CHALLENGES TO CANCER PATIENT ADVOCACY IN NURSING PRACTICE: A NARRATIVE REVIEW

Vincenza Giordano ¹*, Assunta Guillari ², Aniello Lanzuise ³, Rita Nocerino ², Michele Virgolesi ¹, Martina Micera ⁴, Teresa Rea ¹

1. Department of Public Health, University of Naples Federico II (NA)
2. Department of Translational Medical Sciences, University of Naples Federico II (NA)
3. Health Management, Colli Hospital (NA)
4. Department of Medical and Surgical Sciences, Agostino Gemelli University Hospital (RM)

* Corresponding author: Vincenza Giordano, Department of Public Health, University of Naples Federico II (NA). Email: enza-giordano@hotmail.it

 

Cite this article

 

ABSTRACT

Introduction: Advocacy by nurses caring for cancer patients is essential to ensure that their rights and wishes are respected throughout their care pathway. However, the ability of nurses to provide effective advocacy is limited by various organisational and managerial obstacles, potentially affecting the quality of care and patient well-being.

Objective: Description of the barriers to nursing advocacy in oncology, providing a critical summary of the available evidence to identify the main challenges and propose strategies for improvement.

Materials and Methods: A narrative review was conducted using databases such as PubMed, CINAHL and Cochrane Library between June and September 2024, using the Population, Intervention, Outcome (PIO) methodology.

Results: Four articles were deemed to be relevant to the study objective. The main issues that emerged from the narrative review were barriers to advocacy (lack of effective communication and work overload; fragmented continuity of care), improvement strategies (training and psychological support) and patients’ experiences in the transition from distress to empowerment.

Conclusions: Various barriers hinder nursing advocacy in oncology, such as excessive workload, fragmentation of care and difficulties in addressing patients’ emotional needs. This review underscores that the introduction of dedicated professionals, such as case managers, can provide organisational and coordinated support, helping to mitigate some of the barriers identified. Tackling the barriers to nursing advocacy is critical to ensuring high-quality, patient-centred cancer care. Strengthening organisational support, continuing education for nurses and the adoption of innovative care models are essential.

Keywords: Cancer patients, Neoplastic diseases, Nursing advocacy, Patient rights, Quality of life, Patient well-being, Patient healthcare.

 

INTRODUCTION

Nursing advocacy is defined as the active commitment of nurses to represent, protect and promote the rights, preferences and needs of patients, representing “the process through which nurses seek to protect the rights of patients, ensuring that their needs are met and that they receive safe, high-quality care” [1]. This involves a patient-centred approach, aimed at ensuring that patients receive high-quality care and that their decisions are respected within the healthcare system. Advocacy is based on communication skills, empathy and negotiation, as well as the ability to identify situations in which patients may be vulnerable or at risk of neglect [2]. In oncology, patients face complex and prolonged treatment pathways characterised by invasive treatment, debilitating side effects and significant emotional burden. Therefore, advocacy is particularly important for this type of patient, who requires a personalised approach and continuous support due to the changing nature of both the disease and its treatment [3]. Nurses are called upon to actively intervene to prevent patients from being subjected to injustice or neglect and to facilitate informed decision-making, an aspect that is essential to ensuring quality care. Nursing advocacy is not merely clinical support; it is an approach rooted in empathy, communication and the ability to negotiate solutions that respect the dignity and wishes of the patient. This includes support throughout the entire patient care process [2]. However, despite the recognised importance of this aspect, barriers to nursing advocacy remain widespread, including organisational pressure, lack of time and the weight of the doctor-nurse hierarchy. These factors limit the ability of nurses to provide continuous, personalised support [4].

Oncology is a complex field, and these challenges are even tougher because of the need to coordinate multidisciplinary care, which involves doctors, specialists, social workers, and psychologists. This complexity demands a high level of coordination and effective interprofessional communication, which isn’t always achieved in the best way. The fragmentation of roles and responsibilities can create difficulties in information sharing and planning care, increasing the risk of problems that could compromise the patient’s treatment pathway [4]. On top of that, the emotional strain of caring for cancer patients in the later stages of the disease, combined with the need to provide psychological support to patients and their families, makes it hard to balance defending patients’ rights and managing professional stress [5].

