n Online Exclusive Article
Effect of Nurse Navigation on Patient Care Satisfaction and Distress Associated With Breast Biopsy Mariann Harding, PhD, RN, CNE
Background: Navigation during the biopsy period is a superior approach to delivering care, with those patients receiving services experiencing less distress. Critical nurse navigator roles include providing information and facilitating access to the healthcare system, both of which are influential on distress. The information in this article supports the expansion of navigation programs to include women undergoing biopsy and aids in promoting a higher standard of care. Mitar Holod/iStock/Thinkstock Objectives: To evaluate the effect of navigation on care satisfaction and distress in women undergoing breast biopsy. Methods: A descriptive, cross-sectional survey design from two outpatient radiology clinics in Appalachia was used. Findings: Navigated women had lower scores on every distress measure and were less likely to seek information from an outside source. Women who were more satisfied with their care reported decreased distress; the factors influencing distress varied depending on whether they were the recipient of navigation services. In the non-navigated population, general satisfaction with care and accessibility were more likely to influence distress. Mariann Harding, PhD, RN, CNE, is an associate professor in the College of Nursing at Kent State University at Tuscarawas in New Philadelphia, OH. The author takes full responsibility for the content of the article. The author did not receive honoraria for this work. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the author, planners, independent peer reviewers, or editorial staff. Harding can be reached at [email protected], with copy to editor at [email protected]. (Submitted March 2014. Revision submitted May 2014. Accepted for publication May 12, 2014.) Key words: navigation; breast biopsy; healthcare satisfaction; distress Digital Object Identifier: 10.1188/15.CJON.E15-E20
B
reast cancer is the most common cancer diagnosed in women, representing 29% of newly diagnosed cancer cases (Siegel, Ma, Zou, & Jemal, 2014). Triple assessment (physical examination, imaging, and biopsy) is the standard for evaluating breast disease, with biopsy being the standard for diagnosing breast cancer. About 1.6 million women in the United States underwent a breast biopsy in 2014, and an estimated 231,840 new diagnoses of breast cancer will be made in 2015 (American Cancer Society, 2015; Siegel et al., 2014). The presence of a breast abnormality invokes an immediate fear in most women that they have cancer, resulting in distress (Harding, 2014). Being distressed, as well as having difficulties accessing care, can interfere with a patient obtaining necessary health care, possibly leading to higher mortality in the presence of a confirmed cancer diagnosis (Allen, Shelton, Harden, & Goldman, 2008; Raich, Whitley, Thorland, Valverde, & Fair-
clough, 2012). The potential negative effect on survival because of diagnostic delays was a motivating factor in the development of navigator programs (Raich et al., 2012). The literature shows that navigation improves timely diagnosis; however, the effect of navigation on patient satisfaction and distress during the breast biopsy period remains unclear (Hook, Ware, Siler, & Packard, 2012; Paskett et al., 2012; Raich et al., 2012).
Literature Review Interactions with the healthcare team have a high influence on the experience of women undergoing a breast biopsy. Women need information regarding their risk of having cancer and the tests necessary to diagnose the disease. Women who are adequately informed about the process are less distressed, cope better with the possibility of having cancer, have more trust in the healthcare team, and are better able to discuss and
Clinical Journal of Oncology Nursing • Volume 19, Number 1 • Nurse Navigation and Patient Distress With Breast Biopsy
E15
participate in decision making regarding treatment options with biopsy. The study specifically examined whether significant difthe healthcare provider (Gilbert et al., 2011; Harding, 2014; Liao, ferences exist between navigated and non-navigated women in Chen, Chen, & Chen, 2010). Having a specific professional for distress levels, satisfaction with care, and information-seeking women to contact with questions and to clarify any information behavior. The author’s hypothesis was that women receiving lessens distress, as does receiving diagnostic test results in a nurse navigation services will experience less distress, be more timely manner (Liao et al., 2010). satisfied with care, and be less likely to seek outside information Establishing a patient navigation process is an accreditation regarding their biopsy experience. requirement by National Accreditation Program for Breast Centers (NAPBC), administered by the American College of Surgeons (NAPBC, 2012). Navigation programs continue to evolve to improve patient satisfaction and provide higher-quality oncology The study used a descriptive, cross-sectional survey design. care. Although many programs begin services after a cancer After obtaining institutional review board approval, women diagnosis, some provide services during the biopsy period, presenting for a core needle biopsy were recruited from two facilitating access to care and care coordination and providing outpatient radiology clinics: one community hospital and one information and support. Through promoting a better experibreast cancer center in northern Appalachia. The community ence, prebiopsy navigation services should translate into higher hospital provides mammography and biopsy services without patient care satisfaction ratings through better-coordinated care the assistance of a navigation program, relying on radiologic and improved satisfaction with the quality of health care received technicians and support staff to coordinate care. The NAPBC(Korber, Padula, Gray, & Powell, 2011; Markossian & Calhoun, designated center provides a multidisciplinary approach to 2011). A few reports exist of prebiopsy navigation resulting in breast care, with services coordinated by a nurse navigator who increased patient satisfaction in urban minority women and provides education and support to women undergoing diagnoswomen receiving care in comprehensive cancer care centers tic services. In addition to addressing financial and transporta(Campbell, Craig, Eggert, & Bailey-Dorton, 2010; Ferrante, Chen, tion issues, the nurse navigator schedules and coordinates care & Kim, 2008). among healthcare providers and serves as the point of contact In principle, increased satisfaction with health care should for patients and providers. translate into women experiencing less distress; however, the Nonpregnant women older than 18 years and scheduled for a effect of navigation on distress associated with breast biopsy recore needle biopsy were identified from radiology department mains unclear. Ferrante et al. (2008) reported women receiving schedules. While in a private room prior to the biopsy, each was diagnostic navigation services had lower mean anxiety scores. presented with a cover letter describing the study’s purpose, Similar findings are reported with inpatients with various canrisks, benefits, and an affirmation of the right to withdraw at cer diagnoses (Swanson & Koch, 2010). In contrast, Fiscella et any time. Women agreeing to participate completed the study al. (2012) and Weissflog et al. (2011) did not find any difference in distress levels between navigated and non-navigated patients with cancer. TABLE 1. Patient Demographics Although navigation programs have become Community Cancer the norm in oncology centers, their presence and Total Hospital Center the accompanying support are generally missing (N = 137) (n = 52) (n = 85) outside these centers (Robinson-White, Conroy, Slavish, & Rosenzweig, 2010). Women not receiving Characteristic n % n % n % c2 navigation services have described feeling let down Age (years) 1.548 by the healthcare team, recanting the need for assis 50 and younger 44 32 20 39 24 28 tance with referrals to surgeons, being dissatisfied Older than 50 93 68 32 62 61 72 with communication, feeling they received inadRelationship status 1.102 Single 17 12 6 12 11 13 equate information and preparation for procedures, Married 89 65 34 65 55 65 and verbalizing displeasure with making decisions Separated or divorced 10 7 4 7 6 7 when they feel that they lacked the knowledge to Living with partner 13 10 6 12 7 8 do so in an informed manner (Harding & McCrone, Widowed 8 6 2 4 6 7 2013). Subsequently, some patients report spending Education 2.659 time actively seeking outside information to fulfill Less than high school 6 4 4 8 2 2 this need. However, no studies have examined the High school 69 50 26 50 43 51 College graduate 39 28 15 29 24 28 sources of that additional information, particularly Graduate degree 23 17 7 14 16 19 the use of the Internet. With widespread access to Employment 2.575 the Internet and the vast amount of information Full-time 54 39 18 34 36 42 available, better understanding of whether women Part-time 14 10 7 14 7 8 are using the Internet as a source of health informa Not employed 12 9 5 10 7 8 tion would be helpful. Retired 43 31 15 29 28 33 Other 14 10 7 14 7 8 The purpose of the current study was to evaluate the effect of nurse navigation on patient satisfaction Note. Because of rounding, percentages may not total 100. and distress associated with undergoing a breast
Methods
E16
February 2015 • Volume 19, Number 1 • Clinical Journal of Oncology Nursing
instruments at home and returned the packet prior to receiving biopsy results. A convenience sample of 137 women participated. Data was analyzed using SPSS®, version 17.0. Descriptive statistics were used to analyze demographic characteristics. Independent t tests, chi-square tests, and Pearson correlations were used to examine relationships among study variables.
