A Competency-Based Evaluation Index System for Recertification of Breast Specialist Nurses: A Delphi Study in China

Abstract

Introduction

Clinical nurse specialists have crucial roles in team development, patient safety, and work quality of nurses. Breast specialist nurses in China are instrumental in managing breast disorders and providing care for patients experiencing complications. However, despite the growing demand for breast specialty care, there are no unified national recertification standards for breast specialist nurses in China, and relevant research in this area remains scarce. This study aimed to develop an evaluation index system for breast specialist nurse recertification and establish a scientific and objective basis for standardizing such systems.

Methods

Based on the theory of post competency, literature analysis and a two-round Delphi method were used to prepare a recertification evaluation system for breast specialist nurses. Eighteen nursing experts from 14 tertiary hospitals in Guangdong Province participated, selected based on predefined criteria (≥10 years of clinical experience, intermediate/advanced title, and bachelor’s degree or above). Indicator weights at all levels were determined using the proportion allocation method. The mean importance score was ≥ 3.50, and the coefficient of variation (CV) was ≤ 0.25.

Results

The authority coefficients for these rounds were 0.936 and 0.933, and the Kendall coefficients of concordance were 0.245 and 0.406, respectively (P < 0.001). The final evaluation system comprised 7 first-level, 28 second-level, and 105 third-level indicators, with content features specific to breast specialty care—notably, integrative Chinese and Western nursing, lymphedema management, and multidisciplinary team (MDT) collaboration. Among the seven first-level indicators, clinical practice skills, clinical expertise, and critical thinking skills formed a cluster of core clinical competencies with comparable weights, reflecting the balanced emphasis on technical proficiency, specialist knowledge, and clinical judgment. This Delphi study was conducted and reported in accordance with the Conducting and REporting of DElphi Studies (CREDES) guidelines.

Conclusion

The recertification evaluation index system developed here is comprehensive, scientifically robust, and practically applicable. It is a basis for nursing managers to assess the competency and recertification of breast specialist nurses in Guangdong Province, China, supporting the quality and safety of breast cancer care. Furthermore, it offers a reference for future recertification efforts beyond the regional context.

Introduction

Cancer, which is among the leading causes of death worldwide, has severe adverse effects on physical and mental health of individuals. Despite technological advancements, the global incidence of and mortality associated with cancer continue to rise each year;^1,2 besides, it incurs enormous economic and financial burden, making it a global health concern.³ According to GLOBOCAN 2022 statistics, ~2.3 million new breast cancer cases were reported globally.⁴ China, being a populous developing country, has significant disparities in breast cancer screening and treatment across its regions. China has the highest number of breast cancer cases globally, accounting for ~18.4% of all breast cancer cases; similarly, it accounts for the highest proportion (~17.1%) of total number of deaths from breast cancer worldwide.⁵ Consequently, particularly in China, breast cancer has emerged as a leading threat to women’s health.⁶ Early detection, diagnosis, and treatment are critical to ensuring optimal cancer treatment.⁷ This growing patient population demands not only effective medical treatment but also high-quality, long-term specialized nursing care throughout the treatment and survivorship trajectory.

Scientific research advancements drive the continual updating of clinical guidelines for breast cancer diagnosis and treatment, necessitating ongoing education for medical experts and clinical practitioners. Contemporary breast cancer management is increasingly characterized by individualized, complex, and prolonged treatment pathways, underscoring the need for high professional competencies of clinical nurses. A nurse specialist possesses advanced clinical expertise beyond that of a generalist and is authorized to practice within a specific specialty. As leaders of the specialist nursing team, their core competencies drive both the quality of patient care and the strategic development of the nursing profession. These nurses are instrumental in the comprehensive management of patients with breast cancer, fulfilling diverse responsibilities that include research activities, clinical care, care coordination, psychological support, and patient education.^8,9

Breast specialist nurse training in China is still in its early stages and continuously developing.¹⁰ In many hospitals, before the profile of a breast cancer specialist nurse was introduced, breast cancer disease managers performed all duties currently attributed to specialized nurses. Currently, there is no nationally unified continuing education or training program specifically designed for breast specialist nurses. Instead, training and certification programs are primarily organized by provincial or municipal nursing associations, such as those in Guangdong, Zhejiang, and Shanghai. Although the Chinese Nursing Association offers training for oncology specialist nurses, these programs are not specifically focused on breast specialty care. This is not to diminish their value, but rather to recognize that breast disease is a distinct and complex specialty with multiple comorbidities and requires competencies beyond general oncology nursing, which is precisely why various regions have initiated their own training programs based on local needs.

In China, the first training and certification course for breast specialist nurses was conducted by the Guangdong Nursing Association in 2019; thus far, four such sessions—collectively encompassing 150 nurses—have been conducted.¹¹ However, significant variations exist across regions in terms of training standards, certification requirements, and recertification policies, reflecting the uneven development of breast specialty care nationwide. To work in a particular field (eg, breast cancer patient care), specialized nurse certification is necessary, whereas recertification underscores the significance of continuous professional development.^12,13 While international examples—such as the UK Royal College of Nursing Breast Care Nurse certification and the US Oncology Nursing Society recertification—underscore the importance of structured recertification, similar systems are still being explored in China. Nurse specialist recertification mandates periodic validation of nurses’ knowledge, skills, and practice, making it an essential institutional mechanism that ensures sustained clinical competence and safeguards patient safety. Effectively, it transforms the principle of lifelong learning into a tangible, enforceable standard of care. Despite this critical role, existing competency assessment tools for specialist nurses often focus on structural requirements rather than clinical performance, lack content validity specific to distinct specialties, and seldom address the need for recertification. Consequently, given the limited research on the evaluation of recertification programs for breast specialist nurses, unified standards for such programs are lacking.¹⁴

