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A concept analysis of vulnerability during transitions.


AIM Define the concept of vulnerability during transitions.

BACKGROUND There is a need to produce RNs with the knowledge, skills, and attitudes (KSAs) necessary to care for the growing older adult population. The NLN Advancing Care Excellence for Seniors (ACE.S) project developed a framework to help faculty and pre-licensure students develop these KSAs. Key to this framework is the concept of vulnerability during transitions.

METHOD Rogers and Knafl's evolutionary method of concept analysis.

RESULTS The analysis revealed two antecedents (use of multiple medications to treat disease, fragmentation of the health care system), two attributes (inadequate continuity of care, poor communication and coordination of care among health care providers, patients, and families), and two consequences (readmission to a previous or new care setting, potential negative health outcomes).

CONCLUSION Knowledge of the antecedents, attributes, and consequences of vulnerability during transitions will facilitate improved care for older adults in all setting.


As members of the "baby boom" generation increase their access to and utilization of health care services, nurses, physicians, pharmacists, and other providers will require specialized knowledge, skills, and attitudes (KSAs) to address their health care needs. However, there is a shortage of health care professionals, nurses in particular, who are trained and educated to care for the growing population of persons over 65 years of age (Berman et al., 2005; Gilje, Lacey, & Moore, 2007; Institute of Medicine [IOM], 2008; Ironside, Tagliareni, McLaughlin, King, & Mengel, 2010).


The lack of gerontological nursing content in both baccalaureate and associate degree programs has been well described (Gilje, Lacey, & Moore, 2007, 2008; Ironside et al., 2010). A key factor in the failure to teach gerontological nursing content in pre-licensure nursing programs is the shortage of faculty with gerontological expertise, training, and experience who are competent to design and lead curricular revisions that are inclusive of care principles for older adults (Latimer & Thomlow, 2006). Faculty who are qualified to teach these courses are also needed by pre-licensure programs.

As the health care system evolves in response to financial and system-level constraints, older adults will find themselves experiencing multiple transitions across a variety of health care settings.

Therefore, it is important that faculty be well versed in this specific area of gerontological knowledge. Faculty need to understand how transitions across and within health care settings, as well as within an older adult's life (e.g., loss of a spouse), impact health and well-being. This understanding will be crucial for ensuring the delivery of high quality care to older adults; transferring this knowledge to novice nurses should be an important part of all pre-licensure programs.

Over the past several years, nursing organizations and philanthropic foundations have developed a number of strategies and initiatives to ensure that our future nursing workforce is prepared for the specialized care of older adults. Two organizations that have led efforts to address gerontological nursing content deficiencies in pre-licensure programs are the National League for Nursing (NLN) and the American Association of Colleges of Nursing (AACN). A major initiative developed by the AACN, in partnership with the John A. Hartford Foundation (JAHF), was the creation and publication of the Baccalaureate Competencies for Nursing Care of Older Adults (AACN, 2010), designed to enhance the AACN Essentials of Baccalaureate Education for Professional Nursing Practice (2008). This publication provides an impressive list of competencies and serves as an excellent roadmap of the KSAs nurses should have upon graduation. The competencies lace the ability to provide faculty with a deeper understanding of the specialized needs and circumstances that surround the care of older adults.

The NLN centered its efforts to enhance gerontological nursing in pre-licensure nursing programs through the development of the Advancing Care Excellence for Seniors (ACE.S) project (www.nln. org/aces). The ACE.S project, developed in collaboration with the Community College of Philadelphia and funded by the Independence Foundation, the JAHF, Laerdal Medical, and, since 2012, the Hearst Foundations, enhances gerontological nursing content in pre-licensure programs through the development of the NLN ACE.S framework (Tagliareni, Cline, Mengel, McLaughlin, & King, 2012) and content enrichment. Some of the educational enrichments the ACE.S program promotes are online resources for faculty and students, classroom-ready teaching tools and strategies, and unfolding case studies and simulations that target specific gerontological care needs.

