Transitions theory Afaf Meleis

Transitions
Theory
Presented by: Saleh Al Omar
Supervised by: Dr. Lubna Abushaikha
On 6/4/2017
The University of Jordan
Faculty of Nursing

Outlines
• Credentials and Background of the Theorist
• Theory Development and Use of Empirical Evidence
• Major Concepts and Definitions
• Major Assumptions
• Theoretical Assertions
• Logical Form
• Acceptance by the Nursing Community
• Summary
• Critique
• Research Articles

Afaf Ibrahim Meleis
1942–present
• She was born in Alexandria, Egypt.
• Her mother was the first person in Egypt
to obtain nursing PhD from and Egyptian
university.
• Meleis completed her nursing degree at
the University of Alexandria, Egypt.
• She received an MS in nursing from the
University of California, Los Angeles in
1964 and MA in sociology in 1966,
• PhD in medical and social psychology in
1968.

• 1966 - 1968 administrator and acting instructor, University of
California, Los Angeles.
• 1968 - 1971 assistant professor
• In 1971, she moved to the University of California, San Francisco
(UCSF), where she spent the next 34 years.
• In 2002, Meleis was nominated and became dean of the School of
Nursing at the University of Pennsylvania.
• She is currently on the Counsel General of the International
Council on Women’s Health Issues.
• Meleis received numerous honors, medals, awards and honorary
doctorates.
(Alligood, 2014)

• Meleis’ research focuses on global health, immigrant and
international health, women’s health, and the theoretical
development of the nursing discipline.
• She authored more than 170 articles in social sciences, nursing,
and medical journals; 45 chapters; and numerous monographs,
proceedings, and books.
• Her award-winning book, Theoretical Nursing: Development and
Progress (1985, 1991, 1997, 2007, 2011).
• In addition, her book entitled Women’s Health and the World’s
Cities (Meleis, Birch, & Wachter, 2011) supports her recent efforts
on health issues of urban women.
(Alligood, 2014)

The development of
Transitions Theory
• Began in the mid-1960s, when Meleis was working on
her PhD.
• Her master’s and PhD research investigated
phenomena of planning pregnancies and mastering
parenting roles.
• She focused on spousal communication and
interaction in effective or ineffective planning of the
number of children in families (Meleis, 1975).

• Subsequently, her research focused on people who
do not make healthy transitions and the discovery of
interventions to facilitate healthy transitions.
• This shift in her theoretical thinking led her to role
theories as noted in her publications in the 1970s
and 1980s.
• During this period, her research population interests
shifted to immigrants and their health.

• She initiated the development of role supplementation
as a nursing therapeutic.
• Meleis’ theory of role supplementation was used in her
studies on:
1. The new role of parenting (Meleis & Swendsen, 1978).
2. Post–myocardial infarction patients (Dracup, Meleis,
Baker, & Edlefsen, 1985)
3. Older adults (Kaas & Rousseau, 1983)
• These studies using role supplementation theory led
Meleis to question the nature of transitions and the
human experience of transitions.

To further develop this theoretical work …
• Meleis initiated extensive literature searches with
Karen Schumacher, a doctoral student at the University
of California, San Francisco, to discover how
extensively transition was used as a concept or
framework in nursing literature.
• They reviewed 310 articles on transitions and developed
the transition framework (Schumacher & Meleis, 1994).
Transitions Theory Development
and Use of Empirical Evidence

Publication of transition framework was well received and
tested by scholars and researchers who began using it as a
conceptual framework in these studies :
• Description of immigrant transitions (Meleis, Lipson, &
Dallafar, 1998)
• Women’s experience of rheumatoid arthritis (Shaul, 1997)
• Recovery from cardiac surgery (Shih, Meleis, Yu, et al.,
1998)
• Family caregiving role for patients in chemotherapy
(Schumacher, 1995)
• Early memory loss for patients in Sweden (Robinson,
Ekman, Meleis, et al., 1997)
• Aging transitions (Schumacher, Jones, & Meleis, 1999)
• African-American women’s transition to motherhood
(Sawyer, 1997)

• By using the transition framework also, a middle-range
theory for transition was developed. The collective
work was published in 2000 (Meleis, Sawyer, Im, et al.,
2000).
• The theory was built on empirical evidence from five
research studies for conceptualization and theorizing
(Sawyer, 1997; Im, 1997; Messias, Gilliss, Sparacino, et
al., 1995; Messias, 1997; Schumacher, 1994). These
studies were conducted among culturally diverse
groups of people in transition, including African-
American mothers, Korean immigrant midlife women,
parents of children diagnosed with congenital heart
defects.

