Abstract
Life transitions are periods in time when individuals experience major changes. Transitions may occur during periods between two relatively stable states of human development. The associated changes with the transition bring instability as the person passes through the period. During this period, the individual is typically required to make major adjustments, to develop new skills, or to learn to cope with new experiences. One major life transition begins during the final year or years of high school. This transition, unlike childhood transitions, for many individuals will include a move from one’s childhood home and away from their family of origin and from an established network of friends. A successful transition to young adulthood will form a foundation for the individual in future stages of development and transitions. Three frameworks of transition, developmental psychology, counseling, and nursing, are described.
INTRODUCTION
Life transitions are periods in time when individuals experience major changes. These transitions can occur when someone is faced with a new diagnosis, with a death, or during a period between two relatively stable states of human development. The changes associated with transition bring instability as a person passes through the period. During this transition period, the individual is typically required to make major adjustments, to develop new skills, or to learn to cope with new experiences to accommodate the changes. At the end of the transition, the individual is at a new stage in life. Theoretically, the transition has ended at this point, and a period of more stability and less change has begun.
Schumacher and Meleis (1994) described transition as a concept central to the discipline of nursing. The importance of the concept to nursing centers on their observation that nurse–client encounters frequently happen during transitional periods of instability that are generated by developmental, situational, or health changes. It is this instability that may result in vulnerability to risks that may affect health and the need for nursing’s involvement (Meleis et al., 2000). Thus, the nurse is drawn in to assist, support, or prepare clients for changes to ease the transition and enhance the outcome. There are many examples of interventions nurses provide, including anticipatory guidance, for parents during preschool or early childhood screening programs. Anticipatory guidance may also facilitate the adjustment of school-age children entering a new district or beginning middle or junior high school.
One transition of importance and of interest to school nurses is the period of change from late adolescent to young adult that takes place during the last year of high school, which includes graduation and the settling into roles of greater independence. Although this is a common and important period, the role of the school nurse in this transition is virtually unexplored. This transition is the result of a change in which the adolescents move away from the familiar routine of high school and peer group, resulting in a period of instability as they transition to the role of a young adult. Many young adults move away from their home and family to independent living situations for further schooling, to begin careers and full-time employment, or to establish of their own homes and families.
It is during early adulthood that many individuals take responsibility for matters of health, health care, and lifestyle choices that will affect their health. This includes self-care activities, preventive care, and health promotion activities, as well as accessing medical treatment when necessary. Before this period, many health behaviors are learned and influenced by family, peers, and the school. These behaviors may be healthy, such as hygiene, nutrition, and exercise, but unhealthy behaviors, such as tobacco use, unprotected sex, and substance use, also can be experienced or learned. Many values, beliefs, and self-perceptions that influence or regulate adult health behaviors are established during adolescence.
Adolescents, unlike young adults, are not truly able to care for themselves in that their decisions are not made as free agents. Society still imposes legal boundaries on them as minors, and parents still influence many of them. Thus, society continues to shelter the adolescent both legally and developmentally. As adolescents make the transition to adulthood, however, they will assume increasing responsibility for themselves.
The concept of transition is important for school nurses because it relates to the movement from adolescence to adulthood. An understanding of this developmental transition, the instability, vulnerability, and opportunities, offers new possibilities to provide guidance and education to students as they move into adulthood. Murphy (1990) stated that this transition perspective is valuable because nurses may assist clients to prepare for the anticipated role change, and negative outcomes can be prevented. Specific nursing interventions that are planned around the adolescent–young adult transition can assist students to successfully bridge the gap from adolescence to young adulthood. The focus of this article will be on the developmental transition adolescents make in the late high school years as they leave high school and enter young adulthood.
FRAMEWORKS OF TRANSITION
The concept of transition is familiar in a number of disciplines. To understand the concept of transition as applied to the developmental transition from adolescence to young adulthood, three major frameworks were reviewed that offer insight into this process. These were chosen not to view the concept comprehensively from all disciplines, but to provide a perspective of the concept from fields of study familiar to school nurses working in the high school environment. Specifically, these fields are developmental psychology, counseling, and nursing. Although these frameworks may be useful and appropriate for students with specific health needs, the emphasis of this article is on life transitions associated with the overall population during this period.
