1. Zangerle, Claire M. MBA, MSN, RN

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Planning a journey, whether expected or not, can be daunting. Unforeseen obstacles may stall progress, creating frustration. Although the path of least resistance may be the easiest, it may not lead to the expected destination. In air and sea travel, the navigator has primary responsibility for ensuring that the vessel's journey is planned, obstacles are dealt with, and the passengers and captain are kept informed. Much like the navigator on a plane or ship, the nurse navigator provides direction for patients and their families as they travel their healthcare journey. Navigating the healthcare waters is as daunting as the ocean is vast and the sky is endless. Having a navigator at the helm makes all the difference.

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Nurses have been serving as unofficial navigators for patients as a core part of the discipline since the turn of last century.1 However, frontline nurses have very little time to steer their patients through complex systems. With the majority of their time spent on clinical care, documentation, and education, little attention is paid to navigation or coordination. The Affordable Care Act (ACA) has opened the door to formally recognizing the role of nurses as navigators. There are different types of navigators, according to the ACA; for the purposes of this discussion, the focus will be on the nurse as navigator.2


Nurse navigator or care coordinator?

Differentiating between the roles of nurse navigators and care coordinators provides clarity for staff, patients, and families as to the responsibilities of each role. It's important to decrease confusion and create an environment of collaboration. Many organizations suffer from a lack of understanding about the difference between these two roles and, often, even those serving in the roles are unclear about who provides what service. Nurse leaders have the opportunity to define role responsibilities, allowing for the most efficient utilization of these valuable team members.


Put simply, the nurse navigator addresses the needs of the patient from a logistics perspective with a clinical lens, explaining treatment options and providing advice and support to the patient. Nurse navigators guide, educate, advocate for, and encourage patients and their families within the particular diagnosis and related elements. The care coordinator ensures that there are no gaps in the clinical care of the prescribed treatment plan and all disciplines are communicating for the most holistic care of the patient.3


Assessing the need

Nurse leaders are being called on to help bend the healthcare cost curve in the face of providing high-quality care. Improving efficiencies, reducing waste, and utilizing business intelligence tools all lead to reduced costs. However, strategically addressing how to reduce costs is a challenge. Nurse leaders can contribute to decreasing cost by leveraging resources within their sphere of influence that have an effect outside of that sphere.


A quick review of patient satisfaction and rehospitalization-two core outcomes-will provide enough data to determine whether a nurse navigator program is warranted at your facility. Even with an existing, robust care coordination program, if these two outcomes aren't exceeding expectations, a nurse navigator program may make a significant difference. As a collateral benefit, nurse navigators are a resource to staff nurses, easing their burden of heavy caseloads and allowing them to draw on additional expertise as they provide direct care.


Value added

Healthcare in the United States is unparalleled; however, the alignment of services is the weak link that many attribute to suffering outcomes. With all of the resources dedicated to healthcare, not addressing the fragmentation in coordination is indefensible.1 Creating a nurse navigator program is one way to strengthening the system.


For many years, nurse navigator programs have been instrumental in cancer care and, thus, can serve as a model for other patient populations. As healthcare moves to population health management, nurse navigator programs will continue to grow and add value to the overall goal of the Triple Aim: lower cost, better quality, and improved patient experience.4 An exemplar, replicable program was designed by Group Health Cooperative, an integrated delivery system based in Seattle, Wash. Knowing that a diagnosis of cancer is profound, the program developers sought to improve healthcare system failures by addressing significant patient needs during this critical time.


The nurse navigator program was part of a National Cancer Institute-funded study that was analyzed over a 16-week period, testing for its effectiveness compared with the usual care provided to cancer patients. This program was comprised of essential elements that made it comprehensive and, ultimately, successful: defined workflow, training and support for nurse navigators, outlined responsibilities and essential critical behaviors, and implications for practice. (See Elements of a successful nurse navigator program.)


After 2 years of the program, the nurse navigators identified themes and lessons that helped shape future care delivery improvements and supported their theory that the program added value. Most notably, the nurse navigators were empowered with the knowledge to steer patients and families through difficult times while at the same time becoming reinvigorated about the work they do.5


Smooth waters and blue sky

The healthcare journey, no matter the state of health, can be overwhelming. Navigating that journey without assistance makes it even more so. The skills of a nurse navigator can smooth rough waters and help control the turbulence. Through logistical management, advocating for the patient and family, and demonstrating compassion, the journey becomes much more tolerable.


Elements of a successful nurse navigator program

Defined work flow


* At diagnosis: Patients are assigned a nurse navigator, based on geography and existing case load.


* Postdiagnosis: During the 16-week program, there are an average of 17.9 encounters between the patient and the nurse navigator; the initial meeting is face-to-face, with subsequent phone calls on a weekly basis.


* At discharge: Summary notes are created and next steps provided to patients and the primary care provider(s).



Training and support for nurse navigators


* Before beginning the program, nurse navigators are trained to reinforce current skills; they review specific psychosocial skills that will help in their interactions with cancer patients, not normally part of nurse education. Community agencies supporting cancer patients provide information about their services, and current cancer patients provide their personal stories to further enhance the training. Protocols and guidelines for care are developed by the group and reviewed by an oncology nurse consultant before roll out.


* Weekly case conference phone calls with the nurse navigators and other members of the care team are conducted to facilitate teamwork, efficiency, and improved program outcomes.



Responsibilities and critical behaviors


* The nurse navigator reaches out proactively, facilitates communication between providers, prevents delays in treatment, offers psychological support, monitors and manages symptoms, and identifies and recommends resources.


* He or she demonstrates clinical expertise, ease reaching out to patients, active listening, and patience.



Implications for practice


* Serve as one point of contact for the patient who has multiple clinicians and healthcare settings from which to manage information.


* Value the nurse navigator role as it enables the nurse to practice at his or her highest level.





1. American Nurses Association. Position statement: care coordination and the registered nurses' essential role. [Context Link]


2. Centers for Medicare and Medicaid Services. The Affordable Care Act: helping providers help patients: a menu of options for improving care. [Context Link]


3. Westgate A. Care coordinators, patient navigators: emerging roles in healthcare. [Context Link]


4. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769. [Context Link]


5. Horner K, Ludman EJ, McCorkle R, et al. An oncology nurse navigator program designed to eliminate gaps in early cancer care. Clin J Oncol Nurs. 2013;17(1):43-48. [Context Link]