Uncertainty in Illness Theory (UIT)

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CHAPTER 7 Theory of Self-Transcendence

Pamela G. Reed

A central focus of nursing is in understanding and facilitating the human capacity for well-being in the context of diffi cult health-related experiences. The nursing Theory of Self-Transcendence was created from a developmen- tal perspective of human–environment processes of health. The word develop- mental is used in the theory to emphasize inherent change processes that are ongoing, innovative, and context-related while also acknowledging inevitable changes that are random or decremental. Self-Transcendence Theory origi- nated from an interest in understanding how people transcend adversity and the relationship among psychosocial development, mental health, and well- being. The theory is applicable to individuals across the life span regarding challenging life experiences, with supporting empirical fi ndings from research with those in adolescence, adulthood, aging, and end of life.

■ PURPOSE OF THE THEORY AND HOW IT WAS DEVELOPED

According to the intermodern philosophy of nursing science (Reed, 2011), nurs- ing theories most broadly are open systems of knowledge that incorporate var- ious ways of knowing including empirical, ethical, and practice-based sources. Middle range theory in particular is a structure and process for building nursing knowledge through inquiry and practice. Knowledge from research and prac- tice is organized into theories for creative applications with people who need nursing care. The purpose of the middle range Theory of Self-Transcendence is to provide a framework for inquiry and practice regarding the promotion of well-being in the midst of diffi cult life situations. Research and practice using Self-Transcendence Theory may generate new discoveries about the processes by which people attain well-being.

The idea for a Theory of Self-Transcendence was infl uenced by three major events in the history of science, the history of nursing, and my own professional history. First, the 1970s life-span movement in developmental psychology provided philosophical perspective and empirical evidence that the potential for developmental change exists across the life span, beyond childhood and

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adolescence, into adulthood, and throughout the processes of aging and dying (Reed, 1983). Research fi ndings indicated that developmental change was infl uenced less by chronological age or passage of time and more by normative and non-normative life events and the accruement of life experiences.

Second, postulations by the scholar Martha Rogers (1970) about the nature of change in human beings provided further inspiration for development of the theory (Reed, 1997b). Rogerian ideas were congruent with life-span principles of development. Philosophical views include the pandimensionality of human beings and the human potential for healing and well-being. Pandimensionality refers in part to various dimensions, known and as yet unknown, about human beings and their environment, and to the capacity to expand personal bound- aries in various ways. Several nursing theories were also foundational to the Theory of Self-Transcendence.

Third, this theory was motivated by my clinical nurse specialist practice experiences in applying developmental theories in child and adolescent psy- chiatric–mental healthcare. Successful approaches to fostering mental health and well-being required in-depth understanding of patients’ biopsychoso- cial developmental processes and the strengths they may obtain through development.

A detailed explanation of how these elements came together in the devel- opment of Self-Transcendence Theory is described in Reed (1991b). The pre- dominant approach was deductive reformulation, which incorporated various strategies of theory development from philosophical, theoretical, empirical, and practice-based sources. The underlying assumptions, concepts, and relation- ships among the concepts involved in the theory development are described in the next two sections. Research and practice, presented in later sections, also infl uence development and ongoing refi nement of the theory.

■ CONCEPTS OF THE THEORY

The concept of the Theory of Self-Transcendence derived in part from two major assumptions. First, it is assumed that people are integral with their environment and are pandimensional, as postulated in Rogers’s (1980, 1994) Science of Unitary Human Beings. This suggests that human beings may be capable of an awareness that extends beyond physical and temporal dimen- sions (Reed, 1997a). Using current scientifi c methods, this is measurable in reference to everyday experiences of expanding one’s boundaries by reach- ing deeper within the self and reaching out to others, to nature, to one’s god, or other sources of transcendence. An important point is that boundaries not dimensions are transcended. Contrary to views of self-transcendence as mean- ing a separation from self, others, and the environment, in this theory self-tran- scendence refers to connections with self, others, and the environment.

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The second assumption is that self-transcendence is a developmental imper- ative, meaning that it is a human resource that demands expression as do other developmental processes such as walking in toddlers, abstract reasoning in adolescents, and grieving in those who have suffered a loss. These resources are a part of being human and facilitate potential for well-being. As such, the person’s participation in self-transcendence is integral to well-being, and nurs- ing has a role in facilitating this process.

Self-Transcendence

Self-transcendence is the central concept of the theory. It refers to the capacity to expand personal boundaries in many ways, examples of which are as fol- lows: intrapersonally (toward greater awareness of one’s philosophy, values, and dreams), interpersonally (to relate to others and one’s environment), tem- porally (to integrate one’s past and future in a way that has meaning for the present), and transpersonally (to connect with dimensions beyond the typi- cally observable world). Self-transcendence is a characteristic of developmen- tal maturity in terms of an enhanced awareness of the environment and an orientation toward broadened perspectives about life. It is expressed and mea- sured through life perspectives and behaviors that refl ect expansion of per- sonal boundaries.

Developmental Theories

Neo-Piagetian theories about development in adulthood and later life were infl uential in formulating the concept of self-transcendence. Beginning in the 1970s, life-span development researchers discovered postformal patterns of thinking in older adults that extended beyond Piaget’s formal operations, once thought to be the fi nal stage of cognitive development. Life-span devel- opmental theories on social–cognitive development extended Piaget’s origi- nal theory on reasoning, which had identifi ed formal operations (abstract and symbolic reasoning) in youth and young adulthood as the apex of cognitive development. Researchers identifi ed postformal stages from older adults’ continued social and cognitive development well into later life beyond the phase of formal operations, for example, Arlin’s (1975) problem-fi nd- ing stage, Riegel’s (1976) and Basseches’s (1984) dialectic operations, and Koplowitz’s (1984) unitary stage. Researchers found that this mature reason- ing was more contextual, more pragmatic, more spiritual, and more tolerant of ambiguity and paradoxes in life than was the reasoning of earlier devel- opmental phases (e.g., Commons, Demick, & Goldberg, 1996; Sinnott, 1998, 2011). The person using this mature form of reasoning does not seek abso- lute answers to questions in life but rather seeks meaning from perspectives beyond the immediate situation that integrate moral, social, and historical

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dimensions. A perspective of relativism from seeing multiple, sometimes confl icting views is balanced by the ability to make a commitment to one’s beliefs.