The central premise of the post-competency theory established by an American psychologist, David McClelland, in 1973¹⁵ is that exceptional job performance is primarily determined not by intelligence but by a set of deep-seated characteristics. These characteristics are referred to as “competencies” and encompass skills, knowledge, personal traits, and motivations. McClelland’s distinction between implicit (motivations and traits) and explicit (knowledge and skills) competencies is reflected in our framework, which includes both professional identity and clinical practice skills. While it was initially intended to transform corporate human resource management and leadership development, the theory later formed the premise for shifting medical and nursing education from a knowledge-based to a competency-based paradigm.¹⁶ It has had transformative effects on the design of training, assessment, and recertification systems for specialist nurses.^17,18 The Delphi method is suited to this research question as it enables expert consensus-building where empirical evidence is limited. In this study, we used the Delphi expert consultation method, which is grounded in post-competency theory, to explore the development of a recertification evaluation system for breast specialist nurses.

Materials and Methods

Design

To establish a draft index system, expert meetings and literature reviews were used. We conducted a Delphi study to solicit expert consensus from 18 experts regarding a recertification evaluation index for breast disease specialist nurses. As a consensus-based methodology, the Delphi approach relies primarily on expert judgment to refine and validate the evaluation framework; the literature review was conducted to inform the initial indicator pool rather than to serve as a systematic synthesis of evidence. Our study protocol complied with the Conducting and REporting of DElphi Studies (CREDES) guidelines.¹⁹ This study has been approved by the Ethics Committee of Sun Yat-sen Memorial Hospital, Sun Yat-sen University, with approval number SYSKY-2024-227-01. All participants voluntarily signed the written informed consent.

Construction of an Evaluation Index System

First, a research group comprising eight members was set up: four breast specialty experts and ward nurse managers, two breast specialist nurses, one nursing master’s student, and one director of the nursing department. All members were women aged 27–51 and had 2–26 years of experience in their respective field. Their tasks included compiling expert judgment questionnaires, conducting a literature review, selection of experts, administering Delphi expert judgment surveys, and analyzing and discussing the experts’ opinions and results.

Using the keywords “core competence”, “breast cancer”, “clinical nurse specialist”, “breast department”, “breast tumor”, “advanced practice nurse”, and “breast neoplasm”, relevant studies were searched for in WanFang, Embase, PubMed, CNKI, and Web of Science databases. The search period was January 2013 to December 2023, with equivalent Chinese terms applied to the Chinese databases. Studies were included if they focused on competency evaluation for specialist nurses, nurse certification, or recertification systems and if they were published in English or Chinese. We excluded conference abstracts, non-peer-reviewed publications, and studies not relevant to specialist nurse competency or recertification. Data pertinent to core CNS competencies were collected through a literature search, followed by data sorting, discussions, and analyses. Next, based on the framework of the core competencies of CNSs in China and Hamric’s Model of Advanced Practice Nurses, the first draft of the index system of recertification evaluation for breast disease specialist nurses was drafted.^20–22 In this integration, the domestic CNS core competency framework served as the structural foundation, and Hamric’s Model was adopted as a theoretical supplement. Then, the draft was reviewed through internal research team discussions, during which the relevance, clarity, and hierarchy of indicators were assessed; items were added, merged, or deleted based on team consensus. Finally, we sought the guidance of two external experts with relevant research experience—a chief superintendent nurse and a statistics professor—in designing the first draft of the questionnaire. The questionnaire included sections on expert demographics and primary, secondary, and tertiary indicators, the significance of which was quantified on a 5-point Likert scale. The experts provided their additional comments and suggestions in a dedicated field.

Delphi Process

The overall research process is illustrated in Figure 1.

Figure 1.

Development of the breast specialist nurse recertification evaluation index system.

Inclusion Criteria

Based on their qualifications and experience, experts in the field of breast specialist nursing in Guangdong Province were selected. They participated in the Delphi expert judgment process and provided valuable input for the development of an evaluation system for breast specialist nursing recertification. Expert inclusion criteria were (1) practicing in breast disease nursing for >10 years, (2) having an intermediate/advanced professional certificate, (3) practicing as head nurses or senior clinical nurses, (4) having a bachelor’s degree or above, (5) voluntary participation in the investigation and commitment to participate in two consultation rounds, and (6) familiarity with or involvement in training related to breast department nurses.

First Draft of the Expert Consultation Questionnaire

The questionnaire comprised three parts: (1) a letter describing the purpose and significance of the study; (2) general information about the experts, including demographics and social factors; and (3) a recertification index system for breast disease specialist nurses. The first draft of the evaluation indices included 7, 27, and 97 first-, second-, and third-level indices, respectively. The importance of each index was evaluated on a five-point Likert scale (1 = unimportant, 2 = less important, 3 = general, 4 = important, 5 = very important). (4) Furthermore, familiarity of experts with questionnaire contents and factors impacting their judgment (work experience, theoretical analysis, intuitive judgment, and scientific reference) were assessed. Familiarity was categorized into five levels, with each level assigned a value (ie, unfamiliar = 0.1, less familiar = 0.4, fairly familiar = 0.6, familiar = 0.8, and very familiar = 1). In addition, the effect of each factor on judgment was categorized as strong, moderate, or weak. Weighting values were assigned to each assessment criterion across three levels: theoretical analysis (0.3, 0.2, and 0.1), work experience (0.5, 0.4, and 0.3), references to domestic and foreign literature (fixed at 0.1), and intuitive judgment (fixed at 0.1).