Instruments Demographic information was collected using a purposefully designed questionnaire. Distress is defined as a state of unpleasant emotions of a psychological, social, and/or spiritual nature extending along a continuum, ranging from common normal feelings of stress to psychological states that can become disabling, including depression and anxiety (Howell, 2010). Distress was measured with two widely used and well-validated scales, the Hospital Anxiety and Depression Scale (HADS) and State Trait Anxiety Inventory, State (STAI-S) scale. The 14-item HADS has two subscales, seven questions measuring anxiety (HADS-A) and seven questions measuring depression (HADS-D) (Zigmond & Snaith, 1983). The Cronbach alpha in the current study was 0.85 for the HADS-A and 0.89 for the HADS-D. The 20-item STAI-S assesses for the presence of state anxiety (Spielberger, Gorsuch, & Lushene, 1970). The Cronbach alpha for the STAI-S in the current study was 0.96. The 18-item Patient Satisfaction Questionnaire (PSQ-18) has seven subscales (general satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with doctor, and accessibility and convenience) evaluating satisfaction with the health care the woman was receiving during the biopsy experience. Reliability coefficients for the subscales are reported to range from 0.64 (communication) to 0.77 (time spent) (Marshall & Hayes, 1994). The Cronbach coefficient for the total PSQ-18 in the current study was 0.87.
Results Demographic data for each group are presented in Table 1. No significant differences existed in age, level of education, relationship status, or employment status. The women’s ages — ranged from 18–89 years (X = 55.26 years, SD = 12.3). No significant difference existed between the groups in the average time from discovery of the suspicious area to biopsy (navigated, — — X = 19.75 days; usual care, X = 15.67 days). Only nine women were undergoing biopsy within one day of discovery—two at the community hospital and seven at the cancer center. To determine whether a significant difference existed in distress levels between navigated and non-navigated women, scores were analyzed on the STAI-S, HADS subscales, and the PSQ-18. Navigated women had lower scores on all three distress measures, with significantly lower anxiety levels on the HADS-A (see Table 2). Although no significant differences were observed in patient satisfaction between the two groups—as measured by any subscale or the total PSQ-18 (see Table 3)—overall scores on the PSQ-18 were negatively correlated with distress levels, with lower satisfaction scores associated with higher distress in both groups. Significant correlations were observed between each PSQ-18 subscale and at least one distress measure, with the relationship pattern varying by group (see Table 4). In the
non-navigated population, general satisfaction with care and accessibility were most influential. In the navigated population, the relationship-based factors of interpersonal manner and time spent emerged as the stronger relationships. Sixty-six women (48%) sought information from a source outside the healthcare team regarding an aspect of the diagnostic experience. Women not receiving navigation services were significantly more likely to seek outside information (c2 = 7.949; p < 0.01), with a majority (67%) using the Internet as an information source. Satisfaction with care was not related to the likelihood of patients seeking additional information. Overall, those seeking information did have higher levels of anxiety on — — the HADS-A (X = 8.77 versus 8.1) and STAI-S (X = 46.47 versus 42.54); these differences neared but were not quite significant.
Discussion The results provided evidence that navigated women experience less distress, but the relationship was not as strong as the author expected. Receiving navigation services should have translated into higher patient-rated satisfaction with care. However, this relationship was not strongly supported by significant differences in care satisfaction between the groups. Although overall care satisfaction did not differ, care satisfaction was highly associated with distress. Women who were more satisfied with their health care reported less distress; factors influencing their distress varied depending on whether they received navigation. In the non-navigated population, general satisfaction with care (evaluating overall dissatisfaction with care) and accessibility (evaluating the difficulty of finding a surgeon and getting an appointment) were most influential. If a critical role of nurse navigators is to facilitate and coordinate care, then the evident relationship between perceived lack of accessibility and distress in the non-navigated population is unsurprising. In the navigated population, the relationship-based factors “interpersonal manner” and “time spent,” measured by statements such as, “The doctor spent plenty of time with me,” and, “The doctor acted too businesslike toward me,” emerged as the stronger relationships. About half the women spent time seeking information from a source outside the healthcare team regarding an aspect of the biopsy experience; non-navigated women were more likely
TABLE 2. Differences in Distress by Service Navigation (n = 85) Measure
—
X
SD
HADS-A
7.84
3.61
HADS-D
4.76 42.96
STAI-S
Usual Care (n = 52) —
X
SD
t (135)
9.38
4.53
2.21*
4.14
5.21
4.56
0.59
14.88
46.83
14.39
1.493
* p < 0.05 HADS-A—Hospital Anxiety and Depression Score–anxiety subscale; HADS-D—Hospital Anxiety and Depression Score–depression subscale; STAI-S—State Trait Anxiety Inventory, State scale
Clinical Journal of Oncology Nursing • Volume 19, Number 1 • Nurse Navigation and Patient Distress With Breast Biopsy
E17
to do so. Given the number of women seeking information, additional exploration into information-seeking behaviors is needed. Because those seeking information tended to have higher anxiety levels, knowing the direction of the relationship between anxiety and information seeking could be helpful. For example, did using the information alleviate anxiety by making women feel that they had the information necessary to feel prepared, or did reading information not pertinent to a woman’s particular situation heighten distress levels by highlighting worst-case scenarios and causing the woman to believe that was her circumstance? Nurses possess the knowledge and skills to fulfill critical navigation roles of performing patient assessment, providing education and emotional support, and facilitating care and communication among providers. All women undergoing breast evaluations need relevant information regarding diagnostic tests, including test preparation, the type of information a test provides, postprocedure care, and when results will be available. Having a navigator available to contact with questions or concerns may alleviate some information-seeking behaviors, particularly in more anxious patients. Making a routine followup telephone call to see how a woman is doing should directly translate to improved patient satisfaction; patients appreciate someone checking up them (Rush, 2012). In accordance with the NAPBC (2012) accreditation requirements, a simple process for distress screening should be instituted during the diagnostic period, and those with identified distress should be provided with resources and referrals as needed. Navigators could assist women in identifying effective coping behaviors and those strategies that reduced distress previously, as well as provide anticipatory guidance regarding the use of appropriate coping mechanisms. For patients diagnosed with cancer, this assistance can play a critical role in the transition phase. If women are less distressed, they may be better able to discuss and weigh treatment options with the healthcare provider and be better able to actively participate in decision making (Gilbert et al., 2011).
