Application of the Transition and Trajectory Theories to Clinical Practice

Application of the Transition and Trajectory Theories to Clinical Practice

Introduction
Health and illness are part of the human experience. Unfortunately, most people have encountered or know someone that has been diagnosed with a chronic illness at some point in their lives. As nurses, we often encounter chronic illnesses when caring for patients. Nurses must learn how patients experience chronic illness and the best ways to care for those patients. The transition and trajectory theories are important for nursing care because they frame a patient’s experience with and progression through the stages of chronic illness.
The trajectory theory refers to the developmental stages of illness. These include the physiological aspects of the disease as well as the effects a chronic illness can have on the emotional and psychological well-being. The theory allows for framing the patient and family’s experience of living with a chronic illness. According to Corbin (1998) a trajectory “refers not only to the illness/ condition course, but to the actions taken by various participants to shape or control that course” (p. 35). Therefore, it is imperative that nurses and other healthcare providers intervene effectively in the chronic illness trajectory to allow the patient to achieve the best health status possible. The interventions provided should not only be treatments but education and emotional support as well.
The trajectory theory has eight stages: pre- trajectory, onset, crisis, acute, stable, unstable, downward and dying. The pre-trajectory stage begins before the onset of the illness. The onset stage is when the illness presents itself and signs and symptoms appear. The crisis stage is a situation that threatens the health of the client, prompting the client to seek treatment. The acute stage is the active illness stage where clients typically require hospitalization for treatment of their disease. The stable stage is one where the illness is controlled by the treatments being received. If, however, the treatment cannot successfully control the disease, the client moves into the unstable stage. In this stage, however, hospitalization is not necessary. The downward stage is a deterioration in the client’s health with worsening of symptoms. Finally, the death stage is where the client succumbs to their chronic illness (Corbin, 1998, p. 36). Not all clients progress through every stage and clients do not necessarily move through the stages in a linear manner. As a nurse, it is important to intervene with treatments, medications, emotional support and patient teaching. The goal of the nurse is to first prevent the illness from developing and to keep the client in the pre-trajectory stage. However, should an illness develop, the goal is to effectively manage it and to keep the client in the stable stage. Finally, if an illness progresses, the nurse should provide comfort measures and counseling for a client who is in the death stage.
The transition theory is equally as important for nursing because patients in the hospital will often be experiencing turbulent and unstable periods in their lives. Many patients are experiencing a health crisis or the health crisis of a friend or family member. These crises can cause a wide range of emotional responses. Patients and their families will be moving through different transitional periods of their lives and the transition theory provides a framework for thinking about the different types of transitions and how a patient experiences this process. According to Schumacher and Meleis (1994), there are four different types of transitions: developmental, situational, health- illness and organizational (p.120). Developmental transitions are shifts from one developmental stage to another (i.e. becoming a parent). Situational transitions are life changes that arise out of various situations (i.e. becoming a widow). Health- illness transitions are transitions due to changes in health status. Finally, organizational transitions are those that affect persons within an organization or the organization’s clients (Schumacher and Meleis, 1994, p. 120). These two theories allow nurses to think of clients in a holistic manner: as a person going through life changes and transitions and reacting to those changes along a trajectory path. It allows nurses to visualize each unique client and to plan care in an individual manner.
Interview
I interviewed a 56 year- old male client, A.R., recently diagnosed with rectal cancer. Some of the key questions I had prepared prior to the interview were: “What coping mechanisms are you employing to cope with this new diagnosis? How has this diagnosis affected, if at all, your overall life goals and plans? Did this new diagnosis affect your family or friend relationships and if so, how?” Overall, A.R. seemed discouraged by the situation. He was not expecting such a serious diagnosis and stated, “All this… the seriousness of it… is just starting to sink in” (A.R., personal communication, October 15, 2008). In response to the first interview question about his coping mechanisms, A.R. stated that he tried to talk more with his family and friends, with whom he was very close. He also stated, “I try to laugh every day now. Laughter is good for you” (A.R., personal communication, October 15, 2008). According to Kyngas, Mikkonen, Nousiainen, Rytilahti, Seppanen, Vaattovaara, & Jamsa, (2000), “A chronic illness, such as cancer, brings about permanent changes in an individual’s life. These changes in lifestyle present coping demands…” (p.6). A.R. was responding to these increased coping demands he was experiencing by increasing the utilization of resources available to him to meet those needs. While discouraged by his situation, he appeared to be coping well and was utilizing effective mechanisms.
