When a patient receives a cancer diagnosis, a plan is developed by the multidisciplinary care team and presented by a physician to the patient to help guide treatment decisions. Sometimes physicians on the care team have differing opinions based on their specialty or other factors, which can leave the patient feeling confused. This may ultimately lead to delays in treatment, quality of care being at risk, and a decrease in patient satisfaction.
Navigating the cancer continuum is a complex journey that requires a team of professionals who can communicate seamlessly and effectively. Care can be fragmented, and silos in care can cause complexities and barriers to timely treatment. Oncology nurse navigators (ONNs), patient navigators, and oncology social workers are tasked with navigating the patients through their cancer journey with the goal of breaking down barriers and ensuring that key elements of quality care are provided to each patient—elements such as education on treatment options, access to clinical trials, care coordination, and psychosocial support, to name just a few.1 Just as the patient needs a clear plan for treatment, each type of navigator needs a clear job description and role delineation to be successful. And just as the patient is at risk for poor outcomes and dissatisfaction, the navigator is at risk for dissatisfaction with the role and the potential to have poor-quality outcomes with the patient if something is missed.
The role of the ONN within the care team begins with a clear definition of the scope of practice. Inconsistencies or blurred lines regarding role delineation cause “scope creep” in which the ONN assumes the responsibilities of others and sets a precedent for navigation being tasked with all patient difficulties.2 Setting boundaries based on the ONN’s core competencies will allow the ONN to practice within his or her scope and avoid being tasked with clerical duties or duplicative workloads. This allows the focus to remain on the tenets of oncology navigation—providing compassionate patient- centered care.
The ONN’s core competencies are based on guidelines set forth by the Oncology Nursing Society. Competencies that are vital to adequately perform the role of ONN are divided into categories and expand based on the nurse’s experience. Novice ONNs are those who have been practicing less than 2 years. Expert ONNs have been in the role for at least 3 years and are proficient in the role of navigator.3 The competencies are as follow:
Category 1: Coordination of Care
Care coordination begins with identification of the patient’s unmet needs by determining their potential barriers to care, which are often revealed through the assessment of the patient’s distress screening. The ONN focuses on application of their knowledge of clinical guidelines and assists the multidisciplinary team in facilitating timely care as well as in identifying potential candidates for molecular testing, genetic counseling, and clinical trials.
Category 2: Communication
Through building trusting relationships with the patients and their family, the ONN is able to act as a liaison between the patient, caregivers, and healthcare providers. Effective communication promotes the patient- and family-centered care and assures that the multidisciplinary team is abreast of situations pertaining to the patient.
Category 3: Education
The ONN applies clinical experience and learning to provide reinforcement and education about diagnosis and treatment side effects and their management to the patient and caretakers. It is this competency that sets the ONN apart from the social worker, financial counselors, and patient navigators, as the ONN is the only one trained to provide clinically relevant information.
Category 4: Professional Role
As a lifelong learner, the ONN promotes implementation of evidence-based practice methods that improve quality outcomes. Through tracking of metrics related to both the patient’s treatments and the navigation process, the ONN contributes to program development and practice improvement.
Category 5: Expert ONN
An expert ONN is able to assist in further defining the ONN’s role through pathway creation and promotion of adherence to treatment plans through process improvement.
Having at least 1 expert ONN can ensure that both the program setup and the nurses’ roles are well defined, ensuring program success and decreasing scope creep or confusion. It is this last step that aids in the growth and development of an oncology navigation program. Incorporating the above competencies to the case study below, the role delineation of the ONN versus other members of the care team can be defined.
A 45-year-old male presented to the emergency department with tongue pain, difficulty swallowing, pain in right side of face, and neck and ear pain. At the time, the patient was having so much pain he was unable to eat. He is a smoker, drinks 4 to 5 alcoholic beverages daily, and denies recreational drugs. The patient was diagnosed with advanced-stage squamous-cell carcinoma of the oropharynx and will need chemotherapy and radiation. Before beginning treatment, the patient will need a percutaneous endoscopic gastrostomy (PEG) tube placed, central line placement, and dental extraction. The patient does not have any insurance or any income because he is unemployed. Currently he is homeless and has no outside support.
