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A famous American scholar, Professor and Associate Dean at the University of Arizona, College of Nursing, Pamela G. Reed (PhD, RN, FAAN) has developed the middle range theory of self-transcendence. This theory plays a very significant role in the modern national medical science to provide an understanding about enhancing well-being for any person in a life situation where there is an increase in the awareness of vulnerability and mortality (Fitzpatrick & Wallace, 2006, p. 347). Her theory is based on the well-known study of Cloninger on self-transcendence (De Fruyt, Van De Wiele, & Van Heering, 2000, p. 442). An individual should consider himself/herself as an integral part of the universe (Cloninger, Svrakic, & Przybeck, 1993, p. 975). According to it, Pamela G. Reed has offered considering nursing care as relations between individuals and their environment, in which the formation of self-transcendence plays a crucial role in the improvement of their well-being through widening personal boundaries. Therefore, the nursing practice should be considered as a strong connection between a nurse with his or her outlook and the patient with his or her specific interpretation of information to form the particular self-transcendence. According to Smith and Liehr (2003), self-transcendence embodies experience that connect rather than separate a person from self, others, and the environment (p. 106). The goal of current paper is to consider the Pamela G. Reeds Middle Range Theory of Self-Transcendence, its weak and strong qualities, and links between the theory and clinical practice.

As Smith and Liehr (2003) stated, the Reeds theory considers human life as continuous changes in health during a life period of each individual; and death is a natural phenomenon at the end of the life. Such dangerous diseases as cancer, AIDS, and Ebola fever pose a deadly threat to the whole humanity and nobody is insured against them. In addition, various problems at work, in a personal life, changes in climate, natural disasters, armed conflicts, and others impact the humans health, thus increasing mortality. At the same time, Pamela G. Reed (2010) considers any human life as a continuous development of an individual despite all abovementioned factors. She states that each person lives in the certain environment and their interrelations are essential for health. The skill to apply self-transcendence activities is a major means of the human development during the life because it improves the well-being.

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The whole Reeds theory is based on three major concepts. As McEwen and Wills (2007) stated, the first one is the expansion of personal boundaries outwardly (toward others and environment), inwardly (toward greater awareness of beliefs, values and dreams), and temporally (toward integration of past and future in the present (McEwen & Wills, 2007, p. 237). It means that the self-transcendence forms all necessary conditions for the improvement of understanding and considering interrelations with the environment. It forms a characteristic of developmental maturity in the case, when individuals suffer from illnesses and thoughts of increased mortality as from a personal helpless before the danger (Smith & Liehr, 2003, p. 107). In this particular case, self-transcendence forms developmental maturity, emerged with understanding and assessing situations, which are out of the assumed boundaries of self.

The next concept is vulnerability. It is a psychological state of an individual, when his or her personal death is considered to be real in the nearby future, and these thoughts lead to developmental growth. Modern scholars consider difficulty to develop self-transcendence and it helps individuals with overcoming the certain problems by means of turning the problem into curing, thus leading to personal growth. The third concept is well-being. It is a personal perception of the notion of health and everything connected with it. According to Reed (2010), it can be achieved by self-transcendence.

As a matter of fact, the abovementioned three major concepts of the Pamela G. Reeds Theory of Self-Transcendence have relational propositions. For example, the understanding of personal mortality is connected with self-transcendence by believing that individuals experienced vulnerability have a higher self-transcendence. It is based on the Reeds suggestion that individuals go on their development during their whole life, especially when they experience life-changing problems. Nevertheless, Smith and Liehr (2003) stated that it is not a linear relationship because usually this vulnerability does not depend on the degree of self-transcendence. The next relationship is between self-transcendence of elders and their mental health. Reed (2010) stated this in her study and claimed the existence of the inverse relationships between depression and self-transcendence. Thus, an individual with higher level of self-transcendence experiences the lower depression. Therefore, McEwen and Wills (2007) stated that it is possible because self-transcendence improves well-being of the individual by expanding his/her personal boundaries.

