the role of the nurse navigator in establishing quality...

TheRoleoftheNurseNavigatorinEstablishingQualityCommunicationandCollaborationbetweenOncologyServices,PrimaryCare,andPatients

PamelaJ.Haylock,PhD,RN,FAANRebeccaCrane-OkadaPhD,RN,CNS,AOCN

DeborahChristensen,BSN,RN,OCN

COPYWRITEPROTECTED. NOT FOR REUSE IN ANY FORM

Objectives

• Discussbarrierstoqualitycommunicationintheoncologysetting

• Describethe3techniquesforpatient-centeredcommunication

• Analyzethenavigator’sroleindeliveringbadnewstopatients

• Developanactionplanforenhancingcommunicationandcollaborationbetweenoncologyandprimarycareproviders.


“TheDoctor-NurseGame”

Themannerinwhichdoctorsandnursesinteracthasbeentermed“theDoctor-NurseGame”.Hasanythingchangedsince1888?

• Stein.ArchivesofGeneralPsychiatry,1967• Pilliterri &Ackerman.NursingOutlook,1993• Weinberg,Miner,Rivlin.AmericanJournalof

Nursing, 2009


AQUALITATIVESTUDY SHOWS THATRESIDENTS DON’TNECESSARILY VIEWNURSES ASCOLLEAGUES ANDCOLLABORATORS.Weinberg,Miner&Rivlin (2009).AmericanJournalofNursing

‘ItDepends’:MedicalResidents’PerspectivesonWorkingwithNurses


‘I tell them tests that I need, but I don’t give themmuch information. They’re not making decisionsabout treatment or anything.’ ‘Ifthere’sreallyan

acuteproblem,thenurseisprobablygoingtobetheonetocatchitfirst.Thenus.That’swhyyoudohavetotakewhattheysayseriously.’

‘Some might tell you way too much, and it’s like there is no processing of it first . . and others know exactly whatto say and only call you when they really need you.’

‘I trust factual things they tell me. I trust less, you know, their opinions or their interpretation of what’s happening.’

‘They get a little testy when it’s near the end ofthe shift and you need something . . .’


Patient-CenteredCommunicationinCancerCare


Patient-CenteredCommunicationDomains

• ExchangingInformation• FosteringHealingRelationships•ManagingUncertainty•RecognizingandRespondingtoEmotions•MakingDecisions• EnablingSelf-Management&PatientNavigation•Cross-Cutting


ExchangingInformation

•Exploreknowledge,beliefs,andinformationalneeds&preferences

•Sharinginformation•Providinginformationalresources&helpingpatientsandfamilymembersevaluateanduseresources

•Facilitateassimilation,understanding,andrecallofinformation


FosteringHealingRelationships

•Discussroles&responsibilities•Honesty,openness,disclosure•Trustinclinician’stechnicalcompetence,skills&knowledge

•Expressionofcaringandcommitment•Buildrapportandconnection


ManagingUncertainty

•Constructinganddefininguncertainty•Assessing&understandinguncertainty(cognitive)

•Usingemotion-focusedmanagementstrategies(affective)

•Usingproblem-focusedmanagementstrategies(behavior)


RecognizingandRespondingtoEmotions

•Expressionofemotions•Explore&identifyemotions•Assessingdepression,anxietyorpsychologicaldistress

•Validationofemotions•Expressionofempathy,sympathy&reassurance•Providetangiblehelpindealingwithemotions


MakingDecisions

•Communicationaboutdecisionalneeds,support,andprocess

•Preparationforthedecisionanddeliberation

•MakingandimplementingaChoices&ActionPlan

•Assessingdecisionqualityandreflectingonchoice


EnablingSelf-Management&PatientNavigation

•Learningandassessing•Sharingandadvising•Prioritizingandplanning•Preparing,implementing,assisting•Arrangingandfollow-up


Cross-Cutting

•Communicationabouttimeandsettingforcommunication

•Communicationaboutrolesofcancercareteam•Partnershipbuildingcommunicationbehaviors


DeliveryofBadNews• Receivingacancerdiagnosisisterrifyingandlife-changing.

