Oncology nurse navigators, which are also referred to as “ONNs,” are professional registered nurses with oncology-specific clinical knowledge. Professionals in this role help patients navigate the various steps of their cancer care journey by offering education and resources to help promote informed decision making and access to quality health and psychosocial care. They assist patients, families, and caregivers circumvent barriers in the health care system.

Janelle Wagner, RN, OCN, Senior Manager of Patient Navigation Program for Community Sites, Seattle Cancer Care Alliance, recently met with 

® to discuss what skills help make an oncology nurse an effective navigator, some of the challenging elements related to nurse navigation, and how the implementation of a nurse navigation program has added value to the patient experience at her own institution.

®: In your opinion, what skills make an individual a good nurse navigator?

: The biggest thing is confidence and oncology knowledge [and] being able to problem solve and work independently. Somebody who is able to de-escalate stressful situations and able to see a big picture makes the best nurse navigator.

Do you have any advice for prospective nurse navigators or anyone looking for a career shift?

Many health care institutions define nurse navigation differently so it is important for any nurse who is considering the field to make sure the scope of work is well defined.

Being a nurse navigator requires somebody who has a broad understanding of oncology care. So [someone] that has worked in many different aspects of oncology, from inpatient to infusion to the clinic, [experience with] radiation oncology is helpful, [as well as] surgical oncology. Someone who understands the bigger picture of how all aspects of care happen—rather than just one discipline.

In terms of implementation, it's really bringing a full team together. When looking at oncology care, you're looking at multiple disciplines: surgical oncology, medical oncology, radiation oncology, etc. It’s really [about] bringing that whole team together to see what the current state is, how do the patients currently flow through the system? Is it working? Where are the gaps; where does the patient get kind of lost in the system? How can the nurse navigator be that person to help? Again, it's working with the existing system to hold that patient's hand and get them in to the right places and the right timeframe.

What are some of the more difficult components of nurse navigation?

Setting boundaries [are]. Oncology nurse navigation is a newer field, and there are many different opinions on what the job entails. Being able to set those boundaries and kind of sticking with your standard work to be able to best serve the patient [is crucial]. The challenge is understanding [that] our health care system is so complex, and that you really need to be the point person for that patient to navigate through that system [rather than] trying to fix the system.

Is there anything that you wish you had known before you became a nurse navigator?

I had been an oncology nurse for almost 20 years, and I started this program almost 5 years ago. I have quite a bit of prior oncology experience.

If somebody is going to go into this field, they need [to] make sure that they have good leadership, and good pathways for the position. It is really questioning: what does standard work look like? Who is my team? When you are navigating a patient through the whole continuum of care, it could be across many different organizations. [You need to understand] who that team is and how to utilize [your] skills to help the patient go through the system.

I hear many navigators say [that] they're used to having a team that they work with and having collaboration with colleagues. The nurse navigation position is really an independent position. The patients who you're working with? They are your new team; it is your patients and the providers rather than a collaboration of nurses working together.

Is there anything else that we haven't touched upon that you would like to discuss or add?

Our program was really designed to make sure we retained our patients and kept them at the center where they were diagnosed. When we launched the program our main focus was to increase our retention rate.

And within that first year, by assigning a navigator, we saw our patient retention rate increase, just by placing a nurse to help navigate their care. We have also seen a decrease in time to first-line therapy as well as improve our referral rates.

We are not only helping build a strong program for the institution, but also helping the patients move through the system a lot easier.

Hamilton D. Measuring the impact of nurse navigation. Presented at: Oncology Nursing Society Bridge; Sept 9-16, 2021; virtual. https://ons.digitellinc.com/ons/live/player/1438

Articles

Janelle Wagner, RN, OCN, Senior Manager of Patient Navigation Program for Community Sites, discusses the challenges and rewards of nurse navigation in oncology.  

 What Makes an Effective Nurse Navigator?

For this episode of “The Vitals,” we spoke with Nikki Urban, a registered nurse and practice manager at Allegheny Health Network, about the implementation of a successful phone triage program at the oncology institution.

Urban discusses why the program came about, some of its successes, and how a phone triage program can bring value to an oncology center.

“The phone triage process is a patient-centered initiative that really has patient access in mind,” Urban explains. “The initiative has provided the opportunity for patients to call in and have their concerns addressed in a real-time fashion with an oncology-trained nurse.”

Urban added, “I know sometimes patients will call in [and say] ‘Oh, my goodness, I have a real person that I'm speaking to.’ Patients have been excited about it, and the oncology triage team is able to immediately address symptoms, assess patients, and decide if a patient needs a same-day visit or [if] they need to come into our infusion office for supportive care. They can schedule those appointments right at the point of the call.”

Podcasts

In this episode of “The Vitals,” Nikki Urban, RN, discusses the successful implementation of a phone triage program at Allegheny Health Network.

Access-Focused Care: The 4-1-1 on Oncology Phone Triage Programs

Transitions in care can be a complicated process for a patient with cancer. Comprehensive programs are needed to help engage patients and their families’ on multiple levels and always ensure safe care.

