20. Transitions theory



Transitions theory



Eun-Ok Im



Credentials and background of the theorist


Afaf Ibrahim Meleis was born in Alexandria, Egypt. In personal communication with Meleis (December 29, 2007), she reckons that nursing has been part of her life since she was born. Her mother is considered the Florence Nightingale of the Middle East; she was the first person in Egypt to obtain a BSN degree from Syracuse University, and the first nurse in Egypt who obtained an MPH and a PhD from an Egyptian university. Meleis admired her mother’s dedication and commitment to the profession and considered nursing to be in her blood. Under the influence of her mother, Meleis became interested in nursing and loved the potential of developing the discipline. Yet, when she chose to pursue nursing, her parents objected to her choice because they knew how much nurses struggle with having a voice and affecting quality of care. However, they eventually approved of her choice and had faith that Afaf could do it.


Meleis completed her nursing degree at the University of Alexandria, Egypt. She came to the United States to pursue her graduate education as a Rockefeller Fellow to become an academic nurse (Meleis, personal communication, December 29, 2007). From the University of California, Los Angeles, she received an MS in nursing in 1964, an MA in sociology in 1966, and a PhD in medical and social psychology in 1968.


After receiving her doctoral degree, Meleis worked as administrator and acting instructor at the University of California, Los Angeles, from 1966 to 1968 and as assistant professor from 1968 to 1971. In 1971, she moved to the University of California, San Francisco (UCSF), where she spent the next 34 years and where Transitions Theory was developed. In 2002, Meleis was nominated and became the Margret Bond Simon Dean of the School of Nursing at the University of Pennsylvania.


Meleis, a prominent nurse sociologist, is a sought-after theorist, researcher, and speaker on the topics of women’s health and development, immigrant health care, international health care, and knowledge and theoretical development. She is currently on the Counsel General of the International Council on Women’s Health Issues. Meleis received numerous honors and awards as well as honorary doctorates and distinguished and honorary professorships around the world. She received the Medal of Excellence for professional and scholarly achievements from Egyptian President Hosni Mubarak in 1990. In 2000, Meleis received the Chancellor’s Medal from the University of Massachusetts, Amherst. In 2001, she received UCSF’s Chancellor Award for the Advancement of Women for her role as a worldwide activist on women’s issues. In 2004, she received the Pennsylvania Commission for Women Award in celebration of women’s history month and the Special Recognition Award in Human Services from the Arab American Family Support Center in New York. In 2006, Meleis was presented the Robert E. Davies Award from the Penn Professional Women’s Network for her advocacy on behalf of women. In 2007, she received four distinguished awards: an honorary doctorate of medicine from Linkoping University, Sweden; the Global Citizenship Award from the United Nations Association of Greater Philadelphia; the Sage Award from the University of Minnesota; and the Dr. Gloria Twine Chisum Award for Distinguished Faculty at the University of Pennsylvania for community leadership and commitment to promoting diversity. In 2008, she received the Commission on Graduates of Foreign Nursing Schools (CGFNS) International Distinguished Leadership Award based on outstanding work in the global health care community. In 2009, Meleis received the Take the Lead Award from the Girl Scouts of Southeastern Pennsylvania. In 2010, she was inducted to the UCLA School of Nursing Hall of Fame for her work in advancing and transforming nursing science.


Meleis’ research focuses on global health, immigrant and international health, women’s health, and the theoretical development of the nursing discipline. She authored more than 170 articles in social sciences, nursing, and medical journals; 45 chapters; and numerous monographs, proceedings, and books. Her award-winning book, Theoretical Nursing: Development and Progress (1985, 1991, 1997, 2007, 2011), is used widely throughout the world. In addition, her book entitled Women’s Health and the World’s Cities (Meleis, Birch, & Wachter, 2011) supports her recent efforts on health issues of urban women.



The development of Transitions Theory began in the mid-1960s, when Meleis was working on her PhD, and it can be traced through years of research with students and colleagues. In Theoretical Nursing: Development and Progress (Meleis, 2007), she describes her theoretical journey from her practice and research interests. Her master’s and PhD research investigated phenomena of planning pregnancies and mastering parenting roles. She focused on spousal communication and interaction in effective or ineffective planning of the number of children in families (Meleis, 1975) and later reasoned that her ideas were incomplete because she did not consider transitions.


