A Nurse-Led, School-Based Social and Educational Intervention for Siblings of Children With Cancer (SUPREME): Process Evaluation of Perceived Impacts.

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Learn more: PMC Disclaimer | PMC Copyright Notice J Adv Nurs . 2025 Aug 28;82(5):5256–5271. doi: 10.1111/jan.70175 Search in PMC Search in PubMed View in NLM Catalog Add to search A Nurse‐Led, School‐Based Social and Educational Intervention for Siblings of Children With Cancer (SUPREME): Process Evaluation of Perceived Impacts Minna Devantier Minna Devantier 1 Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark 2 Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark Find articles by Minna Devantier 1, 2, ✉ , Mette Asbjoern Neergaard Mette Asbjoern Neergaard 3 Section for Specialist Palliative Care and Child & Youth Palliative Care Team, Department of Oncology, Aarhus University Hospital, Aarhus, Denmark 4 Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark Find articles by Mette Asbjoern Neergaard 3, 4 , Marianne Olsen Marianne Olsen 5 Department of Paediatrics and Adolescent Medicine, Aalborg University Hospital, Aalborg, Denmark Find articles by Marianne Olsen 5 , Ayo Wahlberg Ayo Wahlberg 6 Department of Anthropology, University of Copenhagen, Copenhagen, Denmark Find articles by Ayo Wahlberg 6 , Hanne Bækgaard Larsen Hanne Bækgaard Larsen 1 Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark 2 Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark Find articles by Hanne Bækgaard Larsen 1, 2 Author information Article notes Copyright and License information 1 Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark 2 Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark 3 Section for Specialist Palliative Care and Child & Youth Palliative Care Team, Department of Oncology, Aarhus University Hospital, Aarhus, Denmark 4 Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark 5 Department of Paediatrics and Adolescent Medicine, Aalborg University Hospital, Aalborg, Denmark 6 Department of Anthropology, University of Copenhagen, Copenhagen, Denmark * Correspondence: Minna Devantier ( [email protected] ) ✉ Corresponding author. Revised 2025 Jul 28; Received 2025 May 6; Accepted 2025 Aug 15; Issue date 2026 May. © 2025 The Author(s). Journal of Advanced Nursing published by John Wiley & Sons Ltd. This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made. PMC Copyright notice PMCID: PMC13069242  PMID: 40874639 ABSTRACT Purpose To explore siblings' and parents' experiences of, and perceived impacts of, a nurse‐led school‐based intervention (SUPREME) for siblings of children with cancer in Denmark. Design A qualitative process evaluation. Methods Fifteen siblings (aged 6–14 years) and 16 parents were recruited through criterion‐based sampling following siblings' participation in the SUPREME intervention. Data consisted of semi‐structured interviews and open‐ended responses from an evaluation form, and were analysed thematically. Data were collected between May 2024 and February 2025. Results The intervention created a sense of normality for siblings by providing age‐appropriate and credible information in the familiar school context, thereby strengthening the understanding of the family's cancer journey. The SUPREME nurse played a key role in easing the communication burden on siblings and parents, while also promoting recognition of siblings within the hospital setting as active participants in the family's cancer journey. Additionally, the intervention was perceived to accommodate varying levels of support needs across families. Conclusion The SUPREME intervention benefited siblings—and, by extension, their families—by equipping siblings with essential information, guiding their class communities on how to offer appropriate support and fostering siblings' inclusion in the family's cancer journey. The SUPREME intervention constitutes a new strategy for accessible, universal sibling support. Implications for Profession and/or Patient Care The healthcare system should formally ensure that professionals working with families affected by severe paediatric conditions provide family‐centred care that actively includes siblings. Impact What problem did the study address? The position of siblings of children with cancer is often complex, as they may simultaneously serve as visible front figures of the family while remaining overlooked. This study explored how parents and siblings of children with cancer experienced participating in a new sibling support intervention. What were the main findings? Nurses play a central role in supporting siblings of children with cancer by bridging family, hospital and school contexts. Where and on whom will the research have an impact? Nurse‐led, cross‐sectoral interventions such as SUPREME may help normalise siblings' everyday lives and promote their inclusion in the family's cancer journey. Reporting Method This study followed the Standards for Reporting Qualitative Research checklist. Patient and Public Involvement No patients, participants, or members of the public were involved in the design of this specific study. Keywords: cancer, childhood cancer, nurse, paediatric oncology, psycho‐oncology, qualitative research, siblings, social support 1. Introduction Siblings of children with cancer enter a ‘new normal’ marked by unpredictability and disruptions to their everyday lives following their brother's or sister's diagnosis (Alderfer and Hodges 2010 ). As family routines, roles and dynamics become centred around hospital and treatment (Long and Marsland 2011 ), siblings increasingly rely on parental support to navigate these changes (Long et al. 2015 ). Although parents are generally willing to support their healthy children, the physical and emotional demands of caring for a seriously ill child limit their capacity to do so (Davies et al. 2024 ). A key challenge is that siblings are rarely adequately informed about their brother's or sister's disease and treatment (Alderfer et al. 2010 ). Combined with their limited presence at the hospital during hospitalisations, this lack of information can contribute to feelings of marginalisation within the family (Long et al. 2015 ; Rørbech 2025 ). Additionally, studies highlight that siblings may struggle at school—academically, socially and in terms of attendance (Long et al. 2018 ; Gan et al. 2017 ; Samson et al. 2016 ). Interventions that operate across sectors and contexts to counteract such implications for siblings constitute a new strategy for support. Understanding how such initiatives are experienced by those involved is crucial to assess their potential. The present study presents a qualitative process evaluation of siblings' and parents' experiences with the SUPREME intervention—a nurse‐led, school‐based social and educational programme designed to support siblings of children with cancer. 1.1. Background Siblings respond in diverse ways to the changed family situation, yet common emotional reactions include worry, sadness, fear, loneliness, and jealousy toward their ill brother or sister (Long et al. 2015 ; Prchal and Landolt 2012 ). Some siblings experience somatic symptoms such as stomach pain, sleeping difficulties, and headaches (Lähteenmäki et al. 2004 ; Nolbris and Ahlström 2014 ). At the same time, many describe developing greater maturity, empathy, and a heightened sense of family closeness (Alderfer et al. 2010 ; Long et al. 2018 ; Prchal and Landolt 2012 ). Overall, most siblings adapt to their new circumstances and demonstrate resilience, with no consistent indications of long‐term depression or heightened anxiety (Long et al. 2018 ; Alderfer et al. 2010 ). Yet, siblings still need support (Kazak et al. 2012 ; Gerhardt et al. 2015 ). Previous studies have investigated various intervention designs targeting siblings—with group‐based support being the most frequently used format (Guan et al. 2021 ). However, methodological limitations—such as small sample sizes and variability in outcome measures—have made it difficult to identify the most effective approaches (Guan et al. 2021 ; Mooney‐Doyle et al. 2021 ; Wawrzynski et al. 2021 ). Nonetheless, siblings highlight that social support, including access to cancer‐related information and support from peers and teachers, is particularly valuable (Alderfer and Hodges 2010 ; Wawrzynski et al. 2021 ). Multiple studies emphasise the potential benefits of cross‐sector collaboration between educational and healthcare systems in supporting siblings (Alderfer and Hodges 2010 ; Gan et al. 2017 ; Davis et al. 2025 ). One study demonstrated promising results from a school‐based intervention involving nurse visits (Sjoberg et al. 2018 ), although further research is needed to fully understand the potential of this support model. In 2023, the research group behind the present study initiated a national, empirical investigation of a nurse‐led, school‐based social and educational intervention for siblings of children with cancer in Denmark (SUPREME‐ SUPport and social REhabilitation programME for siblings) (Devantier et al. 2025 ). 