Transition Theory in
Our Patient Populations
Mary Sparks, RN
Matthew Green, RN
Alanna Fant, RN
Dawn Johnson, RN
Transition Theory
• Using Transition Theory we will explore
our specialties in the application of
Transition Theory.
• Transition means to move from one
situation or phase to another (Davidson
et al., 2007).
A Transition
• A transition can be
developmental,
related to stages, or
situational to an
illness or social
situation (Davidson
et al., 2007).
Transition Theory in Patients
with Strokes
• Poor transitioning from pre-stroke to poststroke for a patient can lead to major
depression, low performance of activities of
daily living, and a decrease in mental and
physical abilities (Astrom, Asplund, & Astrom,
1992).
• Transition theory can be applied here to help
decrease these incidents.
• According to Astrom, Asplund, & Astrom (1992) after
having a stroke a patient is less likely to go for walks,
clean their homes, or do their own cooking. By
helping with the transition from independent to
dependent a patient’s outcomes could increase
greatly. Assisting a patient with this transition could
help lower the chances of having another stroke,
developing hypertension, or cardiac condition.
• According to Astrom, Asplund, & Astrom
(1992) the earlier the psychosocial needs of
the patient are recognized and intervened on
the better the outcome for the patient. One
way of using the transition theory is to do a
full assessment.
Patient Assessment
• What kind of lifestyle
did the patient have
before the stroke?
• Did they handle their
ADL’s on their own
before or did they help?
• What kind of support
system does the patient
have in place?
• Was the patient the
sole income for the
family?
• Was the patient the
caregiver to someone
else?
• How active was the
patient socially before
the stroke?
• What kind of therapy
will the patient need?
• Once the medical, physical, mental,
and psychosocial aspects with the use
of the Transition Theory are addressed,
the patient can begin to resume the life
they had pre-stroke.
Transition Theory in Patients
and Family in Nursing Home
Entry
Purpose
• The purpose of the study was to
explore the extent of which Meleis’s
mid-range theory of nursing transitions
is supported from the finding from a
study exploring the relatives’
experiences of moving to a nursing
home (Davies, 2005).
Mid-Range Theories
• Mid-range theories
are useful tools with
understanding the
nursing practice but
many have not yet
been fully tested
(Davies, 2005).
Aims of the Study
• Given the dearth of literature
exploring relatives’
experiencesof the move to a
nursing home the aims of
the study were:
– to describe and interpret
the experiences of family
caregivers
– in relation to helping a
relative to move into a
– nursing home and
continuing to support them
in such a
– setting,
– to describe and interpret
staff and family caregivers’
perceptions
– of current practice within
nursing homes in relation
– to supporting and involving
family caregivers,
– particularly around the time
of admission and
– • to generate
understandings and insights
to inform, assist
– and empower older people
who experience admission
to a
– nursing home in the future
and their family caregivers.
(Davies, 2005, p. 659,661)
Method of study
• Two phases were used
The First Phase
• The first phase started with 37 interviews with 48 people that
experienced admissions of a close relative into a nursing home
(Davies, 2005).
• The participants were recruited by contacting the nurse
managers and asking them to distribute information about the
project to relatives, and for them to contact the researchers.
Using advertisements in local newspapers and publications
were included in recruiting (Davies, 2005).
• The interviews mostly occurred in the participants own homes
and were focused on events leading to the admission,
experience of the relocation and involvement since (Davies,
2005)
The Second Phase
• A detailed study of three nursing homes was done to
inquire about relatives’ experiences with the day to
day living in the nursing homes. This included; field
notes, participant observation and filed notes,
interview with staff, residents and families,
researches experience at the facilities and analyzing
of documents (Davies, 2005).
• Between twelve and fifteen days were spent at each
home for about five to six months (Davies, 2005).
The Findings
• Three phases to the
transition (Davies,
2005)
• “Making the best of
it”
• “Making the move”
• “Making it better”
• Experiences categorized with five
continuums reflecting the extent they
thought they were: feeling (Davies,
2005)
– under pressure or not
– in the know or working in the dark
– working together or working apart
– in control of events or losing control
– feeling supported or unsupported
• At each phase of transition, members should:
– work in partnership with older people and their family
caregivers,
– be aware of the range of pressures which family caregivers
are experiencing and attempt to minimize these pressures
wherever possible,
– ensure that older people and their family caregivers are
well informed,
– enable older people and family caregivers to maintain
control over events and decision-making and
– ensure that older people and family caregivers are
supported, both in practical and emotional terms (Davies,
2005, p.670)
• “Meleis’s theory of nursing transitions
presents a comprehensive framework
which recognizes the significance of
transitions for health and attempts to
encapsulate characteristics and
indicators of healthy transition
processes in order to suggest
appropriate nursing interventions.”
