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Transition from Pediatric to Adult
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Transition from Pediatric to
Adult Healthcare Services for
Adolescents and Young Adults
with Long-term Conditions
An International Perspective on
Nurses’ Roles and Interventions
Cecily L. Betz
Imelda T. Coyne
Editors
123
Transition from Pediatric to Adult Healthcare
Services for Adolescents and Young Adults
Cecily L. Betz • Imelda T. Coyne
Editors
Transition from Pediatric

to Adult Healthcare
Services for Adolescents
and Young Adults
An International Perspective
on Nurses’ Roles and Interventions
Editors
Cecily L. Betz Imelda T. Coyne
Keck School of Medicine School of Nursing and Midwifery
Department of Pediatrics Faculty of Health Sciences
University of Southern California Trinity College
Los Angeles, CA Dublin
USA Ireland
ISBN 978-3-030-23386-0 ISBN 978-3-030-23384-6 (eBook)

https://doi.org/10.1007/978-3-030-23384-6
© Springer Nature Switzerland AG 2020

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The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
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Preface
Although the survival rates of adolescents and young adults with long-term condi-
tions have been on the rise for decades, systems of care have been challenged to
meet the demands pertaining to healthcare, postsecondary education, employment,
and community living of this ever-increasing population. In particular, the system of
healthcare has been particularly impacted responding to the needs of this adult pop-
ulation. The other service systems of social services, employment and education,
have developed programmatic approaches to address the ongoing needs of adults
with long-term conditions for several decades. Although flawed by today’s stan-
dards, these service systems of social service, employment and education, have
been and continue to be reformulated to meet the changing needs of young adults
with long-term conditions. For example, in the past, the educational system was
designed to segregate children, adolescents, and young adults with long-term condi-
tions based on the premise that they needed to be “protected” and isolated from their
typical peers. This group of adolescents and young adults of the past were not
encouraged to dream the dreams for their futures as were their typically developing
peers. Likewise, employment programs for adults with intellectual and develop-
mental disabilities initially focused on enabling employment options within segre-
gated congregate settings with routinized, boring, and monotonous tasks. Other
longitudinal studies have reported significant differences between adults with long-
term conditions and disabilities and those without disabilities on metrics of employ-
ment, educational achievement, standard of living, and quality of life. These metrics
were significantly higher for adults without disabilities and long-term conditions.
Nevertheless, these flawed programs of the past in education and employment were
the precursors to the development of more inclusive, non-discriminatory, and
achievement-oriented programs. The inclusive educational and employment pro-
grams now focus on future planning to attain milestones of adulthood to the fullest
extent possible.
In contrast, the systems of healthcare have been struggling to effect the necessary
linkages between two very different service models of care for children, adoles-
cents, and young adults with long-term conditions and the receiving adult service
model for these new populations of adults. Although progress has been achieved in
effecting modest changes in addressing the discontinuities across the life span of
healthcare needs for services for those with long-term conditions, much work is
needed to develop and establish sustainable, comprehensive healthcare transition
v
vi Preface
systems of care. Unlike the other service systems for individuals across the life span
with long-term conditions, the establishment of healthcare transition service models
can be described in the seminal stages of development. Nevertheless, as evidenced
by the production of this textbook, there are observable benchmarks of progress in
this field of practice and research. This textbook affirms not only the importance of
the role of nurses in the field of healthcare transition, but it is also a reflection of the
contributions nurses have made in this nascent field of practice and research world-
wide. This textbook is designed to assist nursing and interdisciplinary colleagues
with not only knowledge of the developments in the field of healthcare transition but
also with the resources to enable programmatic development and implementation in
their practice settings.
As presented in this text, diversity of nursing practice and research is evident in
the field of healthcare transition. The models of practice presented are reflective not
only of local, community-based needs but also of the cultural practices and stan-
dards of healthcare of the countries represented. The contributions of this textbook
reflect the global efforts of nursing practice, research, and scholarship of experts
from Belgium, Canada, Ireland, Netherlands, United Arab Emirates, Switzerland,
the United Kingdom, and the United States. Although diverse cultural perspectives
are offered in this textbook, the examples of clinical practice models, theoretical
perspectives, evidence, and research demonstrate the commonalities of application
in other countries. International examples provide a description of a range of transi-
tion interventions are relevant for nurses, doctors, students, researchers, and allied
healthcare professionals, that is, for those who are involved with the provision of
healthcare transition care.
Chapters that describe exemplars of interventions developed and implemented
will provide readers with not only the outcomes of the projects themselves, but also
with the insights of the experts directly involved with this effort. These experts pro-
vide the clinical acumen on what worked, what was feasible, and what they would
have done differently in retrospect. Additionally, these experts provide perspectives
not typically found in healthcare transition publications/presentations on the repli-
cation considerations of their programs. That is, what are the optimal conditions for
replication, the necessary conditions and elements that need to be considered for
planning, implementation, and evaluation.
Other chapters will address relevant theoretical and quality improvement issues
pertaining to healthcare transition. Authors of these chapters demonstrate to the
readers the impact on selected concepts of care such as self-management and
empowerment and their importance on the process and outcomes associated with
healthcare transition. In this textbook, issues are explored pertaining to quality
improvement and the development of standards for healthcare transition that are
vital to fostering programmatic refinements to improve outcomes of care for adoles-
cents and young adults with long-term conditions. The application to practice,
research, and education are addressed as well with examples to illustrate.
Each of these chapters contains a section entitled, The Key Advice/Points. In this
section, authors provide readers with useful and key advice in an easy-to-access
format, enabling application to practice. In addition, at the end of each chapter,
Preface vii
authors have provided readers with a section entitled, Useful Resources. The listing
of resources includes websites, discussion groups, networks, and toolkits.
The Editors envisioned each of the chapters as focused on nurse-led efforts in
developing, implementing, and evaluating their program of healthcare transition, be
it a service model, quality improvement project, research study, or some type of
programmatic effort. Each chapter is designed to provide readers with the insights
and understanding of how they might apply these descriptions of efforts and “les-
sons learned” to their own professional practice or institutional setting. It also pro-
vides the readers with a guideline/template/dashboard to enable application in other
settings. This book fills the gap in the availability of current textbooks on the topic
of healthcare transition by explaining how nurses contribute to enhancement of
transition process and support.
As editors, our collaboration reflects the breadth of transition studies in the
United States of America, Canada, United Arab Emirates, Sweden, Belgium,
Switzerland, Netherlands, and the United Kingdom. Two years of efforts have gone
into the production of this book which has been successful due to tremendous hard
work, goodwill and collegiality. We are grateful to our authors for their willingness
to share their research, their commitment to scholarship and for their excellent
chapters. We express our wholehearted thanks for their dedicated efforts and gener-
ous collaboration with us.
We are grateful for the support and steady encouragement we have received from
our partners and friends, particularly my sister Genevieve Mitchell. We are deeply
indebted to the many young people, families, and healthcare professionals who have
kindly shared their experiences of the transition process from pediatric to adult
healthcare services.
Our deep thanks to the commissioning editor, Marie Come-Garry and Springer
Nature team for their professional help in bringing this book to successful comple-
tion. Special thanks to the project co-ordinator Parthiban Bharathi and project man-
ager Vishal Anand for assisting with the artwork, typesetting and proof reading.
Finally, to our readers, thank you for recognizing the importance of healthcare
transition and nurses’ roles in transitional care. We hope that you will enjoy reading
this book and that it will help inform your clinical practice and/or research with
adolescents, young adults and families.
Los Angeles, CA, USA Cecily L. Betz

Dublin, Ireland Imelda T. Coyne
Contents
1 Healthcare Transition: An Overview and Introduction �� 1

Cecily L. Betz and Imelda T. Coyne
1.1 Introduction�� 1
1.2 Healthcare Transition: Now and Then�� 2
1.3 Nursing Practice Roots of Healthcare Transition�� 3
1.4 Primary Nursing�� 3
1.5 Care Coordination�� 4
1.6 Family-Centered Care �� 6
1.7 Nursing Influence and Involvement in Healthcare Transition�� 9
1.8 The Next Generation of HCT Nursing�� 12
1.9 Conclusion�� 13
1.10 Useful Resources�� 13
References�� 13
2 Empowering Young Persons During the Transition to Adulthood�� 19
Mariela Acuña Mora, Carina Sparud-Lundin, Ewa-Lena Bratt,
and Philip Moons
2.2 Patient Empowerment: Relevant Theoretical Grounds �� 20
2.3 Patient Empowerment During the Transition to Adulthood�� 24
2.4 The Road Toward Adolescent Empowerment�� 28
2.5 Application to Practice, Education, and Research�� 37
2.6 Key Advice/Points�� 39
References�� 41
3 Determinants of Quality of Healthcare for Adolescents
and Young Adults �� 47
Nabeel Al-Yateem
3.2 Factors Affecting Adolescent Care �� 49
3.3 Quality Healthcare for Adolescents�� 51
3.4 Impact on Adolescents’ Healthcare Use �� 64
ix
x Contents
3.5 Application to Practice, Training, and Research�� 65

3.6 Key Points �� 66
References�� 67
4 Analysis of Self-Management and Transition Readiness
Instruments for Clinical Practice �� 71
Kathleen J. Sawin, Rachel Margolis, Jaclyn R. MacFarlane
Bookman, Melissa H. Bellin, Lynne Romeiser Logan, Jason
Woodward, and Timothy J. Brei
4.2 Self-Management and Transition Readiness Measures:
Theoretical Approaches and Conceptual Considerations �� 72
4.3 Methodology �� 75
4.4 Results/Instruments�� 75
4.5 Discussion and Application to Practice�� 102
References�� 105
5 Measurable Outcomes for Transition: The Nurses’ Role�� 111
Bethany Coyne and Sara C. Hallowell
5.2 Measuring Transition Outcomes: An Overview�� 112
5.3 Application to Practice, Training, and Research�� 123
6 Best Practice for Healthcare Transition: Development
and Use of the Benchmarks for Transition�� 127
Susie Aldiss and Faith Gibson
6.2 Transition Issue �� 129
6.3 Benchmarking �� 129
6.4 Target Population�� 137
6.5 Ethical Issues�� 138
6.6 How This Issue Influences a Transition Programme�� 138
6.7 Impact on Participants (Outcomes)�� 140
6.8 Application to Practice�� 140
6.9 Application to Training �� 142
6.10 Application to Research�� 142
Contents xi
7 Transition of Care for Adolescents from Child to Adult

