The Ten Essential Shared CapabilitiesSupporting person-centred approaches

A learning resource for health care staff

Module 2

Module 2: Values-based Practice

This module is based on work originally developed by Bill Fulford, Professor of Philosophy and Mental Health, University of Warwick/Honorary Consultant Psychiatrist, Department of Psychiatry, University of Oxford/National Fellow for Values-Based Practice at CSIP/ NIMHE, and Kim Woodbridge, who worked at the Sainsbury Centre for Mental Health. We gratefully acknowledge their contributions.

© NHS Education for Scotland 2012. You can copy or reproduce the information in this document for use within NHSS-cotland and for non-commercial educational purposes. Use of this document for commercial purposes is permitted only with the written permission of NES.

Welcome to Module 2“Values-based practice” or “values-base care” are terms that we hear and use on a regular basis, reflecting the change in practice from focusing on professional values to also focusing on the values of people who use services, their families and carers. But what exactly do we mean by, and how do we demonstrate, values-based practice?

The word “values” can mean different things to different people: what is important to one person may not be to another. Understanding the important role of values within your practice, how values relate, interact and impact on experiences, actions and relationships, is vital to working in a respectful, person-centred manner with a wide range of people, all of whom will have different values and perspectives.

Values-based practice is a way of working positively with diversity and differences of values. It reflects a desire to focus on values as the basis of working practices, recognising that each individual brings with them a set of personal and professional values, and respecting the diversity of values of people who use services, carers and colleagues.

Learning outcomesAfter completing this module, you will be able to:

• demonstrate an understanding of values-based approaches to care and support

• reflect on your own values and how they impact on the care and services you provide

• understand the “10 pointers to good process in values-based practice”

• explain the relationship of values-based practice to the 10 ESCs

• begin to consider human rights and the relevance to values-based and person-centred approaches to care and support

• begin to apply values-based practice in your work.

We will explore values-based practice in this module in relation to Jackie, who we introduced earlier. Here is a reminder of what you know about her so far.

Jackie

Jackie is 22 years old and is unemployed. She recently broke up with her boyfriend. She struggles to keep her weight down, is a smoker and has type 1 diabetes. Jackie has a two-year-old daughter, Tracey, to whom she is devoted. They live together in social housing but Jackie has difficulties in paying the rent, despite receiving benefits. Jackie’s ambition is to complete a college course to enable her to work with children. Her mother, Helen, is very supportive to both Jackie and Tracey.

What are Values?Before exploring values-based care and practice, it is useful to clarify what we are referring to when we use the word “values”.

The word ”value”, although widely used, is a difficult concept to define. The Oxford English Dictionary defines a value as:

“ ... concepts of worth or quantities, generally relating to ethical, personal and cultural or economic value.”

Activity 2.1

This activity will help you to identify what values mean to you. There are no “right” or “wrong” answers.

What are values?

Compare your answer with what other people said in Box 2.1 on the following page – do you match with a particular group, or have you said something new or different?

What are Values?Box 2.1

You may have listed parents, siblings and school friends, the media, relationships – in other words, there is a whole number of factors that can influence your values.

Woodbridge and Fulford1 [http://www.centreformentalhealth.org.uk/pdfs/whose_values_extract.pdf]explain that values are complex because:

• values come in many varieties: they can be associated with ethics, rights and virtues and also include wishes, desires and aesthetic values, such

What are values?Nurses working in hospital Managers/chief executives Student nurses

Respecting patientsKeeping to your own principlesEnsuring people are treated equallyRespect people’s diverse needsValuing friends and familyWorking to a code of ethicsProfessional integritySelf respectSocial valuesBeing reliableWorking togetherMoral valuesHonest and truthfulCommitmentBeing competent at what you do

Right and wrongBelief systemsIdeals and prioritiesThings that govern behaviour and decisionsMoralsPrinciplesStandardsConscienceFluid/changeable

Personal integrityLearn new thingsListen and be listened toTo be usefulBe part of somethingTreat people equally but also to be treated as an equalCultural valuesParents and values from childhoodResponsibilityRespect each otherDo your bestTruthful

You will have thought about what you mean by values in completing this activity. You will also be aware that the word may mean different things to different people.

