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Published in final edited form as: Orthop Nurs. 2024 Mar-Apr;43(2):75–83. doi: 10.1097/NOR.0000000000001013

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Obesity and Malnutrition – Part Four of the Movement is Life Special ONJ Series

Martha Kebeh 1, Chloe C Dlott 1, Donna Kurek 2,3, Jensa C Morris 4,5,6, Daniel H Wiznia 1
PMCID: PMC10987043  NIHMSID: NIHMS1958491  PMID: 38546679

Abstract

Background:

Obesity and malnutrition affect many patients with osteoarthritis (OA) and can predispose patients to worse outcomes after total joint arthroplasty (TJA). However, these modifiable risk factors can be addressed in preoperative optimization programs driven by nurse navigators.

Purpose:

Our aim is to provide resources and recommendations for nurse navigators when addressing obesity and malnutrition among TJA patients.

Methods:

In addition to discussions with nurse navigators regarding obesity and malnutrition, a literature review was conducted to assess the current practice standards for management.

Results:

Nurse navigators often had difficulty implementing long-term interventions, but interventions in the literature included medical and bariatric treatments for obesity and more targeted assessment of nutrition status. These findings are incorporated into our recommendations for nurse navigators.

Conclusion:

Addressing obesity and malnutrition in preoperative optimization can contribute to improved outcomes, as has been demonstrated in current practice and in the literature.

Introduction

This article is part four of the Orthopaedic Nursing Journal (ONJ) series that reviews the role of orthopaedic nurse navigators in preoperative optimization. In this article, we discuss strategies that can be implemented by nurse navigators to improve patients’ comorbidity profile by managing obesity and malnutrition prior to proceeding with total joint arthroplasty (TJA).

Among patients seeking TJA, weight and nutrition status are often identified as risk factors for postoperative complications (Kerbel et al., 2021; Purcell et al., 2022; Rhind et al., 2020; Wall & de Steiger, 2020). Obesity, which is defined by a body mass index (BMI) ≥ 30 kg/m2, is a risk factor for osteoarthritis (OA) (Al-Otaibi, 2021; Changulani et al., 2008), and patients with obesity comprise a growing proportion of TJA patients (Ekhtiari et al., 2021). In reference to surgery outcomes, several studies have found worse functional outcomes and discharge dispositions, as well as increased rates of infections, wound complications, and revision among patients with obesity (Feng et al., 2022; Gwam et al., 2020; Jameson et al., 2014; Kerkhoffs et al., 2012; Keswani et al., 2016; Yeung et al., 2011). In addition, patients who are obese are more likely to need TJA at a younger age and less likely to identify as White and non-Hispanic when it comes to race and ethnicity (Brock & Kamath, 2019). The disparity in prevalence of obesity between patients who are Black or Hispanic and patients who are White is largely influenced by social drivers of health such as neighborhood safety, income level, and locally available food prices (Min et al., 2021). To reduce disparities in utilization of TJA (MacFarlane et al., 2018; Sheth et al., 2021; Wu et al., 2021), it is important to address racially and socioeconomically influenced risk factors like obesity in optimization protocols (Dlott et al., 2022).

Malnutrition definitions vary in practice and in the literature, but albumin levels, transferrin levels, lymphocyte count or body mass index (BMI) below certain thresholds are often used to define the condition (Cross et al., 2014; Wall & de Steiger, 2020). Rather than propose a universal definition of malnutrition, we defer to the referenced works’ definitions of the term and rely on practice standards and data regarding TJA outcomes to help nurse navigators implement interventions related to nutrition. Malnutrition in TJA patients is associated with an increased risk of postoperative complications, readmissions, costs, and length of stay (LOS) following surgery (Black et al., 2019; Nelson et al., 2019; Rudasill et al., 2018). Malnutrition may also affect patients of color and patients with limited financial resources disproportionately, making it another risk factor that can contribute to inequities in TJA access (O’Connor et al., 2022; Papanikolaou et al., 2015; Sheean et al., 2019).

