustainability. Within this context,differences between healthcare disciplines are discussed, along with a consideration of how this disparity between personal and professional actions may be addressed. Methods Thisstudyispartofalargermixedmethodsprojectthatinvolvedanextensiveliteraturereview,writtenques-tionnaires of 158 tertiary healthcare educators and subsequently, semi-structured interviews of healthcare professionalsandacademics.Theliteraturereviewandquestionnaireslargelyfocussedoneducationforsus-tainability, while the interviews had a broader focus, including the identification of barriers to environmen-tally responsible healthcare practice. 12,13 The interview data were used in this study, as described below. Data collection Giventhetransdisciplinarychallengesofenvironmentallyresponsiblehealthcarepractice,purposivechain-referralsamplingwasusedtoensurethatawidebreadthofhealthcareprofessionalsandacademics,fromallstates and territories of Australia, the private and public sectors and differing professional levels, were rep-resented. 12–14 Excluding multidisciplinary professionals, the healthcare professionals were from nursingand midwifery (24 % ); public health (12 % ); medicine, environmental health and dietetics (10 %  each); com-munity and rural health (7 % ); physiotherapy, podiatry, occupational therapy and optometry (5 %  each) and speech pathology, sociology and psychology (2 %  each). 12,13 The inclusion of academics in this study isimportant, as previous literature indicates that professional education can contribute to the lack of actionto support environmental sustainability, and that it can be altered to promote environmentally responsible behaviour. 1 Institutional ethics approval was obtained for data collection. Before interviews were conducted,informed consent was obtained from the 64 participants. Participant anonymity was maintained by deletingworkplace-specific information from quotes, and only referring to the general area of practice.Interviews included questions about key obstacles to improving sustainability awareness and prepared-ness in the healthcare sector, and individual attributes that would allow healthcare professionals to moreeffectively address environmental sustainability issues in their professional contexts. 12,13 This led to Dunphy   415 415  discussions of personal and professional perspectives of environmentally responsible behaviour, and thedifferent actions taken in these contexts. Interviews were recorded and transcribed verbatim. Data analysis Data-driven thematic qualitative analysis, within and beyond the interview period, identified common and  pertinent themes regarding personal and professional perspectives of environmentally responsible beha-viour, and differences between specific healthcare disciplines in this respect. Iterative analysis within thedata collection period altered interviews to allow in-depth discussion of pertinent issues. Further insightswere developed as analysis continued after data collection was complete. This involved revisiting tran-scripts that had already been analysed as new concepts emerged. These data are considered in the contextof dominant professional paradigms and are compared to previous ethics literature on moral distress. 15–25 Findings While analysing transcripts of interviews with Australian healthcare professionals and academics, it becameclearthatmanyintervieweestookmoreactionintheirpersonalthanprofessionallivestosupportenvironmen-tal sustainability. There was often a clear distinction made between the two contexts. For example, a phy-siotherapist explained how environmental sustainability was addressed domestically but not professionally: Professional lives  . . .  no, I mean, you know, I had a bush block and didn’t use weed killer and, you know, it wasall native, and if it died it got ripped out. And, you know, really that sort of critical save the frogs  . . .  But the practice was a practice. (Physiotherapy academic) Differences between personal and professional values and priorities were apparent throughout the anal-ysis,andintervieweesoftenseparatedtheiropinionsonenvironmentalsustainabilityinto‘personal’or‘pro-fessional’ opinions. Economic rationalisation was reported todrive professional decisions and actions morethan those in personal lives. Values that were more likely to help address environmental sustainability wereoften discussed as ‘personal’ values, such as a respect for the environment, other people and other species.For example, the following participant argues that being part of a community, rather than economics, is akey driver for environmental sustainability: This is purely personal. It’s not about the holy dollar. It is about being part of a bigger picture, part of a commu-nity and part of everything. Yes, we all need money to survive and so on but that shouldn’t be the first and fore-most thing  . . .  (Environmental health) This indicates that most participants were making inconsistent ethical judgements about environmen-tally responsible behaviour due to situational constraints in the workplace. Common barriers to environ-mentally responsible healthcare practice included professional identities, workplace cultures and dominant professional paradigms, such as a focus on the curative biomedical model of health and objectiv-ity. Some participants discussed the devaluing of subjectivity and/or a hierarchy of healthcare disciplinesand research methodology, where female-dominated disciplines and experiential methodology with a less‘scientific’ focus were held in low esteem. One participant argued that the healthcare sector values what itcan easily measure, highlighting howa focus on objectivity can increase the disparity between personal and  professional values: I heard a quote once that said that we don’t measure what we value, we value what we can measure. So the wholehealth system is based on – it’s data that we can measure, that we can capture and then that substitutes for qualityreporting. So we measure the number of people seen rather than the genuine impact that that health intervention 416  Nursing Ethics 21(4) 416  has had on the lives of those people. It’s easier to measure, we can count people but we can’t easily count healthimpact. (Allied health project manager and dietician) Although the professional bias towards objectivity contributes to a disparity between personal and pro-fessionalactionstosupportenvironmentalsustainability,intervieweesalsodiscussedtheneedorbenefitsof objectivity in various professional contexts, including when addressing sustainability issues: It was taking away the narrow focus and just trying to put other perspectives and really getting them [nursingstudents] to see a more global view and things from other angles which in itself is a real skill within nursing and that’showIframeditaswell.Youcan’talwaysjustlookatthingsfromoneperspective.Wehavetobeobjective,we have to gather the resources, we have to look at things from other viewpoints to make sure we’ve got all theinformation. That’s part of our ability to assess. (Nurse and academic) Fears of conflict, being offensive or being seen as opinionated, political, extreme or a fringe-elementwerealsodescribedasbarriersthatresultedintheseparationbetweenpersonalandprofessionaljudgementsand actions. Due to these fears, some participants or their colleagues were hesitant to take political or pro-fessional action even though they agreed with the underlying premise for action. In some cases, this alsoinhibited action outside of the professional sphere. For example, when discussing environmental and socialactivism by healthcare professionals, a psychologist explained, . . .  sometimes peoplegetcaughtupinthe–I’mapsychologistIcan’tdothat,Idon’twanttoupsetanyone.ButIthink if you believe in something I think you have to model that too – I mean what do you say to your clients allthe time? Stand up for yourself, encourage them to be assertive, you know all these things. . . .  Then there’s a colleague of mine and he says what you do with your life in general shouldn’t just be all about being a psychologist. (Psychologist) Resource constraints and codes of conduct were also reported to constrain employees: . . .  I think often we might be able todo more in terms of advocating and campaigning formore sustainable waysofdoingthingsifweweren’tboundby–likeI’vealwaysworkedinthepublicsectorandpublicsectorhaskindof strictcodesofconductonwhenyoucanengagethemediaandwhatyoucanuseyourworkresourcestodo  . . .  Sothere are limits on how much public advocacy and campaigning and stuff you can do in your work role I think.(Occupational therapist) Participants described how employees were constrained and silenced by these strong professional iden-tities, workplace cultures and limited resources such that they often felt powerless, with regard to their abil-ity to support environmental sustainability in the workplace. This sense of powerlessness was exacerbated  by the global scale of environmental sustainability issues and the need for systemic change: I suspect from the reactions that I’ve seen are that people have a sense of powerlessness, that, yes, you can dothings personally but the ability to influence at a broader global level isn’t there. And so people then move onor don’t think – can’t deal with that type of thing. And it’s the local versus global problem that is hard to bridge . . .  (Public health) The silencing of healthcare professionals was exacerbated by constrained workers in other disciplinesand sectors that impact healthcare, such as managerial and administrative staff, and employees from sup- porting industries: Dunphy   417 417
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