Select a research study identified in chapter 13 and go to the literature to find its original source. Describe: a) how the theory of self-reliance is presented in the manuscript

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C H A P T E R 1 3

Theory of Transit ions

Eun-Ok Im and Yaelim Lee

INTRODUCTION

Nursing phenomena occur around various life transitions such as during pregnancy and at midlife. There are transitions from a critical care unit to a long-term care facility, from hospital to community, from one country to a different country, and within a hospital due to changes in administrators. People sometimes go through transitions smoothly and suc- cessfully, but frequently they have issues, concerns, and/or problems in transitions due to the disequilibrium caused by changes (Meleis, 2010). Nurses have played a central role in providing care for people in transitions, especially for individuals, families, and commu- nities experiencing changes that trigger new roles and losses of networks and support sys- tems (Meleis, 2010). Nurses could facilitate successful transitions by providing information, support, and/or direct care, which subsequently help prevent diseases, reduce health risks, enhance health/well-being, and facilitate rehabilitation of those in transitions. Meleis (2010) asserted that transitions are central to the mission of nursing.

Transitions theory started from the point of view that nursing phenomena could be ex- plained as a health/illness experience during life changes. The theory has frequently been used to explain nursing phenomena across diverse circumstances related to change in health/illness, life situations, developmental stages, and organizations (Im, 2009; Meleis, 2010). Furthermore, transitions theory has provided a structure for nursing curriculum, a framework for research questions/hypotheses, and directions for nursing care (Im, 2009). In this chapter, the purpose and development process of transitions theory are described. Then, the major concepts of transitions theory and the relationships among the concepts are described. Finally, the current use of transitions theory in nursing research and practice is presented.

PURPOSE OF THE THEORY AND HOW IT WAS DEVELOPED

The purpose of this middle range theory is to describe, explain, and predict human be- ings’ experiences in various types of transitions including health/illness transitions, sit- uational transitions, developmental transitions, and organizational transitions. Because nursing phenomena frequently involve transition, transitions theory has been used in nursing research and practice (Im, 2011). Furthermore, due to its comprehensiveness, transitions theory has been widely accepted in nursing research and practice (Im, 2011). An entire issue of Advances in Nursing Science (Chinn, 2012) was dedicated to transitions, and in her editorial, Chinn recognizes Meleis’s contribution, noting the central impor- tance of transitions for the discipline: “I believe that the concept of transitions, along with the central concept of caring, forms a core around which the practice of nursing is constructed” (p. 191). In 2015, Meleis was designated as a living legend, the highest honor given by the American Academy of Nursing, to honor her lifelong contributions to the

228 ■ I I MIDDLE RANGE THEORIES READY FOR APPLICATION

nursing discipline, including her tremendous contributions to nursing theory. Transitions theory was formulated with the goal of integrating what is known about transition expe- rience across different types of life change to provide direction for nursing therapeutics. This theory also provides a framework guiding direction about integrating the results of previous research related to transitions and manipulating transition-related concepts for further study.

The development of transitions theory can be characterized by the following descriptors (Im, 2011): a borrowed view; research program and collaborative works; and mentoring.

From a Borrowed View

The theory has been developed over the past 50 years. Meleis (2007) initiated her conceptu- alization of transitions theory in her master’s and PhD dissertation research. Then, through her early theoretical works on role supplementation theory and her research on immigrant health, she began to inquire about the nature of transitions and the human experience of transitions. Thus, we can say that development of transitions theory started with the role in- sufficiency theory (Meleis, 1975, 2007; Meleis & Swendsen, 1978; Meleis et al., 1980), which has its theoretical roots in symbolic interactionism and role theories in sociology. In her first theoretical work, Meleis claimed role insufficiency was a result of unhealthy transitions. Role insufficiency was defined as any difficulty in the cognizance and/or performance of a role or in the attainment of its goals, as well as difficulty in the sentiments associated with the role behavior, as perceived by the self or by significant others (Meleis, 1975; Meleis & Swendsen, 1978; Meleis et al., 1980). In the early work, the goal of healthy transitions was the mastery of behaviors, sentiments, cues, and symbols associated with new roles and identities and nonproblematic processes (Meleis, 1975). Meleis (2007) later mentioned her difficulties in conceptualizing the nature of transitions and the nature of responses to dif- ferent transitions, but also thought that the goal of nursing knowledge development should be on developing nursing therapeutics (Jones et al., 1978; Meleis, 1975; Meleis & Swendsen, 1978). Her work in the 1970s shows her efforts to develop the idea of role supplementation with a focus on defining the components, processes, and strategies that may be related to role supplementation.

