Increasing numbers of older adults are entering nursing homes and skilled nursing facilities. Meleis's Theory of Transitions informs nurses how to better understand and develop interventions for the transition process.

1. Meleis’s Middle-Range Nursing
Theory of Transitions
and Nursing Home Entry
Philosophical, Theoretical, and Ethical Basis for Nursing
Anna Chay, Fidela Chiang, and Jessica Dodson
Source: http://www.travischarlessmith.com/wp-content/uploads/2013/04/nursinghome.jpg Source: http://www.hayspost.com/wp-content/uploads/2014/03/Nursing-home-photo.jpg

2. What is the practice setting and problem?
Increasing levels of frailty in the aging population: more family caregivers
find the need to place their loved ones into a nursing home.
THE PROBLEM: When family caregivers assist an older person to move
into a nursing home, they are likely to require support to achieve a
smooth transition, but there is little evidence to suggest which type of
support is most effective (Nolan, 1996).
THE PRACTICE SETTING: Tertiary care facilities (i.e. nursing homes
and assisted living facilities) that provide 24 hour residential services,
including healthcare, to the elderly population. (However, this
theory/approach can be applicable to other major life transitions).

3. The problem (continued)
The move to a nursing home represents a major life event and can be
traumatic (Reed & Payton, 1996).
● While a number of conceptual and theoretical frameworks have been
applied to the needs of older people living in nursing homes, the
research is mostly derived from settings other than a nursing home.
Meleis’s theory of transitions presents a comprehensive framework that
recognizes the significance of transitions for health and attempts to
encapsulate characteristics of transitions to suggest nursing interventions
(Davies, 2005).

4. Facts about the aging population
● The older population (65+) numbered 41.4
million in 2011, an increase of 6.3 million or
18% since 2000.
● The number of Americans aged 45-64 – who
will reach 65 over the next two decades –
increased by 33% from 2000-2012.
● Over 1 in 8, or 13.3%, of the population is an older American.
● Persons reaching age 65 have an average life expectancy of an
additional 19.2 years in 2012 (20.4 years for females, 17.8 years for
males).
● Older women outnumber older men at 23.4 million older women to
17.9 million older men.
(US Department of Health and Human Services, 2012)

5. Why is this significant?
It is known that transitioning from home to a nursing home can be traumatic
and difficult, but there is little research evidence to suggest the type of support
that will be most effective (Davies, 2005).
● The likelihood of developing a disability or chronic disease increases
with age and many older adults have trouble performing tasks, requiring the
assistance of nurses/healthcare professionals in an institution such as an
assisted living or nursing home.
● The application of human factors and ergonomics principles and methods to
the design of assistive and information technologies can improve the lives of
elders in the areas of e-health, medication adherence, health care delivery,
warnings and instructions, home safety, and the design of assistive devices
(Czaja, S. & Sharit, J., 2009).

6. The changing age structure
It is important to
support the needs of
older people and
their families so that
they can live healthy,
independent, and
productive lives.
Figure 1. Changes in the age distribution of people 65 and older in the U.S. population
over the last century and projected through 2050.
Source: U.S. Census Bureau, Decennial Census, Population Estimates and projections.

7. Magnitude of the problem
This problem needs to be solved, as the growth of the 65+ population continues to grow exponentially. If
the support of the transition of older adults and their families from the home to nursing home continues
to be poor, as nurses, we will witness more and more unhappy and unsafe elderly individuals and
families, which continue to represent a large percentage of our overall US population.

8. Why should nurses solve this problem?
● In transitioning from home to assisted living, nurses function as the
caregivers and the importance of relationship-centered care is key
● The culture of the nursing home is shaped by values held by the staff
● The staff, particularly nurses, have the potential to influence the
culture or “type of community” (Davies, 2005).
Source: http://www.piperreport.com/wp-content/uploads/2012/04/Nursing-Home-Quality.jpg

9. A theoretical approach
Meleis’s theory of transitions explains how a person relates to his
or her environment and health - in other words, his or her role
● A change in environment and/or health can change a person’s role
● One’s response to change is influenced by internal (cultural beliefs
and attitudes, knowledge) and external factors (social support,
socioeconomic status)
● Clients experience role insufficiency and role supplementation
o Role insufficiency: incongruence between role behavior and
role expectations
● Nurses fill the gap in role supplementation - where certain
activities or tasks can no longer be done by the individual alone or
by significant others
○ Role supplementation can be preventive or therapeutic
(Meleis, 2010)