Delphi Consulting and Feedback Cycle

The questionnaire was administered to the aforementioned experts via WeChat or Email during May to September 2023. Within 1 month, they scored and made appropriate modifications to index items and returned their feedback. Indices having a coefficient of variation of ≥0.25 or a mean importance score of ≤3.5 were removed, and after sorting and summarizing expert opinions, a redesigned questionnaire was prepared for the second round. Both rounds of expert correspondence were 4–5 weeks apart. In the second round, a similar method as the first round was used to finalize the evaluation index system.

Statistical Analysis

SPSS software (version 30.0) was used for data analysis, and all data entries and statistical procedures were double-checked for accuracy. Using descriptive statistics, the expert panel’s demographic characteristics (ie, professional title, educational background, years of experience, and professional position) were summarized. The representativeness and reliability of the Delphi consultation were evaluated using the expert authority coefficient (Cr), response rate (positive coefficient), Kendall’s coefficient of concordance (W), and coefficient of variation (CV). The expert authority coefficient (Cr) was determined by calculating the arithmetic mean of the judgment basis (Ca) and the familiarity coefficient (Cs): Cr = (Ca + Cs)/2. Statistical significance for the concordance was set at a P value of <0.05. Finally, we applied the proportion allocation method to establish the weights of each evaluation indicator. In this model, the weight of each indicator was calculated as Wi = Mi/ΣM, where Mi is the mean importance score of the i-th indicator and ΣM is the sum of all mean scores at the same level. The internal consistency of weights was verified across all levels—primary, secondary, and tertiary—with minimal rounding discrepancies noted.

Results

Basic Information of the Experts

All 18 participants were women, aged 32–50 years (average age, 45.13 years; standard deviation, 5.33). The average experience working in breast disease was 20.73 (range, 10–33 years; standard deviation, 8.24). They had a varied educational background, with 17 having a bachelor’s degree (94.44%) and 1 having a master’s degree (5.56%). Regarding their job titles, 7 held senior titles (38.89%), 8 held deputy senior titles (44.44%), and 3 held intermediate titles (16.67%).

Experts’ Enthusiasm

Questionnaire responses were indicative of experts’ enthusiasm. Eighteen questionnaires were distributed in the first round of consultation, and all of them were returned with valid and eligible responses (recovery rate, 100%). Among participating experts, 8 individuals (44.4%) offered suggestions to improve the questionnaire. The recovery rate was 100% in the second round of consultation as well, with 4 experts (22.2%) providing suggestions related to the questionnaire.

Expert Authority Coefficient and Opinion Coordination Degree

Experts’ degree of authority was determined by the degree of familiarity with the content of the communication and the basis on which they reached their judgement. In the first round, the authority, familiarity, and judgment coefficients were 0.936, 0.920 and 0.953, respectively. In the second round, these statistics were 0.933, 0.893, and 0.973, respectively. An authority coefficient of >0.7 indicated high reliability. The Kendall’s concordance coefficients for the first and second rounds of expert correspondence were 0.245 and 0.406, respectively. The corresponding χ2 values were 382.820 and 430.821, respectively (both P value < 0.001), and the differences were statistically significant. It indicates relative agreement among the experts and robustness of the results.

The Recertification Evaluation Index System for Breast Specialist Nurses

We herein conducted two rounds of consultation using the Delphi method. In round 1, based on the exclusion criteria and expert opinions, the research team modified 13 indices, added 9 indices, adjusted 4 indices, and deleted 0 indices. Similarly, in round 2, the team deleted and modified 1 index each. This formed the basis for the establishment of the index system of recertification evaluation for breast specialist nurses; the system included 7, 28, and 105 first-, second-, and third-level indices, respectively. The first level indicators were management skills, critical thinking skills, clinical practice skills, clinical expertise, communication and coordination skills, professional and humanistic qualities, and professional development skills. The Delphi method was applied to identify the weight of each indicator. The weight of each index was calculated by dividing the sum of the scores for each item by the score representing the importance of the corresponding index, according to the expert opinions. In the terms of weight, clinical practice skills (0.153) ranked the highest, followed by clinical expertise (0.151) and critical thinking skills; conversely, management skills ranked the lowest (0.128; Table 1, Table 2).

Table 1.

Core Competency Assessment System for Breast Specialist Nurse Recertification, Level 1 (Primary) and Level 2 (Secondary) Indicators (Round 2)

