Gerontological nursing is an evolving field which largely emphasizes on the promotion of highest possible level of quality of life and wellness among the aging population. What one considers as important in the care of older people largely depends on one's theoretical perspective. Various theories have emerged over time within the field of gerontology that guides our academia, practice, research, and the way forward. However, there is still a desire to know why or how these aging phenomena and their consequences occur or varies across various cultures and population. Nurses working in geriatric settings need to be aware of various aging theories, its role, and implications towards the health of aging population. The awareness about various aging theories and its theoretical perspectives will promote a better understanding among nurses about the attitudes and behaviors of older adults in different contexts. It will assist nurses to design effective care interventions to improve satisfaction and quality of life of older adults in the hospital or community settings.

'Successful aging is often understood in terms of physical, economic, or social activities, and endeavors of a person. However, such perspectives have been challenged in the current literature and research evidences. There has been great emphasis in the current gerontological literature to look beyond physical, psychological, or social dimensions of aging and embrace spiritual and philosophical dimensions of aging. A successful aging person can find his role in the society not only by the virtue of his/her physical activity or successful career rather seeking answers to spirituality can engender the virtue of wisdom in the face of decline (Wong, Low, & Yap, 2016). Spirituality embraces the whole person and is relevant to all, even the chronically ill or disabled. Spiritual or existential aspects of successful aging have been highly touched upon in the gerotranscendence theory given by Lars Tornstam in 1989 (Tornstam, 1989). The following paper aims to provide a critical review on theory of gerotranscendence, and how it relates to positive aging, work, retirement, and volunteerism, and end of life care among older adults in the light of current literature evidence. Nurses need to have an in-depth understanding of the theoretical concepts and its meanings underlying the gerotranscendence the theory of successful aging. This will assist nurses to formulate effective interventions as well as to provide enhanced quality care for the older adults and their families in their practice settings.

Gerotranscendence, a theoretical perspective towards positive aging was given by Lars Tornstam, a Swedish sociology professor in 1989. Tornstam based his theory on his own researches, observations, and theoretical work of others. His theory referred to works of Jung, Erikson, Gutman, Peck, Chinen, Chapman, Grotjahn, Holliday, & Chandler, Kramer, and Woodruff, Rosenmayr, and Storr and his own empirical studies (Wadensten, 2007). As per Tornstam (1997), human aging, i.e. living into old age is characterized by a general process towards gerotranscendence. According to the theor y, gerotranscendence is a natural progression towards maturation and wisdom, in search of a new meaning or purpose in life, as the individual grows older. It is described as “a shift in meta-perspective from a materialistic and rational view of the world to a more cosmic and transcendent one, normally followed by an increase in life satisfaction” (Tornstam, 1997, p. 143). The first attempt to empirically illuminate the theory was based on the qualitative interviews with 50 Swedish people between the ages of 52-97 years of age, followed by quantitative analyses of responses of 912 representative Danish men and women between the ages of 74 and 100 years. The findings revealed that gerotranscendence is a process where older adults experience a redefinition of self and their relationships with others and create a new understanding of fundamental existential issues. The process involves change and development at three levels; the cosmic level, the level of self, and the level of social and personal relations (Tornstam, 2000). The older individual becomes less self-occupied and more selective in his/her choice of social and other activities and tends to spend more time in meditation and spiritual activities, thus turning towards a more contemplative way of life (Tornstam, 1997). The individual older adult gradually progresses towards gerotranscendence however, the process can be obstructed or accelerated by life crises or severe illness, cultural expectations, or the caregiving patterns. The definition of reality develops and changes as per one's life experiences and level of maturation (Tornstam, 2000). Subsequently, one might find different degrees of gerotranscendence among older adults (Wadensten, 2007). It is significant to note that during this period of progression towards gerotranscendence, the older adults may isolate himself/herself from various activities and go into the periods of self-reflection or meditation. According to Tornstam(2000), such manifestations among older adults might be misinterpreted by nurses or other closed family members and relatives as signs of depression, dementia, isolation, or negative disengagement. During this period, if the older adults are forced to get involved in social activities or labelled as depressed or lonely, they may feel guilty or even apologetic about their gerotranscendental change. Besides, social activities imposed upon the elderly during this time can impede the development of gerotranscendence.