TABLE 3. Differences in Patient Satisfaction by Service
Measure
Navigation (n = 85)
Usual Care (n = 52)
—
—
X
SD
X
SD
t
14.57
2.71
14.33
2.63
–0.528
Communication
7.67
1.46
7.88
1.59
0.805
Finances
6.75
1.63
6.44
1.82
–1.032
General satisfaction
8.04
1.18
7.98
1.4
–0.244
Interpersonal manner
8.16
1.26
7.81
1.99
–1.286
14.87
2.47
14.77
2.53
–0.231
7.45
1.46
7.44
1.49
–0.064
67.25
9.26
66.58
9.86
–0.401
Accessibility
Technical quality Time Total PSQ-18
PSQ-18—Patient Satisfaction Questionnaire E18
Implications for Practice u
Give patients relevant information regarding breast diagnostic procedures, including test preparation, postprocedure care, and when results will be available.
u
Facilitate access to the health system by assisting with coordinating appointments.
u
Screen all patients for distress and provide the appropriate level of emotional support.
Navigators can promote collaborative relationships and facilitate communication among providers (Hook et al., 2012). They can facilitate access to care and help women maneuver the healthcare system by addressing specific barriers to care through assisting women with overcoming insurance barriers and selecting healthcare agencies and providers for procedures (NAPBC, 2012). For referrals and subsequent testing, navigators can aid in making appointments and transferring test results and records to the next provider. Implementing a navigation program for women undergoing diagnostic evaluations may not be easy to accomplish. Although accredited centers are required to have a navigation process, at least 50% of biopsies are performed outside these centers, and women are more likely to receive fragmented care (RobinsonWhite et al., 2010; Williams et al., 2011). In these settings, the following would be a common scenario. A woman is notified by letter that her screening mammogram is abnormal. She makes arrangements for a diagnostic mammogram, receives those results from a primary care provider and, if a referral is needed for a biopsy, she selects the surgeon and makes that appointment. Who is responsible, then, for providing navigation when women receive fragmented care? Does the responsibility lie with the facility performing the diagnostic mammogram or biopsy, the surgeon performing the biopsy, or the primary care provider? With healthcare costs increasing, cost is an important factor in navigation service decisions. Absent from the literature is any discussion of the cost-benefit ratio of providing diagnostic navigation services. Budgetary restrictions could be a potential issue. In hospitals with a lower volume of women (e.g., performing 100 biopsies per year), the only cost-efficient model may be the use of a part-time navigator or a full-time navigator with job responsibilities beyond providing prediagnosis care. It may be challenging to delineate outcomes associated with prediagnosis navigation. Three direct evaluative measures are patient satisfaction, time to diagnosis and treatment, and adherence rate for completing recommended diagnostic tests. An indirect measure of a program’s benefit may be better use of physician services. In routine clinical practice, time constraints may limit a physician’s ability to offer detailed information or assist a woman with managing distress. However, a navigator providing information and support would better prepare women for appointments and decision making, allowing physicians to more efficiently use their time with each woman (Gilbert et al., 2011). In addition, anxious women tend to make more telephone calls, again using more physician time (Pedersen, Sawatzky, & Hack, 2010).
February 2015 • Volume 19, Number 1 • Clinical Journal of Oncology Nursing
Limitations A few limitations may affect study conclusions. The current study did not use a satisfaction survey specific to nurse navigation or cancer care. Questions on the available nurse navigation surveys were not relevant to the non-navigated population. Cancer care surveys were purposefully avoided because of their use of the word “cancer,” as not to incite distress. The development of a tool specific to the diagnostic period would help in capturing the benefits of a prediagnostic navigation. The use of a cross-sectional design with self-reported instruments may not have captured uncontrolled or unexplored variables that may have influenced study results. Finally, the use of only two settings in one geographic region may limit generalizability.
Implications for Research Future research should evaluate how to best implement or expand navigation services for women undergoing diagnostic evaluations, particularly in the community hospital setting, and to continue to evaluate the overall effect of the navigation
TABLE 4. Correlations Among Distress, Satisfaction With Care, and Services Satisfaction Measure
HADS-D
HADS-A
STAI-S
Accessibility Usual care Navigation
–0.348* –0.369*
–0.175 –0.199
–0.307* –0.252*
Communication Usual care Navigation
–0.297* –0.395**
0.074 –0.192
–0.11 –0.349**
Finances Usual care Navigation
–0.151 –0.24*
0.074 –0.224*
–0.045 –0.363**
General satisfaction Usual care Navigation
–0.486** –0.317**
–0.285* –0.122
–0.459* –0.155
Interpersonal manner Usual care Navigation
–0.261 –0.389**
–0.092 –0.308**
–0.183 –0.324**
Technical quality Usual care Navigation
–0.521** –0.157**
–0.103 –0.135
–0.238 –0.093
Time Usual care Navigation
–0.104 –0.413*
0.009 –0.255*
–0.12 –0.339*
PSQ-18 Usual care Navigation Total
–0.471** –0.411** –0.312**
–0.116 –0.254* –0.236**
–0.309* –0.34** –0.212*
* p < 0.05; ** p < 0.01 HADS-A—Hospital Anxiety and Depression Score–anxiety subscale; HADS-D—Hospital Anxiety and Depression Score–depression subscale; PSQ-18—Patient Satisfaction Questionnaire; STAI-S—State Trait Anxiety Inventory, State scale
process on distress and satisfaction with care. Researchers need to determine how to address logistic issues of moving women through the diagnostic process when services are received at different locations; how best to administer services when women are receiving fragmented care; and how to examine the cost effectiveness of program delivery, particularly in lowervolume facilities.
Conclusion The results suggest that offering navigation during the biopsy period promotes a higher standard of care delivery, with patients who receive services experiencing less distress. Nurses possess the knowledge and skills to have a direct effect on the diagnostic experience and patient outcomes, and a key component of navigation programs should include having a nurse navigator fulfill critical roles in the navigation process. These roles can include performing distress screening, providing emotional support and education, and facilitating communication among providers. Navigators also can facilitate access to care and help women maneuver the healthcare system by addressing specific barriers to care. Offering diagnostic navigation should ultimately translate into higher patient satisfaction ratings through better-coordinated care and improved quality of care.
