Nursing Support for Cancer Symptoms and Caregiver Burden in General Wards: Protocol for a Nationwide Cross-Sectional Survey in Japan

Abstract

Background:

General ward nurses increasingly care for patients with advanced cancer; however, the implementation of evidence-based nursing support remains unclear. Multicenter palliative care unit (PCU) surveys quantified nursing practices for major cancer-related symptoms and caregiver burden using systematically developed item sets; however, findings from PCU settings may not directly generalize to general wards, given differences in staffing, patient populations, and resources.

Objectives:

To describe the frequency of nonpharmacological nursing for five cancer-related symptoms (pain, dyspnea, nausea/vomiting, constipation, and delirium) and family caregiver burden provided by general ward nurses in Japan.

Methods:

We will conduct a multicenter, cross-sectional, web-based survey (Jan–Mar 2026) in designated cancer care hospitals nationwide. Registered nurses working in general wards will report their opportunities to provide symptom-related support in the past 12 months and the frequency of specific practices on a 5-point Likert scale. Item sets are based on scoping reviews and prior PCU surveys and will be refined through pretesting with general ward nurses. Primary outcomes are proportions reporting frequent use of each item; analyses will summarize overall and symptom-specific distributions, excluding respondents with no opportunity. Target sample size is 1,300–1,500, estimated using dyspnea and accounting for clustering.

Expected Implications:

This study will provide nationally representative evidence on nursing support practices in general wards. The findings will inform targeted educational strategies by identifying potential gaps suggested by the observed frequencies of reported practices and enabling contextual interpretation in relation to prior PCU findings, thereby supporting future interventions, strengthening evidence-based palliative care.

Background

Patients with advanced cancer frequently experience multiple distressing symptoms, including pain, dyspnea, nausea and vomiting, constipation, and delirium.^1–4 These symptoms profoundly impair their quality of life (QOL), physical function, and psychological well-being. Effective symptom management, integrating both pharmacological and nonpharmacological approaches, is a cornerstone of palliative care.^5–7

Family caregivers also experience considerable emotional and physical burdens,^8–12 particularly when patients with advanced cancer experience functional decline and increasing care dependency. Although palliative care can be provided at any stage of serious illness, this study focuses on patients with advanced cancer and limited prognoses, for whom symptom burden and caregiver needs often intensify. Structured nursing support, including education on symptom coping strategies and psychosocial care, can reduce caregiver distress.^13–16 Understanding how nurses support family caregivers alongside managing patients’ symptoms is essential for comprehensive palliative care.

In Japan, most cancer deaths occur in general medical–surgical wards rather than in palliative care units (PCUs), ¹⁷ reflecting patterns observed in several other developed countries.^18,19 This distribution largely reflects structural factors, including limited PCU beds, specific admission criteria for specialized PCUs, and because general wards serve as the primary inpatient setting for most hospitalized patients with cancer. General wards differ markedly from PCUs in care quality for patients with advanced cancer and limited prognoses, including suboptimal use of palliative medications, higher nurse workload, and limited opportunities for training and clinical exposure related to care for patients with advanced disease.^20,21 Nevertheless, little is known about how general ward nurses provide nonpharmacological support for cancer-related symptoms or caregiver burden. Consequently, clarifying which nursing practices are implemented in routine clinical settings is crucial for bridging the evidence–practice gap. Limited empirical data represent an important knowledge gap for clinical practice, education, and policy, with implications extending worldwide, beyond Japan.

To bridge this gap, previous multicenter cross-sectional surveys in PCUs across Japan examined nursing practices for patients with cancer-related symptoms and family caregiver burden, stratified by prognosis (months/weeks).^22–27 Key findings included a wide variation in practice implementation, highlighting opportunities for quality improvement, even within specialized PCUs. However, whether these findings apply to general wards remains unknown.

