Practice guidelines in the context of primary care, learning and usability in the physicians' decision-making process - a qualitative study

Background: Decision-making is central for general practitioners (GP). Practice guidelines are important tools in this process but implementation of them in the complex context of primary care is a challenge. The purpose of this study was to explore how GPs approach, learn from and use practice guidelines in their day-to-day decision-making process in primary care. Method: A qualitative approach using focus-group interviews was chosen in order to provide in-depth information. The participants were 22 GPs with a median of seven years of experience in primary care, representing seven primary healthcare centres in Stockholm, Sweden in 2011. The interviews focused on how the GPs use guidelines in their decision-making, factors that influence their decision how to approach these guidelines, and how they could encourage the learning process in routine practice. Data were analysed by qualitative content analysis. Meaning units were condensed and grouped in categories. After interpreting the content in the categories, themes were created. Results: Three themes were conceptualized. The first theme emphasized to use guidelines by interactive contextualized dialogues. The categories underpinning this theme: 1. Feedback by peer-learning 2. Feedback by collaboration, mutual learning, and equality between specialties, identified important ways to achieve this learning dialogue. Confidence was central in the second theme, learning that establishes confidence to provide high quality care. Three aspects of confidence were identified in the categories of this theme: 1. Confidence by confirmation, 2. Confidence by reliability and 3. Confidence by evaluation of own results. In the third theme, learning by use of relevant evidence in the decision-making process, we identified two categories: 1. Design and lay-out visualizing the evidence 2. Accessibility adapted to the clinical decision-making process as prerequisites for using the practice guidelines. Conclusions: Decision-making in primary care is a dual process that involves use of intuitive and analytic thinking in a balanced way in order to provide high quality care. Key aspects of effective learning in this clinical decision-making process were: contextualized dialogue, which was based on the GPs' own experiences, feedback on own results and easy access to short guidelines perceived as trustworthy.