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
1 0. 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 effective nursing happens, as W. B. Yeats
(1928) might have remarked, “How do we tell
The Theoretical Basis of the Tidal Model* the dancer from the dance?” This reminds us
The Tidal Model begins from four simple, yet impor- that genuine caring encounters involve “caring
tant starting points: with” the person, not just “caring about” the
1. The primary therapeutic focus in mental health person, or doing things that suggest we are
“caring for” them.
care lies in the community. A person’s natural
life is an “ocean of experience.” The psychiatric The Three Domains: A Model of the
crisis is only one thing, among many, that might Person*
threaten to “drown” them. Ultimately, mental In the Tidal Model, the person is represented by
health care is aimed to return people to that three personal domains: Self, World, and Others. A
“ocean of experience,” so that they might con- domain is a sphere of control or influence, a place
tinue their life voyage. where the person experiences or acts out aspects of
2. Change is a constant, ongoing process. Although private or public life. Simply, a domain is a place
people are constantly changing, this may be be- where one lives.
yond their awareness. One of the main aims of
the approaches used within the Tidal Model is The domains are like the person’s home address.
to help people develop their awareness of the Their house or flat has several rooms, but the person
small changes that, ultimately, will have a big is not found in each of these rooms all the time;
effect on their lives. rather the person is sometimes in one room, and
3. Empowerment lies at the heart of the caring sometimes in another. The personal domains are
process. However, people already have their similar. Sometimes the person is mainly in the Self
own “power.” We need to help people “power Domain, and at other times the person is mainly in
up,” so they can use their own personal power the World or Others Domain.
to take greater charge of their lives, using this
in constructive ways. The Self Domain is the private place where the
4. The nurse and the person are united (albeit person experiences thoughts, feelings, beliefs, values,
temporarily) like dancers in a dance. When
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
of human experience through the core metaphor
In the Tidal Model, the Self Domain becomes of water. Life is a journey taken on an ocean of
the focus of our attempts to help the person feel experience. All human development—including
“safe” and “secure,” where we try to help the person the experience of health and illness—involves dis-
address and begin to deal with the private fears, coveries made on that journey across the ocean of
anxieties, and other threats to emotional stability experience. At critical points in the journey, peo-
related to specific problems of living. The main ple may experience storms or piracy. The ship may
focus is to develop a “bridging” relationship and to begin to take in water, and the person may face the
help the person develop a meaningful Personal Secu- prospect of drowning or shipwreck. The person
rity Plan. This work is the basis for development of may need to be guided to a safe haven, to under-
the person’s “self-help” program, which will sustain take repairs, or to recover from the trauma. Once
the person on return to everyday life. The World the ship is intact or the person has regained his
Domainis the place where the person shares some of or her sea legs, the journey can begin again as
the experiences from the Self Domain, with other the person sets his or her course on the ocean of
people, in the person’s social world. When people experience.
talk to others about their private thoughts, feelings,
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
human predicament. “Storms at sea” is a metaphor
In the Tidal Model, the World Domain is the focus for problems of living; “piracy” evokes the experience
of our efforts to understand the person and the per- of rape or a “robbery of the self ” that severe distress
son’s problems of living. This is done through the use can produce. Many users describe the overwhelming
of the Holistic Assessment. At the World Domain, nature of their experience of distress as akin to
we try to help the person begin to identify and “drowning,” and this often ends in a metaphorical
address specific problems of living on an everyday “shipwreck” on the shores of an acute psychiatric
basis through use of dedicated One-to-One Sessions. unit. A proper “psychiatric rescue” should be akin to
“lifesaving” and should lead the person to a genuine
The Others Domain is where the person acts out “safe haven,” where necessary human repair work can
everyday life with other people, such as family, take place.
friends, neighbors, work colleagues, and profession-
als. The person engages in different interpersonal Guiding Principles‡
and social encounters that may be influenced by 1. A belief in the virtue of curiosity: the person
others, and may—in turn—influence others. The
organization and delivery of professional care and is the world authority on his or her life and
other forms of support is in the Others Domain. its problems. By expressing genuine curiosity,
However, the key focus of the Tidal Model is dedi- the professional can learn something of the
cated forms of group work—Discovery, Information- “mystery” of the person’s story.
Sharing, and Solution-Finding. 2. Recognition of the power of resourcefulness:
Rather than focusing on problems, deficits,
By participating in these groups, the person de-
velops awareness of the value of social support,
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
boundaries, care is seamless with the intention of
to begin the recovery journey the person returning his or her “ocean of experi-
n That the person is the teacher, and we, the help- ence” within his or her own community. Across
the care continuum, people may need critical or
ers, are the pupils immediate, transitional or developmental care.
n That we need to be creatively curious to learn Practical immediate care addresses searching for
solutions to the person’s problems, generally in the
what needs to be done to help the person now! short term, and focuses upon “what needs to be
done, now.” People enter the care continuum for
Therapeutic Philosophy|| immediate care when experiencing an initial mental
1. Why this—why now? We need to consider, first
of all, why the person is experiencing this par-
ticular life difficulty now. The focus of care is
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.
Use of Empirical Evidence in the early 1960s and Peplau’s paradigm of inter-
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
findings in 1997 as the basis for development of the Two of Barker’s theory-generating studies pro-
Tidal Model. vided the empirical base for the Tidal Model. The
“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
to know what the person wants even if it is not
The power of the nurse-patient relationship dem- verbalized or is not clear, and needs are constantly
onstrated through Altschul’s pioneering research
636 UNIT V Middle Range Nursing Theories Major Assumptions
changing (Jackson & Stevenson, 2004, p. 35). Profes-
sional nursing performance is described in three roles Two basic assumptions underpin the Tidal Model.
identified as (1) ordinary-me, (2) pseudo-ordinary/ First, “change is the only constant.” Nothing lasts. All
engineered-me, and (3) professional-me. Relation- human experience involves flux, and people are con-
ships are fluid, requiring nurses to “toggle” or switch stantly changing. This suggests the value of helping
back and forth from highly professional to distinctly people become more aware of how change is happen-
ordinary presentations of self, and all relationships ing within and around them in the “now” (Barker &
differ depending upon the required role (Jackson & Buchanan-Barker, 2004a). Second, people are their
Stevenson, 1998, 2000). The “pseudo-ordinary or stories. They are no more and no less than the com-
engineered-me is likened to a see-saw” (Jackson & plex story of their lived experience. The person’s story
Stevenson, 2004, p. 41). Sometimes people need is framed in the first person, and the story of how they
someone to take care of them, other times someone came to be here experiencing this ‘problem of living’
to take care with them (Barker, Jackson, & Stevenson, contains the raw material for solutions (Barker &
1999a; 1999b). The studies suggested that nurses Buchanan-Barker, 2004a).
respond sensitively to persons’ and their families’
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
holds the system together (Stevenson & Fletcher, (Barker & Whitehill, 1997, p. 15).
2002, p. 30). • Persons and those around them already possess
The second study focused on the nature of em- the solutions to their life problems.
powerment and how this is enacted in relationship • Nursing is about drawing out these solutions
between nurses and persons-in-care and resulted
in the Empowering Interactions Model (Barker, (Barker, 1995, p. 12).
Stevenson, & Leamy, 2000). This was developed with The Tidal Model assumes that when people are
Flanagan’s Critical Incident Technique (Flannagan, caught in the psychic storm of “madness,” it is
1954) within a cooperative inquiry method (Heron, “as if ” they risk drowning in their distress or foun-
1996), using a modified grounded theory approach dering on the rocks; it is “as if ” they have been
(Glaser & Strauss, 1967). The study developed boarded by pirates and have been robbed of some of
Peplau’s assumptions about the importance of spe- their human identity; it is “as if ” they have been
cific interpersonal transactions, and it provided washed ashore on some remote beach, far from
guidance and strategies for nurses within collabora- home and alienated from all that they know and
tive nurse-person relationships. Strategies included understand.
the following:
• Being respectful of people’s knowledge and expertise Nursing
“Nurses are involved in the process of working with
about their own health and illness people, their environments, their health status and
• Putting the person in the driver’s seat in relation to their need for nursing” (Barker, 1996a, p. 242). Nurs-
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, &
Ward, 1995, p. 390). Nursing as nurturing exists only
experience when the conditions necessary for the promotion of
• Finding a common language to describe the situation growth or development are put in place (Buchanan-
• Taking stock Barker & Barker, 2008). Nursing is “an enduring
• Reviewing collaboratively, and inspiring hope human interpersonal activity and involves a focus on
through designing a realistic future together
the promotion of growth and development” (Barker CHAPTER 32 Phil Barker 637
& Whitehill, 1997, p. 17) and present and future
direction (Barker & Buchanan-Barker, 2007a). Barker Person
extended Peplau’s original definition, clarifying the Within the Tidal Model, interest is directed toward a
purpose of nursing as trephotaxis from the Greek: phenomenological view of the person’s lived experi-
“the provision of the necessary conditions for the ence, and his or her story. “Persons are natural philoso-
promotion of growth and development” (Barker, phers and meaning makers devoting much of their lives
1989, 2009). He emphasizes the distinction between to establishing the meaning and value of their experi-
“psychiatric” and “mental health” nursing. When ence and to constructing explanatory models of the
nurses help people explore their distress, in an attempt world and their place in it” (Barker, 1996b, p. 4). Nurses
to discover ways of remedying or ameliorating it, they are able to see and appreciate the world from the per-
are practicing psychiatric nursing. When nurses help son’s perspective and share this with the person. People
the same people explore ways of growing and develop- are their stories. “The person’s sense of self and the
ing, as persons, exploring how they presently live world of experience, including the experience of others
with and might move beyond their problems of is inextricably tied to their life stories and the various
living, they are practicing mental health nursing. meanings they have generated” (Barker, 2001c, p. 219).
(Barker, 2003a; 2009). People are in a constant state of flux, with great capacity
for change (Buchanan-Barker & Barker, 2008) and
Nursing is a human service offered by one group engaged in the process of becoming (Barker, 2000c).
of human beings to another. There is a power dy- They live within their world of experience represented
namic in the “craft of caring,” one person has a duty in three dimensions: (1) world, (2) self, and (3) others.
to care for another (Barker, 1996b, p. 4). Nursing is a
practical endeavor focused on identifying what peo- Life is a developmental voyage, and people travel
ple need now; collaboratively exploring ways of across their “ocean of experience.” This voyage of dis-
meeting those needs; and developing appropriate covery and exploration can be risky, and people have
systems of human care (Barker, 1995, 2003a). The both a fundamental need for security and a capacity to
proper focus of nursing is the “need” expressed by adapt to changing circumstances. The “journey across
the person-in-care, which “can only be defined as our ocean of experience depends on our physical body
a function of the relationship between a person-with- on which we roll out the story of our lives” (Barker &
a-need-for-nursingand a person-who-has-met-that- Buchanan-Barker, 2007a, p. 21). The Tidal Model
need”. (Barker, 1996a, p. 241; Barker, Reynolds, & “holds few assumptions about the proper course of
Ward, 1995, p. 389). These responses are the phe- a person’s life” (Barker, 2001a, p. 235). Persons are
nomenological focus of nursing (Barker, Reynolds, & defined in relations, for example, as someone’s mother,
Ward, 1995, p. 394; Peplau, 1987); a focus on human father, daughter, son, sister, brother, friend and also in
responses to actual or potential health problems relation with nurses.
(American Nurses Association, 1980). These may
range across behavior, emotions, beliefs, identity, Health
capability, spirituality, and the person’s relationship Barker provides the provocative definition of health
with the environment (Barker, 1998a). put forth by Illich (1976) as “the result of an au-
tonomous yet culturally shaped reaction to socially-
Nursing’s exploration of the human context of be- created reality. It designates the ability to adapt to
ing and caring supports nursing as a form of human changing environments, to growing up . . . to heal-
inquiry. Being with and caring with people is the pro- ing when damaged, to suffering and to the peaceful
cess that underpins all psychiatric and mental health expectation of death. Health embraces the future . . . in-
nursing, and this process distinguishes nurses from all cludes the inner resources to live with it (p. 273).
other health and social care disciplines (Barker, 1997). Health is a personal task where success is “in large
“Nursing complements other services and is congru- part the result of self-awareness, self-discipline,
ent with the roles and functions of other disciplines in and inner resources by which each person regulates
relation to the person’s needs” (Barker, 2001c, p. 216). his/her own daily rhythms and actions, his/her
diet, and his/her sexuality” (Illich, 1976, p. 274).
638 UNIT V Middle Range Nursing Theories settings, from day rooms of hospital wards to the
living room or kitchen of the person’s own home
Our personhood, connections, and fragility “make (Barker, 1996b). With critical interventions, nurses
the experience of pain, of sickness, and of death an make the person and the environment safe and
integral part of life” (Illich, 1976, p. 274). Illich’s secure. Engagement is critical, and the social environ-
(1976) description illustrates both the chaotic and ment is critical for engagement. When people are
Zen sense of “reality.” “Health is not ‘out-there,’ it is deemed to be at risk, they need to be detained in a
not something to be pursued, gained or delivered safe and supportive environment, a safe harbor until
(health-care). It is a part of the whole task of being they return to their ocean of experience in the com-
and living” (Barker, 1999b, p. 240). munity (Barker, 2003a). “Nurses organize the kind of
conditions that help to alleviate distress and begin the
“Health means whole . . . and is likely linked to longer term process of recuperation, resolution or
the way we live our lives, in the broadest sense. This learning. They help persons to feel the ‘whole’ of their
‘living’ includes the social, economic, cultural and experience . . . and engender the potential for heal-
spiritual context of our lives” (Barker, 1999b, p. 48). ing” (Barker, 2003a, p. 9).
The experience of health and illness is fluid. Within a
holistic view, people have their own individual mean- Theoretical Assertions
ings of health and illness that we value and accept.
Nurses engage with people to learn their stories and The Tidal Model is based upon four premises concern-
their understanding of their current situation, includ- ing practice, which Barker developed in the mid-1990s
ing relationships with health and illness within their with the “expert nurse” focus group (Barker, 1997).
worldview (Barker, 2001c). Ill health or illness almost These premises were validated by a group of former
always involves a spiritual crisis or a loss of self psychiatric patients led by Barker’s colleague of many
(Barker, 1996a). A state of disease is a human problem years, the mental health service user and activist,
with social, psychological, and medical relations, a Dr. Irene Whitehill.
whole life crisis. Nursing with the Tidal Model is prag- • Psychiatric nursing is an interactive, developmen-
matic and focused upon persons’ strengths, resources,
and possibilities, maintaining a health orientation; the tal human activity, more concerned with the future
Tidal Model is a healthy theory. development of the person than the origins or
Environment cause of their present mental distress.
The environment is largely social in nature, the con- • The experience of mental distress associated with
text in which persons travel within their ocean of psychiatric disorder is represented through pub-
experience, and nurses create “space” for growth and lic disturbance or reports of private events that
development. “Therapeutic relationships are used in are known only to the person concerned. Nurses
ways that enhance persons’ relationships with their help people access, review, and re-author these
environment” (Montgomery & Webster, 1993, p. 7). experiences.
Human problems may derive from complex person- • Nurses and the people-in-care are engaged in a
environment interactions in the chaos of the every- relationship based upon mutual influence. Change
day world (Barker, 1998b). “Persons live in a social is constant, and within relationships there are
and material world where their interaction with the changes in the relationship and within the partici-
environment includes other people, groups, and or- pants in the relationship.
ganizations” (Barker, 2003a, p. 67). Family, culture, • The experience of mental illness is translated into
and relationships are integral to this environment. a variety of disturbances of everyday living and
Vital areas of everyday living, including housing, human responses to problems in living (Barker &
financing, occupation, leisure, and a sense of place and Whitehill, 1997).
belonging are areas of environment (Barker, 2001c). These premises are framed within the wider philo-
sophical and theoretical perspective, especially the
The divide between community and institution is phenomenological assertion that people own their
artificial and rejected as needs flow with the person experience; only persons can know their experience
across these boundaries. Much psychiatric and men-
tal health nursing takes place in the most mundane of
and what it means. Mental distress is a symbolic force, CHAPTER 32 Phil Barker 639
which is known only, in phenomenological terms, to
the person involved. The lived experience is the me- The theory classifies a body of nursing knowledge
dium through which we receive important messages that is largely story-based. The components are clearly
about our life and its meaning (Barker, 2001c). Barker presented and logically derived from clinical observa-
views mental distress as part of the whole of the tion, practice, theory, research, and philosophy.
person, not something split off from their “normal”
being. The emergent evidence from users of the theory in
the UK, Ireland, Canada, and New Zealand confirms
The Tidal Model assumes and asserts that people the importance of the simple affirmation of the per-
know what their needs are, or can be helped to recog- sonal story, with its emphasis on understanding what
nize or acknowledge them over time. From that is happening for and to the person, and what this
minimally empowered position, people may be means for persons in their own language. Stories gen-
helped to meet these needs in the “short” term. What erated within the caring context are written in the
nurses and everyone else in the person’s social world person’s own voice, helping the person to “take back”
relate to is the expressed behavior. Mental illness is the personal story, which has been lost from view
disempowering, and “people who experience any of by becoming a “patient” or “client.” Even when the
the myriad threats to their personal or social identi- person is severely disabled by problems of living, the
ties, commonly called mental illnessor mental health nurse keeps the focus on helping the person deter-
problems, experience a human threat that renders mine “what needs to be done” and on finding the
them vulnerable.” However, “most people are suffi- personal and interpersonal resources necessary to be
ciently healthy to be able to act for themselves and to empowered.
influence constructively the direction of their lives”
(Barker, 2003a, pp. 6–7). Recovery is possible, and The attempt to understand persons’ constructions
people have the personal and interpersonal resources of their world is expressed through the holistic as-
that enable this recovery process (Barker, 2001c). sessment that helps persons to relate their story and
explore what needs to be done. Care planning is a
Logical Form collaborative exercise with emphasis on developing
an awareness of change and revealing solutions. The
The Tidal Model is logically adequate, the structure of celebration of personhood and the holistic narrative
relationships is clear, and the concepts are precise, approach creates a style of practice of working
developed, and developing. It contains broad ideas, collaboratively with people. It emphasizes persons’
addresses many situations of persons with problems inherent resources and acknowledges change as an
in living, follows the “logic of experience” (Barker, enduring characteristic.
