Developing consensus on the content of a comprehensive cancer nursing model of care (the McGrath Model of Care): A modified Delphi technique protocol

Developing consensus on the content of a comprehensive cancer nursing model of care (the McGrath Model of Care): A modified Delphi technique protocol | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Method Article Developing consensus on the content of a comprehensive cancer nursing model of care (the McGrath Model of Care): A modified Delphi technique protocol Natasha Doherty, Fiona Crawford-Williams, Sherri Butler, Tessa Caton, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6779735/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract BACKGROUND: There has been significant government and non-government organisation investment in specialist cancer nursing roles in Australia with a focus on improving access to care, support and navigation. To ensure equitable access to specialist cancer nursing care, a comprehensive nursing model of care to provide supportive care to people with any type of cancer is needed AIM : The primary aim of this study is to obtain expert consensus on key components to be included in the McGrath Model of Care (MMoC). Secondary aims are to understand the feasibility of the MMoC within the Australian health care context. METHODS : A three-phase study will be conducted including: 1. development of the draft components of the MMoC through co-design and evidence synthesis; 2. expert consensus on appropriate components of the MMoC through a modified Delphi; and 3. workshops with end-users to determine feasibility of the developed MMoC. Phase 1: Themes derived from consultations with over 450+ people with lived experience of cancer; clinicians; and other key stakeholders will be synthesised with literature review results and Optimal Care Pathways to develop the draft components of the model. Phase 2: We aim to recruit 25-50 participants through direct email invitation. Participants will be experts in cancer nursing. Purposive sampling will be employed to ensure maximum variation in location of participants and representation across cancer types. Multiple rounds of an on online survey will be conducted to gain consensus on the appropriateness and necessity of components of the MMoC. Phase 3 : Qualitative workshops will be held to discuss the feasibility of relevant items in clinical practice. RESULTS : The study will be conducted between June – September 2025. CONCLUSION: The study findings will determine the final elements included in the MMoC and ensure the model is appropriate and feasible for implementation. Oncology Nursing Protocol cancer nursing model of care consensus survey Delphi Figures Figure 1 Figure 2 BACKGROUND It is projected that in the year 2034 there will be approximately 209,000 people diagnosed with cancer in Australia, representing a 23% increase on current incidence rates (Australian Institute of Health and Welfare, 2024). As specified in the Australian Cancer Plan (Cancer Australia, 2023), there is a need to ensure that Australia has a skilled workforce that is responsive to new models of care, emerging treatments and technologies, and are equipped to provide culturally safe cancer care. The cancer nursing workforce is the largest group of health professionals involved in the delivery of cancer care in Australia with over 7,000 nurses working in the cancer sector (Department of Health, 2023). There has been significant government and non-government organisation investment in specialist cancer nursing roles with a focus on improving access to care, support and navigation (Department of Health, Disability and Aging, 2025). To ensure equitable access to cancer nursing care, a comprehensive nursing model of care to provide supportive care to people with any type of cancer is needed. A nursing model of care is a framework for how nursing care may be delivered in specific contexts (Clarke, Davis, Douglas & Peters, 2024). Nurse-led models of care typically involve the delivery of specialised, advanced practice nursing care. Development of a model of care must involve all key stakeholders (Agency for Clinical Innovation, 2103; Davidson, Halcomb, Hickman, Phillips & Graham, 2006) – people with lived experience, expert clinicians and relevant health professionals, and professional organisations. Clarke et al (2024) propose that nursing models of care involve three interrelated domains (1) a theoretical basis that underpins conceptualisation of care, (2) organisational work methods that direct task delegation, organisational governance, and care responsibility and (3) practical methods for care delivery that describes practical care methodologies. Nurse-led models of care must be evidence-based, holistic and person-centred and nurses are primarily responsible for the planning and delivery of care, often within a multidisciplinary context (Clarke et al, 2024). The model must specify the methods of care delivery including needs assessments, interventions, monitoring and evaluation and be responsive to the cultural, physical, emotional, spiritual and social needs to the patient. (Agency for Clinical Innovation, 2013; Clarke et al, 2024). Models of cancer care have typically focussed on single tumour streams (Patford, Ernst, Crowe, Mahony & Townsend, 2022; Dunn et al, 2022) however the increased investment in cancer nursing care across the country warrants the development of a nurse-led model of care applicable to the care of people with any type of cancer. With a theoretical basis of equity in care, a co-design methodology has been adopted to develop a nurse-led model of care for the delivery of specialist cancer nursing care. The protocol herein describes the consensus study to be conducted to determine the components of the McGrath Model of Care informed by an extensive collaborative co-design process involving people with lived experience of cancer, clinicians and cancer organisations; literature reviews; and the optimal care pathways. AIMS The primary aim of this study is to obtain expert consensus on components to be included in the McGrath Model of Care for all cancers. Secondary aims include ensuring the model is feasible within the