Values-based practice

It is necessary to note that the provision of health care is inseparable from universal values such as caring, helping, and compassion. Consideration for individual values, particularly those of patients, has been increasing (Burman et al., 2013). However, the maintenance of

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such consideration is difficult within the context of modern health care, where complex and conflicting values are often in play. This is particularly true when a patient’s values seem to be at odds with EBP or widely shared ethical principles or when a health professional’s personal values may compromise the care provided (Petrova et al., 2006).

Conceivably, the most widely acknowledged values in health care are ethical values. However, values are much wider than ethics, including needs, wishes, and preferences as well—indeed, the diverse ways in which people express, directly or indirectly, negative or positive evaluations and value judgements (Fulford, 2011). Also, the particular values held by different individuals differ within various cultures and across historical periods. On the other hand, values are not completely individual; many key values are shared: for example, the values of patient autonomy (freedom of patient choice) and of acting in the person’s best interest are widely shared values that provide the basis for ethical codes and guidelines. However, these shared values are often in conflict: for example, autonomy of patient choice and acting in patient’s best interests are both important elements when thinking of incorporating patient values and preferences in decision-making, but respecting autonomy may be in conflict with the need for acting in the patient’s best interests. On a similar note, confidentiality, although considered as a widely recognised value in current clinical practice, may be in conflict with the need to share information as the basis of good medical care. Nevertheless, acting in a patient’s best interests means different things in different clinical contexts, depending upon the often very diverse values (personal, professional, and cultural) of particular individuals (Fulford, 2011).

One of a variety of new and emerging ways of working with complex and conflicting values in health care is what has recently become known as ‘values-based practice’. Sackett et al. (2000) demonstrated that there is a sense in which medical practice has always been evidence-based. The need for values, then, similar to the need of EBP, arises from the growing complexity of medicine; in other words, as the growing complexity of the evidence in which clinical decision-making depends has led to the need for EBP, the growing complexity of the values underpinning clinical decision-making has led to the need for values-based medicine (Fulford, 2011; Kelly et al., 2015). Building mainly on learnable skills, values-based practice adds a particular focus on the diversity of individual values and the need for health

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professionals to incorporate this diversity more effectively in clinical decision-making (Gradinger et al., 2015).

Values-based practice is considered a partner to EBP. Its aim is ‘to connect generalized best evidence, derived from [EBP] and the knowledge and skills of practitioners, with the particular values—the concerns, preferences, wishes and expectations—of individual patients and their families’ (Fulford, 2011, p. 2). However, while the complexity of the evidence base of clinical decision-making is now broadly acknowledged, it is still commonly assumed that the values base is relatively transparent and straightforward. Thus, Sackett et al., although emphasizing the importance of patient’s values in the beginning of their book (Sackett et al., 2000), focus in the subsequent chapters largely on best evidence. A similar focus is also apparent throughout much of the literature on EBP. It has been clear, however, that patients’ values are very far from being transparent. This is suggested from the growing number of patients narratives (Fulford and Woodbridge, 2004) and surveys and other studies indicating the extent to which health professionals misread their patient’s values (Haynes et al., 2002). Equally as important to values-based practice is the extent to which providers are unaware of their values and how these values influence their practice. To illustrate, a study examined a training workshop in values-based practice completed by a mental health team (Fulford and Woodbridge, 2008). The study showed the perspectives from the comments that were made by the team members participating in a one-hour case review meeting. The team was told to participate in the training for values-based practice because of their shared commitment to person-centred approaches. After exploring the comments in the meeting, most of them came ultimately from the perspectives of the providers rather than reflecting those of their patients. Therefore, despite their explicit commitment to a person-centred approach, their actual values as represented in the team meeting and hence the values most likely to be guiding their decisions were not those of their patients but rather their own (Fulford, 2011). As such, it is highly necessary to raise awareness of the values that actually drive practice as opposed to values that providers believe they hold, which is a crucial step in values-based practice.

As discussed earlier, ascertaining and integrating patient values is an important part of several movements in health care practice, including EBP, values-based practice, and person-centred care. However, these movements vary in their definition of values, their methods of

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respecting patient values, and the integration of these values into medical encounters (Wieten, 2018). It is necessary to note that these different methods can make taking patient values into consideration in a consistent way confusing and difficult.

Although it has been claimed that the values-based practice consideration of values in clinical practice has several flaws (Bae, 2015), it is evidently more attentive to individual patients than rival EBP procedures for taking values into account (Petrova et al., 2006). Studies have argued that EBP procedures concentrate on using data from social science to create population-based accounts of patient values (Wieten, 2018). Given the inconsistency of EBP’s stance on values, current calls for person-centred care, and the uncertainty of the appropriateness of using the same methods to compare and discuss values and evidence, it is claimed that values-based practice ought to be used in place of EBP procedures (Fulford, 2008; Wieten, 2018).