Transitions: A Central Concept in Nursing Karen 1. Schumacher, Afaf lbrahim Meleis Transition is a concept of interest to nurse researchers, clinicians, and theorists. This article builds on earlier theoretical work on transitions by providing evidence from the nursing literature. A review and synthesis of the nursing literature (1 986- 1992)supportsthe claim ofthe centrality oftransitions in nursing. Universal properties of transitions are process, direction, and change in fundamental life patterns. At the individual and family levels, changes occurring in identities, roles, relationships, abilities, and patterns of behavior constitute transitions.At the organizational level, transitional change is that occurring in structure, function, or dynamics. Conditions that may influence the quality of the transition experience and the consequences of transitions are meanings, expectations, level of knowledge and skill, environment, level of planning, and emotional and physical well-being. Indicators ofsuccessful transitionsare subjective well-being, role mastery, and the well-being of relationships. Three types of nursing therapeutics are discussed. A framework for further work is described. [Key words: transition; nursing theory; nursing model1

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eleis (1975; 1985; 1986; 1991) has proposed that transition is one of the concepts central to the discipline of nursing. Nurse-client encounters often occur during transitional periods of instability precipitated by developmental, situational, or health illness changes. Such changes may produce profound alterations in the lives of individuals and their significant others and have important implications for well-being and health. In an earlier paper, Chick and Meleis (1986), approached theory development for the concept of transition through concept analysis. They defined transition as a passage or movement from one state, condition, or place to another; they proposed an array of properties and dimensions of transition; and they examined its relationship to nursing therapeutics, environment, client, and health. In this article, we extend this work through a review of the nursing literature published since 1986. Articles were identified through a MEDLINE search of the nursing literature from 1986 to 1992 using the key word transition. The search was limited to English language publications; 3 10 citations were identified. We then limited our review to publications in which the word transition appeared in the title to capture articles in which transition was a major focus. The initial overview of this body of literature revealed that nurses have used a wide variety of publication modes to communicate their ideas about transitions. Transitions were addressed in an editorial (O’Brien, 1990), a letter to the editor (Schwartz, 1989), regular columns or features (Grady, 1992; Scherting, 1988), and accounts of personal experience (Rice, Volume26, Number2,Summer1994

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* 1988; Shea, Adamzczak, & Flanagan, 1987), as well as in fulllength articles on practice, theory, or research. Entire issues of two journals have been devoted to exploring transitions (Fought, 1992; Murphy, 1990b), as have publications of major professional organizations (Ryan, 1988; Watson, 1988). Two instruments have been developed (Flandemeyer, Kenner, Spaite, & Hostiuck, 1992; Imle & Atwood, 1988). Such variety produced a wealth of ideas and reflects the interest in transitions. Although theory development was the stated intent of only a small subset of these publications, the descriptions of transitions and the many ideas about transitions discussed in the literature can be used as a basis for theory development. This review exemplifies an approach to theory development in which the nursing literature is used as “data” to address three questions: What are the types of transitions addressed in the nursing literature? What conditions influence transitions? What constitutes a healthy transition?

Types of Transitions The literature reveals that nurses think of many diverse situations as transitions. Previously, three types of transitions relevant to nursing were identified: developmental, situational, and health-illness (Chick & Meleis, 1986). This review allowed Karen 1. Schumacher, RN, MS, Alpha Eta, is a doctoral candidate; Afaf lbrahim Meleis, PhD, FAAN, Alpha Eta, is a Professor; both at the University of California, San Francisco. Correspondence to Ms. Schumacher at 1444 Funston Avenue, San Francisco, CA 94122.

