1. Introduction
Child abuse is a high health risk and has emerged as a health issue that threatens children’s human rights and safety, and various efforts have been made to address it in recent years.
In Japan, laws such as the Child Welfare Act, Maternal and Child Health Act, and Child Abuse Prevention Act require municipalities to take proactive measures to prevent abuse and detect it early. Various sectors, including government and healthcare, provide support for child abuse. However, the number of consultations regarding child abuse is on the rise. Prefectural governments, such as public health centers and child consultation centers, are required to respond to cases that require specialized knowledge and skills and to provide logistical support to municipalities, so the need for support for child abuse is increasing.
Previous studies include surveys on the awareness of child abuse among nurses, nursing students, community college students, and university students [1] [2], as well as research on the knowledge of child abuse among nursing students by academic year [3].
In pediatric medicine in hospitals, abuse response teams have been established to work on the early detection of child abuse [4] [5]. Additionally, in nursing education at nursing schools required to become nurses, child and maternal nursing education incorporates abuse into the curriculum, providing nursing students with opportunities to learn about parenting support [6]. Nursing students are human resources who will become parents in the future and who will also be supporters, so it is essential to include education about child abuse in basic nursing education. Impart correct knowledge, increasing awareness of abuse, and educating students to increase their empathy and sociability and enhance their positive interest in children are important [1]. There is a need for improved education and research to enable nursing students to use abuse case studies to link and understand the theories of child development they learn in nursing to the phenomenon of abuse they encounter and to use this information to help them provide health guidance to mothers in order to prevent abuse.
However, research on the awareness and knowledge of nursing students regarding child abuse and infant neglect has not been conducted sufficiently. In particular, no data has been published in the past regarding Case Analysis of Nursing College Students on Infant Neglect. Before entering clinical practice, students need to consider early detection perspectives and care for postnatal mothers and infants through case studies related to infant abuse [7].
The purpose of the study is to analyze the responses and perspectives of nursing students at A Comprehensive University regarding a case of infant neglect presented as a class survey to gain insights that will inform future directions in nursing education.
2. Terminology Definition
The definitions of terms used in this study are as follows. Neglect is defined as substantially reducing the amount of food for the child or abandoning and neglecting the child for an extended period in a manner that may interfere with the normal development of the child mentally or physically or leave a person living together other than the custodian to commit any act that is equivalent to those listed in the preceding two items or the following item, or otherwise materially fail to perform the duty of custody as a custodian (Act on the Prevention, etc. of Child Abuse, Act No. 53 of 2011) [8].
Case analysis is a problem-based teaching and learning method that critically analyzes a challenging case. It places students in a “real-world” situation and applies reflection and critical thinking skills to consider appropriate solutions, decisions, or recommended courses of action. It is a more effective teaching technique than in-class role-playing or simulation activities [9] [10].
The KJ method (the initials of Kawakita) is a creative information processing and problem-solving method devised by Dr. Jiro Kawakita [11]. It is a method of capturing the diversity of voices in the field as individuality, structuring those voices, and grasping the problem while talking [12].
3. Methods
A questionnaire regarding cases of infant neglect was conducted among 63 second-year nursing students at A Comprehensive University in 2020. The study will focus on the contents of this in-class survey.
This study, conducted under the approval of the Institutional Ethics Review Board of SEITOKU University and adhering to the Declaration of Helsinki, was observational and retrospective. It involved an analysis of survey data previously utilized in nursing courses to enhance educational utility.
This study conducted a case analysis. As part of the analytical process, students were guided by questions posed about the case and asked to consider the relevance of the facts and key events presented in the case.
The survey focused on the case of a 30-year-old mother who was arrested on suspicion of abuse after leaving her baby alone at home for 16 hours, which led to the baby’s death. The aim was to understand the reasons for her actions and to explore preventative measures. The questions are: (Q1) Why did the mother leave the baby alone? (Q2) What could a nurse have done to prevent the incident? (Q3) What kind of words could a nurse offer the mother now? We also asked whether the mother’s actions were abusive. (Referred to the attached questionnaire)
The survey, conducted using Microsoft Forms, was explained to students during class. Students had the option to respond anonymously without disclosing personal data. Students were informed that their participation was voluntary and would not affect their grades. Consent was additionally sought for the potential academic publication of the survey results, ensuring no individual could be identified from the data.
Data were securely stored on USB drives in locked cabinets in the research lab for up to ten years from publication with plans for data destruction involving digital erasure and physical damage to storage media to ensure confidentiality.
This comprehensive approach was designed to safeguard participant anonymity while allowing for a thorough exploration of the incident and potential preventative strategies.