Activity 2.2

Reflect on what kinds of things have influenced your values and make some notes.

You may have listed parents, siblings and school friends, the media, relationships – in other words, there is a whole number of factors that can influence your values.

Woodbridge and Fulford1 [http://www.centreformentalhealth.org.uk/pdfs/whose_values_extract.pdf]explain that values are complex because:

• values come in many varieties: they can be associated with ethics, rights and virtues and also include wishes, desires and aesthetic values, such as appreciation of beauty

What are Values?• values vary with time and place: they are your

perspective, fluid and changeable • values vary from person to person: when you

compared your answers to activity 2.1 to those in Box 2.1, they are likely to be different.

In essence, it could be said that values tend to be the things in your life that you consider important. Our values guide our decisions, and Woodbridge and Fulford define values-based practice as:

“... the theory and skills base for effective health care decisions where different (and hence potentially conflicting) values are in play.”

The underlying assumption is that if decisions are underpinned by values as well as evidence, following a process in which values have been explored, clarified and balanced, such decisions are more “owned” and are more likely to be implemented.

Values-based practice is about working constructively with differences and diversity of values. This means putting the values of people who use services at the centre of everything we do, having insight and having an understanding of the effects of our values, and working with positive frameworks and processes rather than telling people what values they should have.

The Importance of ValuesValues have a key role in today’s health care services, in the experiences of people who use services, and also in the experiences of their families and carers.

Here we revisit Jackie’s story, from her perspective. We will build on this story later in the module.

Activity 2.3

Think about Jackie’s account and reflect on these questions.

What is your initial reaction to Jackie’s account? How does it make you feel?

What do you see as the main issues in Jackie’s account that need to be addressed?

What do your responses to the above questions say about what you value?

Drawing on the above, list some of the values you bring to your work.

Jackie’s account (1)

My name is Jackie. I’m 22 years old and unemployed but I am hoping to go to college soon. I recently broke up with my boyfriend. We didn’t have a good relationship and he was rough with me, and this brought up lots of difficult issues from my past. I am trying to get my life on track and have a wee girl, Tracey, who is perfect. My mum helps me a lot and I have good friends and enjoy a great laugh with them when I can.

I was 14-years-old when I was diagnosed with diabetes. The doctor put me on a diet and insulin injections, which made me feel better, and I have mainly coped with this and other issues in my life, but I haven’t been having an easy time lately.

At my last check-up at the hospital, I was seen by a different doctor who was clearly not impressed with me. He noted I had put on weight and gave me a row about my drinking. He told me that there was another kind of insulin I should take and that I should give serious consideration to getting my lifestyle in better order. I didn’t want to change insulin but he told me it was for the best and reminded me of my responsibilities.

The Importance of ValuesCommon answers to the last question in Activity 2.3 include: honesty; reliability; humanity; caring about other people; tolerance; enthusiasm. Sometimes answering this question reminds people why they chose to do the work they do.

It would be useful to discuss your responses in this learning activity with others who have also completed it.

The Role of Professional ValuesSome professional groups have articulated statements of common values. For example, Rights, Relationships and Recovery: the report of the national review of mental health nursing in Scotland [http://www.scotland.gov.uk/Publications/2006/04/18164814/0]2 produced the values statement shown in Box 2.2. The statement was written jointly by mental health nurses, people from other agencies, service users and family/carers’ representatives.

Box 2.2

The values base for mental health nursing2

RelationshipsPutting positive working relationships supported by good communication skills at the heart of practice. Maximising time to build relationships and challenging systems that detract from this.Recognising when relationships are unhelpful and taking steps to address this.

Rights Based on principles in legislation, safeguards and codes of conduct.

Respect

For diversity of values and placing the values of individual users at the centre of practice.Listening to what people say and not basing practice on assumptions about what people need.Seeing the whole person and not just his or her symptoms. Seeing the person as the ‘expert’ in his or her experience.For the contribution of families and carers.For the contribution of other professionals and agencies.For the social context of people’s lives.

RecoveryPromoting recovery and inspiring hope – building on people’s strengths and aspirations.Increasing capacity and capability to maximise choice.

