Durvalumab, a PD-L1 inhibitor, improved progression-free survival (PFS) by 11.2 months compared with placebo in patients with locally advanced, unresectable stage III non–small cell lung cancer (NSCLC) that did not [ Read More ]
Best Practices in lung cancer – November 2017 Vol 8
A Day in the Life of a Thoracic Navigator.
An Interview with Wendy Brooks, RN, ONN-CG(T), HCA Midwest at Research Medical Center
Navigation is on the march and being utilized in many oncology disciplines as the benefits of implementing navigation tactics are being recognized in the oncology community at large. Although navigation was born in breast cancer clinics, its growth continues across many disciplines. This progression was inevitable, as navigators are highly skilled, multidisciplinary team members who serve as advocate, educator, and counselor for patients and their caregivers throughout the continuum of care.
Whereas much of a navigator’s role is consistent across disciplines, there are nuances within specialties that should be recognized. In general, a navigator is the primary point of contact for the patient, providing the following services: (1) Education on disease and treatment options, (2) Identification and removal of barriers to care, (3) Referrals to supportive care and community resources, and (4) Coordination of appointments. However, there can be unique needs of certain patient populations. In considering patients with lung cancer, many present with late-stage disease, which requires navigators to be well versed in palliative and hospice care options. This population also requires programs to assist in lifestyle enhancements, such as smoking cessation programs.
In an effort to understand a day in the life of a thoracic navigator, we spent some time with Wendy Brooks, RN, ONN-CG. Ms Brooks obtained her certification as generalist oncology nurse navigator through the Academy of Oncology Nurse & Patient Navigators (AONN+) and was instrumental in the development of the AONN+ specialty certification exam in thoracic oncology.
JONS Thank you for taking the time to talk with us today. To begin, can you tell us a little about your background?
Ms Brooks Before I became a thoracic navigator, I worked in palliative care and hospice. I worked in a hospital liaison role where I interviewed patients in the hospital to ascertain if they were candidates for hospice or palliative care.
JONS How did you come into your role as a navigator?
Ms Brooks My institution created a nurse navigator position, which intrigued me. It was the perfect opportunity to come alongside patients from diagnosis on. I loved the idea of helping patients earlier in the process.
What’s interesting to me is that, essentially, all nurses are navigators. When you first step onto a patient floor, you’re literally their navigator. Nurses have been providing navigation services for a long time, but to finally give it a title and put someone in that role to manage a patient’s course of care from the very beginning is a positive step that can directly impact clinical outcome.
JONS How does your background in hospice contribute to your current role?
Ms Brooks I was always astounded that patients receive hospice care so very late. We can catch patients who are candidates for hospice earlier through navigation and introduce those resources that help the patient and their caregivers through a trying time. It’s a great thing for patients and very rewarding for the navigator.
JONS We’re interested to know how your institution is employing the AONN+ metrics and the related impact on patient satisfaction, clinical outcomes, and/or return on investment for your navigation program.
Ms Brooks One of the metrics we’ve tracked is wait time from diagnosis to treatment. When navigation was implemented in the lung program at our institution, we saw a reduction in that time. We’ve also found that patients who are navigated have a higher satisfaction rate with their care.
Our facility here in Kansas City measures return on investment for the navigation program. Through navigation, we attempt to retain patients by providing all of a patient’s care under one roof. From diagnosis through survivorship, all patient follow-up is done in our facility. It’s the connection patients have with their navigators that is important. They know us, they know we’re here for them, and they want to follow our directions to help that treatment team. For all these reasons, our return on investment results are very important to us and continue to validate our program.
JONS How would you describe a typical day as a thoracic navigator?
Ms Brooks I’m not sure there’s such a thing as a “typical” day! When I originally interviewed for this position, one thing I recognized was that the position requires you to be flexible and adapt to what is happening on that particular day.
My day is completely dependent on the patients’ needs for that day. I may have patients call me with issues that need to be addressed immediately. And so you have to accommodate for those needs.
It’s a very “on the fly” position. I come into the cancer center, and I have my list of patients to see that day. Some days go smoothly, some not so much. I do a lot of charting. I try to prep the day before for the next day’s patients. I make sure I’m very well versed on what their treatment has been up to this point and what it might be down the road so I can effectively educate them on those treatments.
JONS How do you prioritize your workload?
