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. Author manuscript; available in PMC: 2010 Mar 9.
Published in final edited form as: J Spec Pediatr Nurs. 2009 Oct;14(4):256–261. doi: 10.1111/j.1744-6155.2009.00206.x

Furthering the Understanding of Parent–Child Relationships: A Nursing Scholarship Review Series. Part 1: Introduction

Kristin F Lutz 1, Lori S Anderson 2, Karen A Pridham 3, Susan K Riesch 4, Patricia T Becker 5
PMCID: PMC2835355  NIHMSID: NIHMS176056  PMID: 19796325

Abstract

PURPOSE

Understanding the parent–child relationship is fundamental to nursing of children and families. The purpose of this integrative review is to explore nursing scholarship published from 1980–2008 concerning parent–child relationships. Study approaches are examined, critiqued, and future directions for research identified.

CONCLUSIONS

A historical review of nursing research is presented and methods described as an introduction to a review series of the parent–child relationship.

IMPLICATIONS

Definition and explication of the parent–child relationship is a first-step in understanding factors amenable to nursing intervention. A clear definition of the concept of parent–child relationship will support further study using appropriate theoretical frameworks, and enable development and testing of supportive nursing interventions.

Search terms: Nursing, object attachment, parents, parent–child relations, parenting

Understanding the parent–child relationship is fundamental to nursing of children and families (Blake, 1954). Since Florence Blake’s seminal work, The Child, His Parents and the Nurse, and the case studies that Blake or her students published, pediatric nursing scholarship has emphasized the parent–child relationship as the context in which parenting occurs and the child’s health and development is supported. Understanding this relationship was vital, Blake maintained, to understanding the child’s challenges in dealing with health problems and to supporting the child in negotiating developmental tasks and becoming competent in all aspects of functioning within the context of those problems. This idea, some 50 years after Blake expressed it, continues to garner support from developmental and social science research. The aim of this integrative review was to synthesize findings from empirical nursing studies about the parent–child relationship.

As a focus of study, the parent–child relationship has a prominent place in the social and developmental sciences, primarily because of its influence on child outcomes across cultures and social strata (Bornstein & Cheah, 2006). What does nursing contribute to the body of knowledge? This integrative review was conducted in the belief that the nursing research literature concerning parent–child relationships is important because of the discipline’s perspective on the relationship between the child’s development and both physical and mental health. Although the focus of nurses who care for children from infancy through adolescence is on the child, the child’s health, growth, and developmental functioning are rooted in the parent–child relationship. The nursing perspective encompasses the idea that, in the context of promoting health and preventing illness, the parent–child relationship needs to be understood for its effect on the child’s health, hence as a focus of both assessment and developmental support. In particular, nurses are mindful of and address their interventions to the processes of both everyday living and coping with extraordinary events, and the relationship-building functions of the parent–child interaction. It is through these processes, interactions, and relationships that the health of both children and parents is shaped, expressed, and supported for the short and long term (Bronfenbrenner, 1996; Nightingale, 1969; Skretkowicz, 1992).

Brief History of Nursing Research on the Parent–Child Relationship

Emerging from a surge in developmental research, a momentous change in paradigm in child development was adopted in the 1970s. Conventional wisdom evolved such that newborn infants were, for the most part, recognized as major contributors to their environment. They were no longer considered a tabula rasa or blank slate but were recognized to be neurologically and physically capable of complex social interactions and well-organized protective behavior (Osofsky & Fitzgerald, 2000). These ideas enlarged the study of the parent–child relationship and gave new impetus to scholarship for the discipline of nursing.

In 1984, McBride reviewed 53 studies published in the nursing literature on the topic of being a parent (McBride, 1984). The chief issues identified in the research conducted up to 1982 were that (a) samples were limited primarily to mothers, (b) the age of the child was limited to the first year, and (c) the direction of influence was limited to that of the parent on the child. The need to cite relevant nursing literature; replicate existing studies and build on them; use conceptual frameworks and refined instruments; pay attention to interpersonal characteristics and factors supportive of relationships; describe methods in detail and with precision, particularly qualitative methods; and take advantage of events as they naturally occurred, was advocated.

McBride’s paper (1984) may have been a catalyst for several of the characteristics in the literature during the 1980s and early 1990s. Considerable attention was paid to: the contribution of the infant to the relationship; development of valid and reliable instruments; change in social norms that witnessed fathers as parenting partners, and a trend to venture beyond infant and reproductive health to older child and parent relationships and the experiences, care, and development of interventions for children with special healthcare needs; and a family-centered focus for pediatric nursing.