Reaching out

To make best use of resources available in the wider community.To other agencies involved in mental health care. Being proactive about opportunities for change and mobilising opportunities to work with others to bring about change.

ResponsibilityAt corporate, individual and shared levels to translate the vision and values into practice by evolving current frameworks for practice and challenging and shaping institutional systems and procedures to accommodate this.

The Role of Professional ValuesThe 21st Century Social Work Review in Scotland was commissioned to examine how social work services can adapt to meet present and future needs. A new direction for social work services in Scotland was set out in the report Changing Lives [http://www.scotland.gov.uk/Publications/2006/02/02094408/0],3 which aimed to reinvigorate social work’s core values (Box 2.3).

Box 2.3

Most health professions have codes of conduct. These codes are statements about the values and (more importantly, some would argue) behaviours expected from a particular profession, providing practitioners, professionals from other disciplines and the public with solid indicators of how they should behave in certain situations.

Activity 2.5

If applicable, look at the code that applies to your profession; alternatively, you could look at your organisation’s/agency’s “purpose”, “mission”, “vision” or “aims”.

Look at Jackie’s account 1 again. If you were involved in supporting her, how should you respond to ensure you comply with your professional code or organisation’s/agency’s “purpose”, “mission”, “vision” or “aims”?

Having done this, look again at your responses to Activity 2.2. Is there any conflict between your own values and what is expected of you under the code or organisation’s/agency’s “purpose”, “mission”, “vision” or “aims”?

Changing Lives3

Core values of social work in Scotland:

• respecting the right to self determination • promoting participation• taking a whole-person approach• understanding each individual in the context of

family and community• identifying and building on strengths.

Activity 2.4

Does your area of practice have a similar values statement? And would any aspects of the Rights, Relationships and Recovery or Changing Lives values statements above also apply to your area of practice ?

The Role of Professional ValuesActivity 2.6

Ask a person you work with about the values statement for their discipline, agency or organisation. Complete this activity in a learning group or in the team in which you work, if possible.

Be creative when thinking about who you might ask. Consider your own role and define which person you would benefit most from learning more about. He or she could be a doctor, an AHP, a social worker, an advocacy worker, a psychologist, someone from a service user or carer group – the list of potential candidates is very long.

It will be interesting to note if people are able to easily answer your question.

What are the areas of similarity and difference between what the person told you and the values you hold as an individual?

What are the areas of similarity and difference between what he or she told you and the values your discipline, agency or organisation holds?

What opportunities or challenges might this create for working together?

You will appreciate that we hold common and different values as individuals and as groups.

Not all professions, agencies or organisations will have values statements. Sometimes looking at things like the “purpose”, “mission”, “vision” or “aims” of organisations/agencies can give us an idea of the values that might underpin their work and purpose.

Evidence-based and Values-based PracticeLike values-based practice, evidence-based practice (EBP) has many definitions. The most widely cited is adapted from the definition of Sackett et al [http://www.bmj.com/content/312/7023/71.full]4 for evidence-based medicine (EBM), which states that EBM is:

“... the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”

Values-based practice is about:

• working in a positive and constructive way with differences and diversity of values

• putting the values, views and understandings of individual service users and carers at the centre of everything we do

• understanding and using our own values and beliefs in a positive way

• respecting the values of the other people we work with and being open and receptive to their views.

The University of Warwick places an emphasis on values-based practice in their medical curriculum.5 One of their reasons for making this a focus is the recognition that there may be good intentions to take patients’ values into account, but this may not always happen. Some of the reasons for this include the following.

“If values are presumed to be shared – and this happens when values are not openly conflicting – they will remain unexplored. For example, if a doctor strongly believes that the side effects of a particular drug are more desirable than not taking the drug at all, she may assume that this is a shared view and so has no thought or reason to discuss the preferences of the patient.

“Some values may be difficult to elicit – some concerns may cause embarrassment to the patient and so they do not feel able to raise them. For example concerns about a treatment’s effects on sexual function.

“The power balance in patient-health professional encounters is such that patients rarely volunteer values.

“Values can often be expressed through wishes, preferences, perceptions, choices, expectations, hopes, fears rather than be discussed explicitly. They will often be highly contextual and it may be difficult to identify the personal components in them.