Several studies [2,6] have explored nursing advocacy in a variety of clinical settings, demonstrating that it is essential for promoting a holistic approach that includes patient education, interprofessional communication and psychological support. While the importance of this topic is widely recognised, there are no specific systematic reviews describing the barriers to fully understanding nursing advocacy in oncology. This narrative review therefore aims to bridge this gap by providing a detailed overview of the barriers that limit nursing advocacy in oncology. The identification and description of these needs is essential for developing targeted strategies that improve the effectiveness of nursing care, with consequent benefits for the quality of care and the well-being of cancer patients.

Objective

To describe the barriers that hinder nursing advocacy in the oncology sector, providing a critical summary of the available evidence to identify the main challenges and suggest possible strategies for improvement.

 

MATERIALS AND METHODS

This narrative review was conducted in accordance with guidelines for the preparation of narrative reviews for peer-reviewed journals [7-9].

Study design

The research aims to answer the following question, formulated according to the Population, Intervention, Outcome (PIO) methodology: “What are the barriers that limit nursing advocacy for cancer patients, and how do they affect the quality of care and patient well-being?”

The PIO sets out the population to be analysed, the measures to be taken and the outcomes (Table 1).

P	Cancer Patients
I	Barriers to nursing advocacy
O	Quality of patient care and well-being

Table 1. Query according to the PIO method.

Research strategy

The study was conducted using various scientific databases, consulted between June 2024 and September 2024. The databases chosen for this work include PubMed, CINAHL, APA PsycArticles, and APA PsycInfo. During the research phase, specific keywords were used to narrow down the field of research and identify the most relevant studies, thus optimising the review process. The keywords used for the various searches were: “Cancer”, “Barriers to advocacy”, “Quality of Care”, “Patient well-being”. For each Medical Subject Headings term (MeSH), possible synonyms were identified. The keywords, together with their synonyms, have been combined using Boolean operators “AND” and “OR” to optimise the search and narrow down the most relevant results.

Inclusion and exclusion criteria

During the first phase of research and selection of studies, specific inclusion and exclusion criteria were defined. The following were included: (a) quantitative and qualitative primary studies; (b) studies investigating barriers that limit nursing advocacy for cancer patients and affect the quality of care and well-being of cancer patients; (c) articles in Italian and English language. The following were excluded: (a) secondary studies, reviews, meta-analyses or meta-syntheses; (b) studies investigating the barriers that limit nursing advocacy and affect the quality of care and well-being of non-cancer patients.

 

RESULTS

The survey produced a total of 542 articles, of which 536 came from databases (249 from PubMed, 218 from CINAHL and 69 from APA PsycArticles and APA PsycInfo) and 6 articles from free research. Finally, four articles were included in the review: one qualitative study, one RCT, and two cohort studies. The extraction and summary of the articles is shown in Table 2.

Author and type of study	Population	Study objective	Results
Horner et al., 2012 Randomised Controlled Trial	N= 251 patients (intervention group exposed to the nursing navigator: n=133 patients with lung, breast and colorectal cancer	Investigate the impact of an oncology nursing navigation programme on closing the care gap	Patients who received support from the oncology nurse navigator rated the quality of care and continuity of care as better than those without a navigator, with fewer gaps in the care pathway.
Reiser et al., 2021 Prospective cohort study	n= 118 women with metastatic breast cancer	Explore the impact of a nursing project to enhance coordination of supportive care in women with MBC, identifying barriers to advocacy.	The programme demonstrated that targeted nursing assessment can overcome barriers, improve symptom management and reduce anxiety through nursing advocacy.
Fillion et al., 2006 Observational cohort study	n=158 patients with head and neck tumours (cohort exposed to professional navigators (n=83) and a historical cohort (n=75).	Assess the impact of a case manager on the continuity of care and empowerment of cancer patients, identifying barriers that restrict access to support services and patient care.	The navigator cohort reported better continuity of care, fewer cancer-related problems and improved quality of emotional life, highlighting the role of the navigator in overcoming barriers and supporting patient advocacy.
Chan et al., 2018 Qualitative study	n= 93 (47 women; 46 men)	Exploring patients’ perceptions of nurse-patient communication and barriers to psychosocial care in the oncology setting.	The main barriers include high workloads and insufficient time, which hinder psychosocial support and continuity of care.

Table 2. Data extraction

The studies selected were conducted in several countries, including Hong Kong, Canada, western Pennsylvania, and Washington. All in all, these studies involved 620 cancer patients. In qualitative studies, the average age of participants ranged from 58 years for women with metastatic breast cancer to 60-70 years for men with prostate cancer undergoing radical treatment. In quantitative studies, which included cancer patients hospitalised in hospital wards and patients with head and neck cancer, the average age of participants was between 55 and 63 years.