Weight management and nutrition concerns are both heavily influenced by social factors such as socioeconomic status or neighborhood factors such as proximity to and type of food resources (Kegler et al., 2008; Seguin et al., 2014). In assisting patients with managing weight and nutritional status, nurse navigators have the opportunity to contribute to improving musculoskeletal health equity. Using information from discussions with nurse navigators and a review of the current literature, we provide resources and practical recommendations that orthopaedic nurse navigators can use when optimizing patients with obesity or malnutrition.

Methods

The full methodology for this article series can be found in the introductory article Kebeh et al., 2023.

Nurse Navigator Perspectives

We consulted orthopaedic nurse navigators who were members of the National Association of Orthopaedic Nurses (NAON) to discuss how patients with obesity and malnutrition were identified and managed prior to TJA. Through semi-structured discussions by phone or video conference, we asked each nurse navigator four standard questions regarding optimization practices and resources utilized (Figure 1). In addition, open-ended questions were asked to gather more information based on responses to initial questions.

Figure 1.

Figure 1.

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Context Statement for Orthopaedic Nurse Navigators and Preoperative Optimization Series

Literature Review

Our literature search was conducted in the Scopus and Web of Science databases, which contain multiple indexes and journals across health and social science disciplines. We identified 17 articles specific to obesity and 12 articles specific to malnutrition.

Results

Obesity

Nurse Navigator Perspectives

Seventy-six percent of nurse navigators were employed by institutions that utilized a threshold cutoff for BMI, which meant that patients with BMI values above this level were either not offered surgery or were directed to achieve a BMI below a certain threshold before surgery. The BMI threshold ranged from 35 to 50 kg/m2, with 48% of institutions using a BMI threshold of 40 kg/m2. Among institutions with a threshold cutoff, several nurse navigators described the thresholds as a “soft” cutoff or noted that there were various preferences for instituting BMI cutoffs among different surgeons within the same institution. Twenty percent of nurse navigators were not able to address obesity preoperatively, typically due to the short time period between their initial interaction with patients and patients’ surgical dates.

Nurse navigators described a variety of interventions for obesity including education regarding the impact of obesity on OA and surgical outcomes or connecting patients to weight loss resources such as in-house weight management and wellness programs. Weight management programs featured individualized meal plans, distribution of pre-made meals, weight check-ins, medication-mediated weight management, group exercise, group therapy, and appointments with nutritionists or dietitians, physical therapists, and mental health professionals. Nurse navigators also described referrals to outpatient programs run by their institutions, through partnerships with other healthcare institutions, through private organizations such as WeightWatchers®, or through local organizations serving their community.

Nurse navigators also assisted patients in connecting with providers such as bariatric surgeons, medical weight loss specialists, or nutritionists. One orthopaedic nurse navigator with overlapping duties in bariatric and orthopaedic patient care coordination expressed an interest in developing a stronger link between the two departments to help TJA patients receive bariatric care. Forty percent of nurse navigators said they were able to refer patients to in-house weight management and wellness programs. These services were typically covered by patients’ insurance and provided consistent and specific guidance on nutrition and weight loss. One nurse navigator described a grant-funded 8-week course on nutrition and exercise in which patients could enroll. Another nurse navigator compiled and regularly referenced a resource directory that included local weight loss programs within the state in order to better serve patients in rural areas with difficulty commuting to the nurse navigator’s institution.

Literature Review

Four studies found in our literature review recommended addressing obesity before TJA due to risks for poorer outcomes (Adie et al., 2019; Al-Otaibi, 2021; Keswani et al., 2016; Wall & de Steiger, 2020), and strict cutoffs for BMI are frequently implemented in top orthopaedic programs (Dlott et al., 2022). However, strict cutoffs prohibiting patients with a high BMI from receiving TJA may prevent patients who are Black, female, or socioeconomically disadvantaged from receiving surgery (Wang et al., 2018). A 5% reduction in preoperative weight loss was considered a clinically significant weight loss goal among the studies found in our literature search that described a weight loss goal not based on BMI (Fournier et al., 2016; Gandler et al., 2016).

