Nurses' Awareness of and care for Mothers' Intentional Indulgence

Background: To clarify nurses’ awareness of and care for the indulgence and intentional indulgence of mothers who have children hospitalized with chronic diseases. Method: Between September and November 2014, semi-structured interviews were conducted with nurses who provided written consented. Verbatim transcripts of the audiotaped interviews were made. These transcripts were then encoded, and divided into subcategories and categories. Results: The data obtained from the interviews were divided into 33 labels, 17 subcategories, 8 categories, and 4 core categories. Nurses regarded indulgence as prioritization of mothers' needs, and intervened for them in consideration of such indulgence’s long-term adverse influence on their children. In addition, nurses considered that intentional indulgence shown by mothers had rational reasons, did not have a long-term adverse influence on children, was benefits for children, and was benefits for mothers, and only watched them closely. The conflicted feelings of nurses regarding intentional indulgence were caused by their professional ideas and prejudice about indulgence. To cope with such feelings, nurses aimed to provide care which did not require intentional indulgence, appropriately assessed pediatric patients, and gave their mothers care-related guidance. Conclusion: When investigating nurses’ awareness of and care for mothers’ indulgence and intentional indulgence, the long-term influence of these types of indulgence on children’s development was an important factor. The results of the present study suggest the need to conduct studies investigating the long-term influence of mothers’ intentional indulgence on their children’s development. Nurses' Awareness of and care for Mothers' Intentional Indulgence Publication History: Received: April 25, 2016 Accepted: June 15, 2016 Published: June 17, 2016


Research Article
Open Access

Background
In general, children's emotional dependence on their mothers is important for developing the mother-child relationship, and an essential factor for these children's health and mentality [1]. However, mothers' indulgence towards their children may promote their self-indulgence and regression, and hinder their development. In particular, parents who have children with chronic diseases can feel conflicted about being indulgent towards them. People who have children with juvenile rheumatoid arthritis [2] and those who have children with cancer [3,4] are commonly concerned that they may be overprotective or their children may become ill-disciplined because of the prioritization of treating symptoms. In addition, parents who have children with chronic diseases generally search for appropriate ways to raise them according to their disease symptoms, and encounter difficulties in being consistent about child raising due to these symptoms [5]. Thus, these parents' indulgence towards their children is a significant issue.
On the other hand, Yukimatsu investigated mothers who had children with chronic diseases, and identified these mothers' consistent awareness of and responses to their children's emotional dependence. Because mothers need to raise their children in consideration of limitations from which these children suffer due to their diseases, these mothers intentionally become indulgent with a clear reason [6]. For example, "situation-specific indulgence" is used for hospitalized children who suffer from many limitations and lead an uneventful/restricted life. "Indulgence associated with limitations" represents support for children who are unable to do things due to hospitalization or treatment.
The roles of nurses are to promote children's growth and development, and reduce their parents' burden. However, to the best of our knowledge, no studies have clarified nurses' awareness of or care for mothers' indulgence or intentional indulgence towards their children. Against this background, to clarify nurses' awareness of and care for the indulgence or intentional indulgence of mothers who have children with chronic diseases, we conducted interviews with nurses who worked or had experience of working on a pediatric ward.

Definitions of terms
Using Kojien (Japanese dictionary), indulgence was defined as letting a child be self-indulgent without being strict in discipline [7]. Intentional indulgence was defined as taking a specific action with a clear reason for being indulgent [6].

Study subjects and methods for data collection
The study subjects comprised 5 nurses who were currently working or had worked on a pediatric ward between 2010 and 2014. Using snowball sampling, these subjects were introduced by pediatric nursing researchers and pediatric nurses between September and November 2014. Using an interview guide, semi-structured interviews were conducted with nurses who provided written consented. We asked them their age, years of nursing experience, and years of employment on a pediatric ward. In addition, we surveyed them about cases of mothers who had shown indulgence or intentional indulgence towards their children, these nurses' awareness regarding these 2 types of indulgence, the influence of these types of indulgence on children, and nursing intervention. We investigated infants aged 1-6 years, as children commonly develop their basic lifestyles in this age range. All nurses were interviewed individually for approximately 1 hour, and all interviews were audiotaped after obtaining their consent.

Analysis
Verbatim transcripts of each audiotaped interview were made. While maintaining the main points of these transcripts, they were repeatedly reviewed, classified according to their meaning, and encoded. After being labeled according to their similarities, these data were divided into subcategories and categories based on the similarities noted among the 5 subjects. To ensure data reliability, all analyses were performed with pediatric nursing professionals.

Ethical considerations
During the interviews, questions were asked in a manner so that pediatric patients or their families would not be identified, as well as ensuring the subjects' confidentiality. Before holding interviews, we provided the subjects with a full explanation regarding the purpose, interview details, and ethical considerations, and then obtained their written consent. This study was conducted with the approval of the ethical committee of a university to which the researchers belonged (26-15).

Subject attributes
The subjects comprised 5 nurses; 4 and 1 nurse were in their 20s and 40s, respectively. The duration of employment as a nurse was <5 years, ≥5 years to <10 years, and ≥20 years to <25 years for 2, 2, and 1 subject, respectively. The duration of employment on a pediatric ward specifically was 1, 4, 6, and 13 years for 1, 1, 2, and 1 subject, respectively. The average interview duration was 48±6.96 minutes (35 to 56 minutes).

