Digital Repository Doctoral Projects Spring 2023 Expanding Patient Cancer Care in a Community Hospital through a Cancer Nurse Navigator Kasey Grubb Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Grubb, K. (2023). Expanding patient cancer care in a community hospital through a cancer nurse navigator Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. WSU REPOSITORY MSN/DNP Expanding Patient Cancer Care in a Community Hospital through a Cancer Nurse Navigator by Kasey Grubb A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT April 28, 2023 Kasey Grubb DNP, MSN, RN, CNE Student Name, Credentials (electronic signature) DNP, MSN/Ed, RN, CNE, COI DNP Project Faculty Name, Credentials (electronic signature) DNP, APRN, CPNP-PC, CNE Melissa NeVille Norton (electronic signature) DNP, APRN, CPNP-PC, CNE Graduate Programs Director Note: The program director must submit this form and paper. April 28, 2023 Graduation Date March 13, 2023 Date March 13, 2023 Date Expanding Patient Cancer Care in a Community Hospital 1 Table of Contents Abstract ........................................................................................................................................... 3 Expanding Patient Cancer Care in a Community Hospital through a Cancer Nurse Navigator..... 5 Background and Problem Statement ........................................................................................... 5 Diversity of Population and Project Site..................................................................................... 6 Significance for Practice Reflective of Role-Specific Leadership ............................................. 7 Literature Review............................................................................................................................ 7 Search Methods........................................................................................................................... 8 Synthesis of the Literature .............................................................................................................. 8 Cancer ......................................................................................................................................... 8 Complexity of Cancer ............................................................................................................. 8 Consequences of Not Getting Good Cancer Care................................................................... 9 Oncology Nurse Navigator ....................................................................................................... 10 Role Expectations and Outcomes of using an ONN ............................................................. 11 Role Development ................................................................................................................ 11 Engagement of Patient, Support System, and Interdisciplinary Team ................................. 12 Discussion ................................................................................................................................. 13 Implications for Practice ........................................................................................................... 13 Framework and Project Application ............................................................................................. 14 Framework Description ............................................................................................................ 14 Framework Application to Practice .......................................................................................... 14 Project Plan ................................................................................................................................... 14 Project Design ........................................................................................................................... 15 Needs Assessment/Gap Analysis of Project Site and Population ............................................. 15 Cost Analysis and Sustainability of Project .............................................................................. 16 Project Outcomes ...................................................................................................................... 16 Consent Procedures and Ethical Considerations....................................................................... 17 Instruments to Measure Intervention Effectiveness .................................................................. 17 Project Implementation ................................................................................................................. 18 Project Interventions ................................................................................................................. 18 Outcomes and Intervention Alignment ..................................................................................... 19 Project Timeline ........................................................................................................................ 19 Project Evaluation ......................................................................................................................... 20 Data Maintenance and Security ................................................................................................ 20 Expanding Patient Cancer Care in a Community Hospital 2 Data Collection and Analysis.................................................................................................... 20 Table 1 ...................................................................................................................................... 21 Table 2 ...................................................................................................................................... 22 Table 3 ...................................................................................................................................... 23 Findings .................................................................................................................................... 23 Strengths ............................................................................................................................... 24 Weaknesses ........................................................................................................................... 24 Discussion ..................................................................................................................................... 25 Translation of Evidence into Practice ....................................................................................... 25 Implications for Practice and Future Scholarship ..................................................................... 26 Sustainability......................................................................................................................... 27 Dissemination ....................................................................................................................... 27 Conclusion ................................................................................................................................ 28 References ..................................................................................................................................... 29 Appendix A ................................................................................................................................... 38 Appendix B ................................................................................................................................... 