Patient navigation job roles by levels of experience: Workforce Development Task Group, National Navigation Roundtable

Arti Patel Varanasi PhD, MPH¹ | Linda Burhansstipanov DrPH, MSPH² | Carrie Dorn MPA, LMSW³ | Sharon Gentry MSN, RN⁴ | Michele A. Capossela BA⁵ | Kyandra Fox MHA⁶ | Donna Wilson MSN, RN, CBCN⁷ | Sora Tanjasiri DrPH, MPH⁸ | Olayinka Odumosu BSc, MPSW, MSW, MBA⁹ | Elba L. Saavedra Ferrer PhD, MS¹⁰

¹Advancing Synergy, Baltimore, Maryland, USA
²Native American Cancer Initiatives, Inc. (NACI), Pine, Colorado, USA
³National Association of Social Workers, Washington, DC, USA
⁴Academy of Oncology Nurse and Patient Navigators (AONNþ), Lewisville, North Carolina, USA
⁵American Cancer Society, Framingham, Massachusetts, USA
⁶Patient Navigation, Education and Training, Susan G. Komen Foundation, Allen, Texas, USA
⁷HCA Henrico Doctors' Hospital/Virginia Cancer Patient Navigator Network (VaCPNN), Midlothian, Virginia, USA
⁸Department of Health, Society and Behavior, University of Irvine, Irvine, California, USA
⁹Amorvard Services, Lagos, Nigeria
¹⁰College of Education and Human Sciences, University of New Mexico, Albuquerque, New Mexico, USA

The first two authors contributed equally to this article.

Correspondence
Arti Patel Varanasi and Linda Burhansstipanov.
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Varanasi AP, Burhansstipanov L, Dorn C, et al. Patient navigation job roles by levels of experience: workforce Development Task Group, National Navigation Roundtable. Cancer. 2023;1‐19. doi:10.1002/cncr.35147

Background

Oncology patient navigators (PNs) work in diverse settings from community‐based programs to comprehensive cancer centers to improve outcomes in underserved populations through timely cancer prevention, early detection, diagnosis, treatment, and survivorship in a culturally appropriate and competent manner. Patient navigators assess and eliminate barriers while helping patients understand and use the health care system more effectively and efficiently.^1–3 Greater standardization of navigator roles and responsibilities will lead to enhanced integration of navigators within health care teams and optimize their impact to reduce health disparities and improve sustainability of their role.^4–6 The primary purpose of this article is to clarify the roles and responsibilities of PNs from Entry to Intermediate to Advanced experience levels.

Patient navigation is an evidence‐based strategy that addresses health disparities.^7–11 Research indicates that PNs who are culturally congruent to the patients they serve reduce fear and anxiety, build trust, and decrease literacy and language barriers.^8,12–14 They also facilitate patient–provider communication, provide psychosocial support, and manage logistical obstacles. PNs that are embedded within and trusted by their patients and communities help to bridge the gap between patients and providers, increase adherence to care recommendations, and improve quality of life and survival.^8,15–25 Navigated patients are more likely than non‐navigated patients to receive timely cancer screening, treatment initiation,²⁶ and follow‐up with diagnostic tests.^15,27–31 PNs provide cancer education,³² facilitate access to care,³³ improve patient satisfaction,^15,34,35 assist with financial and insurance issues,³⁶ transportation, childcare, and community resources.³⁷ Research has suggested that patient navigation programs decrease health care costs and resource use,³⁸ including emergency department visits^39,40 and hospitalizations.⁴¹ They also assist in increasing early detection screening services and decreasing related costs.^42,43 Cost analyses performed on government‐funded navigation programs show promising results.⁴⁴ Despite data and evidence supporting navigation,^{6,8,14,16,26,45,46} sustainability of PN has been elusive.⁴⁵

The American Cancer Society (ACS) created the National Navigation Roundtable (NNRT) in 2017 to initiate work on key issues around patient navigation, disseminate best practices, and enhance the field overall. The ACS NNRT is a national coalition of 80 member organizations to advance navigation efforts that eliminate barriers to quality care, reduce disparities, and foster ongoing health equity across the cancer continuum. The ACS provides leadership and expert staff support to the Roundtable.