The NLN ACE.S framework provides a model for teaching and learning the care of older adults (Tagliareni et al., 2012). It has three key components: Essential Knowledge Domains, Essential Nursing Actions, and the Learning Environment. The knowledge domains and the essential nursing actions interact synergistically within the learning environment, thereby contributing to and enhancing student KSAs about older adults.

Within the knowledge domains component are three unique concepts: individualized aging, complexity of care, and vulnerability during transitions. In order to advance understanding of the NLN ACE.S framework and enhance pre-licensure gerontological nursing content, these three concepts must be defined and described. The concepts of individualized aging and complexity of care have been described previously (Cline, 2014,2015).

The purpose of this concept analysis is to define and clarify the NLN ACE.S framework concept of vulnerability during transitions. The Merriam-Webster (2015) dictionary definition of vulnerability is: "capable of being easily hurt or harmed physically, mentally, or emotionally"; transitions is defined as "a change from one state or condition to another." Previous works on the conceptualization of vulnerability have identified the need to conceptualize vulnerability in the context of society, communities, economics, race, gender, and class (Tomme-Bonde, 2013). Vulnerability as a concept has also been described as highly individualized, leaving a person open to positive or negative health outcomes (Purdy, 2004). This article explores the concept for older adults who experience transitions.


The evolutionary method of concept analysis (Rogers & Knafl, 2000) was used for this study as it focuses on the concept's contextual and temporal nature. Concept analysis aims to identify a set of attributes that "constitute a real definition" (Rogers & Knafl, p. 91), so that it is possible to characterize situations or experiences that encompass the concept. It also provides a basis for further research on the concept as antecedents, attributes, and consequences are inclined to change and evolve over time.


Literature relevant to the concept of vulnerability during transitions was identified in the health sciences literature. The following search terms were used to search the PubMed and Web of Science bibliographic databases: vulnerability AND transitions AND a) older adults, b) elderly, and c) geriatric. The search was limited to articles in the English language, sample ages greater than or equal to 65, and published dates between 2007 and 2013. This search, which produced 191 studies, was followed by a review of the article abstracts. Articles were excluded if they were conference presentations or conducted outside the United States. Articles were also excluded if they did not relate to the concept of vulnerability during transitions (e.g., articles on transitions between rapid eye movement [REM] sleep and non-REM sleep in older adults). This left a final sample of 85 articles for review. Of the remaining 85 articles, 26 articles (30 percent) were randomly sampled for use in this review. The Rodgers and Knafl method recommends that at least 20 percent of the sample be used in the analysis.

Data Analysis

Each article was reviewed to understand how the concept of vulnerability during transitions was used. Most articles did not clearly define vulnerabilities during transitions; however, according to Rogers and Knafl (2000), this is not uncommon. Therefore, inductive reasoning was used to examine how authors used or presented the concept. Specific data elements were extracted into a table to organize the data and get a sense of the how the concept was being used.


Analysis of the data revealed two antecedents, two defining attributes, and two consequences. (See Figure) Examples of specific textual data from the sample are used to describe them.


Antecedents are those events that occur prior to the concept of interest (Rogers & Knafl, 2000). This analysis identified two antecedents for the concept of vulnerability during transitions: 1) use of multiple medications to treat disease, and 2) fragmentation of the health care system.

USE OF MULTIPLE MEDICATIONS The use of multiple medications is a key antecedent that contributes to vulnerability during transitions for older adults. A critical aspect of this antecedent is the lack of clear processes to accurately describe and provide detailed information about an older adult's medication regime between transitions in care settings (Foust, Naylor, Bixby, & Ratcliffe, 2012; Gleason et al., 2010; Flu, Capezuti, Foust, Botltz & Kim, 2012; Rose et al., 2013; Toles, Barroso, Colon-Emeric, Corazzini, & Anderson, 2012). This issue can be further complicated when older adults take large numbers of medications (Gleason et al., 2010), when cultural and language barrier challenges are present (Hu et al., 2012), or when there is required monitoring of therapeutic levels (Rose et al., 2013).