Our literature search revealed multiple methods for weight loss, including dietary modification, referral to a dietitian, weight management clinic, or bariatric clinic, providing informational materials regarding weight loss, lending exercise equipment to patients, and setting target weight goals for patients as components of preoperative protocols that showed overall benefits such as decreased LOS and increased discharge rates to home for TJA patients (Adie et al., 2019; Al-Otaibi, 2021; Featherall et al., 2018; Fournier et al., 2016; Hansen et al., 2012; Kerkhoffs et al., 2012; Parsons et al., 2013; Ryan et al., 2019). Some health organizations recommend bariatric intervention before TJA in patients with a BMI greater than 35 kg/m2 (Rhind et al., 2020). A prior study showed that receiving laparoscopic sleeve gastrectomy before TKA lowered complication rates and led to greater average weight loss than receiving TKA prior to bariatric surgery (Purcell et al., 2022). TJA patients in a weight loss program that allowed them to have regular follow-up sessions with a dietitian prior to surgery showed significantly greater weight loss and BMI reduction compared with patients who were not seeing a dietitian (Gandler et al., 2016). Online or app-based patient education and preparation can be an effective way of facilitating weight management by providing patients with increased knowledge and counseling before surgery (Sharif et al., 2020). Our search revealed one ongoing randomized controlled trial seeking to assess the efficacy of a 12-week digital app-based weight loss program involving dietitian support in advance of TJA (Seward et al., 2020).

Malnutrition

Nurse Navigator Perspectives

A variety of methods involving BMI or albumin level screening were used to assess patients’ nutritional status prior to TJA at nurse navigators’ institutions (Table 2), though nurse navigators were not always involved in the screening process. Malnutrition was frequently defined by nurse navigators’ institutions as a BMI below 18 to 20 kg/m2 or an albumin value of less than 3.5 g/dL, though definitions and interventions sometimes varied by surgeon. Potential interventions included providing education regarding nutrition and its impact on TJA recovery and outcomes in joint classes or through online patient education platforms, referring patients to outside resources such as primary care providers (PCP), dietitians, or nutritionists, and connecting patients with community resources that could improve their access to nutritious foods, such as senior centers, church groups, and organizations like Meals on Wheels.

Table 2.

Interventions for Malnutrition Reported by Nurse Navigators.

○ Education in joint class
○ Referral to PCP, dietitian, or nutritionist
○ Assistance with accessing local nutrition resources (such as senior centers, Meals on Wheels)
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PCP: primary care provider

Interventions in bold can be implemented in-house (without referrals or outside resources).

Literature Review

Malnutrition has been identified as a common risk factor for suboptimal outcomes after TJA (Hansen et al., 2012). Malnutrition has a detrimental effect on wound healing that contributes to complications such as wound dehiscence, hematoma formation, and prosthetic joint infection (PJI) (Black et al., 2019; Evans et al., 2014). Patients with a BMI below 18 kg/m2 have demonstrated increased mortality and infection rates as well as longer LOS when compared to patients who are not underweight (Huang et al., 2013; Katakam et al., 2021). Additionally, studies have identified a considerable population of TJA patients who simultaneously have obesity and malnutrition, which leads to higher complication rates when compared to patients with obesity but without evidence of malnutrition (Huang et al., 2013; Wall & de Steiger, 2020). Though some studies that discuss obesity do not mention malnutrition, it is important to note that obese patients can also experience malnourishment (Featherall et al., 2018; Wang et al., 2018).

