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Review Article | Open Access | 10.31586/wjcor.2023.733

ROLE OF ONCOLOGY NURSE NAVIGATORS: AN INTEGRATIVE REVIEW

Jozelle Mae Suazo1, Gold Mendoza1, Al Canaynay1 and Roison Andro Narvaez1,2,*
1
St. Paul University Philippines, Graduate School, Philippines
2
Philippine Oncology Nurses Association, Philippines
Received May 16, 2023
Revised June 25, 2023
Accepted July 23, 2023
Published July 24, 2023

ABSTRACT

Background: Oncology nurse navigators (ONNs) are becoming even more vital as
healthcare continues to develop into a more complicated, confusing maze for
patients. When many specialists on the treatment team have divergent points of
view due to the nature of their respective professions or other factors, the
patient may experience feelings of confusion. In the end, this can cause delays
in treatment, pose a threat to the established standard of care, and lead to a
decrease in patient satisfaction. Aim: To enumerate various ways in which ONNs
may help improve the quality of life of cancer patients. Design: An integrative
review. Results: A total of 19 studies related to the topic are evaluated. Four
main themes namely: provider of psychological support, facilitator of timely
care, oncology nurse navigators perception of their role and patient’s
perception of oncology nurse navigators and 3 sub themes which are: information
giver, source of emotional support and coordinator, were identified to be the
roles of the ONNs. The findings showed that oncology nurse navigators help
reduce patients anxiety and distress, increase patient satisfaction, shorten the
time from diagnosis to treatment, provide necessary information, support them
emotionally and coordinate their care with the different members of the
healthcare team and resources. Conclusion: The main function of the ONNs is to
address any barrier that may hinder the patient’s cancer treatment, survivorship
and even palliative care. ONNs make sure that each patient has individualized
nursing care according to the patients and their families' needs. Implications
for Practice: ONNs have the potential to significantly contribute not only to
the quality of life of cancer patients but also to the process of achieving
better service integration. The result of this integrative review contributes to
the growth of the healthcare system by improving accessibility, fairness,
efficiency, effectiveness, and the ability to maintain health services
throughout time brought about by ONNs.

HIGHLIGHTS

What is already known about this topic?

1. Patients diagnosed with cancer are often puzzled by treatment plans and
confused how to receive appropriate, timely and high-quality therapy.
2. ONNs are specialized nurses who help cancer patients in their treatment
plan.
3. ONNs manage the treatment process, empower patients, provide information and
support, and connect patients with their healthcare providers.

What this paper adds?

1. ONNs assist in patient’s cancer treatment, survivorship, even in palliative
care and extend their roles in finding the resources their patients need.
2. ONNs help patients improve their quality of life by removing the barriers
for them to receive optimal care.
3. Importance of ONNs in the healthcare system that institutions might consider
implementing ONN programs.

1. INTRODUCTION

In 1990, an American physician Harold Freeman laid the groundwork for what would
later become known as patient navigation. He did this to speed up diagnostic
confirmation and ensure that persons with chronic illnesses receive the same
treatment from start to finish, regardless of diagnosis [1]. A patient navigator
helps people overcome socioeconomic, financial, cultural, bureaucratic, and
psychological barriers to health care like when patient navigators cultivate
trust and empowerment in the communities they serve by addressing a number of
the disparities resulting from language and cultural differences and barriers
[2].

Cancer patients and caregivers often face obstacles in accessing timely,
high-quality therapy [3, 4, 5]. Lack of healthcare experience, poor health
insurance, and difficulties with daily tasks like getting to treatment and
taking time off work can be hurdles. One of the most vulnerable groups needing
patient navigation are those diagnosed with cancer6. Cancer patients and
caregivers often struggle to get timely, high-quality therapy [6, 7]. These can
include unfamiliarity with the healthcare system, insufficient health insurance,
and challenges with daily responsibilities like transportation to treatment and
taking time off work. Patient navigation improves cancer patients' treatment
adherence and wellness. Patient navigators can improve cancer care, patient
satisfaction, and health outcomes [8]. These oncology nurses provide physical,
social, and emotional care to their patients. Aside from the clinical works they
do, they also undertake nonclinical works as patient navigators [9]. Navigators
also examine patient needs and design a plan to overcome barriers to
high-quality care [10].

