In 1998, President and Mrs. George H. W. Bush invited more than 100 leaders from the collaborative public, private, and nonprofit sectors to participate in a “National Dialogue on Cancer,” which evolved into the organization, C-Change, now with about 150 C-Change participants [45]. Its mission is “to eliminate cancer as a major public health problem at the earliest possible time by leveraging the expertise and resources of our unique multi-sector membership” [45]. C-Change supported the enactment of the Patient Navigator Outreach and Chronic Disease Prevention Act of 2005 [46] and provides ongoing support for patient navigation services. As a result of its active participation in C-Change, the National Association of Social Workers was an early professional association supporter of patient navigation.

The support provided by C-Change for the American Cancer Society (ACS) navigation model, in which “trained” lay navigators provide the service, was questioned by the National Association of Social Workers (NASW): language proposed by C-Change was (and still is) used in legislation, government and nongovernment grant programs, and other navigation-related initiatives. At issue was the absence of clear delineation of appropriate training, scope of duties, and the necessity of professional supervision (by social workers or registered nurses) of lay navigators. In 2007, the NASW concerns around lay navigator supervision had been resolved, and C-Change and NASW partneredto produce the Cancer Patient Navigation Toolkit: A Guide to Community Navigation to market the concept of patient navigation [47]. The NASW Foundation provided early research funding to analyze processes and outcomes of patient navigation. In an NASW Foundation-funded study reported in 2007, Ell and colleagues [48] devised and tested a structured clinical algorithm and demonstrated improved diagnostic resolution follow-up among low-income, ethnic minority women with abnormal mammograms as a result of applying the algorithm and patient navigation and counseling.

There is no evidence of strategic goals or initiatives on the part of NASW or AOSW after the joint position with the ONS was approved by all three professional organizations in 2010 [13].

Nurses in cancer patient navigation roles during the 1990s and the first decade of the twenty-first century had little to no support or guidance for their roles. There were, however, major questions and controversies: How is patient navigation defined? Should navigators be cancer survivors? Should navigators be nurses… or social workers… or physicians? How does someone become a navigator? What do navigators do? Who pays for navigation services? Does every person with cancer – or suspicion of cancer – need a navigator? Do navigators – or navigation processes – actually make a difference? The ONS would be a logical resource for oncology nurse navigators but did not take its first formal step in navigation issues until 2008 when a group of members in navigation roles formed a focus group – an informal prelude to an established ONS Special Interest Group (SIG).

In 2009, the ONS hosted a meeting of thought leaders affiliated with the ONS, NASW, and AOSW to develop a joint position statement to articulate a consensus opinion on the role of oncology nursing and oncology social workers in patient navigation. That joint position was approved by the three boards of directors in 2010 [13]. Key elements of the position include:

Two professional organizations, the National Coalition of Oncology Nurse Navigators (NCONN) and the Academy of Oncology Nurse Navigators (AONN), were established in 2008 and 2009, respectively, to address the educational, resource, and collegial networking needs of oncology nurse navigators. In 2010, NCONN had over 300 members. Member benefits included a very active Listserv and an annual conference with a navigation-specific focus. NCONN developed the first Oncology Nurse Navigator Core Competencies (Table 2.3) in 2009 and produced a revised version in 2013 [39].

AONN recently altered its original mission to include focus on lay navigators and the needs of cancer survivors:

To advance the role of patient navigation in cancer care and survivorship planning by providing a network for collaboration and development of best practices for the improvement of patient access to care and quality of life [49].

Member benefits offered by AONN include discounted registration fees for regional and national conferences, access to online resources, and subscriptions to the AONN Journal of Oncology Navigation & Survivorship™ and other Green Hill Healthcare Communications publications [50]. Seven AONN chapters represent initial efforts to promote and facilitate networking and support at local and regional levels [51].