Self-transcendence was conceptualized in reference to these views, with goals more in line with Erikson’s generativity and ego integrity than with self-absorbed strivings for identity and intimacy characteristic of earlier devel- opmental phases (Sheldon & Kasser, 2001). Self-transcendence is expressed through various behaviors and perspectives such as sharing wisdom with oth- ers, integrating the physical changes of aging, accepting death as a part of life, having an interest in helping others and learning about the world, letting go of losses, and fi nding spiritual meaning in life.

Nursing Theories

Self-transcendence is a concept relevant to nursing. Themes of self-transcen- dence are evident in other nursing theories. For example, in Parse’s (1992, 2015) paradigm of human becoming, cotranscending is a major theme underlying the philosophical assumptions of her theory and “inspiring transcendence” is an exemplary nursing practice. Newman’s (1994) theory of health as expand- ing consciousness postulates a transcendence of time and space as one reaches beyond illness to develop an awareness of one’s patterns, self-identity, and higher level of consciousness. Although all of these theorists present unique views of transcendence, they generally share the idea of expanded awareness beyond the immediate or constricted views of oneself and the world to trans- form life experiences into healing (Reed, 1996). More recently, developmental psychologists studying self-transcendence suggested it is a universal concept related to well-being in adulthood and aging, as a way of extending personal boundaries outward to others and the community (Hofer et al., 2016).

Nursing Philosophy

Self-transcendence is also congruent with philosophical views of nursing. Sarter (1988) identifi ed the term as one of the central themes in the philosophical foundations of nursing. Newman’s (1992) unitary–transformative paradigm presents human beings as embedded in an ongoing developmental process of changing complexity and organization, a process integrally related to well- being. Furthermore, self-transcendence is an example of Reed’s (1997a) ontol- ogy of nursing, where nursing most basically is defi ned as a self-organizing process inherent among human systems that is related to well-being. Maslow (1969) is frequently cited for his concept of self-transcendence, but his con- ceptualization diverges from nursing by his view of self-transcendence as an elevation or a separation of self from the environment. It is an awareness of person–environment connections when fragmentation threatens one’s well- being (Reed, 1997b).

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Well-Being

A second major concept of the theory is well-being. Well-being is a sense of feeling whole and healthy, in accord with one’s own criteria for wholeness and health. Well-being may be defi ned in many ways, depending upon the indi- vidual or patient population. Indicators of well-being are as diverse as human perceptions of health and wellness, for example, life satisfaction, positive self- concept, hopefulness, happiness, morale, self-care, and sense of meaning in life.

Self-transcendence, as a basic human pattern of development, is logically linked with positive, health-promoting experiences and is therefore a corre- late if not a predictor and resource for well-being. Well-being is a correlate and outcome of self-transcendence. Theoretical analyses and empirical studies have consistently supported this conceptualization of self-transcendence as a contributor to well-being (Lundman et al., 2010; McCarthy, 2011; Reed, 2009; Teixeira, 2008).

Vulnerability

Another key concept of the theory is vulnerability. Vulnerability involves awareness of personal mortality or risk to one’s well-being. It is theorized that self-transcendence, as a developmental capacity (and perhaps as a sur- vival mechanism), emerges naturally in health-related experiences and life events that confront a person with issues of mortality and immortality. Life events that heighten one’s sense of mortality, inadequacy, or vulnerability can—if they do not crush the individual’s inner self—motivate developmental progress toward a renewed sense of identity and expanded self-boundaries (Corless, Germino, & Pittman, 1994; Erikson, 1986; Frankl, 1963; Marshall, 1980). Examples of these life events include serious or chronic illness, dis- ability, aging, parenting, child rearing, family caregiving, loss of a loved one, career, and other life crises. Self-transcendence is evoked through such events and may enhance well-being by transforming losses and diffi culties into growth experiences (Reed, 1996).

■ RELATIONSHIPS AMONG THE CONCEPTS: THE MODEL

The model of the Theory of Self-Transcendence is presented in Figure 7.1. Four basic sets of relationships among the concepts are proposed by the theory. First, there is a relationship between the experience of vulnerability and self-tran- scendence such that increased levels of vulnerability, as brought on by health events, for example, motivate increased levels of self-transcendence. Further, this relationship may be moderated by personal and contextual factors, par- ticularly at high levels of vulnerability.

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A second relationship exists between self-transcendence and well-being. This relationship is direct and positive. For example, self-transcendence relates positively to sense of well-being and morale, and self-transcendence relates negatively to depression as a “negative” indicator of well-being. This relationship represents more than a coping process; it is the integration or transcending of a current situation to move forward toward a changed life rather than simply a return to previous perspectives and behaviors (Willis & Grace, 2011).

Third, self-transcendence functions as a mediator between experiences of vulnerability and well-being. Research fi ndings indicate that self-transcen- dence is a mechanism that helps explain the relationship between vulnerabil- ity and well-being. Self-transcendence may mediate the effects of vulnerability on well-being, with vulnerability experienced as, for example, illness distress; lack of optimism, hope, or power; uncertainty; death anxiety. Without self- transcendence, vulnerability could result in diminishing rather than sustaining well-being. Several studies discussed later provide empirical support for this mediator hypothesis. Self-transcendence, then, may be an underlying process that explains how well-being is possible in diffi cult or life-threatening situa- tions that people endure.

