690731

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WJNXXX10.1177/0193945917690731Western Journal of Nursing ResearchMcCarthy et al.

Article
Western Journal of Nursing Research
1­–20
Facilitating Self- © The Author(s) 2017
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DOI: 10.1177/0193945917690731
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Intervention to Enhance journals.sagepub.com/home/wjn

Well-Being in Late Life

Valerie Lander McCarthy1, Lynne A. Hall1,

Timothy N. Crawford1, and Jennifer Connelly1

Abstract
This randomized controlled pilot study evaluated the effects of the
Psychoeducational Approach to Transcendence and Health (PATH) Program,
an 8-week intervention hypothesized to increase self-transcendence and
improve well-being in community-dwelling women aged 60 years and older (N
= 20). The PATH combined mindfulness exercises, group processes, creative
activities, and at-home practice using community engaged research methods.
Findings provided some support for the effectiveness of PATH. Although
there was no significant Group × Time interaction, self-transcendence,
psychological well-being, and life satisfaction differed significantly pre- and
postintervention in the wait-listed control group, which received a revised
version of the program. Further study is needed with a larger sample to
determine the effectiveness of PATH. Potentially, PATH may be a convenient
and affordable activity to support personal development and improve well-
being among older adults at senior centers, retirement communities, nursing
homes, church groups, and other places where older adults gather.

Keywords
self-transcendence, well-being, life span development, intervention

1University of Louisville, Louisville, KY, USA

Corresponding Author:
Valerie Lander McCarthy, University of Louisville School of Nursing, Louisville, KY 40292,
USA.
Email: vemcca01@louisville.edu
2 Western Journal of Nursing Research 

Why do some older adults reach a state of being in late life that reflects a
palpable sense of fulfillment and meaning in life, regardless of frailty, depen-
dence, pain, or poverty? Why do others, often with better health and greater
economic and social advantages, end life in misery, fear, and despair? Self-
transcendence, a concept based on life span development theory, may help to
account for this difference. Self-transcendence is an inherent late life devel-
opmental tendency toward a broadened worldview, beyond everyday realities
and limitations, involving transformation of one’s perspective on self, rela-
tionships with others, life in this world, and a sense of connection with a
spiritual dimension (McCarthy & Bockweg, 2013; Reed, 2014). Although
self-transcendence has consistently been associated with positive outcomes,
limited research has investigated methods to promote optimal development
of self-transcendence in community-dwelling older adults. Furthermore, no
study has used a theory-based approach combining multiple modalities to
develop a comprehensive psychoeducational intervention to increase self-
transcendence and related outcomes.
The purpose of this randomized controlled pilot study was to evaluate the
effects of the Psychoeducational Approach to Transcendence and Health
(PATH) Program on self-transcendence and well-being in community-dwelling
older adults. It was hypothesized that the PATH Program would increase self-
transcendence and improve indicators of well-being such as psychological
well-being, life satisfaction, acceptance of life situation, proactive coping,
depression, and health-related quality of life. Given the increasing number of
people living to be 80, 90, and even 100 years old, it is important to build on
inherent developmental tendencies toward self-transcendence to increase
well-being in late life.

Theoretical and Empirical Foundation for the

PATH Program
Transcendence Theory
Self-transcendence has been defined as, “a developmental process resulting
in a shift in perspective from a rational, materialistic view to a wider world-
view, characterized by broadened personal boundaries within interpersonal,
intrapersonal, transpersonal, and temporal dimensions” (McCarthy &
Bockweg, 2013, p. 5; Reed, 2014). Self-transcendence allows for a broader
worldview with a more positive outlook and the ability to cope with sad-
ness and ambiguity. Older adults with a high level of self-transcendence
may find greater pleasure in small things, experience fewer everyday mate-
rialistic concerns, and exhibit increased emotional stability and a mindful,
McCarthy et al. 3

