Clinical outcomes of patient navigation performed by nurses in the oncology setting : an integrative review

Rev Bras Enferm. 2021;74(2): e20190804 http://dx.doi.org/10.1590/0034-7167-2019-0804 8 of ABSTRACT Objective: to evidence the clinical outcomes of navigation performed by nurses in cancer patients. Methods: this is an integrative literature review with collection in MEDLINE via PUBMED, LILACS, Web of Science, Scopus, and CINAHL databases. The final sample consisted of seven studies. The data were analyzed and presented descriptively. Data related to clinical outcomes were compiled and described in full. The Agency for Healthcare Research and Quality categorization was used to assess the level of evidence. Results: the clinical outcomes demonstrated were decreased distress, anxiety and depression, improved control and management of symptoms, improved physical conditioning, improved quality and continuity of care, improved quality of life, reduced time to start treatment. Final considerations: there is research that shows better clinical outcomes in cancer patients through navigation by nurses across the continuum of health care. Descriptors: Patient Navigation; Oncology Nursing; Treatment Outcome; Evidence-Based Nursing; Outcome Assessment (Health Care).


INTRODUCTION
The first patient navigation program was developed in 1990 in the State of New York, United States of America, by doctor Harold Freeman. The main objective of the program was to eliminate socioeconomic, sociocultural, psychological, communication and bureaucratic barriers in the course of patient care, covering the entire health continuum process, which includes prevention, early detection, diagnosis, treatment, and end of life care. After its implementation, there was an improvement in education and access to early diagnosis and treatment, increasing the survival rate of patients with breast cancer (1) . After the development of navigation programs, the figure of nurse navigators emerged in the oncology setting (2) .
Navigation is commonly used in the United States and Canada, in order to direct the therapy of cancer patients and increase the chances of adherence to the proposed treatment. Research show evidence regarding the effectiveness of navigation in early diagnosis and in the initial stage of the disease, in effective participation and increased patient compliance with treatments, in reducing delays in starting cancer treatments, and in improving clinical outcomes after cancer diagnosis (3) . In this way, many health institutions are implementing patient support programs, involving mainly nurses, who navigate patients in different settings of health systems (4) . Navigators are in charge of assessing patients' individual needs and developing a care plan, together with them, in order to overcome the barriers that hinder access to high quality care (5) .
The navigation of patients performed by nurses is described as an intervention to reduce delays in accessing health services and providing personalized service throughout the treatment trajectory. It is a patient-centered care delivery model. The focus of navigation is to promote a timely movement and effective guidance of a patient through a continuum of health care that is often complex (1) . Thus, there is a need to obtain professionals with specific skills directed to the art of navigation, emphasizing the role of nurses working in oncology.
In oncology, nurses, over the years, have been developing their role with a focus on the coordination of care, as well as on the education of patients and their families, from diagnosis to end of treatment or end of life care. They are professionals with the necessary skills and attitudes to perform the navigation of cancer patients. They have clinical knowledge related to the disease, types of treatments and possible side effects. They support patients and their families in the decision-making process and have the expertise to work in collaboration with the other multidisciplinary team members, forming a link between professionals, patients and family members (2) .
It is known that many times cancer patients face difficulties that have important consequences during the course of their treatment, initially by screening, followed by diagnosis, which is often not performed early, culminating in late treatments, which considerably reduces the chances of cure and survival (6)(7) . A study (7) carried out in the United States of America (USA), which assessed the performance of nurse navigators in caring for cancer patients, pointed out that the patients' perception of treatment improved significantly with the work of these professionals. Moreover, it described how much patients are exposed to feelings such as anxiety, fear, and confusion during the course of treatment, and how navigating by nurses made them feel safer and more involved in their care, as they had knowledge about future steps treatment and how cancer could affect their lives (7) .
Navigation is an expanding service model and contributes to the trajectory of care for cancer patients. However, at the national level, there is still no clarity about the role of these professional navigators. The navigation performed by nurses is considered an important differential in oncology services in Brazil, as it can bring benefits in the continuum of health care (8) . However, it is noted that currently there is no universal consensus on what constitutes navigation services and there is insufficient evidence on the effectiveness of these programs in the clinical outcomes of cancer patients (2) .
Considering the scenario above, the present research had as guiding question: does navigation performed by nurses provide better clinical outcomes for cancer patients?

OBJECTIVE
To evidence the clinical outcomes of navigation performed by nurses in cancer patients.

