EXPERIENCE OF CARE NURSES: APPROACHES TO THE PRINCIPLES OF NAVIGATION OF CANCER PATIENTS

ABSTRACT Objective: To understand the experiences of nurses assisting cancer patients, according to Harold Freeman´s principles of navigation. Method: A qualitative study conducted in a large public hospital in the State of São Paulo in December 2021. Six nurses were interviewed using a semi-structured script with questions about the care of cancer patients and their families. The data were submitted to content analysis with theoretical framework of Harold Freeman. Results: Five categories emerged from the statements: fluidity in care; integration between teams; bond with patients and families; competencies of care nurses in the navigation of cancer patients; valorization and facilities in team training. Conclusion: According to the categories observed, we can consider that the experiences of care nurses working in an oncology unit revealed the strengthening of navigation principles contributing to the care and minimization of barriers, which can facilitate and/or soften the therapeutic path of the cancer patient.


INTRODUCTION
In 2012, the Ministry of Health decreed, through Law No.12,732, that all patients with malignant cancer would receive, the necessary treatments through the Unified Health System (SUS) free of charge, guaranteeing them the right to the first treatment within a period of up to 60 days, counting from the day they received the diagnosis 1 .
Oncology is considered a highly complex specialty and its patients need to undergo different types of treatment, requiring multiple trips to and from the hospital, as well as collection of laboratory tests that can occur weekly [2][3] .Faced with this scenario, patients in the public service network encounter weaknesses and difficulties that permeate their journeys, understood as barriers that appear from the first symptoms, in the diagnosis and in the search for treatment 4 .
In 2016, the National Supplementary Health Agency (ANS) started the OncoRede project, aimed at reorganizing the oncology care network.The strategy includes the implementation of patient navigation programs in order to facilitate the access of cancer patients to the health system, helping them to overcome institutional, socioeconomic and personal barriers [5][6] .
The project is made up of collaborators who act as navigators, health professionals, students and lay volunteers, and the functions of each member are assigned according to their level of education, professional category, specialty and clinical experience.The navigation program relies on the nursing professional, who assists the patient from the detection of the disease until the end of the treatment.The nurse's role is based on offering effective support to patients, providing information, managing the complexity of diagnosis and oncological treatment together with all members of the multidisciplinary team 7 .
The first patient navigation program was developed in 1990, in Harlem, New York, by the American physician Harold Freeman 3 .This program aims to develop a plan for education, coordination, communication and implementation of actions that promote an effective path to assist the patient and his family in the face of illness, eliminating socioeconomic, sociocultural, psychological, communication and bureaucratic obstacles during the course of care to the patient, from screening, to diagnosis and during end-of-life care [8][9] .
Over 20 years of studies, Harold Freeman described nine basic principles for Patient Navigation, namely: being a care model in which the focus is to make the patient's passage through the health system more fluid and gentle; to be a facilitator in the integration of fragmented spheres of health so that the patient's access to care is continuous; establish a close relationship between patients and navigators, providing for the elimination of barriers that prevent effective access to health care; define a clear scope in relation to task and professional distinctions, in order to keep navigators integrated with their roles and with other care professionals; delivering tasks in a way that is cost-effective and proportionate to the skills and training needed to fully navigate all stages of care; determine which process should be done by each navigator, based on their knowledge and training, whether laymen or professionals; specify at which point in the care the navigation of patients should begin and end; to be the facilitator in connecting disconnected health systems; there must be coordination that understands the navigation process, but is not involved in its way of working 3 .
Research shows better clinical results with the navigation program when it is performed by nurses 9 .Furthermore, when patients are accompanied by the navigator nurse, they feel more protected and empowered in their treatment and therefore, are better prepared for gaining knowledge of how the disease can affect their lives 10 .In addition, the benefits to the user/family and the institution are promising, while also promoting agility in the processes inherent to the treatment 11 .

