About One DNP

I earned my "terminal practice" degree in nursing from the University of Tennessee Health Sciences Center in a journey of excitement and challenge. It inspired me to advocate for an all encompassing clinical credential rather than continuing the hodgepodge of nonsensical initials. I hope these entries will provide entertainment and insight into the Doctor of Nursing Practice experience, which will soon be the entry standard for all advanced practice nurses.

Thursday, January 26, 2012

Theory for Thursday

When I first heard the words "nursing theory," I snickered.  I thought it was yet another example of the white cap club trying to stake a piece of unnecessary territory when they should be changing a bandage or administering an enema.  Seriously, how much of a theory do you need beyond "take care of the patient?" As with many other moments on my nursing education journey, a little dose of the real world to go along with the literature took care of my ignorance. I hope. The following is a report on one of my favorite theorists, Afaf Meleis, who's work on transitions has provided guidance for those times in practice when there is no map.

Meleis: Transitions Theory Evaluation
Transition is an emerging middle range nursing theory that emphasizes the role of the nurse in facilitating healthy individual role sufficiency. While straightforward in concept, transitions theory contains multiple components that have changed over time and encompass more than assisting a patient adjust to new changes in health status. Fawcett (2005) provides an appropriate framework for analysis and evaluation for the developing transitions theory as conceptualized by Afaf I Meleis.

     Meleis first became interested in nursing theory during her master’s studies when she researched the role of meaningful and informative interactions between caregivers with patients and their families (Meleis, 2007). After attending several types of support groups, she found the transition processes were similar whether the group concerned family planning, grief, or illness. Her doctoral dissertation focused on the importance of role clarity through dialogue and interaction in couples planning to start a family. Through her research, she concluded that the major role of the nurse was to prepare the patient to cope well with developmental, situational, and health transitions (Meleis, 2008). Her research focused on people who made poor transitions and on nursing interventions that could facilitate better outcomes. Meleis began forming her role transition theory and created the first concept map in 1984 (Meleis, 2007) with a revision in 2000 (Meleis, Sawyer, Im, Messias, & Schumacher, 2000).
     Meleis (2010) suggests change is addressed in some manner in every nursing theory citing Peplau and Travelbee as examples of how to find growth and meaning though the change of illness, Roy’s adaptation model, patterning from Rodgers and Newman, and change in self-care ability from Orem. The act of caring for a patient using nursing therapeutics incorporates transition as a vital component. Transition theory was formulated to promote healthy evolutions and well-being in individuals by using nursing and social support. The nurse provides education, skills, and strategies for the patient and family to understand and cope with the experience of transition. This theory explains the transition experience as a change from one role to another with individuals having unique circumstance that may facilitate or inhibit the ability to define and master a new role and integrate it into their identity (Meleis, 2007). By providing an understanding of the nature of transition, conditions that potentially facilitate or inhibit positive change, and patterns of response, the nurse has a framework for preventing role insufficiency and anticipating the patient’s physical and psychosocial needs required for successful transition.
     In the initial conception of role transition theory, Schumacher and Meleis (1994) listed time and nature of change as one of the properties of nature in transitions. Later, Meleis, Swayer, Im, Messias and Schumacher (2000) added awareness, engagement, and critical points. Indicators of healthy transition included subjective well-being, role mastery, and well-being of relationships (Schumacher & Meleis, 1994) which were later altered and incorporated into process and outcome indicators (Meleis & Sawyer et al. 2000). There were also changes in and additions to the use of terms including roles, role stress, multiple role stress, transitional gender roles and coping, especially when the theory was used in disciplines other than nursing.
Unique Focus
     Meleis (2010) transition theory focuses on the period of evolution from what has been to what will be and is best classified as a developmental theory. It concentrates on the transition of the individual, family impact and involvement, the role of the nurse in facilitating the transition, and cultural, societal, and community support. Areas of theory application include change in health status; change in social support and relationships, such as relocating to a new city, becoming a parent, or loosing a friend; when an individual looses familiar reference points as with immigration to a new country or nursing home placement; or when there are new needs or an inability to meet old needs in familiar ways.
     Positive role transition is facilitated or inhibited by nursing intervention and personal, social and community conditions. Transition addresses person, nursing, health, and environment (Meleis, 2007). The person is identified as anyone preparing for or involved in a current transition, be it motherhood, immigration, or puberty with a specific focus on women as the central figure in transition (Meleis & Rogers, 1994). Nursing is addressed in either a facilitative manner by providing well-planned interventions and follow-up, or in an inhibitive manner though apathy, generic treatment planning, or insensitivity. A change in health status may be well managed and integrated into an individual’s identity through education and positive outlook, or be managed poorly as a result of negative attitude, denial, or lack of knowledge (Van & Meleis, 2003). Social, cultural, political, and personal environment are addressed as necessary supportive components to healthy transitions (Jones, Zhang, & Meleis, 2003).

