The Trouble With Interdisciplinary Studies: Everybody

For those of you contemplating your capstone projects, take heed of the following.

Although social networking is all the rage in health care, I knew when my provider-focused capstone involved a range of mental health disciplines I would have trouble finding a home for it.  The vast majority of responders were nurses, which makes it unsuitable to publish in psychiatry, psychology or social work journals. Not all of the responders were nurses so the nursing journals passed as well.  Many of the social networking journals have gone under, and most of the interdisciplinary ones either make you pay to get published or require you have an MD, PsyD, or LCSW as the primary author. One reviewer mentioned this would be more appropriate for inpatient psych nursing journals, despite the fact most of the responders wee coming from community-based clinics.  In retrospect, I can think of a number of SN topics that would have "sold" better that were patient, disorder, or single-issue focused. I took a risk, it didn't pan out.

While my ego is nursing the bruise of rejection, I have to remind myself that time not only money, it is time. Rather than continue to edit and rework the article to meet the broad ranges of journal editors' criteria for zero-cents-per-word, I am going to do the unthinkable: Share the results on the Internet. This is probably scholarly publication suicide, but suck-it-dry, it is more important to share the findings than wait for the research to go obsolete. This is the PDF proof from one of my submissions:
Social Networking and Mental Health Providers: Practice Trends and Perspectives to Shape Interdisciplinary Guidelines 

Abstract

Background: Social networking activity and media development in health care are advancing rapidly and without a firm understanding of implication for use among mental health providers. Social networking is used to provide education, foster advocacy, promote the profession, and influence policy, but with potential to violate therapeutic boundaries, infringe upon privacy, create liability, and damage professional credibility.  

Objective: This survey was designed to examine current social networking practice trends and perspectives from psychiatric nurses, psychiatrists, psychologists, and therapists. Determining how mental health providers engage in social networking activity and their viewpoints on best practice offers a basis for recommending interdisciplinary guidelines.  

Design: A 20-question online survey was used to gather data from mental health providers recruited through professional member forums, e-mail distribution lists, and social media.  

Results: Key findings demonstrate an extensive use of social networking sites on personal devices for research, continuing education, and peer collaboration; a need to restrict patient communication and access to a provider’s social network; and a desire for specific guidelines to promote prudent, resourceful use of social media that complies with ethical codes, promotes professionalism, and maintains work-life boundaries.  

Conclusions: Results demonstrate the increasing use and evolving nature of social networking requires that clinicians maintain situational awareness of media platforms and technology and a need for further analysis, education, and collaboration to develop a comprehensive consensus model for social networking behavior.


The article is 60 pages with much of it taken up with figures and graphs. If you want to cut to the chase, these are the the proposed guidelines beginning on page 21:

Proposed Guidelines  

The following are proposed key components for foundational interdisciplinary guidelines that each of the professions could expand upon according to their own licensing and regulation requirements.  

• To protect the therapeutic alliance, maintain confidentiality, and prevent dual relationships, providers should refrain from connecting with current patients on their personal social networks.
• To comply with federal regulations, providers should not initiate communication or interact with patients on social networks to discuss health-protected information. 
• Professional profile pages should include a purpose and disclaimer statement with parameters for use on each site (Appendix B). 
• Office or organizational social networking policies should be included as part of informed consent, and discussed with patients as they are updated (Appendix C). 
• To demonstrate respect and trust for the patient, providers should refrain from searching for patient information online unless expressly requested by the patient during formal treatment time.

Serendipity: DNP Admission Essay

As Robert A. Heinlein put it in Time for The Stars: “Serendipity is when you dig for worms and strike gold.” This is what happened this morning as I was cleaning out my laptop files looking for a concept paper, but found my DNP admission application essay instead.  My nursing network has grown significantly in the past year and a number of folks are planning or in the process of applying to programs. While mine is psych/mental health focused, it might help provide inspiration for potential applicants. 

UTHSC DNP Application Essay 2009

“I’m not taking that disrespect medicine! And get these f*cking rent-a-cops out of here.”

“I respect you. These gentlemen are here for all of our safety. Please take the medicine.”

