Applying Reed's Self‐Transcendence Theory to Support Family Members of Nursing Home Residents Living With Dementia: A Critical Appraisal and Adaptation

ABSTRACT

Background

With the global aging population, the number of individuals living with dementia is increasing and raising the demand for supportive care, particularly in nursing homes (NHs). While family members of individuals with dementia often provide care, individuals with advanced stages of dementia require specialized care in NHs. The transition to NH care creates unique stressors for families, yet it can also foster personal growth and resilience among them. Existing research primarily focuses on stress and coping models that do not fully capture the positive aspects of caregiving, such as meaning and personal growth. This paper explores Reed's Theory of Self‐Transcendence (ST) as a lens for understanding the positive dimensions of family caregiving in NH settings.

Methods

Using Parse's criteria, we critically evaluated ST theory, adapting it to better reflect the experiences of families of NH residents with advanced dementia. Our evaluation confirms that ST is a strong framework, but its application in NH caregiving requires expansion to include ecological and relational factors that influence the caregiving experience.

Theoretical Framework

We propose an adaptation that integrates concepts such as trust in NH staff, communication quality, shared decision‐making, personhood, and caregiver burden, offering a more comprehensive understanding of family involvement in NH care. The adaptation we propose emphasizes the transformative potential of family caregiving, moving beyond stress‐based models to acknowledge resilience and emotional adaptation. By connecting theory to real‐world application, this work offers strategies to enhance family engagement, emotional well‐being, and care quality in NHs.

Conclusions

Future empirical research will test this revised framework and examine how these factors impact caregiver stress, well‐being, and engagement. The findings will inform evidence‐based nursing interventions and policies that view family members as essential partners in dementia care. Ultimately, integrating ST and stress perspectives provides a more nuanced, person‐centered approach to supporting families in NH settings.

1. Introduction

The world is undergoing an unprecedented demographic shift; ageing populations are reshaping societies, economies and healthcare systems across nearly every country. By 2050, the number of people aged 65 and older is projected to rise from 10% to 16% of the global population, reaching approximately 1.6 billion individuals [1]. Although increased longevity is a remarkable public health achievement, it also presents new challenges, particularly the growing burden of dementia. Currently affecting 55 million people worldwide, dementia cases are expected to nearly triple by mid‐century, reaching 152.8 million [2, 3]. This demographic transformation underscores the urgent need for innovative policies, comprehensive care strategies and interdisciplinary research to ensure that ageing populations receive the support, dignity and quality of life they deserve.

Family members, including close friends and significant others, are the backbone of dementia care, providing much of both emotional and practical support [4]. In 2019, family caregivers spent over 89 billion hours assisting individuals living with dementia in activities of daily living [2]. There is extensive evidence demonstrating that family caregivers of individuals living with dementia experience significant physical and mental health burdens, leading to increased morbidity and mortality compared to non‐caregivers [5]. Although the nature of a family caregiver's responsibilities may shift when a loved one moves to a nursing home (NH), the emotional and logistical demands of caregiving often persist [6, 7].

When a loved one moves to a NH, the role of family caregivers shifts from hands‐on care to oversight, advocacy and decision‐making. Instead of providing direct physical assistance, family caregivers navigate institutional policies, coordinate with staff, monitor care quality and make critical medical and end‐of‐life decisions for their loved one [7]. Although they may no longer be primary care providers, families remain essential partners in ensuring their loved one's well‐being. Despite this shift, being a family caregiver in a NH setting remains stressful in new and complex ways. Families often struggle with uncertainty about their loved one's health trajectory, the quality of care and how to best fulfil their evolving role [8]. This is especially true in the advanced stages of dementia when individuals can no longer advocate for themselves, leaving family members with increased responsibility for surrogate decision‐making. Key sources of stress include poor communication with staff, feeling excluded from care decisions and the emotional toll of witnessing a loved one's decline [9].

Although caregiving in an NH can be stressful, some family members also find meaning in their continued involvement. Some experience positive aspects to caregiving, a sense of purpose in advocating for their loved one's care, strengthening family bonds or preserving their relative's dignity [10, 11]. Research suggests that family members of NH residents who find positive aspects to caregiving may experience better mental health, quality of life, satisfaction with life and self‐efficacy [12]. Recognising and supporting this positive aspect of caregiving may help families of NH residents navigate the challenges of long‐term care with greater well‐being.