References Allen, J.D., Shelton, R.C., Harden, E., & Goldman, R.E. (2008). Follow-up of abnormal screening mammograms among low-income ethnically diverse women: Findings from a qualitative study. Patient Education and Counseling, 72, 283–292. doi:10.1016/j .pec.2008.03.024 American Cancer Society. (2015). Cancer facts and figures, 2015. Atlanta, GA: Author. Campbell, C., Craig, J., Eggert, J., & Bailey-Dorton, C. (2010). Implementing and measuring the impact of patient navigation at a comprehensive community cancer center. Oncology Nursing Forum, 37, 61–68. doi:10.1188/10.ONF.61-68 Ferrante, J.M., Chen, P.H., & Kim, S. (2008). The effect of patient navigation on time to diagnosis, anxiety, and satisfaction in urban minority women with abnormal mammograms: A randomized controlled trial. Journal of Urban Health, 85, 114–124. doi:10.1007/s11524-007-9228-9 Fiscella, K., Whitley, E., Hendren, S., Raich, P.C., Humiston, S., Winters, P., . . . Epstein, R. (2012). Patient navigation for breast and colorectal cancer treatment: A randomized trial. Cancer Epidemiology, Biomarkers and Prevention, 21, 1673–1681. doi:10.1158/1055-9965.EPI-12-0506 Gilbert, J.E., Green, E., Lankshear, S., Hughes, E., Burkoski, V., & Sawka, C. (2011). Nurses as patient navigators in cancer diagnosis: Review, consultation and model design. European Journal of Cancer Care, 20, 228–236. doi:10.1111/j.1365-2354.2010.01231.x Harding, M.M. (2014). Incidence of distress and associated factors in women undergoing breast diagnostic evaluation. Western Journal of Nursing Research, 36, 475–494. doi:10.1177/019394 5913506795 Harding, M.M., & McCrone, S. (2013). Experiences of non-navigated women undergoing breast diagnostic evaluation [Online exclusive]. Clinical Journal of Oncology Nursing, 17, E8–E12. doi:10.1188/13.CJON.E8-E12
Clinical Journal of Oncology Nursing • Volume 19, Number 1 • Nurse Navigation and Patient Distress With Breast Biopsy
E19
Hook, A., Ware, L., Siler, B., & Packard, A. (2012). Breast cancer navigation and patient satisfaction: Exploring a community-based patient navigation model in a rural setting. Oncology Nursing Forum, 39, 379–385. doi:10.1188/12.ONF.379-385 Howell, D. (2010). Psychological distress as a nurse-sensitive outcome. In D.M. Doran (Ed.), Nursing outcomes: State of the science (2nd ed., pp. 285–358). Sudbury, MA: Jones and Bartlett. Korber, S.F., Padula, C., Gray, J., & Powell, M. (2011). A breast navigator program: Barriers, enhancers, and nursing interventions. Oncology Nursing Forum, 38, 44–50. doi:10.1188/11.ONF.44-50 Liao, M.N., Chen, P.L., Chen, M.F., & Chen, S.C. (2010). Effect of supportive care on the anxiety of women with suspected breast cancer. Journal of Advanced Nursing, 66, 49–59. doi:10.1111/ j.1365-2648.2009.05139.x Markossian, T.W., & Calhoun, E.A. (2011). Are breast cancer navigation programs cost-effective? Evidence from the Chicago Cancer Navigation Project. Health Policy, 99, 52–59. doi:10.1016/j.health pol.2010.07.008 Marshall, G.N., & Hayes, R.D. (1994). Patient Satisfaction Questionnaire short form. Santa Monica, CA: RAND. National Accreditation Program for Breast Centers. (2014). NAPBC standards manual: 2014 edition. Retrieved from https://www .facs.org/~/media/files/quality%20programs/napbc/2014%20 napbc%20standards%20manual.ashx Paskett, E.D., Katz, M.L., Post, D.M., Pennell, M.L., Young, G.S., Seiber, E.E., . . . Murray, D.M. (2012). The Ohio Patient Navigation Research Program: Does the American Cancer Society patient navigation model improve time to resolution in patients with abnormal screening tests? Cancer Epidemiology, Biomarkers and Prevention, 21, 1620–1628. doi:10.1158/1055-9965.EPI-12-0523 Pedersen, A.E., Sawatzky, J.A., & Hack, T.F. (2010). The sequelae of anxiety in breast cancer: A human response to illness model. Oncology Nursing Forum, 37, 469–475. doi:10.1188/10.ONF .469-475 Raich, P.C., Whitley, E.M., Thorland, W., Valverde, P., & Fairclough,
E20
D. (2012). Patient navigation improves cancer diagnostic resolution: An individually randomized clinical trial in an underserved population. Cancer Epidemiology, Biomarkers and Prevention, 21, 1629–1638. doi:10.1158/1055-9965.EPI-12-0513 Robinson-White, S., Conroy, B., Slavish, K.H., & Rosenzweig, M. (2010). Patient navigation in breast cancer: A systematic review. Cancer Nursing, 33, 127–140. doi:10.1097/NCC.0b013e3181 c40401 Rush, S.K. (2012). Discharge calls: How one call can make the difference for patients, families, and reimbursement. Nurse Leader, 10(2), 45–52. doi:10.1016/j.mnl.2011.07.014 Siegel, R., Ma, J., Zou, Z., & Jemal, A. (2014). Cancer statistics, 2014. CA: A Cancer Journal for Clinicians, 64, 9–29. doi:10.3322/ caac.21208 Spielberger, C.D., Gorsuch, R.L., & Lushene, R.E. (1970). Manual for the State-Trait Anxiety Inventory (self-evaluation questionnaire). Palo Alto, CA: Consulting Psychologists Press. Swanson, J., & Koch, L. (2010). The role of the oncology nurse navigator in distress management of adult inpatients with cancer: A retrospective study. Oncology Nursing Forum, 37, 69–76. doi:10.1188/10.ONF.69-76 Weissflog, G., Götze, H., Klinitzke, G., Distler, W., Brähler, E., & Ernst, J. (2011). Better patient orientation through certified cancer centres in oncological care? Patient satisfaction in breast cancer patients in certified breast cancer centres and noncertified hospitals. Zeitschrift Für Psychosomatische Medizin Und Psychotherapie, 57, 343–355. Williams, R.T., Yao, K., Stewart, A.K., Winchester, D.J., Turk, M., Gorchow, A., . . . Winchester, D.P. (2011). Needle versus excisional biopsy for noninvasive and invasive breast cancer: Report from the National Cancer Data Base, 2003–2008. Annals of Surgical Oncology, 18, 3802–3810. doi:10.1245/s10434-011-1808-y Zigmond, A.S., & Snaith, R.P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361–370. doi:10.1111/j.1600-0447.1983.tb09716.x
February 2015 • Volume 19, Number 1 • Clinical Journal of Oncology Nursing
Copyright of Clinical Journal of Oncology Nursing is the property of Oncology Nursing Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Effect of Nurse Navigation on Patient Care Satisfaction and Distress Associated With Breast Biopsy Mariann Harding, PhD, RN, CNE
Background: Navigation during the biopsy period is a superior approach to delivering care, with those patients receiving services experiencing less distress. Critical nurse navigator roles include providing information and facilitating access to the healthcare system, both of which are influential on distress. The information in this article supports the expansion of navigation programs to include women undergoing biopsy and aids in promoting a higher standard of care. Mitar Holod/iStock/Thinkstock Objectives: To evaluate the effect of navigation on care satisfaction and distress in women undergoing breast biopsy. Methods: A descriptive, cross-sectional survey design from two outpatient radiology clinics in Appalachia was used. Findings: Navigated women had lower scores on every distress measure and were less likely to seek information from an outside source. Women who were more satisfied with their care reported decreased distress; the factors influencing distress varied depending on whether they were the recipient of navigation services. In the non-navigated population, general satisfaction with care and accessibility were more likely to influence distress. Mariann Harding, PhD, RN, CNE, is an associate professor in the College of Nursing at Kent State University at Tuscarawas in New Philadelphia, OH. The author takes full responsibility for the content of the article. The author did not receive honoraria for this work. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the author, planners, independent peer reviewers, or editorial staff. Harding can be reached at [email protected], with copy to editor at [email protected]. (Submitted March 2014. Revision submitted May 2014. Accepted for publication May 12, 2014.) Key words: navigation; breast biopsy; healthcare satisfaction; distress Digital Object Identifier: 10.1188/15.CJON.E15-E20
