Family Nurse Practitioner Paper.

Family Nurse Practitioner Paper.

Family Nurse Practitioner Paper.

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See discussions, stats, and author profiles for this publication at: http://www.researchgate.net/publication/15313084 Facilitating transition: Redefinition of a nursing mission ARTICLE in NURSING OUTLOOK · NOVEMBER 1994 Impact Factor: 1.83 · DOI: 10.1016/0029-6554(94)90045-0 · Source: PubMed CITATIONS DOWNLOADS VIEWS 97 19 1,468 2 AUTHORS, INCLUDING: Afaf Meleis University of Pennsylvania 161 PUBLICATIONS 3,671 CITATIONS SEE PROFILE Available from: Afaf Meleis Retrieved on: 09 September 2015 Facilitating Transitions: Rdefinition of the Nursing Mission Afaf lbrahim Meleis, phD, D~PS(~OIT), FAAN Patricia A. Trangenstein, phD, RN Nursing is concerned with the process and experience of human beings undergoing transitions. T here have been numerous dia- For example, Newman’ has stated that logues in nursing about its mis- the challenge before nursing is to idension and definition, but a refinement of tify and agree on the central focus of existing definitions has yet to be of- nursing. Similarly, one of us (A.M.) has fered. This article is written with the pleaded for substantive knowledge degoal of maintaining a vigorous dis- velopment in nursing and has identicourse. fied constraints to knowledge developThe phenomena of concern to the ment as the multiplicity of educational discipline of nursing that have been preparations, the multiplicity of drivdescribed by various theorists, and gen- ing theories, the lack of an organizing erally accepted by members of the dis- concept, the focus on process rather cipline, are health, person, environthan substance, the devaluation of clinment, and nursing therapeutics. Yet ical focus and valuation of science, and the multiplicity of viewpoints regard- the rise of ethnocentricity.2 What is ing these concepts and the paucity in needed is an organizing concept that their systematic development has allows for a variety of viewpoints and prompted many to question their util- theories within the discipline of nursity in providing the discipline with a ing. Such a concept should not be culcoherent definition. The extent to turally bound, and it should help in which the mere identification of these identifying the focus of the discipline. concepts as central has helped in furWe submit that the transition experithering the development of nursing ence of clien ts, families, communities, knowledge is also questionable. The nurses, and organizations, with health challenge members of the discipline and well-being as a goal and an out face is to define the mission of nursing. come, meets these criteria. The mission, then, could give more Previously, Chick and Meleis,3 Mesubstance to these central concepts. leis,4 and Schumacher and Melei$ arRecently, defining the mission has gued that transjtion is a central concept been advocated by many in nursing. to nursing. Unlike the other identified central concepts in nursing, transition is not a concept that is inherent in the NURS OUTLOOK 1994;42:255-9. writings of many of the nurse theorists. Family Nurse Practitioner Paper.

Copyright @ 1994 by Mosby-Year Book, Inc. 0029.6554/94/$3.00 + 0 35/l/54995 However, the concept of transition NURSING OUTLOOK NOVEMBER/DECEMBER 1994 may be thought of as being congruent with or related to such concepts as adaptatio#; self-care’; unitary human developments; expanding consciousness,9 and human becoming.‘O Therefore the purpose of this article is to propose that facilitating transitions is a focus for the discipline of nursing. We argue that the mission of nursing should be redefined in terms of facilitating and dealing with people who are undergoing transitions, and we provide a framework that clarifies aspects of clients, health, and environment. We further argue that such a focus is not being imposed on the discipline; rather, it is a focus that reflects the practice of nursing as demonstrated by clients’ nursing care needs, by actions of clinicians, and by the choices of investigators of nursing research questions. The challenge members of the discipline face is to define the mission of nursing. THE MISSION OF NURSING Attempts at articulating a substantive focus in nursing have been made by a number of metatheorists, as well as by the authors of the 1980 ANA Social Policy Statement, which defined nursing as “the diagnosis and treatment of human responses to actual and potenMeleis and Trangenstein 255 tial health problems.“9 This definition, used by members of the discipline, has been instrumental in providing nursing with a focus. However, further development of the mission of nursing has been limited. In addition, the definition of nursing practice as described in this important document has lent itself to the development of topologies or listings of human responses without an equal emphasis on the nursing therapeutics needed. Moreover, there is a lack of a framework that may help nurses decide what is a health problem and what are the health care priorities from a nursing perspective. More recently, Newman et all2 proposed that the focus of the discipline of nursing is “caring in the human health experience.” Some questions emanating from Such a focus is not a foiws that is be&y immd on the dkciphe; it re ts the pmice of nwrsiflg. this focus: (1) Is it possible to study caring using empiricism as a framework? (2) If caring is universal and not limited to one discipline, what aspects of caring are unique to nursing?’ (3) Which human health experiences require nurses’ unique contributions? Furthermore, because of the impersonal nature of bureaucratic systems, caregivers in institutions are often un able to provide personalized care, because of limitation in defining the scope of care, the diffusion in their daily responsibilities, their limited power, and the expectations that bedside caregivers compensate for deficiencies in the resources of the system through their caring process. Family Nurse Practitioner Paper.