Subsequently, her research focused on people who do not make healthy transitions and the discovery of interventions to facilitate healthy transitions. Symbolic interactionism played an important role in efforts to conceptualize the symbolic world that shapes interactions and responses. This shift in her theoretical thinking led her to role theories as noted in her publications in the 1970s and 1980s.


Meleis’ earliest work with transitions defined unhealthy transitions or ineffective transitions in relation to role insufficiency. She defined role insufficiency as any difficulty in the cognizance and/or performance of a role or of the sentiments and goals associated with the role behavior as perceived by the self or by significant others (Meleis, 2007). This conceptualization led Meleis to define the goal of healthy transitions as mastery of behaviors, sentiments, cues, and symbols associated with new roles and identities and nonproblematic processes. Meleis called for knowledge development in nursing to be about nursing therapeutics rather than to understand phenomena related to responses to health and illness situations. Consequently, she initiated the development of role supplementation as a nursing therapeutic as seen in her earlier research (Meleis, 1975; Meleis & Swendsen, 1978; Jones, Zhang, & Meleis, 1978).


The gist of Meleis’ works published in the 1970s defined role supplementation as any deliberate process through which role insufficiency or potential role insufficiency can be identified by the role incumbent and significant others. Thus, role supplementation includes both role clarification and role taking, which may be preventive and therapeutic.


With these changes in Meleis’ theoretical thinking, role supplementation as a nursing therapeutic entered her research projects. Her main research questions were to further define components, processes, and strategies related to role supplementation, which she proposed would make a difference by helping patients complete a healthy transition. This led Meleis to define health as mastery, and she tested that definition through proxy outcome variables such as fewer symptoms, perceived well-being, and ability to assume new roles.


Meleis’ theory of role supplementation was used not only in her studies on the new role of parenting (Meleis & Swendsen, 1978), but in other studies among post–myocardial infarction patients (Dracup, Meleis, Baker, & Edlefsen, 1985), older adults (Kaas & Rousseau, 1983), parental caregivers (Brackley, 1992), caregivers of Alzheimer’s patients (Kelley & Lakin, 1988), and women who were unsuccessful in becoming mothers and who maintained role insufficiency (Gaffney, 1992). These studies using role supplementation theory led Meleis to question the nature of transitions and the human experience of transitions. During this period, her research population interests shifted to immigrants and their health. This shift led Meleis to review and question transitions as a concept. Norma Chick’s visit to the University of California, San Francisco, from Massey University in New Zealand accelerated the development of the concept of transitions (Chick & Meleis, 1986) and Meleis’ first transitions article as a nursing concept.


To further develop this theoretical work, Meleis initiated extensive literature searches with Karen Schumacher, a doctoral student at the University of California, San Francisco, to discover how extensively transition was used as a concept or framework in nursing literature. They reviewed 310 articles on transitions and developed the transition framework (Schumacher & Meleis, 1994), which was later developed as a middle-range theory. Publication of the transition framework was well received by scholars and researchers who began using it as a conceptual framework in studies that examined the following:



Using the transition framework, a middle-range theory for transition was developed by the researchers who had used transition as a conceptual framework. They analyzed their findings related to transition experiences and responses, identifying similarities and differences in the use of transition; findings were compared, contrasted, and integrated through extensive reading, reviewing, and dialoguing, and in group meetings. The collective work was published in 2000 (Meleis, Sawyer, Im, et al., 2000) and has been widely used in nursing studies. See Figure 20–1 for a diagram of the middle-range Transitions Theory.



Based on the early works of Transitions Theory, situation-specific theories that Meleis (1997) had called for were developed, including specifics in level of abstraction, degree of specificity, scope of context, and connection to nursing research and practice (Im & Meleis, 1999a; Im & Meleis, 1999b; Schumacher, Jones, & Meleis, 1999). For example, Im and Meleis (1999b) developed a situation-specific theory of low-income Korean immigrant women’s menopausal transition based on research findings, using the transition framework of Schumacher and Meleis (1994). Schumacher, Jones, and Meleis (1999) developed a situation-specific theory of elderly transition. Im (2006) also developed a situation-specific theory of Caucasian cancer patients’ pain experience. These situation-specific theories were derivative of the middle-range Transitions Theory. In 2010, Meleis collected all the theoretical works in the literature related to Transitions Theory and published them in a book entitled Transitions Theory: Middle-Range and Situation-Specific Theories in Nursing Research and Practice. In, 2011, Im analyzed the literature related to Transitions Theory and proposed a trajectory of theoretical development in nursing based on the theoretical works related to Transitions Theory in nursing.