2. Methods 2.1. Aim The aim of this study was to explore how siblings and parents experienced the SUPREME intervention and what outcomes and perceived impacts they associated with participation. 2.2. Design This study was designed as part of a process evaluation utilising qualitative methodology (Ellard and Parsons 2010 ). A qualitative, descriptive design was chosen to explore how siblings of children with cancer and their parents experienced the intervention. This approach is particularly well suited for generating knowledge about new early‐phase initiatives (Doyle et al. 2020 ). The study draws on data from semi‐structured interviews with parents and siblings, as well as written responses to open‐ended items in self‐developed evaluation forms. The findings offer insights that may inform the refinement and implementation of similar support initiatives. The study was part of a larger, multi‐phase, multi‐site project aimed at developing, testing, and potentially implementing a school‐based social and educational intervention for siblings of children with cancer in Denmark. 2.3. Setting Paediatric oncology in Denmark is organised across four treatment centres and adopts a family‐centred approach to care. While no official guidelines exist on how to involve siblings in the care provision, the Danish Regions—responsible for hospital governance—are mandated to strengthen support for children as relatives, including siblings of severely ill children (Indenrigs‐ og Sundhedsministeriet 2023 ). Additionally, Danish municipalities, which oversee public education, are obliged to respond when a student is struggling, while individual schools are responsible for ensuring stable and supportive learning environments (Børne‐ og Undervisningsministeriet 2017 ). These formal structures shape the context within which the SUPREME intervention works. 2.3.1. The SUPREME Intervention FIGURE 1. Open in a new tab Overview of the SUPREME intervention, delivered by a designated and trained SUPREME nurse. Introduction and invitation: Within 1 month of diagnosis, families receive information about the SUPREME intervention and an invitation to participate. (1) First clarifying meeting: Within 2 months of diagnosis, the SUPREME nurse meets with the sibling at the hospital. During this meeting, the intervention's content and format are introduced, and agreements are made regarding communication with the class. (2) First educational session: Delivered shortly after the first clarifying meeting (and within 2 months of diagnosis), this session primarily focuses on medical and practical aspects of the illness and their implications for siblings, with secondary attention to emotional and social consequences. (3) Second clarifying meeting: Approximately 2 months after the first educational session, the SUPREME nurse conducts a follow‐up meeting with the sibling to check in and clarify the relevance and content of a potential second session. The second educational session is optional and its implementation is jointly decided by the sibling, their family, and the school in connection with the second clarifying meeting. (4) Follow‐up educational session: Delivered within 6 months of diagnosis, this session provides an updated medical overview but primarily focuses on the emotional and social consequences experienced by the sibling. Throughout both educational sessions, classmates receive age‐appropriate guidance on how to support their peer who is affected by a sibling's illness. In classes up to Year 5, the parent group is also invited to attend the session. All parents receive a written document with brief information about the sessions. A detailed description of the intervention has been published previously in a study outlining its development (Devantier et al. 2025 ). Each of the four treatment centres has a designated SUPREME nurse responsible for implementing the programme. 2.3.2. Recruitment and Eligibility Criteria for the SUPREME Intervention All school‐aged siblings (5–18 years) of children (0–18 years) with cancer or cancer‐like diseases (e.g., such as life‐threatening non‐malignant haematological diseases) receiving treatment at one of Denmark's four treatment centres are eligible for the SUPREME intervention. Siblings must understand Danish and attend school (Figure 1 ). 2.4. Recruitment and Eligibility Criteria for Interviews We used criterion‐based sampling to recruit parents and siblings from the SUPREME cohort for this study (Quinn 2015 ). Participation in the SUPREME intervention is defined as participation in two clarifying meetings and at least one educational session. Parents could participate in an interview even if the sibling declined, and vice versa. Exclusion criteria were: (1) significant deviations from the standard intervention course, (2) siblings' mental illness (hindering meaningful participation), (3) ill child's terminal declaration, relapse, or death. The local SUPREME nurse contacted the parents of siblings who had completed the intervention to request interviews. If accepted, the family would be contacted either by the author, MD, a student employee or a research nurse who would arrange the interview(s). Parents and siblings were informed about the purpose of the study and provided oral consent. Parents and siblings aged 15 years and older gave written consent. 2.5. Data Collection 2.5.1. Interviews Semi‐structured interviews were conducted using interview guides that addressed experiences with the SUPREME intervention: (1) the inclusion, (2) the clarifying meetings, (3) the educational session(s) and (4) the perceived impacts. Sibling interviews followed an age‐adapted, simplified guide (see Supporting Information Files for the interview guides for parents and siblings respectively). 2.5.2. Evaluation Forms After each educational session, siblings were invited to complete a six‐question evaluation form developed by the authors (see Appendix A ). The forms were distributed digitally to parents, who assisted with completion when needed, depending on the sibling's age. Responses to the open‐ended question (‘Please elaborate’) were included in the present study. 2.6. Participant Characteristics Eight siblings and their parents were matched, representing the same family with a child who has cancer (Tables 1 and 2 ). TABLE 1. Participant characteristics. n Siblings Age 6–10 11 11–14 4 Gender Male 9 Female 6 Educational sessions Received only first educational session 1 Received both educational sessions 14 Total 15 Parents Age 30–39 6 40–49 8 50–59 2 Gender Male 4 Female 12 Educational level Secondary education or lower 2 Higher education 8 Long‐term higher education 4 Missing 2 Present during educational setting Yes 6 No 10 Total 16 Open in a new tab Note: A total of 15 siblings participated in interviews. Additionally, 18 siblings were represented through parent interviews, including two sets of siblings from the same families. Of these, 4 were female and 12 were male, with ages ranging from 7 to 17 years. Seven siblings participated only in the first educational session, while 11 received both educational sessions. Two parents declined to report their educational level. TABLE 2. Characteristics of children with cancer represented in interviews. Characteristic child with cancer n = 22 Age 0–6 6 7–11 5 12–16 11 Sex Male 18 Female 4 Diagnosis Haematological 15 Extracranial tumours 3 Brain tumours 4 Open in a new tab Note: Characteristics of the 22 children with cancer referenced either directly by interviewed siblings ( n = 15) or indirectly through parent interviews ( n = 16). Some parents represented more than one child, including two sibling sets, which accounts for the higher total number of children than interview participants. 2.7. Data Characteristics Interview data were collected between May 2024 and February 2025. In addition to the interviews, a total of 14 evaluation forms were completed by siblings—seven following the first educational session and another seven after the follow‐up session (Figure 2 ). FIGURE 2. Open in a new tab Interview data. The discrepancy between the total number of eligible sibling‐parent dyads and the number of siblings arises because some parent dyads represented more than one sibling. *Reason for exclusion: Ill child's relapse or terminal declaration ( n = 4), siblings' mental illness ( n = 2), deviations from standard intervention course ( n = 4). **Parents declined on behalf of siblings. ***Completion is defined as the last contact point with SUPREME nurse. 