Primary and Secondary Indicators	Importance Assignment (X ± S)	CV	Weight
1. Clinical expertise	4.80 ± 0.414	0.086	0.151
1.1 Basic knowledge of the breast specialty	4.80 ± 0.414	0.086	0.055
1.2 Other basic knowledge related to tumors	4.40 ± 0.507	0.115	0.050
1.3 Other basic knowledge related to surgery	4.00 ± 0.655	0.164	0.046
2. Clinical practice skills	4.87 ± 0.352	0.072	0.153
2.1 Breast disease prevention and healthcare	4.53 ± 0.640	0.141	0.019
2.2 Clinical treatment of breast diseases	4.67 ± 0.617	0.132	0.020
2.3 Professional nursing skills	4.80 ± 0.414	0.086	0.020
2.4 Breast disease rehabilitation management	4.67 ± 0.488	0.104	0.020
2.5 Psychological assessment and care	4.47 ± 0.640	0.143	0.019
2.6 Case management	4.47 ± 0.640	0.143	0.019
2.7 Nursing documentation skills	4.40 ± 0.632	0.144	0.019
2.8 Breastfeeding-related breast care techniques	3.93 ± 0.799	0.203	0.017
3. Critical thinking skills	4.80 ± 0.414	0.086	0.151
3.1 Assessment skills	4.87 ± 0.352	0.072	0.050
3.2 Anticipation skills	4.87 ± 0.352	0.072	0.050
3.3 Evaluation skills	4.80 ± 0.414	0.086	0.050
4. Professional development skills	4.47 ± 0.516	0.115	0.140
4.1 Learning skills	4.87 ± 0.352	0.072	0.036
4.2 Teaching skills	4.73 ± 0.458	0.097	0.035
4.3 Research skills	4.60 ± 0.507	0.110	0.034
4.4 Innovation skills	4.60 ± 0.507	0.110	0.034
5. Professional and humanistic qualities	4.40 ± 0.507	0.115	0.138
5.1 Professional identity	4.80 ± 0.414	0.086	0.036
5.2 Humanistic care skills	4.73 ± 0.458	0.097	0.035
5.3 Self-adjustment skills	4.40 ± 0.507	0.115	0.033
5.4 Ethics	4.60 ± 0.507	0.110	0.034
6. Communication and coordination skills	4.47 ± 0.640	0.143	0.140
6.1 Communication skills	4.67 ± 0.617	0.132	0.036
6.2 Team coordination skills	4.73 ± 0.458	0.097	0.036
6.3 Health guidance skills	4.67 ± 0.617	0.132	0.036
6.4 Publicity and popularization skills	4.27 ± 0.884	0.207	0.033
7. Management skills	4.07 ± 0.704	0.173	0.128
7.1 Organizational management skills	4.20 ± 0.676	0.161	0.061
7.2 Quality management skills	4.53 ± 0.516	0.114	0.066

Abbreviation: CV, coefficient of variation.

Table 2.

Core Competency Assessment System for Breast Specialist Nurse Recertification, Level 3 (Tertiary) Indicators (Round 2)