Without an expectdion of mutuality and reeiprocity in the caring relationship, exploitation and oppression of the care giver at the individual and institu256 tional level may-occur.i3 And without the identi@cation of some de5aing boundaries far the human health ex perience, priorities of care may not be clear. The scope of nursing was also defined. According to Fawcett,i4 who utilized the work of Donaldson and Crowleyr5 and Gortner, I6 four propositions that define the scope of nursing are as follows: The discipline of nursing is concerned with the principles and laws that govern the life process, well-being, and optimal functioning of human beings, sick or well. The discipline of nursing is concerned with the patterning of human behavior in interaction with the environment in normal life events and critical life situations. The discipline of nursing is concerned with the nursing actions or processes by which positive changes in health status are affected. The discipline of nursing is concerned with the wholeness or health of human beings recognizing that they are in continuous interaction with their environment. While these definitions and scope of nursing practice have been instrumental in promoting constructive dialogues about the mission of nursing, we believe that using transitions as a framework adds an important dimension to identifying boundaries of nursing, to refining phenomenon of the discipline, to establishing priorities, and to developing congruent nursing therapeutics. In previous work by Chick and Me&s3 and Schumacher and Meleis5 a framework with which to view the concept of transitions was identified. Transition has been defined as “a passagefrom one life phase, condition, or status to another. . . Transition refers to both the process and outcame of complex per son-environment interactions. It may involve more than one person and is v embedded in the cOntexE and the situA tr@&&-&i denoteS a change in health status, in role relations, in expectations, or in abilities. It denotes a unique constellation of patterns of responses over a span of time. In general, the structure of a transition consists of three phases, entry, passage, and exit.“Commonalities that characterize a transition period include process, disconnectedness, perception, and patterns of response. One important consideration of transition is that the completion of a transition implies that a person has reached a period of less disruption or greater stability through growth-relative to what has occurred before. Increments, as well as decrements, may be viewed as positive, as the potential for disruption and dis organization associated with pretransitional states is countered on successful completion of the transition.” Additional support for transitions as the focus of the discipline of nursing comes from the extensive literature review provided by Schumacher and Meleis.” Three hundred-ten ~citations with the word “transition” appearing in the nursing literature between 1986 and -1992 were reviewed. Family Nurse Practitioner Paper.

