A Practical Approach to Recording Unstructured Field Observations

The 3 Cs of Content, Context, and Concepts: A Practical Approach to Recording Unstructured Field Observations 1 Michael D. Fetters, MD, MPH, MA ABSTRACT 2 Ellen B. Rubinstein, PhD, MA Most primary care researchers lack a practical approach for including field obser- 1Mixed Methods Program, Department of vations in their studies, even though observations can offer important qualitative Family Medicine, University of Michigan insights and provide a mechanism for documenting behaviors, events, and unex- Medical School, Ann Arbor, Michigan pected occurrences. We present an overview of unstructured field observations 2Department of Sociology and Anthro- as a qualitative research method for analyzing material surroundings and social pology, North Dakota State University, interactions. We then detail a practical approach to collecting and recording Fargo, North Dakota observational data through a “3 Cs” template of content, context, and concepts. To demonstrate how this method works in practice, we provide an example of a completed template and discuss the analytical approach used during a study on informed consent for research participation in the primary care setting of Qatar. Ann Fam Med 2019;17:554-560. https://doi.org/10.1370/afm.2453. INTRODUCTION linical observation is a method well known to primary care physicians. It is the rare physician who takes a patient’s words at face Cvalue without also using contextual clues, such as the patient’s appearance and behavior, to construct a picture of the patient’s health.1 Indeed, medical education has recently highlighted the need for physicians to be more observant through innovative curricula that teach observational skills by examining art.2,3 Field observations offer insight into behaviors and the environment4 and can play an important role in primary care research. A decades-long history of observational research in primary care has demonstrated how contextual factors both in and out of the clinic influence the effectiveness of interventions, as well as clinical outcomes.5-9 A recent commentary in JAMA Internal Medicine has called for more “ethnographic and field studies” to capitalize on the “value of direct observation,” particularly in studies of patient safety.10(p1024) Unfortunately, most primary care researchers lack a practical approach for including field observations in their studies. Here, we present an overview of unstructured field observations as a qualitative research method for analyzing material surroundings and social interactions, aimed at researchers new to unstructured observations. We then detail a practical approach to collecting and recording observational data through a “3 Cs” template of content, context, and concepts. To demonstrate how this method works in practice, we provide an example of a completed template Conflicts of interest: authors report none. and discuss the analytical approach used during a study on informed consent for research participation in the primary care setting of Qatar. CORRESPONDING AUTHOR Michael D. Fetters, MD, MPH, MA Mixed Methods Program and Department BACKGROUND of Family Medicine Observational field research has its roots in the social sciences and is University of Michigan Medical School 1018 Fuller St most often associated with participant observation fieldwork in cultural Ann Arbor, MI 48104-1213 anthropology and sociology, though it has spread to disciplines as diverse [email protected] as nursing, education, and social work.11 Although he was not the first to ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 17, NO. 6 ✦ NOVEMBER/DECEMBER 2019 554 UNSTRUCTURED FIELD OBSERVATIONS undertake fieldwork, the Polish anthropologist Bronislaw educational, occupational, or other types of privilege, Malinowski has been ascribed with popularizing partici- or some combination thereof.19 Such differences create pant observation as a research method.12 Unlike struc- a certain power dynamic between researchers and par- tured interview sessions, participant observation allows ticipants that can influence data collection.19 A reflec- for more flexible interactions with research participants tive activity, such as journaling or freewriting, can help through social events, casual conversations, and semi- define the researcher’s lens and help the researcher rec- structured interviews conducted in settings that are ognize how he or she may be perceived in the field.22 a natural part of participants’ everyday lives.13 There is some debate as to how much a researcher should “participate” in daily activities,12 but it is often enough RATIONALE FOR COLLECTING FIELD simply “to be tolerated as an unobtrusive observer.”14(p195) OBSERVATIONS Malinowski’s work was influenced by the scien- Perhaps the most compelling reason for conducting tific positivism of the era, but later social scientists observations is to understand behavior (Table 1). Studies launched an antipositivist (interpretivist) critique that have suggested that nonverbal behavior plays a consider- shifted the focus of observational research from a able role in communicating shared cultural meanings.23 search for social facts to an understanding of cultural Furthermore, emotions are communicated more through meanings.15 We follow an interpretivist approach in facial expression and vocal tone and inflection than believing the purpose of observational research is through spoken word.24,25 Finally, as it pertains to health to arrive at what the anthropologist Clifford Geertz research, individuals tend to underreport their unhealthy called “thick description.”16 In a famous example, or socially undesirable behaviors26,27 and overreport the Geertz explains how the same action (a quick blink of converse.28 Observational research thus contributes to the right eye) holds different meanings based on the understanding human behavior in all of these scenarios. cultural context in which it occurs.16 Only in a specific Field observations can help researchers understand context will a blink be recognized as a wink—a con- how the interactions and activities in a given setting spiratorial signal to a friend—rather than as a meaning- inform behaviors and beliefs (Table 1).29 They con- less twitch of the eye. Thick description, then, uses tribute to uncovering the broader context of a given empirical data from multiple sources to contextualize scenario, making observational research especially individual behavior and interpret its meaning. well suited for studying process.19 In primary care, for A crucial assumption in participant observation example, observational research has deepened under- is that the researcher is the instrument of data col- standing of the clinical contexts in which practice lection.17 This assumption means all data are filtered transformation to patient-centered medical homes through the researcher, through his or her personal has occurred.30-36 Field observations have also helped characteristics, background, and experiences.18 The contextualize the (quantitative) results of randomized result is a different relationship to objectivity than that controlled trials, by providing insight into why certain found in the natural sciences. Observational research does not seek objectivity through a Table 1. Reasons for Conducting Observations in Primary conceptual separation between researcher and Care Research, With Clinical Examples study participants and phenomena.19 Research- ers are not blank slates; instead, they use prior Reasons to Observe Clinical Examples knowledge and experiences as either implicit To understand behavior Describe whether or how staff follow clinical or explicit bases of comparison to understand guidelines or study protocols what they observe in the field.20 Personal bias To understand context Understand environmental factors influencing is not seen as a flaw but as part of data collec- uptake of an intervention 12 To understand process Examine at baseline how clinical preventive ser- tion. Qualitative researchers speak of using vices are delivered in offices bias to explore hunches or ideas, as well as to To recognize patterns Examine variations in how clinical preventive ser- seek out information contrary to their own vices are implemented across multiple practices 21 To see what people are Identify perceived cultural taboos, for example, views. It is critical before going into the field reluctant to discuss parents reluctant to discuss HPV vaccination for for researchers to conduct a personal inven- prepubertal children tory and reflect on their preconceptions, as To gain direct personal Explore patient experiences of undergoing clinical experience and procedures, for example, the experience of colo- 21 these will affect their interpretation of events. knowledge noscopy preparation Researchers must also remain aware of poten- To move beyond Observe how patients respond to universal screen- selected perceptions ing questions, for example, depression screen- tial differences in status between themselves ing, intimate personal violence screening and their study participants, where higher status may be conferred by socioeconomic, HPV = human papillomavirus. ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 17, NO. 6 ✦ NOVEMBER/DECEMBER 2019 ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 17, NO. 6 ✦ NOVEMBER/DECEMBER 2019 554 555 UNSTRUCTURED FIELD OBSERVATIONS randomized controlled trials have succeeded or failed.9,37 Table 2. Potential Reasons for Not Conducting Unstructured Thus, field observations allow Observations in Primary

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