The following clinical trials are currently recruiting patients with cancer for inclusion in several investigations. Each trial description includes the NLM Identifier to use as reference with ClinicalTrials.gov. PROSTATE CANCER [ Read More ]
April 2015, VOL 6, NO 2
A Literature Review of the Navigator Role: Redefining the Job Description
JoAnn Smith, DNP, MSN, RN, OCN (1); Donald D. Kautz, RN, PhD, CRRN, CNE, ACNS-BC (2)
Cancer disrupts and overwhelms the lives of those impacted by it. Treatment is often complex, and there may be challenges to obtaining care. The
American Cancer Society1 predicted 1,665,540 new cases of cancer would be diagnosed last year in the United States, and barriers to care—language issues; cultural, so- cioeconomic, financial, and educational issues; and fear or distrust of the healthcare system—have been document- ed.2 Harold P. Freeman, MD, recognized the hardship that a cancer diagnosis places on patients in poverty and worked to bring awareness to the issues of the poor and their lack of access to care.2 In 1990, Dr Freeman started the first patient navigation program using lay navigators in Harlem, NY.3 The success of the program led to the navigation movement.
Like the Freeman model, early programs focused on screening and removing barriers for people with disparities, and were generally site-specific.2 Over time, navigation models expanded, and many now provide support to pa- tients across the continuum of care.2 Navigators provide assistance during screening, treatment, and survivorship; however, roles differ greatly from institution to institution, and from navigator to navigator. Difficulty in defining the nurse navigator role, combined with a lack of standardization and increasing demands, has created a gap between what is supported by evidence and what is occurring at the practice level.2 Cancer programs frequently customize a navigation program to their community needs.4 This practice is supported by accrediting agencies such as the American College of Surgeons Commission on Cancer (CoC)5 and the National Accreditation Program for Breast Cen- ters (NAPBC).6 Attempts are under way to standardize navigation; however, a consensus on a definition for navigation or navigators does not exist. As more duties are placed on navigators, it is important to review the roles, redefine them, and develop a summary of duties. With clearly defined expectations, navigators can better prioritize to meet job expectations.
The Oncology Nursing Society (ONS), the Association of Oncology Social Work, and the National Association of Social Workers joint position statement released in 2010 defines patient navigation as “individualized assistance offered to patients, families, and caregivers to help overcome healthcare system barriers and facilitate timely access to quality health and psychosocial care from prediagnosis through all phases of the cancer experience.”7 The statement says, “education and knowledge in community assessment, cancer program assessment, resolution of system barriers, the cancer continuum, cancer health disparities, cultural competence, and the individualized provision of assistance to patients with cancer, their families, caregivers, and survivors at risk” are required for navigators regardless of whether the role is held by a nurse or a social worker.7
CoC and NAPBC define patient navigation as “individualized assistance offered to patients, families, and caregivers to help overcome healthcare system barriers and facilitate timely access to quality medical and psychosocial care, and can occur from prior to a cancer diagnosis through all phases of the cancer experience.”5,6
A lack of consensus is seen in titles, job descriptions, credentials, competencies, and training; skills and competencies may be based on program goals. Some programs refer to a patient navigator, whereas other organizations use nurse navigator, breast health navigator, or oncology nurse navigator as a job title. Programs that focus on system barriers, such as scheduling and follow-up for screenings, may use a layperson as a navigator, whereas programs that focus on patient needs may use a social worker, registered nurse, or nurse practitioner. When clinical care, including educa- tion and care coordination, is the goal of the program, nurses or nurse practitioners may fulfill this role.
Standardized competencies for navigators do not exist. Research has suggested some core skills and knowledge are required, but no formal guidelines were available until recently.4 In 2009, the National Coalition of Oncology Nurse Navigators listed 5 competencies required for nurse navigators.4 In December 2013, ONS released competencies for oncology nurse navigators that describe the fundamental knowledge and skills they should have or obtain in their first 1 to 2 years in the role.8
As part of competency development, an ONS advisory team has formulated a definition for the oncology nurse navi- gator, describing him or her as “a professional registered nurse with oncology-specific clinical knowledge who offers individualized assistance to patients, families, and caregivers to help overcome healthcare system barriers. Using the nursing process, an [oncology nurse navigator] provides education and resources to facilitate informed decision making and timely access to quality health and psychosocial care throughout all phases of the cancer continuum.”8
Recent integrative literature reviews of patient navigation suggest that a broad scope of services are provided by navigators4,9-13; several trends were demonstrated. Assess- ments and interventions now include the patient’s needs as well as those of family and caregivers,13 and the supportive role has expanded and includes psychosocial and emotional care.4 Management of barriers extends from the time of an abnormal finding to posttreatment or survivorship; navigators may also assist in meeting compliance standards.4 A new CoC survivorship standard for 2015 requires a comprehensive care summary and follow-up plan for patients at the end of their treatment,5 and nurse navigators are typically the care coordinator and have a role in follow-up. Oncology nurse navigators require a broad skill set, which includes time management, strong critical thinking, problem solving, communication, multitasking, and collaboration.12,14 The ability to collaborate and advocate on behalf of a patient are also important tasks.14 The oncology nurse navigator’s role will continue to evolve as navigation standards are further defined and competencies are further developed.