The identified articles crossed specialty areas and professional roles (educator, practitioner, administrator, and researcher). In the analysis, several categories emerged. These categories, emerging from research and clinical article reviews, lend support to the theoretical categories identified ear1ier.s Types of transitions that nurses deal with are as follows: 1. Individual~-developmn~al transitions, such asadolescence, becoming aware of sexual identity and going into midlife 2. Family development& transitions, such as mother-daughter relationship, parenthood, and childbearing family 3. Situational transitions, such as educational transitions, changing professional roles, widowhood, re-~ location to nursing home, family caregiving, and immigration 4. Health/illness transitions, such ilEic)ft.i’3 6 as the recovery process, hospital discharge, and diagnosis of chronic illne:ss 5. Organizational transitions, such as changes in leadership, implementation of new policies or practices, implementation of a new curriculum, changes in nursing as a profession, and changes in communities In the review of these articles, three indicatorsof successful transitions were described: emotional well-being, mastery, and well-being of relationships. Given the unique focus of nursing on health, additional indicators identified included quality of life, adaptation, functional ability, self-actualization, Nursing’s unique contribution is its goal of a sense of well-being. expanding consciousness, and personal transformation.5 Theoretically, there is support that an additional outcome indicator that should be addressed is purposeful and mobilized energy.181 l9 While some outcomes have been identified fromexistiqg literature, it is most likely that emphasis on selected outcomes will be dictated by the profession’s social commitment and responsibility within a given culture and not only by the theoretical nature of the discipline. Other disciplines may also focus on transition; however, nursing’s unique contribution is it,s goal of a sense of well-being. Defining nursing as “facilitating transitions to enhance a sense of well-being” gives nursing a unique perspective. Only nursing facilitates transitions toward health and a perception of well-being. No other discipline has this process orientation to the transition experience. No other discipline needs as much of a knowledge base to help clients achieve a sense of mastery, a level of functioning, and a knowledge NURSING OUTLOOK of ways by which their energy can be mobilized. Within the transition framework, caring would be seen as a process that facilitates successful transitions that is not bound by a medically determined beginning and ending of an event. Family Nurse Practitioner Paper.

Admission and discharge of patients are events that could be considered either at a point of time or as transitional experiences. The former limits nursing actions to that slice of time; the latter allows preparation for continuity of care, a process of coping within, and a longer time framework. Nursing, then, is concerned with the process and the experiences of human beings undergoing transitions where health and perceived well-being is the outcome. The development of nursing therapeutics could be focused on the prevention of unhealthy transitions, promoting perceived well-being and dealing with the experience of transitions. Theory development should aim to provide greater understanding and insight into the transitional experiences. Within this focus, then, the goals of knowledge development in nursing are to enhance an understanding of2: 1. The processes and experiences of human beings who are in transition 2. The nature of emerging life patterns and new identities 3. The processes or conditions that promote healthy outcomes, such as mastery, perceived well-being, energy mobilization, quality of life, self-actualization, expanding consciousness, personal transformation, and functional ability 4. Environments that constrain, support, or promote healthy transitions 5. Structure and components of nursing therapeutics that deal with transitions A focus on transitions provides a framework that: 1. Acknowledges universal aspects of nursing 2. Enhances nurses’ potential in supporting emerging identities and life patterns NOVEMBER/DECEMBER 1994 3. Supports nurses’ concerns about changing systems and societies 4. Challenges nurses todevelop therapeutics supportive of positive experiences and healthy outcomes It provides nurses with a framework to understand variations in the recovery transition, the hospital admission transition, the immigration transitions, the discharge transition, the rehabilitation transition, as well as the experiences of clients who are in multiple transitions. It highlights the need for knowledge related to transitions into new roles and new skills. The transition experienced by people during the modernization process of societies becomes an important focus within the discipline. The birthing transition, the transition into home care, and the caregiving transition would also receive more attention internationally. None of these events, experiences, and responses becomes ahistorical or isolated. When considering transition as an organizing framework, the events, experiences, and responses are recognized as processes that require a longitudinal and multidimensional approach and a focus on patterns of response over time, all of which are more congruent with nursing than viewing any of their transitional experiences as events creating change. Family Nurse Practitioner Paper.

