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NURSE NAVIGATOR ROLE DESCRIPTION AND PROCESSES FOR BEST OUTCOMES
AMONG AT-RISK PATIENTS
Section 1: Overview of the Evidence-Based Project
Introduction
“To say that the world of health care is in transition is to understate both the magnitude
and scope of the changes taking place in how illness is treated and how health is promoted
around the globe” (Kimberly & Cronk, 2016, p. 162). These changes can impact both delivery of
care and types of services rendered. “U.S. health care spending increased 4.3 percent to reach
$3.3 trillion, or $10,348 per person in 2016” (CMS.gov, 2016, p. 1). There is the added challenge
of trying to meet the consumers’ needs while attempting to contain skyrocketing health care costs
for a population that is aging and thus at greatest risk for acquiring one or more chronic
conditions. “Private employers are increasingly demanding that health care insurers address these
cost through disease management programs and government health plans, notably Medicare”
(Garrett & Martini, 2007, 51).
Beyond cost, the health care system struggles for a variety of reasons, making it is
difficult for the health care system to meet the needs of people with higher risk conditions. Care
often lacks interdisciplinary coordination, leading to a combination of unnecessary testing or
duplication of services. Patients are often left with conflicting information from multiple
providers. This is a cost burden for the patient. This lack of coordination, in turn, can cause
confusion when navigating the health care system. This can impact the patient’s quality of life,
perhaps through accelerated disease progression or acute exacerbation.
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Often, this confusion within the health care system makes it difficult to access services as
an individual patient, creating an inadvertent barrier to appropriate medical care specifically for
their given condition. For the patient newly diagnosed with an acute or chronic condition, their
world is changed by added medical appointments, testing, and lack of knowledge of how this
will impact their life. A chronic medical condition also can create undue stress for the patient
who attempts to manage the condition only to become decompensated with acute symptoms or
with an exacerbation requiring a hospital admission or readmission. If the patient had received
help understanding the resources necessary for their condition, they might have been avoided.
This support gap has now increased the risk of overall morbidity and mortality and created a cost
burden for the patient and the family.
Health care organizations can facilitate navigation of the health care system for the
highrisk patient. “A variety of strategies implemented at an organizational level have been
developed to help prevent hospital admissions or readmissions, accelerate discharges, improve
access to care and the care quality as patients transition between providers and health care
settings” (Manderson et al., 2012, p. 114). This paper will provide an overview of the nurse
navigator role, detail interventions to promote best outcomes for the at-risk patient with an acute
or chronic condition(s), include a thorough review of the evidence regarding the nurse navigator
role, and propose a plan to help patients navigate the health care system more efficiently.
Purpose Statement and Project Objectives
The purpose of this project was to determine which interventions used by nurse
navigators promoted the best outcomes for the at-risk patient. The navigator role was first
developed by Harold Freeman in 1990. This new model resulted from seeing a disparate number
of African American women presenting with late-stage breast cancer, which was attributed in
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part to their inability to access needed cancer care services. The nurse navigator role was
developed to assist patients with a cancer diagnosis to get the benefit of the best possible
oncology care.
In recent years, this role has expanded to assist patients with chronic disease management
and other illnesses. Because this is a relatively new role for nurse navigators, the impact has not
been rigorously documented (Manderson et al. 2012). Outside of oncology, this role is being
pioneered to see if the use of nurse navigators can help contain costs by decreasing hospital
length of stay and avoiding costly penalties for certain high-risk populations such as persons with
heart failure (HF) or chronic obstructive pulmonary disease (COPD) who may have frequent
rehospitalizations, emergency room (ER) visits, and low satisfaction with the delivery of care.
As health care becomes increasingly complex and as more pressure is placed on acute
care settings to decrease length of stay and readmissions, the nurse navigator will likely become
more valuable. When patients come through the hospital door, they become at-risk for several
points of process failure which, in turn, hinders optimal care. “On average, in 2010, Americans
received 70% of indicated health care services and failed to receive 30% of the care they needed
to treat or prevent particular medical conditions” (AHRQ, 2014, p. 2). Barriers that may
contribute to lack of access include poor communication, health care illiteracy, inconsistent
medical management, and lack of accountability by either the patient or the provider.
Utilization of the nurse navigator role provides an alternative to minimize lapses of care.
Nurse navigator programs “seek to improve patient care by reducing barriers to care, through the
provision of information, social and emotional support, links to existing services and resources,
as well as patient referrals to service providers” (Whitley et al., 2011, p. 3617). The nurse
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navigator can help the patient at any point of entry to the health care system and support her or
him through to discharge and follow-up.
To understand the effectiveness of the role, the hospital or other employer must be able to
measure the impact of the nurse navigators on the at-risk populations at each of the critical points
where process failure can occur. For the high-risk patient, the organization must be able to
articulate the process impact of the nurse navigator when the patient comes through the door, at
discharge, and when making the follow-up appointments to provide optimal transitional patient
care.
At entry to the system, the patient must be quickly identified as an at-risk patient based on
an acute presentation, a 30-day readmission, or extenuating circumstances that could hinder
optimal care such as health literacy or language issues, lack of family or a caregiver, or financial
and transportation issues. Any identified barriers to optimal care need to be addressed by the
nurse navigator prior to discharge.
Discharge is a second point of potential failure in patient care. “During the hospital to
home transition, patients are at high-risk for adverse drug events, incomplete or inaccurate
information transfer, preventable hospital readmission, and even death” (Davis et al., 2012, p.
1649). The patient may become overwhelmed with whom to see and what to do to manage their
condition(s). They are discharged where further breakdown in disease management can occur. To
help manage their new or chronic condition, the patient needs a strategy upon discharge to help
with a plan of care.
Finally, follow-up is a third point of potential process failure for patient care. Before
walking out the hospital doors, it is important that each patient has an appointment with the
providers who are best suited to care for their disease process and a way to get to that
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appointment. Collaboration with other health care team members is crucial to set up the patient
for success when they are managing care in the outpatient setting. There are many resources in
the community to help the patient manage his own care, but before discharge occurs, these
resources must be arranged. It is not unusual for a hospital to discharge a patient on a Friday
afternoon without the necessary services in place. If the patient cannot pick up his or her
necessary medications, food, assistive equipment, or other supplies for managing his condition
independently, he may be back in the hospital by Monday.
Significance to Practice
The significance to practice is providing appropriate high level care while being cost
conscious. “As a nation, we spend 86% of our health care dollars on the treatment of chronic
diseases” (CDC, 2015, para 1). People are living through acute injury and as a result living
longer and developing chronic, progressive condition(s). According to Anderson (2010), “in
2009, 145 million people—almost half of all Americans—lived with a chronic condition” (p. 4).
There has been a great deal of push for a decreased hospital length of stay, reduced
avoidable 30-day readmissions, and yet an increased patient satisfaction score to avoid penalties
imposed on acute care organizations. According to the Centers for Medicare and Medicaid
Services (2014), Section 3025 of the Affordable Care Act added section 1886(q) to the Social
Security Act establishing the Hospital Readmissions Reduction Program, which requires CMS to
reduce payments to IPPS hospitals with excess readmissions.” These expectations present
challenges in health care delivery and could place the vulnerable and/or chronically ill patients at
risk for increased morbidity and mortality.
Because of the increasing fragmentation, associated complexities, and limited resources,
patients and their families need help to navigate the health care system. Those patients with
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persistent, chronic, medical conditions require additional support with access to care. Many
organizations have adopted a nurse navigator program driven by the potential cost-effectiveness
of the role. The significance is twofold. For patients, a nurse navigator provides an interpreter of
sorts, helping the patients make sense of their disease process. On the health care provider and
organization side, the goal is to decrease health care costs. The nurse navigator can provide
continuity of care aimed at reducing duplication of testing, unnecessary testing, and readmissions
perhaps, by setting patients up with the right services.
A nurse navigator is in the position for service access. According to Gilbert et al. (2011),
the “core navigation functions include simplifying access and improving continuity of care,
proactive navigation, assistance in overcoming barriers and/or disparities, patient advocacy,
coordination of care, and support in achieving efficiencies” (p. 230). There is a need to
implement strategies aimed at collaborative care coordination among healthcare providers. This
placed the nurse navigator in the forefront to improve care and efficiency within the process.
Implications for Social Change
The implication to social change is to become a catalyst for improving health outcomes
while providing quality services. Healthy People 2020 reported “access to health services means
the timely use of personal health services to achieve the best health outcomes” (Healthy People
2020, 2015, para. 3). The aim of the nurse navigator role is to assist the patient through the
continuum of the health care system while decreasing overall health care associated
expenditures. According to the World Health Organization (2015), the United States ranks 37th of
all world health systems in its effectiveness and surpasses every other country in the money it
spends on health care as a percentage of its gross domestic product.
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This project is expected to improve society by helping patients improve health outcomes
and/or quality of life by adopting care practices that are supported by the evidence. For patients,
this will increase their overall satisfaction while providing them with a liaison to advocate for
their direct care needs. For the health care system, the nurse navigator offers a higher level of
care delivery that will be cost effective because it will avoid readmissions within 30-day and, as a
result, decrease overall health care expenditures.
Project Question
The project question was as follows: What are the tasks, knowledge areas, and skills
necessary for inclusion in a hospital-wide nurse navigator job description to promote best
outcomes for chronically ill and at-risk patients? The consensus in the literature was that the
nurse navigator role was geared toward decreasing fragmentation in health care delivery for
patients and helping them to maneuver through the system; however, there may be ways to
optimize and standardize the role within the project hospital for greater effectiveness of the rôle.
Local Context
The project hospital was an acute care facility with a total of 225 beds in southeastern
Ohio. Currently, a total of 862 registered nurses are employed in various roles with a total of 16
nurses in the nurse navigator role. Two of these nurse navigators also function as case managers.
The role of the nurse navigators is to identify those patients at risk for 30-day readmissions.
There are five nurse navigators employed in cardiovascular services who see patients with heart
failure, atrial fibrillation, acute coronary syndrome, or those in need of coronary artery bypass
graft surgery. Four nurse navigators are employed in oncology services who see patients with
specific cancer diagnoses. The breast cancer nurse navigator is the only certified navigator.
There are four nurse navigators who see patients with chronic obstructive pulmonary disease.
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Finally, the newest addition is a diabetic nurse navigator, formerly known as a diabetic educator.
Project Objectives
Based on the project question, six objectives were accomplished to incorporate
evidencebased best practices for level of education, skill set, duties, policy and procedures, and
the nurse navigator role at the project site. These objectives were as follows:
1. Review all 13 nurse navigator job descriptions at the project site.
2. Develop a comprehensive list of common job expectations and required skill set for
the role from the various job descriptions.
3. Compare the list of common job expectations and skills to best practices for the nurse
navigator role as identified in the literature.
4. Develop a new job description for the nurse navigator role.
5. Develop recommendations to standardize the nurse navigator processes and
procedures at the project hospital.
6. Recommend a method for evaluating the effectiveness of the nurse navigator in
reducing 30-day readmission rates at the project hospital.
Evidence-Based Significance of the Project
The evidence-based significance of the project is role refinement and implementation of
best practices to achieve a higher level of patient care in a cost-effective manner. Titler (2008)
defined “evidence-based practice (EBP) as the conscientious and judicious use of current best
evidence in conjunction with clinical expertise and patient values to guide health care decisions”
(p. I-113). In the role of the nurse navigator, the goal is to provide best care that is clinically
sound and based on practices that promote optimal patient outcomes. For example, heart failure
guidelines are often cited by the American College of Cardiology and American Heart
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Association (ACC/AHA). The basis of these guidelines has been well researched, peer-reviewed,
and graded according to how well the evidence supports the recommendations. A nurse
navigator, in collaboration with the health care team, should have a thorough understanding of
the guidelines and ensure that they are being followed. What sets the nurse navigator apart from
other nursing roles is their interactions with patients to ensure continuity of care throughout and
beyond the current hospitalization with a plan to avoid harm or readmission. In the literature,
there is a great deal of research on defining the nurse navigator role in general, but no research
was found on patient care outcomes and realized cost-effectiveness to the organization.
Assumptions
An assumption in the development of the project was that use of the nurse navigator was
emerging as a role for assisting patients in a system that is complex and full of fragmentation. It
was assumed the role will be used increasingly in hospitals to support patients who are at a
considerable risk of becoming medically decompensated or whose circumstances necessitate a
liaison for access to care. Another assumption is older patients who have at least one chronic
illness are at a higher risk for morbidity and mortality and this risk increases when the patient has
more than one acute and/or chronic condition. These patients can benefit from nurse navigator
interventions to attain an optimal quality of life and slowed disease progression.
Summary
Health care is becoming increasingly complex and fragmented; it is challenged to keep up
with delivery of care and the competitive types of services that it provides. This environment
increases the chances of the patient falling victim to barriers in care. Organizations must avoid
lapses in care due to inattention to these barriers and the nurse navigator role may be able to help
patients at highest risk for falling through the gaps.
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Since nurse navigators first emerged in hospital-based oncology patient care in the 1990s,
the role has expanded to include many other areas and medical diagnoses. With the expansion of
the role, it is necessary to understand which interventions used by the nurses in this role
promoted the best patient outcomes. This understanding must be grounded in the evidence while
considering the clinical expertise required to guide appropriate health care guidance at critical
junctures in hospital care (admittance, discharge education, outpatient care service and resource
planning).
While it was assumed the use of the nurse navigator role was vital in a system that is
complex and fragmented, the ultimate benefit was that promoting the best outcomes for the
patient yielded the most cost-effective manner. At the conclusion of this project, interventions
that best support patients at risk for poor post hospitalization outcomes will be identified.
The next section will focus on the history of the nurse navigator as well as reviewing the
literature as it pertains to the nurse navigator roles. The conceptual model of evidence-based
practice will be discussed as it relates to the necessity for this project.
Section 2: Review of Scholarly Evidence
Introduction
The purpose of this project was to identify which nurse navigator interventions promoted
the best outcomes for at-risk patients. “Whether care is delivered in an urban clinic or in rural
private practices, patients may experience delays in diagnosis and treatment and receive
fragmented, uncoordinated care” (Case, 2011, p. 33). Delivery of care in a complex health care
system presents potential barriers for the patient and/or the care is not conducive to realizing
evidence-based best practices.
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In the subsection on specific literature, I will discuss the first navigator program
introduced by Harold Freeman in 1990 and the role nurse navigators played in care coordination.
Since then, the role has expanded beyond oncology to other areas of chronic disease and to
patients considered to be high-risk, such as elderly patients and who experience barriers that
threaten worse outcomes.
In the subsection on the general literature, I will discuss the nurse navigators’ role(s) in
coordination of care, including barrier identification and discharge planning to promote optimal
outcomes for the patient. The purpose of the general literature review is to broadly outline the
interventions that are necessary to decrease system fragmentation and to align the patient with
resources to achieve optimal outcomes.
Finally, I will discuss the evidence-based practice (EBP) model. According to Satterfield
et al. (2009), EBP “provides a useful framework for guiding health services research with an
interdisciplinary and real-world perspective” (p. 384). The reason for establishing which nurse
navigator interventions promoted the best outcomes for at-risk patients is based on which clinical
practices have proven beneficial for the patient (and their association with the health care
system’s delivery mechanisms). These clinical practices in turn will promote optimal and
sustainable multidisciplinary care.
Specific Literature
Dr. Harold Freeman was the pioneer in development of the first nurse navigator role. He
was involved in two Harlem hospital studies (1986 and 1995-2000) that demonstrated an
increased 5-year survival rate of poor African American women with breast cancer who used a
navigator program. “The 5-year survival was 70%, compared to 39% in the earlier Harlem
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Hospital study” (Freeman, 2006, p. 140). The survival rate demonstrated a need for a liaison to
assist with access to care.
According to the Harold P. Freeman Patient Navigation Institute (2015), “navigators act
as the support hub for all aspects of patients' movement through the health care system” (para 6).
They were shown to be effective with removing barriers to care. “Although Nurse Navigator
programs most commonly target cancer patients, the literature supports that opportunity exists to
extend nurse navigator programs to other chronic diseases” (Pruitt & Sportsman, 2013, p. 593).
The role of patient navigator or nurse navigator has grown since being introduced in 1990
by Dr. Freeman. “The principal function of the navigator is to eliminate any and all barriers to
timely screening, diagnosis, treatment, and supportive care for each individual” (Harold P.
Freeman Patient Navigation Institute, 2015, para 6). Research is emerging in support of the nurse
navigator for patients with chronic illness and other high-risk presentations; however, no research
could be found that assessed the effectiveness of the role outside of oncology.
The literature search used the following databases: Cochrane Library, JBI Library,
Medline, CINAHL, SAGE, and SocINDEX. The following key terms were used alone and in
combination: patient, navigator, nurse, pivot, discharge planning, hospital, care coordination,
chronic disease, and coordination.
The search yielded 5,665 potentially relevant articles. From the articles, a total of 27
articles were found to be applicable. After review of these 27 articles, eight more articles were
excluded leaving a total of 19 articles. The articles were excluded for two reasons: they were not
relevant or were duplicate articles; (b) included literature related to pediatrics, mental health, and
dementia. It was felt, while these populations may be classified as chronic and/or high-risk, there
are special considerations for care of these patients that are not suitable for this. Inclusion criteria
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included literature comprising of the following: (1) the nurse navigator role, (2) barriers to access
of health care, (3) care coordination, and (4) discharge planning aimed at readmission rate
reductions. Literature specific to the nurse navigator role included ten total articles, two of which
focused on barriers to care or treatment; the other eight articles focused on the specific aspects of
the navigator role. Three of the studies were randomized controlled trials, two were longitudinal
studies, and one was exploratory. See Table 1 below.
Table 1
Specific Literature Delineating the Nurse Navigator Role
First Author
Inclusion
Aim(s) of the study
Details of intervention
Reported outcome(s)
Asgary et al.
Barriers to care
Identify and understand
colorectal screening rates,
predictors, and barriers to
screening for homeless in
New York City
Proposed intervention to
improve colorectal cancer
screening by including
private shelter rooms for
colonoscopy prepping.
Patient navigators to assist
with health care
navigation, accompany to
and from procedure,
counseling at all
Patient who were
homeless were less likely
than domiciled patients to
have up-to-date screening
(19.7% vs 41.3%; p <
.001).
Homeless patients were
significantly less likely to
have had a previous
colonoscopy (p < .05).
encounters, and education
to specific patient to curb
misconceptions.
Nurse navigators are
recommended to assist
with barriers to care
Calhoun et al.
Nurse navigator role
To develop a patient
navigator competency
program
Randomized control
design
Standardized training for
patient navigators with a
goal to provide
dissemination of
information, skills, and
competencies aimed at
decreasing barriers by
underserved papulations.
Recommend national
standardized training for all
chronic disease navigators.
Curriculum training; n =
110, with a mean pretest
score of 19.79 (SD =
2.76) and a mean posttest
score of 20.74 (SD =
2.44) showing
improvement in
knowledge
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Dennis et al.
Barriers to care
To assess if patient
navigators and use of the
Direct Endoscopic
Referral System (DERS)
would increase timely
colorectal cancer
screening for a large urban
hospital in a
predominately poor
region
Retrospective analysis
Hired 2 patient navigators
and implemented the
DERS to see if the number
of broken appointments
decreased for colorectal
cancer screening and
diagnostic colonoscopies.
Study suggests when
barriers are addressed,
screening rates increased
The rate of broken
appointment for both
screening and diagnostic
colonoscopies
significantly dropped
from 67% to 5%.
Nurse navigator role in
appointment increased
compliance rates 3-fold
(relative risk = 2.6, 95%,
Cl = 2.2-3.0)
Gunn et al.
Nurse navigator role
To determine if published
nine principle model of
navigation mirrors the
practice in breast cancer
navigator programs.
Exploratory Study
Observation of the
navigators in the 10
programs for a total of
179.5 hours. Codes were
used based on nine a priori
themes derived from the
nine-principle
model
Found individual level
principles were broadly
consistent with the
nineprinciple framework;
whereas program level
principles were variable
across programs
Horner et al.
Nurse navigator role
The aim was to test the
effectiveness of a 16week
oncology nurse navigators
(ONN) program compared
to enhanced usual care to
support cancer patients
early in treatment.
Randomized control trial.
Each patient (n = 251)
was assigned to a group
based on which primary
care clinic they belonged
to. The primary care
clinics (n = 11) were
randomly assigned to
either the ONN program
or enhanced usual care
group.
The results were not
disclosed in the article
pending result analysis.
Jolly et al.
Patient navigator role
The aim of the study was to
design a patient navigator
role from laypersons to
help coordinate care,
address system barriers and
to
Proposed intervention was
developing a patient
navigator role using lay
persons to assist CKD
patients. Electronic medical
record templates
The 2 hired patient
navigators were trained
and responsible for
navigating patients
enrolled in a clinical trial.
They were trained in
educate/motivate their
patients.
were created and
identification of barriers.
general patient navigation,
specific education on
CKD, and patient privacy
and research training.
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May et al.
Nurse navigator role
The aim of the program was
to implement a GI
multidisciplinary care
(MDC) program with
integration of a GI nurse
navigator (NN) to optimize
care of patients newly
diagnosed with GI cancer
The intervention was:
• Nurse
navigator to
contact patient
within 2 days
of diagnosis
(goal 80%)
• Cancer staging
completed
within 5
business days of
referral (goal
80%)
• 90% of the
patients to be
seen by GI MDC in 10
calendar days 70% of
patients to start cancer
treatment within 22
calendar days.
Result of quality
indicators from 1/2010 to
8/2012 with use of GI NN
includes the following:
• Nurse
navigators
contacted
patient within
2 days of
diagnosis
(outcome
89%)
• Cancer staging
was completed
within 5
business days
of referral
(outcome 85%
• 91% of the
patients were
seen by GI MDC in 10
calendar days 75% of
patients were started on
cancer treatment within 22
calendar days.
Percac-Lima et al.
Nurse navigator role
The aim was to understand
if the use of a nurse
navigator with Latina
women having an
abnormal pap smear result
would decrease
Information was obtained
over two-time periods
(2004-2007, and
20082011) to establish if
the use of nurse navigators
verses no use of nurse
navigators (comparison
group) were influential
with the following
outcomes for Latina
women with an abnormal
pap smear result:
• Missed
appointment
for colposcopy
• Time to
colposcopy
Changes in severity of two-
time periods
Nurse navigators were
influential with:
• Missed
appointment
for colposcopy
decreased for
navigated
Latina women
versus
comparison
group (p <
0.001)
• Time to
colposcopy
was shorter for
nurse
navigated
Latina women
versus
comparison group (p =
0.010) Changes in severity
of two-time periods
decreased for navigated
Latina women verses
comparison group (p <
0.001)
Redwood et al.
Patient navigator role
The aim was to have
patient navigators in Alaska
contact first
The patient navigators
contacted the first-degree
relatives by telephone or
The results showed a
significant increase in
colorectal cancer
degree relatives of
colorectal cancer patients to
obtain colorectal cancer
screening
mailed reminders.
screenings with the use of
patient navigators
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Wagner et al
Patient navigator role
To determine if a nurse
navigator intervention
improves quality of life
and patient experience with
care
Two-group clustered
randomized controlled
trial
Study used adults with
recently diagnosed
primary breast, colorectal,
or lung cancer (n = 251)
who received either
enhanced care (n = 118) or
nurse navigator support
for 4 months (n = 133).
No significant differences
found between groups in
FACT-G scores meaning
NN intervention did not
impact quality of life or
delays in receiving care.
However, patients
reported significantly
higher scores on the
PACIC survey and
reported significantly
fewer problems with care,
including psychosocial
care, care coordination,
and information
Most included studies that provided an overview of the nurse navigator role discussed
some form of cancer navigation, although one study by Jolly et al. (2015) discussed
implementing two nurse navigators to assist with care coordination and education of patient with
chronic kidney disease.
Three studies discussed program development, including one by May et al. (2014). The
study provided and discussed measurable interventions from the start of patient contact to start of
the cancer treatment. This study concluded that there was a benefit in having a nurse navigator to
expedite this process.
A randomized, controlled trial conducted by Horner et al. (2013) tested the effectiveness
of a 16-week oncology nurse navigators (ONN) program; however, no results were provided.
Another randomized study by Calhoun et al. (2010) looked at curriculum for training navigators
and recommended national standardized training for all chronic disease navigators.
Overall, the literature referring to the nurse navigator role discussed either curriculum
training, focused on a specific at-risk group, or found an increased compliance rate with care
needs by helping the patient overcome barriers to care. None of the literature specific to the
navigator role discussed discharge planning.
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Role refinement and assessment is crucial. The Oncology Nursing Society (ONS)
conducted a study called the Oncology Nurse Navigator (ONN) Role Delineation Study in 2010.
The purpose of the ONS ONN Role Delineation Study was to examine the job-function activities
and knowledge required of the ONN, thereby providing an understanding of this new role
(Brown et al., 2012). Based on information gathered from the respondents, a list of necessary
skills, tasks, and knowledge was initiated to define the ONN role. A mean rating of 3.5 – 4.49
was considered to be very significant for understanding role delineation.
For tasks, 62% of the task identified were significant for the nurse navigator role. Those
task rating at the highest includes: providing emotional and educational support, practicing in
accordance to professional standards, advocation, orienting patients to the system, receiving and
responding to referrals, pursuing continuing educational opportunities related the specialty and
specific to the nurse navigator role, assisting with informed consent, multidisciplinary
collaboration, identifying patients in need of navigation, and education.
Knowledge areas were considered to be 91% significant in accordance to the very
significant rating scale. Higher on the list of knowledge included: informed consent, advocacy,
symptom management, ethical principles, quality of life, treatment goals, therapeutic options,
evidence-based practice guidelines, and scope of practice.
“The 12 skills included on the survey were rated on the same scale and the skill on the
survey provided a sound basis for defining the skills needed within the navigator role” (Brown et
al., 2012, p. 584). It was ascertained that, overall, more research was needed on this topic.
The study by Wagner et al. (2014), used a clustered randomized controlled trial to
determine if the use of a nurse navigator intervention improved the quality of life and patient
experience for those patients recently diagnosed with breast, colorectal, or lung cancer. It was
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noted that the Functional Assessment of Cancer Therapy–General (FACT-G) quality of life
scores showed no significant impact of the nurse navigator on quality of life or delays in care.
There was a significant difference on the Patient Assessment of Chronic Illness Care (PACIC)
survey: patients reported fewer problems with care; in particular psychosocial care, care
coordination needs, and information. The study also showed in the lung cancer patients a
decrease of $6,852 in care costs among nurse navigator patients. There was no significant cost
reduction in care of breast or colorectal cancer patients.
General Literature
The general literature included studies of discharge planning and care coordination, which
are essential duties of the nurse navigators in the acute care setting at the project hospital.
According to Russell (2013), “these hospital-based navigators primarily manage the patient’s
needs during the hospital stay and discharge planning and they work for the hospital” (para 6).
When looking through the literature, this is a point of failure for the patient after they are
discharge and before they can follow-up with their health care provider.
The nurse navigator’s focus is to assist the patient through the health care system. The
care coordination and discharge planning piece is intertwined in this role. Social workers and
case managers have traditionally assumed this role with general patient admissions. Because the
nurse navigators, social workers, and case managers do not always collaborate, this does not
always allow for a more individualized plan of care to help the patient in terms of reducing ER
visits and readmissions for patients who are at risk. Unfortunately, no literature could be found to
understand which interventions by the nurse navigator promote best outcomes for the at-risk
patient.
19
Holliman et al. (2003) explored the role of social workers versus nurse discharge planners
and found no significant difference in job roles. This was the only article found that met the
inclusion criteria.
In terms of care coordination, eight articles were included. A cross sectional study by
Bradley et al, (2013) was conducted to understand what strategies are independently associated
with a reduction in 30-day readmissions. [Strategies that were associated with lower hospital
RSRR included: 1) partnering with community physicians or physician groups to reduce
readmission (0.33 percentage point lower RSRR, p = 0.017), 2) partnering with local hospitals to
reduce readmissions (0.34 percentage point, p = 0.020), 3) having nurses responsible for
medication reconciliation (0.18 percentage point, p = 0.002), 4) arranging follow-up
appointments before discharge (0.19 percentage point, p = 0.037), 5) having a process in place to
send all discharge paper or electronic summaries directly to the patient's primary physician (0.21
percentage point, p = 0.004), and 6) assigning staff to follow up on test results that return after
the patient is discharged (0.26 percentage point, p = 0.049)] (Bradley et al. 2013, p. 2).
A qualitative study by Kainfar et al. (2014) was the only article found discussing chronic
care coordination. Coordination elements of communication, relationship building, and care
coordination were identified as essential elements for care coordination. For chronic care
coordination, this connection is one which is open and interdisciplinary where collaboration is
occurring. The relationship becomes the interaction between health care professional discussing
care coordination activities or by the patient and health care professional. Monitoring takes on
the patient’s overall status, or changes in status, and monitoring activities of other health care
professional caring for the patient.
20
Legarin et al. (2011), did a randomized controlled trial to determine if a multimodal
approach would decrease ER visits and readmissions in patients older than 70. They looked at
specific risk factors of preventable readmissions which included drug related problems,
depression, and malnutrition. They concluded the multimodal approach was effective at 3 months
but not at 6 months. The authors concluded the following as an explanation of the insignificant
effect at 6 months including: “contamination of the control group (acute geriatric unit physicians
could have integrated parts of the treatment review and implemented them in the control group);
lack of power (it was initially planned to include 800 participants), or lack of post discharge
follow-up” (Legrain et al., 2011, p. 2026).
Often at discharge, patients are faced with multiple medication variations increasing
confusion for the patient or provider trying to manage these changes. These changes can include
increased or decreased dosing of a current medication, new medications additions, and/or
medications discontinued. A knowledge deficit can cause potential harm to the patient or bring
them back as a potential readmission. Kaanan et al. (2013) did a retrospective study to determine
the number of adverse drug events after discharge. They found in their study, 242 patients
(n=1000) had an adverse drug event. More than 50% of the adverse drug events occurred within
14 days post discharge. Overall, at 45 days post discharge, 35% were deemed preventable, 32%
of drug events were classified as a serious event, and 5% were considered life threatening. “The
findings of the current study serve to reinforce the importance of medication safety as a critically
important concern during this period of high vulnerability for older adults” (Kaanan et al., 2013,
p. 1897). The general literature is summarized in Table 2 below. Table
2
21
General Literature Delineating the Nurse Navigator Role
First Author
Inclusion
Aim(s) of the study
Details of intervention
Reported outcome(s)
Bradley et al.
Chronic care coordination
To identify hospital
strategies associated with
lower readmission rates for
heart failure patients
Cross-sectional study of
hospitals participating in a
web-based survey
Risk-standardized 30-day
readmission rate (RSRR)
determined several strategies
were effective with heart
failure (HF) patients
1) partnering with
community physicians or
physician groups 0.33
percentage point lower
RSRR, p = 0.017)
2) partnering with
local hospitals (0.34
percentage point, p =
0.020)
3) nurses
responsible for medication
reconciliation
(0.18 percentage point, p
= 0.002)
4) follow-up
appointments made prior
to discharge (0.19
percentage point, p
= 0.037)
5) EMR sent to
primary care provider after
discharge (0.21 percentage
point, p = 0.004)
6) Follow-up of
after discharge test results
(0.26 percentage point, p =
0.049).
reduction of 0.34
percentage point for each
additional strategy used
Holliman et al.
