April 2015, VOL 6, NO 2

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Patient Navigation

Core Competencies for Oncology Patient Navigators

Mandi Pratt-Chapman, MA (1); Anne Willis, MA (2); Leah Masselink, PhD (3) 

Background: Patient navigators have become critical members of the healthcare team; however, a need exists to provide more clarity around roles across navigator types and to develop competencies to help standardize the profession.

Methods: We developed a set of competency statements for oncology patient navigators (ie, those who are not clini- cally licensed). To validate the 65 competency statements, we conducted a national survey of healthcare professionals who self-identified as working in the field of oncology patient navigation.

Results: Of the 618 individuals who consented to participate in the study, 525 respondents were eligible to participate in the full survey. All competency statements were endorsed by 81% to 98% of participants. Based on qualitative feedback, competencies were edited, combined, and/or deleted for a total of 45 final competencies.

Conclusions: Standardizing oncology patient navigator roles is essential for advancing the field. Role clarification can help clinically licensed oncology navigators (nurses and social workers) to operate at the top of their license while protecting patient navigators and institutions from liability issues.

The profession of patient navigation is fast becoming critical to the delivery of oncology care, particularly for patients from underserved groups1. Evidence suggests that patient navigators (ie, those who are not clinically licensed) can help improve care. For example, patient navigators have been shown to help diverse populations of patients with cancer to receive faster diagnoses for their disease.2,3 Currently, however, patient navigation suffers from a lack of standardization.4 Because no scope of practice exists, patient navigators are underutilized or are performing services that should be done by other professionals.

To guide standards for the profession, The George Washington University (GW) Cancer Institute led a study to develop competencies for oncology patient navigators. While these team members share some responsibilities with oncology nurse navigators and social workers, many oncology patient navigators have not received any training, and training that does exist is limited. In phase 1 of this study, Willis and colleagues distinguished roles of oncology patient navigators from those of social workers, nurse navigators, and community health workers5; however, these role distinctions have not yet been systematically translated into practice. Identifying competencies for oncology patient navigators is particularly critical given that currently no standards exist and this workforce remains unregulated. The goal of this study was to augment previous research to develop and validate competencies for oncology patient navigators.

Methods
First, the GW Cancer Institute utilized a literature re- view and Internet search as the foundation to develop a framework of functions performed by oncology patient navigators, community health workers, and clinically licensed nurse and social worker navigators, and to demonstrate commonalities and differences among these professions.5 The framework highlighted 12 major functional domains: (1) professional roles and responsibilities, (2) community resources, (3) patient empowerment, (4) communication, (5) barriers to care/health disparities, (6) education, prevention, and health promotion, (7) ethics and professional conduct, (8) cultural competency, (9) outreach, (10) care coordination, (11) psychosocial support services/assessment, and (12) advocacy. To ensure that the literature review covered all of the core functions of oncology patient navigators, 2 GW Cancer Institute researchers conducted 6 focus groups with 21 oncology patient navigators across the United States and identified major themes in their roles, responsibilities, and functions.

In 2013, the Association of American Medical Colleges (AAMC) endorsed a taxonomy to guide competency development for all health professions, using the Accreditation Council for Graduate Medical Education (ACGME)/ American Board of Medical Specialties model of interrelated domains of competence. ACGME domains included the following: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. AAMC added 2 additional competency domains—interprofessional collaboration and personal and professional development—after reviewing other health professional competencies.6

The GW Cancer Institute adopted this taxonomy to develop competency statements for oncology patient navigators. One researcher reviewed the AAMC domains and identified competencies in the model that were relevant to oncology patient navigators. The same researcher reviewed the Oncology Nursing Society (ONS) Oncology Nurse Navigator Core Competencies and identified those that an oncology patient navigator might share with a nurse navigator.7 Using the AAMC and ONS competencies as a guide, the researcher then drafted competency statements by adapting content from both lists and incorporating key findings from the focus group results. A team of 5 additional researchers reviewed and refined the competencies through a consensus-based process that included removing duplicate competencies, linking together concepts that supported an integrated competency, and assigning competencies to relevant competency domains. Competencies that were clearly clinical were eliminated.

