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This is a group project my part of the assignment is : A model or theory that can be used to bring about the change ( Treatment of post traumatic stress disorder in Veterans ) .
How the theory influence in to this treatment ?
The word document is a draft that the group did for the 1st assignment, is for you to have and idea . The journals is for you to used in the paper , i also send the references,.
No necessary 2 full pages, 1 1/2 TOPIC . Overview of the theoretical and practical basis of a new model of psychiatric and mental health nursing practice. PURPOSE . To illustrate the history of the development of the model and some of the processes that aim to re-empower the patient and develop genuinely collaborative approaches to care. SOURCES . Literature review, author’s research, and related clinical experience. CONCLUSIONS . The Tidal Model provides a practice framework for the exploration of the patient’s need for nursing and the provision of individually tailored care. Search terms: Empowerment, holism, interdisciplinary teamwork, narrative, nursing theories and models, psychiatric nursing Perspectives in Psychiatric Care Vol. 37, No. 3, July-September, 2001 7 9 Phil Barker, PhD, RN, FRCN, is Professor of Psychiatric Nursing Practice, Department of Neuroscience and Psychia – try, University of Newcastle, England. Despite the popular acceptance of the hypothesized, biological, and/or genetic basis of serious mental disorders (such as schizophrenia), a considerable body of research challenges these assumptions (Dawson, 1997; Johnstone, 1999). More important, there is evidence that viable alternatives to such biological constructions of mental distress exist, suggesting the possibilities for more holistic forms of psychosocial intervention (Alanen, Lehtinen, & Aaltonen, 1991; Pylkkanen, 1997). The Tidal Model springs from a similar set of assumptions to those expressed in the work of Alanen et al. when they suggested that people, their families, and those close to them need to be helped to: Conceive of the situation (e.g., admission) as a consequence of the difficulties the patients and those close to them have encountered in their lives, than as a mysterious illness the patient has developed as an individual. (p. 97) Such a pragmatic and respectful approach to addressing the lived-experience of the person and her/his significant others is diametrically opposed to the so-called p s y – choeducational approach, which assumes an organic basis for schizophrenia (Brooker & Butterworth, 1994). Despite more than 40 years of sustained criticism, the medical model continues to dominate the interpretation of mental health problems and intervention within mental health services (Newnes, Holmes, & Dunn, 2000; Szasz, 2000). Although originally associated with a particular discipline or school of thought, the medical and, more recently, the biopsychosocial model stimulated by Engel (1977) and other ‘psychosocial’ models (e.g., Foa, 2000) are all used by various disciplines in their efforts to establish what needs to be done in the name of care and treatment. It is not surprising that a specific model of Phil Barker, PhD, RN, FRCN The Tidal Model: Developing a Person-Centere d A p p roach to Psychiatric and Mental Health Nursing nursing for psychiatric and mental health care has failed to emerge, at least within the United Kingdom, or that nursing theories have been so badly received by nurses themselves (Gournay, 1995; McKenna, 1997). Unlike medicine and disciplines drawn from the social sciences (e.g., clinical psychology, social work), nursing has long been viewed as an intellectual lightweight, with limited research and no home in either the health or social sciences (Barker, 1997). Traditionally, nurses have been cast as a supporting act in the therapeutic drama. As Nightingale first acknowledged, nurses are akin to foot soldiers: carrying the generals’ plans into the battle against illness (Nightingale, 1860/1969). Despite 200 years of effort to establish an independent voice and a distinct understanding of the need for nursing (Barker, Jackson, & Stevenson, 1999), nursing still appears to be haunted by the ghosts of the Crimea (Group & Roberts, 1974). Given that the overall plan of mental health care continues to involve the attribution of a medical diagnosis and the expression of specific medical interventions, albeit through the medium of nursing, the need for any distinct model of nursing has been seriously challenged (Gournay, 1 9 9 5 ) . The marginalized status of nursing also might explain why so many mental health nurses have tried to validate their therapeutic standing as nurses by training in a parallel discipline, or field of therapy, that is more established and possesses a higher social status (Michael, 1994). The ubiquitous concept of the nurse (psycho)therapist implies, perhaps, that nursing per se is not, or could never be, therapeutic (Williams, 1996). S o m e nurses have explored the possibilities of established general nursing theories or models for mental health nursing practice (Flaskerud, 2000; Jones, 1996; Murphy et al., 2000). However, despite a consistent academic critique of the myriad assumptions of medical and biopsychosocial model (Barker, 1997; Barker & Stevenson, 2000; Hopton, 1996), many nurses appear satisfied to settle pragmatically for a subordinate role within a medically dominated mental health service (Abbondanza et al., 1994; Warner, 1993). 