39 Appendix C ................................................................................................................................... 49 Appendix D ................................................................................................................................... 51 Appendix E ................................................................................................................................... 52 Appendix F.................................................................................................................................... 53 Appendix G ................................................................................................................................... 55 Appendix H ................................................................................................................................... 60 Appendix I .................................................................................................................................... 61 Appendix J .................................................................................................................................... 65 Expanding Patient Cancer Care in a Community Hospital 3 Abstract Defining the Oncology Nurse Navigator (ONN) role, facility tracking metrics, and the creation of an ONN care model can be used to expand the role of the ONN. Using the Care Model and metrics in relation to ONN tasks, providers and navigators can track ONN processes outcomes and improve patient care processes. Purpose: This quality improvement project aims to integrate the Academy of Oncology Nurse & Patient Navigators (AONN) guidelines, tracking metrics, and physician feedback about patientneeded resources to implement an ONN Care Model to expand current cancer patient care processes. Methods: Physicians were surveyed for needed patient resources, knowledge about the ONN role, and satisfaction with ONN care outcomes. Creation of an ONN Care Model and role definition of the ONN were defined for facility needs and improvement. Physician post-surveys and qualitative data were gathered. Aggregated data was gained through anonymous surveys. Results: Post-survey results indicated that improvements were needed to expand the ONN role. Qualitative data suggests that using an ONN care model and metric tracking would benefit patient care and the multidisciplinary team. Discussion: Defining and Implementing an ONN Care Model and Role and Responsibility Program increased the multidisciplinary awareness and resources of current evidence-based practices. Conclusions: Incorporating a defined structured process for ONN cancer patient navigation can expand the role of the ONN, increase multidisciplinary team involvement, and provide holistic patient care. Expanding Patient Cancer Care in a Community Hospital Keywords: oncology nurse navigation, cancer care, cancer guidelines, oncology metrics, multidisciplinary coordination, United States cancer statistics, oncology navigation guidelines. 4 Expanding Patient Cancer Care in a Community Hospital 5 Expanding Patient Cancer Care in a Community Hospital through a Cancer Nurse Navigator Cancer is a prevalent disease and cause of death in the United States and internationally. Cancer is secondary to heart disease in causes of death nationally (Siegel et al., 2021). Data from 2015-2017 reported that around 40% of adults would be identified as having cancer in the United States during their lifetime (National Cancer Institute [NCI], 2020). Approximately 1,806,590 new cancer diagnoses were expected, and about 606,520 Americans would die from the disease in 2020. In 2018, The National Cancer Institute estimated cancer care expenses in the United States were approximately $150.8 billion (NCI, 2020). Cancer diagnosis rates and cancer expenses in the United States are expected to increase with the current aging population (NCI, 2020). The primary purpose of this project is to provide a systematic method for the nurse navigator at Davis Hospital to engage the cancer patient, the patient’s support system, and the interdisciplinary team to advocate for cancer patient-centered best care practices. Cancer is a disease process that can affect the human body. Cancer develops due to genetic changes at the cellular level and can affect almost all cells in the human body. As a result, these changes affect how cells reproduce, causing hypertrophic growth rates of cells that invade and interfere with normal cellular function. Without normal cellular function, the body has difficulty maintaining homeostasis and health. Thus, cancer impacts the health and function of the body and can lead to death due to major cellular interruptions. Causes of cancer can be a genetic inheritance, genetic anomalies in cell division, genetic risk factors, and environmental exposure (NCI, 2021). Background and Problem Statement Holistic patient care is essential to successful cancer treatment and cancer survivorship. Expanding Patient Cancer Care in a Community Hospital 6 Patients experience both physical and psychological effects from the time of a cancer diagnosis that can continue after treatment is completed. Patients reported an improved Quality of life after completing an Oncology Nurse Navigator (ONN) Program (Lee et al., 2011). Mertz et al. (2017) found that a nursing navigation intervention focused on decreasing patient stress, anxiety, depression, and increasing quality of life, significantly improved patient satisfaction of care and reported improved quality of life. A Nurse Navigation program developed to support cancer survivors found increased patient function and increased patient preventative care after interventions (Monterosso et al., 2019). Cancer patients reported holistic care by oncology nurses providing support and empowerment by advocating for patient input on their treatment and care (Kousoulou et al., 2019). Currently, resources and contacts with the patient are limited. At Davis Hospital, patients diagnosed with cancer by a physician or radiologist are referred to the Certified Oncology Nurse Navigator to schedule a meeting to discuss immediate questions and provide the first initial surgical follow-up appointment; limited written materials are provided. The navigation program consists of an initial meeting with the Nurse Navigator; patient follow-up is subjective. Support throughout and after treatment is essential for cancer patients' compliance with their prescribed medical regime, patient success, patient health, and mental well-being. Diversity of Population and Project Site Davis Hospital and affiliating clinic providers accept all adult patients with the following cancer diagnoses; tumors, head & neck cancers, breast cancer, uterine cancer, prostate cancer, lung cancer, cervical cancer, cancer of the gallbladder, cancer of the esophagus, and rectal cancer (Davis Hospital & Medical center, n.d.). The patient population is usually from Davis County, Utah, and surrounding areas. Some providers also specialize in Breast Cancer and Colorectal Expanding Patient Cancer Care in a Community Hospital 7 Cancer in their affiliated clinics. These providers treat a diverse population of patients, including multiple cultural, racial, and socioeconomic backgrounds. Support to the patient is provided through certified translation and financial services (A. Merrell, personal communication, February 22, 2022). Significance for Practice Reflective of Role-Specific Leadership With the complicated components of cancer treatment and care, coordination of treatment and care through a nurse navigator is beneficial to the patient. The nurse navigators’ role can standardize care leading