Health Services: A Systematic Review �� 147
Fiona Campbell, Susie Aldiss, and Katie Biggs
7.2 Background �� 148
7.3 Objectives�� 150
7.4 Methods�� 150
7.5 Results�� 153
7.6 Summary of the Findings�� 162
7.7 Quality of the Evidence�� 164
7.8 Conclusions�� 164
8 Transition in Cystic Fibrosis: An International Experience�� 171
Daniel Office and Susan Madge
8.2 Common Key Features of International Transition
Programmes in Cystic Fibrosis �� 172
8.3 International Transition Survey�� 179
8.4 Recommendations�� 182
8.5 Summary �� 185
9 On Your Own Feet: A Practical Framework for Improving
Transitional Care and Young People’s Self-Management�� 191
AnneLoes van Staa, Mariëlle Peeters, and Jane Sattoe
9.2 The On Your Own Feet Framework�� 192
9.3 Quality Improvement Programs for Transitional Care �� 194
9.4 Interventions for Transitional Care �� 201
9.5 Priorities for Research and Training �� 213
9.6 Key Recommendations for Practice�� 214
Appendix�� 217
10 Bridging Pediatric and Adult Healthcare Settings in a Nurse-Led
Cystic Fibrosis Transition Initiative �� 229
Anna M. Gravelle
10.2 Intervention #1: An Evaluation of the Transfer Period �� 231
10.3 Advantages/Challenges�� 241
10.4 Program Replication �� 241
xii Contents
10.5 Intervention #2: Adaptation and Implementation of a Crossover

Transition Clinical Pathway�� 242
10.6 Advantages/Challenges�� 250
10.7 Program Replication �� 251
10.8 Key Ideas/Advice�� 252
11 Nurse-Led Effort in Developing, Implementing and Evaluating
Healthcare Transition and Promoting Developmentally
Appropriate Healthcare for Young People with Haemophilia �� 257
Kate Khair, Luke Pembroke, and Deborah Christie
11.2 Transforming Transition Programme�� 260
11.4 Advantages and Challenges�� 275
11.5 Programme Replication�� 277
11.6 Key Advice�� 278
12 Transitional Care in Endocrinology�� 281
Andrew A. Dwyer and Michael Hauschild
12.2 Chronic Diseases in Endocrinology�� 282
12.3 Transition of Young Adults with Chronic (Rare)
Endocrine Disorders�� 283
12.4 Multidimensional Challenges to Endocrine Transition�� 284
12.5 Goals for Transition in Endocrinology �� 287
12.6 Endocrine Disease-Specific Transition Care Approaches�� 288
12.7 Lausanne University Hospital Transition Program (Switzerland)�� 300
12.8 Application to Practice, Teaching, and Research�� 303
12.9 Key Advice�� 306
12.10 Conclusions�� 306
13 Nursing Initiatives and Future Directions for Transition
Practice and Research �� 319
Imelda T. Coyne and Cecily L. Betz
13.2 Implications for Practice, Education and Research�� 326
Healthcare Transition: An Overview
and Introduction 1
Cecily L. Betz and Imelda T. Coyne
1.1 Introduction
This textbook is representative of the development of the science and practice of the
field of healthcare transition and the important role nursing has in the field. As this chap-
ter will illustrate, this emerging field of practice has expanded significantly in terms of
literature base of empirical evidence that has accumulated since the 1990s (Betz 2004;
Blum 1995; McGrab and Millar 1989). Evidence of this body of knowledge is demon-
strated by the number of high-quality systematic reviews and research with advanced
designs and methodology that are now being published (Farrell et al. 2014; Heath et al.
2017; Yassaee et al. 2019). The primary aim of this chapter is to provide a succinct
overview of the development of this field and the role of nursing in its past, present, and
future and an introduction to the content in the text chapters. In acknowledging the early
efforts of nursing involvement in the field of healthcare transition, a longitudinal per-
spective of the precursor models of practice that were first developed and implemented
such as care coordination, primary care, and family-centered care is featured. The his-
torical roots of innovative models of nursing care that first surfaced more than a half
century ago deserve attention as these practices find new venues of clinical application.
For nurses, the ease of adopting and adapting long-standing nursing models of
care to this field of healthcare transition has been a central theme of service focus in
transition as evidenced by the development of Meleis’ middle-level theory of
transition and the body of empirical work and scholarship that has been
C. L. Betz (*)
Keck School of Medicine, Department of Pediatrics,
University of Southern California, Los Angeles, CA, USA
e-mail: cbetz@chla.usc.edu
I. T. Coyne
School of Nursing and Midwifery, Faculty of Health Sciences,
Trinity College Dublin, Dublin, Ireland
e-mail: coynei@tcd.ie
© Springer Nature Switzerland AG 2020 1

C. L. Betz, I. T. Coyne (eds.), Transition from Pediatric to Adult Healthcare
Services for Adolescents and Young Adults with Long-term Conditions,
https://doi.org/10.1007/978-3-030-23384-6_1
2 C. L. Betz and I. T. Coyne
subsequently generated (Schumacher and Meleis 1994). The new generation of

practice and science that has emerged in healthcare transition, and in particular by
nurses, is demonstrated by this chapter discussion of their role in the development
of the field. The chapters of this text demonstrate the innovations and contributions
to practice, science, and scholarship that nurses now bring to the field.
1.2 Healthcare Transition: Now and Then
Healthcare transition has become by necessity a recognized clinical need for young
people with long-term conditions as they approach the service termination deadline
of the pediatric facility wherein they receive care. This acknowledgement has
evolved from decades ago by the clarion call of public health figures, now consid-
ered icons of the past such as C. Everett Koop, the former Surgeon of the United
States. Under his direction, a national conference was convened to address issues of
the growing population of adolescents and young people with long-term conditions
whose survival rates now reached into adulthood. That phenomenon was unthink-
able just a relatively few years before (McGrab and Millar 1989).
Since those early calls for service reform for adolescents and young people, the
response has been slow and faltering. To date, the evidence supporting an optimal
system of care to foster the smooth transition for adolescents and young people with
long-term conditions has yet to be fully established anywhere internationally (Sattoe
et al. 2017). Evidence-based standards of care are in the early stages of development
wherein principles of care are recommended (American Academy of Pediatrics
et al. 2011; Betz 2017; White et al. 2018). This field of healthcare transition has yet
to be established as an area of specialty practice unlike other areas of practice such
as critical care, early intervention, or development disabilities to name a few.
The specialty practice of pediatric medicine has been in the forefront with the
development of HCT service recommendations and policies. The leadership of
pediatric medicine has influenced the development of this specialty area of practice
with the long-standing focus of the logistics of the transfer of care (American
Academy of Pediatrics et al. 2002, 2011; Betz 2017; White et al. 2018). To that end,
early recommendations focused on physician-directed service models that concen-
trated on the transition from: (a) pediatric to adolescent to adult services; (b) shared
pediatric and adult clinic services; and (c) joint service appointments with both
pediatric and adult providers. An evolution of service modifications has evolved
wherein age of initiation to transition and transfer of care has been extended down-
ward from late to early adolescence. Service models have expanded to include for-
malized template of benchmarks for provision of more involved services (Betz
2017). This expansion of service deliverables includes self-management instruc-
tion, service coordination and referrals for community-based services and the
emphasis of fostering independence, self-reliance, and the developmental compe-
tences associated with adulthood (McDonagh and Farre 2018; Mackie et al. 2018).
Nursing professionals in pediatric care have been involved with the advancement of
this specialty field of healthcare transition. However, leadership efforts in fostering the
1 Healthcare Transition: An Overview and Introduction 3
development and implementation of nurse-led healthcare transition models of care have

been restrained in the past until more recently (Betz 2013). One need only observe the
proliferation of literature in this field of practice and research generated by nurse schol-
ars, nurse researchers, clinical nurse specialists, and advanced practice nurses. Generic
and specialty-oriented nursing practice standards are being crafted to provide guidance
to nursing colleagues who are involved with the provision of healthcare transition ser-
vices in nurse-led or as members of interdisciplinary teams in physician-directed pro-
grams (Lestishock et al. 2018; National Association of School Nurses (NASN) 2019).
1.3 Nursing Practice Roots of Healthcare Transition
Nursing has a rich history and heritage of leadership with the development of service
models that advance the provision of innovative care. This heritage of nursing role
innovations includes primary nursing, service coordinators/case managers, and clini-
cal specialists. The proud history of service advancements includes promotion of
family-centered care, child-centered care, adolescent-centered care, cultural compe-
tence, and understanding of the importance of health-illness continuum. All of these
innovations of care come to full fruition within the field of healthcare transition prac-
tice and research. Nurses have a long history and rich tradition of viewing the child
and family as inseparable in the provision of care, whether it be in the hospital set-
ting, the outpatient clinic, the school, and home. These historical roots of practice
converge with the development and testing of innovative HCT models of care, explo-
ration of factors such as the social determinates of health that influence the achieve-
ment of benchmarks and outcomes associated with the passage from the dependency
of childhood and early adolescence to the achievements associated with the develop-
mental milestones of adulthood. The concepts of nursing care evident decades ago
are manifested with the innovations reported by nursing and interdisciplinary col-
leagues in healthcare transition planning. Reaching back to the 1970s, the innova-
tions in practice are evident and come to fruition in this burgeoning model of care
that is gaining widespread acknowledgement and support as essential components of
healthcare for all adolescents including those with long-term conditions. A retro-
spective examination of the forerunners of nursing models of roles and care-primary
nursing, family-centered care, and care coordination are warranted to improve under-
standing of the important and valuable role of nurses in providing healthcare transi-
tion services.
1.4 Primary Nursing
In 1975, primary nursing was introduced as a radically different concept of nursing

care. Unlike the pervasive model of team nursing, the focus of primary nurse shifted
from a task-oriented approach to care to a comprehensive model of care wherein the
nurse serves as the primary provider of direct care, and also the coordinator of ser-
vices provided by others. This model of care was designed to ensure continuity of
care, the provision of quality of care, patient involvement in care, and a written plan
of care responsive to the comprehensive needs of the patient and to create an effec-
tive conduit of communication that informs the patient and providers alike (Arnsdorf
1977; Ciske 1974; Daeffler 1975; Felton 1975).
These nursing concepts are apparent in the provision of HCT services and pro-
grams. As evidenced in this text and elsewhere in the literature, HCT models are being
reported and developed which address the comprehensive needs of adolescents and
young adults with long-term conditions, not just the logistics of planning the transfer
of care from one provider to another to avoid the discontinuity with care. As with the
early models of primary nursing, the nurse served as the primary agent of nursing care
to ensure the patient’s needs were being met, monitored, and continuously evaluated
(Arnsdorf 1977; Ciske 1974; Daeffler 1975; Felton 1975). To achieve addressing the
comprehensive patient’s needs, the primary nurse needed to coordinate the efforts of
the team to ensure other evaluations and treatments were being provided to avoid gaps
in services, duplication of services, and smooth integration of services.
Other competencies expected with the primary nurse role were as cited more
than 40 years are relevant today with the practice of healthcare transition:
Encourage the patient to participate in his own care and to express himself: (2) be knowl-
edgeable about the patient’s medical conditions, personal and family data, and the implica-
tions for nursing care; (3) teach the patient and work with the family; (4) plan for other staff
involvement through the kardex and other communication; and (5) refer the patient to other
professionals when appropriate (Ciske 1974, p. 29).
This description of role responsibilities of primary nurses included the nursing efforts
to promote self-management knowledge and skills, encourage self-advocacy, and
address the needs of not only the primary recipient of care, the patient, but also the
family (Ciske 1974). The description of this early model of nursing care, primary
nursing, is relevant and instructive for those who are engaged as HCT service coor-
dinators or involved with and contribute to the development and implementation of
HCT service models. The role of nurses as the primary agents of service provision as
reported in the HCT literature is rooted in this early role of primary nursing.
1.5 Care Coordination
Care coordination has been acknowledged as an essential feature of nursing care.