8 0 Perspectives in Psychiatric Care Vol. 37, No. 3, July-September, 2001 Mental health nursing has for so long accepted what Nolan (1993) saw as a “supportive” role, that the idea of developing a distinct theoretical formulation for practice (or a model from which to map care) increasingly has been described as unnecessary (Gournay, 1995). Although reservations have been expressed about the appropriateness of some models of nursing for mental health nursing (Barker & Reynolds, 1994), there can be no serious objection in principle to establishing the discipline of psychiatric nursing on nursing theory, or to the construction of nursing models to support the enactment of nursing practice. Indeed, the establishment of such a theory-based model of nursing practice could be described as a professional obligation (Hopton, 1996). Emphasis continues to be placed on multidisciplinary teamwork and models such as the biopsychosocial model (Chafetz & Ricard, 1999) that arguably might facilitate such teamwork. Nursing practitioners are aware that the medical model is stronger than ever in clinical psychiatry ( A n t a i- Otong, 2000; Dawson, 1997). Similarly, theorists in the social sciences show no sign of abandoning their development of various psychological and social models that might further illuminate alternatives to traditional psychiatric medical treatment (Callahan & Bauer, 1999; Markowitz, 1999). These developments suggest that any model of psychiatric and mental health nursing practice must emphasize the need for nursing, and be congruent with the responses of other disciplines to the person’s need for medical and other therapeutic interventions. A Research-Based Nursing Model The Tidal Model (Barker, 1998, 2000) was developed from the Newcastle University 5-year study of the need for nursing (Barker, 1996; Jackson & Stevenson, 1998), which generated a substantive theory of nursing practice in mental health care (Barker, Jackson, & Stevenson, 1999). The need-for-nursing study sought to clarify the discrete roles and functions of nursing within a multidisciplinary care and treatment process. In translating into practice the theory of the need for nursing, the Tidal Model developed many of Peplau’s The Tidal Model: Developing a Person-Centered Approach to Psychiatric and Mental Health Nursing assumptions about the importance of interpersonal transaction and incorporated a model of the process of empowerment (Musker & Byrne, 1997) within the nursepatient relationship, developed within a parallel study (Barker, Leamy, & Stevenson, 1999). The Model of Empowering Interactions (Barker, Leamy, & Stevenson, 2000) defined seven specific interpersonal interactions that appeared to be necessary for the person-in-care to experience empowerment. These theory-generating studies continued the tradition of inquiry involving the interpersonal processes of nursing practice (Altschul, 1972; Peplau, 1952), which sought to clarify further what nurses should do as a caring response. This interest in the “proper
focus of nursing” (Barker & Reynolds, 1994) has become unfashionable, as emphasis has switched to multidisciplinary teamwork. Given the key position of nursing as the agent of most therapeutic intervention, however, there is at least some value in clarifying the basis from which nurses might work i n t o the multidisciplinary team. The Tidal Model was introduced into acute psychiatric care settings (Barker, 1998) but has since developed the concept of a care continuum, which emphasizes the person’s need for three discrete forms of care: critical, transitional, and developmental. The concept of the care continuum spans the hospital-community divide, emphasizing that need should be the primary focus for care, rather than the setting within which it is delivered (Barker, 2000). The Tidal Model is a radical, catholic model of psychiatric nursing practice, focused on the care processes that are fundamental (radical) to nursing practice in mental health and possessing a universality of application (catholic) that would render it appropriate for any care setting and any mental health population. The model provides an emphasis on spirituality that often has been lacking from practice models in psychiatric nursing. The emphasis on exploring and developing the lived experience of the person-in-care is focused specifically on the meanings and values the person attaches to or associates with her or his experience. In some cases, this exploration