Running head: PARENT-CHILD INTERACTION MODEL
Theory Critique of the Parent-Child Interaction Model
Karen Collins, Beth Kalkman, Lori Van Zoeren, and Joel Vedders
Ferris State University
1
PARENT-CHILD INTERACTION MODEL
2
Abstract
Numerous nursing theories have been developed in an attempt to describe phenomena
experienced within the discipline of nursing. Theory critique is a process by which these theories
can be evaluated to determine their significance and contribution to knowledge for the nursing
profession. While many frameworks have been created to guide theory critique, for the purpose
of this paper, a six-step process will be utilized to examine the Parent-Child Interaction Model
developed by Kathryn E. Barnard.
PARENT-CHILD INTERACTION MODEL
3
Theory Critique of the Parent-Child Interaction Model
When a nursing theory is generated, it cannot be taken at face value. Rather, an
evaluation or critique must be done to determine the theory’s worth and contribution to
knowledge within the nursing profession (McKenna, 1997). Many frameworks have been
developed for the purpose of theory critique and meta-theorists argue about which criteria and
guidelines should be used for evaluation. While there is no absolute set of criteria, for the
purpose of this paper we will be using a six-step process to examine Kathryn E. Barnard’s
Parent-Child Interaction Model (PCI). These steps will include a discussion of the theory’s
origin, its unique focus, comprehensiveness, further theory generation, credibility, and ultimately
its contribution to nursing.
Origins
Examining a theory’s origin is the first step in a theory critique. According to McKenna
(1997), it is important to inspect two areas that led to the theory's development; first, the
educational background and experience of the theorist; and second, the influence of other
scholars who may have shaped the thinking of the theorist. Addressing these two areas at the
beginning of the critique allows one to see the logic and reasoning behind the theorist's work.
It is easy to see the genesis of Kathryn Barnard's model when researching her educational
background and work experience. According to Baker et al. (1994), after Barnard graduated from
the University of Nebraska, she worked as an assistant instructor in pediatric nursing. When she
finished her Master's degree at Boston University, she was hired as an instructor for the
University of Washington in maternal-child nursing. Here, she earned her doctorate in the
ecology of early childhood development and became a professor of parent-child nursing at the
University of Washington. Dr. Barnard participated in many training projects in the area of
PARENT-CHILD INTERACTION MODEL
4
childhood development. She also directed research studies that led to the formation of the
Nursing Child Assessment Project (NCAP), the foundation of the PCI Model.
In addition to her educational background and work experience, Dr. Barnard
acknowledges certain theorists that influenced her work. According to Baker et al. (1994),
Florence Nightingale, Virginia Henderson, and Martha Rogers are among those to whom credit
is given. Barnard, however, declares Florence Blake as the theorist who most directly influenced
her work. She credits Blake for "elucidating the beliefs and values making up the foundation of
nursing practice, which include turning nurses’ minds toward an orientation on the patient rather
than the procedure and acknowledging the importance of family" (Masters, 2012, p. 312). The
Neal Nursing Construct also directly influenced her work. This construct contains four
expressions of health and illness: cognition, sensation, emotion, and affiliation (Masters, 2012).
Baker et al. (1994), mention that this construct served as a guide in the development of Barnard's
NCAP.
Unique Focus
The focus of Dr. Barnard’s PCI Model is the relationship between the parent, child, and
environment. Barnard states that this interaction offers information “reflective of the nature of
the child’s ongoing environment” (Lin, n.d., p. 56). Dr. Barnard recognized that the motherchild-environment process is interactive and individual characteristics of both the parent and the
child are influenced and affected by each other (Fine, 2002). Additionally, these characteristics
can be altered or modified to meet the needs of the system (Fine, 2002). The study of the parentchild interaction recognizes that these interactions evolve over time (Salonen, 2010). The PCI
Model emphasizes responding to infant cues and encourages support for parents during the first
postpartum year (Salonen, 2010).
PARENT-CHILD INTERACTION MODEL
5
Dr. Barnard has always had an interest in early intervention regarding infants and
children (Melmed, 2009). In a reflective statement, she offers insight into the area of limited
support to parents and families. She states, “…our cultural belief (is) that parenting is the
responsibility of the parents and interference in that arena is wrong” (Melmed, 2009, p. 60).
