Accepted: 30 August 2016

DOI: 10.1111/ecc.12592

ORIGINAL ARTICLE

Navigation programs, are they helpful for perioperative care

with thyroid cancer patients?

K.A. Park MPH, RN1,2|Y.J. Oh MSN, RN1,2 |K.M. Kim MSN, RN2 |S.Y. Eum MSN,
RN2 |M.H. Cho MPH, RN2 |Y.H. Son RN2 |S.H. Park MSN, RN2 |K.M. Woo MSN,
RN2 |Y.S. Lee MD1 |S. Kim PhD, RN3 |H.-S. Chang PhD, MD1 |C.S. Park PhD, MD1

1
Thyroid Cancer Center,Gangnam
Severance Hospital,Yonsei University Health
The purpose of this study was to develop and evaluate a navigation program for pa-
System, Seoul, Korea tients with thyroid cancer. The navigation program was developed following an analy-
2
Division of Nursing, Gangnam Severance sis of the unmet needs of patients who underwent surgery for thyroid cancer.
Hospital, Yonsei University Health System,
Seoul, Korea Ninety-nine patients in the control group received usual care, and 95 in the navigation
3
Department of Clinical Nursing Science group were managed with a navigation program during the perioperative period. The
& Mo Im Kim Nursing Research Institute,
effectiveness of the navigation program was assessed by administering a question-
Yonsei University College of Nursing, Seoul,
Korea naire to both groups. Overall satisfaction scores were significantly higher in the navi-
gation than in the control group (p=.025), as were satisfaction scores on the continuity
Correspondence of information (p<.001), the continuity of management (p=.002), the continuity of
Yong Sang Lee, Department of Surgery,
Gangnam Severance Hospital, Thyroid relationships with healthcare providers (p<.001), and patient empowerment (p<.001).
Cancer Center, Yonsei University Health The newly developed navigation program for patients with thyroid cancer was effec-
System, Seoul, Korea.
Email: medilys@yuhs.ac tive in raising satisfaction levels and in actively managing the disease during the perio-
Sanghee Kim, Department of Clinical perative period.
Nursing Science & Mo Im Kim Nursing
Research Institute, Yonsei University College KEYWORDS
of Nursing, Seoul, Korea.
Email: sangheekim@yuhs.ac
navigation program, perioperative care, satisfaction, thyroid cancer

1| INTRODUCTION
The incidence of thyroid cancer has been increasing throughout the
world (Chen, Jemal, & Ward, 2009; Kent etal., 2007; Leenhardt &
Grosclaude, 2011). In Korea, the incidence of thyroid cancer increased
24.2% per year in both sexes from 1999 to 2010, with thyroid cancer,
which was the fourth most common cancer type in 2006, becoming
the most common type of cancer in 2009 (Jung etal., 2013). Although
the causes of this increase have not been determined, increases in pa-
tients undergoing generalized health examinations and developments
in ultrasonography and fine-needle aspiration biopsy have contributed
to earlier detection of thyroid cancer (Aschebrook-Kilfoy, Ward, Sabra,
& Devesa, 2011; Brown, de Souza, & Cohen, 2011).
As the number of patients undergoing surgery for thyroid cancer
increases, so does their need to receive proper perioperative care.
Patients require sufficient time for medical consultations and for edu-
cation about upcoming surgery.
Several recent studies of thyroid cancer care have focused on dis-
charge education after surgery (van der Meulen, de Leeuw, Gamel, &
Hafsteinsdottir, 2013; Kim & Kim, 2011; Pieper etal., 2006), which is
mainly intended to improve patient quality of life (Almeida, Vartanian,
& Kowalski, 2009; Huang, Lee, Chien, Liu, & Tai, 2004; Husson etal.,
2011). Those studies, however, did not evaluate effective care during
the perioperative period. In most hospitals, care is not sufficient to
satisfy patients. Despite the use of various educational methods in
hospitals, many patients still have questions and feel anxiety about
upcoming surgery (Kim etal., 2013; Roberts, Lepore, & Urken, 2008;
Seok etal., 2013). Moreover, disagreements among the medical staffs
of different departments can lead to patients receiving inconsistent
information, which can cause patient dissatisfaction and confusion.
Because of the importance for providers to maintain continuity of
care across the health care setting, the thyroid cancer treatment
team, which includes doctors and nurses, should maintain a consistent
quality of care for patients and their families during the perioperative