Discharge planning
To explore the roles of
social workers and nurse
discharge planners and
gain further understanding
of the similarities and
differences between these
roles
Convenience sampling of
Alabama hospitals who
were members of Alabama
Hospital
Association
Recommends social worker
participation in advocacy,
outcome research, and
discharge planning
The role of the social
worker and nurse
discharge planner had no
significant difference in
job roles
It was reported social
workers were
predominately hired in
federal and state hospitals
(p < .01); whereas private
hospitals were more likely
to hire discharge nurse
planners. Nurse discharge
planners were
predominately hired in
hospitals with less than
22
250 beds while social
workers were more likely
hired in hospitals with
greater than 250 beds
Kainfar et al.
Chronic care coordination
The overview of
coordination of care with
implications to care of
chronically ill patients
Interview of 12 different
health care professionals
involved in care
coordination of chronically
ill patients with CHF and
COPD
Found through interviews
communication,
relationship building, and
coordination of care as
essential elements with
CHF and COPD patients
Kanaan et al.
Care coordination
To characterize frequency,
preventability, and
severity of adverse drug
events (ADE) within
45 days after
hospitalization in patients
older than 65
Retrospective analysis
Comprehensive chart
reviews conducted on
patient’s part of senior plan
membership (n = 1000) to
determine ADE
Out of 1000 patients, 242
had an ADE, with 35%
preventable, 32% serious,
and 5% life threatening.
Over 6% (6.6%) met
Beers criteria when
looking at high quality of
evidence and strong
strength recommendations
Legrain et al.
Care coordination
To determine if a
multimodal intervention
could decrease ER visits
and hospital readmissions
in patients older than 70 at
3 and 6 months
Randomized,
parallelgrouped of
interventiongroup (IG, n =
317) and control-group (CG,
n = 348), open-label trial
The intervention to reduce
ER visits and hospital
readmissions was effective
at 3 months but ineffective
at 6 months. At 3 months,
IG was 23% compared to
CG at 30.5% (p = .03); at 6
months IG was 35.3% and
CG at 40.8% (p = .15)
Mistiaen
Care coordination
To assess the
effectiveness of follow-up
phone calls up to 1-month
post-discharge from the
hospital in eliminating
problems
Literature review of
randomized and
quasirandomized control
trials to determine if
follow-up phone calls were
effective
in alleviating post
discharge problems
Evidence of effectiveness
of telephone follow-up
was inconclusive
23
Rathert et al.
Clinical outcomes
To determine if patient
centered care (PCC)
influences patient outcomes
Systematic review of PCC
and patient outcomes
Review of 40 articles
reports an inconclusive
result of PCC on patient
outcomes. The studies did
find stronger evidence for
positive influence of PCC
on patient satisfaction and
self-care management
Shepperd et al.
Care coordination
To determine the
effectiveness of
individualized discharge
planning compared to
routine discharge planning
not individualized
Literature review of
randomized control trials
It was determined through
the literature that use of
individualized discharge
planning was statistically
significant in reducing
hospital length of stay and
readmissions. Hospital
length of stay (- 0.91, 95%
Cl = -1.55 to -0.27, 10
trials) and readmissions
(0.82, 95% Cl = 0.73 to
0.92, 12 trials)
Wee et al.
Care coordination
To evaluate if a national
transitional care program
for elderly patients with
complex care needs and a
limited social support
system reduced ER visits
and hospital readmissions
Dedicated care coordinators
were used to educated and
coordinate care needs and
follow-up 1-2 weeks post-
discharge. ER visits and
hospital readmissions were
Use of care coordinator
reduced ER visits and
hospital readmissions 30
days post-discharge
compared to patients
without a care coordinator
(0.5, 95% CI = 0.5 to -0.6
6 months post discharge reviewed to see if the and 0.81, 95% CI = 0.72
patients were previously to -0.90); and 180 days seen by a care
coordinator post-discharge (0.6, 95% or no care coordinator
CI = 0.5 to -0.6 and 0.9,
(comparison group) 95% CI = 0.82 to -0.99)
The general literature provided evidence to support individualized discharge planning and
care coordination aimed at reducing lapses in care, ER visits, and 30-day readmissions.
“Systematic problems such as lack of patient education, and insufficient coordination between
health professionals, especially during care transitions, contribute to readmissions” (Legrain et
al., 2011, p. 2018). For a patient who is already at high-risk or with more than one chronic
condition; this finding augmented confusion as to which evidence-based guidelines to follow by
inadvertently increasing fragmented care. Another obstacle for patients was post discharge
medication errors in general. Kanaan et al. (2013) cited multiple factors increasing the risk of
24
medication errors post discharge including poor therapeutic monitoring, patients not restarted on
medications, or patients started on high-risk medications without ensuring appropriate follow-up
with their primary care provider.
Nurse navigators can play a critical role in coordination of care by partnering with the
patient to reduce potential pitfalls. Legrain et al. (2011) substantiated this statement by reporting
decreased readmissions with effective disease management programs.
Conceptual Models, Theoretical Frameworks
The EBP) model best suited to support the project outcomes is the Rosswurm and
Larrabee conceptual model for change in EBP. [The model provides a pragmatic, theory-driven
framework for empowering clinicians in the process of EBP and includes the following six steps:
(1) assess the need for change in practice, (2) link the problem with interventions and outcomes,
(3) synthesize the best evidence, (4) design a change in practice, (5) implement and evaluate the
practice change, and (6) integrate and maintain the practice change] (Pipe, 2007, p. 235). This
model will provide the necessary means to increase knowledge about the nurse navigator role to
develop and implement a job description conducive to organizational best practice in the use of
the nurse navigator role. This structure will also avoid a haphazard reporting of the evidence as it
unfolds in the project.
Summary
The role of the nurse navigator emerged in 1990, in an attempt to increase survival rates
of poor African American women in Harlem. The nurse navigator role was to be the coordination
of all aspects of care for patients throughout the health care system. The role of nurse navigator
has grown beyond oncology to embrace patients including those at high-risk for increased
morbidity and mortality and those with chronic disease conditions.
25
A literature review was conducted to determine what interventions used by the nurse
navigator promote best outcomes for the at-risk patient. Literature for interventions beyond
oncology could not be found. The literature review focused on aspects of the nurse navigator role
to include the following: nurse navigator role, barriers to access of health care, care coordination,
and discharge planning aimed at readmission rate reductions. From the search, 18 articles were
identified for inclusion.
Of the studies included, three were randomized controlled trials, and two were literature
reviews inclusive of randomized controlled trials. According to Terry (2015), these designs
“provide health care professionals with information regarding the benefits of a specific health
care intervention” (p. 84). These studies provide a strong evidence base for the proposed project.
Overall, many of the studies were either in support of the navigator role, recommended a
navigator for barrier reduction and coordination, or implemented a program with utilization of a
nurse or patient navigator. Further studies will need to be conducted to establish what
interventions by the nurse navigator promote best outcomes for the at-risk patient.
The next section will discuss analysis of the project. This will include the approach to the
project, the data collection, and project evaluation.
26
Section 3: Approach
Introduction
The purpose of this project was to determine the role of the nurse navigator and
understand what job activities provided the best outcomes for patients considered to be at-risk.
Each step will be discussed to provide an overview of the project as well as how the data were
collected, analyzed, and evaluated. The role of the nurse navigator across the different areas of
the project hospital was not clearly defined or outlined. The current job descriptions were
reviewed, and recommendations made (see Section 4) to reflect specific tasks and skills of the
nurse navigator as defined in the literature.
Project Design and Methods
For this project, a qualitative design was used to review the existing nurse navigator job
descriptions and compare these findings to the literature on best practices. Expected tasks,
knowledge areas, and skills were collected from the job descriptions and the literature on nurse
navigators.
At the project site, the tasks, knowledge areas, and skills are not threaded within their job
descriptions but more broadly as tasks to complete as they identify a patient in need of their
services. Currently, different methods are being used at the project site to determine how the
nurse navigators receive referrals to patients. The referral processes were conducted to determine
where and how the information was being retrieved. All units are using the electronic medical
record to determine who should be seen by the nurse navigator, but each unit is retrieving this
information from a different report from within electronic medical record and is oftentimes
generated by a diagnosis. The goal of having a universal report is to provide consistency in the
27
referral process—one standardized method for identifying patients at-risk for readmissions or
with barriers to self-care management.
Finally, data were gathered to determine who was receiving the benefit of the nurse
navigator; these data were compared to information about patients who could benefit from the
service. This information was gathered from the different hospital reports to understand whether
patients were missed due to admission diagnosis or whether there were other unidentified themes
that resulted in overlooked referral opportunities. These data were used to demonstrate possible
changes to the referral report so that all at-risk patients could be identified for referral to the
nurse navigators.
The information (a) gathered for this project identified patients who could benefit from a
nurse navigator and (b) proposed consistent interventions to be used by the nurse navigators in
caring for patients. The goal was to identify best practices and adapt them to the nurse navigator
role at the project hospital in order to decrease the fragmentation of care, increase role
consistency across the organization, and establish a template for promoting and measuring
optimal outcomes for the patients as well as the organization.
Population and Sample
Because the project used a qualitative design, the data were extracted from hospital
documents (job descriptions) and reports being utilized within the organization. Approval for this
secondary data analysis was obtained through the hospital Institutional Review Board (IRB)
committee. The organization determines if projects require IRB approval prior to project
implementation. The application process included completing an IRB application and presenting
a PowerPoint overview of the proposed project to the hospital IRB committee. The IRB
recommended approval of the project, and key persons were contacted by e-mail to request the
28
required information for data collection and analysis. IRB approval from Walden University also
was obtained before data collection and analysis began; the approval number was 08-12-
160459006.
There were no participants in this project, although human resources, current nurse
navigators, directors and managers of nurse navigators, and employees in quality management
and information technology were asked to assist with report identification and data extraction.
Data Collection and Analysis
Information was collected to understand the specific nurse navigator job requirements in
conjunction with findings from the literature. Data collection included review of the current
nurse navigator job descriptions and reports used in the hospital pertaining to the current patient
referral processes. Themes from the job descriptions and data were identified and
recommendations were made based on best practices identified through the literature review.
Challenges to Project Implementation
Each nurse navigator was interviewed to further understand current workflow and
practices. This information was provided to the chief nursing officer (CNO) in a meeting.
Information was collected on how each department utilized the nurse navigator based on
interpretation of the role, which in turn influenced daily activities performed.
No consistency existed within the nurse navigator role across the organization. For
example, not all of the nurse navigators consistently provide discharge planning and/or
consistently enlist the services of the case manager. Case management had their own nurse
navigator who did not consistently touch base with the unit nurse navigators. This finding could
constitute a point of failure for the patients if they did not have appointments made, medications
29
reconciled to reduce errors, or the appropriate contacts made with community resources to reduce
care barriers and decrease potential readmissions.
Most nurse navigators are not available on off hours or on the weekends. The exception
was the oncology nurse navigators. The lack of daily availability potentially added to the
patients’ lengths of stay, increased duplication in services or testing, or delayed points of care
referrals and coordination necessary for the patients to maneuver through the health care system.
The gap in coverage potentially provided an increase in cost to the patient as well as the hospital
system.
An overview of the literature was provided to the CNO detailing aspects of the role
essential for positive patient outcomes with emphasis on discharge planning and follow-up, and a
method for process and impact evaluation of the revised nurse navigator role and data generation
processes was proposed.
A revised nurse navigator job description was presented to the CNO. The literature was
used to make revisions that standardized the role for intervention consistency only. The
information was compiled and laid out using the literature to define the role and the job
descriptions to determine what the nurse navigators’ role did for the patients to promote optimal
outcomes while decreasing readmissions for the organization.
Project Evaluation Plan
Evaluation is essential for any project to understand outcomes and establish where
positive changes may have been made. The evaluation for this project will occur after the
objectives of this project are completed and the organization decides whether to implement the
revised job description and processes proposed as a result of the project. Evaluation places
emphasis on selecting the right type of evaluation to support the program’s goals and objectives.
30
One evaluation type for assessment of the project’s goal of implementing a new job description
for the nurse navigators is a process evaluation. The process evaluation includes review of the
impact of adding tools to capture patients who need to be referred to the nurse navigators and is
expected to determine that patient care needs are better addressed through explicit accountability
and quality matrices built for the role. Providing the right tools to identify at-risk patients and
ensuring the tools are used will allow identification of the project’s effectiveness in improving
patient outcomes and impact on the organization’s goal of reducing unnecessary 30-day
readmissions.
For patients, this project is expected to establish consistency in how patient care needs are
identified and met after referral to the nurse navigator. For the nurse navigators and the
organization, this project provided a way to measure the role effectiveness with at-risk patients as
well as a means to demonstrate the impact nurse navigators had on patient care outcomes such as
decreased ER visits, hospitalizations, and rehospitalizations. Documentation of nurse navigator
outcomes will establish or validate best practices aimed at identifying interventions that help to
increase patients’ quality of life while keeping them out of the acute care setting unless
necessary. Organizational costs can be calculated to determine whether avoided CMS penalties
supported the increased employment costs for nurse navigators.
The end product will be transparency of nurse navigator program outcomes as measured
against outlined goals and objectives to sustain organizational cost-effectiveness and provide
evidence-based care to patients. Monitoring the impact of the changes will be crucial for program
evaluation. For this project, the impact evaluation will determine if the project led to decreased
30-day readmissions in the chronically ill patients or not.
31
Summary
A new job description was developed to encourage consistency across the nurse navigator
role in the hospital. The quality improvement approach was designed to identify those
interventions that promoted effectiveness by meeting both the needs of the patients for expert
transitional care support and organizational cost containment by decreasing 30-day readmissions.
The change in job description and processes was accomplished by reviewing current job
descriptions, the referral process, and which patients are seen or need to be seen by a nurse
navigator. IRB approval was obtained from the project site hospital IRB and Walden University
and, with help from key persons at the project site hospital, necessary documents and data for
analysis were obtained. Recommendations for a revised nurse navigator job description were
presented to the hospital leadership and a method for process and impact evaluation of the
revised nurse navigator role and data generation processes were proposed for future
implementation by the hospital.
The next section will provide insight to the findings from all the information gathered and
a recommendation will be presented. Since this is a qualitative study, it will be important to
provide the strengths and limitations of the project.
Section 4: Findings and Recommendations
Introduction
The purpose of the doctoral project was to determine what interventions used by nurse
navigators promoted the best outcomes for at-risk patients and the hospital. Health care has
become a complex system that has unintentionally created gaps in care for many patients. These
gaps cause confusion for the patient because they do not know what questions to ask, what tests
32
they need, who in the health care team is necessary to see, and what resources are available to
assist them once they go home. Patients have their own set of challenges prior to entering the
complex health care system; those most at risk have the most to lose in terms of quality of life.
At-risk patients often are faced barriers to care before entering the hospital system as well as
when they are within the hospital system. All these issues make the nurse navigator role essential
(and invaluable) for identifying patients who need assistance in their interactions with the health
care system. The ability to identify at-risk patients will yield the best outcomes to patients and to
the organization.
Each inpatient department director and/or manager who had a nurse navigator on staff
was contacted by confidential e-mail requesting information for the project as approved by the
hospital and Walden University IRB committees. A consent form was attached along with written
details describing the objectives for the project. The objectives of the project were explained in
person and any questions were answered. The evidence was obtained after a voluntary, signed
consent form was completed. The data received were current job descriptions and current
workflow sheets if used.
The nurse navigator job descriptions were analyzed for similarities and differences across
their roles in the hospital. The data were compiled and then compared to the list of tasks,
knowledge areas, and skills essential for practice competency from the Oncology Nurse
Navigator Role Delineation Study (Brown et al., 2012). The purpose of this analysis was to
determine oncology nurses’ essential job functions and activities and what activities were
essential to the role of the nurse navigator (see Table 3). A new list was developed. It included a
bridge between what had been established as essential to the role of the nurse navigator and what
the project site included in its nurse navigator job descriptions (see Table 4).
33
Findings and implications
The previously published study, titled Oncology Nurse Navigator Role Delineation Study:
An Oncology Nursing Society Report (Brown et al., 2012), provided the list of essential tasks,
knowledge areas, and skills deemed important for the role (see Table 3). This list provided some
items essential to the job descriptions that could aid in developing metrices for accountability
within the nurse navigator role. This list did not, however, provide a means for evaluation,
measurement of outcomes, nor support in identifying role value. Additionally, this list was
exclusive to cancer patients and did not include aspects of care essential for patients atrisk or
with other chronic conditions. A new list was developed to bridge what had been established as
essential to the role of the nurse navigator in the literature (i.e., Brown et al., 2012) and what the
project site had included in their job descriptions for the nurse navigator roles within the hospital
(see Table 3).
Table 3
Tasks, Knowledge Areas, and Skills Table
Tasks
Knowledge Areas
Skills
34
Provide emotional and
educational support for
patients.
Practice according to
professional and legal
standards.
Advocate on behalf of the
patient.
Demonstrate ethical principles
in practice.
Orient patients to the cancer
care system.
Receive and respond to new
patient referrals.
Pursue continuing education
opportunities related to
oncology and navigation.
Collaborate with physicians
and other health care
providers.
Empower patients to
selfadvocate.
Assist patients to make
informed decisions.
Provide education or referrals
for coping with the diagnosis.
Identify patients with a new
diagnosis of cancer.
Confidentiality and informed
consent
Advocacy
Symptom management
Ethical principles
Quality of life
Goal of treatment
Therapeutic options
Evidence-based practice
guidelines
Professional scope of practice
Legal and professional
guidelines
Communication
Problem solving
Critical thinking
Multitasking
Collaboration
Time management
Advocacy
Note: From “Oncology nurse navigator role delineation study: An oncology nursing society
report” by Brown et al., 2012, Clinical Journal of Oncology Nursing, 16(6), p. 584. Reprinted
with permission.
35
The most comprehensive source of evidence obtained from the project site was the job
descriptions of the nurse navigators. There was a total of 13 job descriptions for the various nurse
navigator roles within the hospital. Of the job descriptions; three were from pulmonary services,
two were from cancer services, five were from cardiovascular services, one was from case
management, one was from neurological services, and one was from endocrinology services.
Each job description followed the hospital template that required a job summary, a list of
essential duties, a list of qualifications, a description of working conditions/physical
requirements, and the organization’s specific behavioral expectations.
For the purpose of this project, all the job descriptions were crosschecked against each
item in Table 1 for specific tasks, knowledge areas, and skills pertinent for the nurse navigator
role. Each item from the Brown et al. (2012) list of tasks, knowledge areas, and skills was
examined for specific coordinating wording from the organization’s job descriptions. If the items
were found, they were tallied. A total was derived and divided by the total number of job
descriptions (13) equaling a percentage of how many included the listed item. For example,
under task, provide emotional and educational support for patients was tallied nine times. This
result (nine) was divided by 13 with a result of 69% for this item. The additional items added to
the table of tasks, knowledge areas, and skills were a result of themes noted through each
individual job description and themes noted through review of the literature review. For example,
one theme, discharge planning, was noted in the literature review.
In addition, the job descriptions were reviewed to determine if there were items that
should be added to the Brown et al. (2012) list. These items were assigned a percentage (see
Table 4) using the process explained previously. The purpose of this process was to determine
36
what items involving the nurse navigator were conducive to the transitional care of patients atrisk
and patients with one or more chronic conditions. Items identified for inclusion on the list were:
involvement of the nurse navigator in discharge planning, follow-up telephone calls after
discharge, knowledge of community resources and connecting discharged patients with them, as
well as the education and experience requirements of a nurse navigator.
The literature defined post discharge as a point of failure for many reasons including
patients not understanding new medications, not understanding with whom they needed to
follow-up, nor resource availability in the community to assist with ongoing health care needs.
Under tasks, providing follow-up telephone calls was added to the Brown et al. (2012) list and,
under skills, discharge nurse was added for the nurse navigator in the acute care setting. Many of
the job descriptions for the project site included the term “discharge nurse” (62%) and “provide
follow-up telephone calls” (62%) as requirements for the job.
Being able to understand and use community resources was both beneficial in reducing
readmissions within 30 days for the organization and essential for improving the patients’ quality
of life. All but two of the job descriptions (85%) included use of community resources as a
necessary component of the nurse navigator knowledge and was, therefore, felt to be an
important item to be included as an essential task for the nurse navigator role in work with at-risk
patients.
Under qualifications for the nurse navigator, all job descriptions (100%) required a
baccalaureate nursing degree. The experience required for the nurse navigator role varied
between 3 years (54%) and 5 years (46%). Education was placed under knowledge and
experience was placed under skills in the new job description.
37
Finally, a critical area necessary for assessment purposes was the need for an evaluation
tool. For nurse navigators to be able to justify their role, there needed to be a tool in place for
data extraction providing descriptors of patient type, resources used, and if the nursing actions
were effective in 30-day readmission reduction. Because of the differences among settings where
the nurse navigator role was enacted in the hospital, this tool needed to be implemented specific
to patient population. From the job descriptions, (69%) clearly identified collecting and reporting
of data as a job requirement; therefore, this item was placed under tasks in the new job
description.
The job descriptions were then tallied to determine if the items from the Brown et al.
(2012) table were included. A revised table was created with additions, subtractions, and changes
based on terminology and percentages obtained from the job descriptions in conjunction with
Table 3. See Table 4 for percentages derived from the review of the organization’s 13 nurse
navigator job descriptions.
Table 4
Revised List of Tasks, Knowledge Areas, and Skills Table with Percentages
Tasks
Knowledge Areas
Skills
Provide emotional and
educational support for
patients (69%).
Practice according to
Confidentiality and informed
consent (54%)
Advocacy (62%)
Communication (100%)
Problem solving (92%)
Critical thinking (92%)
38
professional and legal
standards (31%).
Advocate on behalf of the
patient (62%).
Demonstrate ethical principles in
practice (15%).
Orient patients to the cancer
care system (62%)
Receive and respond to new
patient referrals (92%).
Pursue continuing education
opportunities related to
oncology and navigation
(15%).
Collaborate with physicians
and other health care providers
(100%).
Empower patients to
selfadvocate (62%).
Assist patients to make
informed decisions (69%).
Provide education or referrals
for coping with the diagnosis
(77%).
Identify patients with a new
diagnosis (85%).
Additions
Providing follow-up phone
calls after discharge (62%)
Symptom management (15%)
Ethical principles (38%)
Quality of life (15%)
Goal of treatment (31%)
Therapeutic options (100%)
Evidence-based practice
guidelines (92%)
Professional scope of practice
(0%)
Legal and professional
guidelines (69%)
Education (100%)
Multitasking (92%)
Collaboration (92%)
Time management (54%)
Advocacy (62%)
Discharge nurse (62%)
39
Community resources identification
and connection
(85%)
Experience requirements
(100%)
From the revised list, all of Brown et al. (2012) items were listed and reviewed against
each of the organization’s job descriptions to calculate a corresponding percentage. This
calculation provided a view of what was already on the job descriptions and how the items
ranked accordingly. Found from the literature review were discharge planning and follow-up
after discharge. These items were not on the list by Brown et al. (2012) but were noted from the
job descriptions. Education requirements were noted in every job description and were added to
the revised list. These additions were also assigned a percentage. Finally, the words “cancer” and
“oncology” were removed from the revised table to keep the wording more neutral and flexible
for a variety of nurse navigator patient population(s).
The job descriptions for the hospital followed the organizational templates required for
position requirements. The items most frequently cited in the job descriptions were collaboration;
therapeutic options; communication; receiving and responding to referrals; and use of evidence-
based practice guidelines, problem solving, critical thinking, and multi-tasking. These skills were
found to be present in 90% or more of the job descriptions. The areas ranked lowest for the job
descriptions included demonstrating use of ethical principles in practice and pursuing continuing
40
education opportunities related to nurse navigation, quality of life, symptom management, and
enacting professional scope of practice. These areas were ranked as present in
15% or fewer of the job descriptions.
The role of the nurse navigator is becoming increasingly common in chronic care
management. There is a great deal of data for the nurse navigators employed in oncology;
however, data are limited for the usefulness of the role for patients who are considered at-risk.
When looking at the hospital’s job descriptions, the nurse navigator roles were specific to
population and diagnosis. Each job description had outlined what was expected for a narrow
range of patients. This finding was consistently presented in the job summary paragraph of each
job description. For example, in the stroke nurse navigator job description, the nurse was
described as caring for patients with ischemic or hemorrhagic stroke, or atrial fibrillation.
Also, it was clearly stated in the job descriptions where the patient should be referred
and with whom initial contact should be made. Data related to the purpose and outcomes of these
referrals and contacts are essential to understanding the nurse navigator role and how it is being
defined by hospital structure and process.
The role of the nurse navigator is aimed at helping patients find and use necessary
community and institutional resources when discharged. Assistance with arranging follow-up
appointments with the primary or specialist health care provider, ensuring delivery of durable
medical equipment, or arranging skilled care to address medical needs such as wound care and
medication administration can facilitate the transition to home. The organizational goal is to
decrease unnecessary illness exacerbations resulting in 30-day hospital readmissions just because
the patient did not understand what resources were available and how to access them. This
project outlined the nurse navigator role by specifying tasks, knowledge areas, and skills
41
necessary to successfully transition hospital patients to home. The project can help to avoid
duplications or gaps in services and addresses major points of failure for the patients after
discharge.
The implications for positive social change are to provide patients with a resource (nurse
navigator) who is well equipped through education and training to use evidence-based best
practices and processes to improve patient care in a cost-effective manner. Health care delivery is
complex and constantly changing, which makes it hard for patients to understand and
increasingly frustrating for patients and families. Lack of clarity and gaps between settings take
away from coordination and continuity of care and decrease the overall quality of care, adding to
poorer outcomes for patients at risk. Having a nurse navigator to identify patient needs and
connect patients with necessary resources is a winning solution for all stakeholders.
Recommendations
Differences among the nurse navigator job descriptions were seen across hospital
services. Some job descriptions, for example, required data collection and reporting and others
did not. All the nurse navigator roles required general education for the role; however, most of
the requirements were not tailored to the nurse navigator role itself or the specific knowledge
necessary to support patients with chronic conditions requiring self-care management. Overall,
there was no consistency in the tasks, knowledge areas, and the skills the nurse navigator role
should encompass. Each service identified what the patients’ needs were and how the nurse
navigator should address those needs. Unfortunately, the lack of a consistent approach to the
nurse navigator role may have increased fragmentation and confusion for the patients using the
services.
42
The original intent of the nurse navigator roles was to decrease fragmentation, but
without uniform job descriptions, the role may result in a higher likelihood of care gaps. The first
recommendation, therefore, is for more consistency across the job descriptions as outlined in the
literature (see Appendix A). A second recommendation is that all at-risk patients to be identified
and an individual discharge plan be put into place as soon as the patients enter the hospital. A
third recommendation is that quality matrices will need to be developed and completed for each
patient to identify care gaps and, ultimately, to demonstrate the value of and justification for the
nurse navigator role. Data analysis can identify 30-day readmissions and establish the potential
causes or missed opportunities to ensure that at-risk patients have access to appropriate resources
in the home and the community that will prevent unnecessary rehospitalizations.
Because of the potential for inconsistencies in the interpretation of the nurse navigator
role in the hospital, a fourth recommendation is to place the nurse navigators under one
department with an advanced practice nurse provider managing the department. The feasibility of
this recommendation would need to be examined by the hospital. This recommendation places
one, instead of multiple persons, in charge of the nurse navigators, which may improve role
integrity; decrease lapses of communication among services, providers, or other resources; and
increase collaboration with organizational leadership, quality managers, nursing departments,
and affiliates for consistent, quality care. Finally, the fifth recommendation is the need for a new
position specific to the nurse navigator department to assist with identifying and arranging
community resources for patients prior to discharge. This person could assure that patients have
the services they need in place the day they go home.
43
Strengths and Limitations of the Project
The main strength of this doctoral project was that it revealed for the organization how
the nurse navigator roles are currently being defined and utilized in the hospital. Each service has
developed and employed specific strategies to promote optimal care for patients to avoid
unnecessary readmissions. All services are using established and credible evidence-based
practice guidelines specific to the diagnoses of the patients. For example, patients with chronic
obstructive pulmonary disease receive care as outlined through the Global Initiative for
Obstructive Lung Disease (GOLD) standards (goldcopd.org, 2017). The finding was true for
cardiology, endocrinology, neurology, and all the other hospital services utilizing the nurse
navigator role. The new nurse navigator job description incorporated use of relevant
evidencebased guidelines as a knowledge area expectation of the nurse navigator role.
A limitation of the project is the use of a convenience sample of nurse navigator job
descriptions and internal referral data processes from one hospital. This sample may misrepresent
the nurse navigator role and result in findings and recommendations that cannot be generalized
beyond the project hospital. In hindsight, a survey completed by the nurse navigators may have
been helpful to see what items they found most necessary and appropriate in the Brown et al.
(2012) list of tasks, knowledge areas, and skills. Their input about how well the job descriptions
reflected their duties and expertise would have been helpful in creating a more comprehensive
and accurate picture of the nurse navigator role.
Another limitation identified for this project was the inability of the organization to
provide outcome data related to the role of the nurse navigators. Some of the job descriptions for
the nurse navigator role required outcome data collection and reporting, but the processes to use
for these purposes were not elaborated.
44
Summary
There was a great deal of research and data for the navigator role in oncology and the
tasks, knowledge, skills necessary for success in the role. For the at-risk patients with an acute or
chronic condition, there was a great deal of evidence supporting the need for the nurse navigator,
but little evidence that really focused on which interventions promoted optimal outcomes for the
patient. The purpose of this project was to determine what interventions were used by the nurse
navigators based on the literature and job descriptions at one hospital.
In future projects, it will be essential to test the five recommendations to see if in fact
these suggestions can be implemented and lead to decreased unnecessary readmissions, lower
hospital costs, and increased patient satisfaction and quality of life. Future research will define
interventions that are evidence driven and provide data about the nurse navigators’ effectiveness
for both patients and organizations. Follow up research should include whether practices used by
nurse navigators are universal. This research would support the importance of their practices and
improve patients’ outcomes in turn.
Section 5: Dissemination Plan
The dissemination plan included providing the recommendations from this project to the
CNO of the project hospital. The information provided comprised of the revised job description
and comprehensive literature review with associated recommendations. A podium or poster
presentation of the project is also planned.
The hospital is currently on the journey toward achieving “magnet status” as outlined
through the American Nurses’ Credentialing Center (ANCC) associated with the American
Nurses Association (ANCC, 2018). This project was geared toward enhancing professional
independent nursing practice to promote excellence in the delivery of care, clinical practice, and
45
dissemination of findings toward best practices in nursing services. If accepted by the
organization for implementation, the project findings will be provided to the education champion
for dissemination toward the “Magnet Journey.”
The audiences who may be most impacted by this project are the nurse navigators in the
organization, quality management staff, and organizational leaders. This project defined
necessary cost-effective tasks, knowledge areas, and skills for the nurse navigator role and
offered recommendations for continued improvement through documentation of interventions
and outcomes.
Analysis of Self
This project has been enlightening as a nurse practitioner and scholar. Overall, there was
a great deal more to the potential solution than just stating the problem. It was informative to see
how the nurse navigator role started and has evolved beyond oncology and what the different
departments have done with the role. As an advanced practice provider, the project demonstrated
the importance of considering the literature for direction and seeing where the evidence may
lead. Parts of this project assumed to be easier, were the most difficult parts of the project to
complete. One example was the IRB process. This process was an experience that will be applied
in addressing future practice problems to ensure a broad view is brought to investigation instead
of assumptions that may be ill-guided.
Summary
Health care has become very complex and nurses must embrace and use their clinical
expertise in support of patient navigation through the health care system. The goal of this project
was twofold as it was geared toward both improving nursing care for patients and addressing the
organization’s interest in decreasing 30-day readmissions and providing cost-effective care. For
46
nursing, it provided an avenue for assisting patients through discharge and the transition to home
to delay or interrupt disease progression through best practices. For the organization, the project
worked to decrease costs associated with unnecessary testing and avoidable readmissions. The
project has established the framework for continuing to improve the quality of care delivered
through consistent application of the nurse navigator role and recognition of the value a specific
nurse navigator department may bring to the organization.