2.8. Data Analysis All interviews were transcribed verbatim and compiled into two data sets: (1) parent data and (2) sibling data, including both interviews and open‐ended evaluation items. We conducted an inductive thematic analysis guided by the six‐phase framework of Nowell et al. ( 2017 ), with attention to trustworthiness criteria. First, author MD familiarised herself with the material and documented analytic notes reflecting initial thoughts. Preliminary inductive codes were generated and discussed collaboratively with HBL, leading to the development of a coding framework. This framework was iteratively refined and applied to both data sets. Codes were grouped into hierarchical categories, and candidate themes were identified and reviewed in relation to both coded data and the full data set. Repeated discussions between MD and HBL were held to refine theme definitions, names, and interrelations. Final agreement on themes and interpretations was reached jointly. Illustrative quotations were selected to support key themes. Themes were identified across both data sets, with particular attention to the differing perspectives of participants in relation to the intervention (e.g., direct recipients vs. subsequent recipients). This approach enabled a coherent yet differentiated interpretation grounded in the participants' respective roles. No qualitative data analysis software was used in the coding or theme development process. 2.9. Positioning and Reflexivity Author MD, a trained anthropologist with extensive interview experience, conducted interviews with six parents and two siblings. As the initiator of the SUPREME intervention, MD's involvement carried a risk of framing questions, prioritising specific topics or unintentionally influencing responses in favour of the intervention. To mitigate this, an anthropology master's student in her final year conducted the remaining 10 interviews with parents and nine siblings. Additionally, a research nurse with no direct connection to the SUPREME intervention conducted interviews with four siblings. Although the research nurse had extensive experience communicating with children, she had no prior experience conducting formal interviews. To support her, MD developed a structured guide covering aspects such as introducing the interview, creating a relaxed atmosphere and formulating follow‐up questions. A preparatory meeting was held to review the guide and address any questions. Additionally, the research nurse conducted a pilot interview before initiating data collection. 2.10. Ethical Considerations The Danish Data Protection Agency approved the study (P‐2021‐564). The Regional Health Committee reviewed the protocol and determined that no further notification was required (H‐21038025). The study complied with the Helsinki Declaration II (World Medical Association, 2013). Participants were pseudonymised and identified only by study ID or role (e.g., ‘parent/sibling X’). Interviews were conducted with sensitivity to participant well‐being. Participants chose the interview's timing, location, and presence of others. Moreover, participation was voluntary, and withdrawal was possible at any time. 3. Results The findings are organised into four overall themes: (1) Pathways to normality, (2) Shifts in roles, responsibilities, and positions, (3) A revised narrative about siblings, and (4) Varying levels of support needs. 3.1. Pathways to a New Normality This theme demonstrates that the intervention fostered a sense of normality for siblings by providing information; however, trust and the way the information was deliveredcrucial. 3.1.1. Trust Is Key Both siblings and parents emphasised the importance of meeting the SUPREME nurse before the educational sessions. These preparatory meetings were key to building trust and bridging the family and hospital context with the school setting. Although siblings felt in control– ‘She [SUPREME nurse] said that I was the one who decided what should be mentioned’ (Sibling 2, interview) – and were assured that communication boundaries would be respected, most still felt nervous before the first session. For some, however, the experience was marked by confidence and anticipation. Before the follow‐up session, siblings described feeling more at ease, knowing the format and what to expect. For parents, trust was related to their understanding of the SUPREME nurse's professionalism and position as knowledgeable: ‘We had met her [SUPREME nurse], and she was so professional, calm, and had everything under control. So, we felt completely safe’ (Parent 1, interview). Trusting relationships between parents and the SUPREME nurse, and subsequently between the SUPREME nurse and the sibling, were important for establishing a broader support network around the sibling. Through her involvement, the SUPREME nurse became part of this network, which extended to the class community, including classmates, teachers and other parents. As one parent explained: ‘All of a sudden, there was a network around him [sibling]. If we had to go to the hospital early in the morning, some of the other parents now came and picked him up and brought him to school’ . (Parent 12, interview). These supportive relations among parents within the class community strengthened siblings' attachment to school and their everyday routines. Parents also described how building a local support network–allowing others within the class community to care for the sibling–required trust in the school's ability to act. As one parent expressed: It's also a bit of a signal, right? I mean, like you can totally handle this at school. I'm [referring to the SUPREME nurse] going to tell you about it . (Parent 15, interview). These examples illustrate that various forms of trust were essential for changes in the siblings' support structures. Ultimately, it depended on confidence in the school's and class community's ability to respond and create the best possible conditions for the siblings, guided by the SUPREME nurse. 3.1.2. Empowering Information A key challenge for siblings was the lack of information about the disease and treatment that had drastically changed their everyday lives. The information provided during the clarifying meetings and educational sessions supported their understanding of the family's overall situation. As one parent noted: ‘He [sibling] picked up fragments of what was going on. But suddenly, he understood the full picture’ (Parent 1, interview). This highlights how siblings were able to piece together a previously fragmented reality. When information was offered both in the unfamiliar hospital setting and the familiar school environment, a sense of cohesion emerged: ‘He [sibling] had a meeting with [name of SUPREME nurse] at the hospital and somehow got an understanding of what goes on here, and after her visit [in class], he felt that his worlds became connected’ . (Parent 7, interview). Together, these experiences showed how adequate information fostered siblings' understandings of their situation and helped link their everyday life contexts. Parents further described how the childhood cancer diagnosis quickly became known in the family's local community, including the siblings' schools. This rapid spread of information often led to misrepresentations and misunderstandings: ‘The information runs like fire once it's out, and all of a sudden, there are different stories and misunderstandings circulating’ . (Parent 10, interview). By offering consistent information to the class community, the educational sessions helped demystify the siblings' situation and dispel misconceptions about cancer: Sibling 7: ‘I thought that maybe if the nurse came, the others [classmates] would maybe feel better’. Interviewer: ‘Your classmates would feel better?’ Sibling 7: ‘Yes, because when someone hears about cancer, their stomachs hurt, and they think about it. And they ask if it is contagious’. Interviewer: ‘Did your classmates think it was contagious?’ Sibling 7: ‘Yes, they asked about it’. The SUPREME nurse provided clear and accurate information about the disease and its treatment, which initially helped clarify the medical aspects: ‘Now I know what leukaemia is’ . (Sibling 3, interview). Once these aspects were understood, it became possible to address changes in the sibling's behaviour or routines, such as emotional reactions or school absence. When these changes were discussed in class, it promoted understanding and tolerance: ‘Now my classmates know about my brother and understand it better, like why I'm sad sometimes or take a day off’ . (Sibling 1, open‐ended). Additionally, the educational sessions' practical, instructive approach was seen as particularly valuable in offering the class community clear guidance on how to support the sibling: ‘It became very clear what they [the class] could do to support her [sibling]’ . (Parent 10, interview). This example shows the effectiveness of a step‐by‐step communication model: (1) clear medical information, (2) followed by information on practical and emotional changes in the sibling and (3) action‐oriented advice on how to respond. This sequence was essential for fostering mutual understanding and support within the class community. 