This glossary covers key terms used in relation to values-based practice including its point (to support balanced decision making within frameworks of shared values), premise (of mutual respect for differences of values), and ten-part process.
The glossary starts with brief notes on values and values-based practice, the relationship between values-based practice and others tools in medicine’s values tool kit, and how values-based practice and evidence-based practice come together in supporting clinical judgement.
It is based in part on Appendix A of Fulford, Peile and Carroll’s Essentials of Values-based Practice
Values and Values-based Practice
Values are anything positively or negatively weighted as a guide to action (for example, needs, wishes and preferences)
Values-based practice is a process that supports health care decision making where complex and conflicting values are in play
- 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, and so forth
- 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-centered values of patient choice and their professional commitment to acting in their patients’ best interests
The values that form frameworks of shared values for balanced decision making in values-based practice are complex and conflicting (see below in section on The Point of Values-based Practice)
Medicine’s Values Tool Kit
Values-based practice is complementary to other tools in medicine’s values tool kit
- The values tool kit is the range of disciplines concerned in one way or another with values in healthcare (examples include codes of practice, medical ethics, medical law, decision analysis, health economics, narrative-based medicine and others (including the psychological and social sciences, medical humanities, history, literature, philosophy, visual arts, etc))
Values-based practice complements other tools for working with values in focusing particularly on the unique values of the particular individuals concerned (as clinicians, patients and carers) in a given clinical situation
Clinical Judgment
Values-based practice is a partner to evidence-based practice in supporting the exercise of clinical judgment in individual cases
- Clinical judgment is exercised whenever a clinician uses his or her clinical expertise in progressively ‘squaring down’ on the evidence and values relevant to diagnostic and treatment decisions appropriate to a particular patient in a particular situation
- Squaring down is the term introduced by Ed Peile to describe the process by which a skilled clinician focuses progressively on the more relevant information (about evidence and values), while discarding the less relevant information, arising from history, examination and investigations
In exercising clinical judgment, 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.
It is thus through squaring down in the exercise of clinical judgment that values-based practice links science with the unique values of individual people.
The Point of Values-based Practice
The point of values-based practice is to support balanced decision making within frameworks of shared values appropriate to the decision in question
- Balanced decision making means decision making that is based on a balance between the (often complex and conflicting) values of those concerned in a given clinical situation
- Frameworks of shared values are frameworks of complex and conflicting values which are shared by those concerned in a given clinical situation and that have 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. This is their particular Shared Framework of Values. But exactly what, say, ‘best interests’ means may be understood very differently from the perspectives of the clinician and carer; and what the patient actually wants may be quite different from what either the clinician or carer believes is in his or her best interests.
Note that Frameworks of Shared Values will vary from situation to situation. Values-based practice thus depends on those concerned coming to an understanding of just what their shared values really are.
Read More about Frameworks of Shared Values
The MHA Foundation Workbook, produced to support implementation of the Mental Health Act 2007 in the UK, provides an example of a framework of shared values in action (in this case supplied by the Guiding Principles for the Act itself): see also Practice Guidance and a copy of the Workbook in Full Text Downloads.
For a detailed example of how a Family Practice worked with their local Patients’ Forum to build their own framework of shared values, see Chapter 14, ‘It’s my Back, Doctor!’ in Fulford, Peile and Carroll’s Essentials of Values-based Practice
The Premise of Values-based Practice
Values-based practice is premised on mutual respect for differences of values. This has two key roles in supporting balanced decision-making:
- It marks out excluded 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
- It provides a basis for included values defined by the Framework of Shared Values relevant to the decision in question (see above)
Through these two roles the premise of mutual respect underpins the process of values-based practice in delivering balanced decisions on individual cases.
Read More about the Premise of Values-based Practice
For an example of how the premise of mutual respect excludes values such as racism please go to the The NIMHE Values Framework.
The derivation of the premise of values-based practice is controversial – see Critical Friends
The 10-part Process of Values-based Practice
Process is the ‘engine’ of values-based practice. Building on the premise of mutual respect, the process elements of values-based practice are what support its outputs in balanced decisions on individual cases within frameworks of shared values.
The process of values-based practice includes ten key elements covering four key clinical skills, two aspects of professional relationships, three close links with evidence-based practice, and a dissensual basis for partnership in decision making.
Clinical Skills
The four key clinical skills for values-based practice are awareness, reasoning, knowledge and communication skills
1. Awareness of values includes awareness of the diversity of individual values, awareness of clinicians’ 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)
2. Reasoning about values in values-based practice is aimed at expanding our values horizons rather than (directly) deciding what is right. Reasoning so directed may employ any of the established methods of ethical reasoning (such as principles reasoning, case-based reasoning (or casuistry), utilitarianism, deontology and virtue ethics)
3. Knowledge of values as derived from research and clinical experience has the important limitation that it can never ‘trump’ the actual values of a particular individual. That said, knowledge in values-based practice, as in any other area of medical knowledge, includes both tacit (or craft) knowledge and explicit knowledge; and it includes the skills for knowledge retrieval.
4. Communication skills include skills for eliciting values and skills of conflict resolution. In eliciting values it is important to explore strengths (StAR values, i.e. Strengths, Aspirations and Resources) as well the standard ICE (Interests, Concerns and Expectations). So in values-based practice ICE becomes ICE-StAR.
Professional relationships
The two aspects of professional relationships important for values-based practice are person-values-centered practice and extended multidisciplinary team work
5. Person-values-centered practice is practice 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 in tackling two particular problems of person-centered care, problems of mutual understanding and problems of conflicting values
6. Extended multidisciplinary team work is team work 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
Evidence-based Practice and Values-based Practice
The relationship between evidence-based practice and values-based practice is defined by three principles
7. The two feet principle is that 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’
8. The squeaky wheel principle is that 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’
9. The science-driven principle is 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 above all in high-tech medicine it is vital to ‘think both facts and values’
Partnership
Partnership in decision making, as the 10th element of the process of values-based practice, depends on both consensus and dissensus
Consensus is when differences of values are resolved with one or another value being adopted (as in the adoption of a framework of shared values)
Dissensus is where differences of values remain in play to be balanced sometimes one way and sometimes in other ways according to the particular circumstances presented by different situations (as in values-based decisions made on a case-by-case basis within a framework of shared values, see above)
Read More about the Process of Values-based Practice
For a set of training exercises designed to improve understanding of each of the ten elements of values-based practice, please see Whose Values? A Workbook. The exercises in this workbook can be used for self-study or in a group setting. Arthur Maciel’s ‘Valores de Quem?’ is a Brazilian-Portugese translation of ‘Whose Values?’ Both are available to down load from Full Text Downloads
Also down loadable is Reuben Woo’s Values Based Practice Decision Making Protocol which applies the principles of values-based practice to decision-making in social work
Fulford, Peile and Carroll’s Essentials of Values-based Practice illustrates each of the elements of values-based practice with extended clinical stories. Chapters 1 and 2 show how the need for values-based practice arises using an example of the management of chronic low back pain. Chapter 3 gives an overview of values-based practice. Chapters 4 to 12 explore elements 1–9 of values-based practice (covering clinical skills, professional relationships and links with evidence-based practice). The two concluding chapters, chapters 12 and 13, bring the elements of values-based practice together respectively through an example of balanced dissensual decision making in palliative care, and in the context of building a framework of shared values.
For further reading on values-based practice please go to the Reading Guide