From a Research Program and Collaborative Works

Meleis’s well-known research interests were on immigrant populations and their health (Im & Meleis, 2000; Im et al., 1999; Jones et al., 1978; Lipson & Meleis, 1983, 1985; Lipson et al., 1987; Meleis, 1981; Meleis et al., 1998; Meleis & Rogers, 1987; Meleis & Sorrell, 1981). Most of her publications in the 1980s and 1990s focused on the health/illness experience of Arab immigrants in the United States. Through her research, immigration was conceptualized as a situational transition (Budman et al., 1992; Im et al., 1999; Laffrey et al., 1989; Lipson & Meleis, 1983, 1985; Lipson et al., 1987; Meleis, 1981; Meleis & La Fever, 1984; Meleis & Rogers, 1987; Meleis & Sorrell, 1981; Meleis et al., 1998).

This is also the period when Chick and Meleis (1986) conceptualized transition as a con- cept central to nursing. While working as a faculty member at the University of Califor- nia, San Francisco (UCSF), Meleis met Chick—who was a visiting scholar at UCSF at that time—and they worked together to develop transitions as a concept (Chick & Meleis, 1986). This was the first theoretical work on transitions theory. In addition, Meleis’s collaborative works with international colleagues helped conceptualize transitions as central to nursing (Lane & Meleis, 1991; May & Meleis, 1987; Meleis et al., 1987, 1990, 1994, 1996; Meleis, Kulig, Arruda, & Beckman, 1990; Meleis, Mahidal, Lin, Minami, & Neves, 1987; Shih et al., 1998; Stevens et al., 1992).

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From Mentoring

The development of transitions theory also results from the mentoring process. Meleis’s first major paper on transitions theory resulted from working with and mentoring a student. Based on the work of Chick and Meleis, Schumacher, who was a doctoral student at UCSF at that time, worked with Meleis to conduct an extensive literature review on transitions in nursing and developed the transition framework based on 310 articles (Schumacher & Meleis, 1994). This integrated literature review led to a definition of transitions and creation of a conceptual framework in nursing. This framework was well received by nursing re- searchers, and a few researchers began to use it in their studies.

Transitions theory was later developed based on the research studies by Meleis’s for- mer students who investigated diverse populations in various types of transitions. Former students of Meleis conducted an analysis of their research findings related to transition ex- periences and responses, and integrated similarities and differences to further develop tran- sitions as a middle range theory (Meleis et al., 2000). As a group, the researchers compared, contrasted, and integrated the findings, and developed transitions theory through extensive reading, reviewing, and dialoguing with constant analysis and comparison of the findings related to the major concepts of the theory.

With the emergence of situation-specific theories as a new type of nursing theory (Meleis, 1997), several situation-specific theories were developed based on transitions theory by Meleis’s former students (Im, 2006; Im & Meleis, 1999a, 1999b; Schumacher et al., 1999). These situation-specific theories include the situation-specific theory of low-income Korean immigrant women’s menopausal transition (Im & Meleis, 1999a), the situation-specific the- ory of elderly transition (Schumacher et al., 1993, 1999), and the situation-specific theory of Caucasian cancer patients’ pain experience (STOP; Im, 2006). As a whole, Meleis (2010) published all the theoretical works related to transitions theory in a book in 2010. Im (2011) also published a literature review on transitions theory to identify a trajectory of theoretical development in nursing and provide direction for future theoretical development. Also, in 2015, Meleis (2015) published a book chapter that presented her further developed theoret- ical ideas and developments in transitions theory. This book chapter is based on the most widely and frequently used middle range theory of transitions that was published in Ad- vances in Nursing Science (Meleis et al., 2000).

CONCEPTS OF THE THEORY

The major concepts of transitions theory suggested by Meleis et al. (2000) include the follow- ing: types and patterns of transitions, properties of transition experiences, transition con- ditions (facilitators and inhibitors), patterns of response/process and outcome indicators, and nursing therapeutics. The definitions of each of these concepts were described in two manuscripts (Meleis et al., 2000; Schumacher & Meleis, 1994) more than a decade ago. The definitions are summarized here.

