Experiencing Transitions: An Emerging Middle-Range Theory

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Experiencing Transitions: An
Emerging Middle-Range Theory
Changes in health and illness of individuals create a process of transition, and clients in transition tend to be
more vulnerable to risks that may in turn affect their health. Uncovering these risks may be enhanced by under-
standing the transition process. As a central concept of nursing, transition has been analyzed, its components
identified, and a framework to articulate and to reflect the relationship between these components has been de-
fined. In this article, the previous conceptual analysis of transitions is extended and refined by drawing on the
results of five different research studies that have examined transitions using an integrative approach to theory
development. The emerging middle-range theory of transitions consists of types and patterns of transitions,
properties of transition experiences, facilitating and inhibiting conditions, process indicators, outcome indica-
tors, and nursing therapeutics. The diversity, complexity, and multiple dimensionality of transition experiences
need to be further explored and incorporated in future research and nursing practice related to transitions. Key
words: middle-range theory, research based theory, transition
Afaf Ibrahim Meleis, PhD, FAAN
Linda M. Sawyer, PhD, RN

C HANGES in health status may provide
opportunities for enhanced well-being
and expose individuals to increased illness
risks, as well as trigger a process of transi-
Eun-Ok Im, PhD, RN tion. Vulnerability may be conceptualized as
a quality of daily lives uncovered through an
DeAnne K. Hilfinger Messias, PhD, RN
understanding of clients’ experiences and
Karen Schumacher, PhD, RN responses during times of transition. In this
sense, vulnerability is related to transition
experiences, interactions, and environmen-
tal conditions that expose individuals to po-
tential damage, problematic or extended re-
covery, or delayed or unhealthy coping.
Clients’ daily lives, environments, and inter-
actions are shaped by the nature, conditions,
Meleis: Professor, Department of Community Health

Systems, School of Nursing, University of California, San
Francisco, California; Sawyer: Assistant Clinical
Professor, Department of Community Health Systems,
School of Nursing, University of California, San Francisco,
California; Im: Assistant Professor, School of Nursing,
University of Wisconsin-Milwaukee, Wisconsin; Messias:
Associate Professor, Women’s Studies and Nursing,
University of South Carolina, Columbia, South Carolina;
Schumacher: Assistant Professor, School of Nursing,
University of Pennsylvania, Philadelphia, Pennsylvania.
Adv Nurs Sci 2000;23(1):12–28

