alligood 8th edition_Neat

632 UNIT V Middle Range Nursing Theories

BOX 32-1 The Ten Tidal Commitments: Essential Values of the Tidal Model—cont’d
common story for all people. However, al- process, the professional’s pen can all too
though change is inevitable, growth is optional. often become a weapon: writing a story that
Decisions and choices have to be made if risks inhibiting, restricting, and delimiting
growth is to occur. The tasks of the professional the person’s life choices. Professionals are in
helper are to develop awareness of how change a privileged position and should model confi-
is happening and to support the person in dence by being transparent at all times, help-
making decisions regarding the course of the ing the person understand exactly what is
recovery voyage. In particular, we help the per- being done and why. By retaining the use of
son to steer out of danger and distress, keeping the person’s own language, and by completing
on the course of reclamation and recovery. all assessments and care plan records together
10. Be transparent: If the professional and the (in vivo), the collaborative nature of the pro-
person are to become a team, then each must fessional-person relationship becomes even
put down their “weapons.” In the story-writing more transparent.

Barker, P. J. (2003b). The 10 Commitments: Essential Values of the Tidal Model. Retrieved from http://www.tidal-model.com/Ten%20Commitments.htm.



MAJOR CONCEPTS & DEFINITIONS
The Theoretical Basis of the Tidal Model * effective nursing happens, as W. B. Yeats
The Tidal Model begins from four simple, yet impor- (1928) might have remarked, “How do we tell
tant starting points: the dancer from the dance?” This reminds us
1. The primary therapeutic focus in mental health that genuine caring encounters involve “caring
care lies in the community. A person’s natural with” the person, not just “caring about” the
life is an “ocean of experience.” The psychiatric person, or doing things that suggest we are
crisis is only one thing, among many, that might “caring for” them.
threaten to “drown” them. Ultimately, mental The Three Domains: A Model of the
health care is aimed to return people to that *
“ocean of experience,” so that they might con- Person
tinue their life voyage. In the Tidal Model, the person is represented by
2. Change is a constant, ongoing process. Although three personal domains: Self, World, and Others. A
people are constantly changing, this may be be- domain is a sphere of control or influence, a place
yond their awareness. One of the main aims of where the person experiences or acts out aspects of
the approaches used within the Tidal Model is private or public life. Simply, a domain is a place
to help people develop their awareness of the where one lives.
small changes that, ultimately, will have a big The domains are like the person’s home address.
effect on their lives. Their house or flat has several rooms, but the person
3. Empowerment lies at the heart of the caring is not found in each of these rooms all the time;
process. However, people already have their rather the person is sometimes in one room, and
own “power.” We need to help people “power sometimes in another. The personal domains are
up,” so they can use their own personal power similar. Sometimes the person is mainly in the Self
to take greater charge of their lives, using this Domain, and at other times the person is mainly in
in constructive ways. the World or Others Domain.
4. The nurse and the person are united (albeit The Self Domain is the private place where the
temporarily) like dancers in a dance. When person experiences thoughts, feelings, beliefs, values,

CHAPTER 32 Phil Barker 633

MAJOR CONCEPTS & DEFINITIONS —cont’d

and ideas that are known only to the person. In this which can be received from and given to others.
private world, the distress called “mental illness” is This becomes the basis of the person’s appreciation
first experienced. All people keep much of their pri- of the value of mutual support, which can be accessed
vate world secret, only revealing to others what they in everyday life.
wish them to know. This is why people are often such
a “mystery” to us, even when they are close friends or Water—A Metaphor †
relatives. The Tidal Model emphasizes the unpredictability
In the Tidal Model, the Self Domain becomes of human experience through the core metaphor
the focus of our attempts to help the person feel of water. Life is a journey taken on an ocean of
“safe” and “secure,” where we try to help the person experience. All human development—including
address and begin to deal with the private fears, the experience of health and illness—involves dis-
anxieties, and other threats to emotional stability coveries made on that journey across the ocean of
related to specific problems of living. The main experience. At critical points in the journey, peo-
focus is to develop a “bridging” relationship and to ple may experience storms or piracy. The ship may
help the person develop a meaningful Personal Secu- begin to take in water, and the person may face the
rity Plan. This work is the basis for development of prospect of drowning or shipwreck. The person
the person’s “self-help” program, which will sustain may need to be guided to a safe haven, to under-
the person on return to everyday life. The World take repairs, or to recover from the trauma. Once
Domainis the place where the person shares some of the ship is intact or the person has regained his
the experiences from the Self Domain, with other or her sea legs, the journey can begin again as
people, in the person’s social world. When people the person sets his or her course on the ocean of
talk to others about their private thoughts, feelings, experience.
beliefs, or other experiences known only to them, This metaphor illustrates many of the elements of
they go to the World Domain. a psychiatric crisis and the necessary responses to this
In the Tidal Model, the World Domain is the focus human predicament. “Storms at sea” is a metaphor
of our efforts to understand the person and the per- for problems of living; “piracy” evokes the experience
son’s problems of living. This is done through the use of rape or a “robbery of the self” that severe distress
of the Holistic Assessment. At the World Domain, can produce. Many users describe the overwhelming
we try to help the person begin to identify and nature of their experience of distress as akin to
address specific problems of living on an everyday “drowning,” and this often ends in a metaphorical
basis through use of dedicated One-to-One Sessions. “shipwreck” on the shores of an acute psychiatric
The Others Domain is where the person acts out unit. A proper “psychiatric rescue” should be akin to
everyday life with other people, such as family, “lifesaving” and should lead the person to a genuine
friends, neighbors, work colleagues, and profession- “safe haven,” where necessary human repair work can
als. The person engages in different interpersonal take place.
and social encounters that may be influenced by
others, and may—in turn—influence others. The Guiding Principles ‡
organization and delivery of professional care and 1. A belief in the virtue of curiosity: the person
other forms of support is in the Others Domain. is the world authority on his or her life and
However, the key focus of the Tidal Model is dedi- its problems. By expressing genuine curiosity,
cated forms of group work—Discovery, Information- the professional can learn something of the
Sharing, and Solution-Finding. “mystery” of the person’s story.
By participating in these groups, the person de- 2. Recognition of the power of resourcefulness:
velops awareness of the value of social support, Rather than focusing on problems, deficits,

Continued

634 UNIT V Middle Range Nursing Theories

MAJOR CONCEPTS & DEFINITIONS —cont’d
and weaknesses, the Tidal Model seeks to reveal very much on what the person is experiencing
resources available to the person—both personal now and what needs to be done now to address,
and interpersonal—that might help on the voy- and hopefully resolve, the problem.
age of recovery. 2. What works? We need to ask “what works”
3. Respect for the person’s wishes, rather than being (or might work) for the person under the
paternalistic, and suggesting that we might present circumstances. This represents the
“know what is best” for the person. “person-centered” focus of care. Rather than
4. Acceptance of the paradox of crisis as opportu- using standardized techniques or therapeutic
nity: Challenging events in our lives signal approaches, which may have general value,
that something “needs to be done.” This might we aim to identify either what has worked
become an opportunity for a change in life for the person in the past or what might work
direction. for the person in the immediate future, given
5. Acknowledging that all goals, obviously, belong their history, personality, and general life
to the person. These represent the small steps on circumstances.
the road to recovery. 3. What is the person’s personal theory? We need
6. The virtue in pursuing elegance: Psychiatric to consider how this person understands her
care and treatment are often complex and or his problems. What “sense” does the person
bewildering. The simplest possible means “make” of her or his problems? Rather than
should be sought, which might bring about giving persons professionalized explanations
the changes needed for the person to move of their difficulties in the form of theory or
forward. diagnosis, try to understand how they under-
stand their experience. What is the person’s
Getting in the Swim—Engagement personal theory?
Beliefs § 4. How do we limit restrictions? We should
When people are in serious distress, they often feel aim to use the least restrictive means of
as if they are drowning. In such circumstances, helping the person address and resolve
they need a “lifesaver.” Of course, lifesavers need to their difficulties. The Tidal Model tries to
engage with the person—they need to get close—to identify how little the nurse might do to
begin the rescue process. To get in the swim and to help the person, and how much the person
begin the engagement process, we need to believe might do to bring about meaningful change.
the following: Together, these represent the least restrictive
n That recovery is possible intervention.
n That change is inevitable—nothing lasts
n That ultimately, people know what is best for them Continuum of Care ¶
n That people possess all the resources they need As needs flow with the person across artificial
to begin the recovery journey boundaries, care is seamless with the intention of
n That the person is the teacher, and we, the help- the person returning his or her “ocean of experi-
ers, are the pupils ence” within his or her own community. Across
n That we need to be creatively curious to learn the care continuum, people may need critical or
what needs to be done to help the person now! immediate, transitional or developmental care.
Practical immediate care addresses searching for
Therapeutic Philosophy || solutions to the person’s problems, generally in the
1. Why this—why now? We need to consider, first short term, and focuses upon “what needs to be
of all, why the person is experiencing this par- done, now.” People enter the care continuum for
ticular life difficulty now. The focus of care is immediate care when experiencing an initial mental

CHAPTER 32 Phil Barker 635

MAJOR CONCEPTS & DEFINITIONS —cont’d
health crisis, possibly entering the mental health include liaising with colleagues and ensuring
system for the first time or with people familiar the person’s participation in the transfer of care.
with the system when a crisis occurs. Transitional The other end of the continuum is developmental
care addresses the smooth passage from one setting care, where the focus is on more intensive and
to another, when the person is moving from one longer-term support or therapeutic intervention
form of care to another. Here, nursing responsibilities (See Figure 32–4).
*Barker, P. J., & Buchanan-Barker, P. (2007a). The Tidal Model: Mental health recovery and reclamation. Newport-on-Tay, Scotland: Clan Unity
International.
† From Barker, P. J. (2000d). The Tidal Model—Humility in mental health care. Retrieved from http://www.tidal-model.com/Humility%20in%20mental%20
health%20care.htm
‡ Retrieved from www.tidal-model.com/Clarifying%20the%20value%20base%20of%20the%20Tidal%29Model.htm
§ Barker, P. J. & Buchanan-Barker, P. (2004). Beyond empowerment: Revering the storyteller. . Mental Health Practice, 7(5), 18–20.
|| From Barker, P. J., & Buchanan-Barker, P. (2007a). The Tidal Model: Mental health recovery and reclamation. (pp. 30–31). Newport-on-Tay, Scotland: Clan
Unity International.
¶ From Barker, P. J. (2000e). The Tidal Model Theory and practice. (pp. 22–24). Newcastle, UK: University of Newcastle.




in the early 1960s and Peplau’s paradigm of inter-
Use of Empirical Evidence personal relationships contribute to the empirical
Barker’s long-standing curiosity about the nature and base of the Tidal Model. Altschul’s study of nurse-
focus of psychiatric nursing and the stories of per- patient interaction in the 1960s provides empirical
sons-in-care led to the development of a theoretical support for the complex, yet paradoxically “ordi-
construction of psychiatric nursing, or a metatheory, nary” nature of the relationship (Barker, 2002a).
that could be further explored through empirical in- Altschul’s study of community teams in the 1980s
quiry (Barker, Reynolds, & Stevenson, 1997, p. 663). raised questions about the “proper focus of nursing”
Over 5 years, from 1995, the Newcastle and North and the “need for nursing,” and both Altschul and
Tyneside research team developed an understanding Peplau provided evidence related to interprofes-
of what people experiencing problems in living might sional teamwork.
need from nurses and began using their emergent Two of Barker’s theory-generating studies pro-
findings in 1997 as the basis for development of the vided the empirical base for the Tidal Model. The
Tidal Model. “need for nursing” studies (Barker, Jackson, &
Barker supports learning from, using, and inte- Stevenson, 1999a, 1999b) examined the perceptions
grating extant theory and research, as well as the ex- of service users, significant others, members of mul-
perience of reality—”evidence from the most ‘real’ of tidisciplinary teams, and nurses, and it sought to
real worlds” (Barker & Jackson, 1997). An example is clarify discrete roles and functions of nursing within
the “need adapted” approach to caring with people a multidisciplinary care and treatment process and
living with schizophrenia developed from Alanen’s to learn what people value in nurses (Barker, 2001c,
studies in Finland. One understanding that underpins p. 215). They demonstrated that professionals and
Alanen’s work and flows through the Tidal Model is persons-in-care wanted nurses to relate to people
that people and their families need to think of admis- in ordinary, everyday ways. There was universal
sion to a psychiatric facility as a result of problems of acceptance of special interpersonal relationships
living they have encountered and not as a mysterious between nurses and persons, echoing Peplau’s (1952)
illness that is within the patient (Alanen, Lehtinen, & work. “Knowing you, knowing me” emerged as the
Aaltonen, 1997). core concept in these studies. The nurse is expected
The power of the nurse-patient relationship dem- to know what the person wants even if it is not
onstrated through Altschul’s pioneering research verbalized or is not clear, and needs are constantly

636 UNIT V Middle Range Nursing Theories

changing (Jackson & Stevenson, 2004, p. 35). Profes-
sional nursing performance is described in three roles Major Assumptions
identified as (1) ordinary-me, (2) pseudo-ordinary/ Two basic assumptions underpin the Tidal Model.
engineered-me, and (3) professional-me. Relation- First, “change is the only constant.” Nothing lasts. All
ships are fluid, requiring nurses to “toggle” or switch human experience involves flux, and people are con-
back and forth from highly professional to distinctly stantly changing. This suggests the value of helping
ordinary presentations of self, and all relationships people become more aware of how change is happen-
differ depending upon the required role (Jackson & ing within and around them in the “now” (Barker &
Stevenson, 1998, 2000). The “pseudo-ordinary or Buchanan-Barker, 2004a). Second, people are their
engineered-me is likened to a see-saw” (Jackson & stories. They are no more and no less than the com-
Stevenson, 2004, p. 41). Sometimes people need plex story of their lived experience. The person’s story
someone to take care of them, other times someone is framed in the first person, and the story of how they
to take care with them (Barker, Jackson, & Stevenson, came to be here experiencing this ‘problem of living’
1999a; 1999b). The studies suggested that nurses contains the raw material for solutions (Barker &
respond sensitively to persons’ and their families’ Buchanan-Barker, 2004a).
rapidly fluctuating human needs. They need to “tune The Tidal Model rests on the following assumptions:
in to what needs to be done now,” to meet the per- • There are such “things” as psychiatric needs.
son’s needs (Barker, 2000e). Nurses are translators for • Nursing might in some way meet those needs
the person to the treatment team and the “glue” that (Barker & Whitehill, 1997, p. 15).
holds the system together (Stevenson & Fletcher, • Persons and those around them already possess
2002, p. 30). the solutions to their life problems.
The second study focused on the nature of em- • Nursing is about drawing out these solutions
powerment and how this is enacted in relationship (Barker, 1995, p. 12).
between nurses and persons-in-care and resulted The Tidal Model assumes that when people are
in the Empowering Interactions Model (Barker, caught in the psychic storm of “madness,” it is
Stevenson, & Leamy, 2000). This was developed with “as if” they risk drowning in their distress or foun-
Flanagan’s Critical Incident Technique (Flannagan, dering on the rocks; it is “as if” they have been
1954) within a cooperative inquiry method (Heron, boarded by pirates and have been robbed of some of
1996), using a modified grounded theory approach their human identity; it is “as if” they have been
(Glaser & Strauss, 1967). The study developed washed ashore on some remote beach, far from
Peplau’s assumptions about the importance of spe- home and alienated from all that they know and
cific interpersonal transactions, and it provided understand.
guidance and strategies for nurses within collabora-
tive nurse-person relationships. Strategies included Nursing
the following: “Nurses are involved in the process of working with
• Being respectful of people’s knowledge and expertise people, their environments, their health status and
about their own health and illness their need for nursing” (Barker, 1996a, p. 242). Nurs-
• Putting the person in the driver’s seat in relation to ing is continuously changing, internally and in rela-
the interaction tion to other professions, in response to changing
• Seeking permission to explore the person’s experience needs and changing social structures. “If any one
• Valuing the person’s contribution thing defines nursing, globally, it is the social con-
• Being curious as a way of validating the person’s struction of the nurse’s role” (Barker, Reynolds, &
experience Ward, 1995, p. 390). Nursing as nurturing exists only
• Finding a common language to describe the situation when the conditions necessary for the promotion of
• Taking stock growth or development are put in place (Buchanan-
• Reviewing collaboratively, and inspiring hope Barker & Barker, 2008). Nursing is “an enduring
through designing a realistic future together human interpersonal activity and involves a focus on