The main issues that emerged were barriers to advocacy (lack of effective communication and excessive workload; fragmentation of continuity of care), strategies for improvement (education and psychological support) and patients’ experiences of moving from distress to empowerment.

Barriers to advocacy

Nursing advocacy is an essential component of cancer patient care, providing not only clinical support, but also emotional and informational guidance. However, a number of factors hinder the full exercise of this function, compromising the quality of care and the overall patient experience. Through analysis of the literature, several themes emerged: lack of effective communication and excessive workload, fragmentation of continuity of care, improvement strategies, education and psychological support, and patients’ experiences as they move from distress to empowerment.

The themes were identified through a topical analysis of the studies included in the narrative review, which made it possible to identify recurring conceptual categories by comparing the responses and results of the studies. These were then grouped into main categories, representing the key areas of concern and the proposed strategies.

Lack of Effective Communication and Work Overload

Communication between nurses and patients is a key element of advocacy, but it can be compromised by organisational and management factors. The qualitative study by Chan et al. (2018) [3] highlighted how excessive workloads and fragmented care management pose significant obstacles, with direct repercussions on patient perception. The interviews conducted revealed a general reluctance to approach nurses for non-urgent issues, as they were seen as being too busy: “The nurses are just too busy… they don’t have time to talk to patients“. This results in limited opportunities to address psychological and emotional needs, as highlighted by another patient: “I don’t talk to the nurses about my concerns… it’s not their job to help me with psychological problems” [3]. This scenario points to a vicious circle in which a lack of time and resources hampers the building of a trusted relationship, which is essential to ensuring patient-centred care.

Fragmentation of Continuity of Care

A significant additional obstacle is the fragmentation of continuity of care. Horner et al. (2013) [10] noted an average delay of 42.93 days between diagnosis and the start of treatment in patients without a nursing reference point, demonstrating how the absence of a dedicated figure can negatively influence the clinical pathway. Furthermore, the absence of coordination led to a 30% increase in missed appointments, reflecting organisational difficulties that impact on patients’ ability to adhere to treatment.

Improvement Strategies

Confronted with these barriers, a number of strategies have been developed to enhance nursing advocacy and improve the patient experience.

The development of Nursing Navigation Programmes is one of the first strategies. Studies such as those by Fillion et al. (2009) [11] and Horner et al. (2013) [10] have explored the role of specialised figures, such as the Professional Navigator (PNO) and the Oncology Nursing Navigator (ONN), in coordinating and managing care.

Il Professional Navigator (PNO), supports patients throughout their cancer journey, ensuring continuity of care and reducing logistical barriers. The study by Fillion et al. (2009) [11] highlighted how PNO significantly improves the organisation of care, with a 25% reduction in hospital admissions and a positive impact on quality of life: 60% of patients supported by PNO reported a reduction in anxiety, compared to 48% of the historical cohort.

At the same time, the Oncology Nursing Navigator (ONN), with a particular focus on oncology nursing care, has shown a significant impact in reducing delays in treatment (from 42.93 to 15.15 days) and improving treatment compliance (Horner et al., 2013) [10]. The presence of an ONN allowed for a reduction in missed appointments and guaranteed constant patient support, limiting the risk of interruptions in treatment.

Education and Psychological Support

As well as coordinating care, psychological support and health education are key to boosting patients’ confidence in their treatment. Reiser et al. (2019) [6] have developed a nursing education programme specifically for women with metastatic breast cancer, demonstrating how targeted support can reduce feelings of isolation (42% of participants) and improve their quality of life.

Patient experiences moving from Discomfort to Empowerment

Patient experiences clearly reflect the important role of effective advocacy. Chan et al. (2018) [3] found that physical treatments are also perceived as a form of psychological comfort: “The fact that the nurse takes care of my physical pain makes me feel better mentally as well“. However, the lack of structured emotional support has meant that many patients have lowered their expectations when it comes to discussing their psychological needs with nursing staff. Furthermore, studies such as those by Fillion et al. (2009) [11] and Reiser et al. (2019) [6] have demonstrated that integrating navigation programmes and nursing support can enhance patient empowerment, helping them make more informed decisions and improving compliance with treatment.

Study assessment

The quality of the narrative review was assessed using the SANRA Scale for the Assessment of Narrative Review Articles (SANRA) (Table 3), a validated method for making sure narrative reviews are methodologically sound [12].

