Yearbook on Journal of the Japan Society of Nursing Research 2013

Changes in Awareness and Care Practices on the part of Public Health Nurses throughParticipation in an Action Research-based Case Study Group on Child Abuse and Neglect
Keiko Kobayashi 1)
Key Words :child abuse and neglectpublic health nurse
case study group
action researchfamily support

ABSTRACT
Purpose: To establish a case study group composed of public health nurses and describe changes inawareness and support on the part of the nurses participating in the group, with the aim of making publichealth nurses deal with child abuse and neglect cases.
Method: Utilizing action research, the author established a case study group, described the changes noted
in 11 public health nurses and analyzed the result.
Result: The study proceeded as follows:
1. Proposal to establish a case study group;
2. Pre-establishment publicity and implementation; and3. Evaluation and feedback.
In the course of expressing themselves in the case study group participants became able to tackle theirtasks in advanced ways. They changed their way of looking at the family and the content of their support byshifting the focus of their attention from “problems” to “strengths”, thereby strengthening the preventionof abuse and neglect and promoting the spread of the support network.
Discussion: The above changes resulted from the author’s role as facilitator, listening closely to eachparticipant’s thoughts, promoting interactions among the participants and supporting each individual
participant by promoting the changes in their thinking so as to enable them to focus more closely on “strengths”.

I. Introduction

family relationships which involves various family factors
such as parents’ early developmental history, experience ofabuse and neglect, mental disorder of parents, personality
traits, lack of attachment to children, and husband andwife relationships3)4)6). In addition, intricately entangled
life conditions such as financial or housing situations,living environment, or social isolation are attributable tooccurrences of child abuse and neglect, which requires along-term and broad range of support. Therefore, workers
who provide support see no direction and effects of help
and often end up suffering from a sense of powerlessness
or a feeling of insufficiency7). When public health nurses
who provide support are overwhelmed by a sense of
powerlessness, it is obviously difficult to solve most ofabuse and neglect problems, so their sense of powerlessness
needs to be improved. Also, workers who deal with families
exhibiting domestic violence and sexual abuse may sufferfrom deep stress and traumatic experience. It is, therefore,
considered important for such workers to receive burnout
prevention and supervision 8)9). Nonetheless, few sufficientstress management measures for workers to support abuse
and neglect cases have been taken and very few studies on
this subject have been conducted.
We can see from the above that measures should be taken
to encourage public health nurses with difficulties and asense of powerlessness to notice their potential strengthand proactively help families where child abuse and neglect
take place.

Dr. Kempe, an American pediatrician, and his colleagues
defined child abuse and neglect as “a condition having to dowith those children who have been deliberately injured byphysical assault” by parents, guardians, or caregivers1). The
most tragic and worst result of child abuse and neglect is“death.” Even the cases not ending in death can cause physicalor emotional harm to children, and leave them severely
impaired, cause mental retardation, or evoke emotional or
personality disturbance during the course of their growth.
Child abuse and neglect is a life-threatening issue for children;at the same time it physically and emotionally hurts children
and sometimes causes irreparable developmental disorder ordisability. Also, a generational chain of abuse and neglect issaid to be seen in approximately 30% of abused and neglectedchildren who mistreat their own children when they themselves
become parents2), which is a grave pathological phenomenon offamily and society passed down through generations3-4). Suchpersistent abuse and neglect from parents to children who
are rapidly growing is a serious problem in society as well as
children and must be solved as quickly as possible.
Meanwhile, Japan has an excellent maternal and childhealth system which is incomparable in the world and publichealth nurses are assigned to municipalities throughout thecountry5). Public health nurses are able to have opportunities
to meet most parents with infants through the health services
such as home visits, health checkups, and immunization
programs, and they provide parents with consultations andmake home visits under normal circumstances. Therefore,
expectations on public health nurses who are close toresidents and active at the front lines in local health services
for the prevention and support of child abuse and neglect has
been increasingly raised.
Child abuse and neglect is a pathological phenomenon in

II. Purpose of the Study

This study aims to change awareness and care practice ofthe participants, realize positive support of abusing families,
and describe such changes through the establishment of achild abuse and neglect case study group with local healthcenters and municipal public health nurses using the action
research method.

1) School of Health Sciences, Faculty of Medicine, Niigata University

III. Study Methods

Corresponding author. Tel.: +81 25 227 2397.
E-mail address: keikomegu@clg.niigata-u.ac.jp (K. Kobayashi)This study adopted action research methods. Action
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Yearbook on Journal of the Japan Society of Nursing Research 2013

research is said to be a research method which links
practice, studies and theories10). According to Hart & Bond11),
action research is the most fundamental research strategy
for residents; according to Meyer12), the strength of action
research aims at solving actual problems and enables
empowerment of people who are engaged in tasks on the
spot through participation in studies or later development.
Specifically, referring to studies by Hart & Bond11) and
Morton-Cooper13) which show action research proceduresfor health care, the procedures below were followed. The
procedures are: 1) clarification of problems and proposal
for the establishment of a child abuse and neglect case study
group; 2) pre-establishment publicity and implementation of
the child abuse and neglect case study group;and 3) evaluation and data feedback of the child abuse andneglect case study group. Furthermore, based on the principleof action research where study participants share studies andagree to proceed, we flexibly moved forward by providing
the participants with feedback of the study data at each stageof the study process, reviewing the data together with theparticipants, and obtaining their consensus.

case study group; the case study proceeded as shown in Table
2. I encouraged each participant to express his/her feelings
and thoughts and promoted their proactive participation;
I also encouraged the group members to identify eachother’s strengths to activate mutual interaction and support.
Furthermore, I gave consultations to the participants before
and after the case study group meetings and provided
information which helped them access necessary resources
such as literature and relevant organizations.
4. Analysis methods

Data resources included the description of participant
observation, case progress reports, minutes of meetings,
and records of individual and group interviews. Speech
and behavior of the observed participants and thoughts
and interpretation of the researcher were recorded in
the field notebooks; case study meetings and interviews
recorded on an IC recorder after obtaining the consent fromthe participants were transcribed into a word for word
description. The acquired data on the case study group,
the study participants, researcher, and workplaces of theparticipants were put in chronological order; the contexts
were studied based on the collected data; and the contentsin 1) the participants, 2) groups, 3) workplaces and relevantorganizations, and 4) the changes of case studies wereinterpreted in connection with researcher’ actions. Then, atheme which was drawn focusing on the changes in publichealth nurses’ awareness and care practices was described.