In Japan, the Cancer Control Act promotes integration of palliative approaches into cancer care and nationwide dissemination of high-quality cancer services. Designated cancer care hospitals are expected to serve as core institutions leading and supporting cancer care standardization, including symptom management for patients with advanced disease, across regions and affiliated facilities. However, nationally representative data describing how general ward nurses support patients with advanced cancer and limited prognoses remain limited, hindering efforts to prioritize education and implementation in these settings.

Rationale

General ward nurses often face unique challenges that differ from those in specialized PCUs, including limited opportunities for specialized palliative care training, competing clinical responsibilities for patients with diverse diagnoses and acuity levels, higher patient turnover, and more restricted access to interdisciplinary palliative care consultation teams. These contextual differences may influence both the frequency and type of nonpharmacological nursing support provided for symptom management and caregiver burden. Because many patients with advanced cancer and substantial symptom needs are cared for in general wards, it is essential to examine nursing practices in these settings independently from PCUs. Nationally representative data quantifying the proportion of patients with advanced cancer and limited prognoses cared for in general wards are limited, underscoring the need for a nationwide descriptive survey.

The present study will focus on patients with a short prognosis of months, who constitute the group most frequently encountered in general wards. This study focuses on patients with advanced cancer and limited prognoses in general wards because symptom burden and caregiver needs often intensify during this period. During this phase, when patients may be transitioning from disease-directed treatments to primarily symptom-focused care, proactive nonpharmacological nursing support for symptom management can meaningfully influence patient QOL and may help prevent unplanned health care utilization. Evaluating current nursing practices for this population will contribute essential evidence for developing targeted interventions and educational strategies to improve palliative care delivery in mainstream hospital settings.

Objectives

To describe the frequency of nursing support provided by general ward nurses in Japanese cancer care hospitals for six domains: cancer pain, dyspnea, constipation, nausea and vomiting, delirium, and caregiver burden. These domains were selected to ensure consistency with previous multicenter surveys in PCUs,^22–27 enabling direct comparison of nursing practices across care settings.

Two specific objectives were set.

• Objective 1: To examine nurse-reported opportunities to provide symptom-related support over the past 12 months.

• Objective 2: To quantify the frequency with which general ward nurses implement evidence-based nonpharmacological nursing practices in each domain.

The findings will generate nationally representative descriptive data to guide quality improvement, inform nursing education, and identify priority areas for future intervention research.

Methods

Study design

This multicenter, cross-sectional, Internet-based survey will target nurses working in general wards in designated cancer care hospitals in Japan. Survey will be administered anonymously using LimeSurvey (dIP Co., Ltd., Tokyo, Japan). Data-collection is planned for January to March 2026. The study protocol follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies. ²⁸ The study was approved by the Clinical Research Ethics Review Committee of Mie University Hospital (Approval No. U2025-033, approval date: November 25, 2025) and was prospectively registered with the University Hospital Medical Information Network (UMIN) Clinical Trials Registry before participant enrollment (UMIN000059078).

Setting

In Japan, cancer care is delivered through a nationwide system of designated cancer care hospitals, including Core Cancer Care Hospitals and Regional Cancer Care Hospitals. These institutions are designated by the Ministry of Health, Labor and Welfare (MHLW) based on availability of multidisciplinary cancer care, palliative care services, and educational programs for health care professionals. As of November 2025, a total of 391 designated cancer care hospitals are listed in the national database maintained by the MHLW. ²⁹ All 391 designated cancer care hospitals in Japan will be invited to participate in the study, and hospitals that provide institutional consent will be included without further selection to ensure national representativeness.

Rationale

General wards within these hospitals provide routine acute and chronic care to a broad range of patients, including individuals with cancer. Although patients with advanced disease are also admitted to general wards, the distribution, staffing structures, and availability of specialist palliative care resources differ from those in PCUs. Here, general wards constituted the primary data-collection setting, as they represent the most common inpatient environment for patients with a prognosis of months.