compassionate view of self, others, and the world (McCarthy & Bockweg,
2013; Reed, 2014).
Reed’s midrange nursing theory, the theory of self-transcendence (Reed,
2014), describes self-transcendence as an inherent developmental process
involving expansion of intrapersonal, interpersonal, transpersonal, and tem-
poral boundaries. The intrapersonal dimension, according to Reed, involves
a greater awareness of, and comfort with, one’s self, whereas interactions
with others and with the physical world involve interpersonal boundaries.
Transpersonal boundaries relate to a sense of connection with a dimension
beyond the here and now whereas temporal boundaries refer to a blurring of
past, present, and future which allows one to integrate past and future to make
sense of the present, looking back over one’s life, reinterpreting events and
experiences through a new lens. Reed’s theory described a process initiated
by awareness of vulnerability that resulted in increased well-being.
The theory of self-transcendence (Reed, 2014) differs from other develop-
mental theories in two respects. First, Reed argued that although develop-
ment of self-transcendence is an inherent late life potential, Reed holds it
can also occur at any age when a life-threatening illness creates a sense of
vulnerability. Second, Reed’s theory emphasized that self-transcendence
involves more than “rising above and beyond” this world; Reed’s view of
self-transcendence also focused on connecting individuals to themselves,
others, and the environment in the here and now. According to Reed, self-
transcendence connects rather than “separates a person from self, others and
the environment” (p. 121). Reed suggested ways to foster self-transcendence
such as promoting altruism, generativity, introspection, spirituality, group
therapy, creativity, journaling, and sharing wisdom with others. These sug-
gestions served as a starting point for development of the PATH Program. For
these reasons, Reed’s theory of self-transcendence was selected as the foun-
dation for this study.
Self-transcendence is a developmental potential, and much like other
developmental processes, some individuals will be more successful than oth-
ers in achieving self-transcendence, depending on various life experiences
and availability of resources that may support or interfere with cognitive,
emotional, and spiritual development (Newman & Newman, 2014). There is
evidence that self-transcendence may be fostered by providing opportunities
and resources such as those in the PATH Program.

Empirical Studies of Self-Transcendence

Research has consistently demonstrated associations between self-transcen-
dence with well-being and quality of life (Haugan, 2014; Runquist & Reed,
4 Western Journal of Nursing Research 

2007; Walsh et al., 2011); life satisfaction (Haugan, 2014); depression and
acceptance (Ellermann & Reed, 2001); optimism, coping, and social support
(Matthews & Cook, 2009); successful aging (McCarthy, Ling, & Carini,
2013); mental and physical health (Nygren et al., 2005); and self-care
(Upchurch & Mueller, 2005). Limited interventional research which might
suggest content for the PATH Program was identified. Interventions using
psychotherapy, art, poetry writing, and reminiscing supported the idea that
levels of self-transcendence can be increased and that self-transcendence
positively affects indicators of well-being (Coward & Kahn, 2005; Kidd,
2010; Stinson & Kirk, 2006; Walsh et al., 2011).
In a qualitative study, Coward and Kahn (2005) investigated the effects
of a support group for women with breast cancer. Bonding among women
in the group led to increased self-transcendence, emotional comfort, shift-
ing of priorities, and appreciation of supportive others and of life itself.
Coward and Kahn concluded that these effects helped women to create
meaning from their experiences. Kidd (2010) conducted a longitudinal
mixed methods pilot study that tested an intervention using poetry writing
to increase self-transcendence and resilience, and to decrease depression
and burden in family caregivers of elders with dementia. Findings sug-
gested that poetry writing was a valuable intervention to support family
caregivers of persons with dementia. Stinson and Kirk (2006) conducted a
randomized controlled trial to test the effects of a group reminiscing inter-
vention on depression and self-transcendence in older women living in
assisted living. There was a nonsignificant trend toward increased self-tran-
scendence and decreased depression in the reminiscence group after 6
weeks, as well as an inverse relationship between depression and self-tran-
scendence. Walsh and her colleagues (2011) conducted a qualitative study
to examine outcomes of a creative bonding intervention using simple art
activities among four participants with late-stage Alzheimer’s disease. This
study supported the beneficial effects of using art activities and the impor-
tance of group bonding as part of the PATH Program. It also provided the
idea to videotape intervention sessions which was implemented in the pres-
ent study. No intervention research was found related to mindfulness and
Reed’s view of self-transcendence. However, Vago and Silbersweig (2012)
did describe the interaction between mindfulness and a similar view of self-
transcendence; mindfulness was defined as systematic mental training that
develops self-awareness, ability to regulate one’s behavior, and to create a
positive relationship between self and other that results in self-transcendence,
changes which could be mapped in neural networks, both functionally and
with strong anatomical specificity. Thus, despite the limited interventional
research focused on self-transcendence, support was found for the main
McCarthy et al. 5