1. Study period

The study period lasted for two years and nine months,
from July 2004 to March 2007.
The period for preliminary field work and negotiation wasfrom July 2004 to April 2005; the implementation period wasfrom May 2005 to November 2006; and the period for result
feedback and follow-up was from December 2006 to March
2007.

5. Ethical consideration

2. Study participants

The participants and their supervisors were told about theconcept of the study and informed that the participants may
withdraw from the study at any time; personal informationand privacy protection were secured verbally and in writing;
and written consent was obtained from those concerned.
Since it was difficult to obtain consent from families ofcase study subjects due to the nature of abuse and neglect,
data such as name, date of birth and address of the subjects
remained anonymous and only information necessary forstudy was obtained to the extent of permission given by

A total of 11 public health nurses participated in the study:
One from ‘A’ health care center and 10 from B City and C Town
which were under the control of ‘A’ health care center. The
background of the participants was shown in Table 1.
3. Procedures of case study group and role of facilitator

As the researcher, I facilitated the child abuse and neglect

Table 1. Background of the Participants
Public Health Nurses(fictitious name)

Age

Organization

Fujita30’s

A’ Health Care Center

14

Tanaka30’s

B City, Health Dept.

8

Takiyama

40’s

B City, Welfare Dept.

14

No. of Attendances(participated in the 1st year only)

Maruyama

40’s

B City, Health Dept.

13

Sato

20’s

B City, E branch

8(participated in the 1st year only)

6(participated from the 2nd year)

Yamamoto

30’s

B City, D branch

11

Aoki

20’s

C Town, Health Dept.

14

Nakamura

20’s

B City, Health Dept.

6(participated from the 2nd year)

Takahara

40’s

C Town, Health Dept.

6(participated from the 2nd year)

Konno

Ozawa

30’s

20’s

B City, Welfare Dept.

B City, Health Dept.

*All names of the pubic health nurses are fictitious.

6(participated from the 2nd year)36
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Table 2. Procedures of Case Study Group(1) How to provide cases
The participants provide cases for which they have continuously given proactive support.
(2) Procedures of case study group meetingsa. The participant who provides the case explains the outline of the case, the goal of assistance, processes of assistance, contents to be
discussed, struggles and difficulties when giving assistance.
b. Through Qs and As the participants form the overall picture of the case to share.
c. The participants examine the case as if it is their own case.
d. The participants examine the following points:- The needs of the case recognized by the participant who provided the case;- The goal of assistance or assisting plan made by the participant who provided the case;- Processes of assistance (grounds of approach, appropriateness of timing, observation of reaction/change of the subject); and- Assisting policy in the future (the techniques and resources currently or hereafter used by the participants who provided the caseare discussed)(3) Important points of the case study group meetingsa. In the form of voluntary group learning, the participants can express their opinions from all angles in a free atmosphere as much as
we can.
b. If discussions get stuck, we clarify the focus of discussions, straighten out our thinking, and then reverse the way of thinking.
c. We try to point to conceivable ideas from all standpoints and angles with a broad perspective, considering what the subjects of thecase, people around the subjects, the participants, and people concerned think (or decide on); this process will lead us to solutions.
d. All participants learn the good and effective assistance which the participant who provided the case has given.
(4) Record and reporta. A participant takes the minutes of the meetings, but the participants who provided the case organize the record and hands out to theparticipants the summary of the discussion results of the case study group meetings, learning, and things to be put in practice.
b. The participants apply the ideas discussed at the meetings, implement them, and report the results of the implementation at thesubsequent case study group meeting.
The report written in an A4 page includes the discussion results of the previous meeting, things to be put in practice, the results andissues of such implementation.
(5) Protection of personal information and ethical considerations
Information shall be given anonymously and specific contents shall be collected on the spot.
Information shall be published to the extent permitted by the supervisors.
The participants shall carefully keep the materials taken home.

the supervisors. The analysis results were provided to theparticipants to make sure that there were no mistakes inthe description of facts and interpretation and obtained
approval with regard to the limit of publicity and contents ofthe data; the study results were provided to those who wereinterested. The protocol of this study was submitted to the
Ethical Review Board of Studies of the Japanese Red Cross
College of Nursing and approved by the Board. (October 30,
2006, approval no. of the Rinkeni: 2006-50)

follow-up and feedback on the study results were provided.
All the names below are fictitious.

1) Clarification of problems and proposal for theestablishment of a child abuse and neglect case study group

A health care center asked me to take charge of casestudy examinations at the ‘training for infant abuse andneglect cases’. The participating public health nurses had
no opportunity to discuss problems with each other due totheir busy work schedule even when they came across cases
suspected of abuse and neglect; they wanted to take advice
together. The participants who attended the case study
meetings said: “case study discussion clarified the issue, so
I felt much better”; “I often feel depressed after examining
child abuse and neglect cases, but today I rather felt energized
because I got the idea what to do next”; and “it was aspectacular meeting which I could attend for the first time ina long time, I like the process where the participants gradually
recognize their problems through discussion without strong
leadership of the instructor.”I, therefore, strongly felt the necessity of a child abuse andneglect case study group and proceeded to prepare withsupport from the participants and their workplaces.

