Assessment, Formulation, And Evidence-Based Services

The Tidal Model And Care Programme Approach Framework

This essay discusses on the assessment and formulation of a care plan with the help of evidence based mental health services. According to James et al. (2014), adherence to an evidence based approach, will help in the development and performance of good quality screening, assessment and care planning procedures. Evidence based practice encompasses the performance of research and the utilization of knowledge obtained through  research, during the execution of successful professional practice and also necessitates incorporation  of  ‘tacit knowledge’ – that  is the,  the  information  or knowledge from additional  clinical  professionals (Moreno, Becerril and Alcalde 2018).

For  the  purpose of assessment ‘Care Programme Approach’ has been adopted. This approach to mental health was  formulated with the aim that individuals requiring specialist treatment for mental health  treatment, may also need additional  assessment and  management of their social and physiological needs (Farrelly et al. 2016). This will aid in the development of a multidisciplinary treatment approach for the  mental health  management  of the patient, which  will further specify  the  key  professional services  required. (Tyrer et al. 2017). The essay also discusses about the utilization of the Tidal Model for Mental Health Nursing, which aims at treatment of the individual, through emphasis on patient empowerment and change processes encountered (Ramage, Ellis and Marks-Maran 2018).

For the purpose of keeping the identity of the patient receiving care confidence and anonymous, in accordance to the NMC Code, the name of the service use has been altered. My duties and responsibilities as a student nurse, includes maintenance of confidentiality and anonymity of the individuals to whom I am imparting my treatment and care services, along with obtaining consent prior to execution of treatment procedures and conducting appropriate communication with them concerning the details of their care plan (Fisher 2017).

The Tidal Model, as researched by Sava?an and Çam (2017), entails an approach towards mental health recovery, through the encouragement and empowerment of the concerned patient, through extensive evaluation and emphasis on the changes faced by him or her, the usage of metaphors and by involvement of the patient in the care planning process, by allowing his or her changing needs to direct the treatment, rather than relying solely on professionals. The Tidal Model was developed by Professor Phil Barker  and aims to empower individuals by helping them to recovery through the usage of metaphors and allowance for the patient to liberally engage in their personal expression of needs, preferences and personal stories (Ramage, Ellis and Marks-Maran 2015).

The Care Programme Approach or CPA, as stated by Brooker and Forrester 2017), highlights the key guidelines to be followed for the successful conductance of assessment, planning, coordination and reviewing the essential needs of a person suffering from mental health disorders. According to Kingdon (2018), the usage of CPA has been documented to be effective, especially  in  the  treatment  of patients suffering from severely detrimental symptoms of mental health disorders. Additionally, CPA has also been found to be helpful for clients with sensitive needs, such as victims of abuse, or for those whose treatment of mental difficulties is not financially feasible (Power et al. 2016).   Planning Of Care In Mental Health Nursing Essay Paper

Biography

For the successful conductance of a CPA framework, the service provider must adhere to four salient principles. As stated by Brooker and Webster (2017), these include assessing the requirements of the patient, delegating a coordinator of care, planning the fulfillment of the specialized needs of the patient along with reviewing or follow up of the patient’s  condition  during as well as after the conductance of the chosen treatment procedures. The chosen coordinator of the CPA framework will ensure that the patient possesses complete accessibility of the  required treatment services along with the incorporation of the NHS, additional organizations and the family members in the treatment process. As researched by Kemp (2016), in accordance to the CPA, the treatment plan must also undergo regular monitoring and reviewing by the coordinator to asses patient progress, along with the presence and requirement of additional factors such as medications, side effects, education, social networks or health literacy training. The principles of assessment highlighted by the CPA also includes the evaluation of the presence of substance abuse or alcohol and the potential risk the service user may possess towards others or towards oneself (Moody et al. 2018).

Considering the need for mental health patients to engage in feelings of mental security of reduction of distress during provision of mental health treatment, associating the mental health needs along with the social and emotional needs of the client is of utmost importance, which the CPA saliently highlights (Asaria et al. 2015). However, as researched by Ryan et al., (2016), the CPA framework has not been devoid of criticism, where certain professionals have regarded the practice as being inconsistent and autocratic. Nevertheless, as researched by Eaton, Roberts and Turner (2015), it has been documented that the CPA framework is an ideal approach for mental health nursing, due to adherence of an integrated treatment approach encompassing required referral or specialized services for the management of multifaceted client needs, which has been found to be advantageous. CPA along with the Tidal Model has been documented to be an efficient care planning model of treatment for mental health patients, and hence, has been utilized extensively for the management of the service user highlighted in this essay (Sava?an and Çam 2017).

