Case study: The oncology nurse navigator role
A catalyst for the creation of collaborative care teams
The problem
A decade ago, the province of Quebec developed its program of cancer care and was looking at ways to improve coordination and patient outcomes. The Ministry conducted a large survey asking Quebeckers what they would want and need if they were a cancer patient. One of the central points raised by respondents was that they wanted one person to act as their resource person and coordinate their care. Another finding was that people wanted their caregivers to see them as a whole person and pay attention to every aspect of their experience with cancer. They wanted a navigator. Quebec also faced the challenge of bringing quality care to a large population who live far away from the urban centres.
Nursing initiative
“It took some time to figure out who would fulfill the function of navigator,” said Andréanne Saucier, Associate Director of Nursing in Oncology and Respiratory Services at the MUHC and Co-Executive Director for the MUHC Cancer Care Mission. “Quebec nurses working in oncology took a proactive stance and came together to lead the process of describing the new role.” They presented the proposal to the Ministry and it was accepted. The nurse was seen as well placed to meet the biological, social and spiritual needs of people with a cancer diagnosis and to create partnerships with community and other partners. This role represented a significant shift as the nurse became the patient’s primary resource person from diagnosis onward.
The infirmière pivot in oncology (IPO or oncology nurse navigator in English) was specifically created to meet new expectations in the health care system in Quebec. Many other provinces and countries are now looking at the experience.
Government support
The role was created concurrently with efforts to adopt an interdisciplinary approach to cancer care. One of the specifications in the creation of the role was that the nurse work as part of an interdisciplinary team. The Ministry determined that interdisciplinary cancer teams would be created across the province and that, in order to achieve recognition, each team had to have an IPO. These nurses were seen as catalysts to spur the creation of a new care model.
The first few IPO positions were filled in 2005. The leadership group of oncology nurses in Quebec, which still exists as an advisory group to the Ministry, then proposed a standardized role description, which was communicated to all the regions. “A very small budget from the Ministry was allocated to create the positions,” said Ms. Saucier, “but most organizations, including the MUHC, invested significant resources of their own as well.”
Role definition
The IPO is responsible for four domains of practice:
1. assess and manage needs and symptoms (physical, psychological and spiritual)
2. provide patient information
3. provide support to patients and their families
4. coordinate and ensure continuity of care.
A document was prepared by the province to help explain the role to nurses’ colleagues. It’s a clinical role in that 90% of the IPO’s practice is direct patient care, with the remaining 10% used to develop expertise in oncology nursing. And it’s considered to be a specialized oncology nursing role. The Canadian Association of Nurses in Oncology has been very active in developing standards and competencies.
According to Dr. Jeremy Sturgeon, Director of Medical Oncology at the MUHC, physicians welcome the IPO role. “Many years ago,” he said, “we recognized that the diagnosis, treatment and continuing care of people with cancer was far too complex for one group of practitioners to monopolize. Physicians were ready a long time ago to share this role and forge partnerships with colleagues.”
Education
Educational requirements are a baccalaureate in nursing with a minimum of two years experience in oncology. Canadian certification in oncology is perceived to be an asset. The baccalaureate level was chosen because it was felt that there would not be enough nurses to fill positions in all the regions if a Masters’ degree was required. There is now statistical data for the province, as well as research into practice patterns at the MUHC that finds nurses engaged in all four of the anticipated domains of practice.
The future
The number of IPOs increased from 20 in 2005 to 220 by 2008. Critical mass has been achieved in Quebec. IPOs come together once a year and talk about ongoing skills development, clinical tools, and effective ways to work with other disciplines. The Ministry is now setting targets for the number of IPOs based on anticipated patient needs, and aims to have 70% of patients with a new diagnosis of cancer access an IPO within 72 hours of diagnosis.
“It’s hard to know how long IPOs will remain a Ministry priority,” noted Ms. Saucier. “To keep it there, nurses need to put forth the evidence of benefit. Research so far has found that the IPO role is helpful in integrating the care team. Patient outcome data is a challenge to put together and research at the MUHC didn’t produce clear results.” A new research project is now underway to assess the impact of IPOs on other health care providers and on families in terms of their preparedness to care for the patient and expectations of care.
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