The University of Texas MD Anderson Cancer Center, a National Cancer Institute-designated comprehensive cancer center, takes great pride in its ability to respond to patients who are most in need. Therefore, MD Anderson created
a comprehensive call center available 24/7 to improve the patient experience. The comprehensive program seeks to utilize the right level of staff at the right time with the right service. This has been created through “askMDAnderson,” a comprehensive call program designed by patients for patients, which is staffed with operators, health information specialists, nurses, and associated providers to address each level of care.

AskMDAnderson also increases patient satis- faction by providing discharge phone calls for all patients discharged from inpatient, outpatient surgery, and the emergency department.

The operators represent the first level of service. This team handles over $1 million worth of calls per year. Operators provide patients and families with directions, visitor guidelines, parking details, meal distributions, COVID-19 testing, password reset assistance, code blues, and merit call at all locations. They keep patients and families informed of the most updated information to ensure confidence throughout their cancer journey.

The second level of service is the health information team and referring provider team. These teams are designed to ease the referral process. Patients and referring physicians can call when- ever they want, and the staff gladly walks them through the referral process, discusses research protocols, and estimates when the person will be seen by a physician. These teams provide a critical information link to prospective patients and their family members for all transitions in care needs, as well as education about MD Anderson’s services, programs, treatments, and clinical trials

to prospective patients, families, and health care providers. They also assist patients in assessing the electronic medical record and video visit or any electronic medical record inquiry.

Houston is a very competitive market, and although patients want the best cancer center nationally, they want quick service as well. This team assists 2500 referrals each month and is available 24/7.

Patient Care During the COVID-19 Pandemic


The COVID-19 pandemic resulted in strict visitor restrictions, mandated testing and/or quarantine for patients, trepidation of coming to the emergency center or hospital, and panic among those with fever, coughs, or sore throats. These are all symptoms of COVID-19, but they are also sequela of medical treatments for chronic illnesses, such as cancer. Consequently, AskMDAnderson became a vital source of information and education for patients and their families in real time. Timely answers to questions and education about safety procedures and symptom triage has allayed fears and helped make patient visits efficient and effective.

Two new clinical programs were launched in 2019. These included discharge phone calls after all inpatient, outpatient, and emergency department visits and an After Hours Clinical Support program, which is designed to help the patient and physicians on call after the centers have closed. In the current COVID-19 era, the askMDAnderson clinical team became available 24/7.

Due to the complexity of clinical presentation and limited provider-based resources, patients with cancer and their families often telephone their physician or cancer clinic to seek advice.

 Furthermore, when patient care shifts from an inpatient to outpatient setting, there is need for oncology nurses to not only know about disease processes and clinical patient care but also be skilled in telephone nursing triage.

The After Hours Clinical Support enables patients to speak with a nurse when clinics are closed, rather than paging a provider and waiting for a call back. These clinically trained nurses manage patient issues and concerns that are within their scope, but they will also refer issues to the provider when necessary.

Research has shown activities like these elevate the quality of care patients receive.

 Such activities also lower the overall costs of care of an organization and protects the time and capacity of emergency centers and hospitals to care for their most critical patients.

This results in a safer, more efficient, less expensive, and better experience for patients.

In the initial 6 months of the new program, specific clinical services provided feedback about the algorithms utilized to determine when to page the physician on call. Despite the need to change some of the algorithms, incremental improvements were already seen in readmission rates, which decreased by 1%. In addition to
care coordination, working to protect the health of a uniquely vulnerable cancer population, the cancer network was able to share best practices for entrance screening, critical patient surge preparations, telehealth visit transitions, and personal protective equipment use.

Cancer care cannot stop during a pandemic. Furthermore, the amount of information patients need to successfully navigate their cancer journey can be daunting. Programs like the askMDAnderson call center help alleviate some patient stress and provide critical information. Broad implementations of similar programs may help facilitate easier navigation across health access barriers moving forward. 

Finder JP, Proske A, Overton J, Garcia EC, Frumovitz M. A comprehensive call center supporting safe, efficient operations during a pandemic. 

Rosenbaum, L. The untold toll – the pandemic’s effect on patients without COVID-19.


. 2020;382(24):2368-2371. doi:10.1056/NEJMms2009984

Bunik M, Glazner JE, Chandramouli V, Emsermann CB, Hegarty T, Kempe A. Pediatric telephone call centers: how do they affect health care use and costs? 

. 2007;119(2):e305-e313. Doi:10.1542/peds.2006-1511

Long-term care hospital prospective payment system proposed rule for rate year 2007. News release. CMS; January 19, 2006. Accessed June 30, 2020. 

https://www.cms.gov/newsroom/fact-sheets/long-term-care-hospital-prospective-payment-system-proposed-rule-rate-year-2007

McFarland DC, Walsh L, Napolitano S, Morita J, Jaiswal R. Suicide in patients with cancer: identifying the risk factors. 

Coons K, DuMoulin JP. Telephone triage. American College of Physicians—American Society of Internal Medicine. Accessed June 3, 2020. 

https://www.acponline.org/acp_policy/policies/telephone_triage_diagnostic_techniques_procedures_2000.pdf

Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients after hospitalization. 