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Patient navigation, when performed by nurses, demonstrates an effective strategy to improve standards of care in oncology 8 .The navigator nurse helps the patient to understand the disease better and integrate into the treatment process, showing better clinical results and strengthening the work with the multidisciplinary team in health services 9 .
The experience of the cancer patient is marked by weaknesses from the diagnosis to the entire course of the therapeutic process, this happens, mostly, due to the association of the disease with death, which causes negative feelings.In addition, the lack of knowledge about the operation of the oncological care network and the lack of family support during treatment are additional obstacles in this journey of illness and treatment 12 .
Given the above, and the difficulties faced by cancer patients, the present study had the main guiding question: how can clinical nurses contribute to the therapeutic path of cancer patients?Thus, the objective of this study was to understand the experiences of clinical nurses according to the principles of navigation for cancer patients proposed by Harold Freeman.

METHOD
This is a qualitative study, guided by the COREQ tool (Consolidated Criteria for Qualitative Research Reports) and conducted after approval by the institution's Research Ethics Committee.
The research was carried out in a city located in the state of São Paulo, in a state public hospital focused on teaching, research and extension, which serves patients from 68 municipalities.This hospital is classified as a highly complex oncology unit (UNACON), and provides highly complex specialized care in outpatient clinics and emergency and inpatient units, with radiotherapy, hematology, and clinical and pediatric oncology services.
All nurses who worked directly with patients using the Oncology Outpatient Clinic were included as participants in this study.
The first contact for data collection took place in June 2021, through a meeting with the Nursing Manager of the studied hospital, in order to present the research project and obtain authorization to carry out the study.Then, after approval by the sector's technical manager, a list was made available in electronic format with the names of the nurses who had experience in oncology, containing the following data: name and telephone number of the nurses.
In order to carry out the data collection in person and sequentially, the person responsible for the research voluntarily invited the nurses in the sector, with the criterion respect for the work schedule and the organization of the day's activities.Therefore, specific days and times were scheduled with the nurses who agreed to participate in the study.
Six nurses who worked directly in the health care of cancer patients participated in the study.The interviews took place between December 3 rd and 17 th , 2021.Before starting the interview, the participant was asked to read and sign the TCLE.
Two instruments were used: one that lent itself to sociodemographic characterization and professional history, containing information on age, length of time since graduation, length of time working in the oncology outpatient clinic and completion of a specialization course; and another instrument represented by a semi-structured interview, containing four guiding questions, developed from the theoretical framework of the nine principles of patient navigation by Harold Freeman 3 : tell me how cancer patients are assisted in this hospital; how do you see the integration between sectors for oncology care; how are the training and facilities according to the demand of cancer patients; in your opinion, which strategies are important and enhance the adequate care of cancer patients.All interviews were audio-recorded, lasting an average of 20 minutes, and were conducted 5/14 by two researchers with experience in oncology and qualitative research.The identities of the study participants were identified by letters of the alphabet in the order of data collection.Thus, they were identified as: A, B, C, D, E and F.
For treatment and analysis of the data collected through a semi-structured script, the Content Analysis 13 framework was used, in the thematic aspect, following the three steps proposed by this author: Phase I: pre-analysis (phase of material organization and systematization of ideas, aiming to the formulation of hypotheses and the development of indicators that guide the final interpretation); Phase II: exploration of the material (comprising the categorization of data, which aims to reach the core of understanding of the text and in which the choice of meaning units and categorization takes place); Phase III: data treatment: inference and interpretation (phase in which the raw results are treated in order to make them meaningful and valid, and the researcher can propose themes and carry out interpretations directed to the objectives of the study.The analysis of the interviews was carried out in a coding process, with the interviewee's speech being reproduced in order to make his intention clearer when describing and telling certain situations.Supported by the speeches, the codes were separated into analytical categories, being formed and later discussed from the perspective of the Theoretical framework of the principles proposed by Harold Freeman which, at the end of the analysis, constituted the synthesis of the experiences studied 13 .