They help patients, families, and carers make decisions with the treatment's
interdisciplinary team [11]. Activities go beyond care management. They manage
the treatment process, empower patients, provide information and support, and
connect patients to team specialists. Education empowers patients by teaching
them skills, attitudes, and self-awareness. They can manage their health and
participate in treatment. Empowered patients engage better with healthcare
providers because they are more aware, involved, and responsible [12]. ONNs also
help cancer patients in the field of research. These professionals improved
patients' treatment satisfaction by letting them know how cancer affects their
life and made patients more involved in their care and better prepared for the
future [13]. Patient navigation continues to evolve. International navigators
are currently healthcare professionals, students, and lay volunteers. Tasks vary
by knowledge level [14].

In the Philippines, impoverished cancer patients face high costs. At the moment,
navigators in international programs are made up of healthcare professionals,
students, and lay volunteers. Depending on their level of knowledge, each has
different tasks to do [14]. Whilst locally, the Department of Health-Philippine
Cancer Society Inc. (DOH-PCSI) Access Program for Breast Cancer Medicine has
already started giving free chemotherapy through a patient navigation system at
a hospital in Manila starting in January 2012. This was done to improve the
quality of breast cancer treatment. This is one of the nation's first patient
navigation programs [15].

As for the researchers' knowledge, no other review was done to understand the
role of ONNs in contributing to the betterment of cancer patients' quality of
life. This study aims to find scientific articles about oncology nurses who help
patients find their way around as nurse navigators. This will show the effects
and benefits of ONNs throughout the whole process of managing cancer and how
they affect patients' overall health outcomes. This study will help both the
patients and their families, who are also having a hard time getting used to the
diagnosis of a loved one. This study will also assist health policymakers and
healthcare leaders in formulating policies concerning nurse navigation programs
since this program is new in the country and the ONNs are few here in the
Philippines. The specific objectives are as follows: 1) define and understand
the role of ONNs in the healthcare system; 2) Enumerate various ways in which
ONNs may help improve the quality of life of cancer patients; 3) Highlight the
significance of nurse navigation in the treatment of cancer and; 4) Give insight
to the healthcare industry leaders the importance of developing a program
concerning patient navigation and to have an ONN working in each healthcare
institution.

2. MATERIALS AND METHODS

2.1. DESIGN

This research paper employed an integrated review technique of research. The
integrative review methodology offers a synthesis of knowledge and shows how
important studies' findings can be used in practice [16]. This study employs
that technique to narrate and accurately assess publications related to the most
recent comprehension of the role of ONNs in improving the quality of life of
cancer patients. The researcher followed the Whittemore and Knafl (2005)
framework, which includes the following stages: a) issue attribution, b)
literature inquiries, c) data appraisal, d) data evaluation, and e) discussion
of results of a summary of evidence. It is an approach that allows the inclusion
of several approaches and can be more leading in evidence-based nursing practice
[17].

2.2. SEARCH STRATEGY

This study was conducted in January 2023. Google Scholar, PubMed, CINAHL, SAGE,
Elsevier databases were all used in the search. In order to look for related
literature, keywords were used to search for the associated literatures:
oncology nurse navigator, oncology nurse navigator program, nurse navigator,
oncology, nurse oncology, and oncology navigator. The literature found were
compiled together and go through diligent examination to determine the
significant literature to the study.

As shown in Figure 1. PRISMA flow diagram, the initial search yielded 1,056
studies. Another search engine was used to narrow down the studies using the
keywords. Eighty-four abstracts were reviewed but only thirty-five full articles
have been analyzed. The researchers identified the inclusion and exclusion
criteria, hence, a total of 19 articles were included in this integrative
review.

Figure 1
PRISMA Flow Diagram
Table 1
Characteristics of the study.

2.3. INCLUSION AND EXCLUSION CRITERIA

The beginning of the search of the literature had examined the level of
inclusion and exclusion. The identified literature for inclusion were literature
published within 2008 – 2023 due to the novelty of the topic and the need for a
holistic approach to studying the program in question due to the paucity of
available resources, with an English language, full-text context, patient and/or
nurse inclusion, non-review studies, and conducted research. The incorporated
articles were related to the role of oncology nurse navigator in improving the
quality of life of cancer patients.

