JAN THEORETICAL PAPER

Towards a conceptual evaluation of transience in relation to palliative

care

Philip J. Larkin, Bernadette Dierckx de Casterle & Paul Schotsmans

Accepted for publication 14 March 2007

Towards

Correspondence to P. J. Larkin: LARKIN P.J., DIERCKX DE CASTERLE B. & SCHOTSMANS P. (2007)

e-mail: abqnm6@r.postjobfree.com a conceptual evaluation of transience in relation to palliative care. Journal of

Advanced Nursing 59(1), 86 96

Philip J. Larkin MSc

doi: 10.1111/j.1365-2648.2007.04311.x

Lecturer in Nursing Studies (Palliative Care)

Aras Moyola, Department of Nursing and

Abstract

Midwifery Studies,

Title. Towards a conceptual evaluation of transience in relation to palliative care

The National University of Ireland, Galway,

Aim. This paper is a report of a concept evaluation of transience and its relevance to

Ireland

palliative care.

Bernadette Dierckx de Casterle PhD

Background. A qualitative study into palliative care patients experiences of trans-

Lecturer ition revealed a gap between current de nitions of transition and their expression of

Centre for Health Services and

the palliative care experience. Transience appears to offer a better de nition but

Nursing Research (Centr. Ziekenhous en

remains conceptually weak, with limited de nition in a healthcare context.

Verplegingsswet.), U,Z,

Methods. A qualitative conceptual evaluation of transience was undertaken using

Catholic University, Leuven, Belgium

two case examples, interview data and the literature. Multiple sources were used to

identify the literature (1966 2006), including a search on Cumulative Index to

Paul Schotsmans PhD

Director Nursing and Allied Health Literature Medline, and Ovid and Arts and Humanities

Interfaculty Centre for Biomedical Ethics and Index using the keywords transience and palliative care . Thirty-one papers related

Law (Interfacc. Centr. Biomed. Ethiek & to transience were retrieved. Analysis and synthesis formulated a theoretical de -

recht), U,Z,

nition of transience relative to palliative care.

Catholic University, Leuven, Belgium

Findings. Transience is a nascent concept. Preconditions and outcomes of transience

appear contextually dependent, which may inhibit its conceptual development.

Transience depicts a fragile emotional state related to sudden change and uncer-

tainty at end-of-life, exhibited as a feeling of stasis. De ning attributes would seem

to include fragility, suddenness, powerlessness, impermanence, time, space, uncer-

tainty, separation and homelessness.

Conclusions. Transience is potentially more meaningful for palliative care in

understanding the impact of end-of-life experiences for patients than current con-

ceptualizations of transition as a process towards resolution. As a nascent concept, it

remains strongly encapsulated within a framework of transition and further con-

ceptual development is needed to enhance its maturity and re nement.

Keywords: conceptual analysis, interviews, nursing, palliative care, qualitative

research, transience

critique of the positivist methods advocated by, for example,

Introduction

Walker and Avant (2005). It is cogently argued that reduc-

There is increasing interest in the application of qualitative tionist step-wise approaches to concept analysis often limit

approaches to concept analysis, arising largely from the the possibility of theory construction (Morse 1995). There is

86 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd

JAN: THEORETICAL PAPER Transience a palliative care concept

a call for nursing science to move towards a more iterative demonstrates particular attention to context and culture,

and integrative approach of concept development (Morse which may not be addressed through more positivist methods

1995, Morse et al. 1996b, Morse et al. 2002, Morse 2004). of conceptual analysis (Morse 1995, McKenna 1997). Fur-

ther, the evidence for transience in the literature enables some

level of contemporaneous judgement to be made regarding its

Background

preconditions, attributes and outcomes relative to palliative

care. We utilize two case studies to support, de ne and

consolidate the emerging concept. Finally, we critically

Conceptual development

appraise how far qualitative approaches t the examination

Conceptual development is most bene cial for extant con- of transience as a nascent concept and its potential import-

cepts that require re nement in a speci c discipline or ance to palliative care.

