Establishment of the research group

The research team comprised 10 members, including a postgraduate supervisor, a professor of psychology, two oncology residents, one head oncology nurse, one teaching leader, two oncology nurses, and two postgraduate students collaborating on the study.

Selecting delphi experts

There is no definite optimal number of participants for Delphi studies; however,previous recommendations suggest a minimum of 12 participants [8]. In this study, 14 healthcare professionals and educators from Shenzhen and Zhuhai were invited to participate in the Delphi Expert Consultation, in line with the study’s objective. The selection criteria for the experts were as follows:

(1) Holding an intermediate or higher professional title;

(2) Possessing a bachelor’s degree or higher;

(3) Having more than 10 years of work experience with extensive clinical expertise;

(4) Working in clinical, nursing, or psychological roles related to cancer;

(5) Demonstrating a high motivation to participate in the study and a willingness to engage in multiple rounds of expert correspondence.

Delphi expert consultation

Literature review.

A comprehensive search was conducted in databases such as PubMed, Web of Science, and ScienceDirect for intervention studies related to Benefit Finding (BF). The search period extended from the establishment of the database until July 2024. The search terms included: “cancer/tumor/carcinoma/neoplasm/malignancy/colorectal cancer/colon cancer/rectal cancer” “benefit finding,” and “intervene/intervention.” After systematic screening and analysis by two graduate students trained in evidence-based practice, as shown in Fig 1, a total of 10 articles were ultimately included [9–18]. The core content of the intervention protocols from the included literature was extracted and organized according to “author, intervention measures, sample sizes, measurement tools, intervention duration, evaluation time, and research conclusions,” thereby forming a draft of the intervention protocols. During literature selection and analysis, potential factors like publication bias and database limitations might affect the process. However, we’ve made every effort to ensure the literature review is comprehensive and representative.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Flowchart of literature retrieval and screening.

https://doi.org/10.1371/journal.pone.0321396.g001

This flowchart led to an initial search of 2756 papers through three databases, and then after two rounds of initial screening and full - text reading and rescreening, 10 papers were finally included that fit into the present study.

Ethical consideration

The study did not need institutional review board approval as it did not affect patient care, and the information that it generated was used for developing protocols only. All participants were presented the objectives of the Delphi study, and provided their written consent by WeChat to the research group. To safeguard participant privacy, WeChat used end-to-end encryption for consent collection. Right after collection, PII (e.g., names, WeChat IDs) is removed. Participants get unique non-identifying codes, and no identifying data is used in result presentation. Team members have different access rights based on their roles.

Statistical methods

After the questionnaires were collected, Epidata 3.1 software and SPSS 29.0 were used to establish a database employing a double-entry method. Normally distributed continuous data were expressed as means and standard deviations, while categorical data were presented as frequencies and percentages. Expert enthusiasm was represented by the response rates of the two rounds of questionnaires, and the degree of expert authority was expressed by the authority coefficient (Cr), calculated from the judgment coefficient (Ca) and the index familiarity (Cs) using the formula: Cr = (Ca + Cs)/ 2 [19].

Expert concentration was indicated by the mean of importance assignment (M), while expert coordination was expressed by the coefficient of variation (CV) and the Kendall coefficient (ω). The chi-squared test was used to verify the significance of differences, with P<0.05 indicating statistical significance. The weights were determined using the analytic hierarchy process (AHP) [20] to prioritize the first-level items, followed by the second-level and third-level items, with the combined weights calculated as the average of the AHP and the priority diagram method.

Basic information of the experts

In this study, a total of 14 experts completed two rounds of inquiries, representing various institutions, including tertiary cancer hospitals, tertiary general hospitals, and higher education institutions. The working experience of the consulted experts ranged from 11 to 40 years (mean ± SD: 21.86 ± 8.82). Of the experts, 8 (57.1%) held a master’s degree or higher, and 9 (64.3%) had a deputy senior title or above, as shown in Table 1.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Basic information of experts.

https://doi.org/10.1371/journal.pone.0321396.t001

Expert positive coefficient

The response rates for two rounds both were 100%, indicating a high level of enthusiasm among the experts.

Expert authority coefficient

The judgment coefficient (Ca) and the index familiarity (Cs) were 0.90 and 0.82, respectively, resulting in an authority coefficient (Cr) of 0.86. An authority coefficient above 0.7 is generally considered to indicate a high level of authority [21]. Therefore, the experts in this study demonstrated a high degree of authority and credibility.

Expert concentration

In the two rounds of expert consultations, the mean value assigned to the importance of the items ranged from 3.29 to 5.00 and 4.07 to 5.00, respectively. A mean value above 3.50 is typically acceptable [19], indicating that expert opinions and suggestions were adjusted after the consultations, resulting in a higher degree of consensus.

