THE NZAOT VALUES EXCHANGE CORNER – AUGUST 2010

‘The NZAOT Values Exchange Corner’ is a new initiative in the NZAOT Insight magazine that aims to disseminate news and information about the NZAOT Values Exchange, a website-based ethics tool, and to feature at least one Values Exchange case and or survey each month. In this month’s Values Exchange (VX) Corner we highlight a new innovation on the website, the Values Exchange Forum, which allows you to discuss a case or a survey in more depth with your colleagues or others. Cases that have intrigued you and that create more discussion than can be accomplished in a single case deliberation, and can be discussed and debated at length and in more detail through the Values Exchange Forum. Check it out!

The NZAOT Values Exchange is always undergoing change and improvement, in response to changes to the website, better software designs, and in response to feedback from people who use the website. Recent feedback from an NZAOT Values Exchange working party, formed a couple of years ago and commissioned by NZAOT, enabled positive changes to be made to the site. Such as the debate/forum feature,improved and more easily accessible analysis and case/survey reports, and generally a more user friendly website.

Without the participation of NZAOT members and occupational therapists the NZAOT Values Exchange would not be where it is today. In order to get the maximum benefit from this website-based ethics tool, for us, the people we serve and our community, you need to participate regularly in a range of cases. Case deliberation only takes a few minutes and it can be an enlightening and insightful process. Take the time after completing a case to reflect on the results of yours and other’s views, as this reflection offers greater depth to your deliberation and enables you to understand the differing viewpoints that occur in any case deliberation. You may want to create and set-up a case yourself, which is easy to do. You only need to email the VX administrator,that’s me, and I can talk you through the steps to create your own Values Exchange case.

There are clear benefits for those who use the Values Exchange, such as assisting you to make decisions about difficult cases or problems occurring in your practice area, the VX can help you to meet some of the ethical/legal goals in the CCFR(Continuing Competency Framework for Recertification) with the OTBNZ(Occupational Therapy Board of New Zealand), it can be used as a teaching tool with staff and colleagues, surveys with full and instant analysis can be completed online and can easily be reported back to a team or department, the Values Exchange encourages Values-Based decision making and open or transparent discussion, the Values Exchange has research applications for those who are interested, and political discourse can be enabled using the Values Exchange.

This month’s featured case is ‘Can we befriend our clients?’ The vignette reads:

John is an occupational therapist who has been working with Liz for several months and he now realises he is quite attracted to her. In one of their last sessions together at Liz’s home, Liz asks John if he would like to come to a party with her at her friend’s house. Liz explains to John that she is very attracted to him and would like to develop their friendship. John also continues to have strong feelings for Liz. John reminds himself that Liz will soon no longer be his patient/client. What should John do in such a situation?

It is proposed that John accepts the offer to go out with Liz and start a friendship with her.

Useful links for the case include: a case featured on the New Zealand Health Practitioners Disciplinary Tribunal, detailing a case where professional boundaries between an occupational therapist and a client became ‘blurred’.

What were some of the results from our deliberation in the case of John and Liz?

Check it out on the Reports Dashboard

Alternative suggestions [in the case and as proposed by a selection of the respondents]:

Everyone who answered"I agree"

Alternatives: One option would be for John obviously to end his therapy with Liz, and for them both to have the supervision/psychology support/advice that would help, and have time apart before making the decision to enter into the friendship or not. It would be helpful to clarify the law in this matter.

It is proposed that: John ends his therapy with Liz, and for them both to have the supervision/psychology support/advice, and have time apart before making the decision to enter into the friendship or not.

Everyone who answered,"I disagree"

Alternatives: John reminds himself of professional boundaries and legislation that surrounds them and puts the patient's needs before his own personal needs. John discusses with Liz the nature of their therapeutic relationship. John discusses this with his manager and is transparent with information with management.

Alternatives: The therapist should not cultivate a personal relationship with an active client. If the therapist and client were to accidentally meet a reasonable amount of time after the therapeutic relationship had finished I feel that the client would have had a chance to shake the client role and could be allowed to make a decision about the relationship as a peer.