• Based on the early works of Transitions Theory,
situation-specific theories that Meleis (1997) had
called for were developed. Jones and Meleis (1999)
developed a situation-specific theory of elderly
transition.
• In 2010, Meleis collected all the theoretical works in
the literature related to Transitions Theory and
published them in a book entitled:
Transitions Theory: Middle-Range and Situation-
Specific Theories in Nursing Research and Practice.

Theoretical Sources for
Transition Theory
1. Meleis’ background in nursing, sociology, role
theory and her educational background.
2. A systematic, extensive literature review; During
Meleis’ mentoring process: mentoring of
Schumacher
3. Collaborative efforts among researchers who used
the transition theoretical framework and middle-
range Transitions Theory in their works.
(Aligood, 2014)

MAJOR CONCEPTS &
DEFINITIONS
• Major concepts of the middle-range theory of
transition include:
1. Types and patterns of transitions.
2. Properties of transition experiences
3. Transition conditions (facilitators and inhibitors)
4. Patterns of response (process indicators and
outcome indicators)
5. Nursing therapeutic.

Types of Transitions
• 1. Developmental transition: includes birth,
adolescence, menopause, aging, and death.
• 2. Health and illness transitions: include recovery
process, hospital discharge, and diagnosis of chronic
illness (Meleis &Trangenstein, 1994).
• 3. Situational transitions: involve the addition of
subtractions of persons in a preexisting constellations
of role and complements. (e.g loss of family member
through death) (Meleis, 2010)
• 4. Organizational transitions: to changing
environmental conditions that affect the lives of clients,
as well as workers within them (Schumacher & Meleis, 1994)

Patterns of Transitions
• Include multiplicity and complexity (Meleis, Sawyer, Im, et al.,
2000).
- People experience multiple transitions simultaneously
rather than experiencing a single transition.
-The transitions happen sequentially or simultaneously,
the degree of overlap among the transitions, and the
essence of the associations between the separate
events that initiate transitions for a person.

Properties of Transition
Experiences
(1) Awareness
(2) Engagement
(3) Change and difference
(4) Time span
(5) Critical points and events.

1. Awareness is defined as “perception, knowledge, and
recognition of a transition experience,”
-Level of Awareness is frequently reflected in “the degree of
congruency between what is known about processes and
responses and what constitutes an expected set of responses
and perceptions of individuals undergoing similar
transitions” (Meleis, Sawyer, Im, et al., 2000).
2. Engagement: “the degree to which a person demonstrates
involvement in the process inherent in the transition.” Im, and
colleagues (2000).
* The level of awareness is considered to influence the level
of engagement; there is no engagement without awareness.
Properties of Transition Experiences

• 3. Changes and differences :
• Changes Person’s sense of movement or direction to
internal as well as external processes due to
experiences in her or his identities, roles, relationships,
abilities, and behaviors. (Schumacher & Meleis, 1994),
Transitions are both the result of change and result in
change (Meleis et al., 2000)
• Differences: challenging differences could be
demonstrated by unsatisfied or atypical expectations,
feeling different or seeing the world and others in
different ways.
Example: Immigrant women found differences in the
food, language, and social patterns. (Meleis et al., 2000)

4. Time span: all transitions may be characterized as
flowing and moving over time (Meleis , Sawyer, Im, et al., 2000).
However, also noted that it would be problematic or
infeasible, and possibly even prejudicial, to frame the
time span of some transition experiences.

5. Critical points and events: “markers intensifying
awareness of changes or dissimilarities; such as birth,
death, the cessation of menstruation, or the diagnosis
of an illness.”
Specific marker events might not be evident for some
transitions, although transitions usually have critical
points and events.
Meleis and colleagues (2000)

• “Circumstances that influence the way a person moves
through a transition, and that facilitate or inhibit
progress toward achieving a healthy transition”
(Schumacher & Meleis, 1994).
1. Personal conditions: include meanings, cultural beliefs
and attitudes, socioeconomic status, preparation, and
knowledge.
I. Cultural beliefs and attitudes such as stigma
associated with a transition experience (e.g., Chinese
stigmatization of cancer).
II. Socioeconomic status.
III. Anticipatory preparation or lack of preparation could
facilitate or inhibit people’s transition experiences.
2. Community conditions (e.g., community resources) or
sociacl conditions (e.g., marginalization of immigrants in
the host country). Meleis et al (2000)
Transition Conditions