context of the funding and resources available for its implementation. METHODS The study involves three phases including: 1. development of the draft components of the MMoC through co-design and evidence synthesis; 2. expert consensus on appropriate components of the MMoC through a modified Delphi, and 3. workshops with end-users to determine feasibility of the developed MMoC. PHASE 1: Development of draft components of the McGrath Model of Care Draft components of the model of care will be developed by the project team based on the synthesis of evidence from the following research activities and existing guidance documents: Extensive consultation across the Australian cancer sector including people with lived experience of cancer (this includes patients and carers); oncology healthcare professionals; and representatives from non-government cancer organisations to understand the needs and unmet needs of people affected by cancer. Consultations will include focus groups, individual interviews and surveys. Literature reviews to determine: Patients’ preferences and value placed on specialist cancer nurses as care providers The effectiveness and cost-effectiveness of specialist cancer nurse-led interventions and models of care The optimal evaluation methods and quality indicators for specialist cancer nurse-led interventions and models of care. Cancer Council Optimal Care Pathways: Optimal care pathways are evidence-based guidelines for cancer healthcare professionals to deliver high quality cancer care from prevention and early detection through to end of life care (Cancer Council Victoria, 2022). The MMoC should align with these pathways. These sources of information will be used to review and incorporate evidence-based nursing practices and interventions into the model. It will also authentically incorporate the voices of people with an experience of cancer into the model and ensure the McGrath Model of Care is inclusive of all cancer types and priority populations. PHASE 2: Modified Delphi study The draft McGrath Model of Care will be used as the basis of a modified Delphi. The Delphi will be used to gain consensus on the appropriateness and necessity of components in the draft MMoC. Participants Cancer nurses who have already registered to participate in the Model of Care project will be invited to participate in the modified Delphi. Purposive sampling will be employed to ensure maximum variation in the sample. Representation is sought from all states and territories of Australia including metropolitan, regional, rural and remote locations and across tumour streams. Sample size and recruitment There are no concrete guidelines for the optimal number of Delphi survey participants to achieve consensus, but a sample of 12 participants is generally considered to be the minimum required if the background of participants is homogenous (Trevelyan & Robinson, 2015). We aim to recruit 25-50 participants through direct email invitation to the following groups: Nurses who participated in the co-design phase of the MMoC project and current McGrath Cancer Care Nurses. We will inform participants of the commitment to the study in advance, indicating that they are requested to participate in all rounds of the Delphi if possible. The Delphi is expected to be a minimum of two rounds, with a short period between each round to reduce attrition. Participants will have 10 days to respond to each round with one reminder to be sent during this time. Data Collection The Delphi will be distributed to participants using an online survey platform. A Participant Information Sheet will outline the requirements of the study on the first page of the survey, and participants who continue and complete the survey have implied consent to participate. The draft model of care will be prepared as a list of components to be rated for appropriateness and necessity through a modified Delphi process adapted from the RAND/UCLA Appropriateness Method (RAM) (Fitch et al, 2001). For efficiency and to accommodate the geographical spread of participants, an adapted version of the RAM will be adopted as described below. The draft components of the model of care will be presented in Round 1 of the online modified Delphi survey. Participants will be asked to indicate their level of agreement about the appropriateness and necessity of each component of the draft McGrath Model of Care. Each component will be rated on two linear scales of 1 to 9, where 1 indicates that it is highly inappropriate/unnecessary and 9 that it is highly appropriate/necessary. According to the RAM, an intervention is considered appropriate if “The expected health benefit (e.g., increased life expectancy, relief of pain, reduction in anxiety, improved functional capacity) exceeds the expected negative consequences (e.g., mortality, morbidity, anxiety, pain, time lost from work) by a sufficiently wide margin, exclusive of cost” (Brook et al, 1986). A component is considered necessary if the following criteria are met: The component must be appropriate. It would be considered improper care not to provide this service. There is a reasonable chance that this component will benefit the patient. (A component could be appropriate if it had a low likelihood of benefit but few risks; such components would not be necessary.) The benefit to the patient is not small. (A component could be appropriate if it had a minor but almost certain benefit, but it would not be necessary. Expert participants will be asked to rate the appropriateness and necessity of the draft components of the model using their best clinical judgement and with consideration of the available evidence to support each component. Each component presented will denote whether it is supported by the consultation phases; literature reviews; and/or the optimal care pathways. See Figure 2 for an example survey item. Participants can select ’Don’t Know’ if they do not feel qualified to rate a particular component. Participants are also invited to provide open-ended comments in a free text box next to each component as well as at the end of the section. Data Analysis For appropriateness, components with median and mean scores in the 1-3 range are classified as ‘inappropriate’; 4-6 are ‘uncertain’, and those in the 7-9 range are considered ‘appropriate’. For necessity, components ranked equal to or less than 7 means that the element does not have to be performed or included, not that it should not be performed or included. The appropriateness and necessity ratings will then be analysed together to allocate each element of practice to one of the classifications for final consideration in the feasibility workshops: • Appropriate and necessary • Appropriate but not necessary • Uncertain • Inappropriate Consensus will be defined as greater than or equal to 75% of participants rating a component as 7 or greater AND the median and mean both greater than or equal to 7 for appropriateness or necessity (Diamond et al, 2014; Fitch 2001). Where greater than or equal to75% of participants rate a component as equal to or less than 3 AND the component has a median and mean rating of 3 or less, the component will be considered inappropriate or unnecessary. Components that do not reach consensus or that the median and mean scores are 4-6, are considered uncertain and will be reviewed by the project team who will analyse qualitative feedback and make changes to the components before they are presented again in the next survey round. Future Delphi rounds Future rounds of the modified Delphi surveys will provide a list of the components that reached consensus for appropriateness and necessity and had median and mean scores greater than or equal to 7 in the previous round, for participants information. For components that did not reach consensus, a summary of quantitative ratings and a revised (i.e. new) component based on analysis of qualitative feedback will be provided. Participants will be asked to re-rate these revised components for appropriateness and necessity. The process will continue until all components not reaching consensus have been presented at least once. Components approaching but not reaching consensus (60-75% agreement) after multiple survey rounds will be discussed by the project team. PHASE 3: Workshops to determine feasibly Following the modified Delphi, workshops will be held with a select group of participants to assess the feasibility of the inclusions in the model in alignment with funding and resourcing. Once consensus and an appropriateness and necessity classification has been reached on all draft components of the McGrath Model of Care, workshops will be held to discuss the feasibility of the components which may impact on the implementation of the final McGrath Model of Care in practice. Participants and sample For the feasibility workshop a maximum of 15 participants will be included in each session. The participant groups for each workshop are as follows: 1. People with lived experience of cancer as patients or carers. 2. Oncology healthcare professionals 3. McGrath Foundation Nursing Program team members Recruitment Purposive sampling will be employed to invite selected previous participants and contributors to the co-design of the MMoC. Process Online workshops will be held on MS Teams and will be facilitated by Natasha Doherty. Each workshop will be recorded and transcribed verbatim with the consent of participants. Before the workshop, attendees will be sent a survey asking them to rank the feasibility of components. The outcomes of this process will be presented at the workshop for discussion and a final vote will be held to determine inclusion of items. Data collection and analysis Data collected during the workshops will inform final inclusion of items in the McGrath Model of Care for all cancers. If a component gains consensus and is shown to be appropriate but not necessary through the modified Delphi, and is found to not be feasible to implement, the project team may choose not to include within the final model with justification provided. Feasibility will be considered in relation to affordability, scope of practice of McGrath Cancer Care roles, and accessibility to care across all settings. RESULTS The results for this study will determine the components of the McGrath Model of Care, specifying the activities and support that can be provided by specialist cancer nurses in the provision of supportive cancer care. The McGrath Model of Care will be shared with participants in the study and will be made publicly available for nurses across Australia. Ethical considerations Ethics for all aspects of this project and the study outlined in this paper have been approved by Bellberry Limited No. 2024-06-736. This study is expected to commence in June 2025. DISCUSSION Developing an evidence-based model of nursing care that meets the needs of people with cancer is critical to achieving equitable cancer care. This modified Delphi approach utilises expert consensus to determine the final components of the model and to ensure the model is appropriate and feasible. Broad consultation has enabled identification of the needs of people with cancer across the care trajectory and the involvement of expert cancer nurses in this final stage of the model development will ensure that the model is implementable by nurses. Representation from key stakeholder groups in the feasibility workshops to be held in this study will ensure that the model is both adaptable and adoptable in the various settings where new cancer nurses are being placed. A comprehensive cancer nursing model of supportive care is an important step to ensure consistent and equitable cancer care is delivered This model must be adaptable to local contexts across Australian health services where cancer care is provided and link to local, state and national cancer plans (Agency for Clinical Innovation, 2013). A clearly defined implementation plan will be required for cancer nurses to successfully integrate the model into their practice setting. This will need to be iterative and responsive to local needs and will require ongoing support. Likewise, a clear evaluation framework to monitor the adoption and outcomes of the model of care will be implemented (Agency for Clinical Innovation, 2013). Strengths and Limitations Strengths of this study include the methodology of a modified Delphi technique. This technique provides a