Review of the Literature
This review of the literature is designed to provide information on nurse navigators and navigation programs. Evidence was collected using the Cumulative Index to Nursing and Allied Health Literature database; Medline and PubMed databases were also included. Key words used in the search were as follows: navigators, navigation, cancer, patient navigators, cancer and patient navigators, care co- ordination, and care managers. After eliminating studies that did not meet the definition of navigator using the CoC definition,5 54 studies of navigation were found. Since the focus was on duties of the navigator, only those providing insight into the job were reviewed.
Twenty studies related to the navigator role were found to be credible,13-32 “well-designed studies,” or level 2 evidence, based on the Forsyth NURSE Scale33 for rating re- search evidence. Of these 20 studies, the purpose of 8 of the studies was to identify navigator duties; whereas the pur- pose of the other 12 was measuring other various outcomes of navigators, they identified tasks and duties completed by the navigator in the research report.
The Forsyth NURSE Scale is a rating tool that identifies 5 levels of credibility for best evidence. The first level is defined as “multiple well-designed studies” and reflects a meta-analysis; this is considered to be the highest level and the most credible source. “One well-designed study” or a qualitative research article is the second level of evidence. Level 3 includes “studies with significant limitations” and includes patient satisfaction data. “Internal data” such as patient opinion or interviews comprise level 4. The last category and the lowest level of credible evidence is “early evidence.” One patient’s voice, narrative stories, and nurse opinion all fall into this classification.34
Brown and colleagues completed an oncology nurse navigator delineation study to identify primary job func- tions of this role.14 Oncology nurse navigators completed a survey to determine if a list of tasks were a part of their job functions; if so, they were asked to score the task based on importance using a Likert-type scale. A score of 0 meant the function was “not necessary for my job”; 1 was interpreted as “part of my job, but not too important”; 2 reflected “somewhat important”; 3 was “important to my job”; 4 was “quite important”; and 5 was “highly critical.”14 The survey was completed by 330 nurses who were primarily female, white, >45 years of age, and worked in a suburban healthcare environment. The majority held a bachelor’s degree, and 41% held oncology-certified nurse certification.
Tasks identified by the nurses included the following14:
• Identifying patients newly diagnosed with cancer
• Empowering self-advocacy in patients
• Providing patients with emotional and educational support
• Advocating for the patient
• Helping patients become familiar with the cancer care system
• Receiving and responding to new patient referrals
• Interacting collaboratively with physicians or other healthcare providers
• Helping patients make informed decisions
• Providing referrals or education for patients coping with a diagnosis.
“Confidentiality and informed consent, advocacy, symptom management, ethical principles, quality of life, goal of treatment, therapeutic options, evidence-based practice guidelines, professional scope of practice, [and] legal and professional guidelines” were all reported as essential areas of knowledge for oncology nurse navigators.14 Respondents considered that communication, problem solving, critical thinking, multitasking, collaboration, time management, and advocacy-specific skills were required.
Parker and colleagues identified 2 domains of navigator activity: tasks and networks.15 The task domain included the specific activities navigators performed, such as helping with or navigating the patient, completing or facilitating activities for the patient, addressing system issues, and documentation. Facilitating for the patient included tasks such as locating patients and getting them in for appointments, coordinating team communication, gathering information, and obtaining help for patient fears. Identifying and re-moving barriers through education, inquiry, and coaching were also noted as important roles.
System issues included identifying patients who needed assistance and building internal and external networks. Conducting reviews of laboratory results to seek out patients needing follow-up, developing referral routines and networks, and reviewing cases to ensure that all issues were resolved were system issues. Recording in the medical record, entering and getting test results, and processing information were all listed under documentation.15
The network domain included interactions with patients regarding follow-up or assistance with upcoming diagnostic procedures; navigating with providers and non- clinical staff such as insurance carriers, receptionists, and schedulers; and addressing issues by providing supportive services and working with social workers, translators, transportation staff, or family and friends.15 Reviewing the med- ical record before actions were taken was also considered a network task.