 2001;111(9B):26S-30S. doi:10.1016/s0002-9343(01)00966-4

Patient experience programs can improve quality of care and decrease organization costs, resulting in a more efficient and less expensive cancer care journey for patients.

Patient Experience Programs Improve Overall Quality of Care

After 30 years of experience being an oncology nurse, Kristin Rupp, RN, OCN, BSN, “wouldn’t trade this profession for the world.”

“I know I’ve made the right choice,” she said in an interview with 

®. Rupp, a seasoned oncology nurse “with a wealth of experience and a heart of gold,” according to her coworkers, has spent the past 15 years at the Desert Regional Medical Center’s Comprehensive Cancer Center in Palm Springs, California, where she works full time in the oncology infusion suite and assists in the satellite clinics weekly. Although she is known to have fantastic managerial skills, her coworkers especially appreciate her heart for the patients and her knack for putting them at ease.

“She has been recognized locally by her peers and our hospital administration as a nurse of distinction,” said Timothy Tyler, PharmD, director of pharmacy, lab, and oncology supportive care at the Desert Regional Medical Center’s Comprehensive Cancer Center, “but most of all, she is loved by her patients and fellow clinicians as someone who goes beyond what is expected and is truly exemplary.”

Rupp said she was positively influenced by a variety of encouraging and inspiring mentors when she was still a novice oncology nurse. Today, she helps share her own experience with the next generation of nurses by having assisted at a nursing school in her community and by frequently volunteering to precept nursing students.

She said one of the most inspiring parts of preparing the next generation of nurses is witnessing their interactions with patients. “[They] see how amazing our patients are, how brave they are, what they are going through...[and say], ‘Hey, you know what? This isn’t so scary. And you know what? I’m going to think about oncology nursing.’ To me, that’s priceless,” Rupp said.

When students interact with patients with cancer, it can have a huge impact on them as they realize these individuals will have to live with their disease for the rest of their lives, and in some cases, may have to navigate end-of-life issues, Rupp said. However, she enjoys seeing how many of her students find themselves ready to tackle the world of oncology supportive care once they garner experience.

“I love the students,” she said. “I love their enthusiasm. I love [how] they’re scared and frightened [when they come in, but] when they go back to their class, they say, ‘Gosh, that was great.’”

Rupp recognizes that cancer care not only involves treating the disease itself, but also involves offering supportive care, managing adverse events, and often supporting the needs of the patient and the family caregivers. By imagining the situation from the patient’s perspective, she is able to try to understand what they might be experiencing.

“In a nutshell, I look at these challenges, and [I think] how would I want to be treated? Or how would I want my family members to be treated? We want to look at the situation as a whole and address the needs individually,” Rupp said.

She said one of the benefits of working at a comprehensive cancer center is the interdisciplinary team available to her. “We’re fortunate to have the services of our wonderful social workers, psychologists, [and] dieticians all coming together to address the needs of the patient.”

Rupp’s professional and personal experiences have even intertwined at times. Her career was significantly impacted through losing both her brother and mother to lung cancer. “As an oncology nurse, it hit home in my heart,” Rupp said. She explained that although she knows she tried to be the best nurse, sister, and daughter she could be, the loss continues to weigh on her. At the end of the day, she recognizes that this experience has strengthened her ability to connect with the patients and caregivers she supports.

“I can feel and know the hurt that folks are going through. I had been an oncology nurse for a long time, but when it gets into your inner circle…it’s a whole different story. I am sad I lost them, but [to see] how brave they were to have gone through what they went through—I see things in a whole different light because of it.”

Rupp said one of the biggest challenges she faced in the past year was helping patients overcome the feeling of isolation. “Think of how difficult it must be to go to your first chemotherapy appointment and not have your loved one with you. How scary,” she said. “Think about the nurse talking about all of this medication, [adverse] effects, things that can happen, and instructions of what to do at home. There’s only so much you can absorb if you don’t have that extra set of ears or extra set of eyes. Can you imagine that?”

Oncology nurses were forced to adapt during the COVID-19 pandemic, Rupp said. To do that, nurses needed to demonstrate a lot of patience. Overall, patience was key to surviving the pandemic, she concluded, adding that nurses had to use a lot of patience to provide the level of emotional support required by their patients.

Rupp herself adapted to the needs that COVID-19 had posed. “She jumped in and helped in our outpatient clinic, infusing monoclonal antibodies to those scared and frightened individuals who needed some reassurance that this was good therapy and could make a difference in preventing them from worsening. When the outpatient pharmacy at the hospital was able to procure COVID-19 vaccines early on for the community, she volunteered her time on numerous weekends, vaccinating the community with no remuneration other than a thank you,” Tyler said.

Upon reflecting over the past almost 2 years, Rupp describes excellence in oncology nursing as “when you can sit with someone, hold their hand, laugh, and cry. Talk about life and death, having the most intimate conversations without a thought of the pandemic.” Her advice to new oncology nurses is to know they’ve chosen the best profession in the world, and to go out and be the best oncology nurses they can be.