Type of study and methodological procedures
This is an integrative review of the scientific literature that was carried out through the following steps: 1) research question and objective definition, together with the review protocol development; 2) inclusion and exclusion criteria definition and choice of databases; 3) sample selection; 4) inclusion of previous studies; 5) analysis of previous results, identifying differences and conflicts; 6) discussion and analysis of the final results; 7) study synthesis presentation (9) . Studies that contained search terms listed anywhere in the document, published in full, in any language, with no time frame and that answered the research question were included. Editorials, letters, expert comments, summaries of annals, theses, dissertations, conclusion papers, official documents of national and international programs, books, literature reviews and duplicate studies were excluded.

Data collection and organization
The search strategy used the descriptors (controlled and uncontrolled) from the Medical Subject Headings Section (MeSH) and Health Sciences Descriptors (DeCS -Descritores em Ciências da Saúde) as follows: oncology nursing, patient navigation, of Clinical outcomes of patient navigation performed by nurses in the oncology setting: an integrative review Rodrigues RL, Schneider F, Kalinke LP, Kempfer SS, Backes VMS. treatment outcome, evidence-based nursing, outcome assessment (healthcare), outcomes assessment, case management and continuity of patient care; and the keywords: nurse navigator and nurse navigators. They were combined with each other by the Boolean operators "AND" and/or "OR", as shown in Chart 1: The EndNote Web ® software was used to manage data and eliminate duplicate studies. Subsequently, the selection of studies took place in two stages: 1) reading titles and abstracts, in order to identify the relationship with the research question as well as with the inclusion and exclusion criteria adopted; 2) critical assessment and full reading of pre-selected studies, excluding those that did not meet the inclusion criteria. Figure 1 (Flowchart) details the process of identification, inclusion and exclusion of studies and the reasons for exclusions after assessment.
Chart 1 -Search strategies in databases MEDLINE via PUBMED "oncology nursing" OR ("oncology" AND "nursing") OR "oncology nursing" AND ("patient navigation" OR ("patient" AND "navigation") OR "patient navigation") OR ("nurses" OR "nurse") OR ("nurses" OR "nurse" AND "navigators") AND ("treatment outcome" OR ("treatment" AND "outcome") OR "treatment outcome") OR ("evidence-based nursing" OR ("evidence-based" AND "nursing") OR "evidence-based nursing" OR ("evidence" AND "based" AND "nursing") OR "evidence based nursing") OR ("outcome assessment (health care)" OR ("outcome" AND "assessment" AND ("health" AND "care") OR "outcome assessment (health care)" OR ("outcome" AND "assessment") OR "outcome assessment") AND ("delivery of health care" OR ("delivery" AND "health" AND "care") OR "delivery of health care" OR ("health" AND "care") OR "health care") OR ("outcome assessment (health care)" OR ("outcome" AND "assessment" AND ("health" AND "care)") OR "outcome assessment (health care)" OR ("outcomes" AND "assessment") OR "outcomes assessment") OR ("case management" OR ("case" AND "management") OR "case management") OR ("continuity of patient care" OR ("continuity" AND "patient" AND "care") OR "continuity of patient care") LILACS (Oncology Nursing) AND (Patient Navigation OR Nurse Navigator OR Nurse Navigators) AND ( ("Oncology Nursing" AND "Patient Navigation" OR "Nurse Navigator" OR "Nurse Navigators" AND "Treatment Outcome" OR "Evidence-Based Nursing" OR "Outcome Assessment (Health Care)" OR "Outcomes Assessment" OR "Case Management" OR "Continuity of Patient Care") CINAHL Oncology Nursing AND (Patient Navigation OR Nurse Navigator OR Nurse Navigators) AND (Treatment outcome OR Evidence-Based Nursing OR Outcome Assessment (Health Care) OR Outcomes Assessment OR Case Management OR Continuity of Patient Care)

