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Tidal Model of mental health recovery

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Nancy Brookes at University of Ottawa
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Journal of Psychiatric and Mental Health Nursing,
2006,
13
, 460– 463
Editors: Submission address:
Martin Ward
1 1
Cawston Manor, Aylsham Road, Cawston, Norwich,
Ann Jackson
2
NR10 4JD, UK
2
RCN Institute, Radcliffe Infirmary, Woodstock Road,
Oxford, OX2 6HE, UK
460 ©
2006 The Authors. Journal compilation
©
2006 Blackwell Publishing Ltd
BROOKES N., MURATA L. & TANSEY M. (2006)
Journal of Psychiatric
and Mental Health Nursing
13
, 460–463
Guiding practice development using the Tidal Commitments
The Tidal Model of Mental Health Recovery has contributed to the trans-
formation of nursing practice at the Royal Ottawa Hospital (ROH), a psy-
chiatric and mental health facility in Ontario, Canada. Ten commitments
affirm the core values of the Tidal Model. These commitments guide person-
centred, collaborative, strength-based practice and they facilitate Tidal teach-
ing. In this paper we illustrate fidelity to the values, principles and processes
of the model and the commitments while implementing the model. We share
how some of the commitments are realized in our Tidal teaching and provide
examples of successes and challenges.
Keywords
: Practice Development, Psychiatric and Mental Health Nursing,
Tidal Modal, Values and Commitments
Accepted for publication
: 21 March 2006
et
al
.
Practice Development
Guiding practice development using the Tidal
Commitments
N. BROOKES
1
RN
MSc
(
A
)
PhD
CPMHN
(
C
), L. MURATA
2
BScN
ME
d
CPMHN
(
C
)
CSFT
& M. TANSEY
3
BSN
MSc
(
A
)
CPMHN
(
C
)
ACNP
1
Nurse Scholar,
2
Clinical Nurse Educator, Royal Ottawa Hospital, and
3
Vice President, Professional Practice &
Chief, Nursing Practice, Royal Ottawa Health Care Group, Ottawa, ON, Canada
Correspondence:
N. Brookes
Royal Ottawa Hospital
1145 Carling Avenue
Ottawa, ON
Canada K1Z 7K4
E-mail: nbrookes@rohcg.on.ca
Introduction
In 2002 we began the transformation of nursing
practice at the Royal Ottawa Hospital, a 180-bed
psychiatric and mental health facility in Eastern
Ontario, Canada. Among other changes, we led the
implementation of the Tidal Model of Mental
Health Recovery.
Aware that change is constant, we thoughtfully
embraced the Tidal Model as a vehicle to change to
person-centred, research-based, collaborative care.
We began by providing every nurse with Tidal edu-
cation, using the multimedia education package
developed originally in Newcastle, UK (Barker
2000). This ensured a common perspective among
the nurses and fidelity to the values, principles and
processes of the Tidal Model. However, we also
wanted to encourage creative, locally relevant
implementation on each unit. We have implemented
Tidal in several waves, beginning in 2002 with three
©
2006 The Authors. Journal compilation
©
2006 Blackwell Publishing Ltd
461
Practice development and Tidal Commitments
programmes (Forensic Psychiatry, Mood Disorders,
and Substance Use and Concurrent Disorders), and
the six remaining inpatient units (Crisis and Evalu-
ation, General Psychiatry in Transition, Geriatric
Psychiatry, Psychosocial Rehabilitation, Schizo-
phrenia and Youth) in 2004.
About 18 months after we began, we learned
about the reaffirmation of core Tidal values in the
form of the 10 Tidal Commitments (Buchanan-
Barker 2004). We believe that these values need to
be embraced by persons who aim to pursue and
develop the philosophy of the Tidal Model (Barker
& Buchanan-Barker 2005). These commitments
provide a guide for practice and also facilitate the
teaching of Tidal. We want to share how selected
commitments have been realized in our Tidal teach-
ing and concurrent practice development.