elements of the PATH: mindfulness, group processes, and creative

projects.

Development of the PATH Program

Based on a review of literature and using the process of concept analysis, a
conceptual model of self-transcendence was developed to serve as a basis for
the PATH Program (McCarthy & Bockweg, 2013). Figure 1 provides an
adapted version of the original conceptual model which organized antecedents
and attributes of self-transcendence into five logically related domains: creativ-
ity, relationships, introspection, contemplation, and spirituality. Specific activi-
ties intended to increase self-transcendence were drawn from antecedents
within each domain and combined as elements of the PATH Program. The five
domains and activities within each domain that were incorporated into the
PATH Program are described in Figure 1 and are reviewed briefly here.
Creative activities are not limited to making or experiencing art but include
lifelong learning, innovative thinking, and hobbies such as cooking or gar-
dening, all of which express the self and lend a sense of purpose to life. The
domain of Relationships involves a sense of connectedness with others.
Using reminiscence and discussion of significant relationships in the past
encourages participants to reassess what is important and meaningful in their
relationships today, and group bonding allows participants to experience trust
and acceptance in the present. Introspection focuses on looking at past life
experiences, beliefs and values, locus of control, and self-worth to increase
awareness and acceptance of the self, and may be prompted by activities such
as personal narratives, mindfulness practices, and journaling. Contemplation
involves considering the meaning of life and death, awareness of a cycle of
life, and sense of purpose in life, and may be provoked by group discussion,
readings, and closeness to nature. Finally, Spirituality is used as a broad con-
cept which involves not only religiosity but also each individual’s under-
standing of a higher level of consciousness or the sacred, evoked through
mindfulness practices, music, prayer, reading, and discussion.
An assumption of this model was that individual domains overlap and
interact (McCarthy & Bockweg, 2013). Domains were not intended to be
separate and discreet but together to fully encompass all attributes of self-
transcendence. Thus, there is considerable overlap among activities within
each of the domains; because of this, activities anticipated to increase self-
transcendence were organized into three primary elements of the PATH
Program: creative activities, group processes, and mindfulness practices,
reinforced by daily practice of selected activities at home to increase the
effects of the weekly group sessions.
6 Western Journal of Nursing Research 

Antecedents of Spirituality
Religious beliefs and practices
Participation in a faith community
Spiritual reading and discussion
Spiritual direction/mentoring
Meditation

Antecedents of Contemplation Antecedents of Introspection

Existential questioning Attributes of Spirituality Journaling
Contemplative reading Internal dialogue
Sense of unity with God or the sacred
Philosophical discussion Self-help reading
Closeness to nature Inner peace and acceptance Guided imagery
Positive solitude Psychotherapy
Meditation Meditation

Attributes of Contemplation Attributes or Introspection

Shift in perspective from rationale to cosmic Spirituality Shift from egocentricity to awareness of a
Awareness of being part of a cycle of life dimension greater than the self
Sense of being an integral part of the universe Increased self-acceptance, sense of coherence,
and ego integrity

Introspection
Contemplation

Sellf

Transcendence

Creativity
Relationships

Attributes of Creativity Attributes of Relationships

Self expression Connectedness to others
Sense of fulfillment Acceptance of others
Productive engagement Focus on personally valued people/activities
Sense of purpose Less concern for social role/expectations

Antecedents of Creativity Antecedents of Relationships

Making and experiencing art Altruism and Generativity
Life-long learning Reminiscence
Innovative thinking Sharing wisdom with others

Figure 1.  Conceptual model of transcendence.

