Transition Theory in Our Patient Populations

Mary Sparks, RN Matthew Green, RN Alanna Fant, RN Dawn Johnson, RN

Transition Theory

• Using Transition Theory we will explore our specialties in the application of Transition Theory.

• Transition means to move from one situation or phase to another (Davidson et al., 2007).

A Transition

• A transition can be developmental, related to stages, or situational to an illness or social situation (Davidson et al., 2007).

Transition Theory in Patients with Strokes

• Poor transitioning from pre-stroke to post stroke for a patient can lead to major depression, low performance of activities of daily living, and a decrease in mental and physical abilities (Astrom, Asplund, & Astrom, 1992). • Transition theory can be applied here to help decrease these incidents.

• According to Astrom, Asplund, & Astrom (1992) after having a stroke a patient is less likely to go for walks, clean their homes, or do their own cooking. By helping with the transition from independent to dependent a patient’s outcomes could increase greatly. Assisting a patient with this transition could help lower the chances of having another stroke, developing hypertension, or cardiac condition.

• According to Astrom, Asplund, & Astrom (1992) the earlier the psychosocial needs of the patient are recognized and intervened on the better the outcome for the patient. One way of using the transition theory is to do a full assessment.

Patient Assessment

• What kind of lifestyle did the patient have before the stroke?

• Did they handle their ADL’s on their own before or did they help?

• What kind of support system does the patient have in place?

• Was the patient the sole income for the family?

• Was the patient the caregiver to someone else?

• How active was the patient socially before the stroke?

• What kind of therapy will the patient need?

• Once the medical, physical, mental, and psychosocial aspects with the use of the Transition Theory are addressed, the patient can begin to resume the life they had pre-stroke.

Transition Theory in Patients and Family in Nursing Home Entry

Purpose

• The purpose of the study was to explore the extent of which Meleis’s mid-range theory of nursing transitions is supported from the finding from a study exploring the relatives’ experiences of moving to a nursing home (Davies, 2005).

Mid-Range Theories

• Mid-range theories are useful tools with understanding the nursing practice but many have not yet been fully tested (Davies, 2005).

Aims of the Study

• Given the dearth of literature exploring relatives’ experiencesof the move to a nursing home the aims of the study were: – to describe and interpret the experiences of family caregivers – in relation to helping a relative to move into a – nursing home and continuing to support them in such a – setting, – to describe and interpret staff and family caregivers’ perceptions – of current practice within nursing homes in relation – to supporting and involving family caregivers, – particularly around the time of admission and – • to generate understandings and insights to inform, assist – and empower older people who experience admission to a – nursing home in the future and their family caregivers. (Davies, 2005, p. 659,661)

Method of study

• Two phases were used

The First Phase

• The first phase started with 37 interviews with 48 people that experienced admissions of a close relative into a nursing home (Davies, 2005).

• The participants were recruited by contacting the nurse managers and asking them to distribute information about the project to relatives, and for them to contact the researchers. Using advertisements in local newspapers and publications were included in recruiting (Davies, 2005).

• The interviews mostly occurred in the participants own homes and were focused on events leading to the admission, experience of the relocation and involvement since (Davies, 2005)

The Second Phase

• A detailed study of three nursing homes was done to inquire about relatives’ experiences with the day to day living in the nursing homes. This included; field notes, participant observation and filed notes, interview with staff, residents and families, researches experience at the facilities and analyzing of documents (Davies, 2005).

• Between twelve and fifteen days were spent at each home for about five to six months (Davies, 2005).

The Findings

• Three phases to the transition (Davies, 2005) • “Making the best of it” • “Making the move” • “Making it better”

• Experiences categorized with five continuums reflecting the extent they thought they were: feeling (Davies, 2005) – under pressure or not – in the know or working in the dark – working together or working apart – in control of events or losing control – feeling supported or unsupported

• At each phase of transition, members should: – work in partnership with older people and their family caregivers, – be aware of the range of pressures which family caregivers are experiencing and attempt to minimize these pressures wherever possible, – ensure that older people and their family caregivers are well informed, – enable older people and family caregivers to maintain control over events and decision-making and – ensure that older people and family caregivers are supported, both in practical and emotional terms (Davies, 2005, p.670)

• “Meleis’s theory of nursing transitions presents a comprehensive framework which recognizes the significance of transitions for health and attempts to encapsulate characteristics and indicators of healthy transition processes in order to suggest appropriate nursing interventions.” (Davies, 2005, p.670)

Critique of the research

• “Important limitations of Meleis’s theory highlighted by these data include a failure to represent the reciprocal nature of relationships between nurses and family caregivers, and a lack of recognition of the potential to work in partnership with older people and their families in order to achieve the most positive outcomes for all concerned.” (Davies, 2005, p. 670)

• The research using this model worked well with the transition theory. The research did point out that even though the model works it does not integrate all facets involved with transitioning. Family members of the resident moving into the nursing home are neglected with the model and it does not encourage family participation with the transition.