© 2000 Aspen Publishers, Inc.
12
Experiencing Transitions 13
meanings, and processes of transition expe- cal and research experiences and perspec-
riences. Transitions are both a result of and tives were integrated into the analyses.
result in change in lives, health, relationships, Using an integrative concept analysis strat-
and environments. egy,9 a middle-range theory was developed.
Nurses often are the primary caregivers of In presenting the analysis, each study will
clients and their families who are undergo- be introduced briefly and then the emerging
ing transition. They attend to the changes theoretical framework and the conceptual
and demands that transitions bring into the modifications that were developed from the
daily lives of clients and their families. Fur- analysis of this collective research will be
thermore, nurses tend to be the caregivers outlined.
who prepare clients for impending transi-
tions and who facilitate the process of learn-
ing new skills related to clients’ health and STUDIES USING TRANSITIONS AS A
illness experiences. Examples of transitions FRAMEWORK
that may make clients vulnerable are illness
experiences such as diagnosis, surgical pro- The frameworks articulated by Chick and
cedures, rehabilitation and recovery; develop- Meleis3 and Schumacher and Meleis1 were
mental and lifespan transitions such as preg- used to guide the development of each of the
nancy, childbirth, parenthood, adolescence, following studies and the analysis of data.
menopause, aging, and death; and social and The intent of each study was to uncover
cultural transitions such as migration, retire- emerging themes that may not have been
ment, and family caregiving.1,2 originally a part of the framework. The
As a central concept in nursing, transition process of using inductive and deductive
has been analyzed and a framework has reasoning not only enabled evaluation of
been defined to articulate and reflect the re- the utility of the different components of the
lationships among the components of a framework, but also identified additional
transition.1,3 Transition has been used both emerging components.
as a perspective and as a framework. The The studies reflect cultural diversity in
purpose of this article is: (a) to continue the vulnerable populations including African
conceptual analysis of transition from a Americans, Brazilian immigrants, and
nursing perspective, extending and refining Korean immigrants. They also reflect a vari-
the existing framework by drawing on the ety of transitions that may lead to height-
results of five nursing studies that were ened vulnerability, including pregnancy,
based on a transition framework,4–8 and (b) to motherhood, menopause, work, migration,
identify future directions for nursing re- caregiving, and diagnostic processes.
search and theory building regarding transi- Although different approaches were used
tions and a transition framework. In the for data analysis, each study used a qualita-
process, the findings across studies were tive research design with the goal of theory
compared and contrasted, emerging proper- development. In addition, each study re-
ties were identified, the literature from 1993 flected a feminist perspective in the design
to 1997 was reviewed, and respective clini- and in the interpretation of data, allowing an
14 ADVANCES IN NURSING SCIENCE/SEPTEMBER 2000
examination of the data within the context the woman’s sense of emotional and physical
of race, class, culture, and gender. well-being and inhibited the transition.10
Becoming an African-American mother Neglecting and ignoring the menopausal
Using grounded theory methodology, 17 transition
first-time African-American mothers were The purpose of this study was to describe
interviewed to elicit their experiences of the perceived meanings that low-income
pregnancy and motherhood.4,10 This transi- Korean immigrant women had about their
tion spanned the time period between the menopausal transition, to describe their per-
woman’s decision to get pregnant or to con- ceived symptoms during this transition, and
tinue a pregnancy and the time when mother- to analyze their responses within a context
ing was incorporated into her identity. of immigration and their work situations.5
Women were interviewed both individually The study was cross-sectional, utilizing
and in focus groups from one to three times methodological triangulation.11 For the qual-
during the postpartum period. Engaged itative portion of the study, semi-structured
mothering was identified as the core cate- in-depth interviews were conducted with 21
gory, denoting the active, involved, and mu- perimenopausal or postmenopausal women.
tual process in which African-American Data were analyzed using thematic analysis.
mothers get ready to be a mother, deal with A major conceptual category that emerged
the reality involved, settle in with their ba- was neglecting and ignoring the menopausal
bies, and dream and plan for a good life for transition because of other imminent de-
themselves and their children and families. mands in the women’s lives because of immi-
The outcome of engaged mothering is incor- gration, new work experiences, and the patri-