structured format with controlled feedback and is anonymous in nature in order to reduce group pressure or external influences to responses. The extent of involvement in the study will be limited to those who are able to commit the time required to participate A limitation of using the modified Delphi technique is the uncertainty regarding consensus thresholds. There is no generally accepted threshold for consensus and our study was based on what was reasonable. There is also an inherent risk of incomplete surveys and with multiple rounds there is likely attrition of responders between these rounds. There will be efforts to counteract this with both reminder emails and the provision of responses and feedback in a reasonable time frame to maintain interest with participants. CONCLUSION This study will determine the final elements of the McGrath Model of Care and ensure the model is appropriate and feasible for implementation. This study has adopted the key principles of model of care development and encompasses the recognised domains of nursing models of care. References Australian Institute of Health and Welfare (2024). Overview of cancer in Australia, 2024. Australian Institute of Health and Welfare available from: https://www.aihw.gov.au/reports/cancer/cancer-data-in-australia/contents/overview Cancer Australia (2023) Australian Cancer Plan; Cancer Australia available from: https://www.australiancancerplan.gov.au/ Cancer Council Victoria (2022) Optimal Care Pathways, Cancer Council Victoria, Melbourne, Victoria. Available from: https://www.cancervic.org.au/get-support/for-health-professionals/optimal-care-pathways Clarke, J., Davis, K., Douglas, J., & Peters, M.D.J. (2025) Defining nurse-led models of care: Contemporary approaches to nursing. International Nursing Review, 72, e13076. https://doi.org/10.1111/inr.13076 Department of Health (2023) Health Workforce Data Website. Available at: https://hwd.health.gov.au/ Department of Health, Disability and Aging (2025) Australian Cancer Nursing and Navigation Program. Available at: https://www.health.gov.au/our-work/australian-cancer-nursing-and-navigation-program Diamond, I. R., Grant, R. C., Feldman, B. M., Pencharz, P. B., Ling, S. C., Moore, A. M., & Wales, P. W. (2014). Defining consensus: A systematic review recommends methodologic criteria for reporting of Delphi studies. Journal of Clinical Epidemiology, 67(4), 401–409. https://doi.org/10.1016/j.jclinepi.2013.12.002 Fitch, K., Bernstein, S.J., Aguilar, M.D., Burnand, B., Ramón LaCalle, J., Lázaro, P., van het Loo, M., McDonnell, J., Vader, J.P. & Kahan, J. P. (2001) The RAND/UCLA Appropriateness Method User’s Manual; RAND; Santa Monica, CA. Available at: https://www.rand.org/pubs/monograph_reports/MR1269.htmlTrevelyan, E. G., & Robinson, P. N. (2015). Delphi methodology in health research: how to do it? European Journal of Integrative Medicine, 7(4), 423–428. https://doi.org/10.1016/j.eujim.2015.07.002 Dunn J, Galvão DA, Green A, Lazenby M, Newton RU, Oliffe JL, Phillips J, Phillips R, Ralph N, Sara S, Heathcote P, Chambers SK. A (2022) Psychosocial Care Model for Men with Prostate Cancer: An Essential Element of the Prostate Cancer Survivorship Essentials Framework. Guide for Health Care Professionals. Sydney: Prostate Cancer Foundation of Australia. Available from https://www.pcfa.org.au/model-of-care/ Patford, K., Ernst, K., Crowe, B., Mahony, J. & Townsend, J. (2022) McGrath Model of Care. McGrath Foundation, Sydney, Australia. Available from: https://www.mcgrathfoundation.com.au/about/mcgrath-model-of-care/?gad_source=1&gad_campaignid=1602331866&gclid=Cj0KCQjwlrvBBhDnARIsAHEQgORGLPJ_cZw1J6uq3s1q_UMMgwhVAF7aLjyAZNvzy_xnN8wtZnPJKqMaAvViEALw_wcB Trevelyan, E. G., & Robinson, P. N. (2015). Delphi methodology in health research: how to do it? European Journal of Integrative Medicine, 7(4), 423–428. https://doi.org/10.1016/j.eujim.2015.07.002 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6779735","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Method Article","associatedPublications":[],"authors":[{"id":463864844,"identity":"398cf929-b8ec-46b6-9122-325700af8771","order_by":0,"name":"Natasha Doherty","email":"","orcid":"","institution":"Ethicol","correspondingAuthor":false,"prefix":"","firstName":"Natasha","middleName":"","lastName":"Doherty","suffix":""},{"id":463864845,"identity":"c5db0191-7e9e-460d-8b86-c436ec7399b1","order_by":1,"name":"Fiona 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As specified in the Australian Cancer Plan (Cancer Australia, 2023), there is a need to ensure that Australia has a skilled workforce that is responsive to new models of care, emerging treatments and technologies, and are equipped to provide culturally safe cancer care. The cancer nursing workforce is the largest group of health professionals involved in the delivery of cancer care in Australia with over 7,000 nurses working in the cancer sector (Department of Health, 2023). There has been significant government and non-government organisation investment in specialist cancer nursing roles with a focus on improving access to care, support and navigation (Department of Health, Disability and Aging, 2025). To ensure equitable access to cancer nursing care, a comprehensive nursing model of care to provide supportive care to people with any type of cancer is needed. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA nursing model of care is a framework for how nursing care may be delivered in specific contexts (Clarke, Davis, Douglas \u0026amp; Peters, 2024). Nurse-led models of care typically involve the delivery of specialised, advanced practice nursing care. Development of a model of care must involve all key stakeholders (Agency for Clinical Innovation, 2103; Davidson, Halcomb, Hickman, Phillips \u0026amp; Graham, 2006) – people with lived experience, expert clinicians and relevant health professionals, and professional organisations. Clarke et al (2024) propose that nursing models of care involve three interrelated domains (1) a theoretical basis that underpins conceptualisation of care, (2) organisational work methods that direct task delegation, organisational governance, and care responsibility and (3) practical methods for care delivery that describes practical care methodologies. Nurse-led models of care must be evidence-based, holistic and person-centred and nurses are primarily responsible for the planning and delivery of care, often within a multidisciplinary context (Clarke et al, 2024). The model must specify the methods of care delivery including needs assessments, interventions, monitoring and evaluation and be responsive to the cultural, physical, emotional, spiritual and social needs to the patient. (Agency for Clinical Innovation, 2013; Clarke et al, 2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eModels of cancer care have typically focussed on single tumour streams (Patford, Ernst, Crowe, Mahony \u0026amp; Townsend, 2022; Dunn et al, 2022) however the increased investment in cancer nursing care across the country warrants the development of a nurse-led model of care applicable to the care of people with any type of cancer. With a theoretical basis of equity in care, a co-design methodology has been adopted to develop a nurse-led model of care for the delivery of specialist cancer nursing care. The protocol herein describes the consensus study to be conducted to determine the components of the McGrath Model of Care informed by an extensive collaborative co-design process involving people with lived experience of cancer, clinicians and cancer organisations; literature reviews; and the optimal care pathways.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAIMS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary aim of this study is to obtain expert consensus on components to be included in the McGrath Model of Care for all cancers. Secondary aims include ensuring the model is feasible within the context of the funding and resources available for its implementation.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThe study involves three phases including: 1. development of the draft components of the MMoC through co-design and evidence synthesis; 2. expert consensus on appropriate components of the MMoC through a modified Delphi, and 3. workshops with end-users to determine feasibility of the developed MMoC.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003ePHASE 1: Development of draft components of the McGrath Model of Care\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDraft components of the model of care will be developed by the project team based on the synthesis of evidence from the following research activities and existing guidance documents:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eExtensive consultation across the Australian cancer sector including people with lived experience of cancer (this includes patients and carers); oncology healthcare professionals; and representatives from non-government cancer organisations to understand the needs and unmet needs of people affected by cancer. Consultations will include focus groups, individual interviews and surveys.\u003c/li\u003e\n \u003cli\u003eLiterature reviews to determine:\u003col\u003e\n \u003cli\u003ePatients’ preferences and value placed on specialist cancer nurses as care providers\u003c/li\u003e\n \u003cli\u003eThe effectiveness and cost-effectiveness of specialist cancer nurse-led interventions and models of care\u003c/li\u003e\n \u003cli\u003eThe optimal evaluation methods and quality indicators for specialist cancer nurse-led interventions and models of care.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/li\u003e\n \u003cli\u003eCancer Council Optimal Care Pathways: Optimal care pathways are evidence-based guidelines for cancer healthcare professionals to deliver high quality cancer care from prevention and early detection through to end of life care (Cancer Council Victoria, 2022). The MMoC should align with these pathways.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThese sources of information will be used to review and incorporate evidence-based nursing practices and interventions into the model. It will also authentically incorporate the voices of people with an experience of cancer into the model and ensure the McGrath Model of Care is inclusive of all cancer types and priority populations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003ePHASE 2: Modified Delphi study\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe draft McGrath Model of Care will be used as the basis of a modified Delphi. The Delphi will be used to gain consensus on the appropriateness and necessity of components in the draft MMoC.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipants\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCancer nurses who have already registered to participate in the Model of Care project will be invited to participate in the modified Delphi. Purposive sampling will be employed to ensure maximum variation in the sample. Representation is sought from all states and territories of Australia including metropolitan, regional, rural and remote locations and across tumour streams.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSample size and recruitment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThere are no concrete guidelines for the optimal number of Delphi survey participants to achieve consensus, but a sample of 12 participants is generally considered to be the minimum required if the background of participants is homogenous (Trevelyan \u0026amp; Robinson, 2015). We aim to recruit 25-50 participants through direct email invitation to the following groups: Nurses who participated in the co-design phase of the MMoC project and current McGrath Cancer Care Nurses.\u003c/p\u003e\n\u003cp\u003eWe will inform participants of the commitment to the study in advance, indicating that they are requested to participate in all rounds of the Delphi if possible. The Delphi is expected to be a minimum of two rounds, with a short period between each round to reduce attrition. Participants will have 10 days to respond to each round with one reminder to be sent during this time.