Developmental Psychology
Developmental psychologists hold that individuals pass through a sequence of stages throughout their lifetime; transitions are periods between these stages. For example, childhood and adulthood are both development states and some theorists would consider them stable states of human development. For other developmental psychologists, however, the entire period of adolescence is viewed as a time of transition.
Fuhrmann (1990) stated that every definition of adolescence includes the word transition, indicating that the entire period of adolescence is frequently seen as a bridge between childhood and adulthood, or a period of transition. Fuhrmann viewed adolescence as a 20th century social invention in the United States that emerged following historical events that occurred over the past 150 years. This came primarily from the change in society’s economic structure. Before 1900, society was agrarian based, but advances in industry and technology resulted in a society in which youth have greater educational opportunities, such as high school, college, or technical schools, and more career choices (Fuhrmann, 1990). The social change redefined the transition from adolescence to adulthood for individuals who were physically mature but socially and educationally immature, economically dependent on their parents, and not ready to assume adult roles.
The modern transitional stage of adolescence differs from tribal cultures and agrarian societies in which adulthood was ceremoniously marked with clear rites of passage with no differentiation between sexual maturity and adulthood. Before the puberty rite, the person was a child; after the ritual he or she was accepted as an adult, with the status being clear to both the person and society (Fuhrmann, 1990). In Western societies, adolescence is not about puberty and physical development. Rather, it is a social invention that is dependent on the surrounding culture to define the tasks of adolescent development.
Developmental psychologists describe a number of developmental tasks associated with adolescence. According to Dacey and Travers (1999), one cognitive task is the establishment of formal operations originally described by Piaget in which the ability to think abstractly becomes established by 15 to 16 years of age. Formal operations are defined as the understanding of abstract characteristics that enable a person to operate on a level of a theory instead of observable facts and to analyze purely hypothetical situations and statements.
Along with cognitive development, Baltes and Silverberg (1994) described the developmental tasks of autonomy and self-identity belonging to this period. Autonomy can be viewed as disengagement from parental control and confidence in self-governance. This long-held proposition has come under criticism by a number of contemporary scholars (Baltes & Silverberg, 1994). Baltes & Silverberg stated that typical rebellion is most likely an indicator of problems in the development of autonomy rather than the demonstration of autonomy. Moreover, teens who appear most competent in late adolescence are those who have maintained close and supportive relationships with their parents. Thus, the developmental task of adolescence is a negotiated balance between an emerging sense of self as competent on one hand, but a feeling of connection with significant others on the other.
The young-adult period begins at approximately 16 or 17 years of age or older. The developmental tasks of this period are different from the developmental tasks of adolescence (Dacey & Travers, 1999). These include the stabilization of ego identity or one’s feelings of self, resulting in personal relationships that are less centered on one’s own desires. Young adults are more concerned with the deepening of their interests and the expansion of caring outside their immediate self or peer group. Young adults are searching for meaning in their lives and involvement of self into society. They seek growth and expansion. Dacey and Travers noted that the transition into adulthood raises questions for individuals about what they will become, including family, employment, and careers.
As can be seen by this summary, developmental psychologists view adolescence as a period of transition with many changes, new roles, new relationships, and new behaviors. Entry to young adulthood is also a developmental transition, however, as defined by developmental psychologists Dacey and Travers. The views described by the developmental psychologists are useful for school nurses in that they observe the context in which the human responses to developmental changes can be viewed in the broadest sense. Nonetheless, these views do not provide a specific model of assessment or interventions for nurses working with adolescents.
Nursing
The concept of transition as defined and studied by nurse researchers may be of more use to school nurses. Chick and Meleis (1986) analyzed the concept of transition related to knowledge development in nursing. They identified universal properties related to transitions as seen from a nursing perspective. Transition includes three elements: process, time span, and perception. Process, the first element, incorporates movement across the second element time span. Transitions are a period of time when there is an ending and a period of confusion and distress, leading to a new beginning. There is a period of disconnectedness that is part of the transitional process and includes a disruption of the linkages on which the individual’s feelings of security depend.