3.1.3. Format and Delivery Matters Certain key features needed to be in place for the educational session to effectively support siblings within the school environment. First, it was crucial that the information came from a credible and recognisable authority with specialised knowledge: ‘She [sibling] could relax, because it was a professional that came, both because it [the situation] was serious, but also because it was some from the hospital with a certain professional background.’ (Parent 6, interview). While teachers also held authority, the SUPREME nurse represented an external figure with distinct credibility rooted in professional expertise: ‘ They [siblings] got something, which they couldn't get from us [parents] or their teachers.’ (Parent 3, interview). Second, parents highlighted that the information was presented in a factual and undramatic manner, avoiding excessive emotional weight: ‘It [educational session] wasn't dramatic or too emotional. They [the class] could talk about it on the basis of facts.’ (Parent 3, interview). They also highlighted the importance of adapting the sessions to the students' age. Siblings valued the use of visual teaching tools, which, according to parents, made the information more tangible and easier to understand. Third, parents viewed the classroom as an effective setting for delivering information, as it aligned naturally with educational goals and was recognised as a space for learning: ‘He [sibling] took it [information about disease/treatment] in after the session. I think it is also something about that it was in school, you know, the children listen.’ (Parent 4, interview). The setting also promoted a sense of balance between the affected siblings and their classmates: ‘They [siblings] were educated. Just like their classmates were.’ (Parent 3, interview). While parents generally did not believe that the educational sessions directly influenced siblings' academic performance, they noted that they helped create a more supportive learning environment. The intervention fulfilled a need for information, and the set‐up surrounding the educational sessions (e.g., credible authority, undramatic communication and the classroom setting) was a prerequisite for meeting this need. When these elements were in place, worries, misconceptions and questions about siblings' situation could subside, helping to re‐establish a sense of normality. 3.2. Shifts in Roles, Responsibilities and Positions This theme illuminates how the intervention promoted shifts in responsibilities and roles related to communicating the family's situation. 3.2.1. Taking Over Parents emphasised that siblings often navigated the family's normal life alone, carrying the responsibility of explaining the situation to others: ‘They [siblings] are accountable for so much when they enter the real world, while the rest of the family is in a bubble. They become the front figures for a whole family that has been wrecked.’ (Parent 14, interview). The SUPREME nurse's presence in the classroom was seen as a way to relieve siblings of this role by stepping in to communicate on their behalf. The intervention thus helped redistribute responsibility and ease pressure on both siblings and parents. Moreover, parents described how the SUPREME nurse also relieved them of the task of helping siblings understand the situation, viewing her role as better suited for this purpose: ‘We [parents] felt that it was a helping hand in something that we didn't know how to handle. We didn't know how to explain it to him [brother].’ (Parent 9, interview). This perspective underscored the value of the SUPREME nurse's professional background, which enabled communication of complex information that neither siblings nor parents could manage alone. 3.2.2. Creating Common Ground In addition to shifting communication responsibilities, the SUPREME nurse's presence in the classroom also facilitated a shift in positions. Until that point, siblings had been at the centre of attention—a position paradoxically both reinforced and diminished during the sessions. It was reinforced by the class's awareness of the SUPREME nurse's purpose, yet diminished as focus shifted to her unfamiliar presence. This change allowed siblings to take their place alongside their classmates rather than being singled out. Parents observe that the movement toward equilibrium in the classroom was reinforced by the educational sessions' broad and inclusive focus: ‘She [ SUPREME nurse] involved the whole class. She didn't constantly say “[name of sibling]”, but more generally talked about cancer and what they [classmates] knew about it already.’ (Parent 9, interview). As the quote shows, the SUPREME nurse ensured that discussions extended beyond the individual sibling, creating an inclusive dialogue that engaged the entire class. This wider perspective enabled conversations about difficult life circumstances and offered a platform for discussing adversity and shared experiences beyond childhood cancer: ‘It's also about offering them [the class] a language for when things are difficult and give them a possibility to learn how talk about these things.’ (Parent 6). This approach fostered mutual understanding and a sense of community, as expressed by a sibling: ‘ It was nice to know that others also knew someone with cancer. It made me feel less alone .’ (Sibling 15, open‐ended). Yet, managing experience‐sharing was crucial to ensure that the class's contributions did not dominate: ‘He [sibling] thought that some of his classmates made it a little bit about themselves. You know stories about dead grandparents and so’ . (Parent 12, interview). This example showcases the need to balance shared recognition with the specific relevance that legitimised the SUPREME nurse's presence, allowing siblings to find the experience meaningful. 3.3. A Revised Narrative About Siblings This theme underscores the intervention's potential to strengthen siblings' confidence, redefine their role within the family, and affirm their place in the family's cancer journey. 3.3.1. Overcoming a Challenge As described above, most siblings felt some degree of nervousness before the first educational session, suggesting that their participation held personal significance. One parent linked this uncertainty to concern about how the class would respond: ‘She [sibling] worried a bit about “what if the class gets mad at me or something because they don't think it's interesting?”’ (Parent 5, interview). This perspective reflected an underlying fear of negative peer reactions. However, when siblings chose to participate in the intervention with their parents, it was seen as a sign of courage and a valuable step in coping with adversity. One parent described how their child initially felt anxious but ultimately gained confidence: “She [sibling] was nervous, so nervous. But afterwards, we talked about how she felt—to her own surprise—that she could relax. Kind of like, ‘Oh, was it just that?’ […] It's about bravery in those little things it builds you up.” (Parent 6, interview). A similar sentiment was expressed by another parent, who highlighted their own surprise at how well the sibling coped and what the experience meant to him: ‘He [sibling] was so proud. We [parents] were unsure about how he would feel about it [the educational session]. But he stood tall with pride. It was his nurse who was there in his class.’ (Parent 9, interview). This perspective underscored how the intervention allowed siblings to actively shape their response to an unchosen role. However, this decision also carried a sense of reluctant necessity, as one parent explained: ‘It's [the disease] a part of our everyday life now, so he [sibling] needed to deal with it’ . (Parent 13, interview). This view suggests that, for some siblings, there was an urge to withdraw, which became difficult due to the disease's pervasive presence in family life. As demonstrated, the intervention may present a challenge for siblings, yet one that holds the potential to become a meaningful experience. 