One recommendation for managing malnutrition found in our literature search was to order blood tests such as albumin, lymphocyte count, or transferrin preoperatively and refer patients with malnutrition to a dietitian, an intervention that was associated with decreased costs of care postoperatively (Rudasill et al., 2018; Wall & de Steiger, 2020). These studies used an albumin level of < 3.5 g/dL to indicate malnutrition. One study identified the albumin level associated with an increased postoperative complication rate as 3.0 g/dL, but did not provide recommendations for treating malnutrition (Nelson et al., 2019).

A review of the literature on malnutrition in patients seeking TJA recommended referring patients for nutritional consultation with a dietitian, assisting patients with meal planning, and identifying and addressing nutritional deficits (Cross et al., 2014). For patients with concurrent obesity and malnutrition, strategies also included consideration of bariatric surgery and collaboration with physical therapists to teach about exercise routines. Another study described nutritional supplementation, specific diet modification with the provision of example meals for patients, and visits from a dietitian during admission for surgery as effective interventions for improving cost and LOS outcomes among patients with malnutrition as defined by serum albumin < 3.5 g/L (Schroer et al., 2019). However, these studies did not comment on postoperative albumin levels. Ongoing research suggests there may also be a use for parenteral nutrition among TJA patients as a means of addressing nutrient deficiencies (Katakam et al., 2021).

Discussion

Obesity and malnutrition are some of the most common risk factors for poor TJA outcomes and are also difficult to address in short timeframes (Katakam et al., 2021; Wall & de Steiger, 2020; Wang et al., 2018). Improvements may also be difficult to maintain over time and require long-term strategies, which may be difficult to implement depending on when nurse navigators become involved in patient care.

Based on nurse navigator perspectives and results from our literature search, obesity is more commonly identified as a risk factor and addressed by orthopaedic care providers than malnutrition (Featherall et al., 2018; Wang et al., 2018). However, these conditions are interrelated and may be addressed by similar modes of treatment. We recommend nurse navigators practice multimodal and long-term approaches to weight management prior to TJA using the provided resources for meal planning, weight management strategies, and patient education (Table 3).

Table 3.

Resources for Implementing Recommendations.

Resources
 ○ Diabetic diet meal planning and grocery lists1
 ○ Healthy Living patient resources2
 ○ Lifestyle Change Programs for patients with program locator3
 ○ American Diabetes Association Standards of Care slide deck4
 ○ Enhanced Recovery After Surgery Protocol5
 ○ American College of Surgeons Nutrition Resources6
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List of Resources from Table 3: Resources for Implementing Recommendations

1.

Diabetes Food Hub. (2022). American Diabetes Association. https://www.diabetesfoodhub.org

2.

Healthy Living. (2022). American Diabetes Association. https://diabetes.org/healthy-living

3.

Lifestyle Change Programs. (2022). American Diabetes Association. https://diabetes.org/tools-support/diabetes-prevention/lifestyle-change-programs

4.

Slide Deck. (2022). American Diabetes Association. https://professional.diabetes.org/content-page/slide-deck

5.

Liu, V. X., Rosas, E., Hwang, J., Cain, E., Foss-Durant, A., Clopp, M., Huang, M., Lee, D. C., Mustille, A., Kipnis, P., & Parodi, S. (2017). Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System. JAMA Surgery, 152(7), e171032-e171032. https://doi.org/10.1001/jamasurg.2017.1032

6.

Optimizing Nutrition Prior to Surgery. American College of Surgeons. https://www.facs.org/quality-programs/strong-for-surgery/clinicians/nutrition/

Recommendations – Obesity

We recommend orthopaedic nurse navigators implement preoperative optimization protocols for addressing obesity after patients have been assessed for psychosocial and medical factors that may affect weight management, such as access to nutritious foods, places to exercise, and comorbidities like diabetes and hypertension (Table 4). For example, patients living in food deserts should be provided with access to healthier foods through shuttling programs or subsidized food delivery services. Patients should likewise be supported in accessing gyms, parks, and other exercise spaces. This is especially important for patients who cannot practice simple forms of exercise such as walking or biking in their neighborhoods. Nurse navigators should assist patients in seeking out these types of resources. Weight management programs and interventions by nurse navigators should also take into consideration a patient’s medical comorbidities, such as diabetes and hypertension. Weight loss goals of 5–10% of body weight, which can be more effective than BMI cutoffs and can reduce postoperative complication rates, should be determined with the surgeon and patient through a shared decision-making process (Chen et al., 2018; Heymsfield & Wadden, 2017; Sabesan et al., 2022).