will extend beyond the transpersonal to address Perspectives in Psychiatric Care Vol. 37, No. 3, July-September, 2001 8 1 relationships with conceptions of self and others that might be defined classically as religious, mystical, or spiritual. Although focused on identifying the necessary processes of nursing care, the actual caring practices involved are intended to be complementary to the care and treatment offered by other disciplines. In this sense, the model attempts to aid the development of interdisciplinary teamwork. The Tidal Metaphor Borrowing from chaos theory (Barker, 1996), the Tidal Model emphasizes the fluid nature of human experience, characterized by incessant change and unpredictability. This provides the basis of the core metaphor of the Tidal M o d e l – – w a t e r : Life is a journey undertaken on an ocean of experience. All human development, including the experience of illness and health, involves discoveries made on the journey across that ocean of experience. At critical points in the life journey the person experiences storms or even piracy (crisis). At other times the ship of life may begin to take in water and the person may face the prospect of drowning or shipwreck (breakdown). The person may need to be guided to a safe haven to undertake repairs, or to recover from the trauma (rehabilitation). Once the ship is made intact or the person has regained the necessary sea-legs the ship may set sail again, aiming to put the person back on the life course (recovery). Unlike many normative psychiatric models, the Tidal Model holds few assumptions about the proper course of a person’s life, preferring instead to focus on the kind of support people might need to rescue them from crisis, or to help put them back on the life course (development). The Tidal Model recognizes that the life experiences associated with mental ill health are invariably described in metaphorical terms. People who experience 8 2 Perspectives in Psychiatric Care Vol. 37, No. 3, July-September, 2001 life crises are (metaphorically) in deep water and risk drowning, or they feel as if they have been thrown onto the rocks. People who have experienced trauma (such as injury or abuse), or those with more enduring life problems often report loss of their “sense of self,” akin to the trauma associated with piracy. In all these instances, people need a sophisticated form of lifesaving (psychiatric rescue), followed at an appropriate interval by the kind of development work necessary to facilitate true recovery. This may take the form of crisis intervention in the community or the “safe haven” of inpatient settings. Once the rescue is complete (psychiatric nursing), the emphasis switches to the kind of help needed to get the By acknowledging the need for a continuously flexible response to the person, the Tidal Model also recognizes the chaotic nature of human behavior, and especially of human experience. person “back on course,” returning to a meaningful life in the community (mental health nursing). The model assumes that the practical focus of psychiatric and of mental health nursing differ: the former requiring more direct interventions, involving a highly vulnerable and potentially dependent person; the latter emphasizing a more egalitarian relationship, which involves an even more collaborative approach to education, personal growth and discovery. The Tidal Model recognizes that people’s need for nursing cannot lie in some either/or world of community or hospital, general or specialist service, acute or continuing care, but rather flows across these artificial boundaries, as the nature of the person’s needs shift, often imperceptibly. This focus on the care continuum aims to promote the kind of seamless care that risks becoming mere rhetoric. The caring response, expressed by nursing, needs to flow with the person, adapting itself to the person’s changing needs. Regrettably, the worlds of community and residential care have suffered from artificial distinctions. If we maintain a focus on the needs of the person—for critical, transitional, or developmental care—the interdependence of different services, to meet different needs, becomes apparent. The Tidal Model is represented by a range of holistic (exploratory) and focused (risk) assessments, which generate person-centered interventions that emphasize the person’s extant resources and capacity for solution finding. These various assessment and intervention processes are intended to support rather than restrict practice. The various methods that have been defined in the training program for the model (Barker, 2000) help the nurse gain a better view of the person and the territory of care. The templates for assessment and intervention contained within the training materials act as a springboard for creative exploration of the need for nursing, rather than delimiting the nurse’s practice through the exercise of a tight protocol. This principle may appear to conflict with the overvalued