Kristin Rupp, RN, OCN, BSN, reminiscences about the experiences that made her the nurse she is today, and how she continues to pay it forward. 

Oncology Nurse Champion: Kristin Rupp

When nurses become burnt out, it’s a recipe for disaster, explained Stephanie Jackson DNP, MSN, RN, AOCNS, BMTCN.

“One of the biggest things that I tell the staff is self care [is important]. Whether you work in the inpatient setting where you’re doing three 12[-hour shifts], [or the] outpatient [setting] doing five 8[-hour] or four 10[-hour shifts], the biggest thing on those days off? Self care. Because It’s very hard to keep giving, giving, giving. Across the nation, we’re seeing short staffing, people leaving the profession because they have just seen so much in these past 17 months that they’re done,” she said.

Jackson, unit director at UCLA Health, spoke with Oncology Nursing News® about her experience as a unit director and how she encourages her staff to make self-care a priority in order to prevent burnout.

Jackson suggests “remembering that ‘why.’ Why you came into this, [and] what a privilege it is to be a part of these patients’ and their families’ journeys. But also recognizing when you’ve had enough, you’ve hit that wall, [and asking] is it time for vacation? What can I do for self care? Even if I can’t travel like I’m used to doing.

“But what is the most meaningful to them? Whether it’s family time, walks on the beach, exercising, things that bring them joy, so you don’t lose that, because when they walk back [through] the doors of that hospital or clinic, they have to have all hands on deck.”

Stephanie Jackson, DNP, MSN, RN, AOCNS, BMTCN, Oncology Nursing News co-editor in chief, comments on the importance of self-care for oncology nurses.

Nurse Recommends Self-Care To Be A Priority in Oncology Nursing

Patients with soft tissue sarcoma who experienced wound complications following preoperative and postoperative radiation therapy reported higher levels of anxiety and decreased physical function than those without these complications into the Patient Reported Outcomes Measurement Information System (PROMIS), suggest results from a study published in 

Clinical and Translational Radiation Oncology

The results showed that patients with wound complications were more likely to have a significant increase in anxiety (36.4% vs 8.3%; 

 = .020) and a significant decrease in physical function (57.1% vs 16.2%; 

 = .011) independent of the timing of radiation therapy.

“This study demonstrates minimum significant change thresholds to detect PROMIS changes in soft tissue sarcoma patients undergoing pre- and postoperative radiotherapy. As expected, more patients with preoperative radiation therapy than postoperative radiation therapy had wound complications, but patients with complications in both groups had worse anxiety and function at the completion of treatment compared with those that did not,” wrote lead study author T.M. Moon, MD, of Washington University in St. Louis, and coauthors, in the study publication.

Wide surgical excision and radiation therapy is the recommended local treatment for patients with high-risk soft tissue sarcoma of the extremities. However, the determination of whether to give radiation therapy pre- or postoperatively remains a challenge.

Preoperative radiation therapy can cause a reduced risk of late complications, such as fibrosis and joint stiffness. However, it can also cause an increased risk of significant wound complications that can reduce short-term postoperative function.

Furthermore, few studies in the modern era have evaluated patient-reported outcomes (PROs) during pre- and postoperative radiation therapy for soft tissue sarcoma, and none have used PROMIS, a scoring system which is favored over historical PRO measures and is endorsed by the National Cancer Institute.

Therefore, PROMIS scores were evaluated across perioperative timepoints for patients receiving pre- or postoperative radiation therapy.

All patients included in the study were over the age of 18 years who underwent surgical treatment for primary or repeat surgical resection of a malignant soft tissue sarcoma and had been evaluated in an orthopedic oncology clinic between July 1, 2015, and October 31, 2019.

Radiation therapy was given using 3D conformal or intensity-modulated radiotherapy. Preoperative radiation therapy was dosed between 50 Gy to 50.4 Gy in 25 to 28 fractions with a postoperative boost for positive margins, and postoperative radiation therapy was dosed between 60 Gy to 66 Gy in 30 to 33 fractions. No patients who received preoperative radiation were given postoperative radiation if the margins were positive after surgery.

Anxiety, depression, pain interference, and physical function PROMIS domains were collected preoperatively, immediately postoperatively, and following treatment completion.

Median scores were compared between groups using the Kruskal-Wallis test. The reliable change index (RCI) was used to determine the minimum important change in PROMIS scores and to compare scores between timepoints.

A total of 95 patients were included (n = 19 preoperative; n = 76 postoperative). No significant differences were reported in demographic, surgical, or pathologic data apart from gender between the preoperative (21.1%, female; 78.9%, male) and postoperative (46.1%, female; 53.9%, male) groups (

Incomplete PROMIS data left a total of 89, 93, and 53 patients eligible for analysis in the preoperative, immediate postoperative, and end of treatment cohorts, respectively.

Both cohorts had a significant decrease in function during treatment.