Study participants

Inclusion criteria

• 1.Registered nurses currently employed at a designated cancer care hospital in Japan
• 2.Working in a general ward
• 3.Providing direct bedside nursing care to hospitalized patients with cancer
• 4.Full-time or part-time employment status
• 5.Able and willing to provide informed consent to participate

Exclusion criteria

• 1.Nurses in managerial or administrative positions whose primary role does not involve direct patient care
• 2.Nurses temporarily assigned or rotating to the target ward from other departments
• 3.Nurses visiting from other hospitals for training or educational purposes
• 4.Nurses working in specialized units, including operating rooms, intensive care units, coronary care units, pediatric wards, orthopedic wards, psychiatric wards, or PCUs

Rationale

Inclusion criteria 1–4 ensure that participants have regular, direct exposure to patients with cancer requiring symptom management in general ward settings. Exclusion criteria 1–3 exclude individuals who do not consistently provide direct bedside care or lack sustained familiarity with the ward’s patient population. Exclusion criterion 4 targets wards where care for patients with advanced cancer and limited prognoses is uncommon or where the care context substantially differs from general medical–surgical wards. No minimum employment duration was specified, as eligibility was based on current ward assignment and direct involvement in bedside care. Variability in clinical exposure was addressed by measuring nurse-reported opportunities to provide symptom-related support, which were accounted for in the analysis.

Sample size

Considering the impracticality of calculating sample sizes for all six domains, we selected dyspnea as the index symptom. The rationale for this choice was threefold. Dyspnea is one of the most prevalent and distressing symptoms in advanced cancer^30,31; nonpharmacological nursing interventions for dyspnea are well established in clinical guidelines^32,33; and a previous PCU study provided empirical data suitable for sample size estimation. ²³

In a previous PCU study, the mean frequency score for fan therapy, a representative evidence-based intervention for dyspnea, was approximately 2.8 (standard deviation [SD] 1.2) on a 5-point Likert scale (1 = not at all, 5 = very frequently). ²³ To estimate the proportion of nurses who “frequently” or “very frequently” provide dyspnea interventions with adequate precision, we assumed an expected proportion of 25%–30%, a desired precision of ±2.5%, and a 95% confidence level.

$$\text{Using\hspace{0.17em}the\hspace{0.17em}standard\hspace{0.17em}formula\hspace{0.17em}for\hspace{0.17em}a\hspace{0.17em}single\hspace{0.17em}proportion:}n=Z^2\times p\times \left(1-p\right)/d^2$$

where Z = 1.96, p = 0.30, d = 0.025

This calculation estimated a required sample size of 1152–1291. Considering the survey involves clustering within facilities and wards, we accounted for design effects by assuming an intraclass correlation coefficient of 0.02–0.05 and mean cluster size of 25 nurses per ward, ³⁴ resulting in a design effect of 1.10–1.25, producing an adjusted required sample size of 1300–1500.

Based on previous PCU survey response rates (facility cooperation rate ≈ 40%; nurse response rate ≈ 22%), ²³ we estimated as follows:

In the prior PCU-based survey, the nurse response rate was 22.3% (539/2448), and no incentives were provided.

$$\text{Expected\hspace{0.17em}responses}=391\times 0.40\times 2\times 25\times 0.22\approx 1,720\mathit{responses}$$

This anticipated sample size exceeds the target range (1300–1500) and should provide sufficient precision for the primary descriptive analyses. Although no hypothesis testing was planned in this descriptive survey, a sample size calculation was conducted to ensure adequate precision of key descriptive estimates, accounting for clustering and anticipated response rates, and to support stable descriptive comparisons across domains and care settings.

Site selection and survey administration

We will send formal written requests by postal mail to the nurse directors of all 391 eligible facilities in Japan to invite study participation. The recruitment package will include a study invitation letter, a facility participation agreement form, and instructions for selecting eligible wards. Nurse directors who agree to participate will be asked to: (1) identify two general wards that meet the eligibility criteria; and (2) report the number of eligible nurses working in the selected wards. If no response is received by the initial deadline, a single reminder will be sent to confirm whether the facility wishes to participate.

