2.1 Study design: qualitative and descriptive approach

The study participants comprised nurses and nursery staff members from 11 sick child care facilities in City A. Semi-structured interviews were conducted with them between early August and early September 2015. During the interviews, the participants were asked about their age, years of experience in their field, number of years providing sick child care, the characteristics of care users (children and their parents), and details of sick child care.

In City A, care fees are reduced for families receiving welfare support, those exempt from municipal tax, and those exempt from income taxes; hence, in the present study, the benefits of the care fee reduction systems and related issues were investigated.

During the interviews, questions were asked in a manner ensuring the participants' confidentiality. All participants were interviewed individually for approximately 1 hour. The interviews were audiotaped with consent from the participants and, when a participants did not desire so, written records of their interview were made with their consent.

Using a study cooperation request form, the purpose/methods of the study and ethical considerations were orally explained to the participants and manager of each sick child care facility. Interviews were conducted after obtaining their written consent. The study was implemented with the approval of the ethical review board of an organization to which the researchers belonged (27-01).

For qualitative analyses, verbatim transcripts of each interview were made, and they were classified and encoded depending on their meaning. The encoded data were labeled according to their similarities, based on which the data were divided into categories and subcategories.

3.1 Demographic variables of the participants

Of the 11 sick child care facilities in City A, 6 nurses and 7 nursery staff members from 7 facilities whose managers provided consent participated as participants in the present study. The nurses were in their 20s to 70s, their duration of nursing experience ranged from <5 to 50 years, and their duration of providing sick child care ranged from 2 to 12 years. The nursery staff were in their 20s to 60s, their duration of nursing experience ranged from 5 to 45 years, and their duration of providing sick child care ranged from 2 to 12 years.

3.2 Sick child care

The data obtained from the interviews were divided into the following 5 core categories: 1) characteristics of parents and their children who use sick child care, 2) parents’ issues, 3) care for parents, 4) care for children, and 5) work support provided at sick child care facilities. These core categories comprised 17 categories consisting of 60 subcategories and 131 labels. In this article, categories, subcategories, and participants’ descriptions are shown as [ ], « », and “ ”, respectively.

3.3.1 Characteristics of parents and their children who use sick child care

The sick child care users (referred to as parents) were mainly single parents and parents from double-income nuclear families (Table 1). (Supplementary File) Parents used sick child care because they were unable to take time off from work and had no one to look after their children. Most of the children who used sick child care (referred to as children) had infectious diseases. In addition, such care was used by children with asthma, disabled children (e.g., developmental disorder and cerebral palsy), children with physical and psychological discomfort, and postoperative children.

As some [parents’ lack of caregiving skills], staff members reported «insufficient monitoring and management», «parents do not make their children take necessary drugs in the morning», «meals inappropriate for children’s symptoms», and «children’s hygiene is not maintained». Staff members considered that parents' lack of caregiving skills is caused not only by fatigue and time restraints due to child raising and work, and limited care-related knowledge and experience, but also by reduced motivation for child raising and dependence on sick child care. In addition, staff members were distressed about parents not following the care facility rules. For example, some parents do not call the facility when they want to cancel their reservation, in which case the facility is unable to accept other children.

[Children's characteristics]

“Approximately twice a month, I treat a child who uses a respirator because their mother is busy with her older children.”

“Because they do not want to attend nursery school, some children with physical discomfort desire to continue visiting the care facility even after a cure certification has been issued.”

3.4.2 Parents’ issues

As parents’ issues, participants (referred to as staff members) reported the [idea that convenience for parents should be prioritized over looking after their children], [parents' lack of caregiving skills], and [parents ignoring the rules] (Table 2)(Supplementary File ). Staff members were concerned that parents were placing their children in care facilities as if the children were inanimate objects, with a risk of neglecting them. In addition, staff members were concerned about the ideas of parents that convenience for their work and lives should be prioritized over looking after their children.

[Idea that convenience for parents should be prioritized over looking after their children]

“Some parents blame their children for having to come to care facilities.”

[Parents’ lack of caregiving skills]

“Some parents are unable to make their children take medicine at home, and so ask us to do so at the care facility.”
“When parents are busy and their children have physical discomfort in the morning, they barely feed the children.”
“We sometimes find kelp or corn in the stools that children pass at the care facility, and so we instruct their parents to give them more appropriate food.”
“Considering that sick people should not take a bath, some parents do not clean their children or make them bathe when they are sick. In this case, the children are malodorous due to sweating.”
“The bottoms of some children have a rash, and some children wear the same clothes as the day before.”