 
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Pamela G. Reed based her theory on the relationship between the individual and his/her environment as the primary concept of her study. Therefore, the theory is all about an expansion of individual boundaries, which increases his/her awareness and ability to analyze past, present, and future events in life for their integration in the particular situation at the present. At the same time, an individual and his/her environment become the major components of the theory. Therefore, each individual has many factors in his/her life, which impact their self-transcendence and well-being. These are crucial points for the happiness in life, gaining success, and spirituality for the whole satisfaction with job, life, and people. It forms a persons point of view on the life experiences. Therefore, the environment becomes a critical context for emerging developmental maturity by means of expanding boundaries, as it is reached in self-transcendence.

The Pamela G. Reeds theory expressly provides for applying the self-transcendence study in the nursing practice, when a nurse involves a patient into the process of the formation of self-transcendence through self-awareness. In this case, healing will be conducted with close connection to various methods of self-transcendence. As McEwen and Wills (2007) stated, nursing interventions will manipulate the environment by meditation, self-reflection, visualization, religious expression, counseling and journaling (p. 238). A nurse should observe and monitor vulnerability of the patient to improve an environment for rising treatment efficacy through self-transcendence by broadening of patients boundaries, which will lead to the improvement of his or her well-being. The usage of the Pamela G. Reeds theory in the nursing practice implies that the patient will be healed according to the holistic approach, which stipulates to take into consideration all aspects of the patient as significant circumstances for the improvement of his or her well-being. It will be achieved only through self-transcendence activities. In this connection, the major task of a nurse is to determine vulnerability for helping the patient to gain a certain level of understanding the problem to reduce depression.

As Joyce J. Fitzpatrick and Meredith Wallace (2006) stated, Pamela G. Reed conducted her research, which was focused on well elders, elders who were hospitalized for treatment of depression, the oldest-old..., healthy adults, and adults facing end-of-life experiences with advanced breast cancer and AIDS (Fitzpatrick & Wallace, 2006, p. 348). Pamela G. Reed used the results of her research for the development of the self-transcendence scale, which, in its turn, has become a reliable tool for research works of many modern scholars. For this purpose, Pamela G. Reed formed two groups of patients: control and experimental to compare results in them for the verification of the validity of the self-transcendence study in improving well-being of patients. A modern scholar, Doris Dickerson Coward conducted research on self-transcendence activities within groups of women suffered from breast cancer. She made a report on her research, creating a work, in which Doris D. Coward stated that patients with the abovementioned diagnosis were at potential turning points because choices made within the context of such events may have far reaching consequences in terms of changed priorities and finding new purposes in life (Coward, 2003, p. 291). In addition, Doris D. Coward took into consideration other studies on profits of psychological support for patients, who suffered from dangerous and life-threatening diseases. This helped Coward to design a quasi-experimental pre-/post-intervention approach to solve the problem with the improvement of self-transcendence activities in patients suffering from breast cancer at the initial phase of their treatment (Coward, 2003, p. 292).

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Doris D. Coward (2003) conducted her research by assessing the influence of self-transcendence on psychological condition and well-being of the patients suffered from breast cancer at the initial phase of their treatment for the further comparison of the results obtained in both experimental and control groups. Thus, twenty-two patients were in the experimental group. A special support group performed a task on improving self-transcendence activities among the patients. At the same time, the other group of seventeen ill women did not have such a psychological intervention. As the result, Doris D. Coward (2003) concluded that almost all patients of the experimental group wanted to continue receiving the abovementioned psychological intervention and did not want to change the group. Thus, the psychological intervention in the experimental group lasted for more than eight weeks. Patients of both groups fulfilled some packets for the determination of various indicators to assess their well-being. It was conducted three times during the research.

For improving well-being of the patients from the experimental group, Doris D. Coward designed special self-transcendence activities for eight sessions. The support groups conducted them in the experimental group of the ill women. The abovementioned activities consisted of the special information on getting knowledge of the disease, exercises for the relaxation, and the improvement of communication skills for the clarification of various problems to solve them. In addition, the patients could choose some educational programs on thinking and self-training, and plan pleasant activity to improve their emotional conditions and general state (Coward, 2003, p. 294). Doris D. Coward created such an environment by means of the abovementioned activities that her patients felt easy to express their emotions and feelings, share their thoughts and hopes, thus expanding their boundaries by listening and supporting each other.