Perception, the third element, reflects how the self interprets the process and what meanings are attributed to the transition events (Chick & Meleis, 1986). Perceptions vary among persons, communities, and societies. They influence one’s responses to transition events, making them less predictable. Simply put, transition is a personal phenomenon that offers unique meanings for the individual.
In the Chick and Meleis model, there are factors that mediate the transition process. These factors are individual responses, environmental factors, and nursing therapeutics. Patterns of individual response can be observable or nonobservable behaviors; examples include disorientation, distress, and happiness. The particular environment in which the transition occurs may inhibit or facilitate the transition. In planning nursing therapeutics or interventions, antecedents and consequences related to the transition should be considered.
The goal in nursing is to anticipate times or points when the individual is most vulnerable with respect to health. For example, the majority of daily tobacco users begin smoking between the ages of 15 and 18 years. However, one in five begin smoking daily when they are 19 or older (Everett et al., 1999). By anticipating this, school nurses can prepare high school seniors for the role change that will take place upon graduation and the initiation into young adulthood. They can facilitate increased connectedness for the individual that will lead to healthy outcomes (Murphy, 1990). In this example, a possible outcome would be an increased sense of awareness of stresses experienced during this transition leading to decreased initiation of smoking during this time.
This demonstrates how the transition from adolescence to young adulthood fit into the Chick and Meleis framework. This is a critical period of change in which the stability of high school and family life is about to change as the individuals move the process and take on the developmental tasks of early adulthood. The model is useful in understanding human responses to transition because it reminds professionals that transition periods are ones of disconnectedness. Graduation signals the beginning of a disconnectedness from school and family because it ends 12 to 13 years of the routine of school attendance with peers. For most students, this period will be the first period of such disconnectedness they will experience. Success in coping with this transition will be the foundation for coping with successive transitions during the life span.
In 1994, Schumacher and Meleis advanced the Chick and Meleis model. They identified factors that they believed indicated a positive transition outcome. Three outcomes were identified that are relevant to all types of transitions. These include a subjective sense of well-being, the mastery of new behaviors, and the well-being of interpersonal relationships. When a successful transition occurs, distress gives way to a sense of well-being. This subjective sense of well-being includes effective coping and managing one’s emotions, along with job, marital, or other role satisfaction. Growth, liberation, and empowerment also may occur. Role mastery means achievement of skilled role performance and comfort with the behaviors required in the new situation. Finally, well-being in one’s relationships indicates that a successful transition is in process. Disagreements or family disruption may occur during transition; however, when the process moves to a successful conclusion, the well-being of the family is restored.
Schumacher and Meleis (1994) suggested that intervention during a transition should be directed toward alleviating the disruption in relationships and promoting the development of new relationships. They identified three nursing activities that are widely applicable during transitions. Initially, nurses should begin with an assessment of readiness that includes the indicators of subjective well-being, role mastery, and well-being of relationships. The second activity is preparation for the transition and includes some form of education for creating optimal conditions in anticipation of the transition. It also may include preparation of the environment. An example is orientation programs provided for high school freshmen or new students. The third nursing activity is role supplementation. This could be parent education and reinforcement during the initial postpartum weeks at school-based teen parenting centers
More recently, Meleis et al. (2000) described the emerging middle-range theory of transition. They identified five studies in which the original framework by Chick and Meleis was used to guide the development of the studies. From these studies, they concluded that transitions are complex and multidimensional. Several essential properties of transition experiences were identified. The first property was awareness and relates to the individual’s perception, knowledge, and recognition of the transition. The second property is the level of engagement in the process. An example of engagement is finding information or using role models. Change and difference, the third properties, are essential in that transitions are the result of change and result in change. The individual will confront difference typified by feeling different, as well as by seeing the world and others in a different way. A fourth property is time span as all transitions are characterized by movement over time. The final property is critical points and events. Some transitions are marked by an identifiable event, such as birth or high school graduation. The authors also discussed conditions that facilitate or inhibit the transition. They asserted that to understand the experiences of individuals during transitions, it is necessary to understand the personal and environmental conditions that promote or hinder the progress toward achieving a healthy transition. These conditions can be personal (e.g., the meaning of the event, one’s belief or attitude, socioeconomic status, knowledge), community (e.g., support from family or partners, role models.), or societal conditions (e.g., marginalization, gender, position).