CHAPTER 32 Phil Barker 637

the promotion of growth and development” (Barker Person
& Whitehill, 1997, p. 17) and present and future Within the Tidal Model, interest is directed toward a
direction (Barker & Buchanan-Barker, 2007a). Barker phenomenological view of the person’s lived experi-
extended Peplau’s original definition, clarifying the ence, and his or her story. “Persons are natural philoso-
purpose of nursing as trephotaxis from the Greek: phers and meaning makers devoting much of their lives
“the provision of the necessary conditions for the to establishing the meaning and value of their experi-
promotion of growth and development” (Barker, ence and to constructing explanatory models of the
1989, 2009). He emphasizes the distinction between world and their place in it” (Barker, 1996b, p. 4). Nurses
“psychiatric” and “mental health” nursing. When are able to see and appreciate the world from the per-
nurses help people explore their distress, in an attempt son’s perspective and share this with the person. People
to discover ways of remedying or ameliorating it, they are their stories. “The person’s sense of self and the
are practicing psychiatric nursing. When nurses help world of experience, including the experience of others
the same people explore ways of growing and develop- is inextricably tied to their life stories and the various
ing, as persons, exploring how they presently live meanings they have generated” (Barker, 2001c, p. 219).
with and might move beyond their problems of People are in a constant state of flux, with great capacity
living, they are practicing mental health nursing. for change (Buchanan-Barker & Barker, 2008) and
(Barker, 2003a; 2009). engaged in the process of becoming (Barker, 2000c).
Nursing is a human service offered by one group They live within their world of experience represented
of human beings to another. There is a power dy- in three dimensions: (1) world, (2) self, and (3) others.
namic in the “craft of caring,” one person has a duty Life is a developmental voyage, and people travel
to care for another (Barker, 1996b, p. 4). Nursing is a across their “ocean of experience.” This voyage of dis-
practical endeavor focused on identifying what peo- covery and exploration can be risky, and people have
ple need now; collaboratively exploring ways of both a fundamental need for security and a capacity to
meeting those needs; and developing appropriate adapt to changing circumstances. The “journey across
systems of human care (Barker, 1995, 2003a). The our ocean of experience depends on our physical body
proper focus of nursing is the “need” expressed by on which we roll out the story of our lives” (Barker &
the person-in-care, which “can only be defined as Buchanan-Barker, 2007a, p. 21). The Tidal Model
a function of the relationship between a person-with- “holds few assumptions about the proper course of
a-need-for-nursingand a person-who-has-met-that- a person’s life” (Barker, 2001a, p. 235). Persons are
need”. (Barker, 1996a, p. 241; Barker, Reynolds, & defined in relations, for example, as someone’s mother,
Ward, 1995, p. 389). These responses are the phe- father, daughter, son, sister, brother, friend and also in
nomenological focus of nursing (Barker, Reynolds, & relation with nurses.
Ward, 1995, p. 394; Peplau, 1987); a focus on human
responses to actual or potential health problems Health
(American Nurses Association, 1980). These may Barker provides the provocative definition of health
range across behavior, emotions, beliefs, identity, put forth by Illich (1976) as “the result of an au-
capability, spirituality, and the person’s relationship tonomous yet culturally shaped reaction to socially-
with the environment (Barker, 1998a). created reality. It designates the ability to adapt to
Nursing’s exploration of the human context of be- changing environments, to growing up . . . to heal-
ing and caring supports nursing as a form of human ing when damaged, to suffering and to the peaceful
inquiry. Being with and caring with people is the pro- expectation of death. Health embraces the future . . . in-
cess that underpins all psychiatric and mental health cludes the inner resources to live with it (p. 273).
nursing, and this process distinguishes nurses from all Health is a personal task where success is “in large
other health and social care disciplines (Barker, 1997). part the result of self-awareness, self-discipline,
“Nursing complements other services and is congru- and inner resources by which each person regulates
ent with the roles and functions of other disciplines in his/her own daily rhythms and actions, his/her
relation to the person’s needs” (Barker, 2001c, p. 216). diet, and his/her sexuality” (Illich, 1976, p. 274).

638 UNIT V Middle Range Nursing Theories

Our personhood, connections, and fragility “make settings, from day rooms of hospital wards to the
the experience of pain, of sickness, and of death an living room or kitchen of the person’s own home
integral part of life” (Illich, 1976, p. 274). Illich’s (Barker, 1996b). With critical interventions, nurses
(1976) description illustrates both the chaotic and make the person and the environment safe and
Zen sense of “reality.” “Health is not ‘out-there,’ it is secure. Engagement is critical, and the social environ-
not something to be pursued, gained or delivered ment is critical for engagement. When people are
(health-care). It is a part of the whole task of being deemed to be at risk, they need to be detained in a
and living” (Barker, 1999b, p. 240). safe and supportive environment, a safe harbor until
“Health means whole . . . and is likely linked to they return to their ocean of experience in the com-
the way we live our lives, in the broadest sense. This munity (Barker, 2003a). “Nurses organize the kind of
‘living’ includes the social, economic, cultural and conditions that help to alleviate distress and begin the
spiritual context of our lives” (Barker, 1999b, p. 48). longer term process of recuperation, resolution or
The experience of health and illness is fluid. Within a learning. They help persons to feel the ‘whole’ of their
holistic view, people have their own individual mean- experience . . . and engender the potential for heal-
ings of health and illness that we value and accept. ing” (Barker, 2003a, p. 9).
Nurses engage with people to learn their stories and
their understanding of their current situation, includ-
ing relationships with health and illness within their Theoretical Assertions
worldview (Barker, 2001c). Ill health or illness almost The Tidal Model is based upon four premises concern-
always involves a spiritual crisis or a loss of self ing practice, which Barker developed in the mid-1990s
(Barker, 1996a). A state of disease is a human problem with the “expert nurse” focus group (Barker, 1997).
with social, psychological, and medical relations, a These premises were validated by a group of former
whole life crisis. Nursing with the Tidal Model is prag- psychiatric patients led by Barker’s colleague of many
matic and focused upon persons’ strengths, resources, years, the mental health service user and activist,
and possibilities, maintaining a health orientation; the Dr. Irene Whitehill.
Tidal Model is a healthy theory. • Psychiatric nursing is an interactive, developmen-
tal human activity, more concerned with the future
Environment development of the person than the origins or
The environment is largely social in nature, the con- cause of their present mental distress.
text in which persons travel within their ocean of • The experience of mental distress associated with
experience, and nurses create “space” for growth and psychiatric disorder is represented through pub-
development. “Therapeutic relationships are used in lic disturbance or reports of private events that
ways that enhance persons’ relationships with their are known only to the person concerned. Nurses
environment” (Montgomery & Webster, 1993, p. 7). help people access, review, and re-author these
Human problems may derive from complex person- experiences.
environment interactions in the chaos of the every- • Nurses and the people-in-care are engaged in a
day world (Barker, 1998b). “Persons live in a social relationship based upon mutual influence. Change
and material world where their interaction with the is constant, and within relationships there are
environment includes other people, groups, and or- changes in the relationship and within the partici-
ganizations” (Barker, 2003a, p. 67). Family, culture, pants in the relationship.
and relationships are integral to this environment. • The experience of mental illness is translated into
Vital areas of everyday living, including housing, a variety of disturbances of everyday living and
financing, occupation, leisure, and a sense of place and human responses to problems in living (Barker &
belonging are areas of environment (Barker, 2001c). Whitehill, 1997).
The divide between community and institution is These premises are framed within the wider philo-
artificial and rejected as needs flow with the person sophical and theoretical perspective, especially the
across these boundaries. Much psychiatric and men- phenomenological assertion that people own their
tal health nursing takes place in the most mundane of experience; only persons can know their experience

CHAPTER 32 Phil Barker 639

and what it means. Mental distress is a symbolic force, The theory classifies a body of nursing knowledge
which is known only, in phenomenological terms, to that is largely story-based. The components are clearly
the person involved. The lived experience is the me- presented and logically derived from clinical observa-
dium through which we receive important messages tion, practice, theory, research, and philosophy.
about our life and its meaning (Barker, 2001c). Barker The emergent evidence from users of the theory in
views mental distress as part of the whole of the the UK, Ireland, Canada, and New Zealand confirms
person, not something split off from their “normal” the importance of the simple affirmation of the per-
being. sonal story, with its emphasis on understanding what
The Tidal Model assumes and asserts that people is happening for and to the person, and what this
know what their needs are, or can be helped to recog- means for persons in their own language. Stories gen-
nize or acknowledge them over time. From that erated within the caring context are written in the
minimally empowered position, people may be person’s own voice, helping the person to “take back”
helped to meet these needs in the “short” term. What the personal story, which has been lost from view
nurses and everyone else in the person’s social world by becoming a “patient” or “client.” Even when the
relate to is the expressed behavior. Mental illness is person is severely disabled by problems of living, the
disempowering, and “people who experience any of nurse keeps the focus on helping the person deter-
the myriad threats to their personal or social identi- mine “what needs to be done” and on finding the
ties, commonly called mental illnessor mental health personal and interpersonal resources necessary to be
problems, experience a human threat that renders empowered.
them vulnerable.” However, “most people are suffi- The attempt to understand persons’ constructions
ciently healthy to be able to act for themselves and to of their world is expressed through the holistic as-
influence constructively the direction of their lives” sessment that helps persons to relate their story and
(Barker, 2003a, pp. 6–7). Recovery is possible, and explore what needs to be done. Care planning is a
people have the personal and interpersonal resources collaborative exercise with emphasis on developing
that enable this recovery process (Barker, 2001c). an awareness of change and revealing solutions. The
celebration of personhood and the holistic narrative
approach creates a style of practice of working
Logical Form collaboratively with people. It emphasizes persons’
The Tidal Model is logically adequate, the structure of inherent resources and acknowledges change as an
relationships is clear, and the concepts are precise, enduring characteristic.
developed, and developing. It contains broad ideas,
addresses many situations of persons with problems
in living, follows the “logic of experience” (Barker, Acceptance by the Nursing Community
1996b), and develops “practice-based evidence” The Tidal Model appeals to those interested in per-
(Barker & Buchanan-Barker, 2005). son-centered care and theory-based practice. The
Barker and colleagues constructed a metatheory of literature illustrates the wide acceptance and use of
psychiatric and mental health nursing. Questions the theory in practice and in research. Acceptance
about the nature of persons, problems in living, and of the theory is facilitated by the philosophical, theo-
nursing were followed with systematic inquiry. The retical, research, and practical base, along with clearly
theory informs and is shaped by research. The Tidal stated values and principles.
Model flows from a particular philosophical perspec-
tive and worldview that provides the context for beliefs Practice
about persons and nursing. The Tidal Model was developed in practice between
The theory identifies the core of nursing practice 1995 and 1997 and was introduced formally on two
as “knowing you, knowing me.” It specifies a nursing acute psychiatric wards in Newcastle, England, in
focus of inquiry, identifies phenomena of particular 1998. It was subsequently adopted by the Mental
interest to nurses, and provides a broad perspective Health Program, and in 2000 rolled out across nine
for nursing research, practice, education, and policy. acute psychiatric wards, their associated community

640 UNIT V Middle Range Nursing Theories

support teams, and one 24-hour facility in the com- recently, projects have been established in child and
munity (Barker & Buchanan-Barker, 2005). The Tidal adolescent care in Sydney, with a new development
Model became international as interest spread in in the area of “justice health.” In New Zealand,
the United Kingdom first to Ireland, then throughout nurses at Rangipapa in Porirua were the first to
the world. introduce the Tidal Model into a forensic setting
Most of the early Tidal Model developmental work and the first to investigate the experience with the
was undertaken in the United Kingdom, with projects model from the perspective of staff and clientele
ranging across hospital and community services, (Cook, Phillips, & Sadler, 2005). The Tidal Model’s
from acute through rehabilitation, to specialist foren- emphasis on story has proven particularly attractive
sic services and community care. These ranged from to the indigenous Maori and Pacific Islands people
metropolitan services in cities like central London of New Zealand, who greatly value the power of
and Birmingham, where the clinical populations are storytelling. In Japan, the Model has been the focus
socially, culturally, and ethnically diverse, to Corn- of a major development program for almost a de-
wall, Glamorgan, and Norfolk, where people from cade at the Kanto Medical Center, the largest private
rural English and Welsh communities were served. psychiatric facility in Tokyo. Dr. Tsuyoshi Akayama,
The most extensive project was in Scotland, where the lead psychiatrist, translated the Tidal Model
since 2003 the Glasgow mental health services oper- training materials into Japanese and then taught his
ated a series of Tidal projects, embracing acute, reha- medical and nursing colleagues how to use the
bilitation, adolescent, and elder care, in what was the Model, following his short study tour in Newcastle
largest mental health service in the UK (Lafferty & with Dr. Barker. This was the first formal collabora-
Davidson, 2006). By 2012, the Glasgow projects had tion between psychiatrists and nurses—as nurses
extended to include Greenock, Inverclyde, Paisley, had led the implementation in the earlier projects.
and Ayrshire, representing more than a third of the Dr. Akayama has promoted consideration of the
overall population of Scotland. Tidal Model within the “developing nations” pro-
The Republic of Ireland established a wide range of gram of the World Psychiatric Association. The
projects in County Cork, County Mayo and Dublin, Japanese have set a trend for greater interprofes-
ranging across hospital and community settings. sional collaboration, albeit with nursing taking the
Cork City, Ireland, was the first to introduce and lead role.
develop the Tidal Model within community mental The Tidal Model of Mental Health Recovery is
health care at Tosnu—Gaelic for “fresh start.” directed toward understanding and explaining fur-
At the Royal Ottawa Mental Health Centre in ther the human condition. Central to this effort is
Canada, three programs implemented the Tidal helping people use their voices as the key instrument
Model in September 2002. The Forensic and Mood for charting their recovery from mental distress. The
programs include inpatient wards and outpatient Tidal Model is a person-centered model of mental
components. The Substance Use and Concurrent health care delivery, which is respectful of culture
Disorders Program includes an inpatient ward, out- and creed (Barker & Buchanan-Barker, 2005). This
patient nursing, a day hospital, and a residential pro- practical theory identifies the concepts necessary to
gram in the community and is the first program of its understand the human needs of people with prob-
kind to implement the Tidal Model. In February lems in living, and how and what nurses might do
2004, the Tidal Model was introduced to remaining to address those needs. The theory systematically
inpatient wards, including geriatric, crisis and evalua- explains specific phenomena and suggests the nature
tion, general psychiatry in transition, psychosocial of relationships within a particular worldview.
rehabilitation, schizophrenia, and youth (adoles- Barker, however, has consistently asserted that the
cents). Across Canada, also there has been much theory is “no more than words on paper.” It is not a
interest in the Tidal Model. It has been implemented reified work or recipe for practice, but a practical and
or is in progress in facilities from coast to coast. evolving guide for delivering collaborative, person-
In Australia, the Model was first introduced in centered, strength-based, and empowering care
Sydney followed by Townsville, Queensland. More through relationship.

