The concept of patient navigation was first described by its founder, Harold Freeman, MD, as interventions initiated in cancer care for the purpose of reducing barriers to timely screening, diagnosis, treatment, and supportive care.1 The 2001 Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century, notes that patient-centered care will be a primary initiative to aid in reducing the barriers to care and to increase patient satisfaction.2 Patient navigation fulfills the need for the removal of barriers by providing personalized care that addresses the multitude of patient, provider, cultural, and healthcare system barriers that patients with chronic diseases face.3
Results from the National Cancer Institute Patient Navigator Research Program published in October 2008 indicate that at least 4 primary measurable outcomes of patient navigation exist: time to diagnosis, time to initiation of cancer treatment, patient satisfaction with care, and cost-effectiveness.4 The use of nurse navigators in the oncology setting has been shown to increase patient satisfaction and decrease barriers to care,3,5-8 narrow lag time to first cancer treatment,9 and increase participation in clinical trials for minority populations.10
One year after the establishment of an oncology nurse navigation program, a patient satisfaction study was conducted with an interest in collecting patient feedback and discovering opportunities for improvement of the program. Patient satisfaction has been defined as the quality of the patient’s healthcare experience as it corresponds to the patient’s expectations and is a core element in the measurement of quality care.11 Patient satisfaction measurements help ensure process improvement and are gaining importance for healthcare reimbursement.11 Satisfaction with interpersonal care that promotes access to optimal care is a key driver underlying all patient statisfaction.4,12
The Order of Saint Francis Center for Cancer Care is an urban hospital-based outpatient oncology center located in the Midwestern United States. The oncology nurse navigation program was launched 1 year prior to the initiation of the study. The aim of the study was to explore satisfaction among newly diagnosed cancer patients to evaluate the oncology nurse navigation program from the patients’ perspectives and to identify opportunities for improvement.
Participants were recruited from the outpatient oncology clinic from the pool of patients provided with navigation services. A survey tool was created by the study authors (Figure), and the surveys were given to each patient who had received navigation services at the outset of their diagnoses. The patients were given the surveys during the clinic visit that corresponded with the first chemotherapy or first radiation therapy treatments. The survey tools were handed to the participants in unmarked envelopes by staff members other than the oncology nurse navigators in the clinic during first treatment visits. The patients were educated on the purpose of the survey by the oncology nursing staff verbally; the tool also had written instructions regarding the reason for the survey. To avoid bias in answers on the survey, the oncology nurse navigators did not take part in handing the surveys to the participants, nor did the navigators instruct the participants on the purpose of the study.
The tool was designed to obtain information about patient satisfaction with the service of the oncology nurse navigator program in the realms of education, return phone calls, and emotional support. The tool also provided an area for free text comments.
Participants were given the option of returning the completed survey to a secure collection box located in the clinic waiting room or via the self-addressed stamped envelope (SASE) that was included with the survey. The SASEs were addressed to the administrative assistant in the facility and not to the oncology nurse navigators to avoid participant answer bias.
Participants were asked to rate survey questions on a Likert-type scale ranging from 5 (strongly agree) to 1 (strongly disagree). Participants could also select “not applicable” (NA). The introductory paragraph of the tool included photographs of the 2 oncology nurse navigators with corresponding names to aid participants in identifying the oncology nurse navigators. The tool included passive informed consent at the top of the tool. Institutional review board approval for the conduction of the study was obtained from the sponsoring institution’s local review board.
Inclusion criteria for the study were a diagnosis of breast, lung, colon, prostate, and head and neck cancers, and participation was limited to those patients who had received services from an oncology nurse navigator. Seventy-seven surveys were distributed to participants over a period of 8 months; the collection of surveys continued until accrual was met at 50 returned surveys.
Minimal demographic information was collected (Table 1). The majority of patients were female, likely owing to the fact that breast cancer cases constituted the largest number of analytical cases in the facility during the 8 months the survey was conducted. The majority of participants (90%) answered that they strongly agreed that navigation services were necessary, and that they would recommend navigation services. Results from the study were compared with those from a similarly conducted study done in a rural setting (Table 2) by Hook and colleagues,6 although the rural study focused on breast cancer patients only.