Tertiary Indicators	Importance Assignment (X ± S)	CV	Weight
1.1.1 Physiological anatomy and tissue structure of the breast	4.67 ± 0.488	0.104	0.005
1.1.2 Epidemiology and genetics of common breast diseases	4.20 ± 0.775	0.185	0.005
1.1.3 Clinical manifestations and diagnosis of common breast diseases	4.60 ± 0.632	0.137	0.005
1.1.4 Pathological classification and staging criteria of breast tumors	4.40 ± 0.828	0.188	0.005
1.1.5 Routine physical examination in breast specialty care	4.53 ± 0.640	0.141	0.005
1.1.6 Routine radiological examination in breast specialty care	4.33 ± 0.724	0.167	0.005
1.1.7 Special examination techniques for breasts (e.g, breast imaging, biopsy, PET)	4.13 ± 0.915	0.222	0.005
1.1.8 Principles and treatment options for the comprehensive treatment of common breast diseases (e.g, surgery, radiotherapy, chemotherapy, endocrine therapy, targeted therapy, and immunotherapy)	4.60 ± 0.632	0.137	0.005
1.1.9 Lymphedema causes, prevention, and treatment methods	4.73 ± 0.458	0.097	0.005
1.1.10 Preservation of sexuality and fertility in breast tumor patients	4.60 ± 0.632	0.137	0.005
1.1.11 Integrated nursing methods for common symptoms of breast diseases in Chinese and Western medicine	4.07 ± 0.704	0.173	0.005
1.2.1 New advances in breast tumor treatment	4.47 ± 0.743	0.166	0.009
1.2.2 Occupational protection in breast tumor treatment	4.53 ± 0.640	0.141	0.009
1.2.3 Palliative care-related content	4.20 ± 0.676	0.161	0.008
1.2.4 Hospice care-related content	3.87 ± 0.743	0.192	0.008
1.2.5 Narrative nursing and communication strategies	4.33 ± 0.617	0.142	0.009
1.2.6 Death education	3.80 ± 0.676	0.178	0.008
1.3.1 Perioperative care for surgical patients	4.60 ± 0.507	0.110	0.023
1.3.2 Nursing for accelerated recovery surgery	4.60 ± 0.507	0.110	0.023
2.1.1 The relationship between hormone levels at different stages of women and breast diseases	4.40 ± 0.632	0.144	0.005
2.1.2 Application of characteristic TCM therapies in the prevention and treatment of breast diseases	4.13 ± 0.743	0.180	0.005
2.1.3 Role of TCM health preservation in preventing breast diseases and promoting mammary health	3.93 ± 0.884	0.225	0.004
2.1.4 Tertiary prevention of breast cancer	4.47 ± 0.640	0.143	0.005
2.2.1 New advances in surgical treatment of breast tumors	4.67 ± 0.488	0.104	0.003
2.2.2 Breast reconstruction and remodeling	4.53 ± 0.640	0.141	0.002
2.2.3 New advances in chemotherapy for breast tumors	4.60 ± 0.632	0.137	0.003
2.2.4 New advances in immunotherapy for breast tumors	4.53 ± 0.640	0.141	0.002
2.2.5 New advances in radiation therapy for breast tumors	4.53 ± 0.640	0.141	0.002
2.2.6 Endocrine therapy for breast tumors	4.60 ± 0.507	0.110	0.003
2.2.7 Other treatments for breast tumors	4.20 ± 0.775	0.185	0.002
2.2.8 Clinical treatment of other breast diseases	4.33 ± 0.617	0.142	0.002
2.3.1 Nursing techniques for benign breast diseases	4.67 ± 0.617	0.132	0.002
2.3.2 Application of traditional Chinese nursing techniques in breast diseases	4.27 ± 0.704	0.165	0.001
2.3.3 Symptom assessment and nursing care for breast tumor surgical treatment	4.80 ± 0.414	0.086	0.002
2.3.4 Symptom assessment and nursing care for adverse reactions during chemotherapy for breast tumors (e.g, marrow safety, gastrointestinal reactions, and hand-foot syndrome)	4.87 ± 0.352	0.072	0.002
2.3.5 Symptom assessment and nursing care for adverse reactions during breast tumor radiotherapy (e.g, radiation-related dermatitis)	4.87 ± 0.352	0.072	0.002
2.3.6 Symptom assessment and nursing care for adverse reactions during endocrine therapy for breast tumors	4.87 ± 0.352	0.072	0.002
2.3.7 Vascular access nursing techniques (e.g, peripheral venous placement, central venous catheterization, and handling of chemotherapy drug extravasation)	4.80 ± 0.414	0.086	0.002
2.3.8 Nursing care for breast wounds/cancerous wounds	4.47 ± 0.516	0.115	0.002
2.3.9 Pain management for breast disease patients	4.40 ± 0.737	0.168	0.001
2.3.10 Critical care nursing techniques for breast disease emergencies (e.g, cerebral hemorrhage, cerebral hernia, and severe granulocyte deficiency)	4.60 ± 0.632	0.137	0.002
2.3.11 Symptom management and emergency treatment for end-of-life patients	4.27 ± 0.799	0.187	0.001
2.3.12 Common psychological characteristics and psychological support for breast tumor patients	4.73 ± 0.458	0.097	0.002
2.3.13 Application of mindfulness stress reduction and emotional release techniques in breast tumor patients	4.40 ± 0.632	0.144	0.001
2.4.1 Exercise management for breast tumor patients	4.73 ± 0.594	0.126	0.004
2.4.2 Nursing care for breast tumor-related lymphedema	4.80 ± 0.414	0.086	0.004
2.4.3 Nutritional support and dietary guidance for breast tumor patients	4.80 ± 0.561	0.117	0.004
2.4.4 Bone health management for breast tumor patients	4.73 ± 0.704	0.149	0.004
2.4.5 Selection and wearing methods of breast prosthesis (body management)	4.53 ± 0.743	0.164	0.004
2.5.1 Assessment of patients’ mental health status	4.67 ± 0.617	0.132	0.007
2.5.2 Application of psychological care measures to relieve negative emotions	4.53 ± 0.640	0.141	0.006
2.5.3 Referral for psychological or psychiatric treatment	4.13 ± 0.516	0.125	0.006
2.6.1 Model and practice of case management	4.73 ± 0.458	0.097	0.005
2.6.2 Stage-specific case management of breast tumor patients	4.73 ± 0.458	0.097	0.005
2.6.3 Guidelines for case writing	4.47 ± 0.640	0.143	0.004
2.6.4 Continuity of care and home care	4.67 ± 0.617	0.132	0.005
2.7.1 Key points for writing nursing documents for breast diseases	4.60 ± 0.737	0.160	0.010
2.7.2 Application of related assessment evaluation scales (e.g, chemotherapy-induced vomiting risk and cancer pain)	4.47 ± 0.834	0.187	0.009
2.8.1 Nursing care for lactation, mastitis, and other breast-related symptoms.	4.07 ± 0.799	0.196	0.017
3.1.1 Advanced health assessment of breast diseases	4.67 ± 0.488	0.104	0.026
3.1.2 Surgical consultation and physical examination	4.27 ± 0.704	0.165	0.024
3.2.1 Critical thinking and reflective diary writing	4.53 ± 0.743	0.164	0.025
3.2.2 Application of clinical nurses’ predictive thinking abilities	4.60 ± 0.632	0.137	0.025
3.3.1 Implementation of third-level ward rounds	4.67 ± 0.617	0.132	0.017
3.3.2 Implementation of multidisciplinary consultations	4.53 ± 0.640	0.141	0.016
3.3.3 Discussion of difficult breast-related cases	4.67 ± 0.488	0.104	0.017
4.1.1 Continuously upgrading professional knowledge and learning new skills to improve the level of professionalism	4.73 ± 0.594	0.126	0.012
4.1.2 Reasonable planning of personal development and actively seizing learning and promotion opportunities	4.53 ± 0.640	0.141	0.012
4.1.3 Possessing evidence-based medical knowledge and the ability to practice evidence-based nursing	4.53 ± 0.516	0.114	0.012
4.2.1 Teaching skills and strategies in clinical nursing education	4.73 ± 0.458	0.097	0.012
4.2.2 Health education and knowledge service skills in clinical nursing	4.67 ± 0.617	0.132	0.012
4.2.3 Application of scenario teaching and the flipped classroom in clinical nursing education	4.40 ± 0.507	0.115	0.011
4.3.1 Acquisition and management of nursing research information	4.80 ± 0.414	0.086	0.005
4.3.2 Topic selection and nursing research design	4.67 ± 0.488	0.104	0.005
4.3.3 Writing of nursing research papers	4.67 ± 0.488	0.104	0.005
4.3.4 Data statistical analysis methods	4.33 ± 0.617	0.142	0.004
4.3.5 Conducting qualitative research	4.20 ± 0.775	0.185	0.004
4.3.6 Key points of writing reviews	4.47 ± 0.640	0.143	0.004
4.3.7 Applying for nursing research funds	4.40 ± 0.507	0.115	0.004
4.3.8 Management of clinical drug experiments for breast tumor patients	3.87 ± 0.834	0.216	0.004
4.4.1 Application and protection of nursing invention patents and achievement transformation	4.40 ± 0.737	0.168	0.011
4.4.2 Innovation in nursing work models and processes	4.53 ± 0.640	0.141	0.012
4.4.3 Development and application of new nursing technologies and services	4.53 ± 0.516	0.114	0.012
5.1.1 Recognizing that nursing work can promote health, prevent disease, restore health, and alleviate suffering and believing that nurses have a noble profession	4.60 ± 0.632	0.137	0.012
5.1.2 Having a spirit of dedication and correct views on life, the world, values, and ethics	4.67 ± 0.617	0.132	0.012
5.1.3 Gaining professional identity from the process of breast specialist nursing services	4.47 ± 0.834	0.187	0.012
5.2.1 Establishing a concept of humanistic care and practicing it with a sincere, patient, caring, and loving attitude.	4.73 ± 0.594	0.126	0.018
5.2.2 Focusing on the patient, understanding and respecting patients and their families, actively providing nursing services on the basis of informed consent, and providing emotional support	4.73 ± 0.594	0.126	0.018
5.3.1 Adapting quickly to different work environments	4.33 ± 0.816	0.188	0.016
5.3.2 Maintaining a positive and optimistic attitude toward work, having good self-adjustment ability, and maintaining emotional control in work	4.60 ± 0.828	0.180	0.017
5.4.1 Mastering medical and nursing ethics to avoid violating patients’ rights	4.53 ± 0.640	0.141	0.017
5.4.2 Respecting the culture and religious beliefs of different patients and avoiding criticism and comments	4.47 ± 0.834	0.187	0.017
6.1.1 Communication skills with breast tumor patients and their families	4.73 ± 0.594	0.126	0.013
6.1.2 Delivery of bad news - information support for late-stage patients	4.33 ± 0.816	0.188	0.012
6.1.3 Shared decision-making models and application for breast disease patients	4.33 ± 0.617	0.142	0.012
6.2.1 Enhancing teamwork skills for medical–nursing–technical teams	4.60 ± 0.828	0.180	0.036
6.3.1 Providing disease-related health knowledge to patients and families to promote patient recovery	4.67 ± 0.617	0.132	0.018
6.3.2 Providing professional information and experience guidance on breast care to other medical staff	4.47 ± 0.640	0.143	0.017
6.4.1 Involvement in generating scientific and educational content on breast diseases	4.60 ± 0.507	0.110	0.016
6.4.2 Skills for patient education meetings	4.53 ± 0.64	0.141	0.016
7.1.1 Establishment of specialized breast disease outpatient clinics	4.33 ± 0.617	0.142	0.031
7.1.2 Construction of a three-level diagnosis and treatment system for breast care	4.20 ± 0.775	0.185	0.03
7.2.1 Application of quality management tools	4.53 ± 0.516	0.114	0.022
7.2.2 Establishment and management of quality in specialized nursing practice	4.60 ± 0.507	0.110	0.022
7.2.3 Reflection on adverse events and root cause analysis (RCA)	4.60 ± 0.507	0.110	0.022