     Afaf I Meleis grew up in Egypt and received her nursing degree from the University of Alexandria in 1961 (Meleis, 2008). After briefly teaching nursing in Egypt, she immigrated to the United States where she received her master’s degrees in both nursing and sociology from the University of California Los Angeles. She completed her dissertation “Self concept and family planning” in 1968 and was awarded her doctoral degree in medical and social psychology. Meleis has authored numerous journal articles and is an international keynote speaker in women’s health, doctoral nursing programs, and health care research. She served as a university professor in the United States, Kuwait, and Australia, and is currently the Margaret Bond Simpson Dean of Nursing at the University of Pennsylvania. Her teaching methods focus on organization of nursing knowledge, health transitions, and international nursing.
Transition theory assumes there are universal properties in transition that include change in identity, roles, relationships, behavior patterns, structure, function, and dynamics (Meleis, 2007). Transitions naturally occur throughout life but are not always predictable or sequential and a variety of multiple changes may occur simultaneously. Nurses facilitate, inhibit, or ignore transitions directly affecting the outcome. Personal, cultural, social environmental factors also influence the outcome of a transition.
Comprehensiveness of Content
     Role transition addresses person, nursing, health, and environment (Meleis, 2007). The person is identified as anyone preparing for or involved in a current transition, be it motherhood, immigration, or puberty with a specific focus on women as the central figure in transition (Meleis & Rogers, 1994). Nursing is addressed in either a facilitative manner by providing well-planned interventions and follow-up, or in an inhibitive manner though apathy, generic treatment planning, or insensitivity. A change in health status may be well managed and integrated into an individual’s identity through education and positive outlook, or be managed poorly as a result of negative attitude, denial, or lack of knowledge (Van & Meleis, 2003). Social, cultural, political, and personal environment are addressed as necessary supportive components to healthy transitions (Jones, Zhang, & Meleis, 2003).
     There are four types of transitions: developmental, situational, health-illness, and organizational (Meleis, Sawyer, Im, Messias, & Schumacher, 2000). Developmental transitions are those that occur in the normal process of growth and maturity and include milestones such as puberty, parenthood, and menopause. Situational transitions may be unexpected or sudden such as widowhood or a car accident. Health-illness involves a medical change such as a spinal cord injury, cancer, or autism. Organizational transitions refer to changes in delivery systems including leadership, policy, and administration. Single patterns transitions occur once or one at time such as a developmental milestone. Multiple patterns can occur more than once as with childbirth, marriage or death of a loved one. Sequential patterns occur one after another while simultaneous patterns may be a mix of transition types occurring at the same time. Patterns may or may not be related to each other (Meleis et al., 2000). Nursing interventions, especially those involving education, have an influence on awareness, engagement, change and difference, and critical points and events (Meleis et al., 2000).
     A number of transition conditions are discussed in the literature. Personal conditions include meanings, cultural beliefs, socioeconomic status, and preparation for the individual. Entry into a psychiatric facility can mean abandonment, powerlessness or failure to a newly admitted patient and manifest itself as anxiety or resentment (Aroian & Prater, 1988). Conversely, admission could represent an opportunity to manage a disorder and accept medical and lifestyle assistance. Cultural beliefs and attitudes toward transition should be acknowledged, addressed, and accommodated by culturally competent nurses. The birth process in American born women is different from Arab American women who are often more modest, subordinate to men, and do not regard planning as an important aspect of childbirth (Meleis & Sorell, 1981). The experience of menopause in middle-class or wealthy American women differs from low income Korean immigrants who tend to report fewer symptoms and discount menopause as an unimportant transition (Im, Meleis, & Lee, 1999). Nursing home entry is often a difficult and varied transition; personal preparation and knowledge may hinder or help both the person in transition and the supporting family (Rossen & Knafl. 2003).
     Communities with productive and safe recreation outlets, educational facilities, and accessible health care facilitate effective transitions. Adolescents moving from a comfortable, supportive, and familiar community to a new area of the country are at risk for ineffective role integration and substance abuse (Puskar, Kathryn, & Martsou, 1994). Societal conditions that impact transition include federal and state programs, laws, and cultural norms. A society that seeks to reduce the amount of the population who smokes tobacco may institute bans and offers cessation programs and incentives, thereby making it easier for the individual to quit. Societies who revere the elderly may have less elder abuse and nursing homes then in those who have more negative attitudes toward aging and home care (Davis, 2005).
Once the nature and conditions of transition have been identified, there are patterns of response an individual will exhibit. Process indicators help evaluate and predict the success of a transition and guide the nurse in developing interventions to help plan and meet goals. These indicators include feeling connected, interacting, location and becoming situated, and developing confidence and coping (Meleis et al., 2000). The nurse assists in facilitating these response patterns by providing individually tailored interventions, education, action plans, and community resources. The nurse takes into consideration the conditions and nature of the transitions before forming an intervention plan. The ongoing evaluation of process indicators and response patterns guide future interventions. Outcome indicators are marked by mastery and fluid integrative identities (Meleis et al., 2000). That one copes with and accepts the diagnosis, treatment, and remission of cancer demonstrates mastery of a role. For an individual to identify themselves as a survivor, a parent, and an accountant exemplifies role integration.