Ms Brooks As a Sarah Cannon institution, we have touch points—certain points throughout a patient’s experience where we check in with them. I see patients who I know are newly diagnosed and patients who are having a difficult time. I want to make sure I’m in the room with them when I know their scans weren’t necessarily what they wanted them to be. If I know that they’re not going to get good news, I try to be in the room with them as extra support.
JONS Can you talk about the concept of survivorship, setting life goals for patients, and survivorship care plans?
Ms Brooks Survivorship for us begins at diagnosis. Care plans are created early on and continually updated throughout treatment. We evaluate life goals of the patient from the very first appointment. We tap into our oncology wellness program to focus on nutrition, exercise, and emotional well-being. We need to utilize all of these resources from day 1 to effectively help and manage our patients.
Part of our program includes prehab. We sit with the patient and talk about their diagnosis, expectations of treatment, and goals. We talk about keeping them in good physical condition and trying to maintain their current health status, because we know that treatments will impact their physical and emotional status. Prehab allows us to help the patient to be as healthy as possible before treatment begins.
JONS Can you talk about strategies to implement effective long-term education.
Ms Brooks Education comes with every visit. It’s talking about treatment, diet, lifestyle, and exercise. It’s asking how they’re doing overall—not just about their health. There are other considerations, such as finances and other non–health-related services that can benefit patients.
We have a high rate of smoking in our patient population. To provide relevant education to these patients, I obtained a certification as a smoking cessation counselor with one of my colleagues. We need our patients to stop smoking and maintain a healthy lifestyle.
JONS The issue of smoking cessation must be a frustrating part of your job.
Ms Brooks Yes, it is, and not just for navigators. It’s also frustrating for our patients. Prior to becoming a smoking cessation counselor, we didn’t have a lot of smoking cessation opportunities for our patients. As a result, they were looking out in the community. Recognizing this gap in our offerings, my colleague and I decided to take a class offered by the American Lung Association called Freedom From Smoking, and we became certified instructors. We’re very pleased to offer this to our patients.
JONS Given your background in palliative and hospice care, do you have advice for navigators about how to discuss these topics with patients?
Ms Brooks I think the first thing all nurses need to do before they have a difficult conversation is to check in with themselves to determine where they are emotionally regarding that conversation. We can project our emotions onto our patients, so it’s always good to mentally prepare before a potentially difficult conversation.
It’s also a good idea to know your audience and check the patient’s goals. Is this patient open to hospice? Or is this the kind of patient who wants to get treatment until the very end? Ultimately, it is the patient’s decision.
It’s also important to be familiar with different hospice resources. There are many companies that provide this service, and some may be a better match for your patient than others. Find out who would be a good match and offer multiple companies for them to interview.
It can be helpful to reassure patients that if they can no longer receive treatment, or if they’ve chosen not to receive treatment, it’s okay to receive hospice. That conversation is important. Adjusting the mindset can be a very difficult thing. While patients are seeking treatment, they’re looking for quantity of life, they’re looking for more days. For some, it just becomes too hard, and the mindset needs to shift to quality of life while they have days left.
Considering palliative care, that conversation is much easier. Palliative care comes alongside patients while they’re getting treatment and gives them the best quality of life while gaining quantity of life. It’s important to note that palliative care isn’t another word for hospice.
JONS There are so many more options for patients with lung cancer now. How have advances in treatment options impacted your role as a navigator?
Ms Brooks Yes, there are many treatment options, including immunotherapeutic options. Immunotherapy can give patients hope for more time with a better quality of life and fewer side effects than traditional therapies.
Our hospital just began offering another treatment called stereotactic body radiation therapy—or SBRT. It’s nice that our patients have options outside of the traditional chemotherapy or surgery and regular radiation. Our patients have all these options to choose from, depending on their stage and performance status.
For navigators, there is always something to be learned. It is our job to educate ourselves on treatment options so we can effectively educate our patients.
JONS Do you have any advice for new navigators?
Ms Brooks Navigation is a wonderful and fulfilling field. I would advise a new navigator to utilize all of your available resources. You don’t have to do everything yourself. Utilize financial counselors, social services, wellness coordinators, and nutrition specialists. Learn about all of these assets. The more you learn, the better off your patients will be.
It’s easy to feel like you have to be “the one” to handle everything. But it’s important to tap into your resources to help patients through the continuum of care.
Ali Mokdad, PhD, reported in JAMA that “cancer mortality rates in the United States dropped from 240.2 to 192.0 per 100,000 population between 1980 and 2014.”1 However, according to the [ Read More ]