For facilities that agree to participate, we will provide the required number of individualized study information sheets, each containing a description of the study purpose and procedures, assurances of anonymity and voluntary participation, and a unique QR (Quick Response) linked to the LimeSurvey questionnaire. Eligible nurses will access the web-based survey using the QR code or Uniform Resource Locator. Before answering the questionnaire, participants will be presented with an electronic informed consent page describing the study purpose, voluntary participation, confidentiality protections, and inability to withdraw responses after submission due to anonymization. Participants will provide consent by checking an agreement box before proceeding with the questionnaire.

Invitation letters will be sent in December 2025. Facilities that do not respond to the initial invitation will receive one reminder approximately 3 to 4 weeks later. Completion of the questionnaire is expected to take approximately 15–20 minutes. No financial compensation or incentives will be provided for participation in the main survey.

Measurements

Demographic and professional characteristics to be collected

• •Age (continuous variable, years)
• •Sex (male, female, or prefer not to answer)
• •Educational background (diploma/vocational school, bachelor’s degree, master’s degree, or doctoral degree)
• •Professional certifications related to cancer or palliative care (e.g., certified nurse specialist in cancer nursing, pain management, palliative care, or other)
• •Years of nursing experience (continuous variable)
• •Clinical experience working in a PCU and/or serving as a member of a palliative care team

Opportunities to provide symptom support

Participants will be asked about their opportunities to provide nursing support for five cancer-related symptoms (cancer pain, dyspnea, nausea and vomiting, constipation, and delirium) and family caregiver burden during the past 12 months, using a 4-point scale: 1 = no opportunity at all; 2 = few opportunities; 3 = some opportunities; and 4 = many opportunities.

Rationale

Unlike PCU settings, wherein care for patients with advanced cancer and limited prognoses is routinely provided, nurses working in general wards may have limited or inconsistent exposure to patients requiring palliative symptom management. This scale item allows identification of nurses with insufficient exposure and enables subset analyses among those with adequate experience. Based on preliminary discussions with general ward nurses, we asked participants to focus their responses on patients with a short prognosis (months), as patients with a prognosis of weeks are less frequently encountered in routine general ward practice. No fixed numerical definition was specified for ‘short prognosis (months),’ consistent with prior PCU-based surveys, as prognostic estimation varies in clinical practice and relies on professional judgment. The 12-month recall period was selected to capture overall practice tendencies in general wards, and the survey aims to assess relative frequency patterns rather than exact counts of specific interventions.

Nursing support for each symptom and for caregiver burden

Participants will rate how often they provide specific types of nursing support for each of the five patient symptoms (cancer pain, dyspnea, nausea and vomiting, constipation, and delirium) and for family caregiver burden, using a standardized 5-point Likert scale: 1 = not at all; 2 = rarely; 3 = occasionally; 4 = frequently; and 5 = very frequently.

The nursing support items included in the questionnaire were originally identified through a series of previous systematic scoping reviews, which synthesized evidence on nonpharmacological interventions for each symptom domain.^35–40 To ensure that these literature-derived items reflected real-world clinical practice, we supplemented them with information from semi-structured interviews with experienced PCU nurses.^22–27 These interviews helped verify whether the literature adequately captured common bedside practices.

To evaluate the questionnaire’s content validity and assess the applicability of the PCU-derived items to general ward settings, a pretest will be conducted with general ward nurses (n = 10) with oncology experience before launching the main survey. Based on the pretest results, wording refinements or item additions will be made to ensure that the questionnaire accurately reflects real-world nursing practices in general wards. The questionnaire aims to describe reported nursing support practices (including nurse-initiated or nurse-facilitated supports) and is not intended to define what is universally ‘routine’ in general wards or to delineate regulatory scope boundaries.

