CHAPTER 1
INTRODUCTION TO VALUES FOR CARE PRACTICE
LEARNING OUTCOMES:
In this chapter you will:
• Be introduced to the notion of values in care and distinguish between personal and professional values
• Establish the origin of values in care, including institutional and organisational influences, and explore those defined by professional bodies
• Recognise the significance of patient, service user and carer values
• Establish the importance of a plurality of values for health and social care and the need for practitioners to practise value-based reflection.
Values are an inescapable and integral feature of health and social care. Although not new, this claim was brought sharply back into focus through the findings of the Francis Inquiry which revealed unacceptable and appalling care, patients and families being treated with 'callous indifference', inadequate patient safety, and failures in leadership (Francis, 2013). Similarly, other reports of failures in hospitals and care homes have highlighted cases of poor, inhumane care (Care Quality Commission, 2014; Department of Health (DH), 2012b, 2013b; Keogh, 2013). All of these reports demonstrate incidents where values have been compromised in the provision and delivery of services and particularly in the standards of individual care. It appears that, at least for some, putting patients first had given way to other demands, in a culture that seemed to disregard the values of respect, compassion, dignity and person-centred care.
At the heart of what often troubles us in these narratives of mistreatment and inhumane care, is that our personal value position is challenged in some fundamental way. The actions of others in these scenarios are contrary to what we believe is the right way to behave and the right thing to do. We are shocked and appalled by the apparent disregard by others for the basic value of respect for individual people and humanity and the lack of any sense of compassion. There is an intuitive and emotional response and a need to make sense of others' and our own beliefs, values and behaviour. Care practice does not and should not occur in a moral vacuum and ethical behaviour is not reserved solely for the big issues, dilemmas and challenges in health and social care. Caring is based in the human relationship, and everyday activities and the simplest interactions or interventions have a moral component.
Lapses and failures in care are shocking and cannot ever be condoned, but neither must we make the mistake of suggesting that because some care fails, all care is failing. Most practitioners go to extraordinary lengths to defend and remain committed to their values (Calkin, 2011) and to ensure patients and service users receive excellent care (Jackson et al., 2014; Middleton, 2013). What is clear is that the values held by practitioners are an essential component in determining and practising good care. It is also important to celebrate and promote good care whilst understanding how and why care can be compromised.
The Francis Inquiry (Francis, 2013) emphasised the importance of positive working cultures and the need for a workforce with the 'right values and attitudes' to provide high quality and safe care. There is an expectation of 'value-based recruitment and selection' of staff in health and social care; finding the person with the 'right' values to care (see the 'Cavendish Review' – DH, 2013d; Skills for Care, 2014; Willis Commission, 2012). Thus, in recent years, multiple claims have been made for the values that should guide the behaviours of health and care practitioners to ensure that all people using health and social care services are treated with respect and compassion and receive 'good care'.
Statements of values for health and care come from institutional, professional and organisational standpoints, both nationally and locally. A number of these have been significantly influenced by the 'patient or service user voice', either in a direct sense through consultation with individuals and user groups or through investigations and research into what people (and their families) want and expect when they receive care (Beresford, 2013; Burnell et al., 2015; Cotterell et al., 2010; Foot et al., 2014; Lupton and Croft-White, 2013; National Voices, 2014; Tambuyzer and van Audenhove, 2015).
Examples of policy that incorporates value statements include 'The NHS Constitution' (DH, 2015a), the 'six Cs' (DH and NHS Commissioning Board, 2012c), 'Fundamental Standards' (DH, 2014c) and the Royal College of Nursing's Principles of Nursing Practice (RCN, 2011; see Box 1.1). Various professional organisations have codes and standards for practice which present collective value positions in defining the expectations of their professional group; for example, British Association of Social Workers (BASW), 2014; Nursing and Midwifery Council (NMC), 2015; Health and Care Professions Council (HCPC), 2016. This list is by no means exhaustive and although the values identified by each profession may be similar and interrelate, each organisation or body makes an independent claim. These values may also be defined at a high level and do not always identify their practical application in everyday decision-making and actions.