Types and Patterns of Transitions

Types of TransiTions

The concept of types of transitions includes four different types: developmental transitions, health and illness transitions, situational transitions, and organizational transitions. Devel- opmental transitions are those due to developmental events including birth, adolescence, menopause, aging (or senescence), and death. Health and illness transitions are events such

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as a recovery process, hospital discharge, and diagnosis of chronic illness (Meleis & Trangen- stein, 1994). Situational transitions are those due to changes in life circumstances such as entering an educational program, immigrating from one country to another, and moving from home to a nursing home (Chick & Meleis, 1986). Organizational transitions are those related to changing environmental conditions that affect the lives of clients and workers (Schumacher & Meleis, 1994).

paTTerns of TransiTions

In the transitions theory (Meleis et al., 2000), patterns of transitions include multiplicity and complexity. Multiple transitions frequently occur simultaneously; people experience several different types of transitions at the same time rather than experiencing a single transition. Meleis et al. (2000) suggested that multiple transitions could happen sequentially or simulta- neously, and the degree of overlap among multiple transitions and the associations between separate events that initiate different transitions should be considered because of the com- plexities involved.

Properties of Transition Experience

In the transitions theory (Meleis et al., 2000), the properties of transition experiences include awareness, engagement, change and difference, time span, and critical points and events. These properties of transition experience are interrelated as a complex process.

awareness

Awareness is perception, knowledge, and recognition of a transition experience (Meleis et al., 2000). The level of awareness could be reflected in the degree of congruency between what is known about processes and responses and what constitutes an expected set of re- sponses and perceptions of individuals undergoing similar transitions (Meleis et al., 2000, p. 18). According to Chick and Meleis (1986), a person’s awareness of change may not neces- sarily mean that the person has begun their transition. Meleis et al. (2000) proposed later that a lack of the awareness also does not always mean that the transition has not begun.

engagemenT

Properties of transitions also include engagement (Meleis et al., 2000). Engagement is the degree to which a person demonstrates involvement in the process of transition (Meleis et al., 2000). According to Meleis et al. (2000), the level of awareness influences the level of engagement, and there will be no engagement without awareness.

Changes and differenCes

The properties of transition also include changes and differences (Meleis et al., 2000). Changes in a person’s identities, roles, relationships, abilities, and behaviors result in a sense of movement or direction in internal and external processes (Schumacher & Meleis, 1994). All transitions are considered to be associated with change although not all change indicates a transition. In the theory, Meleis et al. (2000) proposed that disclosing and explaining the meaning, influence, and scope of change (e.g., nature; temporality; perceived importance

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or severity; and personal, familial, and societal norms and expectations) are essential in un- derstanding transition. Differences are conceptualized as a property of transitions. Unsatis- fied or atypical expectations, feeling dissimilar, being realized as dissimilar, or viewing the world and others in dissimilar ways could mean challenging differences. Transitions theory suggests that nurses need to consider a client’s level of comfort and mastery in dealing with changes and differences to provide adequate and appropriate care for people in transitions.

Time span

Another property of transitions is time span (Meleis et al., 2000). Transitions theory indicates that all transitions could be characterized as flowing and moving over time (Meleis et al., 2000). Actually, a transition refers to a span of time with an identifiable starting point, ex- tending from the first signs of anticipation, perception, or demonstration of change; moving through a period of instability, confusion, and distress; and to an eventual ending with a new beginning or period of stability (Meleis et al., 2000). However, Meleis et al. (2000) also warned that framing the time span of some transition experiences can be problematic or even impossible.

CriTiCal poinTs and evenTs

Critical points and events are markers such as birth, death, the cessation of menstruation, or the diagnosis of an illness (Meleis et al., 2000). In transitions theory, it was acknowledged that some transitions may not have specific marker events although most transitions have critical marker points and times. The critical points and times are frequently associated with an awareness of changes or challenging engagement in transition processes. Final indica- tors of critical points may be a sense of comfort with new schedules, competence, lifestyle change, and self-care behaviors.

Transition Conditions

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

personal CondiTions

Personal conditions refer to meanings, cultural beliefs and attitudes, socioeconomic status, preparation, and knowledge (Meleis et al., 2000). The meaning attached to a transition and the transition process facilitates or inhibits successful transitions. Personal conditions also include cultural beliefs and attitudes (e.g., stigma associated with cancer), socioeconomic status, anticipatory preparation, or lack of preparation.

CommuniTy and soCieTal CondiTions

Community conditions and societal conditions could facilitate or inhibit successful transi- tions. An example of community conditions is community resources and an example of so- cietal conditions is marginalized immigrants’ status in the host country (Meleis et al., 2000).