Value the voice
We are very respectful of our nursing colleagues,
and are always interested in and curious about what
our colleagues have to share with us. As we began
Tidal implementation, we participated in weekly
nurses’ meetings on the different units and listened
to what the nurses had to say: their questions,
concerns, challenges and issues. Frequently, nurses
shared their stories in informal ‘hallway’ consulta-
tions as well. We encouraged them to create their
own local implementation, rather than imposing a
one-size-fits-all plan.
We heard over and over many complaints about
paperwork. While we valued this feedback, the
complaints and concerns became repetitive and tire-
some. In the spirit of the Tidal Model, we refocused
and reframed concerns as searching for solutions,
and sharing success stories – and humorous ones as
well!
We were dismayed to hear some nurses tell us
that they should really not talk to persons living
with psychosis as this could reinforce their illness,
and the stories would not make sense anyway.
Other nurses would discount stories, saying that
persons were just telling us what they thought
we wanted to hear. We consistently reassured the
nurses that everyone has a story and what persons
chose to share with us was what we wanted and
needed to hear from persons in care.
One of our implementation strategies was to
visit all the units on all shifts, to provide support
and encouragement, and to engage in dialogue
around Tidal implementation. There were, how-
ever, some surprises. For example, while reviewing
a newly completed holistic assessment on one unit,
solely written in the person’s voice, the nurse admit-
ted that she had added an interpretation of the per-
son’s words on the holistic assessment: ‘But she
really didn’t mean what she said, what she meant
was . . .’.
We celebrated with the nurses who were able to
capture the voices of persons in care in holistic
assessments and daily care plans. Some nurses
shared their astonishment as persons with whom
they had worked for years now began to share their
stories, affording the nurses new insights into estab-
lished ways of being. Nurses often seemed surprised
when ‘It (Tidal) worked!’ We are quick to respond
that Tidal is just words on paper:
it
didn’t work –
rather
they
had done the necessary work.
Respect the language
We know that nurses work ‘in the everyday’, and
that ordinary, everyday language has little currency
among psychiatric professionals. Nurses have
learned the insider language of psychiatry, and this
is useful in communicating with the interdiscipli-
nary team. There was also the cumbersome, arcane
language of nursing diagnosis that did not enhance
communication, and was not helpful for persons in
care and their families. This had come and gone in
our facility. Not only are nurses relearning and
becoming reacquainted with everyday language for
their own practice, they are also learning the natu-
ral, plainspoken language of persons in care and are
representing this voice, complete with idiosyncra-
sies, within the interdisciplinary team.
We consistently refer to
persons
or
persons in
care
having replaced the patient/client terminology
with, we believe, the more respectful – and accurate
‘person.’ This is true for presentations, classes, etc.
However, we also recognize that we are out of sync
with the larger nursing community. When we rec-
ommended that our national psychiatric and mental
health nursing organization replace ‘client’ with
person in documents relating to our competencies
and the certification examination, they demanded
references and evidence for this. After much discus-
sion, this remains a contentious issue.
Nurses have generously shared a number of sto-
ries with us that we have added to our toolkit. One
nurse shared a striking example of respecting the
N. Brookes
et al.
462 ©
2006 The Authors. Journal compilation
©
2006 Blackwell Publishing Ltd
language. After participating in a holistic assess-
ment, the nurse moved on to the Immediate Care
Plan A. Under the section entitled ‘mental state’ she
wrote
delusional
. The person reacted immediately
saying, ‘you weren’t listening to anything I said’.
The person took the form and scribbled all over it
with the pen, crossing everything out and then tore
up the assessment. Another nurse told us a story of
‘scare exaggeration’, another vignette for our tool-
kit. During the holistic assessment, the person iden-
tified one of her problems as
scare exaggeration.
The nurse helped her to describe this ‘nervous state’
so the nurse could translate it for the interdiscipli-
nary team, demonstrating the team’s respect for the
person’s unique expression of her lived experience.
This term was retained in interactions and all Tidal
documentation.