Such consideration limits the events to singular responses in a single slice of time. Transition Versus Change are processes that occur over time and that have a sense of flow and movement. Change, on the other hand, is defined “to take instead of, substitute one thing for another, put, adopt a thing in place of another, and tends to be abrupt.“20 Transition incorporates some aspects of change but extends the concept to incorporate flow and movement. Another universal property is found in the nature of change that occurs in transitions. At the individual and family levels, changes occur in identities, roles, relationships, abilities, and patterns of behaviors. At the organizational level, Transitions Meleis and Tratqenstein 257 changes occur in structure, function, or the dynamics of the organization. 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 been viewed as requiring a process of transitionzl, 22 Similarly, phenomena such as mood changes that are dynamic but do not have a sense of movement or direction are not conceptualized as transitions. Finally, internal processes usually accompany the process of transition, while external processes tend to characterize change.” A Chicaf Example One of the challenging clinical problems is the treatment and management of breathing difficulties. Canceptually, breathing difficulties are similar to other problems in that they are not merely a reflection of a physiologic event but evolve out of a complex interaction of personal, environmental, and health status factars.23t24 Currently, three major approaches to the study and treatment of breathing difficulties have emerged. These are the biomedical/physiologic approaches, with an emphasis on medication and oxygen therapy, breathing retraining, smoking cessation, exercise conditioning, and nutritional evaluation.25-N A second approach has been the exploration of various psychologic and personality characteristics associated with dyspnea primarily in clients with COPD. Findings from this approach have led to the use of psychatropic agents and relaxation methods.26J 31-37 The third approach has focused on 258 Malais and Trwin coping strategies used by clients with dyspnea.24! 38-4o Few interventions have been proposed or clinically tested to relieve breathing difficulties.41 Some nursing interventions, such as teaching breathing techniques, energy-conservation measures, exercise programs, desensitization and guided imagery, and environmental temperature control, have been applied in a clinical setting. However, one of the most challenging and frustrating dilemmas for the nurse at the bedside is the experience of caring for a frightened client sitting up at bedside unable to catch his or her breath. Family Nurse Practitioner Paper.

The focus on symptom control rather than viewing this as a transltional experience may contribute to the lack of long-term, intermittent, and only hospital bound nursing interventions. If the experience of the client with breathing difficulties was viewed as a transitional experience with desired outcomes being mastery, irnproved functional ability, or improved quality of life, and with the goal of achieving a period of less disruption or greater stability through growth, the nursing approach to the problem would be qualitatively ditierent. It could transcend hospitalization and strategies that are biomedically driven. The lived experiences, the daily life events, and lifestyles will more accurately drive nursing therapeutics. A variety of research methods could be used to study which groups of clients do better with selected interventions at different phases of the transitional experience and to identify which kinds of environments support or hinder a healthy transition. Levels of mastery in coping with the transitional phases will need to be explored. Similarly, the cumulative nature of knowledge related to breathing difficulties will be taken into consideration when conceptualizing breathing ease as a transition. There are multiple paradigms and viewpoints that guide and inform the discipline of nursing. This multiplicity has prompted many analyses and critiques and polarized some to prefer and espouse the adaption of one view, one theory, or one paradigm over another. Our intention is not to reconcile the differences between these different viewpoinB. As Skrtic4” has stated: “the point is not to accommodate or reconcile the multiple paradigms; and ro recognize them for what they arcways of seeing that simultaneously reveal and conceal.” Rather, our intent is to suggest that by considering transitions as focal and central to the discipline of nursing ;I more focused dialogue and debate that advances knowledge development could occur. What advantages- does transition offer for the development of nursing? First, it offers an organizing framework that emphasizes processes that~are longitudinal and multidimensional in nature and patterns of responses over time. All are more congruent with nursing. An integrating and organizing conceptual framework makes it easier for a nurse to capitalize on what he or she already knows and to use ~existing knowledge more insightfully. Second, it provides a common language that can encompass all specialty areas, professional roles, and theoretical and methodologic camps. Both the received viewers and perceived viewers can equally find questions to consider and contributions to make. Better articulation across specialties and professional roles is made possible. Third, because transitions arc not bounded by current nursing theories but encompass them, nursing theories could compete to answcr critical questions in nursing. For example, what nursing therapeutics are effective in treating the frightful experience of shortness of breath? Family Nurse Practitioner Paper.