to support throughout and after treatment for patients and their families. A pilot program that introduced the ONN role in a hospital in Brazil found that patients’ time from diagnosis to treatment decreased by an average of six days (Rohsig et al., 2019). Implementation of an inpatient Oncology Nurse Navigator program, led to a 9-day average decrease in Length of Stay (LOS) in the hospital setting and increased quality of life (Lee et al., 2011). A decreased time from positive cancer diagnosis biopsy to the first oncologist consultation was found to be associated with ONN care coordination (Freund et al., 2014). Studies have also found that patient compliance with cancer treatment increased after surgery with the use of an ONN (Bordonada et al., 2020; Wu et al., 2021). This Doctor of Nursing Practice (DNP) quality improvement project will expand the nurse navigator role for all adult cancer patients at Davis County Hospital and affiliating clinics to promote holistic care. Literature Review This literature review discusses current evidence-based empirical data around nurse navigation practice. Emerging themes of the literature to guide practice are a) Complexity of cancer and cancer treatment, b) defining the role of the ONN, and c) patient outcomes with the Expanding Patient Cancer Care in a Community Hospital 8 use of an ONN. In addition, peer-reviewed articles and other nationally-recognized professional organizations were reviewed for pertinent data on the challenges of cancer and the role of the ONN. Search Methods Several search engines were used, including Google Scholar, PubMed, and the Weber State Stewart Library One Search to gather full-text articles. Search terms included: oncology nurse navigator, cancer navigator, nurse navigator, cancer navigator scope of practice, the role of the oncology navigator, definition of a nurse navigator, interdisciplinary cancer team, holistic cancer care, cancer care, cancer treatment, consequences of delayed cancer treatment, and cancer care model. Synthesis of the Literature Cancer Cancer not only affects the physical and physiological body processes, but it can also cause psychological distress and present many mental health challenges for cancer patients and caregivers. Complexity of Cancer Cancer treatment can be complex involving multiple disciplines for comprehensive care. Moreover, treatment can last for extended time frames and may include chemotherapy, radiation, combination treatments, other cancer treatments, and possibly surgical removal of cancer and complications from cancer or treatments (Horlait et al., 2021; Lee et al., 2011; & Pask et al., 2018). Treatment is costly and can affect the patient economically and the ability to afford living and medical expenses (Institute of Medicine, 2008). Treatment of cancer can increase survival rates and increase a person's life span (National Cancer Institute, 2021). Expanding Patient Cancer Care in a Community Hospital 9 Consequences of Not Getting Good Cancer Care Depending on the cancer type, time from diagnosis to treatment is crucial for increasing the odds of cancer survival rates. The World Health Organization promotes early cancer detection and timely treatment to improve survival and eradication rates (World Health Organization, 2017). Breast cancer treatment delays were shown to have a negative effect on tumor size and a decrease in patient outcomes (Bleicher, 2018). A systematic review and metaanalysis (n=1 272 681 patients) by Hanna et al. (2020) found delaying surgical removal of colon, breast, bladder, rectal, cervical, lung, and head and neck cancers measured by each four-week delay had significant implications on patient mortality rates. Conversely, similar systematic reviews for lung, gastric, and head and neck cancers types have found similar results reinforcing the importance of timely cancer treatment (Graboyes et al., 2019; Mazidimoradi et al., 2021; & Vinas et al., 2016). Despite consistent evidence, delays in treatment after a cancer diagnosis are still occurring. During the height of the Covid 19 pandemic, disruptions in the healthcare system created delays in timely cancer treatment. Mortality rates for patients with head and neck cancers with stage I, II, or III cancer types increased from March 2020 to May 2020 due to time delays in treatment (Hartman et al., 20220). A systematic review revealed that treatment delays due to insurance restrictions were related to worse patient outcomes (Yabroff et al., 2020). Other literature found that further treatment delays are multifactorial and can include; Cultural and Ethnic beliefs, distrust of medical treatments, health literacy, socioeconomic status, access to services, age, and interdisciplinary collaboration (Freund et al., 2014; Hanna et al., 2020; Horlait et al., 2021). Treatment delays can also cause psychological distress and decrease quality of life (Neal Expanding Patient Cancer Care in a Community Hospital 10 et al., 2015). In 2017, a multi-disciplinary team participated in a week-long Rapid Improvement Event to identify efficiency for Oncology Nurse Navigators (ONNs). Included in the event was identifying barriers affecting patients in receiving good cancer care. From April 2017 to August 2018, hurdles that patients faced in getting timely treatment included multi-disciplinary care coordination, mental well-being, and patient knowledge of cancer diagnosis and treatment (Binner et al., 2019). Holistic patient care is essential to successful cancer treatment and survivorship (Kousoulou et al., 2019). Patients experience both physical and psychological effects from the time of a cancer diagnosis that can continue after treatment is completed. With the complicated components of cancer treatment and care, coordination of treatment and care through a nurse navigator benefits the patient (Lee et al., 2011). Oncology Nurse Navigator The ONN role is widely accepted as a needed component of patient cancer care. ONNs identify the needs and barriers of cancer patients, help coordinate care, use a holistic approach to patient needs, and are a resource for patients and families (Binner et al., 2019). Academy of Oncology Nurse and Patient Navigators (AONN) Definition The AONN defines (Kelly, 2021) the ONN role as “A nurse navigator is a clinically trained individual responsible for identification and removal of barriers to timely and appropriate cancer treatment. They guide the patient through the cancer care continuum from diagnosis through survivorship. More specifically, the nurse navigator acts as a central point of contact for a patient and coordinates all components involved in cancer care, including surgical, medical, and radiation oncologists; social workers; patient education; community support; financial Expanding Patient Cancer Care in a Community Hospital 11 and insurance assistance; and others. This person has a clinical background and is a critical member of the multi-disciplinary cancer team”. Role Expectations and Outcomes of using an ONN Current treatments allow for more effective yet complex treatment options that can be tailored to the individual to improve cancer suppression (Binner et al., 2019). Coordination is an essential aspect of the ONN's role in improving patient compliance with treatment. Deeb et al. (2017) found that education of the patient in the role of a cancer nurse navigator increased the patient’s attitudes about treatment and treatment options. Patients were also taught how to direct questions to clinical providers to make better-informed treatment decisions. Literature has found that using a cancer navigator reduces treatment expenditures, including