3.5.3 Care for parents

Parents consulted staff members regarding medication, how to prepare meals suitable for their children’s symptoms, and hygiene care (Table 3)(Supplementary File). To facilitate parents’ sense of relief, these staff members showed them the ways in which their children were able to take medication at the care facility successfully. In addition, in order for parents to understand foods suitable for their children’s symptoms, staff members informed them of the meals that their children had at the care facility using pictures of these meals, and provided them with dietary guidance. Furthermore, staff members instructed parents to clean their children and wash their bottoms when the children are unable to bathe. Moreover, staff members let children bring the drawings and crafts that they made at the care facility back home so that their parents could understand the children’s behavior at the facility and feel comfortable placing them there.

[Inappropriate meals]

“When children do not want to eat, it is not necessary to force them to eat. To facilitate their recovery, we give them digestible foods at the care facility, and instruct their parents to provide such foods.”
“We provide parents with pictures of the meals that their children have had at the care facility. The parents seem relieved to know what their children eat at the facility.” “When we inform parents of what their children ate at the care facility, and ask their parents to purchase similar foods for dinner on their way home, the children seem glad.”

3.6.4 Care for children

To ensure children’s safety, peace, and relief, staff members assigned them to rooms based on their age, diseases, and symptoms (acute and recovery phases), as well as the number of children for whom these staff members were responsible. In addition, to facilitate children’s early recovery, staff members compensated for parents’ lack of caregiving skills, and provided their children with medication-related and dietary care (Table 4)(Supplementary File).

Concerning nursing care provided for sick children according to their needs, some children each required one staff member. For example, such one-to-one nursing care was necessary for 1-year-old children for milk feeding, diaper changes, and cuddling; infants with asthma for cuddling to prevent them from crying; and children with mental and physical discomfort to listen to their worries.

For disabled children, nurses constantly provided medical (e.g., suction) and daily-life care (e.g., assisting them with toileting), and nursery staff read picture books to these children. Staff members viewed nursing care as beneficial for both disabled children and their parents, and perceived such care as being unavailable due to the cost as problematic.

[Care for children]

“Once parents accept that their children do not take medication, the children will continue refusing to do so. Therefore, we convince them to take medication at the care facility.” “When mothers are unable to bring soft food to the care facility, we provide rice porridge or udon noodles.”
“The bottoms of some children have a rash due to diarrhea. Their mothers would appreciate it if we wipe their bottoms.”

[Disabled children]

“I would like to help women who have a disabled child. We recommend these women to use the care facility when they are unable to look after their children. However, it is difficult for them to pay care fees (daily rate: 2,000 yen) because they usually do not have a job and need money for necessities for their children, such as diapers and support equipment.”

3.7.5 Work support provided at sick child care facilities

Concerning work support for parents using sick child care, the categories of [avoidance of arriving at the workplace late and leaving early] and the [systems for reducing care fees] were extracted (Table 5)(Supplementary File). To avoid arriving at their workplace late and leaving early, parents used sick child care facilities located near their residence or workplace, care facilities located between their residence and workplace, or those located on a street free from traffic congestion. In addition, to avoid arriving at their workplace late, parents made a reservation the day before or waited at the care facility before the opening hours, and staff members moved the opening hours forward.

The systems for reducing care fees were used mainly by single parents, non-regular employees, and part-time workers. Staff members viewed such systems as beneficial for children’s safety. On the other hand, they were concerned that, if children use care services because of mild symptoms or for a prolonged period, other children may not be able to use the services.

Parents who had difficulty paying fees for both nursery school and sick child care made their children take antipyretics so that they could attend nursery school. When 2 children were sick at any one time, to reduce the burden on their grandparents or care fees, their parents placed only the older child in the care of these grandparents, or made the child with milder symptoms attend nursery school.

[Systems for reducing care fees]

“Without a system for reducing care fees, some children are at risk of accidents while staying at home alone.”

«Measures taken by parents not using the systems for reducing care fees»

“To reduce the financial burden, even when children have developed a fever the day before, their parents sometimes make them attend nursery school the next morning as their fever has subsided by then.”
“It is difficult for some parents to pay care fees (2,500 yen a day per child). Therefore, when 2 children are sick at any one time, their parents sometimes make the child with milder symptoms attend nursery school.”
“When 2 children are sick at any one time, because it is usually more difficult to look after the younger child, for reasons such as having to prepare a weaning diet and make the child eat it, the older child is sometimes placed in the care of their grandparent, and the younger child is sometimes left at a care facility.”

4.1 Parents’ characteristics and child raising support

Sick child care was used mainly by single mothers and parents from double-income nuclear families, for reasons such as being unable to take time off from work or having no one to look after their children. In Japan, children are traditionally taken care of by their grandparents when necessary and, thus, these grandparents are important support resources for child raising. However, the results of the present and previous studies indicate that it is becoming increasingly difficult for grandparents to look after their children because of having to work [17,18]. Some parents hesitate to place their children in the care of their grandparents because the parents do not want to inconvenience them by doing so, or because the grandparents may be infected by the children. In addition, some parents are busy with work and child raising, and have no neighbors to look after their children [19]. Thus, parents have great difficulty in child raising due to reduced mutual support between themselves and their families/neighbors.