Data analysis
The studies were characterized using title, authors, year of publication, country of origin, level of evidence (AHRQ), study design, profile of participants, intervention, outcomes and main conclusions. The data extracted from the studies were analyzed and presented in a descriptive manner. With the complete reading of the selected studies, the clinical outcomes of the navigation of cancer patients performed by nurses were identified. Afterwards, these data were compiled and described in full, according to the evidence presented by them.
For the hierarchical classification of evidence, the categorization of the Agency for Healthcare Research and Quality (AHRQ) of the United States of America was used. Thus, the studies were assessed for the quality of the evidence and classified as: level 1, the evidence comes from a systematic review or meta-analysis of relevant randomized controlled clinical trials or from clinical guidelines based on systematic reviews of randomized controlled clinical trials; level 2, evidence derived from at least one well-designed randomized controlled clinical trial; level 3, evidence obtained from well-designed clinical trials without randomization; level 4, evidence from well-designed cohort studies and control cases; level 5, evidence from systematic review of descriptive and qualitative studies; level 6, evidence derived from a single descriptive or  qualitative study; level 7, evidence from the opinion of authorities and/or expert committee reports (10) .

RESULTS
The geographic distribution of the selected publications was concentrated in the United States of America (USA) (57%), followed by Canada (14%), South Korea (14%), and Denmark (14%). The predominant language was English. The year of publication varied between 2006 and 2017, with the highest publication in 2011 and 2015, with two studies each year, followed by 2006, 2010, and 2017 with one study each year, respectively.
The characteristics of the seven studies (11)(12)(13)(14)(15)(16)(17)  The presence of nurse navigators did not significantly affect the stress levels of hospitalized patients, despite presenting an average stress reduction. A decrease in stress was observed in rural patients when compared to patients in the urban area. Patients who received more than three visits from navigators had a greater reduction in stress than those with less than three visits. On average, the intervention of navigators showed a reduction in the scores of distress of all patients.
Effects of nurse navigators on health outcomes of cancer patients Lee and collaborators (13)  The studies in this review showed results such as the effectiveness of health education, making the understanding, adaptation and coping of patients in the health and disease process better; improvement in assessment, management and continuity of care, and, consequently, improvement in the satisfaction of cancer patients; effective communication, with nurse navigators as communication links with the multidisciplinary team; improving access to health services, enabling treatment initiation.
Lee and collaborators (13) demonstrated that hospital stay decreased considerably compared to the control group. Four studies (11)(12)15,17) (57%) converged highlighting that the interventions performed by oncological navigators reduced the rates of distress, anxiety and/or depression. It is observed in two studies (11,14) the relationship that navigators build with cancer patients, with health education strategies that empower them and help them understand the disease and adhere to treatment. Two studies (13,17) differed on how to improve the quality of life of cancer patients navigated by nurses.
Through the studies selected in this review, the clinical outcomes of the navigation of cancer patients performed by nurses were evidenced, which are presented in full in Chart 3.