“Conflicting values may be difficult to reconcile without one party feeling a sense of substantial loss.”

In this module, values-based practice is defined as:

“The theory and capabilities for effective decision-making in health and social care that builds in a positive way on differences and diversity of values.”

Evidence-based and Values-based PracticeThis is quite a difficult definition. In practice, it means that working in a positive way with differences and diversity of values depends on good process – in other words, good ways of engaging with others on an equal basis, rather than telling people the values they should have.

Woodbridge and Fulford [http://www.centreformentalhealth.org.uk/pdfs/whose_values_extract.pdf]1 identified 10 “pointers” to good process in values-based practice. We will look briefly at these “pointers” in the next section and start to identify some of the ways in which they contribute to the 10 ESCs.

Using Values-based PracticeThe 10 pointers to good process in values-based practice are summarised in Box 2.4. The pointers cover:

• key practice skills • a model of service delivery that is user centred

and multidisciplinary• strong links with evidence-based practice• partnership in all areas of health and social

services.Box 2.4

This framework demonstrates the centrality of person centeredness and partnership working within a values-based approach and the important relationship between evidence-based practice and values-based practice. It also identifies four particular areas of clinical practice skills which Woodbridge and Fulford describe as being at the heart of the process of values-based practice: awareness, reasoning, knowledge and communication.

The 10 Pointers to Good Process in Values-based Practice1

Practice skills:• AWARENESS: being aware of the values in a given

situation• REASONING: thinking about values when making

decisions• KNOWLEDGE: knowing about values and facts that

are relevant to a situation• COMMUNICATION: using communication to

resolve conflicts/complexity.

Models of service delivery:• USER CENTRED: considering the service user’s

values as the first priority• MULTIDISCIPLINARY: using a balance of

perspectives to resolve conflicts.

The 10 Pointers to Good Process in Values-based Practice1

Values-based practice and evidence-based practice:• THE ‘TWO FEET’ PRINCIPLE: all decisions are

based on facts and values; evidence-based practice and values-based practice therefore work together

• THE ‘SQUEAKY WHEEL’ PRINCIPLE: values shouldn’t just be noticed if there’s a problem

• SCIENCE AND VALUES: increasing scientific knowledge creates choices in health care; this can lead to wider differences in values.

Partnership:• PARTNERSHIP: in values-based practice, decisions

are taken by service users working in partnership with providers of care.

Using Values-based PracticeRaising awareness of values Values may not always be evident; they may be implicit or explicit and often go unnoticed. An essential element to good process in values-based practice is the raising of awareness of values. Consider Jackie’s situation below.

You will remember the underlying assumption that if decisions are made with respect for values as well as evidence, following a process in which values have been explored, clarified and balanced, such decisions are more owned and more likely to be acted on.

Activity 2.7

Identify the different people involved in Jackie’s scenario, including Jackie, her mother and her doctor. Put yourself in the role of a worker involved in Jackie’s care. Reflect on what each party’s particular values might be in this situation.

Jackie’s account (2)

After a few days on the new insulin, I was feeling more and more uneasy – nervous and anxious. I didn’t like the new insulin and wanted to go back to my old one. I felt so tired I couldn’t be bothered to do anything, and I stopped following my diet properly.

My mum visited and she was really worried. We went back to the hospital, but the doctor just wouldn’t listen to me. He told me my blood sugar levels were down and this was a good result. I tried to tell him how I felt, but he said that this was the best course for me.

I have put weight on and can’t be bothered to do anything anymore. I had applied for a college course just before my insulin change but don’t see any point in carrying it on.

My mum worries about me. She tries to stop me eating some of the “rubbish” I’ve been eating lately and brings me what she calls “healthy” food.

I decided that I didn’t want to take my insulin injections any more as I felt really bad and my blood sugars were all over the place. I told the consultant at the hospital that I wanted to go back to the old insulin, but he was adamant that the new version was the best option for me. I discussed it with Jude, my social worker, and she set up an appointment at my GP, Dr Brown. He was sympathetic but said he couldn’t overrule what the consultant had said. When I told my mum, she said I had to do what the doctors were saying, otherwise I wouldn’t be well enough to look after Tracey or go to college.