The Stress Process Model is the most used framework for studying family caregivers of people living with dementia [13]. This theory posits that caregiving is inherently stressful due to primary stressors, such as the cognitive and functional decline of the care recipient, and secondary stressors, such as role strain, financial burden and social isolation, which can lead to negative outcomes, such as depression, anxiety and physical health decline. Although this model effectively captures the challenges caregivers face, it has a key limitation: it does not account for the ways in which some caregivers experience growth, resilience or a sense of meaning from their role [10]. By focusing primarily on stress and strain, the model overlooks the complex emotional landscape of caregiving, where both hardship and personal growth can coexist.

Through advocacy, maintaining bonds with their loved ones and finding purpose in their role, family members of NH residents living with dementia may transform their experience from one of distress to one of growth, resilience and personal meaning despite the challenges of caregiving [11]. Reed's Theory of Self‐Transcendence (ST) offers a framework to explore this phenomenon, providing insight into how individuals move beyond self‐interest to achieve a broader perspective of meaning and connection [14], and may guide nursing interventions to support self‐transcendence. This paper critically appraises Reed's Theory of ST using Parse's criteria [15] and adapts it to the unique experiences of family members caring for NH residents living with advanced dementia. By considering ST as a potential outcome of family caregiving, this adaptation seeks to reframe family involvement not only as a source of burden but also as an opportunity for personal and relational growth.

2. Methods

We conducted a critical appraisal of Reed's Theory of ST using Parse's criteria for evaluating nursing theories [15]. Parse's framework provides the criteria for assessing theory, focusing on two major areas: Structure and Process [15]. The Structure criteria guide the examination of a theory's historical evolution, philosophical and theoretical foundations, core concepts and underlying assumptions. They also outline how these concepts interact through relational statements to explain or predict phenomena. The Process criteria focus on correspondence, coherence and pragmatics. Correspondence evaluates whether the theory maintains consistency in terminology and conceptual clarity while aligning with its core principles. Coherence examines the logical flow of the theory, ensuring structural integrity and clear connections between concepts. Pragmatics assesses the theory's applicability to research and practice, determining whether it offers meaningful insights that can guide further inquiry and intervention development. Taken together, these criteria provide a comprehensive framework for evaluating the clarity, coherence and applicability of a theory, ensuring that it is both conceptually sound and practically useful in guiding research and practice.

This paper is organised into three sections. First, we present a critical appraisal of Reed's Theory of ST using Parse's framework. Next, we explore how Reed's concepts align with existing literature on family members of NH residents living with advanced dementia, assessing the theory's applicability to this population. Finally, based on insights from the appraisal and literature review, we propose an adaptation of Reed's theory, refining key constructs to better capture the experiences of family members in NHs and enhance its utility for future research and intervention development.

3. Critical Appraisal

3.1. Structure

3.1.1. Historical Evaluation

According to Parse, historical evaluation involves analysing how a theory was developed, the philosophical and theoretical foundations that influenced it, and any modifications it has undergone since its inception [15]. Pamela Reed developed the Theory of ST in the late 1980s and early 1990s, publishing her foundational work in 1991 [14, 16]. Her theory focuses on how individuals, particularly those facing ageing, illness or life challenges, move beyond themselves (transcend) to find meaning, well‐being and a broader sense of connectedness. Reed was significantly influenced by Martha Rogers' conceptual model [17], which viewed human beings as open systems constantly interacting with their environment. Reed's emphasis on ST as an evolving, boundary‐expanding process aligns with Rogers' holistic perspective on health and well‐being. Reed was also influenced by developmental and existential theories, particularly Abraham Maslow's and Viktor Frankl's work. Maslow's concept of self‐actualisation refers to the process of reaching one's fullest potential by pursuing personal growth, creativity and fulfilment. It is the highest level in his Hierarchy of Needs, where individuals strive for meaning, purpose and the realisation of their unique talents and abilities [18, 19].

