The Tidal Model of psychiatric nursing care

Ever since the dawn of nursing, nurses have long been regarded as intellectually inferior to the other members of the healthcare team (Barker, 1997).

As highlighted by Risjord (2009, p.2), it was only during the mid twentieth centuries that nurses began to realize the importance of having sound theory-based knowledge in order to practice nursing efficaciously. It was indeed a significantly huge step forward in the history of nursing.

Elder, Evans, and Nizette, (2009, p.15), defined theory as a set of constructs, hypotheses, principles and propositions, which provide the rationale for the actions that guide our practice. (Psychiatric and Mental Health Nursing by Ruth Elder, Katie Evans, Debra Nizette; 2009; chatswood, Australia: Elsevier; 2nd ed.; p.15)

Following the emergence of nursing theorists and their various theories which caters to the many different schools of thoughts, the professionality of nurses was further established.

The author would like to discuss about ‘the Tidal Model of psychiatric nursing care’, as it is a nursing model, which is of particular relevance to one’s work.

A psychiatric institution is hardly similar to a general hospital; therefore besides having a specialized body of knowledge, there is also inevitably a need for a different approach in the way the psychiatric nurses work.

Hayes and Collins supported this, by suggesting that, registered nurses with general training do not appear a reliable source of recruits to the field and that a ‘nursing’ approach to the issue may not well serve the interests of mental health (E. W. Hayes; John Collins. 2007)

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The Tidal Model (Barker, 1998, 2000) emphasizes a utilitarian approach in identifying the problems of living, which is at the same time respectful towards the patients. The model aims to construct a narrative-based form of practice (Barker and Kerr, 2001), treating each patient as a singular and unique person. This differs from most other contemporaneous nursing models which employ evidence-based approaches, where features were established on the assumption that each patient is an equivalent subject to that of the research population (Barker and Kerr, 2001).

The main objective is to explore the patient’s life experiences and various needs through using a set of dimensions, namely the World dimension, the Self dimension, and the Others dimension.

Under the World dimension of the Tidal, the nurse explores the patient’s experiences of distress, trauma, or illness, which led to the current state which she or he is in. This may also include factors such as how does the patient feel that her or his condition had affected their relationship with their loved ones in anyway, and what they feel needs to be done to help in their recovery (Barker, 2001, p.83).

The Self dimension of the Tidal Model looks into issues that revolve around the patient’s emotional and physical security, exploring the emotional stability and the likelihood of her or him harming themselves physically. The nurse also explores ways and means which could help the patients maintain their sense of security, through validating with them what were the things that made them felt secured before and what could the nurse do to help in their current situation (Barker, 2001, p.83).

Lastly, the Others dimension, the emphasis is shifted onto the patient’s means of leading a normal life after recovery. The nurse explores which are the resources the patient has, and possibly, equipping them with the resources they lack (Barker, 2001, p.83).

As introduced in Jacqueline Fawcett’s “Analysis and Evaluation of Conceptual Models of Nursing” (1980), the metaparadigms are extremely general concepts that serves as a conceptual basis. Their purpose is to direct the activity of the nursing profession, in aspects such as knowledge, philosophy, theory, educational experience, practice orientation, research methodology and literature identified with the profession (Meleis, 1997 and Marriner-Tomey and Alligood, 1998).

The author shall now attempt to co-relate the Tidal Model of psychiatric nursing care with the four nursing metaparadigms, Health, Person, Environment, and Nursing.

The author’s feels that the ‘Environment’ metaparadigm, with regards to the Tidal Model refers much more to the ’emotional environment’, rather than the physical environment.

(Barker et al. 2000), mentioned that the concept and values of care should be valued as indispensable environmental prerequisites right from the commencement of the recovery journey. Through providing the necessary support to ensure the patient’s emotional and physical safety while assisting her or him in exploring and identifying what needs to be changed, to facilitate recovery and exploring the possible roles of professionals, family and friends, and enlisting their help, in the entire recovery process. All these provide the patient with a metaphorical hopeline, to the supportive environment where it is easier for her or him to begin to feel secure and comfortable enough to begin the recovery process.

Hence, the author feels that the emotional environment is of paramount importance in helping the patient with her or his recovery. As suggested in the Tidal Model, most patients experience ‘shipwrecks’ prior to the onset of their mental illness. These ‘shipwrecks’ may encompass events of extreme stress, or environments which were extremely oppressive and adverse beyond the patient’s point of threshold. Hence, the significance of ‘Environment’ in this model; while the nurse may process the skills to provide a comfortable and stable emotional environment for the patient, physical environment should also be soothing and relaxing. This is of particular relevance in the mental health context; the ‘milieu’ or the venue which surrounds the patient plays an important part in regulating the patient’s emotional stability, and thus should not be neglected.

The ‘Nursing’ metaparadigm looks at what the nurses does to alleviate the patient’s suffering. These include the care, the treatment, and the compassion rendered to the patients. These may be demonstrated in the form of nursing interventions to assist the patients in their recovery; and in the psychiatric setting, first and foremost an effective and efficacious therapeutic nurse-patient relationship needs to be in place. Most psychiatric nurses would agree that the nurse-patient relationship has to be a collaborative one, before the patient would readily participant in any therapeutic activity which the nurse has to offer.