• Deliverofbadnewsisstressfulforproviders.

• Untilthe1960smanyhealthcareprovidersreluctantlydisclosedthecancerdiagnosistopatients.

• Today:• Patient-centeredcommunicationisanationalpriority(Epstein&Street,2011)• Healthcareprovidersexpectpatientstobeinformedandactiveparticipantsintheircare• Tissuebiopsiesareprocessedquickly,necessitatingexpeditiousplanningforthedisclosureofresults• Manyfactorsmaystraintheprocessforeffectivedeliveryofbadnews(e.g.,healthcarereimbursement,fastpaceofeverydaylivesofpatientsandproviders,readilyavailableelectroniccommunications)

• Extensiveliterature:howtoconveythediagnosis;cliniciantraining,andyet….…..

Epstein,R.M.,&Street,R.L.,Jr.(2011).Sharedmind:communication,decisionmaking,andautonomy inseriousillness.[ResearchSupport,Non-U.S.Gov't].AnnFamMed,9(5),454-461.doi:10.1370/afm.1301 COPYWRITEPROTECTED. NOT FOR REUSE IN ANY FORM

Background(continued)• Welackconsensusonhowtodothismosteffectively&westilldon’tdoitwell

• Ineffectivedisclosure(whethermeansormannerofdisclosure),haspotentialnegativecosttothepatient/providerrelationship,andtothepatient’sexperience.

• Effective disclosure mayhelppatientsbecomebetterinformed,moremotivatedintheircare,lessdistressed,betterabletoaskquestions,betterpreparedfordecision-making,betterabletonavigatetheircare,andmoreclearabouttheuncertaintyoftheirdiagnosis(Epstein&Street,2007).

• Literatureontheroleofoncologynurses(nursenavigators)intheprocessofdeliveryofbadnews(e.g.,newdiagnosis,diseaseprogression)limited.

Epstein,R.,&Street,R.L.(2007).Patient-centeredcommunicationincancercare:promotinghealingandreducingsuffering.Bethsda,MD:U.S.Dept.ofHealthandHumanServices,NationalInstitutesofHealth,NationalCancerInstitute.COPYWRITEPROTECTED. NOT FOR REUSE IN ANY FORM

TheNurse’sRole• Preparationofpatientforreceiptofbadnews• Supportduringdisclosurebythephysician• Supportafterdisclosurebythephysician• Partofoptimalcare(Griffithsetal.,2015)

• Nursenavigator’srole(?)

• Abbaszadeh,Aetal.(2014).Nurses'perspectivesonbreakingbadnewstopatientsandtheirfamilies:aqualitativecontentanalysis.JMedEthicsHist Med,7,18.• Arbabi,M.,etal.(2010).Howtobreakbadnews:physicians'andnurses'attitudes.IranJPsychiatry,5(4),128-133.• Eid,A.,Petty,M.,Hutchins,L.,&Thompson,R.(2009)."Breakingbadnews:"standardizedpatientinterventionimprovescommunicationskillsforhematology-oncologyfellowsand

advancedpracticenurses.JournalofCancerEducation,24(2),154-159.doi:10.1080/08858190902854848• Griffiths,Jetal.(2015).Breakingbadnewsabouttransitionstodying:aqualitativeexplorationoftheroleoftheDistrictNurse.PalliatMed,29(2),138-146.doi:

10.1177/0269216314551813• Higgins,D.(2002).Breakingbadnewsincancercare.Part2:Practicalskills.ProfessionalNurse,17(11),670-671.• Price,J.,McNeilly,P.,&Surgenor,M.(2006).Breakingbadnewstoparents:thechildren'snurse'srole.Int JPalliatNurs,12(3),115-120.doi:10.12968/ijpn.2006.12.3.20695• Rassin,M.,Levy,O.,Schwartz,T.,&Silner,D.(2006).Caregivers'roleinbreakingbadnews:patients,doctors,andnurses'pointsofview.CancerNursing,29(4),302-308.• Reid,M.,McDowell,J.,&Hoskins,R.(2011).Communicatingnewsofapatient'sdeathtorelatives.BrJNurs,20(12),737-740,742.doi:10.12968/bjon.2011.20.12.737• Warnock,C.,Tod,A.,Foster,J.,&Soreny,C.(2010).Breakingbadnewsininpatientclinicalsettings:roleofthenurse.JAdv Nurs,66(7),1543-1555.doi:10.1111/j.1365-2648.2010.05325.x