Table 4.

Recommendations for Preoperative Optimization: Obesity.

Obesity
 ○ Assess medical and psychosocial factors followed by shared decision-making between surgeon and patient to create weight loss goals of 5–10% of body weight
 ○ Coordinate with surgeons, nutritionists, and dietitians for referral to metabolic weight loss programs or bariatric treatment
 ○ Coordinate with surgeons for early distribution of weight management information and resources for lifestyle modification through diets, exercise plans, referral to dietitians or nutritionists
 ○ Coordinate with PCP and surgeon to assess and follow patient progress, discuss consideration of pharmacotherapy such as GLP-1 agonists (liraglutide or semaglutide), phentermine-topiramate, bupropion-naltrexone, orlistat, metformin, or SGLT-2 inhibitors, assist with managing comorbidities and directing patient to bariatric surgery or behavioral counseling
 ○ Advocate for patient requirement to attend accessible joint class incorporating education on effects of weight in advance of surgery, supplementation with online patient platforms
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PCP: primary care provider, SGLT-2: sodium-glucose cotransporter-2, GLP-1: glucagon-like peptide-1

Studies of preoperative optimization protocols have identified lack of time before surgery as a common impediment to the optimization of certain risk factors (Bernstein et al., 2018). Some nurse navigators noted that they regularly have initial contact with TJA patients as late as one week prior to surgery, preventing their involvement in the optimization of weight and nutritional status. While it is not always feasible for nurse navigators to work with a patient for months before their surgery date, we recommend that patients be provided with weight management resources as early as possible and ideally during the initial consult with the surgeon. Nurse navigators can facilitate this by compiling resources that surgeons can share with patients and encouraging surgeons to refer patients to a dietitian or nutritionist. Other resources may include local organizations and support groups focused on weight management or directories of other providers such as dietitians and bariatric specialists. Nurse navigators can also advocate for surgeons to facilitate early optimization efforts for patients who face multiple modifiable risk factors.

Nurse navigators should consult with nutritionists or dietitians, if available, to compile resources that share general guidance for dietary modifications, such as ketogenic or diabetic diets, programs like the Supplemental Nutrition Assistance Program (SNAP), and knowledge of local resources patients can access. Nurse navigators and surgeons may also learn more about a patient’s past or ongoing attempts to lose weight by consulting with the patient’s PCP. The nurse navigator should be aware that the patient’s PCP may consider and approve behavioral counseling, pharmacotherapy for weight loss, or bariatric surgery. General weight loss pharmacotherapy options for patients with BMI ≥ 30 kg/m2 or BMI ≥ 27 kg/m2 with comorbidities include liraglutide, semaglutide, phentermine-topiramate, bupropion-naltrexone, and orlistat (Sabesan et al., 2022; Yanovski & Yanovski, 2014). Semaglutide and liraglutide, in particular, are increasingly utilized for diabetes management due to their weight loss effects (Rubino et al., 2021; Singh et al., 2022). As such, there is a potential for these to serve as an alternative to bariatric surgery prior to TJA. In addition, patients with concurrent diabetes mellitus and obesity may benefit from diabetes medications that contribute to weight loss such as metformin, sodium-glucose cotransporter-2 (SGLT-2) inhibitors or glucagon-like peptide-1 (GLP-1) agonists (Grant et al., 2021; Tchang et al., 2022).