Abbreviation: CV, coefficient of variation.

Discussion

Reliability of Delphi Expert Consultation Results

The 18 experts invited for this study, all of whom had over 10 years of experience working in a breast specialty, were from 14 comprehensive tertiary hospitals in Guangzhou, Shenzhen, Dongguan, and Zhaoqing, China. Furthermore, all of them had at least a bachelor’s degree, with one of them having a master’s degree. Fifteen experts were at the associate professor level or higher (83.3%) and had extensive experience in training and assessing breast specialist nurses. The expert response rates of 83.3% and 100.0% for the first and second rounds of questionnaire indicated a high level of enthusiasm for participation, respectively. The Cr for the first and second rounds was 0.936 and 0.933, respectively, indicating that the experts were highly authoritative and that the questionnaire results were suitably reliable. The Kendall coefficients of concordance the first and second rounds were 0.245 and 0.406, respectively (both P values < 0.001), indicating a high level of agreement among the expert judgments. In the first Delphi round, five experts (27.8%) provided a total of 18 suggestions; in the second round, three experts (16.7%) contributed five additional suggestions; this difference was considered significant, suggesting consistency between expert judgments. Taken together, these statistics uphold the reliability of the expert consultation results of this study.

Between the two Delphi rounds, modifications were made based on expert feedback and team discussion. In the first round, no indicators were deleted, but one second-level and eight third-level indicators were added, covering areas like breastfeeding-related breast care, tertiary prevention of breast cancer, psychological nursing and referral, and nursing innovation competencies. In addition, four items were reworded for clarity. In the second round, two indicators initially exceeded the exclusion threshold (CV ≥ 0.25); after further review, one was merged and one was deleted, resulting in a final framework of 7 first-level, 28 second-level, and 105 third-level indicators. The reduction in expert suggestions from 18 in the first round to 5 in the second indicates that the revisions effectively addressed expert concerns and improved the clarity of the framework. Although most indicators met the predefined retention criteria (mean ≥ 3.50, CV ≤ 0.25), few items showed relatively higher heterogeneity and were retained after team discussion based on clinical relevance—for instance, “Breastfeeding-related breast care techniques” (Item 2.8m mean: 3.93 ± 0.799, CV: 0.203) was retained because many postpartum patients with breastfeeding difficulties seek care in breast departments, despite variability possibly reflecting differences in expert backgrounds; “Publicity and popularization skills” (Item 6.4, mean: 4.27 ± 0.884, CV: 0.207) was retained given the substantial patient education responsibilities of breast specialist nurses; finally, indicators related to health preservation using TCM therapies and clinical drug trial management were also retained on the basis of their clinical significance. These decisions ensure that the evaluation system remains both empirically grounded and practically applicable.

