Development of an Indicator of Collaborative Practice and Clinical Judgment Competency for Oncology Nurses in Japan: A Modified Delphi Method

doi:10.21203/rs.3.rs-1972989/v1

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Research Article

Development of an Indicator of Collaborative Practice and Clinical Judgment Competency for Oncology Nurses in Japan: A Modified Delphi Method

https://doi.org/10.21203/rs.3.rs-1972989/v1

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Purpose

This study aimed to develop Collaborative Practice and Clinical Judgment Competency (CPCJC) for oncology nurses and reach a consensus on the validity, importance, and feasibility of an indicator of CPCJC for certified nurse specialists in cancer nursing and graduate students.

Methods

The indicator of CPCJC for oncology nurses enables nurses to identify the challenges faced by patients in cancer wards and their families. This indicator contains 39 items in 13 categories, which correspond to the elements of Tanner’s Model of Clinical Judgment. A two-round modified Delphi study was completed by Japanese certified nurse specialists and graduate students in the Graduate School of Nursing. The first indicator was created by performing a content analysis using case studies and focus group interviews. Panels evaluated the validity, importance, and feasibility of 39 items in 13 categories in Round 1 (R1) and Round 2 (R2) using a 4-level Likert-type scale.

Results

The total number of participants was 46 in R1 and 35 in R2. The Scale-Content Validity Index/Ave values in R1 were 0.98, 0.99, and 0.94 for validity, importance, and feasibility, respectively.

Conclusion

This structured indicator will enable nurses with short clinical experience to collaborate with multidisciplinary teams and provide patient-centered care. This indicator can be used as a consultation tool for nurses belonging to the palliative care team or advanced practice nurses in the oncology team.

home care

palliative care

oncology nursing

clinical judgment

interprofessional collaboration

transitional care

Recently, an increase in the number of the elderly and advances in cancer treatment have correspondingly increased the number of cancer survivors. Today, cancer treatment is no longer limited to surgery, chemotherapy, and radiotherapy but has progressed to gene therapy. Precision medicine by genetic examination promotes treatment based on the patients’ characteristics [1]. The process of precise diagnosis and treatment warrants effective communication between specialists regarding the sharing of goals in the treatment decision about cancer medical treatment [2]. In complex treatment decision-making processes, nurses support patients and their families in making decisions about treatment choices, serving as a bridge between patients and their physicians [3]. Moreover, nurses work with physiotherapists [4], social workers [5], and nutritionists [6] to assess patient issues and promote an environment for home care. Furthermore, nurses are engaged in maintenance and securing support resources for physical condition management after discharge [7].

Nevertheless, various treatment options are available for patients after cancer recurrence, and the period as a survivor post-discharge is long; thus, many issues persist, such as symptom relief treatment and support for moving home [8]. Home-visit nursing care manages not only cancer pain but also complex symptoms and plays a role in end-of-life care for patients. However, home-visit nurses also face several challenges [9]. Studies based on hospital-to-home transition patient and family needs in cancer nursing, especially palliative care, have reported a gap between the needs sought and the care provided [10]. Reportedly, early systematic palliative care for patients improves health-related quality of life [11], although care challenges indicate that it is only available in a limited number of institutions [12].

Additionally, studies have reported efforts to collaborate with professionals to solve palliative care issues. Stewart et al. [13] reported that cancer nursing specialists (UK), in collaboration with interdisciplinary teams, markedly decreased the risk of death in patients with lung cancer and reduced unplanned cancer-related hospitalization rates. Wallace et al. [14] indicated that meetings of multidisciplinary teams are often dominated by physicians in internal medicine and surgery and that nurses face challenges in professional collaboration. Xyrichis and Ream [15] demonstrated that good teamwork enhanced patient satisfaction and improved the quality and outcomes of patient care; moreover, they reported nurses’ role in team conferences with multiple professionals and their effects. Patients with cancer and their families, who encounter multiple challenges, need holistic patient-centered care by nurses. Clinical judgment and interprofessional practice are essential for nurses to provide patient-centered care [16]. Russell [17] created a curriculum that integrated professional cooperation and clinical judgment in the Bachelor of Science course; however, in nursing continuation education, the educational method of nursing for patients with cancer that integrated clinical judgment and interprofessional practice remains unclear. A study explored the “development of an educational program for interprofessional clinical judgment for oncology certified nurse specialists” and developed the initial indicator of Collaborative Practice and Clinical Judgment Competency (CPCJC) for oncology nurses based on case studies [18]. This study focused on nurses in diverse professional settings who support patients and their families after hospital discharge for outpatient cancer treatment, with the goal of leading interprofessional practice by oncology nurses. The patient support in this study did not encompass standardized patient care.

