Yearbook on Journal of the Japan Society of Nursing Research 2014

Experience of Mothers whose Children Undergo Labioplasty and Palatoplasty
Sayori Sakanashi1), Miyako Oike2)
Key Words :children with cleft lip andpalatemother’s experiencelabioplasty and palatoplasty
qualitative research

ABSTRACTThe purpose of this study was to elucidate the experience of mothers whose children undergo labioplasty
and palatoplasty. A constant comparison method with reference to Grounded Theory was used for analyzingsemi-structured interviews with ten mothers. Each mother’s experience was categorized into six types:“entering the treatment process”, “obtaining family support to maintain medical life with their child”, “having
a sound relationship with relatives and neighbors”, “interpreting cleft lip and palate as unrelated to disease
and disability”, “responding to difficulties step by step”, “expanding their role as mother through caring forthe child”. These categories showed that there were. These results suggested the need to understand manyof approaches and efforts in the mother’s experience and to facilitate mother’s roles in the treatment process.

I. Introduction

mothers’ attitudes on it change through the long-term processof treatment9), 10).
These researches are mostly questionnaire surveys which
are conducted shortly after delivery or infant’s operations,focusing on mother’s feelings of distress and anxiety. It is
expected that mothers will have a variety of feeling when theirinfants received surgical treatment when they were 3 or 18
months old. Yet, researchers tend to examine more invasive
operations such as heart and transplant operations when
they address how mothers feel about their children’s surgical operations11), 12). In other words, it has not been clarified
how mothers understand and accept surgical treatment of
their children with cleft lip and palate. Nakanii also reported
that there are few data containing straightforward words
uttered by mothers of children with cleft lip and palate, sothat researchers must listen to their own words seriously forunderstanding the feelings of a mother, her family members,
and her child patient13).
Therefore, in this study we attempt to clarify the experienceof mothers of children with cleft lip and palate by focusing
on the surgery of cleft lip and palate which is considered tohave significant meaning for them. We consider that such ananalysis would bring about new perspective for deepening
our understanding of them.

Cleft lip and palate is a congenital anomaly involving cosmetic disturbance such as aberrations in facial morphology
and functional disorder. It is one of the most common congenital external malformations which occur in about one outof every 500 children born. It is considered to arise from theinteraction between genetic and environmental factors but
the causes for its occurrence and concrete preventive measures are not yet understood well1), 2). It is not expected that its
occurrence rate will decline in the near future because of thenegative effects of pollution on maternal environment3) andrelative increase of genetic disease arising from the changeof disease structure4).
Surgical treatment and speech therapy are the main methods of treatment for cleft lip and palate. They are conductedduring the period from three to four months after birth toadulthood. The surgical treatments of cleft lip and of cleft
palate are performed in three months after birth and inaround sixteen months after birth, respectively. Treatment forcleft lip and palate has been advanced enough to cure it completely if patients receive right treatment in a proper period.
Yet, a mother of an infant with cleft lip and palate is likely
to experience immeasurable suffering when she knows that
her baby’s face is malformed5). This is because we are more
likely to react emotionally to external malformation than to
the malformation of the viscera which cannot be seen6). In
addition, surgical treatment is not enough to cure cleft lip andpalate, necessitating additional treatments such as orthodontic treatment and speech therapy. A mother has to shoulder
an overly burdensome responsibility to engage in childcare
activities and have her child receive treatment for cleft lip andpalate for many years.
For these characteristics of this disease the problem ofwhen a doctor should disclose it to a mother of a child withcleft lip and palate has been addressed7). It is reported that amother is likely to feel disturbed and embarrassed when shesees the face of a baby with cleft lip and palate shortly after
delivery for the first time. Kerin B. Johansson, who conductedinterviews with parents with babies with cleft lip and palate,shows that reactions and support of people around themaffect their attitudes on this disease8). It is also reported that

II. The Purpose of Research

The purpose of this research is to clarify the experience ofmothers whose children undergo labioplasty and palatoplasty
for understanding and supporting mothers of children withcleft lip and palate.
III. Definitions of Terminology

In this research we attempt to elucidate the experienceof mothers not as passive but as active actors. Based on thisresearch purpose we defined experience as the things inwhich an independent-minded person learns through a variety of actual events and involvement with others.
IV. Methods of Research

1. Research Design and Theoretical Premises

1) School of Nursing, Fukuoka Jogakuin Nursing College2) Department of Health Sciences, Faculty of Medical Sciences, Kyushu
University

We conducted a qualitative inductive analysis of the plain
experience of mothers of children with cleft lip and palate
for clarifying how and what they perceive their children’s
disease and surgery for repair of cleft lip and palate. In order

Corresponding author. Tel.: +81 92 801 1011; Fax: +81 92 865 5177.
E-mail address: sakanashi@adm.fukuoka-u.ac.jp (S. Sakanashi)

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Yearbook on Journal of the Japan Society of Nursing Research 2014

to understand mothers’ experience through the interpretative framework which treats them not as passive but as active
actors, we adopted the theoretical premises of H. Blumer’s
Symbolic Interactionism which problematize independentminded attitudes of human being and attempted to uncover
his/her internal aspects from the standpoint of an actor14), 15).

the second interview an interviewer reaffirmed the content
of the first interview and asked about her current feelingsand everyday life.
6. Methods of Data Analysis

This research relied on Grounded Theory Approach witha theoretical background of Symbolic Interactionism. It was
proposed by Barney Glaser and Anselm Strauss16), and Japanese scholars such as Shigeko Saiki, Yasuhito Kinoshita, andMami Kayama17)~19) also used this approach for their own
analysis. This research is based on the constant comparative
method in Grounded Theory Approach20). Subjects are mothers of cleft lip and palate children who undertook primary
labioplasty and palatoplasty in theoretical sampling, collecting data during the period in which they were undertaking
surgery. We extracted data appropriate for our research purpose from one case and coded and categorized them. Then, we
examined its relationship with categories of all cases.
1) We transcribed recordings of interviews and read themover and over.
2) We extracted contexts showing subjects’ active involvement from the linkage of sentences and coded them in eachsubject’s data.
3) We checked both data and codes for ensuring that eachcode represents data appropriately. Then, we classified dataand codes from the standpoint of their similarities and differences for subcategorizing them.
4) Categories were abstracted from subcategories. We
continued to check both data and categories until we wereconfident that no categories could be created further, andimportant codes, subcategories, and categories were collectively exhaustive. At the final stage of analysis we specified
each category, subcategory, and code.
5) A storyline was formed by using categories and subcategories in order to capture a complete picture of research
results. It was represented graphically in order to show the
relationship between categories and subcategories clearly.

