Navigation is one strategy proposed as a solution to many of the problems of American health- care: high costs, uneven quality, and too frequent disappointing patient outcomes. Our fragmented system is often characterized by communication failures and nonbeneficial or redundant healthcare tests and services. Nurse navigation is not a new idea to the nursing profession. Identification of barriers to care was a primary focus of patient navigation that Dr Freeman initiated in the 1990s to help explain delays in diagnosis as well as incomplete care.1 This same premise was the goal of nursing utilization review in the 1970s and remained a focus for utilization management, case management, and care coordination.2 Utilization management did start the communication process with the physician, and case management furthered communication as a team ally, provided education, and addressed psychosocial distresses, financial concerns, and care coordination. Nurse navigation cultivated the bidimensional care concept—patient centered and health system oriented—as oncology care moved to an outpatient setting.3 This holistic navigation effort is integral to facilitate effective interprofessional collaboration and promote patient satisfaction and care quality, as well as the efficient use of healthcare resources to decrease costs across oncology patient populations and healthcare settings.
The guiding principles of patient navigation are to ensure that quality, confidentiality, and professionalism are threaded throughout all aspects of care and programming.4 Inherent in the process is continuous quality care for patients from screening through diagnosis and treatment, based on the following tenets:
- Culturally competent care
- Patient safety
A basic nursing skill is to assess, and then plan, implement, and evaluate. One must assess first. To become a skillful nurse navigator, it is advantageous to take the time to observe the care process of patients in a step-by-step timeline fashion and document what is observed. This simple exercise will allow the nurse navigator to identify ineffective processes, communication gaps, and the needs of an oncology program. Shockney has an example in her book, Becoming a Breast Cancer Nurse Navigator, with a template applicable to any navigation program, and describes the use of a linear flowchart as a prerequisite to navigate patients.5
This overview of the patient flow through the system of care can allow definition of the point at which navigation begins and the point at which navigation ends. This is a fundamental principle of navigation, as is “patient navigation should be defined with a clear scope of practice that distinguishes the role and responsibilities of the navigator from that of all other providers.”1 Blaseg points out that a clear scope of practice with stop and start points will prevent overlap of the roles of others.6 If this basic fundamental is ignored in haste to initiate a navigation program and tasks are assigned to ensure a sense of productivity and value with the role, 2 things can occur—the navigator can assume responsibility for the role of others, and any difficulties associated with an individual patient’s circumstances can be deferred to the navigator. This can create team difficulty and frustration to the navigator as a catchall for patient problems.
Once role boundaries are defined, common responsibilities of a nurse navigator may include:
- Providing education and support to the patient and family
- Identifying special needs of the patient and delegating to appropriate support staff
- Enhancing understanding of treatment options available
- Facilitating patient care plan recommendations by physician
- Connecting patient and family with community resources
- Coordinating multidisciplinary care from time of diagnosis throughout treatment
- Improving timeliness of appointments
- Serving as a resource for the community on health issues, prevention, screening, treatment, and research
Confusion can exist about the navigator role and responsibility. Nurse navigators commonly spend time doing clerical tasks such as faxing documents, waiting on the phone for precertification, and scheduling appointments for patients. This time is best spent with patients in education, psychosocial counseling, or facilitating multidisciplinary care. On the AONN website, the definition of navigators describes this distinction.7 Willis and colleagues published on a collaborative project with national stakeholders in navigation to create a role delineation framework.8 The final framework is composed of 12 functional area domains with differences between community health workers, patient navigators, and clinically licensed navigators described in each frame.
The annual evaluation of the patient navigation process outcomes is the primary element in the American College of Surgeons Commission on Cancer (CoC) Standard 3.1 Patient Navigation Process that will influence modifications to the nurse navigator’s process of care. The patient navigation process, driven by a community needs assessment, is established to address healthcare disparities and barriers to care for patients. Resources to address identified barriers may be provided either on-site or by referral to community-based or national organizations. The intent of the standard is to identify and address a new barrier each year. However, programs are allowed to address the same barrier or disparity for more than 1 year if the cancer committee documents in their minutes that they have put forth significant activity over the year but that there is an ongoing need to continue to address that barrier. The cancer committee may decide to continue work to address the barrier until the issue is resolved, for a period not to exceed the 3 years between CoC program surveys.