FRAGMENTATION OF THE HEALTH CARE SYSTEM A second antecedent that contributes to the concept is the fragmentation of the United States health care system. Gaps in care and the fragmentation of the health care system contribute to vulnerability as they create periods of uncertainty for older adults. For example, older adults are likely to lose their dental health care coverage upon entering retirement, which may contribute to irregular visits to dental health care practitioners (Manski et al., 2011). Dental care is not covered by Medicare, and there is low likelihood of obtaining dental insurance after retirement (Manski et al., 2009). Research has indicated significant associations between oral health and systemic health. This aspect of health care fragmentation contributes to the vulnerability of older adults and is normally not considered by practitioners. To identify gaps in care, practitioners should consider the full range of health care services older adults should be able to access.


Fragmentation of care at the end of life also contributes to vulnerability (Teno et al., 2013). It contributes also to the high utilization of intensive care services and the low utilization of hospice. Teno et al. reported that older adults had three or more hospitalizations in the last 90 days of life and used hospice for three days or less before death.

Fragmentation of care is also seen in the new Affordable Care Act (Naylor et al., 2012), which focuses many innovations on the acute care needs of older adults and excludes older adults in longterm care. Provisions in the law attempt to improve care for specific diseases by incentivizing hospitals to prevent readmissions; however, the complex and multifactorial nature of geriatric syndromes means that hospitals may overlook or ignore the complexity of an older adult's health to focus on a single disease. The new law seems to do little to extend incentives for quality care beyond the acute care episode (Naylor et al). These fragmentations create vulnerabilities for older adults as they move and transition from one setting to the next or from one life event to the next.


The two overarching attribute of vulnerability during transitions are: 1) inadequate continuity of care and 2) poor communication and coordination of care among health care providers and patients and their families.

INADEQUATE CONTINUITY OF CARE McNabney et al. (2009) aptly state that providers should develop the ability to guide patients and families through various care models across the continuum of care accessed by older adults, thereby ensuring continuity of care. Unfortunately, providers often do not have this ability, which becomes a defining feature of the vulnerability of older adults. Continuity of care between outpatient and inpatient settings can reduce the odds of having an intensive care admission during a terminal hospitalization (Sharma, Freeman, Zhang, & Goodwin, 2009), decreasing the likelihood of death taking place in the high-technology and impersonal critical care environment.

For patients with dementia, the failure to have continuity of care during multiple transitions can lead to medical errors, miscommunication, and care that conflicts with the wishes of the patient and family (Callahan et al., 2012). When care providers are well acquainted with typical disease and care transitions for patients and family members dealing with dementia, they can facilitate transitions and the continuity of care by providing guidance and ensuring that the right level of care is provided (Rose, Lopez, & Palan, 2012). Several studies have shown that continuity failures between emergency care settings and home and long-term care settings also contribute to vulnerabilities during transitions (Boltz, Parke, Shuluk, Capezuti, & Galvin, 2012; Terrell et al., 2009; Vashi et al., 2013).

POOR COORDINATION OF CARE AND COMMUNICATION AMONG HEALTH CARE PROVIDERS, PATIENTS, AND FAMILIES Failures Of communication and coordination are core attributes of older adult vulnerabilities during transitions (Arora et al., 2010; Boxer et al., 2012; Enguidanos, Gibbs, & Jamison, 2012; Nahm, Resnick, Orwig, Magaziner, & DeGrezia, 2010; Parrish, O'Malley, Adams, & Coleman, 2009; Parry, Min, Chugh, Chalmers, & Coleman, 2009; Shippe, 2009; Toles, Barros, Colon-Emeric, Corazzini, & Anderson, 2012; Yakahashi et al., 2013). When a patient transitions from the hospital setting to another health care setting, coordination and communication among providers and patients is crucial to preventing adverse outcomes. Arora et al. found that patients identified problems or delays obtaining follow-up tests, appointments, or test results, and that patients were also readmitted to the hospital or emergency department for necessary reevaluations.