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us to add subcategories to each of these types and to identify an additional category of organizational transitions. We present these categories as a typology of transitions to demonstrate the scope of phenomena which can be conceptualized as transitions and to stimulate the reader to think of additional phenomena to further expand the typology. Developmental Transitions

Among developmental transitions, becoming a parent is the transition that has received the most attention. Nurse researchers and theorists have examined the transition to parenthood as it occurs during pregnancy (Imle, 1990; Imle & Atwood, 1988), during the postpartum period (Brouse, 1988; Pridham & Chang, 1992; Pridham, Lytton, Chang, & Rutledge, 1991; Tomlinson, 1987), and up to 18 months after an infant’s birth (Majewski, 1986; 1987). Although it is the mother’s transition to parenthood that is most often studied, transition to fatherhood has also been addressed (Battles, 1988). Other stages in the life cycle have been identified as transitions, but have received less attention. Lauer (1990) conceptualized adolescence as a developmental period encompassing a number of transitions one of which is the transition in body image. Midlife also has been conceptualized in terms of multiple transitions for women (Frank, 1991), one of which is menopause (Fishbein, 1992). Mercer, Nichols, and Doyle (1988) described the transitions experienced by women from childhood to old age, contrasting the transitions of mothers and nonmothers. Most of the work on developmental transitions has focused on the individual. However, several writers have addressed developmental transitions in relationships such as the motherdaughter dyad (Martell, 1990; Patsdaughter & Killien, 1990) and the childbearing family (Imle, 1990). Hollander and Haber (1992) described the developing awareness of a gay or lesbian identity as an ecological transition in that change occurs in the individual and in the social environment. Situational Transitions

Transitions in various educational and professional roles are situational transitions that have received a great deal of attention. Many writers have addressed transitions into and throughout educational programs (Klaich, 1990; Lengacher & Keller, 1992; Myton, Allen, & Baldwin, 1992; Pullen, 1988; Wuest, 1990). The transition to staff nurse at the completion of an educational program also has received a great deal of attention (Alex & MacFarlane, 1992; Andersen, 1991; Cassells, Redman, & Jackson, 1986; Hindman, 1986; Jairath, Costello, Wallace, & Rudy, 1991; Lathlean, 1987; Paterniti, 1987; Talarczyk & Milbrandt, 1988). Subsequent transitions in clinical practice roles occur throughout the career. Among these transitions are changes in practice setting (Ceslowitz & Loreti, 1991; Dunn, 1992; Kane, 1992; Shea et al., 1987), return to clinical practice (Brautigan, Bryson, & Doster, 1989), changes in function and scope of practice (Reed-McKay, 1989), and the role transitions required of nurses who simultaneously care for patients with strikingly different needs (Samarel, 1989). The transition from clinician to administrator has been 120

addressed by several writers (Gardner and Gander, 1992; Rice, 1988; Scherting, 1988; Starke & Rempel, 1990). And, in a series of columns Blouin and Brent (1992a; 1992b; 1992c; 1992d; 1992e; 19920 discussed the transitions experienced by nurses upon leaving executive positions. Hegyvary and de Tornyay (1991) described the transitions into and out of the role of dean. Other writers have conceptualized changes in family situations as transitions. For example, widowhood as a transition has been addressed by Poncar (1989) and by Adlersberg and Thorne (1990). The transition of an elderly family member from home to a nursing home has been explored by Johnson, Morton, and Knox (1992) and Young (1990). Finally, family caregiving has been conceptualized as a series of transitions (Brown & Powell-Cope, 1991). Other situations that have been conceptualized as transitions are immigration (Meleis, 1987), homelessness (Gonzales-Osler, 1989), near-death experiences (Dougherty, 1990), and moving out of abusive relationships (Henderson, 1989). Health-Illness Transitions