To test Pamela G. Reeds Theory of Self-Transcendence, Doris D. Coward applied several tools for her research of thirty-nine patients suffered from breast cancer at the first phase of their treatment. Doris D. Coward grounded her research on the theory developed by Pamela G. Reeds. She used the STS (the self-transcendence scale) to assess at what level the self boundaries of her patients were expanded. The STS consists of special items that show levels of the determination of self-boundaries of the patients. They grounded on a special rating scale fulfilled by the patients from both groups during their three test points. As Doris D. Coward stated, she used other tools in her research to assess self-transcendence activities in patients suffered from breast cancer such as the Purpose-in-Life Test, the Affect Balance Scale, the Profile of Mood States, the Cognitive Well-Being Scale, the Karnofsky Performance Scale, the Symptom Distress Scale, and the Personal Resources Questionnaire (Coward, 2003, p. 293-294). They were applied in the research on thirty-nine patients during three different tests for the determination of self-transcendence activities of the experimental group. Then, she compared the obtained results with the ones which were obtained in the control group.

As Coward (2003) stated, the patients of the control group initially were with a higher level of well-being than those of the experimental one. Taking into consideration the fact of refusing the patients of experimental group to change their group, Doris D. Coward stated that these patients gained significant success in increasing their level of well-being, obtaining the opportunity to discuss their problems, and treatment during the abovementioned sessions of the support group. As a matter of fact, it proved the correctness of the Pamela G. Reeds Theory of Self-Transcendence; therefore, Doris D. Coward made her conclusion that the moderate to strong correlations found between emotional well-being measures and self-transcendence measures in the total sample are similar to the association of self-transcendence with mental health variables found in previous studies (Coward, 2003, p. 297). Nevertheless, Doris D. Coward recognized that the patients in the experimental group needed some time after conducting the psychological intervention by the support group to increase their well-being level. It proved that the Pamela G. Reeds Theory of Self-Transcendence gained success in increasing well-being level of patients when the abovementioned support and intervention were conducted for the certain time.

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As Melanie McEwen and Evelyn M. Willis (2007) stated, the Pamela G. Reeds Theory of Self-Transcendence was applied by a famous scholar Walton in his health care practice in 1991 to identify a significant inverse relationship between self-transcendence and loneliness among 107 healthy older adults (McEwen & Willis, 2007, p. 155). In 1995, Buckanan, Farran, and Clark used self-transcendence theory to research suicidal issues and their connections with self-transcendence; in 1997, Pelusi applied it in the breast cancer therapy and found that the journey of surviving breast cancer very much involved self-transcendence (McEwen & Willis, 2007, p. 156). Mellors, Riley, and Erlen applied the theory to study a group of HIV-positive patients and discovered the significance of self-transcendence for seriously ill persons in 1997. In 1998, Chin-A-Loy applied the theory for the treatment of patients suffered from prostate cancer; and in 1998, Klaas applied it for the treatment of depression in seventy-seven patients. As Pamela G. Reed (2010) stated, her theory provides an approach specifically in reference to a persons self-boundary to facilitating well-being in nursing practice (p. 423).

The Pamela G. Reeds Theory of Self-Transcendence plays a very significant role in the nursing practice because each professional nurse engages in a healing process, in which the improvement of well-being of a patient is considered as a final goal of the nurses activity. In this case, self-transcendence is an integral part of the condition for the improvement of humans well-being. Pamela G. Reed (2010) considered self-transcendence as a capacity and struggle of humans, which improving and encouraging by nurses. Therefore, each nurse should understand and improve the self-transcendence activities into everyday practice for the enhancement of health care and well-being of patients. The Self-Transcendence Theory of Reed includes vast knowledge in philosophy, psychology, sociology, and medicine, which demands to be continuously improved and put into practice by each nurse. Therefore, the self-improvement of nurses plays a major role in the correct application of the abovementioned theory to their practice. Walton, Coward, Buckanan, Klaas, and other researchers proved the correctness of the Reeds Theory of Self-Transcendence in the improvement of well-being of their patients by means of their self-transcendence activities. The benefits will be achieved as the result of everyday activity of support groups on psychological interventions to improve well-being. In this case, ill persons will communicate with each other sharing their problems and emotions which broaden their self-boundaries.

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