As one author observed, “Coordinating patient care is an important part of nursing’s
rich heritage; from the earliest recorded history of the profession, this component
care has been documented” (Cloonan and Shuster 1990, p. 204). The concept of
care coordination first appeared in the nursing literature 50 years ago in the National
League of Nursing publication entitled Patient care coordination or fragmentation?
(Adair 1969). Since these earlier years, care coordination has been widely adopted
by allied/interprofessional health professionals as an essential component of care
for individuals with long-term conditions. Definitions of care coordination offered
by nursing and interdisciplinary professional associations, governmental and inter-
national entities are presented in Table 1.1.
Table 1.1 Care coordination definitions

Organization Care coordination definition
American Association of “Care coordination is a process that links children with special
Pediatrics (Ziring et al. needs and their families to services and resources in a coordinated
1999) effort to maximize the potential of the children and provide them
with optimal ” (Ziring et al. 1999, p. 978)
American Nurses Care coordination promotes greater quality, safety, and efficiency
Association (2012) in care, resulting in improved outcomes and is consistent with
nursing’s holistic, patient-centered framework of care. A
knowledgeable professional deliberately designated to coordinate
care is necessary to effectively utilize resources within the set of
complex health systems and multiple providers in accordance
with patient and family care needs (American Nurses Association
(ANA) 2012, p. 3; McDonald et al. 2014; O’Malley et al. 2009)
ANA standards of care for Care that facilitates access to needed resources and services and
individuals with promotes continuity of care among multiple providers and diverse
intellectual and service systems. Work is done collaboratively with the healthcare
developmental disabilities consumer and/or family/legal guardians to achieve mutually
(Nehring et al. 2013) agreed-upon goals. Timeliness, appropriateness, and
completeness of care are central to this concept (Nehring et al.
2013, p. 51)
National Association of Care coordination, a core professional school nursing principle,
School Nurses (NASN and its related practice components involve developing and
2017) maintaining competence in creating, updating, and implementing
care plans that comprehensively create an environment where
students will maintain optimal health in the school setting so that
they can succeed academically (National Association of School
Nurses (NASN) 2017, p. 40)
U.S. Agency for Care coordination involves deliberately organizing patient care
Healthcare Research and activities and sharing information among all of the participants
Quality (2018) concerned with a patient’s care to achieve safer and more
effective care. This means that the patient’s needs and
preferences are known ahead of time and communicated at the
right time to the right people, and that this information is used
to provide safe, appropriate, and effective care to the patient
(U.S. Agency for Healthcare Research and Quality (AHRQ)
2018)
World Health Organization A proactive approach to bringing together care professionals and
(2015) providers to meet the needs of service users to ensure that they
receive integrated, person-focused care across various settings
(World Health Organization (WHO) 2015, p. 8)
Society of Pediatric Nurses Coordination of care involves the following: (a) organization of
[SPN], National the care plan; (b) documentation of the care provided; (c)
Association of Pediatric instruction that includes health promotion, anticipatory guidance,
Nurse Practitioners injury and disease prevention and home care management; (d)
(NAPNAP and American promotion of independence and quality of live; (e) exploration of
Nurses Association [ANA] care alternatives; (f) communication linkages with transition of
2015) care; (g) advocacy; and (h) referrals and coordination to
community-based services and supports (Society of Pediatric
Nurses et al. 2015, p. 55)
These care coordination definitions share several commonalities. Care coordination

refers to an organized approach that has been arranged by a designated professional who
has the specialized skill set and knowledge. These services are organized based upon a
comprehensive plan of interdisciplinary services for the care recipients. The plan of care
is individualized as it is designed to meet the needs of the child and family. Care coordi-
nation encompasses a spectrum of care, whose source of service origination varies from
inpatient to community-based settings. Most often care coordination involves chronic
long-term management for children with long-term conditions and their families. Care
coordination involves a set of actions that are timely and responsive to the identified and
current needs of the individual and family. These components of care coordination align
with those needed with the provision of healthcare transition services.
Coordination of care is considered an essential nursing competency as identified
in standards of care for generic and specialty care nursing practice worldwide
(Table 1.1) (American Nurses Association (ANA) 2012; McDonald et al. 2014;
O’Malley et al. 2009; Society of Pediatric Nurses et al. 2015; National Association
of School Nurses (NASN) 2017). According to the standards for coordination of
care, the competencies include the following: (a) oversight responsibilities for
developing the plan of care; (b) documentation of coordination activities; (c) pro-
vides child and family-centered education based upon learning needs for condition
management; (d) promotes independence and self-reliance as goals of care; (e) pro-
vides information on other care options; (f) is an child and family advocate and
serves as a liaison between the child/family and members of the interprofessional
team; and (g) identifies and coordinates referrals to community-based services and
supports (Society of Pediatric Nurses et al. 2015).
These care coordination competences are evident in the published reports and the
models published and those presented in this text of the application of services
based upon the healthcare transition models provided by nurses and interdisciplin-
ary colleagues. The care coordination competencies include the following: (a) over-
sight responsibilities for the initiation, review, revision, and evaluation of healthcare
transition plans based upon the adolescent’s/young adult’s needs, interests, and
preferences; (b) assessment of transition readiness and of timeliness for the prepara-
tion for the transfer of care; (c) initiation of the actual transfer of care; (d) self-
management assessment, instruction, and evaluation; (e) referrals to adult healthcare
professionals and to providers associated with transition and adult systems of care
and community-based services; (f) provision of information as to service eligibility
criteria, services offered, and organizational logistics; and (g) promotion of adoles-
cent and young adult self-advocacy (Betz 2017; Coyne et al. 2017; Colver et al.
2018; Sheehan et al. 2015; Sobota et al. 2017).
1.6 Family-Centered Care
Nursing historians and family-centered care experts trace the early origins of
family-centered care (FCC) to the works of Bowlby (1973), Robertson (1970),
and Spitz (1945) who recognized the adverse psychosocial effects upon
children who were separated from their parents while hospitalized. Their work
contributed to the long overdue acknowledgement that children needed, if not
required, parental comfort and nurturance during the traumatic and painful
experience of hospitalization. Of note, Bowlby affirmed the influence of the
work of nurse researcher Claire Fagin who investigated parental visitation that
resulted in the beginnings of effecting changes in hospitalization policies
(Barnsteiner 2009).
The concept of parent visitation and its importance for supporting the develop-
mental needs of hospitalized children was first introduced by Claire Fagin in the
United States in 1966. At that time, Dr. Fagin conducted a study exploring the
effects of parental visitation upon hospitalized children. The beneficial effects of
parental visitation were revealed and served to be pivotal in effecting changes in the
policy pertaining to parental visitation in US hospitals (Barnsteiner 2009). Later, a
collection of papers was published in 1972 by a team of nursing administrators and
advanced practice nurses from Children’s Hospital Los Angeles on family-centered
care, and were among the earliest publications on its clinical application that was
first introduced as a philosophy of care (Beatty 1972). One of the articles entitled
Family-Centered Care and the Adolescent’s Quest for Self-Identity espoused the
importance of facilitating the adolescent’s transition to adulthood, the acquisition of
self-management competencies needed to function independently and engagement
of the adolescent in their care and decision-making (Duran 1972). Concomitant
with the change in the USA, reforms with the care of hospitalized children in the
UK were evident (Jolley and Shields 2009).
Since that time, family-centered care has served as the philosophical foundation
of care for children across the health-illness continuum. Although, the ideal vision
of family-centered care has yet to be fully realized, it has served as the cornerstone
of care standards in pediatric and child health nursing and has been the subject of
research investigations worldwide (Harrison 2009). Key attributes associated with
family-centered care are as follows: (a) parent–professional partnerships wherein
the family care needs and opinions are fully vetted and respected; (b) communica-
tion among the family and team members that is respectful, timely, forthcoming,
and culturally sensitive; (c) negotiation wherein agreements and understandings
associated with care decision-making are evident and emblematic of the communi-
cation among the family and providers; and (d) support based upon the family
needs, cultural values, and the family’s existent support network (Coyne et al.
2018). These components of family-centered care are evident in the practice stan-
dards that have emerged pertaining to healthcare transition models of care.
More recently, a shift in service orientation focus to incorporate child-centered
care as an integral component of family-centered care has been proposed (Coyne
et al. 2018). The evolution to this integrated yet bifurcated family-centered/child-
centered care model of care is in the early stages of development and proposed
application (Ford et al. 2018). Strong advocates of CCC argue “…that the child’s
interests should have primary positioning in care irrespective of their age and abil-
ity.” (Ford et al. 2018, p. e41). This is relevant when we consider adolescents as their
transitional preparation needs to have a much stronger emphasis on independence
and autonomy. Pediatric care tends to have a family-centered focus, whereas in