Development of Valid and Reliable Instruments

Nursing research that concerned the contribution of the infant to the parent–child relationship was advanced by the development of several new valid and reliable observational instruments. The Brazelton Neonatal Behavioral Assessment Scale (BNBAS; Brazelton, 1973) was developed to assess newborn infant behavior and neurological adequacy. It captured years of prior discovery by developmental psychologists, nurses, and physicians. Many nurse researchers viewed the BNBAS as a “teaching” instrument to introduce parents to their newborn infants.

The quality of the parent–child relationship became the focus of instrument development as a means to screen families for relationship risk and to determine outcomes for nursing interventions to support the child’s health and development. Numerous indicators of the relationship were reported, primarily in the psychology literature but also in the medical and nursing literature. Barnard, Eyres, Lobo, and Snyder’s (1983) work on the Nursing Child Assessment Satellite Training (NCAST) was ground breaking for support of the empirical study of interaction.

A Change in Social Norms

Historically, parenthood was mother-focused. The mother was the eye into the family, particularly in research, which showed that her parenting style contributed to child outcomes. In the United States, however, women in greater numbers were interested in roles beyond motherhood. Childbearing among middle class women became increasingly delayed, many women chose or had to return to the workforce post birth, mothers increasingly delegated considerable hours of infant and child care to others (day care centers, relatives), and fathers became increasingly involved in care of the family (Hrdy, 1999). This led to numerous studies by nurses about the challenges to the maternal–child relationship among mothers working outside the home (e.g., Riesch, 1984) and attention to the paternal–child relationship (e.g., May, 1996). How women birthed children was addressed, and changes in practice such as birthing rooms and centers, skin-to-skin contact (e.g., kangaroo care), and 24-hour rooming in were researched and instituted to promote the mother–child relationship (e.g., Anderson, Dombrowski, & Swinth, 2001).

The Parent–Child Relationship Beyond Infancy

When the National Center for Nursing Research was instituted in 1986 (National Institute for Nursing Research [NINR], 2007) and began funding research, studies of infant and reproductive health constituted one of the national research priorities, resulting in a knowledge boon in this area, particularly with respect to low birth weight and prematurity. As the national research priorities evolved, attention to challenges in the parent–child relationship among children with physical, social, and cognitive disabilities developed, as well as attention to the parent–child relationship among adolescent parents, adoptive parents, and grandparents; parents with a chronic illness or dying parents; homeless, impaired, older, lesbian and gay, and immigrant parents; and parents of varying cultures. Indeed, in nursing and other disciplines there is growing interest in cultural diversity and recognition of the importance of cultural context on families, parenting, and the parent–child relationship (Harkness & Super, 2002; Koniak-Griffin, Logsdon, Hines-Martin, & Turner, 2006; Kotchick & Forehand, 2002). Consequently, in order to better understand how parents in various contexts behave, think, and feel within a multicultural society, the relationship between culture and parenting has been an emergent concern of nursing research and practice.

In order to better understand how parents in various contexts behave, think, and feel within a multicultural society, the relationship between culture and parenting has been an emergent concern of nursing research and practice.

As knowledge emerged, intervention studies to address challenges were proposed. Considerable attention to parents and children navigating these challenges also was evident in the policy arena with the establishment of the Child Nutrition Act of 1966 and ongoing development of the Special Supplemental Nutrition Program for Women, Infants, and Children (Child Nutrition Act, 1966); the evolution of the Individuals with Disabilities Education Act (IDEA; Individuals with Disabilities Education Act, 2004); and as part of IDEA, the institution of early intervention services for children with disabilities (Infants and Toddlers with Disabilities, 2004). These historical trends continue to be visible in and to influence contemporary studies of parent–child relationships. It is within this historical context that this integrative review was conducted.

Nursing Scholarship on Parent–Child Relationships from 1980 to 2008

To our knowledge, the nursing scholarship on parent–child relationships of the last quarter century has not been comprehensively brought together, described, and critiqued. In this series of papers, we explore published nursing scholarship concerning parent relationships with children from birth to age 21 with the aim of explicating the dimensions of this body of research and approaches taken to the study of parent-child relationships, critiquing the substantive and methodological contribution of this research for nursing practice, and identifying directions for future nursing research. We examine (a) the early days of the parent–child relationship as it is reported from an insider’s perspective through interviews and self-report instruments with parents of infants (Anderson, Riesch, Pridham, Lutz, & Becker, in press), (b) the parent–child relationship as it is revealed through observation of parent–infant interaction (Pridham, Lutz, Anderson, Riesch, & Becker, in press), (c) the processes that may impinge on the relationship when either the child or parent has a health problem, or when the child is vulnerable to health problems (Anderson et al. in press), and finally (d) the parent–adolescent relationship and adolescents as parents (Riesch, Pridham, Lutz, Anderson, & Becker, in press).

