Julianna Paradisi, RN, OCN, is an oncology nurse navigator and writes a monthly post for this blog. The illustration below is part of a series on mountains as barriers that she is working on.
Untitled oil stick & charcoal on paper by Julianna Paradisi
When I introduce myself to nurses as an oncology nurse navigator, they often respond, “Oh, that’s great,” staring blankly. Sometimes, in the midst of patient care, they say, “Yeah, that’s great, but I’m really busy. Come back later.”
Nurses caring for patients are really busy—so busy that this is one of the reasons the relatively new specialty of nurse navigators exists. Another reason is that oncology care is increasingly complex, and mostly occurs in the outpatient setting where vulnerable patients must fend for themselves.
Patient navigation was founded in 1990 by Harold P. Freeman at Harlem Hospital Center to improve outcomes for poverty-stricken African-American women presenting with stage III and IV breast cancer. Freeman declared, “The core function of patient navigation is the elimination of barriers to timely care across all segments of the healthcare continuum.”
In 2010, the Affordable Care Act (ACA) mandated patient navigation for oncology by 2015. No longer aimed only at serving the poor, the ACA requires navigation services be offered for a defined interval of cancer treatment. The goal is a reduction of health care costs and an increase in quality by decreasing delays in access to care while utilizing a targeted set of health services. Patient navigation improves outcomes, and saves money.
Barriers to care include, but are not limited to: lack of community cancer screening, poverty, lack of transportation to appointments, medical illiteracy, patient anxiety, and fear.
Navigation programs differ among institutions. In many, navigators are registered nurses with extensive backgrounds in oncology. In others, navigators are nonmedical, often social workers, with special certification. The monikers nurse navigator and patient navigator distinguish between the two.
The benefit of hiring nurses as oncology navigators is that our licenses allow us to assess patients, provide education, manage side effects, and offer psychosocial support. On a typical day, I spend time assessing by phone if the rash a patient casually mentions should to be seen by their oncology provider. Does another patient understand their discharge instructions? What resources are available to patients struggling to pay monthly bills? If patients drive in from a rural community to their appointments, are they eligible for gas cards?
When patients are discharged from the hospital, nurse navigators oversee their needs. Nurse navigators are part triage nurse, part case manager, a bit of a social worker, a confidant, and support group for our patients.
“Wait a minute,” you’re thinking, “what you’ve described is a nurse, a plain old nurse. That’s the work of all nurses.”
You’re right. It was nurses’ work when I started my career, and some nurses may still have time to practice these ‘soft’ nursing skills. Ensuring that a patient has proper help at home, identifying financial difficulties, and connecting patients to community resources was part of my education in nursing school. But fewer bedside nurses have time to discover these things about their patients. Nurses are busy making sure that chemotherapy doses are correct and administered on time. They’re busy providing interventions for a patient’s struggling respirations in a heroic effort to keep them out of the ICU. They’re busy answering too many call lights with less staffing to know what happens to a patient after they leave the unit.
There’s not enough time in a shift to do all the things that are part of patient care. We are often forced to choose our technical skills to keep patients safe over our soft nursing skills to keep them warm. There no longer is enough time or energy for both.
Being an oncology nurse navigator is the most soul-satisfying work I’ve ever had. Not every cancer patient needs or wants navigation services. However, it breaks my heart that the state of health care delivery is a barrier to bedside nurses performing this role for those who do.
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