Executive Director, President, and Co-founder

National Coalition of Oncology Nurse Navigators

	The new standard from the American College of Surgeons Commission on Cancer (CoC) calling for the establishment of patient navigation programs in all CoC-accredited facilities by 2015 provides more evidence of the significant role the oncology nurse navigator (ONN) plays in the management of patients with cancer. As both patient advocate and educator, the ONN partners with physicians to help support the cancer patient’s journey throughout the course of disease, with the ultimate goal of improving care and outcomes.

	Currently, 60% of ONNs are employed by a hospital or hospital system, and the balance work for oncology clinics or medical oncology practices. Although the greatest presence is in the community hospital setting, this trend is changing, as more oncology and radiation practices are adding navigation to their cancer programs.

	In 2009, NCONN published the first competencies that defined the role of the ONN. Developed in consultation with active professional oncology nurse navigators throughout the United States, these core competencies cover five areas: 1) professional, legal and ethical nursing practice; 2) health promotion and health education; 3) management and leadership; 4) negotiating the healthcare delivery system and advocacy; and 5) personal effectiveness and professional development.

	ONNs mostly view themselves as clinical facilitators for oncology patients, with a primary focus on education. Their role in patient education is vast, encompassing disease-specific navigation, treatment options, processes, clarification on physician-provided information, directives, and what to expect overall on the patient’s journey.

	Data collected by NCONN confirm this multifaceted role. Navigators consistently report education, explaining and clarifying diagnosis and treatment, coordinating care across multiple disciplines and providers, assisting with financial issues, psychosocial support, and initiating and completing treatment summary plans as their main duties. Navigators view themselves as patient advocates— making connections for the patient to other hospital/ medical professionals, getting answers, finding resources, and removing barriers, whether real or perceived.

	A survey of approximately 1000 NCONN members asked ONN’s to identify the many tasks involved in a typical day in practice, which included new patient intake; patient education; outreach and community education; appointment scheduling; accompany patients to visits; patient phone or in person follow-ups; physician calls/discussions; arrange/ discuss transportation issues; assist/discuss/arrange financial issues; social work/counseling-related discussions; inhouse meetings, such as tumor board/cancer conferences.

	The NCONN survey also asked respondents to name some of the biggest obstacles to a successful navigation program, and these included buy-in by physician and continued support of the navigation program; utilization of navigation services by physicians; management of time; tracking and documenting patient encounters; no resource support for secretarial-type tasks; inability or antiquated process for documenting encounters/time with patients; justifying role to hospital administrators/executives.

	One of the primary goals of ONNs in practice today is to define and determine quality measures. Outcome measures answer the important question, “What is the return on the investment of having an oncology nurse navigator on board?” Some barriers that can prevent effective outcome measurement include staff resistance; lack of appropriate software for data collection; decreased time and resources required to collect, analyze, interpret, and report the data; lack of knowledge; and varied storage/ reporting mechanisms across the organization.1 Without robust outcomes measurement, ONNs are not able to demonstrate what they already know: Positive outcomes are related to navigators and navigation programs.

	The role of the ONN continues to evolve. With the new CoC requirement, facilities looking to comply will need support and resources. NCONN, now more than 1000 members strong, has become a reliable resource and support for new navigators, new programs, and program expansion. To learn more, visit 

	1. Melnyk BM and Fineout-Overholt E, eds. Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice. Philadelphia, PA: Lippincott, Williams & Wilkins; 2004.

Articles

As both patient advocate and educator, the ONN partners with physicians to help support the cancer patient's journey throughout the course of disease, with the ultimate goal of improving care and outcomes.

Today's Nurse Navigator: Educating and Advocating for Cancer Patients

	2011 was a banner year for the National Coalition of Oncology Nurse Navigators (NCONN), as our membership has continued to grow and we held our 3rd Annual 

Conference. Additionally, with our partnership with 

 we have been able to provide oncology nurses and nurse navigators with insight and resources through our 

 columns and coverage of our annual conference. Here’s a look back at some of the areas we covered this past year.

	From the time of engagement, the navigator is “hand in hand” with the patient, identifying obstacles and barriers that may derail a successful completion of treatment and transition to survivorship. This is the navigator’s role and area of expertise.

	Survivorship care plans—individualized survivorship blueprints&mdash;are increasingly being used in oncology care. Navigators can be instrumental in educating patients and helping them to develop these plans. Discussions of survivorship care plans should start as soon as a patient is diagnosed with cancer. 

	Oncology nurses expend a tremendous amount of energy and concern as they care for patients who may or may not recover from their illness. Compassion fatigue may not happen with the care of 1 patient, but the repeated exposure to oncology patients may lead to the condition.

	For the oncology nurse, combating compassion fatigue starts with recognizing the symptoms and making changes that lead to a personal transformation. Develop a personal statement to guide your life, self, and family. Also ask yourself, “Why am I in this profession? What is my mission?”

	Nurses with compassion fatigue need to recharge their batteries daily, by committing to such things as exercise and eating healthier. They should also make it a priority to engage with what they value most, which often means connecting with family and friends. 