3.3.2. Being Recognised and Connected to the Hospital As no formal standards for involving siblings in the family‐based hospital life existed before this intervention, its introduction was perceived as inherently valuable. It signified a dedicated focus on siblings and legitimised their presence within the hospital setting: ‘ He [sibling] got a feeling that he was part of it [the cancer journey] . He also had an appointment at the hospital. That means a lot when you are 6 years old’ . (Parent 1, interview). This perspective highlighted how being actively invited—and expected—at the hospital fostered a sense of belonging and made siblings feel acknowledged. Moreover, as the intervention included information and an introduction to the hospital environment, parents observed that this familiarity enabled siblings to take a more active role in family life during hospital visits. One parent described this shift: ‘She [sibling] suddenly takes part in the hospital life. She knows that she is recognised there now, and she is no longer afraid to be there [the hospital]. She even feels that she can take an ice cream from the freezer now [laughs]. And it is those little things that mean something when you are a family’ . (Parent 10, interview). This view highlighted how the intervention fostered a more integrated family presence in a space previously centred exclusively around the ill child, thereby reinforcing a sense of balance within the family. In line with this, siblings emphasised the importance of being recognised as individuals in their own right, beyond their ill brother or sister: Interviewer: ‘What did you like the most about being part of the study?’ Sibling 5: ‘That many people see me, not only [name of child with cancer]’. For parents, including siblings in the intervention helped ease concerns about neglecting them amidst the demands of treatment. One parent described how the sibling's pride in the SUPREME nurse's classroom visits reaffirmed that he was not overlooked: All the worries we had about forgetting [sibling], that he would just be left to take care of himself—that has suddenly changed to something positive. He's been so proud every time she [ SUPREME nurse] visited his class. It has settled us as parents, too. He's not forgotten. (Parent 9, interview) Hence, parents are emotionally reassured–a potential secondary impact of the intervention–which also influenced siblings' sense of emotional safety: ‘He [sibling] has felt embraced. There are others besides mom and dad who can take care of me and meet me in all of this’ . (Parent 12, interview). This highlights the importance of allowing siblings to experience support beyond their immediate family. Thus, the intervention ensured that siblings felt acknowledged and cared for by others besides their parents. As shown, the intervention fostered a broader network of practical and emotional security during a period of uncertainty, while also affirming siblings as more than bystanders in the cancer journey. 3.4. Varying Levels of Support Needs This theme illustrates how variations in family circumstances shape siblings' participation in the intervention, the level of support needed, and which components are perceived as most valuable. 3.4.1. One‐Time Communication vs. Course Parents and siblings reported support needs along a spectrum—from two clarifying meetings and one educational session to longer‐term involvement with multiple sessions beyond what the current intervention format accommodated. One parent noted: ‘Everything that needed to be said was said [during the first education session]. He [sibling] was relieved and didn't need more’ . (Parent 14, interview) In contrast, others expressed a wish for extended support: ‘It would be nice if there was a possibility to get a third visit [educational session] . I mean, not as something mandatory, but something you could choose. Things change, and siblings react to that.’ (Parent 7, interview). This spectrum suggests that, for some families, the primary goal of participating in the intervention was to provide essential information (mainly medical and practical) within the school context during the early months after diagnosis. For others, sustained support aligned more closely with the unpredictable and often prolonged nature of the cancer journey. Even periods of medical stability were described as sources of evolving concerns: ‘ At that time, it was about explaining that we were less at the hospital, but that other worries occupied him ’. (Parent 4, interview). Siblings valued the ‘reminder’ function of the follow‐up session: ‘I really liked the second visit [educational session], because my friends got a reminder. So those who had forgotten were reminded. If I had the chance, I would probably have picked a third visit too’ . (Sibling 2, interview) This perspective reflected an appreciation of the intervention as a continuous process, recognising that while school life resumed, siblings' lives remained impacted in varying ways depending on the course of treatment. As circumstances evolved, some siblings continued to need ongoing support and understanding. Importantly, some families chose not to participate in follow‐up sessions despite ongoing needs– often out of consideration for the class community. As one parent put it: ‘We [parents] also considered if it [follow‐up session] would benefit the whole class, or only him [sibling]’ . (Parent 16, interview). Their hesitation reflected not lack of need but a desire not to burden the class community. In some cases, reluctance stemmed from a sense that one round of special attention was enough, and that continued visibility might disrupt the fragile sense of normality re‐established after the first session. These findings show that the intervention operated within a framework of multiple, sometimes competing, interests. However, as illustrated, its design accommodates support needs that vary by circumstance and intensity. 3.4.2. Different Weighting of Hospital vs. School‐Based Support Parents and siblings widely described the educational sessions as impactful, yet their accounts revealed varying degrees of value placed on the school‐ and hospital‐based components of the intervention. For some, the clarifying meetings primarily served as trust‐building and preparatory steps leading into the more significant school‐based sessions. In these cases, the school emerged as the main setting of importance, as one sibling emphasised: ‘The best thing was that my whole class heard about it’ . (Sibling 14, open‐ended). For others, however, the hospital‐based clarifying meetings were considered the most meaningful element—offering a confidential, safe space where siblings could express themselves more freely. One parent described the importance of this confidential connection: It was a safe space, where she [sibling] could just talk to [name of SUPREME nurse] without having to worry about our [parents’] feelings. It was a huge safety for her to know that she could talk to [name of SUPREME nurse] if something came up. And to be honest, I think that she primarily requested another school session so that she had an excuse to meet with [name of SUPREME nurse]. (Parent 10¸ interview) This example illustrates a reversal of the intervention's intended logic: the preparatory component became the cornerstone of the experience, rather than a lead‐in to the educational session. Moreover, it reflected the value placed on the SUPREME nurse's relational work and the importance of her availability. For some siblings, this pointed to a need for closure and follow‐up–though not necessarily within the school context. While parents and siblings perceived the school‐ and hospital‐based components as a coherent and complementary effort, the differing emphasis placed on each reflected diverse individual needs and preferences regarding which domains required the most support, and to what extent. 3.4.3. Timing Is Tricky The fixed timing of the intervention required that the first educational session–and the preceding clarifying meeting–be delivered within 2 months of diagnosis, ideally as close to that point as possible. While a few parents and one sibling found the timing appropriate–and one sibling even wished it had occurred slightly later–most expressed a preference for it to have taken place even closer to the time of diagnosis: ‘ It would have been the perfect scenario if it [first educational session] was right when the school heard about that he [child with cancer] had cancer’ . (Parent 5, interview). Despite this retrospective preference for earlier timing, parents acknowledged that the period around diagnosis was often chaotic and overwhelming, making implementation challenging. At this stage, siblings were rarely the top priority, as parents were consumed by urgent medical and emotional demands. As one parent put it: ‘The load of things you must deal with as parents, the list is endless’ . (Parent 5, interview). Additionally, logistical challenges during this early phase further complicated siblings' participation. Even arranging the first meeting with the SUPREME nurse could be difficult as it required parents to bring siblings to the hospital, highlighting a tension between the wish to support siblings