Indicators of healthy transitions in the framework by
Schumacher and Meleis (1994) were replaced by
patterns of response in the middle-range theory of
transitions. They characterize healthy responses.
1. Process indicators: they direct clients into health or
toward vulnerability and risk, make nurses conduct
early assessment and intervention to expedite healthy
outcomes. They include “feeling connected, interacting,
being situated, and developing confidence and coping.”
“The need to feel and stay connected” is a process
indicator of a healthy transition.
Patterns of Response (Process and Outcome Indicators)

2. Outcome indicators: may be used to check if a transition is a
healthy one or not.
• “A healthy completion of a transition” can be decided by the
extent of mastery of the skills and behaviors that people in
transition show to manage their new situations or
environments”.
• Outcome indicators could be associated with irrelevant
events in people’s lives if they are appraised early in a
transition. (Meleis, Sawyer, Im, 2000).
• They include mastery and fluid integrative identities.
• Identity reformulation can also represent a healthy
completion of a transition.
Patterns of Response( Process and Outcome Indicators)

Schumacher and Meleis (1994) conceptualized nursing
therapeutics as “three measures that are widely
applicable to therapeutic intervention during
transitions.”
1.Assessment of readiness.: needs to be
interdisciplinary efforts and based on a full
understanding of the client; it requires assessment of
each of the transition conditions in order to generate a
personal sketch of client readiness, and to allow
clinicians and researchers to determine diverse patterns
of the transition experience.
Nursing Therapeutics

2. The preparation for transition: includes education as
the main modality for generating the best condition to be
ready for a transition.
3. Role supplementation: conveying of information or
experience and providing the support needed necessary
to bring the role incumbent and significant others to full
awareness of the anticipated behavior patterns, units,
sentiments, sensations, and goals involved in each role
and its complement.
(Alligood, 2014; Meleis, 2010)
Nursing Therapeutics

The summary of Meleis’ works published in the 1970s
defined role supplementation as any deliberate process
through which role insufficiency or potential role
insufficiency can be identified by the role incumbent and
significant others.
It includes both role clarification and role taking, which
may be preventive and therapeutic.
(Meleis, 2010)
Role insufficiency: any difficulty in the cognizance and/or
performance of a role or of the sentiments and goals
associated with the role behavior as perceived by the self
or by significant others.

• This conceptualization led Meleis to define the goal of
healthy transitions as mastery of behaviors,
sentiments, cues, and symbols associated with new
roles and identities and non-problematic processes.
• Nurses role is helping patients complete a healthy
transition.
(Meleis, 2010).

Nursing
• Nurses are the primary caregivers of clients and their
families who are undergoing transitions.
• Transitions both result in change and are the result of
change.
Person
• Transitions involve a process of movement and changes in
fundamental life patterns, which are manifested in all
individuals.
• Transitions cause changes in identities, roles, relationships,
abilities, and patterns of behavior.
• The daily lives of clients, environments, and interactions are
shaped by the nature, conditions, meanings, and processes
of their transition experiences.
Major Assumptions

Health
• Transitions are complex and
multidimensional. Transitions have patterns
of multiplicity and complexity.
• All transitions are characterized by flow
and movement over time.
- Meleis to defined health as mastery, and
she tested that definition through proxy
outcome variables such as fewer
symptoms, perceived well-being, and
ability to assume new roles.
Major Assumptions

Environment
• 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.

Theoretical Assertions
• Developmental, health and illness, and organizational
transitions are central to nursing practice.
• Patterns of transition include:
(a) whether the client is experiencing a single transition or multiple
transitions.
(b) whether multiple transitions are sequential or simultaneous.
(c) the extent of overlap among transitions.
(d) 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.

• Humans’ 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.
Theoretical Assertions

Logical Form
• Transitions Theory was formulated and theorized
through induction using existing research literature
and findings.
• The theory provides a framework for understanding
the results of previous transitions research more
clearly and for proposing concepts for further study.

Acceptance by the Nursing Community
• Transitions Theory has been widely used throughout
the world. Transitions Theory was translated and used
extensively.

Practice
• Because of its comprehensiveness, applicability,
and affinity with health:
• Transitions Theory has been applied to many
human phenomena of interest and concern to
nurses, such as illness, recovery, birth, death, and
loss, as well as immigration.
• Transitions Theory is useful in explaining
health/illness transitions such as the recovery
process, hospital discharge, and diagnosis of
chronic disease (Meleis & Trangenstein, 1994).