RESULTS
With regard to the characterization of the participants, it was observed that, among the six participants interviewed, there was a predominance of females, with ages ranging from 35 to 45 years, with length of time since graduation in nursing between 11 and 21 years, with three professionals having completed postgraduate Studies, lato sensu and stricto sensu degrees, two at master's level and one at doctoral level.Regarding the amount of time working in the oncology sector, this ranged from six to sixteen years (Chart 1).After data coding and analysis, five categories emerged, compiling the experiences of nurses working in cancer patient care.It is noteworthy that the categories were constructed from the theoretical framework: the nine principles of Navigation of Cancer Patients proposed by Harold Freeman 3 .

Smooth sailing and fluidity in cancer patient care
When discussing aspects of quality of the work developed in the Oncology Outpatient Clinic, the nurses included aspects of smooth sailing and fluidity in the care provided, highlighting the humanized and multidisciplinary care offered from the entrance of the patient and during his journey through the hospital, including citing the legislation that establishes that the first care should be within a maximum period of 60 days.
I think the patient is well received, from the moment he arrives at the hospital reception [...].they have a very nice passage, I think it's good (C).
Here within the structure of the state hospital, the Oncology Outpatient Clinic, they [patients] are with us here in nursing, they go through the dentistry, with the nutri and with the psychologist, ... we have the law of 60 days (D).
In contrast, weaknesses of the referred health service were reported, such as being a hospital with several specialties of care, not having the entire structure focused only on oncological care.The nurses understand that the fragmentation of care ends up generating barriers in the flow and referral, with regard to multidisciplinary care.
I just wanted a whole hospital for oncology (B).
It would be much easier if, in the emergency room, there were more specific people or specific places to be attending cancer patients [...] if there was a service only for oncology (E).
Outside of the oncology outpatient clinic, I think there are some barriers, some difficulties, it takes a while to be seen.We, nurses, have a little difficulty when this patient needs to be referred to other specialties (F).

Flow, referrals and integration between teams/services
There was recognition of facilities among the teams that provide care to cancer patients.In addition to good integration between the nurses who provide patient care, good integration with the multidisciplinary team was mentioned.
It's very easy [integration between teams]; we have a very important dialogue with the medical team, with the nutritional team, with the psychology team, social worker; so, I think we are very integrated with each other, it works very well (B).
We, nurses, managed to have a good integration with some sectors [...] with the multidisciplinary team, the relationship is very good, nutrition, dentist; the relationship is facilitated (D).
I believe that, here, in the oncology outpatient clinic, the team is well integrated (F).For them, the greatest difficulty related to integration occurs when there is a need for hospitalization, between the high demand of the hospital and the place where the patients are referred.Other professionals point out difficulties in the imaging sectors and in some specialties due to the integration queue, in addition to the delay in service, making the process difficult.
I think our difficulty is hospitalizations.It's the most difficult part for us.Due to the demand of the hospital to which patients are referred, integration is not facilitated (A).
[...] the radiotherapy sector, in my opinion, I think that, for the patient, especially the patients from outside, it is a hassle to leave the oncology outpatient clinic after going to radiology there in the hospital of greater complexity (C). [

...] what sometimes happens Is in tomography, because of the queue ... Image sectors is more difficult because of the queue itself, not because of lack of receptivity, lack of communication (D).
Thus, the reports showed barriers in the passage of the cancer patient due to the geographical distance for care with other specialties, because they are performed outside the structure of the oncology outpatient clinic.

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The problem is when they need other specialties, a urology service, for example, they have to leave here from the oncology outpatient clinic and go to a hospital of greater complexity.I think this flow, it is time-consuming and stressful for the patient and greatly impairs care (B).
What sometimes complicates things a little is the fact that we do not have an emergency room and end up referring these patients to the referred emergency room, the hospital of greater complexity or to the municipal (E).