Become the apprentice
This Tidal Commitment to ‘become the apprentice’
was a good fit with the Tidal implementation team
as we have for many years been quite comfortable
learning from others. Our values and beliefs about
learning and practice are congruent with becoming
the apprentice. We learned about Tidal from the
seminal
Perspectives in Psychiatric Care
article
(Barker 2001). We read all the Tidal literature we
could find, as well as other literature related to per-
son-centred, solution-focused, strength-based nurs-
ing. We talked with other nurses about the gift of
Tidal. We learned what it was like to participate in
holistic assessments with people in care – Margaret
in her Acute Care Nurse Practitioner role, Nancy in
consultations throughout the hospital and Lisa
through her nurse educator role. We recognized
that this was a different way of being in relationship
with persons in care. Perhaps more accurately this
was back to our roots in a system that had not sup-
ported such practice. Fortunately, we are com-
pletely comfortable not being the experts. We learn
from the nurses; they teach us, so we can teach
them.
We learn from our colleagues including each
other. Persons in care teach us about the value of
the model. We practise the model. We continue to
experiment with different strategies, timing and
activities, and contribute to the evolution of the
model. We appreciate that practising Tidal is the
best way to learn it.
We learned that we had made assumptions about
nurses’ attitudes, skills and knowledge – we had
assumed that if we introduced them to colla-
borative, strength-based, solution-focused, person-
centred nursing, they would know what to do.
Many of the nurses have minimal expertise in psy-
chiatry and mental health nursing. Some have little
interest in learning new skills or changing their
established values and beliefs. Others are eager to
practise in new or different ways. We learned that
nurses seemed to think that they must become like
clean slates,
tabula rasa
, to practise Tidal. So, we
built in the strong message that we expect nurses
will come to this enterprise with all their knowl-
edge, skill and experience and build on this, rather
than ‘starting fresh’. We continue to search for solu-
tions to help nurses understand, appreciate and
practise person-centred, strength-based, collabora-
tive nursing.
Use the available toolkit
We valued the nurses’ stories. Now we collect sto-
ries that nurses tell of their successes and their frus-
trations practising Tidal. Some stories are posted
on the Tidal Model website (http://www.tidal-
model.co.uk). Some units have a book where the
stories of persons in care and other Tidal anecdotes
can be recorded and shared with one another. One
of the nurses who completed a Tidal fellowship
wrote her story for the website. She also wrote her
story for the fellowship newsletter and has pre-
sented her story at several conferences and internal
events. We are privileged to have her stories in our
toolkit, so we can share them too.
Valuing the voice of experience led to the cre-
ation of a video.
Sharing Tidal Stories
has four
nurses telling their stories illustrating the model in
practice. The video is a wonderful teaching tool that
is used widely in education and practice. Our first
Tidal presentation at an international best practice
conference in 2003 featured
Sharing Tidal Stories
.
We use the video with our own staff, for example,
in orientation
,
with other facilities implementing
the Tidal Model, and with those who come for site
visits. The video portrays the real stories of nurses
practising the model and illustrates both challenges
and successes.
One nurse tells of writing a paper for a Theories
and Concepts course in the post-basic degree pro-
gramme and how the Tidal Model gave her a dif-
ferent appreciation of nursing theory. She also
speaks of the ‘honour’ of joining the Tidal commu-
nity even though she was not officially part of the
©
2006 The Authors. Journal compilation
©
2006 Blackwell Publishing Ltd
463
Practice development and Tidal Commitments
first wave. Another nurse came to psychiatric and
mental health nursing from Intensive Care where
she was quite ‘directive and certain . . . the expert!’
She continued this stance until she was introduced
to the Tidal Model. She speaks eloquently of her
struggles with control as she learned to work col-
laboratively with persons in care. Another is an out-
patient nurse’s story of practising Tidal early on and
how it resulted in a true connection with the person
in care and how she shared the goals they developed
collaboratively with the team.
We have enjoyed other discoveries about Tidal.