The impact of illness-related transitions on individuals and families has been explored in a number of illness contexts, including myocardial infarction (Christman, McConnell, Pfeiffer, Webster, Schmitt, & Ries, 1988), post-operative recovery (Wild, 1992), HIV infection (Thurber & DiGiamarino, 1992); spinal cord injury (Selder, 1989), advanced cancer, (Reimer, Davies, & Martens, 1991), and chronic illness (Catanzaro, 1990; Loveys, 1990). Bridges (1992) conceptualized weaning from mechanical ventilation as a transition in the process of recovery from critical illness. Similarly, De Bonde and Hamilton (1991) described the progression from tube feeding to oral nutrition as a transition in the process of rehabilitation. Many articles addressed transitions among levels of care within the health care system over the course of an illness. A prominent concern is the transition from hospital to outpatient care and to the home environment (Brooten et al., 1988; Chielens & Herrick, 1990; Christman et al., 1988; Cohen, Arnold, Brown, & Brooten, 1991; Howard-Glenn, 1992; Kenner & Lott, 1990; Ladden, 1990; Michels, 1988; Salitros, 1986; Wong, 1991). Other transitions within the health care system that have been addressed by nurses are the transition from hospital to rehabilitation center (Swarczinski & Graham, 1990), home follow-up care for persons traditionally seen in out-patient clinics (Thurber & DiGiamarino, 1992) and the transition from psychiatric hospital to community (Robinson & Pinkney, 1992; Staples & Schwartz, 1990). Models in which nurses provide transitional care services have been proposed and implemented to increase continuity of care across the health care system and to promote cost effective utilization of health services (Brooten et al., 1988; Cohen et al., 1991; Ritz & Walker, 1989; Thurber & DiGiamarino, 1992). Organizational Transitions

The transitions described thus far have been those occurring at the individual, dyadic, or family level. Organizations can IMAGE: Journal of Nursing Scholarship

Transitions: A Central Concept i n Nursing

also experience transitions that affect the lives of persons who work within them and their clients. Organizational transitions represent transitions in the environment. They may be precipitated by changes in the wider social, political, or economic environment or by intraorganizational changes in structure or dynamics. Changes of incumbents in leadership positions have been described as transitional periods in the life of organizations with far-reaching effects (Gilmore, 1990; Hegyvary & de Tornyay, 1991; Kerfoot, Serafin-Dickson, & Green, 1988; Losee & Cook, 1989; Tierney, Grant, Cherrstrom, & Morris, 1990), as have changes in the qualitative dimensions of leadership roles (Ehrat, 1990). The adoption of new policies, procedures, and practices also has been conceptualized as a transition. Exemplifying this kind of transition are the introduction of restraint-free care in a nursing home (Blakeslee, Goldman, Papougenis, & Torell, 199l), new staffing patterns (Rotkovitch & Smith, 1987), implementation of new models of nursing care (Main, Mishler, Ayers, Poppa, & Jones, 1989; Vezeau & Hallsten, 1987; Walker & DeVooght, 1989), and the introduction of new technology (Shields, 1991; Turley, 1992). Finally, structural reorganization of facilities and the introduction of new programs constitute organizational transitions (Condi, Oliver, & Williams, 1986; Harper, 1989; Swearingen, 1987; Walker & DeVooght, 1989). Transitions experienced by the nursing profession have interested several writers. According to Allen (1986) the history of nursing is a story of transition. Transitions have been described in educational preparation in nursing (Schwartz, 1989), in curricular content (Clifford, 1989), in modes of thinking (O’Brien, 1990), and in research methods (Clarke & Yaros, 1988). The transition of nursing from an occupation to a profession was the subject of an essay by van Maanen (1990). Communities in transition were addressed by one writer. Bushy (1990) examined recent transitions in rural communities, the stressors engendered by such transitions, and the consequences for the health of women. It should be noted that the types of transitions we present are not mutually exclusive. Transitions are complex processes and multiple transitions may occur simultaneously during a given period of time. For example, Catanzaro (1990) explored developmental transitions in midlife in people with progressive neurological disease, demonstrating the complex challenges that occur when developmental and healtldillness transitions overlap. Young (1990) also described the way in which situational, healtldillness, and developmental transitions may occur concurrently for elderly people. Furthermore, a major transition may encompass a number of discrete transitions. As conceptualized by Lauer (1990), adolescence comprises a number of discrete transitions, one of which is the transition in body image. And according to Wild (1992) the transition from pain to comfort postoperatively must be managed within the context of multiple physiologic transitions; understanding these can lead to improved patient outcomes. Finally, a major transition, such as entering graduate school, may have a “ripple effect,” precipitating concurrent transitions in familial relationships and social networks (Klaich, 1990). Volume26, Number2, Summer 1994