Eur J Cancer Care 2016; 16 wileyonlinelibrary.com/journal/ecc 2016 John Wiley & Sons Ltd | 1
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2 PARK etal.

period. Patient navigation programs can support patients with educa-
tional needs and emotional problems.
Patient navigation has been used and evaluated in a various dis-
eases (Dohan & Schrag, 2005; Hendren etal., 2012). Navigation pro-
grams are universally regarded as positive and have been modified
continuously. However, navigation programs do not fit a strict con-
ceptual framework. Patient navigation programs require continuous
development and evaluation to provide timely care, ensure patient
satisfaction, and improve patients quality of life (Wells etal., 2008).
The purpose of this study was to explore the educational needs
of thyroid cancer patients, develop a navigation program in a sys-
tematic way, and evaluate the program statistically. In evaluating the
navigation program, we focused on patient satisfaction with surgery,
which can be evaluated by a questionnaire. We hypothesized that the
navigation program would improve patient satisfaction with thyroid
cancer surgery.
2| METHODS
2.1|Design
This study consisted of methodological research to develop the navi-
gation program, followed by a casecontrol study to evaluate the ef-
fectiveness of the program.
First, the navigation program was developed following an analy-
sis of patients unfulfilled needs. The navigation program was applied
during the perioperative period, from the first outpatient visit to dis-
charge after surgery.
Second, the navigation program was evaluated by a casecontrol
study using non-equivalent control group methods. Patients were
classified into a navigation group and a control group. The navigation
group was managed with the newly developed navigation program
during the perioperative period, whereas the control group received
usual care. To verify the efficacy of the navigation program, all patients
were administered a questionnaire at the post-surgical follow-up visit
to the outpatient clinic (Fig.1). Both groups were post-tested after
perioperative care.
2.2|Navigation program
The navigation program was developed to improve continuity of in-
formation, continuity of management, continuity of relationships, and
to empower patients (Table1). At their first visit to the outpatient de-
partment prior to surgery, patients received a booklet of information
about the perioperative period, face-to-face education and Internet
guidance. An assigned nurse consulted with patients by telephone
during the period of waiting for surgery. Upon admission to the hospi-
tal for the surgery, patients received face-to-face education from the
inpatient nurses, using the booklets provided.
The educational methods included a booklet, a phone consulta-
tion, face-to-face education and websites. The booklets contained
information about pre-operative preparation and post-operative man-
agement, which included a treatment plan, a plan for managing com-
plications, doses of medications and an introduction to the Internet
community. The phone counselling service included pre-
surgical
checkups, responses to questions and emotional support. The website
consisted of professional opinion columns, online booklets, a story of
a patients experiences and a Q & A board. The website was managed
and updated by the designated medical staff.
The educator program was designed to provide accurate and con-
sistent education for nurses. Nurses who worked in outpatient care,
inpatient care, telephone counselling and surgery for thyroid cancer
patients received special training for the navigation program (Fig.1).
The contents of the navigation program were reviewed by thyroid
cancer specialist teams composed of four medical specialists and seven
nurses. The navigation program was approved by the hospital man-
agement, and the nursing manager examined the overall process to
determine if the navigation program was being carried out as designed.

F I G U R E 1 Structure of the navigation program with description
of each process
2.3|Data collection
This study was approved by the Institutional Review Board of the
Yonsei University Gangnam Severance Hospital. Inclusion criteria
included age 18years and diagnosis of thyroid cancer. Participants
were patients whom the nurses met in the outpatient clinic after