Are certain nursing therapeutics more successful with different groups of clients, in a particular sequence, or at selected stages? The challenge is for nurses to develop and test therapeutics suppor tive of healthy experiences and outcomes and not only events. In addition, transitions acknowledge the universal aspects of nursing, and this is not limited by a particular cultural viewpoint. Without an organizing framework such as transitions, the focus of the discipline may be lost; advances in nursing knowledge may be slow and erratic; nurses’ ex:pertise may go unacknowledged and staffing patterns may be limited to caring for events, rather than processes of becoming. Last, using the facilitation of transitions as a defining mission for nursing allows nurses to demonstrate their expertise in supporting admission, recovery, discharge, birthing, parenting, menopausing, battering as processes that are not bound by time and space. The experience of transitions is longer, multidimensional, and far more multilayered than each of the situations when conceptualized asevents. Transitions could be utilized to turn the tide to the advantage of our clients with an emphasis on the process of achieving healthy outcomes. The concept of transition already pervades much of current thinking about nursing, and this suggests it is not a trivial notion or passing fad. We see applications cross-culturally, for all age groups, and independent of clinical specialty or professional role. Certainly nursing needs new knowledge, but it also needs tools and strategies to make the best use of existing knowledge and to use it in a way ,unique to nursing. n REFERENCES 1. Newman MA. Prevailing paradigms in nurs ing. NURS OUTLOOK 1990,40,10-13, 32. 2. Meleis Al. A passion for substance revisited: global transitions and international commitments, Keynote paper at the 1993 National Nursing Doctoral Forum, St. Paul, Minn., June 1993. 3. Chick N, Meleis AI. Transitions, a nursing concern. In: Chinn PL, ed. Nursing research methodology, issues and implementation. Rockville, Maryland: Aspen, 1986,237~57. 4. Meleis AI. Thearetical nursing, develop ment and progress. 2nd ed. Philadelphia: JB Lippincott, 1991. 5. Schumacher KL, Meleis AI. Transitions: a central concept in nursing. Image [In press.] 6. Roy C. The Roy adaptation model. In, RiehlSisca J, ed. Conce:ptual models for nursing practice. 3rd ed. Norwalk, Connecticut, Appleton W Lange, 1989. 7. Orem D. Nursing, concepts of practice. 2nd ed. New York: McGraw-Hill, 1980. NURSING OUTLOOK 8. Rogers ME. Nursing: a science of unitary human beings. In: Riehl-Sisca J, ed. Conceptual models for nursing practice. 3rd ed. Norwalk, Connecticut: Appleton & Lange, 1989. 9. Newman MA. Family Nurse Practitioner Paper.