transition, the focus needs to be on adolescents as they prepare for the transition to
adulthood and adult-oriented services. As Ford continues to contend, “…FCC can
result in the child or young person having a more passive and less prominent role
than that of their parent (s) even when their more active engagement should be pos-
sible” (Ford et al. 2018, p. e40).
In recognition of the developmental differences associated with adolescents and
their healthcare, the WHO and other leading adolescent advocates recommend that
services for this age group be adolescent-centered (World Health Organization
2015). The WHO uses the terminology of adolescent-friendly health services
(AFHS) in reference to services that are sensitive and focused on the needs of ado-
lescents. Eight standards associated with the implementation of AFHS have been
identified as representative of achieving this vision. The eight standards address the
following quality characteristics of AFHS: (1) adolescents’ health literacy; (2)
community support; (3) appropriate package of services; (4) providers’ competen-
cies; (5) facility characteristics; (6) equity and nondiscrimination; (7) data and
quality improvement; and (8) adolescent participation (World Health Organization
2015, p. 4). For additional information on quality adolescent care with emphasis on
healthcare transition services, the reader is referred to Chap. 3, Determinants of
Quality of Healthcare for Adolescents and Young Adults.
Beginning nearly 70 years ago, the evolution of these aforementioned care
models focused on the perspectives of the recipients of care rather than the pro-
viders of care is adapted once again with the provision of healthcare transition
services. The HCT service model integrates the care philosophies of family-cen-
tered care, child-centered care, child and family-centered care, and adolescent-
centered care. In short, the healthcare transition service model is an amalgamation
of slightly differing service orientations as the period of services extends along
the continuum of development beginning in early adolescence and extending
through emerging adulthood. Coupled with this developmental progression, for
many adolescents and young adults with long-term conditions, the roles and
responsibilities for long-term management will be “offloaded” from their parents/
caregivers to them. During this transition process, the focus will evolve as well to
be responsive to not only the primary recipient of care but also the primary deci-
sion-maker as well. Again, for many adolescents with long-term conditions who
reach the legal age of adulthood, they will become both the primary recipient of
care and decision-maker in contrast to earlier times wherein parents were the
legally designated decision-makers and children were the primary recipients of
care.
The evolution of these early nursing practices that converge with the develop-
ment of healthcare transition nursing practice, nurse-led models, nursing initiatives,
and nursing research will be discussed as follows. The growing influence of nursing
practice and science is evident as this field expands more broadly not only in pedi-
atric settings but also into the realm of adult healthcare.
1.7 ursing Influence and Involvement in Healthcare

N
Transition
The concept of transition has long been a programmatic focus for research, clinical,
and educational and policymaking purposes (Schumacher and Meleis 1994). Articles
exploring transition-related topics in nursing were first published in the 1960s explor-
ing a range of topics including nursing education (Bristow 1964), newborn care
(Arnold et al. 1965), clinic practice (Farrisey 1967), and evolution from nursing stu-
dent to employee (Miller 1962). In 1994, the mid-range theory of transition was
published which explored the significance of the individual’s lived experience for
nursing. Justification for examination centered on the following premise: “Nurse-
client encounters often occur during transitional periods of instability precipitated by
developmental, situational, or health illness changes” (Schumacher and Meleis 1994,
p. 119). Subsequently, the knowledge and evidence generated by nursing inquiry has
contributed to the literature on transition. The most recent estimate of citations per-
taining to this seminal work is more than 1000. More recently there have been health-
care transition models developed which have been influenced and applied by nurses
in their practice and research (Schwartz et al. 2011; Betz et al. 2014).
Nursing involvement in the field of healthcare transition became first evident in
the 1990s. Early publications were clinical commentaries of the emerging area of
practice that consisted of descriptions of this newly recognized service area need for
adolescents with long-term conditions (Baker and Coe 1993; Betz, 1998).
Interestingly, these early nursing authors noted that healthcare transition needed to
be comprehensive in scope and not narrowly focused on the transfer of care alone.
The first review of the healthcare transition literature noted that of the 43 studies
included in the review, nearly 30% (n = 12) of the studies were conducted by nurses.
The early studies were primarily descriptive designs that explored five major
themes. The primary areas investigated were the transition experiences of youth,
young adults and their parents, examination of program outcomes, tool develop-
ment and psychometric testing, findings of national surveys, and the provider role in
HCT (Betz 2004). Evidence of the nascent research efforts, few measures were used
with sufficient psychometrics and none of the studies reported use of control groups.
Since these early efforts, the presence of nurses as researchers, scholars, and
practice experts has become evident. The proliferation of studies, commentaries,
and systematic reviews is testimony to the significant contributions nurses have
made in the field. A number of nurse-led programmatic HCT service models have
been reported. These models demonstrate the global efforts undertaken by nursing
experts to address the HCT needs of adolescents and young adults with diverse
long-term conditions as described as follows.
The concepts of a HCT nursing coordinator and nurse-led HCT program were
first introduced in a series of publications 15 years ago (Betz 1998; Betz and Redcay
2002, 2003, 2005a; Betz et al. 2003). In this community-based program, the nursing
coordinator in consultation with an interagency team provided comprehensive HCT
services to adolescents with a variety of diagnoses. This initial model was later
replicated with service modifications in an outpatient clinic of a regional pediatric
medical center for adolescents and young adults with spina bifida (Betz and Redcay
2005b; Betz et al. 2016).
A pilot study conducted in Switzerland with youth with diabetes mellitus reported
the findings associated with testing a nurse consultant component of a structured
HCT model (Zoni et al. 2018). The nurse consultant efforts were focused on indi-
vidualized self-management education and coaching and navigator assistance.
These activities involved ongoing assessment of transition readiness, facilitating the
transfer of care based on preferences for adult provider services, and reinforcement
of self-care competencies that fostered autonomy (i.e., scheduling appointments for
care). HCT nurse consultation was provided using a variety of modalities including
in home visits, phone calls, and electronic communication (i.e., text messaging and
e-mails).
Nurse-led transition clinic for adolescents and young adults with congenital
heart disease in the UK coordinated by an advanced practice nurse was described.
The nurse-led HCT planning services described initiated the services at age 12 and
extended to age 16 and beyond as they were transitioned to adult services. One of
the features of this clinic described a “transition day” offered several times during
the year wherein attending youth learned about helpful community-based adult
resources, adult health-related topics (i.e., pregnancy) and network with peers
(Habibi et al. 2017).
Two other investigations examining the effectiveness of a nurse-led HCT model
involved adolescents with CHD as well. An RCT was conducted to explore the
effectiveness of a one nurse-led transition educational session for adolescents with
CHD, 15–17 years. Measurements of transition readiness and CHD knowledge
indicated significant differences following the HCT intervention as demonstrable
improvement was found in scores for the intervention group (Mackie et al. 2014).
Later, expanding upon the first study, another RCT was conducted to assess the
effectiveness of nurse-led two one-on-one sessions HCT educational program for
Canadian adolescents and young adults with CHD aged 16–17 compared to those
who received usual care. Findings demonstrated that those in the intervention group
were more likely to have scheduled their appointment with the adult cardiologist
within the recommended time frame and scored better on measures of CHD knowl-
edge and self-management as compared to the control group (Mackie et al. 2018).
An RCT was conducted with adolescents with spina bifida to assess the effec-
tiveness of a transition preparation training (TPT) program. The TPT addressed
comprehensive issues pertaining to healthcare, education, employment, community
living, and social relationships. Findings demonstrated no significant differences
between the intervention and control groups as researchers noted that the dose of the
intervention was limited (Betz et al. 2010; Betz et al. 2015a).
A nurse-led transition clinic for adolescents with epilepsy was developed to
provide them with “‘working knowledge’ of developmental, clinical, and life skills
that would prepare adolescents with epilepsy for their upcoming transfer to adult
epilepsy services” (Jurasek et al. 2010). These clinics are offered several times a
year. Clinical evaluations indicated adolescent and parental satisfaction with the
clinic. Other nurse-led healthcare transition programs have been described for ado-
lescents and young adults with spina bifida, long-term bladder continence prob-
lems, and noncategorical groups of adolescents with long-term conditions (Betz
et al. 2018a; Nurse-led project 2014; Ford 2014; Ferguson 2010; Hatchett 2008).
These models of care are representative of the array of approaches undertaken by
nurses to address not only the necessity of preparation for the transfer of care but
also the other more broadly defined developmental challenges adolescents with
long-term conditions encounter as they progress toward adulthood unlike their
typically developing peers.
As with the evolution of a field of practice, empirical support is needed to provide
the rationale needed for the provision of evidence-based care. Systematic, integra-
tive, and scoping reviews provide users with cumulative summary of literature
reviewed enabling an overview of relevant findings and conclusions. Systematic
reviews and meta-analyses are considered the highest level of evidence available
which can be applied for practice implementation and innovation (Mazurek-Melnyk
and Fineout-Overholt 2019). Nurse researchers and scholars have undertaken and
published a number of systematic reviews that have contributed to the HCT science
and practice (Farrell et al. 2014; Coyne et al. 2017; Gray et al. 2018; Campbell et al.
2016; Sheehan et al. 2015; Heery et al. 2015; Lugasi et al. 2011; Rapley and Davidson
2009). These reviews are sources of evidence that have and will continue to assist
with the development of best practice standards for healthcare transition practices.
One of the earliest position statements on healthcare transition was developed in
2002 by the National Association of Pediatric Nurse Practitioners, entitled Age
Parameters for Pediatric Nurse Practitioner Practice (NAPNAP, 2002). This state-
ment referred to the proposed age limits of provision of care to young adults as
being 21 years of age with the caveat of extending the age limits “…in specific
situations to persons older than 21 years” (p. 42A). This position statement has
been reviewed repeatedly, with the most recent position statement issued in 2019
(Heuer et al. 2019; NAPNAP 2008, 2014). This statement addresses the circum-
stantial needs of young adults with long-term chronic conditions who may con-
tinue to be provided services beyond age 21. This new statement notes, “Age
parameters should not be the sole arbiter for optimal, safe, and quality care in
pediatric practice” (Heuer et al. 2019, p. A10). More recently, NAPNAP has under-
taken efforts to develop a more comprehensive position statement on healthcare
transition that should be published in the near future (Lestishock et al. 2018). The
Society of Pediatric Nurses recently published an inclusive position statement that
addresses the needs of all adolescents during the period of transition to adulthood,
entitled Transition of Pediatric Patients into Adult Care (Betz 2017). This state-
ment views healthcare transition comprehensively beginning in early adolescence
and extending into adulthood. Other nursing organizations have acknowledged the
importance of the nurse’s role in healthcare transition planning but not to the level
of specificity described in other position statements (Nehring et al. 2013; Society
of Pediatric Nurses et al. 2015; NAPNAP 2014; Heuer et al. 2019; Betz et al. 2004,
2015b, 2018b; Betz 2006).
1.8 The Next Generation of HCT Nursing
The chapters in this textbook reflect the next generation of HCT practice, scholar-
ship, and research with particular implications for nursing practice and research. In
the chapters written by the authoring team headed by Office and Madge (Chap. 8),
AnneLoes van Staa (Chap. 9), Anna M. Gravelle (Chap. 10), Deborah Christie and
Kate Khair (Chap. 11), the authors provide descriptions of nurse-led efforts to
develop and implement healthcare transition programs. As these experts demon-
strate, the ongoing process of HCT programmatic development is complicated and
involves and requires institutional and professional stakeholder support. The
authors’ descriptions of efforts undertaken reveal the ongoing hard work expended
in creating sustainable partnerships with colleagues and administrators to affect not
only the establishment of the program itself but also the attitudinal changes needed
to support and advocate on a long-term basis.
As this specialty field matures, insights and evidence emerge which sharpen
the understanding and bring into focus the needs to realize the vision of this
model of HCT care. Several chapters reflect this evolving understanding and
knowledge gained through the experience of involvement with HCT practice and
research. The necessity and challenge for the nurses of measuring HCT outcomes
are considered by Coyne and Hallowell (Chap. 5). Complementary to the discus-
sion of outcomes is the chapter on benchmarks authored by Susan Aldiss and
Faith Gibson (Chap. 6). In this chapter, the recommendations for evaluating the
extent to which the healthcare transition services meet the expected standards of
excellence are presented. The benchmarks described in this chapter are the prod-
uct of collective input from interdisciplinary adult and pediatric and adult profes-
sionals who provide care to adolescents and young adults with long- term
conditions, this targeted group of consumers and parents. The systematic review
(SR) authored by Campbell, Aldiss, and Biggs (Chap. 7) examined the evidence
of studies conducted to test HCT models of care. As this SR indicated, evidence
is lacking for application to practice. These topics would not have been possible
to write previously when the field was in its infancy when few services existed.
Two chapters in this textbook provide the reader with substantial information on
the use of instruments to enhance the process of assessment and service delivery for
adolescents and young adults with long-term conditions as they progress along the
continuum of the transition process and the eventual transfer of care. The chapter on
the analysis of self-management and transition readiness instruments authored by
the team of clinical scholars led by Sawin (Chap. 4) provides guidance for the appli-
cation to practice. This review of the instruments presents practitioners with contex-
tual analysis to consider for integration into healthcare transition service programs.
The chapter on empowerment (Chap. 2) introduces the reader to a concept that
heretofore has received scant attention in the literature; however, as the authors
posit, it has relevant application to healthcare transition practice and research.
Al-Yateem (Chap. 3) explores the determinants of quality healthcare for adoles-
cents. Dwyer and Hauschild (Chap. 12) present the salient clinical and program-
matic HCT issues of those with endocrine chronic diseases. Chapters by Betz and
Coyne (Chap. 1 and 13) provide nursing perspectives pertaining to past and current
involvement and future directions in HCT.
1.9 Conclusion
This chapter was presented to offer the reader with not only a succinct overview of
the healthcare transition field but also an introduction as to the pertinence and
importance of the role of nurses. As discussed in this chapter, nurses have and will
continue to be leaders and partners in the development of evidence-based practices
and research and help to shape the practice models in the future. As has been
recounted, pediatric and child health nurses have a long and respected professional
tradition of practice that views the child and family holistically and understands the
consequences of care can and does have far-reaching effects. The chapters in this
text reflect the next wave of development in the field. The content presented in this
text reflect most importantly and above all other considerations the importance of
developing, implementing, and evaluating HCT models of care that improve the
lives of adolescents and young adults with long-term conditions and their families.
1.10 Useful Resources
• Adolescent Health Initiative: This website provides an array of information on

