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Author ORCID Identifier



Open Access Dissertation

Document Type


Degree Name

Doctor of Philosophy (PhD)

Degree Program


Year Degree Awarded


Month Degree Awarded


First Advisor

Cynthia Jacelon Ph.D.

Second Advisor

Terrie M. Black DNP

Third Advisor

Mark C. Pachucki Ph.D.

Subject Categories

Nursing | Rehabilitation and Therapy


This study aims to explore the process of transitioning individuals with traumatic brain injury (TBI) from long-term care settings to the community and develop a theory of transition. Also, it explores the definition of successful transitioning and the perceived role of the nurse in the transitioning process. A constructivist grounded theory method guided by symbolic interactionism was used in this study. The research sample was recruited throughout the Commonwealth of Massachusetts. The sample included individuals with TBI, family caregivers, professional caregivers, and community service providers involved with the Acquired Brain Injury and the Money Follows the Person waiver programs in Massachusetts. Data for this study was obtained through interviews, participant observations, photography, and document reviews. Thematic analysis was used to explore and define successful transitioning and the perceived role of the nurse in transitioning through synthesis and abstraction of the data collected. Analysis using grounded theory methods such as constant comparison, theoretical sampling, coding, memo writing, journaling, and theoretical saturation was employed as theory emerged. The “It’s all about the person model of transitioning to the community” (IPMTC) was the resulting theory developed from this study. As a theoretical model, IPMTC asserts that transitioning from a long-term care facility to community will be successful if: the transitioning process is person-centered; a supportive environment is maintained; the health of the individual transitioning is stable; there are effective transition management processes in place, and there are facilitating individual, process, systems, and organizational factors. The IPMTC asserts that transition outcomes will be suboptimal if there are barriers to the process. As an emerging nursing theory, IPMTC defines the four essential components of nursing (person, health, environment, and the role of the nurse). The IPMTC is ground-breaking as it is the first to describe the process of transitioning individuals with TBI from long-term care setting to the community under a Medicaid waiver program. The first to place transition management processes within the context of a broader transitioning process and shows that the transitioning process is a nursing process. The IPMTC indicate that checking in, planning, relationship-building, and social engagement are key transition management processes.