Anxiety scores were significantly lower at the posttreatment completion timepoint vs the other 2 timepoints (effect size −5.91; 

 = .0015). None of the variables were significantly associated with depression scores at any timepoint, and they were similar across timepoints.

The physical function scores were also significantly lower at the immediate postoperative timepoint vs the other 2 timepoints (effect size – 6.94; 

 < .0001). Physical function scores were significantly lower with increased patient age (effect size −0.14; 

 = .0163) and increased tumor size (effect size −0.44; 

Pain scores were significantly higher with larger tumor size (effect size 0.433; 

 = .0017) and during the immediate postoperative timepoint vs the other 2 timepoints (effect size 6.48; 

 < .001). All these effects were similar for the preoperative and postoperative radiation therapy groups.

The differences in minimum important change between the preoperative and postoperative radiation therapy groups was not significant for any PROMIS domain or timepoint.

The preoperative radiation therapy group had a significant decrease in pain interference (4.17 decrease; RCI = –1.699) and a significant increase in physical function (8.09 increase; RCI = 1.984) between the immediate postoperative and posttreatment completion timepoints. No other groups at any timepoint saw a significant difference at a 90% confidence interval for any of the 4 PROMIS domains.

Patients with tumors greater than 5 cm were also more likely to have a decrease in depression (27.4% vs 4.2%, respectively) between the preoperative and immediate postoperative timepoints. No other groups experienced a significant difference in increases or decreases, and there was no change in PROMIS scores.

Notably, no significant differences in PROMIS scores were reported between the 2 groups at any of the timepoints for any of the 4 PROMIS domains.

“The association of wound complications with worse anxiety and physical function at completion of treatment should be considered when making individualized treatment recommendations regarding the timing of radiation therapy,” concluded the study authors.

Moon TM, Furdock R, Rhea L, et al. PROMIS scores of patients undergoing neoadjuvant and adjuvant radiation therapy for surgically excised soft tissue sarcoma. 

. 2021;31:42-49. doi:10.1016/j.ctro.2021.08.008

This article was originally published on OncLive as “PROMIS Scores Provide Insight Into PROs With Radiation Therapy in Soft Tissue Sarcoma”

Patient Reported Outcomes Measurement Information System scoring suggested that wound complication was associated with more severe anxiety and decreased physical function in patients receiving radiation therapy for soft tissue sarcoma. 

PROMIS Scores Show Patients with Wound Complications Following Radiation Therapy Report Higher Anxiety, Physical Dysfunction

The role of a nurse navigator adds tremendous value to oncology care programs, shared Deidra Hamilton, MSN, RN, OCN, ONN-CG, navigation director/oncology services, Sarah Cannon, at a recent presentation at the Oncology Nursing Society Bridge virtual conference.

Her presentation, “Measuring the Impact of Nurse Navigation,” which was addressed to hospital administrators, current nurse navigators, and oncology nurses who might be considering a career shift towards navigation, highlighted the importance of understanding and quantifying the value of the oncology nurse navigator position.

Oncology nurse navigators, sometimes referred to as “ONNs” are professional registered nurses with oncology specific clinical knowledge. These individuals assist patients alongside all steps of their cancer care journey, offering education and resources to help promoted informed decision making and access to quality health and psychosocial care. Nurse navigators help patients, families, and caregivers circumvent barriers in the healthcare system.

“A nurse navigator is a medical system advocate and helps patients and their families understand each part of the cancer journey while compassionately supporting physical, emotional, and spiritual needs,” summarized Hamilton.

The value of a nurse navigator comes from their ability to identify and address potential barriers to care. A patient’s needs can also keep changing or evolving. For example, a patient may have transportation covered for 1 month, but find that she is unable to driver herself to treatment the following month. A nurse navigator can intervene by arranging transportation or providing useful resources for those patients.

“Navigators are often super detectives,” described Hamilton, about the tenacity of a nurse navigator, “always on the search for another resource to help their patients.”

Google can be an invaluable resource to nurse navigators. Hamilton explained that google holds a lot of great answers to difficult questions on copay assistance and other relevant factors in cancer treatment navigation. She shared that many nurses keep bookmarks of their favorite resources and also create word documents and excel sheets with links to valuable online resources. “The best nurse navigators are like a dog on a bone,” she said.

For new navigators, Hamilton encourages them to lean into the social work and case management colleagues at their facilities. She also emphasized that nurse navigators will often be the first to know some of the more intimate details regarding a patient concerns, “such as a patient wanting to make sure she has all of her hair because her daughter is getting married next month and doesn't want to look like a ‘cancer patient’ in the wedding pictures.”

“Ensuring that a patient's wishes are addressed also helps the patient be more compliant with their treatment plan,” she said. “Encouraging patients to talk about their treatment wishes and goals of care can not only help patients formulate questions for their providers, it can also help to promote advanced care planning that respects the patient's wishes.”

Because nurse navigation required such specialized knowledge, Hamilton recommended certifications such as ONN-CG, OCN, or CBC. Requiring these certifications within 2 to 3 years of hire can be a great way to incentivize new hires to acquire the skills they need to facilitate patient care.

