Values Based Practice
Values Based Practice
Issue 9 – December 2008Author: Phil Houghton (firstname.lastname@example.org)
- Values Based Practice (VBP) stresses that clinical decisions are not just about “evidence”, but are influenced by the differing values people have
- The strengths of VBP are that it argues that the service user perspective should be the start of any clinical discussion and highlights the weaknesses of Evidence based Practice
- The major weakness of VBP is that it fails to acknowledge that the people involved in any decision may have vastly different amounts of power to influence the outcome
Implications for practice
- We need to reflect on our personal values and consider how they influence our decision making
- As well as values we need to consider how power affects the discussions we have
- There is a need to consider on an everyday level how we can promote the service user voice within meetings where clinical decisions are made.
What is Values Based PracticeWithin our everyday clinical practice we are regularly involved in discussions about the best course of action to take in any given situation. This may be with the service user themselves, with their friends or family, or with other members of the team we work in. If it was always obvious what to do there would be little disagreement as to the best course of action. However, it is clear that things are rarely this straightforward, and whilst there are guidelines for practice in certain areas these can often be of limited value (see below). Therefore in most clinical decisions different people can hold very different and sometimes opposing views. One reason for this is that we all have different values which influence what we think will be the best course of action. These values are influenced by lots of things, including: 1) our professional training and what we see is the cause of mental health difficulties; 2) the culture of the particular team or unit we work in; 3) our own personal histories and world beliefs; 4) the nature of the decision being made and; 5) what role we are placed in (e.g. service user vs approved social worker). In light of this, Woodbridge and Fulford1 have recently developed a framework known as Values Based Practice (VBP), which highlights the need for us all to think about and respect the different values involved in clinical decision making, starting with the perspective of the service user. Overall VBP is likened to a political democracy2, where conflicts are resolved through balancing of the different perspectives.
The strengths of Values Based PracticeOne of the major strengths of VBP is that it reminds us all that there are different perspectives and values at play in all clinical decisions, and that we need to start with the position of the service user. VBP also highlights the weaknesses in adopting a position based solely on the “evidence base” (commonly known as Evidence Based Practice or EBP). These weaknesses include the fact that there are many decisions and areas of practice where there is no “best practice” and as Anthony3 acknowledges research is often driven by changes in practice rather that the other way round. Even where there is an evidence base relevant to the particular decision, there remain a number of limitations. Firstly, there are questions over the importance placed on quantitative over qualitative evidence within EBP, with emphasis placed on “gold-standard” randomised control trials (RCT’s). Secondly, the lack of resemblance between RCT’s and everyday clinical practice frequently make it difficult to apply research outcomes to routine care. Finally, much of the research within mental health is based on diagnostic categories, which are highly questionable (see edition 6 of Clinical Psychology Bite-Size4), and fail to consider the significant impact of social context within the research design. This is not, of course to say that we should ignore research findings, but that we also need to be aware of their limitations and use this knowledge alongside relevant values and clinical experience.
The weaknesses of Values Based PracticeVBP puts forward the notion of creating a “democracy” where all views are respected and balanced and where “no group, no particular interest or point of view, has any automatic priority”1 (p.32). However this creates a problem as how can service user views be central without being given priority? This is acknowledged by Fulford and Colombo2 who describe it as a “fudge”, but argue that “fudges” can be a positive part of any democracy. This analogy of clinical decision making to a democracy is unhelpful as it ignores the reality that the different people involved can have vastly differing amounts of power to influence the outcome of the decision. Mental health services are about care, but they are also about control. We operate within a legal framework where we can remove the freedom of an individual, hardly the basis for a democratic process. We also need to remind ourselves that clinical decisions do not impact equally on the people involved in the decision. Whilst decisions may impact on staff to a point, and carers to a larger extent, the main person affected is the service user. Therefore the person most affected by any clinical decision will often have the least amount of power to influence it. Finally, even if we simply examine the different workers involved in any clinical decision, power differences remain large, with there being an explicit or implicit professional hierarchy with regards to the decision making process. In sum, whilst there are a number of positives associated with Values Base Practice, there is a real need to also acknowledge and understand the influence of power if we are to improve clinical decision making. As an example, it is important to ask ourselves whether we could support our clients to have a more powerful voice within decision making meetings. Could we make the meetings less intimidating? Are there too many people in the room? Has the service user had enough support and preparation to feel able to express their opinion? If uncomfortable in expressing an opinion have we done everything we can to make sure their views are still represented? Through considering power as well as values we can pose questions and challenges which will hopefully lead to an enhancement of mental health service provision.
- Woodbridge, K. & Fulford, KWM. (2004a). Whose Values? A workbook for values-based practice in mental health care.
- Fulford, KWM. & Colombo, A. (2004). Professional judgment, critical realism, real people, and, yes, two wrongs can make a right! Philosophy, Psychiatry & Psychology, 11, pp 165-173.
- Anthony, W. A. (2004). Bridging the gap between values and practice. Psychiatric Rehabilitation Journal, 28. pp.105-106.
- Coles, S. (2008). Difficulties with diagnosis. Clinical Psychology Bite-Size, Edition 6
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