Bond between patients and families with nurses
For the participants, the nurse's role goes far beyond just being present with the patient, reporting that this professional offers support and stays with the family, recognizing their difficulties and planning strategies to minimize everyone's suffering.
We try to do our best to make it easier for the patient and family, because it is a delicate moment that they are going through, so we try to make it as easy as possible for the patient and the family, because family care is also important (C).
We make direct contact with the mothers to inform them that the exam is good and do not need to be return to the hospital... not all sectors have this intimate contact; This ends up humanizing the service more.We [nurses] throw birthday parties for them; we try to alleviate their suffering (E).

Delimitation of competencies and roles of care nurses in the navigation of cancer patients
The participants highlighted the fundamental and differentiated role played by the nurse in the care of cancer patients.Thus, one of the strategies planned to improve the flow of cancer patients regarding the nursing consultation.
A nursing pre-consultation would help a lot; we have this plan here, we have the planning, but because of the human resources, we end up not being able to put it into practice (A).
[...] would need the nurse consultation, which provides the primary care (B).
[…] I think it would be good to implement the pre-consultation (F).Thus, the reports evidenced the benefits of having a navigator nurse in the hospital.They also demonstrated an appreciation of the training of the professional nurse to navigate the care of cancer patients, in order to facilitate their journey and that of their family throughout the hospital flow.
[...] I think it's really cool that one day we can at least implement patient navigation in the hospital (A).
[...] I believe that the navigator nurse would help a lot of patients (B).

Valuation and facilities related to team training
According to the participants, the coordination of the nursing team facilitates and provides team training with annual plans in order to improve the care provided.Thus, according to the needs and demands that are presented by the professionals, they end up being included in the programming.In addition, they attested that they are always engaged in case discussions and in the search for new knowledge.
[...] then, as we have this need, we direct it to my immediate boss and she sees this need for training (C). [

...] we [nurses] develop projects and case discussions...we discuss every new case (E).
The training is done as needed and some scheduled during the year (F).

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At the same time, they report difficulties due to the centrality of the training being directed to another geographical structure besides the one in which the nurses work.On the other hand, it is highlighted that the relationship is facilitated when the training is carried out in the same place where they work, that is, in the Oncology Outpatient Clinic itself.
The coordinator of the sector gives a lot of classes to us, but now it's all for the education center, outside the structure of the oncology outpatient clinic, [...] it's a process that, sometimes, ends up not being as we would like.So, if the training was done all here, we would be able to have much more access (A).

DISCUSSION
Harold Freeman describes the nine principles that characterize cancer patient navigation.This study sought to identify the principles of patient navigation in the experiences of nursing assistants, interrelating the thematic categories with the data obtained 3 .
Smooth sailing and fluidity in the care of cancer patients were highlighted in this study by the existence of a physical structure that has been favoring patient care, through multidisciplinary work, as well as the implementation of Law No.12,732, which establishes the start of treatment within 60 days, at most 1 .
The nurses interviewed in this study reported that, from the moment patients arrive at the hospital and receive the diagnosis, the processes are linked so that their treatment begins as soon as possible, without encountering difficulties.In addition, the care is fluid and smooth sailing from the moment the patient enters and throughout their passage in the hospital, facilitated by the multidisciplinary team, which strictly follows the Law of 60 days.
Law No.12,732 from the year 2012 of SUS, which ensures treatment for cancer patients, was reported in this study, being one of the institution's strategies 1 .However, a study carried out at a State Center for Diagnosis and Imaging carried out an analysis of the prediction of compliance with the 60-day law within the navigation program of patients with breast cancer in Rio de Janeiro, identifying that compliance with the said law days reached just over 50%.In this study, the care provided by professionals has been highlighted as a reference in compliance with the law, since the testimonies showed confidence for the patient to start their treatment as soon as possible, before 60 days 14 .
According to Freeman's principle about the passage of the patient through the health system, professionals must be aware of the barriers that impede the fluidity of care, in order to facilitate the process and every patient, when diagnosed, must immediately start navigating to facilitate your journey through the hospital 3 .The navigator nurse will conduct care in a cohesive and facilitated way throughout the trajectory of diagnosis and treatment, assisting in all stages of treatment, contributing to better adherence to treatment 12 .
In order to obtain quality care, it is necessary to have a physical and material structure, in addition to the specialized services provided by the multidisciplinary team, so that the care is comprehensive 15 .Although the nurses in this study revealed some difficulties resulting from the geographical distance and assistance with other specialties, even so, such distance is not an impediment to qualified assistance, highlighting the facilities in the relationship with the entire team involved in the care of cancer patients.
For the patient's access to care to be continuous and integrated between services, professionals must be facilitators in connecting health systems 3 .In this study, the close relationship between patients and nurses was observed, and the research participants demonstrated the importance of integration between the care teams, in addition to being facilitators in this connection.Also, the important role of the nurse in coordinating the care of cancer patients is highlighted, as this professional is responsible for coordinating, guiding and supervising the activities developed in the department.