Theoretical sources


Theoretical sources for Transitions Theory are multiple. First, Meleis’ background in nursing, sociology, symbolic interactionism, and role theory and her educational background led to the development of Transitions Theory as described earlier in the chapter. Indeed, findings and experience from research projects, educational programs, and clinical practice in hospital and community settings have been frequent sources for theoretical development in nursing (Im, 2005). A systematic, extensive literature review was another source for development of Transitions Theory as suggested by Walker and Avant (1995, 2005) for compiling existing knowledge about nursing phenomenon. Collaborative efforts among researchers who used the transition theoretical framework and middle-range Transitions Theory in their studies were a source for development of Transitions Theory. Finally, Meleis’ mentoring process could be another source for development of Transitions Theory. Meleis’ mentoring of Schumacher led to an integrated literature review through which the first Transitions Theory was proposed (Schumacher & Meleis, 1994). Also, the most recent version of Transitions Theory by Meleis Sawyer, Im, Schumacher, and Messias in 2000 could be also considered a product of mentoring students in the ongoing theoretical work.





MAJOR CONCEPTS & DEFINITIONS


Here, the major concepts and definitions from the most current Transitions Theory—the middle- range theory of transition suggested by Meleis, Sawyer, Im, and colleagues (2000)—are presented. Some concepts are defined in greater detail based on the transition framework by Schumacher and Meleis (1994).


Major concepts of the middle-range theory of transition include: (1) types and patterns of transitions; (2) properties of transition experiences; (3) transition conditions (facilitators and inhibitors); (4) patterns of response (or process indicators and outcome indicators); and (5) nursing therapeutics.


Types and patterns of transitions


Types of transitions include developmental, health and illness, situational, and organizational. Developmental transition includes birth, adolescence, menopause, aging (or senescence), and death. Health and illness transitions include recovery process, hospital discharge, and diagnosis of chronic illness (Meleis & Trangenstein, 1994). Organizational transitions refer to changing environmental conditions that affect the lives of clients, as well as workers within them (Schumacher & Meleis, 1994).


Patterns of transitions include multiplicity and complexity (Meleis, Sawyer, Im, et al., 2000). Many people experience multiple transitions simultaneously rather than experiencing a single transition, which cannot be easily distinguished from the contexts of their daily lives. Indeed, Meleis, Sawyer, Im, and colleagues (2000) noted that each of the studies that were the basis for the theoretical development involved people who simultaneously experienced a minimum of two types of transitions, which could not be disconnected or mutually exclusive. Thus, they suggested considering if the transitions happen sequentially or simultaneously, the degree of overlap among the transitions, and the essence of the associations between the separate events that initiate transitions for a person.


Properties of transition experiences


Properties of the transition experience include five subconcepts: (1) awareness; (2) engagement; (3) change and difference; (4) time span; and (5) critical points and events. Meleis, Sawyer, Im, and colleagues (2000) asserted that these properties of transition experience are not fundamentally disconnected, but are interrelated as a complex process.


Awareness is defined as “perception, knowledge, and recognition of a transition experience,” and level of awareness is frequently reflected in “the degree of congruency between what is known about processes and responses and what constitutes an expected set of responses and perceptions of individuals undergoing similar transitions”(Meleis, Sawyer, Im, et al., 2000). While asserting that a person in transition may be somewhat aware of the changes that they are experiencing, Chick and Meleis (1986) posited that a person’s unawareness of change could mean that the person may not have began his or her transition yet; Meleis, Sawyer, Im, and associates (2000) later proposed that this lack of awareness does not necessarily mean that the transition has not begun.


Engagement is another property of transition suggested by Meleis, Sawyer, Im, and colleagues (2000). Engagement refers to “the degree to which a person demonstrates involvement in the process inherent in the transition.” The level of awareness is considered to influence the level of engagement; there is no engagement without awareness. Meleis and colleagues (2000) suggested that the level of engagement of a person who has this awareness of changes is different from that of a person who does not have this awareness.