B
reast cancer is the most common cancer diagnosed in women, representing 29% of newly diagnosed cancer cases (Siegel, Ma, Zou, & Jemal, 2014). Triple assessment (physical examination, imaging, and biopsy) is the standard for evaluating breast disease, with biopsy being the standard for diagnosing breast cancer. About 1.6 million women in the United States underwent a breast biopsy in 2014, and an estimated 231,840 new diagnoses of breast cancer will be made in 2015 (American Cancer Society, 2015; Siegel et al., 2014). The presence of a breast abnormality invokes an immediate fear in most women that they have cancer, resulting in distress (Harding, 2014). Being distressed, as well as having difficulties accessing care, can interfere with a patient obtaining necessary health care, possibly leading to higher mortality in the presence of a confirmed cancer diagnosis (Allen, Shelton, Harden, & Goldman, 2008; Raich, Whitley, Thorland, Valverde, & Fair-
clough, 2012). The potential negative effect on survival because of diagnostic delays was a motivating factor in the development of navigator programs (Raich et al., 2012). The literature shows that navigation improves timely diagnosis; however, the effect of navigation on patient satisfaction and distress during the breast biopsy period remains unclear (Hook, Ware, Siler, & Packard, 2012; Paskett et al., 2012; Raich et al., 2012).
Literature Review Interactions with the healthcare team have a high influence on the experience of women undergoing a breast biopsy. Women need information regarding their risk of having cancer and the tests necessary to diagnose the disease. Women who are adequately informed about the process are less distressed, cope better with the possibility of having cancer, have more trust in the healthcare team, and are better able to discuss and
Clinical Journal of Oncology Nursing • Volume 19, Number 1 • Nurse Navigation and Patient Distress With Breast Biopsy
E15
participate in decision making regarding treatment options with biopsy. The study specifically examined whether significant difthe healthcare provider (Gilbert et al., 2011; Harding, 2014; Liao, ferences exist between navigated and non-navigated women in Chen, Chen, & Chen, 2010). Having a specific professional for distress levels, satisfaction with care, and information-seeking women to contact with questions and to clarify any information behavior. The author’s hypothesis was that women receiving lessens distress, as does receiving diagnostic test results in a nurse navigation services will experience less distress, be more timely manner (Liao et al., 2010). satisfied with care, and be less likely to seek outside information Establishing a patient navigation process is an accreditation regarding their biopsy experience. requirement by National Accreditation Program for Breast Centers (NAPBC), administered by the American College of Surgeons (NAPBC, 2012). Navigation programs continue to evolve to improve patient satisfaction and provide higher-quality oncology The study used a descriptive, cross-sectional survey design. care. Although many programs begin services after a cancer After obtaining institutional review board approval, women diagnosis, some provide services during the biopsy period, presenting for a core needle biopsy were recruited from two facilitating access to care and care coordination and providing outpatient radiology clinics: one community hospital and one information and support. Through promoting a better experibreast cancer center in northern Appalachia. The community ence, prebiopsy navigation services should translate into higher hospital provides mammography and biopsy services without patient care satisfaction ratings through better-coordinated care the assistance of a navigation program, relying on radiologic and improved satisfaction with the quality of health care received technicians and support staff to coordinate care. The NAPBC(Korber, Padula, Gray, & Powell, 2011; Markossian & Calhoun, designated center provides a multidisciplinary approach to 2011). A few reports exist of prebiopsy navigation resulting in breast care, with services coordinated by a nurse navigator who increased patient satisfaction in urban minority women and provides education and support to women undergoing diagnoswomen receiving care in comprehensive cancer care centers tic services. In addition to addressing financial and transporta(Campbell, Craig, Eggert, & Bailey-Dorton, 2010; Ferrante, Chen, tion issues, the nurse navigator schedules and coordinates care & Kim, 2008). among healthcare providers and serves as the point of contact In principle, increased satisfaction with health care should for patients and providers. translate into women experiencing less distress; however, the Nonpregnant women older than 18 years and scheduled for a effect of navigation on distress associated with breast biopsy recore needle biopsy were identified from radiology department mains unclear. Ferrante et al. (2008) reported women receiving schedules. While in a private room prior to the biopsy, each was diagnostic navigation services had lower mean anxiety scores. presented with a cover letter describing the study’s purpose, Similar findings are reported with inpatients with various canrisks, benefits, and an affirmation of the right to withdraw at cer diagnoses (Swanson & Koch, 2010). In contrast, Fiscella et any time. Women agreeing to participate completed the study al. (2012) and Weissflog et al. (2011) did not find any difference in distress levels between navigated and non-navigated patients with cancer. TABLE 1. Patient Demographics Although navigation programs have become Community Cancer the norm in oncology centers, their presence and Total Hospital Center the accompanying support are generally missing (N = 137) (n = 52) (n = 85) outside these centers (Robinson-White, Conroy, Slavish, & Rosenzweig, 2010). Women not receiving Characteristic n % n % n % c2 navigation services have described feeling let down Age (years) 1.548 by the healthcare team, recanting the need for assis 50 and younger 44 32 20 39 24 28 tance with referrals to surgeons, being dissatisfied Older than 50 93 68 32 62 61 72 with communication, feeling they received inadRelationship status 1.102 Single 17 12 6 12 11 13 equate information and preparation for procedures, Married 89 65 34 65 55 65 and verbalizing displeasure with making decisions Separated or divorced 10 7 4 7 6 7 when they feel that they lacked the knowledge to Living with partner 13 10 6 12 7 8 do so in an informed manner (Harding & McCrone, Widowed 8 6 2 4 6 7 2013). Subsequently, some patients report spending Education 2.659 time actively seeking outside information to fulfill Less than high school 6 4 4 8 2 2 this need. However, no studies have examined the High school 69 50 26 50 43 51 College graduate 39 28 15 29 24 28 sources of that additional information, particularly Graduate degree 23 17 7 14 16 19 the use of the Internet. With widespread access to Employment 2.575 the Internet and the vast amount of information Full-time 54 39 18 34 36 42 available, better understanding of whether women Part-time 14 10 7 14 7 8 are using the Internet as a source of health informa Not employed 12 9 5 10 7 8 tion would be helpful. Retired 43 31 15 29 28 33 Other 14 10 7 14 7 8 The purpose of the current study was to evaluate the effect of nurse navigation on patient satisfaction Note. Because of rounding, percentages may not total 100. and distress associated with undergoing a breast
Methods
E16
February 2015 • Volume 19, Number 1 • Clinical Journal of Oncology Nursing
instruments at home and returned the packet prior to receiving biopsy results. A convenience sample of 137 women participated. Data was analyzed using SPSS®, version 17.0. Descriptive statistics were used to analyze demographic characteristics. Independent t tests, chi-square tests, and Pearson correlations were used to examine relationships among study variables.
