Shifting paradigms continued—the emergence and the role of nurse navigator
Introduction
Lung cancer remains the leading cause of cancer related death worldwide with an incidence of 200,000 new cases per year. According to the American Cancer Society, over 160,000 deaths, accounting for 28% of all cancer deaths were attributed to lung cancer in 2012. A 52% 5-year survival rate is realized when localized disease is discovered but only 15% of lung cancer is detected at this early stage (1). This statistic has remained unchanged for the last 3 decades. In a recent study, conducted by a group of researchers from Baptist Cancer Center and the University of Memphis in Tennessee, revealed out of 614 patients only 1 in 10 had the recommended combination of staging tests (CT, PET scan, and invasive biopsy) prior to surgery. Furthermore, it took between 1.5 to 6 months for many patients to undergo surgery following an initial imaging study indicating an abnormal finding suggestive of cancer (2). Prompt initiation of cancer treatment depends on the diagnostic confirmation of a lung cancer tissue type and staging. Nurse Navigation can play a critical role for patients accessing the healthcare system and entry into a timely rapid diagnostic and treatment pathway.
History of patient navigation in the USA
Dr. Harold Freeman and his colleagues implemented the first Patient Navigation program at Harlem Hospital in New York City in the 1990’s. His mission was to reduce the barriers to cancer diagnosis and care to the poor, uninsured, and underinsured in this community (3). Freeman was able to demonstrate that 5-year cancer survival rates can improve with increased access to screening and eliminating barriers to healthcare through a patient navigation system (4). This original concept has expanded to encompass the entire trajectory of the cancer journey for the patient; screening, diagnosis, treatment, and survivorship.
In 2001 a report by the National Cancer Institute, “Voices of a Broken System: Real People, Real Problems” stated that barriers to accessing cancer care was not limited to the underserved and poor but experienced by many Americans across all socioeconomic levels (5). In 2005, President George W. Bush signed legislation which provided Federal funding to patient navigation projects under the Patient Navigator Outreach and Chronic Disease Act (6).
In 2012, the American College of Surgeons Commission on Cancer designed a new standard which must be implemented by 2015 for cancer programs seeking accreditation. Standard, 3.1, requires an accredited Center to perform a community needs assessment to identify barriers to healthcare and determine a navigation process to address these barriers (7). The National Accreditation Program for Breast Centers (NAPBC) also requires a navigation process in order to obtain accreditation as a Breast Center of Excellence.
Nurse navigation
A primary principle of Nurse Navigation is patient centered delivery of care with timely access. Oncology nurse navigators (ONN) play a critical role in cancer screening and coordination of services. They are frequently the primary contact or point person for patients in accessing the healthcare system, as well as, primary care physicians referring patients for evaluation of an abnormal chest imaging finding to a pulmonologist. ONN play a central role in the pathway by managing the patient through multiple processes; often making appointments for initial office consultations with pulmonary specialists, requesting imaging studies such as PET/CT scans, scheduling patients for surgical biopsy for diagnosis and cancer staging, and following up with patients concerning their pathology results and findings. Following a cancer diagnosis, seamless maneuvering through complex multidisciplinary care becomes paramount when treatment plans can include chemotherapy, radiation therapy, and surgery (8). Navigators must possess essential skill sets to be successful in their role in assisting patients throughout their cancer trajectory.
The Nurse navigator has the clinical expertise to provide individualized assistance and education to patients, family members, and care givers throughout the entire healthcare continuum; prevention, screening, diagnosis, treatment, survivorship and end of life. An oncology nursing background allows the navigator to be a resource for questions the patient may have concerning their diagnosis and treatment options. In June 2015, the Oncology Nursing Society issued a position statement advocating that nurses in the ONN role possess certification through one of the National Commission for Certifying Agencies. “Certification validates that nurses have met the stringent requirements for knowledge and experience and are qualified to provide competent oncology care” (9).
Often patients will call the Navigator asking questions about their lung cancer cell type, staging, and treatment plans after the physician has spoken to them about their pathology results. In this “hurry up” world, it is the navigator who often makes the time to sit with patients and families providing patient education both in verbal and written formats.
