Nurse Navigator: development of a program for Brazil*

Objective: to develop a Navigation Program for cancer patients, based on the model proposed by The GW Cancer Institute at George Washington University, adapted to the reality of a Brazilian High Complexity Center in Oncology. Method: a convergent care research applied in the development of a patient navigation care process, based on the model proposed by George Washington University, adapted for a High Complexity Center in Oncology in Brazil. Phases of the Convergent Assistance Research: conception, instrumentation, scrutiny, analysis and interpretation. These were correlated with the stages of the Program Development Cycle. Scale designed to categorize patients into navigation levels, validated by the Delphi Technique, with 12 specialists. Results: in the diagnosis, patients with head and neck cancer were defined for inclusion in the Navigation Program. Planning and implementation took place simultaneously, allowing the basic formatting of the program and its processes to be designed. Navigation Needs Assessment Scale designed to select the patient to join the Program and determine the recommended support. The scale validation had a consensus index of 96.42%. Evaluation of the stages of the cycle occurred through the adapted Plan/Do/Check/Act cycle. Conclusion: a Navigation Program was developed adapted to the Brazilian reality, and attributions of the navigators were created.


Introduction
Approximately two-thirds of the global cancer deaths occur in developing countries, where mortality rates are highest due to late diagnosis and difficulty in accessing treatments (1) . According to the National Cancer Institute (Instituto Nacional de Câncer, INCA), the body that provides epidemiological information regarding cancer in Brazil, it was estimated for the country in the 2018-2019 biennium, the occurrence of approximately 600 thousand new cases of cancer (2) . Globalization, urbanization and increased life expectancy are data that can explain these estimates (3)(4) .
In Brazil, since the 1990s, the Ministry of Health (MoH) has invested efforts to face the growing demand for cancer treatment in the country (5)(6) in a more organized and effective way. In this sense,  (3) . To achieve this goal, they suggest, among other measures, the implementation of patient navigation programs for oncology in Brazil, with the role of the patient navigator figure, named as "Care Assistant" (3) . It indicates for the performance of this function the nurse for his knowledge, training and area of action (3) .
Patient Navigation (PN) is a process in which an individual, called a patient navigator, guides people diagnosed or suspected of having a chronic disease, helping them to "navigate" through the health system and services (7)(8) . It is performed by a patient navigator, involving a series of actions that lead to a certain objective (for example: assistance in a timely manner through the elimination of barriers to access assistance).
In this context, a navigation program is a fusion between the navigation process -navigators -actions, which comprise the assistance and administrative processes of a given service and health system, designed and adapted to the profile of the assisted patients. It is a widely promoted approach to increase the likelihood that patients will have an effective adherence to the recommended treatment, reducing socioeconomic, racial and ethnic barriers to care (8)(9) .
This concept was originally developed by the American physician Harold Freeman in partnership with the American Cancer Society (ACS) in 1990, at the Harlem Hospital in New York (8)(9)(10) . In this context, the first PN Program was originally designed for cancer patients, in which the navigators were volunteers (lay people and/or health professionals) (7)(8)10) . There are nine theoretical principles that underpin PN established by Dr.
Freeman, developed during his more than 20 years of experience, namely (7)(8)(9) : 1. The PN is a health service whose model is centered on the patient and its focus is to make the patient's movement through provide the connection of disconnected health systems; 9. The PN system needs coordination (7)(8)(9) .
PN is constantly evolving and programs, nowadays, have also been targeted at patients with other chronic diseases (11)(12) . This process is also implemented in primary health care in countries like Canada and the United States of America (USA) for patients with diseases such as heart failure, chronic arterial hypertension and type 2 diabetes (13)(14) . Currently, in international programs, navigators are health professionals, students and lay volunteers, each with specific duties according to their level of knowledge (13)(14) . In countries like the USA, there is no consensus on the previous academic training of navigators, however in Canada and Australia most navigators are nurses (3,(15)(16) .
The Navigator Nurses (NNs) emerged to assist cancer patients from the first Navigation Program (NP) (17)(18) . These professionals use their specialized knowledge, clinical experience and skills to provide patients with care focused on the physical, social and emotional aspects (12) . They direct and guide patients, families and caregivers for joint decision-making with a multidisciplinary team responsible for treatment (18) .
The actions developed by these professionals go beyond the management of care (17)(18) . They supervise the entire treatment process, empowering patients, providing information and support, acting as a link between them and the team professionals (17)(18) .
The PN is considered an important differential in oncology services in Brazil, mainly with the role of the navigator nurse (19)(20) . In addition to acting as a care coordinator, this professional contributes to patient care by providing the necessary support to overcome the impact of diagnosis and treatment, helping to overcome the main barriers that hinder access to services and health systems (12,18,20) .