Alternatives: John should definitely terminate his therapy relationship with Liz prior to attending any sort of party with her. He should also discuss the matter with a supervisor or manager, and hand over her case for any ongoing needs or follow up. A cooling off period may be appropriate, before any relationship could commence.

It is proposed that: John declines the offer to go out with Liz and start a friendship with her.

It is proposed that: the therapist wait until the case is closed before beginning a personal relationship with the woman.

What conclusions can we draw from a brief analysis of this case?

19 out of 21 respondents disagreed, and only 2 agreed, with the proposal – ‘that John accepts the offer to go out with Liz and start a friendship with her’.

There were more divergent views about ‘who matters most’ in the case when responded to by the group that ‘disagrees’ with the proposal, versus those that ‘agreed’ or those that ‘disagreed strongly’.

The areas of concern in this case that were most frequently highlighted in the ethical grid section included: support, worries, principles, and health.

There were a range of alternative suggestions and proposals but mostly these views could be summarized by two broad themes that include:

1.)   That John follows professional boundaries, by not forming a relationship with Liz,outside of his occupational therapist role, seeks help from his manager or supervisor, and decline any contact with Liz out of his role as a therapist.

2.)   Or,that John, and possibly Liz, consult with a supervisor, manager, or a psychologist, after terminating their therapeutic and professional relationship, take time out to consider their feelings for each other and their friendship, and consider the views of these support persons before developing their friendship further.

Conclusions

We can say that this sort of issue, that is to say maintaining appropriate and clear boundaries between a health professional and their client, is treated seriously by our governing authorities, as can be seen in the New Zealand Health Practitioners Disciplinary Tribunal case, about an occupational therapist and their client, that was referenced in this case. But who draws the lines about what is appropriate between the client and the therapist, who decides what constitutes professional behaviour, who has the power to decide what is right and wrong in our society, and how do we deliberate on matters such as in this case, that are bound to occur when we work together as human beings? The NZAOT Values Exchange enables us to consider such matters, enquire critically, exploring both our thoughts and feelings, and sharing these together with each other in an open and safe manner. It is through this process that we can learn from each other, and enhance our decision-making process in a mature and ethical manner.

Prepared by Simon Leadley, NZAOT VX Administrator, August 2010.

Harvesting our catch: Hands on NZAOT Values Exchange.

A workshop about the NZAOT Values Exchange,NZAOT Clinical Conference, 2009

Presenters in this workshop include:

Simon Leadley

Organisation: Forensics Unit, Waikato Hospital, WDHB. Hamilton.

Ellen Nicholson

Organisation: Occupational Therapy Professional Leader in Mental Health, ADHB.                                   

Introduction

Acting in an ethical and moral manner in our everyday life is a value many of us believe in. Generally our values and our beliefs in what is ethically and morally good are diverse, but commonalities do exist. This highlights a need for ethical deliberation in our everyday life and in our professional practice, and is one reason why ethics needs to be at the heart of healthcare. Occupational therapists, like other health professionals,need to be able to deliberate and reflect on their ethical behaviour in their everyday practice. As a profession we need a tool that can assist us with this process, that is effective and efficient in this objective, is research-based,is easily recordable, and that is transparent. An ethical reasoning tool that can deliver these results is indispensible to any modern professional as it allows us to clearly evidence the complex decisions we can make in our everyday practice. The NZAOT Values Exchange is such a tool and the benefits of its use for occupational therapists will be outlined briefly in this presentation. The practical part of this workshop will further highlight for you, the benefits of the NZAOT Values Exchange in your practice.

What are ethics?

“Ethics are a set of principles that people use to decide what is right and what is wrong[i].”  “Moral[relates] to right and wrong and the way that people should behave [and is] based on what you believe is right rather than what the law or rules say is right[ii].”

Ethics and morals were once synonymous, but in more recent times have become separate yet related words. “Ethics is the science of morals, and morals are the practice of ethics…[as in the example] his ethics may be sound, but his morals are abandoned[iii].”In modern society there is the sense that ethics are more disconnected from religion than morals, and that ethics have more to do with professional codes of conduct than morals do.

What are values?

“Values [are] the principles and beliefs that influence the behaviour and way of life of a particular group or community[iv].” 