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The chosen case subject is Harper, a 49 year old woman, who was previously engaged in receiving residential care services for the previous 10 weeks. Harper has been found to be suffering from cerebral palsy, mild symptoms of learning disabilities and major symptoms associated with Personality Disorders, namely Emotionally Unstable Personality Disorder. Prior to being admitted to our community health center, we received information from the residential services in which Harper was engaged in previously,  which highlighted incidences of violence, self harm and aggression  towards herself and towards the workforce.  Harper had a  record of over 60 incidents where she exhibited unpredictable behavioral outbursts of violence, aggression  and  self harm, towards herself, as well as towards others involved in her care and treatment.  The residential facility has issued Harper a notice for eviction.

Harper was born as the third child to a single mother. Harper’s parents had previously divorced due to repetitive alcohol abuse by her mother and the constant conflicts between the two. After the divorce, her mother engaged in constantly abusing Harper and her two siblings, her sisters. Harper was born with learning disabilities which resulted in her poor academic performance and further resulted in being constantly abused by her mother, who would hit her repetitively and deprived her of food for days, as punishment for the same. One night, after a period of excessively drinking, Harper’s mother began to recklessly break things in the household, terrorizing the children in the process. As a result, Harper and her sisters ran away from the house and after being reported by a passerby to the nearest police station, they begun living in their aunt’s house. While the rest of the children seemed fine, Harper begun to show detrimental symptoms of violence and aggression which aggravated to worsening conditions leading to her admission in the residential care facility. Harper admitted that she feels impulsive and engages in violent behavior, despite the absence of any major stimulus or trigger as an underlying cause. However, she did admit that she wished to complete her education and become a musician or a music teacher in the future, due to the relaxation she feels upon listening to music. Still, upon recalling her traumatic childhood and her psychological problem, Harper feels that she her future is a lost cause and lacks hope of any improvement in her quality of life or her health condition.

As stated by Bradford and Rickwood (2015), the conductance of appropriate screening and assessment tools is of utmost importance, since it paves the way for guidance for the successfully development of a diagnosis and ongoing treatment plan. A successful assessment report highlights key information such as essential disease signs and symptoms, details of the past medical history possessed by the patient, the required medications and personal needs or preferences of the patient (Washburn, Bordnick and Rizzo 2016). An adequate assessment report also highlights additional details concerning the patient’s family or social networks, along with additional dual diagnosis symptoms such as adherence to substance abuse or alcohol consumption. Hence, an assessment can be defined as the conductance of key communicative and diagnostic procedures for the purpose of uncovering essential details of a patient’s existing as well as past mental health conditions (Edens and Boccaccini 2017).

The assigned coordinator must engage in uncovering the  salient details  of the  past  medical  or disease history  of the  patient (Krist et al. 2014).  For the assessment of Harper, I engaged in conducting her assessment with the aid of Barker’s Tidal Model of Mental Health Nursing. One of the key principles of assessment in Tidal Modelas researched by Teixeira (2018), is the identification of the true identity of the service user. This will help me to saliently understand Harper’s personal story and her personal needs and preferences which may outline her mental health condition. This will also help in centralizing the objectives of the treatment in accordance to the needs of the patient, rather than focusing solely on the diagnosis of Harper’s symptoms (Sampaio et al. 2018). Secondly, in accordance to the Tidal Model I must engage in enquiring about what is wrong with Harper, which will encourage her to share her personal physiological and psychological condition and the factors which have affected her well being. For the successful conductance of this form of assessment, the nurse must engage in performance of empathy in her professional clinical nursing practice, which I utilized in order to make my patient, that is Harper, to discuss her problems with a feeling of peace, comfort and ease and without feeling agitated or threatened (Ramage, Ellis and Marks-Maran 2015). In accordance to the Tidal Model of mental health nursing, the nurse must engage in using a holistic approach for assessment and treatment of the patient, which I actively engaged in while communicating with Harper. This approach, as stated in the Tidal Model, will require me to evaluate multiple factors of Harper’s assessment at the physiological, developmental, psychological, spiritual and functional aspects (Ramage, Ellis and Marks-Maran 2018).