Another reason support is limited is because medical professionals are more interested in fixing
the problem (i.e. poor growth of infants or children) rather than in the prevention of problems
(Melmed, 2009). A third reason for limited support is cost related. According to Barnard, home
visits and parent-child programs are found less frequently in the United States when compared to
other countries (Melmed, 2009). Barnard proposes advocacy for infants and children by
correcting outdated beliefs and building early intervention services into the community (Melmed,
2009).
Barnard’s philosophical claims regarding the PCI Model (referred to in some references
as the Child Health Assessment Interaction Theory (Masters, 2012)) include: (a) identification
of problems before they develop, (b) social-environmental factors are important in determining
child health outcomes, (c) brief observations can provide a valid sample, (d) caregivers are
unique, (e) both caregiver and child are influenced by each other, (f) the process of adaptation is
more modifiable than the foundational characteristics, (g) child-initiated behaviors are important
learning opportunities, (h) nurturing relationships are valuable, (i) the child’s social environment
is important to assess, and (j) the physical environment is also important to assess (Fine, 2002).
The Parent-Child Interaction Model was derived by inductive logic. Barnard reports all
theoretical claims are evidenced-based (Fine, 2002).
PARENT-CHILD INTERACTION MODEL
6
Clarity/Simplicity
Nursing theories are rooted in four meta-paradigms which are commonly accepted
throughout the nursing profession. These include nursing, person, health, and environment.
Tourville and Ingalls (2003) express that these meta-paradigms serve as boundaries for exploring
various subject matter within the discipline of nursing.
These meta-paradigms are represented in Dr. Barnard’s Nursing PCI Model. First, Dr.
Barnard defines nursing as “the diagnosis and treatment of human responses to health problems”
(Fine, 2002, p. 488). Secondly, the person is defined as an individual who can take part in an
interaction in which both parties bring value to the interaction (Fine, 2002). Health is the third
meta-paradigm and encompasses well-being and illness. Barnard believes that heredity and
environment play a significant role in where a person falls on the health-illness continuum (Fine,
2002). The environment is defined as any experience that the individual encounters, including
those that affect the caregiver, such as home and financial variables (Fine, 2002). Finally, Dr.
Barnard stresses the importance of nursing facilitating a change in the environment thus
improving conditions to promote growth and development of the involved individuals (Masters,
2012).
Theorists declare propositional statements to show relationship or non-relationship
between two or more of the concepts in their theory. The concepts can be correlational (causal)
or non-relational (Peterson & Bredow, 2009). An example of a correlational concept is Barnard’s
propositional statement, “through interaction, caregivers and children modify one another’s
behavior” (Masters, 2012, p. 317). An example of a non-relational concept in Barnard’s PCI
Model is the assumptions defined within the model. These are that nursing is a process, the
environment includes all experiences encountered by the child, and the term person includes
PARENT-CHILD INTERACTION MODEL
7
infants, children and adults (Masters, 2012). Utilizing both correlational and non-relational
concepts allows Barnard’s theory to describe, as well as explain and predict (Peterson & Bredow,
2009).
Some reviewers report that Barnard’s PCI Model is clear and easily understood. In fact,
Baker et al. (1994) state, “It is relatively easy for the reader to understand the interrelationships
of her theoretical concepts” (p. 413). However, the 10 propositions made by Dr. Barnard about
the relationships of the parent, child, and their environment make for a more multifaceted and
complex model when explored at greater depth. Because the elements of Dr. Barnard’s model are
interconnected and described in detail, the validity and reliability of this model make for a wide
variety of uses across the healthcare field. Weaknesses of the model are noted, however, in that
health, nursing therapeutics, and client transitions are not well defined (Wojnar, 2008). Another
weakness of the model is that it remains population specific (Masters, 2012).
Simplicity is an important aspect of Dr. Barnard’s theory as it allows the model to be
utilized in various nursing specialties. To meet the needs of children and their families, the PCI
Model must be flexible (Chinn & Kramer, 1995). Due to the focus of the PCI Model on
interactions between children and their caregivers, the theory could be considered limited, or too
specific, to meet the needs of a wide range of nurses and the patients they care for (Chinn &
Kramer, 1995). A theory related to interactions of a more diverse population would serve in the
application of the PCI Model to interactions of caregivers and individuals of all ages (Chinn &
Kramer, 1995).