	Consistent with national trends, NCONN is developing a healthcare oncology nurse navigator (ONN) model that provides education and support for the professional nurse navigator.

	Apart from the roles of a licensed nurse, the ONN needs to develop competencies to integrate the roles of healthcare promoter, educator, counselor, care coordinator, case manager, researcher, and patient advocate. Hence, education programs for preparing ONNs must ensure that professional nurse navigators are equipped with the essential competencies that enable them to fulfill these roles competently and ethically. Contact NCONN (

) to receive a copy of the ONN Core Competencies. 

	NCONN’s 3rd Annual Conference took place from September 8-10 in San Diego, California. ONNs from across the country gathered in the “Golden State” to network, mentor each other, and attend clinical sessions.

	Some of the highlights from the conference covered in the pages of 

 include a discussion with Harold P. Freeman, MD, FACS, on the current and future status of patient navigation, as well as clinical insights in breast cancer, brain cancer, oncofertility, and psychosocial considerations in cancer care.

	Cancer in adolescents and young adults (AYAs) is often detected late, and once diagnosed, these patients frequently receive inconsistent treatment and follow-up care.

	The needs of young adults with cancer have been overlooked historically, leaving these patients feeling neglected and ignored.

	ONNs navigating AYAs require an additional library of resources and a comprehensive understanding of AYA needs. Insurance issues, isolation, and quality-of-life concerns are the top-3 factors to consider when navigating an AYA patient. In all of these areas, assessment comes first and is crucial to successful navigation. 

	In 2012, as navigation continues to grow as a necessary component of oncology care, NCONN will continue to offer navigators the resources they need.

	Keep checking on nconn.org for details on our 4th Annual 

 Conference. Also, if there are issues related to oncology nurse navigation that you would like to see covered in 

2011 was a banner year for the NCONN, as the membership has continued to grow and it held the 3rd Annual Changing the Face of Cancer Care Conference.

2011 in Review: NCONN Continues to Change the Face of Cancer Care

	One of the central themes of the 3rd Annual NCONN Conference was navigating young adults with cancer. Young adults facing a cancer diagnosis have unique needs and barriers to care and survivorship that can present a difficult challenge to oncology nurse navigators (ONNs) tasked with guiding them through the cancer care continuum.

	There are more than 72,000 adolescents and young adults aged 15-39 years who are diagnosed with cancer each year.

 Cancer in young adults is often detected late, and once diagnosed, these patients frequently receive inconsistent treatment and follow-up care.

	The needs of young adults with cancer have been ignored historically, leaving these patients feeling neglected and ignored. In the adolescent and young adult (AYA) population, the 5-year survival rate has stayed constant at about 70% over the last 30 years.

 In the past 25 years, the AYA population has seen increased survivorship in only 8 of the 20 most commonly diagnosed cancers. ONNs navigating individuals in this age group require an additional library of resources and a comprehensive understanding of AYA needs. Insurance issues, isolation, and quality-of-life concerns are the top-3 factors to consider when navigating an AYA patient.

	ONNs know that when navigating patients, regardless of their age, challenges related to insurance coverage can arise. A child is most likely covered under his or her parents’ health plan, and if not, many states offer low-cost affordable insurance. Older adults often have insurance through their jobs, or through Medicaid or Medicare. AYAs, however, present a greater challenge because many do not have insurance or have aged out of their parents’ plan.

	Nearly 21% of the uninsured are aged <18 years, and 63% are aged <34 years. Thus, AYAs are disproportionately uninsured relative to the overall population.

	Working AYA patients may have elected not to insure themselves to avoid a decrease in their net take-home pay, or from a belief that insurance is unnecessary for younger individuals because they generally face fewer health problems.

	Finding resources to cover AYA patients’ medical costs starts with an assessment. Is this patient eligible for a state program that is in existence for the uninsured? Is this patient unaware that he or she is actually still insured under his or her parents’ plan?

	Navigators treating AYA patients who have insurance, employment, or other legal issues related to their cancer should consider referring their patients to the Cancer Legal Resource Center (CLRC). The CLRC provides a national, toll-free helpline (866-THE-CLRC), offering callers confidential information about relevant laws and resources for their particular issues, with available services including advice from attorneys, insurance agents, and accountants.

	AYAs often receive lower levels of social support than other patients with cancer. A person aged 34 years who is diagnosed with cancer is not young enough to get the sympathy/support that a child with cancer receives. Additionally, AYAs are often ineligible for the magnitude of services available to the over-50 crowd, which have been established to assist in the normal aging process.

	Thus, ONNs must often help AYAs obtain the social support they need, which can be highly challenging. Patients in the 15-39 age range are at the prime of their life, and the average age of the ONN is 52. These 2 age groups have uniquely different perspectives regarding life. Navigators are thus faced with finding resources outside of their own demographics and, perhaps, comfort zone.

