Efficacy of the Competency-Based Oncology Patient Navigator Training

Abstract

Background:

Patient navigators play a critical role in working across interdisciplinary cancer teams and guiding patient care throughout the cancer continuum. Training for cancer patient navigators is needed to increase navigator capacity to improve health outcomes, especially given the current climate of provider shortages and high healthcare costs.

Objective:

The objective of the study was to evaluate the efficacy of the competency-based online Oncology Patient Navigator Training: The Fundamentals, designed by The George Washington University Cancer Center to increase confidence among participants in training learning objectives, which align with patient navigator competencies.

Methods:

We analyzed pre- and postlesson data from 671 learners who completed the training from 2015 to 2017 to assess changes in confidence across learning objectives. Questions were asked on a 5-point Likert scale (strongly disagree to strongly agree). We calculated summary statistics and compared pre- and postlesson scores using paired t tests.

Results:

Learners reported statistically significant (P <.001) improvements in confidence across all objectives, increasing from an average mean of 3.6 to 4.3. Learners who completed this training also reported high intention to implement new strategies/skills/information into practice (87.7%).

Discussion:

The Oncology Patient Navigator Training: The Fundamentals was found to be efficacious in improving participant confidence, and learners intended to apply their training in practice. Further research on how effectively the training prepares participants for certification and for ability to perform navigation duties in practice is warranted.

Conclusion:

This fundamental training for patient navigators increased learners’ confidence on competency-based learning objectives.

Freeman and Rodriguez define navigation as “a community-based delivery intervention designed to promote access to timely diagnosis and treatment of cancer and other chronic diseases by eliminating barriers to care.”¹ However, this intervention is now being used in a variety of settings with professionals with differing levels of training serving as a navigator.^2–4 In cancer care, navigators can include nurses, nurse practitioners, social workers, and professionals who are not licensed clinicians.⁵ As demands further strain an already stretched oncology workforce, navigators play a critical role by fostering a one-on-one relationship⁶ with patients across the cancer continuum, from diagnosis to treatment, survivorship, and palliative care, as well as coordinating services across the multidisciplinary team (eg, oncologists, radiologists, primary care providers, dietitians, rehabilitation specialists).^3,7–9

Care coordination is critical for delivering high-quality, patient-centered care. Navigators lower barriers to care by providing culturally sensitive patient education and coaching; providing emotional support and reassurance; scheduling appointments; coordinating social services such as transportation, health insurance, and childcare; assisting with referrals to supportive care, alternative therapies, and palliative services; and serving as a bridge between care specialists.^10–15 Impacts of navigation on the population level include increased adherence to treatment and appointments; increased rates of clinical trial enrollment; improved timeliness of screening, diagnosis, and treatment initiation; reduced wait times; reduced disparities; and improved patient satisfaction.^16–20 Such increased efficiencies can also translate to cost savings. Recent findings from a large-scale study at the University of Alabama Birmingham showed that navigation reduced care costs and number of emergency department visits, as well as hospital and intensive care unit admissions for geriatric patients with cancer.²¹

As cancer navigators become more integrated into the health system, competency-based training for navigators is needed to reduce variation in practice, clarify team expectations of the role, and sustain the profession.^3,22 The Institute for Patient-Centered Initiatives and Health Equity at The George Washington University (GW) Cancer Center (formerly known as GW Cancer Institute) was at the forefront of efforts to establish consensus-based core competencies for cancer patient navigators.²³ More recently, the GW Cancer Center collaborated with the Academy of Oncology Nurse & Patient Navigators (AONN+) to develop a certification process to further advance and standardize the profession of cancer patient navigation by offering a competency-based exam for nonclinically licensed generalists. This article will discuss the learning outcomes of a training developed by the GW Cancer Center based on the core competencies for nonclinically licensed patient navigators. The objective of this study was to evaluate the efficacy of the Oncology Patient Navigator Training in delivering satisfactory content to the intended audience as well as increasing learner confidence in the learning objectives and intent to practice what they learned.

