K. W. M. Fulford

Values-Based Practice: Linking Science with People

Values-based practice is a new skills-based approach to working with complex and conflicting values in health care. In this paper we outline the point of values-based practice (to support balanced decision making), its premise (in respect for differences of values) and the ten elements of the process by which it supports balanced decision making in practice. We give examples of how values-based approaches have been applied in the development of policy and practice in mental health in the UK and outline its potential applications for contemporary psychotherapy. In a brief concluding section we show how the development of values-based practice in mental health is leading the way towards linking science more effectively with people across medicine as a whole.

The clinical skills for values-based practice

With Part 2, we come to the first and foundational group of process elements of values-based practice: the four key areas of clinical skills. Chapter 4 introduces awareness. Without awareness of values and of the often-surprising diversity of values, none of the other process elements of values-based practice can get any purchase. In this chapter, the story of how a young woman, Sally Coombs, reaches a turning point towards recovery from schizophrenia illustrates the importance of raised awareness of values as the basis of effective clinical care. Later chapters will illustrate the importance also of developing tools for self-awareness. Chapter 5 describes reasoning. In Chapter 2, Dr. Gulati applied “top-down” principles reasoning in trying to work out what to do about Roy Walkers demand for an off-work certificate. This chapter shows how “bottom-up” case-based reasoning (sometimes called casuistry) helped a different GP, Dr. Charles Mangate, in managing a case of teenage acne. Chapter 6 discusses knowledge. This chapter focuses the narrative primarily on knowledge of values for training and research. It shows, through the story of a nurse practitioner, Trish Butler, and her patient, Sandy Fraser, with chronic obstructive pulmonary disease, what we can learn but also what we cannot learn about values by searching electronic databases. Chapter 7 describes communication skills. Where Chapter 6 focused on training and research, this chapter brings us back to the challenges of clinical work. Through the story of a teenager, Vicky Bartlett, with type I diabetes, it illustrates the importance of communication skills, particularly for eliciting values and in conflict resolution.

Essential Values-Based Practice: “It's my back, Doctor!” (episode 1): values and clinical decision-making

Topics covered in this chapter Three key points about values in medicine are outlined as illustrated by a GP consultation for chronic low back pain between Dr. Gulati and her patient, Roy Walker. Other topics include: Ethical and other values Clinician and patient values Foreground and background values The network of values Values, decisions and actions NICE guidelines for low back pain. Take-away message for practice Values in medicine (i) include but are wider than ethics , (ii) are everywhere and (iii) are action-guiding . Values-based practice, as we indicated in our introduction, is a new skills-based approach to working more effectively with complex and sometimes conflicting values in medicine. As such, values-based practice is like evidence-based practice: both are responses to the growing complexity of clinical decision-making. Evidence-based practice supports clinical decision-making where complex and sometimes conflicting evidence is in play. Values-based practice supports clinical decision-making where complex and sometimes conflicting values are in play. In this chapter, we illustrate the complexities of values in medicine not with a high-profile “ethics case” but rather as they emerge from the everyday scenario of a GP consultation for chronic low back pain. Three key points will emerge from this scenario, namely that values in medicine: are wider than just ethics , which nonetheless are an important aspect of our values; are everywhere in medicine , although not always recognized for what they are; are important because they stand alongside evidence in guiding decisions and actions .

Essential Values-Based Practice: An outline of values-based practice: its point, premise and ten-part process

Topics covered in this chapter This chapter gives an initial overview of values-based practice by way of preparation for the case studies that follow in the rest of the book. We cover: The point of values-based practice: balanced decision-making within a framework of shared values The premise of values-based practice: mutual respect for differences of values Ten elements of the process of values-based practice: o Four areas of clinical skills o Two aspects of professional relationships o Three links with evidence-based practice o Dissensus: a basis in partnership. Take-away message for practice Values-based practice is a process that supports balanced decision-making within a framework of shared values where complex and conflicting values are in play. In this chapter, we give an outline of values-based practice by way of preparation for the detailed case studies that follow in the rest of the book. We will be drawing in this instance not on a specific clinical scenario but rather on a number of brief examples, mainly from mental health and primary care. Values-based practice aims to support balanced decision-making within a framework of shared values, based on a premise of mutual respect and relying for its practical effectiveness on good process rather than pre-set right outcomes. We start with the point of values-based practice by looking in more detail at what balanced decision-making within a framework of shared values really means. The point of values-based practice – balanced decision-making The need for balanced decision-making on individual cases where complex and conflicting values are involved became clear as we followed the story of Dr. Gulati and Roy Walker in the last two chapters.

