Nurse Navigator Certification Learning Guide – Coordination of Care

June 2016 Vol 7, No 5
Cheryl Bellomo, MSN, RN, HON-ONN-CG, OCN
Oncology Nurse Navigator
Intermountain Cancer Center Cedar City Hospital
Cedar City, Utah

The scope of navigation has evolved from the Freeman model of community outreach and prevention to spanning the entire continuum of care for oncology patients. The current navigation model was developed following several organizational and government reports and recommendations, including the 1989 American Cancer Society Report to the Nation on cancer in the poor (identifying the 4 most critical issues related to cancer in the poor),1 the National Cancer Institute report Voices of a Broken System: Real People, Real Problems (indicating that barriers to cancer care existed for people of all socioeconomic levels),2 and the Patient Navigator Outreach and Chronic Disease Prevention Act of 2005 (navigators to ensure high-quality coordinated care for cancer patients).3 The Commission on Cancer defines navigation, a nationally recognized model of care, as providing individualized assistance to patients, families, and caregivers to overcome healthcare system barriers and facilitate timely access to quality medical and psychosocial care throughout the cancer care trajectory, starting from prior to diagnosis, through all phases of treatment, until the end of life.4

Navigation and the coordination of care are integral components of the Chronic Care Model, which identifies the essential elements of a healthcare system as the community, the health system, self-management support, delivery system design, decision support, and clinical information systems, as well as incorporating patient safety, cultural awareness, care coordination, community policies, and case management.5 The role of the nurse navigator along the continuum of care is bidimensional in nature with a patient-centered (advocate, empowerment with education, and psychosocial support) and health system (member of the multidisciplinary team) orientation to deliver timely, seamless care. Across the cancer continuum, the goals of the nurse navigator are to identify and address barriers to care (utilizing the 5 steps of the nursing process), empower patients with appropriate education and awareness of health literacy so they can make informed decisions, offer psychosocial support and access to resources, advocate for the unique needs with cultural awareness of each patient regarding the use of facility and community resources, encourage patients to be engaged in their care planning, streamline care path transitions and logistic issues (diagnosis, treatment, survivorship, and end of life), and liaise between clinical and nonclinical specialists in the multidisciplinary cancer care team.6

Care Coordination
Addressing Barriers—Health Disparities

To effectively coordinate care, nurse navigators must have an understanding of the health disparities (ie, due to poverty, social injustice, or racial and ethnic biases) and healthcare barriers (ie, cultural, socioeconomic, geographic, and logistic) that patients may face; barriers may be related to the patient, physician, or healthcare system. Socioeconomic barriers, including poverty, lack of health insurance, inadequate insurance and inability to pay out-of-pocket costs, poor education, and unemployment, can have the greatest impact on the existence of health disparities. Nurse navigators need to be competent in addressing, developing, and implementing plans to address barriers experienced by cancer patients. Nurse navigators must understand and practice cultural awareness in recognizing how culture can influence healthcare. A key function of the navigator is the provision of tailored, culturally appropriate education to facilitate communication and collaboration based on findings of a learning needs assessment conducted to establish the patient’s current health literacy, preferred language, motivation, and attitude.

Distress Management

Distress is defined by the National Comprehensive Cancer Network (NCCN) as an unpleasant emotional experience of psychological, social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment. It can be a common barrier along the continuum of care and can negatively impact a patient’s quality of life.7 Nurse navigators have a key role and responsibility in integrating psychosocial assessment into routine practice using evidence-based tools such as the NCCN Distress Thermometer for Patients to identify barriers and issues of distress, to assist in addressing psychosocial needs, and to provide referral to appropriate psychosocial services. The NCCN recommends that distress should be recognized, monitored, documented, treated promptly, followed up, and reassessed at all stages of the care continu­um and in all settings.7

Symptom Management

To provide coordination of care during the treatment and survivorship phases of cancer care, nurse navigators should be knowledgeable about the assessment and management of common treatment-related side effects and late effects such as chemotherapy-induced nausea and vomiting, malnutrition, cancer pain, lymphedema, and fatigue. Side effects and late effects can have a profound impact on a patient’s quality of life and well-being. Nurse navigators can assist by identifying cancer patients at risk for side effects and late effects through screening, assessment and identifying barriers, educating patients and families on coping skills, self-care skills, and symptom management; and coordinating referral to specialists of the multidisciplinary team, palliative care, and community resources to help patients improve their functional status.

Multidisciplinary Team

Coordination of care among various healthcare providers and services is essential in the care of cancer patients along the continuum of care. Nurse navigators interact and communicate closely with various clinical and nonclinical specialists, including medical and radiation oncologists, surgeons, radiologists, pathologists, geneticists, pharmacists, clinical trial research staff, as well as rehabilitation specialists such as physical, occupational, and lymphedema therapists, dietitians, social workers, and financial counselors. The multidisciplinary team approach in cancer care enhances safe, efficient, effective, timely, and quality patient-centered care. Continuing with the role and responsibility of the nurse navigator to facilitate communication and collaboration is the nurse navigator’s participation in the multidisciplinary tumor board. As a participating member of the tumor board, the nurse navigator plays a role in expediting the patient’s care based upon knowledge of NCCN guidelines and evidence-based practice as well as advocating for the individual patient’s needs, beliefs, values, and preferences.