1996b), and develops “practice-based evidence”
(Barker & Buchanan-Barker, 2005). Acceptance by the Nursing Community
Barker and colleagues constructed a metatheory of The Tidal Model appeals to those interested in per-
psychiatric and mental health nursing. Questions son-centered care and theory-based practice. The
about the nature of persons, problems in living, and literature illustrates the wide acceptance and use of
nursing were followed with systematic inquiry. The the theory in practice and in research. Acceptance
theory informs and is shaped by research. The Tidal of the theory is facilitated by the philosophical, theo-
Model flows from a particular philosophical perspec- retical, research, and practical base, along with clearly
tive and worldview that provides the context for beliefs stated values and principles.
about persons and nursing. Practice
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 recently, projects have been established in child and
support teams, and one 24-hour facility in the com- adolescent care in Sydney, with a new development
munity (Barker & Buchanan-Barker, 2005). The Tidal in the area of “justice health.” In New Zealand,
Model became international as interest spread in nurses at Rangipapa in Porirua were the first to
the United Kingdom first to Ireland, then throughout introduce the Tidal Model into a forensic setting
the world. and the first to investigate the experience with the
model from the perspective of staff and clientele
Most of the early Tidal Model developmental work (Cook, Phillips, & Sadler, 2005). The Tidal Model’s
was undertaken in the United Kingdom, with projects emphasis on story has proven particularly attractive
ranging across hospital and community services, to the indigenous Maori and Pacific Islands people
from acute through rehabilitation, to specialist foren- of New Zealand, who greatly value the power of
sic services and community care. These ranged from storytelling. In Japan, the Model has been the focus
metropolitan services in cities like central London of a major development program for almost a de-
and Birmingham, where the clinical populations are cade at the Kanto Medical Center, the largest private
socially, culturally, and ethnically diverse, to Corn- psychiatric facility in Tokyo. Dr. Tsuyoshi Akayama,
wall, Glamorgan, and Norfolk, where people from the lead psychiatrist, translated the Tidal Model
rural English and Welsh communities were served. training materials into Japanese and then taught his
The most extensive project was in Scotland, where medical and nursing colleagues how to use the
since 2003 the Glasgow mental health services oper- Model, following his short study tour in Newcastle
ated a series of Tidal projects, embracing acute, reha- with Dr. Barker. This was the first formal collabora-
bilitation, adolescent, and elder care, in what was the tion between psychiatrists and nurses—as nurses
largest mental health service in the UK (Lafferty & had led the implementation in the earlier projects.
Davidson, 2006). By 2012, the Glasgow projects had Dr. Akayama has promoted consideration of the
extended to include Greenock, Inverclyde, Paisley, Tidal Model within the “developing nations” pro-
and Ayrshire, representing more than a third of the gram of the World Psychiatric Association. The
overall population of Scotland. Japanese have set a trend for greater interprofes-
sional collaboration, albeit with nursing taking the
The Republic of Ireland established a wide range of lead role.
projects in County Cork, County Mayo and Dublin,
ranging across hospital and community settings. The Tidal Model of Mental Health Recovery is
Cork City, Ireland, was the first to introduce and directed toward understanding and explaining fur-
develop the Tidal Model within community mental ther the human condition. Central to this effort is
health care at Tosnu—Gaelic for “fresh start.” helping people use their voices as the key instrument
for charting their recovery from mental distress. The
At the Royal Ottawa Mental Health Centre in Tidal Model is a person-centered model of mental
Canada, three programs implemented the Tidal health care delivery, which is respectful of culture
Model in September 2002. The Forensic and Mood and creed (Barker & Buchanan-Barker, 2005). This
programs include inpatient wards and outpatient practical theory identifies the concepts necessary to
components. The Substance Use and Concurrent understand the human needs of people with prob-
Disorders Program includes an inpatient ward, out- lems in living, and how and what nurses might do
patient nursing, a day hospital, and a residential pro- to address those needs. The theory systematically
gram in the community and is the first program of its explains specific phenomena and suggests the nature
kind to implement the Tidal Model. In February of relationships within a particular worldview.
2004, the Tidal Model was introduced to remaining Barker, however, has consistently asserted that the
inpatient wards, including geriatric, crisis and evalua- theory is “no more than words on paper.” It is not a
tion, general psychiatry in transition, psychosocial reified work or recipe for practice, but a practical and
rehabilitation, schizophrenia, and youth (adoles- evolving guide for delivering collaborative, person-
cents). Across Canada, also there has been much centered, strength-based, and empowering care
interest in the Tidal Model. It has been implemented through relationship.
or is in progress in facilities from coast to coast.
In Australia, the Model was first introduced in
Sydney followed by Townsville, Queensland. More
Education CHAPTER 32 Phil Barker 641
Barker and Buchanan-Barker offer a free training that correlated with the speed of assessment, and a
manual for download from their website (www. decrease in incidents of violence, self-harm, and use of
tidal-model.com). This package is used as the basic restraints. Nurses themselves reported that the Tidal
preparation for implementation of the model, ensur- Model enhanced professional practice and encour-
ing fidelity to the values, principles, and processes aged fuller engagement with persons-in-care. It was
of the Tidal Model, while allowing creative, locally useful in helping persons fulfill care plans and enabled
relevant implementation. nurses to focus their interactions on persons’ needs.
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
great promise for inclusion in educational programs Barker and Walker (2000) studied senior nurses’
concerned with theory-based practice and person- views of multidisciplinary teamwork in 26 acute psy-
centered care. chiatric admission units and the relationship to the
care of persons and their families. While nurses face
Research challenges in implementing “working in partnership,”
The Tidal Model developed from a clinical research the study provides some direction for further inquiry
program. All International Tidal Model network around the interprofessional nature of the theory.
members are encouraged to evaluate the model in
practice. A research and development consultancy The transition for nurses to a solution focus in
was established as a loose network for Tidal Model interactions was the subject of study by the Newcastle
implementation and development projects. The con- team (Stevenson, Jackson, & Barker, 2003). Nurses
sultancy provides a framework for evaluation of the participated in a specially tailored solution education
Tidal Model in action from the perspective of orga- initiative, and the impact was assessed for both nurses
nizational outcome, professional experience, and and persons-in-care using multiple data sources. This
user/consumer experience (Barker & Buchanan- study provides strong evidence of significant im-
Barker, 2005). The important task of evaluating provement in nurses’ solution-focused knowledge,
the implementation, processes, and outcomes of performance, and use in practice. Persons-in-care
the Tidal Model in practice is ongoing in Canada, also found the approach helpful.
Ireland, Japan, and New Zealand and across the
United Kingdom. The Royal Ottawa Mental Health Centre Tidal
team replicated the Newcastle study and assessed the
Two evaluation studies (Fletcher & Stevenson, impact of implementation of the Tidal Model on
2001; Stevenson & Fletcher, 2002) explored outcome selected outcome measures over four time periods in
measures important in evaluating the Tidal Model and the three pioneer programs, with similar results par-
evaluated the impact of the Tidal Model assessment in ticularly in the Mood program. They also replicated
practice (Stevenson & Fletcher, 2002). Results of both the Newcastle study over four time periods in the
studies indicate an increase in the number of admis- Forensic Program at the Brockville site. The Tosnu
sions and a decrease in the length of stay. There was a team completed a user-focused evaluation of the
decrease in need for the highest level of observation Tidal Model implementation. In Birmingham, on the
Tolkien ward, a 4-month evaluation has been com-
pleted and published (Gordon, Morton, & Brooks,
642 UNIT V Middle Range Nursing Theories care have expressed appreciation of the model and the
2005). Evaluation work is ongoing at St. Tydfil Hospital desire to bring it into their practice settings. Other
in Wales. professions support the values, philosophy, and utility
of the Tidal Model. Mental health user/consumer/
In New Zealand, a qualitative, hermeneutic, phe- survivor communities around the world are involved
nomenological study followed the implementation of in the continuing development of this mental health
the Tidal Model in a secure treatment unit (Cook, recovery theory (Barker & Buchanan-Barker, 2005).
Phillips, & Sadler, 2005). Five themes that reflected
meanings attached to providing and receiving care Since its inception, the Tidal Model has gained
emerged: relationships, hope, human face, leveling, national and international attention. It continues to
and working together, suggesting positive experiences be implemented, taught, and studied internationally,
and outcomes with implementation of the Tidal with new sites joining from around the world. In No-
Model. The Tidal Model is set in a research base that vember 2003, the Tidal Model was launched in North
provides the possibility of research utilization or America. As new sites implement and study the Tidal
the more contemporary knowledge transfer. Nurses Model, the practical, theoretical, and research base
practicing within the Tidal Model are actively using is enriched. In 2003, Barker reaffirmed the values
research in practice as well as contributing to the underlying the Tidal Model in the Ten Tidal Commit-
development of nursing practice. The Tidal Model has ments (see Box 32–1). They provide the necessary
potential for participatory action research, uncover- guidance to pursue and develop the philosophy of the
ing knowledge embedded in practice, and developing Tidal Model. Although Barker expects fidelity to the
new knowledge and understandings. principles and values of the Tidal Model (Ten Tidal
Commitments) in its implementation, he cautions
Barker and Buchanan-Barker emphasize that any against slavish importation. Rather, implementation
realistic study of the Tidal Model in practice must needs to be tailored to fit the local context, with the
focus on the “workings” of the team, both individu- result that each implementation will be unique and
ally and collectively. It must take into account the contribute to the theory’s development. This reflects
organizational context, the support available to the Barker’s appreciation of the concept of “practice-based
team, the quality of the environment, and the range evidence”—what he called the “art of the possible,”
of other physical, social, and interpersonal factors. that is, developing philosophically and theoretically
As practitioners begin to work in a Tidal way, key sound forms of practice that are based on consider-
research questions must focus on “what happens?” in ations of what is appropriate, meaningful, and poten-
Tidal practice. tially effective in any given practice context.
Further Development The Tidal Model is developing across cultures
noted above, with different clinical populations, in a
The Tidal Model is clear, concepts are defined, and variety of settings. The body of knowledge framed
relationships are identified. This enables the identifi- within the Tidal Model continues to develop, ac-
cation of areas for further theory development. For knowledging the wide range of complex factors that
example, Barker is reframing his original notion of define people and their human experiences—personal
the “logic of experience” as “practice-based evidence.” history, personal preferences, values and beliefs, social
Practice-based evidence represents the knowledge of status, cultural background, family affiliations, and
what is possible in this particular situation and what community membership (Barker, 2003a).
might contribute further to our shared understanding
of human helping (Barker & Buchanan-Barker, 2005). Critique
Clarity
Several other developments characterize the Tidal
Model. It has evolved from the initial acute, inpatient The concepts, subconcepts, and relationships are logi-
use across the continuum of care, with critical, transi- cally developed and clear, and the assumptions are
tional, and developmental components. The theory consistent with the theory’s goals. Words have multiple
has evolved to the Tidal Model of Mental Health Re- meanings; however, the major concepts, subconcepts,
covery and Reclamation, broadening both its scope
and utility. Colleagues in other fields such as palliative
and relationships are described carefully, specifically, CHAPTER 32 Phil Barker 643
and metaphorically, though not necessarily concisely.
It is Barker’s terms like “problems in living,” mental The Holistic Assessment, the person’s story, is at
distress, and view of people experiencing problems the heart of care planning and is represented as a
as “persons” that guide nurses to a proper focus. The heart. The circle of security assessment and plan sur-
identification of “human needs” rather than psycho- rounds the heart, all of which is surrounded by the
logical, social, or physical needs also provides clarity interprofessional team circle (Figure 32–2).
and focus. How nurses see persons and how persons
want to be nursed are clearly illustrated through The continuum of care (immediate, transitional,
the core category of “knowing you, knowing me.” and developmental) intersects with the focus of care
Three subcategories, ordinary me, pseudo-ordinary or (Barker, 2000e; Barker & Buchanan-Barker, 2007a)
engineered-me, and professional me each have four (Figure 32–3).
dimensions: depth of knowing, power, time, and
translation (Barker, Jackson, & Stevenson, 1999a; Barker and Buchanan-Barker (2007a) provide a
Jackson & Stevenson, 2004). map or overview of the continuum of care or voyage
of the person who enters, progresses through, and
In practice, using the person’s own language, rather exits the service (Figure 32–4).
than jargon or professional language, contributes to
the theory’s success and its clarity. Major concepts of This easily understood theory is accessible concep-
collaboration, empowerment, relationships, solution tually and linguistically through the use of everyday
focus, empowering through relationships, narrative, language.
and the use of “problems in living” are sufficiently Simplicity
clear and open the theory for use in other areas of The Tidal Model is based upon a few simple ideas
nursing and health care. about “being human” and “helping one another”
(Barker, 2000e). It is comprehensive, elegant in its
A number of concepts and relationships are pre- simplicity, and at a level of abstraction to guide prac-
sented elegantly and schematically within the Tidal tice, education, research, and policy. However, the
Model. The person’s unique lived experience is synergis- concepts themselves are complex, and the broad
tic and reciprocal among the World, Self, and Others, relationships among the concepts add to the com-
domains that are represented in a triangle (Figure 32–1). plexity of the Tidal Model; people and relationships
are inherently complex.
Person
Assumptions, concepts, and relationships are de-
Self Others scribed in everyday language and illuminated through
metaphor. For example, simply being respectful of the
World persons’ knowledge and expertise about their own
Person health and illness and listening to persons’ stories is
FIGURE 32-1 Three dimensions of personhood. (From empowering. Abstract and complex concepts or rela-
Barker, P. J., & Buchanan-Barker, P. (2007). The Tidal Model theory tionships are expressed metaphorically as in the ebb
and practice. (p. 38). Newcastle, UK: University of Newcastle. and flow of the tide. Practical and philosophical, the
Copyright Phil Barker & Poppy Buchanan-Barker, 2007.) Tidal Model provides some direction in operational-
izing or using the concepts, but it is careful not to
prescribe practice.
Generality
The Tidal Model is international in scope, suggesting
its relevance cross-culturally and cross-nationally. By
the beginning of 2004, there were almost 100 Tidal
Model projects in progress in different clinical set-
tings in a variety of countries around the world—
Australia, Canada, England, Ireland, Japan, New
Zealand, Scotland, and Wales (Barker, 2004; Barker
& 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 T he 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
Holistic Security
Exit Assessment Assessment
Transitional
Care Plan
Group work One-One Personal
1/2/3 Sessions Security
Planning
Immediate Care Plan
FIGURE 32-4 M ap 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
other disciplines and support general applicability. Barker acknowledges that in order to practice
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 Summary
Accessibility The Tidal Model developed from a discrete focus on
This substantive theory is grounded in data that psychiatric nursing in acute settings to a more flexible
emerged inductively from studies of the need for mental health recovery and reclamation model for any
nursing. Studies guided by the Tidal Model suggest its setting, relevant to any discipline. It emphasizes em-
utility and precision and provide confidence that the powering forms of engagement or bridging, the impor-
theory is useful, practical, and accessible. Studies of tance of the lived experience, and an appreciation of the
the impact of implementation of the theory in prac- potential for healing that lies within the re-authoring of
tice also support its utility and precision. The “need the story (Barker & Buchanan-Barker, 2004a).
for nursing,” the proper focus of nursing, and the
empowering interactions framework provide a strong The Tidal Model provides an orientation to practice
empirical base for the Tidal Model. that is research-based, holistic, and person-centered.
Keen (in Barker & Buchanan-Barker, 2005, pp. 231–241)
Nurses working with different clinical popula- describes a “deeply collaborative, person-centered, so-
tions and in a variety of settings are testing the lution-focused (McAllister, 2003), narrative-based,
Tidal Model in practice. The focus of inquiry is pragmatic, and systemic theory.” The theory describes
person-centered outcomes and the lived experience various assumptions about people, their inherent value,
of persons collaborating in care. Studies addressing and the value of relating to people in particular ways. It
the outcome orientation empower interactions that describes how people might come to appreciate differ-
contribute to empirical adequacy and confidence in ently, perhaps better, their own value and the unique
this solution-oriented perspective. value of their experience. The Tidal Model opens pos-
sibilities of new ways of being with people in relation.
Importance Perhaps some of its appeal is that it harkens back to
The Tidal Model has clearly illustrated that it pro- “our roots” and values, which brought us into nursing
vides direction and focus for nursing. The theory is in the first place. While the theory provides direction
accessible conceptually and linguistically and lends for practice, education, research, and policy, it is not
itself to research. This research, relevant to nurses’ easy. Nurses are aware of the challenge in making the
work, contributes knowledge to guide and inform shift to commit to change and to grow and develop in
practice. Studies guided by the Tidal Model also ex- enacting the essence of the Tidal Model, the Ten Tidal
plore its impact and a variety of outcomes. Narrative Commitments.
knowledge derived from the theory advances the
practice of nursing, nursing education, nursing CASE STUDY
research, and policy. The Tidal Model is represented Scott was a young man described as having a first
by a range of “holistic (exploratory) and focused episode psychosis. He had beaten his father, who
(risk) assessments which generate person-centered subsequently died. Scott was transferred to a secure
interventions that emphasize the person’s extant unit, where his primary nurse began to explore his
resources and capacity for solution-finding” (Barker, story with him through a Holistic Assessment,
2001b, p. 82). which represents Scott’s world of experience at this
moment in time.