In collecting the data for the Tidal study, we found
that a psychiatrist had used the holistic assessment
in his assessment around the dangerous offender
status. A nurse shared a poignant story about using
the miracle question that resulted in a connection
and collaboration with the person. A psychologist
in the Forensic programme told us that she finds the
holistic assessment invaluable to learn about per-
sons before she begins her assessment.
Our Tidal toolkit contains many stories and
vignettes that nurses and persons in care have gen-
erously shared with us, so we can share them with
others. We are creating a library of Tidal stories for
use in practice, education and research.
Give the gift of time
We recognize that change takes time and changes in
practice take time to practise. We first introduced
Tidal in education days, several months before we
began the actual implementation. We suggested that
the nurses take the opportunity to practise Tidal.
Perhaps we should not have been surprised that few
actually took the opportunity.
We built developmental support into our com-
mitment to transform nursing and to create time
and space for Tidal practice. In the beginning, we
provided extra nursing staff so nurses could spend
dedicated time to complete holistic assessments and
daily care plans. In our second wave of implemen-
tation, we were fortunate to have a Tidal implemen-
tation facilitator spend time coaching with each
nurse to ensure that they understood Tidal and the
requirements for Tidal practice. This facilitator
would review holistic assessments, participate in
holistic assessments with nurses or participate in
assessments with nurses observing. She took along a
‘float’ nurse to cover the unit nurses’ persons in
care, so the nurses could attend to the work without
worrying about ‘coverage’.
Many nurses told us that they were too busy and
that there was too much paperwork with the model.
They complained that they never have enough time.
We know that precious time is spent on administra-
tive, non-nursing tasks. We challenged the nurses to
spend at least 10–15 min a day in focused time with
persons, completing collaborative and person-
centred daily care plans. In our Tidal study, we
thought that we would see an increase in time from
admission to holistic assessment completion. So we
were surprised to find in a study that we did over
4 years that the length of time from admission to
completion of the five-page holistic assessment
remained on average 1 day.
We continue to strive to transform nursing prac-
tice and contribute to persons’ journeys of recovery.
There is ebb and flow in the process of implement-
ing the model. Sometimes we faced setbacks, or at
times we felt becalmed. There would also be times
of success, great celebration and breakthroughs. We
are sustained by our passion for excellence in psy-
chiatric and mental health nursing and care – and
by the stories.
References
Barker P.J. (2000)
The Tidal Model: Theory and Practice
.
University of Newcastle, Newcastle.
Barker P.J. (2001) The tidal model: developing a per-
son-centered approach to psychiatric and mental
health nursing.
Perspectives in Psychiatric Care
37
,
79–87.
Barker P.J. & Buchanan-Barker P. (2005)
The Tidal
Model: A Guide for Mental Health Professionals
.
Brunner-Routledge, London.
Buchanan-Barker P. (2004) The tidal model: uncommon
sense.
Mental Health Nursing
24
, 6–10.
... Nurses work on the frontline and meet a significant number of patients during times when suicide risk is especially high, for example, after a suicide attempt, during psychiatric inpatient care, and after discharge from psychiatric care [4]. The support towards living should start with the very first encounter and must be evident throughout the ensuing chain of care, including emergency care and inpatient care [3,5,6]. ...
... In addition, the ability to connect and listen to another person requires specific competence that is all too often neglected in healthcare professional's education [12]. Another explanation is that communicational and therapeutic competence is less valued than competence that corresponds with a biomedical perspective when inpatient care is organized [5,13]. ...
... [14] Similarly, person-centered care is stressed in recommendations for suicide prevention [2] but not evident in actual care interventions, which is demonstrated in a review including 101 multidisciplinary clinical practice guidelines in suicide prevention [15]. Psychiatric treatments are, without doubt, vital to clinical suicide prevention, but these are seldom enough to support the patient in the everyday living on the ward and after discharge [3,5,6]. The change towards a more person-centered inpatient care during suicide crises requires systematic efforts as well as a will to widen the perspective [10]. ...