CHAPTER 32 Phil Barker 641
Education that correlated with the speed of assessment, and a
Barker and Buchanan-Barker offer a free training decrease in incidents of violence, self-harm, and use of
manual for download from their website (www. restraints. Nurses themselves reported that the Tidal
tidal-model.com). This package is used as the basic Model enhanced professional practice and encour-
preparation for implementation of the model, ensur- aged fuller engagement with persons-in-care. It was
ing fidelity to the values, principles, and processes useful in helping persons fulfill care plans and enabled
of the Tidal Model, while allowing creative, locally nurses to focus their interactions on persons’ needs.
relevant implementation. Support workers were more able to help persons iden-
The Tidal Model has been integrated into under- tify goals and targets for the day and carry them out;
graduate and postgraduate programs in most UK they described the Tidal Model as a way of raising
universities and has been the focus of many graduate their profile and professional esteem (Stevenson &
and postgraduate projects and theses at many inter- Fletcher, 2002, p. 35). Similar findings, using the same
national universities from the United States to the method, were reported in Birmingham, the second
Philippines. At the University of Ottawa, Canada, city in England to implement the Tidal Model (Gordon,
and Dalhousie University in Nova Scotia, the Tidal Morton, & Brooks, 2005), Glasgow, the largest city in
Model is included in undergraduate and graduate Scotland (Lafferty & Davidson, 2006), and Dublin, the
courses. The Tidal Model anchors the mental health capital of Ireland. These studies provide evidence
nursing residency program developed collaboratively for the implementation of this person-centered theory
by five tertiary mental health centers in Ontario. The in practice.
holistic, strength-based, narrative Tidal Model holds Barker and Walker (2000) studied senior nurses’
great promise for inclusion in educational programs views of multidisciplinary teamwork in 26 acute psy-
concerned with theory-based practice and person- chiatric admission units and the relationship to the
centered care. care of persons and their families. While nurses face
challenges in implementing “working in partnership,”
Research the study provides some direction for further inquiry
The Tidal Model developed from a clinical research around the interprofessional nature of the theory.
program. All International Tidal Model network The transition for nurses to a solution focus in
members are encouraged to evaluate the model in interactions was the subject of study by the Newcastle
practice. A research and development consultancy team (Stevenson, Jackson, & Barker, 2003). Nurses
was established as a loose network for Tidal Model participated in a specially tailored solution education
implementation and development projects. The con- initiative, and the impact was assessed for both nurses
sultancy provides a framework for evaluation of the and persons-in-care using multiple data sources. This
Tidal Model in action from the perspective of orga- study provides strong evidence of significant im-
nizational outcome, professional experience, and provement in nurses’ solution-focused knowledge,
user/consumer experience (Barker & Buchanan- performance, and use in practice. Persons-in-care
Barker, 2005). The important task of evaluating also found the approach helpful.
the implementation, processes, and outcomes of The Royal Ottawa Mental Health Centre Tidal
the Tidal Model in practice is ongoing in Canada, team replicated the Newcastle study and assessed the
Ireland, Japan, and New Zealand and across the impact of implementation of the Tidal Model on
United Kingdom. selected outcome measures over four time periods in
Two evaluation studies (Fletcher & Stevenson, the three pioneer programs, with similar results par-
2001; Stevenson & Fletcher, 2002) explored outcome ticularly in the Mood program. They also replicated
measures important in evaluating the Tidal Model and the Newcastle study over four time periods in the
evaluated the impact of the Tidal Model assessment in Forensic Program at the Brockville site. The Tosnu
practice (Stevenson & Fletcher, 2002). Results of both team completed a user-focused evaluation of the
studies indicate an increase in the number of admis- Tidal Model implementation. In Birmingham, on the
sions and a decrease in the length of stay. There was a Tolkien ward, a 4-month evaluation has been com-
decrease in need for the highest level of observation pleted and published (Gordon, Morton, & Brooks,

642 UNIT V Middle Range Nursing Theories

2005). Evaluation work is ongoing at St. Tydfil Hospital care have expressed appreciation of the model and the
in Wales. desire to bring it into their practice settings. Other
In New Zealand, a qualitative, hermeneutic, phe- professions support the values, philosophy, and utility
nomenological study followed the implementation of of the Tidal Model. Mental health user/consumer/
the Tidal Model in a secure treatment unit (Cook, survivor communities around the world are involved
Phillips, & Sadler, 2005). Five themes that reflected in the continuing development of this mental health
meanings attached to providing and receiving care recovery theory (Barker & Buchanan-Barker, 2005).
emerged: relationships, hope, human face, leveling, Since its inception, the Tidal Model has gained
and working together, suggesting positive experiences national and international attention. It continues to
and outcomes with implementation of the Tidal be implemented, taught, and studied internationally,
Model. The Tidal Model is set in a research base that with new sites joining from around the world. In No-
provides the possibility of research utilization or vember 2003, the Tidal Model was launched in North
the more contemporary knowledge transfer. Nurses America. As new sites implement and study the Tidal
practicing within the Tidal Model are actively using Model, the practical, theoretical, and research base
research in practice as well as contributing to the is enriched. In 2003, Barker reaffirmed the values
development of nursing practice. The Tidal Model has underlying the Tidal Model in the Ten Tidal Commit-
potential for participatory action research, uncover- ments (see Box 32–1). They provide the necessary
ing knowledge embedded in practice, and developing guidance to pursue and develop the philosophy of the
new knowledge and understandings. Tidal Model. Although Barker expects fidelity to the
Barker and Buchanan-Barker emphasize that any principles and values of the Tidal Model (Ten Tidal
realistic study of the Tidal Model in practice must Commitments) in its implementation, he cautions
focus on the “workings” of the team, both individu- against slavish importation. Rather, implementation
ally and collectively. It must take into account the needs to be tailored to fit the local context, with the
organizational context, the support available to the result that each implementation will be unique and
team, the quality of the environment, and the range contribute to the theory’s development. This reflects
of other physical, social, and interpersonal factors. Barker’s appreciation of the concept of “practice-based
As practitioners begin to work in a Tidal way, key evidence”—what he called the “art of the possible,”
research questions must focus on “what happens?” in that is, developing philosophically and theoretically
Tidal practice. sound forms of practice that are based on consider-
ations of what is appropriate, meaningful, and poten-
tially effective in any given practice context.
Further Development The Tidal Model is developing across cultures
The Tidal Model is clear, concepts are defined, and noted above, with different clinical populations, in a
relationships are identified. This enables the identifi- variety of settings. The body of knowledge framed
cation of areas for further theory development. For within the Tidal Model continues to develop, ac-
example, Barker is reframing his original notion of knowledging the wide range of complex factors that
the “logic of experience” as “practice-based evidence.” define people and their human experiences—personal
Practice-based evidence represents the knowledge of history, personal preferences, values and beliefs, social
what is possible in this particular situation and what status, cultural background, family affiliations, and
might contribute further to our shared understanding community membership (Barker, 2003a).
of human helping (Barker & Buchanan-Barker, 2005).
Several other developments characterize the Tidal Critique
Model. It has evolved from the initial acute, inpatient
use across the continuum of care, with critical, transi- Clarity
tional, and developmental components. The theory The concepts, subconcepts, and relationships are logi-
has evolved to the Tidal Model of Mental Health Re- cally developed and clear, and the assumptions are
covery and Reclamation, broadening both its scope consistent with the theory’s goals. Words have multiple
and utility. Colleagues in other fields such as palliative meanings; however, the major concepts, subconcepts,

CHAPTER 32 Phil Barker 643

and relationships are described carefully, specifically, The Holistic Assessment, the person’s story, is at
and metaphorically, though not necessarily concisely. the heart of care planning and is represented as a
It is Barker’s terms like “problems in living,” mental heart. The circle of security assessment and plan sur-
distress, and view of people experiencing problems rounds the heart, all of which is surrounded by the
as “persons” that guide nurses to a proper focus. The interprofessional team circle (Figure 32–2).
identification of “human needs” rather than psycho- The continuum of care (immediate, transitional,
logical, social, or physical needs also provides clarity and developmental) intersects with the focus of care
and focus. How nurses see persons and how persons (Barker, 2000e; Barker & Buchanan-Barker, 2007a)
want to be nursed are clearly illustrated through (Figure 32–3).
the core category of “knowing you, knowing me.” Barker and Buchanan-Barker (2007a) provide a
Three subcategories, ordinary me, pseudo-ordinary or map or overview of the continuum of care or voyage
engineered-me, and professional me each have four of the person who enters, progresses through, and
dimensions: depth of knowing, power, time, and exits the service (Figure 32–4).
translation (Barker, Jackson, & Stevenson, 1999a; This easily understood theory is accessible concep-
Jackson & Stevenson, 2004). tually and linguistically through the use of everyday
In practice, using the person’s own language, rather language.
than jargon or professional language, contributes to
the theory’s success and its clarity. Major concepts of Simplicity
collaboration, empowerment, relationships, solution The Tidal Model is based upon a few simple ideas
focus, empowering through relationships, narrative, about “being human” and “helping one another”
and the use of “problems in living” are sufficiently (Barker, 2000e). It is comprehensive, elegant in its
clear and open the theory for use in other areas of simplicity, and at a level of abstraction to guide prac-
nursing and health care. tice, education, research, and policy. However, the
A number of concepts and relationships are pre- concepts themselves are complex, and the broad
sented elegantly and schematically within the Tidal relationships among the concepts add to the com-
Model. The person’s unique lived experience is synergis- plexity of the Tidal Model; people and relationships
tic and reciprocal among the World, Self, and Others, are inherently complex.
domains that are represented in a triangle (Figure 32–1). Assumptions, concepts, and relationships are de-
scribed in everyday language and illuminated through
metaphor. For example, simply being respectful of the
persons’ knowledge and expertise about their own
Person health and illness and listening to persons’ stories is
empowering. Abstract and complex concepts or rela-
tionships are expressed metaphorically as in the ebb
and flow of the tide. Practical and philosophical, the
Tidal Model provides some direction in operational-
Self Others
izing or using the concepts, but it is careful not to
prescribe practice.

Generality
The Tidal Model is international in scope, suggesting
World
its relevance cross-culturally and cross-nationally. By
the beginning of 2004, there were almost 100 Tidal
Person Model projects in progress in different clinical set-
FIGURE 32-1 Three dimensions of personhood. (From tings in a variety of countries around the world—
Barker, P. J., & Buchanan-Barker, P. (2007). The Tidal Model theory Australia, Canada, England, Ireland, Japan, New
and practice. (p. 38). Newcastle, UK: University of Newcastle. Zealand, Scotland, and Wales (Barker, 2004; Barker
Copyright Phil Barker & Poppy Buchanan-Barker, 2007.) & Buchanan-Barker, 2005). A wide range of settings

644 UNIT V Middle Range Nursing Theories




Multidisciplinary



Security plan



Core care
plan
based on
holistic
assessment










Teamwork


FIGURE 32-2 The structure of care. (From Barker, P. J. (2000). The Tidal Model theory and practice.
(p. 27). Newcastle, UK: University of Newcastle. Copyright Phil Barker, 2000.)





Immediate care Transitional care Developmental care




Short-term/ Longer-term/
time limited intensive




Focus on Focus on Focus on
solutions ensuring a understanding
smooth passage






FIGURE 32-3 Tidal Model Care Continuum. (From Barker, P. J., & Buchanan-Barker, P. (2007). The Tidal
Model theory and practice. (p. 32). Newcastle, UK: University of Newcastle. Copyright Phil Barker & Poppy
Buchanan-Barker, 2007.)

CHAPTER 32 Phil Barker 645



Enters service




Re-enters service


Developmental Orientation to Immediate Care
Care Plan
Exit
Transitional Holistic Security
Care Plan Assessment Assessment



Group work One-One Personal
1/2/3 Sessions Security
Planning

Immediate Care Plan







FIGURE 32-4 Map of the care continuum. (From Barker, P. J., & Buchanan-Barker, P. (2007). The Tidal
Model theory and practice. (p. 37). Newcastle, UK: University of Newcastle. Copyright Phil Barker & Poppy
Buchanan-Barker, 2007.)



and clinical populations are represented in the Tidal health. The Ten Tidal Commitments (Barker, 2003b)
Model projects: rural and urban, acute, crisis and provide guidance, direction, and support in using the
longer-term care wards, private and public facilities, theory. In Scotland, Lafferty and Davidson (2006) ob-
community programs, rehabilitation, forensic, youth, served that the practice with the Tidal Model helped
adults, and older adults. The Tidal Model has been nurses fulfill the person-centered requirements of the
successful across the continuum of psychiatric and new Scottish Mental Health Act. In Canada, the Best
mental health care and in a range of practice situa- Practice Guideline for Client-Centred Care (Regis-
tions. Universal characteristics of collaboration, tered Nurses’ Association of Ontario, 2006) echoes the
empowerment, relationships, stories, and strengths Tidal Model by using some of the same language.
appeal to nurses, service users, and colleagues in Barker acknowledges that in order to practice
other disciplines and support general applicability. within the Tidal Model, we need to believe that recov-
The Tidal Model is consistent with the Ottawa ery is possible and change is inevitable. “The Tidal
Charter for Health Promotion, where the process of Model per se does not work. The practitioner is the
empowerment and participation is seen as fundamen- instrument or medium of change” (Buchanan-Barker,
tal to good health (World Health Organization, 1986). 2004, p. 8). As the Tidal Model was developed spe-
The Tidal Model parallels the process of enabling cifically for psychiatry and mental health care, the
people to increase control over and improve their criterion of generality is met.

646 UNIT V Middle Range Nursing Theories
Accessibility
This substantive theory is grounded in data that Summary
emerged inductively from studies of the need for The Tidal Model developed from a discrete focus on
nursing. Studies guided by the Tidal Model suggest its psychiatric nursing in acute settings to a more flexible
utility and precision and provide confidence that the mental health recovery and reclamation model for any
theory is useful, practical, and accessible. Studies of setting, relevant to any discipline. It emphasizes em-
the impact of implementation of the theory in prac- powering forms of engagement or bridging, the impor-
tice also support its utility and precision. The “need tance of the lived experience, and an appreciation of the
for nursing,” the proper focus of nursing, and the potential for healing that lies within the re-authoring of
empowering interactions framework provide a strong the story (Barker & Buchanan-Barker, 2004a).
empirical base for the Tidal Model. The Tidal Model provides an orientation to practice
Nurses working with different clinical popula- that is research-based, holistic, and person-centered.
tions and in a variety of settings are testing the Keen (in Barker & Buchanan-Barker, 2005, pp. 231–241)
Tidal Model in practice. The focus of inquiry is describes a “deeply collaborative, person-centered, so-
person-centered outcomes and the lived experience lution-focused (McAllister, 2003), narrative-based,
of persons collaborating in care. Studies addressing pragmatic, and systemic theory.” The theory describes
the outcome orientation empower interactions that various assumptions about people, their inherent value,
contribute to empirical adequacy and confidence in and the value of relating to people in particular ways. It
this solution-oriented perspective. describes how people might come to appreciate differ-
ently, perhaps better, their own value and the unique
Importance value of their experience. The Tidal Model opens pos-
The Tidal Model has clearly illustrated that it pro- sibilities of new ways of being with people in relation.
vides direction and focus for nursing. The theory is Perhaps some of its appeal is that it harkens back to
accessible conceptually and linguistically and lends “our roots” and values, which brought us into nursing
itself to research. This research, relevant to nurses’ in the first place. While the theory provides direction
work, contributes knowledge to guide and inform for practice, education, research, and policy, it is not
practice. Studies guided by the Tidal Model also ex- easy. Nurses are aware of the challenge in making the
plore its impact and a variety of outcomes. Narrative shift to commit to change and to grow and develop in
knowledge derived from the theory advances the enacting the essence of the Tidal Model, the Ten Tidal
practice of nursing, nursing education, nursing Commitments.
research, and policy. The Tidal Model is represented
by a range of “holistic (exploratory) and focused
(risk) assessments which generate person-centered CASE STUDY
interventions that emphasize the person’s extant Scott was a young man described as having a first
resources and capacity for solution-finding” (Barker, episode psychosis. He had beaten his father, who
2001b, p. 82). subsequently died. Scott was transferred to a secure
Working with the Tidal Model has enabled nurses to unit, where his primary nurse began to explore his
articulate their practice and “invisible skills” (Michael, story with him through a Holistic Assessment,
1994). For example, empowerment strategies such as which represents Scott’s world of experience at this
respecting the person and inspiring hope also give voice moment in time.
to nurses themselves. Nurses gain confidence working How this began: “It all started when my father
as interprofessional team members where their contri- punched my mother again, he was totally drunk
bution and focus is clearly articulated. that night. It was so noisy in that room, the T.V., the
Challenges exist at a practical, personal, and sys- banging, and those voices in my head, they kept
tem level with any change, and these are anticipated yelling at me to do something fast to save my
and addressed. However, the Tidal Model is an im- mother. I don’t remember exactly what had hap-
portant and essential theory to develop and guide pened after. I was so confused.”
practice in psychiatry and mental health care.