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Patterns of Response—Process and Outcome Indicators

In the framework by Schumacher and Meleis (1994), indicators of healthy transitions were included as a major concept. In transitions theory, indicators of healthy transitions were replaced with patterns of response that include process indicators and outcome in- dicators (Meleis et al., 2000). Process indicators lead clients toward health or vulnerability and risk. Thus, process indicators help nurses assess and intervene to facilitate healthy transitions. Outcome indicators can be used to assess whether a transition is healthy or not. However, outcome indicators can sometimes be linked to events in people’s lives if they are assessed early in a transition process. The process indicators include feeling con- nected, interacting, being situated, and developing confidence and coping. The need to feel and stay connected is included as a process indicator of a healthy transition because immigrants are usually in a healthy transition when they add new contacts to their old contacts with their family members and friends. The meaning of the transition and the resulting behaviors can be discovered, analyzed, and understood, and this interactive process may result in a healthy transition. In most transitions, place, time, space, and rela- tionships indicate whether the person is in the process of a healthy transition. The extent of increased confidence that people in transition have indicates whether the person is in the process of a healthy transition. As an outcome indicator, mastery and fluid integrative identities are included in the theory. A healthy transition can be indicated by the extent of mastery of skills and behaviors that people in transition use to manage changes in their situations. Integrative identities through which identities are reformulated can also indicate a healthy transition.

Nursing Therapeutics

In the framework by Schumacher and Meleis (1994), nursing therapeutics are described as three measures that are widely applicable to therapeutic intervention during transitions. The three measures include assessment of readiness, preparation of transition, and role supple- mentation (Schumacher & Meleis, 1994). Assessment of readiness requires multidisciplinary efforts and should be based on a comprehensive understanding of the client. This requires the evaluation of each transition condition to produce a comprehensive sketch of people’s readiness during transitions and helps determine various patterns of different transition experiences. The preparation for transition refers to education to produce the best condi- tion/situation for enabling transition. Role supplementation as the last nursing therapeutic was originally suggested by Meleis (1975) and used by several researchers (Brackley, 1992; Dracup et al., 1985; Gaffney, 1992; Meleis & Swendsen, 1978). In the book chapter by Meleis that was published in 2015, she presented her refined ideas on nursing therapeutics with major focus areas for interventions. The areas included: (a) clarifying roles, meanings, com- petencies, expertise, goals, and role training; (b) identifying milestones and using critical points; (c) providing supportive resources, rehearsals, reference groups, and role models; and (d) debriefing (communicating with others regarding transition experience at critical points of transition).

RELATIONSHIPS AMONG THE CONCEPTS: THE MODEL

The relationships among the major concepts can be illustrated as in Figure 13.1 (Meleis et al., 2000). This relationship is based on the transition framework by Schumacher and Meleis (1994) and the middle range theory of transitions by Meleis et al. (2000). The follow- ing statements regarding the relationships have been explicated by Im (2011, p. 423):

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■ Transitions are complex and multidimensional. Transitions have patterns of multiplicity and complexity.

■ All transitions are characterized by flow and movement over time. ■ Transitions cause changes in identities, roles, relationships, abilities, and patterns of

behavior. ■ Transitions involve a process of movement and change in fundamental life patterns,

which are manifested in all individuals. ■ Change and difference are neither interchangeable nor synonymous with transition.

Transitions result in change and are the result of change. ■ The daily lives of clients, environments, and interactions are shaped by the nature,

conditions, meanings, and processes of transition experiences. ■ Vulnerability is related to transition experiences, interactions, and environmental

conditions that expose individuals to potential damage, problematic or extended recovery, or delayed or unhealthy coping.

■ Nurses are the primary caregivers of clients and their families who are undergoing transitions.

Transitions theory also has the following theoretical assertions (Im, 2011, p. 424; Meleis et al., 2000; Schumacher & Meleis, 1994):

■ Developmental, situational, health and illness, and organizational transitions are central to nursing practice.

Nature of transitions Transition conditions:

Facilitators and inhibitors Patterns of response

Personal Meanings Cultural beliefs and attitudes Socioeconomic status Preparation and knowledge

Types Developmental Situational Health/Illness Organizational

Patterns Single Multiple Sequential Simultaneous Related Unrelated

Properties Awareness Engagement Change and

difference Transition time

span Critical points

and events

Community

Nursing therapeutics

Process indicators Feeling connected Interacting Location and being situated Developing confidence and

coping

Outcome indicators Mastery Fluid integrative identities

Society

FIGURE 13.1: The Middle Range Transitions Theory. Source: Reprinted with permission from Meleis, A. I., Sawyer, L. M., Im, E. O., Messias, D. K. H., & Schumacher, K. (2000). Experiencing transitions: An emerging middle range theory. Advances in Nursing Science, 23(1), 12–28. https://doi.org/10.1097/00012272-200009000-00006.