2. Criteria of Selecting Subjects

Labioplasty is usually undertaken when an infant is about
eighteen months after birth. In one university hospital palatoplasty is conducted one time while in the other university
soft and hard palates were closed in two-stage surgery. Most
patients of cleft and palate are treated in university hospitals, therefore, we asked mothers of children who had alreadyundergone labioplasty and palatoplasty in oral surgery wardsof two university hospitals.
3. Data Collection Period

Eleven months from February to December 2008

4. Methods of Data Collection

We conducted semi-structured interviews in a following
procedure:
1) An interviewer explained the purpose of this research
to ward managers and ward nurse managers.
2) An interviewer explained the purpose of this researchand other necessary matters to subjects and obtained theiragreement to participate in the research.
3) An interviewer conducted two interviews with eachsubject.
The first time: The period in which one hour passed aftera child patient entered an operation room and a subject
stayed in a waiting room. She would have a variety of feelings about her infant undergoing surgery. This rare experience
to be away from her infant would also give her an important
opportunity to reflect on herself. We expected, therefore, thata subject will express a variety of feelings in this period. Aninterviewer asked each subject about whether she would
agree to an interview before starting it out of respect for her
feelings.
The second time: We conducted an interview with a subject
about a week from surgery for reaffirming the content of thefirst interview and asking about her current feeling.
4) In a semi-structured interview we tried to let a subject
talk about her own experience freely.
5) An interview was recorded in an IC recorder with subject’s consent. An interviewer wrote down an interview withsubject’s content when she refused audio recording.
6) After an interview an interviewer recalled its situations
and recorded the facial expression and bodily movement of
an interviewee and her conversations with other family members in a field note.

7. Efforts to Enhance Reliability of Data Collection and Analysis

There are a variety of views on validity and reliability ofqualitative research with little consensus. It is considered to
be important to spell out the process of analysis for gaining
them21). Therefore, in addition to Methods of Data Analysis
mentioned earlier, we did following things:
1) We asked a subject how long she could have an interview
in order to let her speak in a relaxed way. We also tried to havesupportive attitudes toward her.
2) During an interview we checked the meaning and intentions of statements a subject uttered carefully in order to eliminate prejudice and dogma researchers tend to have. We also
conducted interviews two times and attempted to clarify what
were unclear and ambiguous points in the second interview.
3) Our analysis was conducted with a supervision by anexpert of qualitative and inductive research. In addition amaternity nursing specialist checked the appropriateness of
research process and results.

5. Main Questionnaire Items

In the first interview an interviewer asked a subject about
following: 1) experience from pregnancy to the present; 2)
feelings when seeing her baby; 3) feelings and everyday life
until cleft lip surgery begins; 4) feelings and everyday life until
cleft palate surgery begins: 5) feeling toward her own child. In

8. Ethical Considerations

This research was approved by the health and nursing

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Yearbook on Journal of the Japan Society of Nursing Research 2014

research ethics board of K University. We explained purposes
and methods of this research fully to subjects verbally andin a written form, and obtained their agreement to participate in this research in a written form. We explained that theparticipation in this research was voluntary and anonymous,and non-participation did not affect medical treatment andnursing of their infants. We also told them that an interview
would be conducted in a room where interviewee’s privacy
could be protected and they could suspend or postpone aninterview at any time.

3. Results of Analysis

We showed the results of analysis in Table 2. Sixty fivecodes and fourteen subcategories were extracted as theexperiences of infants of cleft lip and palate who had undergone primary labioplasty and palatoplasty. Their experienceswere categorized into six types: ≪entering the treatment
process≫, ≪obtaining family support to take care of theirchild≫, ≪having the social support with relatives and neighbors≫, ≪interpreting that cleft lip and palate is not disease≫,≪responding to difficulties step by step≫, and ≪expanding
their role as mother through caring and nurturing for thechild≫. We showed the experiences of mothers of infants
with cleft lip and palate undergoing primary labioplasty andpalatoplasty as a storyline. Category, subcategory, and code
are written in ≪ ≫, < >, and 【 】, respectively.

V. Results

1. Outline of Subjects

The outline of subjects is shown in Figure 1. There were
10 subjects whose ages range from 26 to 38 (the averageage = 31.3 years old). 5 subjects were housewives and 5
subjects were full-time workers. Infants’ ages were from 14
months to 3 years old (the average age = 21 months old) andtheir sexes were 6 males and 4 females. Their cleft lips were
either unilateral (5 infants were on the left side and 2 infants
were on the right side) or bilateral (3 infants). They were diagnosed as cleft lip and palate either before birth (3 infants) orafter birth (7 infants). Their fathers’ ages were 25 to 38 years
old (the average age = 34.2 years old). 7 infants had a sibling,
one of them having a younger sibling.

1) Storyline

A child with cleft lip and palate must undergo several treatments on a continuing basis: surgical treatments (primary
labioplasty at around 3 months of age and palatoplasty ataround 18 months of age), speech therapy, and corrective
treatment. ≪Entering the treatment process≫ is very important for a child with cleft lip and palate to continue to growhealthy with his/her mother’s support.
A mother went through the surprise and confusion of the<first meeting with her baby.> This period did not last long
but the medical staff’s explanation of this disease affected her<understanding of the step-by-step process of treatment>
and her perspectives on nurturing life after a baby’s birth.
At any rate she had to conduct breastfeeding and the plate
treatment for a baby with poor suckling ability, compellingthem to engage in <nurturing life requiring efforts>. During
this process she tended to have <worry about appearance>,
affecting her infant’s living activities.
≪Entering the treatment process≫ implies the continuanceof nurturing life for a long period of time during which theburdens imposed on an infant with cleft lip and palate andhis/her mother were enormous. They relied on ≪obtaining
family support to take care of their child≫ for easing burdens
on them. This <family cooperation and assistance> became an
indispensable support, without which mothers would not beable to continue their infants’ nurturing life and treatment for
years. Furthermore, they met medical staff and other mothers
who have infants with cleft lip and palate. This experience of≪having the social support with relatives and neighbors≫
was helpful for them to learn childhood disease and handicap.