Working with the Tidal Model has enabled nurses to
articulate their practice and “invisible skills” (Michael, How this began: “It all started when my father
1994). For example, empowerment strategies such as punched my mother again, he was totally drunk
respecting the person and inspiring hope also give voice that night. It was so noisy in that room, the T.V., the
to nurses themselves. Nurses gain confidence working banging, and those voices in my head, they kept
as interprofessional team members where their contri- yelling at me to do something fast to save my
bution and focus is clearly articulated. mother. I don’t remember exactly what had hap-
pened after. I was so confused.”
Challenges exist at a practical, personal, and sys-
tem level with any change, and these are anticipated
and addressed. However, the Tidal Model is an im-
portant and essential theory to develop and guide
practice in psychiatry and mental health care.
How this affected me: “I don’t know. I have CHAPTER 32 Phil Barker 647
been in jail for 4 months before coming here. They
told me I killed my father. I don’t remember much Humane Society right now.” “I have a really nice
except that I kept hammering his head; I just re- picture of me and my mom.”
member I was standing in a pool of blood.” “They
told me my mother is still in the hospital; I haven’t Ideas about life that are important: “Able to fit in.”
seen her since.” “I’m scared. I can’t sleep.” Evaluating the problems: “My main problems
are loneliness and what’s going to happen in my
How I felt in the beginning: It “just devastated future. My whole life is complex!” I would rate my
me, turned me upside down.” “I felt awful even loneliness as an 8 for distress, an 8 for disturbance,
though I hated him so much; he never listened to and a 2 for control. My future and what’s going to
me; no one ever listened to me or believes me.” “I happen would be a 10 for distress, a 10 for distur-
hate him because I watched him beating my bance, and I have no control, a zero.”
mother all my life.” How will I know the problem has been solved?
“I’ll know the problem has been solved maybe
How things have changed over time: “It got when the voices stop talking to me, when I get out
worse when my stepbrother ran away. My father of jail and out of the hospital.”
was a sinner, a drunk, wife beater, even conspired What needs to change for this to happen?
with the Communists. I was not allowed to leave “Maybe I need to take medication, maybe I just
the house except school, my mother stayed in all have to start talking to real people, not the voices.”
day to do farm work, he was the only one that ran The nurse recognized that Scott needed some
errands outside the house.” “I’ve always been a bit help to feel more emotionally secure. She engaged
scared and angry too.” him in a security assessment and they developed a
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,
his primary nurse shared her observation and
How do I feel now? “Well, I feel nervous, very asked Scott how it was helpful to him to spend so
shaky and scared. I don’t know what to expect, I much time lying on his bed, alone in the room.
don’t know what is going to happen.” “Confused, I Scott’s reply was, “The voices don’t bother me so
guess, and I’m tired.” much.” This opened a conversation, helping the
nurse begin to understand what this was like for
What do I think this means? “I don’t know, Scott and what might be helpful for him.
that was my question, maybe I will go back to jail, In another conversation, the primary nurse
maybe it means I needed help.” “It means I have a asked “the miracle question.” “Suppose that to-
lot of challenges to meet.” night, while you are asleep, the problem you have
was miraculously solved. How would you know?
What does all this say about me as a person? What would be the first difference you noticed
“I just want to be a better person, I want to be well, when you woke up?” Scott’s unexpected reply—
and I want to take care of my mother.” ”I’d have a friend.” By exploring—rather than
closing down—the narrative, the nurse began
What needs to happen now? “Well, I suppose to involve Scott in “what needed to be done” to
I’m here for an assessment.” help him.
The Holistic Assessment and the Personal
What do I expect the nurse to do for me? Security Plan represent the first steps in helping
“Continue to talk to me the way you are talking Scott reclaim ownership of the story of his diffi-
to me. No one ever talks to me like this. You are culties and/or distress: beginning to explore
listening, and it seems like you believe me. This is what action needs to be taken—by Scott and/or
so different from jail and anywhere else.” others—to reduce his distress and address his
The people who are important: “My mother is Continued
the only important person in this world. My step-
brother came back only for the money.”
Things that are important: “Well, able to share
with others.” “My dog—Pepper, but he is at the
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 part he has played (if any) in the develop- What questions might be asked in a security
ment of his problems and beginning to work out assessment? The security plan has two questions:
what needs to be done to begin to address them. What can I do that will help me to deal with my
When a person like Scott eventually moves present problems? And what help can others offer
outinto the everyday world, he will take with that I might find valuable? What might Scott’s
security plan look like?
CRITICAL THINKING ACTIVITIES 2. Where would you find support for each of the
Ten Tidal Commitments within your workplace?
1. Select three or four of the Ten Tidal Commit-
ments, and consider how these might be realized 3. What is the key Tidal question?
in your practice.
POINTS FOR FURTHER STUDY n Barker, P. J., & Buchanan-Barker, P. (2005). The
Tidal Model: A guide for mental health profession-
The Tidal Model website at www.tidal-model.com als. London: Brunner-Routledge.
enables accessibility to and connection with the inter-
national Tidal community. n Barker, P. J., & Buchanan-Barker, P. (2007a). The
n Barker, P. J. (2003b). The 10 Commitments: Essen- Tidal Model—Mental health recovery and recla-
mation. Newport-on-Tay, Scotland: Clan Unity
tial values of the Tidal Model. Retrieved from International.
http://www.tidal-model.com/Ten%20Commit-
ments.htm. n Buchanan-Barker, P., & Barker, P. (2008). The
n Barker, P. J. (2001b). The Tidal Model: Developing Tidal Commitments: Extending the value base of
a person-centered approach to psychiatric and mental health recovery. Journal of Psychiatric and
mental health nursing. Perspectives in Psychiatric Mental Health Nursing, 15, 93–100.
Care, 37(3), 79–87.
REFERENCES Barker, P. J. (1987). An evaluation of specific nursing interven-
tions in the management of patients suffering from manic-
Alanen, Y., Lehtinen, K., & Aaltonen, J. (1997). Need- depressive psychosis. Unpublished PhD thesis, Dundee
adapted treatment of new schizophrenic patients: Expe- Institute of Technology (University of Abertay), Scotland.
rience and results of the Turku project. Acta Psychiatrica
Scandanavica ,83, 363–372. Barker, P. J. (1989). Reflections on the philosophy of caring
in mental health. International Journal of Nursing Stud-
American Nurses’ Association. (1980). Nursing. A social ies, 26(2), 131–141.
policy statement. Kansas City, (MO): American Nurses’
Association.
Barker, P. J. (1995). Promoting growth through community CHAPTER 32 Phil Barker 649
mental health nursing. Mental Health Nursing, 15(3), Barker, P. J. (2002b). Doing what needs to be done: A
12–15.
respectful response to Burnard and Grant. Journal
Barker, P. J. (1996a). Chaos and the way of Zen: Psychiatric of Psychiatric and Mental Health Nursing, 9,232–236.
nursing and the “uncertainty principle.” Journal of Psy- Barker, P. J. (Ed.). (2003a). Psychiatric and mental health
chiatric and Mental Health Nursing, 3, 235–243. nursing. The craft of caring. London: Arnold.
Barker, P. J. (2003b). The 10 Commitments: Essential values of
Barker, P. J. (1996b). The logic of experience: Developing the Tidal Model. Retrieved from http://www.tidal-model.
appropriate care through effective collaboration. Aus- com/Ten%20Commitments.htm.
tralian and New Zealand Journal of Mental Health Barker, P. J. (2004). Uncommon sense—The Tidal Model of
Nursing, 5, 3–12. mental health recovery. The New Therapist, 33(Sept/Oct),
14–19.
Barker, P. J. (1997). Towards a meta-theory of psychiatric Barker, P. J. (Ed). (2009). Psychiatric and mental health
nursing. Mental Health Practice, 1(4), 18–21. nursing: The craft of caring (2nd ed.). London: Arnold.
Barker, P., & Buchanan-Barker, P. (2004a). Beyond empow-
Barker, P. J. (1998a). It’s time to turn the tide. Nursing erment: Revering the storyteller. Mental Health Practice,
Times, 94(46), 11–12. 7(5), 18–20.
Barker, P. J., & Buchanan-Barker, P. (2004b). Spirituality
Barker, P. J. (1998b). The future of the Theory of Interper- and mental health: Breakthrough. London: Whurr.
sonal Relations? A personal reflection on Peplau’s legacy. Barker, P. J., & Buchanan-Barker, P. (2005). The Tidal
Journal of Psychiatric and Mental Health Nursing, 5, Model: A guide for mental health professionals. London:
213–220. Brunner-Routledge.
Barker, P. J., & Buchanan-Barker, P. (2007a). The Tidal
Barker, P. J. (1999a). Qualitative research in nursing and Model—Mental health recovery and reclamation.
health care. London: NT Books. Newport-on-Tay, Scotland: Clan Unity International.
Barker, P. J., & Buchanan-Barker, P. (2007b). Words of wis-
Barker, P. J. (Ed.). (1999b). The philosophy and practice dom. Nursing Standard, 21(37), 24–25.
of psychiatric nursing. Edinburgh, Scotland: Churchill Barker P, Campbell P., & Davidson B. (1999). From the
Livingstone. Ashes of Experience: Reflections on madness, recovery
and growth. London: Whurr.
Barker, P. J. (2000a). Commentaries and reflections on Barker, P. J., & Jackson, S. (1997). No apologies for “impe-
mental health nursing in the UK at the dawn of the rialist” view [Letter]. Nursing Standard, 11(20), 10.
new millennium: Commentary 1. Journal of Mental Barker, P., Jackson, S., & Stevenson, C. (1999a). The need
Health, 9(6), 617–619. for psychiatric nursing: Toward a multidimensional
theory of caring. Nursing Inquiry, 6, 103–111.
Barker, P. J. (2000b). From chaos to complex order: Barker, P. J., Jackson, S., & Stevenson, C. (1999b). What are
Personal values and resources in the process of psychiatric nurses needed for? Developing a theory of
psychotherapy. Perspectives in Psychiatric Care, essential practice. Journal of Psychiatric and Mental
36(2), 51–57. Health Nursing, 6, 273–282.
Barker, P. J., Reynolds, W., & Stevenson, C. (1997). The hu-
Barker, P. J. (2000c). Reflections on caring as a virtue ethic man science basis of psychiatric nursing: Theory and
within an evidence-based culture. International Journal practice. Journal of Advanced Nursing, 25, 660–667.
of Nursing Studies, 37, 329–336. Barker, P. J., Reynolds, W., & Ward, T. (1995). The proper fo-
cus of nursing: A critique of the caring ideology. Interna-
Barker, P. J. (2000d). The Tidal Model—Humility in mental tional Journal of Nursing Studies, 32(4), 386–397.
health care. Retrieved from http://www.tidal-model. Barker, P. J., Stevenson, C., & Leamy, M. (2000). The philoso-
com/Humility%20in%20mental%20health%20care.htm. phy of empowerment. Mental Health Practice, 20(9), 8–12.
Barker, P. J., & Walker, L. (2000). Nurses’ perceptions of
Barker, P. J. (2000e). The Tidal Model: Theory and practice. multidisciplinary teamwork in acute psychiatric set-
Newcastle, UK: University of Newcastle. tings. Journal of Psychiatric and Mental Health Nursing,
7, 539–546.
Barker, P. J. (2001a). The Tidal Model: Developing an em- Barker, P. J., & Whitehill, I. (1997). The craft of care:
powering, person-centred approach to recovery within Towards collaborative caring in psychiatric nursing.
psychiatric and mental health nursing. Journal of Psy-
chiatric and Mental Health Nursing, 8, 233–240.
Barker, P. J. (2001b). The Tidal Model: Developing a person-
centered approach to psychiatric and mental health
nursing. Perspectives in Psychiatric Care, 37(3), 79–87.
Barker, P. J. (2001c). The Tidal Model: The lived experience
in person-centred mental health nursing. Nursing Phi-
losophy, 2, 213–223.
Barker, P. J. (2002a). Annie Altschul—An appreciation.
Journal of Psychiatric and Mental Health Nursing, 9,
127–128.
650 UNIT V Middle Range Nursing Theories McAllister, M. (2003). Doing practice differently: Solution-
In S. Tilley, (Ed.). The mental health nurse. Views of focused nursing. Journal of Advanced Nursing, 41(6),
practice and education. (pp. 15–27). Oxford: Black- 528–535.
well Science.
Michael, S. P. (1994). Invisible skills: How recognition and
Buchanan-Barker, P. (2004). The Tidal Model: Uncommon value need to be given to the “invisible skills”
sense. Mental Health Nursing, 24(3), 6–10. frequently used by mental health nurses, but often
unrecognized by those unfamiliar with mental health
Buchanan-Barker, P., & Barker, P. (2005). The ten com- nursing. Journal of Psychiatric and Mental Health
mitments: A value base for mental health recovery. Nursing, 1, 56–57.
Journal of Psychosocial & Mental Health Nursing,
44(9), 29–33. Miller, J. (Ed.). (1983). Objections to psychiatry: Dialogue
with Thomas Szasz. In J. Miller (Ed.), States of mind:
Buchanan-Barker, P., & Barker, P. (2008). The Tidal Com- Conversations with psychological investigators. London:
mitments: Extending the value base of mental health British Broadcasting.
recovery. Journal of Psychiatric and Mental Health
Nursing, 15, 93–100. Montgomery, C., & Webster, D. (1993). Caring and nursing’s
metaparadigm: Can they survive the era of managed
Cook, N., Phillips, B., & Sadler, D. (2005). The Tidal care. Perspectives in Psychiatric Care, 29(4), 5–12.
Model as experienced by patients and nurses in a re-
gional forensic unit. Journal of Psychiatric and Mental Morita, M., Kondo, A., Levine, P., & Morita, S. (1998).
Health Nursing, 12, 536–540. Morita Therapy and the true nature of anxiety-based
disorders (Shinkeishitsu). Princeton, (NJ): University
De Shazer, S. (1994). Words were originally magic. New York: of New York.
Norton.
Peplau, H. E. (1952). Interpersonal relations in nursing.
Flannagan, J. C. (1954). The critical incident technique. New York: Putman (reissued 1988. London: MacMillan.)
Psychological Bulletin, 51, 327–358.
Peplau, H. E. (1969). Theory: The professional dimension.
Fletcher, E., & Stevenson, C. (2001). Launching the Tidal In C. M. Norris (Ed.), Proceedings of the first nursing
Model in an adult mental health programme. Nursing theory conference. (pp. 33–46). Kansas City: University
Standard, 15(49), 33–36. of Kansas Medical Center, Department of Nursing
Education.
Glaser, B. G., & Strauss, A. L. (1967). The discovery of
grounded theory: Strategies for qualitative research. Peplau, H. (1987). Interpersonal constructs for nursing
Chicago: Aldine/Atherton. practice. Nurse Education Today, 7, 201–208.
Gordon, W., Morton, T., & Brooks, G. (2005). Launching Podvoll, E. M. (1990). The seduction of madness: Revolu-
the Tidal Model: Evaluating the evidence. Journal of tionary insights into the world of psychosis and a com-
Psychiatric and Mental Health Nursing, 12, 703–712. passionate approach to recovery at home. New York:
Harper Collins.
Heron, J. (1996). Cooperative inquiry: Research into the hu-
man condition. London: Sage. Registered Nurses’ Association of Ontario. (2006). Best
practice guideline: Client-Centred Care. Toronto,
Illich, I. (1976). Limits to medicine: Medical nemesis—The Canada: Author.
expropriation of health. London: Marion Boyars.
Stevenson, C. (1996). The Tao, social constructivism and
Jackson, S., & Stevenson, C. (1998). The gift of time from psychiatric nursing practice and research. Journal of
the friendly professional. Nursing Standard, 12, 31–33. Psychiatric and Mental Health Nursing, 3, 217–224.
Jackson, S., & Stevenson, C. (2000). What do people need Stevenson, C., Barker, P., & Fletcher, E. (2002). Judgement
psychiatric and mental health nurses for? Journal of days: Developing an evaluation for an innovative nurs-
Advanced Nursing, 31(2), 378–388. ing model. Journal of Psychiatric and Mental Health
Nursing, 9, 271–276.
Jackson, S., & Stevenson, C. (2004). How can nurses meet
the needs of mental health clients? In D. Kirby, D. Hart, Stevenson, C., & Fletcher, E. (2002). The Tidal Model: The
D. Cross, & G. Mitchell (Eds.), Mental health nursing— questions answered. Mental Health Practice, 5(8), 29–38.
Competencies for practice. (pp. 32–45). Hampshire, UK:
Palgrave MacMillan. Stevenson, C., Jackson, S., & Barker, P. (2003). Finding
solutions through empowerment: A preliminary study
Jonsson, B. (2005). Ten thoughts about time. London: of a solution-oriented approach to nursing in acute
Constable and Robinson. psychiatric settings. Journal of Psychiatric and Mental
Health Nursing, 10, 688–696.
Kilmer, D. L., & Lane-Tillerson, C. (2013). When still
waters become a soul tsunami: Using the Tidal Model Szasz, T. S. (1961). The myth of mental illness: Foundations of
to recover from shipwreck. Journal of Christian a theory of personal conduct. New York: Hoeber-Harper.
Nursing, 30(2), 100–104.
Lafferty, S., & Davidson, R. (2006). Putting the person
first. Mental Health Today, (March), 31–33.
CHAPTER 32 Phil Barker 651
Szasz, T. S. (2000). The case against psychiatric power. Webster D., Vaughn, K., & Martinez, R. (1994). Intro-
In. P. J. Barker & C. Stevenson (Eds.). The construction ducing solution-focused approaches to staff in inpa-
of power and authority in psychiatry. Oxford, UK: tient settings. Archives of Psychiatric Nursing, 8(4),
Butterworth-Heinemann. 254–261.
Travelbee, J. (1969). Intervention in psychiatric nursing: Process World Health Organization. (1986). The Ottawa charter
in the one-to-one relationship. Philadelphia: F. A. Davis. for health promotion. Geneva, Switzerland: Author.
Vicenzi, A. E. (1994). Chaos theory and some nursing con- Yeats, W. B. (1928). The tower. New York: Macmillan.
siderations. Nursing Science Quarterly, 7,32–44.