A qualitative synthesis of literature on navigators for patients with cancer by Wells and colleagues identified 4 areas of navigation intervention16:
• Overcoming barriers in the health system
• Offering education about the disease across the cancer continuum (ie, from prevention to treatment)
• Addressing barriers to cancer care that patients may face
• Providing psychosocial support
Lin and colleagues studied patient navigation programs at 3 hospitals and found that navigators guided patients and families through the treatment process within the system and helped link them to community resources during and after treatment.17 Access to support groups, cancer education, and screening programs was provided. The navigator duties were classified as in-reach and outreach services. Out- reach referred to collaboration with community resources, while in-reach duties reflected aid within the system.
An average of 2.5 hours were spent on each patient.17 Financial needs, including insurance and out-of-pocket expenses, were reported most frequently and required the most time to address (169 minutes). Transportation issues required 74 minutes, end-of-life issues required 65 minutes, arrangements for dependent care used 60 minutes, scheduling appointments used 34 minutes, and 24 minutes were required to address issues surrounding assistance with daily living.
Koh and colleagues evaluated a patient navigation program for timeliness of access to care and resolution of barriers, as well as patient satisfaction.18 They found that the most frequently identified barriers pertained to the location of the healthcare facility, perceptions or beliefs about treatments or tests, and social or practical support. Records, record keeping, and scheduling of appointments were the most frequently performed activities, requiring an average of 55.27 minutes. Providing education and support demanded the next highest amount of time at 17.5 minutes. Most navigator time was spent on barriers to care related to employment issues, attitudes toward providers, and perceptions or beliefs about tests or treatments. Although the researchers report that the navigators spent a lot of time with records and appointment assistance, they recommend that oncology nurse navigators have special knowledge and skills, and that nonnursing tasks should be limited.
Horner and colleagues provided an overview of the oncology nurse navigator program at their facility.19 Nurses had training in psychosocial skills, including assessment for depression, problem solving, behavioral activation, and communication strategies. Seven responsibilities of this role were identified:
• Actively reach out to patients who are facing a new diagnosis of cancer
• Facilitate communication among patients’ providers
• Prevent treatment delays
• Clarify or explain language related to medical treatment
• Offer psychosocial support
• Monitor and manage symptoms
• Identify and recommend resources that may be helpful
to the patient.
Additional insights into navigator duties were provided by some studies in which tasks were identified but were not the focus of the study.19
Christie and colleagues assessed whether assistance provided by navigators could increase colonoscopy screenings among low-income minorities.20 Patients were assigned to navigation and non-navigation groups; those in the navigation group were contacted by the patient navigator within 1 week of their initial clinic visit. Screenings were scheduled and explanations were provided, including the purpose, risks, benefits, and nature of the procedure, as well as information on preparation. The navigator mailed instructions and then called the participants 1 week prior to the screening to answer questions and remind patients of the procedure. Two days before the screening, a second call was made to address any concerns. Two days after the screening, another call was made by the navigator to discuss any concerns.
Duties of the navigator included providing assistance with referral forms and getting the patient to the scheduler, assisting in getting referrals for the colonoscopy, providing risk education, providing preparation education, sending appointment reminders, providing explanation of procedures, arranging transportation, and rescheduling appointments, if needed.20
Han and colleagues utilized lay Korean-American health workers to promote breast screening behaviors in other Korean-American women, in the hopes of decreasing cultural barriers to breast screening.21 The outcomes measured in the study included increased screening behaviors, including mammograms, clinical breast exams, and breast self-exams, as well as increased knowledge about breast health. Trained lay health workers recruited women at least 40 years of age who had not completed a mammogram in the past 2 years, and who had no history of breast cancer. Questionnaires, education, counseling, and navigation within the healthcare system were provided. Education about breast cancer was given in groups, and counseling services occurred by telephone or by home visits for follow-up. Additional navigation services included providing information about mammogram facilities close to home (54%), information about low-income state cancer programs (36%), appointments for a mammogram (34%), and transportation and translation services (20%).
Clark and colleagues employed case managers to assist women with obtaining mammograms.22 Navigation of the healthcare system included help with setting up appointments, tracking and reporting abnormal test results, and helping clinicians to complete follow-up for abnormal tests. Community resource referrals to social services, health centers, and public healthcare were also included. Navigators tracked patients and contacted them when their next mammogram was due, and offered education and assistance with next steps. The navigators also accompa- nied patients to physician visits to provide support.
