This analysis paper explores the meaning of the concept of transition, focusing on the variety of meanings and uses in healthcare. There are numerous similarities in meaning applied to this concept in healthcare, education, and the sciences. The concept of transition has emerged in healthcare as an approach to the understanding of change and development throughout life processes, particularly regarding an individual’s status within the health illness continuum. The transition theory is based upon nurse-patient interactions that occur during a transition caused by a life change. The use of the transition concept has been used in many nursing practice settings, across cultures, and throughout the human life span. The concept of transition is examined based on the method developed in 2005 by Walker and Avant that identifies antecedents and consequences of transitions established by literature review findings. Exemplars of the concept are presented in model, contrary, related, and borderline cases.
The concept of transitions in nursing is varied and is reflected in both patient care and in the course of a professional nursing career. The transition process has been recognized as an appropriate concept for nursing as transition is related to change and development (Chick & Meleis, 1986). Prior to its use as a concept in nursing, transition was used in developmental and in stress/adaptation theories because the concept can be applied to the life processes of humans (Chick & Meleis, 1986). There are numerous definitions with similarities in meaning of the idea of transition found in nursing, healthcare, education, and other professions.
Schumacher and Meleis (1994) developed the idea of transition as a central concept in nursing practice based upon nurse-patient interactions that occur during a transition period, which is triggered by developmental, situational, and/or health illness change situations. For this reason, nursing scholars, practicing nurses, and nursing theorists have an interest in the concept of transition (Schumacher & Meleis, 1994).
The concept of transition can be used in a variety of nursing practice settings and clinical specialties as well as transculturally and across the human lifespan (Chick & Meleis, 1986) in all aspects of healthcare. The purpose of this article is to analyze the concept of transition meaning and demonstrate various methods in which the concept is used today in the profession of nursing and in healthcare to clarify meaning (Botes, 2002). The analysis employed procedures outlined by Walker and Avant (2005) and demonstrate various methods in which the concept is used today in the profession of nursing.
The definition of a transition varies among healthcare and non-healthcare disciplines. According to Chick and Meleis (1986), the transition process begins with a person's doubts, uncertainties, and anxieties that did not previously exist, that the person now needs to recognize and work through in order to move into recovery from the situation. Chick and Meleis (1986) defined a transition as part of human life processes and consisting of individualized, personal, lived experiences.
When an individual needs to integrate a change or event into their life by adapting to a new situation or circumstance, that individual undergoes a transition (Kralik et al., 2006). In their seminal article, Schumacher and Meleis (1994) described previous definitions of a transition found in developmental and in stress and adaptation theories. These definitions include one from Golan, who described a transition as a period “of moving from one state of certainty to another, with an interval of uncertainty and change in between” (p. 122) and from Murphy, who defined a transition as having “disruption of routine, emotional upheaval, and adjustment required of individuals undergoing life changes” (p. 122). Chick and Meleis (1986) stated that different individuals experience transitions inconsistently, even if the situation is similar. Kralik et al. (2006) described transition as a term utilized when a change, development, or adaptation occurs. This change occurs over a varying time period and extends from the expectation that something will occur until the stable, new form, or status occurs (Kralik et al., 2006).
According to Schumacher and Meleis (1994), all transitions have conditions and influencing factors that affect how an individual experiences a transition. Additionally, how an individual processes the transition and how that transition influences health and well-being influences the individual's perception of whether the transition was a success or failure (Schumacher & Meleis, 1994). The effects of a transition may be positive, negative, or neutral, and the transition experience is affected by the expectations an individual has for the change (Schumacher & Meleis, 1994). For example, if the person has had a previous experience or if the expectations are unrealistic or incongruent with reality, then the transition experiences are affected (Schumacher & Meleis, 1994).
The level of knowledge and skill needed for the transition may be insufficient for the demands of the situation and thus lead to an unsuccessful transition (Schumacher & Meleis, 1994). Schumacher and Meleis (1994) promoted the importance of resources to the individual going through a transition, such as social support from family, preceptors, and mentors in an organization, and collaboration from team members. Other factors that influence the transition process are the level of planning that occurs before the transition and the emotional and physical well-being of the individual (Schumacher & Meleis, 1994).