Health as expanding consciousness St. Louis: CV Mosby, 1986. a theory of 10. Parse RR. Man-living-health, nursing. In: Riehl-Sisca J, ed. Conceptual models for nursing practice. 3rd ed. Norwalk, Connecticut: Appleton & Lange, 1989. 11. American Nurses Association. Nursing: a social policy statement. Kansas City: American Nurses Association, 1980. 12. Newman MA, Sime AM, Corcoran-Perry SA. The focus of the discipline of nursing. Adv Nurs Sci 1991,14,1-6. 13. Condon EH. Nursing and the caring metaphor, gender and political influences on the ethics of care. NURSOUTLWK 1992;40:14-19. 14. Fawcett J. Analysis and evaluation of nursing theories. Philadelphia: FA Davis, 1993. 15. Donaldson SK, Crowley DM. The discipline of nursing. NURS OUTLCXX 1978;26: 13-120. 16. Gortner S. Nursing science in transition. Nurs Res 1980,29,180-3. 17 Bridges W. Managing transitions: making the most of change. Reading, Massachusetts: Addison-Wesley, 1991. 18 Newman MA. Health conceptualizations. Annu Rev Nurs Res 1991;221-43. 19 Levine M. The four conservation principles of nursing. Nurs Forum 1967;6:1, 45-59. 20 Webster Universal Dictionary. New York: Harver Educational Services, 1970. 21 Catanzaro M. Transitions in midlife adults with long-term illness. Holistic Nurs Pratt 1990;4:65-73. 22 Loveys B. Transitions in chronic illness: the at-riskrole. Holistic Nurs Pratt 1990;4:56-64. 23 Carrieri VK, Janson-Bjerklie S, JacobsS. The sensation of dyspnea. Heart Lung 1984, 13:436-47. 24. Carrieri-Kolhman V, Douglas MK, Gormley JM, Stulbarg MS. Desentization and guided mastery, treatment approaches for the management of dyspnea. Heart Lung 1993;22:22634. 25. Adams L, Chronos N, Lane R, Guz A. The measurement of breathlessness induced in normal subjects: validity of two scaling techniques. Clin Sci 1985,69:7-16. 26. Agle DP, Baum CL, Chester EH, Wendt M. Multidiscipline treatment of chronic pulmonary insufficiency: psychologic aspectsof rehabilitation.PsychosomMed 1973;35:41-9. 27. Gift AG, Plaunt M, Jacax A. Psychologic and physiologic factors related to dyspnea in subjects with chronic obstructive pulmonary diseases. Heart Lung 1986,15,595601. 28. Guyatt GH, Townsend M, Berman LB, Pugs ley SO. Quality of life in patients with chronic airflow limitation. Br J Dis Chest 1987;81:45-54. 29. Weaver TE, Narsavage GL. Physiological NOVEMBERjDECEMBER 1994 30 31 32 33 34 35 36 37 38 39 40 41 42 and psychological variables related to functional status in chronic obstructive pulmonary disease. Nurs Res 1992, 41:286-91. Wolkove N, Dajczman E, Colacone A, Kriesman H. The relationship between pulmonary function test and dyspnea in obstructive lung disease. Chest 1989;6:1247-51. Agle DP, Baum GL. Psychological aspects of chronic obstructive pulmonary disease. Med Clin North Am 1977,61,749-58. Dudley DL, Glaser EM, Jorgenson BN, Logan DL. Family Nurse Practitioner Paper.

Psychosocial concomitants to rehabilitation in chronic obstructive pulmonary disease, 1: psychosocial and psychological considerations. Chest 1980,77,413-20. Fishman DB, Petty TL. Physical, symptomatic and psychological improvement in pa tients receiving comprehensive care for chronic airway obstruction. J Chron Dis 1971,24:775-85. Fishman DB, Plaunt M, JacoxA. Psychologic and physiologic factors related to dyspnea in subjects with chronic obstructive pulmonary disease. Heart Lung 1986,15:595-601. Light RW, Merrill EJ, Despars J, Gordon GH, Mutalipassi LR. Prevalence of depres sion and anxiety in patients with COPD. Chest 1985,87:35-8. Rutter B. Some psychological concomitants of chronic bronchitis. Psycho1 Med 1977; 7,459.64. Rutter B. The prognostic significance of psychological factors in the management of chronic bronchitis. Psycho1 Med 1979;9:6370. Carrieri VK, Janson-Bjerklie S. Strategies patients use to manage the sensation of dyspnea. West J Nurs Res 1986,8,284-305. Janson-Bjerklie S, Fahy J, Geaghan S, Golden J. Disappearance of eosinophile from bronchoalveolar lavage fluid after patient education and high dose inhaled corticosteroids. Heart Lung 1993,22,235-8. Parsons EJ.Coping and well-being strategies in individuals with COPD. Health Values 1990;14:9(3):17-23. Moody L, McCormick K, Williams AR. Psychophysiologic correlates of quality of life in chronic bronchitis and emphysema. West J Nurs Res 1991,13:336-52. Skrtic TM. Social accommodation: toward a dialogical discourse in educational inquiry. In: Cuba EG, ed. The paradigm dialogue. Newbury Park, California, Sage, 1990. AFAF I. MELEIS is a professor at the School of Nursing at the University of California, San Francisco. PATRICIA A. TRANGENSTEIN is an assistant professor at the College of Nursing and Health at the University of Cincinnati, Ohio. Meleis and Trangenstein 259