NCONN and AONN not only had similar missions and goals but also competed for the same membership cohort and corporate support and meeting sponsors. Both entities have histories of major support from for-profit marketing and educational groups. AONN⁺™ continues a long partnership with Green Hill Healthcare Communications, LLC [52]; NCONN’s major sponsor for several years was Healthcare Professionals Network, a division of Intellisphere Oncology Specialty Group, a partnership that ended in 2012. In 2014, NCONN declared “mission accomplished” and disbanded, passed its core competency work on to ONS, and recommended its members support and participate in navigation initiatives directed by ONS [54].

At the time of this writing, there is no recognized and accredited navigation credentialing process, although employers, organizations with navigator members, and individual navigators express interest in certification as verification of knowledge and skills necessary to successfully perform in navigator roles. However, certificate programs, certificate of attendance or participation, certification processes, and the use of credentials and titles are often sources of confusion, misunderstanding, and misuse among employers, organizations, and individuals pursuing designation of specialized knowledge and expertise.

The Institute for Credentialing Excellence (ICE) defines “professional certification”:

The voluntary process by which a non-governmental entity grants a time-limited recognition and use of a credential to an individual after verifying that he or she has met predetermined and standardized criteria. It is the vehicle that a profession or occupation uses to differentiate among its members, using standards, sometimes developed through a consensus-driven process, based on existing legal and psychometric requirements [58].

Differentiation of professional certification, certificate program, certificate holder, and certificate of attendance is important. A certificate program is a “training program on a topic for which participants receive a certificate after attendance and/or completion of the coursework” [58]. Some certificate programs do require demonstration of attained course objectives. A person who completes a certificate program is acknowledged as a “certificate holder” but is usually not granted a credential [58].

Certificates of attendance, participation, or completion are “issued after an individual attends, participates in, and/or completes a particular meeting or course” [58]. Most often, no knowledge is assessed before such a certificate is issued, and such a certificate is not a credential since recipients need not demonstrate competence according to identified standards.

Several programmatic approaches claim to verify navigators’ knowledge, skills, and competencies. The three programs mentioned here are exemplars of available programs and also provide a glimpse of the confusion generated by terminology employed.

The Harold P. Freeman Patient Navigation Institute (PNI) offers a patient navigation training program that awards participants certificates of completion [59]. Its curriculum includes five modules, case studies, and patient interaction practicum: topics include patient retention, diagnostic and treatment resolution rates, improved organizational efficiencies, and mechanisms to prevent lost revenue and contribute revenue to facilities [59].

The National Consortium of Breast Centers (NCBC) is an interdisciplinary organization “committed to development, maintenance, advancement and improvement of quality patient-focused Breast Centers by supporting education, certification and interdisciplinary communication among those served” [60]. The NCBC was the first organization to create a certification program to validate the skill sets of breast patient navigators and to thereby standardize the breast patient navigator’s role. The first NCBC certification program was offered at its 21st Annual National Interdisciplinary Breast Center Conference in 2011 and currently offers six Breast Patient Navigator Certifications: The Certified Navigator – Breast in Imaging, Management, Advocate, Clinical, Provider, or Nurse [60].

Qualifications to sit for the NCBC exam include licensure as a medical professional – physician, registered or practical/vocational nurse, physician assistant, and social worker – and certification as a medical professional – radiologic technologist, radiology practitioner assistant, social worker, or advanced practice nurse [60]. Persons prepared at the master’s degree level in a health-related field can apply to sit for this exam [60]. Applicants must have at least 2 years’ experience navigating breast patients, must have navigated patients for at least 50 % of their job responsibilities, and must be NCBC members [60].

An initial step toward becoming a certified breast patient navigator (CBPN) through the NCBC program is the optional but encouraged attendance and participation in its day-and-a-half Breast Patient Navigator Certification Program, which provides information on the background of breast patient navigation, validity and importance of the role, and case study presentations and discussion [60]. The program also offers “certification examinations.” Once attained, Breast Patient Navigator Certification is lifelong, although annual renewal ($50/year), submission of performance data, and eight CEUs with content on breast care and breast navigation and current NCBC membership are required to maintain active certification. NCBC claimed nearly 800 certificates among its six certification programs as of mid-2014 [60].