6. Ensuring of credibility

As for interpretation of study data, the primary data andresearcher’s interpretation were contrasted and supervision
was given by a professor of nursing experienced in qualitative
study. Also, the primary data and researcher’s interpretation
were presented to the researchers experienced in childabuse and neglect study or working as public health nurses
to have the opportunity of discussion and to get commentson the interpretation. In addition, credibility was ensured bypresenting the primary data and interpretation to the study
participants to make sure that there were no mistakes in thedescription and interpretation.
IV. Results

2) Pre-establishment publicity and implementation of thechild abuse and neglect case study group

1. Actual practice procedures

After the preliminary field work and negotiation for 10
months, 14 case study meetings were held in one year sevenmonths; for four months after the completion of the meetings,

The child abuse and neglect case study group aimed at“encouraging the participants to make efforts to solve childabuse and neglect cases and increasing their motivation of
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Table 3. Implementation Outline of Child Abuse and Neglect Case Study Group Meetings

No.

Date

Discussed Cases

1

May 20, 2005

Aoki: ‘Elementary school boys/sisters physicallyabused by their father in the name of discipline’ (A)3

Aug. 22, 2005

Yamamoto: ‘Despite (suspected) abuse and neglect
reported by a day-care center, no support has been
provided’ (C)2July 4, 2005

4

Oct. 7, 2005

5

Nov. 10, 2005

6

Dec. 9, 2005

7

Jan. 20, 2006

9May 12, 2006

8

Feb. 17, 2006

10

July 12, 2006

11

Aug. 21, 2006

12

Sep. 19, 2006

13

14

Oct. 23, 2006

Nov. 17, 2006

Monitored
Cases

Sato: ‘Infant who has head-injured aftereffects of afall due to parents’ incaution’ (B)A

Takiyama: ‘Family with a foreign mother whosechild is truant, which may be due to DV and abuse
and neglect’ (D)A, B, C

Tanaka: ‘Maltreatment was suspected at physicalcheck-up for infants; reconstruction of the scene
they do not know how to deal with this case’ (F)A, C, D, E

Maruyama: ‘Elementary school child whose parents
have psychiatric disorders may have become truant
due to neglect’ (E)Maruyama: ‘Elementary school child whose parents
have psychiatric disorders may have become truant
due to neglect (continuation)’ (E)A, D, EA, D

Takahara: ‘Nursery school infant from a single
parent family; psychological abuse and neglect by
his/her mother is suspected’ (J)A, G, H, I

Konno: ‘Handicapped high school student who
became stay-at-home due to psychological abuseby his/her mother’ (K)E, G, I, J

Maruyama: ‘Unmarried mother with a baby seeking
help with childcare from alcohol-dependent
grandmother’ (L)A, E, H, J, K

Aoki: ‘Elementary school boys/sisters physicallyabused by their father in the name of discipline(continuation)’ (A)support and confidence”; the health care center recruitedparticipants and started the case study group composed ofseven public health nurses applying for the project.
The first case study meeting was held in the form of aparticipant meeting, where, in the brainstorming session, theparticipants freely expressed their own thoughts which they
were not particularly aware of and shared their problems andthe direction of the case study group among the members. The
participants first confirmed their “problems for supportingchild abuse and neglect cases” written on sticky notes; then, toclarify the problem structure, an association chart was madeby categorizing them in similar categories. The problems
sorted out in the association chart included “feelings that
I’m not good at it, anxiousness, and hesitation”, “lack ofawareness of abuse and neglect/ knowledge/ techniques”,“difficulty in dealing with changing cases”, “no adequate
system to take advice for supporting abuse and neglect”, “doProblems and challenges to handle
child abuse and neglect cases

A, E

Participants

7 public healthnurses7 public healthnurses7 public healthnurses7 public healthnursesA, B, C, D

A, E

Takiyama: ‘Elementary school child whose parents
have psychiatric disorders may have become truant
due to neglect (taken over from Maruyama)’ (E)Meetings by Participants

A, B

Ozawa: ‘Infant with a developmental problem; abuse
and neglect by his/her father is suspected’ (G)Fujita: ‘Neglected child with delayed development
in a poor living environment’ (H)Nakamura: ‘Mother's history of abuse was reported
from the maternity hospital, but no support has been
provided due to their move’ (I)*All names of the pubic health nurses are fictitious.

Degree of the challenges achievedby case study discussion

Necessary support system workedout by case study discussion
Necessary support system workedout by case study discussion
Problems and challenges to handle
child abuse and neglect cases

Management and procedures of
the case study group

7 public healthnurses7 public healthnurses7 public healthnurses6 public healthnurses9 public healthnurses9 public healthnurses8 public healthnurses8 public healthnurses8 public healthnursesLearning and achievement throughthe case study group activities, andissues9 public healthnursesnot know how to cooperate with relevant organizations”,
and “need supervisors”. Next, the direction of approaches tosolve “the problems when supporting child abuse and neglect
cases” shown in the association chart was discussed withthe participants and was sorted out in the following way: at“the child abuse and neglect case study group”, the members‘share anxiousness and hesitation when dealing with childabuse and neglect cases’, ‘receive advice without trying tosolve cases alone’, ‘learn problems specific to child abuse
and neglect and how to deal with them’, and ‘learn actual
procedures to collaborate with relevant organizations’. As
stated above, the direction of the case study group and its
participants was shown.
The case study group started in May 2005 and usually had
meetings once every month or two; a total of 14 meetings
were held up to November 2006; all the participants
provided cases to be discussed (Table 3). The actual number
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Yearbook on Journal of the Japan Society of Nursing Research 2013of people participating in the case study group during the
2-year period was 11. A public health nurse providing a casesummarized ‘discussion results’ and ‘practice and results aftercase discussion’ based on the discussed contents and gave areport at a subsequent meeting. This was called ‘monitoring’
where practice was reviewed and the contents of support
were evaluated at the case study group meeting; by repeating
this process at every meeting, we were aiming at improving
support through discussion on difficult situations for persons
who provided support.