Instruments Demographic information was collected using a purposefully designed questionnaire. Distress is defined as a state of unpleasant emotions of a psychological, social, and/or spiritual nature extending along a continuum, ranging from common normal feelings of stress to psychological states that can become disabling, including depression and anxiety (Howell, 2010). Distress was measured with two widely used and well-validated scales, the Hospital Anxiety and Depression Scale (HADS) and State Trait Anxiety Inventory, State (STAI-S) scale. The 14-item HADS has two subscales, seven questions measuring anxiety (HADS-A) and seven questions measuring depression (HADS-D) (Zigmond & Snaith, 1983). The Cronbach alpha in the current study was 0.85 for the HADS-A and 0.89 for the HADS-D. The 20-item STAI-S assesses for the presence of state anxiety (Spielberger, Gorsuch, & Lushene, 1970). The Cronbach alpha for the STAI-S in the current study was 0.96. The 18-item Patient Satisfaction Questionnaire (PSQ-18) has seven subscales (general satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with doctor, and accessibility and convenience) evaluating satisfaction with the health care the woman was receiving during the biopsy experience. Reliability coefficients for the subscales are reported to range from 0.64 (communication) to 0.77 (time spent) (Marshall & Hayes, 1994). The Cronbach coefficient for the total PSQ-18 in the current study was 0.87.
Results Demographic data for each group are presented in Table 1. No significant differences existed in age, level of education, relationship status, or employment status. The women’s ages — ranged from 18–89 years (X = 55.26 years, SD = 12.3). No significant difference existed between the groups in the average time from discovery of the suspicious area to biopsy (navigated, — — X = 19.75 days; usual care, X = 15.67 days). Only nine women were undergoing biopsy within one day of discovery—two at the community hospital and seven at the cancer center. To determine whether a significant difference existed in distress levels between navigated and non-navigated women, scores were analyzed on the STAI-S, HADS subscales, and the PSQ-18. Navigated women had lower scores on all three distress measures, with significantly lower anxiety levels on the HADS-A (see Table 2). Although no significant differences were observed in patient satisfaction between the two groups—as measured by any subscale or the total PSQ-18 (see Table 3)—overall scores on the PSQ-18 were negatively correlated with distress levels, with lower satisfaction scores associated with higher distress in both groups. Significant correlations were observed between each PSQ-18 subscale and at least one distress measure, with the relationship pattern varying by group (see Table 4). In the
non-navigated population, general satisfaction with care and accessibility were most influential. In the navigated population, the relationship-based factors of interpersonal manner and time spent emerged as the stronger relationships. Sixty-six women (48%) sought information from a source outside the healthcare team regarding an aspect of the diagnostic experience. Women not receiving navigation services were significantly more likely to seek outside information (c2 = 7.949; p < 0.01), with a majority (67%) using the Internet as an information source. Satisfaction with care was not related to the likelihood of patients seeking additional information. Overall, those seeking information did have higher levels of anxiety on — — the HADS-A (X = 8.77 versus 8.1) and STAI-S (X = 46.47 versus 42.54); these differences neared but were not quite significant.
Discussion The results provided evidence that navigated women experience less distress, but the relationship was not as strong as the author expected. Receiving navigation services should have translated into higher patient-rated satisfaction with care. However, this relationship was not strongly supported by significant differences in care satisfaction between the groups. Although overall care satisfaction did not differ, care satisfaction was highly associated with distress. Women who were more satisfied with their health care reported less distress; factors influencing their distress varied depending on whether they received navigation. In the non-navigated population, general satisfaction with care (evaluating overall dissatisfaction with care) and accessibility (evaluating the difficulty of finding a surgeon and getting an appointment) were most influential. If a critical role of nurse navigators is to facilitate and coordinate care, then the evident relationship between perceived lack of accessibility and distress in the non-navigated population is unsurprising. In the navigated population, the relationship-based factors “interpersonal manner” and “time spent,” measured by statements such as, “The doctor spent plenty of time with me,” and, “The doctor acted too businesslike toward me,” emerged as the stronger relationships. About half the women spent time seeking information from a source outside the healthcare team regarding an aspect of the biopsy experience; non-navigated women were more likely
TABLE 2. Differences in Distress by Service Navigation (n = 85) Measure
—
X
SD
HADS-A
7.84
3.61
HADS-D
4.76 42.96
STAI-S
Usual Care (n = 52) —
X
SD
t (135)
9.38
4.53
2.21*
4.14
5.21
4.56
0.59
14.88
46.83
14.39
1.493
* p < 0.05 HADS-A—Hospital Anxiety and Depression Score–anxiety subscale; HADS-D—Hospital Anxiety and Depression Score–depression subscale; STAI-S—State Trait Anxiety Inventory, State scale
Clinical Journal of Oncology Nursing • Volume 19, Number 1 • Nurse Navigation and Patient Distress With Breast Biopsy
E17
to do so. Given the number of women seeking information, additional exploration into information-seeking behaviors is needed. Because those seeking information tended to have higher anxiety levels, knowing the direction of the relationship between anxiety and information seeking could be helpful. For example, did using the information alleviate anxiety by making women feel that they had the information necessary to feel prepared, or did reading information not pertinent to a woman’s particular situation heighten distress levels by highlighting worst-case scenarios and causing the woman to believe that was her circumstance? Nurses possess the knowledge and skills to fulfill critical navigation roles of performing patient assessment, providing education and emotional support, and facilitating care and communication among providers. All women undergoing breast evaluations need relevant information regarding diagnostic tests, including test preparation, the type of information a test provides, postprocedure care, and when results will be available. Having a navigator available to contact with questions or concerns may alleviate some information-seeking behaviors, particularly in more anxious patients. Making a routine followup telephone call to see how a woman is doing should directly translate to improved patient satisfaction; patients appreciate someone checking up them (Rush, 2012). In accordance with the NAPBC (2012) accreditation requirements, a simple process for distress screening should be instituted during the diagnostic period, and those with identified distress should be provided with resources and referrals as needed. Navigators could assist women in identifying effective coping behaviors and those strategies that reduced distress previously, as well as provide anticipatory guidance regarding the use of appropriate coping mechanisms. For patients diagnosed with cancer, this assistance can play a critical role in the transition phase. If women are less distressed, they may be better able to discuss and weigh treatment options with the healthcare provider and be better able to actively participate in decision making (Gilbert et al., 2011).