Lasser and colleagues examined the effectiveness of a patient navigator–based intervention to increase colorectal cancer screening rates in community health centers.23 Patient navigators discussed screening and provided assistance, and were found to be effective in increasing screening rates.
Ell and colleagues conducted a randomized clinical trial of 204 women with abnormal mammograms referred for follow-up who were assigned to a patient navigation intervention or usual care.24 The navigators helped with telephone risk assessment, education, psychosocial counseling, navigation of the system, patient tracking, patient reminders, and follow-up calls. Investigators concluded that adding patient navigation can improve the rate of adherence to follow-up through diagnostic resolution.
Palmieri and colleagues used patient navigators for underserved women to eliminate delays in diagnostic resolution of abnormal screening mammograms, provide services for abnormalities noted during screening, and assess follow-up care.25 Navigator duties included confirming patient eligibility criteria, obtaining informed consent, identifying and alleviating barriers, giving appointment reminders, arranging interpretation assistance, guiding patients through the system, helping with communication and coordination of services, and documenting and assisting with appointments and paperwork.
The Community Health Advisors in Action Program was a pilot patient navigation project to increase adherence to follow-up and treatment for underserved women, primarily African Americans, in 23 Alabama communities.26 Twenty-six percent needed help filling out forms and understanding written information, 16% needed guidance through screening and treatment, and 15% needed help with keeping up with appointments. Forty-seven percent needed to know more about Medicare/Medicaid benefits. The navigators guided women through the system by linking them to physicians or facilities and providing breast cancer education, ways to get help, written information that was easy to understand, reassurance about surviving breast cancer, and coping strategies. The use of patient navigators was effective in closing the gap between development and delivery of cancer treatments for the medically underserved.
Chen and colleagues looked at the effectiveness of patient navigation in improving quality care for urban minority women with an abnormal mammogram.27 Navigators provided social and emotional support, helped with arranging appointments, assisted with financial applications, helped patients connect with community resources and support systems, and facilitated communication and collaboration with the healthcare team. Chen and colleagues concluded that patient navigation is an effective strategy to improve timely diagnostic resolution among urban minority women with abnormal mammograms.
The goal of the study by Fillion and colleagues, published in 2009, was to look at the impact of a patient navigator on continuity of care and empowerment of patients with head and neck cancers.28 Clinical functions performed by the navigator included assisting the patient and family with coping with the disease and treatment, promoting decision-making, providing social support and resources, reinforcing coping strategies to help with problem solving and distress management, and providing transitional sup- port and counseling. Organizational duties included provision of timely and tailored information, proper use of communication tools, comprehensive needs assessment aligned with external resources, coordination of treatments, use of care pathways, and being accessible with ease.
Published in 2012, the goal of a later study by Fillion and colleagues was to develop a framework for professional navigation.13 Interviews, focus groups, and formal consultations with clinical experts were conducted. The researchers identified 2 dimensions of navigator activity. The first dimension is “health system”–oriented. Navigators working in this dimension assist with continuity of care by sharing information with the patient and team members. The information is shared in a timely fashion so that appropriate referrals can be made. Part of the navigator responsibility is also to complete a comprehensive assessment of needs and resources; this is done at first contact with the patient and is ongoing throughout the care continuum. Navigators help patients and families with problem solving, and they serve as a liaison and help to coordinate medical and psychosocial care. Relationship building is important in this dimension; therapeutic conversations occur when trust has been developed with the patient and family.
The second dimension is “patient centered” and includes the promotion of patient and family empowerment. In this dimension, navigators facilitate active coping mechanisms of the patient and family members by providing support and referrals. They promote a sense of autonomy and self-determination, and help with adjustments to role changes. Navigators also promote problem solving and decision-making around these changes and help the patient and family to set goals.
In their study, Fillion and colleagues recognize that navigation has spread internationally and that “a comprehensive needs assessment, evidence based interventions and psychosocial support are all a part of the cancer care continuum.”13 According to the researchers, this study helped to clarify the role and functions of professional navigation and may help with program development and evaluations.
Cantril and Haylock studied patient navigation in the cancer setting to determine its evolution and current status.4 Gaps in research and education were evaluated and used as a way to improve navigation outcomes. A history of navigation was reviewed and included the ONS navigator role delineation study as well as the joint position statement on patient navigation developed in 2010 by ONS, the Association of Oncology Social Work, and the National Association of Social Workers. Their review also included the advancement of competency development, as first initiated by the National Coalition of Oncology Nurse Navigators in 2009.
