Table 1.

Discovery Model: Nursing Research Studies on the Insider View of Parent–Child Relationships

Source	Design/theory	Focus	Sample	Results
Anderson and Anderson (1987)	Qualitative—Grounded theory	Maternal–twin relationship development Measures: Semi-structured interview at 1 month	Infant (1 month)/Mothers/Ethnicity not described/10 participants (married; middle class; high school education or >)/Canada	Early maternal–infant twin relationships developed through differentiation of twins’ physical characteristics and polarization of their personality characteristics. Desire for maternal justice reflected mothers’ concern that twins received the same amount of attention.
Anderson and Anderson (1990)	Qualitative—Grounded theory longitudinal	Maternal–twin relationship development Measures: Semi-structured interviews at 1, 4, 8, and 12 months	Infant (1–12 months)/Mothers/Ethnicity not described/10 participants (married; middle class; high school education or >)/Canada	Individuation (core category) was central to and influenced polarization, differentiation, maternal justice, and support. To establish a relationship with their twins, mothers first differentiate between the twins’ personalities and physical characteristics to individuate between the infants. Over time, mothers more easily differentiated between twins and individualized their relationships.
Anderson (1996)	Qualitative—Grounded theory	Maternal–twin relationship development Measures: Semi-structured interviews	Infant (2 months)/Fathers/Caucasian, middle class/14 participants/Canada	Three major categories were operative in early development of the father–infant relationship: (a) making a commitment; (b) becoming connected; and (c) making room for the baby.
Barclay, Everitt, Rogan, Schmied, and Wyllie (1997) (Rogan, Schmied, Barclay, Everitt, Wyllie, 1997 article provides additional description of analytic method.)	Qualitative—Grounded theory	Maternal experience of primiparous women Measures: Nine focus groups with key questions and group discussion	Infant (2–26 weeks)/Mothers/Ethnicity not described/55 participants—married/Australia	Six categories were identified: realizing, unready, drained, aloneness, loss, and working it out. The core category, becoming a mother, integrates the other categories and encapsulates the process of change. Factors mediating the often distressing experience of becoming a mother included the nature of the infant, maternal reactions to infant behavior, prior experiences with infants, and availability of social support.
Bialoskurski, Cox, and Hayes (1999)	Qualitative—Ethnography Leninger’s Sunrise Model (1991) Content analysis	Maternal attachment in the NICU Measures: Unstructured individual interviews and participant observation	Infant (preterm, <5 months)/Mothers/Ethnicity—1 American, 14 British, 2 Indian, 1 Hindu, 1 Turkish, 2 West Indian, 2 West African, 1 Jewish, 1 Egyptian/25 participants/United Kingdom	In the NICU, attachment was an individualized process that was not automatic. Overt and covert attachment processes may depend on the health status of the infant and the mother, environmental circumstances, and on the infant’s quality of care. The presence of the nurse alters attachment process (can facilitate or impede).
Bell, Goulet, St-Cyr Tribble, Paul, Boisclair, and Tronick (2007)	Qualitative—Grounded theory Family systems theory	Interrelatedness of mother–infant and father–infant relationships over first 4 months postpartum and dynamics used to balance these relationships. Measure: Parent–Infant Relationship Interview (Bell, Goulet, St-Cyr Tribble, & Paul, 2000); 108 individual interviews were completed.	Infant (1 week–4 months)/Mothers and Fathers/Ethnicity—36 Caucasian, French-speaking/36 (18 parental dyads)/Canada Low risk status (normal pregnancy, term delivery without complications, and a healthy newborn)	Early family relationships ranged from (a) an undifferentiated relationship between fathers and mothers at 1 week (parents develop knowledge of the infant together and seek agreement about how to feel and behave with the infant) to (b) a highly disorganized unit at 6 weeks with differentiation between mother–infant and father–infant relationships and a rigid systemic organization and family tension; to (c) an integrated family unit at 16 weeks that acknowledges different, but complementary roles. This process allows parents to have unique, specific relationships without competitiveness.