CHAPTER 32 Phil Barker 647


How this affected me: “I don’t know. I have Humane Society right now.” “I have a really nice
been in jail for 4 months before coming here. They picture of me and my mom.”
told me I killed my father. I don’t remember much Ideas about life that are important: “Able to fit in.”
except that I kept hammering his head; I just re- Evaluating the problems: “My main problems
member I was standing in a pool of blood.” “They are loneliness and what’s going to happen in my
told me my mother is still in the hospital; I haven’t future. My whole life is complex!” I would rate my
seen her since.” “I’m scared. I can’t sleep.” loneliness as an 8 for distress, an 8 for disturbance,
How I felt in the beginning: It “just devastated and a 2 for control. My future and what’s going to
me, turned me upside down.” “I felt awful even happen would be a 10 for distress, a 10 for distur-
though I hated him so much; he never listened to bance, and I have no control, a zero.”
me; no one ever listened to me or believes me.” “I How will I know the problem has been solved?
hate him because I watched him beating my “I’ll know the problem has been solved maybe
mother all my life.” when the voices stop talking to me, when I get out
How things have changed over time: “It got of jail and out of the hospital.”
worse when my stepbrother ran away. My father What needs to change for this to happen?
was a sinner, a drunk, wife beater, even conspired “Maybe I need to take medication, maybe I just
with the Communists. I was not allowed to leave have to start talking to real people, not the voices.”
the house except school, my mother stayed in all The nurse recognized that Scott needed some
day to do farm work, he was the only one that ran help to feel more emotionally secure. She engaged
errands outside the house.” “I’ve always been a bit him in a security assessment and they developed a
scared and angry too.” Personal Security Plan together.
The effect on my relationships: “I don’t have Later in the week, the nurses noted that Scott
any relationships with anyone; I don’t like people was spending a lot of time in his room. Instead of
because nobody likes me.” encouraging Scott to participate in ward activities,
How do I feel now? “Well, I feel nervous, very his primary nurse shared her observation and
shaky and scared. I don’t know what to expect, I asked Scott how it was helpful to him to spend so
don’t know what is going to happen.” “Confused, I much time lying on his bed, alone in the room.
guess, and I’m tired.” Scott’s reply was, “The voices don’t bother me so
What do I think this means? “I don’t know, much.” This opened a conversation, helping the
that was my question, maybe I will go back to jail, nurse begin to understand what this was like for
maybe it means I needed help.” “It means I have a Scott and what might be helpful for him.
lot of challenges to meet.” In another conversation, the primary nurse
What does all this say about me as a person? asked “the miracle question.” “Suppose that to-
“I just want to be a better person, I want to be well, night, while you are asleep, the problem you have
and I want to take care of my mother.” was miraculously solved. How would you know?
What needs to happen now? “Well, I suppose What would be the first difference you noticed
I’m here for an assessment.” when you woke up?” Scott’s unexpected reply—
What do I expect the nurse to do for me? ”I’d have a friend.” By exploring—rather than
“Continue to talk to me the way you are talking closing down—the narrative, the nurse began
to me. No one ever talks to me like this. You are to involve Scott in “what needed to be done” to
listening, and it seems like you believe me. This is help him.
so different from jail and anywhere else.” The Holistic Assessment and the Personal
The people who are important: “My mother is Security Plan represent the first steps in helping
the only important person in this world. My step- Scott reclaim ownership of the story of his diffi-
brother came back only for the money.” culties and/or distress: beginning to explore
Things that are important: “Well, able to share what action needs to be taken—by Scott and/or
with others.” “My dog—Pepper, but he is at the others—to reduce his distress and address his
Continued

648 UNIT V Middle Range Nursing Theories


problems. Traditionally, Scott might be given a him the self-knowledge he has gained through the
diagnosis of “psychosis” as an explanation of various relationships established in the individual
his situation, with much of the resultant effort and group work. Instead of expecting Scott to be
focused on managing this abstract, invisible “dis- a passive (or compliant) recipient of care or treat-
order.” Within the Tidal Model, the nurse’s focus ment, the nurse expects him to participate as fully
is much more pragmatic. By joining with Scott as possible in constructing the kind of care that he
in exploring his difficulties from his perspective, needs, establishing ownership not only of his
as he describes his experience in his own words, problems but also of the ultimate means of resolv-
the nurse begins to develop a supportive, em- ing them. Clearly, this approach makes significant
pathic relationship. The main aim is to help Scott emotional and intellectual demands on both the
make his own sense of what has happened to him person and the nurse.
(rather than telling him), helping him identify What questions might be asked in a security
what part he has played (if any) in the develop- assessment? The security plan has two questions:
ment of his problems and beginning to work out What can I do that will help me to deal with my
what needs to be done to begin to address them. present problems? And what help can others offer
When a person like Scott eventually moves that I might find valuable? What might Scott’s
outinto the everyday world, he will take with security plan look like?


CRITICAL THINKING ACTIVITIES
1. Select three or four of the Ten Tidal Commit- 2. Where would you find support for each of the
ments, and consider how these might be realized Ten Tidal Commitments within your workplace?
in your practice. 3. What is the key Tidal question?


POINTS FOR FURTHER STUDY
The Tidal Model website at www.tidal-model.com n Barker, P. J., & Buchanan-Barker, P. (2005). The
enables accessibility to and connection with the inter- Tidal Model: A guide for mental health profession-
national Tidal community. als. London: Brunner-Routledge.
n Barker, P. J. (2003b). The 10 Commitments: Essen- n Barker, P. J., & Buchanan-Barker, P. (2007a). The
tial values of the Tidal Model. Retrieved from Tidal Model—Mental health recovery and recla-
http://www.tidal-model.com/Ten%20Commit- mation. Newport-on-Tay, Scotland: Clan Unity
ments.htm. International.
n Barker, P. J. (2001b). The Tidal Model: Developing n Buchanan-Barker, P., & Barker, P. (2008). The
a person-centered approach to psychiatric and Tidal Commitments: Extending the value base of
mental health nursing. Perspectives in Psychiatric mental health recovery. Journal of Psychiatric and
Care, 37(3), 79–87. Mental Health Nursing, 15, 93–100.


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rience and results of the Turku project. Acta Psychiatrica depressive psychosis. Unpublished PhD thesis, Dundee
Scandanavica ,83, 363–372. Institute of Technology (University of Abertay), Scotland.
American Nurses’ Association. (1980). Nursing. A social Barker, P. J. (1989). Reflections on the philosophy of caring
policy statement. Kansas City, (MO): American Nurses’ in mental health. International Journal of Nursing Stud-
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Barker, P. J. (1995). Promoting growth through community Barker, P. J. (2002b). Doing what needs to be done: A
mental health nursing. Mental Health Nursing, 15(3), respectful response to Burnard and Grant. Journal
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Barker, P. J. (1996a). Chaos and the way of Zen: Psychiatric Barker, P. J. (Ed.). (2003a). Psychiatric and mental health
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33

CHAP TER



















Katharine Kolcaba
1944 to present


Theory of Comfort


Thérèse Dowd



“In today’s technological world, nursing’s historic mission of providing comfort to patients and
family members is even more important. Comfort is an antidote to the stressors inherent in health
care situations today, and when comfort is enhanced, patients and families are strengthened for the
tasks ahead. In addition, nurses feel more satisfied with the care they are giving”
K. Kolcaba (personal communication, March 7, 2012).


Credentials and Background Kolcaba joined the faculty at the University of
of the Theorist Akron College of Nursing after graduating with her
Katharine Kolcaba was born and educated in Cleveland, master’s degree in nursing. She gained and maintains
Ohio. In 1965, she received a diploma in nursing and American Nurses Association (ANA) certification in
practiced part time for many years in medical-surgical gerontology. She returned to CWRU to pursue her
nursing, long-term care, and home care before return- doctorate in nursing on a part-time basis while con-
ing to school. In 1987, she graduated in the first RN to tinuing to teach. Over the next 10 years, she used
MSN class at Case Western Reserve University (CWRU) course work in her doctoral program to develop and
Frances Payne Bolton School of Nursing, with a spe- explicate her theory. Kolcaba published a concept
cialty in gerontology. While in school, she job-shared a analysis of comfort with her philosopher-husband
head nurse position on a dementia unit. It was in this (Kolcaba & Kolcaba, 1991), diagrammed aspects of
practice context that she began theorizing about the comfort (Kolcaba, 1991), operationalized comfort as
outcome of patient comfort. an outcome of care (Kolcaba, 1992a), contextualized



Photo credit: Barker’s Camera Shop, Chagrin Falls, OH.
The author wishes to thank Katharine Kolcaba for her assistance with this chapter.

657

658 UNIT V Middle Range Nursing Theories

comfort in a middle-range theory (Kolcaba, 1994), and recovery was achieved (McIlveen & Morse, 1995).
tested the theory in an intervention study (Kolcaba & The nurse was duty bound to attend to details influ-
Fox, 1999). encing patient comfort. Aikens (1908) proposed that
Currently, Dr. Kolcaba is an emeritus associate pro- nothing concerning the comfort of the patient was
fessor of nursing at the University of Akron College of small enough to ignore. The comfort of patients was
Nursing, where she teaches theory to MSN students. the nurse’s first and last consideration. A good nurse
She also teaches theory to DNP students at Ursuline made patients comfortable, and the provision of com-
College in Mayfield Heights, Ohio. Her interests in- fort was a primary determining factor of a nurse’s
clude interventions for and documentation of changes ability and character (Aikens, 1908).
in comfort for evidence-based practice. She resides in Harmer (1926) stated that nursing care was con-
the Cleveland area with her husband, where she enjoys cerned with providing a “general atmosphere of
being near her grandchildren and her mother. She comfort,” and that personal care of patients in-
represents her company, known as The Comfort Line, cluded attention to “happiness, comfort, and ease,
to assist health care agencies implement the Theory of physical and mental,” in addition to “rest and sleep,
Comfort on an institutional basis. She is founder and nutrition, cleanliness, and elimination” (p. 26).
coordinator of a local parish nurse program and a Goodnow (1935) devoted a chapter in her book, The
member of the ANA. Kolcaba continues to work with Technique of Nursing, to the patient’s comfort. She
students conducting comfort studies. wrote, “A nurse is judged always by her ability to
make her patient comfortable. Comfort is both
physical and mental, and a nurse’s responsibility
Theoretical Sources does not end with physical care” (p. 95). In text-
Kolcaba began her theoretical work diagramming her books dated 1904, 1914, and 1919, emotional com-
nursing practice early in her doctoral studies. When fort was called mental comfort and was achieved
Kolcaba presented her framework for dementia care mostly by providing physical comfort and modify-
(Kolcaba, 1992b), a member of the audience asked, ing the environment for patients (McIlveen &
“Have you done a concept analysis of comfort?” Morse, 1995).
Kolcaba replied that she had not but that would be In these examples, comfort is positive and achieved
her next step. This question began her long investiga- with the help of nurses and, in some cases, indicates
tion into the concept of comfort. improvement from a previous state or condition.
The first step, the promised concept analysis, be- Intuitively, comfort is associated with nurturing activ-
gan with an extensive review of the literature about ity. From its word origins, Kolcaba explicated its
comfort from the disciplines of nursing, medicine, strengthening features, and from ergonomics, its direct
psychology, psychiatry, ergonomics, and English link to job performance. However, often its meaning
(specifically Shakespeare’s use of comfort and the is implicit, hidden in context, and ambiguous. The
Oxford English Dictionary [OED]). From the OED, concept varies semantically as a verb, noun, adjective,
Kolcaba learned that the original definition of com- adverb, process, and outcome.
fort was “to strengthen greatly.” This definition pro- Kolcaba used ideas from three early nursing theo-
vided a wonderful rationale for nurses to comfort rists to synthesize or derive the types of comfort in
patients since the patients would do better and the the concept analysis (Kolcaba & Kolcaba, 1991).
nurses would feel more satisfied. • Relief was synthesized from the work of Orlando
Historical accounts of comfort in nursing are nu- (1961), who posited that nurses relieved the needs
merous. Nightingale (1859) exhorted, “It must never expressed by patients.
be lost sight of what observation is for. It is not for the • Ease was synthesized from the work of Henderson
sake of piling up miscellaneous information or curi- (1966), who described 13 basic functions of human
ous facts, but for the sake of saving life and increasing beings to be maintained during care.
health and comfort” (p. 70). • Transcendence was derived from Paterson and
From 1900 to 1929, comfort was the central goal Zderad (1975), who proposed that patients rise
of nursing and medicine because, through comfort, above their difficulties with the help of nurses.

CHAPTER 33 Katharine Kolcaba 659

Type of Comfort
Relief Ease Transcendence


Physical
Context in Which Comfort Occurs Psychospiritual








Environmental



Social



Type of Comfort:
Relief: The state of a patient who has had a specific need met
Ease: The state of calm or contentment
Transcendence: The state in which one rises above one’s problems or pain
Context in Which Comfort Occurs:
Physical: Pertaining to bodily sensations
Psychospiritual: Pertaining to internal awareness of self, including esteem, concept, sexuality,
and meaning in one’s life; one’s relationship to a higher order or being
Environmental: Pertaining to the external surroundings, conditions, and influences
Social: Pertaining to interpersonal, family, and societal relationships
FIGURE 33-1 Taxonomic structure of comfort. (From Kolcaba, K., & Fisher, E. [1996]. A holistic perspec-
tive on comfort care as an advance directive. Critical Care Nursing Quarterly, 18[4], 66–76.)


Four contexts of comfort, experienced by those The taxonomic structure provides a map of the
receiving care, came from the review of nursing lit- content domain of comfort. It is anticipated that
erature (Kolcaba, 2003). The contexts are physical, researchers will design instruments in the future such
psychospiritual, sociocultural, and environmental. The as the questionnaire developed from the taxonomy
four contexts were juxtaposed with the three types of for the end-of-life instrument (Kolcaba, Dowd,
comfort, creating a taxonomic structure (matrix) Steiner, & Mitzel, 2004). Kolcaba includes the steps on
from which to consider the complexities of comfort as her website for adaptation of the General Comfort
an outcome (Figure 33–1). Questionnaire by future researchers.




