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Evaluation of a Nursing Model: The Tidal Model in the context of a Regional Forensic Psychiatric Unit
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Ngaire Cook, Diane Sadler, Brian Phillips 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 co-creating 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
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".
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. . 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.
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”. 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’.
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 nurse-patient 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”. 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 decision-making. 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". 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” 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.
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