Casteel (1990)	Qualitative Description—Content analysis General systems theory	Affect and cognition of parents of preterm infants Measures: Two open-ended, semi-structured dyadic interviews	Infant (preterm, <3 months)/Mothers and Fathers/Ethnicity (infant)—18 White, 1 Hispanic infant/36 (18 parental dyads)/United States	The affective category included positive and negative responses. Positive responses were amazement, confidence, love, and well-being. Negative responses included anxiety, fear, helplessness, and sadness. Cognitive responses included three types of responses: protection, provision, and attachment. Mothers and fathers expressed more negative feelings during hospitalization than afterwards, and the proportion of total cognitive responses increased after discharge. Mothers’ cognitive responses were more specific about parental role responsibilities than fathers’ responses.
Fegran, Helseth, and Fagermoen (2008)	Qualitative—Descriptive hermeneutic Attachment theory	Compare mothers’ and fathers’ experiences of attachment in the NICU Measures: Individual interviews	Infant (preterm)/Mothers and Fathers/Ethnicity not described/12 (6 parental dyads)/Norway	Two main categories were identified: taken by surprise and building a relationship. Differences between mothers’ and fathers’ experiences were evident. Mothers wanted to be close to their infants despite experiencing strong, negative emotions. Fathers were ambivalent about being close to their infants, but experienced more positive contact than expected. When “taken by surprise,” fathers felt shocked by the sudden birth, but were ready to be involved, while mothers felt powerless and viewed the postpartum period as surreal.
Fenwick, Barclay, and Schmied (2001)	Qualitative—Grounded theory	Women’s experiences of mothering in NICU. Measures: In-depth individual interviews, participant observation, and audiotaped mother–nurse interactions	Infant/Mothers/Ethnicity not described/28 participants/Australia 20 nurses (18 RNs—1 male, 17 female; and 2 student midwives—sex not described)	Inhibitive nursing actions focused on protecting the infant, relegated women to the periphery of care, and created an array of negative maternal emotional responses, which left women feeling irrelevant to the welfare of their infants. Maternal consequences included feeling disaffected, guarding, speaking out, earning a reputation or recriminations, and, if positive relations were not established, maternal disenfranchisement. Speaking out often leads to conflict.
Flacking, Ewald, Nyqvist, and Starrin (2006)	Qualitative—Grounded theory	How mothers of very preterm infants experience breast-feeding and how this is related to the process of becoming a mother from before birth until discharge from neonatal unit Measures: In-depth interviews	Infant (preterm, 3–17 months)/Mothers/Ethnicity not described/25 participants/Sweden	Quality social bonds with the infant, father, staff, and other mothers at the neonatal unit were important. Three themes described experiences, social bonds, and emotions: (a) “loss” of the infant and the emotional chaos—“putting life on hold”; (b) separation—a sign of being unimportant as a person and mother; and (c) critical aspects of becoming more than a physical mother. The qualities were described as trustful or distrustful, characterized by feelings of pride/trust or shame/distrust. Interpersonal interactions, the public environment, and care routines affected social bonds. While mothers desired reciprocal breast-feeding, distrustful bonds and the context made that difficult to achieve.
Flacking, Ewald, and Starrin (2007)	Qualitative—Grounded theory (descriptive)	To find out how mothers of very preterm infants experience the process of becoming a mother and breast-feeding after neonatal unit discharge Measures: In-depth interviews	Infant (preterm, 3–17 months)/Mothers/Ethnicity not described/25 participants/Sweden	The process of becoming a mother and breast-feeding was represented by pendular changes in mothers’ emotional states, in the maternal–infant bond, and in the experience of breast-feeding. Mothers’ emotional states varied considerably and alternated between feeling emotionally exhausted and feeling relieved, experiencing an insecure and a secure bond with their infants, and regarding breast-feeding as nonreciprocal and reciprocal.
Hayes, Stainton, and McNeil (1993)	Case study—Phenomenological hermeneutic	Mother’s lived experience of caring for a chronically ill infant coming home from NICU Measures: In-depth interview	Infant (preterm, 6 months)/Mother/Ethnicity not described/1 participant/United States	Five meanings were identified in the maternal experience: uncertainty; experiencing the baby as powerful; striving to gain acceptance from the baby; blurred territory in caring for the baby; and being alone and vulnerable.