They also discussed various models of navigation delivery, and advocated that navigation models should reflect the strengths and desired results relating to challenges of the community system and facility in which these programs reside.4 Rural, community, and university models as well as the Canadian and Western Australian models were all discussed. Each model has unique challenges and processes.
In the rural model, the navigator helps to link isolated rural hospitals and providers to colleagues and services in a comprehensive cancer care system; geographic, financial, social, information, multidisciplinary, equipment, and technology issues may arise. The community model is impacted by CoC definitions; in this setting, the navigator frequently functions more within a team and may work with a site-specific program such as breast cancer. Community navigators may work with referring physicians and help with follow-up care and management of complex patient needs. University models are similar to the community model; however, they are advocates and provide support, guidance, education, and reassurance for patients and families throughout the cancer care continuum. The Canadian model identifies 4 domains associated with the navigator or pivot nurse within the team: assessment of needs and symptoms, teaching, support, and coordination of care. The Western Australian model considers the cancer nurse coordinator to be the focal point of contact and essential for coordination of all aspects of patient care, providing information and patient education.
The authors state that research and resources are in- creasing, but the evidence on which to base navigation services is still limited. They conclude that common language, structure, roles, and outcome measures are yet to be determined. Challenges remain in defining the role, processes, preparation, qualifications, and job descriptions.4
Allison and colleagues evaluated the varying intensities of navigation services received by different types of patients in a hospital-based navigation program.29 Patients were assigned to 1 of 3 categories based on the intensity of services received: low, medium, or high. The median number of actions taken for a patient was 4, and the average number of days a case was open was 14. High-intensity cases were more likely to need education, transportation, care coordination, and financial assistance; the greatest barrier was travel to treatment. Difficulty scheduling tests, appointments, and therapy was the next greatest barrier. Twenty-three percent of patients received only 1 action, whereas 22.5% had ≥10 actions. Thirty percent of actions included the patient directly, whereas 29.4% of the navigator actions were with the provider or healthcare staff on behalf of the patient. Navigator duties included scheduling appointments (49.2%), arranging transportation (55.8%), coordinating social services (71.1%), discussing patients’ feelings and questions about their illness and care (26.7%), coordinating care (25.8%), and assisting with covering costs of care (20.0%). Data collection was also identified as a task. Family assistance was provided and was believed to enhance the family’s ability to support the patient. The authors concluded that a better data collection system could improve the delivery and evaluation of navigation.
Carroll and colleagues evaluated how patients’ experiences with navigation influenced their perception of the quality of their cancer care.30 Patients’ most common expectation of navigation was education; they were also concerned with receiving information about arranging tests and appointments, as well as managing financial or insurance issues. Patients indicated that care coordination, advocacy, having someone to help them manage their care, and having the navigator present throughout the cancer care process were also important. Most patients also valued emotional support, stating that they felt overwhelmed and expected the navigator to provide comfort and security.
Walsh and colleagues explored experiences and views of cancer care coordination through individual and focus group interviews with healthcare clinicians, cancer care coordinators, nurse coordinators, and patients.31 Several key components of cancer care were identified through this investigation: organization of patient care, healthcare system access and navigation, establishing a key contact person, communication and cooperation efficacy among multidisciplinary team members and other healthcare providers, timely and complementary delivery of services, sufficient and timely communication of information to the patient, and conducting needs assessments. Both clinicians and patients reported that a key contact is essential.
A study by Chen and colleagues examined mostly His- panic and African-American patients who had received direct referrals for screening colonoscopies from primary care clinics.32 A bilingual, female, Hispanic patient navigator contacted the patients and reviewed their medical histories, gathered medication lists, and confirmed insurance status. The navigator provided education about the procedure and scheduled the screening; bowel preparation instructions and procedure date reminder postcards were then mailed. The navigator contacted patients 2 weeks and then again 3 days before the procedure to remind them of their procedure date, confirm receipt of mailed information, and address transportation needs, if indicated. The navigator provided patients details about the day of the procedure; if he or she sensed trepidation, the navigator would meet with the patient immediately before the procedure to answer any questions and help alleviate fears. A call 2 weeks after the procedure was conducted to ad- dress any outstanding issues and to gather patient satisfaction information.