Fourth, personal and contextual factors may also have a role in this healing process. A wide variety of personal and contextual factors and their interac- tions may moderate or otherwise infl uence the process of self-transcendence as it relates to well-being. Examples of these factors are age, gender, cogni- tive ability, health status, past signifi cant life events, personal beliefs, family

Self-Transcendence

Personal and

Contextual Factors

Vulnerability Well-Being

FIGURE 7.1 Self-Transcendence Theory.

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support, and sociopolitical environment. These factors can enhance or dimin- ish the strength of the three key variables and their relationships. For example, advanced age or education may potentiate the relationship between self-tran- scendence and well-being. The idea that personal and contextual factors have a role in the theory derives from Rogers’s (1980) integrality principle about the ongoing person–environment process over the life span.

The relationships posited by Self-Transcendence Theory identify areas for research and, with adequate empirical support, for nursing interventions to facilitate well-being in situations of increased vulnerability. From my nursing perspective, which focuses on understanding inherent resources that foster human well-being, I conceptualized self-transcendence as an independent vari- able—a contributor to and predictor of well-being outcomes—rather than as the dependent or outcome variable. Therefore, nursing interventions that support the person’s inner resource for self-transcendence may focus directly on facilitat- ing self-transcendence as it mediates the relationship between vulnerability and well-being, or as it directly relates to well-being. Interventions may also address infl uential personal or contextual factors that directly relate to vulnerability or to self-transcendence, or that moderate the relationships between vulnerability and self-transcendence, and between self-transcendence and well-being (Figure 7.1).

■ USE OF THE THEORY IN NURSING RESEARCH

Research results to date indicate that self-transcendence is a resource that accompanies serious life experiences that intensify one’s sense of vulnerability or mortality. Self-transcendence is a process of expanding personal boundar- ies that helps people attain some sense of well-being in the context of diffi - cult health situations. Findings also support the theorized direct relationship between self-transcendence and many indicators of well-being across groups of study participants facing a wide variety of health experiences.

The Self-Transcendence Scale

The Self-Transcendence Scale (STS; Reed, 2009) has been used in much of the research concerning the theory. However, other measures may be used—and, in fact, qualitative approaches have been used—to study self-transcendence. The STS is a unidimensional instrument with 15 items measured on 4-point Likert-type scaling. It originated from a 36-item instrument, the Developmental Resources of Later Adulthood (DRLA) scale (Reed, 1986, 1989), which measured the level of developmentally based psychosocial resources refl ective of devel- opmental maturity. The DRLA was constructed from an extensive review of theoretical and empirical literatures on adult development and aging, selected nursing conceptual models and life-span theories, and clinical practice in psy- chiatric–mental health nursing.

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The STS was developed around a self-transcendence factor that explained half of the variance in the DRLA with good internal consistency. The STS factor con- sisted of items describing various behaviors and perspectives by which an indi- vidual may expand personal boundaries inward and outward, and temporally. The STS has demonstrated reliability (internal consistency) and validity (con- tent, construct) across studies of various populations and health experiences. It is brief and easy to administer either as a questionnaire or in an interview format. Many researchers and graduate students have used the instrument in studying self-transcendence as it relates to various health experiences and outcomes.

Initial Research

The initial research used to build the Theory of Self-Transcendence focused on older adults, both well and those hospitalized for psychiatric treatment of depression, as a group more likely to be facing vulnerability or end-of-life issues than younger adults. Correlational and longitudinal studies (Reed, 1986, 1989) were designed to examine the nature and signifi cance of the relation- ship between self-transcendence and mental health outcomes, particularly an inverse relationship between self-transcendence and depression. Quantitative and qualitative fi ndings in a study of oldest-old adults, aged 80 to 100 years, also produced the same results (Reed, 1991a). In addition, four conceptual clus- ters representing different aspects of self-transcendence were generated from a content analysis: generativity, introjectivity, temporal integration, and body transcendence. Elders who scored high on depression refl ected weak patterns in these four areas, particularly in body transcendence, inner-directed activi- ties, and positive integration of present and future.

Similar results were generated later, in research by Haugan, Hannssen, and Moksnes (2013) in a study of self-transcendence in 202 nursing home older adult residents. Their STS results could be empirically organized into two factors, intra- personal and interpersonal, which also included temporal and transpersonal items, providing further support for Self-Transcendence Theory that posited expanding personal boundaries as a correlate of well-being in later adulthood.

Basic and Practice-Based Research by Coward

Doris Coward, who as a doctoral student studied with Reed, continued research into self-transcendence with a focus on middle-aged adults confronting their mortality through serious illness, advanced cancer, and AIDS. Coward (1990, 1995) initially studied the lived experience of self-transcendence in women with advanced breast cancer. Results from her phenomenological study were consistent with fi ndings from quantitative studies. Self-transcendence per- spectives were salient in this group, which had a heightened awareness of personal mortality. Self-transcendence was expressed in terms of reaching out beyond self to help others, to permit others to help them, and to accept the present, unchangeable events in time. This research validated Reed’s (1989)

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quantitative measure of self-transcendence. In subsequent phenomenological research, Coward and Lewis (1993) explored self-transcendence in women and men with AIDS. Despite increased fear and sadness at the prospect of death, all participants indicated self-transcendence perspectives, which in turn helped them fi nd meaning and achieve emotional well-being. Findings from a study of 107 women with stages III and IV breast cancer, in which structural equation modeling was used to analyze responses, indicated that self-transcendence had a signifi cant and direct positive effect on emotional well-being by mediat- ing the effect of illness distress on well-being (Coward, 1991).