BIBLIOGRAPHY Book Chapters
Barker, P. J. (1990). Professional stress. In D. F. S. Cormack
Primary Sources
Books (Ed.), Developing your career in nursing. London:
Barker, P. J. (1985). Patient assessment in psychiatric nursing. Chapman & Hall.
Barker, P. J. (1992). Understanding people—Problems
London: Croom Helm. of development: Stress and distress. In H. Wright
Barker, P. J. (1997). Assessment in psychiatric and mental & M. Giddey (Eds.), Mental health nursing: From
first principles to professional practice. (Chapter 11).
health nursing: In search of the whole person. Chelten- London: Chapman & Hall.
ham, UK: Stanley Thornes. Barker, P. J. (1996). The Interview. In D. F. S. Cormack
Barker, P. J. (1999). The philosophy and practice of psychiat- (Ed.), The research process in nursing (3rd ed.). Oxford,
ric and mental health nursing. Edinburgh, Scotland: UK: Blackwell Scientific.
Churchill Livingstone. Barker, P. J. (1997). Counseling for behavioural change.
Barker, P. J. (1999). The talking cures: A guide to the psycho- In P. Burnard & I. Hulatt (Eds.), Nurses counseling: The
therapies for health care professionals. London: NT Books. view from the practitioners. Oxford, UK: Butterworth-
Barker, P. (2000). Qualitative research in nursing and Heinemann.
health care. Nursing Times Clinical Monographs Barker, P. J. (1998). Advanced practice in mental health nurs-
(No 13). London: NT Books. ing: Developing the core. In G. Rolfe & P. Fulbrook (Eds.),
Barker, P. J. (2000). The Tidal Model: Theory and practice. Advanced nursing practice. Oxford, UK: Butterworth-
Newcastle, UK: University of Newcastle. Heinemann.
Barker, P. J. (2003). Psychiatric and mental health nursing: Barker, P. J. (1998). Psychiatric nursing. In A. C. Butterworth,
The craft of caring. London: Arnold. J. Faugier, & P. Burnard (Eds.), Clinical supervision and
Barker, P. J. (2009). Psychiatric and mental health nursing: mentorship in nursing. Cheltenham, UK: Stanley Thornes.
The craft of caring. (2nd ed.). London: Arnold. Barker, P. J. (1999). History, truth and the politics of
Barker, P. J. (2004). Assessment in psychiatric and mental madness. In P. J. Barker & C. Stevenson (Eds.), The
health nursing: In search of the whole person. (2nd ed.). construction of power and authority in psychiatry.
London: Nelson-Thornes. Oxford, UK: Butterworth-Heinemann.
Barker, P. J., & Baldwin, S. (Eds.). (1991). Ethical issues in Barker, P. J. (1999). The construction of mind and mad-
mental health. London: Croom Helm. ness: From Leonardo to the Hearing Voices Network.
Barker, P. J., & Buchanan-Barker, P. (2004). Spirituality and In P. J. Barker & C. Stevenson (Eds.), The construction
mental health: Breakthrough. London: Whurr. of power and authority in psychiatry. Oxford, UK:
Barker, P. J., & Buchanan-Barker, P. (2005). The Tidal Butterworth-Heinemann.
Model: A guide for mental health professionals. London: Barker, P. J. (2001). Working with the metaphor of life and
Brunner-Routledge. death. In D. Kirklin & R. Richardson (Eds.), Medical
Barker, P. J., Campbell, P., & Davidson, B. (1999). From humanities: A practical introduction. London: Royal
the ashes of experience: The experience of recovery from College of Physicians.
psychosis. London: Whurr. Barker, P. J. (2004). Who cares any more, anyway? In
Barker, P. J., & Davidson, B. (1998). Psychiatric nursing: S. Wilshaw (Ed.), Consultant nursing in mental health.
Ethical strife. London: Arnold. Sussex, UK: Kingsham Press.
Barker, P. J., & Kerr, B. (2001). The process of psychotherapy. Barker, P. (2008). Foreword. In J. Morrissey, B. Keogh,
Oxford, UK: Butterworth-Heinemann. & L. Doyle (Eds.), Psychiatric/mental health
Barker, P. J., & Stevenson, C. (1999). The construction
of power and authority in psychiatry. Oxford, UK:
Butterworth-Heinemann.
652 UNIT V Middle Range Nursing Theories
nursing—Concepts, application, challenges and reflections: Architecture and Comportment: Architecture and Behav-
An Irish perspective. Dublin, Ireland: Gill & MacMillan. iour, 6(3), 233–244.
Barker, P. J., & Baldwin, S. (1991). Change not adjustment: Barker, P. J. (1990). The conceptual basis of mental health
The ethics of psychotherapy. In: P. J. Barker & S. Baldwin nursing. Nurse Education Today, 10, 339–348.
(Eds.), Ethical issues in mental health. London: Barker, P. J. (1990). The philosophy of psychiatric nursing.
Chapman & Hall. Nursing Standard, 3(12), 28–33.
Barker, P. J., & Buchanan-Barker, P. (2004). Spirituality Barker, P. J. (1993). The Peplau Legacy . . . Hildegard Peplau.
and mental health: An integrated dimension. In Nursing Times, 89(11), 48–51.
S. Ramon & J. Williams (Eds.), Mental health at the Barker, P. J. (1995). Seriously misguided. Nursing Times,
crossroads: The promise of the psychosocial approach. 92(34), 56–57.
Sussex, UK: Ashgate. Barker, P. J. (1996). Chaos and the way of Zen: Psychiatric
Barker, P. J., & Buchanan-Barker, P. (2006). The psycholog- nursing and the “uncertainty principle.”Journal of Psy-
ical impact of serious illness. In J. Cooper (Ed.), Step- chiatric and Mental Health Nursing, 3, 235–344.
ping into palliative care 1: Relationships and Barker, P. J. (1996). The logic of experience: Developing
responses. Oxford: Radcliffe. appropriate care through effective collaboration. Aus-
Barker, P. J., & Buchanan-Barker, P. (2008). Patiently, tell- tralian and New Zealand Journal of Mental Health
ing the story. In T. Warne & S. McAndrew (Eds.), Cre- Nursing, 5, 3–12.
ative approaches in health and social care education and Barker, P. J. (1997). Towards a meta theory of psychiatric
practice: Knowing me, understanding you. Basingstoke, nursing. Mental Health Practice, 1(4), 18–21.
UK: Palgrave Macmillan. Barker, P. J. (1998). Sharpening the focus of mental health
Barker, P. J., & Buchanan-Barker, P. (2008). Spirituality and nursing: Primary health care. Mental Health Practice,
mental health. In T. Turner & R. Tumney (Eds.), Criti- 1(7), 14–15.
cal issues in mental health. Basingstoke, UK: Barker, P. J. (1998). Solution-focused therapies. Nursing
Palgrave Macmillan. Times, 94(19), 53–55.
Barker, P. J., & Buchanan-Barker, P. (2008). [tr m. Barker, P. J. (1998). The future of Interpersonal Relations
Kayama]. The Tidal Model of Mental Health Recovery. Theory: A personal reflection on Peplau’s legacy.
In Kayama, Noda, Myamoto, & Ohyama (Eds.), Text- Journal of Psychiatric and Mental Health Nursing,
book of psychiatric nursing. Tokyo: Nankodo (Japanese). 5(3), 213–220.
Barker, P. J., Manos, E., Novak, V., & Reynolds, B. (1998). Barker, P. J. (1998). The humanistic therapies. Nursing
The wounded healer and the myth of mental well-being: Times, 94(6), 52–53.
Ethical issues concerning the mental health status of Barker, P. J. (2000). Commentaries and reflections on mental
psychiatric nurses. In P. J. Barker & B. Davidson (Eds.), health nursing in the UK at the dawn of the new millen-
Psychiatric nursing: Ethical strife. London: Arnold. nium. Journal of Mental Health, 9(6), 617–619.
Barker, P. J., & Whitehill, I. (1997). The craft of care: To- Barker, P. J. (2000). The Tidal Model of mental health care:
wards collaborative caring in psychiatric nursing. In Personal caring within the chaos paradigm. Mental
S. Tilley (Ed.), The mental health nurse: Views of prac- Health Care, 4(2), 59–63.
tice and education. Oxford, UK: Blackwell Science. Barker, P. J. (2000). The Tidal Model: The lived experience
Stevenson, C., & Barker, P. J. (1996). Negotiating boundar- in person-centred mental health care. Nursing Philoso-
ies: Reconciling differences in mental health teamwork. phy, 2(3), 213–223.
In N. Cooper, C. Stevenson, & G. Hale (Eds.), Integrat- Barker, P. J. (2000). The virtue of caring. International Jour-
ing Perspectives on Health. (pp. 47–56). Buckingham, nal of Nursing Studies, 37, 329–336.
UK: Open University Press. Barker, P. J. (2000). Turning the tide. Open Mind,
106(Nov/Dec), 10–11.
Journal Articles Barker, P. J. (2000). Working with the metaphor of life and
Barker, P. J. (1988). Reasoning about madness: The long death. Journal of Medical Ethics, 26, 97–102.
Barker, P. J. (2001). Psychiatric caring. Nursing Times,
search for the vanishing horizon (Part 2). Community 97(10), 38–39.
Psychiatric Nursing Journal, 8(5), 14–19. Barker, P. J. (2001). Response to Duncan-Grant. Journal of
Barker, P. J. (1989). Reflections on the philosophy of caring Psychiatric and Mental Health Nursing, 8, 180–183.
in mental health. International Journal of Nursing Stud- Barker, P. J. (2001). The ripples of knowledge and the
ies, 26(2), 131–141. boundaries of practice. International Journal of Psycho-
Barker, P. J. (1990). Needs and wants and fairy-tale therapy, 6(1), 11–23.
wishes: A Scottish impression of care in the community.
Barker, P. J. (2001). The Tidal Model: Developing an em- CHAPTER 32 Phil Barker 653
powering, person-centred approach to recovery within Barker, P. J., & Buchanan-Barker, P. J. (2003). Death by
psychiatric and mental health nursing. Journal of Psy-
chiatric and Mental Health Nursing, 8(3), 233–240. assimilation. Asylum, 13(3), 10–13.
Barker, P. J., & Buchanan-Barker, P. (2003). Schizophrenia:
Barker, P. J. (2001). The Tidal Model: Developing a person-
centred approach to psychiatric and mental health The “not-so-nice” guidelines [commentary]. Journal of
nursing. Perspectives in Psychiatric Care, 37(3), 79–87. Psychiatric and Mental Health Nursing, 10, 372–378.
Barker, P., & Buchanan-Barker, P. (2004). Beyond empow-
Barker, P. J. (2002). Annie Altschul: An appreciation. Journal erment: Revering the storyteller. Mental Health Practice,
of Psychiatric and Mental Health Nursing, 9(2), 127–128. 7(5), 18–20.
Barker, P., & Buchanan-Barker, P. (2004). Bridging: Talking
Barker, P. J. (2002). Doing what needs to be done: A respect- meaningfully about the care of people at risk. Mental
ful response to Burnard and Grant. Journal of Psychiatric Health Practice, 8(3), 12–15.
and Mental Health Nursing, 9, 232–236. Barker, P., & Buchanan-Barker, P. (2004). Caring as craft.
Nursing Standard, 19(9), 17–18.
Barker, P. J. (2002). Inspiration: My cousin Vinnie. Pendu- Barker, P., & Buchanan-Barker, P. (2004). Does the gold
lum: The Journal of the Manic Depression Fellowship, standard have feet of clay? Mental Health Nursing,
18(4), 11, 180–193. 23(3), 9–11.
Barker, P., & Buchanan-Barker, P. (2004). Experts without
Barker, P. J. (2002). The Tidal Model: The healing potential a voice. Nursing Standard, 18(50), 22–23.
of metaphor within the patient’s narrative. Journal of Barker, P., & Buchanan-Barker, P. (2005). Still invisible
Psychosocial Nursing and Mental Health Services, 40(7), after all these years: Mental health nursing on the mar-
42–50, 54–55. gins. Journal of Psychiatric and Mental Health Nursing,
12, 252–256.
Barker, P. J. (2003). Putting acute care in its place. Mental Barker, P., & Buchanan-Barker, P. (2006). More harm than
Health Nursing, 23(1), 12–15. good. Nursing Standard, 20(30), 28.
Barker, P., & Buchanan-Barker, P. (2006). Post-psychiatry:
Barker, P. J. (2003). The Tidal Model: Psychiatric coloniza- Good ideas, bad language and getting out of the box. Jour-
tion, recovery and the paradigm shift in mental health nal of Psychiatric and Mental Health Nursing, 13, 619–625.
care. International Journal of Mental Health Nursing, Barker, P., & Buchanan-Barker, P. (2006). Staying in touch.
12(2), 96–102. Nursing Standard, 21(1), 16–18.
Barker, P., & Buchanan-Barker, P. (2007). Words of wis-
Barker, P. (2004). Uncommon sense: The Tidal Model of Men- dom. Nursing Standard, 21(37), 24–25.
tal Health Recovery: The New Therapist, 33(Sept/Oct), 14– Barker, P. J., & Buchanan-Barker, P. (2010). The tidal
19. model of mental health recovery and reclamation:
Application in acute care settings. Issues In Mental
Barker, P. J. (2005). Missing pieces. Nursing Standard, Health Nursing 31, 171–80.
19(24), 26. Barker, P. J.& Buchanan-Barker, P. (2011). Mental health
nursing and the politics of recovery: A global reflec-
Barker, P. (2005). People make change happen. Mental tion. Archives of Psychiatric Nursing, 25, 350–358.
Health Practice, 8(5), 10–11. Barker, P. J., & Cutcliffe, J. (1999). Clinical risk: A need for
engagement not observation. Mental Health Practice,
Barker, P. (2005). Voices. Mental Health Practice, 9(3), 46. 2(8), 8–12.
Barker, P. (2006). 30th anniversary commentary on Crowe, Barker, P., & Cutcliffe, J. (2000). Creating a hopeline for
suicidal people: A new model for acute sector mental
M. (2000). Psychiatric diagnosis: Some implications for health nursing. Mental Health Care, 3(4), 190–192.
mental health nursing care. Journal of Advanced Nurs- Barker, P. J., & Jackson, S. (1996). No apology for ‘imperi-
ing, 31(3), 583–589. Journal of Advanced Nursing, 53(1), alist’ views. Nursing Standard, 11(20), 10.
132–133. doi: 10.1111/j. 1365–2648.2006.03692.x. Barker, P. J., & Jackson, S. (1997). Mental health nursing:
Barker, P. (2006). More harm than good. Nursing Standard, Making it a primary concern. Nursing Standard, 11(17),
20(30), 28–29. 39–41.
Barker, P. (2006). Voices. Mental Health Practice, 10(4), 39. Barker, P. J., Jackson, S., & Stevenson, C. (1999). The need
Barker, P. (2007). Voices. Mental Health Practice, 10(10), 38. for psychiatric nursing: Towards a multidimensional
Barker, P. J., & Baldwin, S. (1993). Speaking Out. Nursing theory of caring. Nursing Inquiry, 6, 103–111.
Times 89(8), 62.
Barker, P. J., Baldwin, S., & Ulas, M. (1989). Medical ex-
pansionism: Some implications for psychiatric nursing
practice. Nurse Education Today, 9, 192–202.
Barker, P. J., & Buchanan-Barker, P. J. (2003). Banning
“bonkers.” Openmind, 124(Nov/Dec), 26.
Barker, P. J., & Buchanan-Barker, P. (2003). Beyond em-
powerment: Revering the storyteller. Mental Health
Practice, 7(5), 18–20.
654 UNIT V Middle Range Nursing Theories Higgins, A., Barker, P. J., & Begley, C. M. (2006). Sexual
Barker, P. J., Jackson, S., & Stevenson, C. (1999). What are health education for people with mental problems:
What can we learn from the literature? Journal of
psychiatric nurses needed for? Developing a theory of Psychiatric and Mental Health Nursing, 13, 687–297.
essential nursing practice. Journal of Psychiatric and
Mental Health Nursing, 6(4), 273–282. Parsons, S., & Barker, P. J. (2001). The Phil Hearne Course:
Barker, P. J., Keady, J., Croom, S., Stevenson, C., Adams, An evaluation of a multidisciplinary mental health edu-
T., & Reynolds, B. (1998). The concept of serious men- cation programme. Journal of Psychiatric and Mental
tal illness: Modern myths and grim realities. Journal of Health Nursing, 7(2), 101–108.
Psychiatric and Mental Health Nursing, 5(4), 247–254.
Barker, P. J., Leamy, M., & Stevenson, C. (2000). The philoso- Simpson, A., & Barker, P. J. (2007). The persistence of
phy of empowerment. Mental Health Nursing, 20(9), 8–12. memory: Using narrative picturing to co-operatively
Barker, P. J., & Reynolds, W. (1994). A critique: Watson’s explore life stories in qualitative inquiry. Nursing
caring ideology, the proper focus of psychiatric nurs- Inquiry, 14(1), 35–41.
ing. Journal of Psychosocial Nursing and Mental Health
Services, 32(5), 17–22. Stevenson, C., Barker, P. J., & Fletcher, E. (2002). Judge-
Barker, P. J., & Reynolds, B. (1996). Rediscovering the ment days: Developing an evaluation for an innovative
proper focus of nursing: a critique of Gournay’s position nursing model. Journal of Psychiatric and Mental Health
on nursing theory and models. Journal of Psychiatric Nursing, 9(3), 271–276.
and Mental Health Nursing, 3, 75–80.
Barker, P. J., Reynolds, B., & Stevenson, C. (1998). The Stevenson, C., Jackson, S., & Barker, P. (2003). Finding
human science basis of psychiatric nursing: Theory and solutions through empowerment: A preliminary study
practice. Perspectives in Psychiatric Care, 34, 5–14. of a solution-oriented approach to nursing in acute
Barker, P. J., Reynolds, B., Whitehill, I., Delaval, S., psychiatric settings. Journal of Psychiatric and Mental
& Novak, V. (1996).Working with mental distress. Health Nursing, 10(6), 688–696.