PatientPreferences(Fujimori&Uchitomi,2009)• Reviewof24studiesfrom1980-2008(19inWestern,5inAsiancountries)• Patientpreferencesassociatedwith

• Setting• Mannerinwhichbadnewscommunicated• Whatandhowmuchinformationandemotionalsupportprovided• Demographics

• Patientpreferenceversusactualexperiencevaries• Presenceofanotherattimeofdisclosure• In-persondisclosureversustelephone• Personalversusimpersonalsetting• Durationofconversation(greaterthan10minutesmoresatisfying!--Figgetal.,2010)• Treatmentoptionsincludedinconversation

Figg,W.D.,Smith,E.K.,Price,D.K.,English,B.C.,Thurman,P.W.,Steinberg,S.M.,&Emanuel,E.(2010).Disclosingadiagnosisofcancer:whereandhowdoesitoccur?JClin Oncol,28(22),3630-3635.doi:10.1200/JCO.2009.24.6389

Fujimori,M.,&Uchitomi,Y.(2009).Preferencesofcancerpatientsregardingcommunicationofbadnews:asystematicliteraturereview.Jpn JClin Oncol,39(4),201-216.doi:10.1093/jjco/hyn159


OncologistPerspectives(2themes)(Bousquet etal.,2015)

• Patient-oncologistencounterduringthebreakingofbadnews• Evaluationofpatient’sattitudes,wishes,andneedssoastotailorapproach• Disclosingbadnews:abalancingact• Dealingwithemotions(boththepatient’sandtheoncologist’s)

• Externalfactorsshapingthepatient-oncologistencounter• Familyrelationships• Systemicandinstitutionalfactors(time,privacy,interruptions,internalteamcommunications,training)

• Culturalfactorsandvariation

Bousquet,G.,Orri,M.,Winterman,S.,Brugiere,C.,Verneuil,L.,&Revah-Levy,A.(2015).BreakingBadNewsinOncology:AMetasynthesis.JClin Oncol,33(22),2437-2443.doi:10.1200/JCO.2014.59.6759


Thegood,thebad,andtheugly• “Iwasatwork--shejustsaid‘youhavebreastcancer.’”

• “Ihadnorelationshipwiththedoctorwhophonedme.Hewasverymatteroffactatamoment inmylifewhenIwasrenderedspeechless.”

• “(Theradiologist) toldmetoexpectcancer….Iappreciatedthecandoroftheradiologist.”

• “MydoctorleftmeamessageathomeonaFriday,indicatingsheneededmetocomeintodiscusstestresults.Ididn’tgetthemessageintimetocallherbeforetheweekend.Iassumedtheresultswerebadsinceshewantedmetocomein, soIworriedallweekend.”

• “IwasjusttoldthatIhadbreastcancer….Iwasalone, thedoctor lefttheofficeandhandedmethelabreport….Inshock, Isattheretrying todecipherthelabresultsbymyself.Hesentnursesintochangemydressing.Theymadeotherappointments formeandIleft.Isatinmycarforseveralminutescrying….Gettingthenewsthatyouhavebreastcancerisdevastating.However,Ibelieveinmycaseitcouldhavebeenhandleddifferentlyandbetter.IwassorockedbythatinitialtreatmentthatIchosetohavemycareelsewhere.”

• “MydoctorwantedmetoknowrightawaysothatIcouldstarttakingcareofitasquicklyaspossible.Granted,aphonecallwasprobablynotthebestwaytocommunicate,butforthetimesavedingettingafterthecancer,itwasthebestwayforme.Mydoctorhadalreadygottenthereferralsstarted,surgeon linedup,andMRIreferralinprocessbythetimehecalledmesothathehadalltheinfo.readyformyquestions.”