Coward (1996) also studied healthy adults, who ranged in age from 19 to 85 years. She was interested in extending the Theory of Self-Transcendence by examining its salience in a group of adults who were not as actively confronted with end-of-life issues as other seriously ill populations. Self-transcendence was again found to be a signifi cant and strong correlate of well-being indi- cators, namely coherence, self-esteem, hope, and other variables assessing emotional well-being. Coward concluded that while her research supported the hypothesized relationship between self-transcendence and mental health variables, the fi ndings from her sample of healthy adults suggested that self- transcendence may surface at times in the life span other than end of life, as proposed by Victor Frankl (1969). Coward’s work helped expand the scope of the theory to other age groups where self-transcendence may be salient. Nevertheless, her results do not necessarily dispute the idea that some aware- ness of human mortality is integral to self-transcendence. Awareness of mor- tality is a basic characteristic of the human condition among both healthy and ill adults, and may emerge slowly from the accumulation of life experiences as well as suddenly by a health crisis event.

Intervention research by Coward and Kahn (2004, 2005) focused on the expe- riences and functions of self-transcendence in women newly diagnosed with breast cancer. Self-transcendence practices and perspectives were particularly effective in helping women to resolve spiritual disequilibrium often experi- enced after diagnosis of breast cancer (Coward & Kahn, 2004). In their 2005 study, the investigators compared a traditional community cancer support group with a Self-Transcendence Theory–based group on outcomes regarding the experiences of self-transcendence and physical and emotional well-being. Women in the self-transcendence treatment group were able to attain a bet- ter sense of community with their support group. However, the most striking fi nding was that women in both groups had self-transcendence experiences that sustained them through the diagnosis and treatment of their illness. They expressed themes of outward, inward, and temporal expansion of self-bound- aries such as reaching out for support and information, fi nding inner strength to endure, and constructing meaning out of past experiences and future hopes. The authors interpreted this fi nding as support for Reed’s theoretical idea that the capacity for transcending an adverse event is a universal trait that motivates expansion of one’s conceptual boundaries in multiple and benefi cial ways.

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Research by Reed and Colleagues

In an attempt to examine the theory in a group of adults that was healthy and younger than the elders typically studied, Ellermann and Reed (2001) found evidence of self-transcendence in middle-aged adults in the forms of parenting, self-acceptance, and spirituality as expressions of expanding self-boundaries related to mental health. Their results indicated a strong inverse relationship between self-transcendence and level of depression in middle-aged adults, particularly among women.

Decker and Reed (2005) studied self-transcendence and moral reasoning within the context of several contextual and developmental factors to bet- ter understand end-of-life treatment preferences among older adults. Self- transcendence was found to be signifi cantly and positively related to a higher level of reasoning called integrated moral reasoning, which includes both the autonomous and social domains of moral decision making. This fi nding was expected based on life-span developmental theory on adult cognition. Self- transcendence did not relate signifi cantly to the desired level of aggressiveness of end-of-life treatment, although investigators argued that more research is needed into the role of self-transcendence and end-of-life decisions. The results help explain why reasoning about end-of-life treatment options may involve a complex and integrated approach.

Runquist and Reed (2007) studied correlates of well-being in 61 homeless men and women. Self-transcendence coupled with positive physical health status were identifi ed as independent correlates of well-being, explaining a signifi cant 60% of the variance in well-being in this sample. Self-transcendence held the larger and more signifi cant correlation with well-being. These fi nd- ings suggest that interventions to foster well-being among homeless persons include those that support self-transcendence as well as physical health.

Research by Other Investigators

Other research conducted over the past 25 years has provided support for the Theory of Self-Transcendence. In most but not all of the quantitative studies reported here, researchers measured self-transcendence with Reed’s (2009) STS. In the case of qualitative studies, researchers worked from a conceptu- alization of self-transcendence congruent with Reed’s theory. Research has focused on various populations and health events.

Chronic Physical Illness, Mental Health, and Aging

Several researchers in addition to Reed have studied self-transcendence in older adults in reference to chronic and serious illness and mental health and well-being. The various indicators of well-being found to be associated with self-transcendence, are bolded in the following research descriptions.

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Walton, Shultz, Beck, and Walls (1991) explored self-transcendence using a 58-item scale based on Peck’s (1968) developmental stages of old age. They identifi ed a signifi cant inverse relationship between self-transcendence and loneliness among 107 healthy older adults.

Billard (2001) examined the role of self-transcendence in the well-being of aging Catholic sisters for her doctoral research. Specifi cally, she combined Reed’s (1987) Spiritual Perspective Scale with Reed’s (1991a) STS to measure the concept of spiritual transcendence and found that spiritual transcendence, along with selected personality and demographic factors, contributed signifi - cantly to explaining emotional intelligence in a sample of 377 elder Catholic sisters.

In suicide research with 35 older adults hospitalized for depression, Buchanan, Farran, and Clark (1995) found that self-transcendence was inte- gral to older adults coping with the changes in later life. Desire for death and self-transcendence (as measured by the STS) were signifi cantly and inversely related. Klaas (1998) studied self-transcendence and depression in 77 depressed and nondepressed elders, fi nding self-transcendence was negatively correlated with depressive feelings and positively correlated with meaning in life in these groups. Similarly, in a study of Taiwanese older adults residing in nursing homes, self-transcendence was negatively correlated with depressive symp- toms (Hsu, Badger, Reed, & Jones, 2013).

