Fifty facilities in Japan were randomly selected from hospitals with more than 100 beds registered in the Welfare and Health Information Network Project of the Japan Health and Welfare Organization. Representatives of the nursing departments received a request letter, a consent form, and a return envelope, asking if they would participate in the study and, if so, how many participants would be included. In total, 33 facilities agreed to participate in the survey.

The nursing department representative was asked to select wards with opportunities to care for terminally ill cancer patients suitable for the study. A total of 607 nurses with at least two years of practical nursing experience from the selected wards were chosen as study participants. First-year nurses were excluded because their priority was to learn general nursing tasks and acclimate to the work environment. Managers at the head nurse level or above were also excluded from the study population.

Data were collected through an online survey. A research description with a QR code was distributed to the participants from February to March 2025 by a representative of the nursing department. Participation was voluntary, and responses were requested within two weeks of receiving the documents.

The basic attributes included age, sex, years of nursing experience, years of experience caring for terminally ill cancer patients, experience working in palliative care wards, and certification as a certified nurse or specialist nurse in the field of cancer.

Questions were asked about the existence of visitation restrictions for terminally ill patients in the wards where they work, as well as the visitation hours and the number of visitors allowed under the restrictions.

The revised version of the self-assessment scale for nurses to enhance dialogue support between terminally ill cancer patients and their families [18] was used. This scale emphasizes family beliefs and perspectives and was developed using the Illness Belief Model [19] as its theoretical basis, which is a model that supports the healing of families through therapeutic conversations. The scale consists of the following four factors and 18 items and measures the practice status of dialogue support between terminally ill cancer patients and their families: Focusing on patients and families for a deeper understanding, assessing patients’ and families’ dialogue needs, engaging with patients and families with respect for each other’s perspectives, and utilizing a team approach for seamless dialogue support. The responses were rated using the following 5-point scale: “1. Never,” “2. Rarely,” “3. Sometimes,” “4. Often,” and “5. Always.” The scores ranged between 18 and 90, with higher scores indicating a greater frequency of engaging in dialogue support practices. The opportunities for engaging in dialogue support between terminally ill cancer patients and their families were rated using a 4-point scale as follows: “1. Not at all,” “2. Rarely,” “3. Sometimes,” and “4. Frequently.” Whether they had experience providing dialogue support connecting terminally ill cancer patients and their families using video calls or meeting apps like Zoom (hereafter referred to as “experience in providing dialogue support online”) was also asked.

We asked whether they had participated in training on end-of-life family nursing. Referring to a qualitative study [16] that clarified the difficulties of dialogue support between nurses and terminally ill cancer patients and their families, the following eight items were addressed: “building a trusting relationship with the patient,” “building a trusting relationship with the family,” “addressing topics related to death,” “understanding the values of both the patient and the family,” “assessing the necessity of dialogue support,” “determining the timing of dialogue support intervention,” “evaluating the reactions of patients and families after dialogue support,” and “evaluating one’s own involvement after dialogue support.” When providing dialogue support between terminally ill cancer patients and their families, participants were asked to select multiple items from these eight items that they considered challenging.

Descriptive statistics were calculated using IBM SPSS Statistics (Ver. 28). A normal distribution was confirmed, and correlation coefficients and mean differences were calculated using Pearson’s correlation coefficient and independent t-tests, respectively.

This study was approved by the Ethics Committee of Japanese Red Cross Akita College of Nursing (No. 2024-114). We informed participants in writing that participation was voluntary, refusal would not result in any disadvantages, and results would be published in academic conferences and articles without identifying individuals, since the survey was anonymous. Participants were asked to check items to confirm their consent to participate in the online survey and their agreement with the research.

Responses were obtained from 293 participants (response rate: 48.3%). Since there were no missing values, all responses were considered valid and used in the analysis. There were 277 female respondents (94.5%). The average age was 37.8 ± 9.6 years (range: 23 - 62 years), and the average number of years of nursing experience was 15.2 ± 9.3 years (range: 2 - 42 years).

A total of 90.4% of the participants said that there were “visitation restrictions at their affiliated ward.” Regarding restrictions on visiting hours, the most frequent response was “in the case of patients who are nearing death, permission to relax visiting hours can be obtained from the doctor” (47.8%), followed by “about 15 minutes” (27.0%). Regarding restrictions on the number of allowed visitors per visit, the most frequent response was “2 persons” (50.9%), followed by “in the case of patients who are nearing death, permission to relax the number of allowed visitors can be obtained from the doctor” (28.0%).

Those who responded that there were no visitation restrictions (n = 28, 9.6%) had a higher mean score on the subscale “Focusing on patients and families for a deeper understanding” of the revised dialogue support self-assessment scale than those who responded that there were visitation restrictions (n = 265, 90.4%), with a significant difference (4.2 ± 0.5, 3.9 ± 0.6, p = 0.044). In contrast, no significant difference was observed between the presence or absence of visitation restrictions and the total score on the revised Dialogue Support Self-Assessment Scale.

