Usefulness of the Tidal Model concepts to the care of adolescents deprived of liberty

Utilidad de los conceptos de la Teoría de la Marea para la atención de los adolescentes en privación de libertad

ABSTRACT

Objective:

To reflect on the usefulness of the concepts of the Tidal Model in nursing care for adolescents deprived of liberty.

Method:

Critical reflection of the theory, according to the evaluation proposed by Meleis, focusing on the usefulness of the theory, based on the practice criterion, according to the unit of analysis applicability of the theory.

Results:

The Tidal Model is composed of concepts that allow the understanding of the context in which the adolescent deprived of liberty is inserted and prepare nurses for the operationalization of their clinical practice aimed at this adolescent, enabling the professional to observe its limits, such as issues related to social reintegration, which requires intersectoral partnerships, and the need for anchoring in other theories.

Final considerations:

The concepts of the Tidal Model are useful and can be applied to the nursing care provided to adolescents in situation of deprivation of liberty, promoting the centrality of care for this adolescent.

Keywords:
Nursing theory; Mental health; Adolescent, institutionalized

RESUMEN

Objetivo:

Reflexionar sobre la utilidad de los conceptos de la Teoría de la Marea en la prestación de cuidados de enfermería a los adolescentes en privación de libertad.

Método:

Reflexión crítica sobre la teoría, según la evaluación propuesta por Meleis, centrándose en lo segmento utilidad de la teoría, desde el criterio de la práctica, según la unidad de análisis aplicabilidad de la teoría.

Resultados:

La Teoría de la Marea se compone de conceptos que permiten comprender el contexto en el que se inserta el adolescente privado de libertad y preparan a los enfermeros para la operacionalización de su práctica clínica dirigida a este adolescente, permitiendo al profesional observar sus límites, como las cuestiones relacionadas con la reinserción social, que requieren asociaciones intersectoriales, y la necesidad de anclaje en otras teorías. Consideraciones finales: Los conceptos de la Teoría de la Marea son útiles y pueden ser aplicados a los cuidados de enfermería prestados a los adolescentes en situación de privación de libertad, promoviendo así la centralidad del cuidado de este adolescente.

Palabras clave:
Teoría de enfermería; Salud mental; Adolescente institucionalizado

RESUMO

Objetivo:

Refletir acerca da utilidade dos conceitos da Teoria da Maré no cuidado de enfermagem aos adolescentes em privação de liberdade.

Método:

Reflexão crítica da teoria, segundo avaliação proposta por Meleis, com foco no segmento utilidade da teoria, a partir do critério prática, segundo a unidade de análise aplicabilidade da teoria.

Resultados:

A Teoria da Maré compõe-se de conceitos que permitem a compreensão do contexto em que o adolescente em privação de liberdade está inserido e preparam o enfermeiro para a operacionalização da sua prática clínica voltada para este adolescente, viabilizando ao profissional observar os seus limites, como questões relacionadas à reinserção social, que exigem parcerias intersetoriais, e a necessidade de ancoragem em outras teorias. Considerações Finais: Os conceitos da Teoria da Maré são úteis e podem ser aplicados na assistência de enfermagem aos adolescentes em situação de privação de liberdade, promovendo a centralidade do cuidado neste adolescente.

Palavras-chave:
Teoria de enfermagem; Saúde mental; Adolescente institucionalizado

INTRODUCTION

Adolescence is a development process that involves biopsychosocial phenomena and leads the individual to constant modifications in his personality. These continuous and intense changes, when associated with processes of sociocultural exclusion, mitigate citizenship, and make adolescents socially vulnerable. Low socioeconomic conditions, school dropout, little schooling, early use of licit and illicit drug, such as alcohol, tobacco, marijuana, cocaine, crack and narcotics, lead these adolescents to become involved in crimes and infractions1^,2.

The Statute of Children and Adolescent (Estatuto da Criança e do Adolescente - ECA) regulates the Socio-Educational Measures (SEM) with the objective of inhibiting these infractions and repairing the social damage caused. Among the types that have a character of partial and total deprivation of liberty, are the insertion in a semi-liberty regimen and the internment in a Socio-Educational Unit (SEU), respectively3. This scenario of social exclusion has implications for mental health and in several spheres of adolescents’ lives.