Frankl's existential perspective, rooted in logotherapy, highlights the human drive to find meaning even in suffering [20, 21]. Both theorists contributed to Reed's view that individuals, especially those facing illness or ageing, can achieve growth, meaning and well‐being through ST despite adversity [14, 16, 22].

Since its publication, Reed's Theory of ST has been widely applied in nursing research across various contexts, demonstrating its adaptability and practical significance. In general nursing practice, studies have explored how ST fosters resilience, enhances coping strategies and improves quality of life among patients facing chronic illness [14, 16, 22]. Within oncology nursing, research has shown that ST plays a crucial role in adjusting to life‐threatening illness, reducing psychological distress and improving spiritual well‐being [23, 24]. The theory has also been extended to nursing education and workforce engagement, where it has been used to examine how ST influences job satisfaction, professional identity development and nurses' ability to find meaning in their work [25, 26, 27]. Furthermore, researchers have tested its applicability across cultures, leading to cross‐cultural psychometric validation of the ST Scale, confirming its relevance in diverse populations [28, 29, 30]. The widespread application of Reed's theory underscores its value in promoting psychological and emotional well‐being, guiding professional development and informing culturally responsive, patient‐centred care in nursing practice.

Recently, the theory has faced criticism, particularly for its lack of clear guidance on how nurses can effectively apply it in clinical practice [22]. Although it is widely recognised for its role in promoting well‐being, researchers have emphasised the need for further study to translate its concepts into actionable nursing interventions. Additionally, some scholars have questioned whether the concept of ST is universally applicable, particularly in cultures that prioritise the collective mind‐sets over the individuality [22, 31]. Nonetheless, the core assumptions and structure of Reed's theory have remained unchanged, continuing to serve as a valuable framework for understanding how individuals find meaning and resilience in the face of adversity.

3.1.2. Foundational Elements

Parse defines foundational elements as the explicit articulation of a theory's philosophical assumptions, the clarity and precision of its key concepts, and the way it conceptualises the human‐universe‐health process [15]. Reed's Theory of ST effectively meets these criteria by clearly outlining its underlying assumptions and core theoretical components.

The foundation of Reed's theory is built on two key assumptions [16]. First, humans exist as open systems, inherently connected to their environment. This suggests that well‐being is not achieved in isolation but through engagement with others, nature and dimensions beyond the physical realm [16]. Second, ST is an innate human process that fosters well‐being in the face of adversity by broadening one's perspective, seeking meaningful connections, revising personal beliefs and embracing existential meaning beyond the self.

The theory centres on three primary concepts: ST, vulnerability and well‐being (Figure 1). ST is the core construct, defined as an individual's capacity to expand self‐boundaries through new perspectives, re‐examining beliefs, reaching out to others and connecting with something greater than oneself [14]. This expansion occurs across multiple dimensions: inwardly through self‐reflection, outwardly in relationships with others, temporally by integrating past and future experiences into the present, and transpersonally by engaging with realms beyond the physical world [14].

FIGURE 1.

Reed's theory (copyright 2012 by Pamela G. Reed).

The second concept, vulnerability, refers to an increased awareness of personal mortality, often triggered by life‐altering events, such as illness, disability, ageing, bereavement or end‐of‐life experiences. Reed suggests that vulnerability can act as a catalyst for self‐transcendence, serving as a resource for well‐being by transforming loss into a process of growth and healing [14].

Finally, well‐being is defined as a subjective sense of health or wholeness shaped by an individual's personal judgement and influenced by cultural values, relationships and biophysical factors. Rather than relying on objective health indicators, Reed emphasises that well‐being is determined by the individual's own criteria and lived experiences.

Reed's Theory of ST shares similarities with Maslow's idea of self‐actualisation, as both focus on personal growth and meaning making. Maslow viewed self‐actualisation as the highest level of human motivation, in which individuals strive to reach their full potential and achieve a deep sense of fulfilment [19]. Similarly, ST involves personal reflection and meaning. However, Reed expanded self‐actualisation to include a sense of connection beyond oneself, to others, to nature and to a larger existential purpose [16]. Although this broader perspective distinguishes ST self‐actualisation, the overlap raises questions about whether ST is truly a unique concept or simply an extension of existing psychological theories. Although Reed emphasised the importance of connection and transcendence, her theory does not fully account for external influences, such as culture, social structures or health disparities, that may affect a person's ability to achieve self‐transcendence. Refining the theory to better define its trajectory and clarify how it differs from existing self‐actualisation would strengthen its application.