This study aimed to develop an indicator of CPCJC for oncology nurses and reach a consensus on the validity, importance, and feasibility of the indicator for certified nurse specialists in cancer nursing (CNSC) and graduate students as panels who have worked as oncology nurses. This structured indicator will enable nurses with short clinical experience to collaborate with multidisciplinary teams and provide patient-centered care. In Japan, the introduction of community care and home-visit nursing is faster than in other East-Asian countries [19]. Hence, this study will contribute to the continuous education of nurses and the development of advanced practice nurses in countries other than Japan.

Study design

The indicator of CPCJC for oncology nurses enables nurses to identify patient and family challenges in cancer wards. In addition, it serves as an indicator for addressing patient and family issues, as well as for CNSC and nurses working in the oncology area to reflect on their practices. This index contains 39 items in 13 categories, which correspond to the elements of Tanner’s Model of Clinical Judgment. In addition, 11 of the 13 categories include items related to collaboration with oncology team members other than their own professionals. This study used a two-round, modified Delphi method to identify the consensus and develop the structure of the indicator of CPCJC for oncology nurses. The Ethics Review Committee at the author’s university reviewed the research and approved it in September 2020 (approval number: R2–20).

Participants

The inclusion criteria were as follows: (i) nurses who are CNSC with >3 years of experience as nurses in the oncology area and (ii) graduate students who were recommended by the professors at the CNSC course in the Graduate School of Nursing and had worked as nurses for >3 years in the oncology area. The exclusion criteria were as follows: (i) nurses retired or on a leave and (ii) graduate students on a leave of absence.

Recruitment

CNSC

About 400 CNSC nurses, which is 42% of all CNSC nurses in Japan in 2019, who indicated their intention to participate in this study through the mailing list were invited to participate, and they provided consent to participate by replying to the consent form.

Graduate students

The researcher and co-researcher mailed the request form to the faculty members of the Graduate School of Nursing, requesting them to identify students who fulfilled the inclusion criteria. The researcher explained the study objectives to the graduate students recommended by the faculty and informed them that the consent to participate was obtained by replying to the consent form.

Study overview

This study was conducted in four phases as follows:

Phase 1: In 2013, case studies were conducted with nine participants and content analysis was performed from the perspective of clinical judgment and interprofessional collaboration using three case studies. In addition, a prototype of this indicator was created.
Phase 2: In 2019, focus group interviews were conducted with 13 participants.
Phase 3: In 2020, the first survey was conducted using the modified Delphi method (Round 1).
Phase 4: In 2021, the second survey was conducted using the modified Delphi method (Round 2).

Questionnaire method

The questionnaire survey was conducted using the modified Delphi method.

Round 1

First, participants were asked demographic questions, including age and years of clinical experience. Second, participants were asked to rate the consensus level of the validity, importance, and feasibility of 39 items in the indicator of CPCJC for oncology nurses. Each consensus level was rated on a four-point Likert scale (1 = at all disagree, 4 = at all agree). Participants’ opinion toward all 39 items in the indicator of CPCJC for oncology nurses was then sought as free description.

Round 2

Based on participants’ responses in Round 1, a revised list of the indicator of CPCJC for oncology nurses was created for consideration in Round 2. All participants were asked to rate the consensus level of the validity, importance, and feasibility of 39 items in the indicator of CPCJC for oncology nurses. Each consensus level was rated on a four-point Likert scale (1 = at all disagree, 4 = at all agree). Participants’ opinion toward all 39 items in the indicator of CPCJC for oncology nurses was then sought as free description.

Data analysis

Round 1

Demographic and Delphi survey data were analyzed descriptively using Microsoft Excel. The data calculated the percentage of “3” or “4” level for each item. The Item-level Content Validity Index (I-CVI), which indicates the appropriateness of each question item, was then calculated. Moreover, the average value of I-CVI, including all items, was calculated for the entire scale, and the Scale’s Content Validity Index (S-CVI/Ave), which shows how appropriate all items are in terms of content, was calculated. The consent rate was calculated using the same formulas as those used in a previous study [20] for validity, importance, and feasibility. There is no established consensus rate in the Delphi survey, so it was set according to the research purpose [21]. Being an exploratory survey, the consensus rate was set at an I-CVI of ³0.78 [22]. The content analysis was performed to analyze 39 items of free description.