adolescent health models of care with focus on primary and community-based
services/programs. https://www.umhs-adolescenthealth.org/improving-care/
youth-friendly-care/.
• Institute for Patient-Centered and Family-Centered Care. This website provides
resources on the principles of patient-centered care and FCC. Examples of exem-
plary implementation of these service approaches are presented. http://www.
ipfcc.org/about/pfcc.html.
• The Point of Care Resources: Patient and Family-Centred Toolkit. This website
provides users with resources/toolkit to improve the provision of care to children
and their families in the UK. https://www.pointofcarefoundation.org.uk/resource/
patient-family-centred-care-toolkit/.
• The National Adolescent and Young Adult Health Information Center: This web-
site contains an array of resources that include adolescent-centered health, health
insurance, clinical guidelines, and data on various adolescent health issues.
http://nahic.ucsf.edu/resource_topic/state-data/.
• The National Alliance to Advance Adolescent Health: The Got Transition pro-
gram resources are available from this website. https://www.thenationalalliance.
org/adolescent.
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Empowering Young Persons During
the Transition to Adulthood 2
Mariela Acuña Mora, Carina Sparud-Lundin,
Ewa-Lena Bratt, and Philip Moons
2.1 Introduction
In the past years, it has been suggested that in order to increase patient participation
and move toward more collaborative models of care, healthcare providers should aim
at increasing patient empowerment (Bravo et al. 2015). This concept is understood as
an enabling process or outcome that involves a shift in power that leads to patients
being more involved in care and decision-making. Patient empowerment aims at
increasing autonomy, patient participation, increased awareness, and consciousness,
as well as the development of relevant psychosocial skills (Castro et al. 2016). Previous
research has found that a higher level of patient empowerment is associated with
improved quality of life, well-being, and clinical outcomes (Bravo et al. 2015).
M. A. Mora (*)
Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
KU Leuven Department of Public Health and Primary Care, Leuven, Belgium
e-mail: mariela.acuna.mora@gu.se
C. Sparud-Lundin
e-mail: carina.s-lundin@fhs.gu.se
E.-L. Bratt
Department of Pediatric Cardiology, The Queen Silvia Children’s Hospital, Gothenburg, Sweden
e-mail: ewa-lena.bratt@gu.se
P. Moons
KU Leuven Department of Public Health and Primary Care, Leuven, Belgium
Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
e-mail: philip.Moons@med.kuleuven.be
© Springer Nature Switzerland AG 2020 19