decreased emergency room visits and hospitalizations (Rocque et al., 2017; & Wood et al., 2018). As the gatekeeper of patient care, the ONN creates a positive nurse/patient relationship that can positively impact the quality of life (QOL) (Kagan et al., 2020). Role Development The role of the ONN is comprehensive and requires role development. Recognized professional organizations offer certification programs. The Oncology Nurse Certification Corporation offers several certifications to nurse navigators, including the Oncology Nurse Certification (ONC) and Advance Practice Nurse cancer certifications (ONCC, n.d.). The AONN provides certificates of an Oncology Nurse Navigator- Certified Generalist (ONN-CG), which requires a current nursing license in good standing. A Certified Oncology Patient Navigator requires a background in patient navigation (AONN, n.d.). The Commission on Cancer (COC, 2022) recognizes certifications from these two organizations, certificates for the ONN are a standard of best practice and can be required for specific facility cancer accreditations. Expanding Patient Cancer Care in a Community Hospital 12 The Oncology Nursing Society (ONS, 2017) provides a framework for defining the role of the ONN with the publication of the Oncology Nurse Navigator Core Competencies: 1) Coordination of care, 2) Communication, 3) Education, 4) Professional role, and 5) Expert Oncology Nurse Navigator. Defined are also specified ONN interventions, including a) assessing patient and patient situations to address barriers impacting care, b) providing information, resources, and referrals, c) advocating for and promoting patient decision-making, d) anticipating care needs, and e) providing and advocating for palliative care when needed (ONS, 2017). Using these resources as a guideline, the ONN can develop practice guidelines in a cancer care model to promote individual growth and accountability (McMullen et al., 2016). In addition to the Navigation Core Competencies, the AONN provides nurse navigation metrics to guide patient navigation to qualify and quantify patient care points (Johnston et al., 2017). The National Comprehensive Cancer Network (NCCN, n.d.) also provides patient care standards for the ONN, including patient assessment tools, patient education, and practice guidelines pertaining to cancer diagnosis. Engagement of Patient, Support System, and Interdisciplinary Team Patients need orientation to the ONN role and what services they provide. The ONN can engage patients in optimizing resources by personalizing the patient’s situation, providing patient direction regarding the services offered, and building a trusting relationship for patient resources (Kagan et al., 2020). The ONN also acts in an advocacy role by coordinating care and educating the patient about treatment options; this education and advocacy create patient empowerment through disease processes (Jeyathevan et al., 2017). Finally, the ONN also provides mental and social support to patients through the ONN nurse/patient relationship and by providing support resources such as counseling and support groups (Osowiecka et al., 2020). Expanding Patient Cancer Care in a Community Hospital 13 Engagement of the patient's support system is a component of patient success. Literature has shown that most patients receive emotional support from their family and friends (Osowiecka et al., 2020; Salakari et al., 2017). Cancer not only affects the patient but also has a negative correlation with the patient’s support system. Not only is support imperative to patient outcomes, but engagement and support of the family and friends involved should be considered as treatment of the whole patient (Saita et al., 2016). The ONN role is dynamic and has many components to providing holistic patient care. A triad of engagement opportunities by the ONN is the way to offer high-quality holistic care for cancer patients. Discussion The ONN, as the gatekeep of cancer patient care, engages an interdisciplinary team of professionals, including dieticians, oncologists, palliative care providers, primary care providers, and, if needed, supportive departments such as therapies and mental health professionals (Kagan et al., 2020). In addition, through a patient evaluation of needs, the ONN can engage with and coordinate across disciplines to individualize patient care and maximize patient treatment needs (Canadian Oncology Nursing Journal, 2020). Implications for Practice The literature shows a positive correlation between the physical and psychological needs of cancer patients, holistic care, interdisciplinary approach, and the necessity of ONN. The Quality Control Department and Nurse Navigators at Davis Hospital and Medical Center are investigating the Certified National Accreditation Program for Rectal Cancer (NAPRC) with the end goal of achieving certification. Using evidence-based practice and profession-specific recognized resources, this DNP quality improvement project will implement an expanded nurse navigator role to benefit this community's adult cancer patient population. Expanding Patient Cancer Care in a Community Hospital 14 Framework and Project Application The framework used to guide this project is Lewin’s Change theory. This framework provides structure in defining the movement steps throughout the change process. The end goal is to successfully change and return to equilibrium (McEwen & Willis, 2019). Framework Description During change, opposing forces occur; driving and restraining forces can move and restrict change processes, causing a disruption of balance (McEwen & Wills, 2019). Capitalism as the driving force should be implemented to promote a positive change culture. Conversely, restraining forces can be evaluated and reduced. Lewin’s Change Theory describes the change process in three steps: 1) Unfreeze, 2) Change, and 3) Freeze (Burnes, 2020; McEwen & Willis, 2019). Framework Application to Practice Lewin’s Change Theory describes the framework to address barriers to change and expand patient cancer care in a community hospital. The Quality Improvement Department and the ONNs are the driving forces for change. The first stage in the project's development involves the need to unfreeze current practices at the hospital to explore needs and resources and develop an interdisciplinary team to collaborate on change needs. During this phase, the identification of barriers will be assessed and creatively discussed. The implementation phase is where education, the recommended practices, and the adjustment and adoption of practices will be made. In the third stage of this process, the methods and techniques developed and implemented will become standard in-hospital processes. Project Plan This project includes defining and implementing evidence-based (EB) ONN care process Expanding Patient Cancer Care in a Community Hospital 15 changes at DHMC to improve cancer patient care. The plan consists of leading a multidisciplinary team to evaluate the current ONN process, EB guidelines that define ONN activities, and metrics that meet both team objectives with the intent to improve patient care. Project Design This quality improvement project aims to standardize the ONN care processes through ONN metric tracking by defining an ONN care model (see Appendix A), specifying ONN tasks by creating an ONN Guidelines and Metrics Binder (see Appendix B), and ONN Training Narrated PowerPoint (see Appendix C). Defining processes and metrics of ONs will promote current EB ONN standards. In addition, meeting current standards will improve cancer patient care within the multi-disciplinary oncology team. Needs Assessment/Gap