Nurse navigators play a key role in clinical trial recruitment as they collaborate with clinical research nurses and physicians to identify patients who may be appropriate for a specific trial, advocate for patient enrollment, educate patients on the clinical trial process and assess patient’s understanding, and address any barriers to patient participation. It is imperative for nurse navigators to have an understanding of clinical research trials with respect to the historical background, elements of good clinical practice ethics and guidelines for the protection of human research participants, informed consent, and the various types and phases of clinical trials.

Transition of Care

The continuum of care for cancer patients following active treatment includes the transition to survivorship and end-of-life care. Care transition refers to the movement that patients make between healthcare practitioners and settings as their condition and care needs change during the course of their disease, including survivorship care, palliative care, and hospice care. Poor coordination of care during these periods of transition can lead to poor patient quality of life, increased utilization of emergency department services and hospital readmission rates, duplicated tests, and medication errors, which lead to increased healthcare costs and suboptimal overall patient outcomes.

Nurse navigators play pivotal roles in recognizing the stages of care transition, identifying patients at highest risk for gaps in care and providing logistical support, empowering patients by education about anticipated events throughout the trajectory of care, and facilitating communication among providers and between patients and providers to result in better coordination of care overall. Nurse navigators must be familiar and knowledgeable to prepare patients for transitions in care. Survivorship care and its components are essential competencies of the nurse navigator. Nurse navigators must have an understanding of Mullan’s Seasons of Survival model and its 3 stages of survival (acute, extended, and permanent survival).8 A familiarity and understanding of the Institute of Medicine (IOM) report From Cancer Patient to Cancer Survivor: Lost in Transition and its 4 essentials of survivorship care (prevention of recurrence, second cancer, and other late effects; surveillance for cancer spread, recurrence, second cancer, or late effects; intervention; and coordination between providers) is essential for the nurse navigator to be competent in survivorship.9 The IOM report identifies several barriers to cancer survivorship care, including fragmented systems, poor coordination of care, lack of identified clinician follow-up, deficit in structures for coordinated communication, lack of surveillance guidelines, and lack of education. Nurse navigators also play an integral role in the transition to hospice care, which is a specialized branch of palliative care provided to patients who have a life expectancy of 6 months or less and who are no longer receiving cancer-specific treatment because their disease is deemed incurable.


Nurse navigators are essential for the delivery of cancer care, to address barriers to patient care, coordinate care, and assist with transition of care across all aspects of the cancer care continuum, including screening, diagnosis, treatment, follow-up, survivorship, and end of life. The goal of nurse navigation programs is to provide optimal care to patients and their families throughout the cancer care trajectory.


  1. A summary of the American Cancer Society Report to the Nation: Cancer in the Poor. CA Cancer J Clin. 1989;39:263-265.
  2. National Cancer Institute. Voices of a Broken System: Real People, Real Problems. September 2001. Accessed May 12, 2016.
  3. Patient Navigator Outreach and Chronic Disease Prevention Act of 2005. Public Law 109–18. June 29, 2005. Accessed February 15, 2016.
  4. American College of Surgeons. Commission on Cancer. Cancer Program Standards: Ensuring Patient-Centered Care. 2016 edition. Accessed February 15, 2016.
  5. Improving Chronic Illness Care. The Chronic Care Model. Accessed February 15, 2016.
  6. Oncology Nursing Society. Oncology Nurse Navigator Core Competencies. 2013. Accessed February 15, 2016.
  7. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Distress Management. Version 3.2015. November 16, 2015. Accessed February 15, 2016.
  8. Mullan F. Seasons of survival: reflections of a physician with cancer. N Engl J Med. 1985;313:270-273.
  9. Institute of Medicine. From Cancer Patient to Cancer Survivor: Lost in Transition. Hewitt M, Ganz PA, eds. Washington, DC: National Academies Press; 2006. Accessed February 15, 2016.

Knowledge Test

1. The bidimensional orientation of the nurse navigator role means that the role is
a. Navigator-centered and healthcare system–centered
b. Patient-centered and navigator-centered
c. Patient-centered and healthcare system–centered
d. Navigator-centered and physician-centered

2. A navigation model using community members as lay navigators was developed to help the underserved and poor populations gain access to breast cancer screenings
a. Johns Hopkins model
b. Freeman model
c. Chronic Care Model
d. IOM model

3. The major purpose of patient/nurse navigation programs is to
a. Determine economic costs of cancer disparities
b. Identify trusted information sources or resources in the community
c. Provide personal assistance in eliminating barriers to care
d. Monitor treatment equity to diminish bias in care

4. Informed consent is an example of which ethical principle for research involving human subjects summarized in the Belmont Report?
a. Autonomy
b. Beneficence
c. Justice
d. Randomization

5. Nutritional evaluation and education for a cancer patient by the nurse navigator should
a. Occur at the time of the initial diagnosis
b. Occur at time of treatment to manage side effects
c. Occur at the completion of treatment
d. Occur along the care continuum

1, C; 2, B; 3, C; 4, A; 5, D.

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Last modified: August 10, 2023

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