Nurse navigation is helpful for cancer patients, but with some restrictions.

Background

Much development in nursing care is not based on research but is created from the ideas of health-care professionals, for instance, about benefit for patients. One example is case management (CM), where newer models focus on transitions in the health-care system and have a holistic and empowering approach to information, coordination and other kinds of support needed by the patients [1]. Within CM, nurse navigation (NN) is an innovation in which availability also characterises the model [2,3].

Aims

We were keen to investigate who could benefit from the help on offer and what significance female cancer patients attach to NN.

Methods

A longitudinal phenomenological–hermeneutical study was carried out among 21 consecutively included women. They were referred on suspicion of gynaecological cancer and were followed by first author form the referral had reached a university hospital in Denmark and 3 months ahead. The women were offered help from one of two female NNs from a surgical department, from the time of referral and until they were referred further or hospitalised for cancer surgery. The method has been thoroughly described elsewhere [4-6] and includes patient diaries, observational studies and semi-structured interviews, where women made graphical representations of their emotions over time as visual aid to their memory [6]. From verbatim transcriptions, an open-minded analysis on three analytical levels, inspired by Riceour [7], leads to a comprehensive understanding.

Findings

An overlap was found between women’s experiences of their relationship with the health-care professionals before communicating with the NN, and the subsequent significance an NN had for the women. Important themes were trust and guarded trust [4]. Moreover, although the women said that they were anxious, and to various degrees felt ignorant and feared death, an NN could have or not have a special meaning, and this meaning could be either positive or negative [5] (Table 1).

Table 1

Significance of women who choose or do not choose help from a nurse navigator (NN), and the significance they attach to the NN.

A woman’s experience of the relationship with the health-care professionals before communication with an NN4	The significance female cancer patients attached to an NN
Trusting that a health-care professional among the close relatives can and will help	No special meaning. The NN was a nurse in the crowd of nurses and her help was not useful outside the outpatient setting
Trusting that a known physician can and will help
Not fully trusting that a known health-care professional can and will help. The women felt guarded trust in one or more health-care professionals of special importanceGuarded trust followed the women’s interpretation of non-verbal signals from a physician they counted on in relation to their own health. Such interpretations were always told as the women’s latest experiences with an important physician before the contact to the NN	A special person providing useful help, also after the initial outpatient setting [5]
	In the period with an available NN the women felt a special affinity with the NN and the women felt that the NN was:– Trustworthy, knowledgeable and someone special, who as an easily accessible health-care professional was nice and helpful to act immediately, inform, support, reassure and provide an overview and empowerment In the period after an available NN the women felt the NN was– Disappointing, failing and repelling

Comprehensive understanding and discussion

Each woman had benefit of having a specific health-care professional, whom she trusted could and would help her through the course of her cancer. If the woman did not have such a relationship with a health-care professional at the time of referral, the woman could use the trusting relationship the NN offered. Trust, guarded trust or distrust towards another is created primarily from our interpretations of the other’s non-verbal signals, where we judge whether the corresponding person behaves as expected [8]. A health-care professional’s efforts to maintain or gain patient’s trust therefore requires a kind of cultural sensitivity, which is tested every day and the test is not always passed, if trusting patients are the goal. On the one hand, offering an NN in cancer care can therefore be seen as a patch on a system which is not functioning optimally, but on the other hand we can ask whether optimising communication by health-care professionals can remove all the patient’s needs for extra help from an NN.

When help from the NN became useful for the women, the women’s descriptions were similar to those of close providers (see Table 1). The women were aware of the period of availability of the NN, but nonetheless they still expected her attention. When this was in vain, the patients became disappointed and felt rejected and let down. This cannot be explained solely by patients’ wishes for continuity in care. Bowlbys’ attachment theory [9] explains that in a period where death was felt as a possible close event, the NN offered herself as a special caring figure – an attachment figure – with high levels of availability, knowledge and help. The referred woman without a health-care professional attachment figure started making emotional bonds with the NN. Therefore, a further referral, for instance, which changed the NN’s mode of action, would feel very harsh, although the woman rationally knew that the NN was no longer available. Cancer patients have various degrees of critical periods in the course of their cancer [10], and should emotional bonds to an NN have to be terminated, we recommend that health-care professionals consider both the timing and ways to do this.

Our results cannot be generalised but are rather transferred to similar places.

Conclusion

Women’s trust and guarded trust in health-care professionals are key points in relation to the use of an NN, but we do not know how to find those who need the extra effort. Moreover, the NN might become an attachment figure for the individual woman, and sustain special importance. Therefore, it must be considered whether health-care professionals in general should increase their focus on communication, in combination with offering an NN to the patients for a longer duration of time, if possible in a never-ending attachment.

Conflict of interest statement

None declared.