early and the reality of limited parental capacity. At the same time, parents recognised that even a ‘short’ delay–such as a month or two–could feel significant for siblings, particularly when they were left in uncertainty about what was happening around them: A few nights after the [name of SUPREME nurse] visited his class, he lay awake and out of a sudden he asked: “Mum, does [name of child with cancer] have cancer?” I was really choked, because I was sure that he knew it was serious, and that it was cancer. For almost 2 months, he [name of sibling] didn't know. (Parent 9¸ interview) Importantly, the timing of the intervention was not solely shaped by the family's readiness. Several external factors influenced when the first components could be delivered, including the SUPREME nurse's availability, hospital admission schedules (which affected early access to the family), school breaks and coordination with the school. Although there was broad agreement that ‘the closer to diagnosis, the better,’ this was not universally true. One sibling initially declined to participate but changed his mind a few weeks later, as explained by his parent: ‘He [sibling] needed it to settle within himself first’ . (Parent 13, interview). This example, along with another sibling who preferred the session to have taken place slightly later, underscored the importance of individual readiness. For some, the immediate aftermath of diagnosis was simply too overwhelming to engage with classmates or external support. One parent reflected on the intervention's fixed structure, suggesting that it did not always align with the family's evolving needs: It [intervention] goes from a specific date to a specific date. And I mean, now you have started something up, something that the children [siblings] feel safe about, and then it's over. I don't know, but maybe you could think about some kind of follow‐up. (Parent 10¸ interview) This perspective highlighted the ethical and emotional implications of engaging siblings during a vulnerable period and then ending support at a predetermined time. It also reflected a broader recognition that siblings' challenges, and their corresponding support needs, did not follow fixed timepoints but unfolded along fluctuating and sometimes unpredictable trajectories. Yet, as shown, despite variations in the amount of support needed and the value placed on different components, siblings and parents found the intervention meaningful. Its format accommodated diverse family situations, cancer journeys and school contexts, recognising that similar challenges could present with varying intensity and require different levels of support. To summarise the findings, we have visualised parents' and siblings' perspectives on what the SUPREME intervention facilitates across different domains (Figure 3 ). FIGURE 3. Open in a new tab Parents' and siblings' perspectives on the domains in which the SUPREME intervention provides support. The figure illustrates the perceived impacts of the SUPREME intervention, highlighting interconnected benefits for three key groups: The sibling, their parents and the class community. Siblings, the primary recipients, benefited through improved understanding of the disease and family situation, a sense of normality at school and greater cohesion across life contexts. They were recognised as part of the family‘s cancer journey, and their communication burden was reduced. Parents were supported in their communicative role and experienced emotional relief, knowing that others (SUPREME nurse, class community) helped support the sibling. The class community gained awareness and understanding, with space to ask questions, receive guidance and engage in open discussions about adversity, which created a supportive environment for the affected sibling. 4. Discussion This study found that the SUPREME intervention provided siblings of children with cancer—and their class communities—with important information. The perceived impacts were closely linked to the SUPREME nurse's professional background, which combined clinical expertise, advanced communication skills, and the ability to build trust alongside the educational setting in which the sessions were delivered. Through these sessions, the SUPREME nurse relieved both parents and siblings of a communication task they felt ill‐equipped to manage. Although some siblings expressed nervousness before the first session—even after having been prepared during the clarifying meeting—overcoming this challenge fostered a sense of confidence and helped re‐establish a sense of normality in the school context. Participation in the intervention also made siblings feel recognised as part of the family and the cancer journey within the hospital setting. Different components of the intervention were valued to varying degrees, and its flexibility in accommodating diverse support needs was seen as a key strength. The intervention helped foster a sense of cohesion in siblings' everyday lives–an important outcome given existing literature emphasising the disruptive impact of a cancer diagnosis (Samson et al. 2016 ; Mooney‐Doyle et al. 2021 ; Yang et al. 2016 ). Our study offers insights into the potential of an intervention that spans the family, hospital and school contexts—an approach that remains novel within sibling support. Yet, Sjöberg et al. conducted a feasibility study of a similar initiative involving nurse visits to siblings' schools (Sjoberg et al. 2018 ). Their qualitative findings align with ours, particularly in highlighting the importance of information in helping siblings feel less different at school. However, unlike the SUPREME intervention, their approach did not include preparatory clarifying meetings or require the sibling's presence at the hospital. This difference may help explain why their study does not report on key aspects identified in our research—such as the value of preparation and trust‐building, the development of siblings' connection to the hospital and families' experiences of being recognised as a unit. These elements emerged as central to participation in the SUPREME intervention. Thus, compared to the study by Sjöberg et al., our intervention offered a higher degree of engagement, including the possibility of multiple sessions. Participants' reflections on the relevance of the hospital‐based setting and the flexibility of the format suggest that this more comprehensive approach may accommodate a broader spectrum of sibling support needs. 4.1. Universal Level of Support Our findings suggest a shared reference point among participating siblings: a need for information, normality and integration into the family and the cancer journey. This aligns with previous qualitative research (Rørbech 2025 ; Toft et al. 2019 ), while systematic reviews have highlighted inconsistencies in the literature regarding siblings' challenges, often due to methodological limitations and variation in study design (Long et al. 2018 ; Alderfer et al. 2010 ). Yet, we propose that interventions addressing these three core needs may represent a novel step toward addressing a universal level of sibling support as opposed to therapeutic interventions that tend to dominate the field (Mooney‐Doyle et al. 2021 ). This approach aligns with Kazak et al.'s psychosocial preventative model (Kazak et al. 2012 ), emphasising that all families affected by childhood cancer, including siblings, have a universal need for psychosocial support. In this context, the term universal refers to the level of support provided rather than implying that the intervention model is universally applicable across all cultural settings. We acknowledge that cultural norms regarding communication, privacy, and sibling roles may influence how such support is perceived and received. Furthermore, institutional factors—such as the organisation of school and healthcare systems—will likely shape whether an intervention is perceived as meaningful and feasible in a given local context. While our findings show that the SUPREME intervention supports a meaningful connection between siblings and the hospital, logistical challenges in facilitating their participation in hospital‐based components emerged as a barrier. This concern is echoed in Davis et al.'s study (Davis et al. 2025 ), where psychosocial oncology experts prioritised community‐ and school‐based support over centrally delivered hospital initiatives. Still, our findings suggest that the value of siblings feeling included and connected to the hospital should not be underestimated, and that logistical challenges must be weighed against these potential benefits. Davis et al.'s study further underscores the importance of providing support that transcends subgroups (Davis et al. 2025 ). This reflects a broader discussion: whether to maximise support for those most in need or to offer accessible interventions that meet the more general needs of many (Davis et al. 2025 ). We suggest that the SUPREME intervention aligns with the latter—an inclusive model of sibling support that can complement more targeted interventions where needed. Importantly, we do not claim that the SUPREME intervention addresses all siblings' challenges—particularly not those requiring more intensive or therapeutic support (Long et al. 2018 ). Rather, we propose that, given its educational and social features, along with its locally embedded components, the intervention may be applicable and accessible to a wider group of siblings. 