MAJOR CONCEPTS & DEFINITIONS
In Kolcaba’s theory, those receiving comfort mea- Health Care Needs
sures may be referred to as recipients, patients, stu- Health care needs are comfort needs arising from
dents, prisoners, workers, older adults, communities, stressful health care situations that cannot be met by
and institutions. recipients’ traditional support systems. The needs
Continued

660 UNIT V Middle Range Nursing Theories

MAJOR CONCEPTS & DEFINITIONS—cont’d
may be physical, psychospiritual, sociocultural, or Health-Seeking Behaviors
environmental. They become apparent through mon- Health-seeking behaviors compose a broad category
itoring, verbal or nonverbal reports, pathophysiologi- of outcomes related to the pursuit of health as
cal parameters, education and support, and financial defined by the recipient(s) in consultation with the
counseling and intervention (Kolcaba, 2003). nurse. The category was synthesized by Schlotfeldt

Comfort Interventions (1975) and proposed to be internal, external, or a
Comfort interventions are nursing actions and refer- peaceful death.
rals designed to address specific comfort needs of Institutional Integrity
recipients, including physiological, social, cultural, Corporations, communities, schools, hospitals, re-
financial, psychological, spiritual, environmental, gions, states, and countries that possess the qualities
and physical interventions (Kolcaba, 2001). of being complete, whole, sound, upright, appealing,

Intervening Variables ethical, and sincere possess institutional integrity.
Intervening variables are interacting forces that When an institution displays this type of integrity, it
produces evidence for best practices and best poli-
influence recipients’ perceptions of total comfort. cies (Kolcaba, 2001).
They consist of past experiences, age, attitude, emo-
tional state, support system, prognosis, finances, Best Practices
education, cultural background, and the totality of The use of health care interventions based on evi-
elements in the recipients’ experience (Kolcaba, dence to produce the best possible patient and
1994). Suchintervening variables have an impact on family (institutional) outcomes is known as best
planning and success of patient care interventions. practices.
Comfort Best Policies
Comfort is the state experienced by recipients of Institutional or regional policies ranging from pro-
comfort interventions. It is the immediate, holistic tocols for procedures and medical conditions to
experience of being strengthened when one’s needs access and delivery of health care are known as best
are addressed for three types of comfort (relief, ease, policies.
and transcendence) in four contexts (physical, psy- Figure 33–2 depicts the relationship among these
chospiritual, sociocultural, and environmental) last three concepts.
(Kolcaba, 1994). Types and contexts are depicted in
Figure 33–1.




Use of Empirical Evidence independent, encouraged, worthwhile, and useful.
The seeds of modern inquiry about the outcome of Hamilton concluded, “The clear message is that com-
comfort were sown in the late 1980s, marking a period fort is multi-dimensional, meaning different things to
of collective, but separate, awareness about the con- different people” (p. 32).
cept of holistic comfort. Hamilton (1989) made a leap After Kolcaba developed her theory, she demon-
forward by exploring the meaning of comfort from the strated that changes in comfort could be measured
patient’s perspective. She used interviews to ascertain using an experimental design in her dissertation
how each patient in a long-term care facility defined (Kolcaba & Fox, 1999). In this study, health care
comfort. The theme that emerged most frequently was needs were those (comfort needs) associated with a
relief from pain, but patients also identified good posi- diagnosis of early breast cancer. The holistic interven-
tion in well-fitting furniture and a feeling of being tion was guided imagery, designed specifically for this

CHAPTER 33 Katharine Kolcaba 661







Conceptual Framework for Comfort Theory


Best
Practices
Health Enhanced Health
Care Nursing Intervening Comfort Seeking Institutional
Needs Interventions Variables Behaviors Integrity

Best
Policies

Internal Peaceful External
Behaviors Death Behaviors



© Kolcaba (2007)
FIGURE 33-2 Conceptual framework for the Theory of Comfort. (Copyright Kolcaba, 2007. Retrieved from
www.thecomfortline.com.)



patient population to meet their comfort needs, and In each study, interventions were targeted to all
the desired outcome was their comfort. The findings attributes of comfort relevant to the research settings,
revealed a significant difference in comfort over time comfort instruments were adapted from the General
between women receiving guided imagery and the Comfort Questionnaire (Kolcaba, 1997, 2003) using the
usual care group (Kolcaba & Fox, 1999). Kolcaba and taxonomic structure (TS) of comfort as a guide, and
associates conducted additional empirical testing of there were at least two (usually three) measurement
the Theory of Comfort, which is detailed in her book points used to capture change in comfort over time. The
(Kolcaba, 2003, pp. 113–124) and cited on her web- evidence for efficacy of hand massage as an intervention
site. These comfort studies demonstrated significant to enhance comfort is published in Evidence-Based
differences between treatment and comparison Nursing Care Guidelines: Medical-Surgical Interventions
groups on comfort over time. Examples of interven- (Kolcaba & Mitzel, 2008).
tions that have been tested include the following: Further support for the Theory of Comfort was
• Guided imagery for psychiatric patients (Apóstolo found in a study of four theoretical propositions
& Kolcaba, 2009) about the nature of holistic comfort (Kolcaba &
• Healing touch and coaching for stress reduction Steiner, 2000):
in college students (Dowd, Kolcaba, Steiner, & 1. Comfort is generally state-specific.
Fashinpaur, 2007) 2. The outcome of comfort is sensitive to changes
• Hand massage for hospice patients and long-term over time.
care residents (Kolcaba, Dowd, Steiner, & Mitzel, 3. Any consistently applied holistic nursing interven-
2004; Kolcaba, Schirm, & Steiner, 2006) tion with an established history for effectiveness
• Patient-controlled heated gowns for reducing enhances comfort over time.
anxiety and increasing comfort in preoperative 4. Total comfort is greater than the sum of its parts.
patients (Wagner, Byrne, & Kolcaba, 2006)

662 UNIT V Middle Range Nursing Theories

Tests on the data set from Kolcaba and Fox’s (1999) 3. Comfort is a basic human need that persons
earlier study of women with breast cancer supported strive to meet or have met. It is an active endeavor
each proposition. Other areas of study included in the (Kolcaba, 1994).
Kolcaba website are burn units, labor and delivery, in- 4. Enhanced comfort strengthens patients to engage in
fertility, nursing homes, home care, chronic pain, pedi- health-seeking behaviors of their choice (Kolcaba &
atrics, oncology, dental hygiene, transport, prisons, deaf Kolcaba 1991; Kolcaba, 1994).
patients, and those with mental disabilities. 5. Patients who are empowered to actively engage in
health-seeking behaviors are satisfied with their
Major Assumptions health care (Kolcaba, 1997, 2001).
6. Institutional integrity is based on a value system
Nursing oriented to the recipients of care (Kolcaba 1997,
Nursing is the intentional assessment of comfort 2001). Of equal importance is an orientation to a
needs, the design of comfort interventions to address health-promoting, holistic setting for families and
those needs, and reassessment of comfort levels after providers of care.
implementation compared with a baseline. Assessment
and reassessment may be intuitive or subjective or
both, such as when a nurse asks if the patient is com- Theoretical Assertions
fortable, or objective, such as in observations of The Theory of Comfort contains three parts (proposi-
wound healing, changes in laboratory values, or tional assertions) to be tested separately or as a whole.
changes in behavior. Assessment is achieved through Part I states that comforting interventions, when
the administration of verbal rating scales (clinical) or effective, result in increased comfort for recipients
comfort questionnaires (research), using instruments (patients and families), compared to a preinterven-
developed by Kolcaba (2003). tion baseline. Care providers may be considered re-
cipients if the institution makes a commitment to the
Patient comfort of their work setting. Comfort interventions
Recipients of care may be individuals, families, institu- address basic human needs, such as rest, homeostasis,
tions, or communities in need of health care. Nurses therapeutic communication, and treatment as holistic
may be recipients of enhanced workplace comfort when beings. Comfort interventions are usually nontechni-
initiatives to improve working conditions are under- cal and complement the delivery of technical care.
taken, such as those to gain Magnet status (Kolcaba, Part II states that increased comfort of recipients of
Tilton, & Drouin, 2006). care results in increased engagement in health-seeking
behaviors that are negotiated with the recipients.
Environment Part III states that increased engagement in health-
The environment is any aspect of patient, family, or seeking behaviors results in increased quality of care,
institutional settings that can be manipulated by benefiting the institution and its ability to gather evidence
nurse(s), loved one(s), or the institution to enhance for best practices and best policies.
comfort. Kolcaba believes that nurses want to practice com-
forting care and that it can be easily incorporated with
Health every nursing action. She proposes that this type of
Health is optimal functioning of a patient, family, comfort practice promotes greater nurse creativity
health care provider, or community as defined by the and satisfaction, as well as high patient satisfaction. In
patient or group. order to enhance comfort, the nurse must deliver the
appropriate interventions and document the results
Assumptions in the patient record. However, when the appropriate
1. Human beings have holistic responses to complex intervention is delivered in an intentional and com-
stimuli (Kolcaba, 1994). forting manner, comfort still may not be enhanced
2. Comfort is a desirable holistic outcome that is ger- sufficiently. When comfort is not yet enhanced to its
mane to the discipline of nursing (Kolcaba, 1994). fullest, nurses then consider intervening variables to

CHAPTER 33 Katharine Kolcaba 663

explain why comfort management did not work. Such nurses were doing to prevent excess disabilities (later
variables may be abusive homes, lack of financial re- naming those actions interventions) and how to judge
sources, devastating diagnoses, or cognitive impair- if the interventions were working. Optimum function
ments that render the most appropriate interventions had been conceptualized as the ability to engage in
and comforting actions ineffective. Comfort manage- special activities on the unit, such as setting the table,
ment or comforting care includes interventions, com- preparing a salad, or going to a program and sitting
forting actions, the goal of enhanced comfort, and the through it. These activities made the residents feel
selection of appropriate health-seeking behaviors by good about themselves, as if it were the right activity
patients, families, and their nurses. Thus, comfort at the right time. These activities did not happen more
management is proposed to be proactive, energized, than twice a day, because the residents couldn’t toler-
intentional, and longed for by recipients of care in all ate much more than that. What were they doing in
settings. To strengthen the role of nurses as comfort the meantime? What behaviors did the staff hope
agents, documentation of changes in comfort before they would exhibit that would indicate an absence of
and after their interventions is essential. For clinical excess disabilities? Should the term excess disabilities
use, Kolcaba suggests asking patients to rate their be delineated further for clarity?
comfort from 0 to 10, with 10 being the highest pos- Partial solutions to these questions were to (1) divide
sible comfort in a given health care situation. This excess disabilities into physical and mental, (2) intro-
documentation could be a part of the electronic data duce the concept of comfort to the original diagram,
bases in each institution (Kolcaba, Tilton, & Drouin, because this word seemed to convey the desired state
2006). for patients when they were not engaging in special
activities, and (3) note the nonrecursive relationship
between comfort and optimum functioning. This think-
Logical Form ing marked the first steps toward a theory of comfort
Kolcaba (2003) used the following three types of logical and thinking about the complexities of the concept
reasoning in the development of the Theory of Com- (Kolcaba, 1992a).
fort: (1) induction, (2) deduction, and (3) retroduction
(Hardin & Bishop, 2010). Deduction
Deduction occurs when specific conclusions are in-
Induction ferred from general premises or principles; it proceeds
Induction occurs when generalizations are built from from the general to the specific (Hardin & Bishop,
a number of specific observed instances 2010). The deductive stage of theory development
(Hardin & Bishop, 2010). When nurses are earnest resulted in relating comfort to other concepts to pro-
about their practice and earnest about nursing as a dis- duce a theory. Since the works of three nursing theo-
cipline, they become familiar with implicit or explicit rists was entailed in the definition of comfort (Paterson
concepts, terms, propositions, and assumptions that & Zderad, 1975; Henderson, 1966 and Orlando, 1961),
underpin their practice. Nurses in graduate school may Kolcaba looked elsewhere for the common ground
be asked to diagram their practice as Dr. Rosemary Ellis needed to unify relief, ease, and transcendence (three
asked Kolcaba and other students to do, and it is a major concepts). What was needed was a more ab-
deceptively easy-sounding assignment. stract and general conceptual framework that was
Such was the scenario during the late 1980s as congruent with comfort and contained a manageable
Kolcaba began. She was head nurse on an Alzheimer’s number of highly abstract constructs.
unit at the time and knew some of the terms used The work of psychologist Henry Murray (1938)
then to describe the practice of dementia care, such as met the criteria for a framework on which to hang
facilitative environment, excess disabilities, and opti- Kolcaba’s nursing concepts. His theory was about hu-
mum function. However, when she drew relationships man needs; therefore it was applicable to patients who
among them, she recognized that the three terms did experience multiple stimuli in stressful health care
not fully describe her practice. An important nursing situations. Furthermore, Murray’s idea about unitary
piece was missing, and she pondered about what trends gave Kolcaba the idea that, although comfort

664 UNIT V Middle Range Nursing Theories

was state-specific, if comforting interventions were changes in comfort over time (Dowd, Kolcaba,
implemented over time, the overall comfort of pa- Steiner, et al., 2007). A list of effective comforting in-
tients could be enhanced over time. In this deductive terventions for each patient/family member is readily
stage of theory development, she began with abstract, available and communicated.
general theoretical construction and used the socio- Perianesthesia nurses have incorporated the The-
logical process of substruction to identify the more ory of Comfort into their Clinical Practice Guidelines
specific (less abstract) levels of concepts for nursing for management of patient comfort. In this setting,
practice. comfort management specifies (1) assessing patients’
comfort needs related to current surgery, chronic
Retroduction pain issues, and comorbidities; (2) creating a comfort
Retroduction is useful for selecting phenomena that contract with patients prior to surgery that specifies
can be developed further and tested. This type of effective comfort interventions, understandable and
reasoning is applied in fields that have few available efficient comfort measurement, and the type of post-
theories (Hardin & Bishop, 2010). Such was the case surgical analgesia preferred; (3) facilitating comfort-
with outcomes research, which now is centered on col- able positioning, body temperature, and other factors
lecting databases for measuring selected outcomes related to comfort during surgery; and (4) continuing
and relating those outcomes to types of nursing, med- with comfort management and measurement in the
ical, institutional, or community protocols. Murray’s postsurgical period (Wilson & Kolcaba, 2004).
twentieth-century framework could not account for
the twenty-first–century emphasis on institutional and Education
community outcomes. Using retroduction, Kolcaba Goodwin, Sener, & Steiner (2007) described guide-
added the concept of institutional integrity to the lines for applying the Theory of Comfort in acceler-
middle-range Theory of Comfort. Adding the term ated baccalaureate nursing programs. The theory
extended the theory for consideration of relationships proved to be easy for faculty to understand and apply
between health-seeking behaviors and institutional and provided an effective method to role-model a
integrity. In 2007, the concepts of best practices and supportive learning partnership with the students.
best policies were linked to institutional integrity. The- The Theory of Comfort is included in Core Concepts
ory-based evidence organizes the knowledge base for in Advanced Practice Nursing(Robinson & Kish, 2001).
best practices and policies (see Figure 33–2). The theory is appropriate for students to use in any
clinical setting, and its application can be facilitated
Acceptance by the Nursing Community by use of Comfort Care Plans available on Kolcaba’s
website.
Practice Recently, Goodwin, Sener, and Steiner (2007) uti-
Students and nurse researchers have frequently selected lized the Theory of Comfort as a teaching philosophy
this theory as a guiding framework for their studies in in a fast-track nursing education program for stu-
areas such as nurse midwifery (Schuiling, Sampselle, & dents with baccalaureate degrees in other disciplines.
Kolcaba, 2011), hospice care (Kolcaba, Dowd, Steiner, The taxonomic structure and conceptual framework
et al., 2004), perioperative nursing (Wilson & Kolcaba, guided ways of being a comforting faculty member.
2004), long-term care (Kolcaba, Schirm, & Steiner, The theory provided ways for students to obtain relief
2006), stressed college students (Dowd, Kolcaba, from their heavy course work by facilitating questions
Steiner, et al., 2007), dementia patients (Hodgson & to their clinical problems, maintaining ease with their
Andersen, 2008), and palliative care (Lavoie, Blondeau, curriculum through trusting their faculty members,
& Picard-Morin, 2011). and achieving transcendence from their stressors with
When nurses ask patients or family members to use of self-comforting techniques. The authors antici-
rate their comfort from 0 to 10 before and after an pate “that this adaptation may assist students to trans-
intervention or at regular intervals, they produce form into professional nurses who are comfortable
documented evidence that significant comfort work is and comforting in their roles and who are committed
being done. A verbal rating scale is sensitive to to the goal of lifelong learning” (p. 278).