context. Hupcey et al. (2001) advanced the concept of trust

in this way. Fasnacht (2003) used similar methods to re ne

Transience as a concept emerging from the data

the concept of creativity. Both drew on a relatively strong

body of literature to explore the depth and maturity of their Concepts which arise from within practice hold greater

respective concepts in relation to nursing. Finfgeld-Connett credibility and relevance and lead eventually to stronger

(2006) con rmed that something relatively concrete needs to theory development (McKenna 1997, p. 58). The term

exist before such an approach can be applied: Qualitative transience arose from our study exploring the different, yet

concept development is particularly apt when constructs are not unrelated concept, transition. Transition literature often

relatively [my emphasis] immature and conceptual boundar- describes overtly positive outcomes such as resilience, recon-

ies are dif cult to identify (p. 104). struction, coherence, life purpose, sense of self, transcendence

Conceptual maturity requires critical judgement regarding and transformation (Smith 1994, Holland Wade 1998,

the degree to which the concept can be clearly de ned, Paterson et al. 1999, Block 2001, Neill 2002, Kralik et al.

adapted to different research settings and has robust param- 2003, Nygren et al. 2005). Interview data did not always t

eters or boundaries (Hupcey et al. 2001, Finfgeld-Connett with these descriptions. Patients described having limited

2006). Moreover, maturity should determine the method for knowledge about the purpose and timing of transfer to the

developing the concept (Morse et al. 1996a). Immature or hospice/PCU, uncertainty about who instigated the transfer,

nascent concepts, for example, may bene t from the use of limited involvement in decision-making often due to rapidly

qualitative eldwork data to support or refute their standing. increasing symptom burden and, once transferred, a sense of

Conceptual evaluation is bene cial for such concepts and waiting for something to happen. We therefore sought other

offers criteria to undertake this procedure (Morse et al. explanations to capture their experience. Concepts related to

1996b). process may incur additional dif culties, termed fuzzy

boundaries an unclear beginning or end or variations at

speci c times (Kim 1983). Given the strength of ndings

The empirical study

which suggested that transition did not clarify patients

In this paper, we report a conceptual evaluation of transience experience satisfactorily, critical evaluation of any alternative

applied to the discipline of palliative care (Morse et al. description was warranted. In particular, we needed to test if

1996a, Penrod 2001). In keeping with the constructivist transience was suf ciently robust to be considered a concept

approach, we present data from a qualitative study into per se, and what level of concept could be attributed to it

palliative care patients experiences of transition. We (Morse 2004). Here, we cite two cases where the richness and

addressed the research question How is the transition complexity of the transience experience is present. Names

experience towards end-of-life described by European have been changed to preserve patient con dentiality.

advanced cancer patients, through semi-structured interviews Informed consent was obtained from all patients in this

conducted with 100 palliative care patients across six study, following ethical approval procedures in each country.

European countries: United Kingdom, Ireland, Italy, Spain, Data were analysed using the ATLAS.TI program.

Switzerland and The Netherlands. Data were collected at one Selection of an exemplar is paradoxical in that, working

point in time from a purposeful selection of advanced cancer inductively, the researcher does not yet know what the

patients admitted to a hospice/palliative care unit (PCU) for attributes of the concept are and yet selects examples which

end-of-life care. Although this was a relatively large sample in try to demonstrate it (Morse 1995). Clearly, the example

qualitative terms, we maintain that this breadth of data should be explicit enough to illustrate all the possible

2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd 87

Table 1 The attributes of transience derived from patient interviews

88

Attribute Exemplar

Powerlessness There was no relationship and he constantly contradicted himself in the end you don t know what to think. When you have no experience in these matters,

and you don t know anyone with this illness you are totally lost . (Jeanne, 43, Ca Lung, Switzerland)

P.J. Larkin et al.

Fragility and no-one couldn t come near me. If a doctor came near the bed I d say Please, please doctor don t touch that leg, you can do anything you like with me but

please don t touch that leg, and here he d be I m not going to touch you at all, I wouldn t harm you, and I d go, Please don t touch the clothes, and I was

just lying in the bed and couldn t let anybody near me . (Annie, 74, Ca Breast, Ireland)

Impermanence I have here my radio, a picture of my father and mother, a picture of my wife, I have a piece of my own home taken here. Yes, yes, things from your own home?