Methods

The Training

The GW Cancer Center developed the Oncology Patient Navigator Training: The Fundamentals (henceforth referred to as the Patient Navigator Training), a no-cost, self-paced online training designed to train patient navigators on the core competencies of their practice; basics of healthcare; basics of patient navigation; basics of communication; professionalism; and enhancing practice (Table 1). The training includes 21 lessons organized into 7 modules and totals 20 hours of learning content. The training includes interactive knowledge checkpoints, and videos, including scenarios demonstrating concepts discussed and case studies. The training modules are locked, so participants must complete lessons in sequence. The GW Cancer Center does not impose any prerequisites or criteria that participants have to meet to take the training—it is open to anyone to enroll. The training intends to increase learners’ confidence in the core competencies for patient navigators and provide solid preparation for the AONN+ Oncology Patient Navigator-Certified Generalist (OPN-CG) certification exam. The training also offers 12 continuing education credits to Certified Health Education Specialists (CHES) and Master CHES at no cost. Since the training launched on May 7, 2015, to March 31, 2017, 675 learners completed the training, with hundreds more in progress. The training evaluation framework was informed by the Kirkpatrick Evaluation Model, which is commonly used to evaluate trainings, including those for healthcare professionals.^24,25 Since the training is online and self-paced, evaluation focused on the first 2 levels of the model (Level 1: Learner satisfaction, and Level 2: Learning outcomes).

Table 1.

Modules, Lessons, Topics, and Number of Learning Objectives per Lesson of the Patient Navigator Training

Module/Lesson	Number of Learning Objectives in Lesson
Module 1: Welcome
Lesson 1: Welcome and Introduction	0
Module 2: An overview of Patient Navigation and Competencies
Lesson 1: Overview of Patient Navigation and Competencies	5
Module 3: The Basics of Health Care
Lesson 1: Medical Terminology	3
Lesson 2: Cancer Basics	5
Lesson 3: Clinical Trials	4
Lesson 4: Impact of Cancer	4
Lesson 5: US Health Care System	4
Lesson 6: Health Care Payment and Financing	3
Module 4: The Basics of Patient Navigation
Lesson 1: The Role of the Patient Navigator	2
Lesson 2: Navigating Patients	7
Lesson 3: Shared Decision-Making	9
Lesson 4: Identifying Resources	4
Module 5: Enhancing Communication
Lesson 1: Communicating with Patients	5
Lesson 2: Patient Advocacy	8
Lesson 3: Culturally Competent Communication	9
Module 6: Professionalism
Lesson 1: Scope of Practice	6
Lesson 2: Ethics and Patient Rights	6
Module 7: Enhancing Practice
Lesson 1: Practicing Efficiently and Effectively	8
Lesson 2: Health Care Team Collaboration	5
Lesson 3: Program Evaluation and Quality Improvement	6
Lesson 4: Personal and Professional Development	9

Study Sample

The sample for this evaluation included learners (N = 671) residing in US states, tribes, and territories who voluntarily enrolled and completed the training between May 7, 2015, and March 31, 2017. Learners who practiced outside of US states, tribes, and territories were excluded from the sample (n = 4). Demographic data, such as age, gender identity, race, ethnicity, and state were collected beginning January 13, 2016. All earlier learners for whom demographic and geographic data were missing were kept in the sample and could include international learners; however, this number is expected to be low.

Data Collection and Analysis

Before and after each lesson of the training (except for the training overview: Module 1), learners are required to rate their confidence in their abilities pertaining to the lesson’s learning objectives. Lesson learning objectives correspond to patient navigation core competencies. Learners are only allowed to complete each pre- and postassessment once. The number of learning objectives assessed varies by lesson based on the content covered, ranging from 2 to 9 (Table 1). For example, questions that assess changes in confidence for Module 2, Lesson 1 are: “I am confident in describing the Core Competencies for Patient Navigators,” “I am confident in my ability to define patient navigation,” “I am confident in my ability to describe social determinants of health and health disparities,” “I am confident in my ability to discuss the history and evolution of patient navigation,” and “I am confident in my ability to explain models of patient navigation.” Participants are asked to rate each statement on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Each lesson also has a postevaluation questionnaire assessing self-reported knowledge, strategies and skills gained, and intention to implement them, also measured on a 5-point Likert scale (strongly disagree to strongly agree). This study did not meet the definition of human subjects research per guidance from the Institutional Review Board at the GW.

We used STATA/IC 14.2 for all analyses. Univariate frequencies and descriptive statistics were obtained for all demographic, learning assessment, and process monitoring items. We used paired t tests to compare pre- and postassessment means for both individual learning objectives and for grand means for each lesson.

