Evaluation of the Tidal Nursing Model Paper
Evaluation of the Tidal Nursing Model Paper
Evaluation of a Nursing Model: The Tidal Model in the context of a Regional Forensic Psychiatric Unit
Ngaire Cook, Diane Sadler, Brian Phillips (2003)
Rangipapa is a Regional Secure Forensic Unit at Ratonga Rua O Porirua. It is an admission unit that takes in all of the women admissions and some of the men who are undergoing legal processes as well as having complex mental health needs. The service also has a male only admission unit.
The Tidal Model is a research-based nursing model (Barker, 2000) which has been in use since the unit opened in July 2001. Prior to that time it had been implemented in an interim all male unit. Other members of the MDT continue to implement their own models to guide their work.
Based on the earlier studies of the need for psychiatric nursing, the Tidal Model develops a framework for nursing practice that seeks to engage with the person rather than the disorder. This approach does not dismiss or discount the disorder but rather, seeks to understand the present situation in the context of the person’s experience of distress and what this might mean in terms of what is needed by the
person. The assessment and care planning focuses upon the narrative of the patient so that their experience of distress can be addressed in the nurse’s responses.
The title of the model is a metaphor, which emphasises the fluid nature of human
experience. This is a view of human experience as being characterised by
ongoing change and unpredictability where change, growth and development
occur through small changes. As a practice model, the Tidal Model focuses on cocreating the type of support patients will require to work toward recovery.
The current research project focused on the lived experience of four forensic
psychiatric inpatients that have received nursing care using the Tidal Model, as
well as that of four Registered Nurses.
Semi-structured interviews were used to obtain reflective description of the
nursing care experience from the different perspectives of patients and nurses.
The method used was intended to replicate the Tidal Model processes for
individual nursing practice where the nursing assessment and care plans are
completed with the patient using the patients own narrative. The actual words are written either by the
patient themselves or they can choose to have them written by the nurse.
The methodology and analysis used in the research is Max Van Manen’s (1990)
Hermeneutic Phenomenological Human Science. Van Manen describes doing
phenomenology is a matter of questioning the way that we experience the world,
bound through the research project to the world in a particular perspective.
Each researcher individually analysed the participants responses then came
together as a team to group their findings onto a whiteboard and collectively
identify the initial themes. Following the identification of the initial themes and the
clustering of data a feedback session for verification of findings was established
with participants. Each participant was written a letter by the lead investigator
asking the participant if they would like to meet with two of the investigators for a
feedback meeting. They had the option of meeting with the two researchers who
facilitated the interviews or with any two. One participant was unable to meet and
the discussion was carried out by telephone.
The analysis identified five themes from the participants responses which
reflected their attached meaning to the events of receiving and providing care,
their reactions and integration of this Tidal Model approach. The responses also
showed that the participants were in a process of analysis and synthesis of their
lived experiences either as a nurse or as a patient. Themes were identified from
the interview transcripts in the context of receiving or providing nursing care: My
colleagues will present these results.
The Themes (Evaluation of the Tidal Nursing Model Paper)
1. Relationships
Relationships are about the way people engage with one another. When we judge
the nature of relationships we are describing how well the social needs of
inclusion, control and affection are met. Peplau viewed nursing as an
interpersonal process because it involves interaction between two or more
individuals with a common purpose.
The Tidal Model was reported by both the nurses and the patients to have
influenced their relationships. The need to be involved in communicating was
valued by the patients. One patient stated “There is an expectation from the staff
that I need to talk”. The individual work with their nurse was seen by patients as
a critical part of the process and an increase on previous experiences. For Bernie
“The Tidal model provided more personal interaction”. Jane in discussing what
was helpful for her reported that the amount of one to one reinforces strengths
“rather than coming away feeling I’m just another client you feel as though you
matter.” This one to one time also helped the patient to gain a sense of control.
Jane commented “The nurse being available to talk dealt with the feelings of
being vulnerable”. Ruth identified that “Much of the emotional learning and growth
takes place in the way the nurse responds to the client”
The Tidal Model groups also had a supportive impact upon relationships. The
groups developed trust through sharing. Bernie thought that “‘The recovery group
was a highlight. Recovery group is about opening up and being light-hearted, a bit
of a laugh, and it is good to have positive feedback from the nurses”.