C. L. Betz, I. T. Coyne (eds.), Transition from Pediatric to Adult Healthcare
Services for Adolescents and Young Adults with Long-term Conditions,
https://doi.org/10.1007/978-3-030-23384-6_2
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had left her aunt “resting,” as unusual an employment for Flora as
were the flush on her face and the wire curlers in her hair.
Everyone in the big house had been wrought, now, to a pitch of
expectation bordering upon fever. The last plate was washed, the
last spoon polished; the shelves of long-unused pantries downstairs
were loaded with cakes and pies and cold meats and bread and
sauces and trembling jellies; the big rooms upstairs were aired and
warmed; there were fat comforters folded invitingly across the foot of
the big, freshly made beds; there were open fires and stove fires
everywhere. Floors shone with wax; palms moved green fronds
gently in well-dusted corners; lamps were filled, clocks were ticking
busily. Gabrielle felt in her veins the excitement that is a part of
physical strain. She, like everyone else, was tired, but it was a happy
sort of fatigue, after all.
On this last afternoon she had gone a little deeper into the woods
than was necessary, or than she had planned to go for the last
greens, as a glance at her wrist watch showed her. It was already
half-past three o’clock when, with her arms full of fragrant boughs,
she started back toward the house, perhaps a mile away. The day
had grown a little colder, the wind had steadied to something like a
gale, and the sea—for she never was quite out of sight of the sea—
was in an uproar, running high and wild, breaking furiously upon the
rocks, and flinging itself twenty feet into the air when these stood
fast, as they had stood for a thousand years.
Suddenly, creeping through bare boughs like little silent fairies shod
in down, came drifting the first snowflakes. They came timidly,
irresolutely at first, clinging here to a fir and there to a bare maple
twig, moving restlessly and gently in all directions, fluttering,
changing places, like the breast-feathers of a white baby swan, from
which perhaps, thought Gay whimsically, Mother Nature, who loves
to repeat her forms, had copied them.
“Oh, this is glorious!” she said aloud to the sweet, empty forest. And
she began to walk briskly with that dancing step of hers that meant
utter happiness and felicity.
When she came within sight of Wastewater’s walls the storm was
upon them; the snow was falling rapidly and steadily now, and with a
denseness that made a sort of twilight in the world. It fell dry, close,
only slightly at an angle; Wastewater’s outbuildings were already
furred deep, and John’s wife Etta was laughing as she backed the
little car into the shed for shelter.
“This is a terror, Miss Gabrielle!” she shouted. “It’ll be a white
Christmas, all right! I only hope that Miss Fleming and her company
don’t get held up somewheres! I declare, you can’t see twenty feet in
it!”
Gabrielle shouted back, fled upon her way about the big north wing,
through a sort of tunnel of dry branches above an arbour already
heavily powdered with white.
Her thoughts were all on the house, all intent upon reaching the side
door, all upon the necessary stamping, shaking, disburdening herself
of outer garments and her branches of snow; it was after four now,
she must be ready in the velvet dress when Sylvia came at six——
Suddenly she stopped short in the lonely side garden, where the
snow was falling so fast, recoiled, and heard her own choking
exclamation of dismay. Something was moving in the snow,
something bent and whitened with flakes—but human! Gabrielle’s
heart almost suffocated her, and she felt her throat constrict with
pure terror.
It was a child—it was a little old woman, doubled up with years, with
wisps of white hair showing about a pallid old face that was scarcely
a wholesomer colour than they, or than the falling snowflakes. She
had her back half turned to Gabrielle, and was creeping along
against a sort of hedge of tightly set firs, her old black cape or shawl
topped with white, her thick shoes furred with it. She was muttering
to herself as she went, and Gabrielle could hear her, now that the
wind had died out and the silent, twisting curtains of snow muffled all
other sounds.
Pity and concern for the forlorn old creature almost immediately
routed the girl’s first wild, vague fears, and she dropped her
branches and followed the wavering footsteps, laying a timid hand
upon the woman’s shoulder. Instantly a yellowish ivory face and two
wild eyes were turned upon her, and the stranger shrieked with a
sound that was all the more horrible because so helpless and so
weak. It was almost like the cry of a wind-blown gull, and here in the
unearthly solitude and quiet of the storm it frightened Gabrielle with a
sense of forlornness and horror. The house, only a few feet away,
with fires and voices, seemed unattainable.
“Come in—come in!” cried Gabrielle, guiding her with a strong young
arm. “You’ll die out here—it’s a terrible night! And you know it will be
dark in ten minutes,” she added, half pushing and half dragging the
old form, which was astonishingly light and made but a feeble
resistance. “Daisy—Margret!” called Gabrielle, at last flinging open
the side door upon the blessed security and warmth of the hall. “Call
Mrs. Fleming, will you! This poor old woman’s gotten lost in the
garden——”
“My God—what is this!” It was Flora’s voice, but not one that
Gabrielle had ever heard before. The hallway was instantly filled with
concerned and frightened women, unduly frightened, Gabrielle
thought, for the last of her own terrors had disappeared under the
first ray of lamplight. “It’s nothing, Gabrielle,” said Flora, choking, and
with her face strangely livid, as she stood slightly above the level of
the others, on the stairs, clutching her dressing gown together. “It’s
some poor woman from Crowchester, Margret!” she stammered.
“Come upstairs and dress, Gabrielle. Take her—take her to the
kitchen, Hedda, and give her some tea, and I’ll be right down!”
“Imagine!” Gabrielle said, eagerly. “She might have died in the storm,
the poor old thing!”
The old woman had been turning herself uneasily, looking with
rapidly blinking eyes from one to the other. Now the servants were
gently urging her toward the doorway that led to the warm kitchen
regions, and to Gabrielle’s amazement she seemed to be displaying
a weak disinclination to go.
“Who’s this girl, Flora?” she said now, in a cracked, querulous voice.
“You stop pushing me, Margret!” she added, fretfully.
It was Gabrielle’s turn to show amazement and consternation. She
looked from one stricken, conscious face to another, and her own
bright, frost-glowing cheeks faded a little. This trembling bit of human
wreckage, dragged in from the storm, was not quite a stranger, at all
events.
Flora’s face was ghastly; Hedda looked more than ordinarily idiotic.
But Margret, eighty years old, spoke hearteningly.
“It’s old Mrs. Smith, Mrs. Fleming, from Keyport. She’s——” Margret
had one stout old arm about the cowering stranger, and now she
gave the other women a significant glance and tapped her own
forehead with her free hand. “We’ll give her some tea and dry her out
a bit, and then maybe John’ll take her home,” said Margret, “when he
takes the sleigh in for Miss Fleming!”
Gabrielle, perfectly satisfied with the explanation and the
arrangement, went upstairs beside her aunt.
“Oh, will John have the big sleigh out?” she asked, enthusiastically.
Flora did not answer; she looked ill. She parted from Gabrielle
without a word and went downstairs. But half an hour later, when the
girl had had a hot bath and was busy with the bright masses of her
hair before her mirror, she started suddenly to find that her aunt had
come quietly into the room.
By this time Gabrielle had had time to think over her little adventure,
and even in all the day’s excitement and expectation she had felt an
uncomfortable reaction from it. She shuddered whenever she
remembered herself hurrying so innocently along the snowy lanes in
the twilight, and the hideous fright of that first sight of something
moving—something human, shadowy gray and white against the
gray and white shadows of the hedge.
“That was a horrid experience with that poor old woman, Aunt Flora,”
she said now, distressed at her own emotion.
“You must think no more about it,” Flora, giving no reason for her
visit to Gabrielle’s room, said firmly. “The girls have taken good care
of her, and John is to drive her back when he goes. She’s perfectly
harmless—poor soul. I would rather you didn’t mention it to Sylvia,
Gabrielle, by the way.”
Gabrielle, after a bewildered upward glance, of course agreed never
to mention the circumstance to Sylvia—indeed, never to think of the
poor old soul again. She went cheerfully on toward the pleasant
moment of assuming the velvet gown, when Aunt Flora was gone,
brushing her rich hair simply back, pleased in spite of herself with
her unusual colour, and satisfied with the brown silk stockings and
the brown pumps.
Suddenly there was a sound of laughter and voices and sleigh bells
under her window, and for a moment she thought, with a sense of
panic, that the company had come. She ran to her window and
peeped down.
Below was darkness, through which the snow was falling—falling.
But a great shaft of light shone out from the side door, and in it she
could see the old red sleigh, filled with furry robes, and John on the
front seat, already looking like a snow man. Daisy and Sarah and
Maria and Etta were teasing John; it was evident that he and the two
big horses were about to start off into the storm, and the maids were
amused.
But there was no little old woman being bundled into the sleigh. No,
though Maria shook out all the rugs and Etta put a great waterproof
cover over them, Gabrielle saw nothing of her.
Where was she, then? Had Margret decided to keep her at
Wastewater overnight? Odd!——
Odd, mused Gabrielle, slowly finishing her dressing. Odder still to
have Margret herself, coming upstairs to take a last look at the
waiting rooms, affirm that the poor old lady had gotten off in a great
bustle with John, and surely her family was already wild with fright
over her disappearance on such a night.
But again things of more vital interest to herself put these little
mysteries out of Gabrielle’s head. For when she had gone
downstairs, come up again, gone the rounds of the rooms, touching
a new cake of soap here, and putting a small log into a stove there;
when she had feared that this hall was too warm, and that passage
too cold, and when she had stolen at least a hundred glances at her
pretty flushed face in various mirrors and admired a hundred times
the simple perfection of the velvet gown, Gabrielle really did hear
sleigh bells again in the night, voices, laughter again. Then there
was a sort of flurry downstairs, and the big front doors opened to a
wild rush of wind and night and snow and storm that made the
curtains balloon wildly even upstairs, and the lamps plunge
convulsedly. Gabrielle heard “Mamma!” in what was of course
Sylvia’s voice; then eager greetings and introductions and a perfect
babel of voices.
She had been upstairs in the front hall; now, by simply descending,
she could follow the company into the downstairs sitting room, which
had been made warm and ready for this moment of arrival. Gabrielle
in the darkness above stretched a hand for the smooth guidance of
the wide balustrade and went down in light flight, like a skimming
bird.
She had almost reached the lower level, which was but dimly lighted,
when she saw that two persons were lingering in the hall, and
stopped short, instinctively fearful that she had disturbed them. One
was a woman, dark, furred, slender, and wearing a small, snow-
powdered hat. The other was David.
Gabrielle was eighteen in years, but older in many ways than her
years. She looked down and saw David, smiling that attentive smile
of his, tall, broad, yet leanly built, belted into a brown coat that was
not new, saying nothing that she could hear—just looking at this girl
—just himself—David——
And that instant changed the whole world. Gabrielle did not analyze
the strange sweet weakness that flowed over her like a river, from
head to foot. She did not say even to herself, “He is handsome. He is
good. He is kind.” No need for that—too late for that. Her heart went
to him simply, completely. She had been one woman a moment ago,
she was another now. Much of what she had heard and read of love
had been a sealed book to her; it was all clear now. Reason, logic,
convention had always influenced her; these were all so many words
now.
She heard Sylvia, turning her head to look over her shoulder and so
bring a beautiful face close to his, say affectionately: “So many
thousands of things to tell you, David!” and although she did not hear
the brief words, or perhaps the single word of his reply, she heard
the tone, and she heard Sylvia’s low laugh.
Gabrielle sat down on the stairs in the semi-darkness. Her heart was
hammering, and her mouth dry. The world—youth—beauty, jealousy
—love—marriage—all these things moved before her consciousness
like maskers coming into the light. She stood up, on the halfway
landing, and the woman in velvet with the tawny hair stood up, too.
Gay walked slowly to the mirror, studied her own face. She was
breathing hard, she was confused, half frightened.
She heard Maria calling her. Her aunt was asking for her.
“Say I’m coming!” Gabrielle said, clearing her throat.
David was down there, she would meet him—have to talk to him—
before all their eyes——
She went slowly downstairs.
CHAPTER VII
Flora’s little Christmas house party for her daughter was a small
affair, after all, but to Gabrielle’s confused eyes there seemed to be
eighteen laughing and talking persons rather than eight in the sitting
room when she came in. The girls had flung off their big coats, but
still wore hats, and were apparently only warming their hands and
finishing their greetings before being distributed in bedrooms
upstairs.
From the group, however, Sylvia instantly separated, and Gabrielle
forgot everything else in the pleasure of seeing her cousin again.
Sylvia gave her a warm, laughing kiss and stood talking to her with
one arm still about her, holding the younger girl off while she studied
her face.
“Well, Gay! How you’ve grown up—and with the hair up, too!
Mamma wrote me all about you, but I had quite a different sort of
person in mind! How dare you be fair among all us black Flemings!”
And with her arm still about Gay, she turned to the others for the
introductions. Last of all came David’s greeting with his kindly smile
and keen-eyed inspection, and when his hand touched hers
Gabrielle was conscious of that same suffocating flutter at her heart
again and dared scarcely raise her eyes.
“Mamma, you’re simply a miracle worker!” Sylvia was saying,
gratefully. “I knew there’d be fires, and I knew you’d realize how
weary and cold we are, but upon my word, I hardly know
Wastewater! This room is actually civilized. I promise you nothing for
the halls,” Sylvia said to her guests, “but we can run through them at
full speed. And as long as the rooms are warm——”
She was beautiful, no question of it. Dark, vivid, and glowing, yet
with something queenly and superb about her, too. Instantly it
seemed to Gay that she had never been parted from Sylvia, that all
these separated school years had been a dream. Years ago, as a
bony, pallid, big-toothed little girl, it had been decided that a balmier
climate than Wastewater would be wise for Gay, and she had been
bundled off to the Southern branch of the Boston convent quite
contentedly and had been happy there. But now she remembered
how close she and Sylvia had been in the days of sand castles and
flower ladies, and that Sylvia even then had had this same bright,
sweet, responsive manner that was yet impressive and fine, with
something of conscious high integrity in it; something principled and
constructive even in her gayest moods. Sylvia was really—Gay
came back to the word with another little prick of envy—really
“superior.” She was poised where Gay was simple; she was definite,
where Gay was vague; her voice had pleasant affectations, she
broadened her a’s in the Boston manner.
And Sylvia’s youth and her fresh, glowing beauty kept these things
from being in the least displeasing. She was happy, now, delighted
with the unwonted warmth and brightness of the old house, delighted
to be home, and perhaps delighted, too, to find herself already the
most important person here, with these friends of hers seeing this
big, imposing old mansion as some day to be all her own.
“Not tea, Maria!” she said, eagerly, to the old servant. “Mamma, I
congratulate you upon introducing anything like tea into
Wastewater!”
For Maria, followed by Daisy, one of the newer maids, was indeed
beaming behind a loaded tray.
“I thought we’d dine about seven, dear,” said Flora, crimped, rustling,
flushed with excitement. “And that you might like the hot drink after
your trip. It’s not six yet.”
“I assure you, girls,” Sylvia laughingly said, “my mother’s treating you
like royalty! I’ve been telling them all the way down,” resumed Sylvia,
now dispensing the tea with quick murmurs and dextrous quiet
movements that Gay secretly admired, “that we are absolutely
Victorian here, and rather uncomfortable into the bargain.”
“Tea’s Victorian,” Gabrielle said, as she paused. “It’s just plain bread
and butter,” she added, smiling at the elder Miss Montallen
hospitably.
“Tea’s Victorian, of course, and I daresay coal fires and lamps and
comfort are Victorian, too, and I like them both too much to find any
fault with terminology, Gay!” Sylvia said, cheerfully.
“We live in just such a country house outside of Quebec; we’re quite
accustomed to country winters,” murmured the charming voice of the
older Miss Montallen. The travellers drank their tea standing,
exclaimed over the delicious home-made bread. The young men
were rather silent, exchanging little friendly murmurs and grins,
except that the one named Frank du Spain attached himself instantly
to Gabrielle; Flora chatted, Sylvia made the right comments, David
stood by the mantel, tall, pleased, smiling at them all. Gay hardly
identified the other men until dinner-time, so entirely monopolized
was her attention by the one.
Meanwhile, Sylvia was delighted again, upstairs. Nothing could
make Wastewater anything but old-fashioned, clumsy, draughty. But
the old rooms did look hospitable and comfortable, the beds were
heaped with covers, and there were two more airtight stoves roaring
here. Daisy and Sarah were rushing about with great pitchers of hot
water; the girls scattered their effects from room to room, and went
to and fro in wrappers, laughing and running.
Sylvia’s usual room was on the second floor, next her mother’s. But
for this occasion Flora had grouped all the young persons on the
third floor, where the rooms were smaller, better lighted in winter, and
connecting.
Outside the snow fell—fell. The world was wrapped in winding
sheets, muffled and disguised, and the snow fell softly on the surface
of the running, white-capped waves, and was devoured by them.
Whenever a window was opened, a rush of pure cold snowy air
rushed in and the bare-armed girls who had wanted a breath of it
had to shut it out, laughing and gasping, once more.
But inside Wastewater’s old walls there were noise and merriment,
songs about the old piano, laughing groups about the fires, and the