TABLE 3. Differences in Patient Satisfaction by Service
Measure
Navigation (n = 85)
Usual Care (n = 52)
—
—
X
SD
X
SD
t
14.57
2.71
14.33
2.63
–0.528
Communication
7.67
1.46
7.88
1.59
0.805
Finances
6.75
1.63
6.44
1.82
–1.032
General satisfaction
8.04
1.18
7.98
1.4
–0.244
Interpersonal manner
8.16
1.26
7.81
1.99
–1.286
14.87
2.47
14.77
2.53
–0.231
7.45
1.46
7.44
1.49
–0.064
67.25
9.26
66.58
9.86
–0.401
Accessibility
Technical quality Time Total PSQ-18
PSQ-18—Patient Satisfaction Questionnaire E18
Implications for Practice u
Give patients relevant information regarding breast diagnostic procedures, including test preparation, postprocedure care, and when results will be available.
u
Facilitate access to the health system by assisting with coordinating appointments.
u
Screen all patients for distress and provide the appropriate level of emotional support.
Navigators can promote collaborative relationships and facilitate communication among providers (Hook et al., 2012). They can facilitate access to care and help women maneuver the healthcare system by addressing specific barriers to care through assisting women with overcoming insurance barriers and selecting healthcare agencies and providers for procedures (NAPBC, 2012). For referrals and subsequent testing, navigators can aid in making appointments and transferring test results and records to the next provider. Implementing a navigation program for women undergoing diagnostic evaluations may not be easy to accomplish. Although accredited centers are required to have a navigation process, at least 50% of biopsies are performed outside these centers, and women are more likely to receive fragmented care (RobinsonWhite et al., 2010; Williams et al., 2011). In these settings, the following would be a common scenario. A woman is notified by letter that her screening mammogram is abnormal. She makes arrangements for a diagnostic mammogram, receives those results from a primary care provider and, if a referral is needed for a biopsy, she selects the surgeon and makes that appointment. Who is responsible, then, for providing navigation when women receive fragmented care? Does the responsibility lie with the facility performing the diagnostic mammogram or biopsy, the surgeon performing the biopsy, or the primary care provider? With healthcare costs increasing, cost is an important factor in navigation service decisions. Absent from the literature is any discussion of the cost-benefit ratio of providing diagnostic navigation services. Budgetary restrictions could be a potential issue. In hospitals with a lower volume of women (e.g., performing 100 biopsies per year), the only cost-efficient model may be the use of a part-time navigator or a full-time navigator with job responsibilities beyond providing prediagnosis care. It may be challenging to delineate outcomes associated with prediagnosis navigation. Three direct evaluative measures are patient satisfaction, time to diagnosis and treatment, and adherence rate for completing recommended diagnostic tests. An indirect measure of a program’s benefit may be better use of physician services. In routine clinical practice, time constraints may limit a physician’s ability to offer detailed information or assist a woman with managing distress. However, a navigator providing information and support would better prepare women for appointments and decision making, allowing physicians to more efficiently use their time with each woman (Gilbert et al., 2011). In addition, anxious women tend to make more telephone calls, again using more physician time (Pedersen, Sawatzky, & Hack, 2010).
February 2015 • Volume 19, Number 1 • Clinical Journal of Oncology Nursing
Limitations A few limitations may affect study conclusions. The current study did not use a satisfaction survey specific to nurse navigation or cancer care. Questions on the available nurse navigation surveys were not relevant to the non-navigated population. Cancer care surveys were purposefully avoided because of their use of the word “cancer,” as not to incite distress. The development of a tool specific to the diagnostic period would help in capturing the benefits of a prediagnostic navigation. The use of a cross-sectional design with self-reported instruments may not have captured uncontrolled or unexplored variables that may have influenced study results. Finally, the use of only two settings in one geographic region may limit generalizability.
Implications for Research Future research should evaluate how to best implement or expand navigation services for women undergoing diagnostic evaluations, particularly in the community hospital setting, and to continue to evaluate the overall effect of the navigation
TABLE 4. Correlations Among Distress, Satisfaction With Care, and Services Satisfaction Measure
HADS-D
HADS-A
STAI-S
Accessibility Usual care Navigation
–0.348* –0.369*
–0.175 –0.199
–0.307* –0.252*
Communication Usual care Navigation
–0.297* –0.395**
0.074 –0.192
–0.11 –0.349**
Finances Usual care Navigation
–0.151 –0.24*
0.074 –0.224*
–0.045 –0.363**
General satisfaction Usual care Navigation
–0.486** –0.317**
–0.285* –0.122
–0.459* –0.155
Interpersonal manner Usual care Navigation
–0.261 –0.389**
–0.092 –0.308**
–0.183 –0.324**
Technical quality Usual care Navigation
–0.521** –0.157**
–0.103 –0.135
–0.238 –0.093
Time Usual care Navigation
–0.104 –0.413*
0.009 –0.255*
–0.12 –0.339*
PSQ-18 Usual care Navigation Total
–0.471** –0.411** –0.312**
–0.116 –0.254* –0.236**
–0.309* –0.34** –0.212*
* p < 0.05; ** p < 0.01 HADS-A—Hospital Anxiety and Depression Score–anxiety subscale; HADS-D—Hospital Anxiety and Depression Score–depression subscale; PSQ-18—Patient Satisfaction Questionnaire; STAI-S—State Trait Anxiety Inventory, State scale
process on distress and satisfaction with care. Researchers need to determine how to address logistic issues of moving women through the diagnostic process when services are received at different locations; how best to administer services when women are receiving fragmented care; and how to examine the cost effectiveness of program delivery, particularly in lowervolume facilities.
Conclusion The results suggest that offering navigation during the biopsy period promotes a higher standard of care delivery, with patients who receive services experiencing less distress. Nurses possess the knowledge and skills to have a direct effect on the diagnostic experience and patient outcomes, and a key component of navigation programs should include having a nurse navigator fulfill critical roles in the navigation process. These roles can include performing distress screening, providing emotional support and education, and facilitating communication among providers. Navigators also can facilitate access to care and help women maneuver the healthcare system by addressing specific barriers to care. Offering diagnostic navigation should ultimately translate into higher patient satisfaction ratings through better-coordinated care and improved quality of care.