Importance of Recertification Evaluation Index System for Breast Specialist Nurses

Typically, most countries require a master’s degree as an eligibility criteria for advanced practice nurses. However, given the delayed development of higher nursing education in China, nurses with master’s and doctoral degrees are relatively few, and imposing master’s degree as an eligibility criteria will create a deficit of skilled nursing personnel at a national level. The ICN Guidelines for Advanced Nursing Practice (2020) state that given the differences in the healthcare environment and nursing education level among countries, some countries senior clinical nurses with extensive practical experience can practice as specialized nurses in a particular field after completing a short training course. Breast specialist nurse training in China is still in its early stages. These nurses are registered nurses who have (i) undergone systematic and standardized training in caring for patients with breast diseases, (ii) a high level of practice skills and professional knowledge pertinent to this specialty, (iii) excellent communication and management skills, as well as counselling and teaching skills, and (iv) the ability to provide and supervise clinical nursing care for patients with breast disease.²³ Recertification serves as the cornerstone for maintaining the clinical competencies of specialist nurses and safeguarding patient outcomes. Unlike initial certification, which verifies entry-level competencies at a single time point, recertification evaluates ongoing competency maintenance through periodic assessment. Therefore, this system emphasizes indicators reflecting continuous learning and professional development over time. However, relevant nursing standards for the recertification assessment system of specialized nurses are currently lacking. Therefore, constructing a referenceable recertification and evaluation system for breast specialist nurses carries enormous practical significance.

The Breast Specialist Nurse Recertification Evaluation System Based on Job Competency Is Practical

Research has pointed out the relatively short training time for specialty nurses in China, and when comparing with the requirements for advanced practice nursing, the gap in competency requirements and admission standards for specialty nursing is even more evident.²⁴ Besides, specialty nursing has heavy emphasis on training but little emphasis on practice, with many nursing managers having the opinion that significant quality disparities exist among specialty nurses.²⁵ To resolve these concerns and ensure and promote sustained development of breast specialist nursing, recertification—in addition to the initial certification—is necessary. Recertification evaluation systems need to be more elaborate and better reflect specialty nurses’ self-improvement and self-learning abilities once they resume their roles after the initial certification. The best treatment and nursing practices be achieved only with a solid foundation of clinical judgment thinking skills, professional knowledge, and excellent nursing operational skills, with a collective aim to improve nursing quality and patient satisfaction. Implementing these raised standards will improve the baseline quality of clinical practice.

Furthermore, the professional trajectory of a breast specialist nurse necessitates continuous professional development, which involves fostering the qualities and abilities of communication skills, coordination, innovation, nursing research, and professional and humanistic qualities. Imbibing these attributes will upgrade nurses’ professional identities and enable them to provide better humanistic care to patients. Finally, specialty nurses need to have certain management skills to (i) conduct consultations for difficult cases, (ii) organize the operations of specialty nursing clinics, (iii) provide patients with out-of-hospital support, (iv) improve connections with other hospitals and community health service centers, and (v) assist in developing a tertiary breast nursing diagnosis and treatment system.

Comprehensiveness of Evaluation Index System of Recertification of Breast Disease Specialist Nurses

Embodiment of Core Competencies: Clinical Practice, Expertise, and Critical Thinking

Post competency refers to the traits, skills, and knowledge employees in an organization should have to be competent for their jobs. It includes implicit competency (eg, social roles, self-concept, traits, and motivations) and explicit competency (eg, knowledge and skills). Post competencies for nurses include the professional growth, nursing skills, information utilization ability, critical thinking ability, communication skills, professional knowledge, lifelong learning ability, professional values, and management and cooperation required for the position. The recertification evaluation index system for breast specialist nurses established in this study includes 7, 28, and 105 first-, second-, and third-level indicators, respectively. The following are the first-level indicators in decreasing order of weight: clinical practice skills (0.153, mean: 4.87 ± 0.352, CV: 0.072), clinical expertise (0.151, mean: 4.80 ± 0.414, CV: 0.086), critical thinking skills (0.151, mean: 4.80 ± 0.414, CV: 0.086), professional development skills (0.140, mean: 4.47 ± 0.516, CV: 0.115), communication and coordination skills (0.140, mean: 4.47 ± 0.640, CV: 0.143), professional and humanistic qualities (0.138, mean: 4.40 ± 0.507, CV: 0.115), and management skills (0.128, mean: 4.07 ± 0.704, CV: 0.173). Figure 2 visually illustrates the weight distribution of these seven first-level indicators. Clinical practice skills, clinical expertise, and critical thinking skills formed a cluster of core clinical competencies with comparable weights (0.153, 0.151, and 0.151, respectively), reflecting balanced expert recognition of their importance to breast specialist nursing practice. The weight distribution suggests that recertification assessments should prioritize clinical competencies, particularly PICC and implanted port maintenance, lymphedema management, and tumor wound care, whereas lower-weighted indicators, such as management skills, may be assessed with less emphasis. This differentiation can guide efficient allocation of assessment efforts. Meanwhile, critical thinking ability and professional knowledge also emerged as essential components in this domain.