First Author, year	Justification of the article’s significance for readers	Statement of clear objectives or formulation of questions	Description of Literature Research	Referencing	Scientific Reasoning	Appropriate data presentation	Score
Hornet et al., 2012	1	2	1	2	2	2	10
Reiser et al., 2021	2	2	1	2	2	2	11
Fillion et al., 2006	2	2	1	2	2	2	11
Chan et al., 2018	1	1	1	2	1	2	8
Note: The six items that make up the scale are assessed using whole numbers from 0 (low score) to 2 (high score), with 1 as the midpoint. The maximum score for the overall sum is 12

Table 3. SANRA Scale

An analysis of the selected articles highlights a moderate variability in the methodological quality of the narrative reviews. The overall scores range from a minimum of 8 to a maximum of 11 out of 12, suggesting an overall good level, but with room for improvement in some key areas.

In particular, the articles by Reiser et al. (2021) [6] and Fillion et al. (2006) [11] obtained the highest score (11/12), demonstrating good methodological consistency. Both clearly set out the importance of the topic, outline specific objectives and demonstrate sound scientific reasoning, although the description of the literature review remains limited (score 1), indicating a possible lack of transparency in the criteria for selecting sources. Horner et al. (2012) [10] display a similar profile but with a slightly lower score (10/12), penalised by a less convincing initial justification of the article’s importance (score 1), suggesting that the article may not have clearly explained its added value for the reader. The article with the lowest score is that of Chan et al. (2018) (8/12) [3], which stands out negatively for its lack of well-defined objectives and weak scientific reasoning (scores of 1). Despite its good presentation of data (score 2), the article appears to suffer from poor methodological structure and limited description of the literature consulted, which are fundamental elements for the rigour of a narrative review. Assessment using the SANRA scale [12] reveals variability in the quality of the studies included, with some articles characterised by a more robust methodological structure and others by significant shortcomings. The strength of the conclusions depends on this diversity: studies with higher scores provide a more reliable basis, while those with lower scores should be interpreted with caution. Therefore, the final conclusions of the review must be interpreted taking into account the overall methodological quality, which represents a potential limit to the generalisability of the results.

 

DISCUSSION

The aim of the study was to describe the barriers that hinder nursing advocacy in the oncology context, providing a critical summary of the available evidence to identify the main challenges and propose possible strategies for improvement.

This narrative review has revealed that nursing advocacy in oncology is impeded by a series of barriers that overlap between individual, organisational and systemic dimensions. These include a lack of effective communication and excessive workloads, which have emerged as cross-cutting obstacles limiting nurses’ ability to provide appropriate emotional support and establish empathetic relationships with patients [3-4]. These critical issues have a negative impact on the perception of patients, who see nurses as too busy to address their psychological needs, thus compromising the relationship of trust. Berben et al. [14] confirm this evidence, emphasising how complex nursing interventions focused on quality of life can improve perceived well-being and communication.

The fragmented nature of continuity of care is another significant obstacle. Horner et al. (2013) [14] highlight delays in treatment and difficulty in adhering to therapy when there is no regular nursing reference point. Tomaschewski-Barlem et al. (2017) [13] confirm this finding, suggesting that work environments that promote professional autonomy and collaboration between different professions facilitate better continuity of care.

Among strategies for improvement, the introduction of specialised professionals such as Professional Navigators (PNO) and Oncology Nurse Navigators (ONN) has proven useful in reducing fragmentation of care and providing significant emotional and psychological support [11,12,17,18], confirming the importance of holistic support offered by experienced professionals who are able to address not only clinical aspects, but also relational and social aspects. Likewise, Pautasso et al. (2018) [19] and McMullen et al. (2013) [20] document real benefits in terms of symptom management, care coordination, and psychological well-being.

Guided consultations by experienced nurses are another promising strategy. Drach-Zahavy et al. [15] and Grassi et al. [16] demonstrate that these approaches improve continuity of care, psycho-emotional management and patient satisfaction, underscoring the key role of nurses in the multidisciplinary team.

The experience of cancer patients, from discomfort to empowerment, stands out as a central theme. Chan et al. (2018) [3] observe that patients also see physical care as psychological comfort, but the lack of space for discussion about emotional issues can lead to isolation. Nursing navigation programmes [6,11] demonstrate that active patient involvement encourages empowerment and improves treatment adherence. The lack of specific training in advocacy is a well-documented cross-cutting barrier [21-24], and the integration of dedicated training in nursing curricula is a priority.