People involved What you think their values are

Jackie

Jackie’s mother

Jackie’s doctor

You

Others?

Using Values-based PracticeClearly, values are personal and you cannot really identify other people’s, but this exercise can raise awareness of what may be important to others. It may also be useful to openly acknowledge that there are different values and explore what these are and how they may impact on decision making.

Using reasoning to explore valuesReasoning gives us the skills to identify and explore the different values bearing on a situation. Reasoning skills in values-based practice are concerned with exploring the difference of values that may be involved in a given situation. Woodbridge and Fulford1 explore two strategies for reasoning − case-based and principle-based − and how these fit together with our codes of practice to give us the skills to reason about values.

Case-based reasoning suggests that if we think carefully enough about the details of a particular case, we can solve most of the problems of values.

Activity 2.8

Case-based reasoning Jackie, as we know, is 22 years old and has type 1 diabetes. She is now non-compliant with her insulin and diet, resulting in several recent visits to A&E and two inpatient admissions over the past month. Her most recent admission came as a result of overindulgence in alcohol at a night out with her friends. She is overweight and a smoker. Her non-compliance with her treatment regime is putting her health at serious risk.

What do you think should happen to Jackie to address these issues?

How should health services and professionals intervene?

What reasons do you have for your conclusion?

Now consider this further information.

Jackie broke up with her partner three months ago. The relationship was volatile and she was the victim of gender-based violence. As a child, she was subjected to abuse and has experienced periods of depression and anxiety since.

Does this additional information change your conclusion? If so how?

And consider this.

Jackie is a dedicated mother to her two-year-old daughter, Tracey. Jackie’s ambition is to complete a college course to enable her to work with children. Her mother, Helen, is very supportive to both Jackie and Tracey.

Does this additional information change your conclusion? If so how?

Principles-based reasoningPrinciples-based reasoning suggests that although we may have diverse individual values, a number of general values will be relevant to a greater or lesser extent. These principles were identified by Beauchamp and Childress6 and will be recognisable to many of you who have previously studied ethics.

The four principles are:

• beneficence − the promotion of good• non-maleficence − the concept that one should

not inflict harm• justice − fair opportunity• autonomy − individuals should be enabled to

choose their own course of action.

These four principles can help with reasoning about values by applying them to specific cases/situations.

Activity 2.9

Revisit Activity 2.8 and consider the conclusions you made about Jackie’s situation in light of the four principles. To what degree did these principles influence your decision making and how did they impact?

Beneficence

Non-maleficence

Justice

Autonomy

Using Values-based Practice

The skills of listening and empathy are essential to values-based practice. They enable us to understand the values of others, while skills such as negotiation and conflict-resolution allow us to manage different perspectives. Awareness, reasoning and knowledge are all achieved through the use of effective communication.

Activity 2.10

Using the 10 pointers to good process in values-based practice (see Box 2.4), start to build up your answers in the table below to show which pointers will be particularly important in the team working with Jackie. Note your reasons for these choices and see if you can make a link between the issues you identify and one or more of the ESCs.

When you have completed this activity, you may like to look at the example on the next page, which illustrates how the 10 pointers could have been applied.

Using Values-based Practice

Jackie’s account (2) - example of applicationTen pointers to good process Does this apply? Why is this important?

Number/s of relevent ESCs

Awareness

Reasoning

Knowledge

Communication

User-centred

Multi-disciplinary

‘Two-feet’

‘Squeaky wheel’

Science and values

Partnership

Using Values-based Practice

Jackie’s account (2) - example of applicationTen pointers to good process Does this apply? Why is this important?

Number/s of relevent ESCs

AwarenessWe need to understand and respect why Jackie is making these decisions and recognise what values are informing her choices.

1,3, 4, 5, 6, 7, 8, 9

Reasoning

We need to look at the values held by all involved in this scenario and how this will impact on how they feel about Jackie’s decision. This could involve values being influenced by a particular model of understanding health problems, or a particular personal stance on issues like people’s rights. There is a need for open discussion about how these influence decisions.

Knowledge As above.