When processes are in place to facilitate transitions, either by nurse practitioners (Enguidanos et al., 2012; Takahashi, et al., 2013), registered nurses (Parry et al., 2009), primary care physicians (Arora et al., 2010), or others such as a social workers or trained community workers (Parrish et at, 2009), older adults are less vulnerable. Coordination and communication among providers and patients during transitions can lead to fewer emergency department visits, fewer rehospitalizations, and improved perceived health status in the older adult experiencing the transition (Dedhia et al., 2009). This is also true for older adults in other settings. Boxer et al. (2012) found communication and coordination to be crucial to preventing high recidivism rates for heart failure patients discharged from hospitals to nursing homes.

In a study that examined older adults' transitions within a comprehensive care facility that contained independent living, assisted living, and long-term nursing care options, communication and coordination also contributed to vulnerability during transitions between levels of care (e.g., independent living to assisted living) (Shippe, 2009). Communication and coordination were crucial to mitigating feelings of social disengagement and feelings of disempowerment.


Consequences are contextual factors that occur as a result of the concept. This analysis identified two consequences related to the concept of vulnerability during transitions: 1) readmission to a previous or new care setting, and 2) potential negative health outcomes.

READMISSION TO A PREVIOUS OR NEW CARE SETTING Major consequences of the concept's attributes of inadequate continuity of care and poor communication and coordination are readmissions to previous or new care settings (Dedhia, et al., 2009; Foust, Naylor, Bixby, & Ratcliffe, 2012; Gill, Allore, Gahbauer, & Murphy, 2010; Gleason, et al., 2009; Hu, Capezuti, Foust, Boltz, & Kim, 2012; Quinlan, et al., 2011; Takahashi, et al., 2013; Vashi, et at, 2013). For example, a study by Takahashi et al. (2013) found that 30-day readmission for patients without care-transition interventions were 10.5 percent compared to no readmissions for those with a care intervention; emergency department admissions were 11.8 percent for the intervention group and 31.6 percent for those with no intervention.

Similar findings were reported by Dedhia and colleagues (2009), where 30-day post-discharge emergency department visits were 14 percent for patients with a transitions intervention and 21% for those without. Similarly, hospital readmissions were 14% with transition intervention and 22% without transition intervention. A clear consequence of no transitional care, which makes older adults vulnerable, is readmission to a new or previous care setting.

POTENTIAL NEGATIVE HEALTH OUTCOMES The Second consequence of inadequate continuity of care and poor communication and coordination among providers and patients is the potential for negative health outcomes. Illness and injury that lead to hospitalization and the subsequent transitions from one care setting to another contribute to worsening decline among all levels of function, that is, no disability to severe disability (Gill et al., 2010). Consequences of transitions and potential for harm are particularly relevant to older adults who are taking multiple medications to treat chronic diseases (Foust, Naylor, Bixby, & Ratcliffe, 2012; Gleason, et al., 2010; Hu, Capezuti, Foust, Boltz, & Kim, 2012). Without proper transitional care older adults are at risk for significant harm related to their medication regimes.

Geason and colleagues found that "among 309 prescription medication order errors, 4 (1.3%) were rated as involving potentially longer hospitalization, 32 (10.4%) rated as potentially causing temporary harm, and 163 (52.4%) rated as potentially requiring Increased monitoring or intervention to preclude harm" (p. 444). Potential medication harm during transitions can be particularly concerning for older adults with specific diseases that require close monitoring and management. Among heart failure patients discharged from the hospital, a study by Foust et al. (2012) found that a majority were discharged home with inconsistent or incomplete discharge instructions regarding their medications, and that a majority of the medications were high-risk, previously associated with adverse events.


