KEY CONCEPTS in VALUES-BASED PRACTICE: the point, premise andprocess.
Values-based practice is a partner to evidence-based practice in supportingclinical judgement as we square down in individual cases
- Clinical judgment is exercised whenever a skilled clinician makes diagnostic and treatment decisions appropriate to aparticular patient in a particular situation
- Squaring downis the process by which in exercising clinical judgment a skilled clinician focuses progressively on the more relevant information and discards the less relevant information arising from history, examination and investigations
Evidence-based practice is vital to bringing the clinician’s focus onto the most likely diagnostic and treatment possibilities; values-based practice is vital to matching those possibilities with the particular circumstances presented by this particular patient in this particular situation
The point of values-based practice
To support balanced decision making within frameworks of shared values
Balanced decision making means decision making that is based on a balance between the complex and conflicting values of those concerned in a given clinical situation
- Complex values are values that mean different things to different people: ‘acting with respect’, for example, means different things to people from different cultures, or of different ages, at different historical periods.
- Conflicting values are values that are in conflict one with another either within a given individual or between different individuals: clinicians for example often find there is a conflict between their person-centred values of patient choice and their professional commitment to acting in their patients’ best interests
Frameworks of shared values
Frameworks of complex and conflicting values can beshared by those concerned in any given clinical situation. These frameworkshave to be understood and then balanced according to the particular circumstances presented by that situation.
Thus a clinician, patient and carer deciding what to do in a given situation may all share the values of respect, choice and best interests: but what ‘best interests’ means may be understood very differently from the perspectives of the clinician and carer; and what the patient actually wantsmay be quite different from what either the clinician or carer believes is in his or her best interests.
The premise of values-based practice
The ‘democratic’ premise of mutual respect for differences of values.
Mutual respect for differences of valuesshifts the emphasis in decision-making from pre-set ‘right outcomes’ to good process
- Excluded values are values (like racism) that are incompatible with the premise of mutual respect and hence (however widely shared) are by definition excluded from values-based decision making
- Good process in values-based practice is decision making that is guided by one or more of ten key process elements of values-based practice
The processof values-based practice
Ten key elements covering:
- four clinical skills,
- two aspects ofprofessional relationships,
- threecloselinks with evidence-based practice,
- andpartnership in decision making.
V-BP Clinical Skills
The four keyclinical skillsfor values-based practice are awareness, reasoning, knowledge and communication skills
- Awarenessof values includes awareness of the diversity of values, awareness of one’s own values as well as the values of others, and awareness of positive values (StAR values, ie strengths, aspirations and resources)as well as negative values(such as needs and difficulties)
- Reasoningabout values includes any of the established methods of ethical reasoning (such as principles reasoning, case-based reasoning(casuistry), or utilitarianism) whenused to improve understanding of the values bearing on a given situation (to ‘widen our values horizons’)rather than (directly) to decide what is right
- Knowledgeof values covers tacit (or craft) knowledge as well as knowledge derived from research;and it includes the skills for knowledge retrieval from electronic databases.
- Communication skillsinclude skills for eliciting values(including strengths, as inICE-StAR) and skills ofconflict resolution
V-BP Professional relationships
Professional relationships in values-based practice involve person-values-centred practice and extended multidisciplinary team work
- Person-values-centredpractice means practicing in a way that focuses on the values of the patient while at the same time being aware of and reflecting the values of other people involved (clinicians, managers, family, carers, etc): this is important intackling two particular problems of person-centred care, problems of mutual understanding and problems of conflicting values
- Extended multidisciplinary team workmeans practicing in a way that draws not only on the diversity of skills represented by different team members but also on the diversity of team values: this is important both in identifying the values in play in a given situation and in coming to balanced decisions about what to do
Linking withevidence-based practice
The links withevidence-based practice are defined by three principles, the two feet principle, the squeaky wheel principle and the science-driven principle
- The two feet principleisthat all decisions whether overtly value-laden or not, are based on the two feet of values and evidence: clinically, this translates into the reminder to ‘think facts, think values!’
- The squeaky wheel principleisthat we tend to notice values only when (like the squeaky wheel) they cause trouble: clinically, this translates into the reminder to ‘think values, think facts!’
- The science-driven principleis that advances in medical science and technology in opening up new choices (hence diversity of values) drive the need equally for values-based practice as for evidence-based practice: clinically, this translates into the reminder that as practice changes it is vital to ‘think both facts and values!’
Partnership in decision making
Partnership in decision makingin values-based practice depends on both consensusand dissensus
- Consensus involves differences of values being resolved (as in the development of shared frameworks of values)
- Dissensusinvolves differences of values remaining in play to be balanced sometimes one way and sometimes in other ways according to the particular circumstances presented by different situations