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Suicide risk assessment needs to be a crisis intervention explored together with the person in care. The crisis intervention needs to start at the first encounter with healthcare and should be salient in all ensuing encounters and actions taken during the care. A caring approach which involves qualities like being welcoming, nonjudgmental, open-minded, and respectful can alleviate suffering and is crucial for assessment and forthcoming care, while an uncaring approach may cause the person to hide his or her needs, flee in affect, or refrain from seeking help during forthcoming suicide crises. Despite this, the competence required to connect and listen to another person is all too often neglected in hospital-based suicide prevention. Nurses have an important role to play in suicide risk prevention, since they frequently encounter patients in suicidal crises. Furthermore, nurses’ competence involves both the biomedical and philosophical perspective on the person’s health and care which is needed for assessment and care. Recommendations for care stress the interpersonal relationships with the person’s narrative as essential. However, components often described as person-centered care, such as establishing a therapeutic relationship, showing trust and respect, facilitating communication, getting to know the person, sharing power and responsibility, and empowering the person, require systematic education, training, and implementation. This chapter provides examples on how communication skills and rapport can be developed and applied in acts of care. The chapter also describes an approach for suicide prevention and crisis intervention that synthesizes teachings from caring science with contemporary suicide prevention.
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... This critique follows Chinn and Kramer's theory analysis, with particular assessment of clarity, simplicity, generalizability, importance, and accessibility (Chinn & Kramer, 2018). The Tidal Model Theory was selected for critique as it has been developed directly from within the discipline of psychiatric nursing (Barker, 1996(Barker, , 2000(Barker, , 2001Brookes, 2014;Fletcher & Stevenson, 2001). Therefore, consolidating knowledge of this middle-range theory could assist nurses in applying the theory in practice. ...
... Barker describes the early and continual influence of water in his life, rooted in his experiences of growing up around the shores of Scotland (Barker, 1996). Professionally, Barker became a qualified sculptor, an award-winning painter, and later a qualified psychiatric nurse (Brookes, 2014). Barker brought his artistic passions into the nursing profession, and further refined his perspectives through his consideration of Eastern philosophies (Barker, 1996). ...
... Barker's interest in the patterns of water, his artistic background, and Eastern philosophy all came together in the development of the Tidal Model of Mental Health Recovery, referred to herein as 'the Tidal Model' (Barker, 2000). Barker was particularly interested in understanding the deeper meaning of distress by those experiencing mental health concerns and saw several analogies related to the ocean, such as storms, drowning, and being shipwrecked (Brookes, 2014). He ultimately relates the analogies back to the role of the nurse through philosophical assumptions, commitments, and competencies (Brookes, 2014). ...
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The purpose of this paper is to critically analyze the Tidal Model of Mental Health Recovery. This examination consolidates the existing knowledge used in developing and implementing this model in order to add clarity and explores how its theory relates to practice, research, and educational activities. This paper follows Chinn and Kramer’s theory analysis framework, which includes the following criteria: clarity, simplicity, generalizability, importance, and accessibility. While the Tidal Model theory meets the criterion of clarity, simplicity is impeded due to the complexity of its concepts. That being said, Barker’s theory is applicable across different psychiatric nursing settings because it is general and accessible. To enhance simplicity and make this a more actionable mid-range theory, an illustration is offered to demonstrate how the theory could be utilized and empiricized with a potential population of women who use substances. It is concluded that the Tidal Model appeals not only to mental heath practice, but as the literature indicates, it also supports everyone who needs shelter where they feel safe at some point in their lives.
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... As a reciprocal process, the nurse-patient relationship happens in verbal and non-verbal communication, in affection, in empathy with the other, in the interaction involving the participants' contexts. This process is perceived and interpreted in a meeting, being "with" the patient to develop care and not "for" nursing practice (6) . ...
... The Tidal Model is based on the inherent value of each individual and their potential to change, as well as the capacity for autonomy in health production, with the understanding that people are able to supply their own basic physical needs (6) . ...