poration of mothering into the woman’s archal cultural heritage that makes women’s
identity and a healthy, happy, strong, safe, experiences invisible and inaudible. The num-
and secure child. In this study, all women ber, seriousness, and priority of transitions
demonstrated engaged mothering. However, that these women were experiencing con-
the environment for this group of women in- tributed to neglect of their menopausal tran-
creased their stress during pregnancy. sition.12 In addition, the participants relayed
Women frequently anticipated and dealt with stories of neglect and of their experiences
incidents of racism, stereotyping, and nega- within the context of gender, low-income
tivity in their daily lives. The environment status, and attitudes toward health and ill-
mediated the transition both by providing ness. Participants related these conditions to
support and by increasing stress. Two condi- their menopausal transitions.
tions affected transition experiences and re-
sponses: First, the level of planning for Parents and diagnostic transitions
motherhood was influenced by the degree to Messias et al6 examined the experiences
which the pregnancy was intentional, with of parents of children diagnosed with con-
women who were actively trying to get preg- genital heart defects (CHD). The analysis
nant proceeding through the transition more was part of a larger exploratory investiga-
easily. Second, prior miscarriage or history tion13–15 of the transitions in health, social
of health problems of the mother diminished relations, and development experienced by
adolescents and young adults with CHD in the narratives of 26 Brazilian women who
and their families. The stories collected had migrated to the United States were sto-
from eight parents about the birth and diag- ries of multiple transitions, fluid identities,
nosis of a child with CHD revealed the su- constant comparisons, and changing per-
perimposition of an unanticipated transition spectives on class, culture, and women’s
with possible negative outcomes (becoming work. All of the women in the study experi-
the parent of a child with CHD) on an antic- enced some form of work or occupational
ipated transition with an expected positive transition in conjunction with their transna-
outcome (becoming the parent of a normal, tional migration. For some, migration signi-
healthy newborn). As the parents observed fied the transition from being a Brazilian
health care providers and environments and professional, student, or middle-class house-
their own infants, they began to gather evi- wife to immigrant domestic worker.
dence that something was wrong. They fre- Domestic work was one of the limited em-
quently became confused with the illusive- ployment options for many, particularly for
ness of normality, as they tried to sort out the newly arrived and the undocumented.
the sometimes paradoxical meanings and Women viewed this occupational transition
appearances of “normal pregnancies,” “nor- from different perspectives and found differ-
mal, healthy babies,” and the diagnosis of ent meanings in the experience. Over time,
CHD. For some, the diagnostic event per se domestic or food service work was a tempo-
came as an abrupt shock. For others, com- rary stepping stone for some; for others, do-
ing to know the diagnosis was a gradual mestic work signified a long-term career
process over time, characterized more by change. Such migratory occupational transi-
ambivalence and unknowing. The process tions were embedded in social transitions,
of coming to know, recognize, and acknowl- which in many cases translated into per-
edge the congenital condition in the child ceived downward social mobility. However,
was characterized as a rude awakening. for some of the women who had been em-
Eventually, parents’ acknowledgment and ployed as domestic workers in Brazil, mi-
understanding of the reality of CHD became gration was perceived as an upward social
the work of managing uncertainty, which and economic transition. Within the narra-
would become one of the hallmarks of their tives of the women, there were both strong
parenting in the ensuing years. As parents support and interesting challenges for the
reflected back on their experiences, they use of a transition framework to understand
told of how they created new meanings in and explain migration experiences. What
their own and their children’s lives and characterized their experiences as transitions
talked about taking stock of costs and bene- was not so much the movement across na-
fits of having a child with CHD. tional borders but the resulting passages be-
tween different life phases, conditions, and
Migration, work, and health: complex, statuses, accompanied by some degree of
multidimensional transitions self-redefinition.3 The results of this research
In another study, Messias7 explored the support the concept of migration as a transna-
lived experiences of transnational migration, tional transition. However, the study sug-
work, employment, and health. Embedded gested that transnational migration transitions
concept of the grounded theory. The study

The results of this research support revealed the fluidity of care involvement dur-
the concept of migration as a ing the transition into illness care roles and
transnational transition. the need to study complementary role transi-
tions together.
EMERGING FRAMEWORK
are characterized by movement that is ongo-
ing, recurring, and multidirectional and is be-
Through our collective research, an ex-
tween multiple places, spaces, situations, and
panded theoretical framework emerged
identities, rather than movement that is linear
consisting of:
or unidirectional.
• types and patterns of transitions
The family caregiving study • properties of transition experiences
• transition conditions: facilitators and in-
The purpose of this study was to generate a
hibitors
grounded theory of family caregiver role ac-
• process indicators
quisition among caregivers of persons receiv-
• outcome indicators
ing chemotherapy for cancer.8 Specifically,
• nursing therapeutics
the study sought to identify patterns of role
In this article the first five components of
acquisition and conditions influencing these
the framework are addressed. Concurrently
patterns, using an interactionist perspective.
with the analysis presented here, implica-
Thus, the study included both family care-
tions for nursing therapeutics are addressed;
givers and the persons for whom they were
however, a full exposition of this part of the
providing care. A longitudinal design in
framework is beyond the scope of this article.
which participants were interviewed three
The relationships between the six compo-
times across the course of chemotherapy
nents of the framework are illustrated in Fig 1.
was consistent with a transition perspec-
These components were identified through a
tive.1 The sample consisted of 19 caregivers
collaborative process of dialogue, constant
and 20 patients with solid tumors or lym-
comparison of the findings across the five
phoma. Semi-structured interviews ad-
studies, and analysis. In the following sec-
dressed illness care experiences, strategies,
tions each of the components is discussed,
and interactions. Although the original intent
focusing in particular on the extensions and
of the study was to explore caregivers’ tran-
modifications of previous frameworks and
sitions into the caregiving role, it quickly be-
on the emerging framework.
came apparent that caregiving could not be
isolated analytically from self-care by the ill
person. Thus, self-care and caregiving by the TYPES AND PATTERNS OF
dyad became the focus for analysis. Patterns MULTIPLE AND COMPLEX
of self-care and caregiving were quite fluid TRANSITIONS
and shifted often over the course of che-
motherapy as conditions for care changed, Types of transitions that nurses encounter
leading to the identification of shifting pat- in working with patients and families have
terns of self-care and caregiving as the core been identified as developmental, health
Fig 1. Transitions: a middle-range theory.

and illness, situational, and organiza- At the same time the caregiver was experi-
tional.1,3,16 The results of our research sup- encing the transition to the caregiving role,
ported this typology as representative of the the care receiver was experiencing the tran-
transitions central to nursing practice. sition to having a life-threatening illness.
However, the research also supported the In light of the results of these studies, our
notion of transitions as patterns of multi- analyses of the nature of transitions suggest
plicity and complexity.7 For example, each that nurses need to consider the patterns of
of the previously described studies involved all significant transitions in an individual or
individuals who were experiencing at least family’s life rather than focusing only on
two types of transitions, indicating that tran- one specific type of transition. Patterns of
sitions are not discrete or mutually exclu- transition would include whether the client
sive. Migration scholars have called atten- is experiencing a single transition or multi-
tion to the multiple structural transitions ple transitions. Important considerations are
involved in migration, such as transitions in whether multiple transitions are sequential
employment, socioeconomic status, culture, or simultaneous, the extent of overlap among
and social networks.17 Messias 7 noted that transitions, and the nature of the relation-
the migration experiences of Brazilian ship between the different events that are
women were multiple and complex in na- triggering transitions for a client.
ture and did not occur in isolation, but
rather in conjunction with other situational,
developmental, and health-illness transi- PROPERTIES OF THE TRANSITION
tions. As the women talked about their mi- EXPERIENCE
gration, work, and health experiences, the
interrelations and connections of multiple Transitions are complex and multidimen-
transitions were woven throughout their sional, but several essential properties of
narratives. Similarly, Im5 found that the transition experiences have been identified.
Korean women were not only dealing with These include
the developmental transition of menopause • awareness
but also situational transitions related to mi- • engagement
gration and work. In fact, for these women, • change and difference
the menopausal transition was found to be • time span
less of a priority than the other transitions • critical points and events
they were experiencing. These properties are not necessarily dis-
Messias et al6 found that the diagnosis of crete. Rather, they are interrelated proper-
CHD in newborns or infants created an un- ties of a complex process.
expected transition superimposed on other
personal and family transitions related to Awareness
childbirth and parenting. Schumacher18 Awareness is related to perception, knowl-
found that the transition into the caregiving edge, and recognition of a transition experi-
role could not be understood in isolation ence. Level of awareness is often reflected in
from the health and illness transition experi- the degree of congruency between what is
enced by the family member with cancer. known about processes and responses and
what constitutes an expected set of responses ities. The level of awareness influences the
and perceptions of individuals undergoing level of engagement in that engagement
similar transitions. Chick and Meleis3 in- may not happen without awareness. The
cluded awareness as a defining characteristic level of engagement of a person who is aware
of transition, and they purported that to be in of physical, emotional, social, or environ-
transition, a person must have some aware- mental changes will differ from that of a per-
ness of the changes that are occurring. They son unaware of such changes. Sawyer 4 found
posited that an absence of awareness of various instances of differing levels and
change could signify that an individual may types of engagement in the transition to
not have initiated the transition experience. motherhood among the participants in her
We propose that although awareness appears study. For example, a woman in the early
to be an important property of transition, the months of pregnancy who is unaware of
lack of manifestation of such awareness does changes in her body may not be as careful
not preclude the onset of a transition experi- about potentially harmful medications or bal-
ence. For example, some of the Korean ancing her diet.
women in Im’s5 study did not recognize that
they were experiencing a menopausal transi- Change and difference
tion; others recognized the experience only Change and difference are essential prop-
at the cessation of menstruation. However, erties of transitions. Although similar, these
although the changes related to menopause properties are not interchangeable, nor are
were not fully recognized, there was evi- they synonymous with transition. All transi-
dence that the women were going through a tions involve change, whereas not all change
transition related to menopause. is related to transition.2,19 An example from
We do not believe that our analysis of the study of parents’ diagnostic transitions il-
these studies has completely resolved the lustrates the difference between change and
tension between transition awareness by transition. One of the fathers described the
clients and nurses’ knowledge of whether impact of the diagnosis of CHD as having re-
clients are in transition. Thus, the question sulted in an abrupt change in family focus.
remains: Whose awareness (nurses or However, the transition was a long-term
clients) triggers the beginning of the process, which involved the father adapting
process? These studies provide a context for to new roles and situations, coming to terms
discussion but do not resolve the paradox. with the diagnosis, and eventually resulting
in new meanings and a sense of mastery
Engagement when he understood the “whole picture.”6
Another property of transitions is the Transitions are both the result of change and
level of engagement in the process. result in change.
Engagement is defined as the degree to To fully understand a transition process it
which a person demonstrates involvement is necessary to uncover and describe the ef-
in the processes inherent in the transition. fects and meanings of the changes involved.
Examples of engagement are seeking out Dimensions of change that should be ex-
information, using role models, actively plored include the nature, temporality, per-
preparing, and proactively modifying activ- ceived importance or severity, and personal,
familial, and societal norms and expecta- and less socially engaged. Others identified
tions. Change may be related to critical or themselves as more independent, responsi-
disequilibrating events, to disruptions in re- ble, and autonomous. Migration often re-
lationships and routines, or to ideas, percep- sulted in a blurring of previously perceived
tions, and identities. For example, some par- differences such as social class or gendered
ents of infants with CHD perceived the employment. However, such blurring did
“diagnostic event” itself as the critical dise- not necessarily signify that the differences
quilibrating event, but for others cardiac sur- had been erased. Perceived difference
gery was more forcefully disequilibrating. sometimes resulted in changed behaviors or
Sawyer 4 noted that the African-American perceptions, but not all differences affected
women understood that any changes they women in the same way or held the same
experienced in their bodies could affect the meanings. In examining transition experi-
development of their babies. ences, it may be useful for nurses to con-
Confronting difference is another prop- sider a client’s level of comfort and mastery
erty of transitions, exemplified by unmet or in dealing with change and difference.
divergent expectations, feeling different,
being perceived as different, or seeing the Time span
world and others in different ways. Messias7 All transitions are characterized by flow
noted that immigrant women confronted and movement over time.2 Bridges19,20 char-
difference on many different levels. Those acterized transition as a time span with an
who had expectations of facile, abundant identifiable end point, extending from the
opportunities and easy money frequently first signs of anticipation, perception, or
were confronted upon arrival in the United demonstration of change; through a period
States with the very different reality of re- of instability, confusion, and distress; to an
stricted and sometimes demeaning employ- eventual “ending” with a new beginning or
ment. However, expectations were varied period of stability. However, the results of
and individualized, and the disjuncture the research examined here suggest that it
between expectations and reality was not may be difficult or impossible, and perhaps
always for the worse. Whereas some immi- even counterproductive, to put boundaries
grants were stunned, shocked, or disap- on the time span of certain transition experi-
pointed with the reality they encountered, ences.6 The stories told by parents of infants
others were pleasantly surprised. Immigrant with CHD indicated that their transition did
women also found differences in the food, not always follow the same chronological
supermarkets, health care system, social trajectory. Migration provided another case
patterns and beliefs, landscape, language, in point.7 Immigrants may consider their
and the way Americans show affection. One transition as “temporary” even though they
woman remarked that it involved a lot of may live in another country for an extended
work “not to be affected by all of these dif- period. Even for those who settle perma-
ferences.” Some immigrants admitted that nently, the migration experience may best be
they themselves had changed, that they characterized as an ongoing, undulating, un-
were now different because they had be- ending transition. This does not necessarily
come “more American,” more impersonal mean that immigrants or others experiencing
For example, in the family caregiving

All transitions are characterized by study,8 four critical periods were identified:
flow and movement over time. 1. the diagnostic period
2. the side-effect–intensive periods of
chemotherapy cycles
3. the junctures between treatment
long-term transitions are constantly in a modalities
state of disconnectedness, flux, or change. 4. the completion of treatment
However, such states may periodically sur- These were periods of heightened vulner-
face, reactivating a latent transition experi- ability during which participants encoun-
ence. In evaluating transition experiences, it tered difficulties with self-care and caregiv-
is important to consider the possibility of ing. Illness care conditions were changing,
flux and variability over time, which may self-care and caregiving patterns were shift-
necessitate reassessment of outcomes. ing, access to health care providers was
changing, and participants experienced un-
Critical points and events certainty and anxiety.
Some transitions are associated with an
identifiable marker event; such as birth,
death, the cessation of menstruation, or the TRANSITION CONDITIONS:
diagnosis of an illness; while in other tran- FACILITATORS AND INHIBITORS
sitions specific marker events are not as ev-
ident.19,20 The various studies involving In the discipline of nursing, humans are
multiple transitions provided evidence that defined as active beings who have percep-
most transition experiences involved criti- tions of and attach meanings to health and
cal turning points or events. Critical points illness situations. These perceptions and
were often associated with increasing meanings are influenced by and in turn in-
awareness of change or difference or more fluence the conditions under which a transi-
active engagement in dealing with the tran- tion occurs. Thus, to understand the experi-
sition experience. In addition, there were ences of clients during transitions, it is
final critical points, which were character- necessary to uncover the personal and envi-
ized by a sense of stabilization in new rou- ronmental conditions that facilitate or hin-
tines, skills, lifestyles, and self-care activi- der progress toward achieving a healthy
ties. In each study there was a period of transition. Personal, community, or societal
uncertainty marked with fluctuation, con- conditions may facilitate or constrain the
tinuous change, and disruption in reality. processes of healthy transitions and the out-
Symptoms related to the transition might comes of transitions.
also occur. During a period of uncertainty Personal conditions
there were a number of critical points de-
pending on the nature of the transition. Meanings
Each critical point requires the nurse’s at- The meanings attributed to events precip-
tention, knowledge, and experience in dif- itating a transition and to the transition pro-
ferent ways. cess itself may facilitate or hinder healthy
transitions. In the Korean menopause study,5 nomic status. The women’s experience of
although the participants had ambivalent psychological symptoms was significantly
feelings toward menopause, menopause it- affected by their socioeconomic status rather
self did not have special meaning attached than their menopausal states. As other stud-
to it. Most of the women did not relate any ies have shown,23–27 participants who have
special problems they were having to their low socioeconomic status were more likely
menopausal transition. Furthermore, some to experience psychological symptoms.
participants indicated that they went through
their menopause without experiencing or Preparation and knowledge
perceiving any problems. Therefore, in a Anticipatory preparation facilitates the
sense, “no special meanings” may have faci- transition experience, whereas lack of
litated the women’s menopausal transition.5 preparation is an inhibitor. Inherently re-
On the other hand, the African-American lated to preparation is knowledge about
women attributed intense enjoyment to what to expect during a transition and what
their roles as mothers and described mother- strategies may be helpful in managing it.
hood in terms of being responsible, protect- For one immigrant Brazilian woman, lack
ing, supporting, and being needed.4 In these of preparation was particularly stark.7 The
two examples neutral and positive mean- woman’s limited knowledge and under-
ings may have facilitated menopause and standing of geography, language, and cul-
motherhood. ture were transparent, and upon her arrival
in the United States, the consequences of
Cultural beliefs and attitudes her lack of preparation and understanding
When stigma is attached to a transition immediately became evident. She was
experience, such as menopause in Korean shocked culturally, physically, and emo-
culture, the expression of emotional states tionally. The woman had brought only sum-
related to the transition may be inhibited. mer clothes and the cold April weather
Because women in Korean culture tend to in New York took her by surprise. Crammed
regard menopause as shameful to discuss in into a room with 10 people, she looked out
public,21 they silently go through menopause the window on a strange, unknown world
on their own, and their menopausal experi- and thought she was losing her mind. Her
ence becomes a lonely experience. Symp- nightmares were a reflection of what life it-
toms then get attributed to their emotional self had become. Immigration was not only
state and become stigmatized. Their psy- a move to a different place, a different city, a
chological symptoms were noted only when different country, or a different hemisphere;
expressed physically, through headaches, she found herself literally in a different
muscle aches, and exhaustion. Perhaps Asian world, a world she had no idea existed.
and Middle-Eastern cultures express psy- The transition to motherhood provides
chological symptoms through somatization another example of the importance of
because of the fear of stigma.22 preparation and expectations.4 When a
pregnancy was not planned, or when the
Socioeconomic status mother had a history of either miscarriage
Another inhibitor to healthy menopausal or illness, the transition through the stages
transition was the women’s low socioeco- toward developing a maternal identity was
delayed. In the menopause study, lack of Inhibitors of a healthy transition for these
knowledge about menopause was found to mothers included insufficient resources to
inhibit the menopausal transition. Women support pregnancy and motherhood. Plan-
who lacked knowledge often visited clinics ning and offering classes that were incon-
because of changes in their menstruation. venient for the women was also an inhibitor.
When their physicians recommended surgi- As one woman said, “Well, actually, all the
cal treatment, the women silently followed classes were at the hospital, and I don’t have
the physicians’ suggestions because they a car. And they’re at night. And I didn’t
rarely knew about other alternatives. have a coach.” Other inhibitors of a healthy
transition for these mothers included inade-
Community conditions quate support, unsolicited or negative advice,
Community resources also facilitate or in- insufficient or contradictory information,
hibit transitions. For example, to deal with and the hassles of being stereotyped, facing
their immigration transition, Korean immi- negativity from others, or being treated like
grants turned to restaurants, laundries, and/ “public property.”4
or grocery shops in the Korean community
seeking the support of other immigrants.5 Societal conditions
However, because of the need for privacy Society at large could also be a facilitator
and the mistrust within the Korean immi- or inhibitor for transitions. Viewing a transi-
grant community, women rarely used these tional event as stigmatized and with stereo-
readily available community resources for typed meanings tends to interfere in the
issues related to health and illness. Thus, process of healthy transition. For example,
distrust within immigrant communities may gender inequity is a constraint at the societal
prevent women from using familiar re- level that influences a woman’s menopausal
sources to support their various transitions. transition. In patriarchal Korean culture, the
Until they become familiar with and have position of women in the family structure is
access to host country resources, they may well known.28 Women’s position in the
get inadequate community support during family explains why their own health care
critical times in their transitions.5 needs are put behind other family members’
African-American women also described needs, and why they sacrifice time for them-
community-level conditions that both facili- selves. Therefore, viewing the menopausal
tated and inhibited their transitions to mother- transition alone without considering gender
hood.4 Facilitators included: inequities embedded in the daily experi-
• support from partners and families, es- ences of women cannot be adequate.
pecially from the woman’s mother and Marginalization was another societal in-
other significant women in her life hibitor to the Korean immigrant women’s
• relevant information obtained from menopausal experience. Because they were
trusted health care providers and from in the margin both in the host society and in
classes, books, and other written ma- their own culture, they neglected and ig-
terials nored their menopausal experiences. They
• advice from respected sources rarely recognized menopause as a health
• role models problem. Rather, they gave priority to their
• answers to questions family matters and made their own needs
secondary. Cultural attitudes toward

women’s bodies and experiences were yet The need to feel and stay connected
another societal inhibitor to a healthy is a prominent theme in many
menopausal transition.21 transition narratives.
PATTERNS OF RESPONSE
works as important sources of information,
Process indicators housing, transportation, employment, and
Meleis and Trangenstein2(p257) state that social support. Personal contacts and con-
“nursing . . . is concerned with the process nections were a primary source of informa-
and the experiences of human beings under- tion about health care services and resources.
going transitions where health and per- Feeling connected to health care profession-
ceived well-being is the outcome.” Based als who could answer questions and with
on the studies described in this article, a whom they felt comfortably connected was
healthy transition is characterized by both another important indicator of a positive
process and outcome indicators. Because transition experience.7 This emerging dimen-
transitions unfold over time, identifying sion of transition supports the clinical evi-
process indicators that move clients either dence that providing culturally competent
in the direction of health or toward vulnera- care in hospitals requires continuity in rela-
bility and risk allows early assessment and tionships between health care providers and
intervention by nurses to facilitate healthy patients.35
outcomes.29 In each of the studies, methods
were used to uncover the processes inherent Interacting
in healthy transitions. Some of the observa- Among people with cancer and their fam-
tions about the indicators or patterns of re- ily caregivers,8 intra-dyadic interaction was
sponse that characterized healthy transitions a critical dimension of the transition experi-
are discussed below. These patterns of ence. Through interaction, the meaning of
response included feeling connected, inter- the transition and the behaviors developed in
acting, being situated, and developing confi- response to the transition were uncovered,
dence and coping. clarified, and acknowledged. Although the
diagnosis of cancer was seen by all as a cri-
Feeling connected sis event, the meaning of self-care and care-
The need to feel and stay connected is a giving varied from one dyad to another. In
prominent theme in many transition narra- some dyads, the involvement of the care-
tives. For example, making new contacts and giver was resisted as the person with the
continuing old connections with extended diagnosis of cancer struggled to maintain
family and friends were an important part of self-care. In other dyads, the involvement of
Brazilian women’s migration experiences.7 the caregiver was welcomed as a supportive
Similar to what has been documented by gesture. These strategies were clarified
other researchers,30–34 the immigrant women through interaction and reflection about the
in this study utilized social and kinship net- new and emerging relationship. Through
interaction, dyads created a context in which favorable toward the United States or the
self-care and caregiving could take place ef- postmigration experience. Such compar-
fectively and harmoniously. isons most certainly served different pur-
poses for different women at different
Location and being situated times, but they highlight the multiplicity of
Location is important to most transition perspectives in immigrants’ experiences,
experiences, although it may be more obvi- something that nonmigrants may find diffi-
ous in some than in others, such as migra- cult to understand or may misinterpret as
tion, where location often implies a unidi- criticism or condemnation.7
rectional movement from one place to
another. For immigrants, there is a constant Developing confidence and coping
actual or imaginary migration back and forth Another dimension that reflects the nature
between home and host country, between of the transition process is the extent to which
their pre- and postmigration lives.7 In their there is a pattern indicating that the individu-
stories, the Brazilian women constantly als involved are experiencing an increase in
made comparisons. They compared their their level of confidence. Developing confi-
lives, experiences, practices, and attitudes dence is manifested in the level of under-
pre- and postmigration, from when they first standing of the different processes inherent
arrived, and after they had lived in the United in diagnosis, treatment, recovery, and living
States for a while. They compared almost with limitations; in the level of resource uti-
anything: health care, food, diet, nutrition, lization; and in the development of strategies
family relationships, child rearing, prices, for managing. The dimensions of developing
domestic work, climate, weather, employ- and manifesting confidence are progressive
ment and work opportunities, and gender and from one point to the next in the transition tra-
class relations. The women also brought di- jectory. As one participant in the African-
verse perspectives to their migration experi- American pregnancy study4 put it, “So I fig-
ences. One of the characteristics of transi- ured . . . I guess he’s getting enough milk.
tions is the creation of new meanings and He’s gaining weight. It must be OK. So I
perceptions. Comparisons were one of the didn’t worry.” Another participant in the
ways the immigrant women presented, ex- same study was more confident because, as
amined, and made meaning of their experi- she put it, “I have a schedule, and I’m just so
ences. They understood their new life by in tune with his schedule.” Participants
comparing it to the old. demonstrated cumulative knowledge of situa-
Making comparisons was also a way of tions, more understanding of critical and turn-
“situating” themselves in terms of time, ing points, and a sense of wisdom resulting
space, and relationships; a way to explain from their lived experiences.
and perhaps justify how or why they came,
where they are and where they have been, Outcome indicators
and who and what they are. The compar- Two outcome indicators emerged from the
isons were multidirectional in the sense that studies examined in this analysis: mastery
some were favorable toward Brazil or the of new skills needed to manage a transition
premigration experience, and others were and the development of a fluid yet integrative
identity. The levels at which these outcomes mastery results from blending previously
are experienced may reflect by proxy the established skills with skills newly devel-
quality of life for those who are experiencing oped during the transition process. Also,