Universal Properties of Transitions Despite the diversity of transitions, some commonalities across categories are evident and support properties that were identified earlier (Chick & Meleis, 1986). These commonalities may be thought of as universal properties of transitions. One such universal property, manifested in definitions of transitions (Table 1) and supported by the literature, is that transitions are processes that occur over time. Further, the process involves development, flow, or movement from one state to another (Chick & Meleis, 1986). Many writers have advanced our understanding of the development and flow of transitions by dividing the process into stages or phases (Blakeslee et al., 1991; De Bonde & Hamilton, 1991; Fishbein, 1992; Gilmore, 1990; Hegyvary & de Tornyay, 1991; Reimer et al., 1991; Wong, 1991). Another universal property is found in the nature of change that occurs in transitions. Examples in individuals and families include changes in identities, roles, relationships, abilities, and patterns of behavior (Brown & Powell-Cope, 1991; Catanzaro, 1990; Imle, 1990; Klaich, 1990; Pridham et al., 1991). Examples at the organizational level include changes in structure, function, or dynamics (Condi et al., 1986; Tierney et al., 1990; Walker & DeVooght, 1989). These properties help to differentiate transitions from nontransitional change. For example, brief, self-limiting illness has not been characterized as a transition, whereas chronic illness has (Catanzaro, 1990; Loveys, 1990). Similarly, phenomena such as mood changes, that are dynamic but do not have a sense of movement or direction have not been conceptualized as transitions. Internal processes usually accompany the process of transition, while external processes tend to characterize change (Bridges, 1980; 1986).

Transition Conditions Wide variation occurs among individuals, families, or organizations in transition and nurses must have a framework for assessment that allows them to capture this variation if they are to understand the transition experience of individual clients. In the Chick and Meleis (1986) model, personal and environmental factors that affected the transition process were identified. The nursing literature since then has provided substance and specificity to our understanding of what constitutes important influencing factors. Transition conditions include meanings, expectations, level of knowledge and skill, the environment, level of planning, and emotional and physical well-being (Table 1). Across the four types of transitions, we found considerable consensus that these were important factors influencing transitions. Future research might identify additional factors and amplify our understanding of conditions which are conducive to a smooth transition and conditions which place the client at risk for a difficult transition. Meanings

Meaning refers to the subjective appraisal of an anticipated or experienced transition and the evaluation of its likely effect 121

Transitions: A Central Concept i n Nursing

Table 1 :DefinitionsofTransition inthe NursingLiterature. Bridges ( 1980; 1986):A process that involves three phases: an ending phase tdisengagenient, clisidentiiication, disenchantment), a neutral phase (disorientation, disintegration, discovery), and a new beginning phase (finding me~ningand future, experiencing control and challenge). Chick and Meleis (1986): A passage from one life phase, condition, or status to another ....transition refers to both the process and the outc-onie o i complex person-environment interactions. It may involve more than oiie person and is embedded in the context and the situation. Defining characteristics of transition include process, disconnectedness, perception, and patterns of response. Chiriboga 11979): Marker events with discrete entries and exits. Golan (1981): A period ot moving from one state of certainty to another, with an interval of uncertainty and change in between. Meleis (1986): The period in which J change is perceived by a person or others, as occurring in a person or in the environment. Commonalities that characterize a transition period: 1 ) disconnectedness from usual social network and social support systems, 2) temporary loss of familiar reference points of significant objects or whjects, 3 ) new ncvds that may arise or old ones not met iii a taniiliar way, and 4 1 old sets of expectations no longer congruent with changing situations. A transition denotes a change in health status, in role relations, in expectations, or in abilities. Meleis 11991): A transition denotes J change in health status, in role relations, in expectations, or in abilities. It denotes changes in needs of A human systems. Transition requires the person to incorporate new knowledge, to alter behavior, m c l therefore to change the definition of self in m i d l context, of a healthy or ill self, or of internal and external needs, which .life& the health status. Morris (19791: A process of change from one activity or form of activity to another. Murphy I 1 4 9 0 ~ ) Common : themes i n definitions of transition: disruption in routine, emotional upheaval, and adjustment required of individuals undergoing life changes. Parkes (1971): Processes of change that dre lasting in their effects, force one to give up how one views the world and his or her place in it, and necessitate the tlevelopiiient oi new assumptions and skills to enable the individual to cope with J new altered life space (Pardphrased by hhrphy, 19905). Schlossberg (1981): An event or nonevent that results in changes in relationships, routines, ‘issutnpiions, and/or roles within the settings oi seli, work, family, health, and economics. Tyhurst (1957): A passage or change from one place or state or act or set of circumstances to another. Features common to all transitions: 1 ) J phase of lurnioil, 2 ) disturbances in bodily function, mood, and cognition, 3 ) symptoms of psychologic distress, and 41 altered Iinie perspec-tive. Websfer (1981): The passage trom one state, condition, or place to Jnother.

