Tacit and encoded knowledge in the use of standardised outcome measures in multidisciplinary team decision making: A case study of in-patient neurorehabilitation

Abstract

This paper explores how multidisciplinary teams (MDTs) balance encoded knowledge, in the form of standardised outcome measurement, with tacit knowledge, in the form of intuitive judgement, clinical experience and expertise, in the process of clinical decision making. The paper is based on findings from a qualitative case study of a multidisciplinary in-patient neurorehabilitation team in one UK NHS trust who routinely collected standardised outcome measures. Data were collected using non-participant observation of 16 MDT meetings and semi-structured interviews with 11 practitioners representing different professional groups. Our analysis suggests that clinicians drew on tacit knowledge to supplement, adjust or dismiss 'the scores' in making judgements about a patients' likely progress in rehabilitation, their change (or lack of) during therapy and their need for support on discharge. In many cases, the scores accorded with clinicians' tacit knowledge of the patient, and were used to reinforce this opinion, rather than determine it. In other cases, the scores, in particular the Barthel Index, provided a partial picture of the patient and in these circumstances, clinicians employed tacit knowledge to fill in the gaps. In some cases, the scores and tacit knowledge diverged and clinicians preferred to rely on their clinical experience and intuition and adjusted or downplayed the accuracy of the scores. We conclude that there are limits to the advantages of quantifying and standardising assessments of health within routine clinical practice and that standardised outcome measures can support, rather than determine clinical judgement. Tacit knowledge is essential to produce and interpret this form of encoded knowledge and to balance its significance against other information about the patient in making decisions about patient care.

Implications of Variability in Clinical Bedside Swallowing Assessment Practices by Speech Language Pathologists

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The roles of specialisation and evidence-based practice in inter-professional jurisdictions: A qualitative study of stroke services in England, Sweden and Poland

“…Evidence-based medicine (EBM) changes medical practice from being primarily grounded on tacit knowledge to one characterised by encoded knowledge (Dopson et al 2003;Greenhalgh et al 2008). EBM is not a purely scientific endeavour, what EBM is and how it is defined is contested and hence political (Harrison and McDonald, 2008).…”

“…Critics argue that much EBP is inappropriate in therapists' clinical work and that a fundamental clash exists between the medical research and therapy paradigms leading to the "therapies' dilemma" resulting from the medical model of evidence failing to recognise the value of non-RCT research designs (Grimmer et al 2004). However, clinical practice is not solely governed by evidence, Greenhalgh et al (2008) argue that it results from the synthesis of professional judgement (tacit knowledge) and formal rule based systems such as EBP (encoded knowledge), concluding that encoded knowledge alone was not sufficient for clinical action.…”

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