Nursing Times, 92(2), 25–27.
Barker, P. J., & Stevenson, C. (2002). Reply to Gamble and Walker, L., & Barker, P. J. (1998). The required role of the
Wellman. Journal of Psychiatric and Mental Health CPN: Uniformity or flexibility? Clinical Effectiveness in
Nursing, 9(6), 743–745. Nursing, 2, 21–29.
Barker, P. J., & Walker, L. (2000). Nurses’ perceptions of
multidisciplinary teamwork in acute psychiatric set- Wilkin, P., & Barker, P. (2002). A conversation with Phil
tings. Journal of Psychiatric and Mental Health Nursing, Barker. Sacred Space: International Journal of Spirituality
7, 539–546. and Health, 3(4), 15–23.
Barker, P. J., Walker, L., & Pearson, P. (1998). Extending
the role of the community mental health nurse. British Secondary References
Journal of Community Nursing, 3(10), 496–500. Adam, R., Tilley, S., & Pollock, L. (2003). Person first:
Buchanan-Barker, P., & Barker, P. J. (2002). Lunatic
language. Openmind, 115, 23. What people with enduring mental disorders value
Buchanan-Barker, P. J., & Barker, P. J. (2003). NICE: Does about community psychiatric nurses and CPN services.
the gold standard have feet of clay? Mental Health Journal of Psychiatric and Mental Health Nursing, 10,
Nursing, 23, 9–11. 203–212.
Buchanan-Barker, P. J., & Barker, P. J. (2004). More than a Biley, F. C. (2010). My life: My encounters with insanity.
feeling. Nursing Standard, 19. (11), 18–19. Journal of Holistic Nursing, 28, 150–155.
Buchanan-Barker, P. J., & Barker, P. (2005). Observation: Bowles, A. (2000). Therapeutic nursing care in acute psy-
The original sin of mental health nursing? Journal of chiatric wards: Engagement over control. Journal of
Psychiatric and Mental Health Nursing, 12, 541–549. Psychiatric and Mental Health Nursing, 7, 179–184.
Buchanan-Barker, P. J., & Barker, P. J. (2008). The Tidal Brookes, N. L. (2006). The Tidal Model of Mental Health
Commitments: Extending the value base of mental Recovery. In A. M. Tomey & M. R. Alligood (Eds.),
health recovery. Journal of Psychiatric and Mental Nursing theorists and their work. (6th ed., pp. 696–725).
Health Nursing, 15, 93–100. St. Louis: Mosby.
Cutcliffe, J., & Barker, P. J. (2002). Considering the care Brookes, N. (2010). The Tidal Model® of Mental Health
of the suicidal client and the case for “engagement and Recovery. In M.R. Alligood & A.M. Tomey (Eds.),
inspiring hope” or “observations.” Journal of Psychiatric Nursing theorists and their work,7th Edition(pp. 673–705)
and Mental Health Nursing, 9(5), 611–621. St Louis: Mosby.
Brookes, N., Murata, L., & Tansey, M. (2008). Making
waves: Implementing the new Tidal Model® of Mental
Health Recovery. Canadian Nurse, 104(8), 22–27.
Brookes, N., Tansey, M., & Murata, L. (2006). Guiding
practice development using the Tidal commitments.
Journal of Psychiatric and Mental Health Nursing, 13, CHAPTER 32 Phil Barker 655
460–463. International Journal of Mental Health Nursing, 18,
Buchanan-Barker, P. (2004). The Tidal Model: Uncommon Supplement 1: A8.
sense. Mental Health Nursing, 24(3), 6–10. Forchuk, C., Jewell, J., Tweedell, D., & Steinnagel, L.
Burnard, P. (2002). Not waving but drowning: A personal (2003). Reconnecting: The client experience of recovery
response to Barker and Grant. Journal of Psychiatric from psychosis. Perspectives in Psychiatric Care, 39(4),
and Mental Health Nursing, 9, 221–232. 141–150.
Cameron, D., Kapur, R., & Campbell, P. (2005). Releasing Gamble, C., & Wellman, N. (2002). Judgement impossible.
the therapeutic potential of the psychiatric nurse: A hu- Journal of Psychiatric and Mental Health Nursing, 9,
man relations perspective of the nurse-patient relation- 741–742.
ship. Journal of Psychiatric and Mental Health Nursing, Harnett, P. J., & Greaney, A. M. (2008). Operationalizing
12, 64–74. autonomy: Solutions for mental health nursing prac-
Casey, B., & Long, A. (2003). Meanings of madness: A lit- tice. Journal of Psychiatric and Mental Health Nursing,
erature review. Journal of Psychiatric and Mental Health 15, 2–9.
Nursing, 10, 89–99. Hayne, Y. M. (2003). Experiencing psychiatric diagnosis:
Clark, G., Ferguson, J., O’Brien, L., Fitzgerald, M., & Vella, Client perspectives on being named mentally ill. Journal
N. (2009). Preparing the beach head. An education of Psychiatric and Mental Health Nursing, 10, 722–729.
program in interpersonal skills to prepare for imple- Hosany, Z., Wellman, N., & Lowe, T. (2007). Fostering a
mentation of the tidal model in an adolescent mental culture of engagement: A pilot study of the outcomes
health unit. International Journal of Mental Health of training mental health nurses working in two UK
Nursing, 18: Supplement 1: A4. acute admission units in brief solution-focused therapy
Cleary, M., Horsfall, J., & Hunt, G. (2003). Consumer feed- techniques. Journal of Psychiatric and Mental Health
back on nursing care and discharge planning. Nursing, 14, 688–695.
Journal of Advanced Nursing, 42(3), 269–277. Jackson, S., & Stevenson, C. (2004). How can nurses meet
Davidson, L. (2005). Recovery, self-management and the the needs of mental health clients. In D. Kirby, D. Hart,
expert patient—Changing the culture of mental health D. Cross, & G. Mitchell (Eds.), Mental health nursing—
from a UK perspective. Journal of Mental Health, 14(1), Competencies for practice. (pp. 32–45). Hampshire, UK:
25–35. Palgrave MacMillan.
Delaney, K. R. (2012). Moving to a recovery framework Kidd, J. (2010). Cultural boundary surfing in mental
of care: Focusing attention on process. Archives of health nursing: A creative narration. Contemporary
Psychiatric Nursing, 26, 165. Nurse, 34(2), 277–288. doi: 10.5172/conu.2010.34.2.277.
Delaney, K. R., & Ferguson, J. (2011). Psychiatric mental Lipczynska, S. (2011). Recovery from mental illness. Jour-
health nursing: A dialogue on the nature of our prac- nal of Mental Health, 20, 420–422.
tice. Archives of Psychiatric Nursing, 25, 148–150. Mason, T., Lovell, A., & Coyle, D. (2008). Forensic psychi-
Delaney, K. R. & Shattell, M. M. (2011). Special Edition: atric nursing: Skills and competencies: 1 role dimen-
Inpatient Psychiatric Treatment: Moving the Science sions. Journal of Psychiatric and Mental Health Nursing,
Forward Final. Issues in Mental Health Nursing, 31, 15, 118–130.
158–159. McAllister, M. (2007). Solution focused nursing: Rethinking
Ferguson, J., O’Brien, L., Vella, N., Clark, G., Gillies, D., & practice.Bassingstoke: Palgrave MacMillan.
Fitzgerald, M. (2009). Implementing the Tidal Model: McAllister, M., & Moyle, W. (2008). An exploration of
Nurses developing a mind to care. International Journal mental health nursing models of care in a Queensland
of Mental Health Nursing, 18, Supplement 1: A8. psychiatric hospital. International Journal of Mental
Fiddler, M., Borglin, G., Galloway, A., Jackson, C., & Health Nursing, 17, 18–26.
Lovell, K. (2007). Developing a framework for admis- Morita, M., Kondo, A., Levine, P., & Morita, S. (1998).
sion and discharge: A nurse-led initiative within a Morita Therapy and the true nature of anxiety-based
mental health setting. Journal of Psychiatric and Mental disorders (Shinkeishitsu). Princeton, (NJ): University
Health Nursing, 14, 705–712. of New York.
Fitzgerald, M., O’Brien, L., Ferguson, J., Clark, G., Vella, Murata, L. (2005). The Tidal Model continues to make waves.
N., Hannaford, J., & Scotman, G. (2009). With partner- Worth the change. Mental Health Practice, 9(8), 10.
ship in mind . . . bringing the Tidal Model to life O’Donovan, A. (2007). Patient-centred care in acute psy-
in an adolescent acute inpatient setting: The perspec- chiatric admission units: Reality or rhetoric?
tive of the young person and their family or carer. Journal of Psychiatric and Mental Health Nursing, 14,
542–548.
656 UNIT V Middle Range Nursing Theories Vella, N., Fitzgerald, M., O’Brien, L., Ferguson, J., Clark,
Perraud, S., Delaney, K., Carlson-Sabelli, L., Johnson, M. E., G., & Gillies, D. (2009). Implementing the Tidal Model:
Implications for management and clinical
Shepard, R., & Paun, O. (2006). Advanced practice psy- leadership in the delivery of quality care. International
chiatric mental health nursing, finding our core: The Journal of Mental Health Nursing, 18, Supplement 1:
therapeutic relationship in the 21st century. Perspectives A24–A25.
in Psychiatric Care, 42(4), 215–226.
Stevenson, C., & Fletcher, E. (2002). The Tidal Model: The Wand, T., & White, K. (2007). Progression of the mental
questions answered. Mental Health Practice, 5(8), 29–38. health nurse practitioner role. Journal of Psychiatric
Tilley, S. (1999). Altschul’s legacy in mediating British and and Mental Health Nursing, 14, 644–651.
American psychiatric nursing discourses: Common
sense and the “absence” of the accountable practitioner. Young, B. B. (2010). Using the tidal model of mental health
Journal of Psychiatric and Mental Health Nursing, 6, recovery to plan primary health care for women in resi-
283–295. dential substance abuse recovery. Issues in Mental
Thomas, S. P. (2012). New thoughts on talk therapies. Issues Health Nursing, 31, 569–575.
in Mental Health Nursing, 33, 135–136.
33C H A P T E R
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
master’s degree in nursing. She gained and maintains
Katharine Kolcaba was born and educated in Cleveland, American Nurses Association (ANA) certification in
Ohio. In 1965, she received a diploma in nursing and gerontology. She returned to CWRU to pursue her
practiced part time for many years in medical-surgical doctorate in nursing on a part-time basis while con-
nursing, long-term care, and home care before return- tinuing to teach. Over the next 10 years, she used
ing to school. In 1987, she graduated in the first RN to course work in her doctoral program to develop and
MSN class at Case Western Reserve University (CWRU) explicate her theory. Kolcaba published a concept
Frances Payne Bolton School of Nursing, with a spe- analysis of comfort with her philosopher-husband
cialty in gerontology. While in school, she job-shared a (Kolcaba & Kolcaba, 1991), diagrammed aspects of
head nurse position on a dementia unit. It was in this comfort (Kolcaba, 1991), operationalized comfort as
practice context that she began theorizing about the an outcome of care (Kolcaba, 1992a), contextualized
outcome of patient comfort.
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 recovery was achieved (McIlveen & Morse, 1995).
comfort in a middle-range theory (Kolcaba, 1994), and The nurse was duty bound to attend to details influ-
tested the theory in an intervention study (Kolcaba & encing patient comfort. Aikens (1908) proposed that
Fox, 1999). nothing concerning the comfort of the patient was
small enough to ignore. The comfort of patients was
Currently, Dr. Kolcaba is an emeritus associate pro- the nurse’s first and last consideration. A good nurse
fessor of nursing at the University of Akron College of made patients comfortable, and the provision of com-
Nursing, where she teaches theory to MSN students. fort was a primary determining factor of a nurse’s
She also teaches theory to DNP students at Ursuline ability and character (Aikens, 1908).
College in Mayfield Heights, Ohio. Her interests in-
clude interventions for and documentation of changes Harmer (1926) stated that nursing care was con-
in comfort for evidence-based practice. She resides in cerned with providing a “general atmosphere of
the Cleveland area with her husband, where she enjoys comfort,” and that personal care of patients in-
being near her grandchildren and her mother. She cluded attention to “happiness, comfort, and ease,
represents her company, known as The Comfort Line, physical and mental,” in addition to “rest and sleep,
to assist health care agencies implement the Theory of nutrition, cleanliness, and elimination” (p. 26).
Comfort on an institutional basis. She is founder and Goodnow (1935) devoted a chapter in her book, The
coordinator of a local parish nurse program and a Technique of Nursing, to the patient’s comfort. She
member of the ANA. Kolcaba continues to work with wrote, “A nurse is judged always by her ability to
students conducting comfort studies. 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-
books dated 1904, 1914, and 1919, emotional com-
Kolcaba began her theoretical work diagramming her fort was called mental comfort and was achieved
nursing practice early in her doctoral studies. When mostly by providing physical comfort and modify-
Kolcaba presented her framework for dementia care ing the environment for patients (McIlveen &
(Kolcaba, 1992b), a member of the audience asked, Morse, 1995).
“Have you done a concept analysis of comfort?”
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.
Intuitively, comfort is associated with nurturing activ-
The first step, the promised concept analysis, be- ity. From its word origins, Kolcaba explicated its
gan with an extensive review of the literature about strengthening features, and from ergonomics, its direct
comfort from the disciplines of nursing, medicine, link to job performance. However, often its meaning
psychology, psychiatry, ergonomics, and English is implicit, hidden in context, and ambiguous. The
(specifically Shakespeare’s use of comfort and the concept varies semantically as a verb, noun, adjective,
Oxford English Dictionary [OED]). From the OED, adverb, process, and outcome.
Kolcaba learned that the original definition of com-
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
Zderad (1975), who proposed that patients rise
From 1900 to 1929, comfort was the central goal above their difficulties with the help of nurses.
of nursing and medicine because, through comfort,
CHAPTER 33 Katharine Kolcaba 659
Relief Type of Comfort Transcendence
Ease
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 T axonomic 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 Health Care Needs
Health care needs are comfort needs arising from
In Kolcaba’s theory, those receiving comfort mea- stressful health care situations that cannot be met by
sures may be referred to as recipients, patients, stu- recipients’ traditional support systems. The needs
dents, prisoners, workers, older adults, communities,
and institutions. 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
(1975) and proposed to be internal, external, or a
Comfort Interventions peaceful death.
Comfort interventions are nursing actions and refer-
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,
ethical, and sincere possess institutional integrity.
Intervening Variables When an institution displays this type of integrity, it
Intervening variables are interacting forces that produces evidence for best practices and best poli-
cies (Kolcaba, 2001).
influence recipients’ perceptions of total comfort.
They consist of past experiences, age, attitude, emo- Best Practices
tional state, support system, prognosis, finances, The use of health care interventions based on evi-
education, cultural background, and the totality of dence to produce the best possible patient and
elements in the recipients’ experience (Kolcaba, family (institutional) outcomes is known as best
1994). Suchintervening variables have an impact on practices.
planning and success of patient care interventions.
Best Policies
Comfort Institutional or regional policies ranging from pro-
Comfort is the state experienced by recipients of tocols for procedures and medical conditions to
comfort interventions. It is the immediate, holistic access and delivery of health care are known as best
experience of being strengthened when one’s needs policies.
are addressed for three types of comfort (relief, ease,
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.
Hamilton concluded, “The clear message is that com-
The seeds of modern inquiry about the outcome of fort is multi-dimensional, meaning different things to
comfort were sown in the late 1980s, marking a period different people” (p. 32).
of collective, but separate, awareness about the con-
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 Nursing Intervening Enhanced Health Institutional
Care Interventions Variables Comfort Seeking Integrity
Needs Behaviors
Best
Policies
Internal Peaceful External
Behaviors Death Behaviors
© Kolcaba (2007)
FIGURE 33-2 C onceptual 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:
• Guided imagery for psychiatric patients (Apóstolo Further support for the Theory of Comfort was
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):
1 . Comfort is generally state-specific.
in college students (Dowd, Kolcaba, Steiner, & 2 . The outcome of comfort is sensitive to changes
Fashinpaur, 2007)
• 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)
• Patient-controlled heated gowns for reducing tion with an established history for effectiveness
anxiety and increasing comfort in preoperative enhances comfort over time.
patients (Wagner, Byrne, & Kolcaba, 2006) 4. Total comfort is greater than the sum of its parts.
662 UNIT V Middle Range Nursing Theories 3. Comfort is a basic human need that persons
strive to meet or have met. It is an active endeavor
Tests on the data set from Kolcaba and Fox’s (1999) (Kolcaba, 1994).
earlier study of women with breast cancer supported
each proposition. Other areas of study included in the 4. Enhanced comfort strengthens patients to engage in
Kolcaba website are burn units, labor and delivery, in- health-seeking behaviors of their choice (Kolcaba &
fertility, nursing homes, home care, chronic pain, pedi- Kolcaba 1991; Kolcaba, 1994).
atrics, oncology, dental hygiene, transport, prisons, deaf
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).
Nursing
6 . Institutional integrity is based on a value system
Nursing is the intentional assessment of comfort oriented to the recipients of care (Kolcaba 1997,
needs, the design of comfort interventions to address 2001). Of equal importance is an orientation to a
those needs, and reassessment of comfort levels after health-promoting, holistic setting for families and
implementation compared with a baseline. Assessment providers of care.