10. A theoretical approach (continued)
● One’s response to a transition can lead to either growth or stress
o Disorientation, distress, irritability, anxiety, depression
o Changes in self-concept, role performance, self-esteem
● Health is mastery, defined by having fewer symptoms, perceived
well-being, and an ability to assume new roles (Meleis, 2010)
Source: http://sd.keepcalm-o-matic.co.uk/i/keep-calm-and-know-your-role-34.png
● Types of transitions
o Developmental - birth, adolescence,
aging, death
o Health/illness - recovery process,
chronic illness diagnosis
o Situational - relocation, hospital
discharge
o Organizational - changing
environmental conditions
(Im, 2013)

11. A theoretical approach (continued)
● Properties of transition experience
o Awareness: level of perception, knowledge or recognition of a
transition
o Engagement: degree to which a person is involved in the
transition process
o Change and difference: changes in identities, roles,
relationships, or abilities; differences in expectations and
perceptions of the transition
o Time span: dynamic boundaries of a transition experience
o Critical points and events: significant markers of the
transition (births, deaths, illness diagnosis) as well as a
stability in routines, skills, and lifestyles
● Transition conditions
o Personal: beliefs, attitudes, SES, preparation, knowledge
o Community, society: resources, attitudes, infrastructure

12. Transition theory in the nursing home
When becoming a member of a nursing home, a client experiences a
combination of health/illness, situational, and organizational
transitions. He or she likely is diagnosed with a chronic illness that
necessitates relocation to a different environment, thereby initiating a
change in roles, relationships, routines, and abilities.
Nursing interventions that increase
awareness of and engagement with
the transition process will help facilitate
a smoother adjustment and assumption
of new roles.
(Im, 2013)
Source: http://img.ehowcdn.com/260x217/ds-photo/
getty/article/178/193/86504697_XS.jpg

13. Easing the transition process
The theory guides us to do the following: (Weiss et al, 2007)
1. Assess personal status: pain or discomfort, strength and energy
2. Assess knowledge: about medications, restrictions, follow-up, and
information about services available
3. Coping ability of family and patient: to perform medical
treatments, rehabilitation, medication management and personal
care to transition from home to nursing facility
4. Expected support: Assess support needed to aid family and patient
in order for them to feel emotionally supported during the
transition process.

14. A possible solution
● Assigning a primary nurse/small group of nurses to elderly patients
and their families prior to transferring a patient from a home
setting to a nursing home setting (similar to a nurse case manager
in a hospital setting).
● These nurses would set up a face-to-face meeting with the patient
and their family at the facility prior to the transfer of an elderly
patient to a nursing home to help facilitate a professional nursing
relationship between the family and a nurse in order for the
family’s and patient’s needs to be individualized.
● For example, the primary nurse could meet with the family and
patient prior to the transfer, and provide screening forms
indicating the need for specific interventions in order to facilitate a
smoother transition process.

15. Rationale for using the transitions theory
Transitions theory provides a comprehensive framework through which
the experience of moving to a nursing home can be understood. Its
multidimensional concepts encompass the internal and external factors
that facilitate or hinder one’s changing roles and lifestyle.
Source: http://victoriastrangetherapy.com/wp-content/uploads/2013/03/life-transitions-therapists.jpg
Theory informs nursing interventions, and specific nursing
therapeutics can be employed in creating a holistic and welcoming
environment that meets the needs of both clients and their families.

16. Implications for nurses
In order to ease transitions, it is important for nurses to:
1. Work in partnership with older people and their family caregivers.
2. Be aware of the range of pressures which family givers are
experiences and attempt to minimize pressures wherever possible.
3. Ensure that older people and their family caregivers are well-informed.
4. Enable older people to maintain control over events and decision
making.
5. Ensure that older people and family caregivers are supported, both
in practical and emotional terms.
(Davies, 2005)

17. Tackling potential hurdles
Potential problems include:
1. Discrepancies in the process of filling out the pre-admission
screening form (family members may feel different ways about the
support that they need for a smooth transition for their loved one).
Solution: instead of arguing over which needs are most important,
have each family member fill out an individual form.
2. Unwillingness of a family/patient to be admitted to participate in a
pre-admission meeting.
Solution: acknowledge that the family is busy and suggest a meeting
over the phone, via Skype, or, at bare minimum, have a family member
or the patient complete the pre-screening form.

18. Summary
● The older adult population is on the rise in the US, and is expected
to double from ~41 to 83 million by 2050, and more older adults
will live with chronic illnesses
● As this occurs, more older adults are moving to nursing homes and
skilled nursing facilities
● A change in environment, roles and relationships can be distressing
and alienating
● Meleis’s Transitions Theory informs how to better understand the
experience of transitioning from home to a nursing home, and how
nurses can develop multifaceted interventions to ease the transition
process for older adults
● Nurses should partner with, educate, enable, and support older
adults as well as their caregivers and families to understand and
better cope with changes and transitions