Heermann, Wilson, and Wilhelm (2005)	Qualitative—Domain analysis	Mothers’ experiences of becoming a mother while their infants were in the NICU and ways that the relationship was affected by relationships with nurses Measures: Open-ended individual interviews	Infant (preterm)/Mothers/Ethnicity—White/15 participants/United States	Mothers’ development evolved in predictable patterns. Mothers moved from being outsiders to engaged parents along four continua: (a) focus shifted from NICU to baby; (b) from their baby to my baby; (c) from passive to active caregiving; and (d) from silence to advocacy. Mothers entered the continua at different points and moved at different rates toward “engaged parenting.” Partnering, the final developmental stage, required nurses’ active participation and occurred with a minority of women.
Holditch-Davis and Miles (2000)	Qualitative—Preterm Parental Distress Model	Describe mothers’ experiences surrounding the birth and hospitalization of a preterm infant and determine how well a model of the sources of stress of parents in the NICU—the Preterm Parental Distress Model—fits these data Measures: Semi-structured interview	Infant (preterm, 6 months)/Mothers/Ethnicity—19 White, 11 Black, 1 Asian/31 participants/United States	The Preterm Parental Distress Model adequately depicted the sources of stress and support experienced by mothers with preterm infants in the NICU. More than 80% of the sample experienced all but one of the themes of the model: the effect of preexisting and concurrent personal and family factors. The mothers’ pre- and perinatal experiences provided a context for their interpretation of the NICU experience. Major stresses in the NICU were illness severity, treatments, and infant appearance; concerns about infant outcome; and loss of the parental role. Healthcare providers helped and hindered mothers to deal with these stresses.
Hurst (2001a)	Qualitative—Critical ethnography	Maternal perceptions of their needs in the NICU and actions to address their needs Measures: In-depth individual interviews and participant observation	Infant (preterm, <4 months)/Mothers/Ethnicity—7 White, 4 Latina, 1 African American/12 participants/United States	Mothers identified informational and interactional needs related to becoming a mother in the NICU. Mothers’ priorities for their own care related to becoming a mother, obtaining information and assistance for engaging in parent–child interaction, and concern for their own emotional safety. Mothers perceived their needs as competing with those of their infants, and avoided drawing resources away from their infants, even if that meant compromising their ability to develop a relationship with their infants.
Hurst (2001b)	Qualitative—Critical ethnography	Maternal experiences of having a hospitalized preterm infant and actions to safeguard their babies in the NICU Measures: In-depth individual interviews and participant observation	Infant (preterm, <4 months)/Mothers/Ethnicity—7 White, 4 Latina, 1 African American/12 participants/United States	“Vigilant watching over” was the primary maternal action, a process of ongoing maternal observation, reflection, and action. Mothers feared being labeled a “difficult mother,” lacked empowering information, and perceived a lack of continuity of care. Mothers perceived the allocation of nursing staff resources as critical to their child’s safety in the NICU. Interrelationships emerged between conditions of the NICU and the mothers’ experiences, evaluations, and actions.
Jackson, Ternestedt, and Schollin (2003)	Qualitative—Phenomenology, longitudinal	The experiences of parenthood of mothers and fathers of preterm infants during the first 18 months Measures: Multiple dyadic interviews (1–2 weeks after birth, 2, 6, and 18 months of age)	Infant (preterm, 1 week–18 months)/Mothers and Fathers/Ethnicity—Swedish/14 participants (7 parental dyads)/Sweden	Internalization of parenthood was found to be a time-dependent process, characterized by alienation, responsibility, confidence, and familiarity. Similarities in how mothers and fathers described parental roles involved concern for the child, insecurity, adjustment, and relationship with the child. Differences included mothers feeling greater need for participation in and control of the care and a need to be confirmed as a mother. Fathers described confidence in leaving the care to the staff and wanted to find a balance between work and family life. Important turning points included when the infant could be removed from the incubator, discharged from the ward, and when the infant looked normal compared with full-term infants.
