The aim of this essay is to explore key concepts impacting on mental health issues and their support. It will start by giving a brief history of the evolution of mental health and its definition. It will explore the definition of theory as well as nursing theory.
Once these have been explained two theories will be looked at one Grand Theory, Orem’s Self Care Deficit Nursing Theory (SCDNT), and, Buchanan-Baker and Baker’s Tidal Model, which is considered a mid-range theory. The two theories which will be examined in this essay are theories that put the person at centre of the care and therefore looks at the biopsychosocial aspect of nursing.
There is some confusion between the word theory and model in nursing. In this essay, theory will refer to Grand Theories which have a wide scope and Models will refer to the Mid-Range theories which have a narrower scope.
Evolution of Mental Health
“Madness” has been a term used throughout the centuries to describe the behaviour of someone who does not confirm with societal norms. In the past, anyone who would act differently, not necessarily loud or disturbed, but anyone who would voice very different ideas from the norm would be considered mad (Porter, 2013).
From Babylonian times madness has been believed to relate to magic or spirits that would invade the bodies of the people not behaving according to the society’s rules (Porter, 2013). Later in the 7th century madness was believed to be physiological. In the text by Ibrahim (19th C.E) it is believed that a physical illness that causes fever for example unless treated, would eventually reach the brain and cause the person to go mad, and therefore should be treated with the medical techniques of the time like leeches and evacuation to avoid the illness reaching the brain.
Many centuries later in the early nineteenth century, Sigmund Freud and some of his colleagues started trying to treat people by talking to them, to find out what happened in their lives that could contribute to the distinct behaviour (Eghigian, 2010).
Fast forward to the early and middle twentieth century and the advance in the now discipline of psychiatry has, by experiment tried to come up with a lot of answers regarding the disturbances of the mind without much success. Then in the 1950’s when it was discovered that the ill could be helped by medication, one more step was taken in the ability to treat people. (Eghigan,2010). However still just worried about treating the symptoms not the disturbances.
We could attribute the use of the word “mad” to be as per Freud’s (1910) explanation, word mad was used as doctors back then would not know or understand the reasons behind the “mad” behaviours and therefore not be able to empathise with the patient. The lack of knowledge about the brain and mind could be said to be at fault for the stigma we see today.
Mental health is today in one way or another accepted to be as per Szazs (1960) “problems of the living” and therefore has given rise to non-medical people treating it, like psychotherapists, counsellors and psychologists.
The World Health Organization defines Mental Health as an integral part of Health, “Health is a state of complete physical, mental and social well-being and not merely the absence of
disease or infirmity.” (World Health Organization, 2013). They also accept the fact that mental health can be influenced by the socio-economic factors of one’s life.
What Is Nursing Theory?
Theory has many definitions on its own, and so does Nursing Theory. According to Parker and Smith (2010) “Theories are mental patterns and framework created to help to understand and create meaning from our experiences, organize and articulate our knowing and ask questions leading to new insights”. This definition can also be used to describe Nursing theory, McKenna et al. (2014) describe Nursing theory as “being constructed out from specific nursing phenomena represented as concepts, definitions, assumptions and propositions that help to describe explain or predict how nursing may support and help patients, families or society”.
Nursing theory helps us, as per the definitions above, to observe how things work and theorise according to the nurse’s experience and knowledge. A theory needs to be tested in practice to be deemed useful or not.
It can be said that in Nursing there are four main meta paradigms person, environment, patient and nursing. These metaparadigms are believed to be the origin of Grand Theories resulting in theories like Dorothea Orem’s the Self Care Theory, Florence Nightingale’s Environment Theory and Jane Watson’s the Human Caring theory (Branch et al. 2016), all nursing theories that explore the nursing metaparadigms to cover all the aspects of nursing care.
The earliest nursing theory is believed to be Florence Nightingale’s Environmental Theory, which she theorised when she fought for her patients’ right to have a safe and comfortable environment to get better. In her book “Notes on Nursing, what it is and what it is not” (1898), even though a theory was not per se mentioned, she explains why the environment is so important to the wellbeing of the patients. When you read about this early environmental theory, things like the role of the nurse are very different from more recent theories, however a lot of the principles described in her book regarding lighting, cleanliness and other factors are still part of the nursing profession today.
Orem’s Self Care Deficit Nursing Theory
Dorothea Orem dedicated her life to the conceptualization of nursing theory and practice. Her Grand Theory Self Care Deficit Nursing Theory (SCDNT) was developed throughout her life and career. Orem started conceptualizing back in 1949 when she noticed that nurses do nursing but could not explain what nursing meant, and people who she worked with since, have contributed to her theories, resulting in the general theory of SCDNT (Parker, E.M; Smith, C.M , 2010)
The Self Care Deficit Nursing Theory (SCDNT) by Dorothea Orem is a holistic theory where the whole patient, mind body and soul are looked after or helped, depending on the necessity (Barret. D et all.2009)
SCDNT is made up of 3 sub theories which are interconnected. They are The Theory of Self Care (Dependent Care), The Theory of Self Care Deficit (Dependent Care Deficit) and The Theory of Nursing Systems (Parker, E.M; Smith, C.M, 2010).