The 72 draft competencies were presented to 22 national experts who were invited to provide qualitative feedback on whether each competency was clear, nonclinical, and in the correct domain. Finally, these 22 experts were asked whether they endorsed each of the competencies, and 13 responded with feedback. After incorporating their feedback, a 272-question online survey was disseminated to oncology patient navigators via e-mail through patient navigation professional organizations; patient navigation networks across the country; the GW Cancer Institute Center for the Advancement of Cancer Survivorship, Navigation, and Policy Listserv; and through personal networks of patient navigation leaders (using the snowball sampling method; ie, a nonprobability sampling technique that identifies eligible respondents for a study and uses these respondents to find additional eligible respondents to increase the sample size). Data were collected over a 4-week period in the summer of 2014. Adopting the same methodology used by ONS for finalizing their Oncology Nurse Navigator Core Competencies,7 survey respondents were asked to complete the following for each of the 65 competency statements:
• The extent to which it represents an essential function of the oncology patient navigator in a wide variety of settings (3-point scale: highly, moderately, minimally)
• The extent to which it is clearly written to facilitate consistent interpretation and implementation across practice settings (3-point scale: highly, moderately, minimally)
• I support inclusion of this competency (Yes/No)
• An open-text field to provide any qualitative feedback about the specific competency.

The survey responses were collected and managed using the web-based Research Electronic Data Capture applica- tion hosted at GW.8 Data were analyzed using basic frequencies with subanalyses conducted across participant groups. A visual depiction of the research process is provided (Figure).

aprilfigure1

Results
The original competency statements developed from the functional framework and the focus groups resulted in 72 statements. After review by national experts and elimination of competencies that were identified as clinical in nature, 65 competencies remained and were disseminated via the national survey. Over a 4-week period, 618 individuals consented to participate in the study. A screening question was used to identify eligibility: “Do you work in the field of oncology patient navigation (practice or re- search)?” Of the respondents, 525 answered “yes” and were eligible to participate in the full survey. Table 1 shows a breakdown of the professional roles for the 464 respondents who identified their roles.

apriltable1

All competency statements received a high level of endorsement, with the lowest aggregate percentage of endorsement at 81% for 2 competency statements and the highest percentage of endorsement at 98%. The quantitative data supported inclusion of all 65 competency statements. No competencies were eliminated due to lack of endorsement. However, after the research team analyzed qualitative data provided through the survey to identify competencies that were duplicative, vague, or too set- ting-specific, they omitted 14 competencies due to duplicative intent, 3 because they were too specific to a particular setting, and 1 for being confusing to survey respondents. In addition, 2 competencies were combined with other competencies. This process resulted in the 45 final core competency statements listed in Table 2.

apriltable2
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Limitations
Limitations to this study included use of a convenience sample and a limited time frame for recruitment of survey participants. The professional role distribution of survey participants might also be perceived as a limitation; how- ever, the researchers aimed to recruit at least 100 oncology patient navigators for participation, and this goal was exceeded. In addition, the research team believes that, given the relatively new role of the oncology patient navigator within the healthcare team, it was important to include the input of those with similar roles (such as nurse navigators) as well as supervisors of navigation programs. A significant limitation of the project is the unknown number of oncology patient navigators employed in the United States, which makes it impossible to know what percentage of the overall workforce was sampled.

Conclusions
In 2015, the American College of Surgeons Commission on Cancer (CoC) Standard 3.1 Patient Navigation Process will be required by all CoC-accredited institutions. Many programs have employed oncology nurse navigators, social workers, and patient navigators to fulfill this new standard. Clarifying the role of the oncology patient navigator and how it is distinguished from clinical roles can support interdisciplinary patient-centered teams. Furthermore, standardization and reinforcement of the oncology patient navigator role can help social workers, nurses, and nurse navigators to perform at the top of their license. This is critical, given the diverse needs of many oncology patients and oncology workforce constraints. Finally, clarifying the roles of oncology patient navigators can protect them as well as institutions from legal risks and patient safety concerns by ensuring that they understand role boundaries and refer appropriately to clinical team members for clinical assessment, psychosocial care, and symptom management concerns.

Next Steps: Becoming Competent as an Oncology Patient Navigator
These competencies can be incorporated into training programs to ensure consistency of standards across the profession. The GW Cancer Institute is currently developing a free, online training funded by the Centers for Disease Control and Prevention to provide oncology patient navigators with a solid foundation for meeting these core competencies. The training will be available via the following website: tinyurl.com/GWOnlineAcademy.