“Don’t you tell me what to do little girl. I know you just want to control my mind.”

“I just want you to rest and relax so you can speak to the doctor and get you home.”

“Bullsh*t!”

“Please make the good decision. If you take the medicine you can lie in bed and wait for the doctor. If you refuse we will have to put you in seclusion and maybe restraint. Which one do you think is more disrespectful?”

“Fine – give me the medicine.”

“Thank you.”

            When I relate this and similar encounters to my BSN students, they usually respond with a shudder and ask why I would ever want to work in a place like emergency psychiatry or in the psych field at all. They feel nervous around the unpredictability and worry about violence, sexual advances, and suicidal revelations. They are uncomfortable that the diagnosis of psychiatric illness cannot be confirmed with a lab value or imaging study and that there are no tactile tasks as there are in the medical setting. I tell them these are the exact reasons why I love working with this patient population and being a psychiatric and mental health nurse.

            After I came out of my accelerated BSN program in 2005, I took the advice of some nursing professors and began in the emergency department. It was not a good fit. I wanted to spend more time with patients than what was considered suitable for a department whose priorities were to stabilize and ship off. I had family ask if I could be their loved one’s nurse when they were transferred to ICU and I had individuals who had mania remember me as the nurse who took time to get to know them instead of locking them in a seclusion room just because they had “Bipolar” written in their history.

            I made the switch and took a position as a second shift nurse at Ten Broeck, a private psychiatric facility that catered to adults, children ages 3-12, and active duty military personnel. I also worked with the psychiatric assessment team that went to ER’s all over Louisville to determine level of care and initiate disposition to the appropriate facility. After two years I craved a higher acuity environment and more diverse patient population and took a position in emergency psychiatric services at University of Louisville Hospital. I also became certified through the ANCC as a psychiatric and mental health nurse and began teaching psychiatric clinical for Bellarmine University.

            In 2008 I began the Family Nurse Practitioner Program at Bellarmine. I chose the FNP because, while I love working in psych, I also wanted professional diversity. In addition to prevention, management and education of health conditions across the lifespan, a large percentage of primary care involves treatment of depression, anxiety, ADHD and PTSD and screening for substance abuse and domestic violence. Although I wanted more medical experience, I planned on obtaining my Psych NP certification even prior to beginning my FNP, and this resolve was strengthened during my educational clinical experience. While I enjoyed primary care in pediatric and adult settings, when I got to the psych portion of the rotation is was like a sigh of relief. With the new Doctor of Nursing Practice degree becoming a requirement in the next five years, I also feel it is important to continue my education while I am still in the flow of academia rather than waiting or being grandfathered in.

            In addition to nursing, I have also been an acupuncturist and Doctor of Oriental Medicine for the past ten years and have focused my practice in pain management, women’s health, and mental/emotional disorders. I have had the opportunity during my training and professional practice to work with chemical dependency, depression, anxiety, stress management and PTSD using a combination of modalities including acupuncture, herbal therapy, nutrition, Tui Na, exercise, and mediation. I was also involved in development of a research project that compared the effectiveness of CBT with and without acupuncture intervention in patients with PTSD.

            My professional goals include integrating my specialties to develop a holistic approach to education, prevention and treatment of anxiety disorders. While other disease processes such as bipolar, schizophrenia, and personality disorders are also of interest to me, in the higher levels of education I feel it is important to narrow the field of concentration. I have had experience in Internet blackboard courses and working at an accelerated learning environment while maintaining employment throughout my educational career. The ability to obtain the dual certification in mental health with the DNP allows me to have more freedom and a greater variety of choices to peruse my goals. 

I Passed! A Review of the Review and Exam

In that which we are most confident often results in failure. At least, that was my fear going into the ANCC PMHNP certification exam. Despite hearing this exam was allegedly the easiest test I would take in the long series of nursing hoop jump-training, I did not want to get cavalier. Of all the boards I have taken, this was the most important and with hope, the last. As with my FNP, RN-BC, NCLEX, DOM, DilpAC, and DilpH preparation, I had a study plan, created a "cheat sheet" to write out on scratch paper before starting the test, and worried myself sick that I was a knowledge fraud who managed to graduate by luck or accident.