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
wound healing, changes in laboratory values, or The Theory of Comfort contains three parts (proposi-
changes in behavior. Assessment is achieved through tional assertions) to be tested separately or as a whole.
the administration of verbal rating scales (clinical) or
comfort questionnaires (research), using instruments Part I states that comforting interventions, when
developed by Kolcaba (2003). effective, result in increased comfort for recipients
(patients and families), compared to a preinterven-
Patient tion baseline. Care providers may be considered re-
Recipients of care may be individuals, families, institu- cipients if the institution makes a commitment to the
tions, or communities in need of health care. Nurses comfort of their work setting. Comfort interventions
may be recipients of enhanced workplace comfort when address basic human needs, such as rest, homeostasis,
initiatives to improve working conditions are under- therapeutic communication, and treatment as holistic
taken, such as those to gain Magnet status (Kolcaba, beings. Comfort interventions are usually nontechni-
Tilton, & Drouin, 2006). cal and complement the delivery of technical care.
Environment Part II states that increased comfort of recipients of
The environment is any aspect of patient, family, or care results in increased engagement in health-seeking
institutional settings that can be manipulated by behaviors that are negotiated with the recipients.
nurse(s), loved one(s), or the institution to enhance
comfort. Part III states that increased engagement in health-
seeking behaviors results in increased quality of care,
Health benefiting the institution and its ability to gather evidence
Health is optimal functioning of a patient, family, for best practices and best policies.
health care provider, or community as defined by the
patient or group. Kolcaba believes that nurses want to practice com-
forting care and that it can be easily incorporated with
Assumptions every nursing action. She proposes that this type of
1. Human beings have holistic responses to complex comfort practice promotes greater nurse creativity
and satisfaction, as well as high patient satisfaction. In
stimuli (Kolcaba, 1994). order to enhance comfort, the nurse must deliver the
2. Comfort is a desirable holistic outcome that is ger- appropriate interventions and document the results
in the patient record. However, when the appropriate
mane to the discipline of nursing (Kolcaba, 1994). intervention is delivered in an intentional and com-
forting manner, comfort still may not be enhanced
sufficiently. When comfort is not yet enhanced to its
fullest, nurses then consider intervening variables to
explain why comfort management did not work. Such CHAPTER 33 Katharine Kolcaba 663
variables may be abusive homes, lack of financial re-
sources, devastating diagnoses, or cognitive impair- nurses were doing to prevent excess disabilities (later
ments that render the most appropriate interventions naming those actions interventions) and how to judge
and comforting actions ineffective. Comfort manage- if the interventions were working. Optimum function
ment or comforting care includes interventions, com- had been conceptualized as the ability to engage in
forting actions, the goal of enhanced comfort, and the special activities on the unit, such as setting the table,
selection of appropriate health-seeking behaviors by preparing a salad, or going to a program and sitting
patients, families, and their nurses. Thus, comfort through it. These activities made the residents feel
management is proposed to be proactive, energized, good about themselves, as if it were the right activity
intentional, and longed for by recipients of care in all at the right time. These activities did not happen more
settings. To strengthen the role of nurses as comfort than twice a day, because the residents couldn’t toler-
agents, documentation of changes in comfort before ate much more than that. What were they doing in
and after their interventions is essential. For clinical the meantime? What behaviors did the staff hope
use, Kolcaba suggests asking patients to rate their they would exhibit that would indicate an absence of
comfort from 0 to 10, with 10 being the highest pos- excess disabilities? Should the term excess disabilities
sible comfort in a given health care situation. This be delineated further for clarity?
documentation could be a part of the electronic data
bases in each institution (Kolcaba, Tilton, & Drouin, Partial solutions to these questions were to (1) divide
2006). excess disabilities into physical and mental, (2) intro-
duce the concept of comfort to the original diagram,
Logical Form because this word seemed to convey the desired state
for patients when they were not engaging in special
Kolcaba (2003) used the following three types of logical activities, and (3) note the nonrecursive relationship
reasoning in the development of the Theory of Com- between comfort and optimum functioning. This think-
fort: (1) induction, (2) deduction, and (3) retroduction ing marked the first steps toward a theory of comfort
(Hardin & Bishop, 2010). and thinking about the complexities of the concept
Induction (Kolcaba, 1992a).
Induction occurs when generalizations are built from Deduction
a number of specific observed instances Deduction occurs when specific conclusions are in-
(Hardin & Bishop, 2010). When nurses are earnest ferred from general premises or principles; it proceeds
about their practice and earnest about nursing as a dis- from the general to the specific (Hardin & Bishop,
cipline, they become familiar with implicit or explicit 2010). The deductive stage of theory development
concepts, terms, propositions, and assumptions that resulted in relating comfort to other concepts to pro-
underpin their practice. Nurses in graduate school may duce a theory. Since the works of three nursing theo-
be asked to diagram their practice as Dr. Rosemary Ellis rists was entailed in the definition of comfort (Paterson
asked Kolcaba and other students to do, and it is a & Zderad, 1975; Henderson, 1966 and Orlando, 1961),
deceptively easy-sounding assignment. Kolcaba looked elsewhere for the common ground
needed to unify relief, ease, and transcendence (three
Such was the scenario during the late 1980s as major concepts). What was needed was a more ab-
Kolcaba began. She was head nurse on an Alzheimer’s stract and general conceptual framework that was
unit at the time and knew some of the terms used congruent with comfort and contained a manageable
then to describe the practice of dementia care, such as number of highly abstract constructs.
facilitative environment, excess disabilities, and opti-
mum function. However, when she drew relationships The work of psychologist Henry Murray (1938)
among them, she recognized that the three terms did met the criteria for a framework on which to hang
not fully describe her practice. An important nursing Kolcaba’s nursing concepts. His theory was about hu-
piece was missing, and she pondered about what man needs; therefore it was applicable to patients who
experience multiple stimuli in stressful health care
situations. Furthermore, Murray’s idea about unitary
trends gave Kolcaba the idea that, although comfort
664 UNIT V Middle Range Nursing Theories changes in comfort over time (Dowd, Kolcaba,
Steiner, et al., 2007). A list of effective comforting in-
was state-specific, if comforting interventions were terventions for each patient/family member is readily
implemented over time, the overall comfort of pa- available and communicated.
tients could be enhanced over time. In this deductive
stage of theory development, she began with abstract, Perianesthesia nurses have incorporated the The-
general theoretical construction and used the socio- ory of Comfort into their Clinical Practice Guidelines
logical process of substruction to identify the more for management of patient comfort. In this setting,
specific (less abstract) levels of concepts for nursing comfort management specifies (1) assessing patients’
practice. 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
Practice website.
Students and nurse researchers have frequently selected Recently, Goodwin, Sener, and Steiner (2007) uti-
this theory as a guiding framework for their studies in lized the Theory of Comfort as a teaching philosophy
areas such as nurse midwifery (Schuiling, Sampselle, & in a fast-track nursing education program for stu-
Kolcaba, 2011), hospice care (Kolcaba, Dowd, Steiner, dents with baccalaureate degrees in other disciplines.
et al., 2004), perioperative nursing (Wilson & Kolcaba, The taxonomic structure and conceptual framework
2004), long-term care (Kolcaba, Schirm, & Steiner, guided ways of being a comforting faculty member.
2006), stressed college students (Dowd, Kolcaba, The theory provided ways for students to obtain relief
Steiner, et al., 2007), dementia patients (Hodgson & from their heavy course work by facilitating questions
Andersen, 2008), and palliative care (Lavoie, Blondeau, to their clinical problems, maintaining ease with their
& Picard-Morin, 2011). curriculum through trusting their faculty members,
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).
Research CHAPTER 33 Katharine Kolcaba 665
An entry in the Encyclopedia of Nursing Research theory that is readily applied in many settings for
speaks to the importance of measuring comfort as a education, practice, and research. Kolcaba devel-
nursing-sensitive outcome (Kolcaba, 2006). Nurses oped templates for measurement to facilitate appli-
can provide evidence to influence decision making cation of the comfort theory in additional settings.
at institutional, community, and legislative levels The comfort management templates she provided
through studies that demonstrate the effectiveness of for use in practice settings have been helpful to stu-
comforting care. Kolcaba (2001) called for measure- dents and faculty members. Outcomes of research
ment of comfort in large hospitals and home care to have demonstrated the appropriateness of her the-
expand the theory and develop the literature on evi- ory for measuring whole-person changes that were
dence-based comfort. less effectively captured with other types of instru-
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 General Comfort Questionnaire to measure holis- The original theoretical assertion (Part 1) of the
tic comfort in a sample of hospital and community Theory of Comfort has stood up to empirical testing.
participants. Positive and negative items were gener- When a comfort intervention is targeted to meet the
ated for each cell in the taxonomic structure grid. holistic comfort needs of patients in specific health
Twenty-four positive items and twenty-four negative care situations, comfort is enhanced beyond baseline
items were compiled with a Likert-type format rang- measurement. Furthermore, enhanced comfort has
ing from strongly agree to strongly disagree, with been correlated with engagement in health-seeking
higher scores indicating higher comfort. At the end of behaviors (Schlotfeldt, 1975). Empirical tests of the
the instrumentation study with 206 one-time partici- theoretical assertions for the second and third parts of
pants from all types of units in two hospitals and the theory are to be conducted. Outcomes for desir-
50 participants from the community, the General able health-seeking behaviors could include increased
Comfort Questionnaire demonstrated a Cronbach functional status, faster progress during rehabilita-
alpha of 0.88 (Kolcaba, 1992a). tion, faster healing, or peaceful death when appropri-
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.
Further Development Kolcaba postulates that intentional emphasis on
and support for comfort management by an institu-
Kolcaba has persisted in the development of her the- tion or community increases patient/family satisfac-
ory from the original conception as the root of her tion, because persons are healed, strengthened, and
practice, to concept analysis that provided the taxo- motivated to be healthier. Extending the Theory of
nomic structure of comfort, to development of ways Comfort to the community is of current interest. It is
to measure the concept, and currently to its use for well known that some communities are more com-
practice, education, and research. She uses a full array fortable to live in, grow old in, and go to school in
of approaches to build her theory. than are others.
The methodical development of the concept re- An area of interest for further development is the
sulted in a strong, clearly organized, and logical universal nature of comfort. Currently, the General
Comfort Questionnaire has been translated into
666 UNIT V Middle Range Nursing Theories Simplicity
The Theory of Comfort is simple because it is basic to
Taiwanese, Spanish, Iranian, Portuguese, and Italian nursing care and the traditional mission of nursing. Its
(see Kolcaba website), and translation into Turkish is language and application are of low technology, but
pending. Comfort of children has been accurately ob- this does not preclude its use in highly technological
served and documented in perioperative settings (per- settings. There are few variables in the theory, and se-
sonal communication, Nancy Laurelberry, February 16, lected variables may be used for research or educa-
2008), and the use of Comfort Daisies by children tional projects. The main thrust of the theory is for
who self-report (see website) has been tested in a hospi- nurses to return to a practice focused on the holistic
tal setting (personal communication, Carrie Majka, needs of patients inside or outside institutional walls.
February 28, 2008). It is simplicity that allows students and nurses to learn
and practice the theory easily (Kolcaba, 2003).
The Theory of Comfort has been included in elec-
tronic nursing classification systems such as NANDA Generality
(2011), NIC (2008), and NOC (2008). Kolcaba con- Kolcaba’s theory has been applied in numerous
sults with hospitals to include comfort management research settings, cultures, and age groups. The only
in their documentation systems. Use of the theory has limiting factor for its application is how well nurses
made significant contributions to nursing practice and administrators value it to meet the comfort needs
and the discipline. Kolcaba continues to spend time of patients. If nurses, institutions, and communities
and energy developing and disseminating the theory are committed to this type of nursing care, the Theory
through presentations, publications, and discussions of Comfort enables efficient, individualized, holistic
since retirement from full-time teaching. practice. The taxonomic structure of comfort facilitates
researchers’ development of comfort instruments for
The Theory of Comfort is widely usedas an or- new settings.
ganizing framework for Magnet application and
recertification of Magnet Status. Nurses often Accessibility
choose this framework themselves because it de- The first part of the theory, asserting that effective
scribes what they want to do for patients and fami- nursing interventions offered over time will demon-
lies, and what patients want from nurses during strate enhanced comfort, has been tested and sup-
their hospitalization. An array of possible uses of ported with numerous studies. Furthermore, in the
the framework components is offered to the hospi- study by Dowd, Kolcaba, & Steiner (2000), enhanced
tal, such as Comfort Rounds, performance review comfort was a strong predictor of increased health-
criteria, methods of documentation, clinical ladder seeking behaviors, meaning when patients are more
criteria, and so on. The “value added” benefit when comfortable, they do better in rehab or recovery. This
nurses are supported in their comforting interven- relationship supports the second and third part of the
tions can be empirically demonstrated through comfort theory. The comfort instruments have dem-
measurement of institutional outcomes such as onstrated strong psychometric properties, supporting
patient satisfaction, “Best Hospital” designations, the validity of the questionnaires as measures of com-
and cost savings. fort that reveal changes in comfort over time and
support of the taxonomic structure.
Critique
Clarity Importance
The Theory of Comfort describes patient-centered
Some of the early articles such as the concept analysis practice and explains how comfort measures matter
(Kolcaba & Kolcaba, 1991) may lack clarity but are to patients, their health, and the viability of institu-
consistent in terms of definitions, derivations, assump- tions. The theory predicts the benefit of effective
tions, and propositions. Clarity is much improved in comfort measures (interventions) for enhancing
the article explicating the theory and subsequent arti- comfort and engagement in health-seeking behaviors.
cles. Kolcaba applies the theory to specific practices
using academic, but understandable, language. All
research concepts are defined theoretically and opera-
tionally.
The Theory of Comfort is dedicated to sustaining CHAPTER 33 Katharine Kolcaba 667
nursing by bringing the discipline back to its roots. In research, the theory provides a way to validate
Documentation of comfort strategies and their effects improvement in patient comfort after receiving com-
empirically demonstrates the art of nursing. The out- forting interventions. The concept of comfort accounts
come of comfort describes the effects of memorable for the aspect of quality that the patient describes as
helping interactions with nurses that go beyond “feeling better.” Kolcaba has made consistent efforts to
checklists or physician orders. It encompasses the art develop and expand comfort into all realms of health
and science of nursing. Making electronic data sys- care. Through her own thinking and in interaction
tems inclusive of value-added outcomes such as com- with nurses and other health professionals, the con-
fort is imperative. Collaboration and the openness of cept has continually evolved into patient and nurse
Kolcaba’s website facilitates dissemination of the the- care techniques. Institutions have recognized the value
ory for application. of designing comfort environments for both their
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. CASE STUDY
Refocusing on patient and family comfort represents a A 32-year-old African-American mother of three
return to the roots of nursing and also to the need for toddlers who is 28 weeks pregnant is admitted to
empirical evidence. We can demonstrate through re- the high-risk pregnancy unit with regular contrac-
search that comfort is foundational to patient recovery, tions. She is concerned because the plans for her
to other health-seeking behaviors, and to institutional family are not finalized. She has many comfort
viability. The focus is applicable to other health care needs that are diagrammed in Table 33–1. When
professions and ancillary workers. The use of a comfort nurses assess for comfort needs in any of their
framework implemented throughout a hospital facili- patients, they can use the taxonomic structure, or
tates everyone being “on the same page.” comfort grid, to identify and organize all known
needs. Using the comfort grid (see Figure 33–1) as
Summary a mental guide, nurses can design interrelated
comforting interventions that can be implemented
From its inception, the Theory of Comfort has focused in one or two nurse-patient-family interactions.
on what the discipline of nursing does for patients. As For this case, some suggestions to individualize
the theory evolved, the definition derived from con- the types of comfort interventions that might be
cept analysis expanded to include broader aspects of considered are presented in Table 33–2.
the patient such as cultural and spiritual aspects. The
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,
a comfort questionnaire could be developed and
The theory has relevancy for practice and easily administered, assessing each cell in the comfort
guides nurses in the planning and designing of nurs- grid (see Figure 33–1). A Likert-type scale with
ing care in any setting. Its usefulness in education has responses ranging from 1 to 6 would facilitate a
been described as providing a framework that enables total comfort score. Such a questionnaire could be
students to organize their assessments and plans of given to the patient before and after the interven-
care and learn the art of nursing as well as the science. tions are implemented to demonstrate the level of
It is useful for expert nurses in the delivery of care as effectiveness for the comfort interventions.
they demonstrate what they do beyond the technical
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
Psychospiritual Early strong contractions happen to my family and
Environmental Uncertainty about prognosis to my babies?”
Anxiety and tension
Sociocultural Lack of privacy Need for emotional and
Roommate is a primigravida Telephone in room spiritual support
Room is small, clean, Feeling of confinement
Need for calm, familiar
and pleasant with bed rest environmental elements
Family not present and accessibility of
Absence of family and Language barriers distraction
culturally sensitive care
Need for support from
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
Coaching Laboratory test results
Comfort food for the soul Patient assessment
Medications and treatments
Social worker
Emotional support
Reassurance
Education
Listening
Clergy
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 3 . There is some evidence that comfort is a universal
need. Identify a way you met a comfort need for
1 . If you were asked to diagram your practice, what someone you cared for recently. Would this com-
concepts would you include? Where is comfort in fort intervention work in another culture? Why or
your diagram? why not?
2. Select a patient, and apply the Theory of Comfort in
your nursing practice. How did the theory impact
your style of practice? Where are your comfort mea-
sures in the taxonomic structure? (See Figure 33–1.)
4. How would you apply the Theory of Comfort in CHAPTER 33 Katharine Kolcaba 669
a community setting? What interventions could 5 . Identify an area of nursing practice for comfort
you use to enhance comfort in an aggregate
group? How would you assess to see if your research, and explain why it is needed.
intervention was effective? 6 . How might the Theory of Comfort influence
policy change?
POINTS FOR FURTHER STUDY n Kolcaba, K. (2006). Comfort (including
definition, theory of comfort, relevance to
n American Society of Perianesthesia Nurses at: nursing, review of comfort studies, and future
www.ASPAN.org. directions.) In J. Fitzpatrick (Ed.), The
encyclopedia of nursing research. (2nd ed.).
n Kolcaba, K. (1997). TheComfortLine.com. New York: Springer.
