Abstract
The reviewed paper raises questions about the value of evidence-based practice as the primary source of influence on decision making in nursing. By drawing on Gabbay and le May’s (2004) concept of ‘clinical mindlines’ the author has attempted to justify what general practice nurses’ (GPN) decision making looks like in the everyday work place. They use examples within their data to demonstrate decision making in multi-faceted contexts in which best clinical practice is in tension with best patient interest and pragmatism. They claim that while evidence-based practice is a well-established model of accountability in clinical practice, as a primary source this approach does not offer sufficiently flexible significance to the complexity of social context to influence the decision maker. In other words, without tacit judgement to determine the salient issues in each situation, the practice nurse is not well prepared to make best practice decisions. They also posit that although the general practitioner (GP) is often able to demonstrate this intuitive skill in practice, this skill is not easily or adequately disseminated to the GPNs.
As a qualitative study there are some quotes used as rich data which will be familiar to many readers. These are findings from an ethnographic study which claims that the GPNs’ mindlines have not been sufficiently established to become ‘convention’ and this is because their role is evolving rapidly. It is therefore evident that while there is acknowledgment of standardised decision-making strategies used in practice, these are not flexible enough to adopt without consideration of the considerable influences that come with working in a general practice environment. One of the salient findings was that although GPs have established mindlines which are demonstrated effectively, the formation of these are not shared with the GPNs, who often rely on generating their own ways of thinking from a wide range of resources to manage their decision-making.
One of the challenges for the author is how to convey an understanding of mindlines and bricoleur activity with empirical data. As an ethnographic study, it was possible to hear the variety of educational experiences described and how these could be interpreted using the theoretical model proposed. As forms of decision making these conceptual approaches are interesting and merit discussion. The building of contextual influences that subsequently become ‘mindlines’ is not unfamiliar in decision-making literature, but it is important that we continue to explore practice with insight into the challenges facing nurses in increasingly complex environments. Furthermore, evidence-based practice should be encouraged to evolve to reflect the value of such qualitative studies as an opening discussion about flexible standards to measure what is good practice.