VALUES-BASED PRACTICE
this was what mattered to Mrs Jones. No doubt it did matter. But what mattered more to her was to recover the mobility she needed to do her gardening. It was thus Mrs Jones’ individual values (what mattered most to her) that determined her shared decision with the surgeon to opt for conservative treatment2
.
Mrs Jones’ story illustrates a number of key points about how values-based practice works clinically.
1. AWARENESS OF VALUES IS THE ESSENTIAL FIRST STEP The full ten process elements of values-based practice
may look rather daunting (see Figure 1). Each element is important in different circumstances but, as in Mrs Jones’ story, it is the first element (raised awareness of values) that is essential.
2. NOT THE ONLY ‘TOOL’ IN THE TOOL BOX In practice, many other values besides those of clinician and patient have an impact on practice: the options available to Mrs Jones for example reflect health economic values which in turn reflect political and social values. This is why values-based practice is best understood as just one among a number of ‘tools’ now available for working with values in healthcare: other tools, besides values-based practice and health economics, include ethics and decision analysis.
3. I DON’T HAVE TIME FOR THIS With services under ever-growing pressures a natural reaction to talk of ‘dialogue about values’ is to say ‘Great – but I just don’t have time for all that!’ Mrs Jones’ story shows to the contrary just how cost- and time-effective dialogue about values can be. It took the surgeon a few extra minutes to agree with Mrs Jones that given what mattered to her (ie her values) they should go for anti-inflammatory medication and physiotherapy rather than a knee replacement. The result was a ‘win’ for everyone
• Mrs Jones’ went back to her gardening. • The surgeon and his team saved a precious resource of time.
• The NHS avoided several thousand pounds of wasted operating and related costs.
4. VALUES AND EVIDENCE Mrs Jones’ story, although focusing on values, also reminds us that clinical decision-making should always be evidence-based as well as values-based. The decision to opt for conservative management of her arthritic knee combined the surgeon’s knowledge of the advantages and disadvantages of the evidence-based options available with what mattered to Mrs Jones (ie her individual values).
THE DIAGNOSTIC RADIOGRAPHER – PATIENT defined caring in relation to
RELATIONSHIP In 1979 Goldin12
diagnostic radiography as: ‘Providing emotional support, explaining the procedure in a manner the patient can understand, permitting the patient to express emotion, actively listening to a patient’s concerns and responding in an empathetic manner and recognising the patient as a unique individual rather than just another case’12
(p194). Although this is an old reference, from 1979 we can
still argue that being caring is very much a part of the radiographer’s role.
14 The relationship that diagnostic radiographers
have with their patients is very different from the relationship between other healthcare professionals and their patients. The diagnostic radiographer spends a relatively short period of time with their patient and the interaction is task focused, ie the production of a diagnostic image 13
. Murphy14 says that this could be
seen to be quite different from the more long-term caring relationships that other healthcare professionals appear to have with their patients. Diagnostic radiographers tend to be ‘task focused’. In 2009, Whiting15
provided an insight into the
thoughts of student radiographers who felt they were joining a profession where technical ability is prioritised over other aspects of care. They appear to learn task focus from one another, and they perceive this to be the quickest method of getting through the workload by concentrating on the task in hand, and producing the radiographic image, rather than considering the patients and their needs13
.
Unlike the therapy radiographer, the diagnostic radiographer may only meet a patient once, and has very little time to get to know the patient, their needs and their values. Diagnostic radiographers need to create an instant rapport with their patients. Bolderston et al16
suggest that ‘the short, single patient
visit to an imaging department necessitates highly accelerated rapport-building’ (p205). In building this rapport the diagnostic radiographer seeks to gain the patient’s co-operation and trust.
VALUES IN DIAGNOSTIC RADIOGRAPHY PRACTICE Perhaps we should consider what values mean for diagnostic radiography practice and what values-based practice looks like in an imaging department.
CASE EXAMPLE: MRS SMITH’S CHEST RADIOGRAPH Mrs Smith (not her real name) presented in the imaging department as a frail elderly lady attending following a referral by her GP for a chest radiograph. The radiographer hailed the patient in the waiting room and led her down a corridor through a doorway which Mrs Smith had to hold open for herself. During the journey the radiographer assessed the patient and decided that it would be in the patient’s best interest to ask Mrs Smith to change in the x-ray room. She led Mrs Smith into the x-ray room and asked her to undress. Mrs Smith hesitated, the radiographer assumed that this meant that Mrs Smith needed help and undressed Mrs Smith, slipping her clothes over her head. So why is this not values based care? The radiographer sped the imaging process up by undressing the lady in the room and helped the lady to undress ensuring an efficient examination. Is this what Mrs Smith wanted? In fact, Mrs Smith wears a wig (which may come loose) and undressing in front of the radiographer would not be what she would have chosen. Mrs Smith did not need help undressing but needed the opportunity to express her wishes. She hesitated, looking for the chance to make a choice about her examination but was not given that option.
VALUES IN THERAPEUTIC RADIOGRAPHY PRACTICE In the recent online article on the Society & College of Radiographers’ (SCoR) website Rachel Harris (SCoR Professional and Education Manager) reflected on her experiences of radiotherapy treatment17 feeling ‘exposed and vulnerable’ because she was left unnecessarily exposed during the treatment. When
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