Analysis of Project Site and Population The focus of this quality improvement project impacts DHMC and affiliated physicians at Tanner Clinic in Layton. Primary project participants are the ONNs at the hospital, who will follow the ONN care model and create a process for tracking metrics. Cancer patient providers are participants who will provide feedback about current ONN processes and patient needs. The quality improvement team will participate by gathering metric data for reporting and request purposes at administrative meetings. Key stakeholders include the ONN Multi-disciplinary Team and the Quality Improvement Director. In addition, there is administrative support from the Chief Nursing Officer, Assistant Chief Nursing Officer, Risk Manager/Patient Advocate Officer, and the hospital’s Chief Financial Officer. The stakeholders have worked to align the project with current EB practices and hospital policies and have an investment in the project objectives. Expanding Patient Cancer Care in a Community Hospital 16 Cancer prevention and treatment can be impacted by socioeconomic factors and cause cancer disparities (National Cancer Institute, 2022). Through ONN metric tracking, social determinants of health and cancer disparities will be identified and addressed. Cost Analysis and Sustainability of Project The Quality Improvement Director has approved project costs and budget requirements over the ONN team. The hospital will cover printed materials. The following demonstrates the cost analysis (see Appendix D): • Team Meetings and Education hours totaling approximately 15 hours for three RNs and one Patient Navigator at an hourly wage of $31.00 equal $1860.00 for the educational cost. • Four Oncology Navigation Guidelines Binders with printed deliverables at $10.00 each. • Patient Welcome Letters printed out of house at forty cents per page cost, with a quantity of 100 to start equals $40.00 (see Appendix E). • Provider/Patient Oncology Navigation Marketing Trifold Pamphlets at $1.20 each with a quantity of 150 equals $180.00 (see Appendix F). The project sustainability includes using the ONN Narrated Training PowerPoint to orient new hires to the organization and department processes, maintaining the ONN Guidelines Binders with current ONN activities and metrics, and updating the printed materials as needed. Project Outcomes The measurable project outcomes are: • The DHMC providers and affiliated providers will give feedback on the ONN process before and after the project implementation to identify gaps in patient care coordination. Expanding Patient Cancer Care in a Community Hospital • 17 The DHMC ONN Team will adopt the new ONN care model and ONN Guidelines processes. • The DHMC ONN Team will track and report defined ONN metrics. • The DHMC ONN Multi-disciplinary Team will adopt the new ONN processes to identify cancer patient disparities and work to improve cancer patient care coordination. Consent Procedures and Ethical Considerations Approval for this quality improvement project was provided by the Institutional Review Board (IRB) at Weber State University and did not require formal review. IRB review and approval are not needed through DHMC or Tanner Clinic in Layton, as there is no protected health information or human testing to be gathered. Provider surveys will be collected in an anonymous, aggregated fashion. Instruments to Measure Intervention Effectiveness Two provider surveys will measure the project’s intervention and effectiveness. The preproject original survey (see Appendix G) will be sent to all DHMC cancer providers and affiliated cancer physicians at Tanner Clinic in Layton to identify currently needed resources, current cancer patient survey and survivorship tools, process improvements, standardization, and educational needs of the DHMC ONN department. A physician survey for educational needs will also be gathered (see Appendix H). The post-project original survey (see Appendix I) will be sent to the same providers measuring project implementation of ONN process changes, including care coordination of cancer patients by the multi-disciplinary team. This data will be evaluated to show improvements in care coordination through the implementation of the project and its relation to patient care coordination within the ONN department and with the Multi-disciplinary Cancer Team. Expanding Patient Cancer Care in a Community Hospital 18 Project Implementation Implementation of this project is ongoing and will be complete when the DHMC ONN team adopts the ONN Care Model and tracks and reports metrics to hospital administration and the multi-disciplinary team. The team should also continue to look for opportunities to improve cancer patient care coordination and resources. The Hospital Administration and ONN Team adoption are critical to the success and sustainability of the project and patient-supportive outcomes. Standardizing ONN activities, measurements, and reporting will provide structure to meet evidence-based patient outcomes, data to recommend needed patient resources, team improvements, and cost of care. The Assistant Chief Nursing Officer (CNO) must utilize a top-down approach to approve and implement this needed quality improvement project. Project Interventions Transformational leadership aims to transform clinical processes to incorporate evidencebased practices that improve patient outcomes (Reavy, K., 2016). Interventions for this project included leading a multi-disciplinary team with transformational leadership techniques to encourage team buy-in, collaboration, and evidence-based practice changes. Preliminary interventions included project approval from the assistant CNO and obtaining a DHMC quality improvement team member. After initial interventions were obtained, regular meetings were held with the ONN multi-disciplinary team to discuss evidence-based practices, change processes, problem-solving issues, and approval of project deliverables. The Pre-Project Survey tool was distributed to the providers through meetings and individual appointments. Materials defining ONN guidelines and standardization were created using corporate materials guidelines with the assistance of the hospital marketer and distributed Expanding Patient Cancer Care in a Community Hospital 19 to the ONN multi-disciplinary team. Having defined guidelines allows for tracking of the patient and ONN data. Patient outcomes and barriers to care can be analyzed to meet not only individual patient needs, but provides the ONN team with the ability to improve resources, identify and eliminate time delays to care and track hospital and national patient metrics. Outcomes and Intervention Alignment The main objectives of this project were that the ONNs would adopt the new ONN care plan, ONN guidelines, and metrics tracking process, and cancer patients will receive frequent touchpoints with the ONN; the metrics provided data for the multi-disciplinary team, which was used to improve cancer patient care. The Assistant CNO used a top-down approach to direct needed changes within the ONN processes. Reorganization of the ONN team management was assigned to the quality department to allow for more autonomy for the ONNs, forward movement of this quality improvement project, and metric tracking and reporting. The ONN team was given a time frame for implementing the processes by the middle of October 2022. The frequent evaluation of the project implementation allowed for adjustments to create an inclusive implementation. Qualtrics pre- and post-surveys (see Appendix G & H) were administered, and data were analyzed to determine outcome intervention alignment. Project