Those with experience in online dialogue support using videophones or meeting apps such as Zoom (36.5%) had a significantly higher average total score on the revised dialogue support self-assessment scale than those without such experience (63.5%) (73.3 ± 8.4, 69.2 ± 9.9, p < 0.000).

In terms of learning experience, those with learning experience in end-of-life family nursing (53.2%) had a significantly higher mean total score on the revised dialogue support self-assessment scale than those without learning experience (46.8%) (72.8 ± 9.1, 68.3 ± 9.6, p < 0.000).

In terms of difficulties in dialogue support practice, those who reported difficulty in “addressing topics related to death” (72.0%) had a significantly lower mean total score on the revised dialogue support self-assessment scale than those who reported no difficulty (28.0%) (69.7 ± 9.4, 73.3 ± 9.6, p = 0.003). In addition, those who reported difficulty in “assessing the need for dialogue support” (22.9%) had a significantly lower average total score on the revised dialogue support self-assessment scale than those who reported no difficulty (77.1%) (67.7 ± 9.6, 71.6 ± 9.4, p = 0.003).

^aUnpaired t-test; ^bPearson’s product-moment correlation coefficient.

In the present survey conducted between February and March 2025, approximately 90% of respondents indicated that “visitation restrictions” were in place, suggesting that visitation management continues to this day. Regarding restrictions on visiting hours, the most frequent response was “in the case of patients who are nearing death, permission to relax visiting hours can be obtained from the doctor” (47.8%), followed by “about 15 minutes” (27.0%). Regarding the number of allowed visitors, the most frequent response was “2 persons” (50.9%). These restrictions are thought to still be in use, based on the initial guidelines outlined in the Ministry of Health, Labour and Welfare’s compilation of visitation case examples [2] , which included measures such as “limiting visiting hours to less than 15 minutes” and “limiting the number of visitors to two per group.” The present study showed that, though each facility has its own framework, a certain degree of discretion appears to be given to the frontline, such as allowing physicians to decide whether to relax visitation restrictions as patients are nearing the end-of-life. This decision seems to be made comprehensively based on multiple factors such as the patient’s medical condition, the family’s wishes, and in-hospital infection control policies. The discretionary application of rules by physicians has the advantage of allowing for flexible responses tailored to each patient’s circumstances. However, it is also true that consistency and transparency are required in visitation rules. To achieve this, it is important to establish general standards while ensuring that exceptions related to end-of-life visitation are shared among staff members. Maintaining consistency in standards while preserving flexibility is considered key to healthcare providers building trust with patients and their families. This is expected to help alleviate patients’ and families’ anxieties and concerns, and reduce the sense of unresolved issues among bereaved family members. Given these circumstances, there is a need to reestablish dialogue support strategies to maintain and strengthen the relationship between terminally ill cancer patients and their families. What is referred to here as dialogue support does not simply mean extending visiting hours. It includes nurse interventions before and after visitations that facilitate connections between patients and their families through dialogue. Indirect engagement around the time of visitations is important, for instance, initiating verbal contact before visits, monitoring the expressions of patients and their families, remaining nearby to watch over and help connect the feelings of both parties, assessing reactions after visits, and sharing the meaning of these reactions with the team. These involvements are believed to contribute to providing peace of mind to both patients and their families, as well as to maintain their relationship. A characteristic of dialogue among Japanese people is that patients and their families cope with the terminal stage by denying the imminence of death [20] . Moreover, there is an underlying culture of consideration, assuming that people understand each other without needing to be expressed in words [21] . Given these cultural background characteristics, which value a silent stance toward death and emphasize reading between the lines, what is needed is not the active promotion of dialogue in the short time available, but rather consideration, remaining nearby to watch over, allowing them to communicate with one another in their own words. The process-oriented involvement of nurses before and after the visits transcends the limited time frame of visitations and offers valuable insights that contribute to improving the quality of dialogue support.

The present study showed that nurses were supporting dialogue between terminally ill cancer patients and their families, regardless of whether there were visitation restrictions. Of all the respondents, 86.3% had been engaged in nursing duties since before the COVID-19 outbreak in 2020. The fact that many of the nurses had more than five years of practical nursing experience at the time of the survey (2025) suggests that they possibly had, on a daily basis, in-person experience providing dialogue support to terminally ill patients prior to the infection outbreak. During the COVID-19 pandemic, these nurses were unable to provide adequate end-of-life family care, perhaps resulting in feelings of regret and suffering. These experiences may have served as a turning point, stimulating their “own frames of reference” for supporting dialogue between terminally ill patients and their families. According to the transformative learning theory proposed by Mezirow, this type of stimulation promotes “critical reflection” on past experiences and values, leading to transformation in behaviors and attitudes, in other words, a “perspective transformation” [22] . The infection outbreak created a vacuum in direct family care. After this period, nurses may re-recognize the importance of end-of-life family care, shifting towards a sincere attitude in facing the values and suffering of patients and their families. It could be interpreted that these transformations, prompted precisely by the existence of visitation restrictions, were elevated into the value of wanting to support the relationship between patients and families through dialogue, and they were subsequently reconstructed as a practice integrated into the actions of nurses.