emphasis on guidelines, protocols, and carefully scripted interventions, evident in much of the evidence-based healthcare literature—or some psychotherapies. However, by acknowledging the need for a continuously flexible response to the person, the Tidal Model also recognizes the chaotic nature of human behavior, and especially of human experience (Barker, 1996). The Dimensions of Personhood The Tidal Model embraces a caring construct, which frequently appears to be obscured by a myriad of therapeutic concepts borrowed from other disciplines or fields of human inquiry (Reynolds & Scott, 1999). Whereas most, if not all, therapeutic constructs aim to effect some change in the presentation of the person who is represented as patient or client, the Tidal Model has more The Tidal Model: Developing a Person-Centered Approach to Psychiatric and Mental Health Nursing modest ambitions, which may ultimately be more ambitious. Rather than engaging with the disorder or illness, the Tidal Model focuses on contacting the person (Barker, 1997). The aim of this engagement is to understand the present situation of the person, which includes the relationship with illness and health. Although the nurse expresses a curiosity about the person, this is in pursuit of knowledge of what is happening within the person’s experience of world, self, and others, and what this might mean for the necessary care of the person. The model employs three dimensions as a means of representing personhood: world, self, and others. W o r l d . In the world dimension, the focus is on the person’s need to be understood. This includes a need to have the personal experience of distress
, illness, or trauma validated by others. A specific assessment format (the Holistic Nursing Assessment, Table 1) documents, in the person’s own voice, the significant and meaningful events occurring at this particular time, and what the person perceives as needing to be done to respond to these events. S e l f . In the self dimension, emphasis is given to the person’s need for emotional and physical security. A specific assessment format, the Security Plan (Table 2), identifies the kind of support necessary to ensure personal security and to offset the risk of harm to self or others through direct action or neglect. O t h e r s . In the others dimension, emphasis is given to the kind of support and services the person might need to live an ordinary life. This dimension emphasizes the need for specific medical, psychological, or social interventions, including other vital areas of everyday living such as housing, finances, occupation, and leisure. Within each of these dimensions, the nurse aims to explore the person’s construction of experience through narrative (Saunders, 1997), employing the concept of the therapeutic alliance (Hummelvoll, 1996). In each dimension of assessment and intervention, emphasis is given to engaging the person fully in the process of determining and, where possible, contributing to the interventions that might meet the person’s needs. The narrative structure of the model is developed expressly in the care plans, where the assessment record docuPerspectives in Psychiatric Care Vol. 37, No. 3, July-September, 2001 8 3 ments the person’s needs and problems verbatim, rather than translating the person’s account into professional language. The necessary care required by the person will invariably involve a balance or fusion between the differing Table 1. Overview of the Holistic Nursing Assessment 1 . Problem origins (How current problems began) 2 . Past problem function (How this affected me) 3 . Past emotional context (How I felt in the beginning) 4 . Developmental history (How things have changed over t i m e ) 5 . Relationships (How this has affected my relationships) 6 . Current emotional context (How I feel now) 7 . Holistic content (What do I think all of this means?) 8 . Holistic context (What does all of this say about me as a p e r s o n ? ) 9 . Needs, wants, and wishes (What needs to happen now) 1 0 . Expectations (What do I hope that the nursing team will do for me?) Table 2. Overview of Format Used to Develop the Security Plan 1 . How do I feel today? 2 . How safe do I feel right now? 3 . What would help me feel safer? 4 . What are the chances that I will harm myself? 5 . To what extent do I think the nursing team can help me? 6 . What exactly could the nursing team do to help me? 7 . Who else could help me feel safer? 8 . How, exactly, could they be of help to me? 9 . How confident am I that I can keep myself safe until I meet with my primary nurse again? 1 0 . (If the person is at risk of self-harm) What have I done, or what have others done, in the past that helped me feel more secure? 1 1 . What can I do now to make myself feel more secure? 