The specific nursing support items for each symptom are as follows:

Cancer pain (23 items)

Adjusting comfortable postures and positions, aromatherapy massage, auricular acupressure, cognitive–behavioral interventions, combined relaxation and imagery techniques (e.g., progressive muscle relaxation [PMR], guided imagery, relaxation exercises), comfort care (environmental adjustment, mental health care, oral care), educational and psychological care, self-care management education, information-focused educational programs, coaching-based education, exercise, foot baths, guided imagery, massage therapy, music therapy, narrative approach, poetry listening, PMR, Reiki, reflexology, virtual reality–based relaxation therapy, and self-administered acupressure. ²⁶

Dyspnea (14 items)

Nurse-led interventions (assessment, evaluation of care, information provision, and instruction on breathing techniques), multidisciplinary interventions involving coordination with physicians and other professionals, psycho-educational programs (relaxation, pacing, psychoeducation), breathing techniques, walking therapy, inspiratory muscle training, respiratory rehabilitation (e.g., breathing retraining, mobility exercises), yoga, acupressure, fan therapy, guided imagery, abdominal massage, aromatherapy, and environmental cooling (reducing room temperature or humidity). ²³ The focus of items involving multidisciplinary coordination is nurses’ role in assessment, communication, and referral/coordination processes, rather than the direct implementation of specialist interventions.

Constipation (6 items)

Warm compress, abdominal massage, abdominal massage with essential oils, abdominal acupressure, auricular acupressure, and self-management education. ²⁷

Nausea and vomiting (13 items)

Foot reflexology, acupressure, Reiki, guided relaxation exercises, aromatherapy, abdominal massage, therapeutic touch, psychosocial support, self-monitoring of symptoms, gargling with cold water, providing fresh air, offering shaved ice or ice chips, and avoiding unpleasant odors. ²⁵

Delirium (5 items)

Multicomponent interventions (orientation support, sleep–wake regulation, and cognitive stimulation), bright light therapy, specialist team approaches, family support, and sensory or environmental stimulation (e.g., providing cold sensory input, i.e., ice chips). ²⁴

Caregiver burden (6 items)

Non-face-to-face psychological and educational support (information and communication technology or telephone), face-to-face psychological and educational support, stress-reduction support for caregivers, mindfulness-based approaches for patients and caregivers, dyadic support for patients and caregivers, and general emotional and informational support. ²²

For each nursing support item, a brief explanation was provided in the questionnaire to ensure consistent understanding. Optional free-text fields were included at the end of each symptom domain to allow participants to describe additional practices not captured in the structured list.

Data analysis

Data management

Survey data will be collected using LimeSurvey and exported in Comma-Separated Values format. Data will then be imported into Easy R (EZR) for analysis.

Before analysis, data cleaning procedures will be performed, including checks for duplicate entries, out-of-range values, and internal inconsistencies.

Descriptive statistics

Participant characteristics will be summarized using appropriate descriptive statistics. Categorical variables will be presented as frequencies and percentages, and continuous variables as means and SDs for normally distributed variables and as medians and interquartile ranges for nonnormally distributed variables. Normality will be assessed using histograms, Q–Q plots, and the Shapiro–Wilk test.

The primary descriptive analysis will summarize the frequency of nursing support provision across the six domains. Results will be presented separately for each domain, with item-level summaries within each domain.

For each nursing support item, the distribution of responses across the 5-point Likert scale will be summarized as frequencies and percentages. To evaluate the degree of clinical adoption, two complementary indicators will be calculated: the proportion of participants selecting “frequently” or “very frequently” (score: 4 or 5), representing high-frequency implementation; and the proportion selecting “occasionally,” “frequently,” or “very frequently” (score: 3–5), representing any reported implementation in clinical practice. Category-collapsing summaries of Likert responses have been used in prior PCU-based surveys to facilitate interpretation of practice frequencies (e.g., combining adjacent response categories); therefore, we will report these two complementary summary indicators in addition to the full response distribution.^22,24–27

Given that general ward nurses may have variable levels of exposure to patients requiring palliative symptom management, subset descriptive analyses will be conducted for each symptom by excluding participants who reported “no opportunity at all” to provide support for that symptom during the past 12 months. Within these subsets, frequencies and percentages of nursing support provision will be recalculated and reported. This approach allows for more accurate characterization of practice patterns among nurses with relevant clinical exposure.