Self-Care theory - Assumes that the patient is capable, has the motivation and knowledge to look after himself or herself, and when what he/she needs is greater than what self-care can provide a self-care deficit (the difference between what can be done on its own and what it needs) is generated. The self-care deficit can be resolved with Dependant care (someone who may be a family member or friend who will be able to look after the person in need) (Barret. D et all.2010). This sub theory looks at the I in the relationship of care, it looks after the patient (Hood. J.L 2014)
Dorothea Orem’s theories work with eight Unique Self Care Requisites, which are the tasks or functions that a person should be able to perform unaided (Parker, E.M; Smith, C.M, 2010).
Orem’s Theory USCR (Universal Self Care Requisites) are balanced between physical health and psychosocial factors. From USCR, 1 to 4, the biomedical concerns are addressed from 5 to 8 the psychosocial factors are addressed. Because of the clear interaction and the acceptance by the Orem’s Theory that the patient is more than just its physical health the theory can be used for Mental Health practice. (Cavanagh, 1991).
The eight USCR are: 1- Sufficient intake of air, 2 -Sufficient intake of water, 3 - Sufficient intake of food, 4 - Satisfactory eliminative functions, 5 - Activity balanced with rest, 6 - Balance between solitude and social interactions, 7 - Prevention of hazards to human life, human functioning, human wellbeing, 8 - Promotion of human functioning and development within human groups in accordance with human potential, know human limitations and the desire of normalcy (Barret. D et all.2009).
The ability to perform unaided the eight USCRs, or to learn how to perform the USCRs will determine in Orem’s theory what help will be necessary, and if help is necessary, how it will be delivered and for how long.
Self-Care Deficit theory - Happens when people need nursing. Because of the lack of self-knowledge or skills to perform the self-care duties themselves or because their dependent of care lacks the same knowledge or skills to look after the person in need (Orem’s 2001). This theory looks after the “you and me” on the relationship of care. This sub theory looks after the patient and the helper (Hood. J.L 2014)
Theory of Nursing Systems - Establishes the nurse as a helper to the patient and to the dependent of care, by defining what the nurse can do and how the nurse can help to bring the person in care back to health, using her knowledge and skills, and also to educate the patient to maintain health ((Orem’s 2001). This sub theory looks after the “we”, it looks after all the parts that may influence the care being given or received (Hood. J.L 2014).
According to Cavanagh (1991), the Orem’s theory has been revolutionary as even though it does not discount entirely the medical models, it still looks at the patient as whole including the medical, psychological and social needs and accounts for them in the care planning when nursing is necessary. Also, it is pioneer on seeing the nurse as a helper and only there to complete the lack of knowledge and skills that the patient or their carer may lack to look after themselves or the ill.
The main concept on the Orem’s Theory is the two types of person as she sees it.
The Tidal Model (Mid-Range theory)
The Tidal Model was developed by Poppy Buchanan and Phil Barker in the 1990’s. It is considered to be the first mid-range theory to be recovery focused, developed by mental health nurses for mental health practice. It is said to find to be used in a crisis (Copper, 2011). Having been tested extensively in practice it was the first model to be used across all ages, from child to adults, from acute to community (Copper, 2011). A particular difference between Dorothea Orem’s Theory and the Tidal Model is how each view mental illness, the authors Buchanan-Baker and Baker (2005) uses the term popularized by Thomas Szasz “Problem of the Living” to describe a different view of what mental illness is and how it should be dealt with by the care system, while Orem’s theory looks at Mental illness in the conventional way of an illness.
The model sees the problems of the living as a tide in the ocean (hence the name) as it comes and goes, so do all the problems and situations in life. Everything is in constant change. A person with schizophrenia will not always be in a stage where care needs to be given. They will recover and, maybe in the future, they may relapse and need help again (Cooper, 2011).
Buchanan-Baker and Baker’s model completely revolves around the patient in care and therefore believes that they are the experts of their own life, health and illness and also that their priorities need to be meet before the “problems of the living” can be dealt with (Ramage et al. 2018)
To deliver the recovery model that is the Tidal Model, four assumptions are used about the person in care and the nurse. The first assumption looks to enlighten the person in care, understand the illness and health. The second assumption is that even though the people around the person in care (carers, family members, nurses) may experience some backlash of the symptoms of the illness like anger, verbal abuse, physical abuse amongst others, the only one who really experiences the distress of the illness is the patient in care. Third, both the nurse or helper and the person in care will change or evolve in the therapeutic relationship, and in the fourth assumption the aim is to deal with real life experiences through their (patient in care) stories to enable recovery. ((Baker, Buchanan-Baker, 2005)
The relationship between the patient in care and the nurse or the helper is fundamental in the model, and, because of its importance, the model has four principles to work from regarding the therapeutic relationship.