Howdoyoudisclosethebadnews??• “Thebiopsyshowsitiscancer.”

• “I’vegotgoodnewsandbadnews.”

• “Youhavethegoodkindofcancer.”

• “It’sjustalittlebitofcancer.”

• “Thetumorismalignant.Itwillgetcutoutandyou’llbefine.”

• “Lookatitthisway.Itcouldbeworse.”

• “Whatpartdidn’tyouhear?”


• Inperson

• Byphone

• Email

• Electronicmedicalrecord

• Skype/videoconference

Andwhoelseislistening?

Wheredoyoudisclosethebadnews?


Isthereaplan?• Who• What• When• Where• How

Telephonesurveyof15nursesandimagingsupervisors inbreastcare:• Resultsgiveninpersonor byphone;pre-plannedornot• Nonehadapolicyorprocedureontheprocess


BreastCareandNurseNavigatorSIGSurvey(n=66*)

**“Mostofourphysiciansinformtheirpatients,butonoccasion thebreastnurseorradiologist isrequestedtogiveouttheinformation.Thisisbecomingamorecommonpractice.”*“Wetrytohavepatientswithpositivepathologyreturnforresultsinperson.(It)doesnotalwayshappen...sowemaycallthembutalwayshavethemcomeintoreceivewritteninformation andeducationandsupportwith(a)breastnursenavigator.”

Biopsy Results Disclosure:PersonandMethod

BenignFNAN(%)

BenigncoreN(%)

SuspiciousormalignantFNA

N(%)

Suspicious ormalignant

coreN(%)

Deferredtoreferringprovider 24(36.4) 24(36.4) 25(37.9) 28(42.4)Phonebybreastimagingcenter 24(36.4) 26(39.4) 19(28.8) 19(28.8)Inpersonbybreastimagingcenter 11(16.7) 9(13.6) 12(18.2) 10(15.2)Other* 7(10.6) 7(10.6) 10(15.2) 9(13.6)

• N=37(56.1%)reportedaNurseNavigatorwasconcurrentlyinformed atthetimeofdiagnosisdisclosure.• Findings suggestadiversityofpractice,andphonedisclosuregreaterthanreported intheliterature.

• Representing31statesintheU.S.andCanada• 63.6%(n=42)fromcommunityhospitals• 60.0%(n=40)biopsyresultsavailablewithin48hours


ConsensusGuidelinesforDeliveryofBadNewsinCancerCare• Ensureprivacyandadequate,uninterruptedtime• Assessunderstanding• Provideinformationsimplyandhonestly• Encouragepatientstoexpressfeelings• Giveabroadtimeframe• Arrangereview(atimeintheimmediatefuturetoreviewthesituationwiththepatient)

• Discusstreatmentoptions• Offerassistancetotellothers• Provideinformationaboutsupportservices• Documentinformationgiven

Girgis,A.,&Sanson-Fisher,R.W.(1995).Breakingbadnews:consensusguidelinesformedicalpractitioners.[Review].JClin Oncol,13(9),2449-2456.COPYWRITEPROTECTED. NOT FOR REUSE IN ANY FORM

SPIKESFrameworkforDeliveryofBadNewsinCancer• S-Setting(ofquietandprivacy,withsignificantothersofpatient’schoicepresent)• P-Perception(howmuchdoespatientalreadyknowandwhataretheirperceptions)

• I-Invitationorinformation(askpatienthowmuchandwhatkindofinformationwouldbehelpful)

• K-Knowledge(sharethebadnewssuchas“Ihavesomeseriousnewstotellyou”;smallsegmentsofhonestanddirectinformation;patientallowedtorespond)

• E-Empathy(acknowledgeemotionsandreactionsofpatient;e.g.,“Thisisobviouslydistressingnews”)

• S-Summarizeorstrategize(andplan)

Kaplan,M.(2010).SPIKES:aframeworkforbreakingbadnewstopatientswithcancer.Clin JOncol Nurs,14(4),514-516.doi:10.1188/10.CJON.514-516COPYWRITEPROTECTED. NOT FOR REUSE IN ANY FORM

OncologyNurseNavigator&ScopeofPractice• IsthedeliveryofbadnewswithinthescopeofpracticeofanOncologyNurseNavigator(RN)?