The rest I give away, they are no good to me anymore . (Andre, 60, Leukaemia, Netherlands)

Uncertainty The worst thing that happened to me was the day I came for my check up and I was told the next day I was to be hospitalized when they told me,

Tomorrow you come in, I asked if there was anything wrong. All I got for an answer was, You just come in . The doctor didn t explain anything .

(Claudio, 64, Ca Prostate, Italy)

Time As time goes by, the evolution of the disease progresses more, I mean I notice it much more from one day to the next. It is not like some time ago that a

day or two or one week went by and it seemed that everything was the same. And now, no. From day to day, it can be noticed, it is very different, except for

certain days that are better . (Juan Eusebio, 72, Ca Colon, Spain)

Space I d rather be home, of course, but they brought things from home and when I wake up, nice, cosy, then you don t have that longing . (Herbert, 81, Ca Pancreas,

The Netherlands)

Suddenness I think the thing that I noticed more than anything was the sudden transition from being at home and doing all the things that one does at

home and out and about and then coming in here and suddenly being very, very restricted . (Peter, 70, Ca Lung, UK)

Separation I am sorry I am not going to see my grandchildren grow up, obviously. You know, you promised to take care of them and bring them out and treat them, but

I can t do that, because I won t be here to do that . (Claire, 68, Ca Colon, UK)

Homelessness So coming here I don t regret it no, because this is my home now I haven t got nowhere else to go . (Lily, 77, Multiple Myeloma, UK)

follows:

Search methods

A sense of stasis.

Concept evaluation

experience (Table 1).

Inability to prevent that change.

A personal shift in both time and space.

although evident in a cross-section of interviews.

A sudden and unexpected change in life circumstance.

The realization of a fragile and impermanent existence.

In the cases presented, the impact of patients experience

relation (Morse & Doberneck 1995). These tentatively frame

were: fragility, suddenness, powerlessness, impermanence,

its focus may vary (Robinson & McKenna 1998, Hutch eld

future, contrasting the empowerment construct which

consider these attributes to be embedded within these cases

review of relevant literature should be undertaken, although

appears to be a precondition for negotiating transitional

describes a period of irrevocable change and an unknown

Humanities Index. One hundred and ten papers were

Health Literature (CINAHL) Medline and Ovid and Arts and

rigorous and identify a breadth of resources to explore the

experiences with their present situation. This questioned the

was not so much in process (as would be expected from

change (Bridges 2001). In effect, the reality of their situation

interview data in general (Morse 1995). These attributes

set of attributes from both cases and re ections on the

their lives. We acknowledge that the cases shown are

attributes to support the case. The cases describe two

identi ed which included transience as a keyword. Of these,

1999, Morse 2004). In all cases, the review should be

(1996b) were then applied (Table 2). All authors agree that a

Criteria for conceptual evaluation ascribed to Morse et al.

the concept, offering some preconditions and outcomes as

meaningful structure for exploration, referred to as rules of

time, space, uncertainty, separation and homelessness. We

terms and that the strength of the concept in the unique and

speci cally selected to demonstrate the concept in absolute

respondents from different countries, in receipt of palliative

phic databases Cumulative Index to Nursing and Allied

concept. Multiple sources were used including the bibliogra-

The attributes identi ed were then reformulated into a

validity of transition as a descriptor of the totality of their

transition) but more a sense of stasis, as they rationalized past

number of countries is variable. However, we identi ed a

individual experiences of one hundred people across a

care and living at the palliative care-terminal care interface of

2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd

JAN: THEORETICAL PAPER Transience a palliative care concept

Empirical literature which addresses transience in a health

Table 2 Criteria for concept evaluation

context is relatively sparse. Transience would appear as an

Is the concept well-de ned?

attribute or consequence of larger, more mature concepts as

Are the characteristics/attributes identi ed?

Are the preconditions and outcomes of the concept described and found in psychology, medicine (including medical geography),

demonstrated?

philosophy and social science. For example, Schacter et al.

Are the conceptual boundaries delineated?

