Nursing care in mental health based on the TIDAL MODEL: an integrative review

Objectives: to identify the applicability of the Phil Barker’s Tidal Model in mental health nursing care. Methods: an integrative literature review carried out by LILACS, MEDLINE, Scopus and Web of Science. Data were collected from December 2017 to March 2018. After selecting the studies, the sample totaled 24 articles. Results: the articles are in English (91.7%), were published in nursing journals (87.5%), are reflective and/or theoretical (50%) and have level of evidence VII (79.2%). The model brings contributions to nursing science, enabling person-centered care, with an emphasis on interdisciplinary work, nurses’ protagonism and the empowerment of subjects in mental suffering. Final considerations: the use of the Tidal Model enables changes in nurses practice working in the context of mental health. Its application by nurses who work in mental health services in Brazil is recommended. RESUMO identificar aplicabilidade Tidal Model , de Phil Barker, cuidado enfermagem Saúde Mental. Métodos: revisão integrativa da literatura, realizada pelas bases LILACS, MEDLINE, Scopus e of Science coleta dados ocorreu dezembro 2017 março 2018. artigos. artigos


INTRODUCTION
In order to strengthen the scientific production of mental health nursing, the Tidal Model is an important theory in the foundation and qualification of care. This theory aims to bring answers to the patient and contributions to nursing care, being classified as a Practical Theory. This is a philosophical concept proposed by Phil Barker, born in Scotland and the first Professor of Psychiatric Nursing in the United Kingdom (1) .
The Tidal Model puts the person and the experience she has with mental illness and her distress at the heart of caring. People and narratives of their life histories are important for mental health care. In the interview, dialogue takes place by creating "letters", new possibilities of care. In this interaction, the nurse should ask: what would you like to talk about? (1) .
The model starts from a creative relationship between professional and person through alliances, being the nurse the person who helps the subject to seek meaning for his illness. It is a facilitating model, that is, it gives the conditions for something to happen. Care is seen as a "wrapper, " which holds the nurse close to the subject. Caring for people is to keep change in mind and the professional to be sensitive to change. It is in care for the other that nurses will achieve professional and personal growth. The proposed model escapes the idea that the professional knows what is best for the person. It's the people who know what's best for themselves. Thus, the nurse needs to put herself in the position of "apprentice", to learn from the other (1) .
For this, water is used as a metaphor to represent change. Life is a journey in an ocean of experiences. Learning from life and the way we experience change is the main lesson life teaches us. Every human development, including experiences of health and disease, involves discoveries made in this journey through the ocean of experiences. At critical times, people can suffer from storms or piracy. The boat may begin to flood, and the person may have to face the prospect of drowning or sinking. The person may have to be guided to a safe harbor, undergo repairs or recover from a trauma. Once the boat is intact or the person has become accustomed to the movement of the boat, it can restart the trip as it lays a way back to the ocean of experiences (2) .
The theory in question does not bring formulas, nor step by step, however, part of premises and principles that guide the work of the nurse in mental health. It is based on the premise that nursing action is interactive and focused on identifying what needs to be done to help the person with a view to the future (solve, overcome, adapt). The experience of suffering is invisible (manifested in behavior, but is always invisible), it is up to the nurse to help the person access their experiences, making her the author of the story of her life. The professional and person care are based on mutual influence (caring for and caring for the person). Nursing action is in everyday life of people's experiences (2) .
The Tidal Model has six guiding principles: curiosity virtue, which consists in investigating what brought the person into care, mystery investigation; resourcefulness power, discovering how one can coexist with or coexist with the disease; value of respecting the desires of the person in an active process of collaboration, bringing desire as the center of the caring process; crisis as an opportunity, since crisis is a sign that "something needs to be done", an opportunity for change; possessing goals, where daily small steps and specific goals are met, representing the steps that the person will take for the rest of the journey of his life; and pursuit of elegance through simple and necessary actions so that the person experiences a change, however small, but engaging the person in what "needs to be done", the focus on what is needed (1)(2) .
In addition, the model involves asking four questions, which consist of its philosophical basis: -Why this, why now? Attention is to what is being experienced in the now (particularly significant); -What works? What the person did or think can work to solve the problem at that moment in life; -What is the personal theory of the person? In what she believes, how she understands her problems and how she elaborates understandings; -How to limit restrictions? Being less restrictive, the professional should do as little as possible for the person and emphasize more what the person could do for themselves (2) .
The Tidal Model also offers Ten Commitments that are the essence of professional practice: to value the subject's voice; to respect the language and the way people understand; to develop genuine curiosity by identifying the necessary information; to become an apprentice; to reveal personal wisdom, which will be used to support the person and to guide his journey of recovery; to be transparent; to use the "toolkit" available, what "worked" or "what may work" for the person; to develop the ability to take a step further by seeing what needs to be done "now" with the ultimate goal of recovery; to give the gift of time; to know that change is constant (1)(2) .
In the model, people are represented by domains: the Self (the innermost in each), the World (the social world of the person), and the Other (where the person represents daily life with others). mental health nursing care is seen as a continuum and must intervene in one of the domains, through immediate practical care, acting on the problems of the now, transitional care, which enables the smooth passage from one care setting to another, and the developmental care, which is a long-term care (2) .
This theory was elaborated in the 2000s and is an important theoretical construction to support psychiatric and mental health nurses practice. Since then, it has been improved and developed in several countries. Thus, it was interesting to investigate mental health nursing care experiences using the Phil Barker's Tidal Model, showing its application and possibilities of use in psychiatric nursing and mental health.