Many of the nurse navigators we contacted reported joint classes as a main method of conveying information about the impact of weight on OA and TJA outcomes, but few institutions required that patients attend preoperative joint classes. We recommend that nurse navigators advocate for their institutions to include joint class completion as a requirement prior to TJA. Thoughtful timing and stored recordings of classes may make it more convenient for patients to complete this requirement. Some of the nurse navigators we interviewed stated that they were able to make recorded joint classes available to patients via online education platforms such as Wellbe™, CareSense, HealthLoop, and Care Companion. Some of these systems alerted nurses to patients who had not viewed these recordings within a certain timeframe. This allowed nurse navigators to remind patients to complete this task before moving forward in their preparation for TJA. For patients with limited digital or health literacy, providing information in only a digital format may further limit effective communication of the important information delivered in joint classes. Therefore, we recommend utilizing this technology when possible, while being mindful that some patients may have limited access to digital resources (Mamedova & Pawlowski, 2018).

Recommendations – Malnutrition

We recommend that orthopaedic nurse navigators include interventions for nutrition status assessment (Walker, 2012) in their preoperative optimization protocols (Table 5) because it is a common and modifiable risk factor for poor TJA outcomes (Black et al., 2019; Briguglio et al., 2019; Hansen et al., 2012; Wall & de Steiger, 2020) that may be as important a predictor of poor outcomes as obesity (Schroer et al., 2019). Thus, it is important for nurse navigators to advocate and raise concerns for discussion with surgeons and other surgical care team members as part of departmental meetings and quality improvement initiatives.

Table 5.

Recommendations for Preoperative Optimization: Malnutrition.

Malnutrition
○ Discuss nutrition assessment strategies with surgeon and other team members, including consideration of target albumin level above 3.5 mg/dL
○ Discuss with surgeon and other team members assessment and treatment of iron deficiency (serum ferritin < 30ng/mL) with oral (> 6 weeks before TJA) or parenteral supplementation (< 6 weeks before TJA)
○ Discuss with surgeon and other team members assessment and treatment of vitamin B12 deficiency (serum vitamin B12 below 200 pg/mL accompanied by either serum homocysteine above 15μmol/L or serum methylmalonic acid above 350 nmol/L) with parenteral supplementation
○ Incorporate patient education on effects of malnutrition into joint classes and patient education platforms, including sample meal plans for addressing nutritional deficits
○ Connect patients to local resources and organizations that provide nutritious food or nutritional supplementation
○ Coordinate with patient’s PCP to assess and follow patient progress
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TJA: total joint arthroplasty, PCP: primary care provider

Recent adoption of enhanced recovery after surgery (ERAS) protocols as part of many TJA programs has demonstrated an increased focus on nutrition for wound healing and surgical recovery even in the short-term, as some versions of these protocols include preoperative nutritional supplementation with energy-dense shakes for patients without diabetes and increased dietary protein intake for all patients (Burgess et al., 2018). There is also increasing evidence for shorter perioperative fasting periods and faster nutrient intake postoperatively (Campbell et al.). However, studies are lacking regarding the specific effects of these interventions on postoperative serum albumin and overall outcomes (Katakam et al., 2021; Nelson et al., 2019; Rudasill et al., 2018), and nurse navigators should be aware that more research is needed on these topics.

We also recommend that nurse navigators consult with the orthopaedic surgeons, medical directors, and anesthesiologists at their institutions for potential consideration of an albumin level above 3.5 g/dL as a nutrition goal prior to TJA. Nurse navigators should remain aware of current evidence-based treatment options for addressing nutritional deficiencies so that they can discuss these approaches with surgeons, medical directors, and pre-admission testing (PAT) teams. Guidelines indicate that serum ferritin below 30ng/mL should be treated with oral iron supplementation if the surgical date is greater than 6 weeks away and intravenous iron infusion if the surgical date is less than 6 weeks away (Goodnough et al., 2011; Muñoz et al., 2017). Additionally, guidelines indicate that treatment of vitamin B12 below 200 pg/mL accompanied by either serum homocysteine above 15μmol/L or serum methylmalonic acid above 350 nmol/L requires intramuscular or IV vitamin B12 supplementation (Lee et al., 2019).