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Collection\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe Delphi will be distributed to participants using an online survey platform. A Participant Information Sheet will outline the requirements of the study on the first page of the survey, and participants who continue and complete the survey have implied consent to participate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe draft model of care will be prepared as a list of components to be rated for appropriateness and necessity through a modified Delphi process adapted from the RAND/UCLA Appropriateness Method (RAM) (Fitch et al, 2001). For efficiency and to accommodate the geographical spread of participants, an adapted version of the RAM will be adopted as described below.\u003c/p\u003e\n\u003cp\u003eThe draft components of the model of care will be presented in Round 1 of the online modified Delphi survey. Participants will be asked to indicate their level of agreement about the appropriateness and necessity of each component of the draft McGrath Model of Care.\u003c/p\u003e\n\u003cp\u003eEach component will be rated on two linear scales of 1 to 9, where 1 indicates that it is highly inappropriate/unnecessary and 9 that it is highly appropriate/necessary.\u003c/p\u003e\n\u003cp\u003eAccording to the RAM, an intervention is considered appropriate if “The expected health benefit (e.g., increased life expectancy, relief of pain, reduction in anxiety, improved functional capacity) exceeds the expected negative consequences (e.g., mortality, morbidity, anxiety, pain, time lost from work) by a sufficiently wide margin, exclusive of cost” (Brook et al, 1986). A component is considered necessary if the following criteria are met:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe component must be appropriate.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIt would be considered improper care not to provide this service. There is a reasonable chance that this component will benefit the patient. (A component could be appropriate if it had a low likelihood of benefit but few risks; such components would not be necessary.)\u003c/li\u003e\n \u003cli\u003eThe benefit to the patient is not small. (A component could be appropriate if it had a minor but almost certain benefit, but it would not be necessary.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eExpert participants will be asked to rate the appropriateness and necessity of the draft components of the model using their best clinical judgement and with consideration of the available evidence to support each component. Each component presented will denote whether it is supported by the consultation phases; literature reviews; and/or the optimal care pathways. See Figure 2 for an example survey item.\u003c/p\u003e\n\u003cp\u003eParticipants can select ’Don’t Know’ if they do not feel qualified to rate a particular component. Participants are also invited to provide open-ended comments in a free text box next to each component as well as at the end of the section.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor appropriateness, components with median and mean scores in the 1-3 range are classified as ‘inappropriate’; 4-6 are ‘uncertain’, and those in the 7-9 range are considered ‘appropriate’.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor necessity, components ranked equal to or less than 7 means that the element does not have to be performed or included, not that it should not be performed or included. The appropriateness and necessity ratings will then be analysed together to allocate each element of practice to one of the classifications for final consideration in the feasibility workshops:\u003c/p\u003e\n\u003cp\u003e•\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Appropriate and necessary\u003c/p\u003e\n\u003cp\u003e•\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Appropriate but not necessary\u003c/p\u003e\n\u003cp\u003e•\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Uncertain\u003c/p\u003e\n\u003cp\u003e•\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Inappropriate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsensus will be defined as greater than or equal to 75% of participants rating a component as 7 or greater AND the median and mean both greater than or equal to 7 for appropriateness or necessity (Diamond et al, 2014; Fitch 2001). Where greater than or equal to75% of participants rate a component as equal to or less than 3 AND the component has a median and mean rating of 3 or less, the component will be considered inappropriate or unnecessary. Components that do not reach consensus or that the median and mean scores are 4-6, are considered uncertain and will be reviewed by the project team who will analyse qualitative feedback and make changes to the components before they are presented again in the next survey round.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFuture Delphi rounds\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFuture rounds of the modified Delphi surveys will provide a list of the components that reached consensus for appropriateness and necessity and had median and mean scores greater than or equal to 7 in the previous round, for participants information. For components that did not reach consensus, a summary of quantitative ratings and a revised (i.e. new) component based on analysis of qualitative feedback will be provided.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants will be asked to re-rate these revised components for appropriateness and necessity. The process will continue until all components not reaching consensus have been presented at least once. Components approaching but not reaching consensus (60-75% agreement) after multiple survey rounds will be discussed by the project team.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003ePHASE 3: Workshops to determine feasibly\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing the modified Delphi, workshops will be held with a select group of participants to assess the feasibility of the inclusions in the model in alignment with funding and resourcing.