(Davies, 2005, p.670)
Critique of the research
• “Important limitations of Meleis’s theory
highlighted by these data include a
failure to represent the reciprocal
nature of relationships between nurses
and family caregivers, and a lack of
recognition of the potential to work in
partnership with older people and their
families in order to achieve the most
positive outcomes for all concerned.”
(Davies, 2005, p. 670)
• The research using this model worked
well with the transition theory. The
research did point out that even though
the model works it does not integrate all
facets involved with transitioning.
Family members of the resident moving
into the nursing home are neglected
with the model and it does not
encourage family participation with the
transition.
Transition Theory in Patients
with Congestive Heart Failure
Diagnosis of Heart Failure
• A diagnosis of heart failure often occurs as a
sentinel event in a patient’s life. This is a
critical event in which the patient and family
needs to process new information, make
peace with a new reality and cope with the
loss or perceived loss of a planned future
(Davidson, Philliips, Daly, Dracup, & Padilla,
2007).
This is also known as a trigger event (Davidson et al., 2007).
Trigger Event
• With Heart Failure a
trigger event can be
at the time of new
diagnosis or an
exherbation of the
condition with a time
of deterioration
(Davidson et al.,
2007).
Nursing Role
• Nurses can assist in
these times by
assisting the patient
and family in coping
with their situation
and making peace
with the situation.
This is particularly
important in times of
advancing illness
(Davidson et al.,
2007)
Factors influencing Transition
• Patients diagnosed with Heart Failure
have many factors to confront:
– Alteration in social roles
– Impairment of functional and cognitive
capacity
– Impairment of social roles
– High rates of morbidity and mortality
(Davidson et al., 2007)
Factors Influencing Elements of
Transition
Factor
Examples
Barrier
Facilitator
Individual
•Self-efficacy
•Perceived control
•Socioeconomic
factors
•Socioeconomic
deprivation
•Depression
•Anxiety
•Strong sense of selfefficacy
•Perceived control
•Positive orientation
and hope
Social Relationships
•Cultural beliefs and
values
•Level of societal
support
•Quality of
communication with
Healthcare providers
•Cultural values and
mores
•Living alone and
socially isolated
•Poor communication
with multiple providers
•Strong social support
•Family sense of
responsibility
Organizational and
societal factors
•Healthcare System
•Access to healthcare
services
•Level of insurance
•Inaccessibility to
rehabilitation and
palliative care
services
•Communication
between healthcare
providers
•information
(Davidson et al., 2007)
Nursing Interventions
• Aid patient and family in
coping
• Aid patient and family in
adjusting to new life
situations
• Reduce occurrence of
adverse events
• Promote adjustment to
diagnosis
• Promote self-care
(Davidson et al., 2007)
Nursing interventions for the transition to palliative care are critical
as heart failure progresses (Davidson et al., 2007).
Multidisciplinary Approach
• Care that is supportive and transitional
is a multidisciplinary effort that
addressed the functional, psychosocial,
and spiritual and symptom
management issues during the entire
spectrum of the disease, from
diagnosis to death (Davidson et al.,
2007).
Maintaining Hope in Transition
Hope and Control
• The philosophy of
hope and control
can assist patient
and families in
health and social
circumstances
(Davidson et al.,
2007).
Maintaining Hope in Transition
Model
• The Maintaining Hope in Transition Model
places emphasis on healthcare providers in
guiding patients and their families through
information and support especially through
the uncertainty. The model acknowledges
the interaction between hope and control
(Davidson et al., 2007).
Conceptual Model- Maintaining
Hope in Transition
Clinical Characteristics
Social Circumstances
Level of social support
Existential and spiritual
support
 self-reliance (decreased
dependence on health
professionals eg ER
presentations)
Transition Phase
Critical Event
eg diagnosis
of Heart
Failure
Potential for health professional
intervention to assist with
Information
Instrumental support
Empowerment
Advocacy
Processing of Events
Promotion of Self Care
 Hope
 Control
 positive future orientation
 Quality of life
 self-care behaviors
 Social support
 Uncertainty
 depression
(Davidson et al., 2007)
Transition Theory in Discharge
Planning of High Risk Older
Adults
Reduction in Readmission
• The Centers for Medicare and Medicaid Services
(CMS) has issued a priority to reduce acute care
admission rates, particularly a readmission for the
same or related diagnosis. (Dyer, 2006)
Many issues contribute to rehospitalization including:
• Early discharge
• Poor social support
• Poor medication
adherence
• Poor disease
management
• Frail health
• Poor follow up
(Dyer, 2006)
Cost of Readmission
• In the Medicare
population readmission
for any reason occurs
in 20-50% of patients
within 14 days to 6
months with an average
charge of $15,000 per
readmission. These
numbers prove how
crucial transitional care
planning is. (Dyer,
2006)
Impact of Nursing
• Nurses spend the majority of time with
the patient in the acute care setting
which gives them great opportunity for
education that promotes success in the
transition from hospital to home.