The navigator tasks identified in these studies are summarized in the Table, which illustrates how many different tasks navigators perform and how much the role varies from one navigator to the next.13,15-18,23-26,30,31 We categorized the tasks based on the actual duty or intent, as described in the study. For example, emotional support was defined as including social support, alleviating fears for patients and families, promoting coping for patients and families, providing psychosocial support, being an advocate, or just being present. Health literacy included information-sharing; increasing readiness for receipt of care; coaching; explanation of processes, procedures, or preparations; and assistance with informed decision-making. Although providing information may prompt further questions and more in-depth education, it was hard to determine whether this occurred.
Communication included discussions with the physician or other team members, and a review of the patient’s medical record. Care coordination was defined as guiding the patient through the system, navigating the system, or expediting diagnostic studies. Administrative tasks was the largest category, and included tracking or identifying patients needing assistance, scheduling appointments, sending reminders, making follow-up phone calls, record keeping, obtaining informed consent, collecting insurance, and completion of referral forms. Only 3 of the studies providing emotional support used registered nurses18,19,25; the others used laypeople. Health literacy tasks were carried out by registered nurses in these studies.18,19,25 Although several duties were listed in only 1 respective study and not included in the Table, they may be important for the patient navigator. These included using care pathways24; following ethical, legal, and professional prin- ciples14; and providing clinical backup.15 Other tasks included help with end-of-life care (which was provided by a lay navigator),17 access to clinical trials (type of navigator unknown),16 and symptom management (provided by a nurse navigator).19
As the findings from these 20 studies show, patient navigators play a big role in the delivery of cancer care.13-32 The most common tasks included assessment or identification of needs, alleviating barriers to care, care coordination, communication, providing education, community outreach, emotional support, transportation assistance, financial assistance, counseling, administration, community resource referrals, and attending physician visits.
These studies also show that the major categories for navigator tasks include assessment, care coordination, education, communication, outreach, performance improvement, and supportive roles. As the demand for navigation services continues to increase,2 Pratt-Chapman and Willis have noted 4 additional outcomes34: improved concordance with clinical quality metrics, greater efficiency be- tween providers across the healthcare system, improved service delivery processes, and improved patient satisfaction. National guidelines developed by accrediting agencies now require navigators to assist patients across the continuum of care. Facility and departmental demands for navigators are rising. These expectations include an increase in community outreach, performance improvement, and new program coordination.
Gaps in Literature
The literature has provided substantial information on navigation, but studies defining the role are limited. Because communities base programs on their specific needs, it is hard to compare roles outside of particular areas; however, research into patient navigation has continued to expand. Early studies focused mainly on screening and providing patient assistance, and lay navigators were typically used during this period of navigation.16 Navigation and navigators, however, have evolved. Recent studies reflect the continuum of care from prevention to survivorship, multiple disease sites, and a broader use of navigator skills.2 Nurses are filling many of these roles, and they bring specialized knowledge and skills to the position.
Implications for Nursing
Patient navigation is becoming a best practice in healthcare settings. Although attempts are under way, standardization of duties, training, and credentials are still needed. It is important to define the role to meet increasing work-load demands. Navigator programs vary, and the role of the navigator also varies from setting to setting. Nurse navigators perform a wide variety of patient services and may overlap duties with other disciplines such as case management, social workers, oncology nurses, clinical nurse specialists, or advanced practice nurse practitioners.4 Addressing this overlap of duties, Brown and colleagues stated that “the question remains as to which of the knowledge, tasks, and skills of the role are distinctively different from those held by oncology-certified nurses in other roles.”14 In areas where structural and psychosocial barriers to care—rather than clinical education or coordination of care—are needed, Pratt-Chapman and Willis suggest that lay navigators or social workers may be used.34
The study by Brown and colleagues was among the first to use feedback from oncology nurse navigators to identify tasks, knowledge, and skills required.14 For example, education that focuses on the disease process, clinical care, and treatment is best provided by a nurse who can anticipate questions and answers. Three studies found that when education is geared toward how to access a service or involves instructions about a procedure (ie, preparation for a colonoscopy), a trained lay navigator may be a good choice.17,20,23
Evidence from our review suggests that fear needs intervention, and counseling services may be required. Research clearly shows that saying, “It will be okay,” “Don’t worry, live for today,” or “Let’s get through this,” are not helpful when patients are afraid.35 Nurses and social workers are trained in psychosocial management and may be best suited for this supportive role. Assistance with community services may be effectively provided by lay navigators or nurse navigators. When care coordination involves collaboration and communication with the physician team as a review of clinical data and assessments, it may be that a nurse is the better choice. Because experienced and trained oncology nurse navigators can help patients prepare for and understand tests, explore their options, and reduce their fears, it may be that nurses are best for these activities as well.