2. Summary of Interviews

1) Summary of the First Interview

We conducted interviews in an interview room or a private hospital room. Nine interviews were recorded in an IC
recorder with subject’s consent. We made a note of one interview because a subject declined to be recorded in a recorder.
In one case subject’s husband joined an interview, therefore,
we used some of his statements representing mother’s feelings and situations in the research.
2) Summary of the Second Interview

The second interview was conducted 4 to 7 days after surgery (5.4 days on average). We made an appointment before
visiting a subject’s home. During our visit a subject’s infant
was sometimes in a bad temper and sleeping, which made itdifficult to conduct an interview, therefore, in such a case we
waited for a while to start it.

Table 1. Outline of Subjects

Case No.
A
B
C
D
E
F
G
H
I
J
Average

MotherAgelate 20s
late 20s
late 20s
late 30s
late 20s
early 30s
late 20s
late 30s
late 20s
late 30s
31.3 years old

InfantAge
18 months
17 months
3 years
2 years
15 months
18 months
23 months
27 months
16 months
14 months
21 months

Sexfemalefemalefemalefemale
male
male
male
male
male
male

Time of Diagnosis(before birth or after birth)
after birth
after birth
before birth
before birth
before birth
after birth
after birth
after birth
after birth
after birth
before birth (3), after birth (7)21This paper was published at “the Japan Society of Nursing Research” Vol.33 No.4 in 2010.

Yearbook on Journal of the Japan Society of Nursing Research 2014

Table 2. Results of Analysis: The Experience of Mothers whose Children Undergo Labioplasty and Palatoplasty
Category (6)Subcategory (14)Code (65)First meeting with her baby
The time of diagnosis
The period in which a mother gets pregnant
First meeting with her baby
The period in which a mother gives birth to a baby
Expectation and preparation on the possibility that a handicapped child isborn
Medical professional's response until treatment starts
Understanding of the step-by-step process ofSurgery and treatment undergone in stages
treatment
Palatoplasty undergone in stages
Nurturing life with an infant
1. Entering the treatment process
Tasks on nurturing life with an infant
Nurturing life requiring efforts
Life bound by a palatal plate
Hospital stay with an infant whose environment differs from home
Concern about others
Worry about appearance
Worry about appearance
Outdoor activities affected by appearance
Evaluation of postoperative scar after labioplasty
Request to medical staff
Desire toward medical staff members andRequest to medical environment
health-care environment
Criteria for selecting a hospital
Family response and assistanceFamily cooperation and assistanceStep-by-step response and support by grandparents
Telling family members about a disease
Parent's role and responsibility on other children
2. Obtaining family support to take care of
their child
Role and responsibility on family
Maintenance of everday life through family
Surgery arranged for parents' conveniencerole playing
Maintenance of family life
Changes of family relationshipResponse and assistance of medical professionals
Interaction, relationship, and association with mothers of infants who had
similar disease
Others' response and assistance
3. Having the social support with relatives Having the social support with relatives and Telling others about a disease
and neighbors
neighbors
Request to others
Society's response
Understanding the feeling of those who have a disease and a handicap
The change of understanding a disease and a handicap
Uncommon disease
Disease which can be understood in stages
Understanding of the step-by-step process of
Disease with a handicap
treatment
Disease without a risk of death
Disease which has to have surgery many times
Disease which does not have negative points
4. Interpreting that cleft lip and palate is not
Disease affected by appearance
diseaseEndeavoring to understand cleft lip and palate
Disease which is considered to be someone else's problem
A variety of views on cleft lip and palate
Disease which is considered to be serious
Unacceptable disease
Disease which have positive points
Disease which becomes child's own problem
Tentative comparison and evaluation
Evaluating through comparison
Looking for information and causes
Making use of resources
5. Responding to difficulties step by step
Sustained effort
Changing one's views
Overcoming problems in stages
Prepare oneself
Change of feeling accompanied by the explanation of medical professionals
Transition of feelings during treatment proIncessant anxiety and worry until labioplasty starts
cessChange of feeling after treatment and surgery process ends
A sense of guilt
Parent's role and responsibility
6. Expanding their role as mother throughExpectation for surgery
caring and nurturing for the child
Understanding child's growth
Enlargement of mother's feeling and role
Change of how to perceive a child
Policy on how to raise a child
Parents' hope and expectation
Growth as a mother

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Yearbook on Journal of the Japan Society of Nursing Research 2014

On the other hand, many of them blamed themselves andlooked for <a variety of views on cleft lip and palate> because
the cause of this disease remains to be identified. Soon, mothers observed that their infants changed their appearance after
surgery, focusing less on the <understanding of the step-bystep process of treatment> than on ≪interpreting that cleft
lip and palate is not disease≫. Through this process mothers
made a <sustained effort> by accumulating the experienceof <tentative comparison and evaluation> of infants’ healthconditions. This mother’s behaviors were accumulated as theattempts of ≪responding to difficulties step by step≫, leading
to the resources for conducting nurturing life and the confidence as a mother.
Then, mother’s distress and anxiety changed into hope andexpectation on their children’s healthy growth through <transition of feelings during treatment process> and their consciousness as mothers also transformed into the ≪expanding
their role as mother through caring and nurturing for thechild≫.