Based on the results of our literature search and the broad reach of joint classes and patient education platforms, we recommend incorporating examples of meals that help address common nutritional deficits into education models. Nurse navigators can also assist patients in identifying and accessing local resources that are available to improve their nutrition status, including food pantries or community gardens and larger organizations that distribute food, such as Meals on Wheels. We also recommend nurse navigators help facilitate coordinated efforts with patients’ PCPs to understand more about patients’ nutrition status and what steps may have been taken previously by the patient to improve their nutrition status.

Conclusion

Through preoperative optimization, patients are provided with increased support and resources for the management of modifiable risk factors prior to receiving TJA. Among these risk factors, obesity and malnutrition are of significant prevalence and importance in their impact on outcomes. These risk factors are also strongly influenced by social drivers of health that affect the ability of disadvantaged patients to safely receive TJA. Optimizing these areas is a process that benefits from nurse navigator involvement. By consulting nurse navigators about their optimization strategies and conducting a literature review regarding obesity and malnutrition, we have been able to compile recommendations for optimizing weight and nutrition status.

Figure 2.

Figure 2.

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Standard Questions Asked of Orthopaedic Nurse Navigators.

Table 1.

Interventions for Obesity Reported by Nurse Navigators.

○ Education in joint class
○ Weight management programs including meal plans, nutrition or dietitian involvement, exercise sessions, group therapy (provided by institution or outside organizations such as WeightWatchers, the American Diabetes Association, or local community groups)
○ Support in accessing bariatric treatment
○ Education and motivation through online or app-based education platforms
○ Referral to PCP, dietitian, nutritionist, or mental health professional
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Interventions in bold can be implemented in-house (without referrals or outside resources).

PCP: primary care provider

Acknowledgements

This article is part of a series describing contributions of nurse navigators to patient optimization for total hip and knee arthroplasty. This series was developed in coordination with Movement is Life, a group comprised of healthcare professions whose mission is to eliminate musculoskeletal healthcare disparities. The authors would like to thank the nurse navigators who participated in discussions and provided their perspectives on each of the topics discussed in the series: Paulina Andujo BSN, RN, ONC, Christopher Bautista BSN, RN-BC, Emily Belcher RN, Kerry Boyer MSN, APRN, FNP-C, Pam Cupec BSN, MS, RN, ONC, CRRN, ACM, Madonna Doyle RN, Dawn Ellington MBA, BSN, ONC, Sara Holman RN, MSN, MBA, Diane Marie Jeselskis BSN, RN, ONC, Jillian Knudsen RN, MSN, CMSRN, ONC, CNL, CPHQ, Melissa A. Lafosse RN, ONC, Lyndee Leavitt RN, BSN, ONC, MaryHellen Lezan MS, MSN, APRN, FNP-C, JoAnn Miller-Watts RN, BSN, ONC, Christen Nelson RN, BSN, ONC, Kara Orr MSN, RN, CNL, Misty Robbins RN, Nicole Sarauer APRN, CNS, ONC, Heather Schulte BSN, Kathy Steffensmeier RN, BSN, Ashley Streett MSN, RN, ONC, CCRN, Naomi Tashman RN, BSN, ONC, Maureen Wedopohl BSN, RN, ONC, and Rhyana Whiteley MN, RN, ONC.

Source of Funding:

Support for the conduct of this research was provided by the National Heart, Lung and Blood Institute of the National Institutes of Health. This content does not represent the views of the National Institutes of Health.

Footnotes

Conflicts of Interest: The authors have no conflicts of interest to declare.

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