Source. McCarthy & Bockweg (2013). Originally published in the Journal of Holistic Nursing,
31(2), 83-91 and adapted for use here. Used with permission.

In summary, there is theoretical and empirical support for the hypothesis

that specific activities associated with each of the individual domains are
related to increased levels of self-transcendence and well-being. Self-
reflection, psychotherapy, reminiscence, meditation, spirituality, closeness to
McCarthy et al. 7

nature, poetry writing, and creativity have been used individually to increase
self-transcendence and other favorable outcomes.

Preliminary Study
An early version of the intervention was tested in a feasibility study
(McCarthy, Bowland, Hall, & Connelly, 2015; McCarthy, Ling, Bowland,
Hall, & Connelly, 2015) with 20 older adults at a senior community center.
The purpose was to evaluate the intervention content and format to determine
acceptability to participants. Participants reported they gained a sense of
calmness, bonding, and personal growth (McCarthy, Bowland, et al., 2015).
From pre- to postintervention, all variables trended in the expected directions
and, despite the small sample size, the participants experienced a significant
increase in life satisfaction (McCarthy, Ling, et al., 2015). Based on the find-
ings of the feasibility study, the structure and content of the PATH Program
were significantly altered. Mindfulness exercises were implemented earlier
and added as a component of each weekly session. Discussion topics were
significantly revised, types of creative activities were refined, and at-home
activities were organized around deep breathing and relaxation as a unifying
theme. The revised version of the intervention was examined in the present
study.

Purpose
The purpose of this study was to assess differences between the intervention
and the wait-list control groups as well as baseline and postintervention dif-
ferences in both the intervention group and the wait-list control group. The
initial version of the PATH Program was delivered to the intervention group,
and then the PATH Program was revised and further developed using knowl-
edge gained from the intervention group. Finally, the revised intervention
was delivered to the wait-list control group. It was hypothesized that the
PATH Program would increase self-transcendence and improve indicators of
well-being such as psychological well-being, life satisfaction, acceptance,
proactive coping, depression, and health-related quality of life.

Method
Design
This randomized controlled trial with repeated measures was conducted with a
convenience sample of 20 older women from two senior community centers. The
two centers were randomly assigned using a simple coin flip to intervention
8 Western Journal of Nursing Research 

(Center A; n = 10) or wait-list control (Center B; n = 10) conditions. Random

assignment at the individual level was not conducted due to potential contamina-
tion among participants at a single center. Phase 1 of the study involved deliver-
ing the PATH Program to the intervention group to identify differences in pre- and
postintervention results for the intervention group at Center A and to compare the
intervention group with the wait-listed control group at Center B. Phase 2
included using what was learned about the contents and methods of the PATH
Program in Phase 1 to revise and further refine the PATH Program, then to deliver
the revised version to the wait-listed control group at Center B, comparing pre-
and postintervention results for the second group. Quantitative data were col-
lected pre- and post-intervention via self-report questionnaires on outcomes of
self-transcendence, psychological well-being, life satisfaction, acceptance of life
situation, proactive coping, depression, and health-related quality of life.

Sample and Setting

Both senior centers serve low- and moderate-income populations in urban
neighborhoods and aim to reduce hunger and food insecurity, prevent social
isolation of older adults, and delay adverse health conditions through access
to nutrition and health promotion/disease prevention services. Both centers
provide congregate nutrition services, food pantries, clothes closets, health
promotion activities, screenings and referrals, exercise classes, and recre-
ational activities.
Women were eligible if they were able to see, hear, and speak sufficiently
to participate in the group and were expected to be available for the length of
the study. Exclusion criteria were one or more of the following within the
past 6 months: diagnosis of an acute, life-threatening disease; two or more
hospitalizations; a significant loss in the past 6 months, or abnormal Mini-
Cog Dementia Test (Borson, 2000) indicating cognitive losses likely to pre-
clude participation. Group size of eight to 10 participants in each group was
determined to be optimal based on the literature (Brown, 2004) and opinions
of two consultants experienced in conducting psychoeducational groups.
Thus, 20 participants were recruited, 10 from each center. Of the original 20
participants, 18 completed the study; one participant in the intervention group
did not find the activities worth the time commitment and another participant
in the wait-listed control group dropped out due to transportation problems.