Transition Theory in Patients with Congestive Heart Failure

Diagnosis of Heart Failure

• A diagnosis of heart failure often occurs as a sentinel event in a patient’s life. This is a critical event in which the patient and family needs to process new information, make peace with a new reality and cope with the loss or perceived loss of a planned future (Davidson, Philliips, Daly, Dracup, & Padilla, 2007).

This is also known as a trigger event (Davidson et al., 2007).

Trigger Event

• With Heart Failure a trigger event can be at the time of new diagnosis or an exherbation of the condition with a time of deterioration (Davidson et al., 2007).

Nursing Role

• Nurses can assist in these times by assisting the patient and family in coping with their situation and making peace with the situation. This is particularly important in times of advancing illness (Davidson et al., 2007)

Factors influencing Transition

• Patients diagnosed with Heart Failure have many factors to confront: – Alteration in social roles – Impairment of functional and cognitive capacity – Impairment of social roles – High rates of morbidity and mortality (Davidson et al., 2007)

Factors Influencing Elements of Transition

Factor

Individual Social Relationships Organizational and societal factors

Examples

•Self-efficacy •Perceived control •Socioeconomic factors

Barrier

•Socioeconomic deprivation •Depression •Anxiety •Cultural beliefs and values •Level of societal support •Quality of communication with Healthcare providers •Cultural values and mores •Healthcare System •Access to healthcare services •Level of insurance •Living alone and socially isolated •Poor communication with multiple providers •Inaccessibility to rehabilitation and palliative care services

Facilitator

•Strong sense of self efficacy •Perceived control •Positive orientation and hope •Strong social support •Family sense of responsibility •Communication between healthcare providers •information (Davidson et al., 2007)

Nursing Interventions

• Aid patient and family in coping • Aid patient and family in adjusting to new life situations • Reduce occurrence of adverse events • Promote adjustment to diagnosis • Promote self-care (Davidson et al., 2007) Nursing interventions for the transition to palliative care are critical as heart failure progresses (Davidson et al., 2007).

Multidisciplinary Approach

• Care that is supportive and transitional is a multidisciplinary effort that addressed the functional, psychosocial, and spiritual and symptom management issues during the entire spectrum of the disease, from diagnosis to death (Davidson et al., 2007).

Maintaining Hope in Transition

Hope and Control

• The philosophy of hope and control can assist patient and families in health and social circumstances (Davidson et al., 2007).

Maintaining Hope in Transition Model

• The Maintaining Hope in Transition Model places emphasis on healthcare providers in guiding patients and their families through information and support especially through the uncertainty. The model acknowledges the interaction between hope and control (Davidson et al., 2007).

Conceptual Model- Maintaining Hope in Transition

 Clinical Characteristics  Social Circumstances  Level of social support  Existential and spiritual support Critical Event eg diagnosis of Heart Failure

Transition Phase

Potential for health professional intervention to assist with

 Information  Instrumental support  Empowerment  Advocacy  Processing of Events  Promotion of Self Care  self-reliance (decreased dependence on health professionals eg ER presentations)  positive future orientation  self-care behaviors  Hope  Control  Quality of life  Social support  Uncertainty  depression (Davidson et al., 2007)

Transition Theory in Discharge Planning of High Risk Older Adults

Reduction in Readmission

• The Centers for Medicare and Medicaid Services (CMS) has issued a priority to reduce acute care admission rates, particularly a readmission for the same or related diagnosis. (Dyer, 2006)

Many issues contribute to rehospitalization including: • Early discharge • Poor social support • Poor medication adherence • Poor disease management • Frail health • Poor follow up (Dyer, 2006)

Cost of Readmission

• In the Medicare population readmission for any reason occurs in 20-50% of patients within 14 days to 6 months with an average charge of $15,000 per readmission. These numbers prove how crucial transitional care planning is. (Dyer, 2006)

Impact of Nursing

• Nurses spend the majority of time with the patient in the acute care setting which gives them great opportunity for education that promotes success in the transition from hospital to home.