on one’s life. Meanings attached to transitions may be positive, neutral, or negative. The transition may be desired or not and it may or may not be the result of personal choice. Awareness of the meaning of a transition for clients is essential for understanding their experience of it as well as its health consequences. The inclusion of meanings in a theory of transition draws attention to the importance of understanding a transition from the perspective of those experiencing it. The importance of the perspective of the person undergoing transition has been emphasized by several writers (Adlersberg & Thorne, 1990; 122

Kenner & Lott, 1990; Pridham & Chang, 1992). For example, Adlersberg and Thorne (1990) studied widowhood and found that rather than being a uniformly negative experience of loss, many experienced a sense of relief and new opportunities for personal growth. Meanings must also be understood from the perspective of the cultural context of the transition. For example, the meaning of the transition of menopause varies across cultures (Fishbein, 1992). Meaning also has an existential connotation such as searching for meaning during the family transition of losing a member through death as described by Reimer et al. (1991). Brown and Powell-Cope (1991) found that time was needed to make meaning of events and experiences when caring for loved ones with AIDS. Expectations

Expectations are other subjective phenomena that collectively influence the transition experience (Imle, 1990; Selder, 1989). People undergoing transition may or may not know what to expect and their expectations may or may not be realistic (Kane, 1992; Kenner & Lott, 1990; Rice, 1988). When one knows what to expect, the stress associated with transition may be somewhat alleviated (Hollander & Haber, 1992). Expectations are influenced by previous experience (Reimer et al., 1991). However, the frame of reference created through previous experience may or may not be applicable to a new transition. When it is not applicable, expectations for the new transition may be unclear or unrealistic (Kenner & Lott, 1990). As a transition proceeds, expectations may prove to be incongruent with unfolding reality. Shea and colleagues (1987) described surprise when reality differed from expectations. Incongruity also may occur between expectations of self and those of others such as one’s colleagues (Rice, 1988). High performance expectations may be unrealistic during a transition (Kane, 1992; Rice, 1988). level of Knowledge/Skill

The level of knowledge and skill relevant to a transition is another condition which influences health outcomes and may be insufficient to meet the demands of the new situation. Several researchers and clinicians have documented the need for new knowledge and skill during a transition. Parents of premature infants (Kenner & Lott, 1990; Ladden, 1990), chronically ill children (Howard-Glenn, 1992; Wong, 1991), and adult patients and their caregivers (Michels, 1988) need information during the transition from hospital to home or from inpatient to outpatient care (Chielens & Herrick, 1990). Families need information when a member is moving to a nursing home (Johnson et al., 1992) or dying (Reimer et al., 1991). The transition to new professional roles also necessitates new knowledge and skill (Dunn 1992; Shea et al., 1987; Starke & Rempel, 1990). In the literature reviewed, uncertainty was interwoven with the need for new knowledge and skill development as a significant aspect of transition. Brown and Powell-Cope (1991) found uncertainty to be such a strong theme in interviews with caregivers of persons with AIDS that they called this experience IMAGE: lournal of Nursing Scholarship

Transitions. A Central Concept in Nursing

“transition through uncertainty.” Uncertainty is a similarly central focus of Selder’s (1989) Life Transition Theory. Other transitions characterized by uncertainty are the transition from hospital to home (Christman et al., 1988; Michels, 1988), from home to nursing home (Johnson et a]., 1992), and leadership transitions (Gilmore, 1990).

used Bronfenbrenner’s ecological model to conceptualize multiple levels of environment and showed how each level influences individual transitions. In the specific transition they addressed, the coming out process experienced by gay and lesbian persons, they noted that there is an ecological as well as identity transition.