Results

Of the entire sample (N = 671), demographic characteristics were available for over two-thirds of participants (n = 469). Table 2 illustrates the demographic characteristics of these participants. Most participants identified as female (89.3%), not Hispanic or Latino (74.0%), and white (72.3%). The age distribution concentrated between 30 and 59 years, with the largest percentage falling in the 30- to 39-year bracket (24.5%). Patient navigators were the largest professional group that completed the training (36.5%), followed by nurses (26.9%), health educators (12.6%), and nurse navigators (11.9%). Other professions represented included social workers, medical paraprofessionals, healthcare administrators, and community health workers. Over half of participants (54.8%) worked in oncology, but other specialty areas such as family medicine, gynecology, and support services were represented. Participants practiced in a variety of geographic and practice settings, with the largest percentage of responses indicating urban areas (39.7%) and outpatient cancer care or radiology (33.0%). The training reached participants in all 10 US Department of Health & Human Services regions, with most participation from Region 4 (19.8%, consisting of Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee), Region 6 (19.4%, consisting of Arkansas, Louisiana, New Mexico, Oklahoma, and Texas), and Region 9 (14.1%) consisting of Arizona, California, Hawaii, Nevada, American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, Guam, Marshall Islands, and Republic of Palau).²⁶

Table 2.

Demographic Characteristics of Patient Navigator Training Participants (n = 469)

	Frequency n (%)
Gender Identity
Female	419 (89.3)
Male	50 (10.7)
Age (years)
18–29	90 (19.2)
30–39	115 (24.5)
40–49	106 (22.6)
50–59	113 (24.1)
60 or older	45 (9.6)
Ethnicity
Not Hispanic or Latino	347 (74.0)
Hispanic or Latino	102 (21.7)
Refused	20 (4.3)
Race
White	339 (72.3)
Black or African American	49 (10.4)
Asian	22 (4.7)
American Indian or Alaska Native	3 (0.6)
Native Hawaiian or other Pacific Islander	0 (0.0)
Other	19 (4.1)
Multiracial	12 (2.6)
Refused	25 (5.3)
Profession*
Patient Navigator	171 (36.5)
Nurse	126 (26.9)
Health Educator	59 (12.6)
Nurse Navigator	56 (11.9)
Medical Paraprofessional	41 (8.7)
Social Worker	26 (5.5)
Healthcare Administrator	18 (3.8)
Community Health Worker/Outreach	16 (3.4)
Financial Counselor/Accounts Payable	13 (2.8)
Physician or Physician Assistant	7 (1.5)
Other	66 (14.1)
Site of Practice
Outpatient cancer care or radiology	155 (33.0)
Office practice	98 (20.9)
Community health center	77 (16.4)
Hospital (in-patient or unspecified)	61 (13.0)
Nonprofit/Social services	27 (5.8)
Public health/Health department	20 (4.3)
Other	31 (6.6)
Specialty*
Oncology	257 (54.8)
Family medicine	55 (11.7)
Gynecology/Women’s health	29 (6.2)
Support services/Wellness/Mental health	22 (4.7)
Internal medicine	19 (4.1)
Geriatrics	13 (2.8)
Imaging/Radiology	5 (1.1)
Other medical specialty	16 (3.4)
Other	8 (1.7)
Not applicable	103 (22.0)
Practice Setting
Urban community	186 (39.7)
Suburban community	98 (20.9)
Rural community	91 (19.4)
Unsure/Not applicable	94 (20.0)

^*Participants had the option to select more than 1 answer.

Completion of lessons was associated with statistically significant changes (P <.001) in learners’ perceived confidence for every learning objective item from pre- to postassessment (results not shown for brevity). Across all training preassessments, confidence in learning objectives averaged 3.6 (SD 0.6), whereas across all postassessments, confidence averaged 4.3 (SD 0.4) (Table 3). These increases in learner confidence from pre- to postassessments were statistically significant overall and by lesson (P <.001). On average across all lessons, most participants strongly agreed or agreed the training enhanced their knowledge (93.4%), they gained strategies/skills/information (90.7%), and they intended to implement new strategies/skills/information (87.7%). Process outcomes also indicate positive results. A majority of participants strongly agreed or agreed the training provided them with the skills and resources needed to successfully navigate patients (91.9%), and it was useful to their professional development (94.2%). Further, nearly all participants strongly agreed or agreed content was clear and effective (94.4%), and the training used good, practical examples to teach/illustrate major points (94.5%). More than half of learners (58.2%) strongly disagreed or disagreed that they needed more information before implementing new strategies/skills/information as a patient navigator.

Table 3.