(2003) discussed transience under an investigation of the

Morse, J.M., Mitcham, C., Hupcey, J.E., & Cerdas Tason, M.

concept of self and memory. Shaw (2005) described transience

(1996): Criteria for concept evaluation. Journal of Advanced

as a key descriptor of the concept of spirituality. Westermeyer

Nursing 24, 385 390. Reproduced with permission.

(1982) related transience to persistence in the experience of

depression, emphasizing both cyclical and temporal charac-

teristics to the disease. Reed et al. (1998) focused on the

79 were rejected as having limited reference to the research

experiences of older people moving into care homes and

topic under investigation, since they described transience in

described dependency and adjustment under a heading of

the context of pure sciences only. Thirty-one papers were

transience. However, transience is often used without any clear

then retrieved, including those which offered a conceptual

de nition or expansion of its meaning or application in

de nition of transience or alluded to transience as an example

context, suggesting a deeper exploration of transience is timely.

of other health-related phenomena.

Nineteen articles with particular relevance to our research

study were selected, including philosophy (7), psychology (5),

Themes in the literature and interview data

health or social science context (4) and thanatology (3). The

Themes arising from both literature and interview data were

search was then broadened to include transience in relation to

recon gured under four speci c headings: transience as an

the attributes identi ed from the case studies, using word

ephemeral state of being, transience as an expression of time,

combinations such as transience AND homelessness. A

transience as a spatial phenomenon and transience as a

further three papers were identi ed. Books, texts, dictionaries

construct of home. In presenting this conceptual evaluation,

and landmark works which demonstrated the existence of the

we utilize excerpts from the case studies to ground the

concept over time were also explored (McKenna 1997). The

emerging concept within the study proper.

body of literature identi ed comprised mainly clinical

discussion papers with relatively few empirically based

Transience as an ephemeral state

studies. No data speci cally related to palliative care were

Two psychoanalytical papers offered a concrete description

found.

of transience: one historical and the other contemporary.

Freud s (1916/2006) seminal treatise, On Transience, des-

Findings

cribed it as an ephemeral state of existence where things once

considered permanent, change. Kitayama (1998) delineated

Is the concept well-de ned?

between transition and transience. He described transition as

a phenomenological description of movement whereas

The maturity of a concept appears proportional to the

transience referred to an emotional state often associated

strength and reliability of its de nition (Morse et al. 1996a,

with sadness and painful feelings (p. 937). The aesthetic of

1996b, McKenna 1997, Hupcey et al. 2001, Penrod 2001,

transience re ects something of passing beauty which is both

Penrod & Hupcey 2005a, 2005b). Although qualitative

joyful (as it is currently beautiful) and sad (because it is a

conceptual theorists consider dictionary de nitions too

transient experience which will pass). Important to these

sparse in terms of nuance, we reviewed the Oxford English

descriptions is a dual sense of impermanence and irreversi-

Dictionary (1989) to ascertain properties differing from

bility associated with the transient state, a sense of wanting to

other competing concepts, such as transition. Transience

hold on to something when it is not possible to do so. Barbara

was de ned as the action or fact of passing away

(case study 1) re ected on her fragility since the recent death

re ecting a lack of permanence, something of limited

of her husband, Martin, stating:

durability (Oxford English Dictionary 1989). Transience

was evidenced in the arts, sciences and humanities and

I don t know what to call it but if I was to overcome that but I just

derived from the same etymological root as transition

can t see it happening because of Martin [pauses, smiles]. He was

trans re to go or cross over. Transition was largely

my life, soul-mate everything and I just can t get over him and I

de ned in terms of passage, movement and change from

never will.

one state or place to another.

2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd 89

P.J. Larkin et al.

In these descriptions, transience would appear to re ect

Case 1 Barbara an emotional state where the quality of the present

moment may be all the more meaningful because of its

Barbara was a 49-year-old woman with colon cancer and

fragility and impermanence. As Freud (1916/2006)

widespread gastrointestinal metastases. She lived in a rural

concludes:

community with her husband until his death from prostate

cancer. She cared for him at home, supported by the The beauty of the human form and face vanish for ever in the course

palliative home care team. During this time, her own of our own lives, but their evanescence only lends them a fresh

diagnosis was con rmed. Barbara had one daughter who charm. (Freud, On Transience, p. 1)

lived in a major city about 200 miles away from her. Her

daughter persuaded Barbara that she should move to live Transience as an expression of time

with her. Barbara reluctantly agreed. Once settled with Time, particularly in relation to death, is core to the

her daughter, Barbara s own home was sold at her expression of transience (Wilder 1965, Wolf 1983, Lach-

daughter s instruction. Although she had her own room mann 1985, Feifel 1990, Johnson 2003, Adam 2006). Hu-

in her daughter s house, the space did not allow Barbara man society attempts to use time to stabilize and x

to bring furniture or most of her personal possessions, something that is essentially intangible in order to overcome

which were also sold. Relationships grew strained in the the threat of non-existence, nitude and transience (Adam

house and Barbara sought admission to hospice as respite 2006, p. 121). Elizabeth commented:

from the situation. Barbara deeply regretted the sale of her

I do want to live. I want to live and enjoy until the last minute, you

own home and felt she was simply waiting to join her

know. My daughter said we needed things to look forward to, so I

husband.

had a big birthday party and it was wonderful fun.

Conversely, Barbara spent her time travelling to avoid facing

Elizabeth (Case study 2), in response to a question about

dif cult family situations:

being in a hospice, remarked:

The problems were going on, I kept going away, went to Spain, I

Being here [the hospice] has made me generally a lot calmer. It gives

went to Canada, I went to, anywhere I could go I went, just to get out

you strength and I m at a kind of, underpinned by it and I said to

of the way, get out of their way and for me as well.

them [her parents], you do realise this is where I m going to stay to

die, and I said, it s important because I know I ll be looked after and Johnson (2003) criticized poststructuralist assumptions that

I know you ll be looked after as well . And that is important because all life is essentially transient, arguing that Western culture

they will be. has used this assumption as a way to demean the vitality of

living. He argued that, where transience has been used to

de ne life as shaped by the imminence of death, it neglects the

Case 2 Elizabeth

fact that:

Elizabeth was a 58-year-old woman with a primary brain

Life proceeds at its own pace and therefore does not slip towards

tumour. She had lived with her partner and his children in

death in a transient manner. (Johnson 2003, p. 210)

his home for a number of years. As her disease progressed,

Both cases demonstrate positive and negative aspects of

her need for assistance with personal care increased and

transience as time; Elizabeth describing time spent living until

she required the use of a wheelchair at all times.

she dies and Barbara describing time spent creating distance

Eventually and unexpectedly for Elizabeth, her partner

from family and her own feelings.

told her that he was no longer prepared to care for both

her and the children and that she would have to leave the

Transience as spatial phenomenon

family home. Elizabeth left the home within a few days

and moved in with her adult daughter from a previous I think it s territorial really, dying. As my friend said, this is your

relationship. The daughter was also unable to provide the manor isn t it back to the East End because this is where it all is.

necessary support needed for Elizabeth and she was (Elizabeth)

transferred to the hospice. Elizabeth never saw her partner

Transience has a strong relation to social and philosophical

or his children once she left the family home and, although

constructs of space and home. Auge, for example, de ned

she kept in close contact with her daughter, remained in

transience in terms of the anonymity of non-lieu or non-

the hospice until her death.

place (Auge 1995, p. 104). Hospitals, and more recently

90 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd

JAN: THEORETICAL PAPER Transience a palliative care concept

hospices, t this description by virtue of patients passing homelessness was often traumatic life events, combined with

through (Reed-Danahay 2001, Foggo 2006). Milligan (2003) vulnerability and poverty. Family bereavement, relationship

explored the idea of home as a space of ontological security. breakdown and loss of housing contribute to the context of

Space as dwelling has resonance for conceptualizing transi- homelessness. Elizabeth s story is a good example of someone

ence as something uid and intangible, which differs from who became transient following the loss of her home, a

space as territory, bounded and closed (Williams 1951, decision that left her vulnerable and angry:

MacGregor Wise 2000, Young et al. 2002, Gilmour 2006).