There is a DSM code for that.

After grabbing my usual eggs and lucky Indivisible Blend from Starbucks, I rolled into the parking lot of the testing center at 8:30am just in time to flip through every page of my review notes and psych myself up. After being ID'ed, wanded over, and searched for concealed textbooks, I was escorted to station 15 to live out the next 3.5 hours slugging through 175 questions, 25 of which were secret, experimental items that didn't count. 

Just 2 questions in and I was feeling nervous. By question 50, I doubted I was going to pass. By question 100, I had a boost of confidence. By question 125 I was trying to figure out if the 30-day test window would allow me to re-take the exam before Labor Day. By question 150 I just went numb and fuzzy. With a little over an hour on the timer to go, I ran back through the 45 questions I had marked, change a few answers, said a prayer, and hit submit. Five minutes later, I received the results and was officially certified! 

So, what was so hard?  This test had content that threw me for a bit of a loop. Unlike the Family NP exam that followed the "common diseases occur commonly" model of testing, the Psych Mental Health NP approach assumed you knew all the commonly occurring assessment and management of mood, personality, anxiety, and psychotic disorders and tested around it, with only a couple of bones thrown to topics like Lithium, psychosocial development, and dealing with a borderline in the milieu. 

There was a lot of neurobiology, pharmacokinetics and pharmacodynamics.  The time I put into neurotransmitter pathways, CYP450, and specific drug effects certainly paid off.  I did not spend as much time focusing in on the details of rating scales like the HAM-D, MMPI, and MMSE as I should have, though I was able to activate my hippocampus well enough to pull it out of my memory. There were a number of questions regarding collaboration and consultation, health policy, legal scenarios, and research. Knowing your role and scope was also included in several ways and folks who are FNPs need to be mindful - do not fall into the trap of treating or teaching beyond the scope of the PsychNP role.  There were a few obscure questions on nursing theorists and how to bill for certain procedures (had to be an experimental question). I felt my exam had an overabundance of child and adolescent content, yet not one questions on ADHD!

I used a number of references to prep for the test. 

The Barkley Review home study was an excellent content overview and helped my prioritize my study plan. Too often I go over what I already know to gain confidence and this helped me know what I really did not know. Copy for sale!

Kaplan & Sadock's Study Guide and Self-Examination Review in Psychiatry (STUDY GUIDE/SELF EXAM REV/ SYNOPSIS OF PSYCHIATRY (KAPLANS)
The MDs really like their background and history. Skip those chapters. NPs are more about the here and now of clinical management and interpersonal communication, which are well covered. Some of the questions reflect the essential differences coming from a disease versus a holistic-focus perspective, particularly when it comes to prioritization and adherence. The MDs go into greater depth than NPs when it comes to the "why," and this is particularly useful for psychopharmacology, etiology, and pathology. This book gives you a box of topics to review, several questions on content, and answers with rational.

Psychiatric Nursing Certification Review Guide for the Generalist and Advanced Practice Psychiatric and Mental Health Nurse, Third Edition (Mosack, ... Review Guide for the Generalist and Advance)
Content review is presented at the beginning of the chapter followed by questions. This does a great job going over the basics, which is invaluable for many PMHNPs who never worked in psych at the RN level or did not have experience during their clinical in group dynamics, milieu management, and staffing issues. Even if you are an old-pro, this one is still useful for the way the content blocks are organized, particularly policy and theory. These questions were most like what I encountered on the exam.

Psychopharmacology Demystified
If Stahl made a primer or Cliff's Notes version of Essential Psychopharmacology, this book would be it. The neuro content is well outlined with good visuals, no redundancy, and a clear picture how drugs work in the brain for the most common DSM disorders.

The Psychiatric Interview (Practical Guides in Psychiatry)
I referred to this a number of times while studying assessment. Great mnemonics for those that learn well that way.

Congratulations Doctor Nurses!