The service user, that is Harper, was diagnosed with a complex case of emotionally unstable personality disorder, mild learning disabilities and cerebral palsy by the residential care facility where she was previously admitted. Her diagnosis and disease conditions have been attributed to her past familial history of an abusive childhood. Harper has engaged in detrimental behaviors of violence, aggression, self harming, harming others, suicidal attempts along with a risk of facing falls. Upon communicating empathetically, Harper admitted her impulsiveness towards conductance of harmful behaviors, despite the absence of any form  of trigger or stimulus. In accordance to professional nursing practice and the Tidal Model, as researched by Sava?an and Çam (2017), which necessitates the need for a patient-centered form of treatment, I engaged in a therapeutic relationship with Harper. This involves usage of compassionate interpersonal communication strategies in order to develop an empathetic yet professional relationship with the patient, to gain insight into the patient’s story – a key requisite of the tidal model (Williams, Ilten and Bower 2016). Hence, I engaged in a Phatic communication with Harper, which the tidal model suggests as the usage of communication strategies to induce openness and not content related information from the client.  Hence, I empathetically questioned Harper about her previous experiences in her residential home as well as experiences pertaining to her family. The usage of this assessment approach compelled Harper to be at ease and prompted her to express that her childhood experience was horrifying due to the repeated episodes of physical abuse she received from her parents, as a punishment for her poor learning and academic skills. She also admitted gradually, how she preferred community care rather than institutionalized hospital treatment and how music made her feel relaxed and reduce her impulsive symptoms of violence. Despite the time consuming nature of this method posing as a disadvantage, this aids in gifting the patient time for healing and self-empowerment  – a key need for successful Tidal Model execution (Williams, Kemper and Hummert 2016).

According to Jakimowicz and Perry (2015), one of the most important requisites for the conductance of professional nursing practice is the maintenance of privacy and confidentiality of the patient. This also ensures emergence of feelings of comfort, security and relaxation in the patient, which will aid in his or her expression of personal life experiences and stories – a key requisite of the Tidal Model (Teixeira 2018). Hence, for the purpose of maintaining Harper’s privacy and dignity, a semi-structured interview was conducted in a private room. According to the Tidal Model, not only must the patient be made to feel secure, but also must be involved in the healing process due to focus on life experiences (Ramage, Ellis and Marks-Maran 2015). For successful execution of this, me and my supervisor, introduced ourselves to Harper, and also explained her the need for assessment along with explanation of the assessment tool to be used. For the assessment of her personality disorder, the assessment guidelines presented by the Diagnostic and Statistical Model of Mental Health Disorders, 5^th edition was used (DSM 5) (Benson, Donnellan and Morey 2017). This is essential for ensuring an honest and transparent relationship with the patient, which is essential for tidal model and patient-centered approach to treatment (Hipfner et al. 2017).

Additionally for the assessment of Harper, a semi-structured interview was conducted. According to Kallio et al., (2016), this tool is a form of qualitative study, which involves the usage of open ended questions in order to obtain a clear understanding of the views and opinions presented by the interviewee. Hence, for this purpose, we conducted a semi structured interview with Harper. The tidal model states that the present diagnostic condition of a patient is not a key requisite to meet the personal requirements of the patient (Sava?an and Çam 2017). Hence, following this, instead of discussing her mental condition, we interview Harper with phatic communication, discussing her everyday activities and preferences.

As stated by Ramage, Ellis and Marks-Maran (2018), the essence of successful usage of tidal model, entails encouraging the patient to discuss their life story. For this purpose, open ended questions were used in the interview for Harper to freely discuss her life experiences. According to Melovitz Vasan et al., (2018), open ended questions are subjective in nature, and allows the client to freely express opinions without the presence of any barriers or regulations, further leading to better understanding of the client by the concerned practitioner. The tidal model also necessitates the recognition of the true needs of the client, for which Harper was also interviewed with a few close ended questions (Teixeira 2018).Close ended questions are objective in nature and are efficient in highlighting specific details of the needs of the client. This mix of open and close ended questioning for client assessment is known as funneling and helps in obtaining a large amount of client personal information along with concise identification of her key needs (Sheats, Hammond and Kedrowicz 2018). Hence, me and my supervisor begun interviewing Harper, by enquiring about what led to her residential care admission, for which she replied that she has begun to engage in harmful behaviors such as hitting her siblings and family members while being in her home. Upon being asked about what led her to engage in such behaviors, Harper expressed her childhood history of violence and abuse projected to her by her parents, which led to feelings of anger, loss of control, incompetency and bitterness further resulting in her impulsive behaviors of aggression and violence. In accordance to the tidal model, the client must be freely allowed to express her story without interruption. Hence, by following this, me and my mentor allowed Harper to actively talk about her condition and empathized with her, along with recognizing the fact that she, the patient, possesses the best knowledge suited for her treatment  – which are essential requirements for successful Tidal Model execution (Ramage, Ellis and Marks-Maran 2018).