The Workforce Development Task Group (WFD TG) is one of three within the ACS NNRT. Members include nurses, social workers, and patient navigators, who work in community and clinical settings and/or for professional navigation organizations, and administrators, researchers, and evaluators of navigation programs. During 2017– 2018, the WFD reviewed existing competencies from navigation and other similar programs throughout the United States.² Collectively, these were refined to create the competencies used in subsequent WFD efforts. The priority for the WFD Task Group in 2019 was to define and reach consensus on the competencies for patient navigation.²

Because of the unanticipated disruptions of the COVID‐19 pandemic, ACS TGs reassessed priorities in 2020–2021. In 2022– 2023, the WFD TG decided to build on the 2019 competencies by delineating PN roles and responsibilities as a priority task. Initially, the WFD attempted to use definitions from the Oncology Nursing Society’s oncology nursing navigation website that was limited to Beginning and Advanced, but the TG felt PN required an Intermediate level. The WFD changed “Beginning” to “Entry” and defined “Entry” level as individuals with 1 to 2 years of navigation experience or equivalent and whose skills include knowledge and comprehension. For instance, the navigator may have started a new position without experience in navigation. As part of the role, the PN builds on resources for addressing logistical, economic, cultural, and linguistic, communication, patient‐, and provider‐centered barriers, and basic principles to guide practice. Entry level PNs are able to identify barriers and/or solutions but may need to obtain guidance from other members of the oncology team to whom or when to refer specific resources. In comparison, Intermediate PNs can assess barriers and identify resources independently. “Intermediate” navigators have 3 to 4 years of experience or equivalent effort, and their skills extend to application and analysis. The Intermediate PNs possess basic understanding of patient care flow within job boundaries, matching resources to the unique needs of the patient, identifying resources, analyze barriers in the community, and exploring/collaborating with multidisciplinary team members to advocate for resources for unmet needs for community or clinical setting. Entry Level PNs are learning but frequently need additional guidance from oncology nurse navigators or social workers for solutions that are more tailored to match patient needs are more efficient and effective based on their experience. “Advanced” navigators usually have 5 or more years and can evaluate patient situations holistically based on past experiences. They focus on the unique aspects of the patient assessment and use critical thinking and decision‐making skills pertaining to navigation processes. Their skills include synthesis and evaluation. Advanced navigators often contribute to program planning and communicate with internal and external stakeholders to improve organizational practices.

This article can be used as a resource for administrators in creating job descriptions for the navigator with specific levels of expertise. Similarly, this article can be a resource for patient navigators that are working to attain a higher level of expertise. Navigation has evolved significantly since pioneered by Harold Freeman in 1989. Through the years, various job titles were used to define this role such as cancer care liaison, care coordinator, nurse navigator, and others (Figure 1). This multitude of titles led to mixed skills and tasks in the role, limitations in comparing positions, and unclear boundaries. This ambiguity was resolved as leaders from professional oncology navigation groups created standards that included role definitions, knowledge, and skills that all professional navigators should possess to deliver high‐quality, proficient, and principled services.

Figure 1 Definition of patient navigator levels. Patient navigator roles and responsibilities progress from Entry through Advanced levels beginning with outreach in the community and learning how to identify and address barriers.

In 2022, the Professional Oncology Navigation Task (PONT) group updated and obtained consensus for consistent phrasing for different types of patient navigators. According to PONT, positions that fall under the professional navigator category include oncology patient navigators and clinical navigators, defined as oncology nurse navigators and oncology social work navigators.⁴⁷ Table 1 shows the PONT definitions. In contrast, this article refers to all navigator types as “patient navigators.”