234 ■ I I MIDDLE RANGE THEORIES READY FOR APPLICATION

■ Patterns of transition include whether the client is experiencing a single transition or multiple transitions, 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 transition experience are interrelated parts of a complex process. ■ The level of awareness influences the level of engagement, in which engagement

may not happen without awareness. ■ Human perceptions of and meanings attached to health and illness situations are

influenced by and in turn influence the conditions under which a transition occurs. ■ Healthy transition is characterized by both process and outcome indicators. ■ Negotiating successful transitions depends on the development of an effective

relationship between the nurse and the client (nursing therapeutic). This relationship is a highly reciprocal process that affects both the client and the nurse.

Derivatives of Transitions Theory

In this section, three situation-specific theories that were derived from transitions theory are presented: STOP, situation-specific theory of pain experience for Asian American cancer patients (SPEAC), and situation-specific theory of Asian immigrant women’s menopausal symptom experience in the United States (AIMS).

The siTuaTion-speCifiC Theory of CauCasian CanCer paTienTs’ pain experienCe

The STOP (Im, 2006) is a derivative of transitions theory. The reason for developing the STOP was to provide a better theoretical basis for the explanation of the ethnic-specific cancer pain experience by narrowing the scope of the theory specifically to the pain experience of Cauca- sian cancer patients. STOP was developed to be a comprehensive theory that could be easily applied to nursing research and practice for management of Caucasian cancer patients’ pain. To derive and develop STOP, an integrative approach was used. First, several assumptions were made, which include the following: The theory development process considered the diversity and complexity of the phenomenon from a nursing perspective; it was based on philosophical, theoretical, and methodological plurality; Caucasian cancer patients’ pain ex- perience occurred in a specific sociopolitical context; and it was based on a feminist nursing perspective. Multiple theorizing sources were used, which included a systematic literature review and research findings from a multiethnic study on cancer pain experience and tran- sitions theory.

Deduction From Transitions Theory. Transitions theory provided the theoretical ba- sis for the development of STOP. Caucasian cancer patients’ pain experience can be easily linked to the health/illness transition. The major concepts of transitions theory are related to the pain experience of Caucasian cancer patients. For instance, the concept of transition conditions includes personal, community, and societal conditions (Meleis et al., 2000): So- cioeconomic status can influence the selection of pain management strategies, community resources can influence support for pain management, and societal conditions can make women’s pain experience different from that of men.

Induction Through a Literature Review and a Research Study. To develop STOP, a systematic integrated literature review was conducted and used as a source for theorizing. PubMed was searched for the years of 1995 to 2000 using keywords of “Caucasian,” “White,” “cancer,” “pain,” and/or “experience.” A total of 114 articles were included in the literature

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review (78 retrieved articles and 36 from the reference lists of the retrieved articles). All the articles were sorted by the major concepts of STOP. The literature review findings were ana- lyzed and incorporated into the theorizing process.

In addition to the literature review, findings of a study on cancer pain that developed a decision support computer program for cancer pain management (DSCP study; Im, Chee, et al., 2007; Im, Guevara, & Chee, 2007; Im, Liu, Clark, & Chee, 2008; Im, Liu, Kim, & Chee, 2008; Im et al., 2009) were used as a source for theorizing. The overall purpose of the study was to explore gender and ethnic differences in cancer pain experience among 480 cancer patients from four major ethnic groups in the United States. The study included a quantitative internet survey and four qualitative ethnic-specific online forums. Multiple measurement scales, including questions on sociodemographic characteristics and health/ illness status, three unidimensional cancer pain scales, two multidimensional cancer pain scales, the memorial symptom assessment scale, and the functional assessment of cancer therapy scale—general, were used for the quantitative internet survey. Nine online forum topics were used for the qualitative study component. The quantitative data were analyzed using descriptive and inferential statistics including analysis of variance (ANOVA) and hierarchical multiple regression analyses, and the qualitative data were analyzed using a thematic analysis.

The relationships among the five major concepts of STOP (Im, 2006) are the nature of transition, transition conditions, patterns of response, Caucasian cancer patients’ pain ex- perience, and nursing therapeutics. These five concepts are basically those of the transitions theory except the concept of Caucasian cancer patients’ pain experience, the focus of STOP. Through the literature review and the findings of the DSCP study, all major concepts are confirmed to impact Caucasian cancer patients’ pain experience. For instance, the nature (terminal or chronic) of the transition influences Caucasian cancer patients’ pain experience. Cancer patients’ religion can influence the patients’ attitudes toward pain, which subse- quently influence their pain experience.

Uniqueness of STOP. Compared with the middle range transitions theory, STOP has unique subconcepts (under the major concepts) that are frequently ethnic-specific. For ex- ample, although one’s cancer experience could be a health/illness transition that all ethnic groups go through in a common way, most Caucasian cancer patients tend to