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C H A P T E R 1 3

Theory of Transit ions

Eun-Ok Im and Yaelim Lee

INTRODUCTION

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

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

PURPOSE OF THE THEORY AND HOW IT WAS DEVELOPED

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

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

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

From a Borrowed View

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

From a Research Program and Collaborative Works

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

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

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From Mentoring

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

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

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

CONCEPTS OF THE THEORY

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

Types and Patterns of Transitions

Types of TransiTions

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

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

paTTerns of TransiTions

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

Properties of Transition Experience

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

awareness

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

engagemenT

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

Changes and differenCes

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

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

Time span

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

CriTiCal poinTs and evenTs

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

Transition Conditions

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

personal CondiTions

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

CommuniTy and soCieTal CondiTions

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

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Patterns of Response—Process and Outcome Indicators

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

Nursing Therapeutics

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

RELATIONSHIPS AMONG THE CONCEPTS: THE MODEL

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

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

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

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

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

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

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

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

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

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

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

Nature of transitions Transition conditions:

Facilitators and inhibitors Patterns of response

Personal Meanings Cultural beliefs and attitudes Socioeconomic status Preparation and knowledge

Types Developmental Situational Health/Illness Organizational

Patterns Single Multiple Sequential Simultaneous Related Unrelated

Properties Awareness Engagement Change and

difference Transition time

span Critical points

and events

Community

Nursing therapeutics

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

coping

Outcome indicators Mastery Fluid integrative identities

Society

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

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■ Patterns of transition include whether the client is experiencing a single transition or multiple transitions, whether multiple transitions are sequential or simultaneous, the extent of overlap among transitions, and the nature of the relationship between the different events that are triggering transitions for a client.

■ Properties of transition experience are interrelated parts of a complex process. ■ The level of awareness influences the level of engagement, in which engagement

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

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

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

Derivatives of Transitions Theory

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

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

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

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

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

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

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

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

Uniqueness of STOP. Compared with the middle range transitions theory, STOP has unique subconcepts (under the major concepts) that are frequently ethnic-specific. For ex- ample, although one’s cancer experience could be a health/illness transition that all ethnic groups go through in a common way, most Caucasian cancer patients tend to perceive the health/illness transition as a highly individualistic transition. In other words, depending on individual situations, they perceive health/illness transitions differently. Some experience horrible pain during the transition, while others rarely notice pain. Similarly, under the con- cept of patterns of response, the STOP has several ethnic-specific subconcepts such as control and transcendence. In the DSCP study, many patients thought they did not have control of their pain and/or disease and needed to bear the experience. On the contrary, others tried to control their pain and/or disease by selecting a specific healthcare provider whom they wanted to work with. In the DSCP study, the participants tried to transcend their cancer and cancer pain experience by “living life to the fullest” or by “not sweating the small things” (Im, 2006, p. 242). Because of these ethnic-specific subconcepts, STOP can be directly applied in nursing research and practice for Caucasian cancer patients’ pain experience.

The siTuaTion-speCifiC Theory of pain experienCe for asian ameriCan CanCer paTienTs

The SPEAC (Im, 2008) was also derived from transitions theory. An integrative approach was used to develop the SPEAC. The theoretical development started from the following multiple assumptions: There is diversity and complexity in cancer pain experience, theory development is cyclic and evolutionary, the pain experience of Asian American cancer pa- tients occurs in specific sociopolitical contexts, and a feminist nursing perspective is different

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from other perspectives. The SPEAC was developed using the following multiple sources: transitions theory, an integrative literature review, and research findings from a research study focused on cancer pain.

Deduction From Transitions Theory. Transitions theory was used for the development of the SPEAC primarily because Asian American cancer patients’ pain experience can be easily linked to the health/illness transition. Also, the major concepts of transitions theory are appropriate for a theory about the pain experience of Asian American cancer patients. Transitions theory has a major concept of properties of transitions that includes awareness, engagement, change and difference, time span, and critical points and events (Meleis et al., 2000). All these properties can be easily linked to Asian American cancer patients’ pain experience (Im, 2008). For example, Asian American cancer patients have an awareness of their health/illness transition; are engaged in the diagnosis and treatment process during the transition; experience changes in their physical, psychologic, and social selves due to the health/illness transition; and have specific critical points in their transition process (e.g., diagnosis as a start point of the transition, death or ultimate survival as an ending point of the transition; Im, 2008).