4.2. Prevention or Rehabilitation Our findings indicate that siblings' challenges, such as fragmented understanding or assuming a front‐facing role, have often already begun to emerge by the time the intervention is initiated. The SUPREME intervention takes place during a period when siblings, along with the rest of the family, are under considerable strain (Lähteenmäki et al. 2004 ; Alderfer et al. 2010 ). It remains debatable whether the intervention should be classified as preventive or rehabilitative. A fully preventive approach would require siblings' involvement immediately after diagnosis. However, as the findings show, this is not always feasible due to logistical and emotional constraints. The SUPREME intervention can also be discussed in light of the literature framing siblings as a group ‘at risk’ (Long et al. 2018 ; Alderfer et al. 2015 ). Several studies highlight that siblings are particularly burdened during the initial months after their brother's or sister's diagnosis (Lähteenmäki et al. 2004 ; Guan et al. 2021 ), which is understandable given the upheaval and disruption that typically follow. The notion of being ‘at risk’ implies that adverse outcomes might be mitigated or even prevented. A fundamental question that this study does not resolve is whether the intervention helps prevent the escalation of such challenges—potentially making siblings less ‘at risk’ by distributing responsibility for their care across multiple actors. Conversely, from a rehabilitative standpoint—though often associated with physical rehabilitation (World Health Organization 2025 )—the SUPREME intervention might instead be viewed more as promoting social and emotional ‘functional maintenance’ under changed life conditions. 4.3. Authority, Autonomy, and Ethics in Paediatric Family Care It is essential to acknowledge that the SUPREME intervention encompasses several power dynamics that warrant critical attention. It promotes a normative framework grounded in the assumption that openness and dialogue represent the ideal. However, such assumptions are not universally applicable—neither across individual families nor across cultural contexts. Findings from the study indicate that the SUPREME nurse was perceived as a figure of authority and expertise, which is generally regarded as beneficial, as it provides guidance in a crisis‐laden situation. Nevertheless, this positioning carries the inherent risk that participation in the intervention implicitly involves acceptance of this normative framework. During an acute crisis, families are being asked to consider an offer that the institutional system presumes to be beneficial—an offer that intervenes in their everyday lives at a moment when that life, particularly the child's, is already marked by vulnerablility (Alderfer et al. 2015 ). Moreover, the intervention introduces this normative framework into the school context, shaping class‐level interactions and establishing behavioural expectations for how to interpret and respond to changes in siblings' routines and reactions. These include, for example, framing absences or incomplete homework as norm deviations that should not be penalised. In this way, the intervention becomes prescriptive, potentially creating tensions between families, educational institutions and the healthcare system. This risk also applies in cases where schools decline participation, which may thereby inadvertently exacerbate the sibling's vulnerability. 4.4. The Value of Nurse‐Led Communication Our findings indicate that parents perceive the SUPREME nurse as better suited than themselves for explaining the family's situation—including medical aspects—to siblings. This aligns with previous research showing that parents struggle to communicate disease and treatment information to siblings (Yang et al. 2016 ; Kenny et al. 2021 ). Our findings suggest that siblings may not fully absorb or process information when it comes from their parents, highlighting the critical role of the SUPREME nurse. The SUPREME nurse's clinical expertise and emotionally “neutral” position enable her to communicate in ways that are both accessible and reassuring for siblings. Prior studies have called for healthcare professionals to take the lead in providing siblings with direct information and support (Long et al. 2018 ; Toft et al. 2019 ). Our findings support this call and highlight nurses as particularly well‐equipped to fulfil this role. Although such communication tasks might traditionally be seen as parental responsibilities, our findings suggest that pre‐cancer standards for parental roles often shift in the face of overwhelming emotional and practical demands. Additionally, our findings show that the SUPREME nurse's involvement in siblings' lives can reshape their perception of the healthcare system—from a distant, partly inaccessible institution to a more approachable space. This is a promising finding considering existing standards for sibling support in paediatric oncology (Gerhardt et al. 2015 ). 4.5. Reframing Vulnerability Being the sibling of a child with cancer is not a self‐chosen position. As demonstrated in this study, accepting the invitation to participate in an intervention that brings this experience into the school context requires courage. Nevertheless, our findings suggest that the intervention offers siblings a meaningful opportunity to actively shape their own narrative and clarify their situation to others. While the fear of negative social consequences cannot be fully eliminated, which is a concern raised by both siblings and parents during the development of the intervention (Devantier et al. 2025 ), our findings indicate that participation does not compromise siblings' social standing at school. On the contrary, the intervention appears to contribute to greater understanding and tolerance. Importantly, as highlighted in this study, siblings are the ones who remain in ‘society’ during the family's most intense period of crisis. Previous research has shown that parents often struggle to navigate the profound existential, emotional, and logistical challenges of a child's cancer diagnosis (Mooney‐Doyle et al. 2018 ). Meanwhile, siblings are expected to maintain their daily routines, including attending school (Toft et al. 2019 ), which implicitly requires them to manage the consequences of the family crisis under very different conditions from the rest of the family. We argue, therefore, that it is essential to prepare and support both siblings and their surroundings in navigating this reality. 4.6. Strengths and Limitations This study has several methodological strengths. First, we applied researcher triangulation both during data collection and analytical coding, enhancing the dependability and confirmability of our findings. Second, we utilised data from two sources: semi‐structured interviews and open‐ended responses from a self‐developed evaluation form. This data triangulation strengthens the credibility of the findings as the multimodal approach enabled siblings to contribute in different ways. Notably, the youngest participants were only 6 years old, and interviewing young children can be challenging (Irwin and Johnson 2005 ). In cases where parents completed the evaluation form together with the child at home, this interaction served as a form of ‘interviewing’ within a safe and familiar environment, potentially generating more candid responses. Although several interviews with younger children were brief and may have only offered limited insights, they nonetheless contributed valuable perspectives. Prior research highlights that children may hold views that differ from those of their parents or healthcare professionals regarding what constitutes meaningful support (Murray 2001 ). Therefore, including children's voices, even when methodologically challenging, is essential (Söderbäck et al. 2011 ). Third, the study design allowed for multiple interview formats, including face‐to‐face, telephone and online interviews. While this flexibility constitutes both a strength and a limitation, it was driven by a strong ethical and practical commitment to accommodating families in a highly pressured