Expert coordination coefficient

It is generally accepted that the coefficient of variation (CV) should be below 0.25 [19], with values of the Kendall coefficient (ω) closer to 1 indicating a higher the degree of coordination among expert opinions. In the first round, the CV values were ranged from 0.00 to 0.29 and the ω was 0.169 (P<0.001), respectively. In the second round, these values ranged from 0.00 to 0.17, with a Kendall coefficient of 0.214 (P<0.001), as shown in Table 2, indicating that expert opinions were becoming more consistent. Moreover, the CV in the second round was lower than that in the first round, with a statistically significant difference (t＝7.997, P<0.05), suggesting a higher level of approval for the protocol among the experts.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Coordination coefficient (ω) of expert opinions and test results.

https://doi.org/10.1371/journal.pone.0321396.t002

The analytic hierarchy process

Based on the results of two rounds of Delphi expert consultation, eight primary items were identified: “Confidence-building”, “Identification of pressures”, “Reconstructing perceptions”, “Social support”, “Emotional needs”, “ Emotional management”, “ Value of life”, and “Summary and evaluation.” We constructed an eight-order judgment matrix and conducted analyses using the Analytic Hierarchy Process. The weighted values of the eight primary items were 0.133, 0.131, 0.122,0.116, 0.129, 0.122, 0.124, and 0.124, respectively. The results are summarized in Table 3.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Expert consultation results on psychological management and behavioral intervention plans for colorectal cancer patients.

https://doi.org/10.1371/journal.pone.0321396.t003

Index revision

During the two rounds of consultations, some experts provided suggestions and comments on the items. The main changes were as follows:

1. (1). Deletion of items: in the first round of correspondence, four tertiary items with coefficients of variation above 0.25 were deleted.
2. (2). Addition of items: a total of seven items were added, including the second-level items “meditation and breathing training” and “progressive muscle relaxation training,” which were incorporated into each topic.
3. (3). Modification of entries: two primary items, six secondary items, and twelve tertiary items were modified. Additionally, four tertiary items were combined into two, and the analysis method for understanding the patient’s situation was adjusted accordingly for items 4.1.1 and 4.2.1.

In the second round of consultation, the mean value for all items exceeded 3.5, and the coefficient of variation for all items was below 0.25. Textual changes were made to six items for clarity, indicating that expert opinions and suggestions converged and that the consultation could be concluded. Therefore, the final intervention protocol consisted of 8 primary items, 25 secondary items, and 53 tertiary items. The details are provided in Table 3.

A uthenticity and objectivity of the intervention protocol

In this study, we reviewed a substantial body of international literature on interventions related to BF in tumor patients. This review encompassed various aspects, including intervention methods, sample sizes, measurement tools, intervention durations, evaluation time, and research conclusions, allowing us to formulate a preliminary intervention framework. The research team, which possesses extensive clinical experience and theoretical knowledge, developed the initial draft of the intervention through collaborative brainstorming sessions. Experts from academia and healthcare institutions provided constructive feedback on this proposal, which was subsequently refined based on data analysis from the consultation forms. This iterative process resulted in a final draft that is both representative and reliable.

The effective response rate for the expert consultation questionnaires exceeded 90% in both rounds, and the authority coefficient was 0.86, indicating a high level of enthusiasm and authority among the experts [21]. During the consultation process, ten experts offered valuable insights and suggestions, further enhancing the credibility of the consultation results. Following the second round of consultation, the mean values for all items were above 3.50, with 31 exploratory items also exceeding this threshold. The coefficients of variation for the two rounds were 0.00–0.29 and 0.00–0.17, respectively, while the Kendall coefficients were 0.169 and 0.214 (P<0.001). These results indicate that expert opinions became increasingly consistent, supporting the credibility of the inquiry findings [19].

Thus, this study constructed the intervention plan through a combination of literature review, group discussions, and the Delphi expert consultation method. The favorable objective numerical values reflecting the authority and coordination of expert opinions enhance the scientific rigor and objectivity of the modified proposal, thereby establishing a solid theoretical foundation for subsequent implementation.

The general applicability of the intervention protocol

Cognitive Behavioral Stress Management (CBSM) is a psychological treatment approach designed to help patients recognize and manage stress, ultimately improving their mental health and quality of life [22]. This method integrates various interventions, including expressive writing [10] and mindfulness [11], with a focus on stress, cognition, and emotion. It also incorporates breathing relaxation techniques and homework assignments to enhance BF levels. A literature review [9–14] has identified CBSM as one of the most widely used interventions for promoting BF, primarily through group psychological interventions. Walsh et al [11] selected 256 male patients with prostate cancer who were randomly assigned to either a 10-week CBSM intervention or a one-day psychoeducation, with BF and perceived stress management skills as the intervention targets. The results showed that CBSM significantly improved the psychosocial adaptation and immune status of the patients, effectively enhancing their stress management capabilities.

In this study, the intervention protocol is grounded in practical considerations to address patients’ emotional expression and psychological needs. It employs a combination of online and offline group interventions, including lectures [11], teaching sessions [12], and diary writing [10]. The team has developed a public account for effective health education, offering online guidance for patients and their families through classes, example analysis method, testimonials, emotional journals, and crafting activities. The offline format includes face-to-face presentations of the study, lectures, goal-setting sessions, and summary reviews. Recognizing that the target population is predominantly elderly, all formats are designed to be straightforward and easily comprehensible, with breathing relaxation techniques that are readily adopted by patients.

This protocol aims to cultivate positive emotions, shift negative cognition, and enhance quality of life through both one-to-many and many-to-many approaches, fulfilling physiological needs while also addressing the need for love and belonging. Additionally, the intervention is tailored to align with patients’ treatment plans and home schedules, making it suitable for most cancer patients. Therefore, the intervention formats for each theme are accessible and facilitate implementation, providing targeted support for patients’ mental health and self-management, particularly for those recovering from surgery.