Further Theory Generation
One of the main goals of Dr. Barnard was to provide a means of translating research into
practice (Huber, 1991). Research findings led to new methods of evaluating the growth and
PARENT-CHILD INTERACTION MODEL
8
development of children. More responsive and sensitive health care services have resulted from
the works of Dr. Barnard. The PCI Model is still utilized in on-going research and published in
well-known journals today (Huber, 1991).
Generality
Dr. Barnard’s PCI Model postulates that the interactive relationship between parent and
child directly affects cognitive growth and development. Furthermore, the quality of these
interactions can be measured for their efficacy and this information used to identify at-risk
families (PCI, 2007). According to this model, parent and child hold responsibility for
establishing “cue communication,” or the accurate sending and receiving of cues within their
environment (The Barnard Model, 2007). Appropriate interpretation and timely response by
both parties are important components of the dialogue (Huber, 1991).
Barnard also identifies certain factors in the environment that have significant impact
upon the establishment of the desired relationship (Illman, 1996). To support her theory and
identify at-risk families, Dr. Barnard designed assessment scales known as the Nursing Child
Assessment Feeding Scale (NCAFS) and the Nursing Child Assessment Teaching Scale
(NCATS), to measure behaviors between parent and child accurately (Huber, 1991). These
scales have been tested and found reliable for use as both assessment and outcome measures for
at-risk groups including low socio-economic, preterm infants, and infants of adolescent mothers
(Huber, 1991).
According to Baker et al. (1994), Barnard’s model can also be applied in many other
disciplines that observe parent child relationships. In addition to their adaptability, additional
strengths of Barnard’s assessment scales are short amount of administration time, simplicity of
use, and their ability to be conducted around a child’s normal activities of eating and/ or playing
PARENT-CHILD INTERACTION MODEL
9
without requiring interruption of his or her daily pattern (Huber, 1991). The generality of Dr.
Barnard’s model, originally designed to address the first year of a child’s life, has since
burgeoned to include assessment of children up to three years of age (Masters, 2012).
Empirical Use
Dr. Barnard’s PCI Model exhibits her emphasis on applying research to practice (Tomey,
2006). As such, in 1979 Dr. Barnard established a training program called the Nursing Child
Assessment Satellite Program (NCAST) that trains health care professionals to administer both
NCAFS and her NCATS. In order to ensure the reliability of the NCAST assessments, it is
necessary for training and certification of administrators to occur (Wojnar, 2008). Researchers,
clinicians, and nurses must achieve a reliability score of at least 85% to be certified (Wojnar,
2008). Many thousands of nurses and healthcare professionals have been trained to use these
tests to assess parent-child interactions (Kennedy, 2002).
Derivable Consequences
According to Huber (1991), Barnard’s NCAST scales have not been professed to be
extremely useful for research purposes but have been found to be strongest in clinical application
for assessment and intervention purposes. However, Fowles and Horowitz (2006) state, “The
NCAST scales are exemplars of observational measures of mother-child interaction with strong
evidence of reliability and validity, and widespread use in research and practice with parents
across age, ethnic, and racial groups” (p. 663). Several research studies that have used the
NCAST scales in their measurements have been reviewed. For example, Davis, Edwards, and
Mohay (2003), used Barnard’s assessment scales in their study of interaction between mothers
and their preterm infants following discharge. This study assessed mother-newborn dyads in the
hospital and re-evaluated the pairs 3 months post discharge. The study demonstrated the
PARENT-CHILD INTERACTION MODEL
10
importance of maternal coping strategies in developing mother-infant relationships with preterm
newborns (Davis, Edwards, & Mohay, 2003).
Another study by Horodynski and Gibbons (2004), evaluated the effectiveness of an
Early Head Start (EHS) program in a rural community. Specifically, interactions between lowincome mothers and their children who were enrolled in the EHS program were measured
through use of the NCAST scales. Although there were many additional findings related to this
study, ultimately the results showed that most mother-child units were not at risk before or after
entry into the program (Horodynski & Gibbons, 2004).
Conclusion
Dr. Barnard believes that the interaction between parent, child and the environment
greatly influences a child’s successful developmental processes. This led to the Parent-Child
Interaction Model. Through this model, she demonstrates that the transmission of cues, accurate
interpretation, and timely response to these cues is the responsibility of both parent and child.