OBJECTIVES
To identify the applicability of the Phil Barker's Tidal Model in mental health nursing care.

Ethical aspects
The research was carried out following the ethical principles according to Resolution 466 of December 2012. As it is a review, it does not send the submission to the Research Ethics Committee -REC.

Design, period and place of study
It is an integrative literature review (ILR) that sought to determine the current knowledge about the subject under study, in order to identify, analyze and synthesize results (3) . The criteria established by PRISMA were used for systematic reviews. The following steps were followed: identification of the theme and guiding question; establishment of criteria for inclusion and exclusion of studies; extraction of data from primary studies; assessment of studies to be included in the review; interpretation of results; presentation of knowledge review/synthesis (3) .
Theme identification and research question: question formulation was carried out from the BeHEMoTh strategy (4) . The study was based on five components: Behavior of interest, Health Context, Exclusions, and Models or Theories, thus defined: how does the Tidal Model apply to mental health nursing care?
The research was carried out from December 2017 to March 2018. The search was carried out through the cross-referencing of controlled descriptors using constant vocabulary from the Health Sciences Descriptors (DeCS -Descritores em Ciências da Saúde) and the Medical Subject Headings (MeSH) for presentation of keywords.
Nursing and mental health were the descriptors used. Descriptors cross-over was mediated by the Boolean operator "and". It should be noted that the Tidal Model keyword does not constitute a descriptor, however, it was used in the cross-over. Therefore, in the selected databases, the search was performed by the search key <tidal model and nursing and mental health> in the subject, title and abstract fields.
For study selection, databases were used in the context of health, accessed by Capes Portal: Latin American & Caribbean Literature in Health Sciences (LILACS), Medical Literature Analysis and Retrieval System Online Complete (MEDLINE via EBSCO), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus ® Elsevier, and Web of Science ® .

Population or sample; inclusion and exclusion criteria
Establishment of inclusion and exclusion criteria of studies: after choosing the topic, the literature search in the databases selected for study identification begins. The search in the selected databases met the following criteria: a) inclusion: scientific publications from primary studies published in English, Spanish or Portuguese; available in full; without temporal delimitation of publication; b) exclusion: duplicities, type studies in newspapers and editorials.

Study protocol
Article selection process is described in the flowchart (Figure 1). Data gathering from primary studies: as a scientific support for extracting the relevant data from the articles that make up the review corpus (n=24), a previously elaborated tool was used and submitted to appearance and content validation. This tool presents as variables: identification data of the article (title); type of scientific journal; methodological characteristics of the study; and assessment of methodological rigor (5) .  For analysis of the levels of evidence, the recent quality classification (5) was adopted, establishing: Level I -Evidence from a systematic review or meta-analysis of randomized controlled trials or from clinical guidelines based on systematic reviews of randomized controlled trials; Level II -Evidence derived from at least one well-outlined randomized controlled clinical trial; Nível III -Evidence obtained from well-outlined clinical trials without randomization; Level IV -Evidence from well-outlined cohort and case-control studies; Level V -Evidence from a systematic review of descriptive and qualitative studies; Level VI -Evidence derived from a descriptive or qualitative study; Level VII -Evidence from the opinion of authorities and/or expert committees report.
Assessment of studies included in the review: phase similar to the analysis of conventional research data and to ensure the scientific integrity of the review. The selected studies were analyzed in detail. Study analysis implied the selection of some articles as valid and the exclusion of the others (3) .