CHAPTER 33 Katharine Kolcaba 665
Research theory that is readily applied in many settings for
An entry in the Encyclopedia of Nursing Research education, practice, and research. Kolcaba devel-
speaks to the importance of measuring comfort as a oped templates for measurement to facilitate appli-
nursing-sensitive outcome (Kolcaba, 2006). Nurses cation of the comfort theory in additional settings.
can provide evidence to influence decision making The comfort management templates she provided
at institutional, community, and legislative levels for use in practice settings have been helpful to stu-
through studies that demonstrate the effectiveness of dents and faculty members. Outcomes of research
comforting care. Kolcaba (2001) called for measure- have demonstrated the appropriateness of her the-
ment of comfort in large hospitals and home care to ory for measuring whole-person changes that were
expand the theory and develop the literature on evi- less effectively captured with other types of instru-
dence-based comfort. ments, as noted in a study of urinary incontinence
Using the taxonomic structure of comfort (see (Dowd, Kolcaba, & Steiner, 2000).
Figure 33–1) as a guide, Kolcaba (1992a) developed The original theoretical assertion (Part 1) of the
the General Comfort Questionnaire to measure holis- Theory of Comfort has stood up to empirical testing.
tic comfort in a sample of hospital and community When a comfort intervention is targeted to meet the
participants. Positive and negative items were gener- holistic comfort needs of patients in specific health
ated for each cell in the taxonomic structure grid. care situations, comfort is enhanced beyond baseline
Twenty-four positive items and twenty-four negative measurement. Furthermore, enhanced comfort has
items were compiled with a Likert-type format rang- been correlated with engagement in health-seeking
ing from strongly agree to strongly disagree, with behaviors (Schlotfeldt, 1975). Empirical tests of the
higher scores indicating higher comfort. At the end of theoretical assertions for the second and third parts of
the instrumentation study with 206 one-time partici- the theory are to be conducted. Outcomes for desir-
pants from all types of units in two hospitals and able health-seeking behaviors could include increased
50 participants from the community, the General functional status, faster progress during rehabilita-
Comfort Questionnaire demonstrated a Cronbach tion, faster healing, or peaceful death when appropri-
alpha of 0.88 (Kolcaba, 1992a). ate. health-seeking behaviors are negotiated among
Researchers are welcome to generate comfort ques- the patient, family members, and care providers. In-
tionnaires specific to their areas of research. The verbal stitutional outcomes would include decreased length
rating scales and other traditionally formatted ques- of stay for hospitalized patients, smaller number of
tionnaires may be downloaded from Kolcaba’s website, readmissions, decreased costs, and achievement of
where she also responds to inquiries in an effort to national awards such as the Beacon Award. Kolcaba
enhance the use of her theory. Instructions for use of the consults with hospital administrators who want to
questionnaires are available on her website. Popularity of enhance quality of care. She views quality care as
the theory seems to be associated with universal recog- comforting actions delivered in an intentional man-
nition of comfort as a desirable outcome of nursing care ner in order to create an environment that leads to
for patients and their families. engagement in health-seeking behaviors.
Kolcaba postulates that intentional emphasis on
and support for comfort management by an institu-
Further Development tion or community increases patient/family satisfac-
Kolcaba has persisted in the development of her the- tion, because persons are healed, strengthened, and
ory from the original conception as the root of her motivated to be healthier. Extending the Theory of
practice, to concept analysis that provided the taxo- Comfort to the community is of current interest. It is
nomic structure of comfort, to development of ways well known that some communities are more com-
to measure the concept, and currently to its use for fortable to live in, grow old in, and go to school in
practice, education, and research. She uses a full array than are others.
of approaches to build her theory. An area of interest for further development is the
The methodical development of the concept re- universal nature of comfort. Currently, the General
sulted in a strong, clearly organized, and logical Comfort Questionnaire has been translated into

666 UNIT V Middle Range Nursing Theories

Taiwanese, Spanish, Iranian, Portuguese, and Italian Simplicity
(see Kolcaba website), and translation into Turkish is The Theory of Comfort is simple because it is basic to
pending. Comfort of children has been accurately ob- nursing care and the traditional mission of nursing. Its
served and documented in perioperative settings (per- language and application are of low technology, but
sonal communication, Nancy Laurelberry, February 16, this does not preclude its use in highly technological
2008), and the use of Comfort Daisies by children settings. There are few variables in the theory, and se-
who self-report (see website) has been tested in a hospi- lected variables may be used for research or educa-
tal setting (personal communication, Carrie Majka, tional projects. The main thrust of the theory is for
February 28, 2008). nurses to return to a practice focused on the holistic
The Theory of Comfort has been included in elec- needs of patients inside or outside institutional walls.
tronic nursing classification systems such as NANDA It is simplicity that allows students and nurses to learn
(2011), NIC (2008), and NOC (2008). Kolcaba con- and practice the theory easily (Kolcaba, 2003).
sults with hospitals to include comfort management
in their documentation systems. Use of the theory has Generality
made significant contributions to nursing practice Kolcaba’s theory has been applied in numerous
and the discipline. Kolcaba continues to spend time research settings, cultures, and age groups. The only
and energy developing and disseminating the theory limiting factor for its application is how well nurses
through presentations, publications, and discussions and administrators value it to meet the comfort needs
since retirement from full-time teaching. of patients. If nurses, institutions, and communities
The Theory of Comfort is widely usedas an or- are committed to this type of nursing care, the Theory
ganizing framework for Magnet application and of Comfort enables efficient, individualized, holistic
recertification of Magnet Status. Nurses often practice. The taxonomic structure of comfort facilitates
choose this framework themselves because it de- researchers’ development of comfort instruments for
scribes what they want to do for patients and fami- new settings.
lies, and what patients want from nurses during
their hospitalization. An array of possible uses of Accessibility
the framework components is offered to the hospi- The first part of the theory, asserting that effective
tal, such as Comfort Rounds, performance review nursing interventions offered over time will demon-
criteria, methods of documentation, clinical ladder strate enhanced comfort, has been tested and sup-
criteria, and so on. The “value added” benefit when ported with numerous studies. Furthermore, in the
nurses are supported in their comforting interven- study by Dowd, Kolcaba, & Steiner (2000), enhanced
tions can be empirically demonstrated through comfort was a strong predictor of increased health-
measurement of institutional outcomes such as seeking behaviors, meaning when patients are more
patient satisfaction, “Best Hospital” designations, comfortable, they do better in rehab or recovery. This
and cost savings. relationship supports the second and third part of the
comfort theory. The comfort instruments have dem-
Critique onstrated strong psychometric properties, supporting
the validity of the questionnaires as measures of com-
Clarity fort that reveal changes in comfort over time and
Some of the early articles such as the concept analysis support of the taxonomic structure.
(Kolcaba & Kolcaba, 1991) may lack clarity but are
consistent in terms of definitions, derivations, assump- Importance
tions, and propositions. Clarity is much improved in The Theory of Comfort describes patient-centered
the article explicating the theory and subsequent arti- practice and explains how comfort measures matter
cles. Kolcaba applies the theory to specific practices to patients, their health, and the viability of institu-
using academic, but understandable, language. All tions. The theory predicts the benefit of effective
research concepts are defined theoretically and opera- comfort measures (interventions) for enhancing
tionally. comfort and engagement in health-seeking behaviors.

CHAPTER 33 Katharine Kolcaba 667

The Theory of Comfort is dedicated to sustaining In research, the theory provides a way to validate
nursing by bringing the discipline back to its roots. improvement in patient comfort after receiving com-
Documentation of comfort strategies and their effects forting interventions. The concept of comfort accounts
empirically demonstrates the art of nursing. The out- for the aspect of quality that the patient describes as
come of comfort describes the effects of memorable “feeling better.” Kolcaba has made consistent efforts to
helping interactions with nurses that go beyond develop and expand comfort into all realms of health
checklists or physician orders. It encompasses the art care. Through her own thinking and in interaction
and science of nursing. Making electronic data sys- with nurses and other health professionals, the con-
tems inclusive of value-added outcomes such as com- cept has continually evolved into patient and nurse
fort is imperative. Collaboration and the openness of care techniques. Institutions have recognized the value
Kolcaba’s website facilitates dissemination of the the- of designing comfort environments for both their
ory for application. patients and their staff. Through Kolcaba’s publica-
The orientation to patient and family comfort may tions and Internet activities (website), the Theory of
have been present first in nursing, but it has become Comfort is now worldwide.
invisible and perhaps less valued by a health care system
that promotes the use of medications and technology.
Refocusing on patient and family comfort represents a CASE STUDY
return to the roots of nursing and also to the need for A 32-year-old African-American mother of three
empirical evidence. We can demonstrate through re- toddlers who is 28 weeks pregnant is admitted to
search that comfort is foundational to patient recovery, the high-risk pregnancy unit with regular contrac-
to other health-seeking behaviors, and to institutional tions. She is concerned because the plans for her
viability. The focus is applicable to other health care family are not finalized. She has many comfort
professions and ancillary workers. The use of a comfort needs that are diagrammed in Table 33–1. When
framework implemented throughout a hospital facili- nurses assess for comfort needs in any of their
tates everyone being “on the same page.”
patients, they can use the taxonomic structure, or
comfort grid, to identify and organize all known
Summary needs. Using the comfort grid (see Figure 33–1) as
From its inception, the Theory of Comfort has focused a mental guide, nurses can design interrelated
comforting interventions that can be implemented
on what the discipline of nursing does for patients. As in one or two nurse-patient-family interactions.
the theory evolved, the definition derived from con- For this case, some suggestions to individualize
cept analysis expanded to include broader aspects of the types of comfort interventions that might be
the patient such as cultural and spiritual aspects. The considered are presented in Table 33–2.
basic format of the taxonomic structure and concep- For clinical use, the nurse could ask the patient
tual framework remains the same. The development of to rate her comfort before and after receiving the
the General Comfort Questionnaire was important interventions on a scale from 0 to 10, with 10 be-
to validate that the concept can be measured and ing the highest level possible. To determine
documented, it is positive, and it is related to desirable through research if a specific comforting interven-
patient, family, and institutional outcomes. tion enhanced the comfort of a group of patients,
The theory has relevancy for practice and easily
guides nurses in the planning and designing of nurs- a comfort questionnaire could be developed and
administered, assessing each cell in the comfort
ing care in any setting. Its usefulness in education has grid (see Figure 33–1). A Likert-type scale with
been described as providing a framework that enables responses ranging from 1 to 6 would facilitate a
students to organize their assessments and plans of total comfort score. Such a questionnaire could be
care and learn the art of nursing as well as the science. given to the patient before and after the interven-
It is useful for expert nurses in the delivery of care as tions are implemented to demonstrate the level of
they demonstrate what they do beyond the technical effectiveness for the comfort interventions.
aspects of nursing.

668 UNIT V Middle Range Nursing Theories

TABLE 33-1 Taxonomic Structure of Comfort Needs for Case Study
Context of Comfort Relief Ease Transcendence

Physical Aching back Restlessness and anxiety Patient thinking, “What will
Early strong contractions happen to my family and
to my babies?”
Psychospiritual Anxiety and tension Uncertainty about prognosis Need for emotional and
spiritual support
Environmental Roommate is a primigravida Lack of privacy Need for calm, familiar
Room is small, clean, Telephone in room environmental elements
and pleasant Feeling of confinement and accessibility of
with bed rest distraction
Sociocultural Absence of family and Family not present Need for support from
culturally sensitive care Language barriers family or significant other
Need for information and
consultation





TABLE 33-2 Comfort Care Actions and Interventions
Type of Comfort Care Action or Intervention Example

Standard comfort interventions Vital signs
Laboratory test results
Patient assessment
Medications and treatments
Social worker
Coaching Emotional support
Reassurance
Education
Listening
Clergy
Comfort food for the soul Energy therapy such as healing touch if it is culturally acceptable
Music therapy or guided imagery (patient’s choice of music)
Spending time
Personal connections
Reduction of environmental stimuli



CRITICAL THINKING ACTIVITIES
1. If you were asked to diagram your practice, what 3. There is some evidence that comfort is a universal
concepts would you include? Where is comfort in need. Identify a way you met a comfort need for
your diagram? someone you cared for recently. Would this com-
2. Select a patient, and apply the Theory of Comfort in fort intervention work in another culture? Why or
your nursing practice. How did the theory impact why not?
your style of practice? Where are your comfort mea-
sures in the taxonomic structure? (See Figure 33–1.)

CHAPTER 33 Katharine Kolcaba 669

4. How would you apply the Theory of Comfort in 5. Identify an area of nursing practice for comfort
a community setting? What interventions could research, and explain why it is needed.
you use to enhance comfort in an aggregate 6. How might the Theory of Comfort influence
group? How would you assess to see if your policy change?
intervention was effective?

POINTS FOR FURTHER STUDY
n American Society of Perianesthesia Nurses at: n Kolcaba, K. (2006). Comfort (including
www.ASPAN.org. definition, theory of comfort, relevance to
n Kolcaba, K. (1997). TheComfortLine.com. nursing, review of comfort studies, and future
Retrieved from http://www.thecomfortline. directions.) In J. Fitzpatrick (Ed.), The
com(the Kolcaba website). encyclopedia of nursing research. (2nd ed.).
n Kolcaba, K (2003). Comfort theory and practice: a New York: Springer.
holistic vision for health care, New York, Springer.


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disease: A meta-analysis. Psychotherapy and Psychoso- 145–155. doi: 10.1111/j.1440–172X.2009.01739.x.
matics, 79, 136–148. Yousefi, H., Abedi, H., Yarmohammadian, M., & Elliott, D.
Holliday-Welsh, D., Gessert, C., & Renier, C. (2009). (2009). Comfort as a basic need in hospitalized patients
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Nursing, 30(2), 108–117.

34

CHAP TER



















Cheryl Tatano Beck




Postpartum Depression Theory


M. Katherine Maeve



“The birth of a baby is an occasion for joy—or so the saying
goes . . . But for some women, joy is not an option”
(Beck, 2006d, p. 40).