Human life is a continuous cycle of change, adaptation, and return to a stable condition. Bridges (2004) described Americans as always having been in transition, first as immigrants to the New World, then as part of a thriving, growing new nation. Bridges believed that a transition is a “natural process of disorientation and reorientation marking the turning points in the path of growth” (Bridges, 2004).
Schumacher and Meleis (1994) described a healthy transition as one that demonstrates a sense of well-being from the individual's perspective, the ability to adapt to new skills or behaviors (role mastery), and the stability and healthiness of interpersonal relationships. For example, in the case of practicing nurses transitioning into a faculty position, success leads to the retention of qualified nurse educators (Schoening, 2013).
The commonalities among the definitions and meanings of the concept of transition will: (a) involve some type of change (Kralik et al., 2006), (b) require a forward movement from one relatively stable state to another (Chick & Meleis, 1986), and occur as a process over time (Chick & Meleis, 1986; Kralik et al., 2006; Schumacher & Meleis, 1994). The transition process has three phases - entry, passage, and exit (Chick & Meleis, 1986). A transition incorporates change in some form, whether it is in an identity, a role, a relationship, ability, or behavior (Meleis, 2010; Schumacher & Meleis, 1994) during which the individual is disconnected from their support systems, familiar environmental reference points, and needs that cannot be met by the usual methods, and incongruence between normal expectations and the life-changing situation (Schumacher & Meleis, 1994). Transition results in a change in an aspect(s) of an individual's life world such as in personal, developmental, interpersonal or relational, sociocultural, situational, or environmental areas (Kralik et al., 2006).
The manner in which an individual responds to change is a transition (Kralik et al., 2006). A transition is measured not only by how well the individual adapts or copes with a significant change in their life world, but how that person tolerates the transition process (Meleis, 2010).
Meleis (2010) described the use of the sociopsychological conceptual framework of role insufficiency and role supplementation theory as part of the theoretical development of transition theory in assessing nursing problems and planning nursing interventions. Role theory is an interactionist framework that involves an individual occupying a social status position and adhering to the social norms attached to the position (McEwen & Wills, 2011). Meleis was influenced by family theorists in social psychology, in particular Dr. Ralph H. Turner, in developing her transition theor y (Dr. A. Meleis, personal communication, March 15, 2012).
The concept of transition has also been associated with Erikson's developmental theory, as Erikson emphasized the importance of the adolescent stage as the time when an individual makes the transition from a child to an adult (McEwen & Wills, 2011). Four central metaparadigm concepts of nursing were first introduced in 1978 by Jacqueline Fawcett as person, health, environment, and nursing (McEwen & Wills, 2011). In 1994, Schumacher and Meleis added the concept of transition as a central metaparadigm nursing concept.
Research studies using the framework of transition theory and the concept of transition can be found in nursing research in the areas of patient care, nursing practice, and other life- world changes and involves an individual's experiences of and responses to the transition (Meleis, 2010). Schumacher and Meleis (1994) described a transition as being a complex process that can involve one or more transition types that can overlap or occur at the same time. The four types of transitions identified by Schumacher and Meleis (1994) are developmental, situational, health and illness, and organizational transitions.
Shin and White-Traut (2007) studied the concept of transition to motherhood (a developmental transition process) in mothers who had newborn infants in the Neonatal Intensive Care Unit (NICU). They concluded that nurses needed to provide support to these mothers in order to promote an earlier transition to motherhood. Barimani et al. (2017) also concluded in their study that transition theory was applicable in assisting healthcare professionals in supporting new parents transition to parenthood.
A research example of an organizational transition utilizing transitions theory is found in a study completed by Rose and Lopez (2012). The nursing roles in dementia care were changed in one facility from primarily focusing on the Alzheimer's disease client to both the client and caregiver(s), due to the findings of this study. The authors used the middle-range theory of transitions to expand the nursing roles during the transitions during the course of dementia (Rose & Lopez, 2012). Similarly, researchers concluded the successful transition by patients and families through the common processes of dementia can be accomplished with varying degrees of support from healthcare providers (Drummond et al., 2019).