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A study on the multidisciplinary model of cancer care, observed a positive association between the navigation of the oncology nurse and better outcomes for cancer patients and that the integration of the navigator nurse in oncology care significantly reduces the interval between diagnosis and the beginning of treatment, providing adequate support in the coordination of cancer care 16 .
Better results were observed in the outcome of cancer patients when nurses navigated patients across the continuum of care and health.Relevant aspects of the entire care process were clarified, from diagnosis and initiation of treatment to end-of-life support 9 .The care offered by nurses at the study site revealed important strengths for a favorable outcome, facilitating the continuum of care for cancer patients.In addition, for Freeman, patient navigation is an intervention whose main objective is the elimination of barriers that can occur throughout the continuum of care for the cancer patient 3 .
The navigation program is of great importance for patients and their families, that is, when being diagnosed, accepting the disease, procedures, receiving adequate treatment, experiencing possible adverse reactions, during home care, consultations and exams and in the monitoring of family members 17 .
However, some difficulties were reported by the nurses when patients require hospitalization.They also mentioned that, in the imaging sectors, the relationship is not facilitated due to the high demand of the hospital to which the patient is referred.In a study conducted with patients with lung cancer, patients in the public service network found weaknesses and difficulties that permeate their passage, these being the barriers that appear from the first symptoms and diagnosis and during the search for treatment.It was also noticed that the main barriers encountered during the course of care are the difficulties regarding access to medicines and tests, the long waiting lines for care, the delay in diagnosis, the fragmentation of care at different levels of care, the dehumanization of care environments and the failure in communication to clarify patients about legally established rights related to access to health 4 .
Regarding patient safety, the nurses reported the good quality care and emphasized compliance with the safe administration protocol for chemotherapy which follow the current recommendations established by the institution.The concept of patient safety, according to the World Health Organization 18 , refers to the reduction of risks of unnecessary harm, associated with health care, to an acceptable minimum.It is noteworthy that this subject has been much explored in recent years and, since then, has become a priority, motivating health institutions to create strategies with the aim of reducing avoidable risks 19 .
In this study, it was observed that the nurses follow the safety protocols anchored in the permanent education of the team, in addition to various training courses according to the needs that arise in the sector, in order to favor the safety of cancer patients.For this, it is essential that care is provided by a qualified team, with the necessary skills to conduct the entire continuum of care 3 .Technology can bring potential to the work of nurses in hospitals, contributing to improvements in professional processes, time management, data storage and patient safety.Thus, it is important to have computers available and staff trained in their use 20 .
Chemotherapy does not only mean an application of medication on scheduled days, but also the need for several trips to and from the hospital, in addition to collections of laboratory tests, which may occur weekly.The need for professionals to establish a close relationship with patients and families is of fundamental importance.This study revealed a true link between nurses, patients and family members and, through the interview, professionals expressed their understanding of the painful path that the patient and family go through throughout their process in search of a cure 3 .
It is important to establish educational strategies that favor, through skills offered to navigators, greater skills in caring for cancer patients 3 .Nurses reported having sufficient staff training and reported understanding the benefits of the patient navigation program.In a study at the Diagnostic Center, 10/14 which performs approximately 4,000 mammograms per month, of women from 92 municipalities in the state of Rio de Janeiro, the lack of physical structure, human resources and medical supplies are significant barriers that prevent the effectiveness of the navigation program.This fact was observed in this study, due to the distance between the hospital complexes that care for cancer patients 14 .
