Background: Patients with complex chronic conditions experience fragmentation of care, unnecessary hospitalization and reduced quality of life, with an increased incidence of poor health outcomes. Aim(s):The aim of this paper was to explore how nurse navigators manage client care. This was achieved through an examination of narratives provided by the nurse navigator that evaluated their scope of practice. Method(s):All nurse navigators employed by Queensland Health were invited to participate in a study evaluating the effectiveness of the service. Eighty-four selfreported vignettes were thematically analysed to understand the work from the nurses' perspectives.Results: Two themes emerged from the vignettes. Theme 1, the layers of complexity, is comprised of three sub-themes: the complex patient, the complex system and patient outcomes. Theme 2, professional attributes, has two sub-themes: personcentred care and clinical excellence.Conclusion: Navigators innovatively integrate services and address the fragmented nature of the health system. They apply expert clinical and social skills, through consistent and robust communication, to meet the needs of those with multiple chronic conditions. Implications for nursing management: Results provide insight into the new role, illuminating the work they achieve, despite system complexities. K E Y W O R D S integrated health care systems care, multiple chronic conditions, nurse navigator, nurses' role, patient navigation, quality of life | 815 BYRNE Et al.

Aim With increasing age and chronicity in populations, the need to reduce the costs of care while enhancing quality and hospital avoidance, is important. Nurse‐led co‐ordination is one such model of care that supports this approach. The aim of this research was to assess the impact that newly appointed Navigators have on service provision; social and economic impact; nurses’ professional quality of life and compassion fatigue; and analysis of the change that has occurred to models of care and service delivery. Design A concurrent mixed‐method approach was selected to address the research aims. Methods The research project was funded in July 2018 and will conclude in December 2020. Several cohorts will be studied including; patients assigned to a navigator, patients not assigned to a navigator, family members of patients assigned a navigator; and a sample sized estimated at 140 navigators. Discussion This study provides a comprehensive international longitudinal and mixed method framework for evaluating the impact of nurse navigators on quality of care outcomes for patients with chronic conditions. Impact—What problem will the study address? Even with specialty focused co‐ordinated care, patients get lost in the system, increasing the incidence of non‐compliance and exacerbation of condition. Navigators work with patients across service boundaries allowing for care that is patient responsive, and permitting variables in clinical, social and practical elements of care to be addressed in a timely manner. This novel nurse‐led approach, supports hospital avoidance and patient self‐management, while encouraging expansion and opportunity for the nursing and midwifery workforce.

Aim To understand the impact and causes of ‘Failure to Attend’ (FTA) labelling, of patients with chronic conditions. Background Nurse navigators are registered nurses employed by public hospitals in Queensland, Australia, to coordinate the care of patients with multiple chronic conditions, who frequently miss hospital appointments. The role of the nurse navigator is to improve care management of these patients. Evidence for this is measured through improvement in patient self-management of their conditions, a reduction in preventable hospital admissions and compliance with attendance at outpatient clinics. Failure to attend (FTA) is one measure of hospital utilisation, identifying outpatient appointments that are cancelled or not attended. Method The cohort for this study was patients with multiple chronic conditions, and nurse navigators coordinating their care. Data describing the concept of FTA were thematically analysed twelve months into this three year evaluation. Results Although the patient is blamed for failing to attend appointments, the reasons appear to be a mixture of systems error/miscommunication between the patient and the health services or social reasons impacting on patient’s capacity to attend. Themes emerging from the data were: access barriers; failure to recognise personal stigma of FTA; and bridging the gap. Conclusion The nurse navigators demonstrate their pivotal role in engaging with outpatient services to reduce FTAs whilst helping patients to become confident in dealing with multiple appointments. There are many reasons why a patient is unable to attend a scheduled appointment. The phrase ‘Failure to Attend’ has distinctly negative connotations and can lead to a sense of blame and shame for those with complex chronic needs. We propose the use of the neutral phrase “appointment did not proceed” to replace FTA. Implications for Nursing management This article advocates for further consideration of collaborative models that engage the patient in their care journey and for consideration of the language used within the outpatient acute hospital setting, proposing the term ‘appointment did not proceed.’

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