Teenage acne: widening our values horizons

Topics covered in this chapter The role of reasoning in values-based practice is illustrated by the use of case-based reasoning (casuistry) in the management of a case of teenage acne. Other topics include: Evidence-based medicine and management of teenage acne Cosmetic and medical treatments Values and communication skills Principles reasoning Other methods of ethical reasoning (utilitarianism and deontology). Take-away message for practice You can use case-based and other ways of reasoning about values to explore your own and others values as they as they impact on practice . Where awareness of values as the first skills element of the process of values-based practice provides a wake-up call to values, reasoning about values as the second element is about expanding our values horizons. Reasoning skills in values-based practice are not used to derive particular moral or other evaluative conclusions (to “prove” what is right or wrong). In values-based practice, reasoning skills are used rather to explore and come to understand better our own and others values as these bear on and influence a given situation. Expanding our values horizons with case-based reasoning (casuistry) The importance of expanding our values horizons in this way is illustrated in this chapter by following a consultation between a GP, Dr. Charles Mangate, and his patient Jane Brewer, a 17-year-old aspiring model with mild acne.

Essential Values-Based Practice: Risks in safeguarding children: team values as well as skills

Topics covered in this chapter The importance of diverse team values (as well as knowledge and skills) in values-based practice is illustrated by the issues of risk and safety in a child protection case. Other topics include: Risk assessment and values Strengths and limitations of protocols and procedural guidelines Balanced clinical judgment Diverse team values and person-values-centered care The “extended” multidisciplinary team. Take-away message for practice Working in teams opens up a resource of diverse value perspectives that can support you in making balanced decisions in areas like risk assessment that require difficult judgment calls. Like person-centered care in the last chapter, values-based practice brings an extra dimension to multidisciplinary teamwork. Teamwork is important in modern health care in part because no single profession, let alone individual, can hope to encompass all the diverse knowledge and skills required for effective evidence-based practice in the increasingly complex environment of modern health care. But the complexity of modern health care, as we saw in Part 1, is a complexity as much of the values -base of practice as of its evidence-base. Correspondingly, teamwork is important in values-based practice as much for the diverse values that different team members bring to the decision-making process as for their diverse knowledge and skills. In this chapter, we illustrate the importance of the diverse value perspectives of team members through the story of how a GP, Dr. Lee Chew, manages the child protection issues raised when a young mother, Jade Spence, arrives in an “Extras” clinic on a Friday evening concerned that her four-month-old baby, Brit, has become sore “down below.”

Relationships in values-based practice

Introduction to Part 3 This part is concerned with the relationships, respectively, between professionals and patients, and between professionals of different kinds working together in multidisciplinary teams. “Person-centered practice” means different things in different contexts. Chapter 8, through the story of a woman, Brenda Forest, with early breast cancer, shows that in all its various meanings person-centered practice must include attention to the values – the needs, preferences, strengths and above all aspirations – of the particular person concerned. Person-centered practice, the chapter concludes, is nothing if it is not person- values -centered practice. Multidisciplinary team work has become increasingly the norm in many contexts in the ever more complex environment of modern healthcare. In part, this is because team members from different professions bring with them different skills and experience. In values-based practice, the concept of the multidisciplinary team is extended to include different team values . In Chapter 9, we illustrate the importance of team values in supporting balanced decision-making in a child safeguarding case. “Person-centered practice” and “multidisciplinary teamwork” are both very much among todays buzz words in health care. There are good reasons for this. Like any buzz word, they can become misused as empty mantras. But person-centered practice represents an important shift of focus away from the priorities of providers and back to the needs of individual patients and their families, while multidisciplinary teamwork is essential for the effective delivery of care that is genuinely person-centered. Values-based practice, as we will see in this part, both draws on and in turn contributes to the multidisciplinary delivery of person-centered care.

Prologue: linking science with people

A young woman with schizophrenia finds a turning point towards recovery when a new member of the mental health team recognizes and acknowledges her aspirations. A middle-aged car sales manager finally engages positively with evidence-based management of his hypertension when a cardiologist appointed through his firms occupational health scheme links the need for treatment to his ambitions as an amateur racing car enthusiast. A young couple at risk of being torn apart by conflicting views over IVF are reconciled when their parish priest helps them to understand the real rather than fancied implications of the techniques being proposed by the local infertility clinic. These are some of the stories – based on those of real people, although biographically disguised – that are at the heart of this book. Each story presents a familiar clinical problem; for each problem, there are a variety of possible evidence-based solutions, but in each case matching solution to problem depends critically on engaging with the values of those concerned. Values, evidence and complexity There is nothing new as such about values in medicine. The Hippocratic Oath, on which modern codes of practice still draw, goes back over 2000 years. There is similarly nothing new as such about evidence in medicine. David Sackett and his colleagues, in their early and still influential Evidence-Based Medicine: How to Practice and Teach EBM , to which we will be returning at several points in this book, locate what is possibly the earliest recorded use of evidence-based methods in ancient Chinese medicine.