When you get a death sentence, you don t get a little book of

The achievement of ontological security in hospice would

notes to tell you how to deal with it. And he didn t want me at

seem to be a positive outcome for people experiencing

home and he certainly didn t want me dying in front of his children.

transience in their lives:

I didn t know where to go and within not long I was out of the

Interviewer: If I asked you what [name of hospice] can give you at house as well I lost my home and my relationship. I was air-

this moment in time, what would you say? brushed out of their lives. (Elizabeth)

Elizabeth: Safety. A feeling that I can die and it s OK. Safe to die and

Barbara s reaction to her loss of home was resignation and

all the people will look after me and it s not an embarrassing thing. I

withdrawal:

don t have to apologise. I don t have to pretend.

She [daughter] sees me sitting on a bed and wasting my life away.

However, dying may also be associated with feelings of

Well, as far as I m concerned, it s what I want to do. If I could do it, I

rootlessness and having to face the unknown with minimal

would I would get up and go out everyday and buy something and

mastery (Feifel 1990, p. 539). In Barbara s case, her inability

go shopping. But I ve got nothing, I ve got no home, that s gone from

to accept the new space in her daughter s home left her with

me, so there s no point. (Barbara)

regret and turmoil:

It is evident that there may be speci c differences between

I regret selling up and moving because maybe if I d have stuck it,

transience and being transient, which are neither discrete nor

well, I don t know if I could have lived on my own or but I wasn t

tangible. Transience has some de nitional and descriptive

given the chance. (Barbara)

properties, but further delineation of its characteristics and

attributes is warranted.

Transience as a construct of home

Most empirical studies on transience are evidenced in the

Are the characteristics/attributes identi ed?

concept of homelessness (Rowe & Wolch 1990, Pollio 1997,

Kang et al. 2000, Anderson 2001, Lee et al. 2003, Anderson

Given the etymological links between transience and trans-

& Rayens 2004). Homelessness is particularly associated

ition, it was important to be able to identify what differed

with mental ill-health (Geissler et al. 1995, Anderson &

and what, if anything, made transience unique. The main

Rayens 2004, Muir-Chochrane et al. 2006). Pollio (1997)

attributes emerging were fragility (of the situation and its

identi ed four dimensions to the concept of transience in

impact on the person), impermanence (for example, the

relation to homelessness, migration, duration, intention and

transient state of being homeless) and stasis (limitation in

involvement. Migration refers to an individual s movement

ability to move beyond a given situation). The overt

from their community of origin. Duration and intention

emphasis on transition as a positive process of growth

re ect the length of time spent in the new community and the

and renewal (Bridges 2001) implies an ability to address

reason for the initial migration. Involvement warrants con-

problems of the past and move on. The inability to do so is

siderable investment in the new community in order to create

seen as potentially harmful to well-being. Contemporary

stronger community support. These descriptions, particularly

models of grief and loss refute the passage ideal in favour of

shared community, may re ect the transience experience of

a life biography incorporation model, bringing past experi-

palliative care patients coming into hospice as they seek to

ences and present situation together to create a cohesive

stabilize their emotional turbulence:

pattern (Walters 1996). Transience would seem to be a

response by the patient to incorporate the life biography

You get that sort of rapport with people, whereas, because they

within the present. Bachelard (1955), in The Poetics of

understand, they do understand we ve got the same wavelength,

Space, argued that:

sort of thing. (Barbara)

Radley et al. (2006), in a small ethnographic study of All the spaces of our past moments of solitude, the spaces in which

homeless women in London, identi ed that the reason for we have suffered from solitude, enjoyed, desired, and compromised

2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd 91

P.J. Larkin et al.

2003, White 2003, Kralik et al. 2006). Neither Barbara s nor

solitude, remain indelible within us and precisely because the human

Elizabeth s experiences suggest that it was possible to

being wants them to remain so. (p. 10)

reconstruct their lives at this point in time. This differenti-

Feelings of transience and uncertainty about the future enable

ation remains relatively abstract and does not in itself offer

us to embrace the past, leading to a more authentic humanity

categorical evidence for transience as a concept. Further

(Wilder 1965). Authenticity does not assume transience to be

comparative work is necessary to con rm these relationships.

a wholly negative phenomenon, but rather real life experience

which may affect a range of responses, as demonstrated by

Discussion

Elizabeth and Barbara.