Figure 2.

Weight distribution of the 7 first-level indicators.

Professional Development Skills

The continuous career development of breast specialist nurses also requires their own continuous professional development ability. It demands that they constantly learn new knowledge, apply evidence-based medical knowledge to clinical practice, guide clinical nurses with what they have learned, and at the same time conduct nursing research and innovation.

Professional and Humanistic Qualities

Professional and humanistic qualities are fundamental to nursing. Enhancing nurses’ professional quality is essential to ensuring high-quality care. This indicator system provides detailed requirements, emphasizing the need to strengthen nurses’ professional identity and humanistic abilities. It also requires utmost respect for patients’ informed consent and strict adherence to medical ethics and morality to better serve patients.

Beyond Clinical Expertise: Communication and Coordination Skills and Management Skills

The multidisciplinary team (MDT) model for diagnosing and treating breast cancer has matured and is now widely used. In this context, specialist nurses play a crucial role by effectively coordinating patients with various medical professionals. This collaborative approach significantly improves workflow efficiency and fosters a culture of teamwork.²⁶ In addition, specialist nurses should have organizational and management skills, including consulting on complex cases, operating specialized nursing clinics, conducting root cause analysis (RCA) of adverse events, and strengthening clinical nursing quality management to enhance the overall quality of nursing care.

Recertification for Breast Specialist Nurses Is an Indispensable Part of Achieving Sustainable Development in Breast Specialist Nursing

Compared with other disciplines, breast cancer care is relatively new in China, and thus, the training of specialty nurses in this domain has lagged slightly behind. The “National Nursing Career Development Plan (2021–2025)” emphasizes establishing a nurse training system guided by job demands and focused on job competency to improve the training of specialty nursing talent. This study provides a structured framework for periodic recertification assessment, addressing the gap between initial certification and ongoing competency evaluation, as well as supporting sustainable development of the specialist nursing workforce. Our research team is dedicated to investigating the training of breast specialist nurses and has implemented the recertification program developed in this study in practice. This has promoted the opening of breast specialist nurse clinics, the establishment of relevant assessment systems and standards, full utilization of the professional value of specialty nurses, and clarification of the job responsibilities of breast specialist nurses to promote high-quality development in the field.

Although McClelland’s competency theory provides a useful structural framework, it originated in corporate settings. Nursing’s relational and ethical dimensions may require complementary theoretical perspectives. Future research should explore integrating caring science frameworks with competency-based approaches. The expert panel exclusively comprised clinical experts. Patient perspectives and non-clinical stakeholder inputs were not included, which we acknowledge as a limitation. Future research should also incorporate patient-reported outcomes and stakeholder feedback to enhance patient-centeredness and practical relevance of the system.

Conclusion

This study developed a recertification evaluation index system for breast specialist nurses on the basis of post‑competency theory. Using a two-round Delphi process with 18 clinical nursing experts, the final system comprises 7 first-level, 28 second-level, and 105 third-level indicators, with “clinical practice skills” carrying the highest weight (0.153, mean: 4.87 ± 0.352, CV: 0.072), followed by clinical expertise and critical thinking skills (both, 0.151). This weight distribution suggests that recertification assessments should prioritize direct patient care competencies. The system demonstrates good scientific validity and reliability, as evidenced by high expert authority coefficients and significant concordance (Kendall’s W = 0.406, P < 0.001). This tool provides nursing managers with a standardized foundation for assessing the ongoing competency of breast specialist nurses and supporting recertification decisions.

This study presents a scientifically developed recertification evaluation system for breast specialist nurses. The system provides nursing managers with a practical tool to assess ongoing competency, with “clinical practice skills” weighted as the most important domain—highlighting the centrality of direct patient care in recredentialing decisions.

However, some limitations should be considered when interpreting the findings. The expert panel was drawn from a single province, and the lack of multi-regional, multi-center collaboration limits the generalizability of the system; additionally, no reliability or validity testing was conducted. Future multi-center studies are needed to further validate the stability of the indicator system and make dynamic refinements aligned with evolving disciplinary standards. Future research should also explore indicator simplification and feasibility testing before widespread implementation. Such efforts will enhance the system’s practicality and operational feasibility, ultimately providing actionable guidance for a broader range of breast specialist nursing managers in clinical settings. Despite these limitations, this system provides a foundational reference for other regions developing similar frameworks, with the understanding that it should be adapted to local contexts.

Funding Statement

This study was supported by the Yat-sen Scholarship for Young Nursing Scientists (Grant No. YXHL202101) and the Medical Scientific Research Foundation of Guangdong Province (Grant No. A2024333). The funding bodies had no involvement in study design, data collection, data analysis, or manuscript preparation.

Abbreviations

CV, coefficient of variation; CREDES, Conducting and REporting of DElphi Studies; MDT, multidisciplinary team; RCA, root cause analysis.

Data Sharing Statement

All data generated or analyzed during this study are included in this published article.

Ethics Approval and Informed Consent

This study has been approved by the Ethics Committee of Sun Yat-sen Memorial Hospital, Sun Yat-sen University, with approval number SYSKY-2024-227-01. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. All participants voluntarily signed the written informed consent.

Author Contributions

Ziqing Yang and Lili Wang are joint first authors and contributed equally to this paper.

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas. They participated in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agreed to be accountable for all aspects of the work.

Disclosure

The authors declare no competing interests.