Despite the evolution of navigation and new definitions by PONT, confusion remains about the scope of practice of PNs.⁴⁷ In some settings, community‐based PNs have been requested to clean patient’s homes and run errands. Similarly, clinical navigators have been assigned administrative duties that could have been completed by administrative staff. These activities not only distract PNs from direct patient interaction, but also are examples of inappropriate job roles. There are resources available within the community that the navigator can identify and facilitate to ensure the needed services are provided. Neither licensed nor nonlicensed PNs should be doing clerical duties; their duties focus on patients.

Multiple issues and events have impacted navigation programs in the United States. The Patient Protection and Affordable Care Act (ACA) recognized the role of patient navigation in reducing health disparities in cancer care.⁴⁸ However, the ACA also used the term “patient navigators” to refer to assisters that help enroll individuals in health insurance plans. This is not the focus of oncology patient navigation with the exception that financial navigators may help patients find appropriate health insurance and other resources.⁴ There has been confusion between these two distinct positions.

Currently, there is no Department of Labor code for patient navigation. Such a code would help differentiate between community outreach workers, Promotores/Promotoras de Salud or Community Health Workers (CHW), peer educators, patient coordinators, and other similar job positions who work with chronic conditions in addition to cancer. Among these roles, there are responsibilities that overlap, such as working with minority, underserved, and unserved individuals and cancer patients in culturally appropriate ways. Differences in navigator roles versus other similar positions include the initiation of an interaction in the community that typically continues as patients begin to engage in services within the cancer care facility. As Figure 2 shows, multiple roles may share some duties, but historically roles such as community health workers and Promotores de Salud focus on friendly, culturally respectful outreach to un‐ or underserved community members, helping them access appropriate services and care. PNs also may conduct such outreach, but they are trained to remain with the patient when they cross the clinic threshold and continue providing support throughout the full cancer continuum. The PN frequently is the most recognized face as the patient encounters 5–20 different members of the oncology health care team. Thus, the relationship with the navigator then continues throughout the cancer experience and beyond. Some patient navigators focus on a specific phase within the cancer continuum (such as screening, survivorship, or prevention) and others work with patients throughout the full continuum (prevention through end‐of‐life) (Figure 3). Few of the other roles support patients through the full continuum of care.

FIGURE 2 Roles that MAY overlap with patient navigator roles.

FIGURE 3 Cancer care across the continuum.

The COVID‐19 pandemic greatly affected the evolution of patient navigation. PNs, as well as all health care providers, were required to adjust their roles and responsibilities to address the excessive increase of COVID infections, care, recovery, and deaths. These changes in roles are described in 2022 publications.^49,50

This article identifies appropriate roles and responsibilities for PNs and sets expectations for Entry, Intermediate, and Advanced navigators. This article is a compilation of experiences and insights from 12 professionals working within the field of patient navigation and members of the ACS NNRT WFD. These individuals have over 200 years of collective experience implementing, performing, training, and promoting PNs to perform multiple roles throughout the cancer continuum from outreach through end‐of‐life (Table 2, Authors' details). At the Entry, Intermediate, and Advanced levels, the competencies described in this article apply to patient navigators, nurse navigators, and social work navigators. In alliance with the PONT standards, this article and related resources should serve as a guide for all PN types and programs. It is anticipated that the WFD's recommendations on the PN job roles by level will help inform the hiring, training, and/or evaluation of PNs in the future.

Methods

The ACS NNRT WFD convened from January 2021 through December 2022 to advance progress on the pressing PN workforce need to identify job roles specific to each PN competency,² and clarify the topics of PN functions ranked into three experience categories: Entry, Intermediate, and Advanced. As described above, the definitions refer to number of years or “equivalent.” Equivalent refers to how many hours of experience the navigator has performed PN duties. For example, the navigator may have worked for a community or clinical‐based setting for 2 years but only provided navigation services for 100 hours. This individual would be regarded as “Entry” level. These domains and roles are guidelines. Programs can add or remove language to make the job descriptions relevant and appropriate for their local navigation program.