References Allen, J.D., Shelton, R.C., Harden, E., & Goldman, R.E. (2008). Follow-up of abnormal screening mammograms among low-income ethnically diverse women: Findings from a qualitative study. Patient Education and Counseling, 72, 283–292. doi:10.1016/j .pec.2008.03.024 American Cancer Society. (2015). Cancer facts and figures, 2015. Atlanta, GA: Author. Campbell, C., Craig, J., Eggert, J., & Bailey-Dorton, C. (2010). Implementing and measuring the impact of patient navigation at a comprehensive community cancer center. Oncology Nursing Forum, 37, 61–68. doi:10.1188/10.ONF.61-68 Ferrante, J.M., Chen, P.H., & Kim, S. (2008). The effect of patient navigation on time to diagnosis, anxiety, and satisfaction in urban minority women with abnormal mammograms: A randomized controlled trial. Journal of Urban Health, 85, 114–124. doi:10.1007/s11524-007-9228-9 Fiscella, K., Whitley, E., Hendren, S., Raich, P.C., Humiston, S., Winters, P., . . . Epstein, R. (2012). Patient navigation for breast and colorectal cancer treatment: A randomized trial. Cancer Epidemiology, Biomarkers and Prevention, 21, 1673–1681. doi:10.1158/1055-9965.EPI-12-0506 Gilbert, J.E., Green, E., Lankshear, S., Hughes, E., Burkoski, V., & Sawka, C. (2011). Nurses as patient navigators in cancer diagnosis: Review, consultation and model design. European Journal of Cancer Care, 20, 228–236. doi:10.1111/j.1365-2354.2010.01231.x Harding, M.M. (2014). Incidence of distress and associated factors in women undergoing breast diagnostic evaluation. Western Journal of Nursing Research, 36, 475–494. doi:10.1177/019394 5913506795 Harding, M.M., & McCrone, S. (2013). Experiences of non-navigated women undergoing breast diagnostic evaluation [Online exclusive]. Clinical Journal of Oncology Nursing, 17, E8–E12. doi:10.1188/13.CJON.E8-E12
Clinical Journal of Oncology Nursing • Volume 19, Number 1 • Nurse Navigation and Patient Distress With Breast Biopsy
E19
Hook, A., Ware, L., Siler, B., & Packard, A. (2012). Breast cancer navigation and patient satisfaction: Exploring a community-based patient navigation model in a rural setting. Oncology Nursing Forum, 39, 379–385. doi:10.1188/12.ONF.379-385 Howell, D. (2010). Psychological distress as a nurse-sensitive outcome. In D.M. Doran (Ed.), Nursing outcomes: State of the science (2nd ed., pp. 285–358). Sudbury, MA: Jones and Bartlett. Korber, S.F., Padula, C., Gray, J., & Powell, M. (2011). A breast navigator program: Barriers, enhancers, and nursing interventions. Oncology Nursing Forum, 38, 44–50. doi:10.1188/11.ONF.44-50 Liao, M.N., Chen, P.L., Chen, M.F., & Chen, S.C. (2010). Effect of supportive care on the anxiety of women with suspected breast cancer. Journal of Advanced Nursing, 66, 49–59. doi:10.1111/ j.1365-2648.2009.05139.x Markossian, T.W., & Calhoun, E.A. (2011). Are breast cancer navigation programs cost-effective? Evidence from the Chicago Cancer Navigation Project. Health Policy, 99, 52–59. doi:10.1016/j.health pol.2010.07.008 Marshall, G.N., & Hayes, R.D. (1994). Patient Satisfaction Questionnaire short form. Santa Monica, CA: RAND. National Accreditation Program for Breast Centers. (2014). NAPBC standards manual: 2014 edition. Retrieved from https://www .facs.org/~/media/files/quality%20programs/napbc/2014%20 napbc%20standards%20manual.ashx Paskett, E.D., Katz, M.L., Post, D.M., Pennell, M.L., Young, G.S., Seiber, E.E., . . . Murray, D.M. (2012). The Ohio Patient Navigation Research Program: Does the American Cancer Society patient navigation model improve time to resolution in patients with abnormal screening tests? Cancer Epidemiology, Biomarkers and Prevention, 21, 1620–1628. doi:10.1158/1055-9965.EPI-12-0523 Pedersen, A.E., Sawatzky, J.A., & Hack, T.F. (2010). The sequelae of anxiety in breast cancer: A human response to illness model. Oncology Nursing Forum, 37, 469–475. doi:10.1188/10.ONF .469-475 Raich, P.C., Whitley, E.M., Thorland, W., Valverde, P., & Fairclough,
E20
D. (2012). Patient navigation improves cancer diagnostic resolution: An individually randomized clinical trial in an underserved population. Cancer Epidemiology, Biomarkers and Prevention, 21, 1629–1638. doi:10.1158/1055-9965.EPI-12-0513 Robinson-White, S., Conroy, B., Slavish, K.H., & Rosenzweig, M. (2010). Patient navigation in breast cancer: A systematic review. Cancer Nursing, 33, 127–140. doi:10.1097/NCC.0b013e3181 c40401 Rush, S.K. (2012). Discharge calls: How one call can make the difference for patients, families, and reimbursement. Nurse Leader, 10(2), 45–52. doi:10.1016/j.mnl.2011.07.014 Siegel, R., Ma, J., Zou, Z., & Jemal, A. (2014). Cancer statistics, 2014. CA: A Cancer Journal for Clinicians, 64, 9–29. doi:10.3322/ caac.21208 Spielberger, C.D., Gorsuch, R.L., & Lushene, R.E. (1970). Manual for the State-Trait Anxiety Inventory (self-evaluation questionnaire). Palo Alto, CA: Consulting Psychologists Press. Swanson, J., & Koch, L. (2010). The role of the oncology nurse navigator in distress management of adult inpatients with cancer: A retrospective study. Oncology Nursing Forum, 37, 69–76. doi:10.1188/10.ONF.69-76 Weissflog, G., Götze, H., Klinitzke, G., Distler, W., Brähler, E., & Ernst, J. (2011). Better patient orientation through certified cancer centres in oncological care? Patient satisfaction in breast cancer patients in certified breast cancer centres and noncertified hospitals. Zeitschrift Für Psychosomatische Medizin Und Psychotherapie, 57, 343–355. Williams, R.T., Yao, K., Stewart, A.K., Winchester, D.J., Turk, M., Gorchow, A., . . . Winchester, D.P. (2011). Needle versus excisional biopsy for noninvasive and invasive breast cancer: Report from the National Cancer Data Base, 2003–2008. Annals of Surgical Oncology, 18, 3802–3810. doi:10.1245/s10434-011-1808-y Zigmond, A.S., & Snaith, R.P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361–370. doi:10.1111/j.1600-0447.1983.tb09716.x
February 2015 • Volume 19, Number 1 • Clinical Journal of Oncology Nursing
Copyright of Clinical Journal of Oncology Nursing is the property of Oncology Nursing Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
