Childhood cancer: Generally, leukemia, brain tumors, neuroblastomas, lymphomas, and renal tumors are common. Childhood cancer is a general term encompassing these diseases. In this study, it refers to a malignant tumor that develops during childhood.

Initial treatment: The first treatment received upon hospitalization after disease onset.

This is a quantitative study based on a self-administered questionnaire.

We prepared a questionnaire based on a previous study [2] regarding the impact of hospitalization of children on families during the period “from hospitalization to initial treatment” and the period “from completion of initial treatment to hospital discharge” of their sick child. The study results revealed physical, psychological, and lifestyle-related effects on the parents, siblings, and grandparents when parents accompany a sick child during hospitalization. Questions were created based on 40 items extracted from these results ( Table 1 ).

The questionnaire had six responses: “6 = Very strongly agree”, “5 = Strongly agree”, “4 = Agree”, “3 = Disagree”, “2 = Strongly disagree”, and “1 = Very strongly disagree”. Subjects were asked to respond separately depending on the two periods of “from hospitalization to initial treatment” and “from completion of initial treatment to hospital discharge”. Response time was 20 minutes.

The subjects comprised 1100 nurses engaged in nursing care for childhood cancer patients at a total of 110 facilities in Japan that treat childhood cancer patients. These included university hospitals, childhood cancer core hospitals, and childhood cancer medical facilities.

Data were collected from July 2019 through March 2020. The study purpose, methods, and other details were explained in writing to the nurses in charge at each facility and they were requested for their cooperation. Nursing department directors who agreed with the purpose of the study and consented to cooperate requested—through the head nurse of the relevant ward—the eligible nurses to participate in the research. Eligible nurses were provided a written document that explained the study’s significance, purpose, methods, ethical considerations, as well as the differences between the periods “from hospitalization to initial treatment” and “from completion of initial treatment to hospital discharge”.

The survey investigated subject attributes (age, number of years of experience) and subjects’ facility attributes (whether parental accompaniment was allowed). The questionnaire was titled “Questionnaire on Family Status during Two Time Periods of Their Sick Child”.

Exploratory factorial analysis was performed on the question items. The reliability of the extracted items was investigated. Analysis was performed using the SPSS ver. 30.0 analysis software.

This study was approved by the Ethical Review Board of the affiliated facility (approval no. 2273). Participants were considered to have provided consent to participate by returning the completed questionnaire. Participants were informed in writing that participation was voluntary; that they would not suffer any disadvantages if they did not participate; that the questionnaire was anonymous, and individuals could not be identified from the study content; that, because it was an anonymous questionnaire, they could not revoke their consent; that data obtained in the study would only be used for research purposes; that data would be strictly managed; and that data would be destroyed after being stored for five years.

In terms of age, we identified that 80% of the study subjects were in their 20s, 30s, or 40s, and the number of subjects was similar for each age range. On average, participants had 12.5 years of experience as nurses and seven years of experience in childhood cancer nursing. Accompanying sick children was allowed at 89.6% of the subjects’ affiliated facilities and not allowed at the remaining 10.4%.

We distributed 272 questionnaires (valid responses: 208; valid response rate: 76.5%).

Factorial analysis was performed on the question items. Next, correlation analysis was performed on the periods “from hospitalization to initial treatment” and “from completion of initial treatment to hospital discharge” to clarify relationships amongst the factors.

Exploratory factorial analysis was performed on the 40 items. Consequently, three factors and 19 items for these three factors were identified ( Table 2 ). The contribution ratio of each factor was as follows: 4.32% for factor 1, 3.38% for factor 2, and 2.0% for factor 3. The Kaiser-Meyer-Olkin sampling adequacy precision (hereinafter: KMO value) was 0.796 and Bartlett’s test of sphericity was significant (α < 0.001).

Factor 1 had 12 items and was named “family status”. Factor 2 had four items and was named “critical psychological status of families”. Factor 3 had three items and was named “differences in perspectives between parents”.

Mean values, standard deviation, and Cronbach’s α for the three factors are presented in Table 2 and Table 3 .

Note: factor loading > 0.40 are in boldface. Cronbach’s alpha for the total score was 0.834. Factor extraction method: Principal factor method Rotation method: Promax method with Kaiser normalization.

“Differences in perspectives between parents” during the period from hospitalization to initial treatment did not correlate with “family status” and “critical psychological status of families” from completion of initial treatment to hospital discharge ( Table 4 ).

**Correlation coefficient is considered significant at 1% (two-sided). *Correlation coefficient is considered significant at 5% (two-tailed).

For all three factors, the mean values were lower during the period from completion of initial treatment to hospital discharge than during the period from hospitalization to initial treatment. This indicated that completing initial treatment improved family status and reduced the sense of psychological crisis. During the initial period of hospitalization, parents experience overwhelming psychological confusion as they are forced to make choices regarding their child’s sudden illness, hospitalization, and treatment [5] . Additionally, parents experience the pressure of having to rapidly make medical decisions for their child despite not yet being able to accept or understand their child’s illness [6] . However, when the initial treatment is completed, and this is particularly true for diseases such as leukemia, parents display understanding, including offering support for their child when they experience side-effects of chemotherapy. They begin appreciating and accepting their child’s condition. These findings indicate the gradual alleviation of parents’ psychological confusion [7] [8] .

“Differences in perspectives between parents” during the period until initial treatment did not correlate with “family status” and “critical psychological status of families” during the period from completion of initial treatment onward. This suggested that, during the period until initial treatment, psychologically confused parents exhibited differences in perspectives regarding their child’s illness and treatment. However, during the period from completion of initial treatment onward, these differences in perspectives decreased. Greater social support for parents enables families to overcome challenges better [9] . During this period, parents, who are in a state of psychological confusion, are able to comprehend the situation and cooperate with one another better, which facilitates a convergence of perspectives.

There is no major difference in situations between “families during the period from hospitalization to initial treatment” and “families during the period from completion of initial treatment to hospital discharge”. However, it is assumed that there is a slight reduction in family confusion during the period after completion of initial treatment compared to family confusion during the period when their child’s illness first appeared.

We prepared the category, “Families during the sick child’s hospitalization course” based on existing research results [3] and the results of the present study ( Table 5 ). During the period “from hospitalization to initial treatment”, many observation viewpoints are related to parents’ acceptance and understanding of their child’s illness and treatment, parents’ psychological state as their sick child’s disease progresses, and family functions.

The period “from completion of initial treatment to hospital discharge” was a time of increasing psychological instability and fatigue due to the psychological and physical burdens placed on the parents and siblings. Therefore, observation viewpoints focused on psychological aspects.