HL

Patient-Centred Care through Nurse Navigation

Working as a nurse within a Chronic Disease team in the community sector of Queensland Health (QH) is an eye-opener to the difficulties patients encounter while managing their health/complex conditions. While nursing in the acute setting is patient-centred, it manages a patient’s acute needs and is very rigid and task-orientated. Patients are given the opportunity to receive support and assessments within their hospital admission to assist them on discharge, but they are not always in the right state of mind to make decisions and often decline help. Assisting complex patients within the community using a patient-centred care (PCC) approach is important and rewarding. PCC is when organisations create partnerships between the multidisciplinary healthcare team, the patient, and their relatives, while respecting the patient’s wishes and managing their health (Delaney, 2018). Queensland Health introduced the Nurse Navigator (NN) role within the public healthcare system to assist in coordinating care for patients with chronic or complex health conditions. Nurse Navigation promotes PCC by supporting and involving patients in the management of their conditions in coordination with the multidisciplinary team, family and community services. NN supports patients within the community, which in turn helps reduce hospital admissions especially due to social issues or exacerbation of diseases which can be managed with the assistance of General Practitioner (GP) doctors or nurses or other services within the community (Harvey et al., 2021).

Fig 1

Byrne et al., (2021) explain the NN model of care assists patients’ complex health needs by PCC within a combined care framework, promoting the continuity of care across the multiple external acute and community services, contributing to positive patient outcomes by improving their quality of life (QOL).

Stakeholders:

Patients are categorised as the primary stakeholders, they are considered consumers whose healthcare journey is impacted due to irregularity and inconsistency within their continuity of care. By providing PCC and supporting patients, nurse navigation helps them understand and manage their conditions, and seek assistance before deterioration. This empowers patients to manage their health and in turn avoid hospital admissions. Harvey et al., (2019) explained the importance of nurse navigation in assisting and supporting patients to with their conditions, improving their emotional well-being and QOL.

Drivers/Inputs:

Working with patients to help identify, set, and achieve Health Goals and promoting Health Literacy are essential for patients to navigate and manage their conditions. McMurray & Cooper, (2017) discussed the benefits of the NN role in assisting patients to improve health literacy by educating them specifically about their complex conditions and utilising tools and motivational factors to assist in their understanding of ongoing follow-up and support. Supporting patients and helping them access community assistance can also result in positive outcomes and promotes good quality of life. McMurray & Cooper, (2017) discuss another vital focus of the NN is to assist with improving access to community and social support services.

Outcomes:

The NN provides patient-centred care by supporting patients to navigate the health system, helping them understand their conditions, and coordinating care according to their needs.

Harvey et al., (2019) discussed the NN role in promoting patient engagement has assisted in reduced emergency presentations or decreased length of stay within hospital along with the benefits of the patients maintaining their emotional well-being.

References

Byrne, A., Harvey, C., & Baldwin, A. (2021). Nurse navigators and person‐centred care; delivered but not valued?  Nursing Inquiry,  28(4). https://doi.org/10.1111/nin.12402

Delaney, L. J. (2018). Patient-centred care as an approach to improving health care in Australia.  Collegian,  25(1), 119–123. https://doi.org/10.1016/j.colegn.2017.02.005

Harvey, C., Palmer, J., Hegney, D., Willis, E., Baldwin, A., Rees, C., Heritage, B., Thompson, S., Forrest, R., O’Donnell, C., Marshall, R., Mclellan, S., Sibley, J., Judd, J., Ferguson, B., Bamford‐Wade, A., & Brain, D. (2019). The evaluation of nurse navigators in chronic and complex care.  Journal of Advanced Nursing,  75(8). https://doi.org/10.1111/jan.14041

Harvey, C., Byrne, A.-L., Willis, E., Brown, J., Baldwin, A., Hegney, A. D., Palmer, J., Heard, D., Brain, D., Heritage, B., Ferguson, B., Judd, J., Mclellan, S., Forrest, R., & Thompson, S. (2021). Examining the hurdles in defining the practice of Nurse Navigators.  Nursing Outlook. https://doi.org/10.1016/j.outlook.2021.01.011

McMurray, A., & Cooper, H. (2017). The nurse navigator: An evolving model of care.  Collegian,  24(2), 205–212. https://doi.org/10.1016/j.colegn.2016.01.002

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