Johnson (2007)	Qualitative—Description Content analysis	The maternal experience of kangaroo holding preterm infants in the NICU Measures: Open-ended interviews and participant observation following third kangaroo holding experience	Infant (preterm)/Mothers/Ethnicity—1% White, 28% African American, 11% Asian/18 mother–infant dyads/United States	Three themes were identified: (a) maternal–infant benefits of kangaroo holding included being needed, heart warming, and confidence in knowing; (b) need for support for holding included nursing guidance, schedule for holding, and quiet space; and (c) satisfaction with the interactions included feeling connected to the infant and learning to mother.
Lasby, Newton, Sherrow, Stainton, and McNeil (1994)	Case study—Hermeneutic	Lived experience of becoming a mother to a premature infant Measures: 9 in-depth interviews	Infant (preterm, <4 months)/Mothers/Ethnicity not described/1 participant/United States	The phenomenon of maternal work was found to be embedded in this mother’s experience. Working for love, working for meaningful moments, working amid uncertainty, working against the odds, and working overtime were identified as shifting dimensions of maternal work. Barriers and obstacles increased the burden of maternal work.
Lundqvist and Jakobsson (2003)	Qualitative—Descriptive Content analysis	Swedish men’s experiences of becoming fathers to their preterm infants Measures: Individual interviews	Infant (preterm, 3–5 days)/Fathers/Ethnicity not described/8 participants/Sweden	Manifest content analysis identified six categories: concern, stress, helplessness, security, support, and happiness. The latent content interpretation revealed that the concepts of control and noncontrol were relevant to the fathers’ experiences. Men’s experiences of early fatherhood were influenced by their abilities to experience control. When concern, stress, and helplessness dominated their experiences and coincided with low levels of happiness, support, and security, fathers experienced noncontrol. But when they experienced support, security, and happiness, they felt in control and able to handle situations.
Lundqvist, Hellstom Westas, & Hallstrom (2007)	Qualitative—Hermeneutic Phenomenological	Fathers’ lived experiences of caring for their preterm infants Measures: Individual interviews	Infant (preterm, 1–3 months)/Fathers/Swedish/13 participants/Sweden	Fathers’ lived experiences were expressed as a process moving from initial feelings of distance from their infants toward feelings of proximity. The process was described as a pendulum that was easily disturbed. Feelings of distance included experiences of living beside reality, becoming an outsider, and living with worry. Feelings of proximity included experiences of returning to reality, becoming a family, and facing the future.
Lupton and Fenwick (2001)	Qualitative—Discourse analysis Foucauldian theory	Mothers’ constructions and practicing of motherhood in special care nurseries Measures: Individual interviews, participant observation, and audiotaped mother–nurse interactions	Infant (preterm, 12 weeks)/Mothers/Ethnicity not described/31 participants/Australia 20 nurses (18 RNs—1 male, 17 female; and 2 student midwives—sex not described)	Mothers attempted to construct themselves as “real mothers,” which involved establishing connections with their infants and normalizing them. Many mothers eventually sought to position themselves as “experts” on their infants. Nurses attempted to position themselves as “teachers and monitors of the parents,” “protectors of the infants,” and “experts.” Differences between mothers and nurses resulted in mothers feeling frustrated, resentful, and angry, while many nurses engaged in covert and overt disciplinary and surveillance actions.
Neu (1999)	Qualitative—Naturalistic inquiry	Explore parents’ perceptions of skin-to-skin care with preterm, mechanically ventilated infants and elucidate factors that influenced parents’ decisions to continue or discontinue skin-to-skin care Measures: Two individual open-ended interviews	Infant (preterm)/Mothers and Fathers/Ethnicity—8 White, 1 African American/9 participants/United States	Three themes were found: ambivalence of parents toward skin-to-skin care; need for a supportive environment; and special quality of the parent–infant interaction. Parents who discontinued skin-to-skin care expressed more intense apprehension and perceived environmental factors to inhibit successful skin-to-skin holding.