On the other hand, the study that excluded were inaccessible of full texts,
published articles year 2008 behind, a language other than English, patient
and/or nurse exclusion and studies as review and synthesis methods. The book
chapters are not to be included in this study.

2.4. DATA EVALUATION/ QUALITY APPRAISAL

The researchers utilized the Sparbel and Anderson (2000) tool in data
evaluation. It is a complete table to organize the articles included in the
review [18]. It includes the author’s name, year of publication, design,
setting, sample size and participants, methods and/or instruments used, the
focus of the study and its findings.

As shown on Appendix A (Supplementary File), to evaluate the reliability, worth,
and significance of each article that was included, the researchers make use of
the Mixed Methods Appraisal Tool (MMAT) tool. It is a critical evaluation
instrument for the appraisal phase of systematic mixed studies reviews which
enables evaluation of the methodological quality of studies in five categories
[19]. The articles included were divided into 5 category study designs namely:
qualitative, quantitative randomized control trial, quantitative non-randomized,
quantitative descriptive and mixed methods. Each category has five
methodological quality criteria which can be answered by yes, no and can’t tell.
Each methodological quality criteria has a point of 1 if the answer is yes and a
score of 0 if the answer is no, and N/A if the result is can’t tell. The total
score of each studies and divided it by 5 to get the total score of the the
studies and interpret it with strong if the score is 1, moderate-strong if the
score is 0.80, moderate if the score is 0.60, mild-moderate is the score is
0.40, and mild if the score is 0.20.

In addition, the studies included used the Hierarchy of Evidence for
Intervention Studies to give a level of evidence based on their methodological
quality, validity, and usefulness to patient care [20]. The tool is divided into
seven types of evidences with corresponding level of evidence as follows: Level
I- Systematic review or meta-analysis, Level II- Randomized controlled trial,
Level III- Controlled trial with- out randomization, Level IV- Case-control or
cohort study, Level V- Systematic review of qualitative or descriptive studies,
Level VI- Qualitative or descriptive study and Level VII- Expert opinion or
consensus. Expert review was also utilized and the results were validated and
agreed upon.

3. RESULTS

Table 1 shows the total number of included studies is nineteen (n=19). Out of
the 19 related literature, 4 studies are qualitative, the other 13 literature
are quantitative and 2 have a mixed-method research design. Among the studies,
the majority were conducted in the United States of America (n=10) and Canada
(n=6). The rest were done in Brazil (n=1), Denmark (n=1) and Israel (n=1). As
noted, most of the studies were done in the western continent with only one in
Europe and one in Asia.

The methods used in data collection are the use of questionnaire (n=4),
face-to-face interview (n=8), review of electronic records (n=5) and use of
survey (n=2). In terms of the level of evidence, there are four (n=4) LOE II,
two (n=2) LOE III, two (n=2) LOE IV, eleven (n=11) LOE VI. As shown in Tables
2.1 to 2.5, the MMAT yielded four (n=4) strong qualitative studies, nine (n=9)
strong quantitative studies, four (n=4) moderate-strong quantitative studies and
two (n=2) moderate-strong mixed method articles.

In terms of selecting the samples the following methods were used: purposive
sampling (n=10), convenience sampling (n=4), random sampling (n=4) and cluster
sampling (n=1). The studies having cancer patients as participants have a mean
sample size of 272 while those articles having ONNs as participants have a mean
sample size of 34. The subjects included are patients with breast, colorectal,
gastrointestinal and lung cancer and ONNs.

Four themes have been extracted from the seventeen studies that were reviewed.
The themes are: provider of psychological support, facilitator of timely care,
oncology nurse navigators perception of their role and patient’s perception of
oncology nurse navigators. Three sub themes were extracted from the main theme
patient's perception of oncology nurse navigators which are: information giver,
source of emotional support and coordinator.

1. Provider of Psychological Support

Out of nineteen studies, five studies found that ONNs provide psychological
support to the patient by guiding the patient on their journey toward the course
of treatment [21, 22, 23, 24, 25]. Patients in contact with ONNs have higher
satisfaction levels, lower distress, anxiety and depression levels.