Gerotranscendence has been conceptualized as a potential development accompanying normal aging. The theoretical perspective assists in understanding positive progressive changes in values, attitudes, and behaviors in the later life of the older adults. It can be viewed as part of a search for spiritual, religious, and mystical dimensions of aging (Atchley, 1997). Gamliel (2001) supports that the theory of gerotranscendence offers a new paradigm both for the developmental shift into old age and for the situational shift in the daily life of older people. The theory provides opportunities to identify ways in which older adults can develop beyond our expectations and offers a new understanding for nurses while looking after the needs of old people in the practice settings (Runquist & Reed, 2007). Nurses can identify and respond to the needs of the older people who may be transcenders rather than depressed and do not want to join in several routinely designed activities (Tornstam, 1996). The theory calls for healthcare providers including nurses to generate new ideas and innovative strategies to engage older adults. Based on theory, there are also established scales of measuring the level of gerotranscendence among older adults, and are tested contextually in Sweden, Netherlands, and Japan ( Wadensten, 2007; Hashino, Zarit, & Nakayama, 2012). It is note worthy that the theoretical model of gerotranscendence has also been tested in Taiwan, China, and other Asian populations besides western hemisphere (Liang & Baozhen, 2012). Literature is evident that the concepts involved in gerotranscendence theory reflects most of the eastern philosophies and therefore, applicable in the eastern contexts as well. Some authors believe that the concepts employed in gerotranscendence theory, such as cosmic communion, spirit of the universe, mysticism, and meditation are complex, and carry abstract meanings which are difficult to prove from a scientific and logical perspective. Moreover, it is also perceived that the theory of gerotranscendence focuses on the micro level of individual actors and their behaviors and therefore, does not explicitly address the socio-cultural factors at macro level affecting aging and its influence on gerotranscendence process. Some of these viewpoints are critical and raise additional challenges for the application of these concepts in the actual practice setting. A major shift is therefore required in the attitudes, beliefs, and perceptions of healthcare providers among themselves and at a broader health research and policy level. Overall, in comparison to other aging theories, gerotranscendence theory provides a unique perspective of successful aging among older adults both from a western and an eastern context. The theory has a close relevance towards positive aging, work, retirement, and volunteerism and end of life among older adults.

As per the gerotranscendence theory, 'positive aging' implies a new definition of reality, searching for the value, meaning and purpose in life, expanding self-boundaries, and life-perspectives (Tornstam, 1997). Meaning in life allows older individuals to make sense of their existence, assist them to cope with inevitable changes of later life with a spirit of acceptance and serenity while promoting a positive outlook towards ones' own lives and the lives of others ( Bickerstaff, Grasser & McCabe, 2003 Wadensten & Carlsson, 2003; Adams, 2004). Often stressors or traumatic events faced during one's lifetime leads to personal growth. Older adults use their wisdom to open the doors of self-disclosure and self-reflection which yields attitudes of greater self-acceptance, growth, satisfaction, and positive well-being (Weiss, 2014). Such values of selftranscendence contribute to health, harmony and healing in older adults and facilitates positive aging ( McCarthy, 2005; Wang, 2011). Multiple studies have demonstrated that older adults who have found a sense of meaning in life tend to enjoy better physical health, experience fewer symptoms of depression, are more happier and report higher level of satisfaction with their lives ( Krause, 2004; Parquart, 2002). Expanding self-boundaries assist elders transcend their physical limitations, losses, grief, and other concerns to experience a continued sense of well-being which in-turn provides hope and enhance quality of life despite limitations ( Bickerstaff, Grasser & McCabe, 2003; Lomas, Ivtzan, & Yong, 2016).

Literature recommends a various activities to promote transcendence and positive aging among the older adults in the home, institutional, and community settings. These include: reminiscence therapy ( Gallagher & Carey, 2012; Gunther, 2008; Wadensten & Hagglund, 2006), selfreflections (Wadensten, 2007), mindfulness, (Lomas, Ivtzan, & Yong, 2016), narrative therapy and expressive arts, (Caldwell, 2005), and poetry (Shawler, Skinner, & Bush, 2010). The authors suggest that the expressions of art enabled older individuals to convey their deep personal values, wisdom, and insights around life. Additionally, these activities assist older individuals to extract the meanings from their previous experiences in life, ensure connectedness, promote wellbeing, increased sense of self-worth, self-satisfaction, and ego integrity.

Gerotranscendence supports the view that the older adults in their later life reorient their priorities, refocus their energies, and live day by day with less concern for their future (Tornstam, 1997). Older adults regard retirement as a positive thing and tend to reduce their social contacts and activities. They often become more introspective without the feeling that their quality of life has been impaired (Tornstam, 1997). Multiple research studies have shown that in a low-income retirement community, adaptation, and transcendence were the strong predictors of successful aging among older adults. Despite challenges, the pursuit of transcendence seems to strengthen the resiliency in retirement and leads to a relative appreciation of happiness. Older adults were seen to cope with less resources and poverty through building a rich spiritual life and empowering relationship with God ( Liang, 2011; McCarthy, 2005). The theory of gerotranscendence focuses on micro level of individual actors and their behaviors towards retirement process rather than outlining, how the macro level of social structures and sociodemographic factors influence on the retirement process. A more distinctive and centrally focused approach will allow older individuals in successful transition during retirement phase and help them in overcoming the associated challenges.

