The three sites provided a wide array of contexts for observing navigation. They differed with respect to the scope of the navigation program, the phases of cancer care addressed (i.e., screening, diagnosis, or treatment), the history/longevity of the program, the emphasis placed on various navigator responsibilities, and the background (e.g., clinical, survivor, cultural/ethnic) of the navigators, as well as their physical and organizational location (e.g., community health centers, large medical centers, outpatient primary care, or treatment clinics). These contextual differences appeared to influence, to an undetermined extent, what navigators do. Thus, we sought an observation protocol that would reliably capture activities in these diverse settings.
Domains of Navigator Behavior
Guided by the concepts of task and network, we defined five categories each of navigator tasks and social networks. The task categories include navigating with a patient, facilitating for a patient, maintaining systems for all patients, documenting/reviewing actions, and other tasks. The five network categories include patient(s), clinical provider(s), nonclinical staff, formal and informal support, and medical record systems. Each of these categories is defined, described, and illustrated below.
Navigating tasks consist of identifying and mitigating barriers with patients. They include telling (explaining when and where biopsy will be done, describing what it will be like); inquiring (asking about barriers to attending the appointment, exploring the patient's concerns); supporting (listening to fears about treatment); and coaching (discussing questions that need to be asked at next appointment and how to ask them).
Facilitating tasks are performed for a specific patient. They include finding (locating current patients and ensuring that they will come to appointments); coordinating team communication (ensuring the entire care team is aware of the next steps); integrating information (ensuring that different types of patient data are documented and shared as needed); and seeking collaboration (enlisting other providers in addressing the patient's fears).
Maintaining systems tasks support all patients. They include identifying potential patients (reviewing lab results to note patients who need follow-up); building networks and referral routines (meeting with clinicians to explain navigator role and discuss referral criteria); and reviewing cases (checking on ticklers and open issues).
Documenting activities and reviewing information constitute another major navigator task. They include recording navigator actions (recording steps taken with or on behalf of the patient in the patient's medical record or a separate navigation file); handling test results (retrieving and entering patient data from labs, radiology, or other sources); and processing other necessary information (recording information or activities relevant to navigator role).
Other activities are those apparently unrelated to navigation. It was important to capture all network interactions, even when their relevance to navigation was not apparent. For example, many navigators have other distinct roles unrelated to navigation; documenting these other activities will help in understanding how the navigator role fits in with other roles, both formally and informally. This category includes research-related activities, such as consenting patients, providing clinical back-up, activities unrelated to navigation (interpreting for nonnavigated patients), and socializing (having informal conversation with co-workers).
Navigators may interact with a specific patient, such as when phoning the patient with information about an upcoming diagnostic procedure.
Navigators may also interact with providers, both within and outside their immediate location. For example, s/he might speak with the physician to confirm the meaning of a test result before discussing it with the patient.
Nonclinical staff, such as receptionists or administrators coordinating insurance, represent another group with whom the navigator may interact.
People who provide supportive services, either formally (social workers, translators, transportation staff) or informally (friends, family) within or outside the facility are another group with whom navigators interact.
The final category—paper or electronic medical record systems
—could be perceived as merely a means to communicate with members of the other four network categories, and it does function in that way. However, our preliminary observations indicated that, in the eyes of the navigator, the medical record itself takes on some of the qualities of a person, in that it needs to be informed and/or consulted before other actions are taken. This observation is consistent with those of many studies of human–computer interaction (Turkle 2003
Observation Protocol Refinement
The current observation protocol incorporates solutions to problems encountered in the field using the preliminary observation guide. Initially, observers were required to take continuous notes, recording the duration and mode of the navigator's activity, the person with whom s/he spoke, the activity, and the patient on whose behalf the activity was taken, plus descriptive narrative. This recording burden proved too onerous in the field: recording all observed activities not only interfered with the primary goal of noting tasks and social networks used by the navigators, but it did not produce more useful data.
Based on this early finding, two important changes were made to the observation protocol: activities were observed in 15-minute intervals, and coding focused on the primary activity of each interval. This time sampling methodology facilitates detailed reporting of navigator activities without attempting to capture everything that occurs during an observation. Observers start a new form every 15 minutes, focusing notes and coding on the navigator's primary activity during that period. Thus, each hour of observation time yields four distinct chunks of description and activity coding. This sampling interval provides some sense of the relative proportion of a navigator's time spent on different activities, while allowing observers to record more detailed notes about the main activity. This approach necessarily involves some observer judgment: sometimes a navigator tackles multiple short tasks during a single 15-minute interval. In such instances, observers were instructed to either group-like tasks into a single entry (making appointment reminder calls to a list of patients could be meaningfully described as one task) or focus on the first activity during the time period.
Through discussion, a five-by-five matrix emerged, with tasks on the vertical axis and social networks on the horizontal axis. The observation form itself was redesigned to incorporate on a single page both this simple matrix and an open area for handwritten fieldnotes (see ).1
After field testing, several additional refinements were made. Certain combinations of tasks and networks cannot occur. For example, the task of navigating can be performed only with a patient, while reviewing a patient's file can be done only with the medical record. To further simplify the form, matrix cells representing combinations that cannot occur are blacked out.
Also, observers at some sites reported that a significant amount of navigation is carried out by telephone, leaving and returning voicemail messages. Therefore, for each observation of a navigator action that involves contact with a patient, the observer also notes whether the interaction is synchronous (happening in real time) or asynchronous (delayed, as when leaving a voicemail) by recording either “S” or “A” in the appropriate cell. For all other cells in the matrix, a checkmark is used.
Finally, because some observed activities may involve more than one person or task, observers are encouraged to mark more than one cell if that best reflects what they are seeing. For example, if the navigator accompanies a patient to a physician visit, the observer puts an “S” in the cell representing “navigate/patient” and a checkmark in the box representing “facilitate/provider.”
The matrix supports coding of real-time activities as they occur, but we realized the need for simultaneous, structured, narrative fieldnotes, as well. Hence, we developed observation guidelines directing the observer to note relevant contextual factors, such as the location of navigation activity, the language used in navigation, the racial/ethnic backgrounds of both patient and navigator if known, and the navigator's other roles (if any) in the organization.
This matrix facilitates rapid categorization of tasks and networks, allowing the observer to concentrate on writing narrative description that will document important information about context and content that cannot be fully captured by the matrix. The observer is encouraged to ask the navigator questions to develop a better understanding of what the navigator is doing and why.2
Observers also are asked to record their impressions about interactions, clearly identifying these notes as their perceptions. For example, the observer might write “navigator and patient embraced warmly and seem to know each other well.” While these impressions are particular to specific observers, they nevertheless add richness to the description.