Professional goals for the nurse navigator are quantifiable targets the cancer committee wishes to achieve. The George Washington Cancer Institute Center for the Advancement of Cancer Survivorship, Navigation, and Policy (caSNP) has an Online Academy course titled “Executive Training on Navigation and Survivorship” that teaches the basics of navigation and survivorship program development and implementation.9 They stress the importance of quantifiable targets using the acronym S.M.A.R.T. for the 5 steps of specific, measurable, action-oriented, realistic, and time-bound goals that set an actionable plan for results. The trainings on the website are self-paced and available free of charge. Espinosa and colleagues explain metrics that support and justify the nurse navigator position.10 They provide questions to pose as well as a table of outcome metrics. Sein’s webinar on the AONN site has an excellent section on creating a dashboard and being specific with goals.11
AONN has a Standardized Metrics Project Team that recognizes the challenge navigation programs have encountered as standardized national metrics to measure programmatic success have yet to be created. The team is working to develop standard metrics in the areas of patient experience, clinical outcomes, and return on investment using the AONN DOMAINS for certification, which contain a comprehensive list of all areas of navigator practice. More on this project will be published in the coming months.
Skills such as advocacy, problem solving, time management, critical thinking, multitasking, collaboration, and communication were identified in the Oncology Nursing Society oncology nurse navigation role delineation study.12 AONN has identified additional skills of leadership and systems management. Leadership skills of the nurse navigator are expressed in several publications, and the role is depicted as one that often survives in a macromanaged environment—one that needs minimal supervision. Seek and Hogle stressed this skill as the navigator works through the complex healthcare system to coordinate optimal care.13 Blaseg describes this as a desired quality for a nurse navigator—one who can make decisions and work independently within the bounds of the role and demonstrate personal and professional accountability with a commitment to lifelong learning.6 According to Vargas and colleagues, they remain flexible to possibilities of care.14 Systems management is best described by Fillion and colleagues, who wrote that the workflow of nurse navigation is bidimensional in nature—patient centered and health system oriented.3 Doll and colleagues state that nurse navigators possess oversight of the comprehensive care needs, provide education and advocacy for the patient, link the patient to networks of professional and community resources, and act as a distinct, constant contact to enhance psychosocial care.15 Blaseg describes the nurse navigator’s knowledge of resources as comprehensive across the healthcare system, community, and population served.6 An example of this systemic overview is shown in the work by Christensen and Bellomo with the navigation process that demonstrated decrease in system time as well as a cost advantage to the healthcare system.16
The Oncology Nursing Society17 further defines the nurse navigator professional role as one of lifelong learning and evidence-based practice and encourages contribution to the knowledge base of the profession. The nurse navigator is expected to contribute to program development, participate in ethical decision-making for patients, and collaborate with the cancer committee, administration, and healthcare team members.
Nurse navigation professional roles and responsibilities questions cover the history of navigation, critical thinking, problem solving, ethics, leadership, multidisciplinary team building, patient tracking, and navigation tasks. It is the work that you do as a nurse navigator on a daily basis. The questions will range from basic knowledge to application. Try the questions below!
1. AONN Community Hospital noticed that the head and neck cancer patients experienced high hospital admission rates. The cancer committee chose to address this phenomenon with the hiring of a nurse navigator. What nursing process will best identify the problem in the care continuum?
2. V is a renal cancer patient who comes in for care, and his wife is always with him. V can neither speak nor comprehend English, but his wife can do so fluently. During the Palliative Care Clinic visit today to address V’s pain and increasing fatigue, the question of end-of-life care was raised by the patient. The wife motions for the interpreter not to answer the question and conveys in English to the interpreter and staff to not answer the question. V looks bewildered by the exchange. What is the best action for the navigator to take at this point?
a. Ask the wife to leave the room.
b. Tell the interpreter to ignore the question
c. Address the wife’s discomfort with the question
d. Question V if he is positive he wants to know
One must assess the current care process to identify possible causes before planning and implementing change.
V is the focus of the care visit, but this barrier imposed by the wife needs to be addressed so the question can be answered for the patient.