On the other hand, it was mentioned that there was no relevant difference in
distress, weariness, quality of life, and healthcare use after an ONN
intervention [26].

1. Facilitator of Timely Patient Care

Five of the studies mentioned that those who have been diagnosed with cancer and
who are possibly developing cancer benefit from the different roles of an ONN,
particularly with their role as facilitator of timely patient care [26, 27, 28,
29, 30]. The majority of the respondents of these studies recognize that there
is a shorter time frame from diagnosis to the beginning of therapy, an increase
in patient and caregiver awareness, a greater adherence to the suggested care,
and an improvement in the overall quality of life.

1. Oncology Nurse Navigators Perception of their Roles

Four studies discussed the perception of nurses of their job as ONNs [31, 32,
33, 34]. Among the roles mentioned in the studies are: patient advocate, provide
patient-focused care and educational support.

“Being an advocate was not going to change the course of the disease but helped
them cope with what they were experiencing at the time.” [34]

1. Patient’s Perception of Oncology Nurses

Among nineteen studies that have been reviewed, five articles talked about the
role of ONNs in the eyes of oncology patients [10, 33, 34, 35, 36]. Prior to
implementing a role intended to improve care for a particular group, it is
important to comprehend patient perspectives regarding their experiences and
needs.

3.1. INFORMATION GIVER

Four studies talked about ONNs being the source of information throughout the
participant's cancer journey [10, 33, 34, 36]. Informational support is very
vital to oncology patients. Because of the additional information provided by
the nurse navigators, they expressed the belief that knowledge helps them feel
less anxious and move emotionally forward and feel more at ease in actively
managing their sickness [33, 36].

“She explained everything that was going to happen with the surgery.” [33]

3.2. SOURCE OF EMOTIONAL SUPPORT

Two studies showed that oncology patients highly valued the ONNs as their source
of emotional support that would provide them with consolation, support and
comfort during the most challenging phases of their illness [10, 36].

“She brings us emotional security... and you know that you can count on her.”
[36]

3.3. COORDINATOR

Three studies mentioned how helpful ONNs are in coordinating their treatment
plans [34, 35, 36]. Referrals to resources, guidance on aspects of care as well
as schedule of visits and building relationships with other healthcare workers
were among the works of oncology nurse navigators.

“She creates the links between myself and the hospital MDs.” [36]

Table 1
Characteristics of the study.

4. DISCUSSION

The included studies explored the role of ONNs in improving the quality of life
of patients with different kinds of cancer. The aims of the study- to define the
role of these nurses and enumerate ways in which ONNs may help improve cancer
patients’ quality of life, were discussed. With different patient navigation
strategies being used in cancer care, the role of the ONN has continued to
expand. Patient navigation in cancer care could be broadened even more in order
to meet the patients needs and enhance their quality of life.

4.1. AIDS IN OVERCOMING CHALLENGES WITHIN THE HEALTHCARE SYSTEM

When a patient is given a diagnosis of cancer, the multidisciplinary care team
develops a treatment plan that is then presented to the patient by a physician.
This plan is intended to assist in guiding treatment options. When many
specialists on the treatment team have divergent points of view due to the
nature of their respective professions or other factors, the patient may
experience feelings of confusion. In the end, this can cause delays in
treatment, pose a threat to the established standard of care, and lead to a
decrease in patient satisfaction [37]. Every cancer patient is unique, and so is
their experience of treatment for the disease, which can throw unanticipated
unexpected turns into treatment regimens at inconvenient times. It is likely
that some patients have problematic living situations due to variables such as
distance traveled or absence of public transportation. It is likely that some
individuals have difficulty communicating related to language barriers, whilst
others may have difficulties with memory or organization. Before a person has
been treated for their condition, it can be challenging to ascertain the precise
challenges they may be having. This is where the cancer patient navigators come
in, to maintain constant communication between the patient and their family
throughout the duration of the process [38].