The translation and back translation of the questions from Japanese to English were initially carried out by a university teacher with a Ph.D. who has clinical experience as a midwife/nurse. They were then confirmed by two bilingual interpreters in English and Japanese.
The survey data was primarily analyzed qualitatively using the KJ methodology. However, the answers to one question (e.g., whether the mother’s actions were abusive) were presented quantitatively as numbers.
The qualitative data was exported from Forms to Excel and repeatedly reclassified into new main and sub-categories. This process was repeated until a consensus was reached through discussion with the co-author, an academic researcher, to minimize bias. The main categories are shown in italics in the text.
4. Results
The case analysis focuses on a 30-year-old mother arrested for killing her baby after leaving her baby alone at home for 16 hours. Regarding Q1, the concepts were classified into lack of affection, childcare stress, carelessness in childcare, escape from childcare, lack of awareness of childcare, childcare fatigue, financial difficulties, and personal priority in Table 1. Regarding Q2, the concept is classified into childcare environment analysis, childcare guidance, childcare consultation, family support, home visits, medical examination observation, social resource introduction, understanding infant characteristics, and listening to anxiety/ worries in Table 2. Q3 was categorized into asking, empathy, listening, reprimand, introspection, and questioning in Table 3.
All participants (63/63) reported that the mother’s actions in this case were abuse.
Table 1. The reason why the mother left the baby (Q1).
Category |
Subcategory |
Lack of affection |
Lack of attachment with the child. The child was an unwanted birth. Unwanted pregnancies. The lack of affection toward the child. |
Childcare stress |
Pain, suffering, and exhaustion of single parenting. Feelings of burden, limitation, and challenges in single parenting. The need to escape from the stress of raising a child alone. Inability to care for a child when away from home. Difficulty staying focused due to distractions. Lack of someone to talk to about childcare. |
Carelessness in childcare |
Determined that under certain conditions it is acceptable to leave a child unattended for a short period of time. |
Escape from childcare |
Loneliness, anxiety, stress, and the burden of childcare, leading to a desire to escape. The need to escape from reality. A wish to play alone and temporarily forget about one’s responsibilities as a parent. A desire to distance oneself from one’s daughter. Feelings that the child is a source of distraction. |
Lack of awareness of
childcare |
Insufficient responsiveness to child care. Lack of understanding of infant development. Lack of
awareness regarding childcare. |
Childcare fatigue |
Childcare fatigue/stress due to single parenting. |
Financial difficulties |
Mother lives alone with her child and works to make ends meet. Neglected children to earn necessary living expenses. |
Personal priority |
Putting oneself first. Priority of one’s own pleasure, what one wants to do, and what one wants to play with. Work comes first. Desire for self-freedom. Freedom from single parenting. |
Table 2. What the nurse did to the mother to prevent the incident (Q2).
Category |
Subcategory |
Childcare environment
analysis |
Childcare environment analysis and follow-up at checkups. Assessment of local childcare support systems. Temporary childcare facility services. Support for single parents facing childcare stress. |
Childcare guidance |
Telephone support during one-month checkups and hospital visits. Guidance on infant care, postpartum support, and referrals to childcare services. Help for childcare concerns and anxiety, with advice on seeking support. Explanation of separation risks and consultation recommendations. |
Childcare consultation |
Listening, advice, and referrals for concerns. Telephone consultations available. Support for mothers and childcare, including during health checkups. |
Family support |
Coordinating with relatives to secure their support. Utilizing social resources and sharing information about the newborn’s characteristics. Suggesting suitable childcare arrangements. |
Home visits |
Home visits to address mothers’ childcare concerns, offer consultations, share information on social resources, and provide support. Collaboration with public health nurses. |
Medical examination
observation |
Detection of abuse during the 3-month checkup. Observation of mothers during outpatient exams. |
Observation of maternal attachment behaviors. Assessment of the mother’s ability to care for the infant. |
Notification to the Child Guidance Center. |
Social resource
introduction |
Teaching the dangers of leaving children unattended at the 3-month checkup. Providing opportunities to speak with social workers. Introducing benefit support. Referral to childcare support and social resources at discharge and checkups. Informing about consultation services. |
Understanding infant
characteristics |
Communicate plans to leave the child with someone when going out. Guidance on managing children while going out. Survey of attitudes toward children. |
Listening to anxiety/
worries |
Listening to mothers’ concerns, difficulties, mental and physical burdens, and encouragement related to child-rearing during hospitalization after delivery and at the one-month checkup. |
Table 3. What kind of words the nurse would say to the mother now (Q3).