Round 2

Both I-CVI and S-CVI were calculated for validity, importance, and feasibility in the same manner as in Round 1. The content analysis was performed to analyze 39 items of free description. The modified Delphi surveys were developed as a tool for short-term forecasting. The technique involves a panel of experts who are asked to complete several rounds of questionnaires focusing on their judgments about a topic of interest.

Participants

Table 1 provides an overview of the study results. A total of 28 CNSCs were enrolled in this study; while all 28 responded to the first survey, 25 responded to the second survey. In addition, 20 graduate students were enrolled from 15 of 22 nursing universities. Consent to participate was obtained from 18 graduate students in the first survey and 15 in the second survey, with 100% and 83% response rates, respectively (Fig. 1).

Table 1

Background and related data of participants (Round 1)
CNSC (n = 28)				Graduate students (n = 18)
Age (range)	46.4	(35–58)	years		40.6	(29–52)	years
Years of working as a nurse	21.8	(9–32)	years		16.4	(6–30)	years
				Period of enrollment
Years of working as a CNSC	3–16	years		1 year	6	n
Type of hospital				2 years	7	n
University hospital	5	n		3 years	2	n
National and public hospitals (excluding university hospitals)	2	n		Type of hospital
Private hospital	1	n		University hospital	4	n
Cancer center	4	n		National and public hospitals (excluding university hospitals)	1	n
Others	16	n		Private hospital	3	n
				Cancer center	3	n
Interaction with multiple professionals				Others	3	n
Less than once a week	3	n		Unemployed	3
Several times a week	5	n		Frequency of involvement in nursing care for cancer patients
Every day	12	n		Several times a week	1	n
More than once a day	7	n		Every day	8	n
No answer	1	n		More than once a day	7	n
Experience of performing interprofessional work
Yes	25	n
No	3	n
Training institutions
Educational institutions	16	n
Postgraduate education/continuing education	12	n
Others	5	n
Training satisfaction
Well-satisfied	22	n
Not satisfied	3	n
n indicates the number of participants
CNSC, Certified Nurse Specialist in Cancer nursing

Round 1

The S-CVI/Ave values in Round 1 were 0.98, 0.99, and 0.94 for the validity, importance, and feasibility, respectively, all of which were ≥0.9. Additionally, the validity, importance, and realizability of the scale had a high consent rate. The consent rate of each item calculated with reference to I-CVI revealed a high consent rate of ≥0.8 in all 39 items of the validity, importance, and feasibility (Table 2).