Discharge Planning

• Discharge planning should start with admission assessment and include: – Comprehensive patient history and assessment – Knowledge deficits – disease process, signs and symptoms, emergency care plan and medication management – Barriers to learning language, cultural, past experience, cognitive abilities, physical capabilities – Barriers to compliance knowledge socioeconomic and economic factors – Home safety – Psychosocial, medical and community support (Dyer, 2006)

Discharge Plans

• A comprehensive discharge plan should also include in the care plan development: – Individualized clinical pathways – Medication management plan – Communication between healthcare providers – Referrals using a multidisciplinary approach – Coordination of follow up with appropriate healthcare providers – Primary care physician update (Dyer, 2006)

Patient Education

• When educating the patient, information should always include: – Diet – Disease management – Patient self care management – Safety factors (Dyer, 2006)

Educating Patients

• Nurses should consider the following when educating patients: – Patient caregiver readiness – Language and health behavior – Environment – Appropriateness of verbal/written instructions – Asking for patient understanding verbally – Observe return demonstration if appropriate – Documentation of all education and responses.

Discharge Planning using the Transitional Care Model

• The Transitional Care Model utilizes 10 screening criteria which were developed based on data regarding older adults and common medical-surgical DRG’s. (Bixby and Naylor, 2009)

• Screening Criteria (Bixby and Naylor, 2009) – Age 80 or older – Moderate to severe functional deficits – An active behavioral and/or psychological health issue – Four or more active co-existing health conditions – Six or more prescribed medications – Two or more hospitalizations within past 6 months – Hospitalization within past 30 days – Inadequate support system – Low health literacy – Documented history of non adherence to the therapeutic regimen

• “If two or more criteria present further investigation is warranted and formal collaborative assessment of discharge planning-transitional care needs should be initiated.” (Bixby and Naylor, 2009)

• This model has the ability to identify patients at high risk for poor outcomes when the patient is suffering from an acute or exacerbation of a chronic illness. The screening does not require any advance training and it is quick and easy. The information gathered would trigger the need for any transitional care services which may be needed. (Bixby and Naylor, 2009)

• “This Evidence Based Approach should be completed by registered nurses or advanced practice nurses managing the complex care of the hospitalized older adult.” (Bixby and Naylor, 2009)

• This model aligns with the Transition Theory by assisting the patient safely from hospital to home. An elderly patient with acute conditions or exacerbation of a chronic condition has an increased chance of readmission. Transitional care from hospital to home help reduces the risk of readmission and helps to protect the member when he/she transitions from hospital to home.

Discussion Questions

• With Discharge planning for the high risk adult so important how does the facility where you work handle this issue?

• Is the discharge plan a high priority? If not, do you think it should be? Why?

• What are some things that can be done to help patients and family cope with transition?

• What are some “red flags” to be watching for in patients who may not be transitioning well?

• Does you unit/workplace address transition difficulties? If not, do you feel it would be a valuable tool? Why or why not?

• Do you think transition is applicable to all fields? If not, what are some of its restrictions?

References

• • • • • Astrom, M., Asplund, K., & Astrom, T. (1992). Psychosocial function and life satisfaction after stroke.

The American Heart Association, 23

(4), 527-531. Retrieved from http://stroke.ahajournals.org

Bixby MB; Naylor MD, (2009). The Transitional Care Model (TCM

): Hospital Discharge Screening Criteria for High Risk Older Adults.

Jan-Feb; 19 (1): [62-3] (journal article questionnaire/scale) ISSN: 1092-0811 PMID: 20336990 CINAHL AN: 2010610776 Davidson, P. M., Philliips, J., Daly, J., Dracup, K., & Padilla, G. (2007, January/February). Maintaining hope in transistion: a theoretical framework to guide interventions for people with heart failure.

Jounral of Cardiovascular Nursing

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22

(1), 58-64. Retrieved from CINAHL Database.

Davies, S. (2005). Meleis’s theory of nursing transitions and relatives’ experiences of nursing home entry [Electronic version].

Journal of Advanced Nursing

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52

(6), 658 671. doi:10.1111/j.1365-2648.2005.03637

Dyer, Paul, (2006).

Discharge Planning and Education Can Help Prevent Rehospitalization.

Arkansas State Board of Nursing (ASBN) Update, 10 (5): 8-9. Retrieved from www.cinahl.com/cgi-bin/refsvc?jid=1813&accno=2009519469