Two exemplars for health illness transition use of transitions theory can be found in studies by Fex et al. (2011) and Halding and Heggdal (2012). Fex et al. (2011) used transition theory in a phenomenological study to explore the transition of individuals requiring advanced medical technology at home. The authors employed transition theory in which a person has a period of instability between two stable periods in the health-illness continuum (Fex et al., 2011) as described by Meleis et al. (2000). The researchers concluded that a conscious process and positive attitude existed in the participants to be able to successfully transition into the home setting with different types of medical technology. Halding and Heggdal (2012) employed the transition theory framework to guide the researchers in interpreting and understanding participants' feedback regarding living with Chronic Obstructive Pulmonary Disease (COPD) in activities of daily living and pulmonary rehabilitation. The researchers found that nurses involved in pulmonary rehabilitation needed to work in partnership with clients to promote healthy transitions (Halding & Heggdal, 2012).
A study using transition theory in the area of situational transitions was found in Davies' research (2005) on relatives' experiences of the move of a loved one to a nursing home. This study demonstrated support of the nursing transitions theory to guide nurses in family support during this transition. Schumacher et al. (1999) also investigated the use of a transition framework in gerontological nursing practice and research. The authors used the transitions framework to identify transition processes in gerontological clients that will provide nurses with a way to understand and respond to client needs.
The researchers in these studies consistently demonstrated the usefulness of transition theory as a framework or guidelines for studying a variety of areas of human life world changes: (a) Transition theory is pertinent to explain becoming a mother in the NICU (Shin and White-Traut, 2007), (b) Transition theory framework is useful for the development and implementation of clinical and educational methods for individuals with dementia and their family caregivers (Rose & Lopez, 2012), (c) The transitions perspective is useful in studying COPD patients' experiences during and after pulmonary rehabilitation (Halding & Heggdal, 2012), (d) Insight into the transition process of individuals using medical technology at home contributes to the knowledge of transitions (Fex et al., 2011), (e) Transitions theory is useful in understanding a variety of life changes, including guiding nursing practice in supporting relatives of individuals being placed in a nursing home (Davies, 2005), and (f) The theory is useful in identifying indicators of an individual's progression through a transition and identifying nursing therapeutics with older clients in transition (Schumacher et al., 1999).
A review of literature regarding the concept of transition revealed widespread use of this term in many disciplines, including healthcare and non-healthcare fields of study. The variety and extensive use of the concept of transition indicates that it is an important abstraction. Many applications of the concept of transition exist in other disciplines, including musicology, history, metallurgy, geography, anthropology, science, and health, as described in the use of transition in the nursing and healthcare and the non-healthcare sections of this article.
The concept of transition has been used in nursing literature since the 1970s and, before that time, other disciplines, such as social psychology, family science, chemistry, and physics. One of the first uses of the concept in the nursing realm is seen in the research of Kramer (1974) regarding the transition of graduate nurses into the profession of nursing. Chick and Meleis (1986) introduced transitions as a nursing concern and performed a concept analysis and in 1994, Schumacher and Meleis purported that transition is a central concept in nursing. In 2010, Meleis further expounded on the concept of transitions as the central theme in her transition theory. Meleis was one of the first nursing theorists to put the concept of transitions in nursing vocabulary and to utilize it as a central concept in nursing (personal communication, Dr. A. I. Meleis, March 15, 2012), although another nursing theorist did describe a variation on the use of the concept of transition in a life transition theory, which characterizes a life transition as occurring when disruption of a person's current reality takes place (Selder, 1989).
A transition is a process and is ongoing, not dependent on what initiated it or on how long it lasts or if the transition is successful (Chick & Meleis, 1986). Chick and Meleis (1986) described a transition as having a discernible ending which is perceived and experienced differently by individuals, even under the same circumstances or transition type; a transition can also be perceived and experienced differently by the same person in a similar type of transition at different times. Studying transitions involves looking at people's perceptions and responses during the change occurrence and how people adapt, adjust, and then incorporate the situation or event into their lives (Kralik et al., 2006).