The capacity to engage in activities of daily living and self-transcen- dence was found to be signifi cantly positively related in two studies, one with 88 chronically ill elders (Upchurch, 1999) and another with older African Americans where Upchurch and Mueller (2005) found that self- transcendence was signifi cantly and positively related to the ability to carry out instrumental activities of daily living (IADLs). Self-transcendence was interpreted as a developmental strength infl uential in explaining why some elders continued to remain independent while others did not, regardless of health status. Related to IADLs, investigators Upchurch and Mueller (2005) recommended that caregivers can support older adults’ self-care capacity by approaches that promote self-transcendence. On a similar theme, other investigators suggest continued research into the possible relationship between self-transcendence and medication adherence (N. F. Thomas & Dunn, 2014).

Walker (2002) measured self-transcendence and mastery of stress in test- ing his theory of transformative aging. He proposed that stressful events can bring about transformative change that enables the person to deal with the losses and challenges that accompany aging. Self-transcendence was found to be signifi cantly and positively related to mastery of stress and signifi cantly inversely related to stress of aging. His fi ndings have implications for engag- ing the resource of self-transcendence to assist middle-aged and older adults in mastering stress and existential anxiety over the aging process.

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Self-transcendence was found to be related to mediate and reduce stresses of progressive diseases of multiple sclerosis and systemic lupus erythematosus, prostate cancer, and oral cancer, respectively (H.-C. Chen 2012; Chin-A-Loy & Fernsler, 1998; Iwamoto, Yamawaki, & Sato, 2011). Similarly, in a study of older women living with rheumatoid arthritis, Neill (2002) found that transcendence of self-boundaries and personal transformation represented a process of living successfully with a chronic illness.

In a correlational study of oldest-old adults, Swedish researchers (Nygren et al., 2005) found signifi cant, positive relationships of moderate magnitude between self-transcendence and several mental and physical health outcomes including resilience, sense of coherence, and purpose in life. Their results overall indicated that oldest-old adults were capable of experiencing levels of self-transcendence and other positive factors comparable to those in younger adults, although this capacity may differ between men and women, indicating the need for further research into gender differences. Several researchers have studied inner strength as a variable very similar to self-transcendence in its defi nition and in a way it is proposed to promote well-being in oldest-old men and women, that is, in terms of increased resilience, purpose in life, and sense of coherence (Lundman et al., 2010; Viglund, Jonsén, Strandberg, Lundman, & Nygren, 2014). One major conclusion was that while oldest-old individuals are more vulnerable to illness than are younger people, they also may have increased inner strength to help them not only cope but fi nd joy in later life (Moe, Hellzen, Ekker, & Enmarker, 2013).

Life-Threatening Illness in Adults

Considerable research on self-transcendence has focused on people who have life-threatening or life-limiting illness. Results from these studies provide con- sistent support for Self-Transcendence Theory. Examples of this research include individuals with cancer, HIV/AIDS, and other life-threatening illnesses.

CANCER

In a phenomenological study of eight women who had completed breast cancer therapy, Pelusi (1997) found that surviving breast cancer very much involved self-transcendence, expressed as setting life priorities, fi nding meaning in life, and looking within self. Similar fi ndings occurred in a study by Kinney (1996), who reported on her own journey through breast cancer. A process of listening to and trusting one’s inner voice facilitated transcendence. Self-transcendence in turn was central to the reconstruction of self. Self-transcendence also was signifi cant in adjusting to recurrence of breast cancer (Sarenmalm, Thorén- Jönsson, Gaston-Hohansson, & Öhlén, 2009).

In its mediating role, self-transcendence alone partially mediated the rela- tionship between optimism and the outcome of emotional well-being in a

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group of 93 women receiving radiation treatment for breast cancer (Matthews & Cook, 2009). Farren’s (2010) study of 104 breast cancer survivors produced fi ndings that self-transcendence was a signifi cant mediator in two relation- ships—between power (knowing participation) and quality of life and between uncertainty and quality of life. Uncertainty reduces quality of life by reducing self-transcendence. Farren used Reed’s theory to describe self-transcendence as a profound awareness of one’s wholeness while having awareness of fl uc- tuations in one’s human–environmental fi eld patterns.

HIV/AIDS

Self-transcendence and quality of life were studied in 46 HIV-positive adults by Mellors, Riley, and Erlen (1997). Data analysis revealed a signifi cant mod- erate positive relationship between self-transcendence and quality of life for the group, particularly for those who were the most seriously ill. Similarly, Stevens (1999) found self-transcendence and depression to be signifi cantly and inversely related in young adults with AIDS.

Results from other research also attest to the capacity for seriously ill indi- viduals to transcend their illness. Persons with AIDS were able to transcend the suffering associated with their illness in a study by Mellors, Erlen, Coontz, and Lucke (2001). The participants demonstrated three dominant patterns indica- tive of self-transcendence: creating a meaningful life pattern, achieving a sense of connectedness, and engaging in self-care.

A group of investigators (Ramer, Johnson, Chan, & Barrett, 2006) interested in quality of life among persons with HIV/AIDS studied 420 mostly Hispanic, male patients. Among the fi ndings was a signifi cant positive relationship between self-transcendence and level of energy in the patients. In addition, researchers found that levels of acculturation and self-transcendence were sig- nifi cantly related, suggesting that the meaning of self-transcendence may be infl uenced by cultural factors. Their study not only provided support for the relevance of self-transcendence among these patients but also suggested that acculturation may moderate the relationship between self-transcendence and health outcome variables in people with HIV/AIDS.

OTHER LIFE-THREATENING ILLNESSES

In a study of liver transplant recipients, Wright (2003) found self-transcendence to be positively related to quality of life and negatively related to fatigue, with further research needed to identify potential causal direction in these relation- ships. Bean and Wagner (2006) also studied liver transplant recipients (N = 471) with results indicating that self-transcendence becomes salient following the experience of liver transplant and was related signifi cantly to higher qual- ity of life and also may function as a mediator to decrease the effects of illness distress on quality of life.