From the nurses perspective relationships were influenced by the model. Vanessa
thought it developed “A much more adult to adult relationship, which feels a lot
more comfortable”. Connor commented that “there are changes in the nurses
using the Tidal Model. We all tend to show a more holistic approach. I see a lot of
changes it empowers the patients they feel safe and think we are really interested
in what they have to say therefore are more open and we are interested in what
they have to say”.
Nurses identified that qualities such as respect, empathy being open, energised
and available were important. Vanessa stated “Clients feel respected and valued
and there is a whole culture in the ward, a sense of community which is
engendered by people having a part of what is happening to them and everyone
else”. The nurses saw an empathic approach through the Models use of narrative.
One nurse thought “patients problems in their own words using the patients’
narrative means that we are looking at what’s personally important for them”.
Another nurse found the use of narrative central to the interpersonal relationship
“writing it down the client becomes more enthusiastic as they are a part of it”.
2. Hope: (Evaluation of the Tidal Nursing Model Paper)
Hope gives a view of the future that creates optimism. Hope is a belief that life has
a purpose and a meaning. It gives confidence in the future, a reason to keep on
living.
One patient described the tidal model as a way of showing hope. An approach to
nursing that is qualitatively different. An instillation of hope is the first and most
important factor for those experiencing mental illness. It gives people the belief
they can find help and support that is realistic and within time their problems will
be resolved. For Bernie the tidal model helped him to feel involved in the process
of getting well and in his treatment and care. For Max it was important to be able
to participate in what was going on for him.
For both Bernie and Max being able to communicate in their own words through
the tidal model assessment gave hope. For Bernie it meant whoever was reading
his file he was communicating directly to them. Max described the tidal model
assessment as really neat. You get to put down comments about yourself and
what is going on for you. It is something that is in your own words. He too felt he
would be communicating directly with whoever read his file. Evaluation of the Tidal Nursing Model Paper
For Ruth the tidal model provided a safe environment in which to discuss her
identity. She found the group sessions pivotal to her forward movement. Jane
found the groups supported individuals really well. “These are spaces that create
a sense of fun or hard therapeutic work”. She added “and you are not alone you
have the support of others in the unit.
One nurse summed up the tidal models contribution to recovery as giving the
patients a sense of control when often they have little control over other
circumstances. For Vanessa the use of the tidal model made “the patients feel
respected and valued and this is the whole culture of the ward. With a culture of
respect and valuing, people do move forward”. Another nurse commented “the
tidal model gets to the crux of the matter, what people think is worrying them or
perceive to be their problem. They are individuals with their own hopes, dreams,
goals and understandings. By using the tidal model assessment they are able to
tell us this straight away”.
The tidal model provided hope to the nurses. Connor stated “the tidal model
supports me as a professional, I feel I can give my clients the care they want and
need and this empowers me as a nurse”. Another nurse commented “It offers an
opportunity for the patient to say you are getting it right”. As a registered nurse
Muffy felt “the quality and enjoyment of her work is very much positively affected
by the tidal model and she personally enjoyed it”. Patricia Benner wrote when
nurses think their interventions make a difference in patient progress this is a
healing relationship. It is a relationship that mobilises hope for the nurse as well
as the patient. Evaluation of the Tidal Nursing Model Paper
3. Human Face:
According to Jane the tidal model comes from a humanistic framework, “rather
than coming away feeling as if you are just another client you feel as if you
matter”. Bernie adds his support to this he feels “acknowledged and respected, it
is good to have someone ask you about your needs and nut it out with you”. This
demonstrates the nurse patient relationship defined as humanistic when the
relationship is based on the human to human encounter. The patient’s experience
is seen as important; hope is seen as central to that experience. Ruth told us of
her helpful experience with a nurse who was able to ask her thought provoking
questions; this nurse was “clever enough to engage me in a non threatening
challenging way”.