Studies on the theme show that adolescents who comply with SEM come mostly from family contexts permeated by conflicts and violence, and suffer great repercussions on mental health4, which requires the SEUs appropriate equipment to assist the needs of these subjects.

Ordinance No. 1082/2014 of the Ministry of Health, which redefines the guidelines of the National Policy for Comprehensive Health Care for Adolescents in Conflict with the Law, in Internment Regimen and Provisional Internment (Política Nacional de Atenção Integral à Saúde de Adolescentes em Conflito com a Lei, em Regime de Internação e Internação Provisória - PNAISARI), points out the need for a health team of Primary Care as a reference for the SEUs5, emphasizing the role of the nurse as a mental health professional who can complement the minimal team.

The nursing assistance provided to adolescents deprived of liberty is a challenge for nurses and requires sensitivity and appropriate knowledge from them for a comprehensive, citizen and ethical approach6; assistance that relates physical and mental integrity, in a continuous interaction that results in a change of values between the adolescent and the nurse.

In this sense, the Tidal Theory, or Tidal Model, classified as a mid-range nursing theory, assembles a series of concepts and propositions that may be promising in the care of adolescents deprived of liberty. This theory enables nursing care based on the recovery of individuals’ mental health, placing them at the center of the therapeutic process7. From the creative interaction with the person in mental suffering, the nurse helps to find a meaning for the psychic impairment, providing conditions for positive changes to occur8.

The tide is a metaphor to symbolize changes in the course of life, starting on the premise that this is an ocean of several experiences. For each phase of human development, there are new discoveries during the journey. The boat can start to sink and the individual experiences the sensation of drowning or flooding, needing to be guided by a type of safe harbor in order to recover from the traumas suffered7.

Nursing scientists have been concerned with discussing the applicability of the Tidal Model in adolescent health care. Studies in which the theory was applied to public school students9 and adolescents monitored in Child and Adolescent Psychosocial Care Centers10 showed that the use of the Tidal Model favors nursing work with adolescents, by enabling the appreciation of their voice and the understanding that, in this exchange, the nurse becomes a learner. However, considering that in the deprivation of liberty other contextual elements increases suffering, the question is: does this theory select useful concepts for the nursing care of adolescents who comply with SEM deprived of liberty?

Thus, this study aimed to reflect on the usefulness of the Tidal Model concepts in nursing care for adolescents deprived of liberty.

A recent work11 critically reflected on the conceptual components of the Tidal Model in the application of the mental health care process, according to the perspective of Meleis, pointing out that the theory can be applied and adapted to diverse populations, cultures and service spaces of patient care. The present manuscript progresses with regard to this production by proposing the evaluation of the theory in a setting of adolescent health care, enriching the reflection about nursing practices for this public.

METHOD

This is a critical reflection of the Tidal Model, according to the Theory Evaluation Model proposed by Meleis12. Such instrument, consisting of five components (description, analysis, critics, theoretical test, and theory support test), can be used in full or in part.

In this work, the aspect considered was the critique of theory, which seeks to do a critical examination of theories in order to determine their nature and limitations or their compliance with the guidelines12. This aspect considers five elements: the relation between structure and function; theory diagram; contagion circle; usefulness; and external components of the theory. With the purpose of achieve the proposed objective, the usefulness of the theory was determined as the studied segment, from the perspective of the practical criterion, according to the unit of analysis applicability of the theory, as shown in Figure 1.

Figure 1 -
Components of the usefulness item, their criteria and units of analysis. Crato, Ceará, Brazil, 2021

The critical reflection consists of a weighing, on the part of professionals, about their practice, from the experiences lived - well and/or unsuccessful -, from the lessons learned from the process, in order to delineate an action plan and establish conducts that improve the actions performed on similar occasions in the future13. The reflection of a nursing theory strengthens the understanding of this field of knowledge in its scientific dimension, aligned with clinical practice.