The degree journey has ended, but the DNP adventures are just beginning. As the responsibility for improving the future of healthcare was laid upon us, so was the realization that we all have the strength and knowledge to meet the challenges ahead. Here are some highlights from the convocation and graduation of the UTHSC DNP class of 2012!

Pre-Graduation festivities at a lovely Vietnam Restaurant with the largest, most diverse psych/mental health DNP class that was . . .  or ever will be.  

The faculty address by Melody N. Waller reminded us of the many dimensions of love and loss that come with the nursing profession. Hearing all of the great capstone projects my peers have been working on, especially with diabetes, vulnerable populations, and health promotion behaviors, was inspiring.

Hooded by Cheryl C Stegbauer, who gave me the best complement of my life during Philosophy of Science when she told me I was a thinker.

This Dr. Nurse was voted Class Troublemaker - expect great strides in mental health advocacy from this one! 

With two future Dr. Nurses who are destined for great advancements in integrative care!

After being handed my fake diploma  (actually a lovely picture of the campus),  Chancellor Steve J. Schwab shook my hand and said "Congratulations doctor. Well done."  He did this for the thousand-odd graduates after delivering an address exemplifying how our current knowledge will comprise just a fraction of our future knowledge in a career of life-long learning and innovation.

And so it is official!

The Big Day

For the sake of posterity . . . and in case I loose the instructions!

Graduation Instructions

College of Graduate Health Sciences

The Fed Ex Forum: May 25, 2012, 1:30 p.m.

1. The commencement program will be held in the FedEx Forum, located at 191 Beale Street.

2. Parking is available in the Forum parking garage or surrounding area lots.

3. Students, faculty and staff who are participating in the graduation program are requested to be at the Fed Ex Forum in the appropriate assembly area by 12:45 p.m.

4. The assembly areas are located on the lower concourse and are best reached through the main entrance. Once inside the lobby area, the elevators to the lower level are located to the right at the top of the steps. The areas will be marked with signs for easy identification. Only ceremony participants are allowed in the line-up area.

5. DON'T FORGET TO BRING YOUR CAP AND GOWN. Orders for academic regalia can be made in the UT Bookstore or by calling 901-448-5413. The regalia may be picked up in the Bookstore on the Wednesday and Thursday of graduation week.

The Line-Up and Procession

6. The class president is designated as the class marshal and is responsible for getting the class into the correct line-up. A faculty committee member is designated as the college marshal. The college marshal will have a name/number list indicating the beginning and ending person in each row. You should go to the class marshal for assistance in locating your line-up position. The correct line-up is critical to the issuing of diplomas and to the "hooding sequence." Please stay in position.

7. Tassels on the academic caps for all candidates should be worn on the right front quarter of the cap.

8. The procession is led by the Mace Bearer and leaves the assembly area promptly at 1:30 p.m. Each college will be led in the procession by the college marshal who will also assist in the seating procedure. Please remain in correct order.

The Seating

9. The correct seating order will be directed by the college marshals utilizing the name/number list. Seating is done two rows at a time. Fill up the entire row. The second person in line for the college must leave an empty seat for the banner carrier (the first person in line for the college).

10. Remain standing, the Chancellor will preside and ask for an invocation and the singing of the National Anthem. Following the National Anthem all persons should be seated.

The Charge

11. A “Charge to the Candidates” will be given.

The Conferring of Degrees

12. Each dean will present their candidates for the conferring of their degrees. Follow the instructions given by the Dean and the Chancellor.

13. Tassels will be moved from right to left at the direction of the Alumni Association President.

The Hooding and Diplomas

14. The dean of each college will call for the graduates in the college to rise and come forward to receive their diplomas and academic hoods.

15. Only the front row rises and proceeds to the stairs on the right-hand side of the stage. Follow the directions of the Ceremonies Committee members (in red tams). At the top of the stairs, stand in front of the "hooding box" facing the audience. After the hood is placed over your head, and on signal from the "hooder," step to the right and proceed to the center of the stage to receive your diploma from the Dean.

16. As you approach the Dean, receive your diploma with your left hand and shake hands with your right hand.

17.After receiving the diploma, continue across the stage and down the steps back to your row and seat.