Changes and differences are a property of transitions (Meleis, Sawyer, Im, et al., 2000). Changes that a person experiences in her or his identities, roles, relationships, abilities, and behaviors are supposed to bring a sense of movement or direction to internal as well as external processes (Schumacher & Meleis, 1994). Meleis and associates (2000) asserted that all transitions associate changes, although not all changes are associated with transitions. They then suggested that to comprehend a transition completely, it is essential to disclose and explain the meanings and influences of the changes and the scopes of the changes (e.g., “nature, temporality, perceived importance or severity, personal, familial, and societal norms and expectations”). Differences are also suggested as a property of transitions. Meleis and associates (2000) believed that challenging differences could be demonstrated by unsatisfied or atypical expectations, feeling dissimilar, being realized as dissimilar, or viewing the world and others in dissimilar ways, and they suggested that nurses would need to recognize “a client’s level of comfort and mastery in dealing with changes and differences.”


Time span is also a property of transitions—all transitions may be characterized as flowing and moving over time (Meleis, Sawyer, Im, et al., 2000). Based on the assertion by Bridges (1980, 1991), in the middle-range theory of transition, transition is defined as “a span of time with an identifiable starting point, extending from the first signs of anticipation, perception, or demonstration of change; moving through a period of instability, confusion, and distress; to an eventual “ending” with a new beginning or period of stability.” However, Meleis, Sawyer, Im, and colleagues (2000) also noted that it would be problematic or infeasible, and possibly even prejudicial, to frame the time span of some transition experiences.


Critical points and events are the final property of transitions suggested by Meleis, Sawyer, Im, and associates (2000). Critical points and events are defined as “markers such as birth, death, the cessation of menstruation, or the diagnosis of an illness.” Meleis and colleagues (2000) also acknowledge that specific marker events might not be evident for some transitions, although transitions usually have critical points and events. Critical points and events are usually linked to intensifying awareness of changes or dissimilarities or to a more exertive engagement in the transition process. Also, Transitions Theory conceptualizes that final critical points are differentiated by a sense of counterpoise in new schedules, competence, lifestyles, and self-care behaviors, and that the duration of uncertainty is characterized by variations, consecutive changes, and interruptions in existence.


Transition conditions


Transition conditions are “those circumstances that influence the way a person moves through a transition, and that facilitate or hinder progress toward achieving a healthy transition” (Schumacher & Meleis, 1994). Transition conditions include personal, community, or societal factors that may expedite or bar the processes and outcomes of healthy transitions.


Personal conditions include meanings, cultural beliefs and attitudes, socioeconomic status, preparation, and knowledge. Meleis, Sawyer, Im, and colleagues (2000) considered that the meanings attached to some events accelerating a transition and to the transition process itself would expedite or bar healthy transitions. Cultural beliefs and attitudes such as stigma associated with a transition experience (e.g., Chinese stigmatization of cancer) would influence the transition experience. Socioeconomic status could influence people’s transition experiences. Anticipatory preparation or lack of preparation could facilitate or inhibit people’s transition experiences. Community conditions (e.g., community resources) or societal conditions (e.g., marginalization of immigrants in the host country) could be facilitators or inhibitors for transitions. Compared with personal transition conditions, the subconcepts of community conditions and societal conditions tend to be underdeveloped.


Patterns of response or process and outcome indicators


Indicators of healthy transitions in the framework by Schumacher and Meleis (1994) were replaced by patterns of response in the middle-range theory of transitions. Patterns of response are conceptualized as process indicatorsand outcome indicators. These process indicatorsand outcome indicators characterize healthy responses. Process indicators that direct clients into health or toward vulnerability and risk make nurses conduct early assessment and intervention to expedite healthy outcomes. Also, outcome indicators may be used to check if a transition is a healthy one or not, but Meleis, Sawyer, Im, and associates (2000) warned that outcome indicators could be associated with irrelevant events in people’s lives if they are appraised early in a transition process. The process indicators suggested by Meleis and colleagues (2000) include “feeling connected, interacting, being situated, and developing confidence and coping.” “The need to feel and stay connected” is a process indicator of a healthy transition; if immigrants add new contacts to their old contacts with their family members and friends, they are usually in a healthy transition. Through interactions, the meaning attached to the transition and the behaviors caused by the transition can be disclosed, analyzed, and understood, which usually results in a healthy transition. Location and being situated in terms of time, space, and relationships are usually important in most transitions; these indicate whether the person is turned in the direction of a healthy transition. The extent of increased confidence that people in transition are experiencing is another important process indicator of a healthy transition. The outcome indicators suggested by Meleis, Sawyer, Im, and colleagues (2000) include mastery and fluid integrative identities. “A healthy completion of a transition” can be decided by the extent of mastery of the skills and behaviors that people in transition show to manage their new situations or environments. Identity reformulation can also represent a healthy completion of a transition.