Vulnerability during transitions for older adults is defined as the inadequate continuity of care and poor communication and coordination among health care providers and patients and their families. Contributing to older adults' vulnerable state during transitions is taking multiple medications, as well as the fragmented nature of the United States health care system. Consequences of vulnerable transitions include readmissions to previous or new care settings and the potential for poor health outcomes.

Older adults are the highest consumers of health care services in the country and have many special and unique care needs. These realities, coupled with older adults' multiple care setting transitions and life event transitions, create opportunities for vulnerability. To achieve the best possible outcomes we must ensure that all health care providers, and especially nurses, have the requisite KSAs to provide high quality care (Esterson, Bazile, Mezey, Cortes, & Huba, 2013).

The NLN ACE.S project aims to facilitate nurses and faculty obtaining these unique older-adult-focused KSAs. Part of the knowledge necessary to provide high quality care to older adults is to understand what vulnerabilities older adults' face when making transitions.

The concept of vulnerability during transitions, which is part of the NLN ACE.S framework, provides a reference from which nursing faculty and students can begin to understand the experiences older adults face when transitioning from one setting to the next. Having awareness of how taking multiple medications and the fragmentation of the health care system contribute to inadequate continuity of care and poor communication and coordination among providers and patients is crucial. Further, the knowledge that vulnerabilities can lead readmissions or negative health outcomes provides nurses with the knowledge and ability to take action and proactively prevent potential readmissions or negative outcomes. In clinical teaching settings where older adults are discharged home, nursing students with KSAs related to vulnerabilities during transitions may focus on ensuring patients have a clear understanding of discharge medication regimens and follow-up appointments with their primary care providers.

This analysis was conducted on current health care literature found in two major bibliographic databases. However, what is evident from the analysis of the literature is that very few studies have focused on a broader Interpretation of the concept of transitions. Most of the articles found in the body of literature related physical transitions between known care settings, such as hospital to home or hospital to nursing home, to emergency department and back to home. This provides valuable insights into the current focus and emphasis on care for older adults. It also provides insight into areas of health care that are significantly understudied and valued in the current healthcare climate, for example, the psychosocial aspects of aging and the impact of aging on well-being, versus medical disease outcome measures or financial impacts of health care utilization.

Further exploration and research are needed into how life transitions, such as losing a loved one, the inability to perform activities of daily living due to functional or cognitive decline, or transitioning into the role of grandparent or respected elder affect the risk for vulnerability in older adults. As the health care system evolves, additional work should be conducted to see how older adults' vulnerabilities change during transitions. Better and more effective means of communication through the use of smartphone technology may decrease vulnerabilities related to communication and coordination, whereas advances in gene therapy may create new and yet to be identified vulnerabilities in older adults.


This article defined the concept of vulnerability during transitions, which is part of the NLN ACE.S framework. Two antecedents were identified (use of multiple medications to treat disease, fragmentation of the health care system), two attributes (inadequate continuity of care, poor communication and coordination of care among of healthcare providers and patients and their families), and two consequences (readmission to a previous or new care setting, potential negative health outcomes). An understanding of how this concept impacts older adults will facilitate high quality care in a variety of health care setting. As the nursing profession embarks on the challenge of incorporating care of older adults as core nursing knowledge to be part of every curriculum, the NLN ACE.S framework and the concepts embedded within provide a useful and practical guide to facilitate this process.


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Daniel D. Cline, PhD, RN, is manager of education, St. Mary's Medical Center, San Francisco, California, and former project manager for the NLN Advancing Care Excellence for Seniors (ACE.S) project. The author would like to thank faculty and staff at Community College of Philadelphia and the entire NLN ACE. S Project team for their input, advice, and support on this project. This scholarly project was funded by the Independence Foundation of Philadelphia. For more information, contact Dr. Cline at

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Author:Cline, Daniel D.
Publication:Nursing Education Perspectives
Date:Mar 1, 2016
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