It is considered that for a theory to be useful it must be evaluated in its potential for practice12. For this analysis, the question is to what extent the theory is able of being operationalized in clinical practice. Thus, answers were sought to the following question: does the Tidal Model present concepts that are useful to practice and ease the nursing activities spent on adolescents deprived of liberty? The search for the answer to this question constituted the methodological pathway related to the investigation of the applicability of the theory within the practical criterion, as presented below.

In search of the usefulness of the Tidal Model concepts in the care of the adolescent deprived of liberty, the following steps were followed: a) a careful reading of the Tidal Model, in order to understand in a broader way the authors’ interpretation of the contribution of nurses in the trajectory of the person under mental health care; and b) investigation of how the concepts proposed by the theory can be useful in the context of adolescents deprived of liberty by nurses, based on the questions proposed by Meleis12. Thus, the concepts were reflexively articulated to the context of care, searching for approximations, distances and breaking points that facilitated or not the nursing care.

The analytical corpus consisted of: Tidal Model, based on the original reference7; studies that applied the theory to adolescent care; and studies on adolescents deprived of liberty, so that the reflective process could show the usefulness of the concepts in assisting this public.

Tidal Model: usefulness, principles and concepts

The Tidal Model has the function of systematizing data and providing its users with a unique interpretation of the mental health theme. In this sense, its objectives of promoting nursing care that considers the singularity of the individual, as well as their autonomy, result, as a consequence, in nursing care that is sensitive to the particularities of adolescents in a situation of deprivation of liberty, demonstrating the potential for care practice that the theory has in this context7.

The Tidal Model is based on four interrelated key principles7, regarding the dynamics of the therapeutic relationship and the roles played by the individual under care and by the nurse, which guide nursing actions from the Theory’s perspective.

The first principle addresses the essential therapeutic focus of mental health care: the natural community. Considering that, metaphorically, people live in the midst of an “ocean of experience”, where the psychiatric crisis constitutes an element capable of “drowning them” (and, in the case of adolescents deprived of liberty, this can be represented by the internment in a SEU), the objective of care would be to return people to the “ocean”, in order to continue their “journey”; the second highlights the contribution of small but significant changes that impact people's lives; the third emphasizes the self-responsibility, empowerment and autonomy of the person under nursing care as the “heart” of the process; and the fourth principle values the therapeutic relationship, considering it as a “dance” in which “taking care with” the person takes the place of “taking care of”7.

The key principles of the Tidal Model express the authors’ view that patient autonomy is at the heart of care. The actions taken by nurses are aimed at clarifying and facilitating the individual’s self-responsibility process, within their context and valuing the transformations that seem subtle, but that cause major changes in the general picture. The comparison with dance refers to the fact that the interaction between patient and nurse is temporary, within the period in which one needs the other’s support, since it aims that the person gradually becomes independent from the professional.

The principles of the Tidal Model are operationalized by the concepts: patient/person, nurse, nurse-patient relationship, life, mental illness, nursing problems, life history, nursing care, social inclusion, rehabilitation/recovery. Pragmatically, each of these concepts has its definition that translates the world view of theorists, linked to a comprehensive and existential episteme about the human being.

These concepts structure in theory the concern of nursing that distinguishes it from so many other disciplines in the health area, that is: the focus on human responses beyond biological health/disease issues. In the mental health approach, this perception is particularly important, due to the numerous factors that contribute to the worsening or improvement of illness conditions.

All Tidal Model concepts result in respect for the individual's singular life narrative, because even the elements that deal with the nurse’s performance consider the particularities of the “trip” undertaken by the patient, and the actions are directed to the search for the patient’s autonomous posture in the rehabilitation of their life journey7. In the case of adolescents, offering them the possibility of being in the active conduct of their trajectory is to value their voice and encourage them to take a leading role in their process of coping with the critical periods they experience in mental health demands.

Interface between the Tidal Model concepts and the care of adolescents deprived of liberty

The usefulness of concepts related to understanding of the patient/person, of life, of mental illness, of life history and of social inclusion as necessary elements for comprehensive care for adolescents deprived of liberty can be reflected from the elements of life and context of these people.