According to Hamilton, nurse navigators are sometimes viewed as mythical creatures and it is not uncommon to hear “we don't know what they do, but they sure do get it done.”

Consequently, scope creep is an issue that nurse navigators often confront. Scope creep is “when works starts to extend or creep beyond what was originally agreed.” This typically occurs when there is not a clear definition or job description for the role.

She reminded the audience that “although being a jack of all trades is often seen as a compliment, in this case, when a navigator dabbles in work that isn't part of their scope, the dabbling pulls time away from helping more patients, which can have downstream negative effects.”

For navigators who feel that their role has become a little derailed, Hamilton advises taking an assessment of the situation by keeping a notepad and keeping track of all accomplished tasks for an entire week. “This will help to identify any navigation workflow and scope of practice issues,” she said. “Track the activities that the navigators are currently doing. Do these activities fit with the job description?”

Clearly Defining the Role of a Nurse Navigator at Your Institution

Unfortunately, the specific role of the navigator can sometimes have different understandings across different institution. This can have a negative impact if the patient doesn’t truly understand the meaning of a navigator. At Hamilton’s institution, Sarah Cannon, there is a clearly defined workflow of the responsibilities of an oncology nurse navigator.Navigators initiate a relationship with patients at diagnosis and continue to provide support throughout the trajectory of care, checking in at key benchmarks, such as treatment visits, or post operatively, and end navigation at survivorship or end of active treatment, whichever comes first.

She urged administrators to utilize the oncology nursing society navigator core competencies to establish clear standard operating procedures for the navigators and to help prevent the common “scope creep” that they often face.

A gap analysis can be a useful way for institutions to showcase the value of their program. For effective results, analyses should be conducted before the program begins, as well as at regular checkpoints following implementation.

The five basic steps of a gap analysis are as follows:

Identify the current state of the navigation program,

Identify and define best practice needed to reach the desired state of the navigation program,

Measure how close the organization is to achieving the desired state of the navigation program,

Conduct an analysis of the strength, weakness, opportunities, and threats. Conduct a stakeholder analysis, and

Develop and implement an action plan to achieve desired outcomes.

Hamilton provided an example of an institution that has 2d mammograms but no tomo mammogram units: an institution that 

conducting imaging but could potentially provide a higher level of service.

“After identifying gaps, which in this example includes the lack of a breast cancer navigator, the next step would be to identify and define the best practice needed to reach the disk

sired state of the navigation program,” she explained. “Our example facilities desired state includes a full-time disease specific breast oncology nurse navigator. Perhaps our next step is to analyze the breast cancer volume at our facility and to reach out to our stakeholders to discuss their thoughts. Once we have collected our data, we can develop an action plan to implement to achieve getting that full time breast specific navigator.”

While providing metrics might seem intimidating, they are a valuable resource for showcasing the various responsibilities a navigator might face daily, oftentimes metrics are able to effectively communicate to stakeholders why there is a need for an additional nurse navigator within a certain institution, Hamilton explained.

For nurses who are not familiar with gathering metrics, she informed audiences that the Academy of Oncology Nurse and Patient Navigators released a navigation metrics toolkit with 35 evidence-based metrics relevant not just to patient care, but that demonstrate the value and sustainability of the role. “It will walk you through quality standards, key stakeholders, as well as implementing the right metrics for your navigation program, all helping you to avoid that dreaded scope creep,” she said.

Furthermore, “navigators who do not collect and report even simple metrics may struggle to demonstrate the value of their program,” emphasized Hamilton. “They may find their roles diminished, or even questioned by administrators in the future. Demonstrating the value of navigation is part of the role and responsibilities of every oncology nurse navigator.”

Certain touchpoint metrics can include the number of times a navigator connects with a patient, increased patient compliance, and reduction of 30-day re-admissions. Patient satisfaction can be demonstrated with word-of-mouth referrals, as well as physician engagement, while growth can indicate that a maturation of the program and identification of patients. Improved timeliness can indicate superior program quality. No matter which metrics a program wishes to highlight, it is always useful to establish baseline data.

According to Hamilton, “the best metrics challenge your navigation program and drive practice change… When connecting to others, there are a few considerations to keep in mind. What is the story I'm trying to tell? Who is the audience? What are the key points in the data? Are there emotions involved? Is this idea affordable? Is there an ask? Do we need a policy or procedure?” she concluded. “Preparing a navigation dashboard to use to report out navigation outcome metrics helps to drive improvements, as well as elevates navigation important as well as elevates navigations importance to stakeholders.”

Hamilton D. Measuring the Impact of Nurse Navigation. Presented at: Oncology Nursing Society Bridge; Sept 9-16, 2021; Virtual. https://ons.digitellinc.com/ons/live/player/1438

Deidra Hamilton, MSN, RN, OCN, ONN-CG, recently presented on how cancer institutions can clearly define the role of a nurse navigator to prevent scope creep and use gap analysis and metrics to showcase the value of a navigator in their program. 

Defining and Quantifying the Oncology Nurse Navigator Role

Amelia Mercer, BSN, RN, CBCN, OCN, knew she wanted to work in oncology when she cared for a patient with cancer in her first role as a nurse.