DISCUSSION
Studies related to navigation of cancer patients are on the rise, and the subject has been discussed in nursing practice; however, it is necessary to broaden the discussions regarding the clinical evidence of this model of professional performance. A greater number of publications were observed in the USA, and it is believed that this data may be related to the origin and implementation of navigation programs across the country (1) as well as their inclusion in the American legislation and standards for health care accreditation (18) .
The study population consisted of patients with breast, lung, gastrointestinal and head and neck cancer, which is consistent with cancer incidence and prevalence in the worldwide population (19) . These areas are a priority for navigation expansion.
Nurse navigators are responsible for moving patients across the care continuum, promoting the integration of patients into the healthcare system (20)(21) . Thus, the navigation of cancer patients has demonstrated benefits, such as less time for diagnosis and treatment, greater knowledge of the patient and family, better adherence to treatment and care (22) .
Effective communication is essential for a positive clinical outcome in patient navigation, since its absence can be a barrier to continuity of care (23) , findings that support the present review. Nurse navigators are seen as a connection that unites the healthcare team, patients and family members. With a clear and objective communication, they are able to guide, clarify, reinforce and validate the information that patients receives from different sources (14) .
It is noteworthy that health education is linked to communication. One of the goals of navigation is to provide information for patients and family members, involving them in their own treatments, as well as in decision-making, making care safe and effective (7) . When patients have sufficient information and knowledge, they are able to participate in the planning of their treatment, resulting in greater self-confidence and, consequently, an improvement in their quality of life (7,24) .
Concerning the quality of life of cancer patients, there is no consensus among the studies (13,17) in this review as to the benefit of performing navigation. However, other studies (5,11,25) demonstrate that navigation can increase patient satisfaction, improving treatment adherence and reflecting on improving their quality of life.
Cancer treatment can trigger some symptoms, such as sleep disorders, fatigue, diarrhea, nausea and/or vomiting, which can affect both physically and psychologically patients, often causing delays or even interruption of treatment (26) . In a survey (14) carried out on women diagnosed with breast cancer, the results showed that symptoms during treatment ranged from weak to severe; however, it was agreed that management by navigators was fundamental for coping with the disease and for the success and continuity of treatment. Another study (27) , carried out with patients with breast cancer, demonstrated the high level of patient satisfaction when monitored by nurse navigators. These findings support the effectiveness of patient-centered care performance.
Regarding the psychological and emotional aspects of cancer patients, there is a consensus among studies (11)(12)15,17) that the role of nurse navigators reduces patients' distress, anxiety and depression during treatment. Other studies (11)(12)17) indicate that there is a reduction in anxiety and depression when patients are more frequently followed up by nurse navigators, compared to those who are not included in this professional practice model. Ludman and collaborators (15) demonstrated that navigation by nurses brought benefits to patients, influencing them positively. This influence was exercised both in patients who already had some psychological or emotional symptom at the time of diagnosis and in those who did not have any symptoms.
With regard to the average length of hospital stay, it was shown that patients who were not being monitored by nurse navigators remained in the hospital on average nine to 11 days in addition to those who were being monitored by navigators (13) . It is observed that navigation of patients results in a decrease in visits to the emergency departments of hospitals, shorter hospital stays and better use of resources, with patient guidance being a fundamental part of these data (28) .
A clinical outcome of patient navigation is related to the decrease in the time elapsed from diagnosis to the start of treatment (27) . One of the greatest difficulties for patients is access to specialized services for diagnosis definitions, generating delays that impact the start of treatment (29) . Nurse navigators play a key role in ensuring timely access to treatment and care for cancer patients (30) .
A study (28) demonstrated that cancer patients who were included in the navigation program as part of the multidisciplinary care model had a significantly shorter time (15.15 days) between diagnosis and treatment initiation than those who were not followed up by nurse navigators, who started treatment in 42.93 days. The research (24) that assessed the role of navigators in screening patients confirmed that they started treatment 10 days in advance, when compared with nonnavigated patients. Another study (16) with significant results, developed with patients diagnosed with lung cancer, found a reduction in the time of the first cancer treatment in 19 days, i.e., navigation provided an efficient and favorable access. Without patient navigation, the staging required for diagnosis is less effective, resulting in additional consultations, delayed diagnostic tests and increased patient distress (28) .
Considering these studies, it is emphasized that the earlier the contact of nurse navigators with patients, the better the continuum of care in the entire health system (30) . It is also observed that the role of nurse navigators in oncology, in addition to being related to coordination of care, requires specific knowledge, skills and attitudes that allow them to influence systems and behaviors in health services; assess population's needs; promote advanced service planning; assess their barriers; provide education and resources; facilitate shared decision-making; identify gaps and strategies to meet continuum's needs (21) .

Study limitations
There are limitations related to databases, not considering studies indexed in other databases, as well as being limited to complete articles and available in full, which portrays part of the universe of studies. As for the weaknesses of this review, they refer to the level of evidence of the selected studies, which are mostly at level VI, which denotes the need for nursing to conduct research with better levels of evidence, such as clinical trials.

Contributions to nursing, health, and public policies
It was found the importance of patient navigation performed by nurses as a model of continuum of care throughout the health system, with expressive clinical outcomes for cancer patients and their families. It is suggested that Brazilian oncology nursing develop a consensus, which presents the role of these professionals and all aspects that constitute the navigation processes, thus standardizing the model of performance.

FINAL CONSIDERATIONS
It is noteworthy that there is research that shows better clinical outcomes in cancer patients through navigation by nurses, throughout the continuum of health care. Some of the relevant aspects of patient navigation demonstrated by the studies were: decreased distress, anxiety, fear, stress, and depression; improvement in symptom control and management; improvement in physical conditioning; decrease in the time between screening, diagnosis and beginning of cancer treatment, leading, consequently, to better care conditions. Nurse navigators' work provides patients with better conditions to understand the disease and adapt to treatment as well as multidisciplinary team work improvement in health services. Its role is visibly linked to coordination in the continuum of care, from treatment to end of life care.
It is expected that this review highlights the importance of nurse navigators' role in oncology and encourages professionals implementing navigation programs and developing new research.

FUNDING
This work was supported by the Coordination for the Improvement of Higher Education Personnel -Brazil (CAPES) -Financing Code 001.