December 2014, VOL 5, NO 6

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Review

The Effect of Navigator Intervention on the Continuity of Care and Patient Satisfaction of Patients With Cancer

Cheryl Bellomo, MSN, RN, OCN, ONN-CG 

Nurses serving in the role of navigator can be instrumental in addressing the barriers of timely access to care, implementing interventions to reduce disparities, and improving overall patient satisfaction with cancer treatment. Using 10 primary studies published between 2008 and 2014, this literature review examines the effect of navigator intervention on the continuity of care and on patient satisfaction for those with cancer. The evidence provided by the quantitative and qualitative research studies utilizing a variety of tools supports the positive effect of navigator intervention on continuity of care and the satisfaction of patients during their cancer experience.

When presented with a diagnosis of cancer, patients begin an overwhelming journey filled with fear, uncertainty, and anxiety. They experience varying levels of distress about their disease, treatment, and prognosis, which affects their daily lives and ability to comply with treatment regimens.1 In addition, patients face challenges of a fragmented healthcare system manifested by multiple appointments and difficulties inherent to timely access to care.

Advancements in cancer research and development have contributed to the complexity of cancer care and increased the interval of time from diagnosis to treatment.2 Patients with cancer face a knowledge/education gap in a healthcare system with unfamiliar medical language; they, with their families, also often face barriers to optimal cancer care, including a lack of emotional support and lack of resources (eg, transportation, health insurance, employment/legal issues, and prescription assistance). These challenges can lead to disruption in the continuity of patient care and a decrease in patient satisfaction.

The coordination of care and services, the provision of emotional and psychosocial support, and the provision of education and resources are significant components to the continuity of care and satisfaction with care for patients with cancer.3 The purpose of this literature review is to examine the effect of navigator intervention on the continuity of care (ie, timely access to care and resolution of barriers to care) and satisfaction of patients with their experience throughout their disease trajectory.

Methods
The databases used to obtain research articles for this review included the Cumulative Index to Nursing and Allied Health Literature, PubMed, and manual searches. Research reports, reference lists, and related article links were also reviewed for inclusion. Key words searched in the databases used various combinations of “navigation roles,” “cancer,” “continuity of care,” and “patient satisfaction.” To capture the most recent data, only articles published from 2008 to 2014 were included in the search.

Inclusion criteria for the literature review included the following: (1) peer-reviewed publications in English, (2) available in full text, (3) research article, (4) use of a navigator was clearly defined, and (5) reports of continuity of care and patient satisfaction outcomes. In all the studies, the navigator was considered the independent variable. The effects and outcomes of the navigator varied from study to study. Overall, 10 studies met the inclusion criteria for this review.

A matrix was created and utilized to analyze the studies. Authors, patient population, setting, type of study, purpose, credentials of the navigator, data collection method, tools used to collect data, outcomes or findings of the study, study limitations, and implications for nursing were included in the matrix. Both quantitative and qualitative research methods as well as various study designs (eg, experimental and nonexperimental) to examine the effect of navigator intervention on the continuity of care (ie, timely access to care and resolution of barriers) and patient satisfaction were included. The terms “patient navigator” and “nurse navigator” are used interchangeably, unless referring to a nonmedical lay navigator. The original matrix has been abbreviated to create a table that is suitable for publication (Table).


Table

Results
Effect of Navigator Intervention on the Continuity of Care

With regard to the continuity of cancer care, the researchers examined the effect of navigator intervention on the timely access to care and on the resolution of barriers to care. A qualitative, 2-dimensional study of patients with cancer, their family members, and oncology healthcare providers validated the role of professional navigators in facilitating the continuity of care and in promoting patient and family empowerment for patients with cancer.4 In addition, a quantitative, experimental study of 251 patients with newly diagnosed cancer indicated higher scores in the coordination of care, psychosocial care, and health education among the patients receiving nurse navigation services; patients with access to a navigator intervention felt more informed, involved in their care, and better prepared for their cancer journey.5 Furthermore, a quantitative chart review of emotional distress levels indicated a decrease in distress levels (at admission and prior to discharge) with regard to barriers, coordination of care, education, symptom management, and emotional support for patients with cancer seen by an oncology nurse navigator.1 In a qualitative, phenomenological study, the participants reported that the navigator’s interventions with symptom management, access to financial and community resources, and collaborative teamwork were influential in the completion of their treatment and in their continuity of care.6Finally, a qualitative, descriptive study of older women with breast cancer demonstrated that those having access to the services of a nurse navigator benefited from coordinated care, information/education, and emotional support.7