The participants who listened to the story nodded andpublic health nurse Sato started to talk about a similar
situation at her work.
Sato: In my branch, if they know the background, they tend
to say “it will be all right”; in that respect it is really goodfor someone who had no idea about the background, like
Yamamoto, to see the case through different eyes.

When public health nurses know the background andhistory of cases, they may find it difficult to recognize
abuse and neglect cases because they cannot see the cases
objectively, relying too much on their knowledge. I thoughtthat the purpose of the visit seemed unclear, so I asked
Yamamoto some questions.

3) Evaluation and data feedback of the child abuse and neglectcase study group

At every case study group, we listened to the thoughts fromparticipants and modified them; participants’ meetings were
held once every three to six months to discuss how the issuesof the participants had been changed through the activitiesof the case study group. Also, we reported to the participants
and the leaders of public health nurses of the participants
at work about current practice and evaluation conducted by
the case study group and asked for comments from them. At
the case study group continuous evaluation and modification
were given in this way and the results were fed back to theparticipants.

Author: (You were contacted and) you wanted to confirm
something. What was it?
Yamamoto: Those bruises. What happened at home....(could
not think of words to say).
Author: If you visit their home, I believe that you should
definitely have clear objectives; what you should get fromthe visit....
(Yamamoto could not answer, there was a pause.)
Yamamoto: I have to think about (what a public health nurse
should do, when I visit their home.)
Author: You have to make a concrete plan before you go;
you cannot ‘just visit their home’.... If it is an abuse andneglect case, what do you think you have to confirm? Is
it abuse and neglect, as Takiyama said? If you want toprovide support by confirming the background of abuse
and neglect, (you should probably confirm) what bothers/
sisters the mother most...

2. Changes in awareness and care practices of public healthnurses through the practice processes of the case study group
The analysis of the word-for-word records of the 14 casestudy group meetings held between May 2005 and November
2006 and field notebooks showed the following changes in
the participants.
1) ‘I used to stop there’, but now ‘I can take the first step’

The Yamamoto case shows that when public health nurses
are informed of abuse and neglect, they tend to visit the home
immediately without making a future plan. Public health nurse
Maruyama participating in the meeting said “I have learnt
the importance of having concrete supporting measures fromthe beginning when we visit home.” Public health nurse Aoki
said “at our initial interaction it is important to have an idea
to which direction the case is going when asking questions
or listening to their stories.” After the discussion, Yamamoto
expressed her feelings as follows:

Public health nurse Yamamoto who was just transferredto the branch due to municipality merger presented thecase at the 3rd case study meeting; Yamamoto was confused
about the first response to the case. She was contacted twomonths ago, but she had trouble in providing support because
the family was always away from home when she visited.
Brothers/Sisters of two and four years of age had noticeable
cuts and bruises on their bodies and the doctor who
conducted a health checkup at the nursery school ‘suspectedabuse and neglect’. A few days ago, both had black eyes. Whena nursery teacher asked about the black eyes, their mothersaid “they fell down the stairs; it is not the abuse and neglect
which often happens recently.”
Yamamoto thought that she should visit the family as soon
as possible considering this as an abuse and neglect case,but when she discussed how to deal with the case with othertwo public health nurses at work, they disagreed. Yamamoto
doubted her co-workers’ idea, but had no confidence in her
own decision, either; she explained her wavering mind.

Yamamoto: After the discussion of the case, I feel better...
Now I can see how to start approaching the case. We threepublic health nurses did not clearly recognize what abuse
and neglect cases were; so we could not proceed with ourpolicies from there... I have noticed that the initial response
is very important. I am still worried whether I will be able
to properly use what I learnt when I provide support in
the future.

I was concerned about Yamamoto who said in an uncertain
manner “I am still worried whether I will be able to properly
use what I learnt when I provide support in the future”
although she made a positive remark. I thought that she may
start an action if she had the grounds for her judgment, andI sent her a letter and materials. I suggested she review the
first response for child abuse and neglect cases by following‘the procedures from receiving request for consultation toproviding support’ in the guide.

Yamamoto: I thought that I should visit their home soon; but
two public health nurses said “the mother could (hit herkids)”; since they knew (her personality and behavioral
trait), they did not recognize (the urgency) and said “wedo not have to act so quickly; (we can confirm later at ahealth checkup).” At that point, I felt “I do not need to (visit
their home), then.”

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visited the family, she saw poor diet and unsanitary living
environment; she said “looking at the bad child careenvironment, I could not help but blame the parents andgive up.” At the case study group meeting, we sorted out on a
blackboard ‘what they do’’ and ‘what they fail to do’ for childrearing in order to find the family’s strengths.

Yamamoto said “I was so encouraged by your concern(about me) that I felt I had to act”; she reported at the 4thcase study meeting what she had done at work based on thediscussion results of the case study group meeting.