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In a phenomenological study of individuals with spinal muscular atro- phy (SMA), self-transcendence was central to living with a sense of integrity, hope, and meaning amid the physical limitations experienced by individu- als with these individuals (Ho, Tseng, Hsin, Chao, & Lin, 2016). Williams (2012) conducted a phenomenological study of eight men and women who had received a stem cell translation the previous year. Analyses showed that self-transcendence is brought about by the intense suffering, as lived through the physical effects of the treatment, facing death, and eventually drawing strength from within themselves and from spiritual support. The fi ndings suggested that effects of vulnerability on well-being were mediated by self-transcendence.

Research on Nurses and Other Caregivers

Self-transcendence is studied as it occurs in family caregivers, nurses, and oth- ers providing care to patients. This area of research has increased over the years to reveal the signifi cance of self-transcendence in the well-being of caregivers.

Enyert and Burman (1999) found caregivers’ self-transcendence behaviors, such as being with and doing for their loved one as death approached, facili- tated personal growth and new meaning, and they were able to reach out to help others besides their family member. Poole’s (1999) research revealed that self-transcendence was an important phase in being a caregiver in Grounded Theory research with 19 family caregivers in the process of being a caregiver for frail older adults at home. Three phases of caregiving—connecting, dis- covering self, and transcending self—were identifi ed by which the caregiver became able to work with healthcare personnel as a partner instead of perpetu- ating confl ict in the relationship.

Acton and Wright (2000) and Acton (2002) addressed self-transcendence in family caregivers of adults with dementia, proposing self-transcendence to be a relevant and potentially therapeutic experience for family caregivers. However, when Acton (2002) conducted a naturalistic fi eld study of family caregivers, she found that caregivers of adults with dementia had little oppor- tunity to nurture self-transcendence and instead experienced social isolation, ambivalence, emotional fragility, and burden of caring for their family mem- ber. She concluded that some of these negative experiences associated with caregiving may inhibit development of self-transcendence in caregivers and interfere with their continued growth and well-being. Kim et al. (2011) dem- onstrated signifi cant positive links between self-transcendence and emotional well-being among family caregivers of chronically ill elders.

From interviews with 16 African American and White groups of great- grandmothers, Reese and Murray (1996) identifi ed fi ve domains of self- transcendence: connectedness, religion, being wise, values, and stories. The authors considered great-grandparents vital in facilitating self-transcendence and good relationships among family members.

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As part of her study of spiritual growth in nurses, Kilpatrick (2002) studied the relationships among self-transcendence, spiritual perspective, and spiritual well-being in female nursing students and faculty. She found positive correla- tions among those variables in students and faculty. Nursing students and fac- ulty differed signifi cantly on level of self-transcendence and spiritual well-being, suggesting that self-transcendence may increase with development. Wasner, Longaker, Fegg, and Borasio (2005) found that spiritual care intervention train- ing with 48 palliative care professionals increased their self-transcendence, spir- itual well-being, and positive attitude toward work with dying patients.

McGee (2004) employed the method of interpretive phenomenology to examine self-transcendence and its impact on nurses’ practice. Among results from the moving stories of nurses, McGee found self-transcendence to be an important mechanism of healing for nurses who have experienced diffi cult and traumatic personal life experiences. Her work highlighted the role of self- transcendence in healing the nurse and in enriching the practice of nurses for the mutual benefi t of both patient and nurse.

Along a similar line of thinking, Hunnibell, Reed, Quinn-Griffi n, and Fitzpatrick (2008) conducted dissertation research based on Self-Transcendence Theory. They studied self-transcendence as related to burnout syndrome in hos- pice and oncology nurses. Both groups of nurses face death and life-threaten- ing illness through their work with patients. However, they hypothesized that because of the philosophy of their healthcare setting and opportunities to pro- cess loss, hospice nurses would demonstrate higher levels of self-transcendence and lower levels of burnout than oncology nurses. Their fi ndings also provided empirical support for the hypothesis and for an inverse relationship between self-transcendence and three types of burnout. Hunnibell et al. concluded that self-transcendence is a resource for nurses and may protect them against burnout.

Signifi cant, positive relationships between work engagement (measured as vigor, dedication, and absorption) and self-transcendence were found by Palmer, Quinn Griffi n, Reed, and Fitzpatrick (2010) in their study of 84 acute care staff registered nurses. Through self-transcendence, the nurses increased self-aware- ness and inner strength and made sense of challenging work situations.

In summary, nurses and caregivers experience vulnerability and related health experiences through the challenges of their work as well as in their per- sonal lives. Overall, research fi ndings provide consistent evidence of the signif- icance of self-transcendence in the well-being of nurses and other caregivers.

■ USE OF THE THEORY IN NURSING PRACTICE

Theory-Informed Strategies for Practice

Research results indicate that a variety of strategies derived from Self- Transcendence Theory have been successful in promoting well-being and in

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diminishing negative outcomes in practice settings. The following sections are loosely organized by various strategies of expanding personal boundaries intrapersonally, interpersonally, and transpersonally.

INTRAPERSONAL STRATEGIES

Intrapersonal strategies may help a person expand personal boundaries inward to clarify knowledge about self and fi nd or create meaning and pur- pose in a diffi cult life experience. Meditation, prayer, visualization, life review, structured reminiscence, self-refl ection, and journaling are the techniques of self-transcendence that nurses may facilitate in patients to help them recognize patterns of their own healing.