Category |
Subcategory |
Asking |
Relying on others. Consulting. Taking rest. |
Empathy |
In understanding parenting and child rearing, it is essential to recognize and empathize with the background of harsh parenting practices, the struggles of caregivers, and the impact of strict child-rearing methods. Parenting depends on the support of caregivers and the community. Despite its challenges, child-rearing remains a meaningful endeavor, and children rarely harbor resentment toward their caregivers. Empathy, a sense of security, and mutual understanding are thereby fostered. |
Listening |
Listening to and addressing any concerns or anxieties related to parenting. |
Reprimand |
The multifaceted factors and root causes of neglect. Consequences and adverse effects of neglect. Neglect has a profound negative impact on a child's development and constitutes a severe violation of caregiving responsibilities. |
Introspection |
Guilt awareness. Recognition of guilt. Caregiving neglect recognition. Awareness of caregiving failure. |
Effort to atone. Reparative action. Infant dependency on caregivers. Infant survival dependency. |
Self-reflection on caregiving. Critical reflection on caregiving. Child waiting for mother. Child anticipating care. |
Questioning |
Articulation of questions or concerns. Current emotional state. Rationale for your actions. Experience of social support or isolation. Emotional distress related to loneliness or caregiving anxiety. |
5. Discussion
This study examined nursing students’ responses to a case of infant neglect to enhance education. A survey of 63 second-year nursing students at A Comprehensive University gathered anonymous responses about a mother arrested for neglecting her baby. The study was primarily qualitative, using the KJ method, with some quantitative analysis as a supplement. Responses identified a lack of affection and financial difficulties as reasons for neglect. Preventative strategies included childcare environment analysis and family support. Supportive responses emphasized empathy. Moreover, Nursing students felt empathy and reprimand toward the mother. Findings highlight the need for nursing students to learn effective care strategies to prevent infant neglect, significantly as cases rise in Japan.
The case analysis focuses on a 30-year-old mother arrested for killing her baby after leaving him alone at home for 16 hours. This case analysis highlights the multifaceted factors influencing parental behavior and the potential role of nursing support. Based on the results of each question, nursing students should be provided with the following educational content.
5.1. Why did the Mother Leave the Baby Alone? (Q1)
Reasons for leaving the baby alone included lack of affection, childcare stress, carelessness in childcare, a desire to escape from childcare, luck of awareness of childcare, childcare fatigue, financial difficulties, and personal priority.
First, as shown by the lack of affection, the mother may lack love and a bond with her child, which may have led to a weak awareness of childcare [13]. The mother may have thought that leaving her child alone was no problem. Programs and support should be provided to strengthen the emotional relationship between mothers and children. Second, childcare stress and fatigue indicate that childcare as a single mother is very stressful. The desire to be free from the burden of childcare may have influenced the decision to leave the baby alone. Strengthening support for childcare stress and creating an environment where mothers can receive emotional support is necessary. As for the lack of awareness of childcare, it is thought that it is acceptable to leave a child alone for a long time, and this is due to a lack of knowledge and awareness about childcare. It is an issue to expand educational programs for mothers about childcare. Furthermore, as shown by the escape from childcare, feelings of loneliness, anxiety, and the burden of childcare may increase, and the desire to escape reality may affect childcare behavior [14]. By a literature review, the filicide rate is high in depressive psychoses (4.5 %) but lower in episodes without overt depression (less than 1%) [15]. It is necessary to build a support network for mothers to reduce the feeling of escaping reality, and to deal with postpartum depression.
Regarding financial difficulties, when mothers are exposed to economic poverty, they do not pay enough attention to childcare [13]. Social support is needed to enable them to maintain a sustainable lifestyle through childcare support allowances and vocational training programs. Finally, from the perspective of personal priority, mothers are thought to prioritize their own enjoyment and freedom and, therefore, have a weak sense of responsibility for childcare. Self-development programs and support should be provided to help mothers become aware of and take responsibility for childcare. Local communities, support groups, and governments must work together to build a comprehensive support system.
Based on the results, it is important to provide nursing students with the following education. First, regarding strengthening childcare support and counseling skills, nursing students will be taught the skills to provide stress and emotional support for childcare, leading to improved communication with mothers and increased empathy [1] [6]. Secondly, regarding the importance of childcare education, education to deepen understanding of childcare, especially by having students learn about infants’ developmental stages and the care they need, is expected to raise awareness of childcare [1]. Furthermore, regarding home visits and introductions to local resources, nursing students will be allowed to make home visits and learn about local support services and resources to understand the support necessary for mothers. Finally, regarding mental health education, they will learn ways to reduce fatigue and stress by knowing the importance of maternal mental health [10] [16]. Early interventions for children and families are facilitated by the increased awareness of service providers who understand the risk and protective factors for intentional and unintentional child death [15].