Environment

Level of Planning

A prominent theme in many articles was the importance of resources within the environment during a transition (Battles, 1988; Chielens & Herrick, 1990; Ladden, 1990; Loveys, 1990; Meleis, 1987). In a grounded theory study of the transition to parenthood, Imle (1990) conceptualized environment as external facilitative resources. External facilitative resources were defined as the cyclic process of perceiving, building, and evaluating the helpfblness and supportiveness of support outside the person that may help during transition. Social support from family members, partners, and friends has received a great deal of attention (Battles, 1988; Frank, 1991; Henderson, 1989; Hollander & Haber, 1992; Kenner & Lott, 1990; Majewski, 1987). Support from nurses (Pridham et al., 1991; Wong, 1991) and therapeutic groups (Robinson & Pinkney, 1992; Staples & Schwartz, 1990) also was identified as important. When support was lacking or communication with professional staff was less than optimal, clients in transition experienced feelings of powerlessness, confusion, frustration, and conflict (Johnson et al., 1992; Kenner & Lott, 1990). Personal transitions that occur within the context of formal organizations also are shaped by the environment. The presence of a supportive preceptor, mentor, or role model was identified as an important resource during professional transitions. Preceptors facilitate clinical role transitions (Brautigan et al., 1989; Ceslowitz & Loreti, 1991; Dunn, 1992; Hindman, 1986; Shea et al., 1987) and an experienced teachedmentor can smooth a transition by serving as a guide, role model, and sounding board (Grady, 1992; Rice, 1988; Wuest, 1990). Furthermore, in the relationship between person and organization it is important to take into account many legal and ethical considerations (Blouin & Brent 1992a, 1992b, 1992c, 1992d, 1992e, 1992f). When an organization is in transition, interaction among persons and subsystems within the organization facilitates or impedes the process. Collaboration, team work, effective communication, and support from key persons and groups all contribute to an environment in which the transition can be managed effectively (Condi et al., 1986; Harper, 1989; Losee & Cook, 1989; Main et al., 1989; Vezeau & Hallsten, 1987). The wider sociocultural environment is another factor that shapes the transition experience. Mercer, Nichols, and Doyle (1988) emphasized the importance of the sociocultural context in understanding transitions. Awareness of the sociocultural context of a transition enables nurses to develop therapeutics at the group, community, and societal level (Lauer, 1990). For example, lack of institutional support and flexibility, such as lack of paternity leave and inflexible work hours, impedes the transition to fatherhood (Battles, 1988). Clearly, nurses are concerned with the effect of environment on transitions at many levels. Hollander and Haber (1992)

The level of planning that occurs before and during a transition is another condition that influences the success of the transition. Extensive planning helps to create a smooth and healthy transition (Kerfoot et al., 1988). Even when precipitated by an unplanned or crisis event, such as a catastrophic injury, planning can occur during the ensuing transition process so that optimal preparation for each phase is achieved. Effective planning requires comprehensive identification of the problems, issues, and needs which may arise during a transition (Howard-Glenn, 1992; Ladden, 1990; Vezeau & Hallsten, 1987; Wong, 1991). Key people must be identified including those making the transition and those in a position to provide support. Communication among all these people is a key element in planning (Blakeslee et al., 1991; Condi et al., 1986; Kerfoot et al., 1988; Salitros, 1986; Vezeau & Hallsten, 1987). Planning takes place over time in concert with ongoing assessment and evaluation (Howard-Glenn, 1992; Wong, 1991). Developing a time line that shows stages of the transition facilitates an organized approach to planning (Vezeau & Hallsten, 1987).

