Contributor – Paul Plohr, BSN, RN

While I was going through nursing school, addressing health disparities that afflicted rural populations were always a topic of conversation. After the discussion of rural health was over, it never crossed my mind again until I worked in Wyoming. It is no question that rural populations suffer from a lack of adequate medical access. Terry et al. (2021) shows that there are multiple factors like economic factors, familial factors, and practice environment factors that keep healthcare providers from entering rural health. The process of getting to Wyoming is another story within itself, but coming from urban Missouri to rural Wyoming was eye-opening. Wyoming’s mental health statistics are sobering. In fact the year 2023 was the first year that Wyoming suicide rates dropped since 2018. Despite the drop, Wyoming is still struggling with mental health ailments.

Experiencing the mental health crisis first had me at a loss for actions to help my patients here in Wyoming. The barriers that were talked about in school continually showed themselves as I looked for answers. My Christian faith is my guiding light, and following the second commandment from the gospel of Matt 22:39, loving your neighbor as yourself has guided my nursing practice since the beginning. After continual prayer, the Lord guided me to go back to school to be a change agent. My undergraduate nursing school was always pushing this change-agent idea, which again I brushed off once I hit the surgical intensive care unit (SICU). I just became a nurse who critically thought and followed doctor’s orders while doing the best I could to keep my patients alive. Plus, I was a SICU nurse right out of the nursing fellowship. We were using the best technology and incorporating evidence-based practice techniques to promote positive patient outcomes. In my mind, I was being a change agent. Cusson et al. (2020) described being a change agent as one that identifies ideas to address gaps within the care they are giving and finds the gumption to implement the ideas. The lack of services here in Wyoming astounded me, which led to my prayers for guidance. These prayers led to my decision to go back to school to broaden my scope of practice and address these disparities.

Before committing myself to more education, the idea of theory as a nurse always seemed like higher-level thinking that never correlated to in-patient nursing. Those were my thoughts going into my initial nursing theory course. Through that course, I was tasked with writing a paper on how to incorporate theory to address health disparities within a population. None of the theories stood out to me at the moment and almost reaffirmed my initial thoughts of theory. They sound great on paper but incorporating them into practice was another task that the “higher-ups” were pushing onto bedside nurses. That is until I stumbled upon the Tidal Model developed by mental health nurses and people who have used mental health services.

For those unfamiliar, the Tidal Model is a middle-range nursing theory that allows the patient to be the co-author within their care and sees life as fluid. The Tidal Model recognizes that change is small and allows the provider to focus on the patient to guide them toward recognizing what has incurred this “shipwreck”. With an understanding of how the patient got there, the Tidal Model moves to focus on the present to enact goals that bring forth positive outcomes (Barker & Buchanan-Barker, 2005, p. 11). The healthcare providers are the pupils within the patient’s story and listening is key as the patient is the teacher in the situation. The Tidal Model helps further person-centered care by allowing the provider to meet the needs of each patient on a personal level.

Lines et al. (2015) state that person-centered care drifts away from the biomedical basis of patient-centered care and ushers in a holistic overview of the patient, which is further expounded upon as the patient’s mental, emotional, and spiritual needs. Kim et al. (2019) state that nurses embody a holistic ideal of caring for the patient(s) they are treating despite what capacity or setting the nurse is working in. To nurse a patient, one must take the time to understand the patient’s weaknesses and strengths. This is an important standard to establish because an advanced practice mental health nurse has roles rooted within the nursing process and developing those therapeutic relationships (Kumar et al., 2020).  All of these ideas are consistent with the concepts the Tidal Model promotes, and also resonate deeply with my Christian beliefs and values..

Understanding the shift in language that promotes a holistic lens for patient care allows advanced practice nurses to deepen their understanding of the Tidal Model. Finley (2019) shows that using advanced-practice mental health nurse practitioners (APMHNPs) within the rural setting increases the mental health of that patient population and increases the amount of money saved for the patient. The money-saving techniques are achievable through multiple vectors, but increasing the services available to those is the more important piece of the study. It shows that APMHNPs can make inroads into the rural areas to help reach those who need help but cannot receive it because of the lack of medical providers in the region. 

The Tidal Model helped break down my preconceived ideas of incorporating theory into practice. It is also a model that is congruent with my guiding spiritual traditions. Bolton et al. (2019) show the importance of personalized care planning but write out the challenges that face it. The Tidal Model can help remove those barriers by allowing the provider to foster a deeper relationship with the patient. The gap continues to widen for the need for mental health services and the ability to provide those services, promoting the Tidal Model can embolden nurses to love thy neighbor.

References

Barker, P., & Buchanan-Barker, P. (2005). The tidal model: A guide for mental health professionals. (1st ed.). Routledge.

Bolton, R. E., Bokhour, B. G., Hogan, T. P., Luger, T. M., Ruben, M. A., & Fix, G. M. (2019). Integrating personalized care planning into primary care: A multiple-case study of early adopting patient-centered medical homes. Journal of General Internal Medicine, 35(2), 428–436. https://doi.org/10.1007/s11606-019-05418-4

Cusson, R. M., Meehan, C., Bourgault, A., & Kelley, T. (2020). Educating the next generation of nurses to be innovators and change agents. Journal of Professional Nursing, 36(2), 13–19. https://doi.org/10.1016/j.profnurs.2019.07.004

Finley, B. A. (2019). Phychiatric mental health nurse practitioners meeting rural mental health challenges. Journal of the American Psychiatric Nurses Association, 26(1), 97–101. https://doi.org/10.1177/1078390319886357

Kim, G., Jung, E., Cho, M., Han, S. Y., Mira, J., Lee, M., Lee, S., Suh, Y., Yun, H. Y., Kim, S., & Shim, M. (2019). Revisiting the meaning of a good nurse. The Open Nursing Journal, 13(1), 75–84. https://doi.org/10.2174/1874434601913010075

Kumar, A., Kearney, A., Hoskins, K., & Iyengar, A. (2020). The role of psychiatric mental health nurse practitioners in improving mental and behavioral health care delivery for children and adolescents in multiple settings. Archives of Psychiatric Nursing, 34(5), 275–280. https://doi.org/10.1016/j.apnu.2020.07.022

Lines, L., Lepore, M., & Wiener, J. M. (2015). Patient-centered, person-centered, and person-directed care. Medical Care, 53(7), 561–563. https://doi.org/10.1097/mlr.0000000000000387

Terry, D., Phan, H., Peck, B., Hills, D., Kirschbaum, M., Bishop, J., Obamiro, K., Hoang, H., Nguyen, H., Baker, E., & Schmitz, D. (2021). Factors contributing to the recruitment and retention of rural pharmacist workforce: A systematic review. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-07072-1

The Holy Bible, King James Version. Cambridge Edition: 1769; King James Bible Online, 2024. www.kingjamesbibleonline.org.

About Paul Plohr

Paul Plohr, BSN, RN – Current DNP student at the University of Wyoming and Clinical Adjunct Professor at Laramie County Community College Cheyenne, Wyoming. I am guided through my faith to explore interventions that promote equitable access to healthcare amongst all age groups. Continuing my education will broaden my scope of practice and allow me to explore opportunities that I can leverage to promote positive patient outcomes. The new opportunities enhance my skills as an instructor to be a light to those just beginning their path of nursing.