• Byeducation• Bytraining• Bycertification• Bylaw(nursingpracticeact)• TexasNursePracticeAct(https://www.bon.texas.gov/index.asp)

• “’Professionalnursing’meanstheperformanceofanactthatrequiressubstantialspecializedjudgmentandskill,theproperperformanceofwhichisbasedonknowledgeandapplicationoftheprinciplesofbiological,physical,andsocialscienceasacquiredbyacompletedcourseinanapprovedschoolofprofessionalnursing.Thetermdoesnotincludeactsofmedicaldiagnosisortheprescriptionoftherapeuticorcorrectivemeasures.”


ONSNurseNavigatorRoleDelineationStudy

Brown,C.G.,Cantril,C.,McMullen,L.,Barkley,D.L.,Dietz,M.,Murphy,C.M.,&Fabrey,L.J.(2012).Oncologynursenavigatorroledelineationstudy:anoncologynursingsocietyreport.Clin JOncol Nurs,16(6),581-585.doi:10.1188/12.CJON.581-585


ONSNurseNavigatorProfessionalPracticeFramework• CoordinationofCare(Category3)

• Assesses patientneedsuponinitialencounterandperiodically…• Facilitatestimelyschedulingofappointments,diagnostictesting,andprocedurestoexpedite theplanofcareandtopromotecontinuityofcare

• Participates incoordinationoftheplanofcarewiththemultidisciplinaryteam,promotingtimelyfollow-upontreatmentandsupportivecarerecommendations

• Facilitates individualizedcare….• Demonstratesknowledgeofclinicalguidelines

• Communication(Category4)• Buildstherapeuticandtrustingrelationshipswithpatients….througheffectivecommunicationandlisteningskills

• Actsasaliaisonbetweenpatient….andproviderstooptimizepatientoutcomes.• Advocatestopromoteoptimalcareandoutcomes

OncologyNursingSociety(2013).Oncologynursenavigatorcorecompetencies.Pittsburgh:Author.


ModelLinkingPatientNavigationtoPatient/FamilyReportedOutcomes

Modified from Fiscella K, et al (Crane-Okada co-author) (2011). Patient reported outcome measures suitable to assessment of patient navigation. ACS Patient Navigation Working Group on Patient Reported Outcomes. Cancer, 117(15 Suppl), 3601-3615.

PatientNavigation

AddressInstrumentalneeds/barriers

Education/coaching

ProvideEmotionalsupport

RefertoCommunityresources

Perceivedculturally

competentcare

Perceivedbarrierstocare

SatisfactionwithNavigation

Perceivedselfmanagement

RelationalAlliance

Clinicalcompetence

SatisfactionwithCancerRelatedCare

Liaison/advocate Improved

Function

ReducedSymptoms

ResultsDisclosure


CommunicationwithPrimaryCareProviders


InformationExchange

• Patient’swanttheirprimarycareprovidertoreceiveinformationabouttheircancertreatments

• Studiesindicatethatasfewas16%ofoncologypatientsperceiveapatternofshared-carebetweentheirprimarycareproviderandoncologist

• Nursenavigatorscanenhancecommunicationbetweenoncologyandprimarycare

Aubin et al. (2010)


WheretoStart

• Identifycurrentpatternsofinformationexchange• Identifykeycommunicationtouchpoints• Developaprocessforgettinginformationtoprimarycare

• Modeoftransfer(fax,email,mail)• Content(howmuch,howoften)• Format• Whoisresponsible?


NavigationCommunicationTouchpoints


PatientContactCommunication

OurNurseNavigatormetwithyourpatient ____________onMar21,2016toassisttheminaseamlessexperiencethroughtheironcologycare. NavigatorsatIntermountainSouthwestCancerCenterassistpatientsinavarietyofwaysandidentifyanybarrierstocare. Resourcesandassistanceareprovidedforpatientsandfamilies.

