A complementary process: agenda navigation

Agenda navigation is a complementary process that may or may not be

accompanied by agenda mapping. Navigation involves “accurately ascertaining one’s position and planning and following a route” (Oxford University Press

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2013). Agenda navigation can be provisionally defined as follows: if agenda mapping is the explicit discussion of topics to be covered, agenda navigation is the steering of the conversation by the practitioner, as it unfolds, the shifting of focus, changing of the subject, to reach a conclusion to the consultation. It can be done skilfully, or less so, and with greater or lesser attention to the needs of the patient. Put simply, a practitioner might use agenda mapping at key points but will navigate for much of the clinical encounter time.

The construct is proposed in an attempt to capture the focusing process that extends throughout the clinical encounter. This is important in extending the conceptualisation of agenda mapping as something that is not only relevant to a particular part of the clinical encounter but something that influences that encounter as a whole. In clinical encounters where agenda mapping is present, the “map” provides a structure for how the clinical encounter time may be used.

Clinicians may refer back to it to ensure they cover all items in the available time for example. In this sense they use the map to navigate the clinical encounter.

The concept of agenda navigation may also be useful in thinking about how the focus in a clinical interaction shifts when agenda mapping is not present. When listening to a clinical interaction where a number of different talk topics are covered in a single encounter, there is a difference between those in which the focus shifts effortlessly across topics, and those in which this shifting appears more stilted. Articulating what makes for a more skilful conversation when there are multiple interrelated topic areas may be helpful in understanding how to teach clinicians to manage these conversations.

When asking clinicians about the way in which they structure their clinical encounters (Chapter 3), many referred to models of practice that guide their decision-making (see box 5-6). They also described following intuition that had developed through experience. Clinicians seek opportunities to raise and

integrate their agenda into the conversation. For example they might look to link an agenda item (e.g. smoking) with something the patient has raised (e.g.

exacerbation of asthma symptoms). Inherent in these strategies is a sense of

being aware of where the conversation is focused in the here and now, and to where they might want to steer it, much like a process of navigation. On a broader level, these kinds of actions can be seen against existing model of the consultation. So for example there might be a shift in the focus of the clinical interaction from management of the patient’s presenting concern (exacerbation of asthma symptoms) to opportunistic health promotion (smoking) (Stott and Davis, 1979).

Box 5-6: Reflections from focus group participants about how they structure their consultations

Consultation models

“Well communication skills, that’s where we usually start and the structure of the consultation and looking at consultation models” (focus group participant, GP practice, Cardiff, GP4)

“When they come in during the consultation doing the history then examine and then we’ll sit down then we’ll come to the investigations part and we look at all the numbers and we see how they are and what they can be and how the symptoms are explaining with the numbers that are there on the papers and what else can be done err to invade those symptoms.” (focus group participant, Cystic Fibrosis team, D3)

Intuition and experience

“… a big part of it is intuition that you learn from experience” (Academic GPs, P5) “I’m not sure that I necessarily think to myself “right, how shall I structure this consultation” its maybe a bit more of a free flowing entity than me thinking I’ll do this first. I’ll allocated that a few minutes and then move onto this” (focus group participant, Academic GPs, P4)

Shifting topics

“Sometimes you can use the one thing that they came in to ask for …. to lead you down a different path” (focus group participant, GP practice, Cardiff, GP3)

“…I find relating (my agenda) to something they’ve come in about the most useful way (to raise it)..” (focus group participant, Academic GPs, P5)

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Clinicians appear to do this naturally with varying degrees of expertise, and skilful navigation may be best conceptualised as intuitive and mindful. With clinicians who are more highly skilled, navigation appears seamless and integrated, with different talk topics arising from each other. These clinicians find ways of creating links or “bridges” across topic areas. Where there is less skilfulness, conversations may seem disjointed and even awkward. Clinicians may find that they have delved too deeply into one topic area without knowing how to shift focus for example. Agenda navigation can occur with differing degrees of collaboration. Where this is a shared process, clinicians will pay attention to shared goals and aspirations, and where these are unclear, may take time to formulate these with patients before considering the direction both of the conversation and of the clinical contact overall. Navigation involves

maintaining a dual focus on the immediate happenings of the clinical encounter, and the “meta-process” of where the conversation is going with regard to

immediate and longer-term goals or aspirations. Much like a sailor navigating the seas, clinicians will guide the conversation in a particular direction while shifting flexibly to respond to what arises in the moment.

The concept of agenda navigation is relatively underdeveloped in this thesis. It is proposed in an effort to capture the naturally occurring strategic process that occurs when focus is established in a clinical interaction. It may be particularly relevant in the management of long-term conditions where multiple interrelated areas for discussion are common. In the words of one of the focus group

participants:

“We’re being put under a lot of pressure because we’re not only dealing with … chronic disease but also we’re dealing with all the other things that patients are coming to see us about… there would be a lot of things (to talk about) and we’re having to refocus the way we structure consultations in order to meet those demands.” (Focus group participant, GP surgery, Cardiff, GP4)

A hypothesis arising from attempts to define it here, is that when agenda navigation occurs together with explicit agenda mapping, this will result in a

more collaborative interaction that is more efficient and effective because both parties are focused on the priority area of their work together.

5.5 Conclusion

The model presented in this chapter is a consolidation of the conceptual development phase of this thesis. New terminology of agenda mapping and agenda navigation is proposed as a refinement of the concept of agenda setting.

Agenda mapping is defined as a structured conversation involving two-steps: (1) identifying talk topics, and (2) prioritising these to establish a focus. Agenda navigation is defined as a focusing process that arises more naturally in the clinical interaction and occurs throughout that encounter. Clarification of this conceptual foundation provides a rationale for measure development.

At this stage of the research the candidate needed to decide which direction it should progress toward. On the one hand the candidate (NG) could have developed the construct of agenda navigation more fully. To take this forward the candidate (NG) considered using qualitative techniques such as discourse analysis to examine naturally occurring clinical encounters, i.e. real life clinical encounter. The aim would be to consider where and how the focus of the conversation shifted, if and how any explicit or implicit agreement was made about that shift in direction, and who initiated that shift. In this way the more naturally occurring shift of focus within clinical encounters could be described in rich detail. This work might also provide some insight into if and how this

process may be measured, and consequently if and how it links with agenda mapping.

The second option was to progress with measurement of agenda mapping along the lines that are described in the second part of this thesis. This second option was selected for two reasons. The first was that no measure of agenda mapping had been identified, suggesting that this was a worthwhile piece of work. Having a measure of agenda mapping would also be useful in terms of later work that might be conducted with agenda navigation. Secondly, by progressing with

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measure development, the candidate (NG) would develop research skills in quantitative analysis. Given that the PhD involves training in research it was decided on balance that this would be a suitable option.

The second part of this thesis considers the question “is agenda setting measureable?” and is grounded in the model presented here. From this point onward the emphasis is on agenda mapping and the research question is therefore reformulated, as “is agenda mapping measureable?”