Impressed with the level of knowledge, skill, and patience that it required to help this patient and his family, Mercer recognized that this profession was what she wanted for her career. Nearly a decade later, with experience working both inpatient and outpatient settings; across hematology, solid tumor, and palliative; and as the current nurse navigator for the breast team at Rush University Cancer Center in Chicago, Illinois, Mercer embodies the meaning of “oncology nurse champion.”

“Amelia is an amazing nurse and a true champion for patients,” said Ruta D. Rao, MD, medical director of Rush University Cancer Center. “My patients comment daily on the incredible support she gives them, for whatever their needs and questions are.”

Time management is one of the greatest challenges that Mercer faces in her role as a nurse navigator, she said. Her job is done entirely by phone, which means there is always a queue of patients requiring her assistance. Without seeing these patients face to face, Mercer prioritizes tasks by asking herself, “What do you need to do first? [Is one task] more urgent than another? Can this wait for an hour or two or even be pushed off till tomorrow? Does it need to be acted on right now?”

Moreover, part of her motto is that she never hesitates to reach out to her team as needed.

“I want to be able to give the patient the best knowledge….I always have people that I can turn to because I’m not going to ever know everything. That interdisciplinary team is truly what allows me to provide the best possible care for the patient,” said Mercer.

“She is a true team player,” Rao noted about Mercer. “She delivers outstanding care to the patient by working with the patient, [the] family, and the interdisciplinary team, including other medical professionals, as well as social workers, psychologists, and therapists.”

Mercer understands that cancer care is extremely complex and that a cancer diagnosis, even if a patient goes into active remission or shows no evidence of disease, represents a burden that will stay with patients their entire life. She is, therefore, always working to find better ways to help provide that much-needed comprehensive care.

Currently, she is enrolled in the Adult-Gerontology Primary Care Nurse Practitioner Doctor of Nursing Practice program at Rush University, with an anticipated graduation date of fall 2022. Although she had always wanted to return to school, Mercer credits a coworker who is a nurse practitioner and oncology nurse at Rush with inspiring her and being a role model for how the knowledge acquired through a nurse practitioner degree can be applied in the oncology setting. 

“It is always neat to just apply the knowledge directly as I learn and relearn things with refined understanding. I feel better equipped to educate my patients with what I know and feel as I am learning alongside them throughout their clinical course,” said Mercer.

Mercer adjusts her supportive approach in response to the patient’s specific needs.

“When I used to work on the inpatient side, I worked at a hospital [where] we donned protective equipment every time we went into a patient’s room…We just treated everyone as if they were infectious to protect everybody. And I remember kind of making the analogy [that] when you’re donning that gown to go into a room, you’re donning exactly what that patient needs you to be. Some people need you to be sarcastic and funny. Some people need you to sit and cry with them for a minute. Some people need you to be very quiet and respectful.

“So at the end of that patient encounter, you’re literally taking off that gown—you’re taking off what they have needed you to be, you wash your hands, you go to the next room, and you don the next persona and kind of emotional state that that next patient and those family members need you to be. So it’s very personal.”

Even in her current role as a nurse navigator—which is 100% phone work—Mercer still manages to adapt her supportive approach around what patients need.

“I’m having to gather a lot of that information over the phone, and I’m kind of gently easing my way into those conversations to figure out what is it that they need from me....[I]s it that humor? Or is it the sarcasm, you know, which I can turn on and am pretty good at. Of course, sometimes they just need it to be serious and more educational, or whatever the case is. So I think that the ability to kind of take all of those different [needs] on is a big piece of oncology care.”

Mercer advised oncology nurses to remember to also take care of themselves.

“Vacations, long breaks, [and] time you can give yourself [to] recharge your own battery [are] only going to make you stronger and better...and able to give more,” Mercer said. “And I know for us in the oncology field, it’s really hard to push that stop button because there’s always a need out there.

“But for us to be able to continue to keep going for these patients, it is vitally important that we actually stop and give ourselves a chance to breathe and to focus on our own health and energy and restoration so that we can come back for more.”

“When you’re donning that gown to go into a room, you’re donning exactly what that patient needs you to be.”

Oncology Nurse Champion: Amelia Mercer

Medical cannabis can help alleviate adverse events from cancer treatment, like vomiting, nausea, appetite loss, and sleeping difficulty, explained Eloise Theisen, RN, MSN, AGPCNP-BC. Unfortunately, due to a lack of federal standardization for medical cannabis, navigating the cannabinoid system can be a challenge for nurses and patients alike.

Theisen, current president of the American Cannabis Nurses Association (ACNA), recently spoke to 

 about the appeal of medical cannabis for patients with cancer, as well as transparency on cannabis use between patients and providers, and the direction she hopes to see in cannabis research in the coming years.

 What are some reasons that medical cannabis might be appealing to patients with cancer?

That's a great question. And it's a question I get a lot. Often when patients come to see me in my private practice, it's because they're looking for something to help manage their symptoms that are either related to the cancer treatment or the cancer itself. It may be because they're not getting the relief that they want from traditional therapies. They may be looking for something “more natural,” or they have family members who are insistent that they consider cannabis as a treatment option.