The four principles which the Model was developed from are, the focus of mental health care is to enable people to be part of or continue to be part of the “Natural Community”, whatever it may be for the person in care; Change, it enables people to notice the ever-changing world, people, own emotions, and, by knowing and acknowledging change, to accept that everyone and everything is forever changing aiding the acceptance of the self; Empowerment is everything it aims to aid people to find ways to get back in control of their lives; Therapeutic Relationship is the process of “caring with” people and also the importance of the wellbeing of the nurse or helper to be able to maintain the relationship balance of helping without being personally involved (Baker, Buchanan-Baker, 2005)
The practice of the Tidal model is driven by six principles that reign all the therapeutic relationship Curiosity – Explore what the person knows, feels, thinks about themselves. Resourcefulness – How the person in care deals with the “problems of the living”. Respect – The person is the centre of the care plan and therefore knows best herself/ himself hence they are the experts. Crisis as an Opportunity – believes that crisis is an opportunity to change how they see themselves instead of just managing the symptoms. Think Small - Believes that all goals should be celebrated and cherished, as every little goal achieved is a step closer to recovery. Think Simple - Identify what makes a difference to the person in care even if this is a very small thing to anyone other than the person in care (Baker, Buchanan-Baker, 2005).
The Model has a summary of Ten Commitments which should be used as a guide to measure if the concepts and philosophies of the model are being adhered to (Baker, Buchanan-Baker, 2005).
The Commitments as per Buchanan-Baker and Baker (2007) are:
- Value the voice, actively listen to the stories, and try to encourage them to talk, make sure they know you are listening and that their stories matter;
- Respect the language, do not use medical language when making a care plan, when their own language is used the person in care will have a formal, hard evidence that what they say matters as the minutes will be written in their own words;
- Develop genuine curiosity, show interest on what the person in care is telling you, always probe to find out more information about events, about feelings, the person in care won’t quite often be willing tell you everything but with the right prompts it will be able to tell their stories for their own benefit;
- Became the apprentice, nurse or helper needs to learn from the person what will help them as the person in care is the expert about his/her own life;
- Use the available toolkit, the toolkit is all the stories and the actions that have worked in helping the person in care in the past. If the toolkit is not enough then evidence-based practice should be looked into;
- Craft the step beyond, work with the person in care to decide what needs to be done now so a step forward can be achieved. Once the first step is made the path should be opened to recovery;
- Give the gift of time, make the time spent quality time, productive time, with the person in care, and if this is done the actual amount of time spent will not be as important;
- Reveal Personal Wisdom, is the professional’s role to help the person in care to unravel the wisdom that he/she possesses;
- Know that change is constant, it should be the professional’s aim to help the person in care to accept that change happens and that is unavoidable. The professional role in this is to help the person in care to deal with changes, recognize them and learn how to respond to them to aid their recovery and quality of life;
- Be transparent, the professional needs to make sure that the person in care is aware of all steps being taken, why is being taken. Transparency is the key word in the relationship between the person in care and the professional The main concept of the Tidal model is that the person is placed at the centre of care as they are the experts of their own lives. Concepts and principles above, reinforce the shift on the mental health care scenario from imposing treatment to agreeing to a treatment with the person in care. We can see shadows of the model being implemented everyday sometimes without any knowledge of the model itself because the principles and concepts just reinforce that people should be treated well, with respect, be listened to regardless of being considered mentally ill or not.
After reading a brief history of mental health and one of the earliest nursing theories by Florence Nightingale my idea that nursing theories have helped the profession to see the person in care as a whole has been reinforced.
The essay also reinforced my idea that in Mental Health treatment if the resource of time is not available to be able to have face to face meetings with the person in care, treatment becomes archaic, almost reverting to the old days where the patient did not have a say and had to accept what was offered, which happened because of the lack of knowledge about the brain and the mind.
Dorothea Orem’s Self Care Deficit Theory helped the nursing community to see the person in care as a whole by addressing the biomedical side as much as the psychosocial aspect of the person in care. It addresses all the needs that a person in care may have and also highlights that time with the person in care or the helper is essential to the successful design of a care plan.
The Tidal modal however even though very person centred does not address in its writings any of the biomedical needs that a person in care may have. Biomedical needs will only be identified if this is one of the priorities of the person in care.
The study of both theories reinforced my believe that mental health care is mainly the care of problems of the living which needs to be dealt with by collaborating with the person in care to get them to the optimum recovery level, whatever that may be.
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