\u003c/p\u003e\n\u003cp\u003eOnce consensus and an appropriateness and necessity classification has been reached on all draft components of the McGrath Model of Care, workshops will be held to discuss the feasibility of the components which may impact on the implementation of the final McGrath Model of Care in practice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipants and sample\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor the feasibility workshop a maximum of 15 participants will be included in each session. The participant groups for each workshop are as follows:\u003c/p\u003e\n\u003cp\u003e1.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;People with lived experience of cancer as patients or carers.\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Oncology healthcare professionals\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;McGrath Foundation Nursing Program team members\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRecruitment\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePurposive sampling will be employed to invite selected previous participants and contributors to the co-design of the MMoC.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eProcess\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOnline workshops will be held on MS Teams and will be facilitated by Natasha Doherty. Each workshop will be recorded and transcribed verbatim with the consent of participants. Before the workshop, attendees will be sent a survey asking them to rank the feasibility of components. The outcomes of this process will be presented at the workshop for discussion and a final vote will be held to determine inclusion of items.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData collection and analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData collected during the workshops will inform final inclusion of items in the McGrath Model of Care for all cancers. If a component gains consensus and is shown to be appropriate but not necessary through the modified Delphi, and is found to not be feasible to implement, the project team may choose not to include within the final model with justification provided. Feasibility will be considered in relation to affordability, scope of practice of McGrath Cancer Care roles, and accessibility to care across all settings.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe results for this study will determine the components of the McGrath Model of Care, specifying the activities and support that can be provided by specialist cancer nurses in the provision of supportive cancer care. The McGrath Model of Care will be shared with participants in the study and will be made publicly available for nurses across Australia.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e Ethics for all aspects of this project and the study outlined in this paper have been approved by Bellberry Limited No. 2024-06-736. This study is expected to commence in June 2025.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eDeveloping an evidence-based model of nursing care that meets the needs of people with cancer is critical to achieving equitable cancer care. This modified Delphi approach utilises expert consensus to determine the final components of the model and to ensure the model is appropriate and feasible. Broad consultation has enabled identification of the needs of people with cancer across the care trajectory and the involvement of expert cancer nurses in this final stage of the model development will ensure that the model is implementable by nurses. Representation from key stakeholder groups in the feasibility workshops to be held in this study will ensure that the model is both adaptable and adoptable in the various settings where new cancer nurses are being placed. A comprehensive cancer nursing model of supportive care is an important step to ensure consistent and equitable cancer care is delivered\u003c/p\u003e \u003cp\u003eThis model must be adaptable to local contexts across Australian health services where cancer care is provided and link to local, state and national cancer plans (Agency for Clinical Innovation, 2013). A clearly defined implementation plan will be required for cancer nurses to successfully integrate the model into their practice setting. This will need to be iterative and responsive to local needs and will require ongoing support. Likewise, a clear evaluation framework to monitor the adoption and outcomes of the model of care will be implemented (Agency for Clinical Innovation, 2013).\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eStrengths of this study include the methodology of a modified Delphi technique. This technique provides a structured format with controlled feedback and is anonymous in nature in order to reduce group pressure or external influences to responses.\u003c/p\u003e \u003cp\u003eThe extent of involvement in the study will be limited to those who are able to commit the time required to participate A limitation of using the modified Delphi technique is the uncertainty regarding consensus thresholds. There is no generally accepted threshold for consensus and our study was based on what was reasonable. There is also an inherent risk of incomplete surveys and with multiple rounds there is likely attrition of responders between these rounds. There will be efforts to counteract this with both reminder emails and the provision of responses and feedback in a reasonable time frame to maintain interest with participants.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study will determine the final elements of the McGrath Model of Care and ensure the model is appropriate and feasible for implementation. This study has adopted the key principles of model of care development and encompasses the recognised domains of nursing models of care.