The adolescent deprived of liberty feel that, even with the possibility of experiencing partial freedom, remain cloistered. Thus, the concept patient/person is marked by life experiences, as proposed by theorists in their definition. On the one hand, there are the conditions of coexistence in society, constituted by a historicity of exclusion, of social margin, which strains its development from the coexistence with drug dealers, drug sales, theft practices, family conflicts and violence. On the other hand, the memories of living in the SEU, with a rigid power structure, a context in which it is difficult for him to respond to the demands of adjustment required that conflict with the personal structure already apprehended from these conditioning. This dialectic of the lived will forever marks his identity as subject, in a movement of eternal vigilant navigation.

In the connection between these two links, past-present, the anxieties of the lived experience and the questioning of the directions in which life-is-done are molded. In this turbulent ocean, the concept of life is manifested in the hybridization between the already introjected conditions of violence and the rigid structure of repression and discipline of the daily life of the SEU⁽¹⁴⁾. For theorists, life is a journey of human development that takes place in an ocean of experiences7.

This complexity imposes to nurses to go beyond the conceptual structure of the Tidal Model. Ethnographic, anthropological and linguistic readings about the lives of those deprived of liberty are essential for understanding the meanings and signifiers contained in the social structure present in the lives of adolescents deprived of liberty. Understanding the genesis of the violence and its ideology lined on capitalist society is a challenge for nurses, since they need to rebuild their ideas of the world, from the reflections about their own social structure and how it impacts the therapeutic relationship and the way to produce nursing care.

These studies will provide nurses with the construction of a socio-historical and humanistic view in line with human rights, providing them with greater analytical and comprehensive sensitivity around the lives of these adolescents. Such training will direct nurses to the outskirts of the contextual situation, as an observer of the raging sea who seeks an understanding that is detached, as much as possible, from their own prejudices. This refers to the metaphor of the role of lifeguard played by nurses in organizing the “rescue” of adolescents in situations of suffering and mental illness, driven by the impetus of the rough tide7.

The peripheral zone is the place where the nurses will perform their role as caregivers and will develop links with the adolescent, who is the center of the care structure, as a person to be understood. This performance in the SEU will provide opportunities in the relationship between nurses and the adolescent the creation of an exclusive version of the life narrative, from which the boat (the basis on which the adolescent's particular experiences develop) sails. This relationship has the power to transform “who” and “what” we are7.

The concept of life history permeates the entire context of care. For nurses, being in the peripheral observation zone implies understanding their own history and re-signification of their prejudices. Navigating the adolescent’s life history, understanding the sociocultural and historical conditions that structure a life of exclusion, broadens the nurses’ vision and allows greater sensitivity in the identification of nursing diagnoses. The life history of adolescents deprived of liberty refers to the understanding of other languages: the language of the periphery, its tones, slang and songs understood in its alignment between complaints of exclusion, violence and racism; and its alignment with social struggles.

The outcome of an integrative review15 showed that researchers indicated three categories of adolescents' mental health needs: mental health nursing diagnoses, skills and competences, and interpersonal relationships. Among adolescents deprived of liberty, the following diagnoses are also verified: self-neglect, impaired verbal communication, fear and anxiety, skills and competences in education, vocational goals, health maintenance, financial independence, and personal and family relationships of adolescents; concerns that must be addressed15.

In this scenario, the concept of nursing care denotes continuity of the theoretical structure. Nurses, as participants in the multiprofessional team, are faced with the identification of problems that require the contribution of nursing; they are faced with perspectives of collaboration “with” the teenager in their choices according to their current life problems7; prepare strategies to face the health demands in the routine of the scenario of deprivation of liberty; and work in the promotion and education in health, developing actions aimed at the family and social reintegration of adolescents - even working to prevent the recurrence of infractions that can lead to the return of the situation of deprivation of liberty.

Strategies of care, such as motivational interviewing, harm reduction, cognitive behavioral therapy and group intervention strategies were identified as promising for the care of adolescents in mental distress. These can also adapt to adolescents deprived of liberty, especially with the objectives aimed at the resocialization process14.