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The additional assessment tool was the biopsychosocial model of health, which was developed in the year 1977, by George Engel. As researched by Rodgers, Paxton and McLean (2014). The model recognizes the complex interplay of multiple factors as causes for the occurrences of illness and disrupted health in an individual, such as biological factors pertaining to the biochemical or genetic makeover possessed by the client, psychological factors such as personality changes, attitudes and emotions and social factors such as the client’s medical, cultural, financial, social and economic status.

We observed that Harper presented symptom of emotionally unstable personality disorders, learning disabilities and cerebral palsy which contributed to her distorted and unnatural behavior. Further, the violence exhibited by her family towards her were key social factors which led to her present mental health condition. Psychological and emotional feelings of anger, bitterness, lack of competency and confidence along with loss of hope and control, further aggravated Harper’s condition of exhibiting violent behaviors towards herself and her surroundings. In order to understand her risk of suicide, we empathetically interviewed Harper considering her feelings, in which she expressed that lack of love and affection from her family, led to her feelings of worthlessness and a loss of desire to live. For assessing her risk the Suicidal Affect Behavior Cognition Scale was utilized (Harris et al. 2015).

Lastly, to conclude the assessment, we compassionately interviewed Harper considering her views or needs which she expects the health center to fulfill. As researched by Sava?an and Çam (2017), this sort of enquiry is a key requisite to successful tidal model usage since it encourages the patient to actively participate in his or her own healing process along with inculcation of feelings of self-empowerment by gaining control in conducting the decision-making process of one’s treatment. Harper expressed her desire to have an elaborate bath, which she was devoid of for over a year due to negligence. She also expressed her desire to have facilities pertaining to music by the healthcare center.

As stated by Coffey et al., (2017), the health service providers involved in the treatment of the patient, must also ensure the safety of the workers and additional patients in the clinical facility. According to Wand, Isobel and Derrick (2015), the treatment of mental health patients is often associated with the risk of aggression and violence which can be detrimental to the condition of the patient, as well the surroundings. Assessing the medical history of the patient, along with the uncovering details from previous clinical practices often give essential information concerning the risk of harm exhibited by the patient (Grotto et al. 2015). For Harper, we knew from the residential care facility where she was engaged in previously, that she engaged in self harm and aggressive behaviors. To assess these risks, we decided to compassionately talk to Harper, without any reference to her past history in order to make her feel empowered and comforted as stated in the tidal model. We uncovered that feelings of negligence and lack of understanding of her condition which was prevalent in her precious facility as well as in her family led to feel unworthy and unaccepted, further resulting in suicidal or harmful behavior. Some of the question which guided our assessment were the following (Buchanan-Barker and Barker 2016):

• Where do you see yourself in the future?
• How often do you feel like giving up?
• Do you often feeling that you are losing hope?
• What situations compel you to harm yourself or end your life? (This gave us an idea of the basic needs of Harper, which when unfulfilled, led her to undertake detrimental behaviors).
• How frequently do you get these thoughts?

As stated in the codes of conduct by the Nursing and Midwifery Council, nurses and healthcare professionals must not only ensure recovery and betterment in the patient, but must also ensure health care service and resource accessibility to further ensure sustainable positive health outcomes in the future (Levati 2014). Hence, in the situation of Harper, we identified her special needs through application of the Tidal Model as well as biopsychosocial model, administration of standardized assessment tools, as well as directly involving her in the treatment and decision-making process, as a part of patient-centered approach to treatment (Paul 2016).

As researched by Luitel et al., (2015), the process of care planning, highlights the formulation of a structure or a blueprint, which will emphasize the details pertaining to the fulfillment of treatment objectives and the progress evaluation of the client. According to Hanlon et al., (2014), care planning involves the process of development of the treatment procedures which are to be utilized, the delegation of activities in accordance to the specialist care required, and processes of monitoring patient progress or deterioration. In accordance to the CPA framework, the conductance of successful care planning requires the following four steps of need identification, development of intervention strategies, emphasizing desired outcomes and reviewing (Brooker et al. 2016).