Neu (2004)	Qualitative—Naturalistic inquiry	Describe factors that influence mothers’ choice of kangaroo care versus standard holding with their healthy preterm infants Measures: Two open-ended individual interviews (in hospital and at home)	Infant (preterm, 1 day–15 weeks)/Mothers/Ethnicity—19 White, 2 African American, 2 Asian, 1 Hispanic/24 participants/United States	Mothers’ holding practices divided them into three groups: (a) kangaroo holding in hospital and home; (b) blanket holding in hospital and home; and (c) holding practice switched from hospital to home. Three themes emerged: (a) expression of distress; (b) perception of facilitative environment for holding; and (c) perceived benefits of close contact with the infant.
Nichols (2004)	Qualitative—Grounded theory	Social process of infant care among Cherokee mothers Measures: In-depth interviews and participant observation	Infant (<2 years)/Mothers/Ethnicity—Cherokee/19 participants (13 married, 6 unmarried)/United States	The social process of Native American infant care was identified, with being a Cherokee mother described as the principal concept. Accommodating everyday infant care, accommodating health perspectives, building a care-providing consortium, living spiritually, merging the infant into Native American culture, using noncoercive discipline, and vigilantly watching for the natural unfolding of the infant were the concepts describing patterns of cultural maternal care. Maternal functions included rearing healthy children, passing clan membership to the infant, and spreading care of children to other family members.
Niska, Snyder, and Lia-Hoagberg (1998)	Qualitative—Ethnography, longitudinal Roy’s Adaptation Model (1983) Spradley	Family rituals among Mexican American parents facilitating the transition to parenthood Measures: Audiotaped conversations, interviews, observation, and card-sorting activities	Infant (<6 months)/Mothers and Fathers/Ethnicity—Mexican American/25 families/United States	La cuarentena, a cultural, intergenerational family ritual during the first 40 days postpartum was engaged in by 24 of 25 families. This ritual facilitated adaption to the parental role and allowed parents the opportunity and time to learn from their parents about infant caregiving and to develop a relationship with their new infants.
Nystrom and Axelsson (2002)	Qualitative—Hermeneutic	Mothers’ experiences of being separated from their infants Measures: Individual interviews	Infant (full-term high-risk, 1–2 months)/Mothers/Ethnicity not described/8 participants/Sweden	Three themes were identified: (a) being an outsider with feelings of despair, powerlessness, homelessness, and disappointment; (b) lack of control with emotional instability, threat, guilt, and insecurity; and (c) caring with trust, love, anxiety, relief, closeness, and explanations.
Oehler, Hannan, and Catlett (1993)	Qualitative—Descriptive	Mothers’ views of preterm infant responsiveness and interactions Measures: Interview and demographic questionnaire, SCL-90-R (Derogatis, 1977), Neurobiologic Risk Scoring scale (Brazy, Eckerman, Oehler, Goldstein, & O’Rand, 1991)	Infant (preterm, 7 days–5 weeks)/Mothers/Ethnicity—60% African American, 38% White, 2% Asian/47 participants/United States	In the first month of hospitalization, there was a significant increase in mothers’ pleasure in interacting, knowledge of infant cues, and perceptions that their infants were responding. The most frequently mentioned behaviors were maternal talking and touching and infant eye opening and body activity. Many mothers utilized infants’ behaviors as a guide for their own behaviors and reported infants’ behaviors had specific meanings. But an equal number of mothers did not ascribe meaning to their infants’ behaviors and did not appear to use behavioral cues.
Rogan et al. (1997)	Qualitative—Grounded theory	Developing a theory drawing together women’s experiences of early motherhood, conceptualizing the magnitude of change, and providing strategies to help women negotiate the change Measures: Nine focus groups with key questions and group discussion	Infant (2–26 weeks)/Mothers/Ethnicity not described/55 participants—married/Australia	In the process of becoming a mother, women progressed from “this is not my life anymore,” to being in tune with their babies, realization of the impact of the birth and recognition that “this is my baby and I have to take care of it” occurred. A sense of overwhelming change occurred repeatedly, particularly in the early postpartum. Feeling overwhelmed and uncertain left many mothers drained of energy, leaving them less able to interact with others, seek assistance, have time for self, or resume interests, leaving women to feel alone and mourning loss of old life. Women started working out how to care for their babies and incorporate the babies into their lives. The babies’ behavior, social support, and previous experience mediated women’s processes of becoming a mother.