Notably, the rural study subjects scored higher than the suburban subjects in the education category. A noted difference in the education process of the 2 programs is that the rural study subjects were given an educational binder at their first visit to the clinic, whereas the suburban participants were given information in the form of booklets and summary visit forms at their first visit to the clinic. In both settings, the largest number of nonresponses or NA responses were in the categories of telephone calls. As Hook and colleagues5 have noted, perhaps those participants marking NA did not require phone calls to or from the navigator. It is also important to consider that participants may have chosen not to respond if they did not understand the questions or were hesitant to give a negative response.
Responses to the oncology nurse navigation program were favorable overall. Participants who chose to free text a response on the surveys gave positive feedback in all cases. Some of the free text responses are included in Table 3. The responses, both the free text and on the Likert scale, validated the worth of certain aspects of the oncology nurse navigation program. The program coordinators learned that the personal meetings with the navigators were valuable to the majority of patients, as was the concern shown to patients. The free text comments and the Likert scale scorings in this study suggest that participants were generally highly satisfied with the current oncology nurse navigation model.
While a large majority of participants strongly agreed that phone calls were returned in a timely manner and were valuable, the program coordinators recognized some aberrant lower ratings in that category and identified telephone calling as an area that may be improved upon. The navigators had designated phone lines for ease of contact for patients—however, a faster response time to patient calls was recognized as an area for improvement. Patient feedback regarding telephone calls from the surveys are currently being used as part of a departmental Six Sigma project aimed at revamping the telephone triage workflow.
The study limitations include limited generalizability of the results because of the lack of gender variability and the lack of geographic and possibly socioeconomic diversity. The study is also potentially limited by researcher bias as the researchers were involved in the development and implementation of the oncology nurse navigation program. The tool was created by the authors of the study and therefore lacked validity and reliability testing.
Multidisciplinary patient-centered care requires identification and elimination of barriers to diagnosis and treatment, patient education, psychosocial support, coordination of care, and promotion of survivorship care.2,5,6 Oncology nurse navigators are an essential component of care coordination and serve as a touchstone for patients across the care continuum.4,13-15 Each navigation program is personalized based on community assessments and individual healthcare system needs, so feedback from each program’s unique patient population is important to improve patient satisfaction and provide quality care.
- Harold P. Freeman Patient Navigation Institute. Our model. http://hpfreemanpni.org/our-model/. 2011.
- Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press (US); 2001.
- Campbell C, Craig J, Eggert J, et al. Implementing and measuring the impact of patient navigation at a comprehensive community cancer center. Oncol Nurs Forum. 2010;37:61-68.
- Freund KM, Battaglia TA, Calhoun E, et al. National Cancer Institute Patient Navigation Research Program: methods, protocol, and measures. Cancer. 2008;113:3391-3399.
- Christensen D. Using a nurse navigation pathway in the timely care of oncology patients. Journal of Oncology Navigation & Survivorship.2014; 5(3):13-18.
- Hook A, Ware L, Siler B, et al. Breast cancer navigation and patient satisfaction: exploring a community-based patient navigation model in a rural setting. Oncol Nurs Forum. 2012;39:379-385.
- 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.
- Korber S, Padula C, Gray J, et al. A breast navigator program: barriers, enhancers, and nursing interventions. Oncol Nurs Forum. 2011;28:44-50.
- Kunos C, Olszewski S, Espinal E. Impact of nurse navigation on timeliness of diagnostic medical services in patients with newly diagnosed lung cancer. J Community Support Oncol. 2015;13:219-224.
- Holmes DR, Major J, Lyonga DE, et al. Increasing minority patient participation in cancer clinical trials using oncology nurse navigation. Am J Surg. 2012;203:415-422.
- Ranaghan CP, Boyle K, Fraser P, et al. The effectiveness of a patient navigator on patient satisfaction in adult patients in ambulatory care settings: a systematic review protocol. JBI Database System Rev Implement Rep. 2015;13:54-69.
- Richard ML, Parmar MP, Calestagne PP, et al. Seeking patient feedback: an important dimension of quality in cancer care. J Nurs Care Qual. 2010;25:344-351.
- Shockney LD. The evolution of breast cancer navigation and survivorship care. Breast J. 2015;21:104-110.
- Moore S. Making room at the table. Oncol Nurs Forum. 2010;37:9.
- Case MA. Oncology nurse navigator. Clin J Oncol Nurs. 2011;15:33-40.