Therapeutic nurse-patient relationship has always be regarded as the crux of mental health nursing, considering its potential in instilling support and bringing about insight and behaviour change in the patient (Stuart 2001; Thelander 1997). Hummelvoll (1996) had also described the nurse-client-relationship as the cornerstone of psychiatric nursing.

Barker (1997) highlighted that, the Tidal Model places emphasis on making contact with and understanding the patient, rather than focusing on the disorder or illness. This makes the Tidal Model a relevant and appropriate caring model for use by the nurses, as nurses spend more time with the patients and are blessed with having the opportunity of establishing a higher level of rapport with them, as compared to other members in the multi-disciplinary team.

Clay (2203) also highlighted that, promoting connectedness with the patient is one of the main objectives of the Tidal Model. This is beneficial because it enables patients to feel as though they are working with friends and colleagues, rather than with some care providers whom are “higher-up” in status.

Peter Wilkin (2002) mentioned that psychiatric care is often delivered through surveillance. The author feels that this is true in the context of Singapore as well. The healthcare team, nurses and physicians in particular, would at times confront the patients via the means of threats, implementation of curfews and limiting of relatives’ visiting when patients do not behave in the way they were expected to. Clearly, this is against the nursing’s philosophy of caring. Building an effective and efficacious therapeutic nurse-patient relationship with our patients requires an appreciable amount of effort, and intimidating our patients in anyway would be counter-effective.

Often in the mental health setting, healthcare professionals behave and work in a way as though they do not believe, or are skeptical of a possible recovery in the patients. The author believes this to be the least desirable trait in psychiatric nursing.

(Merton, 1968) mentioned that, “‘self-fulfilling prophecy’ is of critical importance to the therapeutic outlook”. Therefore, to be an effective helper, the nurse also needs to realize that her or his beliefs about the patient, and the possibility of their recovery, can create a marked difference.

The ‘Patient’ metaparadigm refers to the various recipients of care, which includes the patient, their family, and the community (Perry A.G, 2001). Each patient is a unique individual who processes a different set of life stories and problems waiting to be explored. In order to help the patient, there is a need for the nurse to know the patient better. The nurse needs to generate a genuine sense of curiosity in what the patient has to share, rather than merely seeking noticeable signs and symptoms. Healthcare professionals often have the habit of assuming that they are the ones whom know the patients best, this attitude tends to hinder them from getting to know their patients better. Barker (2006) suggested that no matter how much they share, the nurses will never have the same amount of knowledge about their lives than the patients themselves.

The nurse should also employ verbatim techniques, at every opportunity, whilst communicating with the patient. By doing so, the nurse gains an upper hand at gaining a deeper insight into the patient’s inner world of thoughts.

Saunders (1997) emphasized the importance of exploring each of the person’s construction of experience through narrative. The nurse can achieve this by utilizing verbatim whilst interacting with the patient, and recording the person’s accounts of needs and problems in her or his own words, without employing any form of translation, thus minimizing the amount of distortion to the patient’s original message.

After achieving a sound understanding of the patient’s experiences and problems, the nurse should then aim to address the patient’s problems by drawing up an individualized nursing care plan; nursing goals should look into the multidimensional needs of the specific patient in need.

From the mental health perspective, the ‘Health’ metaparadigm looks at the patient’s perception of her or his own health, and addresses what needs to be done to restore emotional health and well-being. The nurse could well borrow concepts from the Tidal Model’s narrative, in accomplishing this task.

The Tidal Model (Barker, 2002) suggests that the narrative, as the metaphoric steering wheel for the nurse. It is an avenue for the nurse to better her or his understanding of how the patient became emotionally, physically or spiritually ‘devastated’. Rapport with the patient can be enhanced through demonstrating a keen interest in learning the patient’s life experiences. There is then, good opportunity to comfort the patient by showing concern, and also to know the patient in a more in-depth matter. This way, the nurse may form a collaborative alliance with the patient, to undo the damages mentioned.

Till the early 19th centuries, ‘keeper’ used to be the term given to those whom were entrusted with the care of the mentally ill. The keepers, who cared for the mentally ill, had controlled the movements of their patients in similarly primitive ways as with how zoo-keepers and game-keepers managed animals and game. (Nolan, 1998, p.6)

It is no surprise that in Singapore itself, psychiatric nursing is also often regarded as being more backward than the other areas of nursing. Psychiatric nursing has always been enveloped by tons of controversies, and these can be at times, overpowering. Locally, psychiatric nurses are often referred to as being nurses of mediocre quality, or nurses with ‘rusty’ nursing knowledge, having being not practicing and honing their nursing skills as often as nurses in the other disciplines.

Nursing is a profession based on caring, compassion, and it is often said that nurses are our patient’s advocates. As a psychiatric nurse, the author dearly affirms by this statement. In the psychiatric health setting, advocating for the mentally ill is ever more so important, for this special group of patients often lack the ability to advocate for themselves. Hence, an important and crucial role of the psychiatric nurse, besides caring for our patients, would be, to be our patient’s advocators, constantly advocating in their best interest. However, in order to render nursing care that is appropriate and beneficial to the patients, one of the most indispensable prerequisite would be a body of wisdom which is used to support nursing practice.

The author firmly believes that, apart from having additional education, to equipping us with specialized knowledge, as registered mental health nurses; the presence and adherence of nursing models, as such of the Tidal Model, are cardinal in maintaining credible standards in the quality of the nursing care we deliver as mental health nurses.