Patient care involves a wide variety of transitions. Each transition in this context represents change and development and can involve situational and health-illness events (Chick & Meleis, 1986). A transition in healthcare is an integral part or stage that is found between stable states of health. Anyone who is admitted to the hospital, has to undergo surgery, and who is discharged from a healthcare facility is likely to go through some time in an adjustment period or transition.
In healthcare, there are uses for the term transition that have different meanings. For example, during the first stage of childbirth, the third of three phases of labor is referred to as the transition phase (Ward & Hisley, 2016). When a child is diagnosed with a life-long condition or disease, there is a physiologic as well as a psychosocial transition for both the child and the parents (Lowes et al., 2005).
The profession of nursing is always changing and adapting to new situations and conditions in medical science, nursing science, and societal needs. A nurse may go through various transitions throughout a career including progressing from a novice nurse to an expert nurse (Benner, 2001), and depending on the nurse's area of interest or concentration, progressing from a staff nurse to a nursing administrator, and transitioning from the work environment to the academic environment. The new nurse must make critical, meaningful adaptations to his/her personal and professional life and progress through the stages of professional role transition (Duchscher, 2008). Newly Graduated Nurses (GNs) struggle for transition from the academic arena to professional practice settings within a relatively short time period after obtaining their nursing license. Kaihlanen et al. (2017) described various interventions can be used during the last practicum in a prelicensure program to facilitate a nursing student's transition into the role of a nurse. During the author's professional career of thirty years, many programs and ideas to assist new graduates have been implemented and much nursing and education research has been conducted to prepare the graduate nurse for the professional arena. The transition concept is important to education and professional nursing practice. Likewise, healthcare facilities spend a considerable amount of time and money for staff to support the progression from student to a practicing nurse. As a result, the concept of transition is used in both nursing education and in nursing practice.
Due to the nursing shortage in many specialty areas of nursing, many hospitals and hospital specialty nursing departments are developing transition programs or orientation programs that focus on a particular nursing subspecialty in order to support the development of knowledge in specific areas (Griffiths & Houghton, 2013). These include intensive care nursing (Juers et al., 2012), RNBSN curricula (Allen & Armstrong, 2013), transition from student to military nurse (Moore, 2006), transition from health care assistant to student nurse (Brennan & McSherry, 2007), transition from paper-based to electronic medical records (Mahan et al., 2010), and transition to practice program for mental health nursing.
A transition experienced in nursing education occurs when the graduate level nurse transitions from nursing practice to academia (Weidman, 2013). The transition process from practice to academia has been challenging to novice faculty due to the hiring of full-time or adjunct faculty without teaching experience or preparation with educational theory related to the current faculty shortage (Weidman, 2013). In order to address the issue of faculty retention, Gilbert and Womack (2012) investigated a methodology that decreased faculty attrition and improved faculty support for novice faculty transitioning from clinical practice. Another transition that nurse educators have experienced in the last few years has been to transition from teaching in the classroom to teaching online. Issues related to the ability of an educator to adequately educate students and transition a course into an appropriate online format have arisen with advances in technology (Johnson, 2008).
There are multiple personal life transitions that can affect an individual's health or socioeconomic status such as transitions in mid-life for women (Dare, 2011), the transition to parenthood and well-being (Keizer et al., 2010), marriage, divorce, moving to another city, state, or country, aging, and many other lifestyle changes. In addition, Dougherty (1990) described another life transition called the Near Death Experience (NDE), which may result in changes in an individual's attitude or acceptance of life and death or new interest in caring relationships. Popkin et al. (2012) described the nutrition transition. This nutrition transition has occurred globally and is attributed to populations having an increasing dependence on processed and fast foods, eating away from home, and decreasing their physical activity, resulting in negative health effects in low- and middle income populations in the 1990s.
Healthcare is also undergoing significant transitions especially in Medicare reimbursements to hospitals used by its beneficiaries. The Medicare reimbursement system changes have resulted in a transitional care role for community based organizations and non-clinical community services to provide care for patients/clients that are not well enough to go home, yet are not sick enough to be an inpatient in a hospital facility (Brock & Boutwell, 2012).