... The Tidal Model is structured with well-established and logically appropriate concepts, with broad ideas of the situations lived by the person and with a process of practical application based on scientific data and theories of mental health and psychiatry (6) . ...
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Full-text available
  • Dec 2014
Questiona-se como construir uma perspectiva estética e sociopoética do cuidar de pessoas com sofrimento psíquico, considerando o Tidal Model. Objetivou-se delinear uma perspectiva de cuidar em enfermagem fundamentada nos valores essenciais propostos por Phil Baker nesse modelo. Buscou-se, sem sucesso, em bases de dados, produção sobre essa teoria, no idioma português, trabalho completo de enfermagem disponível online. Utilizou-se o livro Modelos y teorias en enfermería, publicado em 2011, em inglês e espanhol. Os conceitos e ideias do autor dessa teoria possibilitaram vincular os princípios da Sociopoética à compreensão dos valores essenciais desse modelo, que remete às ações próprias da equipe de cuidados qualificados. Respondeu-se à questão inicial, com alcance do objetivo formulado, mediante a proposição de uma perspectiva estética e sociopoética do cuidar, fundamentada nos 10 compromissos dessa teoria. Compete aos profissionais de enfermagem promover uma interação cuidadosa e sensível com as pessoas, num espaço onde o cuidar é algo sagrado. ABSTRACT It is asked how an aesthetic and sociopoetic perspective on caring for people with mental suffering can be constructed on the basis of the Tidal Model. The aim was to outline a perspective on nursing care grounded in the core val­ues proposed by Phil Barker in the Tidal Model in nursing. A search in databases for full-length nursing studies this theory, published and available online in Portuguese, was unsuccessful. The book Modelos y teorías en enfermería, published in 2011, in English and Spanish. The concepts and ideas of the author of this theory made it possible to link the principles of Sociopoetics to an understanding of the essential values of this model, which relates to actions proper to a skilled care team. Thus the initial question was answered, and the goal achieved, by the proposal of an aesthetic and sociopoetic perspective on caring, based on the 10 commitments of the theory. It is up to professional nurses to foster sensitive, careful interaction with people in a place where caring is sacred. RESUMEN Se indaga acerca de la construcción de una perspectiva estética y sociopoética del cuidar de personas con sufrim­iento psíquico, considerando el Tidal Model. Se objetivó delinear una perspectiva de cuidar en enfermería fundamentada en los valores essenciales propuestos por Phil Barker en esa teoría. Se buscó, sin suceso, en bases de datos, produccíon sobre esa teoría, en português, trabajo completo de enfermería disponible online. Se utilizó el libro Modelos y teorias en enfermería, publicado en 2011, en inglés y español. Los conceptos y ideas del autor de esa teoria posibilitaron vincular los princípios de la Sociopoética a la comprensión de los valores esenciales de ese modelo, que remete a las acciones propias del equipo de cuidados calificados. Se respondió a la pregunta inicial, con alcance del objetivo formulado, a través de una proposición de la perspectiva estética y sociopoética del cuidar, fundamentada em los 10 compromisos de esa teoría. Compete a los profesionales de enfermería promover una interacción cuidadosa y sensible con las personas, en un espacio donde el cuidar es algo sagrado. DOI: http://dx.doi.org/10.12957/reuerj.2014.15663
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The Tidal Model: Developing a Person‐Centered Approach to Psychiatric and Mental Health Nursing
Article
  • Jul 2009
Overview of the theoretical and practical basis of a new model of psychiatric and mental health nursing practice. 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. Literature review, author's research, and related clinical experience. The Tidal Model provides a practice framework for the exploration of the patient's need for nursing and the provision of individually tailored care.
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The Tidal Model: A Guide for Mental Health Professionals
  • Jan 2005
  • P J Barker
  • P Buchanan-Barker
Barker P.J. & Buchanan-Barker P. (2005) The Tidal Model: A Guide for Mental Health Professionals. Brunner-Routledge, London.