Method
It is a convergent care research (Pesquisa Convergente Assistencial, PCA), a methodology that seeks to provide the participatory insertion of the researcher in the field of care practice while being involved with the objectives of the research (20) . It is developed through the following phases: conception, instrumentation, scrutiny, analysis and interpretation (20) .
The PCA, as it has a dynamic and integrated nature of assistance, is an investigative and innovative method that allows the exploration, reflection and deepening of different themes in health (21)(22) . In this sense, it represents a challenge insofar as it seeks to impress changes and technological innovations in the instituted health space (22)(23) .   In the "Instrumentation", second phase, the field of action was defined, the population involved in the study and the data collection and analysis technique, the PN Program Development Cycle, was chosen.
In the "Scrutiny" phase, the diagnosis stage took place, so that this was possible, data collection took place in the electronic medical records system and in the existing management reports of the institution.
In the "Analysis", the process called apprehension occurred, where an organization of the data obtained Pautasso FF, Lobo TC, Flores CD, Caregnato RCA.
in the diagnosis was carried out and was completed in the second and third stages of the cycle (planning and implantation). Each assistance and administrative process was observed (registered in Excel spreadsheets) and through the development of the practice and interaction with the professionals in the service, the basic formatting of the navigation program and its processes was created.
In the last phase of the PCA, the "Interpretation", the processes of synthesis, theorization and recontextualization took place. In the first two processes, subjective data  Defined as a systematic methodology for judging information, DT is considered a research tool that seeks a consensus of opinions from a group of experts on a given topic, through validations articulated stages or cycles (24)(25) . It is intended for situations where there is no and/or a lack of historical data and, in the field of nursing, it has been adopted for the validation of conduct and diagnostics (23)(24)(25) .
For the validation of the instrument, a panel of experts was selected, consisting of 21 health professionals with technical knowledge and experience in oncology.
The cut-off points for obtaining a consensus was set at 80%, since it is not recommended in the literature that, in situations of production scarcity, obtaining consensus with less than 75% percentiles (25) . In the first round of DT, of the invited specialists, 17 participated and in the second, 12 professionals responded to the survey.

Results
During will be the population included in the program and how will they be assessed regarding their real need for navigation? Which navigation model will be developed?
What will be the objectives of the navigation program and the desired outcomes?
The planning stage took place simultaneously with the realization of a navigation pilot during the implementation phase, since the design of its basic format and its processes was built during observation and development in practice with patients.
Based on the definition of the fundamental points and based on the information collected and presented previously, the Basic Structure of the Program was created, designed to guide its functioning, as shown in Figure 2.
The navigation process will start after confirmation of the cancer diagnosis and treatment definition.

NAVIGATION PROGRAM FOR A HIGH COMPLEXITY CENTER IN ONCOLOGY IN RIO GRANDE DO SUL
The patients will be assessed in relation to the need to enter the PN* using a Need for Navigation Assessment Scale The navigation process will finalize at the end of the tratment or, if upon assessment of the need for navigation, the patient no longer shows any indication.
The assessment of the need for navigation performed by the navigator nurse in the first contact with the patient will consist of an interview.
This meeting will take place after the 1 st medical consulation. The navigation plan will be built by the navigatior nurse after the first assessment.
The patient will be monitored by the navigator through access to the electronic medial record of the patients, appointment schedules, surgery, chemotherapy and radiotherapy through the eletronic medical record. Contact with the patients and navigators will be in person, by phone and/or text message.
PN* navigators: navigator nurses, health professional navigators and academic navigators.
The trainings of the navigators will be structured and targeted according to the type of navigator: navigator nurses, health professional navigators and academic navigators.
Indicators that will be monitored to measure and evaluate PN* results; Mean length of stay for the cancer patients during hospitalization; Readmissions of the cancer patients included in the PN*.
The tools that will be used to monitor the results of the assistance and administrative processes of navigation are the following: Care indicators fed by the records in the computerized system and patient satisfaction survery.
The Navigation Program will be directed to patients with head and neck cancer.