Handling of missing data

Given the anonymous nature of the survey, incomplete responses cannot be followed up. For each analysis, the number of participants with complete data for the relevant variables will be reported. Participants with missing data exceeding 20% for the nursing support frequency items of a given symptom will be excluded from analyses of that symptom. The extent and pattern of missing data will be described. If missing data exceeds 10% overall, the characteristics of participants with and without missing data will be compared to assess potential bias.

Statistical software

Statistical analyses will be performed using EZR statistical software (Saitama Medical Center, Jichi Medical University, Saitama, Japan) and R (The R Foundation for Statistical Computing, Vienna, Austria). ⁴¹

Safety considerations

This study involves minimal risk because it is an anonymous, voluntary online survey that collects no personally identifiable information. Participants may skip any question or discontinue the survey at any time. A minor risk of psychological discomfort may occur when reflecting on challenging clinical situations; however, this risk is minimal and comparable to routine professional self-reflection.

All data will be stored on encrypted, password-protected servers, and only the research team will have data access. A contact address for the principal investigator is provided for inquiries.

Follow-up process

Because this is a cross-sectional and anonymous survey, no individual participant follow-up is planned.

Discussion

This protocol describes a nationwide cross-sectional survey designed to characterize nonpharmacological nursing support for common cancer-related symptoms and caregiver burden in general wards in Japan. Because evidence–practice gaps have been reported in PCU settings, and general ward contexts differ in staffing, patient populations, and available resources, the present survey will provide foundational descriptive data specific to general wards.

Several methodological considerations should be noted. First, the survey relies on self-reported retrospective recall, and some recall bias is possible. Second, participation is voluntary at both the facility and individual nurse levels; therefore, selection and nonresponse bias may occur if participating facilities or respondents differ systematically from nonparticipants. Third, the 12-month recall period was selected to capture overall practice tendencies in general wards, where exposure to patients with advanced cancer and limited prognoses may be variable. Fourth, because prognostic estimation varies in clinical practice, we did not impose a fixed numerical cutoff for “short prognosis (months),” consistent with our prior PCU-based surveys. Despite these limitations, the nationwide sampling frame of designated cancer care hospitals is expected to enhance the breadth of descriptive evidence and to help prioritize future education and implementation efforts.

Authors’ Contributions

All the authors (J.K., K.K., M.K., Y.K., K.N., M.M., Y.M., Y.E., Y.K., and M.Y.) contributed to the preparation, drafting, and editing of the review protocols. J.K. conceived the idea of this research, followed by discussions with other authors (K.K., M.K., Y.K., K.N., M.M., Y.M., Y.E., Y.K., and M.Y.), who contributed to finalizing the research idea. All the authors contributed to the preparation and editing of the article and approved the final version.

Abbreviations Used

CSV

Comma-Separated Values

EZR

Easy R

MHLW

Ministry of Health, Labour and Welfare

PCU

Palliative Care Unit(s)

PMR

Progressive Muscle Relaxation

QOL

Quality of Life

QR

Quick Response Code

SD

Standard Deviation

STROBE

Strengthening the Reporting of Observational Studies in Epidemiology

UMIN

University Hospital Medical Information Network

URL

Uniform Resource Locator

Patient and Public Involvement

Patients and/or the public were not involved in the design, conduct, reporting, or dissemination plans of this research.

Cite this article as: Kako J, Kajiwara K, Kobayashi M, Kanno Y, Nakano K, Morikawa M, Matsuda Y, Eto Y, Kishi Y, Yamamoto M (2026) Nursing support for cancer symptoms and caregiver burden in general wards: Protocol for a nationwide cross-sectional survey in Japan, Palliative Medicine Reports, 2026, 7, 26892820261441140, DOI: 10.1177/26892820261441140.