Deciding what is morally right to do in health and care, at policy and service levels and in practitioner–client relationships, has become an increasingly complex activity. This is influenced by the potential for competing personal and professional duties (for example, maintaining confidentiality and preventing harm), by advances in medicine such as genetic technology and by the ways in which limited health and social care resources are distributed. As Gallagher (2013, p.615) reminds us, '... organisational or political values, such as efficiency and effectiveness, may conflict directly with nursing values such as dignity, compassion and honesty'. Thus, practitioners have to find ways through this moral maze and the professional moral landscape to identify and prioritise the values for practice which they espouse and to determine the right ways to behave and act in the delivery of good care. Practitioners need to learn ways that challenge them to think critically and logically about their own and others' moral arguments and to derive morally defensible decisions that guide their practice. Although there may be more than one morally 'right' answer in many practice situations, what is important is that it is exposed to careful and critical ethical analysis and that actions can be morally justified. Authenticity in our decision-making comes when our espoused values are in alignment with those values that we exhibit in our actions, behaviours and attitudes.
In this book, readers will be encouraged to reflect on and critically analyse their personal value base and the core values underpinning health and care work. You will explore the origins of moral values in general and reflect on how these are articulated by organisations and in professional codes. You will consider how core values in health and social care give rise to principles that guide practice and reflect on cases where there are a plurality of relevant values for consideration and where values come into conflict. The text will use activities and case studies to enable the reader to reflect on the relevance of values in care practice and to apply theory in their practice.
This chapter introduces the notion of values in care and explores the distinction between personal and professional values. It considers the origin of values in care, including institutional and organisational influences, those defined by professional bodies and the significance of patient, service user and carer values. It concludes by emphasising the importance of a plurality of values for health and social care and the need for practitioners to practise value-based reflection.
INTRODUCING VALUES AND CARE
The very nature of health or social care work is that it is practical; it involves doing as well as understanding. You will need to know that something is the case, e.g. a fact of law or of anatomy and physiology, as well as knowing how to do something, e.g. a practical skill. The factual or knowledge base to perform the skills associated with health and care can be wide ranging, depending on your area of practice and level of expertise. For example, you may need to know how to perform urinalysis, how to safely move an immobile patient, how to listen effectively, how to apply a dressing to a wound, how to organise and run a group activity with service users, how to communicate with a person with hearing loss. You will learn the facts associated with 'knowing that' and 'knowing how' through teaching, inquiry and through practice.
Competence in practice also requires that you develop the relevant level of expertise, clinical and technical knowledge to assess an individual's needs and to provide safe, effective and quality care which is research- and evidence-based. Competence can be viewed as a holistic concept defined as 'the combination of skills, knowledge and attitudes, values and technical abilities that underpin safe and effective nursing practice and interventions' (NMC, 2010a, p.11 adaptation from Queensland Nursing Council 2009). While competence, efficiency and effectiveness are important components of care, these alone are insufficient to explain what it means to deliver good care; what matters is not just what you do but how you do it.
The verb 'to care' implies not merely a functional activity as, for example, the verb 'to run' may do, but also implies an activity that has a qualitative dimension. This dimension says something about the way in which caring is carried out. The verb 'to care' can be defined by using phrases such as: to be concerned about, to be watchful of, to have a liking for, to pay close attention to. Thus, caring is not a purely practical task that needs to be completed as efficiently as possible, but the implication is that the completion of the activity is undertaken with a particular attitude.
Caring requires a quality of character that involves genuine concern for the health, welfare and wellbeing of the individuals receiving care. In addition, while not universally true, many individuals receiving care may experience times of vulnerability, either by virtue of illness, age, disability, pain, or loss of confidence. Although we should be cautious in assuming that vulnerability demands protection and must avoid the creation of powerlessness or stigmatisation of individuals and groups in situations of vulnerability, patients, service users and their family carers may both expect and require support, advice and 'the care' of others. Thus, as care is essentially an interpersonal activity, caring about and for others requires not only knowledge and skills but a caring attitude that is value-based. It is the very nature of the care relationship and the ways in which we relate to others in our day-to-day practice that brings our value base into focus and demonstrates our respect for, and commitment to, others and their humanity. Knowledge and skills without values are directionless (Toon, 1999, p.58).
WHAT ARE VALUES?