We used Hinde’s (1979) theory of relationships to frame our exploration. Hinde posits that a relationship between two people implies interactions having some degree of mutuality and continuity in time. In addition to the social behaviors observed in an interaction, a relationship has affective and cognitive aspects as well as content and qualities that are patterned over time, and is understood in terms of its social meaning to partners. A relationship refers to the connecting and binding qualities of partners, for example, parent and child. These qualities include closeness, influence, attachment (i.e., security seeking on the part of the child, emotional commitment on the part of the parent), and investment. A parent–child relationship carries with it cultural or normative expectations, activities (e.g., caregiving, playing, disciplining, or guiding) common to parent–child dyads, rituals, and traditions. Family group dynamics emerge from properties and patterns of various relationships within the group, including the parent–child relationship (Hinde & Stevenson-Hinde, 1988). Relationships are, in turn, affected by behavioral interactions, attitudes of participants, and processes of growth and development. Attachment as a relationship concept involves a specific type of relationship with distinct kinds of expectations, goals, values, feelings, cognitions, and norms (Hinde, 1979).

Drawing on Hinde’s (1995) analysis of relationship components, a parent–child relationship may be modeled by five dimensions: (a) an operative system of behavior with a specific goal (e.g., attachment, nurturance, play, guidance); (b) the function of parent and child in the context of the behavioral system (e.g., for the parent and child operating in the system of attachment, the parent provides caregiving and protection and the child seeks security); (c) interpersonal qualities (e.g., sensitivity, responsiveness, warmth, pleasantness, intrusiveness, control); (d) facilitators and barriers to the operation of a relationship (e.g., risk such as a disability or poverty, support such as presence, assistance); and (e) outcomes, ranging from competencies in interacting to child somatic growth; cognitive, affective, and social development; and health in both the short and long term.

Method

Review Method

An integrative review method was used to synthesize findings from published empirical nursing studies about parent–child relationships. The framework for conducting this integrative review followed the process outlined by Whittemore and Knafl (2005) who assert that research reviews require data analysis strategies to ensure methodological rigor. The data analysis process that they outlined to ensure rigor includes the stages of (a) problem identification, (b) literature search, (c) data evaluation, and (d) data analysis, including data reduction, data display, data comparison, and conclusion drawing and verification. These stages were followed in our review process. Details on each stage follow.

Problem Identification

The aim of this integrative review was to synthesize findings from 28 years of empirical nursing scholarship related to the parent–child relationship. A greater understanding of the concept of parent–child relationships was proposed as a way to better understand parent and child challenges in dealing with health and other problems, and to support the dyad and the family in negotiating developmental tasks and thereby improve outcomes. Studies were comprehensively brought together, described, and critiqued, and implications for practice, theory development, and research were determined.

The aim of this integrative review was to synthesize findings from 28 years of empirical nursing scholarship related to the parent–child relationship.

Literature Search—Electronic and Ancestral Searching

A reference librarian specializing in nursing research assisted with the literature search. All the following terms were included: parents OR mother OR father OR parent-child relations OR parenting OR child rearing OR object attachment AND nursing. The following electronic databases were searched from January 1980 to April 2008 to identify studies that met the inclusion/exclusion criteria: MEDLINE, CINAHL, PsychINFO, and Web of Science. The search strategies were customized for each database. Indexing terms, such as MeSH, along with text terms were used in each database. Results of each of the above searches were exported directly into a reference manager. Titles and abstracts were searched and appropriate articles were retrieved and reviewed. Content related to the study’s purpose, methods, and findings were extracted. Ancestral searching was done by reviewing reference lists of selected studies and the work of nurse experts in the field.

Literature Search—Inclusion/Exclusion Criteria

Studies were included if they were nurse-designed or –implemented, and were either experiential/descriptive or experimental. The studies needed to address parent–child relationships specifically, as indicated by terms such as relationship, reciprocity, attachment, and interaction, among others. Studies were included if they were published between January 1980 and April 2008. The year 1980 was chosen because of the appearance in the literature of nursing studies, following the tradition of the single case studies of Florence Blake (1954). Like Blake’s studies, we were influenced by the work of Erikson (1959) and Bowlby (1969). Beginning in the 1980s, nursing studies were influenced by the clinically oriented developmental psychobiology research that Barnard began to publish in the 1970s (Barnard & Bee, 1979; Brazelton, 1973).