Nursing therapeutics


Schumacher and Meleis (1994) conceptualized nursing therapeutics as “three measures that are widely applicable to therapeutic intervention during transitions.” First, they proposed assessment of readiness as a nursing therapeutic. Assessment of readiness needs to be interdisciplinary efforts and based on a full understanding of the client; it requires assessment of each of the transition conditions in order to generate a personal sketch of client readiness, and to allow clinicians and researchers to determine diverse patterns of the transition experience. Second, the preparation for transition is suggested as a nursing therapeutic. The preparation of transition includes education as the main modality for generating the best condition to be ready for a transition. Third, role supplementation was proposed as a nursing therapeutic. Role supplementation was suggested by Meleis (1975) and used by several researchers (Brackley, 1992; Dracup, Meleis, Clark, Clyburn, Shields, & Staley, 1985; Gaffney, 1992; Meleis & Swendsen, 1978). Yet, in the middle-range theory of transitions, there is no further development of the concept of nursing therapeutics.


Use of empirical evidence


In the development of the transition framework by Schumacher and Meleis (1994), a systematic extensive literature review of more than 300 articles related to transitions provided empirical evidence of the conceptualization and theorizing. Then, as mentioned earlier in the chapter, the transition framework was tested in a number of studies to describe immigrants’ transitions (Meleis, Lipson, & Dallafar, 1998), women’s experiences with rheumatoid arthritis (Shaul, 1997), recovery from cardiac surgery (Shih, Meleis, Yu, et al., 1998), development of the family caregiving role for chemotherapy patients (Schumacher, 1995), Korean immigrant low-income women in menopausal transition (Im, 1997; Im & Meleis, 2000, 2001; Im, Meleis, & Lee, 1999), early memory loss for patients in Sweden (Robinson, Ekman, Meleis, et al., 1997), the aging transition (Schumacher, Jones, & Meleis, 1999), African-American women’s transition to motherhood (Sawyer, 1997), and adult medical-surgical patients’ perceptions of their readiness for hospital discharge (Weiss, Piacentine, Lokken, et al., 2007).



Development of the middle-range theory of transition builds on empirical evidence from five research studies for conceptualization and theorizing (Sawyer, 1997; Im, 1997; Messias, Gilliss, Sparacino, et al., 1995; Messias, 1997; Schumacher, 1994). These studies were conducted among culturally diverse groups of people in transition, including African-American mothers, Korean immigrant midlife women, parents of children diagnosed with congenital heart defects, Brazilian women immigrating to the United States, and family caregivers of persons receiving chemotherapy for cancer. Empirical findings of these five studies provided the theoretical basis for the concepts of the middle-range theory of transition, and the concepts and their relationships were developed and formulated based on a collaborative process of dialogue, constant comparison of findings across the five studies, and analysis of findings. For example, one of the personal conditions, meanings, was proposed based on the findings from two studies (Im, 1997; Sawyer, 1997). According to Meleis Sawyer, Im, and colleagues (2000), although Korean immigrant midlife women had ambivalent feelings toward menopause in Im’s study, menopause itself did not have special meaning attached to it. Im found that most participants did not connect any special health/illness problems/concerns they were having to their menopausal transitions. Rather, women went through their menopause without perceiving any health/illness problems/concerns, which means that “no special meaning” might have facilitated the women’s menopausal transition. Yet, Sawyer’s study reported that African-American women related intense enjoyment of their roles as mothers and described motherhood in terms of being responsible, protecting, supporting, and needed. Thus, Meleis, Sawyer, Im, and colleagues (2000) proposed meanings as a personal transition condition because, in both studies, neutral and positive meanings might have facilitated menopause and motherhood. The middle-range theory of transition has been used in studies to develop situation-specific theories (Im, 2006; Im, 2010; Im & Meleis, 1999b; Schumacher, Jones, & Meleis 1999) and to test the theory in a study of relatives’ experience of a move to a nursing home (Davies, 2005).


Major assumptions


Based on Meleis’ former works on role supplementation, the transition framework by Schumacher and Meleis (1994), and the middle-range theory of transitions by Meleis, Sawyer, Im, and colleagues (2000), the following assumptions of Transitions Theory may be inferred.


Nursing


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Jan 8, 2017 | Posted by in NURSING | Comments Off on 20. Transitions theory

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