Continuum of Care in Oncology
Navifation start End of navigation Navigation *NP = Navigation Program    In this stage, based on the competencies described by the US Oncology Nursing Society, the basic assignments of the navigators, the profile of the nurse navigator and the professional navigators were also structured at this stage, based on the knowledge and skills necessary to perform the function, and the qualifications for their qualification, considering the necessary knowledge areas for its performance, as shown below, in Figures 4 and 5.

List of Assignments
Help patients to identify and overcome challenges to obtain quality health care.
Help patients to access care and navigate the health system.
Assist patients to mitigate and overcome barriers to obtain care.

Assess the main barriers to care, involving patients and family members/caregivers in the definition of solutions to overcome them.
Identify the necessary resources to meet the needs of patients (biopsychosocial and spiritual), considering social, cultural and cognitive conditions, making the necessary referrals with the multidisciplinary team.
Educate patients and caregivers about cancer treatment, the roles of multidisciplinary team members and what to expect from the health system and service.
Contribute to the development, implementation and evaluation of the patient navigation program.
Encourage communication between patients, family members/caregivers and professionals responsible for health care to favor and optimize results.

Care Coordination
Assess patients for their need for navigation from the EANN * .
Develop and implement the navigation plan for patients included in the NP † .
Identify possible barriers to obtaining care and facilitate access to the services and resources needed to mitigate them.
Promote and implement a consistent and comprehensive navigation plan, using appropriate tools and methods for assessment, based on the best scientific evidence.
Participate in defining the care plan with the multidisciplinary team and patient.
Coordinate the care plan with the team, accompanying the patient during their treatment and providing support through guidance, health education.
Facilitate the promotion of individualized care considering the physical, cultural, biopsychosocial and spiritual needs for patients and family members/caregivers.
Assist patients to overcome barriers related to treatment goals, palliative care and end of life concerns through an ethical and humanized approach.
Know health systems and the impact of their processes for treatment in a timely manner, providing support to patients and favoring safe decision-making in conjunction with the multidisciplinary team.
Provide support to patients for the organization of appointments, exams and other procedures necessary for their treatment, aiming to promote their adherence and participation in planning.
Assist and make it possible for patients to attend consultations and other tests and procedures necessary for treatment.
Coordinate the operation of the NP † and performance of the navigator team.

Leadership
Supervise the execution of navigation processes.
Evaluate the results and outcomes related to the NP † . Implement improvements and/or new processes to improve the quality of the NP † .
Develop tools to optimize NP results † .
Act as a link between patients, their families/caregivers and the care team, favoring the strengthening of the bond between them.

Promote effective communication between the multidisciplinary team and patients.
Work with the multidisciplinary team to promote patient-centered care that includes shared decision-making, setting goals related to treatment and evaluating outcomes.
Favor and direct access to psychological and/or social support according to the needs of patients and family members/caregivers throughout the treatment trajectory.
Ensure that communication is culturally appropriate for the level of understanding and cognition of patients and family members.
Empower patients through the development of a personalized educational plan, aimed at promoting patients' autonomy in relation to their treatment.

Health education
Develop an educational plan for patients and family members/caregivers considering possible and existing barriers to care.
Promote health education for patients, families and caregivers on diagnosis, treatment, management of side effects and other care to prevent the occurrence of complications.
Provide health education and personalized support, favoring patients' autonomy in decision making regarding their treatment.
Give to patients and family members/caregivers information based on the best scientific evidence to answer questions about treatment and potential expected results.
Provide information aimed at promoting quality of life during treatment, guiding you on the importance of maintaining a healthy and self-care lifestyle.
Promote and favor adherence of the patients to treatment through health education.
Guide and inform patients and families/caregivers about the health system, access to available resources and services, about the roles of members of the multidisciplinary team.