Timeline The project timeline encompassed initial research and development of the ONN guidelines and metrics binder, ONN care model, provider/patient marketing pamphlet, and physician surveys. Progression of the timeline continued through interventions that allow the ONN team to meet the project implementation goals and serve as a project plan (see Appendix J) to keep track of project outcomes and provide team updates. Expanding Patient Cancer Care in a Community Hospital 20 Project Evaluation The DHMC ONN quality improvement project was introduced to the multidisciplinary cancer team at the tumor board meeting on October 8, 2022, and at the hospitalist meeting on September 21, 2022, with a review of the Oncology Navigation Role and Metrics Definitions and the ONN Care Model. After the project introduction and before the project implementation, a physician pre-survey evaluating the ONN team and current patient needs was distributed. The barriers to the complete project implementation and the project implementation timeline were discussed at the January 26, 2023, tumor board meeting and again at the February 15, 2023, hospitalist meeting. In addition, a post-survey was requested from the physician team. Data Maintenance and Security Qualtrics software was used to create, collect, and analyze the project surveys, and corresponding data was projected by login-specific protected access. The goal of the project included marketing Tanner Clinic physicians. Thus, a physician survey for educational information that collected provider names and contact information was included with the presurvey. The confidential pre-& post-surveys were kept secure on a password-protected computer and contained no identifying markers. Data Collection and Analysis The pre-survey varied slightly on two questions from the post-survey. The surveys analyzed the physician’s use of a distress thermometer in screening their patients, rating the ONN team’s ability to collaborate with the multidisciplinary team, the patient, overall satisfaction with the ONN role, and what patient resources were needed to ensure holistic patient care. All survey data was presented in a Likert scale with select answers exported into tables to Expanding Patient Cancer Care in a Community Hospital 21 evaluate project outcomes. The responses were analyzed for any decreases or increases in the rating of the ONN team and patient needs. As shown in Table 1, pre-survey data results revealed a lack of patient distress screening at office visits as recommended by the NCCN (n.d.). Table 1 As shown in Table 2, the findings indicated needed project interventions to expand the ONN role at DHMC. Expanding Patient Cancer Care in a Community Hospital 22 Table 2 Table 3 demonstrates provider-requested hospital and ONN-provided patient resources. Expanding Patient Cancer Care in a Community Hospital 23 Table 3 Findings During multidisciplinary meetings where the project aims were discussed and surveys were introduced, provider feedback was positive. Dr. Abdulelah Y. Abu Qare ( personal communication, September 21, 2022) felt that the project was positive and would aid in providing better care to inpatient hospital patients. Dr. Glen Morrell (personal communication, January 26, 2023) discussed the implications of the project and improvements that would come from metric tracking. Improvement areas identified were timeliness and coordination of care. However, overall, the providers were satisfied with the ONN team and the care they provided. The post-survey results demonstrated similar results with a slight increase in survey respondents. Timeliness in care coordination and coordination with providers was identified as a needed improvement area Expanding Patient Cancer Care in a Community Hospital 24 of the ONN team. Improvements were made in providing patient financial counseling, transportation, caregiver support, pain management, and palliative care services. These areas of patient resources were discussed as a team, with ONN resources put into practice during project implementation meetings. Strengths Project strengths were the use of nationally recognized guidelines to develop a quality improvement process that would meet the needs of DHMC in expanding the ONN role to benefit patient care. In addition, the application of the project recommendations is generalizable and implementable. The project is cost-effective and can be utilized to improve processes in a facility to provide ONN-led care. Weaknesses There were several project limitations identified during various stages of the project implementation. First, data participation was low in the pre-survey administration. Hospital ownership and a pending corporate sale to Healthcare Corporation of America (HCA) could have contributed to the low survey response. Initially, in coordination with the physician teams, hospital administration was attempting to achieve accreditation through the Commission on Cancer (COC). Discussion of HCA COC accredited facilities pointed at Ogden Regional already having accreditation status and possibly changing corporate ONN contracting services. During the project’s implementation phase, several barriers prevented the full implementation of the project objectives. First, the Federal Trade Commission denied the buyout of DHMC by HCA. The Utah Steward healthcare facilities were offered for an open sale, and corporate support decreased, decreasing staff morale, including limited resources and staffing positions. Providers who had been working as part of the DHMC physician team left the facility Expanding Patient Cancer Care in a Community Hospital 25 for other opportunities. The Assistant CNO and Quality Director left for employment at HCA. An ONN team member left employment at the hospital, with corporate dissolving the position. Also, there were staffing shortages on the ONN team due to personal challenges. As expected, the follow-up survey did not indicate the expansion of the ONN role and project successful implementation. Limitations of the post-survey were low response numbers, possible different physicians surveyed, and corporate limitations. Discussion This DNP project provided a plan to providers and DCH for future development and expansion of the cancer nurse navigator role. However, it recommends continuous improvement efforts by the ONN to provide quality patient care as part of the multidisciplinary team and to identify patient barriers to care. This project demonstrated the scholarship of discovery by identifying evidence-based practices to improve patient care through expansion of the ONN role. Translation of Evidence into Practice The evidence-based practice incorporates current research recommendations, clinician knowledge, and patient preference input (Abu-Baker et al., 2021). The use of evidence-based practice in nursing provides a foundation for nursing judgment to implement safe, operational, and efficient care (Li et al., 2019). To incorporate an evidence-based approach for this project, a comprehensive review of the literature on oncology navigation role expectations, patient outcomes, and roles within a multidisciplinary team was completed. Evidence reveals that using an ONN can reduce care costs, decrease complications (Rocque et al., 2017; & Wood et al., 2018), and increase the patient’s quality of life (Kagan et al., 2020). Evidence demonstrates that using an ONN can assist patients in overcoming barriers to care and care coordination (Binner et al., 2019). Finally, a holistic approach to cancer care is needed for successful care outcomes and Expanding Patient Cancer Care in a Community Hospital 26 patient survivorship (Kousoulou et al., 2020). These themes throughout the literature revealed the role of the oncology navigator as essential to quality cancer care and their value to the multidisciplinary team. The literature review also revealed that until recently, there was no standardization for tracking and measuring oncology navigation. The AONN & American Cancer Society Navigation Metrics Toolkit (2020) provides a framework to evaluate and track patient care metrics. Data from metrics can provide an opportunity for the ONN and multidisciplinary team to implement quality improvement initiatives. Several professional organizations (AONN, 2020; COC, 2022; NCCN, n.d.; & ONS, 2017) provide a framework for defining the ONN role. In addition, ONN interventions and ONN tracking metric frameworks give current practice standards in creating a patient care model and improvement process. This project's aims pursued defining the ONN's role, defining ONN tracking metrics, and creating an ONN care model to implement evidence into practice for a holistic approach to patient care as a valued multidisciplinary team member. Although the project implementation did not materialize during the allotted time frame, the groundwork was laid for a method of evaluating and expanding the ONN role to meet current practice recommendations. In addition, the multidisciplinary team members found the project valuable and want to see the evidence implemented into practice in the near future. Implications for Practice and Future Scholarship Patient care processes should be continuously reviewed for effective, efficient, safe, and value-based care to provide quality-based care (O’Donnell & Gupta, 2022). The project provides an underpinning for ONN practice guidelines and continuous quality improvement. Implementation of the guidelines of the project would provide structure to ONN processes and Expanding Patient Cancer Care in a Community Hospital 27 provide future research opportunities. Expanding this project to a larger clinical setting would provide the opportunity for more inclusive involvement, an increased multidisciplinary survey sample, and the ability to collect more data on tracking metrics to evaluate a comprehensive patient care model and patient outcomes. Sustainability To make a sustainable change, the literature discusses the need to implement evidencebased practices and evaluate team efforts to make sustainable changes that include process evaluation and adjustment when needed (AONN, 2022 & ONS, 2017). In addition, changes in practice should be implemented after thoughtful consideration and systematically, with driving forces being stronger than opposing forces (McEwen & Willis, 2019). For the sustainability of this quality improvement project, direction and tracking processes for change should be consistent and measured at regular intervals by management to ensure the buy-in of stakeholders. Buy-in of all stakeholders was limited due to internal and external forces of change, including resistance to change and the pending corporate merger. Dissemination Dissemination of the findings of this project can be completed through various methods. The practice of disseminating research findings validates the research processes by allowing for peer review and identifying research gaps within the nursing profession (Curtis et al., 2017). Sharing of project findings will be presented to the facility and corporate management with recommendations for standardization of the ONN role within the corporation. This research will be disseminated at the national Western Institute of Nursing Conference and submitted to professional journals for publication. Expanding Patient Cancer Care in a Community Hospital 28 Conclusion ONN is a comprehensive process that can be essential to cancer patient treatment and care outcomes. It can also be used to enhance and support patients, patient support persons, and the multidisciplinary team, therefor it is peremptory to implement patient care models and metric tracking methods to provide better patient outcomes. The frameworks developed in this quality improvement project used the multidisciplinary team to identify gaps in patient care and current recommended ONN processes that would close the gaps in practice. Furthermore, the interdisciplinary team recommends that this quality improvement project be implemented into practice and continuously evaluated for progressive patient care. Expanding Patient Cancer Care in a Community Hospital 29 References Abu-Baker, N. N., AbuAlrub, S., Obeidat, R. F., & Assmairan, K. (2021). Evidence-based practice beliefs and implementations: a cross-sectional study among undergraduate nursing students. BMC nursing, 20(1), 13. Academy of Oncology Nurses & Patient Navigators & American Cancer Society (2020). Navigation metrics toolkit. https://aonnonline.org/images/resources/navigation_tools/2020-AONN-NavigationMetrics-Toolkit.pdf https://doi.org/10.1186/s12912-020-00522-x Academy of Oncology Nurses & Patient Navigators (n.d.). Certification. Retrieved March 28, 2022, from https://aonnffl.org/ Binner, M., Figlioli, A., Shanahan, J., Putscher, T., Davis, J., Stewart, K., & Waite, K. (2019). 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G., Dunn-Henriksen, A. K., Kroman, N., Johansen, C., Andersen, K. G., Andersson, M., Mathiesen, U. B., Vibe-Petersen, J., Dalton, S. O., & Envold Bidstrup, P. (2017). The effects of individually tailored nurse navigation for patients with newly diagnosed breast cancer: A randomized pilot study. Acta oncologica (Stockholm, Sweden), 56(12), 1682– 1689. https://doi.org/10.1080/0284186X.2017.1358462 Monterosso, L., Platt, V., Bulsara, M., & Berg, M. (2019). Systematic review and meta-analysis of patient reported outcomes for nurse-led models of survivorship care for adult cancer patients. Cancer Treatment Reviews, 73, 62-72. https://doi.org/10.1016/j.ctrv.2018.12.007 National Cancer Institute (2020, September 25). Cancer statistics. https://www.cancer.gov/about-cancer/understanding/statistics National Cancer Institute (2021, May 5). What is cancer? https://www.cancer.gov/aboutcancer/understanding/what-is-cancer National Cancer Institute (2022, March 28). 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JNCI : Journal of the National Cancer Institute, 112(7), 671-687. https://doi.org/10.1093/jnci/djaa048 Expanding Patient Cancer Care in a Community Hospital Appendix A 38 Expanding Patient Cancer Care in a Community Hospital Appendix B 39 Expanding Patient Cancer Care in a Community Hospital 40 Expanding Patient Cancer Care in a Community Hospital 41 Expanding Patient Cancer Care in a Community Hospital 42 Expanding Patient Cancer Care in a Community Hospital 43 Expanding Patient Cancer Care in a Community Hospital 44 Expanding Patient Cancer Care in a Community Hospital 45 Expanding Patient Cancer Care in a Community Hospital 46 Expanding Patient Cancer Care in a Community Hospital 47 Expanding Patient Cancer Care in a Community Hospital 48 Expanding Patient Cancer Care in a Community Hospital Appendix C 49 Expanding Patient Cancer Care in a Community Hospital 50 Expanding Patient Cancer Care in a Community Hospital 51 Appendix D Project Costs Quantity Cost per 60 $31.00 Oncology Navigation Guidelines Binder 4 $10.00 Patient Welcome Letters 100 $0.40 Provider/Patient Trifold Brochures 150 $1.20 urEd Education Hours Total Cost $2080.00 Expanding Patient Cancer Care in a Community Hospital Appendix E 52 Expanding Patient Cancer Care in a Community Hospital Appendix F 53 Expanding Patient Cancer Care in a Community Hospital 54 Expanding Patient Cancer Care in a Community Hospital 55 Appendix G Davis Hospital and