reason why she could not express her feeling well: “My baby
had such a lip. Then I waited in a delivery room for about
3 hours. I did not know what happened. Then, I was moved
to another room. Many nursing staff members were there.
Doctors also came and I was told that my baby had cleft lip.
I could not make out what’s going on.” (postnatal diagnosis)[I1-1] 【the time of diagnosis】② <understanding of the step-by-step process of treatment>This is to understand the step-by-step process of treatment(e.g., labioplasty → palatoplasty). Mothers could estimate
what would happen to their infants through this treatment
process.
Ms. H was a mother who delayed to take her baby to achildren’s hospital where cleft lip and palate treatment wasoffered due to the lack of knowledge on this disease among
medical staff members. She was relieved that she could understand and estimate the process and outcomes of treatment bymaking her infant undergo medical treatment in a specialized
hospital. She noted that: “I’m not nervous because I can knowwhat treatment is waiting for us in each stage of treatment forcleft lip and palate.” [H1-91] 【step-by-step process of surgeries and treatment】
She was realizing that her infant would be cured in stages
by seeing her child being cured after cheiloplasty: “My baby’scleft lip was repaired and other parts would be repaired at
the next stage. The doctor said this part was also going to
be repaired. Finally, a Hotz plate was taken off. Another surgery is necessary but I believe and expect that teeth would
be repaired next time and everything would be repaired at
the completion of treatment.” [J1-33] 【step-by-step processof surgeries and treatment】
In addition, professional doctors including a doctor of
dental surgery needed to explain the process of treatment
in order to start medical treatment smoothly and in stages.
Ms. F, to whom professional doctors were introduced, toldthat she could have prospects for her baby’s treatment fromwhat a doctor said: “The doctor told me that he would writea referral letter to a university hospital, every cleft lip patient
went to that hospital, and it would be surely repaired if yourbaby was treated there. I did what he said (because he told
me that my baby’s lip would be repaired).” [F1-3] 【doctor’shandling until medical treatment starts】
On the other hand, in the case where a doctor failed to
explain the process of treatment well, a mother was not surewhat she had to do in her baby’s medical treatment. Ms. D told
it to us: “(In prenatal diagnosis) the doctor (in the Departmentof Obstetrics and Gynecology) did not say anything special.
I asked a doctor in the Department of Pediatrics about mybaby’s medical treatment. But the pediatrician did not talkabout the lengthy process of treatment but was just saying
to me, “if the baby cannot drink, it was necessary to insert atube through the mouth and put the baby on a drip...” [D2-38]【doctor’s handling until medical treatment starts】
Ms. H, who delayed visiting a special hospital and failed tostart treatment process smoothly, showed impatience withsuch a medical care system: “I was told that it was late...itwas too late to come to (a special hospital). Usually we mustbring a baby born with cleft lip or palate to a special hospital
within a few hours or days after delivery for making a plate,but it took 2 weeks for me to go to a special hospital...” [H1-87]【doctor’s handling until medical treatment starts】

2) Explanation of Each Category

Statements of a representative subject were written downin order to show that a category was based on data we collected. A statement of a subject and a subject was represented
by “ ” and Case No. [ ], respectively. We added another wordor changed her statement in ( ) when a statement whose
meaning was difficult to understand and revealed subject’s
identity.
(1) ≪entering the treatment process≫This category shows that mothers of cleft lip and palate
infants had to experience a long-term course of treatment.
It means that this experience contributes to avoid excessive embarrassment and confusion and leads to understandthe disease and prepare for the future. This category was
extracted from the following subcategories: <first meetingwith her baby>, <understanding of the step-by-step process oftreatment>, <nurturing life requiring efforts>, <worry about
appearance>, and <desire toward medical staff members andhealth-care environment.>① <first meeting with her baby>

This subcategory refers to the first meeting between amother and her baby with complex feeling. One mother talked
to us in tears: “When I saw my baby coming out of my body forthe first time...I was perplexed. Why was my baby’s lip cleft?
This was my first impression.” (postnatal diagnosis) [F1-1]【first meeting with her baby】
Mothers knew that their baby’s lip was cleft either on
prenatal diagnosis or on postnatal diagnosis. In each casethey showed confusion and puzzlement. In the case wherea mother underwent prenatal diagnosis that her baby would
have cleft lip she said that she could not expect how severe
her baby’s case was until he/she was actually born: “This baby
was found out to have cleft lip in the sixth month of pregnancy
when I got a sonogram. I was told that it must be cleft lip
but until the baby is born it is difficult to make a diagnosis...”(prenatal diagnosis) [E1-1] 【the time of diagnosis】
One mother could not understand the meaning of sudden
diagnostic explanation in postnatal diagnosis, telling us the23This paper was published at “the Japan Society of Nursing Research” Vol.33 No.4 in 2010.

Yearbook on Journal of the Japan Society of Nursing Research 2014
③ <nurturing life requiring efforts>of a mother and a child patient by all family members.

This means the life in which a mother puts efforts into
taking care of her child with cleft lip and palate by spending
most of her time in a home and hospital. She breastfed herbaby all day and took care of her breast: “I thought breastfeeding is good for my baby, so I tried to obtain breast milk
but it began to dry up. I tried my best to breastfeed my baby.
I thought it’s good for a baby to drink milk from nipples but
I could not... My baby was not good at drinking milk from abottle.” [H1-20] 【Tasks on Nurturing Life with an Infant】
An infant with cleft lip and palate had to wear a palatal plate
for the proper growth of his/her chin and appropriate breastfeeding. But this plate was easy to unfasten and brought a
discomfort to an infant, so that a child often tried to detach itby himself/herself when his/her mother was away. A mothertold us how difficult it was to keep a plate safe without losing
or damaging it: “The plate disappeared. My child unfastened
and discarded it, so I had to look for it many times. Sometimes
it took several hours to find it in a store. It was a lot of trouble.
The plate was so easy to come off. This was the problem.” [B174] 【Life Bound by a Palatal Plate】
In such a life a mother tried to find out a good way to breastfeed her infant easily: “I breastfed my child as she wished. If
she wanted to drink milk, I gave it to her. If she wanted only asmall amount of milk, I adjusted it for her.” [B1-17] 【Nurturing
Life with an Infant】① <family cooperation and assistance>

This refers to the situations in which a child with cleft
lip and palate and his/her mother are warmly treated andcooperated by her family members. The positive responseof a father, brothers and sisters to a child patient provided
psychological support to a mother: “The baby’s brother said
just that ‘cute!’ when he saw the baby for the first time. It
has become my mental support.” [H1-4] 【Family Response
and Assistance】; “My husband said to me, ‘The cleft lip must
be repaired. So, it’s OK.’ I was relieved to hear that.” [A2-8]【Family Response and Assistance】② <maintenance of everyday life through family role playing>

This means that each family member plays her/her own
role and current lifestyle is maintained in a situation in which
a mother has to be devoted to her child’s care and nurturing.
Her husband and other children tried to maintain it by playing
their own roles: “Last year an elder child went to a nurseryschool. So he stayed in a grandmother’s home when my baby
was hospitalized. This time my husband told that he would dothings around the house.” [E1-13] 【Changes of Family Relationship】; “Many children would miss their mother but myolder daughter remained unchanged. It’s amazing.” [H1-37]【Parent’s Role and Responsibility on Other Children】
There were also the cases in which a mother and her family
members gave priority to their own daily activities: “This was
the only period I can go off work for many days at a time.
My husband also had to get out of office because he needed
to pick up and drop off another child in a kindergarten. The
doctor told me to have surgery around April but I asked him
to do it in the summer because my husband could take offwork in this period. That is, the timing of surgery was determined by parents’ convenience.” [H1-34] 【Surgery Arranged
for Parents’ Convenience】④ <worry about appearance>