Although none of the five studies examined the adolescence to young adult developmental transition, points of interest that these studies make invite further research to identify whether this transition supports the theory. For example, one of the five studies studied the menopausal transition of low-income Korean immigrant women. A major finding of this study was “the conceptual category that emerged of neglecting and ignoring the menopausal transition” (Meleis et al., 2000, p. 14). These women were making multiple transitions in culture (immigration) and development (menopause) during the same time span. The number, seriousness, and priority of transitions these women experienced contributed to the neglect of their menopausal transition. Extrapolating the results of this study, one questions whether students undergoing multiple transitions neglect their own health. Also, do students of low socioeconomic status experience more stress related to the transition into young adulthood than those with more resources?
Another point of interest for school nurses would be the effect anticipatory role preparation has on the transition to young adulthood. No research was found on the effect of this intervention. However, anticipatory guidance has been found to be beneficial in other areas. For example, one of the five studies describes a grounded theory study of first-time African American mothers and two conditions that affected the mothers’ transition experiences. One of these was the level of planning for motherhood. If the pregnancy was intentional or planned, the women proceeded through the transition easier. Transition theory offers a rich area for research with many areas needing further exploration (Figure 1).
Counseling
The third framework that is applicable to the transition of adolescents to young adults is the model proposed by Schlossberg (1981), who viewed transitions more broadly than Meleis and colleagues. She stated that transitions occur if an event or nonevent results in a change in one’s view about self or the world. Schlossberg’s model identifies three sets of factors that influence the adaptation to transition, including the characteristics of the transition, the environment before and after the transition, and the characteristics of the person in transition.
Characteristics of the transition are variables such as role change, affect, source, timing, onset, duration, and degree of stress. Schlossberg (1981) noted that most transitions can be described using these variables. For high school seniors making the transition to young adults, it includes a role change. The source of the transition is external, although the onset has been gradual because the point of graduation has been known. The duration of the transition is temporary, and the degree of stress is dependent on the individual and on environmental factors.
Schlossberg (1981) described the environment before and after the transition as interpersonal support systems. These include intimate relationships, the family unit, and one’s network of friends. In addition, institutional supports such as religious institutions, community groups, and the physical setting that includes the location, living arrangements, climate, and workplace are factors in the environment. Among high school students in transition, some have families that provide advice, protection, information, and reinforcement of a sense of worth; other families do not provide this environment. The institutional supports are also individualistic. Some high school students are involved in their community, church, or other groups, whereas others are not.
The last factor that influences the adaptation to transitions are the characteristics of the individual. These characteristics include psychosocial competence, gender, age, health status, race–ethnicity, socioeconomic status, value orientation, and previous experience with a transition of a similar nature. Psychosocial competence includes self, world, and behavioral attitudes. Self attitudes are similar to an internal locus of control that includes a sense of responsibility. World attitudes are ones that help the individual develop a pattern of constructive interaction with the community. Schlossberg stated that optimism and goal-directed behavior are more favorable. Behavioral attitudes are ones in which the person can set realistic goals, plan, and persevere through failure as well as success.
An advantage of the Schlossberg (1981) model is that it can be used by many helping professionals. She described the model as tentative and exploratory in that it is useful for research but subject to revision. The model provides a starting place to view transition. When working with students, the various factors affecting an individual’s transition can be determined and placed in the model to facilitate identification of problems and discussion of needed interventions. The major strength of the model is the possibility of its use in planning intervention, such as providing individual counseling to students in transition. It also can be useful in guiding population-based interventions by acknowledging factors that contribute to successful adaptation and supporting these factors through health promotion and educational activities. The drawback of this model is that it may be unfamiliar to nurses, and no research supporting its use was found for the adolescence to young adult transition. However, a number of studies linking practice with the theory were found for adult transitions.
Summary of Transition Models
Each of the three frameworks of transition offers information that could assist school nurses to promote a successful transition from adolescence to young adulthood. The goal of a successful transition is an important one. For many young adults, it is the first time they will experience a critical transition. This transition, unlike childhood transitions, may include a move from one’s childhood home and away from the family of origin and from an established network of friends. A successful transition to young adulthood will form the foundation for future stages of development and transitions.