According to the findings of the studies, ONNs are critically important in their
role as patient advocates, ensuring that all patients receive the highest
quality of care beginning with the preliminary consultation and continuing
throughout the entirety of the care plan for each individual patient [39].
Because they had a foundation in nursing, a complete grasp of oncology
components, and a thorough comprehension of the diagnostic evaluation phase, the
oncology nurse navigators were highly skilled at advocating for their patients.
This was one of the most important aspects of their job [33]. The majority of
patient navigator programs in transitional care employ healthcare professionals,
primarily registered nurses, who have both the clinical expertise and the system
experience necessary to be able to perform advanced tasks. These professionals
are responsible for guiding high-needs patients along their treatment pathways
[40]. During the course of therapy, the importance of the nurse's role in
providing continuity of care as patients move from the hospital to their own
homes is emphasized.

Furthermore, one of the roles of ONNs that was highlighted in the studies was
care coordination. Care coordination is an essential component of providing
high-quality patient care regardless of the patient's health, disease, or
location, and it is an important aspect of oncology nursing [31]. They are not
only responsible for managing the patient's treatment schedule, check-ups, and
referrals, but they are also responsible for supporting the patient with
concerns such as transportation, childcare, and financial resources [31, 34].
This is one of the extended roles of ONNs from its previous definition. They are
the overall coordinator of their patients' needs.

4.2. ENSURING HIGH-QUALITY, APPROPRIATE AND TIMELY PATIENT CARE

The studies showed that ONNs should reach out to patients with cancer or those
at risk of it and their caregivers in order to assist them in overcoming any
healthcare system hurdles they may be encountering and to facilitate timely and
effective access to care throughout the entirety of the cancer journey [41].
This indicates that the provision of this service or commencement of this
program ought to begin promptly. It was discovered that having an ONN present
early on in the course of cancer treatment, in collation to improved standard
care, resulted in a significantly better patient experience and significantly
fewer problems with care [21]. When those working in healthcare, particularly
ONNs, are able to manage their time more effectively, they are able to complete
a greater quantity of work, the work that they complete will be of a higher
quality, and they will miss fewer deadlines. When terrifying test results like a
cancer diagnosis are received, ONNs not only provide referrals and knowledge
quickly, but they also offer a great service for the community as a whole [40].
Also, ONNs have a significant amount of potential to increase the percentage of
patients who are satisfied with cancer care services and who finish receiving
treatment. In the foreseeable future, it is strongly recommended that ONNs
assist with interdisciplinary care [42]. The outcomes for cancer patients are
improved by ONNs because the delivery of care may be carried out in a more
timely manner.

In addition, it is helpful for ONNs to know what their patients require so that
they can appropriately address them. This topic was covered in some of the
studies that were examined. The overall quality of life of cancer patients
undergoing treatment is intended to be enhanced by the use of person-centered
[35]. A further benefit of gaining this understanding is that it will empower
patients and their families to take an active role in the formulation of their
treatment strategy. Also, it is really important for ONNs to comprehend the
requirements of their patients [43]. They will be able to give the necessary
assistance for them and respond effectively to any issues that may arise.

Overall, the articles that were looked over show that ONNs now play a more
significant function. Screening and diagnosis were the initial stages of patient
navigation; however, this process is now ongoing all the way through survival
and care provided at the end of life [31]. Some of these additional tasks
revolve around the psychological aspects of therapy and include things like
screening for signs of distress, facilitating difficult conversations,
communicating with survivorship care providers, and providing support for
advanced care planning.

On the other hand, two of the reviewed studies resulted in no significant change
in hospital visits, symptom alleviation, fatigue, distress and quality of life
among the navigated participants. This was because the symptoms of the
post-chemo navigated and non-navigated patients visiting the hospital are the
same [27, 44]. Also, in the result of one study, participation of the
participants in clinical trials was not increased [45]. To fully comprehend the
long-term financial and operational results of ONNs, more investigation is
required.

The COVID-19 pandemic has brought challenges to the ONNs as well. A study also
mentioned that during the first phase of the pandemic, the number of patients
using the diagnostic services dropped, the routines of those receiving cancer
treatment changed, and there was a rise in virus exposure [46]. Teleconsult and
diagnostics access via digital platforms are found to be difficult as well.
However, ONNs focused on maintaining the services and giving information about
the COVID-19 virus and keeping the regular therapeutics and early diagnostics
procedures. They also innovated the drive-thru service for the application of
medicines. This shows that ONNs must have scientific knowledge, technical
expertise, and imagination to devise activities that can ensure the efficacy and
quality of nursing treatment.