Each contributor identified a specific competency and delimited roles based on levels of expertise of the PN. The active members of WFD reviewed, critiqued, came to a consensus, and finalized the table through an iterative process (Figure 4) that involved monthly meetings, small group work sessions, and individual meetings with the WFD co‐chairs. Members talked with PNs in their respective organizations and reviewed what they could do when they entered their position as PN and what they can do now as Intermediate or Advanced PNs. These discussions helped to identify the feasibility of activities at each level. An example of a WFD discussion included one member talking about PNs picking up cleaning, doing grocery shopping and other daily activities. The WFD agreed that such activities were inappropriate for PNs at any level. A second example highlighted PN roles for administering and interpreting patient surveys and tools. The group agreed that Entry level PNs can conduct “stress distress scales” that include easy‐to‐understand interpretation scales. However, other types of tools, such as survivorship or treatment care plans, usually require more experience and assistance from other members of the health care team, such as the oncology nurse, and are grouped as Intermediate level.

FIGURE 4 Iterative process to develop competency table.

Topics were added to each row such as confidentiality, cultural knowledge, advocacy, social justice, etc. The roles specified in the “Entry” column reflected knowledge and comprehension for someone with 1 to 2 years of experience or equivalent. The skills, knowledge, and roles increased or improved to allow for application and analysis for PNs in the “Intermediate” column. Advanced PNs demonstrate significant growth in skills and roles to allow for synthesis and evaluation of information. For example, Competency I as defined in the 2019 WFD publication² is: Demonstrate sensitivity and responsiveness to a diverse patient population, including but not limited to respecting confidentiality, organizational rules and regulations, ethical principles and diversity in gender, age, culture, race, ethnicity, religion, abilities, sexual orientation, and geography. Figure 5 shows the 2019 competencies and domains.

FIGURE 5 Domains and competencies based on Professional Oncology Navigation Task Force standards.

There are eight topics associated with this competency. As an example, the row I.2 topic is “Assessment and record keeping” and the skills required at each level are listed below.

• The Entry level job behavior is “Be cognizant of all assessments and record information that contributes to a patient’s needs, priorities, and preferences.”
• The Intermediate level job behavior is “Use assessment information to follow plans to address health and related patient needs in cooperation with the patient and based on patient priorities.”
• The Advanced level job behavior is “Develop, maintain, and utilize an organizational system to record and update health care, cultural‐relevance, health‐literacy, and linguistically appropriate resources for patients and their communities.”

Thus, for each row, there is a topic and the PN’s skill advances from Entry, to Intermediate, and then to Advanced roles. The tables reflect the professional growth of a PN through several years of experience.

Findings

The WFD resource posits a total of seven domains of competencies for PNs: I. Ethical, Cultural, Legal and Professional; II. Client and Care Team Interaction; III. Health Knowledge; IV. Patient Care Coordination; V. Practice‐Based Learning; VI. Systems‐Based Practice; and VII. Communication/Interpersonal Skills. Table 3 provides the WFD’s recommended Intermediate PN competencies, broken down by competency domain (e.g., ethical and cultural) and topics within domains (e.g., confidentiality).

Table 3 can help generate a job announcement/position for an Entry, Intermediate, or Advanced PN. Each level can be used to help generate a position description for the desired level of navigator. To do this, the reader needs to contact either of the coauthors for a password to a Google shared feedback sheet.

Table 4 can track how PN skills increase from Entry level through Intermediate to Advanced. For example, the domain for Competency III is health knowledge and the topic for the first row is “Use of Knowledge.” The following scenario illustrates the power of these distinct levels to guide PN hiring and/or promotion. For example, a PN who works with a prostate cancer patient who is receiving Lupron (leuprolide acetate for depot suspension) injections for his treatment can provide different information based on their level. The Entry level PN has basic knowledge about prostate cancer treatment and understands that Lupron is an androgen deprivation therapy that is designed to reduce prostate‐specific antigen and testosterone that subsequently reduces or prevents cancer cells from multiplying and growing. Entry level PN also understands when, where, and how the injections are administered and would need to engage additional resources, such as a clinical trials nurse, if interacting with Lupron outside of advanced prostate cancer as it is being studied in the treatment of other types of cancer, because this knowledge is outside Entry level knowledge and expertise.