	Fear of recurrence, latent treatment effects, financial problems, employment issues, fertility problems, changes in physical appearance, poor self-image, and dating are just a few of AYAs’ potential concerns. ”

	Again, assessment becomes critical when navigating the AYA. What resources are age-appropriate? Does your facility offer programs specifically designed for the AYA?

	One crucial resource for ONNs is the I’m Too Young For This! Cancer Foundation (i[2]y, stupidcancer.com), which offers a wealth of resources and information for AYAs. i[2]y offers local happy hours, tweetups, retreats, financial scholarships, peer groups, fertility advocacy, legal assistance, relationship workshops, and an annual young adult cancer conference. The organization’s website is a one-stop resource and is essential to the ONN navigating the AYA.

	When navigating AYA patients during their transition from active treatment to survivorship, ONNs need to consider several quality of life issues. Fear of recurrence, latent treatment effects, financial problems, employment issues, fertility problems, changes in physical appearance, poor self-image, and dating are just a few of AYAs’ potential concerns.

	ONNs must recognize that survivorship starts at diagnosis. Assessment of what is important to the AYA should be done when a treatment plan is being formulated at the AYA’s initial visit. This will help ensure the best possible quality of life for the AYA during survivorship.

			Adolescents and young adults with cancer: survivorship. National Cancer Institute at the National Institutes of Health.

 cancer.gov/cancertopics/aya/survivorship

			US Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation. Overview of the uninsured in the United States: an analysis of the 2005 current population survey. 

aspe.hhs.gov/ health/reports/05/uninsured-cps/ib.pdf

. Published September 22, 2005. Accessed November 7, 2011.

Young adults facing a cancer diagnosis have unique needs and barriers to care and survivorship that can present a difficult challenge to ONNs.

Assessment Comes First in Navigating Young Adults With Cancer

	Increasing numbers of cancer treatment programs striving for improvements in efficiency and adherence to care look to nurses as a key element to improved patient outcomes. Over the past 20 years, the concept of patient navigation through a complex and fragmented healthcare system has evolved. Oncology Nurse Navigators (ONNs) have emerged from the field of oncology nursing to answer the call within the healthcare system for patient navigation for all cancer types. The ONN is the clinical professional with the knowledge and skills necessary to assess patient needs and make referrals to appropriate resources and services.

	The role of the ONN is evolving as the healthcare delivery system continues to undergo major changes. Internet access and other advances in technology have opened new avenues for patients and family members to educate themselves and gain resource information. This increased capacity to access information has improved care, reduced delays in treatment, and produced an overwhelming amount of resources and information to be interpreted and managed.

	Consistent with national trends, the National Coalition of Oncology Nurse Navigators (NCONN) is developing a healthcare ONN model that provides education and support for the professional nurse navigator. ONNs are the clinical professionals with the knowledge and skills necessary to support the cancer patient, the family, and other support persons throughout the entire cancer experience, from point of entry (which is variable) through treatment and survivorship.

	Apart from the roles of a licensed nurse, the ONN needs to develop competencies to integrate the roles of healthcare promoter, educator, counselor, care coordinator, case manager, researcher, and patient advocate.”

	The ONN is responsible for coordination of care across the continuum. By accompanying the patient through every aspect of his or her cancer journey, the ONN is best positioned to advocate for and provide guidance to patients and their families. The ONN is able to ensure access to the information necessary for the patient to make the best possible decisions about treatment, providing the counsel and advice to improve the patient’s quality of life, and ultimately, improving patient satisfaction. Furthermore, the ONN helps decrease healthcare costs through appropriate utilization of healthcare resources.

	Apart from the roles of a licensed nurse, the ONN needs to develop competencies to integrate the roles of healthcare promoter, educator, counselor, care coordinator, case manager, researcher, and patient advocate. Hence, education programs for preparing ONNs must ensure that professional nurse navigators are equipped with the essential competencies that enable them to fulfill these roles competently and ethically.

	One of the initial items NCONN addressed when it started was developing the first set of core competencies for the ONN. The core competencies developed serve the following purposes:

		To frame the philosophy of oncology nurse navigation based on accepted nursing practice.

		To define the professional role of oncology nurse navigation and the competencies required to successfully fulfill the role.

		To lead the development of curriculum and navigation models that prepare ONNs to guide and support cancer patients in a safe and ethical manner.

		To inform healthcare employers and the public of what they may expect from an ONN upon entry to practice.

		To educate currently practicing ONNs to further develop and/or establish a successful navigation program regardless of practice size, type, or geographical location.

	To receive a copy of the ONN Core Competencies, contact NCONN at 

	Hopkins J, Mumber MP. Patient navigation through the cancer care continuum: an overview. J Oncol Pract. 2009;5(4):150-152.

Increasing numbers of cancer treatment programs striving for improvements in efficiency and adherence to care look to nurses as a key element to improved patient outcomes.

Sharon Francz, BHA

Articles

Today's Nurse Navigator: Educating and Advocating for Cancer Patients

2011 in Review: NCONN Continues to Change the Face of Cancer Care

Assessment Comes First in Navigating Young Adults With Cancer

Core Competencies for the Oncology Nurse Navigator