All the patient participants appreciated and valued the group work. Janes
experience was that of “enthusiasm by the nurses in groups, the nurses bring their
own interests and personalities which widen my thoughts”. Max found the staff
joked with patients more, it was less formal there was not such a divide between
patients and staff and this benefited him. Max liked “getting to know the staff
better, seeing we are not so different after all”. Evaluation of the Tidal Nursing Model Paper
The nurses using the tidal model all had knowledge of the patients world and its
issues. They were better able to work with the patient genuinely and empathically.
Brigit stated “previously you nursed the illness, with the tidal model it is focussed
on the person, it is more individual”. Vanessa commented “it feels like I am doing
with not doing to. Feels the right way to do it, I feel a lot more comfortable”. What
Muffy liked best was “the patients problems in their own words, how it is for them.
Using the patients narrative means we are not looking so much at the illness but
what is important for them personally”. Muffy went on to say “I really love working
with the tidal model it makes the ward a more positive place and the job more
enjoyable”. A patient participant captured the essence when she talked of the tidal
model. She said yes it has been a positive experience forensic psychiatry has a
human face to it”.
The human face of nursing is acknowledged when the nurse does not stand
outside the patients’ realm of experience; instead they are seen standing
alongside the patient. This is the ability to presence oneself, to be with the patient
in a way that acknowledges your shared humanity, is the base of nursing as a
caring practice (Benner & Wrubel 1989). This is the humane model Jane spoke of.
Noddings (1984) describes this as caring; it is a reciprocal process between the
‘one caring’ and the ‘cared for’. Evaluation of the Tidal Nursing Model Paper
4. Levelling:
Levelling is experienced as a shift in the power and structure of the Registered
Nurse – Patient relationship.
“The one thing I like is that it involves nurses talking about themselves. It can be a
levelling exercise” (Max)
Levelling describes a strong shift in perception about the nature of the nursepatient relationship. From the experiences of our research participants, this has
had a real and positive impact on the therapeutic relationship between nurses and
patients. Both nurses and patients clearly related this to a shift in power using
both the words “power” and “empower” in their narratives.This seemed to be a
profound, real, and positive shift in the relationship from both perspectives. Max
saw this as a shift from patients and nurses divided and in opposition, to one of a
shared aim: “As opposed to being on the other side of the fence… divided.”
From the patients’ experiences, of the Tidal Model there was a perceptible shift to
now being able to participate in their own care. There were some areas that they
contrasted this participation, being around certain aspects of mandated care.
Nonetheless, they clearly distinguished a levelling of the relationship. Examples
they recollected were of nurses being “quite personal at times” and “being on the
same side”. For Max this, “involves nurses talking about themselves… so we can
see that we have a lot in common; likes, dislikes, funny things that have
happened.”
For the Registered Nurses, Vanessa observed that the Tidal Model enabled a
more collaborative approach than in her previous nursing care. She stated that
the Tidal Model was more “collaborative and not prescriptive”, finding that she
uses “presence and personality” more than she previously did.The Registered
Nurses confirmed the reality of this power shift, and reported that using the Tidal
Model made the rhetoric of “doing-with” rather than “doing-to” a lived reality. Brigit
defined this in her observation that previously it was the illness that was the focus
of her nursing whereas the focus was no upon the person.
The nurses also observed that a key change to practice was the patients being
able to write in their own records. Again, the shift in power was observed by both
nurses and patients. And indeed Jane noted that custodial care and differences in
power were still there but attributed this to “being within the forensic unit”. From
the perspective of Connor; she stated:
“It empowers the patient when they are writing for the Tidal Model. It tells them we
care about what they are saying [and] we are interested.”
The nurses commented on an enhanced sense of ethical practice through the
“honesty” engendered from patients writing in their own records and reaching
agreement on the actual language in assessments. They noted that this seemed
to have a “strong influence”; Vanessa said that “for the first time ever, can get
constructive criticism from the client”. Evaluation of the Tidal Nursing Model Paper
5. Working together:
The nurse and the patient are involved in working together as they share time and
energy with each other in individual and group work. As a theme, “working
together” is a real investment of self rather than simply rhetoric. Of this, one of the
special patients, Bernie, stated that “There are personal moments in the groups”
while Ruth said “we all need to feel as though we are working in a communal
situation for our own gain”. Jane also thought that the “amount of one to one” was
helpful and that the experience of the Tidal Model was:
“A real intangible. Difficult to describe… In a way of modelling ‘hey you could be
involved’. An approach to nursing that is qualitatively different.”