Analysis of results
Interpretation of results: after literature search, article selection and data organization, besides translation, data reading and interpretation, result discussion were started so that it was possible to proceed with the integrative review.
Knowledge review/synthesis presentation: finally, the data result and discussion obtained were presented in a descriptive way, in order to allow applicability assessment of the review, in order to reach the objective of this method and, with this, lead to a reflection and criticism on the application of the Tidal Model in mental health nursing care.

RESULTS
Search result indicates a final sample of 24 articles, evidencing the application of the Tidal Model in mental health nursing care. Table 1 summarizes the information in relation to language, year of publication, thematic, index base and methodological outline.
The articles are predominantly in English and reveal that theory has been worked on for more than 10 years internationally. These articles, for the most part, are reflective works aimed at discussing and improving the Tidal Model. The most recent studies point out the concern and the interest of the researchers in validation and application of the model.
With respect to the methodology presented, seven articles (79.2%) with level of evidence VII, four articles (16.7%) were applied to the framework that classifies evidence quality into seven levels (5). There were 19 articles (79.2%) with level of evidence VII, four articles (16.7%) with level of evidence VI, and one article (4.1%) with level of evidence II. This points to the need for more research with higher levels of evidence of the Tidal Model use in practice. In order to present the interpretive results of the selected studies, a synthesis chart was prepared, support for theoretical and reflective analysis on the Tidal Model, described in Chart 1.

DISCUSSION
Regarding the Tidal Model application in mental health nursing practice, ILR identified the different spaces and places in which the nurse can use the model, either in clinical practice in psychiatric hospitals or as a possible theoretical framework for health care reorientation. The Ten Tidal Model commitments can be applied in all areas of mental health nursing (16) , among which clinics, primary care spaces, alcohol and drug centers stand out.
Studies by Henderson (9) , Stevenson (21) , Brookes (22,24) point to psychiatric hospitals as places of experience using the model. In New Zealand, the model was used to change the hospital environment, focusing on the recovery of service users, promoting autonomy and independence (9) . In the experiments reported in Canada, Tidal transformed the practices at Royal Ottawa Hospital (ROH), the first North American site to implement the Tidal Model, from compromises orientation proposed by the theory, focusing the approach in the history of the people (17,19) .
Other spaces, besides psychiatric hospitals, are presented with successful experiences of model implementation (17,19,23) , such as primary care, forensic units, alcohol center and other drugs. In Cook's study, the use of theory in a forensic context in New Zealand brought

Mental Health
Nursing and the Politics of Recovery: a Global Reflection (6) 2011 Australia Reflective/ Theoretical Article Analysis of the concept of recovery from the perspective of the "Tidal Model" Theory on the policy and practice agenda from a "psychiatric nursing" perspective and "mental health nursing" The definition of recovery brings a theoretical and practical confusion in the work of the nurse in mental health; the concept of recovery worked by the model implies a better development of personcentered care Level of evidence VII The tidal model: the livedexperience in person-centred mental health nursing care (7)

Title Year/ Country
Outlining/ Nmber of Patients Interventions Result/Outcome Level of evidence (5) Reclaiming nursing: making it personal (8)  The ten commitments: a value base for mental health recovery (16) 2006 Australia Reflective/ Theoretical Article Discussion on the concept of recovery, as well as the ten essential commitments for the mental health nursing care Nurses following the ten appointments become part of the team and the client becomes the "captain of his ship" (his own life)