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Emotional and Physical Well-Being

Transitions are accompanied by a wide range of emotions, many of which attest to the difficulties encountered during transition. Several writers have noted that stress and emotional distress occur during transition (Christman et al., 1988; Fishbein, 1992; Kerfoot et al., 1988; Ladden 1990; Meleis, 1987; Shea et al, 1987)-specifically, anxiety, insecurity, frustration, depression, apprehension, ambivalence, and loneliness (Chielens & Herrick, 1990; Kerfoot et al., 1988; Rice, 1988; Salitros, 1986; Shea et al., 1987; Tierney et al., 1990). Role conflict and low self-esteem also may be present (Condi et al., 1986; Majewski, 1986; Rice, 1988). Some of the most vivid descriptions of the distress that may be experienced during transition were found in personal accounts of transitions (Rice, 1988; Shea et al., 1987). Fear of failure and unwarranted selfcriticism were described as well as feeling overwhelmed, defeated, and isolated which can result in an inability to concentrate, unwillingness to take risks, and avoidance of the unknown. Physical well-being is also important during a transition. When physical discomfort accompanies transition, it may interfere with the assimilation of new information (Kenner & Lott, 1990). Bodily unpredictability may be distressing, whereas energy, bodily predictability, and normal operation facilitate transition (Imle, 1990). Profound bodily changes are inherent in some developmental transitions (Fishbein, 1992; Lauer, 1990) and the level of comfort with these changes in the body influences well-being during the transition. 123

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Indicators of Healthy Transitions We found that more emphasis has been placed on the process of transition than on the identification of factors which indicate a positive transition outcome. It is critical that nurses identify healthy transition outcomes in order to facilitate research on transitions and the evaluation of clinical interventions. We have identified three indicators of healthy transition that appear relevant across all types of transition: a subjective sense of well-being, mastery of new behaviors, and the well-being of interpersonal relationships (Table 1). Although we have used the term outcome in describing these indicators of successful transition, we do so with the caveat that these “outcomes” may occur at any point in the transition process. For example, mastery may occur early in the transition for some and later for others. Thus, the assessment of these indicators of healthy transition is appropriate periodically throughout the transition and not simply at the end of the transition period. Subjective Well-Being When a successful transition is occurring feelings of distress give way to a sense of well-being. Subjective well-being during transition includes effective coping (Hollander & Haber, 1992; Kane, 1992) and managing one’s emotions (Johnson et al., 1992) as well as a sense of dignity (Robinson & Pinkney, 1992), personal integrity (Myton et al., 1992), and quality of life (Robinson & Pinkney, 1992). Job, marital, or other role satisfactions are other subjective responses indicative of a successful transition (Cassells et al., 1986; Main et al., 1989; Majewski, 1986; Rice, 1988; Rotkovitch & Smith, 1987). Growth, liberation, self-esteem, and empowerment also may occur during a transition (Fishbein, 1992; Kane, 1992). Role Mastery Another indicator of healthy transition is role mastery, which denotes achievement of skilled role performance and comfort with the behavior required in the new situation. Mastery has several components, including competence (Alex & MacFarlane, 1992; Chielens & Herrick, 1990; Dunn, 1992; Meleis, 1987; Salitros, 1986), which entails knowledge or cognitive skill, decision-making, and psychomotor skills, and self-confidence (Alex & MacFarlane, 1992; Brautigan et al., 1989; Flandermeyer et al., 1992; Grady, 1992; Lathlean, 1987; Robinson & Pinkney, 1992; Salitros, 1986). Transitions of particular interest to nurses may require competence with complex skills in self care (Chielens & Herrick, 1990; Thurber & DiGiamarino, 1992) and in the care of others (Imle, 1990; Pridham et al., 1991). Mastery is indicative of successful transition at the organizational as well as individual level. In this context, the components are high quality care and efficient work performance (Condi et al., 1986; Main et al., 1989; Rotkovitch & Smith; 1987; Turley, 1992). Well-Being of Relationships Well-being in one’s relationships indicates that a successful transition is occurring. Transitions that ostensibly involve one or two family members must be evaluated in terms of the whole 124