This implies that facial deformity of one’s child and facialchanges after surgery affect living activities such as outdoor
activities. Especially child’s outdoor activities became an
important task: “I could not take my child outside because
I got worried about stares from others.” [A1-18] 【Outdoor
Activities Affected by Appearance】
However, the change of child’s facial appearance after
cheiloplasty brought relief and the change of behaviors tomothers: “I was so relieved that my kid could close his mouthproperly. The incision also healed well. The doctor told methat surgery on a lip went very well. I was reassured to see
my kid’s face without a scar.” [J2-27] 【Evaluation of Postoperative Scar after Cheilosplasty】; “My child started to go for awalk with me after her face looked good.” [D1-24] 【Outdoor
Activities Affected by Appearance】(3) ≪having the social support with relatives and neighbors≫

In this category a mother associates with others by adjusting her relationship with those around her under the situations in which she gets support from medical staff members,
other mothers of children born with cleft lip and palate, those
who were burdened with cleft lip and palate, friends, andothers, deepens the understanding of the disease and people
with disabilities, and changes the perspective on them. A subcategory of <associating with other people around them andtheir infants> was treated as a category.
The interaction with other mothers of infants born withcleft lip and palate and those who were burdened with it
became a good opportunity to exchange useful information
about this disease and medical treatment. It was also helpful to have a clear view of treatment process: “In this outpatient care others talked to me about a variety of things. For
instance, one woman whose child had similar disease asked
me about a course of treatment. Then, she taught us theprocess of treatment. I was so relieved to talk to her. I could
expect the course of treatment after talking to her.” [E2-87]【Interaction, Relationship, and Association with Mothers ofInfants Who Had Similar Disease】
Yet, it sometimes happens that a mother felt frustrated by⑤ <desire toward medical staff members and health-care

environment>This is a request toward medical staff members and healthcare environment during treatment process. Some mothers
told that they wanted medical experts to know what cleft lip
and palate was: “I want every infant born with cleft lip andpalate in Japan to undergo a proper medical procedure as
quickly as possible. So I want every doctor know about thisdisease.” [H1-88] 【Request to Medical Staff】(2) ≪obtaining family support to take care of their child≫This category was extracted from subcategories of <family
cooperation and assistance> and <maintenance of everday life
through family role playing>. It refers to the maintenance ofthe living conditions of the current family through the support
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Yearbook on Journal of the Japan Society of Nursing Research 2014

what people around her said: “When my acquaintance saw mykid, she said to me, “Oh you poor thing! Is your baby cured?”
It was so frustrating. That others saw a tube passed throughmy baby’s nose and gave us a pitying glance was the mostirritating thing. Can they say other things such as ‘you done
good’?” [G2-41] 【Others’ Response and Assistance】

relieved that my child was better than other children.” [B1-26]【Evaluating Through Comparison】② <sustained effort>

This is an effort to solve or fixes a variety of tasks andproblems occurring in the treatment process, through which
mothers overcome them step by step and modify their viewson the disease: “I’m dealing with the problems one by one.
This was my tentative goal. I must set a new goal.” [D1-71]【Overcoming Problems Step by Step】; “It is not still clear why
cleft lip and palate infants is born, so I do not think it’s a goodidea to think about the reason my child was born with cleft
lip and palate. I thought that I should not look backward but
forward... It seems that I could easily do that.” [H1-58] 【Changing One’s Views】(4) ≪interpreting that cleft lip and palate is not disease≫

This category refers to the transformation process in which
a mother struggles to understand what cleft lip and palate is.
It was extracted from subcategories of <understanding of thestep-by-step process of treatment> and <a variety of views on
cleft lip and palate>.
① <understanding of the step-by-step process of treatment>This means that a mother modified her understandingof cleft lip and palate which had been an unknown diseasename. At first, cleft lip and palate was recognized as a disease name which was unknown among the public. Ms. C told
that: “Nobody around me knew about cleft lip and palate. My
friends did not know it. My relatives also did not know it.
Noboby knew it.” [C1-8] 【Uncommon Disease】
Yet, mothers started to talk about cleft lip and palate as adisease which did not interrupt the growth and developmentof children as they underwent treatment process: “This is nota type of disease which we have to worry about the life of achild. My child grows up normally as of this moment.” [J1-58]【Non-life-threatening Disease】(6) ≪expanding their role as mother through caring and nurturing for the child≫This category refers to the process in which a motherenlarges her role through her involvement with a childpatient. It was extracted from subcategories - <transitionof feelings during treatment process> and <enlargement ofmother’s feeling and role>.
① <transition of feelings during treatment process>This means that mother’s complex feelings change into therealization of one’s responsibility and enthusiasm toward achild patient. Mothers start to care for their kids much more
seriously as treatment process advances: “I bottle-fed myolder children while they were lying down. I was also lying
down. But in the case of this child, I had her on my hip while I
bottle-fed him. I did that even at midnight. [G1-48] 【Transitionof Feeling Through the Process of Treatment and Surgery】② <a variety of views on cleft lip and palate>This refers to the process in which mothers change theirviews on cleft lip and palate by attaching a variety of meaning
to this disease for accepting this situation. They named cleft
lip and palate in a variety of ways (e.g. “disease” or “handicap”). They sometimes asked us, “Is this a disease?”: “I do notthink that cleft lip and palate is a disease. That’s because it is
not an illness which cannot be cured permanently. I also heardthat a patient can speak exactly the same as everyone else. So,
I do not think it is a disease.” [G2-20] 【Do Not Consider That
Cleft Lip and Palate Is a Disease】② <enlargement of mother’s feeling and role>

This means the change of mother’s response to her children
by recognizing herself as a responsible mother. After the surgery for cleft palate, a mother who concentrated on raising her
child began to think about the hope and expectation for child’s
self-reliance: “I want my kid to recognize his own handicap... I
want him to accept his disease and continue to receive medical treatment for himself. I really want him to think that it ishis handicap.” [H1-73] 【Parents’ Hope and Expectation】
3) Above categories are shown on Figure 1. This showsthat in order to ≪entering the treatment process≫, a mother≪obtaining family support to take care of their child≫ and≪having the social support with relatives and neighbors≫and has the experience of ≪interpreting that cleft lip andpalate is not disease≫, ≪responding to difficulties step bystep≫ and ≪expanding their role as mother through caring
and nurturing for the child≫.