Medical Center Physician Survey of Nurse Navigation Program PreSurvey Start of Block: Default Question Block Q1 The following is an online survey that takes approximately 10 minutes to complete. The survey questions will be about Oncology Nurse Navigation Services offered at Davis Hospital and Medical Center. By participating in this survey, you are giving your consent. The results of this survey are reported using aggregated data, keeping responses anonymous and confidential. Data will be used for educational or quality improvement purposes to improve outcomes. If you have any questions, please contact (kaseygrubb@weber.edu). o I agree to participate (1) o I do not agree to participate (2) Skip To: End of Survey If The following is an online survey that takes approximately 10 minutes to complete. The survey que... = I do not agree to participate Q2 Do you use Oncology Navigation Services for your patients through Davis Hospital and Medical Center or affiliated Tanner Clinic Oncology Navigation Services? o Yes (1) o No (2) o Sometimes (3) ________________________________________________ Expanding Patient Cancer Care in a Community Hospital 56 Q3 Are you aware of the Oncology Nurse Navigator Services through Davis Hospital and Medical Center? o Yes (1) o No (2) Q4 Do you screen your cancer patients at their office visits with a well-being or distress survey? o Yes (1) ________________________________________________ o No (2) Q5 I am satisfied with the nurse navigator's awareness of appropriate resources. o Satisfied (1) o Neutral (2) o Dissatisfied (3) Q6 I am satisfied with the nurse navigator's timeliness in the coordination of care. o Satisfied (1) o Neutral (2) o Dissatisfied (3) Expanding Patient Cancer Care in a Community Hospital Q7 The nurse navigator helps provide education to my patients. o Satisfied (1) o Neutral (2) o Dissatisfied (3) Q8 The nurse navigator works with me or my office to address patient concerns. o Satisfied (1) o Neutral (2) o Dissatisfied (3) Q9 Overall, I value the nurse navigation service to my practice. o Satisfied (1) o Neutral (2) o Dissatisfied (3) 57 Expanding Patient Cancer Care in a Community Hospital Q10 What patient resources would you like to see available to your cancer patients? (select all that apply) ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ Financial Counseling (1) Transportation Resources (2) Genetic Counseling (3) PT/OT/ST (4) Support Groups (5) Caregiver Support Groups (6) Registered Dieticians (7) Mental Health Specialists (8) Pain Management (9) Survivorship Care Plan (10) Palliative Care Services (11) Hospice Services (12) Chaplain/Religious Representatives (13) Other (14) ________________________________________________ 58 Expanding Patient Cancer Care in a Community Hospital Q11 What other activities or standards would you like the nurse navigator to be involved in? o n/a (1) o other (2) ________________________________________________ Q12 Any other suggestions or feedback for Davis Hospital and Medical Center or the Nurse Navigators? ________________________________________________________________ Q13 I would like to receive more information for myself and my patients about Oncology Navigation Services at Davis Hospital and Medical Center? Pamphlets will be provided. My name and specialty are listed below. (Your survey results will be kept confidential, as such you will be directed to a separate one entry survey to put your information in). o Yes (1) o No (2) End of Block: Default Question Block 59 Expanding Patient Cancer Care in a Community Hospital 60 Appendix H Davis Hospital and Medical Center Physician Survey for Educational Information Start of Block: Default Question Block Q1 Thank you for your interest in learning more about our Oncology Navigation Services. Please put your name and specialty below to receive Pamphlets on the services we offer. ________________________________________________________________ End of Block: Default Question Block Expanding Patient Cancer Care in a Community Hospital 61 Appendix I Davis Hospital and Medical Center Physician Survey of Nurse Navigation Program PostSurvey Start of Block: Default Question Block Q1 The following is an online survey that takes approximately 10 minutes to complete. The survey questions will be about Oncology Nurse Navigator services offered through Davis Hospital and Medical Center or affiliated Tanner Clinic Oncology Nurse Navigator. By participating in this survey, you are giving your consent. The results of this survey are reported using aggregated data, keeping responses anonymous and confidential. Data will be used for educational or quality improvement purposes to improve outcomes. Please contact (insert your WSU email) if you have any questions. o I agree to participate (1) o I do not agree to participate (2) Skip To: End of Survey If The following is an online survey that takes approximately 10 minutes to complete. The survey que... = I do not agree to participate Q2 Do you use the Oncology Nurse Navigation services for your patients through Davis Hospital and Medical Center or affiliated Tanner Clinic Oncology Nurse Navigator? o Yes (1) o No (2) o Maybe (3) ________________________________________________ Expanding Patient Cancer Care in a Community Hospital 62 Q3 Are you aware of the Oncology Nurse Navigator Services through Davis Hospital and Medical Center? o Yes (1) o No (2) Q4 Do you screen your cancer patients at their office visits with a well-being or distress survey? o Yes (1) o No (2) Q5 I am satisfied with the nurse navigator's timeliness in the coordination of care. o Satisfied (1) o Neutral (2) o Dissatisfied (3) Q6 I am satisfied with the nurse navigator's timeliness in the coordination of care. o Satisfied (1) o Neutral (2) o Dissatisfied (3) Expanding Patient Cancer Care in a Community Hospital Q7 The nurse navigator helps provide education to my patients o Satisfied (1) o Neutral (2) o Dissatisfied (3) Q8 The nurse navigator works with me or my office to address patient concerns. o Satisfied (1) o Neutral (2) o Dissatisfied (3) Q9 Overall, I value the nurse navigation service to my practice. o Satisfied (1) o Neutral (2) o Dissatisfied (3) 63 Expanding Patient Cancer Care in a Community Hospital 64 Q10 What patient resources do you feel have improved or are available for your patient needs? (select all that apply) ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ ▢ Financial Counseling (1) Transportation Resources (2) Genetic Counseling (3) PT/OT/ST (4) Support Groups (5) Caregiver Support Groups (6) Registered Dietician (7) Mental Health Specialists (8) Pain Management Services (9) Survivorship Care Plan (10) Palliative Services (11) Hospice Services (12) Chaplain/Religious Representatives (13) Other (14) Expanding Patient Cancer Care in a Community Hospital 65 Q11 Any recommendations for the Nurse Navigator Team or Davis Hospital and Medical Center? ________________________________________________________________ Appendix J Oncology Navigation Project Timeline Task Start Meet with Quality & Assistant CNO for Needs Assessment Gathered Evidence Practice Guidelines for Interventions Introduction of Project to Multi-disciplinary Team Creation of Project Deliverables Implementation of Interventions Evaluation of Interventions August 2021 Finish/Projected Finished Date September 2021 October 2021 May 2022 May 2022 May 2022 May 2022 August 2022 September 2022 On task to finish November 2022 On task to finish December 2022 On task to finish January 2023 Recommendations for Administration and Dissemination of Project December 2022 December 2022 Expanding Patient Cancer Care in a Community Hospital 66