3.1.3. Relational Statements

Parse emphasises that relational statements should demonstrate how a theory's philosophical assumptions are embedded within its principles and how these principles uniquely integrate the theory's core concepts [15]. This evaluation considers how Reed's theory reflects its foundational assumptions within its guiding principles and examines the distinct ways in which self‐transcendence, vulnerability and well‐being interconnect within the framework.

Reed's philosophical assumptions are clearly articulated within the theory's relational statements, and their relevance becomes evident when we consider examples involving family members of NH residents living with advanced dementia [32, 33]. Reed's propositions further clarify the interrelationships between ST, vulnerability and well‐being. The first proposition asserts that vulnerability intensifies during end‐of‐life challenges, compared to individuals not facing such circumstances. Although this insight offers valuable understanding of emotional complexities, caution is needed to avoid overgeneralisation, given the diversity of individual responses. The second proposition suggests a positive correlation between ST and well‐being, showcasing a potential pathway for personal growth and fulfilment. However, it is essential to recognise that this relationship's dynamics can vary significantly based on individual and contextual factors not fully addressed by the theory. Finally, the third proposition posits that ST serves as a mediator between vulnerability and well‐being, particularly in the presence of vulnerability. Although this offers a theoretical framework for resilience, the complexity of these interactions may require further exploration to avoid oversimplification. Overall, although Reed's propositions provide valuable insights, their limitations in capturing the nuanced and multifaceted nature of human experiences suggest the need for ongoing refinement and contextualisation in practical applications.

3.2. Process Criteria

3.2.1. Correspondence and Coherence

Correspondence and coherence assess how well a theory maintains clarity, consistency and logical structure [15]. Parse suggests that a strong theory uses clear and precise language, ensuring that key terms are consistently defined and used throughout its assumptions, concepts and principles. It should present ideas in a logical and organised manner so that terms retain the same meaning across different parts of the framework. Additionally, the theory's principles should connect its core concepts at the same level of complexity, allowing it to effectively describe, explain or predict human experiences. Finally, a well‐developed theory aligns with a specific perspective or worldview, reinforcing its internal consistency and overall coherence [15].

The Theory of ST exemplifies these qualities, maintaining a clear and cohesive theoretical framework with well‐defined concepts and relationships that remain consistent across Reed's various formulations. The theory's logical flow is evident, as its key concepts—self‐transcendence, vulnerability and well‐being are directly linked to its philosophical foundations in humanistic and existential perspectives. Even complex ideas, such as expansion across multiple dimensions (inward, outward, temporal and transpersonal), are clearly articulated, making them accessible and applicable in both research and practice [16]. The internal consistency of the theory is reinforced by the seamless integration of its assumptions, concepts and principles, ensuring a uniform level of discourse throughout [16].

3.2.2. Pragmatics: Effectiveness and Heuristics Potential

According to Parse, pragmatics considers a theory's effectiveness in guiding research and practice, as well as its heuristic potential for further inquiry. The theory has shaped research, influenced practice and led to publications that advance nursing knowledge. Findings from these studies have generated new insights and inspired further research and practice initiatives. Reed's theory has been widely applied to guide research across diverse populations throughout the lifespan [14, 16, 34], including the oldest‐old, middle‐aged adults [24, 35, 36] and even young adults [37]. It has also been used to guide research on a wide variety of health conditions, including mental illness, suicide, AIDS and cancer, but also in the samples of healthy population [24, 35, 38, 39]. In addition, it has included research in varied contexts, such as homelessness and nursing staff burn out [40, 41]. The theory has also been used to guide practice—for example, in care programmes aimed at intervening and empowering women facing breast cancer—rooted in the principles of ST and other similar interventions [24, 42].

