ABSTRACT
Knowing decisions? ‘But do we ever actually make decisions?’ Nick laughingly, but only half jokingly, asked us about our observations of the practice. What he meant was that most of the clinical work was fairly routine and did not require a great deal of conscious reasoning to determine the next step to be taken.1 And he was also perhaps trying to defend why he and his colleagues were frequently unable to explain properly why they had decided to act as they had with any particular patient. As has been repeatedly found in other sectors (e.g. Boden 1994), clinicians often had to deal with fuzzy, incomplete and flexible information that continually needed to be clarified, refocused or even occasionally completely realigned, often through talking with other people involved. Thus they might inch forward step by step, layer by layer – arriving at reasonable and ‘satisficing’2 ways to act that never quite looked like a decision. Yet clearly at some level they were making decisions all
the time, if only through a series of fine-grained and fluid interactions that took account of the multifarious considerations discussed in Chapter 2. Whereas the evidence-based practice movement appears to be based on the premise that clinical practice is a series of decisions, in reality the process is often one of weaving one’s way through complex and often intangible negotiations that both react to and impact upon the task in hand (Greenhalgh et al. 2009).3
