December 2013 VOL 4, NO 6

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Evidence into Practice

Sharon Gentry, RN, MSN, AOCN, CBCN

Sharon S. Gentry, RN, MSN, CBCN 

I have traveled the road to nurse navigation via roles of a CNA, staff nurse, patient educator, clinical trial site coordinator, clinical manager, and case manager at the same hospital I have maintained employment with for 33 years. Each nursing position has applied purpose, value, and clinical measure to the patient-centered focus of nurse navigation. The positive experience on the oncology 4 bed wards during nursing school and as a new staff nurse working “swing shifts” between second and third time tracts set the foundation for time management, problem solving, and critical thinking. As an older oncology nurse, the admixture of chemotherapy in the medication room…before chemo hoods or the vertical-laminar-airflow-hood…was the norm. The BSN degree opened doors that allowed me to serve on such committees as the Cancer Center Cancer Education Committee, Nursing Education Quality Management Committee, and the Nursing Education Finance Committee. The standards for safe administration of chemotherapy were established for our healthcare facility through these committees. Those formative years developed collaborative practice traits, an interest in the professional scope of practice using legal and professional guidelines, and communication proficiencies.

Strong leadership from our oncology administration introduced the Oncology Nursing Society (ONS) for standard resources and that involvement led to the participation in the founding of our local chapter, Piedmont Triad ONS. I was the first OCN and AOCN nurse for our institution and have championed the cause since 1988. At the same time, my role change to Oncology Patient Educator allowed interaction with all oncology patients and their individualized education needs. This opportunity allowed teamwork with the cancer unit to develop patient-specific education and teaching sheets. This involved the Joint Practice Committee for nurses, doctors, and other healthcare team members to look at care practices. Leading 2 groups, 1 for patients and 1 for caregivers, as part of the educator role, allowed me to witness the care from the eyes of the nurse, patient, and caregiver. This was truly the start of patient-centered care, advocacy, and response to patient and caregiver needs.

The journey with breast care began the national P1 study or the Breast Cancer Prevention Trial. As site coordinator and data manager, the concept of prevention became a reality for someone who had always supported the treatment continuum of care. The foundation for patient navigation was developed as healthcare reimbursement changed and an oncology case manager was requested for the inpatient unit. The ideas of using community resources, being a good steward of the healthcare dollars, and practicing care in a safe and efficient way for the patients and caregivers was a constant in this role.

While obtaining an MSN in education, the advanced nursing project relating to end-of-life care-setting choices led to the idea of separating palliative care and hospice care from acute care. This actually stemmed from case management and the dilemma nurse case managers faced when a physician gave the patient and caregiver permission to stay in an acute care bed for palliative care when the utilization review criteria defined the patient as needing subacute care. Our community had a strong hospice program as well as a hospice inpatient facility that would allow follow-up bereavement care to caregivers. After successful implementation of this program, a challenge to navigate the breast care for our institution was presented when our breast patients were uncomfortable with “not receiving the same care other ladies in the neighborhood got at our facilities.”

Nurse navigation has been a perfect combination of patient education, joint practice, proactive care, and case management from prevention/detection through palliative and hospice care. Initial education through the National Consortium of Breast Centers, EduCare’s Breast Health Training, involvement in the Piedmont Triad Susan G Komen affiliate (now NW Komen of the Triad), and feedback from patient surveys led to the basis of the breast nurse navigation program as it exists today. Within 2 years, changes in the breast process had streamlined care and changed the way the community survivors interacted with newly diagnosed patients. The community acknowledged the difference patient-centered–directed care made in the patients’ lives by awarding me the local Komen Volunteer of the Year award in 2002 and Cancer Services Inc. Patient Advocate of the Year award in 2003. At the institution level, exploring the local increase in prophylactic mastectomies from the patient point of view was a result of this role. The breast navigators heard very different reasons from the patient that were being cited by healthcare professionals at patient conferences. The voice of the patient was gathered and shared with institution members. This was shared as an original research abstract titled “Influencing Factors for a Contralateral Prophylactic Mastectomy” at the Academy of Oncology Nurse & Patient Navigators (AONN+) conference in 2011.

In 2012, a process abstract “Evaluation Why Some High-Risk Patients Do Not Use Genetic Consultation Services” was shared. The patient-centered concept of this role is invaluable to the community and healthcare institution as they meet the needs of the patients. National recognition was bestowed in 2012 as peers nominated me for one of the 2012 HealthLeaders honorees and I was recognized as someone who changes healthcare for the better.

With the help of Pfizer, local and state nurse navigators started meeting in 2005 and the NC Oncology Navigation Nursing Association was founded in April 2008. Pfizer Oncology’s recognition of the development and growth of our navigation program has allowed me the opportunity to speak about navigation and hear about other program in travels across the United States. It has been heartwarming to hear the successes on behalf of the patients as navigation process models have been applied to individual cultures and communities. It is challenging to hear of the barriers navigators face in their community and healthcare institutions. It is rewarding when a collaborative, critical analysis of the challenge reveals a method to overcome the barrier.

The ONS has been a mainstay in this role as the patient education, breast care, and nurse navigation special intrest groups have provided education and resources to grow and develop the role. As a member of the Oncology Nursing Certification Breast Care Task Force and Oncology Nursing Certification Test Development Breast Committee, the education in developing and maintaining a certification examination has been an invaluable experience. Participation on the Oncology Nursing Certification Breast Care examination team as an item writer and committee chair of the group has set a firm belief that all breast nurse navigators need Certified Breast Care Nurse (CBCN) as part of their basic education and training. All nurse navigators need the basic genetic and clinical trial course to direct patients to best care along with the site-specific cancer course that they navigate.

The opportunity to be a part of the AONN+ Leadership Council since its inception and experiencing the co-chair position for the Third and Fourth Annual Navigation and Survivorship conferences has allowed me to witness the development and history of this new role, explore the philosophy of this care, and support ongoing education and professional development of navigation. This experience has allowed growth in expertise on breast cancer navigation, overall patient navigation, literary expertise, and the ability to serve as a mentor for new navigators joining our profession. The website blog featuring expert commentary (AONN+ Community forum) has allowed interaction with all types of navigators across the United States. I have appreciated the stimulating conversations and comments readers have shared after reading the column. Being a part of the editorial board of The Oncology Nurse-APN/PA and the Journal of Oncology Navigation & Survivorship has brought to light different navigation ideas and concepts. Thank you for sharing your research and practice ideas. This experience has encouraged me to write and contribute articles for publication.

Navigation is a commitment to patient-focused care across the continuum. There will be roles for different levels of the healthcare field to contribute as the patient journeys through cancer care. The voice of the nurse navigator is critical in the care of the patients at cancer centers, since it is through their advocacy that the patient’s voice is heard. Navigation is a field in its infancy and evidence/research is needed to direct the best use of navigation in the care of patients. In order to take this concept forward, successful practices need to share their ideas through commentaries, journal articles, and presentations at the AONN+ Conference. The patient will always be the winner as “best” patient navigation care is shared among this profession. Listening to different healthcare systems describe how they deal with care for their communities and cultures will hopefully spark ideas of improved patient care in other parts of the country. The key to all navigation, throughout the care continuum, is the focus on the patient. I look forward to hearing about the creative navigation care in your community.

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