Credentials and Background Beginning at the rank of instructor in 1973, Beck
of the Theorist has held academic appointments with increasing rank
Cheryl Tatano Beck graduated from the Western at several major universities, including the University
Connecticut State University with a baccalaureate in of Maryland, the University of Michigan, Florida
nursing in 1970. She recognized during her first clini- Atlantic University, the University of Rhode Island,
cal rotation that obstetrical nursing was to be her and Yale University, and as professor at the University
lifelong specialty. After graduation, Beck worked as a of Connecticut, where she holds a joint appointment
registered nurse at the Yale New Haven Hospital on in the School of Nursing and School of Medicine.
the postpartum and normal newborn nursery unit. Beck has served as consultant on numerous research
By 1972, Beck had graduated from Yale University projects for universities and state agencies in the
with a master’s degree in maternal-newborn nursing northeastern United States. During her career, Beck
and a certificate in nurse midwifery. In 1982, she re- has received more than 30 awards, including Distin-
ceived a doctorate in nursing science from Boston guished Researcher of the Year from the Eastern
University. Nursing Research Society in 1999. She was inducted


The author wishes to thank Dr. Cheryl Tatano Beck for her generosity of spirit in allowing me liberties with the interpretation of her
life’s work. Dr. Beck’s work represents an enormous contribution to nursing, made even more remarkable because it did not depend
on boatloads of NIH funding. That alone is an inspiration. Thanks are also extended to Dr. Peggy L. Chinn, who happily has not
retired as a mentor or friend.

672

CHAPTER 34 Cheryl Tatano Beck 673

as a fellow in the American Academy of Nursing locally, nationally, and internationally. She has served
in 1993. on the editorial boards of many nursing journals,
This body of work has resulted in a substantive including Advances in Nursing Science, Nursing
theory of postpartum depression (Beck, 1993) and Research, and the Journal of Nursing Education. Beck
the development of the Postpartum Depression served on the executive board for the Marce Society,
Screening Scale (PDSS) (Beck, 2002c; Beck & Gable, an international society for the understanding, pre-
2000) and the Postpartum Depression Predictors vention, and treatment of mental illness associated
Inventory (PDPI) (Beck, 1998, 2001, 2002b). A time- with childbirth, and on the advisory committee of
line of Beck’s research that demonstrates the logical the Donaghue Medical Research Foundation in
progression of her work is outlined in Table 34–1. Connecticut. Over her career, Beck has been given
A prolific author and disseminator of her research, numerous local, national, and international awards
Beck has authored more than 100 research-based for her work. Most recently, in 2011, Beck was given
articles and given scores of research presentations the Best Publication by Sigma Theta Tau International


TABLE 34-1 Timeline of Beck’s Perinatal Research
Year Focus of Research Year Focus of Research

1972 Women’s cognitive and emotional responses to 1998 Effects of PPD on child development
fetal monitoring (master’s thesis) 1998 Checklist to identify women at risk for PPD
1977 Replication of master’s thesis 1999 Maternal depression and child behavioral
1982 Parturients’ temporal experiences during labor problems
(doctoral dissertation) 2000 PDSS: Development and psychometric testing
1985 Mothers’ temporal experiences in postpartum 2001 Comparative analysis between PDSS and two
period after vaginal and cesarean deliveries other depression instruments
1988 Postpartum temporal experiences of primiparas 2001 Item response theory in affective instrument
1989 Incidence of maternity blues in primiparas and development
length of hospital stay 2001 Ensuring content validity
1990 Teetering on the edge: A grounded theory study 2002 PPD—metasynthesis
of PPD 2002 Revision of PDPI
1992 The lived experience of PPD 2002 Mothering multiples
1994 Nurses’ caring with postpartum depressed 2003 PPD in mothers of babies in the NICU
mothers
1995 Screening methods for PPD 2003 PDSS—Spanish version
Birth trauma
2004
1995 PPD and maternal-infant interaction
2004 Posttraumatic stress disorder after childbirth
1995 Mothers’ with PPD perceptions of nurses’ caring
2004 Benefits of internet interviews
1996 Relationship between PPD and infant
temperament 2005 DHA in pregnancy
2005 Birth trauma and breastfeeding
1996 Predictors of PPD metaanalysis
2005 Mapping birth trauma narratives
1996 Mothers with PPD and their experiences
interacting with children 2007 PDSS—Internet
1996 Concept analysis of panic 2009 Mothers caring for a child with a brachial plexus
injury
1997 Developing research programs using qualitative
and quantitative approaches 2012 Subsequent childbirth after previous birth trauma
NICU, Neonatal intensive care unit; PDPI, Postpartum Depression Predictors Inventory; PDSS, Postpartum Depression Screening Scale; PPD, postpartum
depression.

674 UNIT V Middle Range Nursing Theories

Honor Society award for Best of Journal of Nursing evolution of grounded theory in nursing. Throughout
Scholarship-Profession, World Health, and Health all of Beck’s work and consistent with feminist theory,
Systems. there is explicit valuing of the importance of under-
Many in nursing recognize the classic Polit and standing pregnancy, birth, and motherhood through
Hungler research text, a fixture in countless graduate “the eyes of women” (Beck, 2002a). Furthermore,
nursing programs. Beck became coauthor of Polit’s Beck acknowledges that childbirth occurs in many
seventh edition (Polit & Beck, 2003), reflecting Beck’s simultaneous contexts (medical, social, economic)
research expertise. In 2011, this text received the and that mothers’ reactions to childbirth and mother-
American Journal of Nursing Book of the Year Award hood are shaped by their contextual responses.
for the 9th edition. Beck has also written articles re- An unusual theoretical source came from the
garding statistical analysis strategies and approaches work of Sichel and Driscoll (1999), who developed an
for qualitative research. earthquake model to conceptualize how interactions
Although Beck conducted seven major studies between biology and life result in what they term bio-
regarding educational and caring issues with under- chemical loading. Over time, with constant chemical
graduate nursing students, for over 3 decades she challenges related to stressors, women’s brains may
contributed to knowledge development in obstetrical develop a kind of “fault line” that is less likely to remain
nursing. Her research career began by studying women intact during critical moments in women’s lives, such
in labor, with interest in fetal monitoring. Beck’s research as the challenges women face around childbirth, result-
focus eventually became the postpartum period and ing in a kind of “earthquake.” Beck understood Sichel
specific studies of postpartum mood disorders. and Driscoll’s model to “suggest that a woman’s genetic
makeup, hormonal and reproductive history, and life
experiences all combine to predict her risk of ‘an earth-
Theoretical and Philosophical Sources quake’ which occurs when her brain cannot stabilize
Although Beck does not address caring as a theoreti- and mood problems erupt” (Beck, 2001, p. 276).
cal or philosophical construct specific to her research, Although it is easy to understand the physiological and
she has conducted studies that evidence her belief hormonal challenges of pregnancies for women, Sichel
about the importance of caring in nursing . Beck’s use and Driscoll’s earthquake model was important in
of the ideas of Jean Watson with regard to caring helping Beck to holistically conceptualize the phenom-
theory endorses caring as central to nursing, while ena that might affect the development of postpartum
acknowledging Watson’s concern that quantitative depression for women. Although Beck states that she
methodologies may not adequately reflect the ideal never experienced postpartum depression after the
of transpersonal caring. It is obvious throughout birth of her own children, those who have may relate
Beck’s writings, including research reports using both to the earthquake metaphor complete with tremors
quantitative and qualitative methods, that advancing culminating in postpartum depression or, worse, post-
nursing as a caring profession is desirable and achiev- partum psychosis.
able in practice, research, and education. Beck has identified Robert Gable as a particularly
Because many of the studies used to develop Beck’s important source in her work. As Professor Emeritus at
Postpartum Depression Theory were qualitative in the University of Connecticut, Neag School of Educa-
nature, Beck has cited various theoretical sources re- tion, Gable had coauthored an important text called
flecting the philosophical and theoretical roots of Instrument Development in the Affective Domain (Gable
methodologies important for the kind of knowledge & Wolf, 1993). After developing a wealth of knowledge
developed in each study. Phenomenology was used in about postpartum depression, the next logical steps for
the first major study of how women experienced post- Beck became developing instruments that could predict
partum depression, with Colaizzi’s (1978) approach. and screen for postpartum depression. Gable assisted
In her next study, Beck used grounded theory as Beck with theoretical operationalization of her theory
influenced by the theoretical and philosophical ideas for practical use. Gable has remained directly involved
of Glaser (1978), Glaser and Strauss (1967), and through the step-by-step development of the PDSS,
Hutchinson (1986), all seminal contributors to the including the Spanish version (Beck & Gable, 2003).

CHAPTER 34 Cheryl Tatano Beck 675

MAJOR CONCEPTS & DEFINITIONS
Beck’s major concepts have undergone refinement baby (and perhaps other children) are in grave dan-
and clarification over years of work on postpartum ger of harm. Although postpartum psychosis often
depression. The first two concepts, postpartum begins to appear during the first week postpartum,
mood disorders and loss of control, were developed it is frequently not detected until serious harm has
utilizing phenomenology and grounded theory occurred.
methods.
Postpartum Obsessive-Compulsive Disorder
Concepts 1 to 2 Only recently identified, the prevalence rates of post-
1. Postpartum Mood Disorders partum obsessive-compulsive disorder have not been
Postpartum depression and maternity blues have reported. Symptoms include repetitive, intrusive
become better delineated over time, as has the un- thoughts of harming the baby, a fear of being left alone
derstanding of postpartum psychosis. Two other with the infant, and hypervigilance in protecting the
perinatal mood disorders, postpartum obsessive- infant.
compulsive disorder and postpartum-onset panic Postpartum-Onset Panic Disorder
disorder, have been identified, as has how these dis-
orders are different and how they are interrelated Postpartum-Onset Panic Disorder has been identified
(Beck, 2002c). only recently and is also without reported prevalence
rates. It is characterized by acute onset of anxiety, fear,
Postpartum Depression rapid breathing, heart palpitations, and a sense of
Postpartum depression is a nonpsychotic major impending doom.
depressive disorder with distinguishing diagnostic
criteria that often begins as early as 4 weeks after 2. Loss of Control
birth. It may also occur anytime within the first year Loss of control was identified as the basic psychoso-
after childbirth. Postpartum depression is not self- cial problem in the 1993 substantive theory of
limiting and is more difficult to treat than simple Beck’s early work. This descriptive theory captured
depression. Prevalence rates are 13% to 25%, with a process women go through with postpartum
more women affected who are poor, live in the inner depression. Loss of control was experienced in all
city, or are adolescents. Approximately 50% of all areas of women’s lives, although the particulars of
women suffering from postpartum depression have the circumstances may be different. The concept of
episodes lasting 6 months or longer. loss of control fit with extant literature and left
women with feelings of “teetering on the edge”
Maternity Blues (Beck, 1993). The process identified consisted of the
Also known as postpartum blues and baby blues, following four stages:
maternity blues is a relatively transient and self- 1. Encountering terror consisted of horrifying anxi-
limited period of melancholy and mood swings ety attacks, enveloping fogginess, and relentless
during the early postpartum period. Maternity blues obsessive thinking.
affects up to 75% of all women in all cultures. 2. Dying of self consisted of alarming unrealness,
contemplating and attempting self-destruction,
Postpartum Psychosis and isolating oneself.
Postpartum Psychosisis a psychotic disorder charac- 3. Struggling to survive consisted of battling the
terized by hallucinations, delusions, agitation, and system, seeking solace at support groups, and
inability to sleep, along with bizarre and irrational praying for relief.
behavior. Although postpartum psychosis is relatively 4. Regaining control consisted of unpredictable
rare (1 to 2 women per 1000 births), it represents a transitioning, guarded recovery, and mourning
true psychiatric emergency because both mother and lost time.

Continued

676 UNIT V Middle Range Nursing Theories

MAJOR CONCEPTS & DEFINITIONS—cont’d
Concepts 3 to 9 n Crises (e.g., accidents, burglaries, financial crises,
The conceptual ideas and definitions described illness requiring hospitalization)
above were used to develop specific foci for testing. n (Effect size 5 Medium)
Initially, Beck (1998) identified eight risk factors
for postpartum depression. Many studies have ex- 6. Social Support
panded areas where Beck determined that more Social support pertains to instrumental support (e.g.,
conceptual clarity was needed. babysitting, help with household chores) and emo-
Another important change is marriage. Through tional support. Structural features of a woman’s social
subsequent research, it was noted that there were network (husband or partner, family, and friends)
two marital factors of concern: marital status and include proximity of its members, frequency of con-
the nature of the marital relationship satisfaction tact, and number of confidants with whom the
(Beck, 2002b). Two other risk factors identified were woman can share personal matters. Lack of social
socioeconomic status and issues of unplanned and support is when a woman perceives that she is not
unwanted pregnancies. receiving the amount of instrumental or emotional
support she expects. (Effect size 5 Medium)
Concepts 3 to 15
These are major concepts found to be significant 7. Prenatal Anxiety
predictors or risk factors for postpartum depression Prenatal anxiety occurs during any trimester or
(Beck, 2002b). The most current interpretation of throughout the pregnancy. Anxiety refers to feelings
effect size was assigned from a metaanalysis of 138 of uneasiness or apprehension concerning a vague,
extant studies and is at the end of each concept defi- nonspecific threat. (Effect size 5 Medium)
nition (Beck, 2002b).
8. Marital Satisfaction
3. Prenatal Depression The degree of satisfaction with a marital relationship is
Depression during any or all of the trimesters of preg- assessed and includes how happy or satisfied the woman
nancy has been found to be the strongest predictor of is with certain aspects of her marriage, such as com-
postpartum depression. (Effect size 5 Medium) munication, affection, similarity of values (e.g., finances,
child care), mutual activity and decision making, and
4. Child Care Stress global well-being. (Effect size 5 Medium)
Child care stress pertains to stressful events related to
child care such as infant health problems and diffi- 9. History of Depression
culty in infant care pertaining to feeding and sleep- A woman has a history of depression if there is
ing. (Effect size 5 Medium) report of having had a bout of depression before this
pregnancy. (Effect size 5 Medium)
5. Life Stress
Life stress is an index of stressful life events during 10. Infant Temperament
pregnancy and postpartum. The number of life expe- The temperament is the infant’s disposition and per-
riences and the amount of stress created by each of sonality. Difficult temperament describes an infant
the life events are combined to determine the amount who is irritable, fussy, unpredictable, and difficult to
of life stress a woman is experiencing. Stressful life console. (Effect size 5 Medium)
events can be either negative or positive and can
include experiences such as the following: 11. Maternity Blues
n Marital changes (e.g., divorce, remarriage) Maternity blues was previously defined as a non-
n Occupational changes (e.g., job change) pathological condition after giving birth. Prolonged

CHAPTER 34 Cheryl Tatano Beck 677

MAJOR CONCEPTS & DEFINITIONS—cont’d
episodes of maternity blues (lasting more than 17. Anxiety and Insecurity
10 days) may predict postpartum depression. (Effect Anxiety and insecurity includes overattention to
size 5 Small to medium) relatively minor issues, feelings of jumping out of
one’s skin, feeling the need to keep moving, or pac-
12. Self-Esteem ing. There is an ever-present feeling of insecurity
Self-esteem is a woman’s global feelings of self-worth and a sense of being overwhelmed in the new role
and self-acceptance. It is her confidence and satis- of mother.
faction in self. Low self-esteem reflects a negative
self-evaluation and feelings about oneself or one’s 18. Emotional Lability
capabilities. (Effect size 5 Medium) A woman experiencing emotional lability has a
sense that her emotions are unstable and out of her
13. Socioeconomic Status control. It is commonly characterized as crying for
Socioeconomic status is a person’s rank or status no particular reason, irritability, explosive anger,
in society involving a combination of social and and fear of never being happy again.
economic factors (e.g., income, education, and
occupation). (Effect size 5 Small) 19. Mental Confusion
Mental confusion is characterized by a marked
14. Marital Status inability to concentrate, focus on a task, or make a
Marital status is a woman’s standing in regard to decision. There is a general feeling of being unable
marriage; it denotes whether a woman is single, to regulate one’s own thought processes.
married or cohabiting, divorced, widowed, sepa-
rated, or partnered. (Effect size 5 Small) 20. Loss of Self
Women sense that the aspects of self that reflected
15. Unplanned or Unwanted Pregnancy their personal identity have changed since the
Unplanned or unwanted pregnancy refers to a birth of their infant, so they cannot identify who
pregnancy that was not planned or wanted. Of they really are and are fearful that they might
particular note is the issue of pregnancies that never be able to be their real selves again.
remain unwanted after initial ambivalence. (Effect
size 5 Small) 21. Guilt and Shame
A woman experiences guilt and shame when she
Concepts 16 to 22 perceives that she is performing poorly as a mother
These final concepts represent the distillation of all and has negative thoughts regarding her infant.
predictor and risk factors that are used to screen This results in an inability to be open with others
women for symptoms of postpartum depression in about how she feels and contributes to a delay in
the PDSS (Beck, 2002c). diagnosis and intervention.