Retrieved from http://www.thecomfortline.
com(the Kolcaba website).
n Kolcaba, K (2003). Comfort theory and practice: a
holistic vision for health care, New York, Springer.
REFERENCES Kolcaba, K. (1991). A taxonomic structure for the concept
comfort. Image: The Journal of Nursing Scholarship,
Aikens, C. (1908). Making the patient comfortable. The 23(4), 237–240.
Canadian Nurse, 4(9), 422–424.
Kolcaba, K. (1992a). Holistic comfort: Operationalizing
Apóstolo J. L. A., & Kolkaba K. (2009). The effects of the construct as a nurse-sensitive outcome. Advances in
guided imagery on comfort, depression, anxiety, and Nursing Science, 15(1), 1–10.
stress of psychiatric inpatients with depressive disorders.
Archives of Psychiatric Nursing, 23(6), 403–411. Kolcaba, K. (1992b). The concept of comfort in an environ-
mental framework. Journal of Gerontological Nursing,
Dowd, T., Kolcaba, K., Steiner, R., & Fashinpaur, D. (2007). 18(6), 33–38.
Comparison of healing touch and coaching on stress
and comfort in young college students, Holistic Nursing Kolcaba, K. (1994). A theory of holistic comfort for nursing.
Practice, 21(4), 194–202. Journal of Advanced Nursing, 19, 1178–1184.
Dowd, T., Kolcaba, K., & Steiner, R. (2000). Using cogni- Kolcaba, K. (2001). Evolution of the mid range theory of
tive strategies to enhance bladder control and comfort. comfort for outcomes research. Nursing Outlook, 49(2),
Holistic Nursing Practice, 14(2), 91–103. 86–92.
Goodnow, M. (1935). The technique of nursing. (p. 95). Kolcaba K., Dowd T., Steiner R., & Mitzel, A. (2004). Effi-
Philadelphia: Saunders. cacy of hand massage for enhancing comfort of hos-
pice patients. Journal of Hospice & Palliative Care,
Goodwin, M., Sener, I., & Steiner, S. H. (2007). A novel 6(2), 91–101.
theory for nursing education: Holistic comfort. Journal
of Holistic Nursing, 25(4), 278–285. Kolcaba K: TheComfortLine.com. Retrieved from: www.
TheComfortLine.com. Copyright, 1997.
Hamilton, J. (1989). Comfort and the hospitalized chroni-
cally ill. Journal of Gerontological Nursing, 15(4), 28–33. Kolcaba, K. (2003). Comfort theory and practice: A holistic
vision for health care, New York: Springer.
Hardin, S., & Bishop, S. (2010). Logical reasoning. In
M. R. Alligood & A. M. Tomey (Eds.), Nursing theorists Kolcaba, K. (2006). Comfort (including definition, theory
and their work. (7th ed., pp. 26–35). Maryland Heights, of comfort, relevance to nursing, review of comfort
(MO): Mosby-Elsevier. studies, and future directions). In J. Fitzpatrick (Ed.),
The encyclopedia of nursing research. (2nd ed.). New
Harmer, B. (1926). Methods and principles of teaching the York: Springer.
principles and practice of nursing. (p. 26). New York:
Macmillan. Kolcaba, K., Tilton, C., & Drouin, C. (2006). Comfort theory:
A unifying framework to enhance the practice environ-
Henderson, V. (1966). The nature of nursing. New York: ment. Journal of Nursing Administration, 36(11), 538–544.
Macmillan.
Kolcaba K., & Steiner, R. (2000). Empirical evidence for the
Hodgson, N. A., & Andersen, S. (2008). The clinical nature of holistic comfort. Journal of Holistic Nursing,
efficacy of reflexology in nursing home residents with 18(1), 46–62.
dementia. Journal of Alternative and Complementary
Medicine, 14(3), 269–275.
670 UNIT V Middle Range Nursing Theories
Kolcaba K., Schirm V., & Steiner R. (2006). Effects of NANDA: Ackley, B. J. & Ladwig, G. B. (2011). Nursing
hand massage on comfort of nursing home residents, diagnosis handbook: An evidence-based guide to planning
Geriatric Nursing, 27(2), 85–91. care (9th ed.; pp 349–356, 390). St. Louis: Mosby
Kolcaba K., Dowd T., Steiner R., & Mitzel, A. (2004). Efficacy NIC: Bulecheck, G. M., Butcher, H. K., & McCloskey-
of hand massage for enhancing comfort of hospice patients. Dochterman, J. (2008). Nursing interventions classification.
Journal of Hospice & Palliative Care, 6(2), 91–101. (5th ed., pp 78–79, 532–533, 578–579). St. Louis: Mosby.
Kolcaba, K., & Fox, C. (1999). The effects of guided imag- Nightingale, F. (1859). Notes on nursing. London: Harrison.
ery on comfort of women with early stage breast cancer NOC: Moorehead, S., Johnson, M., Maas, M. L., & Swanson, E.
undergoing radiation therapy. Oncology Nursing Forum,
26(1), 67–92. (2008). Nursing outcomes classification. (4th ed., 280–284,
753–756). St. Louis: Mosby.
Kolcaba, K., & Kolcaba, R. (1991). An analysis of the concept Orlando, I. (1961). The dynamic nurse-patient relationship:
of comfort. Journal of Advanced Nursing, 16, 1301–1310. Function, process, and principles. New York: Putnam.
Patterson, J. & Zderad, L. (1975). Humanistic nursing.
Kolcaba, K., & Mitzel, A. (2008). Two chapters: Hand New York: National League for Nursing.
Massage; Simple Massage. In B. J. Ackley, G. B. Ladwig, Schlotfeldt, R. (1975). The need for a conceptual frame-
B. A. Swan, & S. J. Tucker (Eds.), Evidence-based work. In P. Verhovic (Ed.), Nursing research. (pp. 3–25).
nursing care guidelines: Medical-surgical interventions. Boston: Little, Brown.
(pp. 402–407, 504–508). St. Louis: Mosby. Schuiling, K., Sampselle, C., & Kolcaba, K. (2011). Exploring
the presence of comfort within the context of childbirth.
Kolcaba, K., & Wilson, L. (2002). The framework of comfort In R. Bryar & M. Sinclair (Eds.), Theory for midwifery
care for Perianesthesia Nursing. Journal of Perianesthesia practice. (2nd ed., pp. 197–214). Basingstoke, UK:
Nursing, 17(2), 102–114. With post-test for 1.2 contact Palgrave Macmillan.
hours. Wagner, D., Byrne, M., & Kolcaba, K. (2006). Effect of com-
fort warming on preoperative patients. AORN Journal,
Lavoie, M., Blondeau, D., & Picard-Morin, J. (2011). The 84(3), 1–13.
autonomy experience of patients in palliative care. Wilson, L. & Kolcaba, K. (2004). Practical application
Journal of Hospice & Palliative Care, 13(1), 47–53. of Comfort Theory in the perianesthesia setting
(invited article). Journal of Perianesthesia Nursing,
McIlveen, K., & Morse, J. (1995). The role of comfort in 19(3), 164–173.
nursing care: 1900–1980. Clinical Nursing Research,
4(2), 127–148.
Murray, H. (1938). Explorations in personality. New York:
Oxford Press.
BIBLIOGRAPHY Kolcaba, K. (2011). Impaired Comfort. In B. Ackley &
G. Ladwig, Nursing Diagnosis Handbook (pp. 222–225).
Book Chapters St. Louis: Mosby.
Primary Sources
Kolcaba, K. (2001). Holistic care: Is it feasible in today’s Kolcaba, K., & Kolcaba, R. (2011). Integrative theorizing:
Linking middle-range nursing theories with the
health care environment? In H. Feldman (Ed.), Nursing Neuman systems model. In B. Neuman & J. Fawcett
leaders speak out. (pp. 49–54). New Yark:Springer . (Eds.), The Neuman Systems Model (5th ed.). Upper
Kolcaba, K. (2001). Kolcaba’s theory of comfort. In D. Robinson Saddle River, (NJ): Pearson.
& C. Kish (Eds.), Core concepts in advanced practice nursing
(pp. 418–422). St. Louis: Mosby. Secondary Sources
Kolcaba, K. (2006). Comfort (including definition, theory Sitzman, K., & Eichelberger, L. (2004). Understanding
of comfort, relevance to nursing, review of comfort
studies, and future directions). In J. Fitzpatrick (Ed.), the work of nurse theorists: A creative beginning.
The encyclopedia of nursing research. (2nd ed.). New York: (pp. 117–122). Sudbury, (MA): Jones & Bartlett.
Springer.
Kolcaba, K. (2009). The theory of comfort. In S. J. Peterson Journal Articles
& T. S. Brednow (Eds.), Middle range theories: Application Primary Sources
to nursing research (2nd ed., pp. 255–273). Philadelphia: Dowd, T., Kolcaba, K., & Steiner, R. (2006). Development
Lippincott.
Kolcaba, K. (2010). Katharine Kolcaba’s Comfort Theory. of an instrument to measure holistic client comfort as
In M. Parker, & M. Smith (Eds.), Nursing Theories and an outcome of healing touch. Holistic Nursing Practice,
Nursing Practice. (pp. 389–401). Philadelphia: F.A. Davis. 20(3), 122–129.
Kolcaba, K. (1995). The art of comfort care. Image: The CHAPTER 33 Katharine Kolcaba 671
Journal of Nursing Scholarship, 27(4), 287–289. Kim, K., & Kwon, S. (2007). Comfort and quality of life of
Secondary Sources cancer patients. Asian Nursing Research, 1(2), 125–135.
Benson, G. (2004). Changing patients’ position in bed after Kinsman-Dean, R. A., & Major, J. (2008). From critical
non-emergency coronary angiography reduced back care to comfort care: The sustaining value of humour.
pain, Evidence Based Nursing, 7(1), 19. Journal of Clinical Nursing, 17, 1088–1095.
Berman, R., Iris, A., Bode, R., & Drengenberg, C. (2009). Kjellberg, K., Lagerstrom, M., & Hagberg, M. (2004).
The effectiveness of an online mind-body intervention Patient safety and comfort during transfers in relation
for older adults with chronic pain, Journal of Pain, to nurses’ work technique. Journal of Advanced Nursing,
10(1), 68–79. 47(3), 251–259.
Chair, S., Taylor-Piliae, R., Lam, G., & Chan, S. (2003). Lin, M., Hsieh, Y., Hsu, Y., Fetzer, S., & Hsu, M. (2011). A
Effect of positioning on back pain after coronary angi- randomized controlled trial of the effect of music ther-
ography. Journal of Advanced Nursing, 42(5), 470–478. apy and verbal relaxation on chemotherapy-induced
Eide, H., Sibbern, T., & Johannessen, T. (2011). Empathic anxiety. Journal of Clinical Nursing, 20, 988–999.
accuracy of nurses’ immediate response to fibromyalgia Persson, A., Veenhuizen, H., Zachrison, L., & Gard G. (2008).
patients’ expressions of negative emotions: An evalua- Relaxation as a treatment for chronic musculoskeletal
tion using interaction analysis. Journal of Advanced pain—a systematic review of randomized controlled
Nursing, 67(6), 1242–1253. studies. Physical Therapy Reviews, 13(5), 355–365.
Gallaher, M., & Long, D. (2011). Demystifying behaviors, Peters, J. (2007). Examining and describing skin conditions.
addressing pain, and maximizing comfort research Practice Nurse, 34(8), 39–40, 43, 45.
and practice: Partners in care. Journal of Hospice and Schneider, S., & Hood, K. (2007). Virtual reality: A distraction
Palliative Nursing, 13(2), 71–78. intervention for chemotherapy. Oncology Nursing Forum,
Harris, M., & Richards, K. (2010). The physiological and 34(1), 39–46.
psychological effects of slow-stroke back massage and Thrane, S. (2010). Hindu end of life. Journal of Hospice and
hand massage on relaxation in older people. Journal of Palliative Nursing,12(6), 337–342.
Clinical Nursing, 19, 917–926. Wilkinson, J., & VanLeuven, K. (2007). Fundamentals of
Hartmann, M., Bäzner, E., Wild, B., Eisler, I., & Herzog, W. nursing. Philadelphia, F.A. Davis.
(2010). Effects of interventions involving the family in Williams, A. M., Davies, A., Griffiths, G. (2009). Facilitating
the treatment of adult patients with chronic physical comfort for hospitalized patients using non-pharmacological
disease: A meta-analysis. Psychotherapy and Psychoso- measures: Preliminary development of clinical practice
matics, 79, 136–148. guidelines. International Journal of Nursing Practice, 15(3),
Holliday-Welsh, D., Gessert, C., & Renier, C. (2009). 145–155. doi: 10.1111/j.1440–172X.2009.01739.x.
Massage in the management of agitation in nursing Yousefi, H., Abedi, H., Yarmohammadian, M., & Elliott, D.
home residents with cognitive impairment. Geriatric (2009). Comfort as a basic need in hospitalized patients
Nursing, 30(2), 108–117. in Iran: Hermeneutic phenomenology study. Journal of
Clinical Nursing, 65(9), 1891–1898.
34C H A P T E R
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
at several major universities, including the University
Cheryl Tatano Beck graduated from the Western of Maryland, the University of Michigan, Florida
Connecticut State University with a baccalaureate in Atlantic University, the University of Rhode Island,
nursing in 1970. She recognized during her first clini- and Yale University, and as professor at the University
cal rotation that obstetrical nursing was to be her of Connecticut, where she holds a joint appointment
lifelong specialty. After graduation, Beck worked as a in the School of Nursing and School of Medicine.
registered nurse at the Yale New Haven Hospital on Beck has served as consultant on numerous research
the postpartum and normal newborn nursery unit. projects for universities and state agencies in the
By 1972, Beck had graduated from Yale University northeastern United States. During her career, Beck
with a master’s degree in maternal-newborn nursing has received more than 30 awards, including Distin-
and a certificate in nurse midwifery. In 1982, she re- guished Researcher of the Year from the Eastern
ceived a doctorate in nursing science from Boston Nursing Research Society in 1999. She was inducted
University.
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
as a fellow in the American Academy of Nursing CHAPTER 34 Cheryl Tatano Beck 673
in 1993. locally, nationally, and internationally. She has served
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
numerous local, national, and international awards
A prolific author and disseminator of her research, for her work. Most recently, in 2011, Beck was given
Beck has authored more than 100 research-based the Best Publication by Sigma Theta Tau International
articles and given scores of research presentations
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
1999 Maternal depression and child behavioral
1977 Replication of master’s thesis
problems
1982 Parturients’ temporal experiences during labor 2000 PDSS: Development and psychometric testing
(doctoral dissertation) 2001 Comparative analysis between PDSS and two
1985 Mothers’ temporal experiences in postpartum other depression instruments
period after vaginal and cesarean deliveries 2001 Item response theory in affective instrument
1988 Postpartum temporal experiences of primiparas development
2001 Ensuring content validity
1989 Incidence of maternity blues in primiparas and 2002 PPD—metasynthesis
length of hospital stay 2002 Revision of PDPI
2002 Mothering multiples
1990 Teetering on the edge: A grounded theory study 2003 PPD in mothers of babies in the NICU
of PPD 2003 PDSS—Spanish version
2004 Birth trauma
1992 The lived experience of PPD 2004 Posttraumatic stress disorder after childbirth
2004 Benefits of internet interviews
1994 Nurses’ caring with postpartum depressed 2005 DHA in pregnancy
mothers 2005 Birth trauma and breastfeeding
2005 Mapping birth trauma narratives
1995 Screening methods for PPD 2007 PDSS—Internet
2009 Mothers caring for a child with a brachial plexus
1995 PPD and maternal-infant interaction
injury
1995 Mothers’ with PPD perceptions of nurses’ caring 2012 Subsequent childbirth after previous birth trauma
1996 Relationship between PPD and infant
temperament
1996 Predictors of PPD metaanalysis
1996 Mothers with PPD and their experiences
interacting with children
1996 Concept analysis of panic
1997 Developing research programs using qualitative
and quantitative approaches
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 evolution of grounded theory in nursing. Throughout
Honor Society award for Best of Journal of Nursing all of Beck’s work and consistent with feminist theory,
Scholarship-Profession, World Health, and Health there is explicit valuing of the importance of under-
Systems. standing pregnancy, birth, and motherhood through
“the eyes of women” (Beck, 2002a). Furthermore,
Many in nursing recognize the classic Polit and Beck acknowledges that childbirth occurs in many
Hungler research text, a fixture in countless graduate simultaneous contexts (medical, social, economic)
nursing programs. Beck became coauthor of Polit’s and that mothers’ reactions to childbirth and mother-
seventh edition (Polit & Beck, 2003), reflecting Beck’s hood are shaped by their contextual responses.
research expertise. In 2011, this text received the
American Journal of Nursing Book of the Year Award An unusual theoretical source came from the
for the 9th edition. Beck has also written articles re- work of Sichel and Driscoll (1999), who developed an
garding statistical analysis strategies and approaches earthquake model to conceptualize how interactions
for qualitative research. between biology and life result in what they term bio-
chemical loading. Over time, with constant chemical
Although Beck conducted seven major studies challenges related to stressors, women’s brains may
regarding educational and caring issues with under- develop a kind of “fault line” that is less likely to remain
graduate nursing students, for over 3 decades she intact during critical moments in women’s lives, such
contributed to knowledge development in obstetrical as the challenges women face around childbirth, result-
nursing. Her research career began by studying women ing in a kind of “earthquake.” Beck understood Sichel
in labor, with interest in fetal monitoring. Beck’s research and Driscoll’s model to “suggest that a woman’s genetic
focus eventually became the postpartum period and makeup, hormonal and reproductive history, and life
specific studies of postpartum mood disorders. experiences all combine to predict her risk of ‘an earth-
quake’ which occurs when her brain cannot stabilize
Theoretical and Philosophical Sources and mood problems erupt” (Beck, 2001, p. 276).