“To say that the world of health care is in transition is to understate both the magnitude
and scope of the changes taking place in how illness is treated and how health is promoted
around the globe” (Kimberly & Cronk, 2016, p. 162). These changes can impact both delivery of
care and types of services rendered. “U.S. health care spending increased 4.3 percent to reach
$3.3 trillion, or $10,348 per person in 2016” (CMS.gov, 2016, p. 1). There is the added challenge
of trying to meet the consumers’ needs while attempting to contain skyrocketing health care costs
for a population that is aging and thus at greatest risk for acquiring one or more chronic
conditions. “Private employers are increasingly demanding that health care insurers address these
cost through disease management programs and government health plans, notably Medicare”
(Garrett & Martini, 2007, 51).
Beyond cost, the health care system struggles for a variety of reasons, making it is
difficult for the health care system to meet the needs of people with higher risk conditions. Care
often lacks interdisciplinary coordination, leading to a combination of unnecessary testing or
duplication of services. Patients are often left with conflicting information from multiple
providers. This is a cost burden for the patient. This lack of coordination, in turn, can cause
confusion when navigating the health care system. This can impact the patient’s quality of life,
perhaps through accelerated disease progression or acute exacerbation.
47
Often, this confusion within the health care system makes it difficult to access services as
an individual patient, creating an inadvertent barrier to appropriate medical care specifically for
their given condition. For the patient newly diagnosed with an acute or chronic condition, their
world is changed by added medical appointments, testing, and lack of knowledge of how this
will impact their life. A chronic medical condition also can create undue stress for the patient
who attempts to manage the condition only to become decompensated with acute symptoms or
with an exacerbation requiring a hospital admission or readmission. If the patient had received
help understanding the resources necessary for their condition, they might have been avoided.
This support gap has now increased the risk of overall morbidity and mortality and created a cost
burden for the patient and the family.
Health care organizations can facilitate navigation of the health care system for the
highrisk patient. “A variety of strategies implemented at an organizational level have been
developed to help prevent hospital admissions or readmissions, accelerate discharges, improve
access to care and the care quality as patients transition between providers and health care
settings” (Manderson et al., 2012, p. 114). This paper will provide an overview of the nurse
navigator role, detail interventions to promote best outcomes for the at-risk patient with an acute
or chronic condition(s), include a thorough review of the evidence regarding the nurse navigator
role, and propose a plan to help patients navigate the health care system more efficiently.
Purpose Statement and Project Objectives
The purpose of this project was to determine which interventions used by nurse
navigators promoted the best outcomes for the at-risk patient. The navigator role was first
developed by Harold Freeman in 1990. This new model resulted from seeing a disparate number
of African American women presenting with late-stage breast cancer, which was attributed in
48
part to their inability to access needed cancer care services. The nurse navigator role was
developed to assist patients with a cancer diagnosis to get the benefit of the best possible
oncology care.
In recent years, this role has expanded to assist patients with chronic disease management
and other illnesses. Because this is a relatively new role for nurse navigators, the impact has not
been rigorously documented (Manderson et al. 2012). Outside of oncology, this role is being
pioneered to see if the use of nurse navigators can help contain costs by decreasing hospital
length of stay and avoiding costly penalties for certain high-risk populations such as persons with
heart failure (HF) or chronic obstructive pulmonary disease (COPD) who may have frequent
rehospitalizations, emergency room (ER) visits, and low satisfaction with the delivery of care.
As health care becomes increasingly complex and as more pressure is placed on acute
care settings to decrease length of stay and readmissions, the nurse navigator will likely become
more valuable. When patients come through the hospital door, they become at-risk for several
points of process failure which, in turn, hinders optimal care. “On average, in 2010, Americans
received 70% of indicated health care services and failed to receive 30% of the care they needed
to treat or prevent particular medical conditions” (AHRQ, 2014, p. 2). Barriers that may
contribute to lack of access include poor communication, health care illiteracy, inconsistent
medical management, and lack of accountability by either the patient or the provider.
Utilization of the nurse navigator role provides an alternative to minimize lapses of care.
Nurse navigator programs “seek to improve patient care by reducing barriers to care, through the
provision of information, social and emotional support, links to existing services and resources,
as well as patient referrals to service providers” (Whitley et al., 2011, p. 3617). The nurse
49
navigator can help the patient at any point of entry to the health care system and support her or
him through to discharge and follow-up.
To understand the effectiveness of the role, the hospital or other employer must be able to
measure the impact of the nurse navigators on the at-risk populations at each of the critical points
where process failure can occur. For the high-risk patient, the organization must be able to
articulate the process impact of the nurse navigator when the patient comes through the door, at
discharge, and when making the follow-up appointments to provide optimal transitional patient
care.
At entry to the system, the patient must be quickly identified as an at-risk patient based on
an acute presentation, a 30-day readmission, or extenuating circumstances that could hinder
optimal care such as health literacy or language issues, lack of family or a caregiver, or financial
and transportation issues. Any identified barriers to optimal care need to be addressed by the
nurse navigator prior to discharge.
Discharge is a second point of potential failure in patient care. “During the hospital to
home transition, patients are at high-risk for adverse drug events, incomplete or inaccurate
information transfer, preventable hospital readmission, and even death” (Davis et al., 2012, p.
1649). The patient may become overwhelmed with whom to see and what to do to manage their
condition(s). They are discharged where further breakdown in disease management can occur. To
help manage their new or chronic condition, the patient needs a strategy upon discharge to help
with a plan of care.
Finally, follow-up is a third point of potential process failure for patient care. Before
walking out the hospital doors, it is important that each patient has an appointment with the
providers who are best suited to care for their disease process and a way to get to that
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appointment. Collaboration with other health care team members is crucial to set up the patient
for success when they are managing care in the outpatient setting. There are many resources in
the community to help the patient manage his own care, but before discharge occurs, these
resources must be arranged. It is not unusual for a hospital to discharge a patient on a Friday
afternoon without the necessary services in place. If the patient cannot pick up his or her
necessary medications, food, assistive equipment, or other supplies for managing his condition
independently, he may be back in the hospital by Monday.
Significance to Practice
The significance to practice is providing appropriate high level care while being cost
conscious. “As a nation, we spend 86% of our health care dollars on the treatment of chronic
diseases” (CDC, 2015, para 1). People are living through acute injury and as a result living
longer and developing chronic, progressive condition(s). According to Anderson (2010), “in
2009, 145 million people—almost half of all Americans—lived with a chronic condition” (p. 4).
There has been a great deal of push for a decreased hospital length of stay, reduced
avoidable 30-day readmissions, and yet an increased patient satisfaction score to avoid penalties
imposed on acute care organizations. According to the Centers for Medicare and Medicaid
Services (2014), Section 3025 of the Affordable Care Act added section 1886(q) to the Social
Security Act establishing the Hospital Readmissions Reduction Program, which requires CMS to
reduce payments to IPPS hospitals with excess readmissions.” These expectations present
challenges in health care delivery and could place the vulnerable and/or chronically ill patients at
risk for increased morbidity and mortality.
Because of the increasing fragmentation, associated complexities, and limited resources,
patients and their families need help to navigate the health care system. Those patients with
51
persistent, chronic, medical conditions require additional support with access to care. Many
organizations have adopted a nurse navigator program driven by the potential cost-effectiveness
of the role. The significance is twofold. For patients, a nurse navigator provides an interpreter of
sorts, helping the patients make sense of their disease process. On the health care provider and
organization side, the goal is to decrease health care costs. The nurse navigator can provide
continuity of care aimed at reducing duplication of testing, unnecessary testing, and readmissions
perhaps, by setting patients up with the right services.
A nurse navigator is in the position for service access. According to Gilbert et al. (2011),
the “core navigation functions include simplifying access and improving continuity of care,
proactive navigation, assistance in overcoming barriers and/or disparities, patient advocacy,
coordination of care, and support in achieving efficiencies” (p. 230). There is a need to
implement strategies aimed at collaborative care coordination among healthcare providers. This
placed the nurse navigator in the forefront to improve care and efficiency within the process.
Implications for Social Change
The implication to social change is to become a catalyst for improving health outcomes
while providing quality services. Healthy People 2020 reported “access to health services means
the timely use of personal health services to achieve the best health outcomes” (Healthy People
2020, 2015, para. 3). The aim of the nurse navigator role is to assist the patient through the
continuum of the health care system while decreasing overall health care associated
expenditures. According to the World Health Organization (2015), the United States ranks 37th of
all world health systems in its effectiveness and surpasses every other country in the money it
spends on health care as a percentage of its gross domestic product.
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This project is expected to improve society by helping patients improve health outcomes
and/or quality of life by adopting care practices that are supported by the evidence. For patients,
this will increase their overall satisfaction while providing them with a liaison to advocate for
their direct care needs. For the health care system, the nurse navigator offers a higher level of
care delivery that will be cost effective because it will avoid readmissions within 30-day and, as a
result, decrease overall health care expenditures.
Project Question
The project question was as follows: What are the tasks, knowledge areas, and skills
necessary for inclusion in a hospital-wide nurse navigator job description to promote best
outcomes for chronically ill and at-risk patients? The consensus in the literature was that the
nurse navigator role was geared toward decreasing fragmentation in health care delivery for
patients and helping them to maneuver through the system; however, there may be ways to
optimize and standardize the role within the project hospital for greater effectiveness of the rôle.
Local Context
The project hospital was an acute care facility with a total of 225 beds in southeastern
Ohio. Currently, a total of 862 registered nurses are employed in various roles with a total of 16
nurses in the nurse navigator role. Two of these nurse navigators also function as case managers.
The role of the nurse navigators is to identify those patients at risk for 30-day readmissions.
There are five nurse navigators employed in cardiovascular services who see patients with heart
failure, atrial fibrillation, acute coronary syndrome, or those in need of coronary artery bypass
graft surgery. Four nurse navigators are employed in oncology services who see patients with
specific cancer diagnoses. The breast cancer nurse navigator is the only certified navigator.
There are four nurse navigators who see patients with chronic obstructive pulmonary disease.
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Finally, the newest addition is a diabetic nurse navigator, formerly known as a diabetic educator.
Project Objectives
Based on the project question, six objectives were accomplished to incorporate
evidencebased best practices for level of education, skill set, duties, policy and procedures, and
the nurse navigator role at the project site. These objectives were as follows:
7. Review all 13 nurse navigator job descriptions at the project site.
8. Develop a comprehensive list of common job expectations and required skill set for
the role from the various job descriptions.
9. Compare the list of common job expectations and skills to best practices for the nurse
navigator role as identified in the literature.
10. Develop a new job description for the nurse navigator role.
11. Develop recommendations to standardize the nurse navigator processes and
procedures at the project hospital.
12. Recommend a method for evaluating the effectiveness of the nurse navigator in
reducing 30-day readmission rates at the project hospital.
Evidence-Based Significance of the Project
The evidence-based significance of the project is role refinement and implementation of
best practices to achieve a higher level of patient care in a cost-effective manner. Titler (2008)
defined “evidence-based practice (EBP) as the conscientious and judicious use of current best
evidence in conjunction with clinical expertise and patient values to guide health care decisions”
(p. I-113). In the role of the nurse navigator, the goal is to provide best care that is clinically
sound and based on practices that promote optimal patient outcomes. For example, heart failure
guidelines are often cited by the American College of Cardiology and American Heart
54
Association (ACC/AHA). The basis of these guidelines has been well researched, peer-reviewed,
and graded according to how well the evidence supports the recommendations. A nurse
navigator, in collaboration with the health care team, should have a thorough understanding of
the guidelines and ensure that they are being followed. What sets the nurse navigator apart from
other nursing roles is their interactions with patients to ensure continuity of care throughout and
beyond the current hospitalization with a plan to avoid harm or readmission. In the literature,
there is a great deal of research on defining the nurse navigator role in general, but no research
was found on patient care outcomes and realized cost-effectiveness to the organization.
Assumptions
An assumption in the development of the project was that use of the nurse navigator was
emerging as a role for assisting patients in a system that is complex and full of fragmentation. It
was assumed the role will be used increasingly in hospitals to support patients who are at a
considerable risk of becoming medically decompensated or whose circumstances necessitate a
liaison for access to care. Another assumption is older patients who have at least one chronic
illness are at a higher risk for morbidity and mortality and this risk increases when the patient has
more than one acute and/or chronic condition. These patients can benefit from nurse navigator
interventions to attain an optimal quality of life and slowed disease progression.
Summary
Health care is becoming increasingly complex and fragmented; it is challenged to keep up
with delivery of care and the competitive types of services that it provides. This environment
increases the chances of the patient falling victim to barriers in care. Organizations must avoid
lapses in care due to inattention to these barriers and the nurse navigator role may be able to help
patients at highest risk for falling through the gaps.
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Since nurse navigators first emerged in hospital-based oncology patient care in the 1990s,
the role has expanded to include many other areas and medical diagnoses. With the expansion of
the role, it is necessary to understand which interventions used by the nurses in this role
promoted the best patient outcomes. This understanding must be grounded in the evidence while
considering the clinical expertise required to guide appropriate health care guidance at critical
junctures in hospital care (admittance, discharge education, outpatient care service and resource
planning).
While it was assumed the use of the nurse navigator role was vital in a system that is
complex and fragmented, the ultimate benefit was that promoting the best outcomes for the
patient yielded the most cost-effective manner. At the conclusion of this project, interventions
that best support patients at risk for poor post hospitalization outcomes will be identified.
The next section will focus on the history of the nurse navigator as well as reviewing the
literature as it pertains to the nurse navigator roles. The conceptual model of evidence-based
practice will be discussed as it relates to the necessity for this project.
Section 2: Review of Scholarly Evidence
Introduction
The purpose of this project was to identify which nurse navigator interventions promoted
the best outcomes for at-risk patients. “Whether care is delivered in an urban clinic or in rural
private practices, patients may experience delays in diagnosis and treatment and receive
fragmented, uncoordinated care” (Case, 2011, p. 33). Delivery of care in a complex health care
system presents potential barriers for the patient and/or the care is not conducive to realizing
evidence-based best practices.
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In the subsection on specific literature, I will discuss the first navigator program
introduced by Harold Freeman in 1990 and the role nurse navigators played in care coordination.
Since then, the role has expanded beyond oncology to other areas of chronic disease and to
patients considered to be high-risk, such as elderly patients and who experience barriers that
threaten worse outcomes.
In the subsection on the general literature, I will discuss the nurse navigators’ role(s) in
coordination of care, including barrier identification and discharge planning to promote optimal
outcomes for the patient. The purpose of the general literature review is to broadly outline the
interventions that are necessary to decrease system fragmentation and to align the patient with
resources to achieve optimal outcomes.
Finally, I will discuss the evidence-based practice (EBP) model. According to Satterfield
et al. (2009), EBP “provides a useful framework for guiding health services research with an
interdisciplinary and real-world perspective” (p. 384). The reason for establishing which nurse
navigator interventions promoted the best outcomes for at-risk patients is based on which clinical
practices have proven beneficial for the patient (and their association with the health care
system’s delivery mechanisms). These clinical practices in turn will promote optimal and
sustainable multidisciplinary care.
Specific Literature
Dr. Harold Freeman was the pioneer in development of the first nurse navigator role. He
was involved in two Harlem hospital studies (1986 and 1995-2000) that demonstrated an
increased 5-year survival rate of poor African American women with breast cancer who used a
navigator program. “The 5-year survival was 70%, compared to 39% in the earlier Harlem
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Hospital study” (Freeman, 2006, p. 140). The survival rate demonstrated a need for a liaison to
assist with access to care.
According to the Harold P. Freeman Patient Navigation Institute (2015), “navigators act
as the support hub for all aspects of patients' movement through the health care system” (para 6).
They were shown to be effective with removing barriers to care. “Although Nurse Navigator
programs most commonly target cancer patients, the literature supports that opportunity exists to
extend nurse navigator programs to other chronic diseases” (Pruitt & Sportsman, 2013, p. 593).
The role of patient navigator or nurse navigator has grown since being introduced in 1990
by Dr. Freeman. “The principal function of the navigator is to eliminate any and all barriers to
timely screening, diagnosis, treatment, and supportive care for each individual” (Harold P.
Freeman Patient Navigation Institute, 2015, para 6). Research is emerging in support of the nurse
navigator for patients with chronic illness and other high-risk presentations; however, no research
could be found that assessed the effectiveness of the role outside of oncology.
The literature search used the following databases: Cochrane Library, JBI Library,
Medline, CINAHL, SAGE, and SocINDEX. The following key terms were used alone and in
combination: patient, navigator, nurse, pivot, discharge planning, hospital, care coordination,
chronic disease, and coordination.
The search yielded 5,665 potentially relevant articles. From the articles, a total of 27
articles were found to be applicable. After review of these 27 articles, eight more articles were
excluded leaving a total of 19 articles. The articles were excluded for two reasons: they were not
relevant or were duplicate articles; (b) included literature related to pediatrics, mental health, and
dementia. It was felt, while these populations may be classified as chronic and/or high-risk, there
are special considerations for care of these patients that are not suitable for this. Inclusion criteria
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included literature comprising of the following: (1) the nurse navigator role, (2) barriers to access
of health care, (3) care coordination, and (4) discharge planning aimed at readmission rate
reductions. Literature specific to the nurse navigator role included ten total articles, two of which
focused on barriers to care or treatment; the other eight articles focused on the specific aspects of
the navigator role. Three of the studies were randomized controlled trials, two were longitudinal
studies, and one was exploratory. See Table 1 below.
Table 1
Specific Literature Delineating the Nurse Navigator Role
First Author
Inclusion
Aim(s) of the study
Details of intervention
Reported outcome(s)
Asgary et al.
Barriers to care
Identify and understand
colorectal screening rates,
predictors, and barriers to
screening for homeless in
New York City
Proposed intervention to
improve colorectal cancer
screening by including
private shelter rooms for
colonoscopy prepping.
Patient navigators to assist
with health care
navigation, accompany to
and from procedure,
counseling at all
Patient who were
homeless were less likely
than domiciled patients to
have up-to-date screening
(19.7% vs 41.3%; p <
.001).
Homeless patients were
significantly less likely to
have had a previous
colonoscopy (p < .05).
encounters, and education
to specific patient to curb
misconceptions.
Nurse navigators are
recommended to assist
with barriers to care
Calhoun et al.
Nurse navigator role
To develop a patient
navigator competency
program
Randomized control
design
Standardized training for
patient navigators with a
goal to provide
dissemination of
information, skills, and
competencies aimed at
decreasing barriers by
underserved papulations.
Recommend national
standardized training for all
chronic disease navigators.
Curriculum training; n =
110, with a mean pretest
score of 19.79 (SD =
2.76) and a mean posttest
score of 20.74 (SD =
2.44) showing
improvement in
knowledge
59
Dennis et al.
Barriers to care
To assess if patient
navigators and use of the
Direct Endoscopic
Referral System (DERS)
would increase timely
colorectal cancer
screening for a large urban
hospital in a
predominately poor
region
Retrospective analysis
Hired 2 patient navigators
and implemented the
DERS to see if the number
of broken appointments
decreased for colorectal
cancer screening and
diagnostic colonoscopies.
Study suggests when
barriers are addressed,
screening rates increased
The rate of broken
appointment for both
screening and diagnostic
colonoscopies
significantly dropped
from 67% to 5%.
Nurse navigator role in
appointment increased
compliance rates 3-fold
(relative risk = 2.6, 95%,
Cl = 2.2-3.0)
Gunn et al.
Nurse navigator role
To determine if published
nine principle model of
navigation mirrors the
practice in breast cancer
navigator programs.
Exploratory Study
Observation of the
navigators in the 10
programs for a total of
179.5 hours. Codes were
used based on nine a priori
themes derived from the
nine-principle
model
Found individual level
principles were broadly
consistent with the
nineprinciple framework;
whereas program level
principles were variable
across programs
Horner et al.
Nurse navigator role
The aim was to test the
effectiveness of a 16week
oncology nurse navigators
(ONN) program compared
to enhanced usual care to
support cancer patients
early in treatment.
Randomized control trial.
Each patient (n = 251)
was assigned to a group
based on which primary
care clinic they belonged
to. The primary care
clinics (n = 11) were
randomly assigned to
either the ONN program
or enhanced usual care
group.
The results were not
disclosed in the article
pending result analysis.
Jolly et al.
Patient navigator role
The aim of the study was to
design a patient navigator
role from laypersons to
help coordinate care,
address system barriers and
to
Proposed intervention was
developing a patient
navigator role using lay
persons to assist CKD
patients. Electronic medical
record templates
The 2 hired patient
navigators were trained
and responsible for
navigating patients
enrolled in a clinical trial.
They were trained in
educate/motivate their
patients.
were created and
identification of barriers.
general patient navigation,
specific education on
CKD, and patient privacy
and research training.
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May et al.
Nurse navigator role
The aim of the program was
to implement a GI
multidisciplinary care
(MDC) program with
integration of a GI nurse
navigator (NN) to optimize
care of patients newly
diagnosed with GI cancer
The intervention was:
• Nurse
navigator to
contact patient
within 2 days
of diagnosis
(goal 80%)
• Cancer staging
completed
within 5
business days of
referral (goal
80%)
• 90% of the
patients to be
seen by GI MDC in 10
calendar days 70% of
patients to start cancer
treatment within 22
calendar days.
Result of quality
indicators from 1/2010 to
8/2012 with use of GI NN
includes the following:
• Nurse
navigators
contacted
patient within
2 days of
diagnosis
(outcome
89%)
• Cancer staging
was completed
within 5
business days
of referral
(outcome 85%
• 91% of the
patients were
seen by GI MDC in 10
calendar days 75% of
patients were started on
cancer treatment within 22
calendar days.
Percac-Lima et al.
Nurse navigator role
The aim was to understand
if the use of a nurse
navigator with Latina
women having an
abnormal pap smear result
would decrease
Information was obtained
over two-time periods
(2004-2007, and
20082011) to establish if
the use of nurse navigators
verses no use of nurse
navigators (comparison
group) were influential
with the following
outcomes for Latina
women with an abnormal
pap smear result:
• Missed
appointment
for colposcopy
• Time to
colposcopy
Changes in severity of two-
time periods
Nurse navigators were
influential with:
• Missed
appointment
for colposcopy
decreased for
navigated
Latina women
versus
comparison
group (p <
0.001)
• Time to
colposcopy
was shorter for
nurse
navigated
Latina women
versus
comparison group (p =
0.010) Changes in severity
of two-time periods
decreased for navigated
Latina women verses
comparison group (p <
0.001)
Redwood et al.
Patient navigator role
The aim was to have
patient navigators in Alaska
contact first
The patient navigators
contacted the first-degree
relatives by telephone or
The results showed a
significant increase in
colorectal cancer
degree relatives of
colorectal cancer patients to
obtain colorectal cancer
screening
mailed reminders.
screenings with the use of
patient navigators
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Wagner et al
Patient navigator role
To determine if a nurse
navigator intervention
improves quality of life
and patient experience with
care
Two-group clustered
randomized controlled
trial
Study used adults with
recently diagnosed
primary breast, colorectal,
or lung cancer (n = 251)
who received either
enhanced care (n = 118) or
nurse navigator support
for 4 months (n = 133).
No significant differences
found between groups in
FACT-G scores meaning
NN intervention did not
impact quality of life or
delays in receiving care.
However, patients
reported significantly
higher scores on the
PACIC survey and
reported significantly
fewer problems with care,
including psychosocial
care, care coordination,
and information
Most included studies that provided an overview of the nurse navigator role discussed
some form of cancer navigation, although one study by Jolly et al. (2015) discussed
implementing two nurse navigators to assist with care coordination and education of patient with
chronic kidney disease.
Three studies discussed program development, including one by May et al. (2014). The
study provided and discussed measurable interventions from the start of patient contact to start of
the cancer treatment. This study concluded that there was a benefit in having a nurse navigator to
expedite this process.
A randomized, controlled trial conducted by Horner et al. (2013) tested the effectiveness
of a 16-week oncology nurse navigators (ONN) program; however, no results were provided.
Another randomized study by Calhoun et al. (2010) looked at curriculum for training navigators
and recommended national standardized training for all chronic disease navigators.
Overall, the literature referring to the nurse navigator role discussed either curriculum
training, focused on a specific at-risk group, or found an increased compliance rate with care
needs by helping the patient overcome barriers to care. None of the literature specific to the
navigator role discussed discharge planning.
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Role refinement and assessment is crucial. The Oncology Nursing Society (ONS)
conducted a study called the Oncology Nurse Navigator (ONN) Role Delineation Study in 2010.
The purpose of the ONS ONN Role Delineation Study was to examine the job-function activities
and knowledge required of the ONN, thereby providing an understanding of this new role
(Brown et al., 2012). Based on information gathered from the respondents, a list of necessary
skills, tasks, and knowledge was initiated to define the ONN role. A mean rating of 3.5 – 4.49
was considered to be very significant for understanding role delineation.
For tasks, 62% of the task identified were significant for the nurse navigator role. Those
task rating at the highest includes: providing emotional and educational support, practicing in
accordance to professional standards, advocation, orienting patients to the system, receiving and
responding to referrals, pursuing continuing educational opportunities related the specialty and
specific to the nurse navigator role, assisting with informed consent, multidisciplinary
collaboration, identifying patients in need of navigation, and education.
Knowledge areas were considered to be 91% significant in accordance to the very
significant rating scale. Higher on the list of knowledge included: informed consent, advocacy,
symptom management, ethical principles, quality of life, treatment goals, therapeutic options,
evidence-based practice guidelines, and scope of practice.
“The 12 skills included on the survey were rated on the same scale and the skill on the
survey provided a sound basis for defining the skills needed within the navigator role” (Brown et
al., 2012, p. 584). It was ascertained that, overall, more research was needed on this topic.
The study by Wagner et al. (2014), used a clustered randomized controlled trial to
determine if the use of a nurse navigator intervention improved the quality of life and patient
experience for those patients recently diagnosed with breast, colorectal, or lung cancer. It was
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noted that the Functional Assessment of Cancer Therapy–General (FACT-G) quality of life
scores showed no significant impact of the nurse navigator on quality of life or delays in care.
There was a significant difference on the Patient Assessment of Chronic Illness Care (PACIC)
survey: patients reported fewer problems with care; in particular psychosocial care, care
coordination needs, and information. The study also showed in the lung cancer patients a
decrease of $6,852 in care costs among nurse navigator patients. There was no significant cost
reduction in care of breast or colorectal cancer patients.
General Literature
The general literature included studies of discharge planning and care coordination, which
are essential duties of the nurse navigators in the acute care setting at the project hospital.
According to Russell (2013), “these hospital-based navigators primarily manage the patient’s
needs during the hospital stay and discharge planning and they work for the hospital” (para 6).
When looking through the literature, this is a point of failure for the patient after they are
discharge and before they can follow-up with their health care provider.
The nurse navigator’s focus is to assist the patient through the health care system. The
care coordination and discharge planning piece is intertwined in this role. Social workers and
case managers have traditionally assumed this role with general patient admissions. Because the
nurse navigators, social workers, and case managers do not always collaborate, this does not
always allow for a more individualized plan of care to help the patient in terms of reducing ER
visits and readmissions for patients who are at risk. Unfortunately, no literature could be found to
understand which interventions by the nurse navigator promote best outcomes for the at-risk
patient.
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Holliman et al. (2003) explored the role of social workers versus nurse discharge planners
and found no significant difference in job roles. This was the only article found that met the
inclusion criteria.
In terms of care coordination, eight articles were included. A cross sectional study by
Bradley et al, (2013) was conducted to understand what strategies are independently associated
with a reduction in 30-day readmissions. [Strategies that were associated with lower hospital
RSRR included: 1) partnering with community physicians or physician groups to reduce
readmission (0.33 percentage point lower RSRR, p = 0.017), 2) partnering with local hospitals to
reduce readmissions (0.34 percentage point, p = 0.020), 3) having nurses responsible for
medication reconciliation (0.18 percentage point, p = 0.002), 4) arranging follow-up
appointments before discharge (0.19 percentage point, p = 0.037), 5) having a process in place to
send all discharge paper or electronic summaries directly to the patient's primary physician (0.21
percentage point, p = 0.004), and 6) assigning staff to follow up on test results that return after
the patient is discharged (0.26 percentage point, p = 0.049)] (Bradley et al. 2013, p. 2).
A qualitative study by Kainfar et al. (2014) was the only article found discussing chronic
care coordination. Coordination elements of communication, relationship building, and care
coordination were identified as essential elements for care coordination. For chronic care
coordination, this connection is one which is open and interdisciplinary where collaboration is
occurring. The relationship becomes the interaction between health care professional discussing
care coordination activities or by the patient and health care professional. Monitoring takes on
the patient’s overall status, or changes in status, and monitoring activities of other health care
professional caring for the patient.
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Legarin et al. (2011), did a randomized controlled trial to determine if a multimodal
approach would decrease ER visits and readmissions in patients older than 70. They looked at
specific risk factors of preventable readmissions which included drug related problems,
depression, and malnutrition. They concluded the multimodal approach was effective at 3 months
but not at 6 months. The authors concluded the following as an explanation of the insignificant
effect at 6 months including: “contamination of the control group (acute geriatric unit physicians
could have integrated parts of the treatment review and implemented them in the control group);
lack of power (it was initially planned to include 800 participants), or lack of post discharge
follow-up” (Legrain et al., 2011, p. 2026).
Often at discharge, patients are faced with multiple medication variations increasing
confusion for the patient or provider trying to manage these changes. These changes can include
increased or decreased dosing of a current medication, new medications additions, and/or
medications discontinued. A knowledge deficit can cause potential harm to the patient or bring
them back as a potential readmission. Kaanan et al. (2013) did a retrospective study to determine
the number of adverse drug events after discharge. They found in their study, 242 patients
(n=1000) had an adverse drug event. More than 50% of the adverse drug events occurred within
14 days post discharge. Overall, at 45 days post discharge, 35% were deemed preventable, 32%
of drug events were classified as a serious event, and 5% were considered life threatening. “The
findings of the current study serve to reinforce the importance of medication safety as a critically
important concern during this period of high vulnerability for older adults” (Kaanan et al., 2013,
p. 1897). The general literature is summarized in Table 2 below. Table
2
66
General Literature Delineating the Nurse Navigator Role
First Author
Inclusion
Aim(s) of the study
Details of intervention
Reported outcome(s)
Bradley et al.
Chronic care coordination
To identify hospital
strategies associated with
lower readmission rates for
heart failure patients
Cross-sectional study of
hospitals participating in a
web-based survey
Risk-standardized 30-day
readmission rate (RSRR)
determined several strategies
were effective with heart
failure (HF) patients
7) partnering with
community physicians or
physician groups 0.33
percentage point lower
RSRR, p = 0.017)
8) partnering with
local hospitals (0.34
percentage point, p =
0.020)
9) nurses
responsible for medication
reconciliation
(0.18 percentage point, p
= 0.002)
10) follow-up
appointments made prior
to discharge (0.19
percentage point, p
= 0.037)
11) EMR sent to
primary care provider after
discharge (0.21 percentage
point, p = 0.004)
12) Follow-up of
after discharge test results
(0.26 percentage point, p =
0.049).
reduction of 0.34
percentage point for each
additional strategy used
Holliman et al.
Discharge planning
To explore the roles of
social workers and nurse
discharge planners and
gain further understanding
of the similarities and
differences between these
roles
Convenience sampling of
Alabama hospitals who
were members of Alabama
Hospital
Association
Recommends social worker
participation in advocacy,
outcome research, and
discharge planning
The role of the social
worker and nurse
discharge planner had no
significant difference in
job roles
It was reported social
workers were
predominately hired in
federal and state hospitals
(p < .01); whereas private
hospitals were more likely
to hire discharge nurse
planners. Nurse discharge
planners were
predominately hired in
hospitals with less than
67
250 beds while social
workers were more likely
hired in hospitals with
greater than 250 beds
Kainfar et al.
Chronic care coordination
The overview of
coordination of care with
implications to care of
chronically ill patients
Interview of 12 different
health care professionals
involved in care
coordination of chronically
ill patients with CHF and
COPD
Found through interviews
communication,
relationship building, and
coordination of care as
essential elements with
CHF and COPD patients
Kanaan et al.
Care coordination
To characterize frequency,
preventability, and
severity of adverse drug
events (ADE) within
45 days after
hospitalization in patients
older than 65
Retrospective analysis
Comprehensive chart
reviews conducted on
patient’s part of senior plan
membership (n = 1000) to
determine ADE
Out of 1000 patients, 242
had an ADE, with 35%
preventable, 32% serious,
and 5% life threatening.
Over 6% (6.6%) met
Beers criteria when
looking at high quality of
evidence and strong
strength recommendations
Legrain et al.
Care coordination
To determine if a
multimodal intervention
could decrease ER visits
and hospital readmissions
in patients older than 70 at
3 and 6 months
Randomized,
parallelgrouped of
interventiongroup (IG, n =
317) and control-group (CG,
n = 348), open-label trial
The intervention to reduce
ER visits and hospital
readmissions was effective
at 3 months but ineffective
at 6 months. At 3 months,
IG was 23% compared to
CG at 30.5% (p = .03); at 6
months IG was 35.3% and
CG at 40.8% (p = .15)
Mistiaen
Care coordination
To assess the
effectiveness of follow-up
phone calls up to 1-month
post-discharge from the
hospital in eliminating
problems
Literature review of
randomized and
quasirandomized control
trials to determine if
follow-up phone calls were
effective
in alleviating post
discharge problems
Evidence of effectiveness
of telephone follow-up
was inconclusive
68
Rathert et al.
Clinical outcomes
To determine if patient
centered care (PCC)
influences patient outcomes
Systematic review of PCC
and patient outcomes
Review of 40 articles
reports an inconclusive
result of PCC on patient
outcomes. The studies did
find stronger evidence for
positive influence of PCC
on patient satisfaction and
self-care management
Shepperd et al.
Care coordination
To determine the
effectiveness of
individualized discharge
planning compared to
routine discharge planning
not individualized
Literature review of
randomized control trials
It was determined through
the literature that use of
individualized discharge
planning was statistically
significant in reducing
hospital length of stay and
readmissions. Hospital
length of stay (- 0.91, 95%
Cl = -1.55 to -0.27, 10
trials) and readmissions
(0.82, 95% Cl = 0.73 to
0.92, 12 trials)
Wee et al.
Care coordination
To evaluate if a national
transitional care program
for elderly patients with
complex care needs and a
limited social support
system reduced ER visits
and hospital readmissions
Dedicated care coordinators
were used to educated and
coordinate care needs and
follow-up 1-2 weeks post-
discharge. ER visits and
hospital readmissions were
Use of care coordinator
reduced ER visits and
hospital readmissions 30
days post-discharge
compared to patients
without a care coordinator
(0.5, 95% CI = 0.5 to -0.6
6 months post discharge reviewed to see if the and 0.81, 95% CI = 0.72
patients were previously to -0.90); and 180 days seen by a care
coordinator post-discharge (0.6, 95% or no care coordinator
CI = 0.5 to -0.6 and 0.9,
(comparison group) 95% CI = 0.82 to -0.99)
The general literature provided evidence to support individualized discharge planning and
care coordination aimed at reducing lapses in care, ER visits, and 30-day readmissions.
“Systematic problems such as lack of patient education, and insufficient coordination between
health professionals, especially during care transitions, contribute to readmissions” (Legrain et
al., 2011, p. 2018). For a patient who is already at high-risk or with more than one chronic
condition; this finding augmented confusion as to which evidence-based guidelines to follow by
inadvertently increasing fragmented care. Another obstacle for patients was post discharge
medication errors in general. Kanaan et al. (2013) cited multiple factors increasing the risk of
69
medication errors post discharge including poor therapeutic monitoring, patients not restarted on
medications, or patients started on high-risk medications without ensuring appropriate follow-up
with their primary care provider.
Nurse navigators can play a critical role in coordination of care by partnering with the
patient to reduce potential pitfalls. Legrain et al. (2011) substantiated this statement by reporting
decreased readmissions with effective disease management programs.
Conceptual Models, Theoretical Frameworks
The EBP) model best suited to support the project outcomes is the Rosswurm and
Larrabee conceptual model for change in EBP. [The model provides a pragmatic, theory-driven
framework for empowering clinicians in the process of EBP and includes the following six steps:
(1) assess the need for change in practice, (2) link the problem with interventions and outcomes,
(3) synthesize the best evidence, (4) design a change in practice, (5) implement and evaluate the
practice change, and (6) integrate and maintain the practice change] (Pipe, 2007, p. 235). This
model will provide the necessary means to increase knowledge about the nurse navigator role to
develop and implement a job description conducive to organizational best practice in the use of
the nurse navigator role. This structure will also avoid a haphazard reporting of the evidence as it
unfolds in the project.
Summary
The role of the nurse navigator emerged in 1990, in an attempt to increase survival rates
of poor African American women in Harlem. The nurse navigator role was to be the coordination
of all aspects of care for patients throughout the health care system. The role of nurse navigator
has grown beyond oncology to embrace patients including those at high-risk for increased
morbidity and mortality and those with chronic disease conditions.
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A literature review was conducted to determine what interventions used by the nurse
navigator promote best outcomes for the at-risk patient. Literature for interventions beyond
oncology could not be found. The literature review focused on aspects of the nurse navigator role
to include the following: nurse navigator role, barriers to access of health care, care coordination,
and discharge planning aimed at readmission rate reductions. From the search, 18 articles were
identified for inclusion.
Of the studies included, three were randomized controlled trials, and two were literature
reviews inclusive of randomized controlled trials. According to Terry (2015), these designs
“provide health care professionals with information regarding the benefits of a specific health
care intervention” (p. 84). These studies provide a strong evidence base for the proposed project.
Overall, many of the studies were either in support of the navigator role, recommended a
navigator for barrier reduction and coordination, or implemented a program with utilization of a
nurse or patient navigator. Further studies will need to be conducted to establish what
interventions by the nurse navigator promote best outcomes for the at-risk patient.
The next section will discuss analysis of the project. This will include the approach to the
project, the data collection, and project evaluation.
71
Section 3: Approach
Introduction
The purpose of this project was to determine the role of the nurse navigator and
understand what job activities provided the best outcomes for patients considered to be at-risk.
Each step will be discussed to provide an overview of the project as well as how the data were
collected, analyzed, and evaluated. The role of the nurse navigator across the different areas of
the project hospital was not clearly defined or outlined. The current job descriptions were
reviewed, and recommendations made (see Section 4) to reflect specific tasks and skills of the
nurse navigator as defined in the literature.
Project Design and Methods
For this project, a qualitative design was used to review the existing nurse navigator job
descriptions and compare these findings to the literature on best practices. Expected tasks,
knowledge areas, and skills were collected from the job descriptions and the literature on nurse
navigators.
At the project site, the tasks, knowledge areas, and skills are not threaded within their job
descriptions but more broadly as tasks to complete as they identify a patient in need of their
services. Currently, different methods are being used at the project site to determine how the
nurse navigators receive referrals to patients. The referral processes were conducted to determine
where and how the information was being retrieved. All units are using the electronic medical
record to determine who should be seen by the nurse navigator, but each unit is retrieving this
information from a different report from within electronic medical record and is oftentimes
generated by a diagnosis. The goal of having a universal report is to provide consistency in the
72
referral process—one standardized method for identifying patients at-risk for readmissions or
with barriers to self-care management.
Finally, data were gathered to determine who was receiving the benefit of the nurse
navigator; these data were compared to information about patients who could benefit from the
service. This information was gathered from the different hospital reports to understand whether
patients were missed due to admission diagnosis or whether there were other unidentified themes
that resulted in overlooked referral opportunities. These data were used to demonstrate possible
changes to the referral report so that all at-risk patients could be identified for referral to the
nurse navigators.
The information (a) gathered for this project identified patients who could benefit from a
nurse navigator and (b) proposed consistent interventions to be used by the nurse navigators in
caring for patients. The goal was to identify best practices and adapt them to the nurse navigator
role at the project hospital in order to decrease the fragmentation of care, increase role
consistency across the organization, and establish a template for promoting and measuring
optimal outcomes for the patients as well as the organization.
Population and Sample
Because the project used a qualitative design, the data were extracted from hospital
documents (job descriptions) and reports being utilized within the organization. Approval for this
secondary data analysis was obtained through the hospital Institutional Review Board (IRB)
committee. The organization determines if projects require IRB approval prior to project
implementation. The application process included completing an IRB application and presenting
a PowerPoint overview of the proposed project to the hospital IRB committee. The IRB
recommended approval of the project, and key persons were contacted by e-mail to request the
73
required information for data collection and analysis. IRB approval from Walden University also
was obtained before data collection and analysis began; the approval number was 08-12-
160459006.
There were no participants in this project, although human resources, current nurse
navigators, directors and managers of nurse navigators, and employees in quality management
and information technology were asked to assist with report identification and data extraction.
Data Collection and Analysis
Information was collected to understand the specific nurse navigator job requirements in
conjunction with findings from the literature. Data collection included review of the current
nurse navigator job descriptions and reports used in the hospital pertaining to the current patient
referral processes. Themes from the job descriptions and data were identified and
recommendations were made based on best practices identified through the literature review.
Challenges to Project Implementation
Each nurse navigator was interviewed to further understand current workflow and
practices. This information was provided to the chief nursing officer (CNO) in a meeting.
Information was collected on how each department utilized the nurse navigator based on
interpretation of the role, which in turn influenced daily activities performed.
No consistency existed within the nurse navigator role across the organization. For
example, not all of the nurse navigators consistently provide discharge planning and/or
consistently enlist the services of the case manager. Case management had their own nurse
navigator who did not consistently touch base with the unit nurse navigators. This finding could
constitute a point of failure for the patients if they did not have appointments made, medications
74
reconciled to reduce errors, or the appropriate contacts made with community resources to reduce
care barriers and decrease potential readmissions.
Most nurse navigators are not available on off hours or on the weekends. The exception
was the oncology nurse navigators. The lack of daily availability potentially added to the
patients’ lengths of stay, increased duplication in services or testing, or delayed points of care
referrals and coordination necessary for the patients to maneuver through the health care system.
The gap in coverage potentially provided an increase in cost to the patient as well as the hospital
system.
An overview of the literature was provided to the CNO detailing aspects of the role
essential for positive patient outcomes with emphasis on discharge planning and follow-up, and a
method for process and impact evaluation of the revised nurse navigator role and data generation
processes was proposed.
A revised nurse navigator job description was presented to the CNO. The literature was
used to make revisions that standardized the role for intervention consistency only. The
information was compiled and laid out using the literature to define the role and the job
descriptions to determine what the nurse navigators’ role did for the patients to promote optimal
outcomes while decreasing readmissions for the organization.
Project Evaluation Plan
Evaluation is essential for any project to understand outcomes and establish where
positive changes may have been made. The evaluation for this project will occur after the
objectives of this project are completed and the organization decides whether to implement the
revised job description and processes proposed as a result of the project. Evaluation places
emphasis on selecting the right type of evaluation to support the program’s goals and objectives.
75
One evaluation type for assessment of the project’s goal of implementing a new job description
for the nurse navigators is a process evaluation. The process evaluation includes review of the
impact of adding tools to capture patients who need to be referred to the nurse navigators and is
expected to determine that patient care needs are better addressed through explicit accountability
and quality matrices built for the role. Providing the right tools to identify at-risk patients and
ensuring the tools are used will allow identification of the project’s effectiveness in improving
patient outcomes and impact on the organization’s goal of reducing unnecessary 30-day
readmissions.
For patients, this project is expected to establish consistency in how patient care needs are
identified and met after referral to the nurse navigator. For the nurse navigators and the
organization, this project provided a way to measure the role effectiveness with at-risk patients as
well as a means to demonstrate the impact nurse navigators had on patient care outcomes such as
decreased ER visits, hospitalizations, and rehospitalizations. Documentation of nurse navigator
outcomes will establish or validate best practices aimed at identifying interventions that help to
increase patients’ quality of life while keeping them out of the acute care setting unless
necessary. Organizational costs can be calculated to determine whether avoided CMS penalties
supported the increased employment costs for nurse navigators.
The end product will be transparency of nurse navigator program outcomes as measured
against outlined goals and objectives to sustain organizational cost-effectiveness and provide
evidence-based care to patients. Monitoring the impact of the changes will be crucial for program
evaluation. For this project, the impact evaluation will determine if the project led to decreased
30-day readmissions in the chronically ill patients or not.
76
Summary
A new job description was developed to encourage consistency across the nurse navigator
role in the hospital. The quality improvement approach was designed to identify those
interventions that promoted effectiveness by meeting both the needs of the patients for expert
transitional care support and organizational cost containment by decreasing 30-day readmissions.
The change in job description and processes was accomplished by reviewing current job
descriptions, the referral process, and which patients are seen or need to be seen by a nurse
navigator. IRB approval was obtained from the project site hospital IRB and Walden University
and, with help from key persons at the project site hospital, necessary documents and data for
analysis were obtained. Recommendations for a revised nurse navigator job description were
presented to the hospital leadership and a method for process and impact evaluation of the
revised nurse navigator role and data generation processes were proposed for future
implementation by the hospital.
The next section will provide insight to the findings from all the information gathered and
a recommendation will be presented. Since this is a qualitative study, it will be important to
provide the strengths and limitations of the project.
Section 4: Findings and Recommendations
Introduction
The purpose of the doctoral project was to determine what interventions used by nurse
navigators promoted the best outcomes for at-risk patients and the hospital. Health care has
become a complex system that has unintentionally created gaps in care for many patients. These
gaps cause confusion for the patient because they do not know what questions to ask, what tests
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they need, who in the health care team is necessary to see, and what resources are available to
assist them once they go home. Patients have their own set of challenges prior to entering the
complex health care system; those most at risk have the most to lose in terms of quality of life.
At-risk patients often are faced barriers to care before entering the hospital system as well as
when they are within the hospital system. All these issues make the nurse navigator role essential
(and invaluable) for identifying patients who need assistance in their interactions with the health
care system. The ability to identify at-risk patients will yield the best outcomes to patients and to
the organization.
Each inpatient department director and/or manager who had a nurse navigator on staff
was contacted by confidential e-mail requesting information for the project as approved by the
hospital and Walden University IRB committees. A consent form was attached along with written
details describing the objectives for the project. The objectives of the project were explained in
person and any questions were answered. The evidence was obtained after a voluntary, signed
consent form was completed. The data received were current job descriptions and current
workflow sheets if used.
The nurse navigator job descriptions were analyzed for similarities and differences across
their roles in the hospital. The data were compiled and then compared to the list of tasks,
knowledge areas, and skills essential for practice competency from the Oncology Nurse
Navigator Role Delineation Study (Brown et al., 2012). The purpose of this analysis was to
determine oncology nurses’ essential job functions and activities and what activities were
essential to the role of the nurse navigator (see Table 3). A new list was developed. It included a
bridge between what had been established as essential to the role of the nurse navigator and what
the project site included in its nurse navigator job descriptions (see Table 4).
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Findings and implications
The previously published study, titled Oncology Nurse Navigator Role Delineation Study:
An Oncology Nursing Society Report (Brown et al., 2012), provided the list of essential tasks,
knowledge areas, and skills deemed important for the role (see Table 3). This list provided some
items essential to the job descriptions that could aid in developing metrices for accountability
within the nurse navigator role. This list did not, however, provide a means for evaluation,
measurement of outcomes, nor support in identifying role value. Additionally, this list was
exclusive to cancer patients and did not include aspects of care essential for patients atrisk or
with other chronic conditions. A new list was developed to bridge what had been established as
essential to the role of the nurse navigator in the literature (i.e., Brown et al., 2012) and what the
project site had included in their job descriptions for the nurse navigator roles within the hospital
(see Table 3).
Table 3
Tasks, Knowledge Areas, and Skills Table
Tasks
Knowledge Areas
Skills
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Provide emotional and
educational support for
patients.
Practice according to
professional and legal
standards.
Advocate on behalf of the
patient.
Demonstrate ethical principles
in practice.
Orient patients to the cancer
care system.
Receive and respond to new
patient referrals.
Pursue continuing education
opportunities related to
oncology and navigation.
Collaborate with physicians
and other health care
providers.
Empower patients to
selfadvocate.
Assist patients to make
informed decisions.
Provide education or referrals
for coping with the diagnosis.
Identify patients with a new
diagnosis of cancer.
Confidentiality and informed
consent
Advocacy
Symptom management
Ethical principles
Quality of life
Goal of treatment
Therapeutic options
Evidence-based practice
guidelines
Professional scope of practice
Legal and professional
guidelines
Communication
Problem solving
Critical thinking
Multitasking
Collaboration
Time management
Advocacy
Note: From “Oncology nurse navigator role delineation study: An oncology nursing society
report” by Brown et al., 2012, Clinical Journal of Oncology Nursing, 16(6), p. 584. Reprinted
with permission.
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The most comprehensive source of evidence obtained from the project site was the job
descriptions of the nurse navigators. There was a total of 13 job descriptions for the various nurse
navigator roles within the hospital. Of the job descriptions; three were from pulmonary services,
two were from cancer services, five were from cardiovascular services, one was from case
management, one was from neurological services, and one was from endocrinology services.
Each job description followed the hospital template that required a job summary, a list of
essential duties, a list of qualifications, a description of working conditions/physical
requirements, and the organization’s specific behavioral expectations.
For the purpose of this project, all the job descriptions were crosschecked against each
item in Table 1 for specific tasks, knowledge areas, and skills pertinent for the nurse navigator
role. Each item from the Brown et al. (2012) list of tasks, knowledge areas, and skills was
examined for specific coordinating wording from the organization’s job descriptions. If the items
were found, they were tallied. A total was derived and divided by the total number of job
descriptions (13) equaling a percentage of how many included the listed item. For example,
under task, provide emotional and educational support for patients was tallied nine times. This
result (nine) was divided by 13 with a result of 69% for this item. The additional items added to
the table of tasks, knowledge areas, and skills were a result of themes noted through each
individual job description and themes noted through review of the literature review. For example,
one theme, discharge planning, was noted in the literature review.
In addition, the job descriptions were reviewed to determine if there were items that
should be added to the Brown et al. (2012) list. These items were assigned a percentage (see
Table 4) using the process explained previously. The purpose of this process was to determine
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what items involving the nurse navigator were conducive to the transitional care of patients atrisk
and patients with one or more chronic conditions. Items identified for inclusion on the list were:
involvement of the nurse navigator in discharge planning, follow-up telephone calls after
discharge, knowledge of community resources and connecting discharged patients with them, as
well as the education and experience requirements of a nurse navigator.
The literature defined post discharge as a point of failure for many reasons including
patients not understanding new medications, not understanding with whom they needed to
follow-up, nor resource availability in the community to assist with ongoing health care needs.
Under tasks, providing follow-up telephone calls was added to the Brown et al. (2012) list and,
under skills, discharge nurse was added for the nurse navigator in the acute care setting. Many of
the job descriptions for the project site included the term “discharge nurse” (62%) and “provide
follow-up telephone calls” (62%) as requirements for the job.
Being able to understand and use community resources was both beneficial in reducing
readmissions within 30 days for the organization and essential for improving the patients’ quality
of life. All but two of the job descriptions (85%) included use of community resources as a
necessary component of the nurse navigator knowledge and was, therefore, felt to be an
important item to be included as an essential task for the nurse navigator role in work with at-risk
patients.
Under qualifications for the nurse navigator, all job descriptions (100%) required a
baccalaureate nursing degree. The experience required for the nurse navigator role varied
between 3 years (54%) and 5 years (46%). Education was placed under knowledge and
experience was placed under skills in the new job description.
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Finally, a critical area necessary for assessment purposes was the need for an evaluation
tool. For nurse navigators to be able to justify their role, there needed to be a tool in place for
data extraction providing descriptors of patient type, resources used, and if the nursing actions
were effective in 30-day readmission reduction. Because of the differences among settings where
the nurse navigator role was enacted in the hospital, this tool needed to be implemented specific
to patient population. From the job descriptions, (69%) clearly identified collecting and reporting
of data as a job requirement; therefore, this item was placed under tasks in the new job
description.
The job descriptions were then tallied to determine if the items from the Brown et al.
(2012) table were included. A revised table was created with additions, subtractions, and changes
based on terminology and percentages obtained from the job descriptions in conjunction with
Table 3. See Table 4 for percentages derived from the review of the organization’s 13 nurse
navigator job descriptions.
Table 4
Revised List of Tasks, Knowledge Areas, and Skills Table with Percentages
Tasks
Knowledge Areas
Skills
Provide emotional and
educational support for
patients (69%).
Practice according to
Confidentiality and informed
consent (54%)
Advocacy (62%)
Communication (100%)
Problem solving (92%)
Critical thinking (92%)
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professional and legal
standards (31%).
Advocate on behalf of the
patient (62%).
Demonstrate ethical principles in
practice (15%).
Orient patients to the cancer
care system (62%)
Receive and respond to new
patient referrals (92%).
Pursue continuing education
opportunities related to
oncology and navigation
(15%).
Collaborate with physicians
and other health care providers
(100%).
Empower patients to
selfadvocate (62%).
Assist patients to make
informed decisions (69%).
Provide education or referrals
for coping with the diagnosis
(77%).
Identify patients with a new
diagnosis (85%).
Additions
Providing follow-up phone
calls after discharge (62%)
Symptom management (15%)
Ethical principles (38%)
Quality of life (15%)
Goal of treatment (31%)
Therapeutic options (100%)
Evidence-based practice
guidelines (92%)
Professional scope of practice
(0%)
Legal and professional
guidelines (69%)
Education (100%)
Multitasking (92%)
Collaboration (92%)
Time management (54%)
Advocacy (62%)
Discharge nurse (62%)
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Community resources identification
and connection
(85%)
Experience requirements
(100%)
From the revised list, all of Brown et al. (2012) items were listed and reviewed against
each of the organization’s job descriptions to calculate a corresponding percentage. This
calculation provided a view of what was already on the job descriptions and how the items
ranked accordingly. Found from the literature review were discharge planning and follow-up
after discharge. These items were not on the list by Brown et al. (2012) but were noted from the
job descriptions. Education requirements were noted in every job description and were added to
the revised list. These additions were also assigned a percentage. Finally, the words “cancer” and
“oncology” were removed from the revised table to keep the wording more neutral and flexible
for a variety of nurse navigator patient population(s).
The job descriptions for the hospital followed the organizational templates required for
position requirements. The items most frequently cited in the job descriptions were collaboration;
therapeutic options; communication; receiving and responding to referrals; and use of evidence-
based practice guidelines, problem solving, critical thinking, and multi-tasking. These skills were
found to be present in 90% or more of the job descriptions. The areas ranked lowest for the job
descriptions included demonstrating use of ethical principles in practice and pursuing continuing
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education opportunities related to nurse navigation, quality of life, symptom management, and
enacting professional scope of practice. These areas were ranked as present in
15% or fewer of the job descriptions.
The role of the nurse navigator is becoming increasingly common in chronic care
management. There is a great deal of data for the nurse navigators employed in oncology;
however, data are limited for the usefulness of the role for patients who are considered at-risk.
When looking at the hospital’s job descriptions, the nurse navigator roles were specific to
population and diagnosis. Each job description had outlined what was expected for a narrow
range of patients. This finding was consistently presented in the job summary paragraph of each
job description. For example, in the stroke nurse navigator job description, the nurse was
described as caring for patients with ischemic or hemorrhagic stroke, or atrial fibrillation.
Also, it was clearly stated in the job descriptions where the patient should be referred
and with whom initial contact should be made. Data related to the purpose and outcomes of these
referrals and contacts are essential to understanding the nurse navigator role and how it is being
defined by hospital structure and process.
The role of the nurse navigator is aimed at helping patients find and use necessary
community and institutional resources when discharged. Assistance with arranging follow-up
appointments with the primary or specialist health care provider, ensuring delivery of durable
medical equipment, or arranging skilled care to address medical needs such as wound care and
medication administration can facilitate the transition to home. The organizational goal is to
decrease unnecessary illness exacerbations resulting in 30-day hospital readmissions just because
the patient did not understand what resources were available and how to access them. This
project outlined the nurse navigator role by specifying tasks, knowledge areas, and skills
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necessary to successfully transition hospital patients to home. The project can help to avoid
duplications or gaps in services and addresses major points of failure for the patients after
discharge.
The implications for positive social change are to provide patients with a resource (nurse
navigator) who is well equipped through education and training to use evidence-based best
practices and processes to improve patient care in a cost-effective manner. Health care delivery is
complex and constantly changing, which makes it hard for patients to understand and
increasingly frustrating for patients and families. Lack of clarity and gaps between settings take
away from coordination and continuity of care and decrease the overall quality of care, adding to
poorer outcomes for patients at risk. Having a nurse navigator to identify patient needs and
connect patients with necessary resources is a winning solution for all stakeholders.
Recommendations
Differences among the nurse navigator job descriptions were seen across hospital
services. Some job descriptions, for example, required data collection and reporting and others
did not. All the nurse navigator roles required general education for the role; however, most of
the requirements were not tailored to the nurse navigator role itself or the specific knowledge
necessary to support patients with chronic conditions requiring self-care management. Overall,
there was no consistency in the tasks, knowledge areas, and the skills the nurse navigator role
should encompass. Each service identified what the patients’ needs were and how the nurse
navigator should address those needs. Unfortunately, the lack of a consistent approach to the
nurse navigator role may have increased fragmentation and confusion for the patients using the
services.
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The original intent of the nurse navigator roles was to decrease fragmentation, but
without uniform job descriptions, the role may result in a higher likelihood of care gaps. The first
recommendation, therefore, is for more consistency across the job descriptions as outlined in the
literature (see Appendix A). A second recommendation is that all at-risk patients to be identified
and an individual discharge plan be put into place as soon as the patients enter the hospital. A
third recommendation is that quality matrices will need to be developed and completed for each
patient to identify care gaps and, ultimately, to demonstrate the value of and justification for the
nurse navigator role. Data analysis can identify 30-day readmissions and establish the potential
causes or missed opportunities to ensure that at-risk patients have access to appropriate resources
in the home and the community that will prevent unnecessary rehospitalizations.
Because of the potential for inconsistencies in the interpretation of the nurse navigator
role in the hospital, a fourth recommendation is to place the nurse navigators under one
department with an advanced practice nurse provider managing the department. The feasibility of
this recommendation would need to be examined by the hospital. This recommendation places
one, instead of multiple persons, in charge of the nurse navigators, which may improve role
integrity; decrease lapses of communication among services, providers, or other resources; and
increase collaboration with organizational leadership, quality managers, nursing departments,
and affiliates for consistent, quality care. Finally, the fifth recommendation is the need for a new
position specific to the nurse navigator department to assist with identifying and arranging
community resources for patients prior to discharge. This person could assure that patients have
the services they need in place the day they go home.
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Strengths and Limitations of the Project
The main strength of this doctoral project was that it revealed for the organization how
the nurse navigator roles are currently being defined and utilized in the hospital. Each service has
developed and employed specific strategies to promote optimal care for patients to avoid
unnecessary readmissions. All services are using established and credible evidence-based
practice guidelines specific to the diagnoses of the patients. For example, patients with chronic
obstructive pulmonary disease receive care as outlined through the Global Initiative for
Obstructive Lung Disease (GOLD) standards (goldcopd.org, 2017). The finding was true for
cardiology, endocrinology, neurology, and all the other hospital services utilizing the nurse
navigator role. The new nurse navigator job description incorporated use of relevant
evidencebased guidelines as a knowledge area expectation of the nurse navigator role.
A limitation of the project is the use of a convenience sample of nurse navigator job
descriptions and internal referral data processes from one hospital. This sample may misrepresent
the nurse navigator role and result in findings and recommendations that cannot be generalized
beyond the project hospital. In hindsight, a survey completed by the nurse navigators may have
been helpful to see what items they found most necessary and appropriate in the Brown et al.
(2012) list of tasks, knowledge areas, and skills. Their input about how well the job descriptions
reflected their duties and expertise would have been helpful in creating a more comprehensive
and accurate picture of the nurse navigator role.
Another limitation identified for this project was the inability of the organization to
provide outcome data related to the role of the nurse navigators. Some of the job descriptions for
the nurse navigator role required outcome data collection and reporting, but the processes to use
for these purposes were not elaborated.
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Summary
There was a great deal of research and data for the navigator role in oncology and the
tasks, knowledge, skills necessary for success in the role. For the at-risk patients with an acute or
chronic condition, there was a great deal of evidence supporting the need for the nurse navigator,
but little evidence that really focused on which interventions promoted optimal outcomes for the
patient. The purpose of this project was to determine what interventions were used by the nurse
navigators based on the literature and job descriptions at one hospital.
In future projects, it will be essential to test the five recommendations to see if in fact
these suggestions can be implemented and lead to decreased unnecessary readmissions, lower
hospital costs, and increased patient satisfaction and quality of life. Future research will define
interventions that are evidence driven and provide data about the nurse navigators’ effectiveness
for both patients and organizations. Follow up research should include whether practices used by
nurse navigators are universal. This research would support the importance of their practices and
improve patients’ outcomes in turn.
Section 5: Dissemination Plan
The dissemination plan included providing the recommendations from this project to the
CNO of the project hospital. The information provided comprised of the revised job description
and comprehensive literature review with associated recommendations. A podium or poster
presentation of the project is also planned.
The hospital is currently on the journey toward achieving “magnet status” as outlined
through the American Nurses’ Credentialing Center (ANCC) associated with the American
Nurses Association (ANCC, 2018). This project was geared toward enhancing professional
independent nursing practice to promote excellence in the delivery of care, clinical practice, and
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dissemination of findings toward best practices in nursing services. If accepted by the
organization for implementation, the project findings will be provided to the education champion
for dissemination toward the “Magnet Journey.”
The audiences who may be most impacted by this project are the nurse navigators in the
organization, quality management staff, and organizational leaders. This project defined
necessary cost-effective tasks, knowledge areas, and skills for the nurse navigator role and
offered recommendations for continued improvement through documentation of interventions
and outcomes.
Analysis of Self
This project has been enlightening as a nurse practitioner and scholar. Overall, there was
a great deal more to the potential solution than just stating the problem. It was informative to see
how the nurse navigator role started and has evolved beyond oncology and what the different
departments have done with the role. As an advanced practice provider, the project demonstrated
the importance of considering the literature for direction and seeing where the evidence may
lead. Parts of this project assumed to be easier, were the most difficult parts of the project to
complete. One example was the IRB process. This process was an experience that will be applied
in addressing future practice problems to ensure a broad view is brought to investigation instead
of assumptions that may be ill-guided.
Summary
Health care has become very complex and nurses must embrace and use their clinical
expertise in support of patient navigation through the health care system. The goal of this project
was twofold as it was geared toward both improving nursing care for patients and addressing the
organization’s interest in decreasing 30-day readmissions and providing cost-effective care. For
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nursing, it provided an avenue for assisting patients through discharge and the transition to home
to delay or interrupt disease progression through best practices. For the organization, the project
worked to decrease costs associated with unnecessary testing and avoidable readmissions. The
project has established the framework for continuing to improve the quality of care delivered
through consistent application of the nurse navigator role and recognition of the value a specific
nurse navigator department may bring to the organization.
“To say that the world of health care is in transition is to understate both the magnitude
and scope of the changes taking place in how illness is treated and how health is promoted
around the globe” (Kimberly & Cronk, 2016, p. 162). These changes can impact both delivery of
care and types of services rendered. “U.S. health care spending increased 4.3 percent to reach
$3.3 trillion, or $10,348 per person in 2016” (CMS.gov, 2016, p. 1). There is the added challenge
of trying to meet the consumers’ needs while attempting to contain skyrocketing health care costs
for a population that is aging and thus at greatest risk for acquiring one or more chronic
conditions. “Private employers are increasingly demanding that health care insurers address these
cost through disease management programs and government health plans, notably Medicare”
(Garrett & Martini, 2007, 51).
Beyond cost, the health care system struggles for a variety of reasons, making it is
difficult for the health care system to meet the needs of people with higher risk conditions. Care
often lacks interdisciplinary coordination, leading to a combination of unnecessary testing or
duplication of services. Patients are often left with conflicting information from multiple
providers. This is a cost burden for the patient. This lack of coordination, in turn, can cause
confusion when navigating the health care system. This can impact the patient’s quality of life,
perhaps through accelerated disease progression or acute exacerbation.
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Often, this confusion within the health care system makes it difficult to access services as
an individual patient, creating an inadvertent barrier to appropriate medical care specifically for
their given condition. For the patient newly diagnosed with an acute or chronic condition, their
world is changed by added medical appointments, testing, and lack of knowledge of how this
will impact their life. A chronic medical condition also can create undue stress for the patient
who attempts to manage the condition only to become decompensated with acute symptoms or
with an exacerbation requiring a hospital admission or readmission. If the patient had received
help understanding the resources necessary for their condition, they might have been avoided.
This support gap has now increased the risk of overall morbidity and mortality and created a cost
burden for the patient and the family.
Health care organizations can facilitate navigation of the health care system for the
highrisk patient. “A variety of strategies implemented at an organizational level have been
developed to help prevent hospital admissions or readmissions, accelerate discharges, improve
access to care and the care quality as patients transition between providers and health care
settings” (Manderson et al., 2012, p. 114). This paper will provide an overview of the nurse
navigator role, detail interventions to promote best outcomes for the at-risk patient with an acute
or chronic condition(s), include a thorough review of the evidence regarding the nurse navigator
role, and propose a plan to help patients navigate the health care system more efficiently.
Purpose Statement and Project Objectives
The purpose of this project was to determine which interventions used by nurse
navigators promoted the best outcomes for the at-risk patient. The navigator role was first
developed by Harold Freeman in 1990. This new model resulted from seeing a disparate number
of African American women presenting with late-stage breast cancer, which was attributed in
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part to their inability to access needed cancer care services. The nurse navigator role was
developed to assist patients with a cancer diagnosis to get the benefit of the best possible
oncology care.
In recent years, this role has expanded to assist patients with chronic disease management
and other illnesses. Because this is a relatively new role for nurse navigators, the impact has not
been rigorously documented (Manderson et al. 2012). Outside of oncology, this role is being
pioneered to see if the use of nurse navigators can help contain costs by decreasing hospital
length of stay and avoiding costly penalties for certain high-risk populations such as persons with
heart failure (HF) or chronic obstructive pulmonary disease (COPD) who may have frequent
rehospitalizations, emergency room (ER) visits, and low satisfaction with the delivery of care.
As health care becomes increasingly complex and as more pressure is placed on acute
care settings to decrease length of stay and readmissions, the nurse navigator will likely become
more valuable. When patients come through the hospital door, they become at-risk for several
points of process failure which, in turn, hinders optimal care. “On average, in 2010, Americans
received 70% of indicated health care services and failed to receive 30% of the care they needed
to treat or prevent particular medical conditions” (AHRQ, 2014, p. 2). Barriers that may
contribute to lack of access include poor communication, health care illiteracy, inconsistent
medical management, and lack of accountability by either the patient or the provider.
Utilization of the nurse navigator role provides an alternative to minimize lapses of care.
Nurse navigator programs “seek to improve patient care by reducing barriers to care, through the
provision of information, social and emotional support, links to existing services and resources,
as well as patient referrals to service providers” (Whitley et al., 2011, p. 3617). The nurse
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navigator can help the patient at any point of entry to the health care system and support her or
him through to discharge and follow-up.
To understand the effectiveness of the role, the hospital or other employer must be able to
measure the impact of the nurse navigators on the at-risk populations at each of the critical points
where process failure can occur. For the high-risk patient, the organization must be able to
articulate the process impact of the nurse navigator when the patient comes through the door, at
discharge, and when making the follow-up appointments to provide optimal transitional patient
care.
At entry to the system, the patient must be quickly identified as an at-risk patient based on
an acute presentation, a 30-day readmission, or extenuating circumstances that could hinder
optimal care such as health literacy or language issues, lack of family or a caregiver, or financial
and transportation issues. Any identified barriers to optimal care need to be addressed by the
nurse navigator prior to discharge.
Discharge is a second point of potential failure in patient care. “During the hospital to
home transition, patients are at high-risk for adverse drug events, incomplete or inaccurate
information transfer, preventable hospital readmission, and even death” (Davis et al., 2012, p.
1649). The patient may become overwhelmed with whom to see and what to do to manage their
condition(s). They are discharged where further breakdown in disease management can occur. To
help manage their new or chronic condition, the patient needs a strategy upon discharge to help
with a plan of care.
Finally, follow-up is a third point of potential process failure for patient care. Before
walking out the hospital doors, it is important that each patient has an appointment with the
providers who are best suited to care for their disease process and a way to get to that
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appointment. Collaboration with other health care team members is crucial to set up the patient
for success when they are managing care in the outpatient setting. There are many resources in
the community to help the patient manage his own care, but before discharge occurs, these
resources must be arranged. It is not unusual for a hospital to discharge a patient on a Friday
afternoon without the necessary services in place. If the patient cannot pick up his or her
necessary medications, food, assistive equipment, or other supplies for managing his condition
independently, he may be back in the hospital by Monday.
Significance to Practice
The significance to practice is providing appropriate high level care while being cost
conscious. “As a nation, we spend 86% of our health care dollars on the treatment of chronic
diseases” (CDC, 2015, para 1). People are living through acute injury and as a result living
longer and developing chronic, progressive condition(s). According to Anderson (2010), “in
2009, 145 million people—almost half of all Americans—lived with a chronic condition” (p. 4).
There has been a great deal of push for a decreased hospital length of stay, reduced
avoidable 30-day readmissions, and yet an increased patient satisfaction score to avoid penalties
imposed on acute care organizations. According to the Centers for Medicare and Medicaid
Services (2014), Section 3025 of the Affordable Care Act added section 1886(q) to the Social
Security Act establishing the Hospital Readmissions Reduction Program, which requires CMS to
reduce payments to IPPS hospitals with excess readmissions.” These expectations present
challenges in health care delivery and could place the vulnerable and/or chronically ill patients at
risk for increased morbidity and mortality.
Because of the increasing fragmentation, associated complexities, and limited resources,
patients and their families need help to navigate the health care system. Those patients with
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persistent, chronic, medical conditions require additional support with access to care. Many
organizations have adopted a nurse navigator program driven by the potential cost-effectiveness
of the role. The significance is twofold. For patients, a nurse navigator provides an interpreter of
sorts, helping the patients make sense of their disease process. On the health care provider and
organization side, the goal is to decrease health care costs. The nurse navigator can provide
continuity of care aimed at reducing duplication of testing, unnecessary testing, and readmissions
perhaps, by setting patients up with the right services.
A nurse navigator is in the position for service access. According to Gilbert et al. (2011),
the “core navigation functions include simplifying access and improving continuity of care,
proactive navigation, assistance in overcoming barriers and/or disparities, patient advocacy,
coordination of care, and support in achieving efficiencies” (p. 230). There is a need to
implement strategies aimed at collaborative care coordination among healthcare providers. This
placed the nurse navigator in the forefront to improve care and efficiency within the process.
Implications for Social Change
The implication to social change is to become a catalyst for improving health outcomes
while providing quality services. Healthy People 2020 reported “access to health services means
the timely use of personal health services to achieve the best health outcomes” (Healthy People
2020, 2015, para. 3). The aim of the nurse navigator role is to assist the patient through the
continuum of the health care system while decreasing overall health care associated
expenditures. According to the World Health Organization (2015), the United States ranks 37th of
all world health systems in its effectiveness and surpasses every other country in the money it
spends on health care as a percentage of its gross domestic product.
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This project is expected to improve society by helping patients improve health outcomes
and/or quality of life by adopting care practices that are supported by the evidence. For patients,
this will increase their overall satisfaction while providing them with a liaison to advocate for
their direct care needs. For the health care system, the nurse navigator offers a higher level of
care delivery that will be cost effective because it will avoid readmissions within 30-day and, as a
result, decrease overall health care expenditures.
Project Question
The project question was as follows: What are the tasks, knowledge areas, and skills
necessary for inclusion in a hospital-wide nurse navigator job description to promote best
outcomes for chronically ill and at-risk patients? The consensus in the literature was that the
nurse navigator role was geared toward decreasing fragmentation in health care delivery for
patients and helping them to maneuver through the system; however, there may be ways to
optimize and standardize the role within the project hospital for greater effectiveness of the rôle.
Local Context
The project hospital was an acute care facility with a total of 225 beds in southeastern
Ohio. Currently, a total of 862 registered nurses are employed in various roles with a total of 16
nurses in the nurse navigator role. Two of these nurse navigators also function as case managers.
The role of the nurse navigators is to identify those patients at risk for 30-day readmissions.
There are five nurse navigators employed in cardiovascular services who see patients with heart
failure, atrial fibrillation, acute coronary syndrome, or those in need of coronary artery bypass
graft surgery. Four nurse navigators are employed in oncology services who see patients with
specific cancer diagnoses. The breast cancer nurse navigator is the only certified navigator.
There are four nurse navigators who see patients with chronic obstructive pulmonary disease.
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Finally, the newest addition is a diabetic nurse navigator, formerly known as a diabetic educator.
Project Objectives
Based on the project question, six objectives were accomplished to incorporate
evidencebased best practices for level of education, skill set, duties, policy and procedures, and
the nurse navigator role at the project site. These objectives were as follows:
13. Review all 13 nurse navigator job descriptions at the project site.
14. Develop a comprehensive list of common job expectations and required skill set for
the role from the various job descriptions.
15. Compare the list of common job expectations and skills to best practices for the nurse
navigator role as identified in the literature.
16. Develop a new job description for the nurse navigator role.
17. Develop recommendations to standardize the nurse navigator processes and
procedures at the project hospital.
18. Recommend a method for evaluating the effectiveness of the nurse navigator in
reducing 30-day readmission rates at the project hospital.
Evidence-Based Significance of the Project
The evidence-based significance of the project is role refinement and implementation of
best practices to achieve a higher level of patient care in a cost-effective manner. Titler (2008)
defined “evidence-based practice (EBP) as the conscientious and judicious use of current best
evidence in conjunction with clinical expertise and patient values to guide health care decisions”
(p. I-113). In the role of the nurse navigator, the goal is to provide best care that is clinically
sound and based on practices that promote optimal patient outcomes. For example, heart failure
guidelines are often cited by the American College of Cardiology and American Heart
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Association (ACC/AHA). The basis of these guidelines has been well researched, peer-reviewed,
and graded according to how well the evidence supports the recommendations. A nurse
navigator, in collaboration with the health care team, should have a thorough understanding of
the guidelines and ensure that they are being followed. What sets the nurse navigator apart from
other nursing roles is their interactions with patients to ensure continuity of care throughout and
beyond the current hospitalization with a plan to avoid harm or readmission. In the literature,
there is a great deal of research on defining the nurse navigator role in general, but no research
was found on patient care outcomes and realized cost-effectiveness to the organization.
Assumptions
An assumption in the development of the project was that use of the nurse navigator was
emerging as a role for assisting patients in a system that is complex and full of fragmentation. It
was assumed the role will be used increasingly in hospitals to support patients who are at a
considerable risk of becoming medically decompensated or whose circumstances necessitate a
liaison for access to care. Another assumption is older patients who have at least one chronic
illness are at a higher risk for morbidity and mortality and this risk increases when the patient has
more than one acute and/or chronic condition. These patients can benefit from nurse navigator
interventions to attain an optimal quality of life and slowed disease progression.
Summary
Health care is becoming increasingly complex and fragmented; it is challenged to keep up
with delivery of care and the competitive types of services that it provides. This environment
increases the chances of the patient falling victim to barriers in care. Organizations must avoid
lapses in care due to inattention to these barriers and the nurse navigator role may be able to help
patients at highest risk for falling through the gaps.
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Since nurse navigators first emerged in hospital-based oncology patient care in the 1990s,
the role has expanded to include many other areas and medical diagnoses. With the expansion of
the role, it is necessary to understand which interventions used by the nurses in this role
promoted the best patient outcomes. This understanding must be grounded in the evidence while
considering the clinical expertise required to guide appropriate health care guidance at critical
junctures in hospital care (admittance, discharge education, outpatient care service and resource
planning).
While it was assumed the use of the nurse navigator role was vital in a system that is
complex and fragmented, the ultimate benefit was that promoting the best outcomes for the
patient yielded the most cost-effective manner. At the conclusion of this project, interventions
that best support patients at risk for poor post hospitalization outcomes will be identified.
The next section will focus on the history of the nurse navigator as well as reviewing the
literature as it pertains to the nurse navigator roles. The conceptual model of evidence-based
practice will be discussed as it relates to the necessity for this project.
Section 2: Review of Scholarly Evidence
Introduction
The purpose of this project was to identify which nurse navigator interventions promoted
the best outcomes for at-risk patients. “Whether care is delivered in an urban clinic or in rural
private practices, patients may experience delays in diagnosis and treatment and receive
fragmented, uncoordinated care” (Case, 2011, p. 33). Delivery of care in a complex health care
system presents potential barriers for the patient and/or the care is not conducive to realizing
evidence-based best practices.
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In the subsection on specific literature, I will discuss the first navigator program
introduced by Harold Freeman in 1990 and the role nurse navigators played in care coordination.
Since then, the role has expanded beyond oncology to other areas of chronic disease and to
patients considered to be high-risk, such as elderly patients and who experience barriers that
threaten worse outcomes.
In the subsection on the general literature, I will discuss the nurse navigators’ role(s) in
coordination of care, including barrier identification and discharge planning to promote optimal
outcomes for the patient. The purpose of the general literature review is to broadly outline the
interventions that are necessary to decrease system fragmentation and to align the patient with
resources to achieve optimal outcomes.
Finally, I will discuss the evidence-based practice (EBP) model. According to Satterfield
et al. (2009), EBP “provides a useful framework for guiding health services research with an
interdisciplinary and real-world perspective” (p. 384). The reason for establishing which nurse
navigator interventions promoted the best outcomes for at-risk patients is based on which clinical
practices have proven beneficial for the patient (and their association with the health care
system’s delivery mechanisms). These clinical practices in turn will promote optimal and
sustainable multidisciplinary care.
Specific Literature
Dr. Harold Freeman was the pioneer in development of the first nurse navigator role. He
was involved in two Harlem hospital studies (1986 and 1995-2000) that demonstrated an
increased 5-year survival rate of poor African American women with breast cancer who used a
navigator program. “The 5-year survival was 70%, compared to 39% in the earlier Harlem
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Hospital study” (Freeman, 2006, p. 140). The survival rate demonstrated a need for a liaison to
assist with access to care.
According to the Harold P. Freeman Patient Navigation Institute (2015), “navigators act
as the support hub for all aspects of patients' movement through the health care system” (para 6).
They were shown to be effective with removing barriers to care. “Although Nurse Navigator
programs most commonly target cancer patients, the literature supports that opportunity exists to
extend nurse navigator programs to other chronic diseases” (Pruitt & Sportsman, 2013, p. 593).
The role of patient navigator or nurse navigator has grown since being introduced in 1990
by Dr. Freeman. “The principal function of the navigator is to eliminate any and all barriers to
timely screening, diagnosis, treatment, and supportive care for each individual” (Harold P.
Freeman Patient Navigation Institute, 2015, para 6). Research is emerging in support of the nurse
navigator for patients with chronic illness and other high-risk presentations; however, no research
could be found that assessed the effectiveness of the role outside of oncology.
The literature search used the following databases: Cochrane Library, JBI Library,
Medline, CINAHL, SAGE, and SocINDEX. The following key terms were used alone and in
combination: patient, navigator, nurse, pivot, discharge planning, hospital, care coordination,
chronic disease, and coordination.
The search yielded 5,665 potentially relevant articles. From the articles, a total of 27
articles were found to be applicable. After review of these 27 articles, eight more articles were
excluded leaving a total of 19 articles. The articles were excluded for two reasons: they were not
relevant or were duplicate articles; (b) included literature related to pediatrics, mental health, and
dementia. It was felt, while these populations may be classified as chronic and/or high-risk, there
are special considerations for care of these patients that are not suitable for this. Inclusion criteria
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included literature comprising of the following: (1) the nurse navigator role, (2) barriers to access
of health care, (3) care coordination, and (4) discharge planning aimed at readmission rate
reductions. Literature specific to the nurse navigator role included ten total articles, two of which
focused on barriers to care or treatment; the other eight articles focused on the specific aspects of
the navigator role. Three of the studies were randomized controlled trials, two were longitudinal
studies, and one was exploratory. See Table 1 below.
Table 1
Specific Literature Delineating the Nurse Navigator Role
First Author
Inclusion
Aim(s) of the study
Details of intervention
Reported outcome(s)
Asgary et al.
Barriers to care
Identify and understand
colorectal screening rates,
predictors, and barriers to
screening for homeless in
New York City
Proposed intervention to
improve colorectal cancer
screening by including
private shelter rooms for
colonoscopy prepping.
Patient navigators to assist
with health care
navigation, accompany to
and from procedure,
counseling at all
Patient who were
homeless were less likely
than domiciled patients to
have up-to-date screening
(19.7% vs 41.3%; p <
.001).
Homeless patients were
significantly less likely to
have had a previous
colonoscopy (p < .05).
encounters, and education
to specific patient to curb
misconceptions.
Nurse navigators are
recommended to assist
with barriers to care
Calhoun et al.
Nurse navigator role
To develop a patient
navigator competency
program
Randomized control
design
Standardized training for
patient navigators with a
goal to provide
dissemination of
information, skills, and
competencies aimed at
decreasing barriers by
underserved papulations.
Recommend national
standardized training for all
chronic disease navigators.
Curriculum training; n =
110, with a mean pretest
score of 19.79 (SD =
2.76) and a mean posttest
score of 20.74 (SD =
2.44) showing
improvement in
knowledge
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Dennis et al.
Barriers to care
To assess if patient
navigators and use of the
Direct Endoscopic
Referral System (DERS)
would increase timely
colorectal cancer
screening for a large urban
hospital in a
predominately poor
region
Retrospective analysis
Hired 2 patient navigators
and implemented the
DERS to see if the number
of broken appointments
decreased for colorectal
cancer screening and
diagnostic colonoscopies.
Study suggests when
barriers are addressed,
screening rates increased
The rate of broken
appointment for both
screening and diagnostic
colonoscopies
significantly dropped
from 67% to 5%.
Nurse navigator role in
appointment increased
compliance rates 3-fold
(relative risk = 2.6, 95%,
Cl = 2.2-3.0)
Gunn et al.
Nurse navigator role
To determine if published
nine principle model of
navigation mirrors the
practice in breast cancer
navigator programs.
Exploratory Study
Observation of the
navigators in the 10
programs for a total of
179.5 hours. Codes were
used based on nine a priori
themes derived from the
nine-principle
model
Found individual level
principles were broadly
consistent with the
nineprinciple framework;
whereas program level
principles were variable
across programs
Horner et al.
Nurse navigator role
The aim was to test the
effectiveness of a 16week
oncology nurse navigators
(ONN) program compared
to enhanced usual care to
support cancer patients
early in treatment.
Randomized control trial.
Each patient (n = 251)
was assigned to a group
based on which primary
care clinic they belonged
to. The primary care
clinics (n = 11) were
randomly assigned to
either the ONN program
or enhanced usual care
group.
The results were not
disclosed in the article
pending result analysis.
Jolly et al.
Patient navigator role
The aim of the study was to
design a patient navigator
role from laypersons to
help coordinate care,
address system barriers and
to
Proposed intervention was
developing a patient
navigator role using lay
persons to assist CKD
patients. Electronic medical
record templates
The 2 hired patient
navigators were trained
and responsible for
navigating patients
enrolled in a clinical trial.
They were trained in
educate/motivate their
patients.
were created and
identification of barriers.
general patient navigation,
specific education on
CKD, and patient privacy
and research training.
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May et al.
Nurse navigator role
The aim of the program was
to implement a GI
multidisciplinary care
(MDC) program with
integration of a GI nurse
navigator (NN) to optimize
care of patients newly
diagnosed with GI cancer
The intervention was:
• Nurse
navigator to
contact patient
within 2 days
of diagnosis
(goal 80%)
• Cancer staging
completed
within 5
business days of
referral (goal
80%)
• 90% of the
patients to be
seen by GI MDC in 10
calendar days 70% of
patients to start cancer
treatment within 22
calendar days.
Result of quality
indicators from 1/2010 to
8/2012 with use of GI NN
includes the following:
• Nurse
navigators
contacted
patient within
2 days of
diagnosis
(outcome
89%)
• Cancer staging
was completed
within 5
business days
of referral
(outcome 85%
• 91% of the
patients were
seen by GI MDC in 10
calendar days 75% of
patients were started on
cancer treatment within 22
calendar days.
Percac-Lima et al.
Nurse navigator role
The aim was to understand
if the use of a nurse
navigator with Latina
women having an
abnormal pap smear result
would decrease
Information was obtained
over two-time periods
(2004-2007, and
20082011) to establish if
the use of nurse navigators
verses no use of nurse
navigators (comparison
group) were influential
with the following
outcomes for Latina
women with an abnormal
pap smear result:
• Missed
appointment
for colposcopy
• Time to
colposcopy
Changes in severity of two-
time periods
Nurse navigators were
influential with:
• Missed
appointment
for colposcopy
decreased for
navigated
Latina women
versus
comparison
group (p <
0.001)
• Time to
colposcopy
was shorter for
nurse
navigated
Latina women
versus
comparison group (p =
0.010) Changes in severity
of two-time periods
decreased for navigated
Latina women verses
comparison group (p <
0.001)
Redwood et al.
Patient navigator role
The aim was to have
patient navigators in Alaska
contact first
The patient navigators
contacted the first-degree
relatives by telephone or
The results showed a
significant increase in
colorectal cancer
degree relatives of
colorectal cancer patients to
obtain colorectal cancer
screening
mailed reminders.
screenings with the use of
patient navigators
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Wagner et al
Patient navigator role
To determine if a nurse
navigator intervention
improves quality of life
and patient experience with
care
Two-group clustered
randomized controlled
trial
Study used adults with
recently diagnosed
primary breast, colorectal,
or lung cancer (n = 251)
who received either
enhanced care (n = 118) or
nurse navigator support
for 4 months (n = 133).
No significant differences
found between groups in
FACT-G scores meaning
NN intervention did not
impact quality of life or
delays in receiving care.
However, patients
reported significantly
higher scores on the
PACIC survey and
reported significantly
fewer problems with care,
including psychosocial
care, care coordination,
and information
Most included studies that provided an overview of the nurse navigator role discussed
some form of cancer navigation, although one study by Jolly et al. (2015) discussed
implementing two nurse navigators to assist with care coordination and education of patient with
chronic kidney disease.
Three studies discussed program development, including one by May et al. (2014). The
study provided and discussed measurable interventions from the start of patient contact to start of
the cancer treatment. This study concluded that there was a benefit in having a nurse navigator to
expedite this process.
A randomized, controlled trial conducted by Horner et al. (2013) tested the effectiveness
of a 16-week oncology nurse navigators (ONN) program; however, no results were provided.
Another randomized study by Calhoun et al. (2010) looked at curriculum for training navigators
and recommended national standardized training for all chronic disease navigators.
Overall, the literature referring to the nurse navigator role discussed either curriculum
training, focused on a specific at-risk group, or found an increased compliance rate with care
needs by helping the patient overcome barriers to care. None of the literature specific to the
navigator role discussed discharge planning.
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Role refinement and assessment is crucial. The Oncology Nursing Society (ONS)
conducted a study called the Oncology Nurse Navigator (ONN) Role Delineation Study in 2010.
The purpose of the ONS ONN Role Delineation Study was to examine the job-function activities
and knowledge required of the ONN, thereby providing an understanding of this new role
(Brown et al., 2012). Based on information gathered from the respondents, a list of necessary
skills, tasks, and knowledge was initiated to define the ONN role. A mean rating of 3.5 – 4.49
was considered to be very significant for understanding role delineation.
For tasks, 62% of the task identified were significant for the nurse navigator role. Those
task rating at the highest includes: providing emotional and educational support, practicing in
accordance to professional standards, advocation, orienting patients to the system, receiving and
responding to referrals, pursuing continuing educational opportunities related the specialty and
specific to the nurse navigator role, assisting with informed consent, multidisciplinary
collaboration, identifying patients in need of navigation, and education.
Knowledge areas were considered to be 91% significant in accordance to the very
significant rating scale. Higher on the list of knowledge included: informed consent, advocacy,
symptom management, ethical principles, quality of life, treatment goals, therapeutic options,
evidence-based practice guidelines, and scope of practice.
“The 12 skills included on the survey were rated on the same scale and the skill on the
survey provided a sound basis for defining the skills needed within the navigator role” (Brown et
al., 2012, p. 584). It was ascertained that, overall, more research was needed on this topic.
The study by Wagner et al. (2014), used a clustered randomized controlled trial to
determine if the use of a nurse navigator intervention improved the quality of life and patient
experience for those patients recently diagnosed with breast, colorectal, or lung cancer. It was
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noted that the Functional Assessment of Cancer Therapy–General (FACT-G) quality of life
scores showed no significant impact of the nurse navigator on quality of life or delays in care.
There was a significant difference on the Patient Assessment of Chronic Illness Care (PACIC)
survey: patients reported fewer problems with care; in particular psychosocial care, care
coordination needs, and information. The study also showed in the lung cancer patients a
decrease of $6,852 in care costs among nurse navigator patients. There was no significant cost
reduction in care of breast or colorectal cancer patients.
General Literature
The general literature included studies of discharge planning and care coordination, which
are essential duties of the nurse navigators in the acute care setting at the project hospital.
According to Russell (2013), “these hospital-based navigators primarily manage the patient’s
needs during the hospital stay and discharge planning and they work for the hospital” (para 6).
When looking through the literature, this is a point of failure for the patient after they are
discharge and before they can follow-up with their health care provider.
The nurse navigator’s focus is to assist the patient through the health care system. The
care coordination and discharge planning piece is intertwined in this role. Social workers and
case managers have traditionally assumed this role with general patient admissions. Because the
nurse navigators, social workers, and case managers do not always collaborate, this does not
always allow for a more individualized plan of care to help the patient in terms of reducing ER
visits and readmissions for patients who are at risk. Unfortunately, no literature could be found to
understand which interventions by the nurse navigator promote best outcomes for the at-risk
patient.
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Holliman et al. (2003) explored the role of social workers versus nurse discharge planners
and found no significant difference in job roles. This was the only article found that met the
inclusion criteria.
In terms of care coordination, eight articles were included. A cross sectional study by
Bradley et al, (2013) was conducted to understand what strategies are independently associated
with a reduction in 30-day readmissions. [Strategies that were associated with lower hospital
RSRR included: 1) partnering with community physicians or physician groups to reduce
readmission (0.33 percentage point lower RSRR, p = 0.017), 2) partnering with local hospitals to
reduce readmissions (0.34 percentage point, p = 0.020), 3) having nurses responsible for
medication reconciliation (0.18 percentage point, p = 0.002), 4) arranging follow-up
appointments before discharge (0.19 percentage point, p = 0.037), 5) having a process in place to
send all discharge paper or electronic summaries directly to the patient's primary physician (0.21
percentage point, p = 0.004), and 6) assigning staff to follow up on test results that return after
the patient is discharged (0.26 percentage point, p = 0.049)] (Bradley et al. 2013, p. 2).
A qualitative study by Kainfar et al. (2014) was the only article found discussing chronic
care coordination. Coordination elements of communication, relationship building, and care
coordination were identified as essential elements for care coordination. For chronic care
coordination, this connection is one which is open and interdisciplinary where collaboration is
occurring. The relationship becomes the interaction between health care professional discussing
care coordination activities or by the patient and health care professional. Monitoring takes on
the patient’s overall status, or changes in status, and monitoring activities of other health care
professional caring for the patient.
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Legarin et al. (2011), did a randomized controlled trial to determine if a multimodal
approach would decrease ER visits and readmissions in patients older than 70. They looked at
specific risk factors of preventable readmissions which included drug related problems,
depression, and malnutrition. They concluded the multimodal approach was effective at 3 months
but not at 6 months. The authors concluded the following as an explanation of the insignificant
effect at 6 months including: “contamination of the control group (acute geriatric unit physicians
could have integrated parts of the treatment review and implemented them in the control group);
lack of power (it was initially planned to include 800 participants), or lack of post discharge
follow-up” (Legrain et al., 2011, p. 2026).
Often at discharge, patients are faced with multiple medication variations increasing
confusion for the patient or provider trying to manage these changes. These changes can include
increased or decreased dosing of a current medication, new medications additions, and/or
medications discontinued. A knowledge deficit can cause potential harm to the patient or bring
them back as a potential readmission. Kaanan et al. (2013) did a retrospective study to determine
the number of adverse drug events after discharge. They found in their study, 242 patients
(n=1000) had an adverse drug event. More than 50% of the adverse drug events occurred within
14 days post discharge. Overall, at 45 days post discharge, 35% were deemed preventable, 32%
of drug events were classified as a serious event, and 5% were considered life threatening. “The
findings of the current study serve to reinforce the importance of medication safety as a critically
important concern during this period of high vulnerability for older adults” (Kaanan et al., 2013,
p. 1897). The general literature is summarized in Table 2 below. Table
2
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General Literature Delineating the Nurse Navigator Role
First Author
Inclusion
Aim(s) of the study
Details of intervention
Reported outcome(s)
Bradley et al.
Chronic care coordination
To identify hospital
strategies associated with
lower readmission rates for
heart failure patients
Cross-sectional study of
hospitals participating in a
web-based survey
Risk-standardized 30-day
readmission rate (RSRR)
determined several strategies
were effective with heart
failure (HF) patients
13) partnering with
community physicians or
physician groups 0.33
percentage point lower
RSRR, p = 0.017)
14) partnering with
local hospitals (0.34
percentage point, p =
0.020)
15) nurses
responsible for medication
reconciliation
(0.18 percentage point, p
= 0.002)
16) follow-up
appointments made prior
to discharge (0.19
percentage point, p
= 0.037)
17) EMR sent to
primary care provider after
discharge (0.21 percentage
point, p = 0.004)
18) Follow-up of
after discharge test results
(0.26 percentage point, p =
0.049).
reduction of 0.34
percentage point for each
additional strategy used
Holliman et al.
Discharge planning
To explore the roles of
social workers and nurse
discharge planners and
gain further understanding
of the similarities and
differences between these
roles
Convenience sampling of
Alabama hospitals who
were members of Alabama
Hospital
Association
Recommends social worker
participation in advocacy,
outcome research, and
discharge planning
The role of the social
worker and nurse
discharge planner had no
significant difference in
job roles
It was reported social
workers were
predominately hired in
federal and state hospitals
(p < .01); whereas private
hospitals were more likely
to hire discharge nurse
planners. Nurse discharge
planners were
predominately hired in
hospitals with less than
112
250 beds while social
workers were more likely
hired in hospitals with
greater than 250 beds
Kainfar et al.