Discharge Planning
• Discharge planning should
start with admission
assessment and include:
– Comprehensive patient
history and assessment
– Knowledge deficits
– disease process, signs and
symptoms, emergency care
plan and medication
management
– Barriers to learninglanguage, cultural, past
experience, cognitive
abilities, physical
capabilities
– Barriers to complianceknowledge socioeconomic
and economic factors
– Home safety
– Psychosocial, medical and
community support
(Dyer, 2006)
Discharge Plans
• A comprehensive discharge
plan should also include in
the care plan development:
– Individualized clinical
pathways
– Medication management
plan
– Communication between
healthcare providers
– Referrals using a
multidisciplinary approach
– Coordination of follow up
with appropriate healthcare
providers
– Primary care physician
update
(Dyer, 2006)
Patient Education
• When educating the patient,
information should always include:
– Diet
– Disease management
– Patient self care management
– Safety factors
(Dyer, 2006)
Educating Patients
• Nurses should consider the
following when educating
patients:
– Patient caregiver readiness
– Language and health
behavior
– Environment
– Appropriateness of
verbal/written instructions
– Asking for patient
understanding verbally
– Observe return
demonstration if appropriate
– Documentation of all
education and responses.
Discharge Planning using the Transitional Care Model
• The Transitional
Care Model utilizes
10 screening criteria
which were
developed based on
data regarding older
adults and common
medical-surgical
DRG’s. (Bixby and
Naylor, 2009)
• Screening Criteria (Bixby and
Naylor, 2009)
– Age 80 or older
– Moderate to severe functional
deficits
– An active behavioral and/or
psychological health issue
– Four or more active co-existing
health conditions
– Six or more prescribed
medications
– Two or more hospitalizations
within past 6 months
– Hospitalization within past 30
days
– Inadequate support system
– Low health literacy
– Documented history of nonadherence to the therapeutic
regimen
• “If two or more criteria present further
investigation is warranted and formal
collaborative assessment of discharge
planning-transitional care needs should
be initiated.” (Bixby and Naylor, 2009)
• This model has the ability to identify patients
at high risk for poor outcomes when the
patient is suffering from an acute or
exacerbation of a chronic illness. The
screening does not require any advance
training and it is quick and easy. The
information gathered would trigger the need
for any transitional care services which may
be needed. (Bixby and Naylor, 2009)
• “This Evidence
Based Approach
should be
completed by
registered nurses or
advanced practice
nurses managing
the complex care of
the hospitalized
older adult.” (Bixby
and Naylor, 2009)
• This model aligns with the Transition Theory
by assisting the patient safely from hospital
to home. An elderly patient with acute
conditions or exacerbation of a chronic
condition has an increased chance of
readmission. Transitional care from hospital
to home help reduces the risk of readmission
and helps to protect the member when
he/she transitions from hospital to home.
Discussion Questions
• With Discharge planning for the high
risk adult so important how does the
facility where you work handle this
issue?
• Is the discharge plan a high priority? If
not, do you think it should be? Why?
• What are some things that can be done
to help patients and family cope with
transition?
• What are some “red flags” to be
watching for in patients who may not be
transitioning well?
• Does you unit/workplace address
transition difficulties? If not, do you feel
it would be a valuable tool? Why or why
not?
• Do you think transition is applicable to
all fields? If not, what are some of its
restrictions?
References
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Astrom, M., Asplund, K., & Astrom, T. (1992). Psychosocial function and life
satisfaction after stroke. The American Heart Association, 23(4), 527-531.
Retrieved from http://stroke.ahajournals.org
Bixby MB; Naylor MD, (2009). The Transitional Care Model (TCM): Hospital Discharge
Screening Criteria for High Risk Older Adults. Jan-Feb; 19 (1): [62-3] (journal article
questionnaire/scale) ISSN: 1092-0811 PMID: 20336990 CINAHL AN: 2010610776
Davidson, P. M., Philliips, J., Daly, J., Dracup, K., & Padilla, G. (2007, January/February).
Maintaining hope in transistion: a theoretical framework to guide interventions for
people with heart failure. Jounral of Cardiovascular Nursing, 22(1), 58-64. Retrieved
from CINAHL Database.
Davies, S. (2005). Meleis’s theory of nursing transitions and relatives’ experiences of
nursing home entry [Electronic version]. Journal of Advanced Nursing, 52(6), 658671. doi:10.1111/j.1365-2648.2005.03637
Dyer, Paul, (2006). Discharge Planning and Education Can Help Prevent
Rehospitalization. Arkansas State Board of Nursing (ASBN) Update, 10 (5): 8-9.
Retrieved from www.cinahl.com/cgi-bin/refsvc?jid=1813&accno=2009519469