Nurses may use cognitive strategies to support self-transcendence in help- ing patients integrate a diffi cult health event into their lives. Targeting infor- mation about the illness, using positive self-talk, and engaging in meaningful and challenging activities are techniques that can help a person integrate and grow from the illness experience (Coward & Reed, 1996).

The personal narrative was tested in a randomized, clinical trial as an inter- vention for enhancing self-transcendence in women with HIV, multiple scle- rosis, and systemic lupus erythematosus (Diener, 2003). STS scores increased signifi cantly in the intervention groups, suggesting that the intervention was successful in helping the women address issues related to having a life-threat- ening or life-altering illness.

McCarthy, Jiying, and Carini (2013) and McCarthy, Jiying, Bowland, Hall, and Connelly (2015) developed and tested a “Psychoeducational Approach to Transcendence and Health” (PATH) program to facilitate self-transcendence in promoting well-being in older adults. Strategies that promote self-transcen- dence may even be helpful with individuals with Alzheimer’s disease, as dem- onstrated in a case study of a family with a family member having this disease (Vitale, Shaffer, & Fenton, 2014).

INTERPERSONAL STRATEGIES

Interpersonal strategies for facilitating self-transcendence focus on connect- ing the person to others through formal or informal means, ranging from face to face or telephone to connecting on the Internet. Nurse visits, peer counsel- ing, informal networks, and formal support groups are examples of interper- sonal strategies that the nurse may arrange for the person (Acton & Wright, 2000). Maintaining meaningful relationships and strengthening affi liations with civic groups or a faith community are strategies that the nurse can facil- itate (McCormick, Holder, Wetsel, & Cawthon, 2001). A computer-mediated self-help intervention was designed to facilitate connections among lesbian, gay, bisexual, and transgender (LGBT) persons who shared similar interests (DiNapoli, Garcia-Dia, Garcia-One, O’Flaherty, & Siller, 2014).

7 . THEORY OF SELF -TRANSCENDENCE  135

Support groups are often cited as an effective way to connect people facing a diffi cult life situation. Groups that bring together people of similar health experiences can facilitate self-transcendence by connecting the person to others who can share the loss and exchange information and wisdom about coping with the experience and by providing an opportunity to reach beyond the self to help another. Joffrion and Douglas (1994) reported that nurses can facilitate self-transcendence during bereavement by helping the person participate in church or civic groups, develop or resume a hobby, share personal experiences of grief with others, and support others who have experienced loss.

In a series of pre-experimental and quasi-experimental studies, Coward (1998, 2003) developed and refi ned a series of support group sessions to facili- tate self-transcendence. These sessions provided a variety of activities designed to support self-transcendence in women facing breast cancer: orientation and information sessions, sharing cancer stories, problem solving, assertive commu- nication training, relaxation training, values clarifi cation, ongoing educational components, constructive thinking and self-instructional training, feelings management, and pleasant activity planning. In another quasi-experimental study with individuals with multiple sclerosis, peer support groups facilitated self-transcendence and physical well-being (JadidMilani, Ashktorab, Aben- Saeedi, & AlaviMaid, 2014). Similarly, Norberg et al. (2015) suggested that self- transcendence facilitated social contact, outdoor activities, and other functions that can increase longevity in elders with life-limiting medical conditions.

Group psychotherapy is another intervention strategy for enhancing self- transcendence. Young and Reed (1995) found that this intervention approach was effective in generating a variety of outcomes for a group of elders, for example, intrapersonally in terms of achieving self-enrichment, self-esteem, and self-affi rmation; interpersonally in terms of bonding with and helping oth- ers, enabling self-disclosure, and overcoming self-absorption; and temporally in terms of gaining acceptance of one’s past and feeling empowered about the future. A 6-week group reminiscing intervention showed an increase in self- transcendence and a nonsignifi cant decrease in depression for women in an assisted living facility (Stinson & Kirk, 2006). Self-transcendence and depres- sion level were signifi cantly, inversely related in this group.

Altruistic activities facilitate self-transcendence by providing a context for learning new things and expanding awareness about oneself and one’s world (Coward & Reed, 1996). Altruism also enhances a person’s inner sense of worth and purpose. McGee (2000) explained that practicing humility and providing service to others are tools of self-transcendence that can empower individuals to maintain a healthy lifestyle. Connections between people, whether to receive or provide support, are key strategies for enhancing self-transcendence. Chan and Chan (2011) tested interventions designed to expand boundaries toward others through participation in volunteer work and social activities. These activities promoted acceptance and fi nding meaning in spousal death by facilitating the passing of time among bereaved Hong Kong Chinese older adults.

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In a study by Willis and Griffi th (2010) of school-age boys victimized by bullying, altruistic views and practices were found to facilitate healing. The boys reached out to others in helping and seeking help, having an interest in learning and engaging in fun hobbies, and feeling empathy toward others. The authors emphasized to practitioners the importance of planning activities and interactions that can foster self-transcendence.

Elderly nursing home residents were studied for their perceptions on what personal qualities allowed them to rise above the diffi culties of advanced age (Bickerstaff, Grasser, & McCabe, 2003). Results from this qualitative study were consistent with patterns of self-transcendence identifi ed earlier by Reed (1991a) in her study of community-dwelling oldest-old adults: generativity, introjectivity, temporal integration, body transcendence, and one not previ- ously identifi ed, “relationship with self/others/higher being.” Many partici- pants exhibited more than one pattern of self-transcendence. The researchers concluded that caregivers of older adults in long-term care facilities and at home should look beyond custodial care to incorporate activities that build upon the residents’ capacity for self-transcendence that can help them cope with the losses of later life. Results from several studies support self-transcen- dence as clinically important in nurse–patient interactions to promote mental health among older adults in long-term care (Haugan, 2014; Haugan, Hanssen, & Mokenes, 2013; Haugan, Rannestad, Hammervold, Garasen, & Espnes, 2013, 2014).