5.2. What Could a Nurse Have Done to Prevent the Incident? (Q2)
A nurse could have prevented the incident through childcare environment analysis, childcare guidance, childcare consultation, family support, home visits, medical observations, social resource introductions, understanding infant characteristics, and listening to anxiety/ worries.
First, the development and support of the childcare environment is required. In particular, the evaluation of the local childcare support system and temporary childcare facilities is necessary through childcare environment analysis [17]. In addition, in childcare guidance, telephone support and guidance on childcare are effective means for mothers. It is important to listen to mothers’ concerns and introduce them to appropriate consultation centers regarding childcare consultation. In family support, strengthening cooperation with relatives and sharing the information that mothers need is necessary to obtain support from the family. Home visits and cooperation with local public health nurses are essential for mothers to address and consult about childcare concerns. Medical observations allow early detection of abuse and evaluation of mothers’ parenting skills, which are important for ensuring the safety of children. Regarding social resource introductions, childcare support and introductions to social resources can help mothers deal with their problems.
Understanding infant characteristics can help mothers better understand how to interact with and manage their children when they are out. From the perspective of listening to anxiety/worries, it is important to provide encouragement and support for mothers’ mental and physical burdens. Strengthening education and resources throughout the community is necessary to ensure that support is provided appropriately. Furthermore, there needs to be more opportunities to listen to mothers’ voices and make improvements to tailor support to individual needs.
Based on the results, providing the following education to nursing students is essential. First, to improve their skills in evaluating the childcare environment, students will be taught how to evaluate the home environment to identify childcare risks. Training will be provided on safety in the home and strengthening the mother’s support system. Secondly, in order to improve their child-rearing consultation and guidance skills, nursing students will learn communication skills and counseling methods so that they can provide effective child-rearing guidance and reduce mothers’ anxiety and stress. In addition, regarding the importance of home visits, practical training will be incorporated to teach students the significance of home visits and help them understand how information obtained from actual visits can help provide support. Finally, as an introduction to social resources, students will develop the skills to introduce appropriate resources to mothers by deepening their knowledge of local support services and resources. Feeling emotionally isolated can lead to experiencing prenatal depression, so connecting with other female friends through peer support and having a “going place” to meet during your pregnancy can help [18].
5.3. What Kind of Words Could a Nurse Offer the Mother Now? (Q3)
Suggested supportive words from a nurse to the mother could include asking, empathy, listening, reprimand, introspection, and questioning.
Nurses’ support of mothers is important in understanding and supporting their feelings and situations in childcare. First, in asking, nurses emphasize the importance of mothers relying on others and seeking support. For example, saying things like, “Why don’t you ask someone for help?” is adequate. It is also important for mothers to take a rest if they need it. Next, in empathy, nurses need to understand the difficulties mothers face in childcare and their difficulties in raising their children and be sympathetic to their feelings. Acknowledging and showing understanding of the mother’s efforts is important by saying things like, “You are trying so hard.” Children usually do not harbor resentment toward their parents, and nurses can reaffirm that childcare is a meaningful experience. In listening, nurses must listen carefully to mothers’ concerns and anxieties about childcare. By asking questions like, “Is there anything you are worried about?” nurses create an environment where mothers feel comfortable talking.
In reprimand, nurses need to think about the causes of child abandonment and the adverse effects it has on children. Neglect is a serious problem that violates child-rearing responsibilities, so recognizing and working to improve it is important [3]. In introspection, mothers must reflect on their guilt about child-rearing and their actions and learn from their failures in child-rearing. Support such as “Why did you act like that? Why don’t you take a look at yourself?” is one possible approach. Finally, in questioning, mothers are asked to think about the reasons for their emotions and actions and the social support situation. It is practical to ask mothers questions such as “How do you feel now?” and “How do you feel about raising a child alone?” Through these types of support, childcare environment analysis is also important. Future challenges include evaluating the local childcare support system [19] and improving temporary childcare facility services and support for single parents experiencing childcare stress. At 3 months postpartum overall, 15 of 88 mothers (17%) who participated in the university hospital survey were categorized as depression cases [20]. It is expected to improve the childcare environment and mothers’ mental health.