Even the simplest navigator tasks may best be performed by nurses, if education, health literacy, emotional support, and decision-making are involved. Nurses can assess the patient before the appointment, take care of additional needs, prepare the patient for the appointment, relieve fears, and uncover the questions the patient has about the test or appointment. By being present during the appointment, the nurse can ensure that the patient’s questions are answered and the patient understands the findings, so that the patient can make an informed choice about further tests and treatments. Once the patient makes a decision, the nurse can ensure that timely follow-up occurs.
Navigation programs have evolved from a focus on the poor and underserved to overcoming barriers to care and improving health outcomes for all cancer patients.4 Nurse navigators share characteristics with other clinical patient services, including health educators, case management, social workers, community health workers, patient advocates, and lay health advisors.
Navigation is an important model of care delivery that has evolved from care coordination for the underserved and uninsured. Current programs frequently use nurses to provide patient education and coordinate care in health-care systems.4 Clearly defining network and task domains is important, and the next steps in defining this role should include a task analysis with critical evaluation of the time spent doing each task. A few studies have addressed this aspect, but due to geographic location and demographics,15,17,18 they may not be generalizable.
The patient’s perspective is a missing piece that is of great importance. The goal of navigation is to help patients access and move through the healthcare system by coordinating care, providing education, and promoting informed decisions.2 Patients using navigation programs can provide valuable information on the effectiveness of services and on the services that are most important to them. Physician/ team evaluation is also important, since several duties as- signed to the navigator result from the request of a physician or another team member.4
Multidisciplinary care requires coordination of care and common goals, and the nurse navigator is frequently the person tasked with coordinating the team. By including feedback from team members on the duties of the oncology nurse navigator, the role can be further defined and focused on the most important aspects of care for the patient and team. As healthcare continues to change, more education and guidance may be anticipated. The nurse navigator provides a consistent approach to care coordination, and the model may be useful in oncology and in areas outside of oncology. The authors believe that the model will continue to evolve, bringing navigators into multiple settings and making them a cornerstone of patient care.
Acknowledgments: The authors acknowledge Elizabeth Tornquist, MA, FAAN, and Dawn Wyrick for their assistance with this manuscript.
Author Disclosure Statement: The authors have no disclo- sures and no conflicts of interest to report.
Corresponding Author: JoAnn Smith, DNP, MSN, RN, OCN, Oncology Service Line Manager, Frye Regional Medical Center, 420 North Center Street, Hickory, NC 28601. E-mail: firstname.lastname@example.org.
2. Freeman HP. The history, principles, and future of patient navigation: commentary. Semin Oncol Nurs. 2013:29:72-75.
3. Freeman HP, Muth BJ, Kerner JF. Expanding access to cancer screening and clinical follow-up among the medically underserved. Cancer Pract. 1995;3:19-30. 4. Cantril C, Haylock PJ. Patient navigation in the oncology care setting. Semin Oncol Nurs. 2013;29:76-90.
5. American College of Surgeons Commission on Cancer. Cancer program standards 2012: ensuring patient-centered care v1.2.1. www.facs.org/cancer/ coc/programstandards2012.pdf. Accessed March 24, 2015.
6. American College of Surgeons. 2013 Breast center standards manual. www. facs.org/~/media/files/quality%20programs/cancer/napbc/2013standards manual.ashx. Accessed March 24, 2015.
7. Oncology Nursing Society. Oncology Nursing Society, the Association of Oncology Social Work, and the National Association of Social Workers joint position on the role of oncology nursing and oncology social work in patient navigation. www.ons.org/advocacy-policy/positions/education/patient- navigation. Updated January 2013. Accessed March 24, 2015.
8. Oncology Nursing Society. Oncology nurse navigator core competencies. www.ons.org/sites/default/files/ONNCompetencies_rev.pdf. Accessed March 24, 2015.
9. Willis A, Reed E, Pratt-Chapman M, et al. Development of a framework for patient navigation: delineating roles across navigator types. J Oncol Navig Surviv. 2013;4:20-26.
10. Paskett ED, Harrop JP, Wells KJ. Patient navigation: an update on the state of the science. CA Cancer J Clin. 2011;61:237-249.
11. McVay S, Toney T, Kautz DD. The effect of different types of navigators on patient outcomes. J Oncol Navig Surviv. 2014;5:17-24.