Your personal beliefs and attitudes regarding how you should behave towards others, why you should act in a particular way, what is the right and wrong thing to do, are heavily influenced by your moral understanding, moral conscience and your values. Values are different from factual knowledge because they are harder to quantify, standardise or provide evidence of; however, their impact on the care relationship is fundamental. Put simply, values are particular kinds of beliefs that are concerned with the worth or value of an idea or behaviour and are important in guiding our actions, our judgements, our behaviour and our attitudes towards others. In this way, values play an essential role in articulating the standards for the delivery of care and the manner in which the practitioner interacts with others in the care relationship. The values explored in this book are those that dominate care in modern, western societies.
The concept of values may encompass a range of meanings and be understood in different ways and contexts, not all of which will be directly associated with morality. A value may describe an emotional disposition towards a person, object or idea, may be something we recognise as good or worthwhile, or reflect a personal belief or attitude about the truth, beauty or worth of a thought, object or behaviour (Pattison, 2004, pp.5–6). For example, when asked the value you attribute to a picture, you could respond by simply telling me how much it cost, you could talk about the reputation of the artist, you could say that it is beautiful and that you love it or you could tell me that it cost very little but it is priceless to you because of its sentimental value in reminding you of a special relationship.
Values may be used to describe the worth, importance or usefulness of something to someone. Seedhouse (2009, pp.48–9) identifies a number of categories of things we may attribute value to:
• Physical objects, e.g. our car, our house
• Aesthetic qualities, such as beauty, e.g. works of art, beautiful gardens
• Intangibles, e.g. friendships, creativity
• Principles or rules of behaviour, e.g. truth-telling, sanctity of life
• Ideologies, e.g. liberalism.
Pattison (2004, pp.3–5) outlines a number of synonyms used either in conjunction with, or instead of, the language of values:
• Preferences, desires and choices – from the economic domain, i.e. people value or confer worth on what they prefer, desire or choose (and are prepared to pay for).
• Attitudes and beliefs – from the psychological domain, i.e. what people are attitudinally or predisposed to, or believe in, is what they value and can be discerned by watching their behaviour, e.g. voting for a particular political party.
• Social norms, assumptions, expectations, judgements and prejudices – the sociological domain, i.e. what holds people together in groups so that society is coherent and individual behaviour is predictable; shared views of what is good or bad, desirable and undesirable.
• Standards, visions and goals – the domain of management and governance. Standards are norms of what is expected and required and define sufficient value, visions provide a set of ideal standards to which people can aspire, while goals are the intermediate specific value targets which must be reached.
• Morals, principles and commitments – the domain of morality and ethics. Morals are precepts or habits that aim to attain what is good and desirable, i.e. what is valued. Principles aim to ensure certain values are realised. Commitments are a form of consent to a set of values; the values you espouse and have committed to follow, those you are morally obliged or compelled to observe and that guide your actions.
The definition of value is therefore multifaceted and complex. We will draw on all of the different expressions of values listed above. However, what is commonly meant when discussing values in health and social care (and is our main concern here) are the moral beliefs, principles or rules of personal conduct that guide our social interactions and human relationships. Humans are essentially social beings and individuals hold personal beliefs and values that are important to them and which influence their attitudes, actions and behaviours towards others. Our values in practice are also inextricably linked to the quality and acceptability of the care experience for those receiving care. Thus practitioners must not only identify with their own value base but should also respect and engage with the moral beliefs and position of others – the moral dimension of practice.
WHERE DO OUR BELIEFS AND VALUES COME FROM?
Much of our development of values and moral reasoning takes place during childhood and adolescence. These values may not be consciously selected or subjected to any scrutiny but inculcated from family and early socialisation or assimilated from cultural norms in education and play. Our development of moral knowledge is influenced by a number of factors including our parents and siblings, peer groups, culture, personality, education, religion and some form of ideology. Values are often subjective in nature, and can also be relative to the individual and their circumstances, culture, relationships and experiences. So, although our basic moral foundations of right and wrong, good and bad, what we ought or ought not to do are laid down in childhood, our values are not static and will inevitably be influenced by our experiences throughout life, including those values acquired from education, professional codes, organisations and working practices. Individuals may even reprioritise their values several times in the same day as they attempt to fit in with group norms or they will reprioritise their values at different stages of life or in response to various experiences. Yet there may also be some values that remain unchanged, that you are not willing to compromise and would take risks to defend.