T A B L E 1 Composition of the navigation program

Navigation field Tools Contents

Continuity of information
Continuity of management
Continuity of relationship
Empowerment of patients
Booklets The education booklets cover all information, from before surgery to management after surgery
Patients were encouraged to read these booklets
Educator program Nurses completed the education program to provide consistent education for patients
Telephone counseling The patient was provided the assigned nurses phone number and assigned nurse provided counseling
Website Internet community answered questions and provided emotional support
PARK etal.
surgery. Participants were informed that participation was voluntary
and would not appear in any public document. Patients were asked to
complete the questionnaire in private and to submit it anonymously.
Data were coded, and safety monitoring was conducted regularly.
The study enrolled 202 patients who underwent thyroid cancer
surgery between September 2013 and February 2014 at the Thyroid
Cancer Center, Gangnam Severance Hospital, Yonsei University
College of Medicine. Eight patients were excluded either because data
were missing from their questionnaires or they underwent other sur-
geries shortly before or after thyroid surgery. Thus, this study evalu-
ated questionnaires form 194 patients.
The study procedure followed a three-step plan. In the first step,
the control group, consisting of 99 patients who received usual care
between September and November 2013 following thyroid cancer
surgery, completed questionnaires. In the second step, the navigation
program was developed from September to December 2013. In the
third step, the navigation group, consisting of 95 patients managed
by the navigation program from December 2013 to February 2014
following thyroid cancer surgery, completed questionnaires.
2.4|Survey instrument
The questionnaire was developed to evaluate the satisfaction of pa-
tients managed by the navigation program. It was based on Kwons
survey tool (Kwon etal., 2012) and modified by specialists, including
four medical specialists and seven nurses.
Kwons survey tool was based upon the professional navigation
framework (Fillion etal., 2009). The questionnaire included four ques-
tions regarding the continuity of information, two on continuity of
management, two on continuity of relationship, and four on empower-
ment of patients. Scores were evaluated according to a 5-point Likert
scale, where a higher score indicated great satisfaction. The patients
were also asked to express their general satisfaction using a 10-point
scale and to provide any remaining questions or suggestions. The reli-
ability of the satisfaction evaluation tools was Cronbachs alpha=0.95.
2.5|Statistical analysis
The first analysis assessed the control groups satisfaction to deter-
mine if satisfaction differed according to patient characteristics. The
relationship between satisfaction and patient characteristics was
analyzed using independent samples t-tests, one-way analysis of vari-
ance, and post-research analysis.
In the second analysis, equivalence between the navigation and
control groups was assessed using chi-square tests. Because this study
used a non-equivalent control group design, differences between the
navigation and control groups could be due to factors other than the
integrated educational program. To verify that higher satisfaction was
due to the navigation program, general characteristics that could po-
tentially affect satisfaction were compared statistically.
Third, to evaluate the integrated educational program, between
group differences in areas of patient satisfaction were analysed using
independent samples t-tests.
|
3
3|RESULTS
3.1|Characteristics of the patient population
All 194 patients had undergone surgery for thyroid cancer. Their
mean age was 47 years (range, 1878years), 75.8% were female, and
66% were college graduates. Of these patients, 29.4% had undergone
less-than-total thyroidectomy (Table2).
3.2|Patient needs
The navigation program was developed following an analysis of con-
trol patients unfulfilled needs. Analysis of satisfaction of the control
group showed that the continuity of information depended signifi-
cantly on the age of the patient. Older patients had more trouble un-
derstanding information and getting timely information. There were
no statistically meaningful differences in satisfaction due to gender,
employment or education. The internet was the most influential infor-
mation source, and patients preferred individual counselling (Table2).
The satisfaction score regarding the sufficiency of the educational
material was lower than that of the other satisfaction scores (Table3).
3.3|Patient satisfaction
Table2 shows that general characteristics of the navigation and con-
trol groups did not differ significantly. Assessments of control patients
satisfaction were used to develop the navigation program and deter-
mine its efficacy. The overall satisfaction score was significantly higher
in the navigation group than in the control group, as were satisfaction
scores regarding the continuity of information, the continuity of man-
agement, the continuity of relationship with health care providers, and
empowerment of patients (Table3). Other measures of satisfaction
were also higher in the navigation group than in the control group.
4|DISCUSSION
The navigation program described in this study was applied to thy-
roid cancer patients during the perioperative period. The navigation
program resulted in significant improvements in the continuity of in-
formation, continuity of management, continuity of relationship, and
empowerment of patients. Navigators have been shown to positively
influence measures of continuity of care and empowerment (Fillion
etal., 2009). The nurse, as a navigator, provides supports to patients,
eliminating problems that could otherwise be caused by insufficient
care (Wagner etal., 2014). The navigator helped patients identify
unmet needs and tailor solutions that helped patients proceed through
the healthcare system as smoothly as possible (Doll etal., 2007).
As each treatment stage involves different educational topics and
environments, it is necessary to provide adaptive care for each stage.
Because needs for information and support change continuously
throughout the stages of cancer, a structured education is important
(van der Molen & Hutchison, 1999; Todd, Roberts, & Black, 2002).
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4 PARK etal.