Level of evidence VII
The tidal model as experienced by patients and nurses in a regional forensic unit (17)  Nurses responded that the model is the basis for developing the person-centered care plan, but in practice some report the use of coercion, rigorous application of punishment, centered on the medical figure. The framework did not help to promote a person-centered  about changes in the industry, generating hope, leveling, connection in relationships, nurse-patient collaboration, a sense of humanity (17) . In the Gordon's article in Birmingham, one year after the Tidal Model introduction in the acute unit of psychiatric patients, results showed that the total number of serious incidents, such as physical aggression, violence and harassment, decreased by 57%. Nurses' satisfaction with their work also improved, classifying the model as superior to their previous way of working. The assessment of the users of inpatient services on the general quality of care received was also positive (19) . In a study by O'Donovan (23) conducted in Ireland, in a psychiatric admission unit, research nurses rated the use of the patient-centered model as positive. However, in practice, often the discourse was not effective and the medical-centered model persisted, which was a limiting factor for the development of the proposal.
Experiences have been reported with subjects in different life cycles and gender, such as adolescents, women and men in studies by Vella (10) , Young (11) , Savasan (29) . The use of the model allowed the development of a program of planned, structured and inclusive practices that transformed the nursing culture and significantly improved care for adolescents who are in an acute state of distress at a mental health unit in Australia. An educational program was developed that adopted the Tidal Model as a reference for mental health nursing practice in the unit, incorporating clinical reasoning sessions and presentations of journal articles to consolidate and maintain the change in nursing care (10) .
The study also emphasized that during the meetings, which involved members of the nursing team, members of the multidisciplinary team and administration staff, the service model is always reviewed. Patients and families, as well as any new ideas for improvement of practice are also considered and discussed, contributing to the culture of improvement. There was a reduction in the total number of incidents in the unit and the drop rates of sick staff decreased dramatically, indicating an improvement in the therapeutic and moral practice of the staff (10) . The Tidal Model is seen as appropriate for women in recovery from substance abuse. The model is used to guide health care planning in primary care for women residing in a Substance Abuse and Mental Health Care from USA. Young's study shows that the model does not have arrows to use and follow, instead it is a way of thinking, a paradigm to give person-centered attention. The text ends, encouraging the future exploration of the use of the Tidal Model with adolescents and men (11) .
Similar results were obtained in the Savasan article by applying the One-to-One interview sections to a control group. The relationship between the use of the model and the improvement in coping strategies and self-esteem of patients admitted to a treatment center for alcohol and other substances can be identified. Thus, the model would facilitate the process of recovery of dependents and improvements in coping with mental illness (29) .
The model for the reorientation of mental health care practices is important, taking the biological and pharmacological focus as central to its practice. Studies by Barker (12) , Biley (25) and Buchanan-Barker (26) show that the Tidal Model can modify the doing in the contexts of the health service where nurses work (12,(25)(26) . Tidal provides a model of practice for exploring the patient's need for nursing and providing individually tailored care. It assumes that nurses need to approach the people in their care so that they can explore (together) the experience of health and illness. According to the source, health care is becoming increasingly technical and emotionally distant (eg through the use of computers), with this, many people with mental health problems are calling for care and treatment to emphasize relationships (12) .
One of the studies indicates that there is a personal rejection of nursing practices in mental health, which were based on a reductive pharmacological approach. Instead, it was suggested to adopt a more holistic ideology that places the person at the center of mental health nursing as a holistic and human-centered activity. This process can be guided, for example, by the adoption of Tidal principles (25) .
Moreover, other authors emphasize that contemporary mental health nursing is caught in a relationship with psychiatric medicine. Tidal appears as a possibility of change in psychiatric nursing practices, not working the "risk", but rather, the person with risk. It proposes to substitute the observation for the creation of "bridges" as a way of managing the risk, establishing interdisciplinary relations (26) .
One of the main changes driven by the model is the possibility of reorienting care, pointing the work of the nurse centered on the narrative of people, a fact evidenced in Barker's articles (7)(8)13) . This subjectcentered care is a radical alternative to the paradigm shift in mental health, strongly centered on the figure of the physician and asylum.
Nursing theories and nursing models have low adherence within psychiatric and mental health nursing in the United Kingdom, since nursing still shows relative dependence on the medical paradigm. In this context, the Tidal Model develops on the centrality of interpersonal relationships in nursing practice, emphasizing in particular the importance of the perceived meanings within the lived experience of the person under care and the role of the narrative in the development of person-centered care plans. The model also integrates processes for the rehabilitation of the person who is in mental distress and provides a practical model for exploring the spiritual dimensions of the person's lived experience (7) .
The model recognizes that life problems that go beyond and threaten to "drown" people described as having mental illness have a spiritual dimension and that nursing care must act in this dimension. The Tidal Model has brought a considerable impact on mental health nursing after its creation, being used to rescue the subject narratives, helping him (re)build his own life history and redefine the mental health nursing performance (8) .
Over the last decade, the model has been developed across the spectrum of community care to the hospital, but remains particularly relevant to the acute care setting. The use of narratives of personal experiences still remains as idea of the original model. In addition, in most intensive care institutions where it was implemented, the model is implemented along with a number of other health and social care interventions considered desirable. Thus, it shows the characteristics of an interdisciplinary practice with a view to the integrality of the attention, as proposed in the model (13) .
Although the strategies developed to deal with specific life problems, and the personal knowledge on which they are based, is used to guide the multidisciplinary team. This set of knowledge and information belongs mainly to the person in care. The idea is that patients should be able to read their medical records and have access to copies of their care plans, a fact that is gaining credibility around the world today. The model takes this philosophy of patient involvement, building care around the person's own records and the lived experience of mental health care (13) .
Theory contributions to a perspective that respects culture and ethnicity of people in mental distress in Kidd's study are presented (15) . People who access mental health services from a cultural perspective other than mental health services do not achieve their best potential results. Thus, the Tidal Model provides nurses with the means to work with different cultures without going beyond the limits, suggesting the ability to negotiate areas where cultures meet without breaking or reformulating. When implementing the Ten Commitments, an embracement process, collaborative work is outlined that is consistent with existing literature and is readily applicable in practice, so the model shows the need for careful attention to the individual construction of cultural identity (15) .
Theory discussion as an important benchmark for psychiatric nursing and mental health is also emphasized by Barker (6,14) . The difference between mental health nursing and psychiatric nursing is that the former is a practice that seeks to be egalitarian, positive, health-oriented and collaborative; in contrast, the psychiatric is paternalistic, negative, disease-oriented, and often coercive (6) .
This study argues that people need help to live their lives in the most meaningful and effective way possible, given the personal, interpersonal and social resources available. Arguably, what people in such situations do not need is more paternalism, restraint, and coercion. This study points to the Tidal Model regarding recovery and rehabilitation as an example of how nurses can play a facilitative and empowering role, rather than focused primarily on paternalism and coercion. In doing so, they could move forward in building a new mental health (6) . In this sense, the model enables the development of autonomy and "empowerment" of nurses and users. The model integrates processes for (re)empowerment of the person who is "disempowered" by their own suffering, mental health institutions or both (14) .
The only studies in Portuguese that approach the theory of Phil Barker, bring a reflection on the concepts and ideas of the Tidal Model (27)(28) . Santos' (27) article proposes an aesthetic and sociopoetical perspective of care, based on the 10 Commitments of the theory, affirming that it is the duty of nursing professionals to promote a careful and sensitive interaction with people, in a space where caring is precious. In Teixeira's study (28) , a critical analysis is done assessing and reaffirming the clarity of the concepts and assumptions and consistency of the theory. They are theoretical articles that do not address experiences or application of this model in mental health services in Brazil.