Excluded from this series of review papers on the parent–child relationship were studies published in a language other than English, exclusively prenatal research, research on parenting of adult children over the age of 21 years, methods papers, conceptual or theoretical papers, and reviews. Reports were also excluded if they did not specifically address parent–child relationships within the study purpose, specific aims, or major findings.

Data Evaluation

The studies in this review were all published in peer-reviewed journals and included diverse methodologies incorporating both qualitative and quantitative data. Each study’s methodological rigor was reviewed; no studies were excluded based on methodological rigor. A baseline level of rigor was assumed by virtue of publication in a peer-reviewed journal, thus, all studies meeting the inclusion criteria were included.

Data Analysis

There were 165 articles that met the criteria for inclusion. After the articles were read and the team discussed the foci of studies meeting inclusion criteria, the articles were divided into four broad domains: (a) Parents’ perspectives on early parenting; (b) Interaction and the parent-child relationship; (c) Parent–child relationships at risk; and (d) Parent–adolescent relationships and the teen parent–child relationship.

The studies in each broad domain were organized by research design categories, which, based on Diers’ (1979) work, were termed: Discovery Model, Assessment Model, and Intervention Model. The Discovery Model involves the description, development, and identification of phenomena and concepts that constitute the parent–child relationship. The Assessment Model focuses on child, parent, family, or environmental indicators, correlates, or predictors of the parent–child relationship. The Intervention Model involves strategies to support, improve, or otherwise have an effect on the parent–child relationship. The papers were read sequentially and data extracted (Whittemore & Knafl, 2005). The data included the sample characteristics, methods, the variables, and purpose of the paper. Each of the review papers in this series includes a table to summarize the data. Patterns, themes, and relationships are discussed and a synthesis of results is presented.

Limitations

The integrative review reported in the four papers to follow has several limitations. First, the intent is to identify nursing’s contribution to the development of knowledge about parent–child relationships. Therefore, the vast knowledge from related social and behavioral sciences is not addressed. In many cases, such knowledge provided the background and theory for nursing investigations and is foundational to the discipline’s understanding of parent–child relationships. Second, programs of research by notable nurse investigators may be truncated across papers because of the four-domain conceptualization of (a) Parents’ perspective on early parenting, (b) Interaction and the parent–child relationship, (c) Parent–child relationships at risk, and (d) Parent-adolescent relationships and the teen parent–child relationship. For example, a noted nurse researcher may be included in several domains and his or her work included as a single study rather than as a program of research. Third, though several noted nurse researchers have contributed to the evidence base for care of families and children, their work may not have focused specifically upon the parent–child relationship and, hence, would not be included in this integrative review. Fourth, the methods used to identify studies were limited by the search terms, for example, the use of the term nursing, and the inclusion and exclusion criteria applied. Because of the broad search terms used, some studies may not have been identified and inadvertently excluded from this review.

How Do I Apply This Evidence to Nursing Practice?

This integrative review was designed to gain an understanding of the knowledge about parent–child relationships as studied by nurse researchers so that practitioners could translate the findings into practice. Nursing studies tended to be conceived based on prominent and prevailing psychology and development theories and frameworks with the aim of application to nursing science and practice. Pediatric nursing specialists assess, plan, implement, and evaluate interventions with families within a framework of family-centered care that includes the parent–child relationship. The work reported in the four papers to follow should assist practitioners to incorporate relationship theory, assessment methods, interventions, and recommendations from studies into their practice and policies. Each of the following papers has a section addressing application to practice. More fundamentally, understanding why the relationship matters needs continued exploration because the relationship is embedded in labile cultural, ethnic, and social patterns.

Acknowledgments

We would like to acknowledge Kirstin C. Monroe, RN, MS, CPNP, American Family Children’s Hospital, Pediatric Orthopedic Surgery Clinic, Madison, Wisconsin, and Katherine A. Logee, RN, MS, CPNP, CNE, Catholic Healthcare West System, Sacramento, California, for their assistance.

Contributor Information

Kristin F. Lutz, Oregon Health & Science University School of Nursing, Portland, Oregon, USA.

Lori S. Anderson, University of Wisconsin—Madison School of Nursing, Madison, Wisconsin, USA.

Karen A. Pridham, University of Wisconsin—Madison School of Nursing, Madison, Wisconsin, USA.

Susan K. Riesch, University of Wisconsin—Madison School of Nursing, Madison, Wisconsin, USA.

Patricia T. Becker, University of Wisconsin—Madison School of Nursing, Madison, Wisconsin, USA.

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