Amy DePue, BS, RN, OCN, CBCN, is a breast oncology nurse navigator at the UNC Lineberger Comprehensive Cancer Center, a cancer research and treatment center at the University of North Carolina at Chapel Hill. She has served as a nurse navigator since May 2011.
Q: How would you define your role as a nurse navigator?
Amy DePue: In defining the role of nurse navigator, one must look at the state of health care today. We have more specialties, more complex medical and surgical regimes, and we know more about specific disease processes than ever before. The role of nurse navigator is a role intended to place a registered nurse into a direct line to help patients through the medical system.
While the definition of navigation changes from facility to facility, the one constant is the assistance patients need as they journey throughout health care system. Nurse navigation places nursing at the heart of helping the patient through teaching, nurturing, supporting, and directing care for patients who might otherwise be lost in a huge system. Nurse navigators practice with evidenced-based care and provide the link that is necessary for patients to receive the best outcomes for their individual diagnoses.
Q: What is the most important work you do as a nurse navigator?
AD: One of the commonalities of disease process for all patients is the lack of personal insight to the process and procedures of their care. As in most life-altering events, being diagnosed with cancer often leaves patients with anxiety related to the fear of the unknown. In most instances throughout our lives, we are capable of compartmentalizing next steps in whatever we face. Most of us can “deal” with unexpected detours in life, but a cancer diagnosis can bring the strongest of us to our knees.
There may seem to be consistency in treatment or procedure protocols, but each individual responds differently physiologically (and psychologically), making change the only constant available. When a nurse navigator is present in the lives of these patients, part of the unknown becomes known as he or she works with the navigator and becomes more able to “fill in the blanks.” The most important and most valuable benefit of navigation is reducing the stress that comes from a life-altering diagnosis, not only for the patient but for the caregivers and families who support that patient.
Q: Can you share any patient stories or experiences that demonstrate the value of nurse navigation?
AD: While there are many examples of great navigation, one patient exemplifies the above. When I first began navigating for the breast group, I received a call from a patient who had been diagnosed three years prior. She had a hormone receptor-positive, HER2-positive breast cancer and had been through most of her active treatment before falling out of contact. When she called with a request to come back to see one of my providers, she stated that she had not returned before because she lost her insurance. I encouraged her to return and talk with one of our financial counselors.
When she returned, we discovered that she was now metastatic, and while this was initially bone-only disease, she did not respond as well as we hoped. Throughout the next couple of years and whenever she progressed, she would call and ask for the “English version” of what the provider had said at the visit. When she knew she was getting close to not having any more treatment options, she brought me a cartoon of a heron who was attempting to swallow a frog that, in turn, was choking the heron. Underneath the cartoon characters where the words “Don’t ever give up.” When she gave it to me, she said she wasn’t sure whether I was the frog or the heron, but she knew that I would never give up on her and for that reason she would be able to face whatever came next.
I keep that cartoon front and center at my desk as a reminder that no matter what, either frog or heron, giving up is not the option. Navigation is that extra piece that can help provide direction, give support emotionally, and give that patient the ability to feel in control because of the open communication that this relationship provides.
Q: What do you see as ways or opportunities to improve nurse navigation?
AD: While the definition of navigation varies from facility to facility, the overall concept is central to patient care. When Dr. Harold Freeman started this movement, the intent was to make sure that the underserved patient was given the same type of excellent care that insured patients were receiving. That concept has driven health care to invest in navigation as a way to support the diversified patient populations that we serve.
I would love to see a more unified definition of navigation that supports the patient and their caregivers through education and pathways to the various services that the patient needs to complete their treatment plan, and helps them feel as if their individual cancer journey is not walked alone and provides a caring connection for their fears, confusion, and even their anger.
Q: What would you say to an organization that is contemplating whether to implement a nurse navigation program?
AD: I would have to ask what type of program they had in mind. For example, some facilities regard navigation as a “catch-all” program. The navigator is responsible for all aspects of the patients care except for the treatment plan. Other facilities regard navigation as a benefit to the patient but only for the initial consultation. Still other facilities regard navigators as more physician directed than patient directed.
My belief is that the navigator is the connection for the patient to overcome the obstacles that prevent that patient from achieving the best possible outcome for that disease process. Since the health care system has become so specialized, it is most important that the patient have as much information possible, delivered in a manner which suits their learning curve and with the support of someone who can provide consistent direction for them.
I would also want to point out that the facility needs to support their navigation program as an important piece of patient care and as a valued resource that compliments treatment plans and enhances other resources such as social work.
There is some question about the relationship between provider and navigator as to whether the navigator should support the physician. In my experience, continuity between the care team is essential to break the communication barrier and for consistency in care plans, but the primary navigator focus should be on the patient.