KEY CONCEPTS in VALUES-BASED PRACTICE: the point, premise and process.
Values-based practice is a partner to evidence-based practice in supporting clinical
judgement as we square down in individual cases

Clinical judgment is exercised whenever a skilled clinician makes diagnostic and
treatment decisions appropriate to a particular patient in a particular situation

Squaring down is the process by which in exercising clinical judgment a skilled
clinician focuses progressively on the more relevant information and discards the less
relevant information arising from history, examination and investigations
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
The point of values-based practice
To support balanced decision making within frameworks of shared values
Balanced decision making means decision making that is based on a balance between the
complex and conflicting values of those concerned in a given clinical situation

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.

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-centred values of patient choice and their
professional commitment to acting in their patients’ best interests
Frameworks of shared values
Frameworks of complex and conflicting values can be shared by those concerned in any
given clinical situation. These frameworks 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: but what ‘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.
The premise of values-based practice
The ‘democratic’ premise of mutual respect for differences of values.
Mutual respect for differences of values shifts the emphasis in decision-making from preset ‘right outcomes’ to good process

Excluded values are 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

Good process in values-based practice is decision making that is guided by one or
more of ten key process elements of values-based practice
The process of values-based practice
Ten key elements covering:
 four clinical skills,
 two aspects of professional relationships,
 three close links with evidence-based practice,
 and partnership in decision making.
V-BP Clinical Skills
The four key clinical skills for values-based practice are awareness, reasoning, knowledge
and communication skills

Awareness of values includes awareness of the diversity of values, awareness of
one’s 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)

Reasoning about values includes any of the established methods of ethical reasoning
(such as principles reasoning, case-based reasoning (casuistry), or utilitarianism)
when used to improve understanding of the values bearing on a given situation (to
‘widen our values horizons’) rather than (directly) to decide what is right

Knowledge of values covers tacit (or craft) knowledge as well as knowledge derived
from research; and it includes the skills for knowledge retrieval from electronic
databases.

Communication skills include skills for eliciting values (including strengths, as in
ICE-StAR) and skills of conflict resolution
V-BP Professional relationships
Professional relationships in values-based practice involve person-values-centred practice
and extended multidisciplinary team work

Person-values-centred practice means practicing in a way 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-centred care, problems of mutual understanding
and problems of conflicting values

Extended multidisciplinary team work means practicing in a way 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
Linking with evidence-based practice
The links with evidence-based practice are defined by three principles, the two feet
principle, the squeaky wheel principle and the science-driven principle

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!’

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!’

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 valuesbased practice as for evidence-based practice: clinically, this translates into the
reminder that as practice changes it is vital to ‘think both facts and values!’
Partnership in decision making
Partnership in decision making in values-based practice depends on both consensus and
dissensus

Consensus involves differences of values being resolved (as in the development of
shared frameworks of values)

Dissensus involves differences of values remaining in play to be balanced sometimes
one way and sometimes in other ways according to the particular circumstances
presented by different situations