Mrc's Transition Theory

In reevaluating the data and experience of Mr. C’s transition, the complex adaptive system should be used to better understand his potential health outcome as it generates a broader and more integrative framework. In combining the transition theory and complexity science, we can better support our roles as health care providers. Perspectives, relationships, rules, sense-making, emergence, culture, and multidisciplinary nature of health care are all concepts brought forth by complexity science. From the pictured integrated model, it seems that there is perfect overlay and integration of theories and further develops the concept that new perspectives and added dynamics will always affect all of those involved no matter how great or small.

For

our patient, the concept of self-organization is both emergent and directed as evidenced by his hesitancy in going to the ED and our encouragement that this is an urgent matter. Without our encouragement and the involvement of his partner, the outcome might look very different. In this framework, I can add a dimension of restructuring his lifestyle because of his new diagnosis. Changes in diet will most likely be the biggest hurdle for him, however his partner will play a major role in helping him with a smooth transition as she does the shopping and cooking and tracking of his blood sugars.
Sense - making is integrated with the transition theory framework properties and conditions, where Mr. C attempts to find meaning in the situation, diagnosis, and information provided by health care providers and students. In light of this framework, I think it’s more difficult to predict the outcome, because of the fluidity and dynamics of the transition. Here we can bring back in Meleis concept of process indicators “because transitions unfold over time, identifying process indicators that move clients either in the direction of health or toward vulnerability and risk allows early assessment and interventions by nurses to facilitate healthy outcomes” (Meleis 2000). Folding back in on complexity science, we can see the importance of the broader view to encompass a complex adaptive system (CAS) of the health care system. In this situation, the system came to him; he didn’t come to the system. Whether or not this is important to the implications of the theory, it definitely has had an impact on the client as well as the students that cared for him. It has solidified the importance of early assessment, intervention, and patient centered care.
Geary and Schumacher describe emergence as the process and outcome of interactions that allow new behaviors, structures, and systems to emerge (Geary and Schumacher 2012). This is applicable to our client and everything described within this framework can shape the quality of his transition. Integrating into a complex system, according to the authors, is relationship, where information flow, connection, and cognitive diversity are characteristics. The availability of all of them can enhance how he is to shape his new behaviors and how that might shift his self organization.
The idea of relationships as mentioned above, is beneficial in the delivery of care of the health care providers (HCP) as they attempt to fulfill their roles. Though the authors don’t specifically define those roles, we can at least extract that they are involved in the plan of care prior to discharge, as they are needed to provide for a safe and acceptable care transition (Geary and Schumacher 2012). Though the boundaries are open between the HCP’s, nursing students, and Mr. C and his partner, other interacting agents are at play. Mr C hasn’t seen a doctor in 20 years. His literacy of how to navigate the system is low and is need of new supplies for the management of his blood glucose. Without knowing what questions to ask the providers, and the providers possibly not realizing the broader implications of lack of access Mr. C has been experiencing. In this scenario then, there was a temporary closed boundary, that opened back up again with the intervention of the nursing students going to get the supplies he needed on a Saturday, when the other HCP’s were not around.
In my understanding of the clients situation and care provided by the nursing students, that this transition had the potential to be high risk, but evolved into a high quality transition due to the interaction given by the students, which helped facilitate the acceptance, engagement, and coping of the this new diagnosis. Allowing for his self - organization, emergence, and sense making to direct the level of care needed is what patient centered care is all about.
The framework in both the middle range theory and in the integration into complexity science definitely seems to be exhaustive.

It provides the fluidity and multidimensional complexity that is definitive of any patient’s experience that a nurse might play a part. In both experiences of transitions and the theory that attempts to understand it evolve and emerge, the gap seems to be in the implementation due to system breakdown. We are all aware that there is fragmented care, and it’s not for lack of concern by HCP and policy makers alike (Geary and Schumacher 2012). The health care system has been transforming to allow for more positive health outcomes across the continuum and attempts to identify and close the gap on the health disparities. Care coordination seems to be the missing link with not only Mr. C, but with many of the clients we have met throughout the term. Care coordination has been identified by the Institute of Medicine as one of the key strategies for potentially closing this gap. A working definition formed by the Agency for Healthcare Research and Quality reveals that care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care (www.ahrq.gov). In a critical analysis of Quality Improvement Strategies, they found that care coordination for patients with diabetes showed improved outcomes, and that both disease management and case management improved glycemic control (Shojania, McDonald, Wachter, and Owens

2007).
By taking a step back from all of these concepts, I conclude by adding accountability as an overarching additional concept. The idea may be assumed through the interaction of all agents and systems within complex adaptive systems, and it may even weave through the more patient focused transitions theory. It is not however made apparent that having transparency in the system is being held accountable. Having all HCP explain results, diagnoses, and medications to our patients appropriately based on their culture, routine, and language is being held accountable. So that the patients in turn can be empowered to take responsibility for their own health so that they can held accountable, and for the appropriate agencies find better ways to teach people how to navigate the system and for the bigger system at large to have more transparency in the economics of the industry. This all may be too good to be true, but seems to be a way to promote patient centered care, prevent hospitalizations, keep costs down, and maybe even prevent a personal bankruptcy. We obviously can’t stop chronic illness, but we can always promote healthy and positive transitions by being accountable.