Although it is easy to understand the physiological and
Although Beck does not address caring as a theoreti- hormonal challenges of pregnancies for women, Sichel
cal or philosophical construct specific to her research, and Driscoll’s earthquake model was important in
she has conducted studies that evidence her belief helping Beck to holistically conceptualize the phenom-
about the importance of caring in nursing . Beck’s use ena that might affect the development of postpartum
of the ideas of Jean Watson with regard to caring depression for women. Although Beck states that she
theory endorses caring as central to nursing, while never experienced postpartum depression after the
acknowledging Watson’s concern that quantitative birth of her own children, those who have may relate
methodologies may not adequately reflect the ideal to the earthquake metaphor complete with tremors
of transpersonal caring. It is obvious throughout culminating in postpartum depression or, worse, post-
Beck’s writings, including research reports using both partum psychosis.
quantitative and qualitative methods, that advancing
nursing as a caring profession is desirable and achiev- Beck has identified Robert Gable as a particularly
able in practice, research, and education. important source in her work. As Professor Emeritus at
the University of Connecticut, Neag School of Educa-
Because many of the studies used to develop Beck’s tion, Gable had coauthored an important text called
Postpartum Depression Theory were qualitative in Instrument Development in the Affective Domain (Gable
nature, Beck has cited various theoretical sources re- & Wolf, 1993). After developing a wealth of knowledge
flecting the philosophical and theoretical roots of about postpartum depression, the next logical steps for
methodologies important for the kind of knowledge Beck became developing instruments that could predict
developed in each study. Phenomenology was used in and screen for postpartum depression. Gable assisted
the first major study of how women experienced post- Beck with theoretical operationalization of her theory
partum depression, with Colaizzi’s (1978) approach. for practical use. Gable has remained directly involved
In her next study, Beck used grounded theory as through the step-by-step development of the PDSS,
influenced by the theoretical and philosophical ideas including the Spanish version (Beck & Gable, 2003).
of Glaser (1978), Glaser and Strauss (1967), and
Hutchinson (1986), all seminal contributors to the
CHAPTER 34 Cheryl Tatano Beck 675
MAJOR CONCEPTS & DEFINITIONS baby (and perhaps other children) are in grave dan-
Beck’s major concepts have undergone refinement ger of harm. Although postpartum psychosis often
and clarification over years of work on postpartum begins to appear during the first week postpartum,
depression. The first two concepts, postpartum it is frequently not detected until serious harm has
mood disorders and loss of control, were developed occurred.
utilizing phenomenology and grounded theory
methods. Postpartum Obsessive-Compulsive Disorder
Only recently identified, the prevalence rates of post-
Concepts 1 to 2 partum obsessive-compulsive disorder have not been
1. Postpartum Mood Disorders reported. Symptoms include repetitive, intrusive
Postpartum depression and maternity blues have thoughts of harming the baby, a fear of being left alone
become better delineated over time, as has the un- with the infant, and hypervigilance in protecting the
derstanding of postpartum psychosis. Two other infant.
perinatal mood disorders, postpartum obsessive-
compulsive disorder and postpartum-onset panic Postpartum-Onset Panic Disorder
disorder, have been identified, as has how these dis- Postpartum-Onset Panic Disorder has been identified
orders are different and how they are interrelated only recently and is also without reported prevalence
(Beck, 2002c). rates. It is characterized by acute onset of anxiety, fear,
rapid breathing, heart palpitations, and a sense of
Postpartum Depression impending doom.
Postpartum depression is a nonpsychotic major
depressive disorder with distinguishing diagnostic 2. Loss of Control
criteria that often begins as early as 4 weeks after Loss of control was identified as the basic psychoso-
birth. It may also occur anytime within the first year cial problem in the 1993 substantive theory of
after childbirth. Postpartum depression is not self- Beck’s early work. This descriptive theory captured
limiting and is more difficult to treat than simple a process women go through with postpartum
depression. Prevalence rates are 13% to 25%, with depression. Loss of control was experienced in all
more women affected who are poor, live in the inner areas of women’s lives, although the particulars of
city, or are adolescents. Approximately 50% of all the circumstances may be different. The concept of
women suffering from postpartum depression have loss of control fit with extant literature and left
episodes lasting 6 months or longer. women with feelings of “teetering on the edge”
(Beck, 1993). The process identified consisted of the
Maternity Blues following four stages:
Also known as postpartum blues and baby blues, 1. Encountering terror consisted of horrifying anxi-
maternity blues is a relatively transient and self-
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.
Initially, Beck (1998) identified eight risk factors n (Effect size 5 Medium)
for postpartum depression. Many studies have ex-
panded areas where Beck determined that more 6 . Social Support
conceptual clarity was needed. Social support pertains to instrumental support (e.g.,
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
1 4. 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
1 5. 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.
1 6. Sleeping and Eating Disturbances 2 2. 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
Nursing
When Beck began to examine postpartum depression
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-
logical, sociological, and psychological components.
In 1993, after four major studies regarding women in Further, there is a strong commitment to the idea that
the postpartum period (Table 34–1), Beck developed a persons or personhood is understood within the con-
substantive theory of postpartum depression using text of family and community.
grounded theory methodology. The substantive theory
was entitled “teetering on the edge,” with the basic Health
psychosocial problem identified as loss of control (Beck, Beck does not define health explicitly. However, her
1993). Since development of the substantive theory, writings include traditional ideas of physical and
Beck has designed 14 other studies to refine the theory mental health. Health is the consequence of women’s
by examining the experiences of postpartum depression responses to the contexts of their lives and their envi-
on mother-child interactions, postpartum panic, post- ronments. Contexts of health are vital to understand-
traumatic stress disorder (PTSD), and birth trauma to ing any singular issue of health.
tease out differences among postpartum mood disorders
(postpartum depression, maternity blues, postpartum Environment
psychosis, postpartum obsessive-compulsive disorder, Beck writes about the environment in broad terms
postpartum-onset panic disorder). Metaanalyses were that include individual factors as well as the world
conducted on predictors of postpartum depression, the outside of each person. The outside environment
relationship between postpartum depression and infant includes events, situations, culture, physicality eco-
temperament, and the effects of postpartum depression systems, and sociopolitical systems. In addition, there
on mother-infant interaction. In addition, two qualita- is an acknowledgment that women in the childbear-
tive metasyntheses were conducted on postpartum ing period receive care within a health care environ-
depression and mothering multiples. ment structured in the medical model and permeated
with patriarchal ideology.
Beck used ten qualitative studies of postpartum
depression in women from a wide variety of geographic Theoretical Assertions
locations and cultures. Women represented in these
studies included Black Caribbean women, Irish women, The theoretical assertions within Beck’s theory are well
Indian women, Hong Kong Chinese women, Hmong represented throughout her writings. She acknowl-
women, Middle Eastern women (living in the UK), edges the importance of Sichel and Driscoll’s (1999)
Asian women, Portuguese women, Australian women, work related to the biological factors involved in post-
Canadian women, and African American women. These partum depression in the following assertions:
new data were used to compare Beck’s original teeter- • The brain can biochemically accommodate various
ing on the edge grounded theory with women in other
cultures. Beck found that the theory’s modifiability was stressors, whether related to internal biology or
in keeping with theoretical expectations of a relevant external events.
substantive grounded theory. Therefore, the theory of • Stressful events (internal or external), particularly
“teetering on the edge,” with “loss of control” as the basic over long periods, cause disruption of the bio-
psychosocial process has functionally expanded to chemical regulation in the brain. The more insults
women in other cultures (Beck, 2006a, 2012b).
to the brain, the more chronically deregulated the CHAPTER 34 Cheryl Tatano Beck 679
brain becomes. Because an already deregulated inductive and deductive logic significantly contrib-
brain is challenged again with new stressors (inter- uted to the development of the theory. Chinn and
nal or external), it is likely that serious mood and Kramer (2011) identify inductive logic as founda-
psychiatric disorders will result. tional to qualitative methods, with reasoning from
• Women’s unique and normal brain and hormonal the particular to the general. In contrast, deductive
chemistry result in a vulnerability to mood disor- reasoning moves from the general to the particular,
ders at critical times in their lives, including after drawing conclusions that represent the general.
giving birth.
• Postpartum depression is caused by a combination Because Beck’s theory reflects a very complex and
of biological (including genetic), psychological, focused path in its evolution, it is helpful to be clear
social, relational, economic, and situational life about what criteria were used to understand and pres-
stressors. ent the theory. The definition of theory currently used
• Postpartum depression is not a homogenous dis- is… “a creative and rigorous structuring of ideas that
order. Women may express postpartum depres- projects a tentative, purposeful, and systematic view
sion with a single symptom but are more likely to of phenomena” (Chinn & Kramer, 2011, p. 257).
have a constellation of varying symptoms. This is Middle-range theories may be derived using grounded
related to varying life histories of internal and theory approaches, and they identify social processes
external stressors. that may occur in various social events. For example,
• Culturally, women are expected to feel happy, look Beck’s substantive theory of postpartum depression
happy, act happy, understand how to be a mother found that loss of control was the basic psychosocial
naturally, and experience motherhood with a sense problem facing women, but this problem could also
of fulfillment. These expectations make it difficult occur in contexts other than the postpartum period.
for women to express genuine feelings of distress.
• The stigma attached to mental illness increases The evolution of Beck’s theory is instructional for
dramatically when a mental illness is related to the several reasons. First, Beck’s unceasing, linear, and
birth of a child, leading women to suffer in silence. logical efforts to develop the theory for pragmatic
• Within a level of prevention framework, postpar- practice concerns led to a theory that addresses a
tum depression can be prevented through identifi- specific practice problem. Because her theory is rela-
cation and mitigation of risk factors during the tively new, there are few contributors to the substance
prepartum period. Postpartum depression can be of the theory. Therefore, there is opportunity to follow
identified early with careful screening and can be a very clear and focused process of theory develop-
treated effectively. Prevention can alleviate months ment by a scholar who began the work as a young
of suffering and decrease the harmful effects on woman. Beck has tested her theory, used it with vari-
women, their infants, and their families. ous populations, tested instruments, and developed
• A number of biological, sociological, and psychologi- a work in which other scholars can join her to con-
cal issues and challenges are entirely normal in all tribute to the science. Second, Beck’s theory of post-
pregnancies. These may include fatigue, sleep altera- partum depression is remarkable as an example of
tions, questioning one’s abilities, and the like. Com- extensive inductive theory development in a specific
prehensive prenatal and postnatal care can eliminate area of nursing practice addressing a specific patient
troublesome pathological symptoms and help women problem. Although Beck began her work with a
normalize expected symptoms, thus reducing the global understanding of caring, her focused work on
degree of stress they actually experience. postpartum depression was advanced through the
development of a substantive middle-range theory
Logical Form and continues to advance. From the beginning, Beck’s
goal has been to understand postpartum depression
Beck’s Postpartum Depression Theory, as described in in a way that would allow professionals to develop
previous sections of this chapter, identifies how both adequate prevention strategies, develop screening
programs for early intervention, and develop ade-
quate treatment strategies to prevent harm to women,
their children, and their families. True to her research
680 UNIT V Middle Range Nursing Theories Beck’s work has also been instrumental in com-
munity intervention and education projects such as
aims, what began as a descriptive substantive theory the Ruth Rhoden Craven Foundation for Postpartum
of postpartum depression has evolved into an exten- Depression Awareness located in South Carolina.
sive research program. Helena Bradford founded this organization because
of a tragic postpartum mood disorder within her
Acceptance by the Nursing Community own family. Ms. Bradford advocates for postpartum
Practice awareness within her community and conducts sup-
port groups (H. Bradford, personal communication,
As Beck’s research findings have been disseminated April 28, 2004).
more widely, the theory and the instruments based on Education
the theory have been utilized increasingly in nursing Beck is a frequently invited speaker for professional
practice throughout the United States. In addition, the educational conferences and workshops. Her work is
PDSS is in use and translated as appropriate in Canada, cited frequently in nursing maternal and newborn
Australia, Brazil, New Zealand, Ireland, South Africa, nursing texts, such as that of Davidson, London, &
Germany, Russia, Turkey, Hungary, China, and Israel. Ladewig (2011). At both undergraduate and graduate
(The References section titled Bibliography of Research levels, Beck’s work sets the standard for knowledge
Using the Screening Scale includes international use of and understanding about postpartum depression. In
the PDSS.) addition, Beck’s work has been used to educate mem-
bers of other disciplines, such as physicians, mental
The PDSS became a standard of care for women in health workers, public health professionals, social
the high-risk obstetrical clinic of the Medical Univer- workers, and those who work in social service agen-
sity of South Carolina Hospital (A. Raney, personal cies that provide protective care for women and
communication, April 28, 2004). The clients in this children. Beck also brings her work to the general
clinic vary in age across the spectrum, come from vari- public and policy makers through active community
ous ethnic backgrounds, and have a wide range of involvement at the local, state, national, and interna-
medical risk factors. She has noted that the tool is a tional levels.
vehicle for opening discussions with women that had Research
not occurred prior to implementation of the tool. High The long research development of Beck’s theory is
scores on the PDSS have given physicians evidence to evident in Table 34–1. As previously noted, she has
understand how postpartum depression is expressed in received numerous awards recognizing the impor-
their patients, increasing their sensitivity and aware- tance of her research. Nurses increasingly are using
ness. Predictably, marshaling of community resources Beck’s work for master’s and doctoral level research.
to meet the specific needs of individual clients has been In addition, Beck facilitates practice implementation
a challenge; however, the landscape for the Charleston research for academic and nonacademic sites.
community in understanding and responding to the
special needs of women during this time has occurred. Further Development
Public health initiatives that involve working with Beck identified what became another major concept
new mothers and babies are also utilizing Beck’s theory in her theory, as well as a restructuring of postpartum
of postpartum depression via the PDSS. For example, mood disorder definitions (Beck, 2004a, 2004b).
the Healthy Start CORPS: Inter-Conceptual Care Case Because of increasing reports of PTSD after childbirth,
Management Project in North Carolina begins to fol- she examined women’s experiences of traumatic
low women when they are 6 weeks postpartum. All births (Beck, 2004a). In this work, birth trauma was
new clients, many of whom are Native American, are defined as “an event occurring during the labor and
given the PDSS so that intervention and management delivery process that involves actual or threatened
strategies can be built into plans of care for individual
women and their families (L. Baker, personal commu-
nication, April 29, 2004). The director of the program
emphasizes the ease with which women are able to
discuss symptoms of postpartum depression after com-
pleting the tool.
serious injury or death to the mother or her infant. CHAPTER 34 Cheryl Tatano Beck 681
The birthing woman experiences intense fear, help-
lessness, loss of control, and horror” (Beck, 2004b, postpartum depression follows a logical progression
p. 28). Beck noted that women who actually had been specific to observations made in nursing practice. It is
suffering from PTSD were misdiagnosed as having accessible empirically and theoretically. Importantly,
postpartum depression and were treated incorrectly concepts and definitions used for predicting a wom-
with antidepressant medications. She recommended an’s risk for postpartum depression and concepts and
that postpartum mood disorders be changed to post- definitions used to screen women for symptoms of
partum mood and anxiety disorders (Beck, 2004b). postpartum depression are directly meaningful for
PTSD would then be differentiated as a distinct women, the lay public, and practitioners from nursing
diagnosis with different treatment approaches. Birth and other related disciplines.
trauma, as a concept, will be examined empirically Generality
and included in predictor and screening instruments Beck has accounted for the complexity of postpartum
as appropriate. Beck (2006c) examined women’s expe- depression within the expansion of the concepts
rience of the anniversary of their birth trauma, noting within the theory. Generality issues relate to how
that the birthday of a woman’s child might represent broadly the theory describes human experience, and
a time of reexperiencing the trauma all over again. this is supported by applicability of the theory in dif-
Current research by Beck and co-investigator Carol ferent cultural contexts. Chinn and Kramer (2011)
Lammi-Keefe focuses on docasahexaenoic acid in note that generality refers to a theory’s ability to
pregnancy and its effect on postpartum depression remain conceptually simple, yet account for a broad
(Judge & Beck, 2008). range of empirical experiences. Postpartum depression
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 Accessibility
diagnosis. Future research focuses on ways to connect The PDSS (Postpartum Depression Screening Scale)
women in an Internet group with appropriate services has been subjected to a rigorous statistical process for
for intervention for prevention and treatment. development and standardization. Beck and Gable
(2000) examined the psychometric properties of the
Critique scale with regard to reliability of the measure within
Clarity developmental and diagnostic samples. Validity anal-
yses were conducted with the two samples, as were
Beck’s theory evidences a semantic clarity as concepts procedures used to establish cutoff scores for clinical
are defined clearly and consistently. Within and between interpretations. These studies indicated that the
research reports, Beck uses terms, ideas, definitions, and PDSS is a reliable and valid screening instrument for
concepts in a way that reflects growth, yet they are detection of postpartum depression (Beck & Gable,
defined and easily understood. Her research and writ- 2000, 2001a, 2001b, 2001c, 2001d). The theory and
ings use both inductive and deductive language, and her the PDSS are relatively new and have therefore not
verbiage is economical and clear. been critiqued empirically by a wide variety of schol-
ars. Beck has two instruments: the PDSS, which
Simplicity is well established, and the Postpartum Depression
Postpartum depression is a complex phenomenon, Prediction Inventory (PDPI), which has more recently
experientially and theoretically. Yet Beck’s theory of
The words you are searching are inside this book. To get more targeted content, please make full-text search by clicking here.
Nursing Theory alligood 8th edition
Discover the best professional documents and content resources in AnyFlip Document Base.
Search
Nursing Theory alligood 8th edition
- 1 - 50
- 51 - 100
- 101 - 150
- 151 - 200
- 201 - 250
- 251 - 300
- 301 - 350
- 351 - 400
- 401 - 450
- 451 - 500
- 501 - 550
- 551 - 600
- 601 - 650
- 651 - 700
- 701 - 750
- 751 - 765
Pages: