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Role Paper Grading RubricArea of FocusPoints PossiblePoints Earned1. Introduction – Presented purpose of paper2 – Identified specific topics to be discussed in an introduction22. Identified a specific APN role after graduation and validated purpose for selecting this role.103. Briefly discussed history of the APN role selected64. Discussed the events that supported the development of this specific APN role.105. Presented your personal philosophy of nursing for the APN role.156. Discussed a personal vision for advanced practice in this specific APN role area AND one needed personal change to implement this vision.107. Discussed one needed change at the national level and one needed change at the state level to achieve your personal vision.108. Discussed three specific individual actions that can advance your personal vision.159. APA format/Maximum length 5 pages (body of paper) excluding title page, abstract and reference page.1010. Used correct grammar, sentence structure, spelling, punctuation, etc. Correctly cites all references and used no more than one short quote.10Total Points Earned = _________*Please follow the rubric closely. *The answer to question number 2 is Family Nurse Practitioner
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Facilitating transition: Redefinition of a nursing
mission
ARTICLE in NURSING OUTLOOK · NOVEMBER 1994
Impact Factor: 1.83 · DOI: 10.1016/0029-6554(94)90045-0 · Source: PubMed
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Afaf Meleis
University of Pennsylvania
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Retrieved on: 09 September 2015
Facilitating Transitions: Rdefinition
of the Nursing Mission
Afaf lbrahim Meleis, phD, D~PS(~OIT), FAAN
Patricia
A. Trangenstein, phD, RN
Nursing is concerned with the process
and experience of human beings
undergoing transitions.
T
here have been numerous dia- For example, Newman’ has stated that
logues in nursing about its mis- the challenge before nursing is to idension and definition, but a refinement of tify and agree on the central focus of
existing definitions has yet to be of- nursing. Similarly, one of us (A.M.) has
fered. This article is written with the pleaded for substantive knowledge degoal of maintaining a vigorous dis- velopment in nursing and has identicourse.
fied constraints to knowledge developThe phenomena of concern to the ment as the multiplicity of educational
discipline of nursing that have been preparations, the multiplicity of drivdescribed by various theorists, and gen- ing theories, the lack of an organizing
erally accepted by members of the dis- concept, the focus on process rather
cipline, are health, person, environthan substance, the devaluation of clinment, and nursing therapeutics. Yet ical focus and valuation of science, and
the multiplicity of viewpoints regard- the rise of ethnocentricity.2 What is
ing these concepts and the paucity in needed is an organizing concept that
their systematic development
has allows for a variety of viewpoints and
prompted many to question their util- theories within the discipline of nursity in providing the discipline with a ing. Such a concept should not be culcoherent definition. The extent to turally bound, and it should help in
which the mere identification of these identifying the focus of the discipline.
concepts as central has helped in furWe submit that the transition experithering the development of nursing
ence of clien ts, families, communities,
knowledge is also questionable. The nurses, and organizations, with health
challenge members of the discipline
and well-being as a goal and an out
face is to define the mission of nursing.
come, meets these criteria.
The mission, then, could give more
Previously, Chick and Meleis,3 Mesubstance to these central concepts.
leis,4 and Schumacher and Melei$ arRecently, defining the mission has gued that transjtion is a central concept
been advocated by many in nursing.
to nursing. Unlike the other identified
central concepts in nursing, transition
is not a concept that is inherent in the
NURS OUTLOOK
1994;42:255-9.
writings of many of the nurse theorists.
Copyright
@ 1994 by Mosby-Year
Book, Inc.
0029.6554/94/$3.00
+ 0 35/l/54995
However, the concept of transition
NURSING OUTLOOK
NOVEMBER/DECEMBER
1994
may be thought of as being congruent
with or related to such concepts as adaptatio#; self-care’; unitary human
developments; expanding consciousness,9 and human becoming.‘O Therefore the purpose of this article is to
propose that facilitating transitions is a
focus for the discipline of nursing. We
argue that the mission of nursing
should be redefined in terms of facilitating and dealing with people who are
undergoing transitions, and we provide
a framework that clarifies aspects of
clients, health, and environment. We
further argue that such a focus is not
being imposed on the discipline; rather,
it is a focus that reflects the practice of
nursing as demonstrated by clients’
nursing care needs, by actions of clinicians, and by the choices of investigators of nursing research questions.
The challenge
members of the
discipline face is to
define the mission
of nursing.
THE MISSION OF NURSING
Attempts at articulating a substantive
focus in nursing have been made by a
number of metatheorists, as well as by
the authors of the 1980 ANA Social
Policy Statement, which defined nursing as “the diagnosis and treatment of
human responses to actual and potenMeleis and Trangenstein
255
tial health problems.“9 This definition,
used by members of the discipline, has
been instrumental in providing nursing with a focus. However, further development of the mission of nursing
has been limited. In addition, the definition of nursing practice as described
in this important document has lent
itself to the development of topologies
or listings of human responses without
an equal emphasis on the nursing therapeutics needed. Moreover, there is a
lack of a framework that may help
nurses decide what is a health problem
and what are the health care priorities
from a nursing perspective. More recently, Newman et all2 proposed that
the focus of the discipline of nursing is
“caring in the human health experience.” Some questions emanating from
Such a focus is not
a foiws that is
be&y immd
on
the dkciphe;
it
re
ts the pmice
of nwrsiflg.
this focus: (1) Is it possible to study
caring using empiricism as a framework? (2) If caring is universal and not
limited to one discipline, what aspects
of caring are unique to nursing?’ (3)
Which human health experiences require nurses’ unique contributions?
Furthermore, because of the impersonal nature of bureaucratic systems,
caregivers in institutions are often un
able to provide personalized care, because of limitation in defining the
scope of care, the diffusion in their
daily responsibilities, their limited
power, and the expectations that bedside caregivers compensate for deficiencies in the resources of the system
through their caring process. Without
an expectdion of mutuality and reeiprocity in the caring relationship,
exploitation and oppression of the care
giver at the individual and institu256
tional level may-occur.i3 And without
the [email protected] of some de5aing
boundaries far the human health ex
perience, priorities of care may not be
clear.
The scope of nursing was also defined. According to Fawcett,i4 who utilized the work of Donaldson and Crowleyr5 and Gortner, I6 four propositions
that define the scope of nursing are as
follows:
The discipline of nursing is concerned with the principles and
laws that govern the life process,
well-being, and optimal functioning of human beings, sick or well.
The discipline of nursing is concerned with the patterning of human behavior in interaction with
the environment in normal life
events and critical life situations.
The discipline of nursing is concerned with the nursing actions
or processes by which positive
changes in health status are affected.
The discipline of nursing is concerned with the wholeness or
health of human beings recognizing that they are in continuous
interaction with their environment.
While these definitions and scope of
nursing practice have been instrumental in promoting constructive dialogues
about the mission of nursing, we believe that using transitions as a framework adds an important dimension to
identifying boundaries of nursing, to
refining phenomenon of the discipline,
to establishing priorities, and to developing congruent nursing therapeutics.
In previous work by Chick and Me&s3
and Schumacher and Meleis5 a framework with which to view the concept
of transitions was identified. Transition
has been defined as “a passagefrom one
life phase, condition, or status to another. . . Transition refers to both the
process and outcame of complex per
son-environment interactions. It may
involve more than one person and is
v
embedded in the cOntexE and the situA [email protected]&&-&i denoteS a change
in health status, in role relations, in
expectations, or in abilities. It denotes
a unique constellation of patterns of
responses over a span of time.
In general, the structure of a transition consists of three phases, entry,
passage, and exit.“Commonalities
that
characterize a transition period include
process, disconnectedness, perception,
and patterns of response. One important consideration of transition is that
the completion of a transition implies
that a person has reached a period of
less disruption or greater stability
through growth-relative to what has
occurred before. Increments, as well as
decrements, may be viewed as positive,
as the potential for disruption and dis
organization associated with pretransitional states is countered on successful
completion of the transition.”
Additional support for transitions as
the focus of the discipline of nursing
comes from the extensive literature review provided by Schumacher and
Meleis.” Three hundred-ten ~citations
with the word “transition” appearing
in the nursing literature between 1986
and -1992 were reviewed. The identified articles crossed specialty areas and
professional roles (educator, practitioner, administrator, and researcher).
In the analysis, several categories
emerged. These categories, emerging
from research and clinical article reviews, lend support to the theoretical
categories identified ear1ier.s Types of
transitions that nurses deal with are as
follows:
1. Individual~-developmn~al transitions, such asadolescence, becoming aware of sexual identity and
going into midlife
2. Family development&
transitions, such as mother-daughter
relationship,
parenthood,
and
childbearing family
3. Situational transitions, such as
educational transitions, changing
professional roles, widowhood, re-~
location to nursing home, family
caregiving, and immigration
4. Health/illness
transitions, such
ilEic)ft.i’3
6
as the recovery process, hospital
discharge, and diagnosis of
chronic illne:ss
5. Organizational transitions, such
as changes in leadership, implementation of new policies or practices, implementation
of a new
curriculum, changes in nursing
as a profession, and changes in
communities
In the review of these articles, three
indicatorsof successful transitions were
described: emotional well-being, mastery, and well-being of relationships.
Given the unique focus of nursing on
health, additional indicators identified
included quality of life, adaptation,
functional ability, self-actualization,
Nursing’s unique
contribution
is its
goal of a sense of
well-being.
expanding consciousness, and personal
transformation.5 Theoretically, there
is support that an additional outcome
indicator that should be addressed is
purposeful and mobilized energy.181 l9
While some outcomes have been identified fromexistiqg literature, it is most
likely that emphasis on selected outcomes will be dictated by the profession’s social commitment and responsibility within a given culture and not
only by the theoretical nature of the
discipline.
Other disciplines may also focus on
transition; however, nursing’s unique
contribution is it,s goal of a sense of
well-being. Defining nursing as “facilitating transitions to enhance a sense of
well-being” gives nursing a unique
perspective. Only nursing facilitates
transitions toward health and a perception of well-being. No other discipline
has this process orientation to the transition experience. No other discipline
needs as much of a knowledge base to
help clients achieve a sense of mastery,
a level of functioning, and a knowledge
NURSING OUTLOOK
of ways by which their energy can be
mobilized.
Within
the transition
framework, caring would be seen as a
process that facilitates successful transitions that is not bound by a medically
determined beginning and ending of
an event. Admission and discharge of
patients are events that could be considered either at a point of time or as
transitional experiences. The former
limits nursing actions to that slice of
time; the latter allows preparation for
continuity of care, a process of coping
within, and a longer time framework.
Nursing, then, is concerned with the
process and the experiences of human
beings undergoing transitions where
health and perceived well-being is the
outcome. The development of nursing
therapeutics could be focused on the
prevention of unhealthy transitions,
promoting perceived well-being and
dealing with the experience of transitions. Theory development should aim
to provide greater understanding and
insight into the transitional experiences. Within this focus, then, the
goals of knowledge development in
nursing are to enhance an understanding of2:
1. The processes and experiences of
human beings who are in transition
2. The nature of emerging life patterns and new identities
3. The processes or conditions that
promote healthy outcomes, such
as mastery, perceived well-being,
energy mobilization, quality of
life, self-actualization, expanding
consciousness, personal transformation, and functional ability
4. Environments that constrain, support, or promote healthy transitions
5. Structure and components of
nursing therapeutics that deal
with transitions
A focus on transitions provides a
framework that:
1. Acknowledges universal aspects
of nursing
2. Enhances nurses’ potential in supporting emerging identities and
life patterns
NOVEMBER/DECEMBER
1994
3. Supports nurses’ concerns about
changing systems and societies
4. Challenges nurses todevelop therapeutics supportive of positive
experiences and healthy outcomes
It provides nurses with a framework
to understand variations in the recovery transition, the hospital admission
transition, the immigration transitions,
the discharge transition, the rehabilitation transition, as well as the experiences of clients who are in multiple
transitions. It highlights the need for
knowledge related to transitions into
new roles and new skills. The transition experienced by people during the
modernization process of societies becomes an important focus within the
discipline. The birthing transition, the
transition into home care, and the caregiving transition would also receive
more attention internationally. None
of these events, experiences, and responses becomes ahistorical or isolated.
When considering transition as an organizing framework, the events, experiences, and responses are recognized as
processes that require a longitudinal
and multidimensional approach and a
focus on patterns of response over time,
all of which are more congruent with
nursing than viewing any of their
transitional experiences as events creating change. Such consideration limits the events to singular responses in a
single slice of time.
Transition
Versus Change
are processes that occur
over time and that have a sense of flow
and movement. Change, on the other
hand, is defined “to take instead of,
substitute one thing for another, put,
adopt a thing in place of another, and
tends to be abrupt.“20 Transition incorporates some aspects of change but extends the concept to incorporate flow
and movement. Another universal
property is found in the nature of
change that occurs in transitions. At
the individual
and family levels,
changes occur in identities, roles, relationships, abilities, and patterns of behaviors. At the organizational level,
Transitions
Meleis and Tratqenstein
257
changes occur in structure, function,
or the dynamics of the organization.
These properties help to differentiate
transitions
from
nontransitional
change. For example, brief, self-limiting illness has not been characterized
as a transition, whereas chronic illness
has been viewed as requiring a process
of transitionzl, 22 Similarly, phenomena such as mood changes that are dynamic but do not have a sense of
movement or direction are not conceptualized as transitions. Finally, internal processes usually accompany the
process of transition, while external
processes tend to characterize change.”
A Chicaf Example
One of the challenging clinical problems is the treatment and management
of breathing difficulties. Canceptually,
breathing difficulties are similar to
other problems in that they are not
merely a reflection of a physiologic
event but evolve out of a complex interaction of personal, environmental,
and health status factars.23t24 Currently, three major approaches to the
study and treatment of breathing difficulties have emerged. These are the
biomedical/physiologic
approaches,
with an emphasis on medication and
oxygen therapy, breathing retraining,
smoking cessation, exercise conditioning, and nutritional evaluation.25-N A
second approach has been the exploration of various psychologic and personality characteristics associated with
dyspnea primarily in clients with
COPD. Findings from this approach
have led to the use of psychatropic
agents and relaxation methods.26J 31-37
The third approach has focused on
258
Malais and Trwin
coping strategies used by clients with
dyspnea.24! 38-4o
Few interventions have been proposed or clinically tested to relieve
breathing difficulties.41 Some nursing
interventions, such as teaching breathing techniques, energy-conservation
measures, exercise programs, desensitization and guided imagery, and environmental temperature control, have
been applied in a clinical setting. However, one of the most challenging and
frustrating dilemmas for the nurse at
the bedside is the experience of caring
for a frightened client sitting up at
bedside unable to catch his or her
breath. The focus on symptom control
rather than viewing this as a transltional experience may contribute to
the lack of long-term, intermittent,
and only hospital bound nursing interventions. If the experience of the client
with breathing difficulties was viewed
as a transitional experience with desired outcomes being mastery, irnproved functional ability, or improved
quality of life, and with the goal of
achieving a period of less disruption or
greater stability through growth, the
nursing approach to the problem would
be qualitatively ditierent. It could transcend hospitalization and strategies that
are biomedically driven. The lived experiences, the daily life events, and
lifestyles will more accurately drive
nursing therapeutics. A variety of research methods could be used to study
which groups of clients do better with
selected interventions
at different
phases of the transitional experience
and to identify which kinds of environments support or hinder a healthy
transition. Levels of mastery in coping
with the transitional phases will need
to be explored. Similarly, the cumulative nature of knowledge related to
breathing difficulties will be taken into
consideration when conceptualizing
breathing ease as a transition.
There are multiple paradigms and
viewpoints that guide and inform the
discipline of nursing. This multiplicity has prompted many analyses and
critiques and polarized some to prefer
and espouse the adaption of one view,
one theory, or one paradigm over another. Our intention is not to reconcile
the differences between these different
viewpoinB. As Skrtic4” has stated: “the
point is not to accommodate or reconcile the multiple paradigms; and ro
recognize them for what they arcways of seeing that simultaneously reveal and conceal.” Rather, our intent is
to suggest that by considering transitions as focal and central to the discipline of nursing ;I more focused
dialogue and debate that advances
knowledge development could occur.
What advantages- does transition offer for the development of nursing?
First, it offers an organizing framework
that emphasizes processes that~are longitudinal and multidimensional in nature and patterns of responses over
time. All are more congruent with
nursing. An integrating and organizing
conceptual framework makes it easier
for a nurse to capitalize on what he or
she already knows and to use ~existing
knowledge more insightfully. Second,
it provides a common language that
can encompass all specialty areas, professional roles, and theoretical and
methodologic camps. Both the received
view …
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