Moreover, according a research the evolving requirements of their patients had a
significant impact on ONNs' roles and responsibilities as navigators [47]. The
findings of their study demonstrate that ONNs have flexibility, versatility and
ability to quickly train and deploy for an emergency situation. ONNs keep an eye
on reported problems throughout the entire cancer care continuum, from screening
to survivorship and end of life care.

4.3. IMPLICATIONS FOR PRACTICE

By promoting patient-centered care in which patients receive timely, seamless,
culturally appropriate guidance and assistance for increasing their health
literacy, the nurse navigator, who serves as the focal point of the
interdisciplinary team, has the potential to make a significant contribution to
the effort to reform the healthcare system. The ability of a patient to engage
in shared decision-making is substantially affected by their degree of health
literacy, which enables them to more successfully navigate the resources they
require. In addition to this, it contributes to the growth of the healthcare
system by improving accessibility, fairness, efficiency, effectiveness, and the
ability to maintain health services throughout time. These benefits become more
apparent during transitions from acute to long-term care, which is precisely
when the nurse navigator has the potential to make a significant contribution to
the process of achieving better service integration. The nurse navigator
profession holds a lot of potential for helping people who are underserved or
are going through treatment patterns that aren't connected with one another,
which is a group that is always growing and includes a lot of people who have
difficult and chronic conditions.

5. LIMITATIONS AND RECOMMENDATIONS

The study's limitation is that it only included papers from certain countries. A
number of reviewed articles were done in the USA and Canada. Only a few were
performed in different countries hence, the perspective of other cancer patients
living outside those areas were not explored. It is recommended to do further
research to consider other roles of oncology nurse navigators in improving
cancer patient’s quality of life particularly in the Philippines.

Moreover, a number of studies utilized the review of medical records in which
patients cannot express their specific point of view on the role of ONNs that
may improve the quality of their life. A qualitative approach using interviews
might be a better option to extract a more accurate response on the topic.

The results of the included articles showed that ONNs played a significant role
in improving the quality of life of cancer patients. The researchers recommend
considering an ONN program in hospitals and cancer institutions to help oncology
patients and their families have a better experience in dealing with their
cancer treatment.

6. CONCLUSION

The synthesis presented the functions of oncology nurse navigators in enhancing
cancer patients' quality of life. Their main goal is to address any barrier that
may hinder the patient’s cancer treatment, survivorship and even palliative
care. Oncology nurse navigators make sure that each patient has individualized
nursing care according to the patients and their families needs. They ensure
that the patients and their families will be given the best options, will have
informed decisions and active involvement in the treatment plan.

To improve the life of oncology patients, an oncology nurse navigator entails
in-depth understanding, specialized abilities, and sound clinical judgment. With
the help of oncology nurse navigators, patients are able to reduce treatment
anxiety, able to get timely and appropriate therapy and improve level of
satisfaction.

7. PATENTS

N/A

Author Contributions: JMS, GM & AC: Conceptualization, Methodology, Formal
analysis, Investigation, Data curation, Writing – original draft, Project
administration. RAN: Conceptualization, Formal analysis, Investigation,
Supervision, Validation, Visualization, Writing – review & editing,

Funding: N/A

Data Availability Statement: N/A

Acknowledgments: The authors acknowledges the moral support and guidance of St.
Paul University Philippines – Graduate School

Conflicts of Interest: The authors declare no conflict of interest.

APPENDIX A (SUPPLEMENTARY FILE)

Table 2.1
MMAT Scoring- Qualitative Studies
Table 2.2
MMAT Scoring- Quantitative- Randomized Controlled Trials
Table 2.3
MMAT Scoring- Quantitative- Non-randomized Controlled Trials
Table 2.4
MMAT Scoring- Quantitative- Descriptive Studies
Table 2.5
MMAT Scoring- Mixed Methods

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Suazo, J. M., Mendoza, G., Canaynay, A. ., & Narvaez, R. A. (2023). Role of
Oncology Nurse Navigators: An Integrative Review. World Journal of Cancer and
Oncology Research, 2(1), 66–84. Retrieved from
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