Considering the dynamics of this case and the complex psychosocial issues, it will be paramount to involve as many supportive resources as are available. A social work navigator will need to get involved early to ensure that the patient’s basic needs are met. A patient cannot go through chemotherapy and radiation without a place to stay. It will be imperative to find transportation for the patient, as well. This patient will require tube feedings eventually during treatment, and the social worker can assist with getting the patient set up with home health and tap into resources that can provide free tube feeding. This treatment will be extremely difficult for a patient with so many psychosocial concerns. The patient should continue to meet with the social worker throughout treatment.
A financial navigator will be key in setting up this patient for success to begin treatment. The financial navigator will need to assist with getting the patient set up on Medicaid. This patient would benefit from any other grants or foundations for which he might be eligible. The financial navigator can assist the patient in applying for any grants. Anything to ease the financial burden to the patient will be crucial to the patient’s journey.
The patient navigator role will be to assist in coordinating central line placement, dental evaluation, and PEG tube placement. Because the patient does not have his own transportation, it will be extremely beneficial for him to have appointments grouped together whenever possible. The patient navigator will also make sure that all necessary records are available for the physician appointment, if necessary.
The ONN will be key to explain the plan of care to the patient and to make sure he is part of the informed decision-making. The patient will need education on why dental extraction and PEG tube placement are necessary. The nurse navigator will be able to assess what type of central line placement is most appropriate for the patient. With the uncertainty of living conditions, a port-a-catheter is a better option and will have less risk of infection. The ONN can help assess the patient for symptom management during the course of treatment and communicate with the providers on identified needs. The ONN can support the patient throughout his journey and pull in other team members when needed during the course of treatment.
It will truly take a village to manage such a complex case. The importance of role delineation allows everybody to function independently of one another and not duplicate any work. By spreading out the patient needs among the team, it allows the team to shoulder the burden together. Communication and documentation on the patient are key to allow everybody to be on the same page and ensure seamless care.
Defining the Process
Oncology programs across the country function slightly differently from one another, and so do navigation programs. Navigation is not a one-size-fits-all program; it needs to be tailored to meet the goals and the needs of the program. When defining the roles of navigation, one must first evaluate the goals and needs of a program. It is also beneficial to look at the needs of the community to determine what type of navigator is needed. There might be more of a clinical need, and an ONN would be better. Care coordination might be an issue, and a patient navigator would make more sense. Perhaps the program is large enough to support both.
When both the ONN and patient navigator work together in a program, it is key to map out their function, dividing tasks into what suits the role more. The patient navigator can focus on more clerical tasks and allow the ONN to focus on the clinical aspects of care. Most programs like for the patient navigator to do most of the preparation up front with the patient, with the ONN to follow the patient throughout the journey. These roles also need to be defined to the patient to eliminate confusion. When mapping out the roles and responsibilities, it is also important to consider the other roles within the facility. It is important to clearly define the role of the clinic nurses and how they work with the ONN and patient navigator.
David Allen, an expert in personal productivity, coined the phrase, “You can do anything, but you can’t do everything.” To build a really successful navigation program, you have to keep that quote in mind and set healthy boundaries. Pick a few things to be really good at and let the rest fall into place. Continue to look at new opportunities, and do not be afraid to change the current processes to meet new needs.
- Shockney LD, ed. Team-Based Oncology Care: The Pivotal Role of Oncology Navigation. Baltimore, MD: Springer; 2018.
- Shockney L. Oncology Nurse Navigation; Transitioning into the Field. Burlington, MA: Jones & Bartlett Learning; 2019.
- Oncology Nursing Society. 2017 Oncology Nurse Navigator Core Competencies. www.ons.org/sites/default/files/2017-05/2017_Oncology_Nurse_Navigator_Competencies.pdf. 2017.