18. As the last person in the row proceeds to the stage, the next row rises in unison in order that the first person in the next row may be ready to proceed to the stage. The previous row will sit, when the last person of that row has returned to their original seat. Do not leave the arena floor.

The Benediction and Recessional

19. Rise and men remove caps at the benediction. Replace cap and remain standing.

20. Recessional: Faculty and administration are led by the Mace Bearer and are followed by the graduates.

21. The recessional moves from the Forum floor back to the assembly/ gowning area. Please do not break the line and congest the recessional.

22. Caps, gowns, hoods and honor stoles must be turned in immediately following the ceremony in the gowning area.

23. Diplomas, in graduation jackets, will be distributed in the same area immediately following the recessional.

24. A photographer will be photographing each graduate as you are hooded and as you receive your diploma. Proofs of the photos will posted on the web site listed in the commencement program within a few days after graduation so that you may purchase copies, if you so desire.

Capstone Update (with life thrown in)

Topping out at nearly 7236 words, 53 pages, and more tables and figures than I want to reflect on,  the culmination of nearly two years of work, Social Networking and Mental Health Providers:  Practice Trends and Perspectives to Shape Interdisciplinary Guidelines  has been submitted for subjugation to the red pen. Hallelujah!

Now, who wants to publish it?

For that matter, who want to come along for some travel and networking? In the past two weeks I had the opportunity to hob-knob with writers from the ASJA and entertain guests for Derby Week. Monday I am taking off for Las Vegas to attend the Contemporary Forums #Psych12 conference. The psychopharmacology units will be especially useful as I prepare for my ANCC psych-nurse practitioner boards. Graduation in Memphis comes the following week, then in June I will be attending the Army Medical Experience in San Antonio as he APNAs representative. For some reason I agreed to do a tandem jump with the Golden Knights which is perhaps a sign I need my dosage checked.

In the midst of all this fun come the job hunt and quandary over how best to use my new found genius. One one hand, I can continue to do what I have been doing - adjunct teaching and running a private practice 3-4 days per week.  The freedom is phenomenal and I love the variety of practice with teaching. Option two is to take up teaching on a full time basis with practice taking on more of a part time role. Benefits include . . . well, benefits, loan repayment, and the collaborative opportunities for research and speaking which do not come as a solo-provider. Option three is to focus on intensive clinical experience working with the VA (application submitted) while maintaining my practice on a part time basis. The advantage here is to hone my clinical skills with a population I enjoy working with in an area that is finally getting the funding it requires, and possibly the opportunity to ingrate acupuncture with PTSD treatment.

Any decision is a good decision and I will be able to apply the leadership skill I have learned throughout he DNP program.   Note that every scenario includes an element of private practice. I realized long ago I do not thrive in a 9-to-5-one-job environment.

My routine is variety. Except for sleep.

Abstract Accepted!

Acupuncture News: Pushing the Point: Integrating Acupressure and Chi...: Integrative therapies are all the rage, particularly in psychiatric and mental health settings. It is an honor to be accepted for a pre-conference session at the American Psychiatric Nurses Association's 26th annual conference in Pittsburgh this November. Check out the abstract . . .

New Grad Self-Care

As I prepare for my own graduation, another year of BSN students are heading toward their own commencement. The first year a practice can be an enormous reality shock, so much so that we have attrition rates in the double-digets. Several of my students who graduated last year have already changed jobs, and a few from two years ago have already left nursing entirely. I have a vested interest, both as a peer and as a patient, to make sure each graduating class produces intelligent, competent, committed nurses who enjoy their work and represent the profession well. This is a brief presentation I created a few years ago to help navigate the role transition and promote life-long job satisfaction. Congratulations class of 2012!


Self Care for Nurses

An Important Announcement

To Graduating MSN, DNP & PhD Students:
Congratulations on your upcoming graduation from the University of Tennessee Health Science Center College of Nursing! In conjunction with the UTHSC Commencement the afternoon of May 25th, the College of Nursing will host a Dean’s Convocation the morning of commencement honoring our graduates and their families. A reception will follow the ceremony. Attendance is required at both the Dean’s Convocation and Commencement unless excused by the Dean.