Effect of Navigator Intervention on Patients’ Satisfaction

The effect of navigator intervention on patients’ satisfaction with their cancer care throughout their disease trajectory was examined in several studies. In a quantitative, descriptive study that involved 103 patients with breast cancer who used navigation services, researchers concluded that the patients were highly satisfied with navigation services offered during their cancer journey.8 In addition, in a quantitative, experimental study of patients with newly diagnosed cancer in 2 hospitals in Korea, researchers concluded that patients in nurse navigation programs were more satisfied with their care and had significantly shorter lengths of hospital stays compared with patients who did not participate in nurse navigation programs.9 Furthermore, in a quantitative, descriptive study of patients with newly diagnosed breast cancer, the breast center noted a reduction in the time interval from biopsy to treatment, resolution of barriers prior to treatment, and high patient satisfaction results after participating in oncology nurse navigator services.2 The evidence of the research in the reviewed articles supports the positive effect of navigator intervention on patient satisfaction.

Tools Used to Measure Effectiveness of Navigation Services

Researchers in the reviewed literature used a variety of tools to measure the impact of a navigator intervention on the continuity of care and on the satisfaction of patients during their cancer experience. These tools allowed for the reliable collection and statistical analysis of data, and replication of results.

To collect measurable data for statistical analysis, several researchers who used quantitative research methods implemented standardized healthcare assessment tools, including the Functional Assessment of Cancer Therapy-General (FACT-G), Patient Assessment of Chronic Illness Care (PACIC), the National Comprehensive Cancer Network Distress Thermometer, the Brief Fatigue Inventory, and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30. These standardized assessment tools revealed quality of life (QOL) issues, barriers to care, emotional distress, and coordination of care.

Other researchers who used quantitative research methods implemented standardized survey tools, such as the Picker Institute Patient Experience Survey, as well as researcher-developed survey tools, such as the Likert-type scale, to measure the effect of navigation service on the resolution of barriers and patient satisfaction. The tools utilized in the quantitative research methods allowed for consistent measurement of the researchers’ topics of interest (ie, the effect of navigation services on patient satisfaction).

The investigators who used qualitative research methods implemented different ways to gather descriptive data regarding the continuity of care and patient satisfaction. The researchers who followed a descriptive or phenomenology design in their method used focus groups and interviews; they conducted telephone or in-person interviews with patients with cancer, using structured and semistructured questions about the interventions provided by the navigator with regard to the continuity of care and their satisfaction with their experience (Table). Several of the researchers also used focus groups of patients with cancer to gather data regarding the role of the navigator in eliminating barriers to care, facilitating continuity of care, and providing emotional support (Table).

Discussion 
Since its initiation by Harold P. Freeman, MD, in 2001, navigation as a health-accessed, barrier-focused intervention has become increasingly adopted in the healthcare system as a means to address cancer-related health outcomes. The disparities and barriers with regard to healthcare faced by individuals of varying income, ethnicity, and cultural status have been well documented in the literature. With recent policy changes, specifically the Affordable Care Act of 2010, healthcare delivery models that improve outcomes and the quality of care need to be identified and implemented to match the expanded insurance coverage to millions of previously uninsured individuals.

In the area of oncology, navigation was initially instituted to improve cancer screening, early detection, and timely follow-up among low-income populations. Over time, navigation programs have expanded their purpose and goals by addressing the barriers to care to improve the continuity of care and patient satisfaction. Because of the complexity of cancer care, patients often face overwhelming challenges, including emotional distress, timeliness of care, lack of coordination of care, and lack of resources (eg, transportation and financial). These challenges can lead to a disruption in the continuity of patient care and decreased patient satisfaction.