Yamamoto: After the previous case study group discussion,
three public health nurses at work reviewed all of our past
involvement according to this guideline. We did not quickly
respond to the request for consultation and could not meetthe family when we visited their home.... and we gave up atthat point. We discussed at work that we lacked awarenessof issues. The public health nurses who are working in thecommunity strongly believe that we know the cases well;therefore, we tend to think that ‘it will be all right.’ The
nurse in charge of this case could finally make a home
visit and confirmed the current situation; she plans tocontinue regular visits. Also, we have been talking with
the nursery school teachers about extended day care tohelp the mother vent her frustrations.

Author: Shall we assess the family’s rearing abilities? Let’s
pick up ‘what they do’’ and ‘what they fail to do’ for childrearing (we made a table on a blackboard to sort out theparticipants’ opinions.)
Fujita: As for their rearing abilities, I would say they have‘none at all’.

Fujita simply said that they had no ‘strength’; first we
accepted her opinion and started to sort it out.

Author: What do they do to take care of their infant?
Fujita: They do not do the laundry; they leave his/her clothes
unwashed.
Author: (Writing on the board), are the clothes very dirty?
Fujita: A little dirty.
Author: A little dirty? They don’t do the laundry at all or theyoccasionally do?
Fujita: They occasionally do (the laundry). The infant goesto the nursery school in dirty clothes. He/she goes there
without taking a bath or washing his/her face.
Author: (Writing on the board), doesn’t he/she take a bathfor a long time? How frequently does he/she take a bath?
Fujita: Once in every 2-3 days, not every day. He/she doesn’t
wash his/her face; many other things he/she fails to do
from a sanitary viewpoint.

Yamamoto who reported, with a little more self-confidence,
the results of putting the awareness of the case study group
into action gave a push to other public health nurses who had
hesitated to move forward. At the subsequent 5th meeting
public health nurses Aoki and Sato who seemed not to havechanged their attitudes even after discussion reported theresults of their changes like starting delayed home visits orcommunication with doctors to put the awareness of the casestudy group into action. Furthermore, I started to hear fromthe leaders of public health nurses that ‘after participatingin the case study group meeting, they have proactively madehome visits and asked advice from the leaders for how toprovide supports.’

We started to sort out the information so that we could
objectively see the family; the focus, however, was on
problems only and no ‘strength’ of the family was found.

2) Turning attention to ‘strengths’(1) Turning our attention to the strengths of abusing families

Author: What do ‘they do’? I have been asking ‘what they do’,but you mentioned what they fail to do (laughs).
Fujita: I don’t think there is anything the family can do.
Author: But they survive, don’t they (laughs)?
Takiyama: Yes, they survive.
Author: Certainly there are a plenty of things the family failto do. But ‘they do things.’ In other words, they do thingseven once in two times.
Fujita: Also..... They do read comments from the nurseryschool teacher written in the notebook.
Author: It is important.
Fujita: The mother wrote back as well; for example, “I’msorry, I didn’t bring a bath towel.”

The participants who provided cases often said “these cases
have a pile of family problems and we have no idea whereto start.”
However, in this study, when we discussed the cases, we
tried to turn our attention to the families’ ‘strengths’ (abilities
and resources) such as ‘their abilities to feed and clean theirchildren’ without just looking at family problems. We focusedon the families’ ‘strengths’ because according to the literature
by Kirino14) and Zerwekh15), nursing personnel who makehome visits to provide support to the families first try to findthe families’ existing abilities (‘strengths’) to be able to support
them focusing on the good aspects the parents have and tofoster trust with the families and to develop their abilities, andhelps the parents establish self-confidence and self-esteem.
I also thought that, from my experiences as a public healthnurse, if we turn our attention to their good and successful
features rather than their problems and communicate suchstrengths to them, we would be able to foster trust with thefamilies and provide support more smoothly.
Next, the changes of the participants which arose out ofthe discussion focusing on the families’ ‘strengths’ are shownin the case of public health nurse Fujita (the 10th case study
group meeting).
The case provided by Fujita was a neglect case abouta prematurely-born underdeveloped infant. When she

Fujita began to recognize what this family did to raise theirinfant through my statement to encourage her to change herview on the family and the response from Takiyama. She
looked at the board and gave impressions like “they somehow
manage to survive.” Some other participants also mentioned“it looks like they do things which are essential to survive.”
At first Fujita was bothered by the problem of neglect andhad no idea how to initiate support; she, however, graduallybecame able to grasp the situation in an objective way andfocus on the abusing family’s ‘strengths’ through the processof sorting out the information with the participants and she
seemed to recognize the importance of approach which
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After Tanaka explained her feelings, at my suggestion, oneof the participants read the mother’s part in the record atconsultation.

encourages the family to further develop their strengths. Afterthe meeting, Fujita made a home visit and reported what was
confirmed on their rearing activities which had been sortedout at the case study group meeting. She said “I confirmed thatsurprisingly the family made efforts to do things which I firstconsidered as neglect such as feeding and cleaning; I leantthat we need to seek cooperation from the nursery school on
the matters which are difficult for the family to accomplish
without help like face washing or toilet training.”
In this way, the participants who only looked at the abusing
families’ problems and struggled to provide support, after
the discussion which eyed the families’ ‘strengths’, changed
their view on the families and recognized what the families
did and altered their support so that the families’ strengths
were developed further.

Tanaka: What makes you irritated while you are taking careof your children? And what do you usually do when you
are irritated?
Mother: When the younger one is there together, he/she
won’t listen to me. If it happens, the only thing I can do isto try to hold my temper.
Tanaka: It must be hard, right? If you have any trouble,
please let us know.

After reading the conversation, Tanaka said “I often say
to mothers “if you have any trouble, please let us know”,
but I don’t actually expect many of them to come back; I
am worried about how I should communicate with them”.
Tanaka would like to provide some kind of child care support,
but since she has no idea what she should do, she could notact, which worried her. I encouraged the participants to put
themselves in the position of a mother.

(2) Finding the participants’ ‘strengths’

At the case study group meetings, we also focused on
finding the ‘strengths’ (advantages) of support provided by
the participants and increased willingness to support throughmutual learning.
At the final case study group meeting (the 14th meeting),
each participant expressed their own or other participants’‘strengths’. They accepted the ‘strengths’ of each other suchas: ‘immediately doing what she comes up with (Yamamoto)’;‘facing difficulties without avoiding them (Aoki)’; and‘good at asking for advice (Ozawa)’. Fujita said “finding the‘strengths’ of other people means observing them closely
and respectfully”. I think that through the activity to focus
on the ‘strengths’ the participants tried to respect for andunderstand each other.

Author: Everybody, what do you think would make you feelrelieved in such a situation?
Yamamoto: I wish (the public health nurse) to come close tome. I think that mothers want to have a feeling that thenurse has understood her irritation which nobody else hasever understood.
Author: Yes, I agree. For example, “I can tell you are introuble.”Yamamoto: Even such words could make the mother feelrelieved when she goes home (after the infant healthcheckup).
Author: The mother becomes happy if somebody understands
her feelings and may think “maybe I can talk to this nurse
who has understood my feelings”. I do not think thatpatterned interviews and guidance can communicate
your real worries to mothers. It is important to show yourapproval to mothers like “you are raising your baby very
well.”
Tanaka: Sure.
Fujita: They feel complimented.

3) Linkage to infant health checkups from the perspective ofabuse and neglect prevention

At the case study group meetings, we reviewed how we
responded at infant health checkups where we had a chance
to meet the subjects of all cases. Dealing with difficult cases,
the participants questioned to themselves: “couldn’t wenotice any problems at infant health checkups before thecase becomes so serious?” or “what if we listened to what theparents talked about their child-rearing a little more carefully
at consultation”.
At the beginning of the case study group Aoki expressed
her thought that ‘she could not support parents and infants
when she suspected problems at infant health checkups; andYamamoto said “even when one of the public health nurses
suspected a high risk of abuse and neglect, other people
involved in infant health checkups do not always share herthought, which frustrates her”. I thought that we shouldmake use of case study group meetings to review how infant
health checkups should function; and at the 6th case study
group meeting, the participants discussed the topic using therecords of consultation at infant health checkups.

Each participant who was concerned about what could bedone for parents and infants when problems were suspected
at infant health checkups tried to imagine parents’ feelings
and what they sought from public health nurses at thecheckups through the review of conversations held at usual
checkups. Tanaka adopted the idea and began to offer positive
words to parents like “you are raising your baby very well” atcheckups. Also, she reported at the following case study groupmeeting that whenever she recognized something ‘unusual’ atcheckups, she confirmed with other staff without leaving suchsituation untouched and reported at a conference.
At the final case study group meeting, the participants
reported how they changed their responses at checkups, etc.
Ozawa reported that the awareness of abuse and neglectprevention has grown among people concerned and said
“when I suspected problems at interviews, I introducedsocial resources to parents to prevent abuse and neglect andtold them not to worry on their own; and I believe that moresuspected cases come up at the general conference; I havea feeling that the staff members move in that direction all

Tanaka: The interview sheet has a question “I am often
irritated by child-rearing”; we tend to think that ‘it is not
surprising’. We only ask mothers/fathers “What makes you
irritated? What do you usually do when you are irritated?”
I am worried that such responses are appropriate andwhat we should actually do.

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Yearbook on Journal of the Japan Society of Nursing Research 2013

now started working with NPOs and the police as well.
In addition, case study groups themselves are increasing in
number and gaining greater influence in this region.
Yamamoto from a branch of B City started an article study
group and a case study group with nursery school teacher
sand administration staff at work as from October 2005; inC town six public health nurses started their own case study
group which included summary reporting of this case study
group activities and the members did a role-play about thecases and the leader of public health nurses accompanied
home visits. In B City the participants of the case study group,
consulting with their leader, have been taking the initiativein establishing their own case study group since March 2007.

together”.
The participants wished to prevent serious situations
presented at case study group meetings from occurring;
they discussed not only support for abuse and neglect
cases, but also regular health checkups and daily operations
emphasizing prevention.
Takiyama: When I look at survey slips of the nursery schoolwith family structure or other information, I sometimes
think that ‘this person may look for help for child-rearing’;
I used to check the development of babies and children onlyand determined that ‘there is no problem’.

It is considered that Takiyama seems to have acquired
the ability to convert the information on survey slips whichused to have little meaning for providing support intomeaningful information which implies needs for care after
she participated in the case study group meetings and gained
firsthand knowledge about the background of various risky
cases.