In Japan, where the non-regular employment rate is approximately 40% [20], some parents need to use nursery school from early morning (open at 7:00-8:30 AM) 5 days a week [21]. Therefore, they hope that the sickness of their children will not worsen their lifestyle [22]. When parents have difficulty balancing work and child raising due to the sickness of their children, the children are not able to receive fundamental care (appropriate meals, hygiene, and medication), and their recovery is delayed.

Staff members supported parents and their children in a manner facilitating the parents’ child raising. In addition, on the basis of the advice sought by parents and their children’s situation, staff members assessed the child raising ability of these parents and compensated for their lack of caregiving skills. Furthermore, to improve the ways in which parents care for their children, and help them develop their caregiving skills, staff members provided them with specific instructions (e.g., showing them the photos of the meals that their children had at the care facility) comprehensible to them. Moreover, children were provided with activities by staff members in which they made things (e.g., drawings) that they could bring back home so that their parents were able to understand the children's behavior at the facility and feel comfortable placing them there.

Parents strongly need nursing care for and supervision of their children when the children are sick [23,24]. In Japan, such care is provided mainly by primary care physicians. However, it is difficult for working mothers to seek a consultation during the regular business hours of such physicians [25]. Therefore, child raising support that such parents are able to receive using sick child care is highly beneficial. Instructions given to parents by staff members are usually based on the nursing care that these members provide for children and the parents’ working conditions; therefore, such instructions may be persuasive, practical, and markedly individualized.

4.2 Characteristics of and nursing care for children

Sick child care was used mainly by young children with infectious diseases, and it was also used by disabled children requiring medical care and those with physical and psychological discomfort. At some care facilities, to ensure children’s safety and peace or provide individualized care, the number of staff members was increased and some children were each taken care of by one staff member. According to the current systems of sick child care, at least one nurse and one nursery staff member must be appointed per 10 and 3 children, respectively [3]. Although sick child care is responding to various types of sick children by increasing the number of staff members, the cost of such an increase is generally borne by care facilities.

In City A, nursing care is provided for disabled children using a respirator at sick child care facilities because the city has no institutions in which these children are able to receive such care. In Japan, disabled children requiring medical care (e.g., suction and tube feeding) number approximately 16,000 [26], meaning that slightly more than one child per 10,000 of the population is disabled. However, 60.9% of the temporary daytime support service providers do not accept disabled children requiring specialized medical care. In addition, public institutions for younger children function more inadequately; temporary daytime support services are used by 1.8% of the infants requiring medical care, and 11.5% of the young children requiring such care [27].

The monthly fee for using temporary daytime support services is 4,600 yen regardless of the frequency of use. In contrast, sick child care is charged based on the number of times used. Therefore, some disabled children are unable to use temporary daytime support services, and they have difficulty using sick child care for financial reasons. Sick child care is beneficial for disabled children in that they are able to receive both medical care and childcare. Through conducting further discussions, nursing care provided for disabled children based on the function of sick child care may become more practicable.

4.3 Work support

Sick child care helped low-income individuals (systems for reducing care fees), and supported parents in a manner so that they would be able to avoid arriving at their workplace late and leaving early. Sick child care available from the early morning was intended for parents who wanted to avoid arriving at their workplace late, and such care was available due to an increase in the care facilities’ labor cost and the burden on staff members. Although some parents desire extended opening hours (7 AM to 7 PM) at sick child care facilities, it is a heavy burden for their children to stay there for a long time. In addition, many sick child care facilities have a clinic run by a single physician in the same location and, hence, these physicians may become overworked due to such prolonged hours [28]. Because it is difficult to extend the opening hours of care facilities, it may be rational to develop support systems for reducing the working time, which include subsidies for employers (companies).

The systems for reducing care fees facilitate child raising and work support for low-income individuals (single parents, non-regular employees, and part-time workers), as well as rest and health recovery for their children. On the other hand, due to the burden of paying fees for both nursery school and sick child care, service utilization by more than one child at any one time, and/or the prolonged use of care services, some children suffered from delayed health recovery or aggravated symptoms as a result of attending their school without using sick child care. To ensure the health of and welfare fairness for children, it may be necessary to refine public support by improving the systems for reducing care fees and providing subsidies for highcost care fees.

The present study investigated staff members from sick child care facilities in one municipality, and all these facilities employed the same care fee reduction system. Therefore, the results of the present study were unable to clarify the differences in the usage of sick child care and parents’ care-related requests according to the type of support system. To improve sick child care suitable for service user’s needs, it may be necessary to conduct care-related comparisons and assessments in consideration of the characteristics of service users and support systems for them.