Table 2

I-CVI of the indicator of Collaborative Practice and Clinical Judgment Competency for oncology nurses
	Validity		Importance		Feasibility
Category and items	Round 1	Round 2	Round 1	Round 2	Round 1	Round 2
A: Grasp the multifaceted problems that the cancer patient is experiencing (Noticing)
1. Understand not only information about the patient's cancer treatment but also thoughts and values	1.00	1.00	1.00	1.00	1.00	0.95
2. Gather information in relation to the patient's problem	1.00	1.00	1.00	1.00	0.98	0.95
3. Recognize the relationship between the patient's medication therapy and changes in end-of-life symptoms and daily life	1.00	0.97	1.00	1.00	1.00	0.93
4. Focus on family backgrounds that influence the patient’s problems	1.00	1.00	1.00	1.00	1.00	0.93
5. Predict the potential patient problems	1.00	1.00	1.00	1.00	0.95	0.85
6. Figure out perspectives of the patient, family, and team members in the area of concern	0.98	1.00	1.00	1.00	0.93	0.90
B: Focus on the problems that the cancer patient is facing (Interpretation)
1. Understand the structure of the patient's problem	0.91	0.90	1.00	0.98	0.93	0.78
2. Clarify the situation in which the problem is occurring	0.93	1.00	0.95	1.00	0.93	0.92
3. Clarify requirements for the patient's problem solving	0.91	0.90	0.98	0.98	0.91	0.84
C: Understand the characteristics of multiple professionals who care for the cancer patient (Noticing)
1.Recognize the capabilities, abilities, and experiences of the oncology team	1.00	1.00	1.00	1.00	0.91	0.85
2. Focus on the power of the ward nurses	1.00	1.00	1.00	1.00	0.98	0.93
3. Focus on the recognition and role of professionals involved in the patient and the family	1.00	0.97	1.00	1.00	0.95	0.87
4. Communicate and predict the thinking process of the patient's physician	0.95	0.92	0.98	0.93	0.93	0.80
D: Share goals with physicians, ward nurses, and other professionals to solve problems (Interpretation)
1. Share goals with the patient’s physicians, ward nurses, and other professionals involved in the patient’s treatment	1.00	0.98	1.00	1.00	0.98	0.98
2. Plan an effective conference for collaboration between the patient’s physician and the ward nurses and other professionals	1.00	0.98	1.00	0.98	0.86	0.90
E: Gather the necessary information to get an accurate picture of the situation of the cancer patient and the oncology team (Response)
1. Collect necessary information to accurately grasp the situation of the patient and the family	1.00	0.97	1.00	0.97	0.98	1.00
2. Understand the progress of the team members toward problem solving and the problems they have in collaboration	1.00	1.00	1.00	1.00	0.95	0.97
F: Share goals and information in the oncology team and suggest opinions and methods for problem solving (Response)
1. Share the information and coordinate relationships among the oncology team as a mediator	1.00	1.00	1.00	1.00	0.98	0.98
2. Set goals according to the situation of the patient and the family with the oncology team	0.98	1.00	1.00	1.00	0.93	0.98
3. Share problems and goals with the oncology team	1.00	0.98	1.00	1.00	0.98	0.98
4. Prioritize methods for problem solving with the oncology team	0.98	1.00	1.00	1.00	0.93	0.95
5. Discuss the direction of methods to solve the problem with the oncology team	1.00	1.00	1.00	1.00	0.95	0.98
G: Make an approach to solve the problem and involve people who have relationships with the patient (Response)
1. Engage with relevant departments and people to achieve the patient goals	0.95	1.00	1.00	1.00	0.93	0.90
2. Ask members in the oncology team who share goals to take on the role	0.98	1.00	0.98	1.00	0.95	0.95
3. Share information with the family in the oncology team	0.98	0.95	0.95	0.98	0.95	0.88
H: Build relationships within the oncology team and facilitate smooth communication among members of the oncology team (Response)
1. Act as a liaison between team members, share information, and coordinate relationships	0.98	1.00	1.00	1.00	0.98	0.88
2. Understand the phenomenon from the position and perspectives of members and share awareness	0.98	1.00	0.95	1.00	0.98	0.88
3.Build relationships that allow easy requests and consultations through daily communication	0.98	1.00	1.00	1.00	1.00	0.95
I: Identify the role of the oncology team and change one's role depending on the situation and settings (Response)
1. Change one's role according to the competency of ward nurses and culture in the ward	1.00	0.98	1.00	1.00	0.93	0.85
2.Examine the role of the oncology team and work according to the role	0.91	1.00	0.91	1.00	0.89	0.85
J: Give positive feedback to collaborating team members, the patient, and the family (Response)
1. Provide positive feedback to the patient and the family to enhance their self-efficacy	1.00	0.97	1.00	1.00	0.98	0.95
2. Provide positive feedback to the oncology team related to the patient and the family	1.00	1.00	1.00	1.00	0.95	0.92
K: Guarantee care in the oncology team for the patient and the family (Response)
1. Understand and consider the physical and psychological conditions of the patient and the family	0.95	1.00	0.95	1.00	0.91	0.98
2. Ensure continuous team care for the patient	1.00	1.00	1.00	1.00	0.86	0.88
L: Clarify the factors that influenced the oncology team collaboration (Reflection)
1. Reflect on the factors that led to sharing of awareness and consensus building among the oncology team members	1.00	1.00	1.00	1.00	0.84	0.83
2. Examine factors that interfere with the team members’ collaboration	1.00	1.00	1.00	1.00	0.86	0.83
M: Evaluate intervention for better collaboration in the future (Reflection)
1. Reflect on the process and examine the appropriate timing of the intervention conducted	1.00	1.00	1.00	1.00	0.93	0.88
2. Conduct self-evaluation for development for daily relationships with the oncology team	1.00	0.98	0.98	0.98	0.93	0.90
3. Consider how to create good collaboration for problem solving with members in the oncology team	0.98	0.98	1.00	0.98	0.95	0.93