Also a value is simply a preference for some thing or some process: ‘I like this’, ‘This makes me feel sick’, ‘I am afraid of this’, ‘I find this beautiful’. Value means, “the amount that something is worth…[or] the degree to which someone or something is important or useful…[and] the particular interesting quality that something has[v].”

Values, either positive or negative, are expressed through our behaviours and words.

Why values are important

People, and different cultures have different values and beliefs and will at times see a good moral act in quite different ways. The extent to which our values and beliefs influence our decision-making and choice of morals is made clearer through philosophical deliberation. Philosophically speaking there are no right or wrong answers, but it is unhelpful to us if we cannot make decisions, and sound ones at that. Therefore we need to make our decisions and resolve our problems/challenges in life, based on evidence and on our values or beliefs. Professor Seedhouse would assert that in our day-to-day deliberation we make decisions based on our values first, and then the evidence[vi].This is what Seedhouse calls values-based decision-making (VBDM)[vii].When we deliberate using a VBDM process we need to examine both our values and the evidence at hand. It is, however, our values that ultimately guide our decision-making. The VBDM and the use of the Values Exchange enable us to engage in this process in an explicit and transparent way.

Ethics. The heart of healthcare.

Western health care systems such as in NewZealand/Aotearoa have been undergoing significant change and facing important debates about the funding and cost effectiveness of our public health care system. An intellectual crisis has emerged that concerns the very nature of our health care system and this has fueled tension between old and new paradigms or ideas about what good health care looks like. Ideas such as more open access to medical knowledge, holistic health care practices, increasing awareness of ethics in healthcare, and a debate about whether to focus health work on asocial versus an individual level have been occurring[viii].This process of change is beset with tension, but ethics offers a helpful way forward. That is by teaching ethics to all health workers and by involving ethics at the heart of healthcare we help to ensure that health intervention exhibits the highest degree of morality. Also by clearly placing ethics at the centre of our health care system we help to ensure that debates about what we value in healthcare are made transparent, and the differences between what we value and believe in can be deliberated on effectively. We do however need a clear model of health and it is helpful for us to have tools that enable us to complete effective ethical deliberation. This will support health workers to make good decisions in their work and ensure their work is of the highest moral nature.

We need a model of health. Total Health Promotion.

The idea of Total Health Promotion is based on Seedhouse's Foundations Theory of Health. Many other models of health have limitations such as a narrow focus about what health is, being individually focused,or being ethnocentric or discounting other cultural points of view. Health care from Seedhouse’s perspective is more concerned with attempts to “liberate the enhancing potentials that people possess…[or to prevent] dwarfing [or the limiting of human potential][ix].” It is not limited to the individual, nor does it limit itself to artificial human constructs, without first realizing these and acknowledging them explicitly.The model is not limited to traditional or a specialist form of healthcare such as health professions like doctors, surgeons, nurses or therapists, but includes all work that has as its aim the improvement in the health of others.This health model is ethically mature, allows for self-critical reflection, and importantly is focused on autonomy creation[x].

The Values Exchange can help occupational therapists and the people they serve.

The Values Exchange assists occupational therapists to explore what is immoral in any particular decision relating to health work, and by giving a clear core rationale the Values Exchange enables the therapist to decide for themselves between possible alternative interventions.

The Values Exchange offers occupational therapists, like you, the chance to choose actions that produce the highest degree of morality, the means to justify these choices, and to explain how these choices can be shown to enhance the person who you serve or your client’s ability to reach their full potential in life.

The NZAOT Values Exchange offers occupational therapists, like you, the ability to demonstrate your commitment to ethics and ethical deliberation. Your participation in NZAOT Values Exchange cases, which is recorded, can serve as evidence for your part in the Occupational Therapy Board’s compulsory Continuing Competence Framework for Recertification (CCFR) process.

The Values Exchange addresses important social issues that relate to healthcare using a safe, and structured environment.

The Values Exchange allows therapists to have a personal educational experience each time they address a proposal.

The Values Exchange allows occupational therapists the ability to immediately explore other people's views in great depth.