In the present study, it was observed that nurses define the nursing pre-consultation as an effective strategy that facilitates the flow of cancer patients.From the users' point of view on comprehensive care for cancer patients, the importance of the nursing consultation was identified as a guiding instrument and to form an affective bond, which is an important space for patients and family members to clear up doubts and tensions about the process of care and self-care 21 .They also reported that the coordination of care in the care process is understood within the scope of professional attributions and tasks, whose process is carried out according to the professional category and through training 3 .
Reflection on the nurses' testimonies showed that nurses are valued for navigating cancer patients and that, through this professional's care, there is a facilitation during the journey of the patient and his family in the hospital complex.The performance of the navigator nurse in oncology provides great benefits to patients, with favorable outcomes in the quality of treatment 22 .In Canada, the navigator nurse is recognized as a key component within the health system, in the treatment of cancer, significantly contributing to the provision of care to cancer patients 23 .
In this research, it was possible to observe the appreciation of the professional nurse.Although the participants did not have advanced training or knowledge for the practice of navigation, they reported the importance of implementing this program in the institution.In an integrative review study, the authors suggest that it is essential to have effective communication, which is a facilitating link between professionals, organizational culture and patients, in order to improve the development of hospital services 24 .
A study on the effects of nurse navigators during the transition from cancer screening to the first phase of treatment identified that navigators were able to reduce waiting times and facilitate the use of health services, from the moment of screening to the first consultation.In addition, there was an increase in satisfaction with the services 25 .In this study, the facilitation of the path of the patient and family was reported, from entering the hospital to the first consultation and throughout the care journey.In addition, the flow of the patient's passage occurs in an easier way due to the good integration with the multidisciplinary team.
The contribution of nurse navigators to integrated care was explored in a qualitative study with seven nurses in Queensland, Australia, and it was noticed that navigators are involved in clinical integration, providing education, professional integration and connections between health professionals and in establishing relationships, trust and shared communication 25 .
In a study conducted with cancer patients at university-affiliated cancer centers in Montreal, Quebec, it was observed that experiences and satisfaction with cancer care were significantly expressed when compared to the group that were not seen by nurse navigators 26 .
Finally, the implementation of the patient navigation program brings benefits and these are highlighted as sources of satisfaction for patients and family.Thus, the importance of institutions articulating actions that enable their adoption is revealed, in search of quality and safety in the provision of care to cancer patients 11 .
In conclusion, some points reflect limitations in this study: it was carried out during the COVID-19 pandemic and, for this reason, measures and health care had to be improved and expanded, moreover, as it was a qualitative research, it was not possible to generalize the findings, as situated analyzes are part of the nature of this type of study.

CONCLUSION
The experiences of clinical nurses in oncology contribute to the therapeutic path for cancer patients, demonstrating convergence with some of the principles proposed by Harold Freeman for navigating cancer patients, such as systematized care, integration between the team and different sectors, ease of training and acquisition of competence, the valuation of interprofessional teams in the care of cancer patients and their families.Thus contributing to the qualification of the care provided.
Such findings support the consideration that, even without specific specialization and without institutional implementation of the navigation program for cancer patients, nurses provide qualified care, contributing to the minimization of barriers and what can facilitate the therapeutic path of the oncology patient.Although some difficulties have been reported due to the distance between the hospital complexes for the care of cancer patients, these were not an impediment to achieving good patient and family care.
The study contributes to reiterating the importance of the navigator nurse, whose role is materialized in conducting and facilitating the patient's entire journey, from diagnosis to the treatment, carried out in a cohesive manner and contributing to greater adherence.
Thus, it is expected that, based on understanding the daily life of clinical nurses, this study can show the importance of the navigator nurse's role in oncology, encouraging these professionals to implement navigation programs in the care of cancer patients.