- Freeman H, Rodriguez RL. History and principles of patient navigation. Cancer. 2011;117:3539-3542.
- Shockney L. Evolution of patient navigation. Clin J Oncol Nurs. 2010;14:405-407.
- Fillion L, Cook S, Veillette A, et al. Professional navigation framework: elaboration and validation in a Canadian context. Oncol Nurs Forum. 2012;39:E58-E69.
- Freeman HP. A model patient navigator program. Oncology Issues. 2004;19:44-46.
- Shockney L. Becoming a Breast Cancer Nurse Navigator. 1st ed. Sudbury, MA: Jones and Bartlett Publishers; 2010.
- Blaseg K. Getting Started as a Nurse Navigator. In: Blaseg K, Daugherty P, Gamblin K, eds. Oncology Nurse Navigation Delivering Patient-Centered Care Across the Continuum. Pittsburgh, PA: Oncology Nursing Society; 2014:20-42.
- AONN website. FAQ. What is the difference between a nurse navigator and a patient navigator? www.aonnonline.org/about/faq.
- Willis A, Reed E, Pratt-Chapman M, et al. Development of a framework for patient navigation: delineating roles across navigator types. Journal of Oncology Navigation & Survivorship. 2013;4(6):20-26.
- George Washington Cancer Institute Online Academy. http://smhs.gwu.edu/gwci/education.
- Espinosa AR, Gabel M, Vlahakis P. Patient navigation: defining metrics that support and justify the nurse navigator position. Journal of Oncology Navigation & Survivorship. 2012;3(5):16-20.
- Sein E. What Is the Patient Navigator Role in Oncology Quality Metrics? www.aonnonline.org/education/interactive-learning/. Accessed June 12, 2016.
- Brown CG, Cantril C, McMullen L, et al. Oncology nurse navigator role delineation study: an Oncology Nursing Society report. Clin J Oncol Nurs. 2012;16:581-585.
- Seek A, Hogle W. Modeling a better way: navigating the healthcare system for patients with lung cancer. Clin J Oncol Nurs. 2007;11:81-85.
- Vargas RB, Ryan GW, Jackson CA, et al. Characteristics of the original patient navigation programs to reduce disparities in the diagnosis and treatment of breast cancer. Cancer. 2008;113:426-433.
- Doll R, Barroetavena MC, Ellwood AL, et al. The cancer care navigator: toward a conceptual framework for a new role in oncology. Oncology Exchange. 2007;6(4):28-33.
- Christensen D, Bellomo C. Using a nurse navigation pathway in the timely care of oncology patients. Journal of Oncology Navigation & Survivorship. 2014;5(3):13-18.
- Oncology Nursing Society. Oncology Nurse Navigator Core Competencies. www.ons.org/sites/default/files/ONNCompetencies_rev.pdf.
Accreditation Committee Clarifications for Standards 3.1 Patient Navigation Process and 3.2 Psychosocial Distress Screening. www.facs.org/publications/newsletters/coc-source/special-source/standard3132.
American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics-For-Nurses.html.
Braun K, Kagawa-Singer M, Holden A, et al. Cancer patient navigator tasks across the cancer care continuum. J Health Care Poor Underserv. 2012;23:398-413.
Case MA. Oncology nurse navigator. Clin J Oncol Nurs. 2011;15:33-40.
Fiscella K, Ransom S, Jean-Pierre P, et al. Patient-reported outcome measures suitable to assessment of patient navigation. Cancer. 2011;117:3603-3617.
Gentry SS, Sellers JB. Navigation Considerations When Working With Patients. In: Blaseg K, Daugherty P, Gamblin K, eds. Oncology Nurse Navigation: Delivering Patient-Centered Care Across the Continuum. Pittsburgh, PA: Oncology Nursing Society; 2014:71-120.
Johnston D. Current state of care transitions and cancer survivorship. Journal of Oncology Navigation & Survivorship. 2013;4(4):11-20.
Mack NA, Shalkowski L. How to Start and Expand a Nurse Navigation Program. In: Blaseg K, Daugherty P, Gamblin K, eds. Oncology Nurse Navigation Delivering Patient-Centered Care Across the Continuum. Pittsburgh, PA: Oncology Nursing Society; 2014:43-70.