The Intermediate PNs for Competency III would know how to collect stress distress scales, conduct National Comprehensive Cancer Network problem surveys, eliminate barriers to care screening, complete social determinants of health needs assessments, and use other tools to assess the patient’s side effects, such as severe hot flashes. Based on such assessments and knowledge of the side effects of Lupron, the Intermediate PN helps the patient learn to recognize cues that increase the likelihood of hot flashes, such as eating a heavy meal. The Intermediate PN and patient collaborate on creating a plan of action to reduce the cues that set off more frequent and intense hot flashes. The Intermediate PN would obtain supervisor’s approval of the plan for safety and effectiveness.

The Advanced PN would implement and evaluate that plan of action and document additional ideas based on the analyses of the plan. The Advanced PN also would present findings about the outcomes to the plan of action to professionals and Entry and Intermediate PNs during meetings, conferences, symposia, tumor boards, and similar venues. The Advanced PN also educates, mentors, and supervises new navigators and health care team members. Such a continuum from Entry through Advanced outlines relevant PN training opportunities designed to improve their skills.

Another example for “use of knowledge” may be the Entry level PN working with a community member recently diagnosed with breast cancer. The Entry level PN can help the patient understand that a cancer diagnosis is not a death sentence and that many types of treatments are available to manage the cancer and help the patient have both high‐quality care and quantity of life following the cancer treatment experiences. The Intermediate level PN helps the patient identify her personal goals and daily behaviors that she may be ready to change (e.g., increase daily physical activity). The Advanced level PN can help the patient address severe side effects (e.g., cardiac) from treatments.

Discussion

PNs, regardless of working directly within a clinical setting or in a community‐based organization, would benefit from standardization of their established roles and functions across settings. As the field of PN expands, it is imperative that employers and health professionals understand the specific skills, knowledge, roles, and value that PNs bring to health care systems. It is essential that PNs are assigned duties applicable to their scope of work and skillset (e.g., addressing patient barriers to care). This article was designed to clarify the types of roles an employer may be able to expect from an “Entry” level PN and how those skills differ and improve for a PN who is at the “Intermediate” or “Advanced” level. Patients, families, health care teams, and PNs benefit when navigators are assigned responsibilities that are appropriate for their role and experience level. As practices are implementing and expanding navigation programs, this article can serve as a guide to decrease overlapping or inappropriate duties assigned to the PN.

PNs should be included as members of the interdisciplinary team. The navigator provides holistic approach to care delivery and focuses on care coordination, education, and physical, social, and emotional aspects of care. This holistic approach views the entire community, health care systems, and provider organizations from the patient’s perspective. Existing team members can engage PNs in conversations and meetings that promote collaboration among oncology health care providers and improve communication with and support for patients, family, and caregivers. This involvement helps demonstrate how and why PNs are valued members of the oncology care and interdisciplinary teams. The competencies described in this article can be used to support professional growth and build career ladders that correspond to years of experience. Several of the topics identified throughout the competencies are centered around health equity (including traditional culture care, social justice, cultural competence, etc.). As health systems strive to reduce health disparities, they must be cognizant of the important role that PNs serve in advancing health equity through direct patient encounters.

In conclusion, competency‐based training is essential for efficient and effective PNs. Patient navigators, regardless of their work setting need to possess competency‐based skills. The competencies developed by the WFD in 2019, were used as a foundation for the processes the WFD used to define three levels of performance based on years of experience or comparable experience into “Entry, Intermediate, and Advanced.” PN roles were organized into a table specific to competencies and levels (Tables 3 and 4). Examples of how tasks evolve for a single competency topic from Entry to Intermediate to Advanced were provided on table rows. The columns can be used to help generate a position description for the desired level of navigator. To do this, the reader needs to contact either of the coauthors for a password to a Google shared feedback sheet. The table rows help illustrate how PNs skills increase from Entry through Advanced levels.