_______________isscheduledtosee__________M.D.,on_________

ThankyouforreferringyourpatienttoIntermountainSouthwestCancerCenter. Ifyouhaveanyquestionsorconcernspleasecontactournavigators.


NavigationCommunicationTouchpoints


• EMR• EPIC,Aria

• JourneyForward• Breast,colon,lung,lymphoma,generic

• ASCO• Breast,colon,lung,lymphoma,prostate,generic

• OncoLife

TreatmentSummaryandCareplan


DevelopYourActionPlan

Basedonyourorganization:

Determine2communicationtouchpoints

Identifymethodforsendingcommunication

Formulatecommunication


ReferencesEpstein,R.M.,&Street,R.L.,Jr.(2011).Thevalues andvalueofpatient-centeredcare.Annual ofFamilyMedicine, 9(2),100-103.doi:10.1370/afm.1239

Fiscella K,RansomS,Jean-PierreP,Cella D,SteinK,BauerJE,Crane-OkadaR,GentryS,Canosa R,SmithT,SellersJ,Cantril C,Jankowski E,WalshK,DeanM,GodwinR,EdgeP.(2011).Patientreportedoutcomemeasuressuitable toassessment ofpatientnavigation.ACSPatient NavigationWorkingGrouponPatientReportedOutcomes.Cancer,117(15Suppl), 3601-3615.doi:10.1002/cncr.26260

HarphamWS.(2009).Only 10Seconds toCare:HelpandHopeforBusyClinicians. Philadelphia: ACPPress.

Mannahan CA.(2010).DifferentWorlds: Aculturalperspectiveonnurse-physician communication.NCNA,45:71-79.

McCormackLA,etal.(2011).Measuringpatient-centeredcommunication incancercare:Aliteraturereviewandthedevelopment

ofasystematicapproach.SocialScience&Medicine.72:1085-1095.

ScheinEH.(2013).HumbleInquiry:TheGentleArtofAskingInsteadofTelling.SanFrancisco:Barrett-KoehlerPublications, Inc.

ThorneS&TruantT.(2010).Willdesignatednavigatorsfixtheproblem?Oncologynursing intransition.CONJ,Summer.Pp116-121.

WeaverAC,etal.(2014).Assessing interprofessional teamworkininpatientmedicaloncology units.JOP,Jan1,2015:19-22.

WeinbergDB,MinerDC,Rivlin L.(2009).’ItDepends’:Medicalresidents’ perspectivesonworkingwithnurses.”AJN.109(7):34-43


ReferencesGosselin TK,Crane-OkadaR,IrwinM,Tringali C,WenzelJ.(2011).Measuringoncologynurses’ psychosocial carepracticesandneeds.2009ONSPsychosocialMembership SurveyResults.FocusonPracticeImplications.OncologyNursingForum,38(6), 729-737.doi:10.1188/11.ONF.729-737

Kaplan,M.(2010).SPIKES:aframeworkforbreakingbadnewstopatientswithcancer.ClinicalJournal ofOncologyNursing,14(4), 514-516.doi:10.1188/10.CJON.514-516

McCormack,L.A.,Treiman,K.,Rupert,D.,Williams-Piehota, P.Nadler,E.,Arora,N.K.,...Street,R.L.,Jr.(2011).Measuringpatient-centeredcommunication incancercare:aliteraturereviewandthedevelopmentofasystematicapproach.SocialScienceandMedicine, 72(7),1085-1095.doi:10.1016/j.socscimed.2011.01.020

Aubin,M.,Vézina,L.,Verreault,R.,Fillion, L.,Hudon, É.,Lehmann, F.,…Morin,D.(2010).Familyphysician involvement incancercarefollow-up:Theexperienceofacohortofpatientswithlungcancer.

Annals ofFamilyMedicine, 8(6),526–532.doi:10.1370/afm.1171

Hudson, S.V.,Miller,S.M.,Hemler,J.,Ferrante,J.M.,Lyle, J.,


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