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Where Does Your Role of Navigation Begin and End (and Possibly Overlap with Someone Else's Responsibilities)?

January 12, 2011 | AONN+ Blog | Role of the Navigator
Featuring:
Lillie D. Shockney, RN, BS, MAS, HON-ONN-CG
Lillie D. Shockney, RN, BS, MAS, HON-ONN-CG
Editor-in-Chief, JONS; Co-Founder, AONN+; University Distinguished Service Professor of Breast Cancer, Administrative Director, The Johns Hopkins Breast Center; Director, Johns Hopkins Cancer Survivorship Programs; Professor of Surgery and Oncology, JHU School of Medicine; Co-Creator, Work Stride-Managing Cancer at Work

It’s hard to turn on the radio or pick up an ad about a cancer center without reading something about patient navigation. There has been an explosion of oncology nurse navigator positions in the past year or so, and that number is growing even more. Perhaps you are a new nurse navigator and are part of these statistics.

Something that has become a touchy issue in some work environments relates to territorial responsibilities. Who is to do what, when, where, for whom and, perhaps most importantly, why? There seems to be some gray areas when clearly defining the scope and skill set for oncology nurse navigators. This delineation can be especially tricky in center with navigators in various areas, several of whom will be involved in each patient’s care and support. Add to that an appointment scheduling coordinator, social worker, psychotherapist, and perhaps others, and it doesn’t take very long before you see the risk for redundancy, overlap, and confusion.

Having a preemptive meeting of the minds can help prevent people from feeling paranoid about which duties are being done by which staff working with the same patients. Come together and discuss your roles and responsibilities. This will help each of you to clearly identify what actions you are to be doing. In addition, you will be able to give patients an unambiguous understanding of when they are to come to you and for what purpose.

Make a flowchart of the patient’s cancer diagnosis and treatment pathway, and record underneath each phase along the continuum of care what each member of the oncology support team is responsible to do. Several of you may be working together at various points in time and, at other periods of time, there may be just one point person working with the patient. (And keep in mind, if you feel confused about functions and tasks, your patients are going to be even more confused. Remain focused on your patients and your patients’ needs, not your own.)

I’ve seen many navigation models as I travel around the country visiting various cancer centers to speak to nursing groups or conduct Grand Rounds for physicians. Some smaller institutions have one nurse navigator who sees and follows all of the cancer patients, because the volume of any one specific type of cancer is too low to warrant having a navigator for each cancer site.

In other models, though, where there is large volumes and the centers are NCI-designated comprehensive cancer centers, there can be multiple navigators. One navigator may perform community outreach to recruit patients to come for screening exams (mammography, Pap smears, colonoscopy) and/or establish better lifestyle habits to reduce their risk (like stopping smoking and wearing sunblock). One nurse navigator may work specifically with patients having biopsies in the breast imaging setting who hands off the patient after a confirmed diagnosis of breast cancer. The next hand-off may be postoperatively to a medical oncology nurse navigator during chemotherapy, and then finally perhaps onto a radiation navigator. In this mix, however, can be a social worker getting women qualified for medical assistance because they have no insurance, a nurse practitioner discussing the surgical preparation and postoperative recovery care process, a scheduler arranging for transportation for a patient who has no way of getting to her radiation therapy appointments, and a psychotherapist meeting with the patient and/or family facing treatment for locally advanced cancer that looks destined to progress to metastatic disease and take the patient’s life.

Each patient’s needs are different, but the process must always function smoothly to ensure that the patient is assessed for barriers, informed of the navigation process, educated about his/her care and treatment that lies ahead, and connected with the right people at the right time. Ideally, in the eyes of the patient, the process should look seamless.

So if you are feeling concerned about your job security, rather than using avoidance as the way to deal with the problem, adopt an engaging method to bring the support team together and talk. When you finish, everyone should have a clear understanding of who is doing what and why. Remember to put it in writing so there is no confusion in the future. Consider meeting at least quarterly to come together and see how things are progressing, always looking for ways to enhance the patient experience. Remember, above all else, we are here for the patient

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