situation. Although we preferred in‐person interviews with siblings, especially the younger ones, we prioritised accessibility and feasibility. A key strength of the study lies in the inclusion of both sibling and parent perspectives. Parents offer insights into the broader family experience and can articulate systemic or long‐term implications—often identifying patterns or concerns that children may not voice. In contrast, siblings contribute more immediate, experience‐based reflections rooted in their everyday lives. Together, these perspectives enrich the data and align with literature emphasising the importance of capturing children's voices in matters that concern them (Söderbäck et al. 2011 ). However, several limitations should be acknowledged. One concerns the timing of data collection. While we aimed to interview participants within 1 month after completing the intervention, this proved difficult in most cases. Some interviews occurred much later, which may have affected participants' ability to recall specific details. Completing the evaluation forms together with parents may also represent a methodological limitation, as parental presence could have influenced siblings' responses, as siblings are known to withhold or adapt their expressions to avoid burdening their parents. As the evaluation forms focused on the educational sessions, it would not have been appropriate for the SUPREME nurse to assist. A more neutral third party, such as the siblings' teacher, might have been a suitable alternative. Moreover, parents have different capacities for engaging in interviews, which may have resulted in their voices being more prominently represented in the study. This may have contributed to a predominance of parental perspectives on the siblings' emotional experiences and introduced an interpretive layer between the siblings' lived experiences and the narratives conveyed by the parents. Furthermore, the sibling sample was skewed toward younger children (aged 6–10), which represents a limitation of the study. Although participants were included consecutively as they completed the intervention—resulting in a naturally occurring sample—this reflects an early, broader trend in the overall intervention cohort, where families with younger siblings were more likely to participate. This age distribution may limit the transferability of findings to older siblings. Importantly, this study does not include teachers' perspectives. Their insights are crucial for understanding whether the intervention is perceived as meaningful in the classroom—an important factor in determining whether its intended effects are sustained over time. When a SUPREME nurse enters the classroom, she steps into an existing pedagogical space shaped by the teacher's priorities, the sibling's social position and the class dynamic. These contextual elements likely influence how the intervention is received and activated, and future research should explore teachers' perspectives. Another limitation is the lack of ethnic diversity in the sample. The intervention introduces a culturally embedded set of norms, and the absence of participants from diverse ethnic backgrounds limits our ability to assess how it may be experienced across cultural contexts. We also acknowledge that participation in research can be both helpful and burdensome. For some families, being involved in the study may have felt like an additional task during an already overwhelming period, requiring reflection, data collection, and decision‐making. Not all families have the resources to engage in such processes, and their perspectives are understandably absent. Similarly, families who did not find the intervention beneficial may have opted out of participating. These limitations should be considered when assessing the transferability of the findings. Lastly, a potential critique concerns the inclusion of perspectives from participants who received different ‘doses’ of the intervention—that is, some siblings received one educational session, while others received two (besides two clarifying meetings). We acknowledge that the study and the intervention itself might have appeared more uniform if only one session had been offered, or had both sessions been mandatory, ensuring that all participants evaluated the intervention from the same baseline. However, the aim of this study was not to measure the intervention's effects in a controlled or comparative sense, but rather to explore participation and perceived impacts. In this regard, variation in participation reflects real‐world implementation and provides valuable insights into how the intervention functions across different levels of engagement—making this limitation less relevant to the study's purpose. Similar flexibility in intervention pathways has also been applied in other research within paediatric oncology (Aagesen et al. 2024 ). 4.7. Recommendations for Future Research Future research should explore how hospital‐initiated interventions are perceived and received by key actors in the school context. Importantly, this study did not include teachers' perspectives. Yet their insights are crucial for understanding whether an intervention like SUPREME is experienced as meaningful within the classroom—an essential factor in assessing the sustainability and embeddedness of its intended effects. When a nurse enters a classroom, she steps into an existing pedagogical space shaped by the teacher's priorities, the sibling's social position, and the class dynamic. These contextual elements likely influence how a cross‐sectoral intervention is received and enacted in practice. In addition, feasibility analyses across the full cohort will be relevant for identifying broader patterns of participation and variation in uptake. Such analyses could contribute important insights into which families engage with the intervention, under what conditions, and with what levels of intensity. Longitudinal analyses of school absence and well‐being—including indicators of family‐level well‐being—should also be pursued to explore more systematically the potential longer‐term impacts of the intervention in families affected by childhood cancer. 4.8. Implications for Practice and Policy This study highlights the need to reframe how healthcare systems support siblings of children with serious illness. Rather than relying on individually focused interventions, early, structured, and cross‐sectoral efforts—such as the SUPREME intervention—can help integrate siblings into the family's care trajectory. By providing timely information, legitimising their presence in clinical settings, and involving their everyday social environments, such models offer a practical strategy for strengthening family‐centred care. To ensure equity in access, sibling support should be embedded as a formal responsibility within routine paediatric care. 5. Conclusion By exploring siblings' and parents' experiences with the nurse‐led SUPREME intervention, this study found that cross‐sector, educational and social support can effectively address siblings' needs for information, a sense of normality and inclusion in the family's cancer journey. Importantly, the intervention also appears to promote greater cohesion in siblings' everyday lives. While not a substitute for more intensive support when needed, the SUPREME intervention offers a promising model of universal‐level support that complements broader family‐centred approaches within healthcare. Author Contributions All authors contributed to the study in terms of study design, data interpretation, review, and critical revision of the manuscript to ensure the intellectual content and accepted the final version. Conflicts of Interest The authors declare no conflicts of interest. Supporting information Data S1: jan70175‐sup‐0001‐Supinfo.docx. JAN-82-5256-s001.docx (17.8KB, docx) Acknowledgements The study is part of the Childhood Oncology Network Targeting Research, Organisation & Life Expectancy (CONTROL), which is supported by the Danish Cancer Society (R‐257‐A14720) and the Danish Childhood Cancer Foundation (2019‐5934). Appendix A. Evaluation Forms Did you feel comfortable having a nurse visit your class to explain your brother's/sister's disease? Yes/No Please elaborate: _______________ What did you like most about the nurse's visit to your class? Was there anything you did not like about the nurse's visit to your class? Yes/No Please elaborate: _______________ Did the nurse's visit to your class make it easier for you to be in school? Yes/No Please elaborate: _______________ Would you recommend that other siblings of children with cancer agree to have a nurse visit their class? Yes/No Please elaborate: _______________ Would you have preferred that the nurse visit your class only once? 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