TRANSPERSONAL STRATEGIES

Transpersonal strategies of self-transcendence are designed to help the person connect with a power or purpose greater than self. The nurse’s role in this pro- cess is often one of creating an environment in which transpersonal exploration can occur. It is worth noting here that several of the intervention strategies that foster intrapersonal growth can also foster a sense of transpersonal connection, such as meditation, prayer, visualization, artistic expression, and journaling.

Spiritual perspective or spiritual well-being, rather than religion per se, has been found to relate to self-transcendence by several researchers over the years, including Haase, Britt, Coward, Leidy, and Penn (1992), J. C. Thomas, Burton, Quinn Griffi n, and Fitzpatrick (2010), and Sharpnack, Quinn Griffi n, Benders, and Fitzpatrick (2010, 2011) in their two studies on the Amish community’s use of spiritual and alternative healthcare practices to foster well-being. Religious activities and prayer are also identifi ed as signifi cant to the well-being of per- sons facing life crises. McGee (2000) explained the need for the nurse to pro- vide an environment in which patients can look beyond themselves toward a higher power for help and be inspired to help others.

Schumann (1999) found that self-transcendence enhanced well-being in ven- tilated patients. Spiritual connections enabled patients to use temporal per- spectives of past and future to empower themselves; they synchronized their

7 . THEORY OF SELF -TRANSCENDENCE  137

lives with the realities of being on a ventilator and anticipating extubation and were then better able to manage this life-threatening health experience.

Artistic modalities such as art-making activities, creative bonding practice, memorial quilt making, and watching a therapeutic music video were based on Self-Transcendence Theory. These artistic modalities expand personal bound- aries and facilitate transcendence, which in turn increase well-being (Burns, Robb, & Haase, 2009; S. Chen & Walsh, 2009; Kausch & Amer, 2007; Walsh, Radcliffe, Castillo, Kumar, & Broschard, 2007). Robb et al. (2014) used Haase’s Resilience in Illness model to study a music video intervention with adolescents and young adults undergoing hematopoietic stem cell transplantation. They found this intervention facilitated self-transcendence and resilience along with factors relevant to well-being in these young individuals.

Other researchers found that poetry writing was an expressive therapy for facilitating self-transcendence in caregivers facing diffi cult life situations, and subsequently leading to positive outcomes of self-affi rmation, sense of achievement, catharsis, and acceptance among dementia caregivers (Kidd, Zauszniewski, & Morris, 2011). However, caregivers may need pragmatic assistance before they can engage in activities that support self-transcendence; for example, to foster self-transcendence in family caregivers of adults with dementia, Acton and Wright (2000) identifi ed the importance of helping arrange for in-home assistance or day care so that the family members have the time and energy to engage in activities that promote transpersonal awareness.

■ SUMMARY

Research fi ndings have shown that self-transcendence is integral to well-being across a diversity of health experiences that nurses address in practice. Nursing practices that facilitate self-transcendence result in healing outcomes during these health events, as in, for example, diminished depression and loneliness among depressed elders; increased hopefulness and self-care among chroni- cally ill elders; and increased meaning in life among persons with advanced breast cancer and other life-threatening illnesses; and increased well-being and self-affi rmation in family and professional caregiving.

■ CONCLUSION

Adequacy of the Theory

Professional nurses are defi ned in large part by their ability to engage human capacities for healing and well-being. Self-transcendence was presented as a resource for well-being. It represents “both a human capacity and a human struggle that can be facilitated by nursing” (Reed, 1996, p. 3). A goal in

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developing the theory was to gain better understanding of the dynamics of self-transcendence as it relates to health and well-being. This knowledge, in addition to that acquired through personal and ethical knowing and practice experience, can be used by nurses to foster well-being through strategies of self-transcendence.

There is internal consistency among the elements within the theory—the concepts, their defi nitions, and proposed relationships. Positive relationships were identifi ed between vulnerability and self-transcendence and between self-transcendence and well-being. Self-transcendence functions as a resource, correlate, or facilitator of specifi c indicators of well-being. Self-transcendence is often found to be a mediator between vulnerability experiences and well- being outcomes. Self-transcendence has also been conceptualized as an out- come or a process of well-being in its own right. Finally, in addition to the three key concepts in the theory, research fi ndings provide evidence on the role of various moderators in the process of self-transcendence.

The scope of Self-Transcendence Theory now reaches beyond the initial focus on older adults to include children, adolescents, and adults of all ages who experience vulnerability. The theory is being studied across cultures around the world. Research fi ndings are broadening applications of the theory to include a variety of normative life transitions and developmental events where processes of self-transcendence have yet to be explored in depth.

The theory provides a perspective relevant to nursing practice in pro- posing self-transcendence as a process by which human beings may sustain well-being in times of vulnerability. That is, self-transcendence is a process of expanding one’s boundaries to gain new insights for organizing and tack- ling health-related events. This process has empirical support. Findings from research consistently indicate that self-transcendence is associated with a wide variety of well-being indicators, from successful aging and meaning in life, to specifi c outcomes such as decreased fatigue or increased self-care activities of daily living. In addition, the scholarship of advanced practice nurses, graduate students, and researchers continues to build knowledge about personal, con- textual, and cultural factors that infl uence the process of self-transcendence.

Self-Transcendence Theory has social congruence. Self-transcendence has emerged as a foundational process in promoting societal welfare, as a devel- opmental imperative across the life span for a wide variety of health-related events. As such, nursing must be there to develop the knowledge and pro- vide the expert support that facilitates this cost-effective and holistic process of well-being for society.

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