12. McMullin L. Oncology nurse navigators and the continuum of cancer care. Semin Oncol Nurs. 2013;29:105-117.
13. Fillion L, Cook S, Veillette AM, et al. Professional navigation framework: elaboration and validation in a Canadian context. Oncol Nurs Forum. 2012; 39:e58-e69.
14. Brown CG, Cantril C, McMullen L, et al. Oncology nurse navigator role delineation study: an Oncology Nursing Society report. Clin J Oncol Nurs. 2012;16:581-585.
15. Parker VA, Clark JA, Leyson JA, et al. Patient navigation: development of a protocol for describing what navigators do. Health Serv Res. 2010;45:514-531. 16. Wells KJ, Battaglia TA, Dudley DJ, et al. Patient navigation: state of the art, or is it science? Cancer. 2008;113:1999-2010.
17. Lin CJ, Schwaderer KA, Morgenlander KH, et al. Factors associated with patient navigators’ time spent on reducing barriers to cancer treatment. J NatlMed Assoc. 2008;100:1290-1297.
18. Koh C, Nelson JM, Cook PF. Evaluation of a patient navigation program. Clin J Oncol Nurs. 2011:15:41-48.
19. Horner K, Ludman EJ, McCorkle R, et al. An oncology nurse navigator program designed to eliminate gaps in early cancer care. Clin J Oncol Nurs. 2013;17:43-48.
20. Christie J, Itzkowitz S, Lihau-Nkanza I, et al. A randomized controlled trial using patient navigation to increase colonoscopy screening among low income minorities. J Natl Med Assoc. 2008;100:278-284.
21. Han HR, Lee H, Kim MT, et al. Tailored lay health worker intervention improves breast cancer screening outcomes in non-adherent Korean-Ameri- can women. Health Educ Res. 2009;24:318-329.
22. Clark CR, Baril N, Kunicki M, et al. Addressing social determinants of health to improve access to early breast cancer detection: results of the Bos- ton REACH 2010 Breast and Cervical Cancer Coalition Women’s Health Demonstration Project. J Womens Health (Larchmt). 2009;18:677-690.
23. Lasser K, Murillo J, Medlin E, et al. A multilevel intervention to promote colorectal cancer screening among community health center patients: results of a pilot study. BMC Fam Pract. 2009;10:2296-3010.
24. Ell K, Vourlekis B, Lee P, et al. Patient navigation and case management following an abnormal mammogram: a randomized clinical trial. Prev Med. 2007;44:26-33.
25. Palmieri FM, Deperi ER, Mincey BA, et al. Comprehensive diagnostic program for medically underserved women with abnormal breast screening evaluations in an urban population. Mayo Clin Proc. 2009;84:317-322.
26. Fouad M, Wynn T, Martin M, et al. Patient navigation pilot project: re- sults from the Community Health Advisors in Action Program (CHAAP). Ethn Dis. 2010;20:155-161.
27. Chen F, Mercado C, Yermilov I, et al. Improving breast cancer quality of care with the use of patient navigators. Am Surg. 2010;76:1043-1046.
28. Fillion L, de Serres M, Cook S, et al. Professional patient navigation in head and neck cancer. Semin Oncol Nurs. 2009;25:212-221.
29. Allison Al, Ishihara-Wong DDM, Domingo JB, et al. Helping cancer patients across the care continuum: the navigation program at The Queen’s Medical Center. Hawaii J Med Public Health. 2013;72:116-121.
30. Carroll JK, Humiston SG, Meldrum SC, et al. Patient’s experiences with navigation for cancer care. Patient Educ Couns. 2010;80:241-247.
31. Walsh J, Young J, Harrison JD, et al. What is important in cancer care co- ordination? A qualitative investigation. Eur J Cancer Care (Engl). 2011;20: 220-227.
32. Chen LA, Santos S, Jandorf L, et al. A program to enhance completion of screening colonoscopy among urban minorities. Clin Gastroenterol Hepatol. 2008;6:443-450.
33. Kring D. The NURSE Scale: nursing’s unique rating scale of evidence. Abstract presented at: 13th American Nurses Credentialing Center National Magnet Conference; October 28, 2011; Louisville, KY.
34. Pratt-Chapman M, Willis A. Community cancer center administration and support for navigation services. Semin Oncol Nurs. 2013;29:141-148.
35. Smith D. Nurse-patient communication. In: Keltner NL, Bostrom CE, Mc- Ginness T, eds. Psychiatric Nursing. 6th ed. St. Louis, MO: Mosby Elsevier; 2010.