As stated by Teixeira (2018), the application of tidal model is also simultaneously compatible with the development of a care plan, since the model necessitates the crafting of further steps beyond assessment for smoothening the journey of recovery for the client.

In the first step at development of a care plan for Harper, me and supervisor engaged ourselves actively in indentifying the key preferences and requirements which Harper would like to met in the clinical setting. For the identification of the same, as stated by Hunter et al., (2015), the tidal model necessitates the conductance of emphathetic and phatic modes of communication with interpersonal communication strategies which would require asking questions accordingly to Harper without referring to her disease or past medical condition, in order to avoid feelings of insecurity and agitation in her. Hence, after interviewing her with open ended, phatic-based questions, me and my supervisor could identify, as confessed by Harper, that the patient’s needs include a feeling of safety and security, a feeling of being understood as well a feeling of being worthy resulting in gaining control of her life. Harper also expressed her desire to engage in bathing and her need to feel hygienic and refreshed. She also expressed her need of music which induces relaxation in her. Upon risk assessment, me and my supervisor could identify that feelings of safety and adequate physical health is also a key need for Harper, considering her engagement in suicidal and violent behaviors, along with susceptibility to falls. Harper also communicated to us, concerning her need to feel a sense of belonging and be a part of the community, since an institutionalized treatment within a residential or hospital setting affected her mental health and made her feel agitated.

Upon identification of her needs, the formulation of intervention strategies in accordingly was the next step in the development of a care plan. According to Paton et al., (2015), one of the key symptoms of emotionally unstable personality disorders is the sudden exhibition of violence and aggression. Hence, for the management of the same, psychotherapeutic procedures were selected as an intervention strategy, where me and my supervisor, focused on utilizing Mentalization based therapy (MBT) as an intervention strategy. According to Kvarstein et al., (2015), MBT focuses on self reflection and talking to oneself in order to encourage the patient in the identification of his or her own thoughts before reaction to a situation, and uncovering alternative modes of responses rather than violence or aggression. MBT, due to its client-centered approach resonates wells with tidal model, which also focuses on the person as the key individual possessing the best knowledge for his or her recovery. For inducing relaxation as suggested by Harper, music therapy, a form of complementary therapy was also decided as an intervention strategy, which, according to Strehlow, and Lindner (2016), will require the intervention of a music therapist for the management of Harper’s symptoms. In order to keep a check on Harper’s engagement in suicide or aggression, a separate nursing staff will be employed to ensure her as well as others safety, prevent falls and assist Harper in her daily life activities such as bathing (Williams et al. 2016). This team will be instructed with engage sensitively with Harper using empathy – which is essential as stated by tidal model, to foster the needs of the patient to feel comfortable, understood and secure (Sava?an and Çam 2017). For the regulation of her suicidal thoughts, cognitive behavioral therapy would be utilized as an intervention, which will include regulation and modification of disruptive thoughts and behaviors in response to specific stimuli (Trockel et al. 2015). Considering Harper’s need for feelings of acceptance, we decided to include her in the weekly self help group discussion sessions which were held in our community center. According to Markowitz (2015), self help groups have been found to be beneficial for mental health patients overcome with detrimental symptoms, due to their provision of mutual support and feelings of belongingness.

As researched by Hunter et al. (2015), the tidal model explicitly focuses on the development of a treatment based on the expression of needs and experiences shared by the patient. Hence, this necessitates the performance of the final steps of care planning, where Harper was informed and explained clearly, the key features of the chosen intervention plan, where she was again enquired about her expectations, in order to make he feel understood and secure. Harper seemed happy and ready to undertake the care plan chosen for her and restated her needs. We then formulated that the desired outcomes of this care plan would involve feelings of control, relaxation, competence, high self-esteem and positivity in Harper along with a sense of responsibility for her actions. The plan was reviewed, agreed upon and signed.

Conclusion

The essay sheds light on the various challenges of mental health nursing and ways to overcome to same through extensive negotiating and discussion with the client. I focused on assessment and care planning of Harper, who presented dangerous behaviors of harm, violence and aggression. I could identify the complex needs of the patient and understood the necessity of a compassionate, therapeutic relationship along with ensuring the management of risk of the patient. I learned that empathy, compassion and understanding are essential qualities required in a mental health nurse, for the purpose of quickening the recovery process of the patient.

Reference

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