(5) ≪responding to difficulties step by step≫This category is about perception and behavior in which amother solves or fixes a variety of tasks and problems occurring in the treatment process. This category was extracted
from subcategories - <tentative comparison and evaluation>and <sustained effort>.
① <tentative comparison and evaluation>

This subcategory refers to situations in which a motherattempts to obtain positive results by comparing her own
child and herself with other children and their mothers.
Targets for comparison are a variety of children including ahealthy child, a seriously handicapped child, a cleft lip andpalate child, and their mothers. She tried to rethink that theseverity of her child’s malformation was milder than otherchildren by comparing between them: “This may sound rude
to you... I saw children who eat through a tube. I was a bit

VI. Discussion

Previous studies of mothers of children with cleft lip andpalate have clarified that mother’s worry and anxiety changed
as their children grew up. This research also revealed that
their worry and anxiety changed by ≪entering the treatment
process≫. They ≪expanding their role as mother through25

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Yearbook on Journal of the Japan Society of Nursing Research 2014
ӐInfant's
AgeӑTreatment
Process

3 years and3 months

18 months 6 months old

Labioplast

Palatoplast

Obtaining family support totake care of their child< 㸨1 >  㸺 㸨2 㸼

Speech6 years
Corrective

18 to 20

10 years
Cleft jaw surgery/
Bone grafting*RDO
Corrective

Having the social support
with relatives and neighbors

Entering the treatment process <First meeting with her baby><Understanding of the step-by-step process of treatment><Nurturing life requiring efforts><Worry about appearance><Desire toward medical staff members and health-care environment>

㸨1 Family cooperation and assistance㸨2 Maintenance of everday life through familyrole playing㸨3 Understanding of the step-by-step process      that cleft lip andInterpreting
palate is not disease

Expanding their role as motherthrough caring and nurturing
for the child< 㸨3 >  㸺 㸨4 㸼

 < 㸨7 >  㸺 㸨8 㸼of treatment
㸨4 A variety of views on cleft lip and palate㸨5 Tentative comparison and evaluation
㸨6 Sustained effort
㸨7 Transition of feelings during treatment
process

Responding to difficulties
step by step< 㸨5>  㸺 㸨6 㸼

㸨8 Enlargement of mother's feeling and role㸸Category㸺  㸼 㸸Subcategory

Figure 1. Relations between categories that the Experience of Mothers whose Children Undergo
Labioplasty and Palatoplasty

expected to be given by them, so that it is more important
to make a complete explanation of how treatment proceeds
than to care about the timing of disclosure in order to realize
a smooth treatment process.
It is said that when something is wrong with a child, a
mother tends to feel that she fails to fulfill her role, loses her
pride, shows a sense of guilt29), keenly feels one’s incompetence, and has a sense of alienation, anger, and despair30).
On the other hand, through the hard times of child-rearing amother experiences her own growth31) and plays the role ofa mother32) with an interaction with nursing specialists andother mothers of handicapped children.
A mother of a child with cleft lip and palate tends to havecomplex feelings when she sees her baby for the first time but
through treatment process she is likely to become consciousof mother’s responsibility and enthusiasm for child-rearing,enlarging the role of a mother. This shows that treatment process mothers of children with cleft lip and palate encountercan be regarded as the process of mother’s growth and development as well as the process in which a child recover fromcleft lip and palate.

caring and nurturing for the child≫ by ≪responding to difficulties step by step≫ and ≪interpreting that cleft lip andpalate is not disease≫. Based on these findings we examine
the changes and characteristics of the experience of mothersof cleft lip and palate.
1. Mother’s ≪Entering the treatment process≫ and The
Changes of Her Experience

It is generally considered that there is an appropriate treatment process in most diseases. Those who have cleft lip andpalate also has to experience a long-term treatment processuntil they become adults. The category of ≪entering the treatment process≫ revealed that stable treatment process of cleft
lip and palate is important for mothers.
There was a task of prenatal diagnosis on an early stage of≪entering the treatment process≫. This is a stage in which
an obstetrician and gynecologist found out that a baby in thewomb was likely to have cleft lip when a mother got a sonogram. It is expected that more babies are found to have thisdisease during a mother’s pregnancy as a three-dimensionalsonogram has become more commonly used since the latter
half of the 1990s22). Taking this situation into consideration,
researches on mothers of children with cleft lip and palate
have examined a way to tell a mother about prenatal diagnosis and support system after it23)~25). Yet, it is not still clear
whether it is appropriate to tell a mother about the diseaseof her baby in the womb because it would have a negative
psychological effect on a pregnant mother26)~28).
In our sample 3 mothers and 7 mothers were told about
their babies’ disease in prenatal diagnosis and in postnatal
diagnosis, respectively. Mothers’ comments on the timingof disclosure were not uniform. A variety of responses are

2. overcoming problems step by step

It is reported that mothers of handicapped children deal
with their surroundings in a variety of ways33)~35). These
include: to acquire information on disease and disability,
to adapt to situations flexibly, to deal with daily affairs; tobe ready for the worst, and to motivate herself. Some mothers of children with disease and disabilities tend to blame
themselves by comparing their own child with healthy children or refuse to admit their children’s malformation36). It
is also reported that some mothers tried to feel relieved by
26