Study limitations
The fact that the "Tidal Model" is not a controlled descriptor is one of the limitations, because it makes difficult the search of its productions. Five major international search databases were selected, but to compose a greater number of articles of the review it is recommended to increase this quantity, making publications from all continents. In addition, there is also a shortage of Brazilian publications that disseminate the experiences with the applicability of the Tidal Model and the low level of evidence of the studies found, thus, it is suggested to the researchers, mainly from Brazil, to broaden the research with high level of evidence and disseminate their results internationally.

Contributions to Mental Health Nursing and the interdisciplinary approach
The study of nursing theories, in particular, Phil Barker's model, brings contributions to the theoretical framework of nursing when thinking concepts that make up the metaparadigm of science nursing, contributing to care scientificity. Consequently, contributions extend to nursing practice, enabling care centered on the person and experiences she has, giving voice to subjects and reorienting the mental health care paradigm. Furthermore, it is a theory that confronts the hegemonic psychiatric model, still focused on medical and drug approaches. Moreover, it emphasizes a new paradigm for mental health nursing, with a view to interdisciplinary work, and the empowerment of nurses and subjects in mental suffering.

FINAL CONSIDERATIONS
It is noteworthy that the objective of the study was reached, pointing out the main studies on nursing care in mental health based on Tidal Model. The model is still under development, which is used internationally and can be applied to subjects in different life cycles and in several services related to mental and psychiatric health nursing practice. In Brazil, the theory is still little known and without studies that show practical experiences or application of the model in mental health services.
It is recommended carrying out research that deepens the concepts discussed in the theory, perfecting the model and adapting it to the different contexts of mental health. In addition, Tidal Model should be disseminated and used in nurses practice working in the comprehensive mental health care network in Brazil, and that studies, prioritizing those with a high level of evidence, should be produced demonstrating what changes occurred after implementing the model.