The concept of transition is used in the sciences, education, sociology, business/career, and literature/arts in different contexts. Exemplars in the sciences include a nucleotidepair mutation in genetics (Mitchell, 2006), a breeding transition program for bison (Pyne et al., 2010), a discussion in anthropology of a transition fossil called the Nichollsia borealis that is an example of a transition fossil in anthropology (Lloyd, 2009), human gender transition (Gibson, 2011), in chemistry, transition metals (The Bodner Group, 2011), and a phase transition in physics (March et al., 2010).
There are transitions throughout education, both in the delivering and receiving of education. For example, the transition process from high school mathematics educationto the university setting is discussed by Engelbrecht (2010); the transition from school to the workforce for students with disabilities (Rutkowski et al., 2006), intergenerational mentoring to ease the transition for the new graduate from the school environment into the workforce (Schlimbach, 2010), and transitioning from clinical practice or the work setting to an academic setting is a common education transition (Schoening, 2013).
Scientists in the fields of sociology describe the transition to the work force as part of the maturation process for a young adult (Schlimbach, 2010). Other examples of the use of transition in sociology include studying the effects of interpersonal influences and mutual adaptation (Newcomb et al., 1965) and exploring the transition of an individual from their residential home to an assisted living facility (Fields et al., 2012).
The concept of transition is used in a variety of contexts in the business and career arenas. A transition outsourcing or interim management occurs when a business hires an outside management company (Sutherland Global Services, n.d), and the use of a transitional, interim, or provisional government when a country's government collapses (Johnson, 2009). Transitions exist in occupational situations and role changes such as when a worker is injured and has to transition to living life without work or transition into a new job, a different role, or an alternative occupation (Arnold et al., 2009), and each time a person moves from one job or position to another (Chudzikowski et al., 2009). Suto (2009) assessed career transitions in a cultural context when a person immigrates and resettles in a different country. Levin (2010) studied transitioning into a leadership role from the role of a lower-level employee. An athlete's career in team sports may depend on his/her ability to transition between playing in an offensive position and transitioning to a defensive position and vice versa in hockey, basketball, and volleyball or if an athlete mustleave sports (Stambulova et al., 2009).
In academic and professional writing, a transition word or a phrase establishes a congruent relationship between a sentence, among paragraphs, and amid sections of a paper (The Writing Center, 2012). There is also a transition phase or stage in making a video/movie in which one image or picture takes the place of another image or between two scenes (Media College, 2012) and, in music, a transition can reflect a brief alteration or a movement from one key to another or a passage that links or connects two themes or section of a piece or music that is played between two different events (Songs for Teaching, 2012).
The model case clearly exemplifies the concept of transition and includes all of the relevant attributes and excludes irrelevant attributes. The model case reflects the criteria for a transition as it involves a forward movement from one stable state to another, occurs over time, and incorporates a change in role, ability, and behavior (Meleis, 2010). The transition process of newly licensed nurse into nursing practice has three phases, reflecting the phases of a transition (Chick & Meleis, 1986).
The successful transition of a newly graduated nurse who enters the nursing workforce involves the new nurse transitioning through a predictable adjustment process in both personal and professional roles (Duchscher, 2008). Duchscher (2008) described the transition to professional nursing practice in the acute care setting as a “process of becoming” (p. 449), which takes around 12 to 18 months. The transition process consists of three stages through which each nurse evolves: (a) doing (the orientation process, preceptor time, adjusting to a new set of expectations and responsibilities), (b) being (rapid advancement in thinking, knowledge level, and skill competency), and (c) knowing (achieve individuality from peers and become part of the professional community) (Duchscher, 2008).
A contrary case is the antithesis of the transition concept. A case that is not representative of the concept of transition is occurring in national educational progress in the United States as compared to other top-performing nations (Duncan, 2014). Duncan stated that U.S. student performance on the Program for International Student Assessment (PISA) tests demonstrated the stagnation of educational programs and potential complacency and lower expectations in education nationally. Fifteen-yearold students in the U.S. are not progressing as are their peers in other countries who are advancing (Duncan, 2014).