In our exploration of literature focusing on the examination of the ST theory for family members of NH residents living with dementia, we discovered significant insights. Notably, Vitale et al.'s study, ‘ST in Alzheimer's Disease: The Application of Theory to Practice’ (2014) [43], highlighted that despite the challenges, elements of ST can manifest in individuals experiencing cognitive decline, potentially aiding them in achieving self‐fulfilment and optimal comfort. Furthermore, the study concluded that caregivers, including nurses and family members, can elevate their levels of ST through the same principles when caring for individuals living with dementia even in long‐term care facilities, such as NHs. Additionally, Kidd's doctoral dissertation emphasised the positive effects of a poetry writing intervention on ST, resilience, depressive symptoms and subjective burden in family members of older adults living with dementia. The family, fraught with challenges, may serve as a catalyst for individuals' movement towards ST [44]. Although social isolation, ambivalence, burden of care and emotional fragility might impede the development of ST, opportunities for caregiving can foster personal growth and meaning among family members of NH residents living with dementia.

4. Theory Adaptation

Although Reed's Theory of ST provides a strong conceptual foundation for understanding the experiences of family caregivers of NH residents living with advanced dementia, it does not fully encompass all the key ecological and relational factors that shape their caregiving experience. Integrating these ecological considerations into ST theory allows for a more comprehensive understanding of how external systems shape the ST process, ultimately informing strategies to enhance family well‐being and engagement in NH settings. To address these gaps, we systematically adapted Reed's theory based on empirical research and contextual factors specific to caregiving in long‐term care (see Figure 2). In the following sections, we expand on the application of Reed's theory, outlining the specific modifications made, justifying these adaptations and proposing a methodology for empirically validating our revised model. This adaptation aligns with established methodologies for integrating theories into nursing research and practice [45].

FIGURE 2.

Adaptation of Reed's theory.

4.1. Expanding Vulnerability to Capture Family Members' Unique Experiences

Reed's Theory of ST defines vulnerability as a heightened awareness of mortality, which becomes particularly salient during major life events, such as illness or ageing. This concept is highly relevant to family members of NH residents living with advanced dementia, who not only anticipate the loss of their loved ones but also experience chronic emotional distress as they witness their loved ones' decline. Studies have consistently documented the psychological and physical toll on family caregivers, highlighting high levels of stress, depression and helplessness, all of which align with Reed's concept of vulnerability [46, 47, 48].

However, our adaptation of Reed's theory expands vulnerability to account for additional stressors unique to family members in NH settings, including decision‐making burdens related to life‐sustaining treatments and end‐of‐life care, which force caregivers to confront not only their loved one's mortality but also their own [32]. As Lopez [33] emphasised, these decision‐making responsibilities further intensify vulnerability, requiring caregivers to navigate complex ethical and emotional challenges. Additionally, vulnerability is influenced by the duration of the caregiving experience; the longer family members remain engaged in caregiving and the more advanced their loved one's dementia becomes, the greater their vulnerability [49]. By adapting Reed's concept of vulnerability, we deepen our understanding of how these factors shape family members' experiences and highlight the need for targeted interventions to support their well‐being.

4.2. Broadening the Concept of Self‐Transcendence

ST is a core tenet of Reed's theory and plays a critical role in supporting family members of NH residents living with advanced dementia. ST can be a powerful coping mechanism for caregivers navigating the challenges of dementia care. Family caregivers describe finding meaning, connection and purpose in their caregiving role, which appears to contribute to greater resilience and emotional well‐being [11].

Reed acknowledges that ST is shaped by contextual factors. In our adaptation, we expand these influences to include family members' trust in NH staff and their perception of caregiving burden. Trust in healthcare providers is a well‐documented factor that can reduce stress and improve the caregiving experience [50, 51]. However, even after transitioning a loved one to a NH, family members often continue to experience burden, which remains intertwined with their perceived caregiving journey, a dynamic process shaped by their interactions with healthcare providers, evolving health conditions and emotional responses to illness and ageing [52, 53, 54].

Additionally, our adaptation integrates ecological factors, moving beyond an individualistic view of ST to incorporate the relational and systemic dynamics of caregiving in NHs. Specifically, we emphasise: (1) ensuring quality basic care to promote residents' physical well‐being; (2) recognising and valuing personhood to foster dignity and respect for both residents and their family members; (3) promoting open communication between family members and healthcare providers to enhance trust and shared understanding; (4) facilitating shared care planning to actively involve family members in decision‐making.

These adaptations align with existing research demonstrating that basic care quality significantly impacts resident satisfaction and family trust [11, 51, 52]. Additionally, recognising personhood has been linked to greater emotional well‐being for both residents and caregivers [6, 55, 56, 57], while open communication and family involvement in care planning have been shown to reduce stress and improve overall satisfaction with NH care [8, 58, 59, 60, 61]. By addressing these key contextual and relational factors, our model provides a more holistic framework for understanding and supporting family members of NH residents living with advanced dementia.

4.3. Comparing Reed's Theory With the Stress Process Model

Reed's ST Theory expands the caregiving discourse by shifting the focus from stress and burden to the transformational potential of caregiving. At the same time, the Stress Process Model [13] complements the ST Theory by offering a structured approach to identifying stressors, measuring caregiver burden and assessing the impact of external support systems. Together, these frameworks provide a balanced perspective, acknowledging both the challenges of caregiving and the potential for resilience and growth. Their integration can guide nursing practice by shaping interventions that not only reduce caregiver burden but also enhance meaning making and emotional well‐being. For example, while Stress Process Model‐informed interventions may focus on care coordination, respite care and stress reduction strategies [13], ST‐informed interventions could incorporate guided reflection, peer support groups and strategies to help caregivers find purpose in their role. By leveraging both approaches, nursing practice can move beyond simply mitigating distress to fostering long‐term psychological well‐being and empowerment among caregivers in NH settings. As the demand for long‐term dementia care continues to rise, nursing interventions must move beyond burden reduction to fostering caregiver well‐being, empowerment and relational connection. A deeper understanding of how stress and ST intersect can inform the development of evidence‐based caregiving models that better support caregivers in navigating the complexities of NH‐based dementia care.

4.4. Postscript: Towards Empirical Validation

Our ongoing work is examining how ecological factors, trust and caregiver burden shape ST and well‐being in this population. Using a multi‐method approach, we aim to capture the nuanced interplay between stress and meaning making, offering a clearer roadmap for tailoring interventions to enhance both psychological resilience and caregiver quality of life. Future findings will provide empirical support for refining nursing interventions that extend beyond burden reduction to promote caregiver empowerment and meaning making in long‐term care. As the landscape of dementia caregiving evolves, our research will continue to explore how theory‐driven, holistic approaches can better support family members navigating the complexities of advanced dementia care.

5. Conclusion

In this paper, we critically evaluated Reed's Theory of ST using Parse's criteria for evaluating theories and found that it meets all the hallmarks of a strong, well‐developed theory. It provides a clear conceptual foundation, aligns with existing research and offers a meaningful framework for understanding the caregiving experience. By incorporating trust in NH staff, caregiver burden and key contextual factors, such as satisfaction with care, recognition of personhood, communication quality and participatory decision‐making, we have expanded its applicability to family members of NH residents living with advanced dementia. These adaptations strengthen its relevance to this population while staying true to its original focus on growth, meaning making and resilience. Moving forward, we will empirically test these adaptations through a cross‐sectional study, assessing how these factors influence caregiver well‐being and engagement. These findings will not only refine the theoretical framework but also provide practical guidance for supporting family members in NH settings. As the landscape of long‐term care continues to shift, ensuring that family members are recognised as essential partners in care will be critical to creating a more compassionate, family‐centred approach to NH care.

Author Contributions

All authors contributed to the conceptual development and theoretical analysis presented in this manuscript. The initial draft was written by D.Z.‐G., and all authors were involved in revising, editing, and refining the manuscript. All authors reviewed and approved the final version.

Ethics Statement

This paper is theoretical in nature and does not involve human participants or the use of personal data. Therefore, ethics approval was not required.

Conflicts of Interest

The authors declare no conflicts of interest.

Zaguri‐Greener D., Zisberg A., and Lopez R. P., “Applying Reed's Self‐Transcendence Theory to Support Family Members of Nursing Home Residents Living With Dementia: A Critical Appraisal and Adaptation,” Scandinavian Journal of Caring Sciences 39, no. 3 (2025): e70054, 10.1111/scs.70054.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.