Indulgence
{Indulgence} comprised the following 2 categories: 1) [Long-term adverse influence on children] and the [Prioritization of mothers' needs] (Table 1). Nurses considered the following situation to be indulgence: an act that may have an adverse influence on a child's future as a result of their mother being indulgent when no treatmentrelated limitations are imposed on the child and no rational reason for being indulgent exists. Category 1 consisted of «negligent disease management», «hindered independence», and «delays in developing social skills». To respond to such indulgence, nurses provided support facilitating children's development. When a child's disease was not appropriately managed due to a lack of knowledge on the part of their mother, nurses judged this situation as indulgence that is not beneficial for the child, and provided educational intervention for her. Category 2 comprised the «prevention of mothers from being , such as a «support for children who continue suffering from treatment-related limitations», and the «consideration given to hospitalized children». For example, nurses perceived that mothers helped their children to change clothes when undergoing infusion for [rational reasons]; in other words, the need to avoid risks. When mothers were being intentionally indulgent in order to ensure [benefits for children], such as «smooth treatment», a «reduction in children's psychological burdens», and the «establishment of the mother-child relationship», nurses only watched them closely.
In particular, because medication is essential for pediatric patients, nurses considered that these children are not allowed to reject medication. For children who had difficulty taking medication, nurses actively employed intentional indulgence (e.g. waiting until they take medication, or giving them a treat after taking medication) in a manner so that they would become able to take medication.
In addition, when mothers showed intentional indulgence to express «mothers' affection towards their children» or for a «sense of satisfaction obtained through fulfilling their roles as a mother», nurses regarded such indulgence as [

Nurses' conflicted feelings regarding intentional indulgence
Nurses have a «professional idea» that children's growth and development should be promoted despite their diseases or treatment. Hence, while understanding the necessity of intentional indulgence, nurses made a «negative prejudgment about indulgence», and felt conflicted about treatment-related limitations imposed on children's development.

"Essentially, intentional indulgence is not ideal from the perspectives of both treating the diseases of children and their growth/development. However, in fact, mothers often have no choice but to become intentionally indulgent given that their children suffer from treatmentor hospitalization-related limitations. "
"I have always wondered whether or not intentional indulgence was better for pediatric patients, when their mothers would change their parenting styles, and whether or not the ways in which these women were indulgent were reasonable. "

Coping with conflicted feelings
Nurses with more than 19 years of experience felt conflicted about intentional indulgence, and provided mothers with «professional advice». In addition, these workers provided «intentional indulgencefree care» for children requiring extra time to take drugs; in other words, nurses began to help such children with medication early enough.
"If I have any suggestions, I would offer them to mothers at least once. " "Children requiring extra time for medication could take drugs at the specified time if we begin to help them with (medication) early enough. "

Discussion
Mothers' actions that nurses considered to be intentional indulgence had rational reasons, were beneficial for children and mothers, and did not have a long-term adverse influence on these children. However, nurses tend to negatively view mothers' indulgence. Against this background, Yukimatsu clarified that mothers who had children with chronic diseases could be intentionally indulgent in response to stressful situations or limitations from which these children were suffering, such as those caused by infusion, and warned against nurses' negative perceptions regarding such indulgence [6].
On the other hand, nurses in the present study positively viewed intentional indulgence shown by mothers, and only watched them closely. In addition, these professionals were also being intentionally indulgent to ensure essential benefits for children, such as those generated by medication.
[No long-term adverse influence applied to children] was a factor that mothers who had children with chronic disease were less likely to note, and was a viewpoint specific to nurses. In general, mothers have no choice but to prioritize treatment for their children during hospitalization, and pay attention to these children's development after discharge [8,9]. Thus, it may be difficult for mothers to take a longterm view regarding the development of hospitalized children. We propose that, while considering limitations from which hospitalized children suffer and their mothers' intentional indulgence, nurses should only watch them closely in actions that do not have a longterm adverse influence on these children's development.
The results of our study indicate that nurses not only have negative views and feel conflicted regarding intentional indulgence, but are also concerned about its adverse post-discharge influence on children, particularly on their psychosocial development. Nurses deliberated about the long-term adverse influence of rewards given to children, and interacted with them in a manner so that they could be encouraged to do things even if they are not provided with these rewards. Appropriate assessment-based nursing care, in which children requiring time for medication are encouraged to take drugs early enough, is a form of "care that does not need intentional indulgence". We suggest that nurses aim to provide "nursing care in which intentional indulgence is not required" in consideration of factors that are beneficial for children's development.
To reduce indulgence aimed at meeting the needs of mothers, it is important to alleviate their stress and provide them with opportunities to fulfill their roles as a mother. Some skilled nurses provide mothers with support aimed at increasing their level of satisfaction; such support includes teaching mothers how to please their children [10]. In addition, if a trusting relationship exists between healthcare providers and mothers, mothers would be more likely to accept these providers' opinions [11], which may eventually lead to [benefits for children].
As the present study investigated nurses' awareness regarding mothers' intentional indulgence, there is also a need to study the longterm influence of mothers' intentional indulgence on children with chronic diseases.

Conclusion
Nurses regarded actions deemed likely to have an adverse influence on children as indulgence. In addition, nurses considered that, if an action has rational reasons, is beneficial for children or their mothers, or does not adversely influence children, this action will represent intentional indulgence. Furthermore, nurses not only felt conflicted about intentional indulgence, but also aimed to provide nursing care which did not require intentional indulgence in consideration of its post-discharge adverse influence on children.
Nurses' awareness of and care for mothers' indulgence and intentional indulgence indicate the importance of providing care based on caregiving provided by families, as well as on children's development over the long-term. The results of this study suggest the need to investigate the long-term influence of mothers' intentional indulgence on their children's development. IJNCP

Author Contributions
Mayu Yoshitsugu and Ikuko Sobue contributed to the conception and design of the study. Mayu Yoshitsugu contributed to the acquisition, analyses, and interpretation of the data, as well as the drafting of the manuscript. Ikuko Sobue contributed to the supervision of the drafting and critical revision of the manuscript. All the authors have read the manuscript and have approved this submission.