Transition Theory

Transition Theory

Eun-Ok Im


Afaf Ibrahim Meleis was born in Alexandria, Egypt. In personal communications 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 considered nursing to be in her blood, and she admired her mother’s dedication and commitment to the profession. 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 in having a voice and affecting quality of care. However, they eventually approved of her choice and had faith that Meleis could do it.

Meleis completed her nursing degree at the University of Alexandria, Egypt. She came to the United States to pursue graduate education as a Rockefeller Fellow in order 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.

Her career combined academic and administrative positions. After getting her doctoral degree, she worked as an acting instructor at the University of California, Los Angeles, from 1966 to 1968, and as an Assistant Professor at the same university 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 her Transition Theory was first developed. In 2002, she was nominated the Margret Bond Simon Dean of Nursing, and became the 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 healthcare, international healthcare, 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, she received the Chancellor’s Medal from the University of Massachusetts, Amherst. In 2001, she received the UCSF’s Chancellor Award for the Advancement of Women in recognition of her role as a worldwide activist on behalf of 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, she was awarded the Robert E. Davies Award from the Penn Professional Women’s Network for her advocacy on behalf of women.

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 150 articles in social sciences, nursing, and medical journals; 40 chapters; and numerous monographs, proceedings, and books. Her award winning book, Theoretical Nursing: Development and Progress (1985, 1991, 1997, 2007), is used widely throughout the world.

The development of Transition Theory began in the mid-1960s, when Meleis was working on her PhD, and can be traced through the years of her research with students and colleagues. In her book (Meleis, 2007), describes how her theoretical journey started from her practice and research interests. In her master’s and PhD dissertation research, Meleis investigated phenomena of planning pregnancies and processes involved in becoming a new parent 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 earlier ideas were incomplete since she did not consider transitions.

Subsequently, her research interests were focused on people who do not make healthy transitions and discovery of interventions that would facilitate healthy transitions. For these research questions, 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 were referenced in her publications in those years of 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 non-problematic processes. Meleis believed that knowledge development in nursing should be geared toward nursing therapeutics and not toward understanding the 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 her theoretical thinking, role supplementation as a nursing therapeutic entered her research projects. Her main research questions were to further define the components, the processes, and the strategies related to role supplementation, which she believed 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.”

Her 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), elders (Kaas & Rousseau, 1983), parental caregivers (Brackley, 1992), caregivers of Alzheimer’s patients (Kelley & Lakin, 1988), and women who were not successful in becoming mothers and who maintained role insufficiency (Gaffney, 1992). In these studies using role supplementation theory, Meleis began to question the nature of transitions and the human experience of transitions. Her research population interests shifted to immigrants and their health. This shift led Meleis to look back and question “transitions” as a concept. Meleis met Norma Chick from Massey University, New Zealand, and they developed transition as a concept that was published in 1985 (Chick & Meleis, 1986). This was actually Meleis’ first article on transitions as a major concept of nursing.

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. Three hundred ten articles focused on transitions, so Meleis further developed the transition framework (Schumacher & Meleis, 1994) that was later further developed as a middle range theory. Publication of the transition framework was well received by nurse scholars and researchers and began to be used as a conceptual framework in a number of 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, Schumacher, & Messias, 2000) and has been widely used in nursing studies. See Figure 20-1 for a diagram of the middle range transition theory.

The situation-specific theories based on the transition framework that Meleis (1997) called for, with specifics in level of abstraction, degree of specificity, scope of context, and connection to nursing research and practice, were similar to the emerging midrange transition theory by Meleis et al. (Im, 2006; 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 their research findings, while using the transition framework of Schumacher and Meleis (1994). Schumacher et al. (1999) developed a situation-specific theory of elderly transition. Im (2006) also developed a situation-specific theory of white cancer patients’ pain experience. These situation-specific theories were derivative of the middle range transition theory.


Theoretical sources for Transition Theory are multiple. First, Meleis’ background in nursing, sociology, symbolic interactionism, and role theory and her education led to the development of Transition Theory as described above. 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 Transition Theory. A systematic, extensive literature review has been suggested as a way of compiling currently existing knowledge about a nursing phenomenon and has been used frequently as an excellent source for theory development (Walker & Avant, 1995, 2005). Finally, collaborative efforts among researchers who used the transition theoretical framework and the middle range transition theory in their studies were another source for development of Transition Theory. As Im (2005) asserted, experts in different areas of nursing who are working on the same nursing phenomenon could give different and new views/visions of the same nursing phenomenon.


Here, the major concepts and definitions from the most current transition theory, the middle range theory of transition suggested by Meleis et al. (2000), are presented. Some concepts that were briefly presented in the middle range theory of transition 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 the following: (a) types and patterns of transitions; (b) properties of transition experiences; (c) transition conditions (facilitators and inhibitors); (d) process indicators; (e) outcome indicators; and (f) nursing therapeutics.


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 et al., 2000). Many people are experiencing multiple transitions at the same time rather than experiencing a single transition, which cannot be easily distinguished from the contexts of their daily lives. Indeed, in the article by Meleis et al. (2000), it was noted that each of the studies that were the basis for the theoretical development involved individuals who were experiencing at least two types of transitions at the same time, which could not be discrete or mutually exclusive. Thus, they suggested that important considerations are whether multiple transitions are sequential or simultaneous, the extent of overlap among transitions, and the nature of the relationship between the different events that are triggering transitions for a client.


Properties of the transition experience include (a) awareness; (b) engagement; (c) change and difference; (d) time span; and (e) critical points and events. Meleis et al. (2000) asserted that these properties are not necessarily discrete, but are interrelated as a complex process.