family (Wong, 1991). Disagreements or family disruption may occur during a transition (Johnson et al., 1992; Tomlinson, 1987), but when the process moves toward a successful conclusion, the well-being of family relationships is restored or promoted. Relationship well-being has been conceptualized in terms of family adaptation (Patsdaughter & Killien, 1990), family integration (Salitros, 1986), enhanced appreciation and closeness (Reimer et al., 1991), and meaningful interaction (Battles, 1988). Integration with broader social networks and the community are also indicators of healthy transition (Meleis, 1987; Robinson & Pinkney, 1992; Staples & Schwartz, 1990; Swearingen, 1987) and are crucial in preventing social isolation as a result of transition. Intervention during a transition should be aimed at mitigating disruption in relationships and promoting the development of new relationships (Hollander and Haber, 1992). At the organizational level, undesirable transition outcomes include lack of cohesiveness, increased absenteeism and turnover, rumors, suspicion, an increase in fighting, a decrease in cooperation, resignations, and failure to recruit and retain new people (Kerfoot et al., 1988). On the other hand, cooperation among staff, effective communication, team work, and trust reflect a healthy transition (Condi et al., 1986; Losee & Cook, 1989; Scherting, 1988).

Nursing Therapeutics We have identified three nursing measures that are widely applicable to therapeutic intervention during transitions. The first is assessment of readiness, which is a multidisciplinary endeavor and requires a comprehensive understanding of the client (Battles, 1988; Bridges, 1992; Brooten et al., 1988; Wong, 1991). In some instances, a trial transition may be possible and provides a means for assessing readiness (Wong, 1991). We suggest that assessment of readiness should include each of the conditions identified above to create individual profiles of client readiness and enable clinicians and researchers to identify various patterns of the transition experience. Preparation for transition is another nursing therapeutic that has been widely discussed in the literature. Education is the primary modality for creating optimal conditions in preparation for transition. Approaches to education have been described by many (Brautigan et al., 1989; Condi et al., 1986; Howard-Glenn, 1992; Kane, 1992; Vezeau & Hallsten, 1987; Wong, 1991). Adequate preparation requires sufficient time for the gradual assumption of new responsibilities and implementation of new skills (Ladden, 1990; Patemiti, 1987). Several nurses have described environments that have been specially created for preparing clients or colleagues for transition. Included are Transitional Infant Care (Salitros, 1986), the Transitional Treatment Program (Swearingen, 1987), the Transitional Orientation Nursing Unit (Patemiti, 1987), Project Adventure (Losee & Cook, 1989), and a transition house for abused women (Henderson, 1989). Many other formal programs designed to facilitate transition include orientation programs for new nurses (Lathlean, 1987; Talarczyk & Milbrandt, 1988), inservice programs, seminars, and preceptorships for nurses entering new professional roles (Andersen, 1991; Dunn, 1992; IMAGE: Journal of Nursing Scholarship

- Transitions: A Central Concept in Nursing

Jairath et al., 1991; Reed-McKay, 1989; Rotkovitch & Smith, 1987), transition courses (Pullen, 1988), and support groups (Kane, 1992). Educational programs to provide skill development and rehearsal are needed during organizational transition to prepare staff (Blakeslee et al., 1991; Condi et al., 1986). The third nursing therapeutic is role supplementation which was initially introduced theoretically and empirically by Meleis (1975) and used for first time parents (Meleis & Swendsen, 1978), and patients recovering from myocardial infarction (Dracup, Meleis, Baker, & Edlefsen, 1984). More recently it has been used with family caregivers (Brackley, 1992) and battered children (Gaffney, 1992). A variation on role supplementation is the Transition Model used by Brooten and colleagues to decrease cost and enhance quality of care for people being discharged from acute care settings (Brooten et al., 1988).

Discussion and Conclusions

UNIVERSAL PROPERTIES Process Direction Change in: identity, roles, relationships, abilities, patterns of behavior, structw, function, dynamics

\ Meanings Expectations kvel of KnowledgdSkill Environment kvel of Planning Emotional & Physical Well-being

TYPES Developmental Situational Health/lllness Organizational

J