Based on our recently published ethnography of primary care we will show how (a) knowledge from many sources is collectively transformed by practitioners into what we have called “knowledge-in-practice-in-context”; (b) this involves complex social processes, often within communities of practice; (c) “contextually adroit” practitioners use knowledge-in-practice-in-context to meet practical needs that go far beyond just the technical (e.g. clinical). They must encompass the many other competing demands and constraints that stem from their multiple roles, (e.g. managerial, financial, political) and therefore their knowledge-in-practice-in-context must be flexible and multifaceted, relying not simply on clear-cut, research-based guidance but instead on what we have termed “mindlines”, internalised, malleable, tacit guidelines, which over a lifetime are continually developing and collectively reinforced. We argue that a clear understanding of these processes is essential for the implementation of effective care.
Andrée le May qualified in nursing at Chelsea College, University of London in 1982. After working in the community she was appointed as a Specialist Nurse for Research and Development at West Middlesex University Hospital and became interested in how nurses used knowledge in practice. This led to early research on the use of evidence. Since then she has continued to work in this area, publishing books on evidence-based practice, the dissemination and implementation of research and the use of communities of practice for improving learning (Communities of Practice in Health and Social Care: Wiley 2009). Before retiring from full-time work she was Professor of Nursing at Southampton University where she ran a large, pioneering doctoral programme in clinical practice.
John Gabbay is Emeritus Professor at the University of Southampton. After qualifying in medicine in 1974 he worked at the University of Cambridge on the historical and social origins of medical knowledge. As a public health physician in the 1980s in Oxford and London he developed an interest in the organisation and management of acute health services, especially the interface between medicine and management, and was involved in the development and evaluation of clinical audit. From 1992 to 2004 he directed the Wessex Institute for Health R&D including from 1996 directing the National Coordinating Centre for Health Technology Assessment. His main recent research has been on the social and organisational aspects of the way knowledge enters clinical practice and policy.
Their recent book, Practice-based evidence for health care: clinical mindlines (Routledge 2011) is based chiefly on an ethnography of primary care and challenges existing assumptions about the way the clinicians use knowledge in practice. They are also co-authors (with Cathy Pope and Glenn Robert) of Organisational Innovation in Health Services Lessons from the NHS Treatment Centres (Policy Press 2011), which uses case studies to critically examine how national policy was translated into new local services.