Awareness is defined as perception, knowledge, and recognition of a transition experience, and level of awareness is often 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 et al., 2000). While asserting that a person in transition may have some awareness of the changes that are occurring, Chick and Meleis (1986) posited that an absence of awareness of change could signify that an individual may not have initiated the transition experience; Meleis et al. (2000) later proposed that the lack of manifestation of awareness of changes does not by necessity preclude the onset of a transition experience. However, the tension between transition awareness by clients and nurses’ knowledge of whether clients are in transition has not been resolved yet (Meleis et al., 2000).

Engagement is another property of transition suggested by Meleis et al. (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 in that engagement may not happen without awareness. Meleis et al. (2000) suggested that the level of engagement of a person who is aware of physical, emotional, social, or environmental changes would differ from that of a person unaware of these changes.

Changes and differences are a property of transitions (Meleis et al., 2000). Changes in identities, roles, relationships, abilities, and patterns of behavior are supposed to bring a sense of movement or direction to internal processes, as well as external processes (Schumacher & Meleis, 1994). Meleis et al. (2000) asserted that all transitions involve change, whereas not all change is related to transition. Then, they suggested that to fully understand a transition process, it is necessary to uncover and describe the effects and meanings of the changes involved and the dimensions of 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 et al. (2002) believed that confronting differences could be exemplified by unmet or divergent expectations, feeling different, being perceived as different, or seeing the world and others in different ways, and suggested that it might be useful for nurses to consider 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 et al., 2000). According to 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 et al. (2000) also made the point that it might be difficult or impossible, and perhaps even counterproductive, to put boundaries on the time span of certain transition experiences.

Critical points and events are the final property of transitions suggested by Meleis et al. (2000). Critical points and events are defined as markers such as birth, death, the cessation of menstruation, or the diagnosis of an illness. Meleis et al. (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 associated with increasing awareness of changes or differences or more active engagement in dealing with transition experiences. Also, Transition Theory conceptualizes that there are final critical points that are characterized by a sense of stabilization in new routines, skills, lifestyles, and self-care activities, and that a period of uncertainty is marked by fluctuation, continuous change, and disruption of reality.


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 facilitate or constrain the processes and outcomes of healthy transitions.

Personal conditions include meanings, cultural beliefs and attitudes, socioeconomic status, preparation, and knowledge. Meleis et al. (2000) considered that the meanings attributed to events precipitating a transition and to the transition process itself may facilitate or hinder healthy transitions. Cultural beliefs and attitudes such as stigma attached to 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.


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 indicators and outcome indicators. These process indicators and outcome indicators characterize healthy responses. Process indicators that move clients in the direction of healthy or toward vulnerability and risk allow early assessment and intervention by nurses to facilitate healthy outcomes. Also, outcome indicators may be used to check if a transition is a healthy one or not, but Meleis et al. (2000) warned that outcome indicators may be related to other events in people’s lives if they are examined too soon in a transition process. The process indicators suggested by Meleis et al. (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 make new contacts and continue old connections with extended family and friends, they are usually in a healthy transition. Through interaction, the meaning of the transition and the behaviors developed in response to the transition can be uncovered, clarified, and acknowledged, which usually leads to 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 to which there is a pattern indicating that the people involved are experiencing an increase in their levels of confidence is another important process indicator of a healthy transition. The outcome indicators suggested by Meleis et al. (2000) include mastery and fluid integrative identities. A healthy completion of a transition can be determined by the extent to which people demonstrate mastery of the skills and behaviors needed to manage their new situations or environments. Identity reformulation can also represent a healthy completion of a transition.


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 a multidisciplinary endeavor and requires a comprehensive understanding of the client; it requires assessment of each of the transition conditions in order to create an individual profile of client readiness, and to enable clinicians and researchers to identify various patterns of the transition experience. Second, the preparation for transition is suggested as a nursing therapeutic. The preparation of transition includes education as the primary modality for creating optimal conditions in preparation for transition. Third, role supplementation was proposed as a nursing therapeutic. Role supplementation was introduced theoretically and empirically by Meleis (1975) and was used by many researchers (Brackley, 1992; Dracup, Clark, Meleis Clyburn, Shields, & Stanley 1985; Gaffney, 1992; Meleis & Swendsen, 1978). Yet, in the middle range theory of transitions, no further development of the concept of nursing therapeutics was made.


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 above, the transition framework was tested in a number of studies to describe immigrants’ transitions (Meleis et al., 1998), women’s experiences with rheumatoid arthritis (Shaul, 1997), recovery from cardiac surgery (Shih et al., 1998), development of the family caregiving role for patients in chemotherapy (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, Wahlund, & Winbald, 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 et al., 2007).

In the process of developing the middle range theory of transition, five research studies provided empirical evidence for conceptualization and theorizing (Sawyer, 1997; Im, 1997; Messias, Gilliss, Sparacino, Tong, & Foote, 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 et al. (2000), in Im’s study, although Korean immigrant midlife women had ambivalent feelings toward menopause, menopause itself did not have special meaning attached to it. Im found that most of the participants did not connect any special problems they were having to their menopausal transitions. Rather, women went through their menopause without experiencing or perceiving any problems, 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 et al. (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 was used recently in several studies to develop situationspecific theories (Im, 2006; Im & Meleis, 1999b; Schumacher et al., 1999) and to test the theory in a study on relatives’ experience of the move to a nursing home (Davies, 2005). In turn, these studies also provide empirical evidence for the middle range theory of transition.

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Feb 9, 2017 | Posted by in NURSING | Comments Off on Transition Theory

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