Round 2

The S-CVI/Ave values in Round 2 were 0.98, 0.99, and 0.91 for the validity, importance, and realizability, all of which were ≥0.9. In addition, the validity, importance, and realizability of the scale had a high consent rate. The content analysis revealed “wording issues,” “challenges in setting the stage of cancer patients,” “nurse practical skills issues,” “challenges due to team situation,” and “challenges for reflection issues.” The consent rate of each item calculated with reference to I-CVI revealed a high consent rate of ≥0.8 in all 39 items of the validity and importance and 38 items of feasibility (Table 2).

Content Analysis

Table 3 presents the types of opinion and representative contents.

Table 3

Types of opinion and representative contents
Types of opinion	Representative contents
Wording issues	As the structure is difficult, familiar expressions, such as related diagrams, are good.
	There are multiple expressions for collecting information.
	Items limited to physicians and nurses should include other professionals as well.
Challenges regarding the stage of cancer patients	Currently, treatments such as genomic medicine, molecular-targeted drugs, and immune checkpoint inhibitors are diversified, and it is difficult to determine the end of life, so some items may not be applicable when limited to the end of life.
Challenges regarding the stage of cancer patients	The situation surrounding patients is complicated and rapidly changes, and the problem solving tends to be delayed.
Challenges regarding the practical skills of nurses	There are items that can be done by CNSC in management positions.
	Foreseeing the future and predicting potential problems for patients requires a certain level of practical ability.
	It is possible for nurses working in the consulting team, but it is difficult for general nurses and they require the advice of nurses from another section or professionals.
Challenges due to team situation	I wonder if ordinary nurses can understand the structure of the patient’s problem.
	It may be difficult for general nurses to understand the structure of a patient’s problem.
	It is even better to include not only ward nurses but also outpatient nurses.
	The thinking process of the attending physician is not easy to understand because it requires medical knowledge.
Challenges for reflection	It is even better to have a supervisor with a reliable team, not just nurses’ own reflection.
Challenges for reflection	It is better to get the evaluation from team members.
CNSC, Certified Nurse Specialist in Cancer nursing

Cancer patients and their families face many challenges while receiving patient-centered care. Thus, clinical judgment and professional collaboration are essential for nurses to provide patient-centered care. This study evaluated the validity, importance, and feasibility of the Collaborative Practice Competency Scale Based on the Clinical Judgment of Oncology Nurses using the modified Delphi method. The 39 items of S-CVI/Ave included in the A to M categories revealed values of ≥0.80, as recommended by Polit et al. [22] and Junger [23], suggesting that an overall consent rate was as high as the indicator.J

Our study sample exhibited sophisticated interprofessional collaboration practice in their graduate school or in continuing education in their hospitals. Regarding the number of subjects to reach consensus, Skulmoski and Krahn [24] reported that for a single group or homogeneous subjects, a small sample of 10–15 might be useful.” Although the final round sample in this study was not around 40, we recruited participants from a highly homogeneous group of professionals specializing in specialized fields, which led to a high concordance rate.

Despite the high consent rate, the feasibility of S-CVI/Ave tended to be low compared with its validity and importance in Round 2. In particular, more than half of the items in categories of “B: Focus on the problems that the cancer patients are facing,” “C: Understand the characteristics of multiple professionals to the cancer patient,” “H: Build relationships within the oncology team and facilitate smooth communication among members of the oncology team,” “I: Identify the role of the oncology team and change one's role depending on the situation and settings,” and “L: Clarify the factors that influenced the oncology team collaboration” showed a consent rate of 0.8 in Round 2.

The indicators of CPCJC for oncology nurses included four aspects of Tanner’s Model of Clinical Judgment [25, 26]; A and C are noticing; B and D are interpretation; E, F, G, H, I, J, and K are response; and L and M are a reflection—all are related. Additionally, all categories, except A and B, included the content on collaboration with other professions, including nurses. The I-CVI of each item in the category had a concordance rate of ≥0.8 for items other than B-1, exhibiting a high agreement rate. Only the feasibility of B-1 “Understand the structure of the patient’s problem” was 0.78 and ≤0.8, which was a moderate concordance rate. Perhaps, the value of B-1 was low from the free description because the item was difficult to understand owing to the difficulty of the meaning of words and the assessment ability of nurses. As B1 means that showed integral assessment was not routine care, when solving a patient’s problem in collaboration with other professionals, highly specialized assessment competencies are needed compared with general assessment. The evaluation of the high-level concordance rate validity and importance of B1 revealed that it should not be removed from the indicator of CPCJC for oncology nurses.