The AONN announced the development of a certification program and published a timeline to launch that extends to the first testing in 2016 with test results available in early 2017 [61]. The first certification examination targets general oncology nurse navigators – those who navigate oncology patients with any cancer diagnosis. According to details posted on the AONN website, the objectives of the certification program are twofold [61]:

1.

To have oncology navigation recognized as a professional specialty by national, regulatory, and community organizations; nursing peers; physicians; institutional leadership; and patients and their families.

 

2.

To establish baseline competencies for oncology navigators centered on their roles, responsibilities, educational level of knowledge, and evidence-based best practices that will help to ensure consistent delivery of optimized patient care across the care continuum.

 

Eligibility to sit for the AONN+ certification exam includes [61]:

For various reasons, neither the NCBC’s Breast Patient Navigator Certification Program nor the Academy of Oncology Nurse Navigators’ Oncology Nurse Certification Program (as it is designed in 2015) meets nationally accepted accreditation requirements. “Core” features of certification programs accredited by the American Nurses Credentialing Center (ANCC) Magnet Recognition Program® [62], the National Commission for Certifying Agencies (NCCA) [58], and Accreditation Board for Specialty Nursing Certification (ABSNC) [63] are as follows:

Encouraged by the ONS Nurse Navigator Special Interest Group, the ONS and ONCC undertook the Oncology Nurse Navigator Role Delineation Study (RDS) in 2011, with methods and findings published in 2012 [34]. The RDS, an initial procedure used to explore the feasibility of certification program development, is a formal process used to identify domains, tasks or competencies, knowledge, and skill needed to accomplish certain work. The ONS/ONCC Oncology Nurse Navigator RDS followed practices delineated and accepted by the Institute for Credentialing Excellence [34, 58]. As part of the RDS, an electronic survey was sent to the 280 members of the ONS Navigation SIG and members of AONN. The survey yielded 330 useable responses (50 %), a response rate considered highly acceptable for role delineation studies. The top tasks, knowledge areas, and skills associated with oncology nurse navigation, rated by survey respondents, are presented in Fig. 2.1. Based on these data, the RDS process failed to adequately differentiate tasks, knowledge, and skills of oncology nurse navigators from other oncology nursing roles represented in the existing eight certification processes offered by the ONCC [34]. These findings do not lend support to investing significant resources for the development of a navigation certification program. One could argue that study design, methods, definition of terms, survey population, and instrumentation failed to depict the breadth and depth of the navigation role observed in earlier explorations of what navigators do [11, 36].

Since the publication of the navigation RDS, neither the ONS nor ONCC committed to substantial support for the evolving oncology nurse navigation role, until late 2015 when ONCC initiated a second role delineation effort. The ONS publishedthe first book to focus on oncology nurse navigation – Oncology Nurse Navigation: Delivering Patient-Centered Care Across the Continuum in 2014 [64]. The Nurse Navigation Special Interest Group (SIG), now with over 2100 members, identified strategic goals for the years 2013–2016. Priority activities include [65]:

When and where does a cancer patient navigation service make sense? There are no parameters to respond to this question. Health-care delivery system leaders could gather outcomes data associated with care and services currently available to people with cancer-related concerns throughout the continuum of cancer care and compare these data with norms and standards associated with quality cancer care. Findings serve as a gap analysis, revealing aspects of care and services that are lacking. For example, what is the follow-up from cancer screening programs? Do people with abnormal findings from screening return to the screening facility for additional diagnostic testing? At what stages of disease are patients diagnosed? Does diagnostic testing lead to treatment and follow-up in the same facility – or do patients go elsewhere for treatment? What is the time interval between suspicious screening findings to definitive diagnosis? And, what is the interval between definitive diagnosis and intiation of treatment? Can gaps in care and services be identified and can resources be made available to fill those gaps? What is the institutional impact of these gaps in care and services?