Often patients reach out to the ONN in emotional distress whereby the ONN must be able to assess their psychosocial state. In many institutions and physician practices, the ONN has a collaborative relationship with a Psycho-Social Oncology professional and patients are frequently referred to a social worker to assist with behavioral, financial and insurance support. Based on the patient’s needs, patients may also be referred to local community resources.
The thoracic/pulmonary ONN is often a first contact for the patient after they have been found to have a suspicious mass or nodule in their lung. At initial telephone conversation, a compassionate, intimate connection is made between patient and nurse and reinforced when the patient presents to the physician’s office for consult. This relationship continues throughout the cancer diagnosis process with the patient given resources for immediate accessibility. Many patients state that this act alone provides a sense of relief, caring, and belonging.
Additional navigator considerations
In addition to patient navigational services, the ONN is an integral team member within the Interdisciplinary Lung Tumor Board at many institutions. Medical disciplines responsible in the diagnosis and treatment of lung cancer; Interventional Pulmonology, Radiation Oncology, Thoracic Surgery, Medical Oncology, Pathology, and Tumor Registry, meet to present and review patient cases and make treatment recommendations according to NCCN guidelines. The ONN has a seat at the table submitting patient data including CT, PET/CT imaging reports and pathology reports for discussion to take place. Multidisciplinary Tumor Boards are an additional venue whereby recommendations are made for additional staging or restaging requests for lung cancer patients. During these times, the ONN connects with the patient and facilitates scheduling of procedures.
The thoracic/pulmonary ONN is very involved in patient and family teaching for those patients requiring in-dwelling pleural catheters for recurrent malignant pleural effusions. The ONN meet with family members and provides verbal, written, and return demonstration patient teaching on the care and drainage of the catheter. Placement of the catheter is often done as an outpatient procedure and arrangements for drainage supplies to be dropped shipped to the patient’s residence is provided by the Navigator. The family is provided with the Navigator’s contact information so that they have an immediate resource should a question or issue arise.
Another area of responsibility for an ONN is participating in a Lung Nodule Screening Program. Recent results from the National Lung Screening Trial (NLST) showed a survivor benefit in high risk patients undergoing a low dose CT scan (10). Many institutions are implementing a Lung Nodule Screening Program for high risk patients and the ONN may be involved in collaborative efforts in implementing an outreach program, designing a tracking tool, and surveillance management of the patient with a solitary nodule. As screening programs are implemented, the number of patients presenting with solitary pulmonary nodules will increase thus increasing the need of the role for nurse navigation.
Conclusions
The role of the pulmonary nurse navigator is still evolving. As recent as this year, 2015, ONN role and qualification position statements have been established by the Oncology Nursing Society assisting in providing standardization and definition to the role of ONN (9,11). We do know that this role calls for a trained healthcare professional to facilitate timely access to care, to reduce barriers, be a skilled communicator, and have a well-rounded knowledge of lung cancer and its treatments. National organizations supporting ONNs are continuing to explore this role and its functions. The charge of patient navigation in cancer care extends beyond addressing the needs of the underserved; its goal is to navigate all patients throughout the cancer continuum with a qualified, competent healthcare individual. This is the role of the ONN.
Acknowledgements
None.
Footnote
Conflicts of Interest: The author has no conflicts of interest to declare.
References
- American Cancer Society (April 14, 2009). Navigating difficult waters: The history of the patient navigator. Available online: www.cancer.org
- Faris N, Yu X, Sareen S, et al. Preoperative Evaluation of Lung Cancer in a Community Health Care Setting. Ann Thorac Surg 2015;100:394-400. [Crossref] [PubMed]
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- National Cancer Institute. Voices of a Broken System: Real People, Real Problems. President’s Cancer Panel Report of the Chairman, 2000-2001. 2001. Available online: http://deainfo.nci.nih.gov/advisory/pcp/archive/pcp00-01rpt/PCPvideo/voices_files/PDFfiles/PCPbook.pdf
- H.R. 1812, 109th Congress of the United States. 2005. Available online: https://www.congress.gov/bill/109th-congress/house-bill/1812/text/pl
- American College of Surgeons Commission on Cancer (2012). Cancer program standards 2012: Ensuring patient centered care. Available online: www.facs.org
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- Oncology Nurse Navigator Core Competencies. Available online: https://www.ons.org/sites/default/files/ONNCompetencies_rev.pdf