1 2 . How can the nursing team help me feel more secure? constructions of the person and her/his significant others. The empowerment, narrative basis of the Tidal Model, acknowledges that what needs to be done will be determined largely by the person’s personal science ( M ahoney, 1974). The model draws heavily on systemic and solution-oriented approaches (Webster, Vaughn, Webb, & Playter, 1995), which emphasize personal problem solving, and reveal and employ personal resources. The Tidal Model gives precedence to the story told by the person, since this is the location for the person’s enactment of life. The Tidal Model assumes that people a r e their narratives (McIntyre, 1981). People’s sense of self and world of experience, including experience of others, is inextricably tied to their life stories and the various meanings they have generated. The Tidal Model generates a narrativebased form of practice that differs markedly from the concept of evidence-based practice, which holds sway at present. The former is always about particular human instances, whereas the latter is based on the behavior of populations whose elements are merely assumed to be equivalent. More important, perhaps, the narrative focus of the Tidal Model is not concerned with unraveling the causative course of the person’s present problems of living, but aims to use the experience of the person’s journey and its associated meanings to chart the next step that needs to be taken on the person’s life path. As part of this conjoint exploration of the person’s world of experience, the assessment record is written in the person’s own voice, rather than translated into third person or professional language. Emphasis is given to the livedexperience of distress, by using a first-person narrative: e.g., “ This all began for m e . . . when I started to . . . and then I began to . . . and this made m e feel . . . so I b e l i e v e d 8 4 Perspectives in Psychiatric Care Vol. 37, No. 3, July-September, 2001 that . . .” Research suggests that this simple strategy may empower the person (Barker et al., 2000). The nurse and the person in care cocreate the narrative of the world of experience, which includes an identification of what the person believes she/he needs in the form of nursing. The Tidal Model gives precedence to the story told by the person, since this is the location for the person’s enactment of life. The caring process begins and ends here since people invariably need to develop (create) a coherent account of what has happened and is happening to them in light of their personal experience. In the course of mental health care and treatment, it is commonplace for nurses to note that people change their stories. This is a reflection of considering the past in light of the present (which is changing) and serves notice that people are involved in creating their future. It is folly, therefore, to talk of some putative “true” story: This is no more than a pattern of context or agency. Instead, the nurse aims to help the person develop a story, which takes account of how she/he is making sense of life events (including the process of care) as they occur. Moving From Disempowering to Empowerment The experience of mental ill health is disempowering, limiting the person’s ability to function in everyday life. When mental health problems endure or recur frequently, the family or community often view the person as disabled. Although the person is offered a mental h e a l t h s e rvice, this invariably is focused only on limiting the personal and interpersonal damage that can be caused by living with mental illness. The processes of psychiatric care and treatment often add to the disempowerment of the person. This ranges from the manifest restrictions imposed by confinement under the law to the subtler limitations enacted by being placed under observation in the hospital or deemed noncompliant by an assertive outreach team. The model attempts to address directly the most common form of disempowerment, which involves the failure to afford a proper hearing to the person’s story of the experience of problems of living. Traditionally, the medical model has served as a means of deflecting attenThe Tidal Model: Developing a Person-Centered Approach to Psychiatric and Mental Health Nursing tion from the lived experience of the person, translating this unique, subjective account into the paralanguage of medicine, where the person’s account is reduced to the level of its apparently commonly occurring parts. This is not a condemnation of psychiatric diagnosis per se, but is merely an acknowledgment of the limitations of this way of representing the human experience of problems of living, especially where this is afforded primacy. The three dimensions of the Tidal Model aim to avoid reducing the person to a “patient phenomenon,” while recognizing the impossibility of developing anything more than a provisional account of the person’s life experiences and the per