transitions. The determination of when a skill develops over time with experience.
transition is complete must be flexible and Thus, mastery is unlikely to be seen early in
variable depending on the type of change or a transition experience. However, by the
the event initiating the transition, as well as time clients are experiencing a new sense of
the nature and patterns of transition. If out- stability near the completion of a transition,
comes are considered too soon in a transition their level of mastery will indicate the ex-
process, they may be process indicators. If tent to which they have achieved a healthy
they are examined too long after a transition transition outcome.
is complete, they may be related to other
events in the client’s life. In some transitions, Fluid integrative identities
it is easier to determine a beginning and an Transition experiences have been charac-
ending point. In all transitions, there is a sub- terized as resulting in identity reformula-
jective element of achieving a sense of bal- tion.3,38 The results of Messias’7 research sup-
ance in one’s life. In the studies reported port the conceptualization of immigrants’
here, mastery and having a new sense of reformulated identities as fluid rather than
identity reflected healthy outcomes of the static, as dynamic rather than stable. Some
transition process. degree of ambiguity is also a part of the no-
tion of a fluid migrant identity. The concept
Mastery of fluid migrant identities as identified in the
A healthy completion of a transition is stories of these Brazilian immigrant women
determined by the extent to which individu- also supports the incorporation of a transna-
als demonstrate mastery of the skills and be- tional perspective within a transition frame-
haviors needed to manage their new situa- work of migration. For the women in this
tions or environments.36 In the motherhood study, one of the characteristics of the “new
study,4 one participant described mastery by identity” that came with migration was that
indicating that “At about 2 months I started their perspectives were now bicultural rather
making my own decisions.” Another de- than monocultural.
scribed mastery as taking charge of her In moving to, settling in, working, and in-
care: “I had to ask for that test you know. I teracting within another social, political, eco-
would think that the doctors would know nomic, and cultural environment and context,
. . . she had forgotten.” Skills needed to the migrant acquires added baggage, in that
achieve mastery in the caregiving situation she begins to carry around the baggage of two
included monitoring and interpreting symp- (or more) cultures, two (or more) different
toms, making decisions, taking action, pro- ways of being. At different times and in dif-
viding hands-on care, making adjustments, ferent spaces in a migrant’s life, she may
accessing resources, working collabora- carry more baggage from the home or host
tively with the care receiver, and negotiat- country or culture. In terms of space, she may
ing the health care system.37 The results of have more home country baggage in her do-
the family caregiving study suggest that mestic or social arena, in contrast to the
workplace where she may have adapted more Middle-range theories are characterized by
to the host country. However, there is no set more limited scope and less abstraction than
pattern or formula. Because the migration grand theories. Also, they address specific phe-
transition is dynamic and ongoing, over time nomena or concepts and reflect practice.9
an immigrant may periodically pick up or Because diverse types and patterns of transi-
leave behind different pieces of this identity tions were considered in this theoretical devel-
baggage. Situations that may trigger a change opment, we believe that the emerging frame-
in focus or perspective include developmen- work gives a more comprehensive view of
tal, situational, or health-illness transitions transitions, providing more specific guidelines
such as marriage, pregnancy, personal or for practice and driving more systematic and
family illness, or a change in employment. coherent research questions.
These transitions are then likely to be viewed As the studies presented in this article in-
from a bifocal perspective.7 dicate, transition experiences are not unidi-
mensional. Rather, each transition is charac-
terized by its own uniqueness, complexities,
CONCLUSION and multiple dimensions. Future endeavors
should be directed toward defining the di-
Knowledge is empowering to those who versities and complexities in transition expe-
develop it, those who use it, and those who riences through research with diverse popu-
benefit from it. Understanding the properties lations in diverse types and patterns of
and conditions inherent in a transition process transitions. Each concept proposed here
will lead to the development of nursing thera- needs to be further developed and refined.
peutics that are congruent with the unique ex- Similarly, research to discover the levels and
periences of clients and their families, thus nature of vulnerability at different points
promoting healthy responses to transition. during transitions could be driven by this
Theories provide frameworks for under- middle-range theory. Finally, nursing thera-
standing complex situations such as vulnerable peutics that reflect the diversities and com-
clients’ processes and responses to transitions. plexities of the transition experiences need
A middle-range theory of transitions emerged to be identified, clarified, developed, tested,
from the analyses of the studies presented here. and evaluated.
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Experiencing Transitions: An Emerging Middle-Range Theory

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Article2 07/13/00 5:45 pm Page 12 PageWork 1 PageWork 1:Desktop Folder:ANS 2301/Revision/Final:Article 2:

Afaf Ibrahim Meleis, PhD, FAAN

Linda M. Sawyer, PhD, RN

Meleis: Professor, Department of Community Health

Adv Nurs Sci 2000;23(1):12–28

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concept of the grounded theory. The study

Fig 1. Transitions: a middle-range theory.

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For example, in the family caregiving

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secondary. Cultural attitudes toward

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28 ADVANCES IN NURSING SCIENCE/SEPTEMBER 2000

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