Practice
• Studies have indicated that Transitions Theory could
be applied to nursing practice with diverse groups of
people, including geriatric populations, psychiatric
populations, maternal populations, family caregivers,
menopausal women, Alzheimer patients, and
immigrant women
• Transitions Theory leads to development of nursing
therapeutics that are congruent with the unique
experience of clients and their families in transition,
thus promoting healthy responses to transition.

Education
• Transitions Theory is used widely in graduate
education and undergraduate education
throughout the World nursing curricula across
countries University of Connecticut and Clayton
State University in Morrow, Georgia, for the past 15
years.
• Meleis taught an independent graduate elective
course on transitions and health at the University
of California, San Francisco.

Research
• Internationally, a number of researchers have used
Transitions Theory in their studies as a theoretical
basis for research.
• Researchers have tested the empirical precision of
Transitions Theory through their studies (Davies,
2005; Weiss, Piacentine, Lokken, et al., 2007).
• Transitions Theory was often used as a parent
theory for situation-specific theories.
• Doctoral dissertations.

Further Development
• Transitions Theory continues to be refined and
tested to explain the major concepts and
relationships among diverse groups of
populations in various types of transition.
• Also, as Meleis (2007) envisioned, situation
specific theories continue to be developed
based on Transitions Theory.

Critique
Clarity
• The conceptual definitions of Transitions Theory
are clear and provide a comprehensive
understanding of the complexity of transitions.
• The relationships among the major concepts are
clearly depicted in a visually simple diagram.
• The variables are independent of each other, yet
the interactive effects among the variables are
clearly depicted by arrows.

Simplicity
• Transitions Theory is simple and clear to
understand.
• The major concepts are logically linked, and the
relationships are obvious in their theoretical
assertions.

Generality
• Transitions Theory is a middle-range theory in
scope. Middle-range theories have more limited
scope and less abstraction than grand theories,
and they address specific phenomena or concepts,
which make them applicable in nursing practice.
• Transitions Theory tends to be generalizable to
people in transitions. When diverse types of
transitions are considered, Transitions Theory is
relevant for any population in transition.

Accessibility
• Transitions Theory has been tested and supported
by Meleis and others as a framework for explaining
the transition experiences of diverse groups of
populations in different types of transitions.
• Transitions Theory continues to evolve through
planned programs of research, and continuous
empirical research studies will further refine the
theory.

Importance
• Transitions Theory with a focus on people in diverse
types of transitions provides a comprehensive and
evolving guide for all health-related disciplines.
• The inherent consideration of diversities of health
care clients and its basis in research among diverse
groups contribute to its importance.

Critique using Fawcett Criteria
Significance.
• Metaparadigms, concepts, and propositions
addressed by the theory explicitly.
• Philosophical claims on which the theory is
based are explicit.
• The conceptual model from which the theory
was derived is explicit.
• Antecedent knowledge acknowledged and
bibliographical citations given.

Internal Consistency
• Context and content of the theory are
congruent.
• Concepts reflect semantic clarity and
semantic consistency.
• Propositions reflect structural consistency

Parsimony
• Are content stated are clear and concise ?

Testability
• Research methodology reflect the middle-range
theory.
• Middle-range theory concepts observable through
instruments that are appropriate empirical indicators
of those concepts.
• Data analysis techniques permit measurement of
propositions.

Empirical Adequacy
• Theoretical assertions are congruent with empirical
evidence.

Pragmatic Adequacy
• Education and special skill training required
before application of the theory in nursing
practice.
• Transitions theory has been applied in the real
world of nursing practice.
• It is generally feasible to implement practice
derived from the theory.
• The theory-based nursing actions can lead to
favorable outcomes.

Pragmatic Adequacy
• Understanding the properties of specific transitions
guides the nurse in planning effective interventions to
assist the patient in adapting to a change in identity
• It also provides a framework for planning nursing
interventions with the goal of healthy stability.
• It assists the nurse in assessing areas of
vulnerability, readiness, environment, and support.
• It demonstrates that education prior to, during and
following transition increases the likelihood of
successful role integration.

References
• Alligood, M. R. (2014). Nursing theorists and their work.
(8th edition). St. Louis: Mosby.
• Meleis, A. I. (2010). Transitions theory: Middle range and
situation specific theories in nursing research and
practice. Springer publishing company.
• Fawcett, J. (2005). Criteria for evaluation of theory.
Nursing Science Quarterly, 18(2), 131-135.

Transitions theory Afaf Meleis

Transitions theory Afaf Meleis

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