EONS Magazine Winter/Spring 2019 edition

The introduction of Oncology Nurse Navigators in a German thoracic oncology service

Laura Hagelskamp on a qualitative study of German nurses’ attitudes to nursing role expansion (with Sarah Berger, Matthias Villalobos, Michael Thomas, Michel Wensing, Cornelia Mahler)

Laura Hagelskamp

Laura Hagelskamp

Patients with metastatic lung cancer with a limited prognosis have a high symptom burden as well as complex and specific care needs making coordinated health service delivery important for this patient group1,2. The limited prognosis as well as associated substantial existential uncertainty have a negative impact on patients and caregivers3,4. Furthermore, fragmentation in service provision makes adequate and timely responsiveness to changing patient needs difficult. Improvements in coordination of care is one key strategy for addressing this issue5. One promising development to overcome these provision gaps has been seen in the introduction of Oncology Nurse Navigators (ONN), as has emerged in the US and Canada2,6.

Introduction of the Heidelberg Milestone Communication Approach and Oncology Nurse Navigators 

Embedded in a project called the Milestone Communication Approach at the Thoracic Hospital in Heidelberg (THHD), we planned the introduction of ONNs as one part of a complex intervention7. In order to become an ONN at THHD, interested nurses need to have post-qualification training in oncology or palliative care and extensive clinical experience in clinical oncology or palliative care. These ONNs attend an interprofessional communication training course with physicians and carry out so-called Milestone Consultations together with physicians at four pivotal points during the lung cancer patient’s disease trajectory. Additionally, the ONNs hold regular follow-up calls with patients and their caregivers. Their responsibilities include: monthly follow-up calls with their patients and their caregivers; participation in diagnostic and prognostic disclosure; increased responsibility in the coordination of patient care throughout the disease trajectory and increased responsibility for documenting Milestone-Consultations and maintaining contact to healthcare providers across service sectors. The overall aim of the project is, among other things, to enhance Advance Care Planning, continuity of care and the early integration of palliative care7

Figure 1: The Heidelberg Milestone Communication Approach (Hagelskamp 2018)

Figure 1: The Heidelberg Milestone Communication Approach (Hagelskamp 2018)

Expanding nurse roles – the opportunities and the obstacles

As the role of ONNs is new in this form in Germany, a critical step towards effective implementation has been gaining insight into German nurses’ perceptions and attitudes towards such new and expanded nursing roles. For this reason, a study exploring attitudes of nurses in a German thoracic oncology service to the implementation of this new ONN role has been instigated at THHD (results are currently in preparation).

Previous studies indicate that attention needs to be paid to the introduction of new roles in nursing, as nurses’ acceptance of and trust in new roles can have an important influence on implementation success8. A benefit seen in the introduction of expanded nursing roles is that hospitals with a higher skill mix have shown to have lower patient mortality rates and less adverse events9.

In Germany, regulatory aspects currently hinder expanded roles in nursing. In addition, physicians’ attitudes towards new and expanded nursing roles may be a barrier to change. Individual physicians as well as members of the German Federal Medical Council have expressed objections to the advancement of the nursing profession primarily because this is perceived as nurses encroaching on traditionally medical territories10. Furthermore, the absence of a German federal nursing council, due to existing political, legal and regulatory structures at national level, makes the professionalisation process in German nursing more challenging11.


Although the implementation of an expanded nursing role, as with the ONN, is not completely new to the German healthcare system, the results of this study may help in informing planned change processes and educational strategies for roll-out of the ONN role in Heidelberg.

For patients with metastatic lung cancer and limited prognosis, expanded nursing roles, such as an ONN, can reduce fragmentation of care and improve communication between service providers to enhance timely and effective responsiveness to specific and complex patient needs.

Laura Hagelskamp is based at the Thoracic Hospital in Heidelberg, Heidelberg University, Germany.