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Yearbook on Journal of the Japan Society of Nursing Research 2014

comparing oneself with mothers of children who had more
serious cleft lip and palate (“My baby is much better because
his cleft lip and palate is more likely to be repaired”37).). Thisis a coping technique relying on <tentative comparison andevaluation>.
This mothers’ behavior to “compare” is an attempt to examine the difference between more than two things38), whosefindings depend on the judgment of those who evaluate it.
It may sometimes lead to negative evaluation. It may bringabout positive results which raise the hope of more favorable conditions. Cleft lip and palate surgery and treatment
can significantly improve the form and function of nose andmouth, therefore, an act of “comparison” does not necessarily
distort the judgment of current situations. Rather, it can be agood opportunity to find out better aspects of treatment. For
this reason, we consider that an act of “comparison” mothersof children with cleft lip and palate make is a means to cometo terms with the disease and to justify a variety of events
happening during treatment process.
Cleft lip and palate is a disease in which a patient must
continue to undergo appropriate treatment and rehabilitationin each growth stage from birth to adulthood. Mothers haveto deal with not only the treatment of their children’s morphological and functional damage39). They also must consider
their children’s social adaptation and the appropriate timingof notice to children. These problems arise in the course oftreatment, implying that mothers have to prepare for a complex and variety of tasks now and in the future. Yet, many ofthem are expected to be solved or cured through treatment
process, that is, each task does not necessarily remain to besolved forever. The growth of her child or the improvementof facial appearance after surgery can be a good opportunity
to complete tasks one by one, bringing a sense of accomplishment to a mother. It is considered that this sense of accomplishment supports mother’s effort, encouraging her attempt
to dealing with problems one by one.

issue of how a mother sees and thinks about her own child,reported that it wasaffected by social and cultural values andaffected attitudes and behaviors toward children43). ≪interpreting that cleft lip and palateis not disease≫ is a perspectivein which how a mother thinks about her child’s disease. It canlead to the transformation of her views on children, affecting
her attitudes and behaviors on children.
Therefore, it is considered that mother’s ≪interpretingthat cleft lip and palate is not disease≫ is not an attempt tounderstand the cause of cleft lip and palate but to have a newview and attitude toward her own child.
VII. Conclusion

Previous studies of mothers of children with cleft lip andpalate tended to focus on the state and change of their anxiety and distress. This study, however, clarified the characteristics and the changes of mothers’ experience by extracting
the following six categories: ≪entering the treatment process≫, ≪obtaining family support to take care of their child≫,≪having the social support with relatives and neighbors≫,≪interpreting that cleft lip and palate is not disease≫,≪responding to difficulties step by step≫, and ≪expanding
their role as mother through caring and nurturing for thechild≫. ≪Entering the treatment process≫ is important formothers of children with cleft lip and palate to make theirchildren continue treatment for a long period of time. Our
study suggests that this process is also a process in which
they grow up as mothers. They also engaged in ≪responding
to difficulties step by step≫. Such an engagement can bringa sense of accomplishment. Their recognition of ≪interpreting that cleft lip and palate is not disease≫ also affects theirattitudes and behaviors toward children.
VIII. Suggestions to Nursing Practice

We need to understand that the experience of mothers ofchildren with cleft lip and palate during treatment process
can be a process in which they grow up as mothers. There arethree implications for nursing practice.
1) Medical professionals must understand treatment process of cleft lip and palate and strengthen coordination tovarious medical experts.
2) We should not react negatively to mother’s proactive
efforts but understand their own reasons and explanations
for doing them.
3) We need to focus on the process of mother’s changes,
bearing in mind that treatment process can lead to mother’srole enlargement.

3. The Significance to Change How the Disease Name of Cleft
Lip and Palate Are Perceived by Mothers

Doctors specify particular disease situations by diagnostic names but disease conditions of cleft lip and palate canbe cured by treatment and surgery. The name of diagnosis
does not necessarily have a significance to a mother and her
infant over a long period of time. Most mothers feel the curing
process in a positive way as their children grow up. Mother’srecognition of ≪interpreting that cleft lip and palate is notdisease≫ can be understood as the expression of an uncomfortable feeling and doubt. That cleft lip and palate is a disease
with no known cause and causes facial malformations puts
a shame and stigma to the name of this disease. In order todispel such negative feelings mothers have to possess cognitive framework to interpret and explain their children’s disease from a standpoint of mothers, which differ conceptuallyfrom cleft lip and palate understood by medical professionals.
≪interpreting that cleft lip and palate is not disease≫ can beconsidered to derive from such a mother’s initiative.
It is also said that attitudes on child-rearing40), prejudiceagainst handicap, and a sense of guilt toward one’s child which
a mother possesses bring about child’s feelings of low selfconcept and inferiority41). Paying extremely close attention tochildren42) is also considered to have an adverse effect on theshaping of their characters. Sumida and others, taking up the

IX. The Limits of This Study and Remaining Tasks

Mothers of children with cleft lip and palate in this study
were the ones who agreed to participate in the interviews,
which might not necessarily represent the whole populationof mothers of children with cleft lip and palate in Japan. It
is expected that mothers who did not agreed to participate
in the interviews would have peculiar characteristics suchas extreme negative sentiment or regional characteristics
of family relations. Therefore, we need to clarify a variety of
aspects of mothers’ experiences in the future study.
27