Areas of concern, identified through use of the NCAST scales created by Dr. Barnard, can then
be the focus of effective interventions. Through this theory critique, it is evident that the PCI
Model has been considered a reliable means to evaluate the important relationship between
parents and their children. In addition to nursing, many other disciplines involved with parentchild interactions utilize the PCI Model to supplement their practice. The PCI Model reinforces
the need for care providers to facilitate positive parent-child interactions from the earliest
opportunity possible.
PARENT-CHILD INTERACTION MODEL
11
References
Baker, J. K., Borchers, D. A., Cochran, D., Kaltofen, K. G., Orcutt, N., Peacock, J. A., &
...Yeager, L. A. (1994). Parent-child interaction model. In A. M. Tomey, Nursing
Theorists and Their Work (3rd ed., pp. 406-422). St. Louis, MO: Mosby Yearbook, Inc.
Chinn, P. L., & Kramer, M. K. (1995). Theory and Nursing (4th ed.). St. Louis, MO: MosbyYear Book.
*Davis, L., Edwards, H., & Mohay, H. (2003). Mother-infant interaction in premature infants at
three months after dischage. International Journal of Nursing Practice, 9, 374-381.
Retrieved from: http://dx.doi.org/10.1046/j.1440-172X.2003.00447.x
Fine, J. M. (2002). Parent-child interaction model. In A. M. Tomey, & M. R. Alligood (Eds.),
Nursing Theorists and Their Work (5th ed., pp. 484-495). St. Louis, MO: Mosby.
*Fowles, E. R., & Horowitz, J. A. (2006). Clinical assessment of mothering during infancy.
Journal of Obsetetric, Gynecologic, and Neonatal Nursing, 35(5), 662-670. Retreived
from: http://dx.doi.org/10.1111/j.1552-6909.2006.00090.x
*Horodynski, M. A., & Gibbons, C. (2004). Rural low-income mother's interactions with their
young children. Pediatric Nursing, 30(4), 299-305.
Huber, C. J. (1991). Documenting quality of parent-child interaction: Use of the NCAST Scales.
Infant and Young Children, 4(2), 63-75.
Illman, D. L. (1996, November). 1979: Parent-child interaction. Retrieved from Pathbreakers: A
Century of Excellence in Science and Technology at the University of Washington:
http://www.washington.edu/research/pathbreakers/1979a.html
Kennedy, M. (2002). Rock on, Kathryn Barnard, champion of newborns. American Journal of
Nursing, 102(6), 110-111.
PARENT-CHILD INTERACTION MODEL
12
Lin, Y.-H. (n.d.). Helping parents interact with their hospitalized preschooler. Retrieved from
http://ir.fy.edu.tw/ir/bitstream/987654321/7078/1/P55-P74
Masters, K. (2012). Nursing Theorists: A framework for professional practice (pp.311-322).
Sudbury, MA: Jones & Bartlett Learning.
McKenna, H. (1997). Nursing theories and models. New York, NY: Routledge.
Melmed, M. (2009). Zero to three reflections: Past achievements and future challenges. Zero to
Three, 30(2), 59-65.
Parent-child interaction (PCI) feeding and teaching scales. (2007) Retreived from
http://www.ncast.org/index.cfm?category=2
Peterson, S. J., & Bredow, T. S. (2009). Middle Range Theories: Application to Nursing
Research (2nd ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams &
Wilkins.
The Barnard Model. (2007). Retrieved from http://www.ncast.org/BarnardModel.html
Salonen, A. (2010). Parenting satisfaction and parenting self-efficacy during the postpartum
period. (Doctoral dissertation, University of Tempere). Retrieved from
http://acta.uta.fi/english/teos.php?id=11365
Tomey, A. M. (2006). Nursing theorists of historical significance. In A. M. Tomey, & M. R.
Alligood (Eds.), Nursing theorists and their work (6th ed., pp. 54-67). St. Louis, MO:
Mosby.
Tourville, C., & Ingalls, K. (2003). The living tree of nursing theories. Nursing Forum, 38(3),
21-36. doi: org/10.1111/j.0029-6473.2003.t01-1-00021.x
Wojnar, D. (2008). Application of the Barnard parent/caregiver-child interaction model to care
of premature infants. In M. de Chesnay & B. A. Anderson (Eds.), Caring for the
PARENT-CHILD INTERACTION MODEL
Vulnerable: Perspectives in Nursing Theroy, Practice, and Research (2nd ed., pp. 125134). Sudbury, MA: Jones and Bartlett Publishers.
* Denotes scholarly articles
13