What are some of the advantages to cannabis as opposed to a more traditional treatment option?

We have limited research in some areas. The areas that we have really good data are with nausea and vomiting, appetite loss, chronic pain, [and] sleep. We're starting to see more research come out around chemotherapy-induced peripheral neuropathy. And one of the advantages of working with cannabis is you can really personalize the treatment plan to the patient's needs and goals. So, there's a lot of flexibility [and] there's a lot of individuality. It really allows patients to find a dose that may produce the best benefit with the least amount of side effects.

Do you believe that there might be some patients who might be interested in medical cannabis, but are nervous to ask their providers about it out of fear of the stigma?

Yeah, actually, that happens quite a bit. You know, I've been doing this work since 2013. And I've seen an evolution of how patients have come to cannabis. And there are still some that really struggle with the stigma; they're afraid that their health care provider will judge them or potentially no longer treat them if they are using it or want to use it. And we've found that, in some states, oncology providers are more favorable to their patients using cannabis, but many of them are unsure of dosages or side effects, or even different profiles to recommend to their patient. So many patients, unfortunately, end up looking to dispensary staff or “Dr. Google” or [even] friends or family to start their treatment. I always encourage [patients] to start the conversation with their health care provider, even if that health care provider doesn't know a lot about it. At least there's some transparency there.

For health care professionals looking for resources for dosage, what might be some good first steps?

Dosage is one of those things. It's very individualized and personalized, and it's an area of research that we're lacking. We don't have good double-blind, placebo studies to demonstrate what dosage should be applied for what condition.

At the American Cannabis Nurses Association (ACNA), our mission is to help educate health care professionals, particularly nurses, on the endocannabinoid system. We also have the National Council of State Boards of Nursing, who issued guidelines in 2018 on how to care for the patient using medical cannabis. We also have resources through the American Cannabis Nurses Association that we've vetted. It is challenging right now to find programs that are evidence based. And that's part of the work that the American cannabis nurses does as well. All of our companies that we work with are vetted to make sure that they're evidence based and [have] reliable information, because there's so much misinformation out there. We want to make sure that people get the right information.

Can you discuss some of the work that your organization does to try and obtain these evidence-based answers?

We've been around since 2010 and we are now about 1,500 members strong, predominantly in the United States, in all 50 states. We also have a couple members outside of United States, like the United Kingdom and Canada. And again, our mission really is to educate, collaborate, increase research, and partnerships. We do a lot of vetting around products, manufacturers, different sponsors, and education, to really ensure that, again, members are getting the most accurate and up-to-date information. We're also doing a lot of work to become an anti-racist organization, because a lot of the history in cannabis is rooted in racism, and prohibition as well.

We’re largely focusing on education because about 60% of our members consider themselves novices when it comes to cannabis. We really want to provide that foundational information to them so that they can become more empowered to talk to their patients or health care providers, lobbyists, etc. So, we're trying to educate our members, as well, on a lot of the political challenges out there around cannabis.

In states where medical cannabis is legal, what is the process like for patients to get that recommendation or prescription and then to get the actual product?

Well, it's not universal. It's not standardized. It really depends on what the state has determined to be a qualifying condition. We have 36 states, plus the District of Columbia, that have a medical cannabis program. And they vary. Some states like Oklahoma and California, that have medical programs [that] essentially allow anyone to qualify if that physician feels that their condition would benefit from the use of cannabis. And then we have other states like Texas, where they have a medical program that's incredibly restrictive, and only a few qualifying conditions. You can always check out the state website to determine whether somebody qualifies or not.

Then we have 18 states and the District of Columbia that allow for adult use, which also makes it [for] anybody over the age of 21 [who] can access it. But of course, most of those people are using it for symptom management because of an underlying health condition, but they're not getting medical guidance. So, it is challenging, overwhelming, and confusing for patients right now to navigate the space for sure.

What tips or advice would you give to these patients who are attempting to navigate the space?

Look for qualified health care professionals in their area that are knowledgeable in cannabis and the endocannabinoid system. There's a growing group of providers that have the specialized knowledge. I would really discourage them from using the internet to try to figure out what they need. There are some trusted sources out there are some nonprofit organizations that are dedicated to helping patients specifically like leaf411.org, and projectcbd.org. These are organizations that are consumer facing that are trying to help patients navigate the space and they do it free of charge.

Is there any research that you’ve seen that you are excited about?

We did have the National Academy of Sciences, Engineering, and Medicine report come out in 2017. They looked at over 10,000 peer reviewed studies. And they did publish their recommendations. They found conclusive evidence that cannabinoids are effective for chronic pain in adults. And they listed their report, you can also find where there's moderate evidence for sleep and other conditions. It also talks about some of the adverse effects, that you can get from using cannabinoids.

An expert weighs in on the advantages of cannabis treatment for patients with cancer, and how nurses can help patients navigate the cannabis-oncology space, in spite of certain research limitations.  

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