The views from developmental psychology offer insight into the stages of human development along with the developmental activities and cognitive processes associated with the transition to young adulthood. On the other hand, the models discussed by Chick and Meleis and Schlossberg describe a period of disconnectedness or period of instability in which life patterns are interrupted with a change or changes that causes the individual to learn new tasks, new behaviors, new self-perceptions, or simply new patterns of living. Chick and Meleis and Schlossberg described possibilities for those in the environment to foster adaptation and successful coping with transitions. Schumacher and Meleis (1994) identified three nursing measures for intervention during transitions, whereas Schlossberg and Schumacher and Meleis identified indicators to analyze adaptation throughout the transition.
For nursing, the Meleis model, which was further developed by Meleis et al. (2000), offers a rich framework in which nursing practice and research could be expanded. The emerging middle-range theory of transition that these authors offer provides critical points of interest for school nurses who work with adolescents in transition to young adulthood. Research is needed to provide school nurses with the knowledge of the most effective nursing interventions to meet the needs of these individuals. The framework presented by Meleis and colleagues (2000) provides numerous possibilities for further research and practice.
IMPLICATIONS FOR SCHOOL NURSING PRACTICE
For school nurses, one specific concern during this transition period is the young person’s behavioral or lifestyle choices. These behavioral choices have the potential to form the foundation for future health or illness. Tobacco use is one behavioral choice known to contribute to numerous health problems. Nationally, the number of young adults 18 to 24 years of age using cigarettes has risen from 22.9% in 1991 to 28.7% in 1997 (Centers for Disease Control, 1999). In an effort to determine when college students initiate smoking, DeBernardo et al. (1999) conducted a cross-sectional study of 513 undergraduate students from a major northeastern university in 1997. About half of the smokers (49.3%) had started smoking after enrolling in college. Stress was a motivational factor for almost half of the current smokers (49.3%), and one of the most frequently cited reasons for nonsmokers to start was stress (6.5%). Similar findings regarding stress were found in a study by Siqueira, Diab, Bodian, and Rolnitzky (2000). The respondents identified stress relief (72%) as the most common reason to progress from having tried smoking to becoming regular smokers.
Using the transition model as described by Meleis and colleagues (2000) and the findings regarding tobacco use, school nurses could provide anticipatory guidance for high school seniors. These early intervention programs could help seniors recognize the nature of the impending transition and the associated stresses. In addition, stress management training and the use of positive coping methods other than nicotine use may help prevent the progression from experimentation to daily tobacco use.
Another area of concern is depressive symptoms among young adults making the transition from home to university life. The incidence of depression has been increasing among women who have been shown to have a greater tendency for depression (2:1 compared with men; Beeber, 1999). Beeber found depressive symptoms of female college students were related to specific stressors, including separation from home and establishing new bonds with the new community. In another study of 1st-year college students, Paul and Brier (2001) found that friendsickness (preoccupation with and concern for the loss of precollege friendships) was seen as a significant source of distress for college students that affected their adjustment to college.
Anticipatory guidance before the college transition might be effective in preparing students for the changes they will confront. Although some colleges and technical schools offer orientation programs to facilitate this transition, other do not. School nurses working at the high school level can play a pivotal role in facilitating the transition for both students and parents. One possibility would be to host a pregraduation “transition fair” at which students could be guided through an exploration of life transitions through which they have already passed and the impact these transitions had on friendships; another topic could be healthy coping mechanisms for reducing the distress associated with transitions. High school graduates who have completed their 1st-year of postsecondary education or full-time employment could be invited to speak about the transition. Parents could be given booklets offering suggestions on how they can assist in this critical transition. These interventions, as depicted in the Meleis and colleagues (2000) model, provide students with additional perspectives beyond their own and foster a healthy transition.
CONCLUSION
The transition model offers a rich potential for the expansion of school nursing in both the area of nursing interventions and nursing research. Viewing high school students within the context of an impending developmental transition allows school nurses the freedom to practice nursing outside the confining boundaries of disease treatment. Anticipatory guidance, health promotion, disease prevention, and health maintenance activities are important nursing interventions that will assist students develop to healthy response patterns during the transition from adolescence to young adulthood.