V. Consideration

1. Mind frame shift from ‘solution of problems’ to ‘use ofstrengths’

It is said that in the field of family support ‘the social service
assessment has traditionally focused on the weaknesses of thefamily rather than the abilities of family’9). The participantsof the case study group had a tendency to focus on family’s
problems more closely than their strengths when they
provided support by screening children’s development or
grasping child-rearing problems at infant health checkups
or home visits. Especially in child abuse and neglect cases
the first priority is given to the security of children; thetendency it to try to quickly discover family problems whichcause such abuse and neglect and solve those problems.
More attention has therefore been paid to finding abusing
families’ problems rather than their strengths. The ‘strengths’
mean the individual’s inner strengths (skills, knowledge,
desire, abilities, and confidence) and external environment
surrounding the individual (resources, social relationship,
and opportunities) 16).
Most abusing families refuse to admit their abuse andneglect in the first place and are unwilling to cooperate withus on solving problems. Under the circumstances, if we takenegative approaches such as pointing out family problems
to seek improvement, the families become increasingly
stressed and turn down the offer of support; as a result,even after problems are found, it is difficult to tackle themand to plan future support. To make matters worse, someworkers who provide support end up suffering from a senseof powerlessness and losing their confidence.
Furthermore, since abuse and neglect cases are caused bymultiple factors and most parents and children whom publichealth nurses are helping continuously in local communities
live together, it is necessary for the nurses to provide support
from long-term perspectives cooperating with childcare
centers and schools5). Therefore, they are required to support
the lives of parents and children by encouraging the families
to make use of their own strengths.
As explained in Results above, once we turned attention
to families’ ‘strengths’, we stopped blaming abusing parents
and began to understand parents’ feelings more; then we
gradually admitted parents’ efforts and in turn they accepted
our support. Abusing parents who used to be abused by theirown parents when they were young or who believe they
were not loved by their parents have low self-esteem5). Also,
abusing families are often rejected by people around them orrarely evaluated positively.

4) Expansion of supporting networks and their influence on
workplaces and regions

As for Takiyama’s case discussed at the 4th meeting,sexual abuse on children of a foreign mother came tolight; we initially planned to give guidance to the father ata child consultation center with the assistant principal of
the elementary school. When the case was reported at thecase study group meeting, I determined that we had to seek
cooperation from an NPO with broad experiences in DV andabuse and neglect on foreign women; and suggested theidea to Takiyama. This led Takiyama to work on the NPO
to send a consultant to the conference held by the parties
concerned; and we made a leap forward to protect the motherand children. Takiyama talked about the process as follows:
Takiyama: At the conference held by the parties concerned(in January 2006) we came to a conclusion that it was
imperative and urgent for us to protect the children
and change the environment considering their healthy
development. We knew that the mother definitely wanted
to run away because the father had said “I will kill all (ofmy family) and myself”. As a result, the NPO consultant
successfully confirmed the mother’s intention and also
knew how to protect the children and the mother, so we
protected them on the day.
Author: It is good that you could manage to put an end tothe case there. If you couldn’t.....
Takiyama: If we (the public health nurses) didn’t know what
to do and carried on in the same way for a few more years,
the family might have died....
Author: A serious incident might have been caused.
(All the participants gave a big nod with a grave look.)

The case provided by Takiyama was quickly solved byasking the NPO which offered advice to foreign women tojoin our supporting team. The NPO consultant who had had alittle experience in collaborating with the public health nurses
said “we could more smoothly cooperate with the police,
schools, and child consultation centers by working together
with public health nurses”. Thus, the supporting team whichcollaborated with schools and child consultation centers has
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Yearbook on Journal of the Japan Society of Nursing Research 2013

Providing support focusing on the ‘strengths’ of abusing
families encourages parents to build confidence and selfesteem14), to foster trust relationship with the families, andto develop families’ abilities15). Kaplan & Girard9) emphasized
the strength-oriented support in the social work practice forhigh-risk families; and workers providing support believe
changes of families and the necessity of support admitting
the ‘strengths’ of family members. It means that we provide
support so that people feel confident about their abilities; andto sustain and expand families’ strengths and resources. Oncethe public health nurses who used to focus their attention
on abusing families’ problems takes a positive view on suchfamilies, relations focusing on problems and increasing
families’ stress change to those reducing families’ stress,
raising their self-esteem, and building their confidence.
People are usually motivated to make more changes when
their strengths are supported9). It is said that the changes in
attitude made by being praised gradually make up a large partof one’s usual attitude and eliminate an unfavorable attitude.
I believe that when public health nurses take and express
an interest in families’ efforts, which is the use of a positive
mirror to reflect ‘strong aspects’, the families become awareof the ‘strong aspects’ and make more efforts to develop those.
Furthermore, as mentioned above, I encouraged theparticipants to focus on the ‘strengths’ of families and at thesame time to become aware of good and excellent points
of support provided by the public health nurses. It is said
that “dealing with high-risk families is very stressful; theprevention of burnout starts when the staff feel that theirapproaches are highly evaluated and approved”9). In childabuse and neglect cases, since workers who provide support
can see little evidence of improvement, they are likely tolose their confidence and find it difficult to keep motivatedto provide support. It is not easy to improve child abuse andneglect cases through support from public health nurses.
Therefore, it is considered that the participants gradually
recognized their own potential power through their
discussion on each other’s strengths in providing support,
not successful results of support which improved the abusecases provided at the case study group; for example, “I havepositively worked on the cases without giving up”, or “I often
work together with the people concerned”. As mentioned
by Rapp “focusing on strengths will motivate people” 16), I
think that by paying attention to their own excellent aspects(‘strengths’) of support, they recovered their confidence andbecame motivated to give support again.

me” or “I may fail to support them”.
The participants strongly felt the necessity of support
and were able to put it into practice when their thoughts
gained acceptance at the case study group and the grounds
and support methods which had been vague became
clearer. As Yanagi et. al.17) said ‘the members can experience
encouragement in a group like “although I cannot do it when
I am alone, I can work on the problems with my peers”, I
think that each of the participants of the case study group
was able to face problems being encouraged by the voice ofother participants.
Moreover, I had an intention to maintain the child abuse
and neglect case study group as a peer support group where
public health nurses could discuss problems of support andgive and receive advice or consultation. This is why I tried
to seek solution to problems by utilizing interactions among
the participants and drawing their strengths, as the managerof ‘A’ Health Care Center said “I felt comfortable with theprocess where the participants spontaneously recognized
their problems not through the strong leadership of theteacher (the author) but through our discussion”. According
to Zander18), in order to increase interactions among thegroup members, ‘the group should have a small number ofmembers’ and ‘the members should spend time discussing
important matters and seeking opinions’. In this study I
believe that we could increase interactions among the groupmembers because we had a small group of fixed members
each time and secured enough time to discuss problems.
The participants who expressed their desire to ‘have a place
where I can speak of my thoughts and problems’ or ‘have aplace where I can seek advice for support’ enthusiastically
discussed how to handle the cases as if they were theirown cases, and after they discussed cases, they consulted
or advised on supporting one another. It is said that when
the individual’s goals are consistent with those of the group,
positive interactions develops within the group18); here, inthis group, since the goals of each participant and those of thegroup mutually affected each other, the participants reached
out to their supervisors or public health nurses at work andtake the initiative in continuing case study groups at healthcare centers and municipalities.

It seems that changes of awareness and support of theparticipants were brought about by the group power of thecase study group which the facilitator helped to develop.
Which power of the group actually moved the participants?
For a long time, public health nurses have not been involvedin the support of child abuse and neglect cases; sufficient
practice experiences have not been accumulated and effective
supporting methods have not been studied yet. The publichealth nurses who participated in the child case study groupwere able to take a step forward from their usual self and toprovide different support for the abuse cases with the help of
the voice of other participants encouraging them when they
were facing the cases in scenes where they hesitate, if they
are alone, to give support, thinking “the parents may refuse

I tried to ensure that the participants could freely express
their opinions. In order to encourage out-of-the-box thinking
in the participants regardless of their workplace or position,
I proceeded with the case study group meetings taking theapproach that ‘I would like to listen to the participants’thoughts and problems’. I believe that because of thisapproach the participants felt an atmosphere where they
could freely express their opinions. The participating publichealth nurses gradually shared secure feelings and a senseof togetherness like ‘I can tell them my troubles’ or ‘I am notthe only person who has problems’; and tried to talk about
and understand one another’s serious ‘thoughts’ regardlessof their positions or titles at work.
I sometimes made severe comments to the participants

3. Role of the facilitator

Now I describe my role as a facilitator when I encouraged
the participants to change with the help of group power.
(1) Elevation of positive feelings and review of support

2. Group power of the case study group

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Yearbook on Journal of the Japan Society of Nursing Research 2013

although I basically maintained the free and comfortable
atmosphere. Yoshida19) said that ‘strict comments’ and‘affirmative feelings’ are both necessary to stimulate themutual growth of the group members. Strict comments
revealed the mistakes of the participants and we sometimes
wrapped up the case study discussion without having animage for support. However, since I sought feedback fromthe participants including the one providing the case and I
expressed my desire to help them whenever necessary at theend of each case study group meeting, they put the awarenessinto action saying “I was so encouraged by your concern(about me) that I felt I had to act”. I thought that they might
have also felt heavy pressure from the facilitator. Therefore,
I carefully observed the reactions from the participants and I
asked Fujita, who played a role like a coordinator between theparticipants and me, to give me feedback on their reactions.
Moreover, when I thought that someone else should giveassistance, I asked other participants to do so after obtaining
consensus from both sides with the intention of building amutually-helping relationship among the participants.

workplaces including the leaders of public health nurses. In
this way, I gradually involved the participants’ workplaces.
I believe that the participants’ practice was accelerated
further by figuring out difficulty of the cases and capacity ofthe participants and thinking together of the system to assist
workers providing support.
VI. Limit of Study and Issues

As for the data sources in this study I made efforts to obtain
information from diverse and multiple sources as much as
possible with regard to the participants’ statements anddiscussion materials at the case study group meetings orinformation offered by the supervisors of the participants;
however, considering the particularity of child abuse andneglect cases and ethical aspects I did not observe home visits
or conferences of concerned parties. Therefore, although I
checked the credibility or added information by returning
recorded data to the participants, there is a limit of the quality
and amount of information obtained in this study.
Furthermore, it is necessary to verify the difference
produced by the changes in support provided by the publichealth nurses participating in the case study group from along-term perspective.

(2) System to put the awareness into action

I had a strong desire that the participants of the case study
group put their learning into practice, not just attend an
unpractical training session, so I considered the following
system to implement our discussion.
I asked the participant who provided the case to explain
the concrete actions for subsequent support and her imageof the result of such actions at the end of each case study
group meeting. I thought that she would be able to take actionby having concrete successful images where she took a step
forward from current herself and began walking toward
future positive herself by combining the two approaches suchas looking at her current problems which she was sufferingfrom and imagining an altered, positive self20). For instance, I
asked the participants ‘what do you think you can actually do?’to draw concrete action plans from them. Also, I narrowed
down the points of discussion records and elaborated therecords so that the participants could implement them moreeasily. That is, I prioritized and itemized the discussion
results, highlighted important points, and added charts which
would help them quickly visualize the ideas.
Also, I communicated my desire to give necessary
assistance to the participants whom I worried about after thecase study group meetings by calling, e-mailing, or sending
letters. I tried to maintain the valuable awareness at the casestudy group meetings and encourage the participants to put
the awareness into action.
On the other hand, I sent reference materials containingsome clues for practice to the participants who had no
idea how to put the awareness into action and asked themto implement the awareness and report the result at thefollowing monitoring session. Also at the monitoring session
I suggested to such participants that they make a report which
combined the results of case discussion and implementation.
Thus, I built a multi-layered system which would put theawareness into practice.
At the same time, I intentionally proceeded withthe establishment of the support system involving theparticipants’ workplaces. I arranged a meeting where theparticipants who were dealing with difficult cases discussed
how to provide support with the help of people from theirThis study is my doctoral thesis for the Graduate School of
The Japanese Red Cross College of Nursing on which I mademinor additions or alterations.
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