A noteworthy point is that respondents who answered that they had visitation restrictions tended to have a significantly lower frequency of practicing Focusing on patients and families for a deeper understanding of the revised dialogue support self-assessment scale. Focusing on patients and families for a deeper understanding is a factor that evaluates the extent to which nurses are interested in the families. It includes items such as, “I pay attention to the family as well as the patient from the time of admission” and “I try to face the patient and their family without any prejudice” [17] . The quantitative results of the present study provide support for a previous qualitative study [23] , which found that, under visitation restrictions, nurses have fewer opportunities to interact with families, making it challenging to provide care that considers the relationship between families and the patients. These findings further emphasize that the decreased opportunities for direct interaction with families hinder practices that are conscious of the family’s presence and make it more difficult for nurses to take on a bridging role that connects patients with their families. Nurses are there to help patients confront their remaining time, and they also serve to protect family dignity as the narrator. An attitude of seeking a deeper understanding of patients and their families, even in the face of these difficulties, forms the core of dialogue support provided by nurses. The findings of the present study confirm that “striving to maintain interest in and respect for the family as the expert of the illness,” as described in the Illness Beliefs Model [19] , has a greater impact on the quality of practice under visitation restrictions. The present study provides a theoretical and practical foundation for reexamining the role nurses should fulfill under visitation restrictions and the value of dialogue support in this context.

Recent advances in infectious disease control and telemedicine have brought attention to the use of video calls and meeting apps such as Zoom for visitations on the frontlines of medical care. The present study also showed that 36.5% of all nurses had experience in providing dialogue support online, indicating that a certain number of nurses are adopting these technologies. Nurses who are incorporating innovative approaches, such as using online meeting tools, tended to engage in dialogue support between terminally ill cancer patients and their families more frequently as part of their daily routine practice. It was suggested that the introduction of online technology may be affecting the frequency of everyday dialogue support practice. Since this survey only asked whether the subjects had experience providing dialogue support online, future surveys will need to clarify the specific extent of their involvement. According to a previous study on online visitation for terminally ill patients, it was reported that greater emotional consideration is required than for regular patients [24] . Furthermore, in the case of patients who withhold their true thoughts, it can be difficult to understand their intentions. A study reported that the patient’s genuine feelings were not conveyed over the phone [25] . Patients in a weakened overall physical condition may not be able to operate their phones or social media on their own, further highlighting the need for visitations and individualized handling [26] . Thus, while in person, one can gauge the timing of communication with one another and say what they want to say, whereas once facing a screen, there may be things that cannot be expressed or may cause unexpected misunderstandings. Terminally ill cancer patients tend to be in poor overall physical condition; therefore, emotional consideration should be given to families who may feel anxious and saddened upon seeing such an appearance on screen. Dialogue support that considers such difficulties and incorporates thoughtfulness is expected to serve as a trigger for increasing awareness of nurses towards improving the quality of dialogue support, while also contributing to daily nursing practices. Providing dialogue support online is not only about acquiring technical skills; it can also be said to be a practice that promotes transformation in the attitudes of the nurses themselves. Even under physical restrictions, the desire and actions to connect patients with their families serve as a driving force, leading to an understanding of the essence of dialogue support and adding depth to the support. Moreover, sharing the findings of those with experience in providing support online can initiate a cycle of learning in nurses, leading to raising the organization’s support capabilities.

Furthermore, those who found “addressing topics related to death” and “assessing the necessity of dialogue support” challenging tended to practice dialogue support less frequently than those who did not find them challenging. This difficulty may be rooted in inadequate training in end-of-life family care, likely due to the nurses’ own emotional instability when facing death, as well as insufficient understanding of the relationship between patients and their families. However, some nurses have transcended these and are developing practical skills that can be used in providing support. An attitude of pausing before engaging in practice to contemplate questions such as how nurses themselves should perceive death and how to approach the distance between patients and their families is believed to influence the quality of dialogue support. The ability to empathize with their narratives and simply be present with them in their silence, remaining by their side, is a nursing practice nurtured through daily reflection. It was suggested that, in addition to specific methods and know-how for dialogue support, it is also desirable to incorporate training content that fosters the qualities needed to confront death.

In addition, those who had experience receiving training for end-of-life family nursing care tended to practice dialogue support more frequently. Knowledge and insights gained through past training experiences can deepen the understanding of the importance of dialogue support and may lead to implementation in practice. Educational Needs for Nurses to Support Dialogue between Terminally Ill Patients with Cancer and Their Families include enhancing the ability to be empathetically present and to see patients and their families through without turning away, while deepening the understanding of the patients and families and naturally introducing dialogue [27] . This study proposes training that includes educational content for modules on navigating conversations about death or best practices for facilitating emotionally sensitive online interactions, based on nurses’ concerns and the practical implications for education. Future efforts are needed to develop educational programs that incorporate such context.