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAustralian Institute of Health and Welfare (2024). Overview of cancer in Australia, 2024. Australian Institute of Health and Welfare available from: https://www.aihw.gov.au/reports/cancer/cancer-data-in-australia/contents/overview\u003c/li\u003e\n\u003cli\u003eCancer Australia (2023) Australian Cancer Plan; Cancer Australia available from: https://www.australiancancerplan.gov.au/\u003c/li\u003e\n\u003cli\u003eCancer Council Victoria (2022) Optimal Care Pathways, Cancer Council Victoria, Melbourne, Victoria. Available from: https://www.cancervic.org.au/get-support/for-health-professionals/optimal-care-pathways\u003c/li\u003e\n\u003cli\u003eClarke, J., Davis, K., Douglas, J., \u0026amp; Peters, M.D.J. (2025) Defining nurse-led models of care: Contemporary approaches to nursing. International Nursing Review, 72, e13076. https://doi.org/10.1111/inr.13076\u003c/li\u003e\n\u003cli\u003eDepartment of Health (2023) Health Workforce Data Website. Available at: https://hwd.health.gov.au/\u003c/li\u003e\n\u003cli\u003eDepartment of Health, Disability and Aging (2025) Australian Cancer Nursing and Navigation Program. Available at: https://www.health.gov.au/our-work/australian-cancer-nursing-and-navigation-program\u003c/li\u003e\n\u003cli\u003eDiamond, I. R., Grant, R. C., Feldman, B. M., Pencharz, P. B., Ling, S. C., Moore, A. M., \u0026amp; Wales, P. W. (2014). Defining consensus: A systematic review recommends methodologic criteria for reporting of Delphi studies. Journal of Clinical Epidemiology, 67(4), 401\u0026ndash;409. https://doi.org/10.1016/j.jclinepi.2013.12.002\u003c/li\u003e\n\u003cli\u003eFitch, K., Bernstein, S.J., Aguilar, M.D., Burnand, B., Ram\u0026oacute;n LaCalle, J., L\u0026aacute;zaro, P., van het Loo, M., McDonnell, J., Vader, J.P. \u0026amp; Kahan, J. P. (2001) The RAND/UCLA Appropriateness Method User\u0026rsquo;s Manual; RAND; Santa Monica, CA. Available at: \u003c/li\u003e\n\u003cli\u003ehttps://www.rand.org/pubs/monograph_reports/MR1269.htmlTrevelyan, E. G., \u0026amp; Robinson, P. N. (2015). Delphi methodology in health research: how to do it? European Journal of Integrative Medicine, 7(4), 423\u0026ndash;428. https://doi.org/10.1016/j.eujim.2015.07.002\u003c/li\u003e\n\u003cli\u003eDunn J, Galv\u0026atilde;o DA, Green A, Lazenby M, Newton RU, Oliffe JL, Phillips J, Phillips R, Ralph N, Sara S, Heathcote P, Chambers SK. A (2022) Psychosocial Care Model for Men with Prostate Cancer: An Essential Element of the Prostate Cancer Survivorship Essentials Framework. Guide for Health Care Professionals. Sydney: Prostate Cancer Foundation of Australia. Available from https://www.pcfa.org.au/model-of-care/\u003c/li\u003e\n\u003cli\u003ePatford, K., Ernst, K., Crowe, B., Mahony, J. \u0026amp; Townsend, J. (2022) McGrath Model of Care. McGrath Foundation, Sydney, Australia. Available from: https://www.mcgrathfoundation.com.au/about/mcgrath-model-of-care/?gad_source=1\u0026amp;gad_campaignid=1602331866\u0026amp;gclid=Cj0KCQjwlrvBBhDnARIsAHEQgORGLPJ_cZw1J6uq3s1q_UMMgwhVAF7aLjyAZNvzy_xnN8wtZnPJKqMaAvViEALw_wcB\u003c/li\u003e\n\u003cli\u003eTrevelyan, E. G., \u0026amp; Robinson, P. N. (2015). Delphi methodology in health research: how to do it? European Journal of Integrative Medicine, 7(4), 423\u0026ndash;428. https://doi.org/10.1016/j.eujim.2015.07.002\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"McGrath Foundation","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Protocol, cancer nursing, model of care, consensus survey, Delphi","lastPublishedDoi":"10.21203/rs.3.rs-6779735/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6779735/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBACKGROUND:\u003c/strong\u003e There has been significant government and non-government organisation investment in specialist cancer nursing roles in Australia with a focus on improving access to care, support and navigation. To ensure equitable access to specialist cancer nursing care, a comprehensive nursing model of care to provide supportive care to people with any type of cancer is needed\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAIM\u003c/strong\u003e: The primary aim of this study is to obtain expert consensus on key components to be included in the McGrath Model of Care (MMoC). Secondary aims are to understand the feasibility of the MMoC within the Australian health care context.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMETHODS\u003c/strong\u003e: A three-phase study will be conducted including: 1. development of the draft components of the MMoC through co-design and evidence synthesis; 2. expert consensus on appropriate components of the MMoC through a modified Delphi; and 3. workshops with end-users to determine feasibility of the developed MMoC. \u003cem\u003ePhase 1:\u003c/em\u003e Themes derived from consultations with over 450+ people with lived experience of cancer; clinicians; and other key stakeholders will be synthesised with literature review results and Optimal Care Pathways to develop the draft components of the model. \u003cem\u003ePhase 2:\u003c/em\u003e We aim to recruit 25-50 participants through direct email invitation. Participants will be experts in cancer nursing. Purposive sampling will be employed to ensure maximum variation in location of participants and representation across cancer types. Multiple rounds of an on online survey will be conducted to gain consensus on the appropriateness and necessity of components of the MMoC. \u003cem\u003ePhase 3\u003c/em\u003e: Qualitative workshops will be held to discuss the feasibility of relevant items in clinical practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRESULTS\u003c/strong\u003e: The study will be conducted between June – September 2025.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONCLUSION:\u003c/strong\u003e The study findings will determine the final elements included in the MMoC and ensure the model is appropriate and feasible for implementation.\u003c/p\u003e","manuscriptTitle":"Developing consensus on the content of a comprehensive cancer nursing model of care (the McGrath Model of Care): A modified Delphi technique protocol","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-03 13:26:25","doi":"10.21203/rs.3.rs-6779735/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"94b07ce3-2978-4816-af39-09b79c7860fe","owner":[],"postedDate":"June 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":49255197,"name":"Oncology"},{"id":49255198,"name":"Nursing"}],"tags":[],"updatedAt":"2025-06-03T13:26:25+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-03 13:26:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6779735","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6779735","identity":"rs-6779735","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}