It is important to note that no nationally recognized credential for oncology patient navigators currently exists. While many programs offer certificates to show completion of a course, this is not the same as certification or credentialing. Since 2008, a certification program specific to breast imaging and breast cancer nurse navigators has been offered through the National Consortium of Breast Centers, and it has since been expanded to provide certification for varying levels of breast patient navigation.9 However, there is no nationally recognized certification program for oncology patient navigators who serve patients with other types of cancer. The Academy of Oncology Nurse & Patient Navigators is working to remedy this by providing certification for nurse navigators and patient navigators in the near future.

Author Disclosure Statement: Ms Pratt-Chapman reports being a consultant to Pfizer and a recipient of grants from Genentech and Amgen. Ms Willis reports being a recipient of grants from Genentech and Amgen. Dr Masselink did not report any conflicts of interest.

Corresponding Author: Mandi Pratt-Chapman, MA, Director, The George Washington University Cancer Institute, 2030 M Street NW #4070, Washington, DC 20036. E-mail: mandi@gwu.edu.

Acknowledgments: The Avon Foundation provided modest funds to support participant incentives for the focus groups. The following individuals reviewed and provided feedback specifically on the competency statements prior to survey dissemination. The GW Cancer Institute thanks these individuals for their support. All final competency statements are those of the research team and do not necessarily represent the views of these individuals: Amanda Allison, MA, Queen’s Medical Center, Hawaii; Susan Bowman, RN, OCN, CBCN, MSW, Oncology Nursing Society; Elizabeth Clark, PhD, ACSW, MPH; Margaret Darling, Nueva Vida; Andrea Dwyer, BS, University of Colorado Cancer Center; Ginny Pate, Executive Director, Carmella Rose Health Foundation; Angela Patterson, Vice President, Georgia Center for Oncology Research and Education; Terri Salter, RN, MSN, MBA, UAB Administrative Director, Cancer Community Network; Karen Schwaderer, RN, BSN, OCN, Breast Nurse Navigator, Allegheny Health Network; Lillie Shockney, RN, BS, MAS, Academy of Oncology Nurse & Patient Navigators; Virginia Vaitones, MSW, OSW-C, Association of Community Cancer Centers; Patricia Valverde, PhD, MPH, Colorado School of Public Health; Etta-Cheri Washington, Capital City Area Health Education Center. The following GW Cancer Institute staff members were also critical to this effort: Elizabeth Hatcher, RN, BSN; Monique House, MS, CHES; Kanako Kashima; Shaira Morales; Adrienne Thomas, LGSW; and Elisabeth Reed, MPA.

References

1. Natale-Pereira A, Enard KR, Nevarez L, Jones LA. The role of patient navigators in eliminating health disparities. Cancer. 2011;117(15 suppl):3543-3552. 2. Hoffman HJ, LaVerda NL, Young HA, et al. Patient navigation significantly reduces delays in breast cancer diagnosis in the District of Columbia. Cancer Epidemiol Biomarkers Prev. 2012;21:1655-1663.
3. Battaglia TA, Bak SM, Heeren T, et al. Boston Patient Navigation Re- search Program: the impact of navigation on time to diagnostic resolution after abnormal cancer screening. Cancer Epidemiol Biomarkers Prev. 2012; 21:1645-1654.
4. Clark JA, Parker VA, Battaglia TA, Freund KM. Patterns of task and network actions performed by navigators to facilitate cancer care. Health Care Manage Rev. 2014;39:90-101.
5. Willis A, Reed E, Pratt-Chapman M, et al. Development of a framework for patient navigation: delineating roles across navigator types. J Oncol Navigation Survivorship. 2013;4:20-26.
6. Englander R, Cameron T, Ballard A, et al. Toward a common taxonomy of competency domains for the health professions and competencies for physicians. Acad Med. 2013;88:1088-1094.
7. Oncology Nursing Society. Oncology Nurse Navigator Core Competencies, 2013. Pittsburgh, PA: Oncology Nursing Society; 2013. www.ons.org/sites/ default/files/ONNCompetencies.pdf. Accessed February 24, 2015.
8. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377-381.
9. National Consortium of Breast Centers. Certification. NCBC Web site. www2.bpnc.org/certification/. Accessed February 23, 2015.
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