16. Sleeping and Eating Disturbances 22. Suicidal Thoughts
Sleeping and eating disturbances include inability to Women experience suicidal thoughts when they
sleep even when the baby is asleep, tossing and turn- have frequent thoughts of harming themselves or
ing before actually falling asleep, waking up in the ending their lives to escape the living nightmare of
middle of the night, and difficulty going back to postpartum depression.
sleep. Even though she is consciously aware of the
need to eat, the woman may experience loss of ap-
petite and inability to eat.

678 UNIT V Middle Range Nursing Theories


Use of Empirical Evidence Major Assumptions
When Beck began to examine postpartum depression Nursing
in 1993, she noted that only two qualitative studies Beck describes nursing as a caring profession with car-
contributed to the knowledge base of the disorder. ing obligations to persons we care for, students, and each
Most studies were based upon knowledge developed other. In addition, interpersonal interactions between
in disciplines other than nursing. Beck’s background nurses and those for whom we care are the primary ways
as a nurse midwife undoubtedly gave her a view of nursing accomplishes the goals of health and wholeness.
women throughout the postpartum period that was
not commonly available to those in other disciplines Person
involved with women during the perinatal period. Persons are described in terms of wholeness with bio-
In 1993, after four major studies regarding women in logical, sociological, and psychological components.
the postpartum period (Table 34–1), Beck developed a Further, there is a strong commitment to the idea that
substantive theory of postpartum depression using persons or personhood is understood within the con-
grounded theory methodology. The substantive theory text of family and community.
was entitled “teetering on the edge,” with the basic
psychosocial problem identified as loss of control (Beck, Health
1993). Since development of the substantive theory, Beck does not define health explicitly. However, her
Beck has designed 14 other studies to refine the theory writings include traditional ideas of physical and
by examining the experiences of postpartum depression mental health. Health is the consequence of women’s
on mother-child interactions, postpartum panic, post- responses to the contexts of their lives and their envi-
traumatic stress disorder (PTSD), and birth trauma to ronments. Contexts of health are vital to understand-
tease out differences among postpartum mood disorders ing any singular issue of health.
(postpartum depression, maternity blues, postpartum
psychosis, postpartum obsessive-compulsive disorder, Environment
postpartum-onset panic disorder). Metaanalyses were Beck writes about the environment in broad terms
conducted on predictors of postpartum depression, the that include individual factors as well as the world
relationship between postpartum depression and infant outside of each person. The outside environment
temperament, and the effects of postpartum depression includes events, situations, culture, physicality eco-
on mother-infant interaction. In addition, two qualita- systems, and sociopolitical systems. In addition, there
tive metasyntheses were conducted on postpartum is an acknowledgment that women in the childbear-
depression and mothering multiples. ing period receive care within a health care environ-
Beck used ten qualitative studies of postpartum ment structured in the medical model and permeated
depression in women from a wide variety of geographic with patriarchal ideology.
locations and cultures. Women represented in these
studies included Black Caribbean women, Irish women,
Indian women, Hong Kong Chinese women, Hmong Theoretical Assertions
women, Middle Eastern women (living in the UK), The theoretical assertions within Beck’s theory are well
Asian women, Portuguese women, Australian women, represented throughout her writings. She acknowl-
Canadian women, and African American women. These edges the importance of Sichel and Driscoll’s (1999)
new data were used to compare Beck’s original teeter- work related to the biological factors involved in post-
ing on the edge grounded theory with women in other partum depression in the following assertions:
cultures. Beck found that the theory’s modifiability was • The brain can biochemically accommodate various
in keeping with theoretical expectations of a relevant stressors, whether related to internal biology or
substantive grounded theory. Therefore, the theory of external events.
“teetering on the edge,” with “loss of control” as the basic • Stressful events (internal or external), particularly
psychosocial process has functionally expanded to over long periods, cause disruption of the bio-
women in other cultures (Beck, 2006a, 2012b). chemical regulation in the brain. The more insults

CHAPTER 34 Cheryl Tatano Beck 679

to the brain, the more chronically deregulated the inductive and deductive logic significantly contrib-
brain becomes. Because an already deregulated uted to the development of the theory. Chinn and
brain is challenged again with new stressors (inter- Kramer (2011) identify inductive logic as founda-
nal or external), it is likely that serious mood and tional to qualitative methods, with reasoning from
psychiatric disorders will result. the particular to the general. In contrast, deductive
• Women’s unique and normal brain and hormonal reasoning moves from the general to the particular,
chemistry result in a vulnerability to mood disor- drawing conclusions that represent the general.
ders at critical times in their lives, including after Because Beck’s theory reflects a very complex and
giving birth. focused path in its evolution, it is helpful to be clear
• Postpartum depression is caused by a combination about what criteria were used to understand and pres-
of biological (including genetic), psychological, ent the theory. The definition of theory currently used
social, relational, economic, and situational life is… “a creative and rigorous structuring of ideas that
stressors. projects a tentative, purposeful, and systematic view
• Postpartum depression is not a homogenous dis- of phenomena” (Chinn & Kramer, 2011, p. 257).
order. Women may express postpartum depres- Middle-range theories may be derived using grounded
sion with a single symptom but are more likely to theory approaches, and they identify social processes
have a constellation of varying symptoms. This is that may occur in various social events. For example,
related to varying life histories of internal and Beck’s substantive theory of postpartum depression
external stressors. found that loss of control was the basic psychosocial
• Culturally, women are expected to feel happy, look problem facing women, but this problem could also
happy, act happy, understand how to be a mother occur in contexts other than the postpartum period.
naturally, and experience motherhood with a sense The evolution of Beck’s theory is instructional for
of fulfillment. These expectations make it difficult several reasons. First, Beck’s unceasing, linear, and
for women to express genuine feelings of distress. logical efforts to develop the theory for pragmatic
• The stigma attached to mental illness increases practice concerns led to a theory that addresses a
dramatically when a mental illness is related to the specific practice problem. Because her theory is rela-
birth of a child, leading women to suffer in silence. tively new, there are few contributors to the substance
• Within a level of prevention framework, postpar- of the theory. Therefore, there is opportunity to follow
tum depression can be prevented through identifi- a very clear and focused process of theory develop-
cation and mitigation of risk factors during the ment by a scholar who began the work as a young
prepartum period. Postpartum depression can be woman. Beck has tested her theory, used it with vari-
identified early with careful screening and can be ous populations, tested instruments, and developed
treated effectively. Prevention can alleviate months a work in which other scholars can join her to con-
of suffering and decrease the harmful effects on tribute to the science. Second, Beck’s theory of post-
women, their infants, and their families. partum depression is remarkable as an example of
• A number of biological, sociological, and psychologi- extensive inductive theory development in a specific
cal issues and challenges are entirely normal in all area of nursing practice addressing a specific patient
pregnancies. These may include fatigue, sleep altera- problem. Although Beck began her work with a
tions, questioning one’s abilities, and the like. Com- global understanding of caring, her focused work on
prehensive prenatal and postnatal care can eliminate postpartum depression was advanced through the
troublesome pathological symptoms and help women development of a substantive middle-range theory
normalize expected symptoms, thus reducing the and continues to advance. From the beginning, Beck’s
degree of stress they actually experience. goal has been to understand postpartum depression
in a way that would allow professionals to develop
adequate prevention strategies, develop screening
Logical Form programs for early intervention, and develop ade-
Beck’s Postpartum Depression Theory, as described in quate treatment strategies to prevent harm to women,
previous sections of this chapter, identifies how both their children, and their families. True to her research

680 UNIT V Middle Range Nursing Theories

aims, what began as a descriptive substantive theory Beck’s work has also been instrumental in com-
of postpartum depression has evolved into an exten- munity intervention and education projects such as
sive research program. the Ruth Rhoden Craven Foundation for Postpartum
Depression Awareness located in South Carolina.
Acceptance by the Nursing Community Helena Bradford founded this organization because
of a tragic postpartum mood disorder within her
Practice own family. Ms. Bradford advocates for postpartum
As Beck’s research findings have been disseminated awareness within her community and conducts sup-
more widely, the theory and the instruments based on port groups (H. Bradford, personal communication,
the theory have been utilized increasingly in nursing April 28, 2004).
practice throughout the United States. In addition, the
PDSS is in use and translated as appropriate in Canada, Education
Australia, Brazil, New Zealand, Ireland, South Africa, Beck is a frequently invited speaker for professional
Germany, Russia, Turkey, Hungary, China, and Israel. educational conferences and workshops. Her work is
(The References section titled Bibliography of Research cited frequently in nursing maternal and newborn
Using the Screening Scale includes international use of nursing texts, such as that of Davidson, London, &
the PDSS.) Ladewig (2011). At both undergraduate and graduate
The PDSS became a standard of care for women in levels, Beck’s work sets the standard for knowledge
the high-risk obstetrical clinic of the Medical Univer- and understanding about postpartum depression. In
sity of South Carolina Hospital (A. Raney, personal addition, Beck’s work has been used to educate mem-
communication, April 28, 2004). The clients in this bers of other disciplines, such as physicians, mental
clinic vary in age across the spectrum, come from vari- health workers, public health professionals, social
ous ethnic backgrounds, and have a wide range of workers, and those who work in social service agen-
medical risk factors. She has noted that the tool is a cies that provide protective care for women and
vehicle for opening discussions with women that had children. Beck also brings her work to the general
not occurred prior to implementation of the tool. High public and policy makers through active community
scores on the PDSS have given physicians evidence to involvement at the local, state, national, and interna-
understand how postpartum depression is expressed in tional levels.
their patients, increasing their sensitivity and aware-
ness. Predictably, marshaling of community resources Research
to meet the specific needs of individual clients has been The long research development of Beck’s theory is
a challenge; however, the landscape for the Charleston evident in Table 34–1. As previously noted, she has
community in understanding and responding to the received numerous awards recognizing the impor-
special needs of women during this time has occurred. tance of her research. Nurses increasingly are using
Public health initiatives that involve working with Beck’s work for master’s and doctoral level research.
new mothers and babies are also utilizing Beck’s theory In addition, Beck facilitates practice implementation
of postpartum depression via the PDSS. For example, research for academic and nonacademic sites.
the Healthy Start CORPS: Inter-Conceptual Care Case
Management Project in North Carolina begins to fol-
low women when they are 6 weeks postpartum. All Further Development
new clients, many of whom are Native American, are Beck identified what became another major concept
given the PDSS so that intervention and management in her theory, as well as a restructuring of postpartum
strategies can be built into plans of care for individual mood disorder definitions (Beck, 2004a, 2004b).
women and their families (L. Baker, personal commu- Because of increasing reports of PTSD after childbirth,
nication, April 29, 2004). The director of the program she examined women’s experiences of traumatic
emphasizes the ease with which women are able to births (Beck, 2004a). In this work, birth trauma was
discuss symptoms of postpartum depression after com- defined as “an event occurring during the labor and
pleting the tool. delivery process that involves actual or threatened

CHAPTER 34 Cheryl Tatano Beck 681

serious injury or death to the mother or her infant. postpartum depression follows a logical progression
The birthing woman experiences intense fear, help- specific to observations made in nursing practice. It is
lessness, loss of control, and horror” (Beck, 2004b, accessible empirically and theoretically. Importantly,
p. 28). Beck noted that women who actually had been concepts and definitions used for predicting a wom-
suffering from PTSD were misdiagnosed as having an’s risk for postpartum depression and concepts and
postpartum depression and were treated incorrectly definitions used to screen women for symptoms of
with antidepressant medications. She recommended postpartum depression are directly meaningful for
that postpartum mood disorders be changed to post- women, the lay public, and practitioners from nursing
partum mood and anxiety disorders (Beck, 2004b). and other related disciplines.
PTSD would then be differentiated as a distinct
diagnosis with different treatment approaches. Birth Generality
trauma, as a concept, will be examined empirically Beck has accounted for the complexity of postpartum
and included in predictor and screening instruments depression within the expansion of the concepts
as appropriate. Beck (2006c) examined women’s expe- within the theory. Generality issues relate to how
rience of the anniversary of their birth trauma, noting broadly the theory describes human experience, and
that the birthday of a woman’s child might represent this is supported by applicability of the theory in dif-
a time of reexperiencing the trauma all over again. ferent cultural contexts. Chinn and Kramer (2011)
Current research by Beck and co-investigator Carol note that generality refers to a theory’s ability to
Lammi-Keefe focuses on docasahexaenoic acid in remain conceptually simple, yet account for a broad
pregnancy and its effect on postpartum depression range of empirical experiences. Postpartum depression
(Judge & Beck, 2008). is a relatively narrow experience; however, its nature
Researchers utilized the PDSS to screen for postpar- and causation are especially complex. Importantly,
tum depression in a sample acquired on the Internet Beck (2007) has studied the experiences of many
compared with a community-based sample (Le, Perry, women and has also used research from numerous
& Sheng, 2008). Initial results suggested a high degree sources that address postpartum depression in various
of internal consistency and construct validity between geographical and cultural groups. Embracing findings
the two groups. Findings indicated that the Internet from these studies to compare and contrast with the
group included greater numbers of participation among extant theory has given new breadth to the theory and
Hispanic and Asian women, and the Internet group evi- significantly impacts its generality.
denced more risk factors for a postpartum depression
diagnosis. Future research focuses on ways to connect Accessibility
women in an Internet group with appropriate services The PDSS (Postpartum Depression Screening Scale)
for intervention for prevention and treatment. has been subjected to a rigorous statistical process for
development and standardization. Beck and Gable
Critique (2000) examined the psychometric properties of the
scale with regard to reliability of the measure within
Clarity developmental and diagnostic samples. Validity anal-
Beck’s theory evidences a semantic clarity as concepts yses were conducted with the two samples, as were
are defined clearly and consistently. Within and between procedures used to establish cutoff scores for clinical
research reports, Beck uses terms, ideas, definitions, and interpretations. These studies indicated that the
concepts in a way that reflects growth, yet they are PDSS is a reliable and valid screening instrument for
defined and easily understood. Her research and writ- detection of postpartum depression (Beck & Gable,
ings use both inductive and deductive language, and her 2000, 2001a, 2001b, 2001c, 2001d). The theory and
verbiage is economical and clear. the PDSS are relatively new and have therefore not
been critiqued empirically by a wide variety of schol-
Simplicity ars. Beck has two instruments: the PDSS, which
Postpartum depression is a complex phenomenon, is well established, and the Postpartum Depression
experientially and theoretically. Yet Beck’s theory of Prediction Inventory (PDPI), which has more recently