This review examined the effect of navigation on the continuity of care and patient satisfaction in different healthcare settings and countries. The review was based on 10 primary research articles that involved navigation intervention involving various types of patients with different types of cancers. Taewha Lee and colleagues measured 3 outcomes of QOL, satisfaction with care, and length of hospital stay of 78 participants with newly diagnosed gastric, liver, gallbladder, and thyroid cancers.9 Jay Swanson, RN, BSN, OCN, and Lisa Koch, RN, BSN, MSHS, included all types of cancer diagnosed in their quantitative study evaluating the oncology nurse navigator intervention in decreasing distress levels of patients.1 Edward H. Wagner, MD, MPH, and colleagues included primary breast, colorectal, and lung patients with cancer in their study of the nurse navigator intervention on QOL FACT-G scores and coordination-of-care PACIC scores.5

Cheryl Campbell, RN, BSN, OCN, and colleagues measured the variable of navigation on 5 areas/barriers significant to cancer care (access, resources, education, financial assistance, and satisfaction) for patients with cancer in a comprehensive community cancer center.3 Susan F. Korber, MS, RN, OCN, and colleagues looked at the effectiveness of the interventions provided by a navigator in a hospital setting.6 Myriam Skrutkowski, RN, MSc, CON(c), and colleagues examined the impact on continuity of care (symptom management, fatigue, QOL, and resources) delivered by a pivotal nurse in oncology with outpatient oncology facilities in Quebec, Canada.10The previously mentioned study conducted by Dr Lee enrolled patients with cancer from 2 hospitals in Korea.9

Evidence in the literature review indicated that regardless of whether the studies included only 1 type of cancer or various types of primary cancers, and in varying healthcare settings, there was a positive effect of navigator intervention on the continuity of care and satisfaction for the patients with cancer. Patients with access to navigation services had better coordination of care, information/education, and emotional support. In addition, patients received resolution of their barriers, experienced decreased distress levels, experienced increased QOL, and were highly satisfied with navigation services and their care.

Conclusion
The findings from the studies revealed that patients with cancer who had access to navigation services benefited from the resolution of barriers, coordination of care, and emotional support; these patients experienced less distress, improved QOL, and greater satisfaction with their care.

The navigator can play an important role in improving quality and outcomes in the healthcare system. As indicated by the evidence of the research studies, the nursing strategy of navigator intervention can be implemented in hospital settings at the time of diagnosis, as well as throughout the cancer trajectory in outpatient oncology centers. Also, patients of varying types of cancer can benefit from navigation services. The navigator can eliminate the barriers to care, thus improving the continuity of care and patient satisfaction for patients with cancer.

Author Disclosure Statement: Author reports being an employee of Huntsman-Intermountain Cancer Center.

Corresponding Author: Cheryl Bellomo, RN, BSN, OCN, CN-BN, Huntsman-Intermountain Cancer Center, 1303 North Main Street, Cedar City, UT 84720. E-mail: cheryl.bellomo@imail.org.

References
1. Swanson J, Koch L. The role of the oncology nurse navigator in distress management of adult inpatients with cancer: a retrospective study. Oncol Nurs Forum. 2010;37(1):69-76.
2. Koh C, Nelson JM, Cook PF. Evaluation of a patient navigation program. Clin J Oncol Nurs. 2011;15(1):41-48.
3. Campbell C, Craig J, Eggert J, Bailey-Dorton C. Implementing and measuring the impact of patient navigation at a comprehensive community cancer center. Oncol Nurs Forum. 2010;37(1):61-68.
4. Fillion L, Cook S, Veillette A, et al. Professional navigation framework: elaboration and validation in a Canadian context. Oncol Nurs Forum. 2012; 39(1):E58-E69.
5. Wagner EH, Ludman EJ, Aiello Bowles EJ, et al. Nurse navigators in early cancer care: a randomized controlled trial. J Clin Oncol. 2014;30(1):12-18. 
6. Korber SF, Padula C, Gray J, Powell M. A breast navigator program: barriers, enhancers, and nursing interventions. Oncol Nurs Forum. 2011;38(1):44-50.
7. Pieters HC, Heilemann MV, Grant M, Maly RC. Older women’s reflections on accessing care across their breast cancer trajectory: navigating beyond the triple barriers. Oncol Nurs Forum. 2011;38(2):175-184. 
8. Hook A, Ware L, Siler B, Packard A. Breast cancer navigation and patient satisfaction: exploring a community-based patient navigation model in a rural setting. Oncol Nurs Forum. 2012;39(4):379-385.
9. Lee T, Ko I, Lee I, et al. Effects of nurse navigators on health outcomes of cancer patients. Cancer Nurs. 2011;34(5):376-384. 
10. Skrutkowski M, Saucier S, Eades M, et al. Impact of a pivot nurse in oncology on patients with lung or breast cancer: symptom distress, fatigue, quality of life, and use of healthcare resources. Oncol Nurs Forum. 2008;35(6):948-954

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