delicious odours, the clatter and tinkle of china and silver around the
solemnly wavering candles on the dining-room table.
Gabrielle could not talk much, for Sylvia and these particular friends
had shared several holidays, and their chatter was of other times
and places. But her cheeks glowed with excitement, and she moved
her star-sapphire eyes from one face to another eagerly, as if
unwilling to lose a word of their talk. And again, Sylvia was always
“superior.”
She was evidently a girl who took her college life seriously; studied
and excelled, and enjoyed studying and excelling. She was
prominent in various undergraduate organizations; interested in the
“best” developments of this and that element in school life, the “best”
way to handle problems of all sorts. Laura and Gwen Montallen
immensely admired her, Gabrielle could see, and were continually
referring to her in little affectionate phrases: “Ah, yes, but you see
you can do that sort of thing, Sylvia, for they’ll all listen to you!” or
“Sylvia here, with her famous diplomacy, went straight to the Dean
——”
The men, Gabrielle thought, were unusually nice types, too. They
were all in the early twenties, none was rich, and all seemed serious
and ambitious. Bart Montallen was to have a small diplomatic berth
when he graduated in June; Arthur Tipping was already well started
toward a junior membership in his uncle’s law firm and spoke
concernedly of “making a home” for his mother and little sisters as
soon as he could; and Frank du Spain was a joyous, talkative youth,
who confessed, when he sat next to Gay at dinner, that his people
were not especially pleased with his college record, and that, unless
he wanted trouble with his parents, he had to “make good, by gum.”
He told Gay that his father had a ranch near Pasadena, and Gay
widened her eyes and said wistfully, “It sounds delicious!” David,
looking approvingly at her from the head of the table, thought the
velvet gown with the embroidery collar and cuffs a great success.
Altogether the young guests were simple, unspoiled, enthusiastic
about the delicious triumph of a meal, and over the pleasantness of
being free from studies and together. Gay, impressed by this and
anxious to establish cousinlike relations with Sylvia, said something
of it rather shyly when Sylvia came in for a few friendly moments of
chat alone, late that night.
The evening had been delightful, Gay thought; for a while they had
all played a hilarious card game for the prize David offered, the prize
being a large conch shell which David himself had selected upon a
hilarious and candlelighted search through the freezing wilderness of
some of the downstairs rooms. And then they had stood talking
about the fire, and finally had grouped themselves about it; the girls
packed into chairs in twos, the men on the floor, for five more
minutes—and five more!—of pleasant, weary, desultory
conversation. David had held his favourite position, during this talk,
standing, with one arm on the mantel and his charming smile turned
to the room, and Gabrielle noticed, or thought she did, that he rarely
moved his eyes from Sylvia’s face.
But when he did, it was almost always to give her, Gay, a specially
kind look; every moment—she could not help it!—made him seem
more wonderful, and every one of his rare words deepened the
mysterious tie that drew her, strangely confused, strangely happy,
and strangely sad, nearer and nearer to him.
There was another portrait of Roger here, this one painted in about
his fortieth year; handsomer than ever, still smiling, a book open
before him on a table, a beautiful ringed hand dropped on a collie’s
lovely feathered ruff.
“That was your father, Mr. Fleming?” Gwen Montallen had asked,
looking up at Roger’s likeness.
“Stepfather. My father died before I was born,” David said, with his
ready, attentive interest. “My mother married Mr. Fleming when I was
only a baby.”
“And where does Gabrielle come in?” asked Gwen, who had taken a
fancy to the younger girl and was showing it in the kindly modern
fashion.
“Well, let’s see. Gay’s mother was Aunt Flora’s sister,” David
elucidated. “They were Flemings, too. It’s complicated,” admitted
David, smilingly. “To get us Flemings straightened out you really
have to go back thirty years, to the time I was a baby. My mother
was a young widow then, who had married a David Fleming, who
was a sort of cousin of Uncle Roger. He doesn’t come into the story
at all——”
“And that’s Uncle Roger?” Laura Montallen asked, looking up at the
picture.
“That’s Uncle Roger,” David nodded. “I was only a baby when my
mother married him, and he was the only father I remember. A year
after she married him, my mother had another boy baby, so there
were two of us growing up here together.”
“Ah, you’ve a half-brother?” Laura asked.
“I think I have,” David answered, with a grave smile. “But Tom ran
away to sea when he was about fourteen—fifteen years ago now,
and we’ve not heard of him since!”
“Is it fifteen years?” they heard Flora say, in a low tone, as if to
herself.
“But how romantic!” Gwen said, with round eyes. “Wouldn’t you know
a wonderful old place like this,” the girl added, as in the little silence
they heard the winter wind whine softly about the sealed shutters of
Wastewater, “wouldn’t you know that an old place like this would
have a story! So there’s a runaway son?”
“We did hear from him once, from Pernambuco, and once from
Guam, David!” Gay reminded him, animatedly.
“Do get it in order,” Laura begged. “I’ve not yet fitted Sylvia in, much
less Gabrielle!”
“Well,” David said, returning to his story. “So there was my mother—
she was pretty, wasn’t she, Aunt Flora?”
“Beautiful!” Flora said, briefly.
“There was my mother, Uncle Roger her husband, and Tom and me,”
resumed David. “Then—this was an old-fashioned household, you
know—there was a sort of cousin of his”—David nodded at the
picture—“whom we called Aunt John. That was my Aunt Flora’s
mother, and she kept house for us all, and Aunt Flora and Aunt Lily
were her daughters. Oh, yes, and then there was Uncle Roger’s
younger brother Will, who used to play the banjo and sing—what
was that song about the boy ‘and his sister Sue!’ The boy that ate
the green apples, Aunt Flora, and ‘A short time ago, boys, an
Irishman named Daugherty, was elected to the Senate by a very
large majority’——”
“Oh, wonderful!” said Laura Montallen, and Gay said eagerly, “Oh,
David, go on!”
“I wish I could remember it all,” David said, regretfully. “And there
was another about the Prodigal Son, and one about ‘the blow almost
killed Father’——”
“Oh, David, David!” said Aunt Flora, between a laugh and a sob.
“Well, anyway, Tom and I used to think Uncle Will’s songs the most
delightful things we ever heard,” David went on. “So that was the
family when I was very small: Mother, Dad, as we both called Uncle
Roger, Aunt Flora, Aunt Lily—who was very delicate and romantic—
Uncle Will and his banjo, and of course Aunt John, who was a little
wisp of a gray woman—— What is it, Gay?”
For Gay had made a sudden exclamation.
“Nothing,” the girl said, quickly, clearing her throat. She looked very
pale in the warm firelight.
“Then they sent Tom and me off to school in Connecticut. And then,”
and David’s voice lowered suddenly, and he looked straight ahead of
him into the coals, “then our mother died very suddenly—do you
remember that you drove the buckboard into Crowchester to meet
us, Aunt Flora, when we came home?”
“Ah, yes!” Flora said, from a deep reverie.
David, fitting it all together in his memory, remembered now that in
here, chronologically, came Flora’s engagement to Roger Fleming.
But he looked up at the picture above the mantel, and then at her
face, absent-eyed and stern now, and cupped in her hand, as if to
promise that that secret at least should not be betrayed.
“Less than a year after my mother’s death,” he went on, “Uncle
Roger married again, a very young girl—Cecily—Kent, was it, Aunt
Flora?”
“Cecily Kent,” Flora echoed, briefly.
“Who was very delicate, and who was in fact dying for years,” David
went on. “Anyway, that same year Aunt Flora married Uncle Will and
—well, that’s where Sylvia comes in, and little Aunt Lily married a
man named Charpentier, and that’s where Gabrielle comes in. And a
few years later Tom ran away. That broke my stepfather’s heart, and
I suppose his wife’s health didn’t cheer him up exactly. And then my
stepfather’s little second wife died, and then Uncle Will died,” David
summarized it all rapidly, “and after he had hunted my half-brother,
Tom, for years, he died!” And David finished with a final nod toward
Roger’s picture.
“And you’ve never found Tom? Not even when his father died?”
“We don’t know that he knows it, even. It was just before all the
confusion and change of the big war.”
“Yes, but if your Aunt Lily was only a third cousin of your stepfather,
and married a man named Charpentier, he—your stepfather, I mean
—wasn’t really any relation to Gabrielle, then?” Gwen persisted, with
another puzzled look from the portrait to Gay’s glowing face.
“A sort of distant cousin, but that goes pretty far back,” Flora said,
unexpectedly, breaking through another conversation that she had
been having on the other side of the fireplace. “My sister and I were
cousins of Roger Fleming, third cousins, and my mother lived here,
kept house for him, for years. My husband was William Fleming,
Roger’s brother. But Gabrielle is my sister’s child—a sister named
Lily, who died many years ago.”
“It’s hopelessly tangled!” Gay said, with a laugh.
“No, but look—look here!” Gwen Montallen had persisted. Gently
catching Gay by the shoulder, for they were all standing at the
moment, she wheeled her about so that the company could
encompass with one look the painted likeness of the man of forty
and the eighteen-year-old girl. “Do you see it, Laura?” she said,
eagerly. “The mouth and the shape of the eyes—I saw it the instant
she came into the room!”
“I see it,” young Bart Montallen agreed, with a nod. “For a while I
couldn’t think who Miss Gabrielle looked like, and then I knew it was
the picture.”
“Nonsense!” Sylvia said, looking from one to the other. “Uncle Roger
had such black hair and such a white skin——”
“Really your colouring, Sylvia,” David suggested. “But apart from the
colouring,” he added. “I see the likeness. Look at Gay’s mouth—
look, Aunt Flora——”
“No, you may see it in the picture,” Flora said, with her voice
plunging in her throat like a candle flame in the wind. “But they—they
are not alike. Lily—my sister—Gabrielle’s mother—was dark, with
rosy cheeks, something like Roger. But Roger—Roger never looked
much like that picture—he hated it—always said it made him look fat
——”
She was battling so obviously for calm that Sylvia remembered, with
sudden compunction, that Mamma was the last of her generation,
after all, and that—it was no secret!—she had certainly once, if not
twice, been engaged to marry Roger Fleming. Sylvia exchanged a
significant warning look with David, and they immediately guided the
conversation into safer channels. But David was shocked and
astonished to notice a few minutes later that his aunt’s forehead,
under the festive crimping of the gray hair, was wet.
That was all of that. Nobody apparently paid any more attention to
the trivial episode, unless Gay felt an odd and indefinable
satisfaction in being thought like Uncle Roger, in being thus included
in the Fleming ranks.
She was trying to see this likeness at her own mirror an hour later,
when Sylvia, brushing her hair and in a red wrapper infinitely
becoming, came in.
“The girls are asleep,” reported Sylvia, “and I don’t like to light my
lamp because Gwen is in with me. I stayed downstairs a few minutes
to talk to David—I see him so little nowadays.”
A sharp stiletto twisted in Gay’s heart. She could see them lingering
in the darkened room, by the dying fire: Sylvia so beautiful, with her
glossy black coils of hair drooping, and her face glowing with firelight
and winter roses, and David looking down at her with that kindly,
half-amused, half-admiring look. Just a few moments’ intimate talk,
perhaps only of Sylvia’s affairs, perhaps only of her mother’s health,
but binding these two together in that old friendship, kinship, utter
ease and understanding, mutual liking and admiration.
Despair came suddenly upon Gabrielle, and she wanted to get away
—away from Sylvia’s superiorities and advantages, away from
Sylvia’s long outdistancing upon the road to David’s friendship. Gay
thought, braiding and brushing her own long hair, that she did not
want Sylvia’s money, she did not want anything that Sylvia had, she
only wanted to be where she need not hear about it!
“They all say such kind things of you, Gay,” Sylvia told her, with that
pleasantness that was quite unconsciously, and only faintly, tinged
with patronage.
It was then that Gay, aware of little pin-pricks of hurt pride, said
something of the delightful quality of the guests.
“The Sisters had the idea that all college girls are either terrible
bobbed-haired flappers who smoke cigarettes,” Gay said, laughing,
“or blue-stockings who think science can disprove all that religion
has ever claimed!”
Sylvia smiled at her through the mirror.
“And what made you think I could make such girls my friends?” she
asked, lightly reproachful, with an air of quietly posing her cousin,
and even in this pleasant little phrase Gay detected the pretty pride
in herself, her line, her blood, her code and intelligence and
judgment that indeed actuated all that Sylvia did. “No, the Montallens
are—unusual,” Sylvia added, half to herself. “And so,” she said,
smiling, as she dextrously pinned up her rich black braid, “so it was
all the nicer that they should like my cousin Gabrielle! Tell me,” she
went on, “how do things go here? Are you happy—getting nicely
rested? Not too lonely?”
“Rested?” Gay echoed, at a loss.
“Between school,” Sylvia explained, “and—and what?”
She said the last word with a really winning and interested smile, and
sat looking expectantly at Gay, with an air almost motherly.
“Or have you plans?” she elucidated, as Gay looked puzzled. “Is
there something you tremendously want to do? If you are like me,”
Sylvia added, now with just a hint of academic enlightenment in her
voice, “you have forty, instead of one! I almost wish sometimes that I
had to choose what I would do. I adore teaching! I love languages.
I’d love anything to do with books—old books, reviewing books,
library work, even bindings. My professor of economics wants me to
go after a doctor’s degree and my English man wants me to write
books. So there you are! And here is David telling me that I must
learn to manage my own estate.”
Gay flushed, and hated herself for flushing. She had often enough, in
the last quiet weeks, thought that she would like to work, to do
anything rather than dream through all her quiet days at Wastewater;
she had thought vaguely of little tea shops with blue cotton runners,
and the companionship of some little girl of fourteen who would
adore her—of offices—schools——
But embarrassed and taken by surprise, with her thoughts in no sort
of order, she stammered, half laughingly, she knew not why, that she
had thought she might like to be an actress. Sylvia’s look of
astonishment was so perfectly what it should have been that Gay felt
even less comfortable than before.
“But, my dear child,” she said, amusedly, “I don’t believe that would
be practical! We have—absolutely—no connections in that line, you
know. And you’re quite too young. I don’t mean,” Sylvia went on,
kindly, as Gay, hot-cheeked, was silent, very busy with night ribbons,
“I don’t mean that it isn’t a splendid profession for some women. But
it takes character, it takes experience, associations. What makes you
feel that you are fitted for it? Have you—you can’t have!—seen more
than a dozen plays in your life?”
“I just thought of it!” Gay said, with an uncomfortable laugh.
“Then I think I should just stop thinking of it!” Sylvia said. And with an
affectionate arm about Gay’s waist, she nodded toward the thick
rope of tawny braided hair. “Such pretty hair. Gay!”
“Yours is gorgeous, Sylvia,” the younger girl returned. “I noticed to-
night that it is so black that it actually made David’s dinner coat look
gray when you stood beside him.”
“I like my black wig,” Sylvia returned, contentedly, “because it’s—
Fleming. I don’t think I should feel quite right with anything but the
family hair! But when all’s said and done this colour of yours is the
hair of the poets, Gay.”
She said it charmingly, and she meant it, too. For like many women
of unchallenged beauty, Sylvia was very simple and unselfconscious
about her appearance, and seemed to take no more personal credit
for the milk-white skin, rose cheeks, and midnight hair than for her
perfect digestion or the possession of her senses.
“You’re the one who looks like Uncle Roger, Sylvia!”
“In colouring, perhaps. How much do you remember him, Gay?”
“Oh, clearly. I was nearly seven when he died, you know.”
“I really loved him,” Sylvia said, dreamily. “And I hope I can keep up
all the old traditions and customs he loved so here at Wastewater. I
inherit a love for him,” she added, with a significant look and smile.
“There’s no question that my mother loved him dearly for years. Oh,
she loved my father, too, later on, and perhaps in a finer way,” went
on Sylvia, who could fit such meaningless phrases together with all
the suavity of college-bred twenty. “But her first love was for Uncle
Roger.”
“Do you think he——?” Gay began, and paused.
“He——? Go on, Gay. Do you mean did he break the engagement?
No,” Sylvia stated, definitely. “I imagine he did not. He was a
gentleman, after all! But probably there was a quarrel—Mamma was
much admired and a beauty—and she’s a perfect Lucifer for pride,
you know, and neither one would give way.”
Gay accepted this with all the pathetic faith of her years. She could
not possibly imagine Aunt Flora as a beauty; but every middle-aged
woman who talked of her own youth had been one, and Gay was
perfectly willing to believe the last a beautiful generation. She
thought of a picture she had seen of Aunt Flora as a bride, in a
plumed hat, enormous puffed sleeves, a five-gored skirt sweeping
the ground, a wasp-waist with a chatelaine bag dangling from the
belt, and a long-handle parasol held out like Bo-Peep’s crook, and
lost the thread of Sylvia’s conversation.
There was not much more. Sylvia expressed for the twentieth time
her entire delight and gratitude for all that had been done to start the
house party successfully and parted from Gay with a final kiss and a
few warm words about the pleasantness of having a nice little cousin
in the house. It was only when the room was dark, that Gay,
snuggling resolutely down against icy pillows to sleep, began to
review the whole long day with that wearisome thoroughness that is
a special attribute of tired, excited eighteen on a winter night.
The flowers, the dusting, the beds, the tramp in the woods, the funny
old woman bunching herself along in the snow, the arrival and the
tea, and the warm rooms and icy halls, and the splendid dinner and
the talk——
Gay ached all over. With her eyelids actually shutting she said to
herself in a panic that she was too tired to sleep.
Her big room was dark, cool, full of dim shapes; but a fan of friendly
light came through the hall transom, and she could hear men’s
voices somewhere, laughing and talking gruffly; David and the boys,
there was nothing to fear. Outside the snow fell, whispering, tickling,
piling up solemnly and steadily in the dark.