Literature supports that the sense of altruism and community service increases in the later stages of life. Older adults in their late retirement ages prefer to get more involved in altruistic activities that are personally meaningful and may facilitate an increased sense of selfworth and purpose that is associated with healing ( Tornstam, 1997; Degges-White, 2005). Multiple studies have shown that older adults were found to be more willing to participate in research studies which may be of benefit to others with a similar disease or disability and were found ready to assist other people to make sense out of their personal adversities. In addition, older adults identified these altruistic activities as helping them transcend their own worries and problems of aging, provided them selfsatisfaction and created a context for learning new things about oneself and one's world ( Kahana et al., 2013; Gondo, Nakagawa, & Masui, 2013). Purposeful volunteering was linked to increased happiness, motivation, and well-being among retired older adults (Dulin et al., 2012). These activities offered valuable meanings in older individuals' lives, enhanced their selfesteem, and self-satisfaction.

Gerotranscendence theory can be used with the healing experiences of older adults facing end-of-life issues related to aging or life-threatening illnesses. According to the theory, older adults in their late stages of life go through a spiritual transformation, prefer to spend more time in meditation, have less fear of death, and therefore, are better able to cope with the grief and losses in the later life (Tornstam, 2005). Transcendence is a mechanism by which end-of-life experiences are transformed into healing and are considered as a vital resource of well-being at the end of life (Haugan et al., 2012). Self-transcendence results in an intensified awareness of wholeness and integration among all dimensions of one's being and may lead to personal growth or spiritual transformation (Harris, 2008). According to Patton (2006), as an individual approach death, there is an increased sense of a new self, and of being alive to the present, a desire for reconciliation, and an enhanced sense of meaning, and connectedness towards, self, others, and the transcendent, i.e. a higher supreme being. An individual who is successful in achieving these needs has more self-acceptance of death, increased sense of self integrity and meaning (Patton, 2006). Personal views about the end of life are shaped by both reminiscence and life disposition (Tornstam, 1999). The process of reviewing or extracting meaning out of previous life successes and struggles may lead to appreciate and comprehend one's present life. Furthermore, it assists older adults to prepare themselves for death as well as raises their ability and willingness to accept their suffering and issues surrounding end of life (Harris, 2008; Weiss, 2014). The spiritual experiences, such as prayer, forgiveness, belief in a power greater than oneself and belief in a form of life after death tend to promote subjective well-being, healing, and transcendence in later life of older adults (Runquist & Reed, 2007). Further researches are recommended to re-examine these outcomes of care among older adults within varied contexts in relation to gerotranscendence theory and its role in end of life.

This paper implies the valuable role and application of gerotranscendence theory among older adults within various aspects of their lives, such as positive aging, retirement, and end of life. The contributions of gerotranscendence theory in these several aspects of aging entails several implications for nurses and nursing profession. Nurses caring for the older adults need to be knowledgeable about the theory and its various perspectives to be able to assess and recognize gerotrascendental needs and values of the elderly population in their settings. Nurses should try to formulate specific interventions that attend to these values and promote the quality of life and care satisfaction levels of the older adults in the practice settings. Literature highly recommends that elderly nursing homes should include activities like reminiscence therapy, mindfulness, art, music, and story-telling to satisfy the gerotranscendental needs of the older adults as well as to promote peace and comfort among the older individuals. Nurses should create spaces where older adults can perform self-reflection and selfdisclosure about themselves and their life events. Older adults should be engaged in several voluntary activities to promote their self-integrity and self-esteem.

Nurses play an essential role in preparing patients and their families for advance care planning and end of life care. Researches have shown that the principles of the gerotranscendence theory can also be used while preparing the patients and families for the advance care planning. Older adults often perceive end of life with broader psychosocial and spiritual meanings. These meanings are mostly shaped by their life long events and personal experiences. Preparing patients and their families for advance care planning can direct them to different level of appreciation of self and transcendence (Jeong, Higgins & McMillan, 2011) . During end of life, older adults and their families often go through various existential concerns and spiritual transformation where their search for meaning becomes evident. Supporting an individuals' spirituality is an essential component of care during the end of life. Research is evident that using gerotranscendence interventions, nurses can foster mental and spiritual wellbeing (Wang, Lin, & Hsieh, 2011), increased hopefulness and care of self among chronically ill elders (Andersson, Hallberg, & Edberg, 2008), sense of well-being among elders with terminal stages of cancer (Thompson & Chochinov, 2010). In palliative and hospice care settings, nurses can use gerotranscendence interventions to offer peaceful and comfortable dying among older adults and support their families.

The theory of gerotranscendence provides a unique perspective to successful aging and guides us to take different approaches of caring for the older individuals in the society. Unlike other aging theories, it sheds light on spiritual, existential, and philosophical dimensions of aging. The theory recognizes various transcendental needs of older adults in the later stages of their life, during changing or loss of roles and end of life. Meeting such needs promotes successful aging and satisfaction among older adults and their families. Nurses play an essential role in supporting and facilitating the process of gerotranscendence among the older adults and their families in the society.