The Tidal Model understands that the human crisis is similar to the back-and-forth movement of the tides in the ocean, with various moments of ups and downs7. The adolescent deprived of liberty may experience constant episodes of emotional and existential crises, without knowing the importance of the resocialization process offered to them. He/she objects the methodology of this pathway, requiring unlimited support and qualified listening from the nurses of this service, who make the adolescent reflect on what the socio-education process can provide.

In this scenario, the concepts of social inclusion and rehabilitation/recovery are in perfect harmony for the care of the adolescent deprived of liberty. Social inclusion emphasizes the collaboration of other people in care support7. Thus, the family context and social support that permeate the ocean of experience of adolescents can be a support for strengthening their autonomy and empowerment in the midst of the turbulence of the ocean, constituting the safe harbors to which they can resort.

On the other hand, daily situations in this same social network, in a sense, imponderable, which outlined a form of human life, can be conditions for vulnerability to infractions, contributing to the recidivism of these adolescents14. The complex capitalist ideology with its strong structure of social exclusion maintains difficult conditioning for nurses to intervene in their therapeutic processes. The need for collaborative network dialogues with social reintegration structures is essential to achieve a minimal recovery of these people. This complex reality shows the need to expand the care network, housing the social structure in which these adolescents participate in order to maintain the rehabilitation/resocialization and inhibition of new crimes.

Rehabilitation can be understood as the time needed to reorganize, refurbish the ship; and the recovery would be to go back to sailing, to resume the course of the journey of life7. In this scenario, nurses must support the individual to identify what types of changes are represented at this stage, and what they can do in the immediate future towards this life goal, taking the step forward, as recommended in the theory commitments7.

The concept of rehabilitation in the scenario of deprivation of liberty is an amalgamation that refers to rehabilitation in mental health and at the same time to rehabilitation for the adolescent's return to life in society. Working on the rehabilitation of these subjects is, at the time of this distinction, a challenge for nurses, since the theory does not allow for the splitting of the subject, and, therefore, rehabilitation must be thought through in its entirety and in its complexity. The establishment of goals to mental health rehabilitation needs to go in the same direction and at the same time as social rehabilitation goals.

As a limitation of this study, it is highlighted the lack of indexed national scientific production on the theme, since there is still no official translation of the theory into Brazilian Portuguese, so theses and dissertations constituted some of the main sources of research for this work.

FINAL CONSIDERATIONS

The Tidal Model is composed of concepts that are useful, allow the understanding of the context in which the adolescent deprived of liberty is inserted and prepare the nurse for the operationalization of their clinical practice focused on this adolescent, enabling the professional to observe their limits, such as issues related to social reintegration that require intersectoral partnerships, and the need to anchor in other theories, such as anthropology, ethnography and linguistics, to structure care for this adolescent.

The applicability of the Tidal Model in nursing care practice developed for adolescents in a situation of deprivation of liberty allows us to glimpse new possibilities for reflection on how nursing professionals assume the role of lifeguards to this public, already so surrounded by vulnerabilities and subject to more specific demands for mental health care.

In this way, it is expected that this work will contribute to the discussion on the subject in the context of teaching, subsidizing the reflection in the health training process, especially in nursing, about the need to develop specific skills for mental health care of the adolescent deprived of liberty; in the field of research, when discussing a theory that opposes the predominant psychiatric model and values ​​the role of nursing in this scenario; and in assistance, promoting the centrality of care for adolescents deprived of liberty, as well as the empowerment of professional nurses. In addition, the study contributes to the reflection on the ideological structure that conditions people’s ways of life; and on how nurses need to critically rethink/restructure their role within this structure.

Acknowledgment:

The authors thank the Foundation for Support to Scientific and Technological Development (Fundação Cearense de Apoio ao Desenvolvimento Científico e Tecnológico - Funcap), pelo financiamento deste trabalho.

REFERENCES

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Edited by

Associate editor:

Helena Becker Issi

Editor-in-chief:

Maria da Graça Oliveira Crossetti

Publication Dates

• Publication in this collection
  24 Mar 2023
• Date of issue
  2023

History

• Received
  07 Feb 2022
• Accepted
  09 June 2022