son’s immediate need for nursing. By embracing the principles of empowering interactions drawn from empirical research (Barker, 2000), the Tidal Model puts the person’s experience and unfolding life narrative center stage, and, in so doing, powers up the person in the process (Parse, 1981). Research and Development The Tidal Model was introduced in two pilot sites in acute psychiatric admission wards in Newcastle, England, in 1997. Over a period of 30 months, the original model was revised and adapted, and the present model was introduced in May 2000 across the whole adult mental health program, comprising eight admission wards and their associated community support teams. An interdisciplinary evaluation of the model in practice is being conducted, involving nursing, medicine, occupational therapy, and patient advocates. The evaluation is employing an action research methodology to monitor the processes and effects of the implementation of the model across three main domains: nurses’ perceptions of the utility of the model in practice, patients’ perceptions of the personal benefits of receiving care within this model of nursing practice, and other disciplines’ perceptions of the extent to which the model enhances interdisciplinary working. A number of pilot sites have been established across a range of clinical settings worldwide—from a rural mental health service in Adelaide, Australia, to a medium secure facility in Cardiff, Wales, to Japan, AusPerspectives in Psychiatric Care Vol. 37, No. 3, July-September, 2001 8 5 tralia, New Zealand, Finland, Ireland, and Scotland. These additional pilot sites (about 15) will allow a degree of cross-national, as well as cross-cultural, comparison of the model in action (Narayasamy, 1999). For example, one of the sites in New Zealand offers a culture-specific mental health program for the indigenous Maori people; it largely eschews the assumptions about illness that are characteristic of western psychiatric accounts. C o n c l u s i o n Although nursing has a longstanding attachment to the concept of caring through interpersonal relationships, increasingly this has been usurped by demands for “evidence” of their utility within a postpositivist research paradigm (Barker, 1999; Stevenson, 1996). As Taylor (1994) has demonstrated, however, the dynamic processes involved in nurses and the people in their care, encountering and negotiating (through narrative) the experience of illness, can ultimately engender healing, and are experienced as such by people receiving nursing care. The Tidal Model assumes that nurses need to get close to the people in their care, so they may explore (together) the experience of health and illness. Although (or perhaps because) health care is becoming increasingly technical and emotionally distant (e.g., through the use of computers), many people with mental health problems are calling for care and treatment to reemphasize the relationships between themselves and their careers. In this context it is notable that Harry Stack Sullivan’s biographer suggested that Sullivan’s key contribution to psychotherapy and psychiatry was his “ever present awareness of the need to convey respect for the patient and to maintain the patient’s own self-esteem” (Evans, 1996, p. 3). In quite a different context, the Irish philosopher and theologian John O’Donohue (1997) has argued that contemporary culture possesses . . . an excessive concentration on the notion of relationships. It is a constant theme on TV, film and media. Technology and media are not uniting the The Tidal Model: Developing a Person-Centered Approach to Psychiatric and Mental Health Nursing world. They pretend to provide a world that is i n – t e r n e t t e d , but in reality, all they deliver is a simulated world of shadows . . . “relationship” has become an empty centre around which our lonely hunger forages for warmth and belonging. (p. 39) O’Donohue (1997) notes that in the early Celtic church, a person who acted as a teacher, companion, and spiritual guide was called an anam cara (a soul friend), someone “to whom you confessed, revealing the hidden intimacies of your life” (p. 35). It is evident that the practice of psychiatric and mental health nursing is still predicated on a kind of confession (of trauma and physical and emotional vulnerability) within an intimate conversation (interview/assessment/therapeutic dialogue). Only our postmodern secular society feels uncomfortable about acknowledging (as O’Donohue does) that this process is spiritual, since it involves, as Frankl (1964) defined it, an exploration of the meanings that people have attributed to the experiences in their lives. The Tidal Model acknowledges that the life problems that overtake and threaten to drown people described as suffering from mental illness can be construed at a fundamental level as spiritual crises (Morris, 1996). It also acknowledges that the kind of care nurses need to deliver to respond effectively to such crises may appear ordinary (Taylor, 1994), but, given the context of care and the often-limited resources available, can represent acts of extraordinary courage and compassion. 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