Induction Through a Literature Review and a Research Study. A systematic integrated literature review was conducted to provide the basis for theorizing. First, the literature was searched through PubMed from 1998 to 2008 with the keywords of “Asian American,” “can- cer pain,” and “experience”; “Asian American,” “cancer,” and “pain”; and “Asian American” and “cancer.” There were 24 retrieved articles and 15 additional articles from the reference lists of the retrieved articles. All the articles were sorted by the major concepts that were the focus of the SPEAC, and major findings were analyzed and incorporated into the theory development process.

The findings of the DSCP study were also used as the basis for the theorizing process of the SPEAC. As mentioned earlier, the overall goal of the DSCP study was to explore differ- ences in cancer pain experience by gender and ethnicity. The study was conducted among 480 cancer patients from four major ethnic groups in the United States using multiple mea- surement scales and nine online forum topics. Then data were analyzed using descriptive and inferential statistics and a thematic analysis. Only the findings among Asian American cancer patients were the focus of the SPEAC.

The SPEAC includes five major concepts (Im, 2008): (a) the nature of transition, (b) transi- tion conditions, (c) patterns of response, (d) Asian American cancer patients’ pain experience, and (e) nursing therapeutics. These major concepts are identical to those of the transitions theory except for the concept of Asian American cancer patients’ pain experience. All major concepts were found to influence Asian American cancer patients’ pain experience in the lit- erature review or in the DSCP study findings. The nature of transitions (terminal or chronic) can influence Asian American cancer patients’ pain experience. Transition conditions such as background characteristics can also influence Asian American cancer patients’ pain ex- perience; for example, cancer patients’ gender can influence the patients’ cultural attitudes toward pain, which subsequently influence pain experience in their unique culture.

Uniqueness of the SPEAC. The unique aspects of the SPEAC compared to the transitions theory are the subconcepts (under the major concepts) that are ethnic-specific. For example, although cancer experience is a universal health/illness transition, most Asian American cancer patients tend to experience the health/illness transition with a situational transition (immigration transition), which is a unique aspect of the SPEAC. Similarly, under the ma- jor concept of transition conditions, the SPEAC includes several ethnic-specific subconcepts such as being Asian American, country of birth, and subethnicity. Finally, the major concept of pattern of response includes ethnic-specific subconcepts such as tolerance, natural, nor- mal, and mind control. In the DSCP study, Asian American cancer patients tended to tolerate pain instead of treating it aggressively.

They also tended to consider their pain experience natural, and they tried to normalize or minimize their conditions to overcome cultural stigma attached to cancer. Many of them also

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tried to manage their pain through mind control by having a strong will, hope, and positive thinking. These ethnic-specific subconcepts give the SPEAC the power to uniquely explain Asian American cancer patients’ pain experience, and the SPEAC can be directly applied to nursing research or practice related to Asian Americans’ cancer pain experience.

The siTuaTion-speCifiC Theory of asian immigranT women’s menopausal sympTom experienCe in The uniTed sTaTes

The AIMS (Im, 2010; Im, Lee, & Chee, 2010; Im et al., 2011) was also derived from transitions theory. The AIMS was developed using an integrative approach like STOP and SPEAC. The theorizing process began with multiple assumptions of theorizing (Im, 2010, p. 145):

■ There are diversities and complexities in Asian immigrant women’s menopausal symptom experience.

■ The theory development process is cyclical and evolutionary and occurs in specific sociopolitical contexts.

■ The inadequate management of menopausal symptoms reported by Asian immigrant women stems from biology and women’s continuous interactions with their environments.

■ The menopausal symptom experience is influenced by ethnicity and thus significantly interacts with gender, race, and class to structure relationships among individuals.

Deduction From the Transitions Theory. The reason for developing the AIMS begin- ning with transitions theory was that Asian immigrant women’s menopausal symptom experience could be linked to the health/illness and developmental transitions that they experience in their menopausal transition and to the situation transition due to their immi- gration from one country to another. The major concepts of transitions theory are relevant to a theory about Asian immigrant women’s menopausal symptom experience. For example, transitions theory has a subconcept of critical points and events under a major concept of properties of transitions (Meleis et al., 2000). This subconcept can be easily linked to the nature of menopausal symptom experience that Asian immigrant women go through. For instance, women’s menopausal symptom experience has a specific beginning point with physical and psychologic changes and a specific ending point even though it can be vague for some women (Im, 2010).

Induction Through a Literature Review and a Research Study. A systematic integrated literature review was also conducted to provide the basis for theorizing. A literature search through PubMed, PsycINFO, and CINAHL for the past 5 years was conducted using var- ious keywords including “midlife,” “women,” “menopause,” “symptom,” “Asian,” “im- migrant,” “Chinese,” “Korean,” “Japanese,” “predictors,” and/or “factors.” The literature review included a total of 75 articles written in English and published in nursing and clin- ical journals. The articles were sorted by the major foci of AIMS to explain the menopausal symptom experience of Asian immigrant women in the United States. Finally, the major findings of the retrieved articles were analyzed and incorporated into the AIMS theory.

A study on menopausal symptom experience of four major ethnic groups of midlife women in the United States (MOMS) provided another element of foundation for the AIMS (Im, Lee, Chee, Brown, & Dormire, 2010; Im, Lee, Chee, Dormire, & Brown, 2010; Im et al., 2011). The overall goal of the study was to explore ethnic differences in menopausal symptom experience for White, African American, Asian, and Hispanic women. The study included a quantitative internet survey and four qualitative ethnic-specific online forums. For the inter- net survey, the questions on background, self-reported ethnic identity, and health and meno- pausal status and the midlife women’s symptom index were used. For the online forums,

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seven online forum topics related to the menopausal symptom experience were used. The data analysis process included descriptive and inferential statistics including ANOVA and hierarchical multiple regression analyses for the internet survey data and thematic analysis for the qualitative online forum data.

The AIMS includes three major concepts illustrated in Figure 13.2 (Im, 2010): (a) transition conditions, (b) patterns of response, and (c) nursing therapeutics. These major concepts came from the middle range theory of transitions; however, the subconcepts under the major con- cepts are different for AIMS, the situation-specific theory. Transition conditions include four subconcepts: (a) demographic factors, (b) genetic factors, (c) health and menopausal status, and (d) lifestyle factors.

The subconcepts under the pattern of response for AIMS include the type, number, and severity of symptoms, as well as the ethnic-specific response to menopausal transition. Pro- cess and outcome indicators are not separated because they tend to be mingled in the symp- tom experience. For instance, the types of symptoms (e.g., hot flash) experienced during the menopausal transition could indicate both the process of menopausal transition and the outcome of the menopausal transition. The subconcept of ethnic-specific response includes four major themes from the MOMS study: restricted, being strong, appreciating, and be- ing silent. In the MOMS study, women perceived certain restrictions in their menopausal

Transition conditions

Patterns of Response: Menopausal Symptom Experience of Asian Immigrant Women in the United States

Nursing therapeutics: Culturally competent menopausal

symptom management

Health and menopausal status

Demographic factors

Lifestyle factors

Genetic factors

• Type of symptoms • Number of symptoms • Severity of symptoms • Ethnic-specific responses (restricted, being strong, appreciating, and being silent)

• No management • Hormone replacement therapy • Complementary and alternative medicine • Counseling and self-help group

FIGURE 13.2: The Situation-Specific Theory of Asian Immigrant Women’s Menopausal Symptom Experience in the United States. Source: Reprinted with permission from Im, E. O. (2010). A situation specific theory of Asian immi- grant women’s menopausal symptom experience in the U.S. Advances in Nursing Science, 33(2), 143–157. https://doi.org/10.1097/ans.0b013e3181dbc5fa.

13 THEORY OF TRANSITIONS ■ 239

symptom experience; for example, women perceived some restrictions given that their cul- tural heritage limits behaviors, emotions, and actions related to menopausal symptom ex- perience. Women thought that the difficulties in their menopausal transition were nothing compared with what they had gone through with their immigration transition and that they became strong and faced their menopausal transition without problems. Women also con- sidered menopause a relief and benefit because they would not need to worry about poten- tial pregnancies or purchase feminine products for their menstrual periods. Finally, women considered silence the best strategy to cope with their menopausal symptoms. The concept of nursing therapeutics includes the following subconcepts: no management, hormone re- placement therapy, complementary and alternative therapies, and counseling and self-help groups (Im, 2010). Finally, transition conditions influence menopausal symptom experience and nursing therapeutics to intervene and influence (enhance/worsen) the menopausal symptom experience of Asian immigrant women in the United States.

Uniqueness of the AIMS. The AIMS is unique from the middle range theory of transi- tions because the specific subconcepts can be applied only to Asian immigrant women in menopausal transition. For example, menopausal transition could be a universal health/ill- ness transition, but Asian immigrant women’s menopausal transition is different from other ethnic groups because of their unique cultural attitudes and values related to women’s health and menopausal symptoms. Thus, AIMS includes several ethnic-specific subconcepts such as responses like restricted, being strong, appreciating, and being silent. As in the SPEAC, these ethnic-specific subconcepts give AIMS the power to explain the menopausal symp- tom experience of Asian immigrant women in the United States. Also, the ethnic specificity makes the AIMS directly applicable to nursing research and practice with Asian immigrant women in the United States.

USE OF THE THEORY IN NURSING RESEARCH

Transitions theory has been nationally and internationally used in research studies across a broad spectrum of life transitions (Davies, 2005; Weiss et al., 2007). In addition, the theory was often used as the parent theory for situation-specific theories (Baird, 2012; Clingerman, 2007; Davidson et al., 2007; Geary & Schumacher, 2012; Im, 2006, 2010; Im & Meleis, 1999b; Schumacher et al., 1999). The theory has been translated for use in Sweden, Taiwan, and many other countries (Im, 2009). After testing transitions theory in her investigation of tran- sition experience of relatives related to older people’s move to nursing homes, Davies (2005) concluded that the nature of transitions, transition conditions, and patterns of response could be helpful in explaining diverse factors that influence each person’s transition and their unique experience. Weiss et al. (2007) concluded that their study findings supported transitions theory as a useful theoretical basis for conceptualizing and investigating pre- dictors and outcomes of adult medical–surgical patients’ perceptions of their readiness for hospital discharge. In addition, Weiss and Lokken (2009) concluded that transitions theory was a useful basis to determine predictors and outcomes of postpartum mothers’ perceived readiness for hospital discharge. In 2015, there was an international conference dedicated to transitions theory in Japan. Based on the thoughts and discussion from the conference, a special issue dedicated to transitions theory was published in the Japanese Journal of Nursing Research in March–April, 2016.

In a review on situation-specific theories (Im, 2014b), transitions theory was the most fre- quently used parent theory of situation-specific theories. In 2007, Meleis (2007) envisioned that many situation-specific theories could be developed based on transitions theory, which actually happened during the past decade. During the past decade, nine situation-specific theories were developed based on the middle range transitions theory, theorists’ own re- search studies, and/or integrated literature reviews on existing research studies (Im, 2014a). They include the situation-specific theories of migration transition for migrant farmworker

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women (Clingerman, 2007), transition to adult day health services (Bull & McShane, 2008), guiding interventions for people with heart failure (Davidson et al., 2007), care transitions (Geary & Schumacher, 2012), well-being in refugee women experiencing cultural transition (Baird, 2012), pain experience for Asian American cancer patients (Im, 2008), Caucasian can- cer patients’ pain experience (Im, 2006), and Asian immigrant women’s menopausal symp- tom experience (Im, 2010; Im et al., 2011). This capability to readily generate situation-specific theories from the middle range theory of transitions is a big contrast to other theories; it may reflect higher usability and applicability of the middle range theory of transitions for nursing practice and research.

Transitions theory has also been evaluated through a number of studies about immigra- tion transitions (Im, 2010; Im & Meleis, 1999a, 1999b; Im et al., 1999), health/illness transitions with chronic diseases and/or conditions (Cerqueira et al., 2016; da Silva et al., 2017; Madsen et al., 2019; Shaul, 1997), developmental transitions including maternal transitions (Barimani et al., 2017; Korukcu et al., 2017; Ozkaya et al. 2020), parenthood transition (Barimani et al., 2017), aging transition (Schumacher et al., 1999), and care transitions (Gaskin, 2018; Weiss et al., 2007). Furthermore, transitions theory was used to examine the motherhood transition of specific populations such as women who were blind (de Oliveira Silva et al., 2020), who used a wheelchair (Santos et al., 2019), or who cared for infants with cleft palates and lips (da Silva et al., 2017) or with special care needs (Korukcu et al., 2017). In addition, the theory was utilized in research to explain the family role transition of caregivers of persons with dementia (Lethin et al., 2016) or of older adult spouses (Lima et al., 2017).

Transitions theory has been further applied to research on transition experiences related to changes in care settings. Such research has explored, for instance, facilitators and inhib- itors in the relocation of older adults to a long-term care facility (Fitzpatrick & Tzouvara, 2019), experiences in transitioning from home care to a nursing home (Müller et al., 2017), or transitions from a hospital to a homecare setting after colorectal surgery (Ruel et al., 2020). The theory has been used in research on health/illness transitions due to changes in health perceptions, the diagnosis process, and the treatment process. For instance, it guided re- search to explore changes in health perceptions among Syrian refugee women (Korkmaz & Avci, 2019), transition experiences in developing cancer (Madsen et al., 2019), and factors related to the transition from legal to illicit drug usages (Ozuna Esprinosa et al., 2019). Also, the theory was used in research that examined transition experiences associated with the diagnosis of diseases, including head and neck cancer (Koinberg et al., 2018), kidney disease (Oliveira et al., 2020), and polycystic ovary syndrome (Young et al., 2019). In addition, tran- sitions theory was frequently adopted in research to investigate the transition experiences of transplant recipients of a pediatric solid organ (Lerret et al., 2014), a lung (Lundmark et al., 2016), and a kidney (McCaffery Sweeney, 2020). The theory was also used in research on the process by which patients adjust to a post-treatment status with ileostomy (da Silva et al., 2017) and stoma (Mota et al., 2015).

USE OF THE THEORY IN NURSING PRACTICE

Transitions theory has been widely used in nursing practice for people across unique health-related transitions, including illness, recovery, birth, death, loss, and immigration (Meleis & Trangenstein, 1994). It has been used with geriatric populations, psychiatric popu- lations, maternal populations, family caregivers, menopausal women, Alzheimer’s patients, immigrant women, and people with chronic illness (Aroian & Prater, 1988; Baird, 2012; Betz et al., 2016; Blum & Sherman, 2010; Brackley, 1992; Cooley et al., 2011; Djukanović & Peterson, 2016; Galeano & Carvajal, 2016; Im, 1997; Kaas & Rousseau, 1983; Schumacher et al., 1993; Shaul, 1997; Waldboth et al., 2021). Furthermore, transitions theory has been used in practice to explore the experiences of transitioning from a registered nurse role to a nurse practitioner role (Barnes, 2015; Eika et al., 2014; Owens, 2019) and from a staff nurse role to a managerial

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role (Pilat & Merriam, 2019). The theory has provided a comprehensive perspective on the nature and type of transitions, transition conditions, and process and outcome indicators of patterns of response to transitions. Importantly for nursing practice, the theory can be used to develop nursing therapeutics that are congruent with the unique experience of clients and their families to facilitate healthy, successful transitions.

USE OF THE THEORY IN NURSING EDUCATION

Other than clinical practice, transitions theory has been nationally and internationally used in nursing education (A. I. Meleis, personal communication, December 29, 2011). It has been incorporated into university nursing curricula (A. I. Meleis, personal communication, Janu- ary 2008), including the University of Connecticut and Clayton State University in Morrow, Georgia. At UCSF, Meleis taught an independent graduate elective course on transitions and health to address student learning needs and requests from graduate students. In 2007, a center called Transitions and Health was established at the University of Pennsylvania (Mary Naylor, director), which is the first center of its kind based on transitions theory. In addition, transitions theory has been used in a number of doctoral dissertations. Further- more, in 2020, transitions theory was used in an analysis of nursing students’ transition experiences as students and post-graduates. Transitions theory was used because first-year undergraduate nursing students often encountered major challenges in adapting to their new life as college students, which involved a major transition demanding coursework and their first clinical placement (Hughes et al., 2020). In addition, in the context of the COVID-19 pandemic, transitions theory was used in one educational study to consider the transition experience of nursing students in adopting remote learning (Wallace et al., 2021) and in an- other study on the early transition into the professional world in Spain (Míriam et al., 2021). Two recent studies have focused on the transition experience in a nursing residency program (de Oliveira Silva et al., 2020; Wallace et al., 2021). Upon graduation, nursing students ex- perienced high levels of stress as novice nurses (de Oliveira Silva et al., 2020), and a nurse residency program was offered to nursing students for their smooth transition into clinical practice (Wildermuth et al., 2020).

CONCLUSION

The middle range theory of transitions has evolved from a borrowed perspective—through research studies and international and national collaborative works—and from the mento- ring process. The theory has been developed based on multiple sources including research studies among diverse groups of people in various types of transitions. An increasing number of situation-specific theories have been derived from the middle range theory of transitions. Also, transitions theory has guided nursing education and practice in current healthcare systems that are characterized by diversities and complexities. However, as Meleis et al. (2000) mentioned nearly two decades ago, transitions theory needs to be further developed, tested, and refined. Transitions theory could be further developed through research studies, nursing practice, and nursing education. The book chapter by Meleis that was published in 2015 could be an example of further development of the middle range transitions theory through theoretical deduction. Yet, the theory still needs to be further refined and tested to explain the major concepts and relationships among the major concepts with diverse pop- ulations in both common human transitions and unique health transitions. This testing will increase the theory’s explanatory and predictive power. Most of all, future studies need to specifically aim to develop and test interventions based on the theory, through which it will gain prescriptive power to direct nursing practice.

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DISCUSSION QUESTIONS

1. Why do you or don’t you think “transitions” is a central concept of nursing? 2. If you are going to use the theory of transitions in your research, practice, and education, what

would be the benefits of using the theory of transitions (compared with using other existing theories)?

3. Please think of a recent transition that you have experienced and apply the theory of transitions to your transition. What are the concepts and subconcepts that could be easily applied to your transition? What are the concepts and subconcepts that could not be easily applied to your transition?

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