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Transition from Pediatric to Adult

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Pediatric Primary Care: Practice Guidelines for Nurses

Transition from Pediatric

ISBN 978-3-030-23386-0 ISBN 978-3-030-23384-6 (eBook)

© Springer Nature Switzerland AG 2020

Los Angeles, CA, USA Cecily L. Betz

1 Healthcare Transition: An Overview and Introduction ������������������������ 1

3.5 Application to Practice, Training, and Research�������������������������������� 65

7 Transition of Care for Adolescents from Child to Adult

10.5 Intervention #2: Adaptation and Implementation of a Crossover

© Springer Nature Switzerland AG 2020 1

subsequently generated (Schumacher and Meleis 1994). The new generation of

1.2 Healthcare Transition: Now and Then

development and implementation of nurse-led healthcare transition models of care have

1.3 Nursing Practice Roots of Healthcare Transition

1.4 Primary Nursing

In 1975, primary nursing was introduced as a radically different concept of nursing

1.5 Care Coordination

Care coordination has been acknowledged as an essential feature of nursing care.

Table 1.1 Care coordination definitions

These care coordination definitions share several commonalities. Care coordination

1.6 Family-Centered Care

and autonomy. Pediatric care tends to have a family-centered focus, whereas in

1.7  ursing Influence and Involvement in Healthcare

1.8 The Next Generation of HCT Nursing

1.10 Useful Resources

• Adolescent Health Initiative: This website provides an array of information on

American Academy of Pediatrics, American Academy of Family Physicians, American College of

© Springer Nature Switzerland AG 2020 19

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7 Transition of Care for Adolescents from Child to Adult

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1.2 Healthcare Transition: Now and Then

1.3 Nursing Practice Roots of Healthcare Transition

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