This conceptual evaluation derived from the need to explain

Are the preconditions and outcomes of the concept transition experiences which current conceptual descriptions

described and demonstrated? failed to capture. In choosing transience as a possible descrip-

tor, the lack of evidence looking at transience in a palliative

Preconditions and outcomes link concept and context, central

care context is a distinct limitation. Transience, when used to

to the qualitative approach (Morse et al. 1996a). In support

consolidate other concepts, indicates that it is an immature and

of Kitayama s re ection on transience (1998), the precondi-

underdeveloped low-level concept in its own right (Morse

tions and outcomes identi ed seem to arise from an emotional

2004). It would be important to delineate the state of transience

response to a speci c set of life circumstances. However, we

from the process of transition and, more speci cally, to

noted an overlying emphasis in the conceptual analysis

question why we seek transition as a positive outcome.

literature on behavioural concepts (Morse 1995, Morse

Transition theory indicates potential for transformative

et al. 1996a, Morse 2004) and transience as a behavioural

experiences to arise out of a transition process, including the

concept remains unclear. There is a need to qualify precon-

acute care-palliative care interface (Meleis & Rogers 1987,

ditions and outcomes for transience and this gap hinders the

Schumacher & Meleis 1994, Paterson et al. 1999, Meleis et al.

evaluation of this concept. For example, universal character-

2000, Kralik 2002, Johnston 2004, O Connor 2004, Schul-

istics and attributes should be apparent in all contexts where

man-Green et al. 2004, Kralik et al. 2006, Thompson et al.

transience exists (Morse 2004). This did not appear to be the

2006). Transformative experience would require a restruc-

case. Homeless women s experiences of transience were often

turing of the illness and self in order to regain some degree of

precipitated by abuse or deprivation (Radley et al. 2006).

control (Paterson et al. 1999, p. 787). It may be that we seek for

This differed from the case of an older person s relocation to

transition to be transformative because the hope of a positive

residential care (Reed et al. 1998). Both hold agreed prop-

outcome is easier to deal with than the fragility and imper-

erties of transience, but with mutually exclusive characteris-

manence which transience offers. The task of understanding

tics. Morse (2004) advises caution in developing a single

such relationships should form the basis of further work,

concept with many similar meanings. Further exploration of

particularly focusing on the transience-transition interface in

the distinction between behavioural and emotional compo-

relation to transience as a state of being and transition as a

nents of transience may bene t conceptual clarity.

process of becoming (Mueller 1943, Wilcock 1999).

The multidisciplinary nature of palliative care means that

Are the conceptual boundaries delineated? transience can be experienced and examined by practitioners

simultaneously and yet differently. A social worker may be

Given the description of transience as an ephemeral state of

more interested in transience as a consequence of homeless-

being, it is dif cult to conceive of boundaries and structure in

ness. A psychologist may emphasize its impact on the self.

its description. Time and space, which contribute to our

Thus, in the context of palliative care, transience should be

understanding of transience, are clearly in nitesimal. Dis-

seen as a multi-faceted concept re ecting the complex nature

tinction between the characteristics of transience and trans-

of human experience. Evident from the two cases discussed

ition would constitute a boundary, albeit it an ambiguous

here is the particular status of hospice as a place that

one. However, transience shows characteristics of uniqueness

promotes healing and maintains well-being (Williams 1951,

which may separate it from other concepts. Transience

Gilmour 2006). Lawton s (2000) seminal work on the

clearly differs from current descriptions of transition as

experience of dying in a hospice concurs with descriptions of

reconstruction and mastery (Schumacher & Meleis 1994,

place based on connection, memory and identity. In her

Holland Wade 1998, Bridges 2001, Gwilliam & Bailey 2001,

research, connectedness to the place and community of

Boeijea et al. 2002, Young et al. 2002, Vaartio & Kiviniemi

92 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd

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