An example of a similar but a slightly different concept from transition is developmental theory, in particular Erikson's Psychosocial Developmental Theory or Ego Developmental Theory (McEwen & Wills, 2011). Erikson believed that the whole person or adult personality develops on his or her own timetable through designated stages of development that each build upon one another (McEwen & Wills, 2011). Erikson developed the concept of ego as the strongest part of an individual's personality; ego uses inner willingness and outer circumstances to find inventive solutions to effectively handle problems at each stage of development (McEwen & Wills, 2011).
A borderline case is an example of transition that is lacking some of the relevant essential attributes of a transition. A pseudo example of transition exists in tactics utilized during the web-based search process. A web search involves tactics and strategies that are usually planned, with a transition occurring between the search tactics employed by an individual (Xie & Joo, 2010). The transition can occur at the beginning, in the middle, and at the end of the search session designed to facilitate achievement of a successful web search (Xie & Joo, 2010). This type of transition does not involve a change in a person or that person's world or look at someone's perceptions and responses during the transition, or how an individual adapts and incorporates the transition into their life (Kralik et al., 2006).
Antecedents that take place prior to the occurrence of a transition are related to the person undergoing the transition and the context (Shin & White-Traut, 2007). A transition occurs during a period of instability in a person's life and/or health and is triggered by a change in that person's life (Chick & Meleis, 1986). When a nurse transitions into the academic setting, inadequate teaching/education preparation, and a difference in values and skills from the clinical setting affects successful transitioning into the new environment (Schoening, 2013). Nursing faculty successfully transitioning to online education is inhibited by a deficiency of technological skills and insufficient knowledge regarding online learning background (Johnson, 2008). Antecedents such as prior experiences in healthcare, exposure to nurses, unclear role identity, and the realities of nursing school and the nursing profession can interfere with the CNA's successful transition into nursing courses and the nurse perspective (Brennan & McSherry, 2007).
The consequences or the results of a successful or unsuccessful transition are related to the individuality of the person undergoing the transition and the context (Shin & White-Traut, 2007). The consequences of an unsuccessful transition due to a change in a person's developmental, situational, or health illness status may cause serious or difficult life alterations for the person and/or their family (Schumacher & Meleis, 1994). The consequences of a transition are affected by the meanings and importance attached to the transition experience (positive, neutral, or negative) by the individual (Schumacher & Meleis, 1994). An individual who does not successfully perform transition may experience continued feelings of distress or discomfort, lack of role mastery, and inadequate or unhealthy relationships (Schumacher & Meleis, 1994).
Attributes of a transition that are observable and measurable include the process of transition (sense of movement, a development, an associated flow), a disconnectedness and disruption of an individual's sense of security, perceptions, and meaning associated with the transition, a personal awareness, and a pattern of response (observable and non-observable behaviors) in the individual (Chick & Meleis, 1986). Transition triggers include what a person perceives as critical events and changes within the individual or in an individual's environments (Chick & Meleis, 1986).
The clarification of the meaning of concepts has not commonly included scientific investigations which may result in limitations of the concept analysis (Botes, 2002). This analysis used a more philosophical methodology to analyze and explain the meanings of the transitions concept.
Combining literature studies with quantitative and qualitative scientific inquir y could improve the understanding of the transitions concept and to promote empirical reliability and validity to the concept analysis (Botes, 2002; Chinn & Kramer, 2011). The addition of scientific inquiry with the traditional methodologies could overcome limitations and enhance the quality of the concept analysis (Botes, 2002).
A transition has many meanings dependent on the profession and context of its use. A transition generally seems to signify a change for the better or an improvement over a status. In nursing and healthcare, a transition incorporates change in some form whether it is in a particular context, a patient's position on the health-illness continuum, a change in status, or a healthcare provider position or relationship. The author's focus of interest regarding the concept of the transition is in the process that a nursing student with previous healthcare experiences (for example, a CNA) goes through to effect successful adaptation and socialization into a nursing program. By investigating this phenomenon through the lens of the transition concept, the author hopes to increase nursing knowledge regarding the topic.