The convocation will be held at Lindenwood Christian Church, 2400 Union Avenue at 9:00am on Friday, May 25, 2012. Students and faculty will be in full academic regalia during the convocation and, of course, in appropriate dress afterwards. Lindenwood Church is located on Union Avenue immediately east of the intersection of Union Avenue and East Parkway, approximately 3 miles from the College of Nursing. Plan to arrive at the church at 8:30am. We anticipate the ceremony & reception will be completed no later than 11:00am. Invitations are being printed for the convocation ceremony and will be forwarded to you shortly for your use in inviting family and friends.

Congratulations again and we look forward to celebrating with you and your family on May 25th.

! Sent with high priority (no kidding!)

Mental Health Providers & Social Networking

I have not been blogging much about the DNP experience this semester for a couple of reasons. First, life. Second, class is over with all of the focus and attention going toward our capstone projects. With that in mind, I am embedding the survey here for the next month to try and capture as many mental health providers (nurses, psychiatrists, psychologists, social workers, therapists) as possible. You can also access it at www.SurveyMonkey.com/s/OneDNP 

My goal is to gather at least 500 responses and publish the results later this year. Feel free to post any comments or questions. Thanks!

Create your free online surveys with SurveyMonkey, the world's leading questionnaire tool.

Interprofessional Education and Practice

The Association of American Medical Colleges (2012) put out this press release last week that falls in line with our discussion topic, especially for those interested in using your DNP role as an educator:  


Six Leading Health Education Associations Unite to Form a New Organization Focused on Interprofessional Education and Practice (click to read more)


Washington, D.C., February 15, 2012—Six national health professions associations have formally joined to create the Interprofessional Education Collaborative (IPEC), a new national organization that will focus on better integrating and coordinating the education of nurses, physicians, dentists, pharmacists, public health professionals, and other members of the patient health care team to provide more collaborative and patient-centered care. The founding members include the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the American Association of Colleges of Pharmacy, the American Dental Education Association, the Association of American Medical Colleges, and the Association of Schools of Public Health. 

The new IPEC organization will formalize the collaborative work that began three years ago and led to the release of a May 2011 report, “ Core Competencies for Interprofessional Collaborative Practice” (click to read the report).  This seminal document identified individual-level core competencies needed by all health professionals to provide integrated, high-quality care. Disseminated broadly to health professions schools, the report has sparked a wave of implementation efforts by educators looking to prepare clinicians to meet contemporary practice standards.

As a stand-alone entity, the new IPEC will provide leadership around national initiatives to advance interprofessional education (IPE) and share information on IPE best practices and collaborative practice innovations. A growing body of work demonstrates that shared learning experiences among health professions students across disciplines can improve health outcomes. Leading authorities including the World Health Organization, the Institute of Medicine, the Robert Wood Johnson Foundation, and the Josiah Macy Jr. Foundation, among others, have all identified IPE as an effective way to enhance the preparation of the health care workforce and improve care delivery. 

In May, IPEC will sponsor its first faculty development institute, “ Building Your Foundation for Interprofessional Education.”  The program will enable faculty from across the health professions to meet with peers in plenary and interactive learning sessions focused on building strong programs for team-based learning. Registration will open on February 22.    

The six IPEC organizations also are founding members of the Institute of Medicine’s Global Forum on Innovation in Health Professional Education, which is set to launch later this month.  Inspired in large part by the 2010 Lancet Commission report, “Health Professionals for a New Century,” this forum will convene stakeholders to illuminate issues in health professions education and support an ongoing, innovative mechanism to incubate and evaluate new ideas.

Interprofessional Education Collaborative (2011). Core competencies for interprofessional collaborative practice. Retrieved from http://www.aacn.nche.edu/education-resources/IPECReport.pdf 

Association of American Medical Colleges (2012). Six leading health education associations unite to form a new organization on interprofessional education and practice. Retrieved from https://www.aamc.org/newsroom/newsreleases/273754/120214.html

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.

Analysis

Origins
     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.
Content
     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).

Evaluation

Explication
     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.
Generation
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.
Credibility
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.