Navigation as a Team Effort

At the bedside/chairside, nurses and social workers are often the ones identifying issues and attempting to manage care. To do this well, we need to be aware of what is going on with our patients and families. Look beyond stated needs, assess further and ask the “hard questions.” What is the plan for transportation? When patients are absent from treatment or appointments, instead of labeling them as noncompliant, ask directly about their challenges and how the team can help. Making assumptions doesn’t serve anyone well. How is your patient managing with the increased expenses? Does your patient need to be connected to a financial counselor? What kind of feedback have you requested about patient experiences at your institution?

Once these issues are brought out, the next question is what can be done to assist our patients, and who can do it. Certainly, social workers — both in-patient and out-patient — have the knowledge of how and where to get help in many instances. Social workers recognize issues that the environment, social relationships, distress related to loss or family problems, caregiving strain, and difficulties at work may play in determining patient support needs. Although providers may not be able to completely address patients’ social support needs, assessing those needs, engaging family and friends in treatment plans, and intervening to bolster support networks all constitute a social work approach to health.4

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But no one group can do it alone. As nurses and social workers “in the trenches,” we should be working together with the entire healthcare team to assist our patients and their families. Use of hospital finance departments to get public assistance or charity care, neighborhood or regional support agencies, churches/synagogues/mosques, and/or hospital-based donations for patient support are all areas that nurses should be somewhat aware of and are able to share information on contacts and phone numbers or email addresses for them. Involve hospital administrators when issues of access are brought to light. Regardless of whether things change, the realization that changes are needed is always the first step.

Nurses need to recognize their roles in identifying issues in and managing change within the healthcare system to better serve our patient populations. Working closely with social services as well as the entire healthcare team, we can start to identify disparities and perhaps, find solutions.


1. Strategies for reducing health disparities: selected CDC-sponsored interventions, United States, 2016. Centers for Disease Control and Prevention website. Accessed June 20, 2019.

2. Access to health services. Healthy People 2020 website. Accessed June 20, 2019.

3. Agenda for Fighting Disparities. HealthAffairs. 2001;30(10). 4. Findlay RA. Interventions to reduce social isolation amongst older people: where is the evidence? Ageing Soc. 2003;23:647-658.