In addition, the categories of H and I were related to interprofessional collaborative practice, and in the free description, nurses were in the professional team, demonstrating that nurses were CNSC nurses or nurse managers and belonged to the consultation team [27]. Perhaps, these items would be available when the role of a leader is assigned. Heinen et al. demonstrated that the synthesis of 150 identified competencies led to a set of 30 core competencies in the clinical, professional, healthcare systems, and health policy leadership domains; moreover, in the clinical leadership domain, core competencies focused on delivering excellent patient care and concern items such as collaboration with professionals and other healthcare agencies [28]. Reportedly, items of the indicators of CPCJC for oncology nurses related to interprofessional collaboration are essential; however, nurses could not actually do much or did not do in the current situation [29]. Therefore, it might be challenging to use the indicator of CPCJC for oncology nurses where CNSC or nurses cannot take their role for interprofessional collaboration as a ward nurse of oncology. Hence, proper placement is imperative so that nurses can play a role in the team.

The indicator of CPCJC for oncology nurses developed in this study was created on the basis of a case study in the Clinical Judgment Education Program for Nurses to Promote Team Health Care for CNSC; thus, it included items that do not apply to nurses practicing in outpatient areas in hospitals. This study focused on Japanese nurses in diverse professional settings who support patients and their families after hospital discharge for outpatient cancer treatment, and the results were shown to be limited to the medical environment in Japan. Hence, further studies are required to overcome the limitations of this study. In the future, it will be necessary to present how to use the competency scale and develop teaching materials for CNSC nurses to improve their practical skills in the oncology team.

Clinical judgment and professional collaboration are essential for nurses to provide patient-centered care. A previous study explored the development of an educational program for interprofessional clinical judgment for oncology certified nurse specialists and developed an initial indicator of CPCJC for oncology nurses based on case studies. The current study aimed to develop an indicator of CPCJC for oncology nurses and reach a consensus on the validity, importance, and feasibility of this indicator of CNSCs and graduate students as panels who have worked as oncology nurses. A total of 28 CNSCs and 20 graduate students were enrolled in this study. The 39 items of S-CVI/Ave included in the A to M categories of the indicator of CPCJC for oncology nurses revealed values of ≥0.80. This structured indicator will enable nurses with short clinical experience to collaborate with multidisciplinary teams and provide patient-centered care. The indicator can be used as a consultation tool for nurses in the palliative care team or advanced practice nurses in the oncology team. In addition, the indicator can be used to devise a collaborative education program in hospitals where oncology nursing practices are performed.

Funding

This study was supported by the Grant-in-Aid for Scientific Research (C) (no.: 18K10140) based on the Development of the Collaborative Education Program Based on Clinical Judgment of Nurses in the Oncology Team.

Competing interests

The authors have no relevant financial or non-financial interests to disclose.

Author contributions

Tomoko Majim wrote the first draft of the manuscript. Madoka Matsudo designed the survey tools and participant information, performed the analysis, and commented on previous versions of the manuscript. Yukari Kunitake designed the survey tools and participant information, performed the analysis, and commented on previous versions of the manuscript. Megumi Umeda collected the data and commented on previous versions of the manuscript. Junko Kusunoki collected the data, performed the analysis, and commented on previous versions of the manuscript. Miwa Watanabe collected the data, performed the analysis, and commented on previous versions of the manuscript. Mariko Masujima commented on previous versions of the manuscript. Tomoko Otsuka collected the data and performed the analysis. Ikuyo Nagasaka collected the data and performed the analysis. All authors read and approved the final manuscript.Akemi Okamoto collected the data, performed the analysis, and commented on previous versions of the manuscript.

Ethics approval

The Ethics Review Committee at the Graduate School of Nursing, Chiba University reviewed the research and approved it in September 2020 (approval number: R2–20).

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent to publish

Not applicable.

Data availability

The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.

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No competing interests reported.

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Development of an Indicator of Collaborative Practice and Clinical Judgment Competency for Oncology Nurses in Japan: A Modified Delphi Method

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