T A B L E 2 General characteristics of the patients T A B L E 3 Evaluation of the navigation program

Navigation Control Navigation Control

group group group group
(n=95) (n=99) p-value Variables (n=95) (n=99) p value
a
Age General satisfaction 9.131.24 8.731.23 .025
1839 28 (29.5) 26 (26.3) .121 Continuity of information 4.460.62 4.010.69 <.001
4049 34 (35.8) 31 (31.3) Consistency 4.450.74 4.15 0.71
5059 25 (26.3) 22 (22.2) Understanding 4.470.68 4.140.65
6070 8 (8.4) 20 (20.2) Opportuneness 4.490.67 4.040.79
Gender Sufficient educational 4.420.66 3.710.94
material
Male 20 (21.1) 27 (27.3) .312
Continuity of management 4.430.74 4.120.60 .002
Female 75 (78.9) 72 (72.7)
Smooth progress 4.470.80 4.170.71
Religion
Reflection of my opinion 4.390.80 4.060.65
Buddhism 14 (14.7) 21 (21.2) .526
Continuity of relationship 4.350.71 3.890.74 <.001
Catholic 12 (12.6) 16 (16.2)
Clear recognition of the 4.250.83 3.890.82
Christianity 33 (34.7) 24 (24.2)
counselor
Others 36 (37.9) 38 (38.4)
Connection by telephone 4.450.73 3.890.83
Education
Empowerment of patients 4.530.55 4.130.64 <.001
<High school 8 (8.4) 8 (8.1) .352
Expressions and feelings 4.400.75 3.890.81
High school graduate 21 (21.1) 30 (30.3) of anxiety
College graduate or higher 67 (70.5) 61 (61.6) Sufficient guidance and 4.530.58 4.070.75
Employment support
Employed 66 (69.5) 56 (56.6) .063 Physical preparation 4.590.56 4.290.66
Unemployed 29(30.5) 43 (43.4) Emotional preparation 4.590.54 4.290.69
Extent of surgery a
General satisfaction score was measured using a 10-point scale, whereas
Less-than-total 30 (30.3) 27 (28.4) .705 other scores were evaluated using 5-point scale.
thyroidectomya
Total thyroidectomy 56 (56.6) 54 (56.8) opinions and feelings, and communicate with each other through
b
Others 13 (13.1) 14 (14.7) websites. Although patients have access to considerable information
Route of information through the Internet, they often experience difficulty in understand-
Medical team 12 (12.1) 17 (17.9) .302 ing medical information online. Nurses also play an important role in
Internet 60 (60.6) 45 (47.4) promoting patient understanding and fulfil their educational needs by

Other patients 12 (12.1) 16 (16.8)

