Mindlines in multiple contexts: current uses and future development

18 January 2018

Student and Clinical Lecturer at Queen Mary University of London, Dominic Hurst (DPhil Evidence-Based Healthcare) reports on an examination of the concept of mindlines, in the context of the actions of healthcare teams, during a day of discussion in Cambridge. 

Clinicians don’t just follow published clinical guidelines. They follow their “mindlines”. John Gabbay and Andrée Le May coined this phrase to describe the “collectively reinforced, internalised, tacit guidelines” that guide the actions of the general practitioners (GPs) they observed in practice [1, 2]. Mindlines might be informed by the best available research but they also drew on multiple other sources of information and experiences as they developed over time. Rather than rigid entities, mindlines were conceived as flexible, responsive internal processes that guide practitioners in their context as they go about their practice. In the article that reported their ethnographic study of GP practices, Gabbay and Le May found that not once did GPs seek and use guidelines in the linear fashion promulgated by the evidence-based medicine movement. Instead, the GPs described guidance that was stored in their heads. It was shaped a little by reading guidelines but was deeply based on earlier learning and experience and, mainly through informal discussions with colleagues, was constantly checked against their practices’ and other professional norms. Thus, it was mindlines, not guidelines, that guided clinicians’ practices.

Mindlines are guiding more than just GP activity. Gabbay and le May also reported on the development of mindlines as observed among trainee hospital practitioners in the USA [2]. Over the 12 or so years since the article describing mindlines was published several researchers of practice have found the concept of mindlines to be a helpful way to describe what they observe or experience. It’s been suggested, for example, that this is what is guiding over-diagnosis of malaria in Africa [3]. Consultant psychologists’ prescribing was only partly informed by guidelines as they also managed competing and complex sources of knowledge that were held in their heads as mindlines [4]. And mindlines seem to have been guiding public health groups as they planned public health programmes [5]. In a recent systematic review 340 publications were identified that referred to mindlines [6]. It seems that the use of collective and personal, tacit internalised guidelines may be a more helpful way to understand how practices are guided beyond the realm of GPs.

The concept of mindlines is being used to guide ongoing research into practices in several disciplines. Five researchers using and developing the concept of mindlines met with Andrée Le May and John Gabbay for a day of discussion about mindlines in Cambridge on June 29th 2017. Fiona Cowdell is exploring how patient and clinician mindlines around self-management of eczema are formed. Kate Beckett is using Forum Theatre among other methods to try to improve clinician mindlines in relation to post-injury care. Tricia Tooman is exploring mindlines in the contexts of nursing practice around sepsis care in hospitals. Sietse Wieringa has been examining how GP mindlines develop and how they link to clinical guidelines. And Dominic Hurst has been exploring the role of mindlines in guiding general dental practitioner care in the moment of practice. Whilst we come from nursing (Andrée, Fiona and Kate), educational (Tricia), medical (John, Sietse) and dental (Dominic) backgrounds, we all share a common interest in how to use mindlines to explore and improve clinical practice, and how to develop the concept of mindlines to further these aims.

The notion of mindlines still needs work. The aims of the day were twofold: to share and discuss our experiences of engaging with the mindlines concept in our own contexts; and to explore ambiguous, under-developed or conflicting aspects of the mindlines concept. The latter surfaced as we discussed the former and included: What is the role of (political or interpersonal) power in mindlines? How do we describe mindlines around specific practices or problems without reifying them? How might mindlines be integrated into guidelines? How do the mindlines of different actors (including patients) within encounters link, combine or otherwise interact? Are there boundaries to mindlines and, if so, what are they? Through a day of engaged and challenging discussions we furthered our collective idea of what mindlines are but we have much more work to do to explore what is a rich and multi-layered concept of practice.

  1. Gabbay J, le May A. Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care. BMJ. 2004;329(7473):1013.
  2. Gabbay J, Le May A. Practice-based evidence for healthcare: clinical mindlines. Abingdon: Routledge; 2011.
  3. Chandler CIR, Jones C, Boniface G, Juma K, Reyburn H, Whitty CJM. Guidelines and mindlines: Why do clinical staff over-diagnose malaria in Tanzania? A qualitative study. Malaria Journal. 2008;7.
  4. Barley M, Pope C, Chilvers R, Sipos A, Harrison G. Guidelines or mindlines? A qualitative study exploring what knowledge informs psychiatrists decisions about antipsychotic prescribing. Journal of Mental Health. 2008;17(1):9-17.
  5. Kothari A, Rudman D, Dobbins M, Rouse M, Sibbald S, Edwards N. The use of tacit and explicit knowledge in public health: a qualitative study. Implementation Science. 2012;7(1):20.
  6. Wieringa S, Greenhalgh T. 10 years of mindlines: a systematic review and commentary. Implement Sci. 2015;10:45.