     Although there are several components to transition theory, the theoretical propositions and relational statements are clear and concise. Transition leads to the development of a new role. Understanding the properties of specific transitions guides the nurse in planning effective interventions to assist the patient in adapting to a change in identity. If transition conditions in personal, societal and communal spheres are facilitative, the individual and their family will develop positive patterns of response. Promotive nursing interventions increase the amount of positive process indicators. The more process indicators and individual possesses, the greater the ability to master and integrate the transition into their self-concept (Meleis & Sawyer et al. 2000).
Logical Congruence
     Transition theory aligns well with the partnership model of health care and holistic practice of nursing. A patient should be informed about every procedure they undergo, every medication they take, and every viable treatment option available. It is the professional responsibility of health care providers to increase the patient’s knowledgeable about the current process and feel empowered in the management of their condition. Encouraging patients to enlist as many tools as possible to manage their conditions including family support, community group therapy, online resources, and mind-body techniques provides autonomy and aids the practice of cultural competence. This theory puts responsibility on the nurse to educate, use critical thinking to develop effective treatment strategies that involve patient and family, and assess effectiveness of strategies. Social values are covered in relation to how an individual perceives and is assisted by society. Americans expect knowledgeable, courteous, ethical health care providers and this theory implies that nurse will exhibit these behaviors. This theory was born using a variety of cross-cultural observations and research on transitions. Provided the nurse refrains from assumptions regarding meaning to the patient and his or her own personal bias, transition theory is applicable among many diverse worldviews and nursing areas.
Meleis intended the transition theory to be used in practice, education and research specific to nursing and healthcare. Transition is moderate in scope and defines a facet of nursing practice. It is classified as a middle range theory because it is not precise and restricted enough for situational or practice theory, but too limited in scope and abstraction to be considered a grand theory (McEwen & Wills, 2002). It is also used as a framework for developing situation specific theories (A. I. Meleis, personal communication November 2008; Nelson, 2006). While conceived for the field of nursing, role transition is a theme in sociology and psychology that is applied in works concerning women and cultural issues (Meleis & Rogers, 1987; Im et al. 1999). In these applications, different inconsistent terminology and meaning made comprehension and identifying major concepts difficult. Due to Meleis’ (2008) profusion of published journal articles, it was cumbersome and confusing to differentiate between those articles that discussed transition as a theory rather than a cultural or developmental process. As this theory evolves and more elements are added, parsimony decreases.
Social Utility. Transition theory is used in areas such as psychiatry (Aroian & Prater, 1988), long-term care (Davis, 2005), cardiac rehabilitation (Dracup, Meleis, Baker, & Edlefsen, 1985), and motherhood (Sawyer, 1999) to either prepare an individual for change, or evaluate the effectiveness of intervention prior to or following a particular transition. It has been used to guide research and develop situation-specific interventions in the sibling experience of childhood cancer (Wilkins & Woodgate, 2006) and transition to adulthood in adolescents with developmental disorders (Pearson, 2002). Transition theory is currently used as a framework in undergraduate and graduate nursing programs at institutions including University of Connecticut and University of Pennsylvania (A. I. Meleis, personal communication, November 2008). Transition may be adapted from nursing and used for changes in social and political spheres such as the recent health care reform act.
Social Congruence.  Transition theory is a cross-cultural, adaptable theory that can be used by nurses and other health care professionals to elicit positive role integration in an individual, family, organization, or community. While the origins are based in nursing, the social and psychological aspect of application makes this a useful framework for multiple disciplines. Using this model to prepare for, understand, and anticipate change, increases the probability of successful transition.
Social Significance.  Those who are prepared for change are more apt to accept a new role to the benefit of their family and community. When people are knowledgeable, adapt easily to changes, and are able to integrate a new role into their self-concept with a sense of well-being, society benefits. The world is moving toward globalization in several arenas including healthcare and the environment. This theory provides strategies for society and individuals to have healthy transitions through knowledge and use of available resources. An understanding of universal properties of these transitions assists in devising successful strategies in international social, political, and health policies.
Contribution to Nursing
     Role transition clarifies and specifies the major role of the nurse. It assists the nurse in assessing areas of vulnerability, readiness, environment, and support. It demonstrates that education prior to, during and following transition increases the likelihood of successful role integration. It also provides a framework for planning nursing interventions with the goal of healthy stability. In a study involving the sibling experience with childhood cancer, nurses used transition theory to develop educational interventions that allowed the sibling to understand the disease process and provide support to enhance the therapeutic outcome for the affected sibling (Wilkins & Woodgate, 2006). When transition theory was applied to the recovery process in major depression, Skarsater and Willman (2006) concluded transition planning facilitated health, recovery and quality of life. The role of the nurse in preparing parents for the discharge of their children from hospital care to homecare validated that education and preparation for transition led to healthy and adaptive outcomes ( Weiss, Johnson, Malin, Jerofke, Lang, & Sherburns, 2008).

Summary and Recommendations
Meleis provides a detailed framework to execute successful role transition by illustrating and describing the role nurses have been playing for decades. As an evolving theory, there remain issues of consistency and clarity when researching the origins and evolution of concepts. There is also a lack of relevant data in relation to men and a need for expanded theory testing. Despite these shortcomings, role transition is an adaptable theory that has applications beyond the scope of nursing practice.

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