What is already known about this topic?

Patients diagnosed with cancer are often puzzled by treatment plans and confused how to receive appropriate, timely and high-quality therapy.

ONNs are specialized nurses who help cancer patients in their treatment plan.

ONNs manage the treatment process, empower patients, provide information and support, and connect patients with their healthcare providers. 

What this paper adds?

ONNs assist in patient’s cancer treatment, survivorship, even in palliative care and extend their roles in finding the resources their patients need.

ONNs help patients improve their quality of life by removing the barriers for them to receive optimal care.

Importance of ONNs in the healthcare system that institutions might consider implementing ONN programs.

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.

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].

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 inFigure 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.

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.

The researchers utilized the Sparbel and Anderson (2000) tool in data evaluation. It is a completeTable 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.

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.

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].

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.

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]

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.

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]

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]

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]

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.

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.

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.

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. 

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. 

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.

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Author Contributions: JA, MGF, MGM: 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.