To the second key question about how the diagnosis had affected his life goals, A.R. answered that he had put a new emphasis on his family. He stated, “My family has become so much more important to me now, especially my kids. I just want to try and spend as much time as possible with them” (A.R., personal communication, October 15, 2008). This response led into the third question about how the diagnosis had affected his personal relationships. Due to his diagnosis he had tried to grow closer with his children and fiancée. At this point, as I learned more about A.R. and what was most important to him, the interview progressed into talking more about his fiancée and children and his relationship with them. He said that he had had some ups and downs and his fiancée was one of the major positive forces in his life. He stated that she had become even more important in his life now because she had been so supportive. They had grown even closer as a couple due to her continued support. A.R. stated the progression of his illness had been fast. Though he was recently diagnosed with rectal cancer, he had also had a colostomy just two days prior to the interview. Obviously, the rapid progression of his illness was a little overwhelming, however, he stated that without the continued support of his fiancée, he “did not know how he would have done it” (A.R., personal communication, October 15, 2008). A.R. expects that since the cancerous part of his bowel had been removed and a colostomy placed that he could begin to recover and be discharged home. He hoped the cancer would not metastasize to other parts of his body so he would not have to get chemotherapy.
Within the trajectory theory A.R. is currently in the acute stage because he has an active illness (cancer) that requires him to get treatment in the hospital (colostomy). The nursing implications for A.R. would be to monitor him to make sure he is still stable after surgery, encourage deep breathing and coughing, and to teach him about colostomy care so that he can be discharged and hopefully move into the stable stage of the trajectory theory. A.R. is experiencing some difficult transitions at this time. He is dealing with a situational transition from being in the hospital and adjusting to his new colostomy. A.R. is also dealing with a health- illness transition from recently having a decline in his health status due to being diagnosed with rectal cancer.
Variables Affecting the Client’s Trajectory
There are many variables affecting A.R.’s trajectory within his chronic illness. The first key variable is his economic status. A.R. is unemployed but receives Medicaid financial assistance. However, he may not be able to afford adequate housing or food and not all of his medical expenses may be covered. This affects his care because in order to move into the stable stage of the trajectory theory he will need to effectively manage his care at home, which requires these necessary resources. It would be appropriate to refer A.R. to the social and financial services provided by the hospital. Another variable affecting A.R.’s trajectory is his family’s support. His strong emotional support from his fiancée is a positive influence in his life. A.R.’s children are fully grown and live out of the area, however, he reported that he was close with his children and frequently talked with them on the phone. This healthy relationship with his family and loved-ones has a positive impact on his trajectory. His family relationships will ease his situational transition as he deals with his recent hospitalization. A.R. also mentioned that his family was one of the most important influences in his life and a very effective coping mechanism. In fact, his fiancée was willing to attend the colostomy teaching provided by the colostomy nurse and wanted to learn as much as possible about proper care. Therefore, his family will help advance his stage in the trajectory theory to stable by helping to support him as he attempts to control his illness regimen.
The third key variable is A.R.’s other illness factors. A.R. suffered a heart attack a few years ago; however, his cardiac problems are effectively controlled by his medication regimen. This cardiac history could affect his stage within the trajectory theory because if he were to have another heart attack or other complications he could move to the crisis stage or other stages of the trajectory theory. Therefore, we as nurses must be aware of his cardiac history and work to prevent any future complications.
Conclusion
There are many factors that determine a patient’s placement within the trajectory theory. The patient’s stage can be altered not just by their most pressing illness but also by other factors such as previous illness, coping mechanisms or available support systems. All patients are unique and have different needs. In order to provide complete and adequate care as nurses we must formulate a plan encompassing many factors. The transition and trajectory theories allow nurses to frame their thinking and understand the patient’s needs and situation. Utilizing these frameworks in practice allows nurses to better plan care for better patient outcomes.



References

Corbin. (1998). The Corbin and Strauss Chronic Illness Trajectory Model: An Update. Scholarly Inquiry for Nursing Practice: An International Journal, 12, 33-41

Kyngas, Mikkonen, Nousiainen, Rytilahti, Seppanen, Vaattovaara, & Jamsa. (2000). Coping with the Onset of Cancer: Coping Strategies and Resources of of Young People with Cancer. European Journal of Cancer Care, 10, 6-11

Schumacher and Meleis. (1994). Transitions: A Central Concept in Nursing. IMAGE: Journal of Nursing Scholarship, 26, 119- 127