At first, nursing students should be taught the importance of empathizing with the mother and cultivating the skills to empathize with her emotions [21]. Specifically, they should learn how non-verbal support, not just verbal support, can bring emotional relief. Second, as for listening skills, practicing listening improves one’s ability to understand the mother’s anxieties and worries so that the mother can more easily express her feelings and accept support. In addition, as a questioning technique that encourages introspection, they should be trained to ask questions that will encourage the mother to think deeply, and they should acquire the skills to explore the source of their feelings and stress related to child-rearing. Regarding appropriate feedback, they should be taught how to gently scold the mother and give specific advice to encourage improvement in their child-rearing behavior.
Finaly, Nursing students felt empathy and reprimand toward the mother. It is important to provide specific methods and support systems for nursing students to effectively manage the conflict between these feelings.
In nursing education, it will be necessary to provide training on appropriate scolding while still being empathetic and allow time for introspection to consider how to approach depending on the situation. It would also be beneficial to train students to think about how to support the mother from her perspective through role-playing that focuses on improving skills to understand and empathize with the other person’s situation.
5.4. Limitations
Regarding the study’s limitations, in terms of sample size and representativeness, the limited sample may be insufficient to reflect general opinions and trends. In addition, regarding bias in questions, if the content of the case study presented as an assignment contains many questions that reflect specific emotions and values, bias may occur. Regarding the interpretation of qualitative data, analysis using the KJ method is prone to subjectivity, and even if it is carried out in collaboration with a co-author, there may be individual differences in interpretation, and the same conclusion may not be reached. In addition, regarding the lack of feedback, there is no follow-up to verify how the survey results have influenced nursing education, making measuring the impact on education difficult. Using quantitative research in combination is also effective, and it is possible to obtain empirical data on the themes discovered. In addition, verification of long-term effects is also necessary. It is necessary to track how the survey results have been applied to nursing education and evaluate the impact of educational interventions on students’ practice. Based on the survey results, it is important to develop programs and workshop s to provide support and education on parenting and to study their effectiveness.
5.5. Improvements in Nursing Education Programs
Improvements in nursing education programs are first required for practical applications. Strengthening nurses’ education on the parenting and mental health challenges they face would improve the quality of patient care. Policy proposals are also needed. Strengthening measures against child abuse and neglect would result in better support for mothers. Local parenting support programs are required to reduce maternal stress and promote a positive approach to parenting.
Nursing students felt empathy and reprimand toward the mother. It is important to provide specific methods and support systems for nursing students to effectively manage the conflict between these feelings.
6. Conclusions
We conducted a case analysis of infant neglect by nursing students. In order to prevent infant neglect, nursing students need to learn how to observe mothers and children and what kind of care should be given to mothers and children before going to clinical practice. With the increasing number of consultations regarding infant neglect in Japan, it is an issue to deepen the insight of infant neglect and prevention in nursing education.
Improved education and research are needed to help nursing students use abuse case studies to provide health guidance to mothers to prevent abuse. However, as insufficient evidence is lacking, further research is needed.
Authors’ Contributions
Yuko Harding: participated in the conception and design, analysis, and interpretation of data, drafting the article, revising it for intellectual content, and final approval of the finished article.
Masako Yano: participated in the conception and design, analysis of data, revising it for intellectual content, and final approval of the finished article.
Questionnaire
In-class survey: Case of infant death: 30-year-old mother arrested for leaving baby at home for 16 hours after going out.
A 30-year-old mother was arrested by the Police Department on suspicion of abandonment of a child by a person in her care after leaving a baby girl, about three months old, at her apartment for approximately 16 hours. The girl died at the hospital where she was taken, and the suspect arrested is a female suspect (30) of unknown occupation. She is suspected of abandonment of a child by a person in her care after leaving her daughter, about three months old, at her apartment for approximately 16 hours in the evening.
When the suspect returned from outside, she found her daughter unconscious and reported it to the police, but the girl died at the hospital where she was taken. It is said that she admitted to the charges during the investigation. The suspect lived alone with her daughter, and the Police Department is investigating the details of the incident, such as where they went out.
In light of the above incident, we highly value and would like to hear the opinions of all nursing students. Your insights are crucial in understanding and addressing such sensitive cases.
□Do you think the mother’s actions were abusive? Yes, No
□Why did the mother leave the baby alone? (Q1)
□What could a nurse have done to prevent the incident? (Q2)
□What kind of words could a nurse offer the mother now? (Q3)
This questionnaire is intended to be useful for education in lectures.
The above responses may be compiled and published both inside and outside the university, and we will ask for your consent to publication in that case.
Your responses will be kept confidential and will not be used in a way that could identify you. Your privacy and security are our top priorities.
I agree , I disagree