Chronic care coordination
The overview of
coordination of care with
implications to care of
chronically ill patients
Interview of 12 different
health care professionals
involved in care
coordination of chronically
ill patients with CHF and
COPD
Found through interviews
communication,
relationship building, and
coordination of care as
essential elements with
CHF and COPD patients
Kanaan et al.
Care coordination
To characterize frequency,
preventability, and
severity of adverse drug
events (ADE) within
45 days after
hospitalization in patients
older than 65
Retrospective analysis
Comprehensive chart
reviews conducted on
patient’s part of senior plan
membership (n = 1000) to
determine ADE
Out of 1000 patients, 242
had an ADE, with 35%
preventable, 32% serious,
and 5% life threatening.
Over 6% (6.6%) met
Beers criteria when
looking at high quality of
evidence and strong
strength recommendations
Legrain et al.
Care coordination
To determine if a
multimodal intervention
could decrease ER visits
and hospital readmissions
in patients older than 70 at
3 and 6 months
Randomized,
parallelgrouped of
interventiongroup (IG, n =
317) and control-group (CG,
n = 348), open-label trial
The intervention to reduce
ER visits and hospital
readmissions was effective
at 3 months but ineffective
at 6 months. At 3 months,
IG was 23% compared to
CG at 30.5% (p = .03); at 6
months IG was 35.3% and
CG at 40.8% (p = .15)
Mistiaen
Care coordination
To assess the
effectiveness of follow-up
phone calls up to 1-month
post-discharge from the
hospital in eliminating
problems
Literature review of
randomized and
quasirandomized control
trials to determine if
follow-up phone calls were
effective
in alleviating post
discharge problems
Evidence of effectiveness
of telephone follow-up
was inconclusive
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Rathert et al.
Clinical outcomes
To determine if patient
centered care (PCC)
influences patient outcomes
Systematic review of PCC
and patient outcomes
Review of 40 articles
reports an inconclusive
result of PCC on patient
outcomes. The studies did
find stronger evidence for
positive influence of PCC
on patient satisfaction and
self-care management
Shepperd et al.
Care coordination
To determine the
effectiveness of
individualized discharge
planning compared to
routine discharge planning
not individualized
Literature review of
randomized control trials
It was determined through
the literature that use of
individualized discharge
planning was statistically
significant in reducing
hospital length of stay and
readmissions. Hospital
length of stay (- 0.91, 95%
Cl = -1.55 to -0.27, 10
trials) and readmissions
(0.82, 95% Cl = 0.73 to
0.92, 12 trials)
Wee et al.
Care coordination
To evaluate if a national
transitional care program
for elderly patients with
complex care needs and a
limited social support
system reduced ER visits
and hospital readmissions
Dedicated care coordinators
were used to educated and
coordinate care needs and
follow-up 1-2 weeks post-
discharge. ER visits and
hospital readmissions were
Use of care coordinator
reduced ER visits and
hospital readmissions 30
days post-discharge
compared to patients
without a care coordinator
(0.5, 95% CI = 0.5 to -0.6
6 months post discharge reviewed to see if the and 0.81, 95% CI = 0.72
patients were previously to -0.90); and 180 days seen by a care
coordinator post-discharge (0.6, 95% or no care coordinator
CI = 0.5 to -0.6 and 0.9,
(comparison group) 95% CI = 0.82 to -0.99)
The general literature provided evidence to support individualized discharge planning and
care coordination aimed at reducing lapses in care, ER visits, and 30-day readmissions.
“Systematic problems such as lack of patient education, and insufficient coordination between
health professionals, especially during care transitions, contribute to readmissions” (Legrain et
al., 2011, p. 2018). For a patient who is already at high-risk or with more than one chronic
condition; this finding augmented confusion as to which evidence-based guidelines to follow by
inadvertently increasing fragmented care. Another obstacle for patients was post discharge
medication errors in general. Kanaan et al. (2013) cited multiple factors increasing the risk of
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medication errors post discharge including poor therapeutic monitoring, patients not restarted on
medications, or patients started on high-risk medications without ensuring appropriate follow-up
with their primary care provider.
Nurse navigators can play a critical role in coordination of care by partnering with the
patient to reduce potential pitfalls. Legrain et al. (2011) substantiated this statement by reporting
decreased readmissions with effective disease management programs.
Conceptual Models, Theoretical Frameworks
The EBP) model best suited to support the project outcomes is the Rosswurm and
Larrabee conceptual model for change in EBP. [The model provides a pragmatic, theory-driven
framework for empowering clinicians in the process of EBP and includes the following six steps:
(1) assess the need for change in practice, (2) link the problem with interventions and outcomes,
(3) synthesize the best evidence, (4) design a change in practice, (5) implement and evaluate the
practice change, and (6) integrate and maintain the practice change] (Pipe, 2007, p. 235). This
model will provide the necessary means to increase knowledge about the nurse navigator role to
develop and implement a job description conducive to organizational best practice in the use of
the nurse navigator role. This structure will also avoid a haphazard reporting of the evidence as it
unfolds in the project.
Summary
The role of the nurse navigator emerged in 1990, in an attempt to increase survival rates
of poor African American women in Harlem. The nurse navigator role was to be the coordination
of all aspects of care for patients throughout the health care system. The role of nurse navigator
has grown beyond oncology to embrace patients including those at high-risk for increased
morbidity and mortality and those with chronic disease conditions.
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A literature review was conducted to determine what interventions used by the nurse
navigator promote best outcomes for the at-risk patient. Literature for interventions beyond
oncology could not be found. The literature review focused on aspects of the nurse navigator role
to include the following: nurse navigator role, barriers to access of health care, care coordination,
and discharge planning aimed at readmission rate reductions. From the search, 18 articles were
identified for inclusion.
Of the studies included, three were randomized controlled trials, and two were literature
reviews inclusive of randomized controlled trials. According to Terry (2015), these designs
“provide health care professionals with information regarding the benefits of a specific health
care intervention” (p. 84). These studies provide a strong evidence base for the proposed project.
Overall, many of the studies were either in support of the navigator role, recommended a
navigator for barrier reduction and coordination, or implemented a program with utilization of a
nurse or patient navigator. Further studies will need to be conducted to establish what
interventions by the nurse navigator promote best outcomes for the at-risk patient.
The next section will discuss analysis of the project. This will include the approach to the
project, the data collection, and project evaluation.
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Section 3: Approach
Introduction
The purpose of this project was to determine the role of the nurse navigator and
understand what job activities provided the best outcomes for patients considered to be at-risk.
Each step will be discussed to provide an overview of the project as well as how the data were
collected, analyzed, and evaluated. The role of the nurse navigator across the different areas of
the project hospital was not clearly defined or outlined. The current job descriptions were
reviewed, and recommendations made (see Section 4) to reflect specific tasks and skills of the
nurse navigator as defined in the literature.
Project Design and Methods
For this project, a qualitative design was used to review the existing nurse navigator job
descriptions and compare these findings to the literature on best practices. Expected tasks,
knowledge areas, and skills were collected from the job descriptions and the literature on nurse
navigators.
At the project site, the tasks, knowledge areas, and skills are not threaded within their job
descriptions but more broadly as tasks to complete as they identify a patient in need of their
services. Currently, different methods are being used at the project site to determine how the
nurse navigators receive referrals to patients. The referral processes were conducted to determine
where and how the information was being retrieved. All units are using the electronic medical
record to determine who should be seen by the nurse navigator, but each unit is retrieving this
information from a different report from within electronic medical record and is oftentimes
generated by a diagnosis. The goal of having a universal report is to provide consistency in the
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referral process—one standardized method for identifying patients at-risk for readmissions or
with barriers to self-care management.
Finally, data were gathered to determine who was receiving the benefit of the nurse
navigator; these data were compared to information about patients who could benefit from the
service. This information was gathered from the different hospital reports to understand whether
patients were missed due to admission diagnosis or whether there were other unidentified themes
that resulted in overlooked referral opportunities. These data were used to demonstrate possible
changes to the referral report so that all at-risk patients could be identified for referral to the
nurse navigators.
The information (a) gathered for this project identified patients who could benefit from a
nurse navigator and (b) proposed consistent interventions to be used by the nurse navigators in
caring for patients. The goal was to identify best practices and adapt them to the nurse navigator
role at the project hospital in order to decrease the fragmentation of care, increase role
consistency across the organization, and establish a template for promoting and measuring
optimal outcomes for the patients as well as the organization.
Population and Sample
Because the project used a qualitative design, the data were extracted from hospital
documents (job descriptions) and reports being utilized within the organization. Approval for this
secondary data analysis was obtained through the hospital Institutional Review Board (IRB)
committee. The organization determines if projects require IRB approval prior to project
implementation. The application process included completing an IRB application and presenting
a PowerPoint overview of the proposed project to the hospital IRB committee. The IRB
recommended approval of the project, and key persons were contacted by e-mail to request the
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required information for data collection and analysis. IRB approval from Walden University also
was obtained before data collection and analysis began; the approval number was 08-12-
160459006.
There were no participants in this project, although human resources, current nurse
navigators, directors and managers of nurse navigators, and employees in quality management
and information technology were asked to assist with report identification and data extraction.
Data Collection and Analysis
Information was collected to understand the specific nurse navigator job requirements in
conjunction with findings from the literature. Data collection included review of the current
nurse navigator job descriptions and reports used in the hospital pertaining to the current patient
referral processes. Themes from the job descriptions and data were identified and
recommendations were made based on best practices identified through the literature review.
Challenges to Project Implementation
Each nurse navigator was interviewed to further understand current workflow and
practices. This information was provided to the chief nursing officer (CNO) in a meeting.
Information was collected on how each department utilized the nurse navigator based on
interpretation of the role, which in turn influenced daily activities performed.
No consistency existed within the nurse navigator role across the organization. For
example, not all of the nurse navigators consistently provide discharge planning and/or
consistently enlist the services of the case manager. Case management had their own nurse
navigator who did not consistently touch base with the unit nurse navigators. This finding could
constitute a point of failure for the patients if they did not have appointments made, medications
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reconciled to reduce errors, or the appropriate contacts made with community resources to reduce
care barriers and decrease potential readmissions.
Most nurse navigators are not available on off hours or on the weekends. The exception
was the oncology nurse navigators. The lack of daily availability potentially added to the
patients’ lengths of stay, increased duplication in services or testing, or delayed points of care
referrals and coordination necessary for the patients to maneuver through the health care system.
The gap in coverage potentially provided an increase in cost to the patient as well as the hospital
system.
An overview of the literature was provided to the CNO detailing aspects of the role
essential for positive patient outcomes with emphasis on discharge planning and follow-up, and a
method for process and impact evaluation of the revised nurse navigator role and data generation
processes was proposed.
A revised nurse navigator job description was presented to the CNO. The literature was
used to make revisions that standardized the role for intervention consistency only. The
information was compiled and laid out using the literature to define the role and the job
descriptions to determine what the nurse navigators’ role did for the patients to promote optimal
outcomes while decreasing readmissions for the organization.
Project Evaluation Plan
Evaluation is essential for any project to understand outcomes and establish where
positive changes may have been made. The evaluation for this project will occur after the
objectives of this project are completed and the organization decides whether to implement the
revised job description and processes proposed as a result of the project. Evaluation places
emphasis on selecting the right type of evaluation to support the program’s goals and objectives.
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One evaluation type for assessment of the project’s goal of implementing a new job description
for the nurse navigators is a process evaluation. The process evaluation includes review of the
impact of adding tools to capture patients who need to be referred to the nurse navigators and is
expected to determine that patient care needs are better addressed through explicit accountability
and quality matrices built for the role. Providing the right tools to identify at-risk patients and
ensuring the tools are used will allow identification of the project’s effectiveness in improving
patient outcomes and impact on the organization’s goal of reducing unnecessary 30-day
readmissions.
For patients, this project is expected to establish consistency in how patient care needs are
identified and met after referral to the nurse navigator. For the nurse navigators and the
organization, this project provided a way to measure the role effectiveness with at-risk patients as
well as a means to demonstrate the impact nurse navigators had on patient care outcomes such as
decreased ER visits, hospitalizations, and rehospitalizations. Documentation of nurse navigator
outcomes will establish or validate best practices aimed at identifying interventions that help to
increase patients’ quality of life while keeping them out of the acute care setting unless
necessary. Organizational costs can be calculated to determine whether avoided CMS penalties
supported the increased employment costs for nurse navigators.
The end product will be transparency of nurse navigator program outcomes as measured
against outlined goals and objectives to sustain organizational cost-effectiveness and provide
evidence-based care to patients. Monitoring the impact of the changes will be crucial for program
evaluation. For this project, the impact evaluation will determine if the project led to decreased
30-day readmissions in the chronically ill patients or not.
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Summary
A new job description was developed to encourage consistency across the nurse navigator
role in the hospital. The quality improvement approach was designed to identify those
interventions that promoted effectiveness by meeting both the needs of the patients for expert
transitional care support and organizational cost containment by decreasing 30-day readmissions.
The change in job description and processes was accomplished by reviewing current job
descriptions, the referral process, and which patients are seen or need to be seen by a nurse
navigator. IRB approval was obtained from the project site hospital IRB and Walden University
and, with help from key persons at the project site hospital, necessary documents and data for
analysis were obtained. Recommendations for a revised nurse navigator job description were
presented to the hospital leadership and a method for process and impact evaluation of the
revised nurse navigator role and data generation processes were proposed for future
implementation by the hospital.
The next section will provide insight to the findings from all the information gathered and
a recommendation will be presented. Since this is a qualitative study, it will be important to
provide the strengths and limitations of the project.
Section 4: Findings and Recommendations
Introduction
The purpose of the doctoral project was to determine what interventions used by nurse
navigators promoted the best outcomes for at-risk patients and the hospital. Health care has
become a complex system that has unintentionally created gaps in care for many patients. These
gaps cause confusion for the patient because they do not know what questions to ask, what tests
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they need, who in the health care team is necessary to see, and what resources are available to
assist them once they go home. Patients have their own set of challenges prior to entering the
complex health care system; those most at risk have the most to lose in terms of quality of life.
At-risk patients often are faced barriers to care before entering the hospital system as well as
when they are within the hospital system. All these issues make the nurse navigator role essential
(and invaluable) for identifying patients who need assistance in their interactions with the health
care system. The ability to identify at-risk patients will yield the best outcomes to patients and to
the organization.
Each inpatient department director and/or manager who had a nurse navigator on staff
was contacted by confidential e-mail requesting information for the project as approved by the
hospital and Walden University IRB committees. A consent form was attached along with written
details describing the objectives for the project. The objectives of the project were explained in
person and any questions were answered. The evidence was obtained after a voluntary, signed
consent form was completed. The data received were current job descriptions and current
workflow sheets if used.
The nurse navigator job descriptions were analyzed for similarities and differences across
their roles in the hospital. The data were compiled and then compared to the list of tasks,
knowledge areas, and skills essential for practice competency from the Oncology Nurse
Navigator Role Delineation Study (Brown et al., 2012). The purpose of this analysis was to
determine oncology nurses’ essential job functions and activities and what activities were
essential to the role of the nurse navigator (see Table 3). A new list was developed. It included a
bridge between what had been established as essential to the role of the nurse navigator and what
the project site included in its nurse navigator job descriptions (see Table 4).
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Findings and implications
The previously published study, titled Oncology Nurse Navigator Role Delineation Study:
An Oncology Nursing Society Report (Brown et al., 2012), provided the list of essential tasks,
knowledge areas, and skills deemed important for the role (see Table 3). This list provided some
items essential to the job descriptions that could aid in developing metrices for accountability
within the nurse navigator role. This list did not, however, provide a means for evaluation,
measurement of outcomes, nor support in identifying role value. Additionally, this list was
exclusive to cancer patients and did not include aspects of care essential for patients atrisk or
with other chronic conditions. A new list was developed to bridge what had been established as
essential to the role of the nurse navigator in the literature (i.e., Brown et al., 2012) and what the
project site had included in their job descriptions for the nurse navigator roles within the hospital
(see Table 3).
Table 3
Tasks, Knowledge Areas, and Skills Table
Tasks
Knowledge Areas
Skills
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Provide emotional and
educational support for
patients.
Practice according to
professional and legal
standards.
Advocate on behalf of the
patient.
Demonstrate ethical principles
in practice.
Orient patients to the cancer
care system.
Receive and respond to new
patient referrals.
Pursue continuing education
opportunities related to
oncology and navigation.
Collaborate with physicians
and other health care
providers.
Empower patients to
selfadvocate.
Assist patients to make
informed decisions.
Provide education or referrals
for coping with the diagnosis.
Identify patients with a new
diagnosis of cancer.
Confidentiality and informed
consent
Advocacy
Symptom management
Ethical principles
Quality of life
Goal of treatment
Therapeutic options
Evidence-based practice
guidelines
Professional scope of practice
Legal and professional
guidelines
Communication
Problem solving
Critical thinking
Multitasking
Collaboration
Time management
Advocacy
Note: From “Oncology nurse navigator role delineation study: An oncology nursing society
report” by Brown et al., 2012, Clinical Journal of Oncology Nursing, 16(6), p. 584. Reprinted
with permission.
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The most comprehensive source of evidence obtained from the project site was the job
descriptions of the nurse navigators. There was a total of 13 job descriptions for the various nurse
navigator roles within the hospital. Of the job descriptions; three were from pulmonary services,
two were from cancer services, five were from cardiovascular services, one was from case
management, one was from neurological services, and one was from endocrinology services.
Each job description followed the hospital template that required a job summary, a list of
essential duties, a list of qualifications, a description of working conditions/physical
requirements, and the organization’s specific behavioral expectations.
For the purpose of this project, all the job descriptions were crosschecked against each
item in Table 1 for specific tasks, knowledge areas, and skills pertinent for the nurse navigator
role. Each item from the Brown et al. (2012) list of tasks, knowledge areas, and skills was
examined for specific coordinating wording from the organization’s job descriptions. If the items
were found, they were tallied. A total was derived and divided by the total number of job
descriptions (13) equaling a percentage of how many included the listed item. For example,
under task, provide emotional and educational support for patients was tallied nine times. This
result (nine) was divided by 13 with a result of 69% for this item. The additional items added to
the table of tasks, knowledge areas, and skills were a result of themes noted through each
individual job description and themes noted through review of the literature review. For example,
one theme, discharge planning, was noted in the literature review.
In addition, the job descriptions were reviewed to determine if there were items that
should be added to the Brown et al. (2012) list. These items were assigned a percentage (see
Table 4) using the process explained previously. The purpose of this process was to determine
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what items involving the nurse navigator were conducive to the transitional care of patients atrisk
and patients with one or more chronic conditions. Items identified for inclusion on the list were:
involvement of the nurse navigator in discharge planning, follow-up telephone calls after
discharge, knowledge of community resources and connecting discharged patients with them, as
well as the education and experience requirements of a nurse navigator.
The literature defined post discharge as a point of failure for many reasons including
patients not understanding new medications, not understanding with whom they needed to
follow-up, nor resource availability in the community to assist with ongoing health care needs.
Under tasks, providing follow-up telephone calls was added to the Brown et al. (2012) list and,
under skills, discharge nurse was added for the nurse navigator in the acute care setting. Many of
the job descriptions for the project site included the term “discharge nurse” (62%) and “provide
follow-up telephone calls” (62%) as requirements for the job.
Being able to understand and use community resources was both beneficial in reducing
readmissions within 30 days for the organization and essential for improving the patients’ quality
of life. All but two of the job descriptions (85%) included use of community resources as a
necessary component of the nurse navigator knowledge and was, therefore, felt to be an
important item to be included as an essential task for the nurse navigator role in work with at-risk
patients.
Under qualifications for the nurse navigator, all job descriptions (100%) required a
baccalaureate nursing degree. The experience required for the nurse navigator role varied
between 3 years (54%) and 5 years (46%). Education was placed under knowledge and
experience was placed under skills in the new job description.
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Finally, a critical area necessary for assessment purposes was the need for an evaluation
tool. For nurse navigators to be able to justify their role, there needed to be a tool in place for
data extraction providing descriptors of patient type, resources used, and if the nursing actions
were effective in 30-day readmission reduction. Because of the differences among settings where
the nurse navigator role was enacted in the hospital, this tool needed to be implemented specific
to patient population. From the job descriptions, (69%) clearly identified collecting and reporting
of data as a job requirement; therefore, this item was placed under tasks in the new job
description.
The job descriptions were then tallied to determine if the items from the Brown et al.
(2012) table were included. A revised table was created with additions, subtractions, and changes
based on terminology and percentages obtained from the job descriptions in conjunction with
Table 3. See Table 4 for percentages derived from the review of the organization’s 13 nurse
navigator job descriptions.
Table 4
Revised List of Tasks, Knowledge Areas, and Skills Table with Percentages
Tasks
Knowledge Areas
Skills
Provide emotional and
educational support for
patients (69%).
Practice according to
Confidentiality and informed
consent (54%)
Advocacy (62%)
Communication (100%)
Problem solving (92%)
Critical thinking (92%)
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professional and legal
standards (31%).
Advocate on behalf of the
patient (62%).
Demonstrate ethical principles in
practice (15%).
Orient patients to the cancer
care system (62%)
Receive and respond to new
patient referrals (92%).
Pursue continuing education
opportunities related to
oncology and navigation
(15%).
Collaborate with physicians
and other health care providers
(100%).
Empower patients to
selfadvocate (62%).
Assist patients to make
informed decisions (69%).
Provide education or referrals
for coping with the diagnosis
(77%).
Identify patients with a new
diagnosis (85%).
Additions
Providing follow-up phone
calls after discharge (62%)
Symptom management (15%)
Ethical principles (38%)
Quality of life (15%)
Goal of treatment (31%)
Therapeutic options (100%)
Evidence-based practice
guidelines (92%)
Professional scope of practice
(0%)
Legal and professional
guidelines (69%)
Education (100%)
Multitasking (92%)
Collaboration (92%)
Time management (54%)
Advocacy (62%)
Discharge nurse (62%)
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Community resources identification
and connection
(85%)
Experience requirements
(100%)
From the revised list, all of Brown et al. (2012) items were listed and reviewed against
each of the organization’s job descriptions to calculate a corresponding percentage. This
calculation provided a view of what was already on the job descriptions and how the items
ranked accordingly. Found from the literature review were discharge planning and follow-up
after discharge. These items were not on the list by Brown et al. (2012) but were noted from the
job descriptions. Education requirements were noted in every job description and were added to
the revised list. These additions were also assigned a percentage. Finally, the words “cancer” and
“oncology” were removed from the revised table to keep the wording more neutral and flexible
for a variety of nurse navigator patient population(s).
The job descriptions for the hospital followed the organizational templates required for
position requirements. The items most frequently cited in the job descriptions were collaboration;
therapeutic options; communication; receiving and responding to referrals; and use of evidence-
based practice guidelines, problem solving, critical thinking, and multi-tasking. These skills were
found to be present in 90% or more of the job descriptions. The areas ranked lowest for the job
descriptions included demonstrating use of ethical principles in practice and pursuing continuing
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education opportunities related to nurse navigation, quality of life, symptom management, and
enacting professional scope of practice. These areas were ranked as present in
15% or fewer of the job descriptions.
The role of the nurse navigator is becoming increasingly common in chronic care
management. There is a great deal of data for the nurse navigators employed in oncology;
however, data are limited for the usefulness of the role for patients who are considered at-risk.
When looking at the hospital’s job descriptions, the nurse navigator roles were specific to
population and diagnosis. Each job description had outlined what was expected for a narrow
range of patients. This finding was consistently presented in the job summary paragraph of each
job description. For example, in the stroke nurse navigator job description, the nurse was
described as caring for patients with ischemic or hemorrhagic stroke, or atrial fibrillation.
Also, it was clearly stated in the job descriptions where the patient should be referred
and with whom initial contact should be made. Data related to the purpose and outcomes of these
referrals and contacts are essential to understanding the nurse navigator role and how it is being
defined by hospital structure and process.
The role of the nurse navigator is aimed at helping patients find and use necessary
community and institutional resources when discharged. Assistance with arranging follow-up
appointments with the primary or specialist health care provider, ensuring delivery of durable
medical equipment, or arranging skilled care to address medical needs such as wound care and
medication administration can facilitate the transition to home. The organizational goal is to
decrease unnecessary illness exacerbations resulting in 30-day hospital readmissions just because
the patient did not understand what resources were available and how to access them. This
project outlined the nurse navigator role by specifying tasks, knowledge areas, and skills
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necessary to successfully transition hospital patients to home. The project can help to avoid
duplications or gaps in services and addresses major points of failure for the patients after
discharge.
The implications for positive social change are to provide patients with a resource (nurse
navigator) who is well equipped through education and training to use evidence-based best
practices and processes to improve patient care in a cost-effective manner. Health care delivery is
complex and constantly changing, which makes it hard for patients to understand and
increasingly frustrating for patients and families. Lack of clarity and gaps between settings take
away from coordination and continuity of care and decrease the overall quality of care, adding to
poorer outcomes for patients at risk. Having a nurse navigator to identify patient needs and
connect patients with necessary resources is a winning solution for all stakeholders.
Recommendations
Differences among the nurse navigator job descriptions were seen across hospital
services. Some job descriptions, for example, required data collection and reporting and others
did not. All the nurse navigator roles required general education for the role; however, most of
the requirements were not tailored to the nurse navigator role itself or the specific knowledge
necessary to support patients with chronic conditions requiring self-care management. Overall,
there was no consistency in the tasks, knowledge areas, and the skills the nurse navigator role
should encompass. Each service identified what the patients’ needs were and how the nurse
navigator should address those needs. Unfortunately, the lack of a consistent approach to the
nurse navigator role may have increased fragmentation and confusion for the patients using the
services.
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The original intent of the nurse navigator roles was to decrease fragmentation, but
without uniform job descriptions, the role may result in a higher likelihood of care gaps. The first
recommendation, therefore, is for more consistency across the job descriptions as outlined in the
literature (see Appendix A). A second recommendation is that all at-risk patients to be identified
and an individual discharge plan be put into place as soon as the patients enter the hospital. A
third recommendation is that quality matrices will need to be developed and completed for each
patient to identify care gaps and, ultimately, to demonstrate the value of and justification for the
nurse navigator role. Data analysis can identify 30-day readmissions and establish the potential
causes or missed opportunities to ensure that at-risk patients have access to appropriate resources
in the home and the community that will prevent unnecessary rehospitalizations.
Because of the potential for inconsistencies in the interpretation of the nurse navigator
role in the hospital, a fourth recommendation is to place the nurse navigators under one
department with an advanced practice nurse provider managing the department. The feasibility of
this recommendation would need to be examined by the hospital. This recommendation places
one, instead of multiple persons, in charge of the nurse navigators, which may improve role
integrity; decrease lapses of communication among services, providers, or other resources; and
increase collaboration with organizational leadership, quality managers, nursing departments,
and affiliates for consistent, quality care. Finally, the fifth recommendation is the need for a new
position specific to the nurse navigator department to assist with identifying and arranging
community resources for patients prior to discharge. This person could assure that patients have
the services they need in place the day they go home.
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Strengths and Limitations of the Project
The main strength of this doctoral project was that it revealed for the organization how
the nurse navigator roles are currently being defined and utilized in the hospital. Each service has
developed and employed specific strategies to promote optimal care for patients to avoid
unnecessary readmissions. All services are using established and credible evidence-based
practice guidelines specific to the diagnoses of the patients. For example, patients with chronic
obstructive pulmonary disease receive care as outlined through the Global Initiative for
Obstructive Lung Disease (GOLD) standards (goldcopd.org, 2017). The finding was true for
cardiology, endocrinology, neurology, and all the other hospital services utilizing the nurse
navigator role. The new nurse navigator job description incorporated use of relevant
evidencebased guidelines as a knowledge area expectation of the nurse navigator role.
A limitation of the project is the use of a convenience sample of nurse navigator job
descriptions and internal referral data processes from one hospital. This sample may misrepresent
the nurse navigator role and result in findings and recommendations that cannot be generalized
beyond the project hospital. In hindsight, a survey completed by the nurse navigators may have
been helpful to see what items they found most necessary and appropriate in the Brown et al.
(2012) list of tasks, knowledge areas, and skills. Their input about how well the job descriptions
reflected their duties and expertise would have been helpful in creating a more comprehensive
and accurate picture of the nurse navigator role.
Another limitation identified for this project was the inability of the organization to
provide outcome data related to the role of the nurse navigators. Some of the job descriptions for
the nurse navigator role required outcome data collection and reporting, but the processes to use
for these purposes were not elaborated.
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Summary
There was a great deal of research and data for the navigator role in oncology and the
tasks, knowledge, skills necessary for success in the role. For the at-risk patients with an acute or
chronic condition, there was a great deal of evidence supporting the need for the nurse navigator,
but little evidence that really focused on which interventions promoted optimal outcomes for the
patient. The purpose of this project was to determine what interventions were used by the nurse
navigators based on the literature and job descriptions at one hospital.
In future projects, it will be essential to test the five recommendations to see if in fact
these suggestions can be implemented and lead to decreased unnecessary readmissions, lower
hospital costs, and increased patient satisfaction and quality of life. Future research will define
interventions that are evidence driven and provide data about the nurse navigators’ effectiveness
for both patients and organizations. Follow up research should include whether practices used by
nurse navigators are universal. This research would support the importance of their practices and
improve patients’ outcomes in turn.
Section 5: Dissemination Plan
The dissemination plan included providing the recommendations from this project to the
CNO of the project hospital. The information provided comprised of the revised job description
and comprehensive literature review with associated recommendations. A podium or poster
presentation of the project is also planned.
The hospital is currently on the journey toward achieving “magnet status” as outlined
through the American Nurses’ Credentialing Center (ANCC) associated with the American
Nurses Association (ANCC, 2018). This project was geared toward enhancing professional
independent nursing practice to promote excellence in the delivery of care, clinical practice, and
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dissemination of findings toward best practices in nursing services. If accepted by the
organization for implementation, the project findings will be provided to the education champion
for dissemination toward the “Magnet Journey.”
The audiences who may be most impacted by this project are the nurse navigators in the
organization, quality management staff, and organizational leaders. This project defined
necessary cost-effective tasks, knowledge areas, and skills for the nurse navigator role and
offered recommendations for continued improvement through documentation of interventions
and outcomes.
Analysis of Self
This project has been enlightening as a nurse practitioner and scholar. Overall, there was
a great deal more to the potential solution than just stating the problem. It was informative to see
how the nurse navigator role started and has evolved beyond oncology and what the different
departments have done with the role. As an advanced practice provider, the project demonstrated
the importance of considering the literature for direction and seeing where the evidence may
lead. Parts of this project assumed to be easier, were the most difficult parts of the project to
complete. One example was the IRB process. This process was an experience that will be applied
in addressing future practice problems to ensure a broad view is brought to investigation instead
of assumptions that may be ill-guided.
Summary
Health care has become very complex and nurses must embrace and use their clinical
expertise in support of patient navigation through the health care system. The goal of this project
was twofold as it was geared toward both improving nursing care for patients and addressing the
organization’s interest in decreasing 30-day readmissions and providing cost-effective care. For
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nursing, it provided an avenue for assisting patients through discharge and the transition to home
to delay or interrupt disease progression through best practices. For the organization, the project
worked to decrease costs associated with unnecessary testing and avoidable readmissions. The
project has established the framework for continuing to improve the quality of care delivered
through consistent application of the nurse navigator role and recognition of the value a specific
nurse navigator department may bring to the organization.