providing online resources (Anderson & Klemm, 2008). Patients also
received face-to-face education from and phone consultations with
Other 15 (15.2) 17 (17.9)
assigned nurses throughout the navigation program.
Patient preference of education
Furthermore, all nurses received special training to ensure that all
Individual counseling 35 (35.4) 32 (33.7) .849
thyroid cancer patients would be given proper and consistent infor-
Small groups 24 (24.2) 22 (23.2)
mation. Previous studies have shown that nurses have greater educa-
Written material 26 (26.4) 29 (30.5)
tional needs than patients for thyroid cancer, but that barriers prevent
Other 14 (14.1) 12 (12.6) health care staff from getting that education (Kim & Kim, 2011; Ward
a
Including less-than-total thyroidectomy and hemithyroidectomy. & Wood, 2000). To overcome these barriers, nursing managers are cru-
b
Others include total thyroidectomy along with lateral neck dissection and cial in the educational process, providing regular training to educators
re-operation.
to ensure that education remains consistent education.
Our results showed that patient satisfaction with a sufficient
The navigation program provided patients with educational booklets amount of educational material showed the biggest improvement,
for self-learning and access to pre-developed websites for more de- from 3.71 to 4.42, following implementation of the navigation pro-
tailed information and emotional support during the perioperative pe- gram. This was largely due to the booklets distributed to patients. The
riod. The Internet is currently regarded as one of the most influential satisfaction score for relationship continuity was also higher in pa-
sources of information (Anderson & Klemm, 2008; Kim etal., 2013; tients receiving the navigation program because these patients were
Roberts etal., 2008). Internet-based support groups help patients able to freely contact their assigned nurses, who were well-educated
understand medical information, and enable patients to exchange about patient needs. Regarding consumers, health professionals insist
PARK etal.
on the importance of making medical consulting services more acces-
sible (Rasmussen, Wellard, & Nankervis, 2001). The improved satis-
faction score for empowerment suggests that the navigation program
may lead patients to better prepare, both physically and psychologi-
cally, for treatments.
Patient navigation programs were originally developed to as-
sist with cancer care delivery and to assess underserved patients
(Freeman, Muth, & Kerner, 1995; Vargas, Ryan, Jackson, Rodriquez, &
Freeman, 2008). Current professional navigation programs were de-
signed to provide continuous care to patients diagnosed with cancer
(Doll etal., 2007). Professional cancer patient navigators help newly
diagnosed patients, patients undergoing treatment and follow-up,
and patients who survived after a diagnosis of cancer (Fillion etal.,
2009). After discharge, patients require sufficient information about
side effects and unmet needs (Pieper etal., 2006). Patient naviga-
tion involves all stages of cancer care, but little has been reported
about the outcomes and efficacy of patient navigation during cancer
treatment (Guadagnolo, Dohan, & Raich, 2011; Ko etal., 2014). This
study analysed a navigation program adapted for the perioperative
period in thyroid cancer patients. An assigned nurse played the role of
navigator, to relieve patient anxiety before surgery. Also, systematic
education was provided during the patients hospitalization. In gen-
eral, cancer patients need to be properly educated from the time of
diagnosis to post-surgical discharge, enabling them to manage their
health for the rest of their lives. Providing these patients with system-
atic education about thyroid cancer and treatment plans is essential.
Some patients expressed dissatisfaction with their education
booklets and the navigation program, as both focused solely on con-
ventional surgery. In the future, it will be necessary to develop addi-
tional individualized educational material for endoscopic, robotic, and
revision surgery for thyroid cancer.
This study had several limitations. First, the study involved thyroid
cancer patients treated at a single institution, making it necessary to
evaluated patients treated at other hospitals and institutions. Second,
the navigation program cannot be fully customized to the individual
characteristics of each participant. Finally, the efficacy of the navi-
gation program was evaluated based on patient satisfaction scores,
which may have been affected by patients knowledge, attitudes, and
skills. Many studies of navigation programs have evaluated clinical pre-
dictors of quality of life, but quality of life is associated with several rel-
evant confounding variables (Fillion etal. 2009; Hendren etal., 2012;
Wagner etal., 2014). Also, thyroid cancer patients have relatively good
physical and functional status during perioperative periods, making it
difficult to evaluate quality of life. In future studies, it will be mean-
ingful to evaluate the efficacy of the navigation program using other
possible indicators.
In conclusion, the navigation program for thyroid cancer patients
was effective in raising the satisfaction level of patients and in actively
managing the disease. Clinical nurses played an important role in pa-
tient care. The findings of this study may contribute to the develop-
ment of navigation programs for perioperative care.
It is important to ensure that a navigation program can con-
sistently and effectively deliver information to patients. A proper
|
5
navigation program should undergo continuous development and
improvement by medical staff. Doctors and nurses must work coop-
eratively to ensure that the navigation program has been properly
developed. Further research is also necessary to evaluate navigation
programs, as they are likely to improve patient satisfaction and the
quality of patient care.
The number of thyroid cancer patients worldwide is increasing,
suggesting the need for a proper navigation program, which should be
continuously developed and improved. Although patients can easily
access information using the Internet, some of information may be in-
correct. Thus, and it is important for medical teams to provide correct
information to patients.
Furthermore, the long-term effectiveness of the navigational
program should be evaluated. Future studies should focus on the
development and evaluation of a navigation program for radioiodine
therapy, as many thyroid cancer patients receive radioiodine therapy
after surgery.
AC KNOW L ED G EM ENT
The authors especially thank the nurses who work in the outpatient
department (Thyroid Cancer Center), inpatient department (52, 73,
and 74 wards).
CO NFL I C T O F I NT ER ES T
None.
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How to cite this article: Park, K. A., Oh, Y. J., Kim, K.M., Eum, S. Y.,
Cho, M. H., Son, Y. H., Park, S. H., Woo, K. M., Lee, Y. S., Kim, S.,
Chang, H.-S. and Park, C. S. (2016), Navigation programs, are they
helpful for perioperative care with thyroid cancer patients?
European Journal of Cancer Care, 00: 16. doi: 10.1111/ecc.12592