Working together showed up as a characteristic of the Tidal Model in such things
as the co-creation of the assessments, care goals, and plans. Working together
involved patients in a way that was perceived as collaboration. Another special
patient, Max stated that, “The Tidal Model gives you the opportunity to be involved
in your care”. Bernie had similar views: “The model motivates us to make a
contribution.”
Working together was demonstrated by staff listening to patients’ needs:
“When we couldn’t get out at first something evolved in recognition of this as a
constraint. A sense of being caged. OT and nursing staff (have) gone beyond
(what was) established in establishing yoga and dance.” (Jane)
And later she says: “It’s about being collaborative and taking time; it creates a
sense of control, more of a sense of control for me and freedom”.
Working together can also be defined by the level of participation in decisionmaking. This is also clear in patients’ comments.
Max informed us that, “The nurses are involved in our process of getting well, they participate and share of themselves, we also have some fun”. Bernie supported this view, “Good to see
the nurses get involved and participate though sharing and openness. Max also
commented on the level of participation by nurses in their recovery process: “The
nurses work with us and our family so we feel involved in the process of getting
well, in treatment and care”. Evaluation of the Tidal Nursing Model Paper
The reality of participation in decision-making for patients was clearly stated by
Jane in her comments on what questions nurses put to her in the assessment
process: “what are your priorities? What’s happening at this point? Key Issues? [It
was about being] collaborative and taking time.”Finally, Bernie saw the nurses as
“trying to motivate us to socialise, motivate and fell confident in a group situation.
For us to make a contribution”.
The views of the patients were emphatically supported by the nurses we
interviewed. Vanessa reported that, with the Tidal Model, she found there is “a lot
more collaboration with the client. A lot more client-led in terms of the problem
client care is easier because it is client led”. Brigit identified that the tidal model
gave her a fresh look, “The model makes you look at it the clients need
differently”. She goes on to say that “The purpose of the Tidal Model is to work
alongside with the client telling what care they need”. Vanessa thought the Tidal
Model approach increases the willingness of nurses to listen and the patients to
share: “It tells them we care about what they are saying we are interested”. Muffy
considered that the model allows you, “to work with the patient on how they see
there problems and work with patients not always on illness but on the positive
things they have at times of crisis”.
Vanessa commented that the model also changes the way she practices:
“The key-worker nurse makes a specific commitment to nursing with the patient.
One of the things is it is collaborative and not prescriptive because of that spend a
lot of time face to face and one to one. Need a fair level of collaboration to move
forward. I think you are using presence and personality in the way you operate a
lot more.”
The comments from the nurses support the view that working together helps to
ensure the nurse and the patient have compatible goals at each point in the
treatment. It minimises patient resistance that arises when nurses dominate the
goals and intervention process. Considering this, one of the Registered Nurses,
Brigit, stated that the Tidal Model approach prevented misunderstandings:
“When working through the client goals I have found what I think is most
distressing for them, is not the same as what the client will identify, however they
do tie in are related” Evaluation of the Tidal Nursing Model Paper
Conclusion:
From our interviews, it seems clear to us that the Tidal Model pilot has been successful. Both Registered Nurses and the Special Patients we interviewed stated quite clearly that they not only liked the Tidal Model, but from their different perspectives, were able to articulate the differences it made to them.
For nurses, using the Tidal Model made a positive difference to their practice, particularly in terms of a therapeutic engagement with clients. This is significant because: The ANZCMHN (2002) advanced practice competencies which states that the “the core of psychiatric mental health nursing is the ability to engage in relationships at a meaningful level” (p. 6). For Special Patients, the experience of the Tidal Model gave them a tangible beneficial impact on the opportunity for recovery. As mentioned earlier, the Tidal Model didn’t change their custodial arrangements, but it did make for a more human face to it.
And finally, the pilot phase is completed, and the intention is to explore a wider implementation; and in doing so, institute a comprehensive evaluation of outcomes. Evaluation of the Tidal Nursing Model Paper.