Communication This is a complex situation and everyone will need time to discuss the issues and reflect on their values.

User-centred Jackie’s values are the first priority.

Multi-disciplinary There needs to be a balance of perspectives while valuing different standpoints.

‘Two-feet’ Knowledge of medication effects vs. distress and discomfort being experienced by Jackie.

‘Squeaky wheel’Jackie wanting to revert to her original insulin is being perceived by others as a problem rather than trying to understand her point of view.

Science and values

The key here is Jackie’s choice. Her current medication is not acceptable and she feels her only option is to go back to the previous insulin type. Offering information about evidence related to the pros and cons of changing medication will assist her in making informed choices.

PartnershipIn values-based practice, decisions are taken by individuals working in partnership with providers of services.

All the ESCs could be seen as relevant, but we have selected only those that are particularly pertinent.

There is an obvious connection between the values-based practice pointers of service user-centred care and partnership and ESC 1 (Working in partnership) and ESC 7 (Providing person-centred care). The relationship between the pointers to values-based practice and the ESCs identified in the example of application can be further explained by seeing values-based practice as the process that can help achieve the ESCs.

Using Values-based Practice

Values-based Practice and Human RightsHuman rights, principles and standards should be used alongside values-based practice to support the delivery of improved person-centred care and strengthen existing work on equality and diversity.

The Universal Declaration of Human Rights was adopted in 1948, spelling out individual rights and freedoms for everyone. The Declaration remains central to 21st century human rights law and the universal human rights movement. Built on the fundamental principle that human rights are based on the inherent dignity of every person, this dignity, and the rights to freedom and equality which arise from it, is undeniable. Although the Declaration does not have the binding force of a treaty, it has acquired universal acceptability.

The Human Rights Act (1998)The Act requires that:

• UK legislation (both Scottish and Westminster) complies with the requirements of the European Convention on Human Rights (ECHR), unless there are compelling reasons not to do so

• all public authorities – and this includes hospitals, prisons, local authorities and courts – act and interpret the law in accordance with the requirements of the ECHR

• people within the UK are allowed to enforce their ECHR rights against public authorities by, if necessary, an action through our national courts.

The Human Rights Act makes it easier to challenge abuses of human rights and is designed to protect individuals. Many of these rights and freedoms fit

within the frameworks for values-based practice. A better understanding of human rights should ensure that individuals’ rights are incorporated into practice as a matter of course. The Department of Health has produced a guide to human rights in health care [http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_088971.pdf] and the Scottish Human Rights Commission has developed training resources on human rights relating to the care and support of older people [http://scottishhumanrights.com/careaboutrights].

Scotland’s progressive legislation, including the Adults with Incapacity (Scotland) Act 2000, the Mental Health (Care and Treatment) (Scotland) Act 2003 and the Adult Support and Protection (Scotland) Act 2007, have introduced significant changes in the ways that adults are supported in health and social care services. These changes bring a welcome and significant emphasis on human rights, values and attitudes. To learn more about this, visit the NES Learning Resource Respecting and Protecting Adults at Risk in Scotland - legislation and practice[http://www.nes.scot.nhs.uk/education-and-training/by-theme-initiative/mental-health-and-learning-disabilities/publications-and-resources/respecting-and-protecting-adults-at-risk-in-scotland-legislation-and-practice.aspx].

We will continue to build on your learning about values and human-rights based practice as we progress through the other modules in this learning resource.

ConclusionNow that you have completed this module, you should have an understanding of values-based practice and should have considered how to start to apply the 10 pointers to good process. You have also had the opportunity to think about how these link with the ESCs.

We hope that you will continue to think about values-based practice as you work through the rest of the ESCs learning resource. Here are some questions that will help you to apply values-based practice within your own role.

• What are the values of the team/network/group you work with?

• How are differences in values resolved in your team/network/group?

• How do the 10 pointers to good process relate to your everyday work and fit with your development plan?

Action into PracticeApply the 10 pointers to good process to a person you are working with, or to a situation that might be challenging you or your team. This would be best achieved either in your supervision session or through discussion with your team.

From what you’ve learned, what changes do you plan to make in relation to providing person-centred care and to developing partnerships?