“To say that the world of health care is in transition is to understate both the magnitude
and scope of the changes taking place in how illness is treated and how health is promoted
around the globe” (Kimberly & Cronk, 2016, p. 162). These changes can impact both delivery of
care and types of services rendered. “U.S. health care spending increased 4.3 percent to reach
$3.3 trillion, or $10,348 per person in 2016” (CMS.gov, 2016, p. 1). There is the added challenge
of trying to meet the consumers’ needs while attempting to contain skyrocketing health care costs
for a population that is aging and thus at greatest risk for acquiring one or more chronic
conditions. “Private employers are increasingly demanding that health care insurers address these
cost through disease management programs and government health plans, notably Medicare”
(Garrett & Martini, 2007, 51).
Beyond cost, the health care system struggles for a variety of reasons, making it is
difficult for the health care system to meet the needs of people with higher risk conditions. Care
often lacks interdisciplinary coordination, leading to a combination of unnecessary testing or
duplication of services. Patients are often left with conflicting information from multiple
providers. This is a cost burden for the patient. This lack of coordination, in turn, can cause
confusion when navigating the health care system. This can impact the patient’s quality of life,
perhaps through accelerated disease progression or acute exacerbation.
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Often, this confusion within the health care system makes it difficult to access services as
an individual patient, creating an inadvertent barrier to appropriate medical care specifically for
their given condition. For the patient newly diagnosed with an acute or chronic condition, their
world is changed by added medical appointments, testing, and lack of knowledge of how this
will impact their life. A chronic medical condition also can create undue stress for the patient
who attempts to manage the condition only to become decompensated with acute symptoms or
with an exacerbation requiring a hospital admission or readmission. If the patient had received
help understanding the resources necessary for their condition, they might have been avoided.
This support gap has now increased the risk of overall morbidity and mortality and created a cost
burden for the patient and the family.
Health care organizations can facilitate navigation of the health care system for the
highrisk patient. “A variety of strategies implemented at an organizational level have been
developed to help prevent hospital admissions or readmissions, accelerate discharges, improve
access to care and the care quality as patients transition between providers and health care
settings” (Manderson et al., 2012, p. 114). This paper will provide an overview of the nurse
navigator role, detail interventions to promote best outcomes for the at-risk patient with an acute
or chronic condition(s), include a thorough review of the evidence regarding the nurse navigator
role, and propose a plan to help patients navigate the health care system more efficiently.
Purpose Statement and Project Objectives
The purpose of this project was to determine which interventions used by nurse
navigators promoted the best outcomes for the at-risk patient. The navigator role was first
developed by Harold Freeman in 1990. This new model resulted from seeing a disparate number
of African American women presenting with late-stage breast cancer, which was attributed in
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part to their inability to access needed cancer care services. The nurse navigator role was
developed to assist patients with a cancer diagnosis to get the benefit of the best possible
oncology care.
In recent years, this role has expanded to assist patients with chronic disease management
and other illnesses. Because this is a relatively new role for nurse navigators, the impact has not
been rigorously documented (Manderson et al. 2012). Outside of oncology, this role is being
pioneered to see if the use of nurse navigators can help contain costs by decreasing hospital
length of stay and avoiding costly penalties for certain high-risk populations such as persons with
heart failure (HF) or chronic obstructive pulmonary disease (COPD) who may have frequent
rehospitalizations, emergency room (ER) visits, and low satisfaction with the delivery of care.
As health care becomes increasingly complex and as more pressure is placed on acute
care settings to decrease length of stay and readmissions, the nurse navigator will likely become
more valuable. When patients come through the hospital door, they become at-risk for several
points of process failure which, in turn, hinders optimal care. “On average, in 2010, Americans
received 70% of indicated health care services and failed to receive 30% of the care they needed
to treat or prevent particular medical conditions” (AHRQ, 2014, p. 2). Barriers that may
contribute to lack of access include poor communication, health care illiteracy, inconsistent
medical management, and lack of accountability by either the patient or the provider.
Utilization of the nurse navigator role provides an alternative to minimize lapses of care.
Nurse navigator programs “seek to improve patient care by reducing barriers to care, through the
provision of information, social and emotional support, links to existing services and resources,
as well as patient referrals to service providers” (Whitley et al., 2011, p. 3617). The nurse
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navigator can help the patient at any point of entry to the health care system and support her or
him through to discharge and follow-up.
To understand the effectiveness of the role, the hospital or other employer must be able to
measure the impact of the nurse navigators on the at-risk populations at each of the critical points
where process failure can occur. For the high-risk patient, the organization must be able to
articulate the process impact of the nurse navigator when the patient comes through the door, at
discharge, and when making the follow-up appointments to provide optimal transitional patient
care.
At entry to the system, the patient must be quickly identified as an at-risk patient based on
an acute presentation, a 30-day readmission, or extenuating circumstances that could hinder
optimal care such as health literacy or language issues, lack of family or a caregiver, or financial
and transportation issues. Any identified barriers to optimal care need to be addressed by the
nurse navigator prior to discharge.
Discharge is a second point of potential failure in patient care. “During the hospital to
home transition, patients are at high-risk for adverse drug events, incomplete or inaccurate
information transfer, preventable hospital readmission, and even death” (Davis et al., 2012, p.
1649). The patient may become overwhelmed with whom to see and what to do to manage their
condition(s). They are discharged where further breakdown in disease management can occur. To
help manage their new or chronic condition, the patient needs a strategy upon discharge to help
with a plan of care.
Finally, follow-up is a third point of potential process failure for patient care. Before
walking out the hospital doors, it is important that each patient has an appointment with the
providers who are best suited to care for their disease process and a way to get to that
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appointment. Collaboration with other health care team members is crucial to set up the patient
for success when they are managing care in the outpatient setting. There are many resources in
the community to help the patient manage his own care, but before discharge occurs, these
resources must be arranged. It is not unusual for a hospital to discharge a patient on a Friday
afternoon without the necessary services in place. If the patient cannot pick up his or her
necessary medications, food, assistive equipment, or other supplies for managing his condition
independently, he may be back in the hospital by Monday.
Significance to Practice
The significance to practice is providing appropriate high level care while being cost
conscious. “As a nation, we spend 86% of our health care dollars on the treatment of chronic
diseases” (CDC, 2015, para 1). People are living through acute injury and as a result living
longer and developing chronic, progressive condition(s). According to Anderson (2010), “in
2009, 145 million people—almost half of all Americans—lived with a chronic condition” (p. 4).
There has been a great deal of push for a decreased hospital length of stay, reduced
avoidable 30-day readmissions, and yet an increased patient satisfaction score to avoid penalties
imposed on acute care organizations. According to the Centers for Medicare and Medicaid
Services (2014), Section 3025 of the Affordable Care Act added section 1886(q) to the Social
Security Act establishing the Hospital Readmissions Reduction Program, which requires CMS to
reduce payments to IPPS hospitals with excess readmissions.” These expectations present
challenges in health care delivery and could place the vulnerable and/or chronically ill patients at
risk for increased morbidity and mortality.
Because of the increasing fragmentation, associated complexities, and limited resources,
patients and their families need help to navigate the health care system. Those patients with
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persistent, chronic, medical conditions require additional support with access to care. Many
organizations have adopted a nurse navigator program driven by the potential cost-effectiveness
of the role. The significance is twofold. For patients, a nurse navigator provides an interpreter of
sorts, helping the patients make sense of their disease process. On the health care provider and
organization side, the goal is to decrease health care costs. The nurse navigator can provide
continuity of care aimed at reducing duplication of testing, unnecessary testing, and readmissions
perhaps, by setting patients up with the right services.
A nurse navigator is in the position for service access. According to Gilbert et al. (2011),
the “core navigation functions include simplifying access and improving continuity of care,
proactive navigation, assistance in overcoming barriers and/or disparities, patient advocacy,
coordination of care, and support in achieving efficiencies” (p. 230). There is a need to
implement strategies aimed at collaborative care coordination among healthcare providers. This
placed the nurse navigator in the forefront to improve care and efficiency within the process.
Implications for Social Change
The implication to social change is to become a catalyst for improving health outcomes
while providing quality services. Healthy People 2020 reported “access to health services means
the timely use of personal health services to achieve the best health outcomes” (Healthy People
2020, 2015, para. 3). The aim of the nurse navigator role is to assist the patient through the
continuum of the health care system while decreasing overall health care associated
expenditures. According to the World Health Organization (2015), the United States ranks 37th of
all world health systems in its effectiveness and surpasses every other country in the money it
spends on health care as a percentage of its gross domestic product.
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This project is expected to improve society by helping patients improve health outcomes
and/or quality of life by adopting care practices that are supported by the evidence. For patients,
this will increase their overall satisfaction while providing them with a liaison to advocate for
their direct care needs. For the health care system, the nurse navigator offers a higher level of
care delivery that will be cost effective because it will avoid readmissions within 30-day and, as a
result, decrease overall health care expenditures.
Project Question
The project question was as follows: What are the tasks, knowledge areas, and skills
necessary for inclusion in a hospital-wide nurse navigator job description to promote best
outcomes for chronically ill and at-risk patients? The consensus in the literature was that the
nurse navigator role was geared toward decreasing fragmentation in health care delivery for
patients and helping them to maneuver through the system; however, there may be ways to
optimize and standardize the role within the project hospital for greater effectiveness of the rôle.
Local Context
The project hospital was an acute care facility with a total of 225 beds in southeastern
Ohio. Currently, a total of 862 registered nurses are employed in various roles with a total of 16
nurses in the nurse navigator role. Two of these nurse navigators also function as case managers.
The role of the nurse navigators is to identify those patients at risk for 30-day readmissions.
There are five nurse navigators employed in cardiovascular services who see patients with heart
failure, atrial fibrillation, acute coronary syndrome, or those in need of coronary artery bypass
graft surgery. Four nurse navigators are employed in oncology services who see patients with
specific cancer diagnoses. The breast cancer nurse navigator is the only certified navigator.
There are four nurse navigators who see patients with chronic obstructive pulmonary disease.
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Finally, the newest addition is a diabetic nurse navigator, formerly known as a diabetic educator.
Project Objectives
Based on the project question, six objectives were accomplished to incorporate
evidencebased best practices for level of education, skill set, duties, policy and procedures, and
the nurse navigator role at the project site. These objectives were as follows:
19. Review all 13 nurse navigator job descriptions at the project site.
20. Develop a comprehensive list of common job expectations and required skill set for
the role from the various job descriptions.
21. Compare the list of common job expectations and skills to best practices for the nurse
navigator role as identified in the literature.
22. Develop a new job description for the nurse navigator role.
23. Develop recommendations to standardize the nurse navigator processes and
procedures at the project hospital.
24. Recommend a method for evaluating the effectiveness of the nurse navigator in
reducing 30-day readmission rates at the project hospital.
Evidence-Based Significance of the Project
The evidence-based significance of the project is role refinement and implementation of
best practices to achieve a higher level of patient care in a cost-effective manner. Titler (2008)
defined “evidence-based practice (EBP) as the conscientious and judicious use of current best
evidence in conjunction with clinical expertise and patient values to guide health care decisions”
(p. I-113). In the role of the nurse navigator, the goal is to provide best care that is clinically
sound and based on practices that promote optimal patient outcomes. For example, heart failure
guidelines are often cited by the American College of Cardiology and American Heart
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Association (ACC/AHA). The basis of these guidelines has been well researched, peer-reviewed,
and graded according to how well the evidence supports the recommendations. A nurse
navigator, in collaboration with the health care team, should have a thorough understanding of
the guidelines and ensure that they are being followed. What sets the nurse navigator apart from
other nursing roles is their interactions with patients to ensure continuity of care throughout and
beyond the current hospitalization with a plan to avoid harm or readmission. In the literature,
there is a great deal of research on defining the nurse navigator role in general, but no research
was found on patient care outcomes and realized cost-effectiveness to the organization.
Assumptions
An assumption in the development of the project was that use of the nurse navigator was
emerging as a role for assisting patients in a system that is complex and full of fragmentation. It
was assumed the role will be used increasingly in hospitals to support patients who are at a
considerable risk of becoming medically decompensated or whose circumstances necessitate a
liaison for access to care. Another assumption is older patients who have at least one chronic
illness are at a higher risk for morbidity and mortality and this risk increases when the patient has
more than one acute and/or chronic condition. These patients can benefit from nurse navigator
interventions to attain an optimal quality of life and slowed disease progression.
Summary
Health care is becoming increasingly complex and fragmented; it is challenged to keep up
with delivery of care and the competitive types of services that it provides. This environment
increases the chances of the patient falling victim to barriers in care. Organizations must avoid
lapses in care due to inattention to these barriers and the nurse navigator role may be able to help
patients at highest risk for falling through the gaps.
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Since nurse navigators first emerged in hospital-based oncology patient care in the 1990s,
the role has expanded to include many other areas and medical diagnoses. With the expansion of
the role, it is necessary to understand which interventions used by the nurses in this role
promoted the best patient outcomes. This understanding must be grounded in the evidence while
considering the clinical expertise required to guide appropriate health care guidance at critical
junctures in hospital care (admittance, discharge education, outpatient care service and resource
planning).
While it was assumed the use of the nurse navigator role was vital in a system that is
complex and fragmented, the ultimate benefit was that promoting the best outcomes for the
patient yielded the most cost-effective manner. At the conclusion of this project, interventions
that best support patients at risk for poor post hospitalization outcomes will be identified.
The next section will focus on the history of the nurse navigator as well as reviewing the
literature as it pertains to the nurse navigator roles. The conceptual model of evidence-based
practice will be discussed as it relates to the necessity for this project.
Section 2: Review of Scholarly Evidence
Introduction
The purpose of this project was to identify which nurse navigator interventions promoted
the best outcomes for at-risk patients. “Whether care is delivered in an urban clinic or in rural
private practices, patients may experience delays in diagnosis and treatment and receive
fragmented, uncoordinated care” (Case, 2011, p. 33). Delivery of care in a complex health care
system presents potential barriers for the patient and/or the care is not conducive to realizing
evidence-based best practices.
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In the subsection on specific literature, I will discuss the first navigator program
introduced by Harold Freeman in 1990 and the role nurse navigators played in care coordination.
Since then, the role has expanded beyond oncology to other areas of chronic disease and to
patients considered to be high-risk, such as elderly patients and who experience barriers that
threaten worse outcomes.
In the subsection on the general literature, I will discuss the nurse navigators’ role(s) in
coordination of care, including barrier identification and discharge planning to promote optimal
outcomes for the patient. The purpose of the general literature review is to broadly outline the
interventions that are necessary to decrease system fragmentation and to align the patient with
resources to achieve optimal outcomes.
Finally, I will discuss the evidence-based practice (EBP) model. According to Satterfield
et al. (2009), EBP “provides a useful framework for guiding health services research with an
interdisciplinary and real-world perspective” (p. 384). The reason for establishing which nurse
navigator interventions promoted the best outcomes for at-risk patients is based on which clinical
practices have proven beneficial for the patient (and their association with the health care
system’s delivery mechanisms). These clinical practices in turn will promote optimal and
sustainable multidisciplinary care.
Specific Literature
Dr. Harold Freeman was the pioneer in development of the first nurse navigator role. He
was involved in two Harlem hospital studies (1986 and 1995-2000) that demonstrated an
increased 5-year survival rate of poor African American women with breast cancer who used a
navigator program. “The 5-year survival was 70%, compared to 39% in the earlier Harlem
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Hospital study” (Freeman, 2006, p. 140). The survival rate demonstrated a need for a liaison to
assist with access to care.
According to the Harold P. Freeman Patient Navigation Institute (2015), “navigators act
as the support hub for all aspects of patients' movement through the health care system” (para 6).
They were shown to be effective with removing barriers to care. “Although Nurse Navigator
programs most commonly target cancer patients, the literature supports that opportunity exists to
extend nurse navigator programs to other chronic diseases” (Pruitt & Sportsman, 2013, p. 593).
The role of patient navigator or nurse navigator has grown since being introduced in 1990
by Dr. Freeman. “The principal function of the navigator is to eliminate any and all barriers to
timely screening, diagnosis, treatment, and supportive care for each individual” (Harold P.
Freeman Patient Navigation Institute, 2015, para 6). Research is emerging in support of the nurse
navigator for patients with chronic illness and other high-risk presentations; however, no research
could be found that assessed the effectiveness of the role outside of oncology.
The literature search used the following databases: Cochrane Library, JBI Library,
Medline, CINAHL, SAGE, and SocINDEX. The following key terms were used alone and in
combination: patient, navigator, nurse, pivot, discharge planning, hospital, care coordination,
chronic disease, and coordination.
The search yielded 5,665 potentially relevant articles. From the articles, a total of 27
articles were found to be applicable. After review of these 27 articles, eight more articles were
excluded leaving a total of 19 articles. The articles were excluded for two reasons: they were not
relevant or were duplicate articles; (b) included literature related to pediatrics, mental health, and
dementia. It was felt, while these populations may be classified as chronic and/or high-risk, there
are special considerations for care of these patients that are not suitable for this. Inclusion criteria
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included literature comprising of the following: (1) the nurse navigator role, (2) barriers to access
of health care, (3) care coordination, and (4) discharge planning aimed at readmission rate
reductions. Literature specific to the nurse navigator role included ten total articles, two of which
focused on barriers to care or treatment; the other eight articles focused on the specific aspects of
the navigator role. Three of the studies were randomized controlled trials, two were longitudinal
studies, and one was exploratory. See Table 1 below.
Table 1
Specific Literature Delineating the Nurse Navigator Role
First Author
Inclusion
Aim(s) of the study
Details of intervention
Reported outcome(s)
Asgary et al.
Barriers to care
Identify and understand
colorectal screening rates,
predictors, and barriers to
screening for homeless in
New York City
Proposed intervention to
improve colorectal cancer
screening by including
private shelter rooms for
colonoscopy prepping.
Patient navigators to assist
with health care
navigation, accompany to
and from procedure,
counseling at all
Patient who were
homeless were less likely
than domiciled patients to
have up-to-date screening
(19.7% vs 41.3%; p <
.001).
Homeless patients were
significantly less likely to
have had a previous
colonoscopy (p < .05).
encounters, and education
to specific patient to curb
misconceptions.
Nurse navigators are
recommended to assist
with barriers to care
Calhoun et al.
Nurse navigator role
To develop a patient
navigator competency
program
Randomized control
design
Standardized training for
patient navigators with a
goal to provide
dissemination of
information, skills, and
competencies aimed at
decreasing barriers by
underserved papulations.
Recommend national
standardized training for all
chronic disease navigators.
Curriculum training; n =
110, with a mean pretest
score of 19.79 (SD =
2.76) and a mean posttest
score of 20.74 (SD =
2.44) showing
improvement in
knowledge
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Dennis et al.
Barriers to care
To assess if patient
navigators and use of the
Direct Endoscopic
Referral System (DERS)
would increase timely
colorectal cancer
screening for a large urban
hospital in a
predominately poor
region
Retrospective analysis
Hired 2 patient navigators
and implemented the
DERS to see if the number
of broken appointments
decreased for colorectal
cancer screening and
diagnostic colonoscopies.
Study suggests when
barriers are addressed,
screening rates increased
The rate of broken
appointment for both
screening and diagnostic
colonoscopies
significantly dropped
from 67% to 5%.
Nurse navigator role in
appointment increased
compliance rates 3-fold
(relative risk = 2.6, 95%,
Cl = 2.2-3.0)
Gunn et al.
Nurse navigator role
To determine if published
nine principle model of
navigation mirrors the
practice in breast cancer
navigator programs.
Exploratory Study
Observation of the
navigators in the 10
programs for a total of
179.5 hours. Codes were
used based on nine a priori
themes derived from the
nine-principle
model
Found individual level
principles were broadly
consistent with the
nineprinciple framework;
whereas program level
principles were variable
across programs
Horner et al.
Nurse navigator role
The aim was to test the
effectiveness of a 16week
oncology nurse navigators
(ONN) program compared
to enhanced usual care to
support cancer patients
early in treatment.
Randomized control trial.
Each patient (n = 251)
was assigned to a group
based on which primary
care clinic they belonged
to. The primary care
clinics (n = 11) were
randomly assigned to
either the ONN program
or enhanced usual care
group.
The results were not
disclosed in the article
pending result analysis.
Jolly et al.
Patient navigator role
The aim of the study was to
design a patient navigator
role from laypersons to
help coordinate care,
address system barriers and
to
Proposed intervention was
developing a patient
navigator role using lay
persons to assist CKD
patients. Electronic medical
record templates
The 2 hired patient
navigators were trained
and responsible for
navigating patients
enrolled in a clinical trial.
They were trained in
educate/motivate their
patients.
were created and
identification of barriers.
general patient navigation,
specific education on
CKD, and patient privacy
and research training.
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May et al.
Nurse navigator role
The aim of the program was
to implement a GI
multidisciplinary care
(MDC) program with
integration of a GI nurse
navigator (NN) to optimize
care of patients newly
diagnosed with GI cancer
The intervention was:
• Nurse
navigator to
contact patient
within 2 days
of diagnosis
(goal 80%)
• Cancer staging
completed
within 5
business days of
referral (goal
80%)
• 90% of the
patients to be
seen by GI MDC in 10
calendar days 70% of
patients to start cancer
treatment within 22
calendar days.
Result of quality
indicators from 1/2010 to
8/2012 with use of GI NN
includes the following:
• Nurse
navigators
contacted
patient within
2 days of
diagnosis
(outcome
89%)
• Cancer staging
was completed
within 5
business days
of referral
(outcome 85%
• 91% of the
patients were
seen by GI MDC in 10
calendar days 75% of
patients were started on
cancer treatment within 22
calendar days.
Percac-Lima et al.
Nurse navigator role
The aim was to understand
if the use of a nurse
navigator with Latina
women having an
abnormal pap smear result
would decrease
Information was obtained
over two-time periods
(2004-2007, and
20082011) to establish if
the use of nurse navigators
verses no use of nurse
navigators (comparison
group) were influential
with the following
outcomes for Latina
women with an abnormal
pap smear result:
• Missed
appointment
for colposcopy
• Time to
colposcopy
Changes in severity of two-
time periods
Nurse navigators were
influential with:
• Missed
appointment
for colposcopy
decreased for
navigated
Latina women
versus
comparison
group (p <
0.001)
• Time to
colposcopy
was shorter for
nurse
navigated
Latina women
versus
comparison group (p =
0.010) Changes in severity
of two-time periods
decreased for navigated
Latina women verses
comparison group (p <
0.001)
Redwood et al.
Patient navigator role
The aim was to have
patient navigators in Alaska
contact first
The patient navigators
contacted the first-degree
relatives by telephone or
The results showed a
significant increase in
colorectal cancer
degree relatives of
colorectal cancer patients to
obtain colorectal cancer
screening
mailed reminders.
screenings with the use of
patient navigators
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Wagner et al
Patient navigator role
To determine if a nurse
navigator intervention
improves quality of life
and patient experience with
care
Two-group clustered
randomized controlled
trial
Study used adults with
recently diagnosed
primary breast, colorectal,
or lung cancer (n = 251)
who received either
enhanced care (n = 118) or
nurse navigator support
for 4 months (n = 133).
No significant differences
found between groups in
FACT-G scores meaning
NN intervention did not
impact quality of life or
delays in receiving care.
However, patients
reported significantly
higher scores on the
PACIC survey and
reported significantly
fewer problems with care,
including psychosocial
care, care coordination,
and information
Most included studies that provided an overview of the nurse navigator role discussed
some form of cancer navigation, although one study by Jolly et al. (2015) discussed
implementing two nurse navigators to assist with care coordination and education of patient with
chronic kidney disease.
Three studies discussed program development, including one by May et al. (2014). The
study provided and discussed measurable interventions from the start of patient contact to start of
the cancer treatment. This study concluded that there was a benefit in having a nurse navigator to
expedite this process.
A randomized, controlled trial conducted by Horner et al. (2013) tested the effectiveness
of a 16-week oncology nurse navigators (ONN) program; however, no results were provided.
Another randomized study by Calhoun et al. (2010) looked at curriculum for training navigators
and recommended national standardized training for all chronic disease navigators.
Overall, the literature referring to the nurse navigator role discussed either curriculum
training, focused on a specific at-risk group, or found an increased compliance rate with care
needs by helping the patient overcome barriers to care. None of the literature specific to the
navigator role discussed discharge planning.
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Role refinement and assessment is crucial. The Oncology Nursing Society (ONS)
conducted a study called the Oncology Nurse Navigator (ONN) Role Delineation Study in 2010.
The purpose of the ONS ONN Role Delineation Study was to examine the job-function activities
and knowledge required of the ONN, thereby providing an understanding of this new role
(Brown et al., 2012). Based on information gathered from the respondents, a list of necessary
skills, tasks, and knowledge was initiated to define the ONN role. A mean rating of 3.5 – 4.49
was considered to be very significant for understanding role delineation.
For tasks, 62% of the task identified were significant for the nurse navigator role. Those
task rating at the highest includes: providing emotional and educational support, practicing in
accordance to professional standards, advocation, orienting patients to the system, receiving and
responding to referrals, pursuing continuing educational opportunities related the specialty and
specific to the nurse navigator role, assisting with informed consent, multidisciplinary
collaboration, identifying patients in need of navigation, and education.
Knowledge areas were considered to be 91% significant in accordance to the very
significant rating scale. Higher on the list of knowledge included: informed consent, advocacy,
symptom management, ethical principles, quality of life, treatment goals, therapeutic options,
evidence-based practice guidelines, and scope of practice.
“The 12 skills included on the survey were rated on the same scale and the skill on the
survey provided a sound basis for defining the skills needed within the navigator role” (Brown et
al., 2012, p. 584). It was ascertained that, overall, more research was needed on this topic.
The study by Wagner et al. (2014), used a clustered randomized controlled trial to
determine if the use of a nurse navigator intervention improved the quality of life and patient
experience for those patients recently diagnosed with breast, colorectal, or lung cancer. It was
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noted that the Functional Assessment of Cancer Therapy–General (FACT-G) quality of life
scores showed no significant impact of the nurse navigator on quality of life or delays in care.
There was a significant difference on the Patient Assessment of Chronic Illness Care (PACIC)
survey: patients reported fewer problems with care; in particular psychosocial care, care
coordination needs, and information. The study also showed in the lung cancer patients a
decrease of $6,852 in care costs among nurse navigator patients. There was no significant cost
reduction in care of breast or colorectal cancer patients.
General Literature
The general literature included studies of discharge planning and care coordination, which
are essential duties of the nurse navigators in the acute care setting at the project hospital.
According to Russell (2013), “these hospital-based navigators primarily manage the patient’s
needs during the hospital stay and discharge planning and they work for the hospital” (para 6).
When looking through the literature, this is a point of failure for the patient after they are
discharge and before they can follow-up with their health care provider.
The nurse navigator’s focus is to assist the patient through the health care system. The
care coordination and discharge planning piece is intertwined in this role. Social workers and
case managers have traditionally assumed this role with general patient admissions. Because the
nurse navigators, social workers, and case managers do not always collaborate, this does not
always allow for a more individualized plan of care to help the patient in terms of reducing ER
visits and readmissions for patients who are at risk. Unfortunately, no literature could be found to
understand which interventions by the nurse navigator promote best outcomes for the at-risk
patient.
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Holliman et al. (2003) explored the role of social workers versus nurse discharge planners
and found no significant difference in job roles. This was the only article found that met the
inclusion criteria.
In terms of care coordination, eight articles were included. A cross sectional study by
Bradley et al, (2013) was conducted to understand what strategies are independently associated
with a reduction in 30-day readmissions. [Strategies that were associated with lower hospital
RSRR included: 1) partnering with community physicians or physician groups to reduce
readmission (0.33 percentage point lower RSRR, p = 0.017), 2) partnering with local hospitals to
reduce readmissions (0.34 percentage point, p = 0.020), 3) having nurses responsible for
medication reconciliation (0.18 percentage point, p = 0.002), 4) arranging follow-up
appointments before discharge (0.19 percentage point, p = 0.037), 5) having a process in place to
send all discharge paper or electronic summaries directly to the patient's primary physician (0.21
percentage point, p = 0.004), and 6) assigning staff to follow up on test results that return after
the patient is discharged (0.26 percentage point, p = 0.049)] (Bradley et al. 2013, p. 2).
A qualitative study by Kainfar et al. (2014) was the only article found discussing chronic
care coordination. Coordination elements of communication, relationship building, and care
coordination were identified as essential elements for care coordination. For chronic care
coordination, this connection is one which is open and interdisciplinary where collaboration is
occurring. The relationship becomes the interaction between health care professional discussing
care coordination activities or by the patient and health care professional. Monitoring takes on
the patient’s overall status, or changes in status, and monitoring activities of other health care
professional caring for the patient.
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Legarin et al. (2011), did a randomized controlled trial to determine if a multimodal
approach would decrease ER visits and readmissions in patients older than 70. They looked at
specific risk factors of preventable readmissions which included drug related problems,
depression, and malnutrition. They concluded the multimodal approach was effective at 3 months
but not at 6 months. The authors concluded the following as an explanation of the insignificant
effect at 6 months including: “contamination of the control group (acute geriatric unit physicians
could have integrated parts of the treatment review and implemented them in the control group);
lack of power (it was initially planned to include 800 participants), or lack of post discharge
follow-up” (Legrain et al., 2011, p. 2026).
Often at discharge, patients are faced with multiple medication variations increasing
confusion for the patient or provider trying to manage these changes. These changes can include
increased or decreased dosing of a current medication, new medications additions, and/or
medications discontinued. A knowledge deficit can cause potential harm to the patient or bring
them back as a potential readmission. Kaanan et al. (2013) did a retrospective study to determine
the number of adverse drug events after discharge. They found in their study, 242 patients
(n=1000) had an adverse drug event. More than 50% of the adverse drug events occurred within
14 days post discharge. Overall, at 45 days post discharge, 35% were deemed preventable, 32%
of drug events were classified as a serious event, and 5% were considered life threatening. “The
findings of the current study serve to reinforce the importance of medication safety as a critically
important concern during this period of high vulnerability for older adults” (Kaanan et al., 2013,
p. 1897). The general literature is summarized in Table 2 below. Table
2
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General Literature Delineating the Nurse Navigator Role
First Author
Inclusion
Aim(s) of the study
Details of intervention
Reported outcome(s)
Bradley et al.
Chronic care coordination
To identify hospital
strategies associated with
lower readmission rates for
heart failure patients
Cross-sectional study of
hospitals participating in a
web-based survey
Risk-standardized 30-day
readmission rate (RSRR)
determined several strategies
were effective with heart
failure (HF) patients
19) partnering with
community physicians or
physician groups 0.33
percentage point lower
RSRR, p = 0.017)
20) partnering with
local hospitals (0.34
percentage point, p =
0.020)
21) nurses
responsible for medication
reconciliation
(0.18 percentage point, p
= 0.002)
22) follow-up
appointments made prior
to discharge (0.19
percentage point, p
= 0.037)
23) EMR sent to
primary care provider after
discharge (0.21 percentage
point, p = 0.004)
24) Follow-up of
after discharge test results
(0.26 percentage point, p =
0.049).
reduction of 0.34
percentage point for each
additional strategy used
Holliman et al.
Discharge planning
To explore the roles of
social workers and nurse
discharge planners and
gain further understanding
of the similarities and
differences between these
roles
Convenience sampling of
Alabama hospitals who
were members of Alabama
Hospital
Association
Recommends social worker
participation in advocacy,
outcome research, and
discharge planning
The role of the social
worker and nurse
discharge planner had no
significant difference in
job roles
It was reported social
workers were
predominately hired in
federal and state hospitals
(p < .01); whereas private
hospitals were more likely
to hire discharge nurse
planners. Nurse discharge
planners were
predominately hired in
hospitals with less than
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250 beds while social
workers were more likely
hired in hospitals with
greater than 250 beds
Kainfar et al.
