Evidence based guidelines or collectively constructed "mindlines?" Ethnographic study of knowledge management in primary care

doi:10.1136/bmj.329.7473.1013

BMJ 2004;329:1013 (30 October), doi:10.1136/bmj.329.7473.1013

Primary care

Evidence based guidelines or collectively constructed "mindlines?" Ethnographic study of knowledge management in primary care

John Gabbay, professor of public health¹, Andrée le May, reader in nursing²

¹ Wessex Institute for Health Research and Development, Community Clinical Sciences, University of Southampton, Southampton SO16 7PX, ² School of Nursing and Midwifery, University of Southampton

Correspondence to: J Gabbay j.gabbay{at}soton.ac.uk

Objective To explore in depth how primary care clinicians (generalpractitioners and practice nurses) derive their individual andcollective healthcare decisions.

Design Ethnographic study using standard methods (non-participantobservation, semistructured interviews, and documentary review)over two years to collect data, which were analysed thematically.

Setting Two general practices, one in the south of England andthe other in the north of England.

Participants Nine doctors, three nurses, one phlebotomist, andassociated medical staff in one practice provided the initialdata; the emerging model was checked for transferability withgeneral practitioners in the second practice.

Results Clinicians rarely accessed and used explicit evidencefrom research or other sources directly, but relied on "mindlines"—collectivelyreinforced, internalised, tacit guidelines. These were informedby brief reading but mainly by their own and their colleagues'experience, their interactions with each other and with opinionleaders, patients, and pharmaceutical representatives, and othersources of largely tacit knowledge. Mediated by organisationaldemands and constraints, mindlines were iteratively negotiatedwith a variety of key actors, often through a range of informalinteractions in fluid "communities of practice," resulting insocially constructed "knowledge in practice."

Conclusions These findings highlight the potential advantageof exploiting existing formal and informal networking as a keyto conveying evidence to clinicians.

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