As a whole, the comparison with external studies complements and validates the findings, highlighting critical issues and suggesting practical solutions. The introduction of specialised figures, the enhancement of nurse training and the promotion of collaborative environments emerge as key interventions to make nursing advocacy more effective and focused on the needs of cancer patients.

Limitations and strong points

This review brings to light both significant aspects that offer opportunities for improvement and critical issues that limit its full implementation. One of the strengths that emerged is the clear identification of multidimensional barriers that include psychological, social, management and institutional aspects. A wide range of databases were included in the search, such as PubMed, CINAHL, APA PsycArticles and APA PsycInfo, ensuring broad coverage of relevant sources. This interdisciplinary approach has been beneficial in providing a comprehensive insight into the topic. Moreover, the combination of qualitative and quantitative studies allowed for the integration of experiential perspectives with measurable data, enriching the overall understanding of the challenges related to nursing advocacy. Another strong point is the focus on oncology, which is a complex field in which nursing advocacy plays a crucial role in improving the quality of care and the lives of patients. Furthermore, the review highlighted applicable operational solutions, such as the introduction of specialised roles (e.g. case managers) and proactive support programmes, which demonstrate the potential to address management barriers and improve overall care. Nevertheless, the review has some limitations. Although the narrative review method offers a broad and flexible overview, it can introduce bias in the selection and interpretation of studies, thereby limiting the generalisability of the results. A further limitation is the small number of studies included and the heterogeneity of the healthcare contexts, making it difficult to apply the findings uniformly to different healthcare systems, including the Italian one.

Finally, this narrative review was based mainly on articles published in peer-reviewed journals, excluding grey literature (e.g., theses, conference proceedings and technical reports). However, it is acknowledged that grey literature could offer further insights into barriers to nursing advocacy, in particular in settings that are less documented in the academic literature. Future studies may integrate these elements to provide a more comprehensive view of the phenomenon.

Implications for clinical practice

The implications drawn from the literature review point to the need to systematically address the barriers that limit the efficacy of nursing advocacy in the oncology setting. The most significant barriers identified include excessive workloads, fragmented continuity of care and a lack of psychological and educational support, all of which have a negative impact on the quality of care and patient well-being.

An initial priority is to improve organisational and working conditions for nursing personnel. Strategies that provide for a more even redistribution of the workload and the enhancement of human resources can mean that nurses are able to devote time to providing emotional and psychological support to patients, thereby overcoming the perception that their role is limited to physical care alone, as highlighted in the study by Chan et al. (2018) [3].

A second crucial aspect is the adoption of innovative, patient-centred care models, such as the introduction of dedicated professionals, such as the Professional Navigator and the Oncology Nurse Navigator, described in the studies by Fillion et al. (2009) [11] and Horner et al. (2013) [10]. In facilitating coordination between patients and multidisciplinary teams, these professionals are better able to improve continuity of care and reduce organisational gaps that often hinder advocacy. For example, the provision of a nursing navigator has been shown to reduce the time between diagnosis and the start of treatment and to improve treatment compliance, while providing greater emotional and psychological support for cancer patients.

Last but not least, investment in continuing education for nurses is a key step towards empowering them in their role as advocates. Training should be focused on advanced communication skills and managing the complex emotional needs of cancer patients, as recommended by the study by Reiser et al. (2019) [6]. These training initiatives not only improve the quality of care, but also increase patient confidence in the treatment process, helping to improve their quality of life.

 

CONCLUSIONS

In conclusion, this narrative review highlights the complex and multidimensional nature of the barriers that stand in the way of nursing advocacy in oncology. The evidence collected reveals how organisational, managerial and psychological elements limit the ability of nurses to fully establish themselves as defenders of patients’ rights. Recognising these critical issues clears the way for targeted action, in particular through the adoption of specialised roles – such as Nurse Navigator and Professional Navigator – and specific training, enabling more effective coordination and consolidating advocacy practices. Furthermore, consideration of socio-cultural factors emerges as an essential factor in developing intervention strategies that are increasingly in line with the reality of different care contexts. Addressing these barriers systematically is, therefore, a fundamental step towards a model of care that integrates and enhances the role of nurses as advocates, helping to make cancer care more cohesive and focused on patients’ needs.

Funding statement

This research received no external funding.

Conflict of interest   

The authors report no conflict of interest.

Authors’ contribution

All Authors equally contributed.

 

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