In recognition of the Oncology Navigation Standards of Professional Practice,⁴⁷ clarification of the roles and responsibilities of navigators per experience level will lead to clearer job descriptions and training and evaluation opportunities for the navigator. Standardization of navigator roles and responsibilities will lead to better integration of navigators within health care teams and improve care coordination. Clarification of PN roles could lead to tasksharing or task‐shifting with non‐navigator team members or others providing support to overcome barriers. As an example, task‐sharing occurs when both the CHW and PN may conduct outreach in respectful manners to un‐ or underserved community members. The PN is well trained on cancer knowledge, whereas the CHW is not unless it is for a specific funded grant. An example of “task shifting” occurs when the PN who has experience working with helping patients complete early detection screening (breast, cervix, colorectal, lung, and/or prostate) and is starting to work with other types of cancer. They may begin to expand knowledge to include cancers, such as lymphomas or myelomas that differ greatly from screenable cancers (i.e., expanding their learning). The PN may work with other healthcare providers who have training and experience with those cancers. The PN may also shadow colleagues to increase their understanding and comprehension of cancer site diversity. Another example of “task shifting” may be that the nurse who has been recruiting patients to screening is able to shift some of the patient load to the trained PN. The promotion of PNs to attain a higher level of expertise will lead to better integration of navigators within health care teams and improve care coordination to further address health disparities and advance health equity.

Author Contributions

Arti Patel Varanasi: Writing–original draft, writing–review and editing, and supervision. Linda Burhansstipanov: Writing–original draft, writing–review and editing, and supervision. Carrie Dorn: Writing–original draft and writing–review and editing. Sharon Gentry: Writing–original draft and writing–review and editing. Michele A. Capossela: Writing–original draft and writing–review and editing. Kyandra Fox: Writing–original draft and writing–review and editing. Donna Wilson: Writing–original draft and writing–review and editing. Sora Tanjasiri: Writing–original draft and writing– review and editing. Olayinka Odumosu: Writing–original draft and writing–review and editing. Elba L. Saavedra Ferrer: Writing–original draft and writing–review and editing.

Acknowledgments

The authors would like to acknowledge the American Cancer Society National Navigation Roundtable Workforce Development Task Group.

Conflict of Interest Statement

Michele A. Capossela is employed by the American Cancer Society, which receives grants from private and corporate foundations, including foundations associated with companies in the health sector, for research outside the submitted work. Linda Burhansstipanov reports fees for professional activities from Native American Cancer Research Corporation. Sharon Gentry reports fees for professional activities from Pfizer. Donna Wilson reports fees for professional activities from Pfizer and serving as a fiduciary officer for Cancer Action Coalition of Virginia and Virginia Cancer Patient Navigator Network. Olayinka Odumosu reports serving as a fiduciary officer Amorvard Development Foundation and Amorvard Medical Services Limited. Arti Patel Varanasi reports fees for professional activities from American Cancer Society. The other authors declare no conflicts of interest.

Data Availability Statement

Data sharing is not applicable to this article because no new data were created or analyzed in this study.

ORCID

Arti Patel Varanasi https://orcid.org/0000-0002-7594-0959
Linda Burhansstipanov https://orcid.org/0000-0002-7954-3993
Sharon Gentry https://orcid.org/0000-0001-9142-0681
Donna Wilson https://orcid.org/0009-0001-6581-7615

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How to cite this article:
Varanasi AP, Burhansstipanov L, Dorn C, et al. Patient navigation job roles by levels of experience: workforce Development Task Group, National Navigation Roundtable. Cancer. 2023;1‐19. doi:10.1002/cncr.35147