Guidance and Information
Guide and inform patients about times of procedures, consultations, exams and necessary accompaniments for their treatment.
Guide patients on care and management of possible complications related to their treatment.
Provide access to information on the assistance needed according to the needs of patients.
Inform patients about their rights and duties in relation to their treatment and diagnosis.
Direct patients to the necessary services for the proper progress and continuity of their treatment.
*EANN = Navigation Needs Assessment Scale; † NP = Navigation Program The consulted literature suggests that NP is more effective, when directed at patients with barriers to care, and can be identified through an assessment of the social determinants of health (29) . Therefore, it is recommended that the services analyze their populations to determine which patients need navigation before implementing a program (29)(30)(31) . is outlined by the type of navigator active, when the assistance will start and end the process and structured, according to the population to be assisted, being able to be directed to only one type of cancer or not, be adaptable to different social, cultural and economic realities of the service (7,28) . In this perspective, the beginning of the  This is a quality management tool that establishes the evolution of the system through the continuous learning of people and organizations resulting in innovation and improvement of products and processes (26) . Each of them was analyzed in terms of meeting the objectives and obtaining the expected results and all reached the established goals.

Discussion
The NP is a process that involves a series of actions necessary to achieve a certain outcome/objective (8,19,27) .
In this perspective, a NP program consists of formatting this process to meet the needs of patients assisted in a given health service, whose actions involving the assistance and administrative routines of the place for which it is designed, are carried out by the navigators.
Its operating structure, in order to be adequate and directed to achieve the desired outcomes, needs to be planned in a detailed way and as personalized as possible, as the model of one institution will not always meet the peculiarities of another.  (28) . These stages were strictly followed for the development of the NP Program, being adapted to meet the Brazilian reality of a CACON, since the model used in the rationale is American.
as surgical treatment, for the total or partial removal of the tumor or affected tissue, chemotherapy, where antineoplastic medications are administered on a regular basis, and radiotherapy, with direct irradiation of the site or region affected, demand an expressive amount of information that is usually released to patients and their families in this first moment and are hardly assimilated by them (4,32) . As a result, the barriers to access the services and exams required at this stage became evident from this moment on.
It was observed during planning and implantation that patients had different difficulties and deficiencies, regardless of their socioeconomic status. Psychosocial, economic and cultural aspects represent factors of great impact on the population's access to recommended cancer treatment and timely care (29) . The format and scope of the NP, together with the roles and responsibilities of its navigators, must reflect the needs of patients, the community and the health institution, for which it is designed, and the service conditions and service functioning must be adapted (28,(33)(34) .
The patients selected to take advantage of the developed NP are the head and neck cancer (HNC) patients that occupy the sixth position, worldwide, representing about 3% of all the neoplasms (35) . The location of this disease ends up imposing physical, social and psychological suffering on the patient and his family, due to the changes caused in the individual's basic functions, such as food, breathing and speech (36)(37)(38) . The effective management of cancer treatment, particularly those with HNC, represents a substantial challenge for health systems (36)(37)(38) .
The first assessment of the need for navigation and the construction of the navigation plan was established as a specific function of the NN. This professional, due to his knowledge and his ability to interact with the interdisciplinary team, is able to assess patients who need more support and/or more urgent care (27,(39)(40) . Thus, among the benefits of the nurse in the role of navigator is the certainty of patient-centered care and effective care management in all phases of the continuum (27,(39)(40) . In this context, the implementation of Navigation Programs, with nurses as the main actor in the coordination of care in the continuum of care, ensures patients, services and the health system a differential in relation to the quality of oncology care (13)(14)19) . The qualification of the navigators will be carried out in a way directed to each one of the three types, contemplating the knowledge of the oncology care practice and administrative procedures and routines, to bring about a better understanding of the context in which the patients are inserted and subsidize their health education and family members/caregivers. There is currently no evidence in the literature that reports a pattern for the level of training, indicated for the success of the performance of the patient navigator (29,42) .
It was established that the navigators will guide the treatment of the patient trajectory and perform care management by monitoring the records in the TASY system (appointment schedules, exams, chemotherapy and radiotherapy; patient movement; records in the electronic medical record). Communication between patients and navigators will be carried out by phone, text messages, messages from the WhatsApp app and in person, with prior appointment and/or need signaled by the assistance team and/or by the patient and family.

The benefits of effective communication between patients
and health care professionals are multiple, promoting the Pautasso FF, Lobo TC, Flores CD, Caregnato RCA.
general well-being of both (43) . Effective dialog positively influences the recovery of the patient, helping to control pain, adhere to treatment, cope with the disease and improve the quality of life of individuals navigated (43) . patients. In addition, the necessary assignments for the navigators' performance were elaborated, according to their profile (whether nurse, student or layperson).