Comparison of Pretest and Posttest Mean Scores (N = 671)

	Pretest Mean (SD)	Posttest Mean (SD)	Change Score Mean (SD)	t Test P Value
All lessons combined	3.6 (0.6)	4.3 (0.4)	0.7 (0.5)	<.001
Module 2 Lesson 1	3.3 (0.8)	4.2 (0.6)	0.9 (0.8)	<.001
Module 3 Lesson 1	3.7 (0.8)	4.4 (0.6)	0.7 (0.7)	<.001
Module 3 Lesson 2	3.7 (0.7)	4.4 (0.6)	0.6 (0.7)	<.001
Module 3 Lesson 3	3.2 (0.9)	4.3 (0.6)	1.1 (0.8)	<.001
Module 3 Lesson 4	3.6 (0.8)	4.4 (0.5)	0.8 (0.7)	<.001
Module 3 Lesson 5	3.4 (0.8)	4.4 (0.5)	1.0 (0.8)	<.001
Module 3 Lesson 6	3.4 (0.9)	4.3 (0.6)	0.9 (0.8)	<.001
Module 4 Lesson 1	3.6 (0.8)	4.2 (0.6)	0.6 (0.8)	<.001
Module 4 Lesson 2	3.6 (0.7)	4.2 (0.5)	0.6 (0.6)	<.001
Module 4 Lesson 3	3.6 (0.7)	4.3 (0.5)	0.7 (0.6)	<.001
Module 4 Lesson 4	3.7 (0.7)	4.3 (0.5)	0.7 (0.7)	<.001
Module 5 Lesson 1	3.6 (0.7)	4.3 (0.5)	0.6 (0.6)	<.001
Module 5 Lesson 2	3.5 (0.7)	4.3 (0.6)	0.8 (0.7)	<.001
Module 5 Lesson 3	3.6 (0.7)	4.3 (0.5)	0.7 (0.6)	<.001
Module 6 Lesson 1	3.7 (0.7)	4.4 (0.5)	0.6 (0.7)	<.001
Module 6 Lesson 2	3.6 (0.7)	4.3 (0.5)	0.7 (0.7)	<.001
Module 7 Lesson 1	3.7 (0.7)	4.3 (0.5)	0.6 (0.6)	<.001
Module 7 Lesson 2	3.8 (0.7)	4.3 (0.5)	0.5 (0.6)	<.001
Module 7 Lesson 3	3.6 (0.7)	4.3 (0.5)	0.7 (0.7)	<.001
Module 7 Lesson 4	3.7 (0.6)	4.3 (0.5)	0.7 (0.6)	<.001

Discussion

The results of this evaluation suggest the efficacy of the Patient Navigator Training in improving learners’ knowledge, self-reported strategies and skills, and increasing confidence in competency-based learning objectives. Results are not only statistically significant but also practically significant, as participants reported intention to apply what they learned in practice. Furthermore, on average, learners achieved almost a 1-point increase from pre to post—moving from an average confidence rating of “neutral” to “agree.”

The training reached a broad geographic audience, likely because the training was online and available at no cost. Despite being developed for patient navigators who are not clinicians, the training still attracted nurses, social workers, and other clinician learners, possibly filling a gap in practical continuing education for reducing barriers to care across the cancer continuum. The vast majority of learners were female, non-Hispanic, and white. These demographics may reflect limitations of existing reach or the need for greater diversity within the navigation profession. Going forward, the GW Cancer Center plans to partner with community-based organizations that represent more diverse navigators and add closed captioning to expand reach to hearing-impaired learners.

Limitations of this study include selection bias and response bias. This study only assessed the outcomes of participants who completed all lessons in the training, who are likely motivated learners. Additionally, the self-reported nature of the assessment is susceptible to response bias. The assessment uses a 5-point Likert scale, which does not qualitatively detail reasons for self-reported ratings.

Future directions for research could include qualitative research that would provide details on reasons for self-reported ratings and assessing impact of the training on longer-term outcomes, such as how effectively the training prepares participants for certification, navigation practice, and improved patient-reported outcomes.

Conclusions

As the demand on cancer care systems increases, patient navigators will continue to play a critical role in providing access to quality, timely, and culturally competent care, especially for historically underserved populations. This study demonstrates that the Patient Navigator Training delivers content to a wide audience and increases self-reported confidence across all learning objectives.

The training evaluation framework was informed by the Kirkpatrick Evaluation Model, which is commonly used to evaluate trainings, including those for healthcare professionals.