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X. Acknowledgmentsal.): The Discovery of Grounded Theory, 29-167, Shin-yo-sha,
Tokyo, 1996.
17) Shigeko Saiki-Craighill: Jissen Grounded Theory Approach – Rirono umidasumade, 8-11, 73-75, Shin-yo-sha, Tokyo, 2006.
18) Yasuhito Kinoshita: Grounded Theory Approach no jissen, 140206, Koubundo, Tokyo, 2003.
19) 
Mami Kayama: Shitsuteki kenkyu jissen nouto – kenkyuu
purosesu o susumeru clue to pointo, 31-33, Igaku-shoin, Tokyo,
2007.
20) op. cit. 16)21) 
I. Holloway and others (translated by Miwako Noguchi):
Qualitative Research in Nursing, 246-259, Igaku-shoin, Tokyo,
2006.
22) 
Mihoko Nakanii, Hitomi Shinohara, et al.: Koushinretsu
kougairetsu no shussei-mae kokuchi o ukeru hahaoya ni taisuru
kokuchi-ji shien moderu no teian, Kawasaki Iryo Fukushigaku
Kaishi, 15(2), 393-401, 2006.
23) Yasuo Takeda: Koushin kougairetsu no shussei-mae shindan toshussei-mae kaunseringu, Shouni Shika-gaku Zasshi, 39(5), 966973, 2001.
24) Mihoko Nakanii, Hitomi Shinohara, et al.: Koushin kougairetsu-ji
no hahaoya ni taisuru shuusei-mae kokuchi no jittai to shien no
kentou, Kawasaki Iryo Fukushigaku Kaishi, 15(1), 103-116, 2005.
25) V. Martin: Prenatal cleft lip and palate parent programme -- phase
I, British Journal of Midwifery, 13(2), 90-5, 2005.
26) Nobuyuki Sagehashi: Koushin kougairetsu no taiji shindan – Igi
to mondaiten, Gunma Igaku, 64-1-5, 1996.
27) op. cit. 10)28) op. cit. 7)29) Yuko Okamoto: Shin jyosei no tame no raifu saikuru shinrigaku,
155-156, Fukumura Shuppan, Tokyo, 2002.
30) Keiko Kashiwagi: Kazoku shinrigaku, 197-198, University ofTokyo Press, 2002.
31) ibid.
32) op. cit 29)33) H. K. Marshall, et al. (translated by Toru Takeuchi): Parent-Infant
Bonding, 209-226, Igaku-shoin, Tokyo, 2001.
34) Shigeko Saiki-Craighill: Tatakai no kiseki: Shouni-gan ni yoru
kodomo no soushitsu to hahaoya no seichou, 38-52, Kawashima
Shoten, Tokyo, 1999.
35) Taeko Hori: NICU ni nyuuin shiteiru tei-shussei-taijyuuji nohahaoya no sutoresu to sono taisho ni tsuite, Journal of Japanese
Academy of Neonatal Nursing, 7(1), 33-41, 2000.
36) Akiko Nobe, Kyoko Yokoo, et al.: Shougai o motsu ko ga sodatsu
to iukoto, 117-118, Chuohoki Publishing, Tokyo, 2008.
37) op.cit. 34) 70-73.
38) Izuru Shinmura: Koujien, 826, Iwanami Shoten, Tokyo, 2008.
39) Adachi Tomoaki: Hahaoya no ikuji taido jyouhou ni yoru koushin
kougairetsu-ji no jiritsusei no yosoku, Shouni Hoken Kenkyu,
59(6), 703-709, 2000.
40) ibid.
41) Atsuko Sado, Masatoshi Ishii, et al.: Koushin kougairetsu kanjya
no byoumei kokuchi ni kansuru kenkyu, Journal of Japanese Cleft
Palate Association, 26, 97-113, 2001.
42) K. Coy, M. Speltz, et al.: Facial appearance and attachment ininfants with orofacial cleft: a replication, Cleft Palate-Craniofacial
Journal, 39(1), 66-72, 2002.
43) Masaki Sumida: A study of the Japanese views of children in
the present day, 2001-2003 Kagaku kenkyu-hi hojyokin kiban
kenkyu (C) (2), Kenkyu seika houkokusho, 1-6, 2004.

The authors appreciate all mothers of children with cleft
lip and palate and hospital staff members who cooperated
with our research.

Additional Note: This article is revised from a section of
the master’s thesis submitted to Graduate School of Medical
Sciences, Kyushu University in 2008.
References

1) Tatsuo Nakajima, Tohru Oka, and Shigenobu Iwata: Koushin kougairetsu no souki sougou chiryo, 2-19, Ishiyaku Publishers, Inc,Tokyo, 1994.
2) Shojiro Takahashi: Koushinretsu kougairetsu no kiso to rinsho,
1-2, 57, 127, Nihon Shika Hyouronsha, Tokyo, 1996.
3) Nagato Natsume, Yoshitaka Toyama, et al.: Aichi Gifu Mieken de 2000-nen ni shussei shita 48,491-nin chuu no koushin
kougairetsu no hassei hindo ni kansuru kenkyu, Shogai Shikagaku
Kaishi, 26, 210-215, 2005.
4) op. cit. 1)5) Kumiko Sato, Inoue Keiko, et al.: Koshin kougaiji o motsu hahaoyano shinriteki hannou ni kansuru kenkyu, Yamanashi Nursing
Journal, 3(1), 33-40, 2004.
6) Naomi Funasima: Omo na kenko shougai to kango kea – Sentensei
no shougai, Shouni Kangogaku (Hyoujun Kangogaku Kouza 29),356-361, Kanehara Shuppan, Tokyo, 1994.
7) Mihoko Nakanii, Hitomi Shinohara, et al.: Koushin kougairetsuji
no hahaoya ni taisuru shussei mae kokuchi no jittai to shien no
kentou, Kawasaki Iryo Fukushigaku Kaishi, 15(1), 103-116, 2005.
8) B. Johansson and C. R. Kerin: Parents’ experiences of having achild with cleft lip and palate: Journal of Advanced Nursing, 47(2),165-173, 2004.
9) Nagato Natsume, Suzuki Toshio, et al.: Koushin, kougairetsu-ji omotsu kazoku, tokuni hahaoya no shinri – II. Shujyutsu shikou ni
yoru shinri henka, Journal of Japanese Cleft Palate Association,
111(1), 94-104, 1986.
10) F. J. Kramer and C. Baethge: An analysis of quality of life in
130 families having small children with cleft lip/palate using
the impact on family scale, International Journal of Oral andMaxillofacial Surgery, 36, 1146-1152, 2007.
11) Kayo Cho: Seitai jin-ishoku o uketa kodomo no hahaoya no taiken,
Journal of Japanese Society of Child Health Nursing, 10(2), 1-8,
2001.
12) Chifumi Miyamoto and Yukimi Hirose: Sentensei shinshikkan oukeru nyuuyouji o motsu hahaoya no omoi – jyutsumae ni jitaku
ryouyou keiken no aru hahaoya no baai, Journal of JapaneseSociety of Child Health Nursing, 15(1), 9-16, 2006.
13) Mihoko Nakanii: Koushin kougairetsu-ji no kazoku ga shakai karauketa kotoba ya taido no chuushutsu to iryousha no kadai – Kokunai
bunken kara no kentou, Kawasaki Iryo Fukushigaku Kaishi, 16(1),173-178, 2006.
14) H. G. Blumer (translated by Masayuki Goto): Symbolic Internationalism:
Perspective and Method, 1-26, Keiso Shobo, Tokyo, 1991.
15) Mamoru Funatsu and Makoto Hogetsu: Shinborikku sougo
sayouron no sekai, 3-12, 37-98, 135-143, Kouseisha Kouseikaku,
Tokyo, 1995.
16) B. G. Glaser and A. L. Strauss (translated by Takashi Gotou, et28This paper was published at “the Japan Society of Nursing Research” Vol.33 No.4 in 2010.