In any difficult decision that an occupational therapist needs to make, at an individual, community,social or organizational level, the Values Exchange enables the therapist to evidence their rationale and feelings clearly, and enables participation in this decision by a wide range of people such as colleagues, other professionals, their clients, and the general public.

The Values Exchange offers scope for education, teaching and research through its system of web-based technology, theoretical and research based foundations, and a clear system for collating, analyzing, recording and storing case and survey data.

Anecdotes from two NZ/Aoteroan occupational therapists: some of the benefits they have experienced when using the NZAOT Values Exchange.

The Values Exchange is a forum to discuss dilemmas, conflicts, and clinical, professional, social, and political issues both locally and worldwide.

Work completed on a Values Exchange case, on a particular topic, can form the basis of further research or education; or assist in particular action regarding political/organisational issues. E.g. occupational or social justice matters.

The Values Exchange offers a way to understand our values and beliefs, and those of others by sharing in our views in a safe and open way.

Above all I like the Values Exchange because it is transparent and open to all, including our clients/patients or the people we serve.

From a personal point of view the benefits are:

- Challenges or supports my thinking.

- Challenges or supports my rationale/decision making.  

- Provides a more indepth picture due to varied responses.  

- Adds to my HPCA requirements on safe practice and ethics. 

- Reading other responses provides a more global picture and helps me to have insight into other thoughts/ideas. 

- Assists me to become less black and white and understand alternative reasoning/rationale.

From a practice point of view the benefits are:

- Case study analysis.  

- Teams can respond and analyse responses.  

- Issues which are difficult to discuss openly or are confrontational can be posted on the website. 

- Issues, which are not confined to one workplace, can have NZ wide responses/input (and can eventually have global input).  

- If the response group is defined, a workplace or DHB can use the website for their particular issue.

A quick tour of the Values Exchange

Conclusion:

The Values Exchange is an online Values-Based Decision-Making (VBDM) and ethical reasoning tool. It is founded on the philosophical and research based work of Professor David Seedhouse. The NZAOT runs a Values Exchange site and this has links to the many other Values Exchange sites worldwide. We need such tools in our profession to enhance our decision-making and ethical deliberation. The benefits to occupational therapists, our clients and others we serve includes the ability to share in our values, provides for a transparent decision-making process, it is open to all, participation in this process is recorded and serves as evidence of our ongoing commitment to professional and ethical deliberation, it supports our moral behaviour, and the people we serve can participate in the process too. The Values Exchange can serve as an important tool in education and research, and work completed using the Values Exchange can provide a clear analysis for political activity aimed at improving our work for health or for justice-based issues.

Take Home message

Further benefits of the Values Exchange[xi]include:

The Values Exchange provides transparent web-based access to all citizens' views - enabling and encouraging decision-makers to take account of the public's views.

The Values Exchange enables every participant, who has submitted a view, to see everyone else's views - there is no editorial control.
The Values Exchange creates a searchable public record.

The Values Exchange actively seeks consensus: once a case is closed citizens can review it and learn from it - the same or a revised proposal can then be posted to see how consensus is developing.

The Values Exchange is a continuing process of personal learning and group debate - members’ benefit in proportion to the effort they invest.
 
Endnotes

[i] Rundell, M. (ed.) (2007). MacMillan English Dictionary For Advance Learners, A&C Black Publishers Ltd,Oxford.

[ii] Ibid.

[iii] Gowers, E. (ed.) (1965). Fowler’s Modern English Usage, Oxford University Press, Oxford.

[iv] Rundell, M. (ed.) (2007). MacMillan English Dictionary For Advance Learners, A&C Black Publishers Ltd,Oxford.

[v] Ibid.

[vi] Seedhouse, D. (2005). Values-Based Decision-Making For The Caring Professions.  West Sussex, England: John Wiley & Sons, Ltd

[vii] Ibid.

[viii] Seedhouse, D. (1998). Ethics.The Heart of Health Care, John Wiley& Sons Ltd, West Sussex.

[ix] Ibid.

[x] Seedhouse, D. (2002). Total Health Promotion. Mental Health,Rational Fields and the Quest for Autonomy, John Wiley & Sons Ltd, England.

[xi] Values Exchange website, FAQs page: http://allschools.au.values-exchange.com/FAQ.(2009).