Chronic care coordination
The overview of
coordination of care with
implications to care of
chronically ill patients
Interview of 12 different
health care professionals
involved in care
coordination of chronically
ill patients with CHF and
COPD
Found through interviews
communication,
relationship building, and
coordination of care as
essential elements with
CHF and COPD patients
Kanaan et al.
Care coordination
To characterize frequency,
preventability, and
severity of adverse drug
events (ADE) within
45 days after
hospitalization in patients
older than 65
Retrospective analysis
Comprehensive chart
reviews conducted on
patient’s part of senior plan
membership (n = 1000) to
determine ADE
Out of 1000 patients, 242
had an ADE, with 35%
preventable, 32% serious,
and 5% life threatening.
Over 6% (6.6%) met
Beers criteria when
looking at high quality of
evidence and strong
strength recommendations
Legrain et al.
Care coordination
To determine if a
multimodal intervention
could decrease ER visits
and hospital readmissions
in patients older than 70 at
3 and 6 months
Randomized,
parallelgrouped of
interventiongroup (IG, n =
317) and control-group (CG,
n = 348), open-label trial
The intervention to reduce
ER visits and hospital
readmissions was effective
at 3 months but ineffective
at 6 months. At 3 months,
IG was 23% compared to
CG at 30.5% (p = .03); at 6
months IG was 35.3% and
CG at 40.8% (p = .15)
Mistiaen
Care coordination
To assess the
effectiveness of follow-up
phone calls up to 1-month
post-discharge from the
hospital in eliminating
problems
Literature review of
randomized and
quasirandomized control
trials to determine if
follow-up phone calls were
effective
in alleviating post
discharge problems
Evidence of effectiveness
of telephone follow-up
was inconclusive
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Rathert et al.
Clinical outcomes
To determine if patient
centered care (PCC)
influences patient outcomes
Systematic review of PCC
and patient outcomes
Review of 40 articles
reports an inconclusive
result of PCC on patient
outcomes. The studies did
find stronger evidence for
positive influence of PCC
on patient satisfaction and
self-care management
Shepperd et al.
Care coordination
To determine the
effectiveness of
individualized discharge
planning compared to
routine discharge planning
not individualized
Literature review of
randomized control trials
It was determined through
the literature that use of
individualized discharge
planning was statistically
significant in reducing
hospital length of stay and
readmissions. Hospital
length of stay (- 0.91, 95%
Cl = -1.55 to -0.27, 10
trials) and readmissions
(0.82, 95% Cl = 0.73 to
0.92, 12 trials)
Wee et al.
Care coordination
To evaluate if a national
transitional care program
for elderly patients with
complex care needs and a
limited social support
system reduced ER visits
and hospital readmissions
Dedicated care coordinators
were used to educated and
coordinate care needs and
follow-up 1-2 weeks post-
discharge. ER visits and
hospital readmissions were
Use of care coordinator
reduced ER visits and
hospital readmissions 30
days post-discharge
compared to patients
without a care coordinator
(0.5, 95% CI = 0.5 to -0.6
6 months post discharge reviewed to see if the and 0.81, 95% CI = 0.72
patients were previously to -0.90); and 180 days seen by a care
coordinator post-discharge (0.6, 95% or no care coordinator
CI = 0.5 to -0.6 and 0.9,
(comparison group) 95% CI = 0.82 to -0.99)
The general literature provided evidence to support individualized discharge planning and
care coordination aimed at reducing lapses in care, ER visits, and 30-day readmissions.
“Systematic problems such as lack of patient education, and insufficient coordination between
health professionals, especially during care transitions, contribute to readmissions” (Legrain et
al., 2011, p. 2018). For a patient who is already at high-risk or with more than one chronic
condition; this finding augmented confusion as to which evidence-based guidelines to follow by
inadvertently increasing fragmented care. Another obstacle for patients was post discharge
medication errors in general. Kanaan et al. (2013) cited multiple factors increasing the risk of
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medication errors post discharge including poor therapeutic monitoring, patients not restarted on
medications, or patients started on high-risk medications without ensuring appropriate follow-up
with their primary care provider.
Nurse navigators can play a critical role in coordination of care by partnering with the
patient to reduce potential pitfalls. Legrain et al. (2011) substantiated this statement by reporting
decreased readmissions with effective disease management programs.
Conceptual Models, Theoretical Frameworks
The EBP) model best suited to support the project outcomes is the Rosswurm and
Larrabee conceptual model for change in EBP. [The model provides a pragmatic, theory-driven
framework for empowering clinicians in the process of EBP and includes the following six steps:
(1) assess the need for change in practice, (2) link the problem with interventions and outcomes,
(3) synthesize the best evidence, (4) design a change in practice, (5) implement and evaluate the
practice change, and (6) integrate and maintain the practice change] (Pipe, 2007, p. 235). This
model will provide the necessary means to increase knowledge about the nurse navigator role to
develop and implement a job description conducive to organizational best practice in the use of
the nurse navigator role. This structure will also avoid a haphazard reporting of the evidence as it
unfolds in the project.
Summary
The role of the nurse navigator emerged in 1990, in an attempt to increase survival rates
of poor African American women in Harlem. The nurse navigator role was to be the coordination
of all aspects of care for patients throughout the health care system. The role of nurse navigator
has grown beyond oncology to embrace patients including those at high-risk for increased
morbidity and mortality and those with chronic disease conditions.
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A literature review was conducted to determine what interventions used by the nurse
navigator promote best outcomes for the at-risk patient. Literature for interventions beyond
oncology could not be found. The literature review focused on aspects of the nurse navigator role
to include the following: nurse navigator role, barriers to access of health care, care coordination,
and discharge planning aimed at readmission rate reductions. From the search, 18 articles were
identified for inclusion.
Of the studies included, three were randomized controlled trials, and two were literature
reviews inclusive of randomized controlled trials. According to Terry (2015), these designs
“provide health care professionals with information regarding the benefits of a specific health
care intervention” (p. 84). These studies provide a strong evidence base for the proposed project.
Overall, many of the studies were either in support of the navigator role, recommended a
navigator for barrier reduction and coordination, or implemented a program with utilization of a
nurse or patient navigator. Further studies will need to be conducted to establish what
interventions by the nurse navigator promote best outcomes for the at-risk patient.
The next section will discuss analysis of the project. This will include the approach to the
project, the data collection, and project evaluation.
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Section 3: Approach
Introduction
The purpose of this project was to determine the role of the nurse navigator and
understand what job activities provided the best outcomes for patients considered to be at-risk.
Each step will be discussed to provide an overview of the project as well as how the data were
collected, analyzed, and evaluated. The role of the nurse navigator across the different areas of
the project hospital was not clearly defined or outlined. The current job descriptions were
reviewed, and recommendations made (see Section 4) to reflect specific tasks and skills of the
nurse navigator as defined in the literature.
Project Design and Methods
For this project, a qualitative design was used to review the existing nurse navigator job
descriptions and compare these findings to the literature on best practices. Expected tasks,
knowledge areas, and skills were collected from the job descriptions and the literature on nurse
navigators.
At the project site, the tasks, knowledge areas, and skills are not threaded within their job
descriptions but more broadly as tasks to complete as they identify a patient in need of their
services. Currently, different methods are being used at the project site to determine how the
nurse navigators receive referrals to patients. The referral processes were conducted to determine
where and how the information was being retrieved. All units are using the electronic medical
record to determine who should be seen by the nurse navigator, but each unit is retrieving this
information from a different report from within electronic medical record and is oftentimes
generated by a diagnosis. The goal of having a universal report is to provide consistency in the
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referral process—one standardized method for identifying patients at-risk for readmissions or
with barriers to self-care management.
Finally, data were gathered to determine who was receiving the benefit of the nurse
navigator; these data were compared to information about patients who could benefit from the
service. This information was gathered from the different hospital reports to understand whether
patients were missed due to admission diagnosis or whether there were other unidentified themes
that resulted in overlooked referral opportunities. These data were used to demonstrate possible
changes to the referral report so that all at-risk patients could be identified for referral to the
nurse navigators.
The information (a) gathered for this project identified patients who could benefit from a
nurse navigator and (b) proposed consistent interventions to be used by the nurse navigators in
caring for patients. The goal was to identify best practices and adapt them to the nurse navigator
role at the project hospital in order to decrease the fragmentation of care, increase role
consistency across the organization, and establish a template for promoting and measuring
optimal outcomes for the patients as well as the organization.
Population and Sample
Because the project used a qualitative design, the data were extracted from hospital
documents (job descriptions) and reports being utilized within the organization. Approval for this
secondary data analysis was obtained through the hospital Institutional Review Board (IRB)
committee. The organization determines if projects require IRB approval prior to project
implementation. The application process included completing an IRB application and presenting
a PowerPoint overview of the proposed project to the hospital IRB committee. The IRB
recommended approval of the project, and key persons were contacted by e-mail to request the
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required information for data collection and analysis. IRB approval from Walden University also
was obtained before data collection and analysis began; the approval number was 08-12-
160459006.
There were no participants in this project, although human resources, current nurse
navigators, directors and managers of nurse navigators, and employees in quality management
and information technology were asked to assist with report identification and data extraction.
Data Collection and Analysis
Information was collected to understand the specific nurse navigator job requirements in
conjunction with findings from the literature. Data collection included review of the current
nurse navigator job descriptions and reports used in the hospital pertaining to the current patient
referral processes. Themes from the job descriptions and data were identified and
recommendations were made based on best practices identified through the literature review.
Challenges to Project Implementation
Each nurse navigator was interviewed to further understand current workflow and
practices. This information was provided to the chief nursing officer (CNO) in a meeting.
Information was collected on how each department utilized the nurse navigator based on
interpretation of the role, which in turn influenced daily activities performed.
No consistency existed within the nurse navigator role across the organization. For
example, not all of the nurse navigators consistently provide discharge planning and/or
consistently enlist the services of the case manager. Case management had their own nurse
navigator who did not consistently touch base with the unit nurse navigators. This finding could
constitute a point of failure for the patients if they did not have appointments made, medications
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reconciled to reduce errors, or the appropriate contacts made with community resources to reduce
care barriers and decrease potential readmissions.
Most nurse navigators are not available on off hours or on the weekends. The exception
was the oncology nurse navigators. The lack of daily availability potentially added to the
patients’ lengths of stay, increased duplication in services or testing, or delayed points of care
referrals and coordination necessary for the patients to maneuver through the health care system.
The gap in coverage potentially provided an increase in cost to the patient as well as the hospital
system.
An overview of the literature was provided to the CNO detailing aspects of the role
essential for positive patient outcomes with emphasis on discharge planning and follow-up, and a
method for process and impact evaluation of the revised nurse navigator role and data generation
processes was proposed.
A revised nurse navigator job description was presented to the CNO. The literature was
used to make revisions that standardized the role for intervention consistency only. The
information was compiled and laid out using the literature to define the role and the job
descriptions to determine what the nurse navigators’ role did for the patients to promote optimal
outcomes while decreasing readmissions for the organization.
Project Evaluation Plan
Evaluation is essential for any project to understand outcomes and establish where
positive changes may have been made. The evaluation for this project will occur after the
objectives of this project are completed and the organization decides whether to implement the
revised job description and processes proposed as a result of the project. Evaluation places
emphasis on selecting the right type of evaluation to support the program’s goals and objectives.
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One evaluation type for assessment of the project’s goal of implementing a new job description
for the nurse navigators is a process evaluation. The process evaluation includes review of the
impact of adding tools to capture patients who need to be referred to the nurse navigators and is
expected to determine that patient care needs are better addressed through explicit accountability
and quality matrices built for the role. Providing the right tools to identify at-risk patients and
ensuring the tools are used will allow identification of the project’s effectiveness in improving
patient outcomes and impact on the organization’s goal of reducing unnecessary 30-day
readmissions.
For patients, this project is expected to establish consistency in how patient care needs are
identified and met after referral to the nurse navigator. For the nurse navigators and the
organization, this project provided a way to measure the role effectiveness with at-risk patients as
well as a means to demonstrate the impact nurse navigators had on patient care outcomes such as
decreased ER visits, hospitalizations, and rehospitalizations. Documentation of nurse navigator
outcomes will establish or validate best practices aimed at identifying interventions that help to
increase patients’ quality of life while keeping them out of the acute care setting unless
necessary. Organizational costs can be calculated to determine whether avoided CMS penalties
supported the increased employment costs for nurse navigators.
The end product will be transparency of nurse navigator program outcomes as measured
against outlined goals and objectives to sustain organizational cost-effectiveness and provide
evidence-based care to patients. Monitoring the impact of the changes will be crucial for program
evaluation. For this project, the impact evaluation will determine if the project led to decreased
30-day readmissions in the chronically ill patients or not.
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Summary
A new job description was developed to encourage consistency across the nurse navigator
role in the hospital. The quality improvement approach was designed to identify those
interventions that promoted effectiveness by meeting both the needs of the patients for expert
transitional care support and organizational cost containment by decreasing 30-day readmissions.
The change in job description and processes was accomplished by reviewing current job
descriptions, the referral process, and which patients are seen or need to be seen by a nurse
navigator. IRB approval was obtained from the project site hospital IRB and Walden University
and, with help from key persons at the project site hospital, necessary documents and data for
analysis were obtained. Recommendations for a revised nurse navigator job description were
presented to the hospital leadership and a method for process and impact evaluation of the
revised nurse navigator role and data generation processes were proposed for future
implementation by the hospital.
The next section will provide insight to the findings from all the information gathered and
a recommendation will be presented. Since this is a qualitative study, it will be important to
provide the strengths and limitations of the project.
Section 4: Findings and Recommendations
Introduction
The purpose of the doctoral project was to determine what interventions used by nurse
navigators promoted the best outcomes for at-risk patients and the hospital. Health care has
become a complex system that has unintentionally created gaps in care for many patients. These
gaps cause confusion for the patient because they do not know what questions to ask, what tests
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they need, who in the health care team is necessary to see, and what resources are available to
assist them once they go home. Patients have their own set of challenges prior to entering the
complex health care system; those most at risk have the most to lose in terms of quality of life.
At-risk patients often are faced barriers to care before entering the hospital system as well as
when they are within the hospital system. All these issues make the nurse navigator role essential
(and invaluable) for identifying patients who need assistance in their interactions with the health
care system. The ability to identify at-risk patients will yield the best outcomes to patients and to
the organization.
Each inpatient department director and/or manager who had a nurse navigator on staff
was contacted by confidential e-mail requesting information for the project as approved by the
hospital and Walden University IRB committees. A consent form was attached along with written
details describing the objectives for the project. The objectives of the project were explained in
person and any questions were answered. The evidence was obtained after a voluntary, signed
consent form was completed. The data received were current job descriptions and current
workflow sheets if used.
The nurse navigator job descriptions were analyzed for similarities and differences across
their roles in the hospital. The data were compiled and then compared to the list of tasks,
knowledge areas, and skills essential for practice competency from the Oncology Nurse
Navigator Role Delineation Study (Brown et al., 2012). The purpose of this analysis was to
determine oncology nurses’ essential job functions and activities and what activities were
essential to the role of the nurse navigator (see Table 3). A new list was developed. It included a
bridge between what had been established as essential to the role of the nurse navigator and what
the project site included in its nurse navigator job descriptions (see Table 4).
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Findings and implications
The previously published study, titled Oncology Nurse Navigator Role Delineation Study:
An Oncology Nursing Society Report (Brown et al., 2012), provided the list of essential tasks,
knowledge areas, and skills deemed important for the role (see Table 3). This list provided some
items essential to the job descriptions that could aid in developing metrices for accountability
within the nurse navigator role. This list did not, however, provide a means for evaluation,
measurement of outcomes, nor support in identifying role value. Additionally, this list was
exclusive to cancer patients and did not include aspects of care essential for patients atrisk or
with other chronic conditions. A new list was developed to bridge what had been established as
essential to the role of the nurse navigator in the literature (i.e., Brown et al., 2012) and what the
project site had included in their job descriptions for the nurse navigator roles within the hospital
(see Table 3).
Table 3
Tasks, Knowledge Areas, and Skills Table
Tasks
Knowledge Areas
Skills
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Provide emotional and
educational support for
patients.
Practice according to
professional and legal
standards.
Advocate on behalf of the
patient.
Demonstrate ethical principles
in practice.
Orient patients to the cancer
care system.
Receive and respond to new
patient referrals.
Pursue continuing education
opportunities related to
oncology and navigation.
Collaborate with physicians
and other health care
providers.
Empower patients to
selfadvocate.
Assist patients to make
informed decisions.
Provide education or referrals
for coping with the diagnosis.
Identify patients with a new
diagnosis of cancer.
Confidentiality and informed
consent
Advocacy
Symptom management
Ethical principles
Quality of life
Goal of treatment
Therapeutic options
Evidence-based practice
guidelines
Professional scope of practice
Legal and professional
guidelines
Communication
Problem solving
Critical thinking
Multitasking
Collaboration
Time management
Advocacy
Note: From “Oncology nurse navigator role delineation study: An oncology nursing society
report” by Brown et al., 2012, Clinical Journal of Oncology Nursing, 16(6), p. 584. Reprinted
with permission.
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The most comprehensive source of evidence obtained from the project site was the job
descriptions of the nurse navigators. There was a total of 13 job descriptions for the various nurse
navigator roles within the hospital. Of the job descriptions; three were from pulmonary services,
two were from cancer services, five were from cardiovascular services, one was from case
management, one was from neurological services, and one was from endocrinology services.
Each job description followed the hospital template that required a job summary, a list of
essential duties, a list of qualifications, a description of working conditions/physical
requirements, and the organization’s specific behavioral expectations.
For the purpose of this project, all the job descriptions were crosschecked against each
item in Table 1 for specific tasks, knowledge areas, and skills pertinent for the nurse navigator
role. Each item from the Brown et al. (2012) list of tasks, knowledge areas, and skills was
examined for specific coordinating wording from the organization’s job descriptions. If the items
were found, they were tallied. A total was derived and divided by the total number of job
descriptions (13) equaling a percentage of how many included the listed item. For example,
under task, provide emotional and educational support for patients was tallied nine times. This
result (nine) was divided by 13 with a result of 69% for this item. The additional items added to
the table of tasks, knowledge areas, and skills were a result of themes noted through each
individual job description and themes noted through review of the literature review. For example,
one theme, discharge planning, was noted in the literature review.
In addition, the job descriptions were reviewed to determine if there were items that
should be added to the Brown et al. (2012) list. These items were assigned a percentage (see
Table 4) using the process explained previously. The purpose of this process was to determine
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what items involving the nurse navigator were conducive to the transitional care of patients atrisk
and patients with one or more chronic conditions. Items identified for inclusion on the list were:
involvement of the nurse navigator in discharge planning, follow-up telephone calls after
discharge, knowledge of community resources and connecting discharged patients with them, as
well as the education and experience requirements of a nurse navigator.
The literature defined post discharge as a point of failure for many reasons including
patients not understanding new medications, not understanding with whom they needed to
follow-up, nor resource availability in the community to assist with ongoing health care needs.
Under tasks, providing follow-up telephone calls was added to the Brown et al. (2012) list and,
under skills, discharge nurse was added for the nurse navigator in the acute care setting. Many of
the job descriptions for the project site included the term “discharge nurse” (62%) and “provide
follow-up telephone calls” (62%) as requirements for the job.
Being able to understand and use community resources was both beneficial in reducing
readmissions within 30 days for the organization and essential for improving the patients’ quality
of life. All but two of the job descriptions (85%) included use of community resources as a
necessary component of the nurse navigator knowledge and was, therefore, felt to be an
important item to be included as an essential task for the nurse navigator role in work with at-risk
patients.
Under qualifications for the nurse navigator, all job descriptions (100%) required a
baccalaureate nursing degree. The experience required for the nurse navigator role varied
between 3 years (54%) and 5 years (46%). Education was placed under knowledge and
experience was placed under skills in the new job description.
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Finally, a critical area necessary for assessment purposes was the need for an evaluation
tool. For nurse navigators to be able to justify their role, there needed to be a tool in place for
data extraction providing descriptors of patient type, resources used, and if the nursing actions
were effective in 30-day readmission reduction. Because of the differences among settings where
the nurse navigator role was enacted in the hospital, this tool needed to be implemented specific
to patient population. From the job descriptions, (69%) clearly identified collecting and reporting
of data as a job requirement; therefore, this item was placed under tasks in the new job
description.
The job descriptions were then tallied to determine if the items from the Brown et al.
(2012) table were included. A revised table was created with additions, subtractions, and changes
based on terminology and percentages obtained from the job descriptions in conjunction with
Table 3. See Table 4 for percentages derived from the review of the organization’s 13 nurse
navigator job descriptions.
Table 4
Revised List of Tasks, Knowledge Areas, and Skills Table with Percentages
Tasks
Knowledge Areas
Skills
Provide emotional and
educational support for
patients (69%).
Practice according to
Confidentiality and informed
consent (54%)
Advocacy (62%)
Communication (100%)
Problem solving (92%)
Critical thinking (92%)
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professional and legal
standards (31%).
Advocate on behalf of the
patient (62%).
Demonstrate ethical principles in
practice (15%).
Orient patients to the cancer
care system (62%)
Receive and respond to new
patient referrals (92%).
Pursue continuing education
opportunities related to
oncology and navigation
(15%).
Collaborate with physicians
and other health care providers
(100%).
Empower patients to
selfadvocate (62%).
Assist patients to make
informed decisions (69%).
Provide education or referrals
for coping with the diagnosis
(77%).
Identify patients with a new
diagnosis (85%).
Additions
Providing follow-up phone
calls after discharge (62%)
Symptom management (15%)
Ethical principles (38%)
Quality of life (15%)
Goal of treatment (31%)
Therapeutic options (100%)
Evidence-based practice
guidelines (92%)
Professional scope of practice
(0%)
Legal and professional
guidelines (69%)
Education (100%)
Multitasking (92%)
Collaboration (92%)
Time management (54%)
Advocacy (62%)
Discharge nurse (62%)
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Community resources identification
and connection
(85%)
Experience requirements
(100%)
From the revised list, all of Brown et al. (2012) items were listed and reviewed against
each of the organization’s job descriptions to calculate a corresponding percentage. This
calculation provided a view of what was already on the job descriptions and how the items
ranked accordingly. Found from the literature review were discharge planning and follow-up
after discharge. These items were not on the list by Brown et al. (2012) but were noted from the
job descriptions. Education requirements were noted in every job description and were added to
the revised list. These additions were also assigned a percentage. Finally, the words “cancer” and
“oncology” were removed from the revised table to keep the wording more neutral and flexible
for a variety of nurse navigator patient population(s).
The job descriptions for the hospital followed the organizational templates required for
position requirements. The items most frequently cited in the job descriptions were collaboration;
therapeutic options; communication; receiving and responding to referrals; and use of evidence-
based practice guidelines, problem solving, critical thinking, and multi-tasking. These skills were
found to be present in 90% or more of the job descriptions. The areas ranked lowest for the job
descriptions included demonstrating use of ethical principles in practice and pursuing continuing
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education opportunities related to nurse navigation, quality of life, symptom management, and
enacting professional scope of practice. These areas were ranked as present in
15% or fewer of the job descriptions.
The role of the nurse navigator is becoming increasingly common in chronic care
management. There is a great deal of data for the nurse navigators employed in oncology;
however, data are limited for the usefulness of the role for patients who are considered at-risk.
When looking at the hospital’s job descriptions, the nurse navigator roles were specific to
population and diagnosis. Each job description had outlined what was expected for a narrow
range of patients. This finding was consistently presented in the job summary paragraph of each
job description. For example, in the stroke nurse navigator job description, the nurse was
described as caring for patients with ischemic or hemorrhagic stroke, or atrial fibrillation.
Also, it was clearly stated in the job descriptions where the patient should be referred
and with whom initial contact should be made. Data related to the purpose and outcomes of these
referrals and contacts are essential to understanding the nurse navigator role and how it is being
defined by hospital structure and process.
The role of the nurse navigator is aimed at helping patients find and use necessary
community and institutional resources when discharged. Assistance with arranging follow-up
appointments with the primary or specialist health care provider, ensuring delivery of durable
medical equipment, or arranging skilled care to address medical needs such as wound care and
medication administration can facilitate the transition to home. The organizational goal is to
decrease unnecessary illness exacerbations resulting in 30-day hospital readmissions just because
the patient did not understand what resources were available and how to access them. This
project outlined the nurse navigator role by specifying tasks, knowledge areas, and skills
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necessary to successfully transition hospital patients to home. The project can help to avoid
duplications or gaps in services and addresses major points of failure for the patients after
discharge.
The implications for positive social change are to provide patients with a resource (nurse
navigator) who is well equipped through education and training to use evidence-based best
practices and processes to improve patient care in a cost-effective manner. Health care delivery is
complex and constantly changing, which makes it hard for patients to understand and
increasingly frustrating for patients and families. Lack of clarity and gaps between settings take
away from coordination and continuity of care and decrease the overall quality of care, adding to
poorer outcomes for patients at risk. Having a nurse navigator to identify patient needs and
connect patients with necessary resources is a winning solution for all stakeholders.
Recommendations
Differences among the nurse navigator job descriptions were seen across hospital
services. Some job descriptions, for example, required data collection and reporting and others
did not. All the nurse navigator roles required general education for the role; however, most of
the requirements were not tailored to the nurse navigator role itself or the specific knowledge
necessary to support patients with chronic conditions requiring self-care management. Overall,
there was no consistency in the tasks, knowledge areas, and the skills the nurse navigator role
should encompass. Each service identified what the patients’ needs were and how the nurse
navigator should address those needs. Unfortunately, the lack of a consistent approach to the
nurse navigator role may have increased fragmentation and confusion for the patients using the
services.
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The original intent of the nurse navigator roles was to decrease fragmentation, but
without uniform job descriptions, the role may result in a higher likelihood of care gaps. The first
recommendation, therefore, is for more consistency across the job descriptions as outlined in the
literature (see Appendix A). A second recommendation is that all at-risk patients to be identified
and an individual discharge plan be put into place as soon as the patients enter the hospital. A
third recommendation is that quality matrices will need to be developed and completed for each
patient to identify care gaps and, ultimately, to demonstrate the value of and justification for the
nurse navigator role. Data analysis can identify 30-day readmissions and establish the potential
causes or missed opportunities to ensure that at-risk patients have access to appropriate resources
in the home and the community that will prevent unnecessary rehospitalizations.
Because of the potential for inconsistencies in the interpretation of the nurse navigator
role in the hospital, a fourth recommendation is to place the nurse navigators under one
department with an advanced practice nurse provider managing the department. The feasibility of
this recommendation would need to be examined by the hospital. This recommendation places
one, instead of multiple persons, in charge of the nurse navigators, which may improve role
integrity; decrease lapses of communication among services, providers, or other resources; and
increase collaboration with organizational leadership, quality managers, nursing departments,
and affiliates for consistent, quality care. Finally, the fifth recommendation is the need for a new
position specific to the nurse navigator department to assist with identifying and arranging
community resources for patients prior to discharge. This person could assure that patients have
the services they need in place the day they go home.
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Strengths and Limitations of the Project
The main strength of this doctoral project was that it revealed for the organization how
the nurse navigator roles are currently being defined and utilized in the hospital. Each service has
developed and employed specific strategies to promote optimal care for patients to avoid
unnecessary readmissions. All services are using established and credible evidence-based
practice guidelines specific to the diagnoses of the patients. For example, patients with chronic
obstructive pulmonary disease receive care as outlined through the Global Initiative for
Obstructive Lung Disease (GOLD) standards (goldcopd.org, 2017). The finding was true for
cardiology, endocrinology, neurology, and all the other hospital services utilizing the nurse
navigator role. The new nurse navigator job description incorporated use of relevant
evidencebased guidelines as a knowledge area expectation of the nurse navigator role.
A limitation of the project is the use of a convenience sample of nurse navigator job
descriptions and internal referral data processes from one hospital. This sample may misrepresent
the nurse navigator role and result in findings and recommendations that cannot be generalized
beyond the project hospital. In hindsight, a survey completed by the nurse navigators may have
been helpful to see what items they found most necessary and appropriate in the Brown et al.
(2012) list of tasks, knowledge areas, and skills. Their input about how well the job descriptions
reflected their duties and expertise would have been helpful in creating a more comprehensive
and accurate picture of the nurse navigator role.
Another limitation identified for this project was the inability of the organization to
provide outcome data related to the role of the nurse navigators. Some of the job descriptions for
the nurse navigator role required outcome data collection and reporting, but the processes to use
for these purposes were not elaborated.
179
Summary
There was a great deal of research and data for the navigator role in oncology and the
tasks, knowledge, skills necessary for success in the role. For the at-risk patients with an acute or
chronic condition, there was a great deal of evidence supporting the need for the nurse navigator,
but little evidence that really focused on which interventions promoted optimal outcomes for the
patient. The purpose of this project was to determine what interventions were used by the nurse
navigators based on the literature and job descriptions at one hospital.
In future projects, it will be essential to test the five recommendations to see if in fact
these suggestions can be implemented and lead to decreased unnecessary readmissions, lower
hospital costs, and increased patient satisfaction and quality of life. Future research will define
interventions that are evidence driven and provide data about the nurse navigators’ effectiveness
for both patients and organizations. Follow up research should include whether practices used by
nurse navigators are universal. This research would support the importance of their practices and
improve patients’ outcomes in turn.
Section 5: Dissemination Plan
The dissemination plan included providing the recommendations from this project to the
CNO of the project hospital. The information provided comprised of the revised job description
and comprehensive literature review with associated recommendations. A podium or poster
presentation of the project is also planned.
The hospital is currently on the journey toward achieving “magnet status” as outlined
through the American Nurses’ Credentialing Center (ANCC) associated with the American
Nurses Association (ANCC, 2018). This project was geared toward enhancing professional
independent nursing practice to promote excellence in the delivery of care, clinical practice, and
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dissemination of findings toward best practices in nursing services. If accepted by the
organization for implementation, the project findings will be provided to the education champion
for dissemination toward the “Magnet Journey.”
The audiences who may be most impacted by this project are the nurse navigators in the
organization, quality management staff, and organizational leaders. This project defined
necessary cost-effective tasks, knowledge areas, and skills for the nurse navigator role and
offered recommendations for continued improvement through documentation of interventions
and outcomes.
Analysis of Self
This project has been enlightening as a nurse practitioner and scholar. Overall, there was
a great deal more to the potential solution than just stating the problem. It was informative to see
how the nurse navigator role started and has evolved beyond oncology and what the different
departments have done with the role. As an advanced practice provider, the project demonstrated
the importance of considering the literature for direction and seeing where the evidence may
lead. Parts of this project assumed to be easier, were the most difficult parts of the project to
complete. One example was the IRB process. This process was an experience that will be applied
in addressing future practice problems to ensure a broad view is brought to investigation instead
of assumptions that may be ill-guided.
Summary
Health care has become very complex and nurses must embrace and use their clinical
expertise in support of patient navigation through the health care system. The goal of this project
was twofold as it was geared toward both improving nursing care for patients and addressing the
organization’s interest in decreasing 30-day readmissions and providing cost-effective care. For
181
nursing, it provided an avenue for assisting patients through discharge and the transition to home
to delay or interrupt disease progression through best practices. For the organization, the project
worked to decrease costs associated with unnecessary testing and avoidable readmissions. The
project has established the framework for continuing to improve the quality of care delivered
through consistent application of the nurse navigator role and recognition of the value a specific
nurse navigator department may bring to the organization.
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