Measures
Self-transcendence.  Reed’s (1989) Self-Transcendence Scale measures older
adults’ perceptions of the degree or level of transcendence. The 15 item,
McCarthy et al. 9

4-point Likert-type scale varies from not at all to very much, with higher
mean values indicating greater self-transcendence. Validity of the Self-
Transcendence Scale is indicated by alphas ranging from .80 to .93, with
test–retest reliability of .95.

Psychological well-being. The Philadelphia Geriatric Center Morale Scale

(Lawton, 2003) measures psychological well-being. The scale consists of 17
dichotomous items; summary scores range from high (13-17) to low (<9),
correlate with the Life Satisfaction Index-A (.57), and have demonstrated
alphas from .81 to .85, with test–retest reliability ranging from .91.

Life satisfaction.  The 12-item Life Satisfaction Index for the Third Age (Bar-
rett & Murk, 2009) measures overall life satisfaction. This updated version of
Neugarten’s Life Satisfaction Index-A uses a 6-point Likert-type scale, rang-
ing from strongly disagree to strongly agree, with higher scores indicating
greater dissatisfaction. The authors report alphas which approach .90 and
excellent goodness of fit scores in factor analysis.

Acceptance of life situation.  Acceptance was assessed using the 10-item Accep-
tance and Action Questionnaire (Hayes et al., 2004), which measures non-
avoidance of aversive stimuli, tolerance of unpleasant emotions, and capacity
for productive response using a 7-point Likert-type scale ranging from never
true to always true, with reported alphas ranging from .81 to .87.

Proactive coping. The 14-item Proactive Coping subscale of the Proactive

Coping Index (Greenglass, Schwarzer, Jakubiec, Fiksenbaum, & Taubert,
1999) measured coping in this study. The 4-point Likert-type scale ranges
from not at all true to completely true. The Proactive Coping Inventory (PCI)
correlated with subscales of the Brief Cope in two samples: Active Coping
(.52 and .50), Planning (.42 and .45), and Behavioral Disengagement (−.42
and −.54), and demonstrated alpha of 86.

Depression.  Depression was measured using the 15-item Geriatric Depres-

sion Scale (Sheikh & Yesavage, 1986), which indicates depression based on
psychiatric diagnostic criteria. Sheikh and Yesavage (1986) report the dichot-
omous scale (yes/no) has sensitivity of 92% and specificity of 89% and evi-
dence supported construct validity (r = .84, p < .001).

Health-related quality of life. The 20-item Medical Outcomes Study Short

Form Health Survey (SF-20; Stewart, Hays, & Ware, 1988) measured health-
related quality of life. The SF-20 survey assesses physical, social, and mental
10 Western Journal of Nursing Research 

health, role functioning, pain and pain perceptions, and self-rated health with
alphas for four subscales .81 (role functioning) to .88 (mental health). Cron-
bach’s alphas for the measures in this sample ranged from .82 to .96 except
for the Acceptance and Action scale which had an alpha of .59.

Intervention
Details of the initial version of the PATH Program were reported previously
(McCarthy, Bowland, et al., 2015; McCarthy, Ling, et al., 2015). The original
PATH Program was revised based on findings of the feasibility study
(McCarthy, Bowland, et al., 2015; McCarthy, Ling, et al., 2015). The revised
version tested in the present study was structured as eight weekly 1.5 hr group
sessions reinforced by 10 to 15 min of independent at-home practice each
day. The principal investigator, a doctorally prepared gerontological nurse,
and a research associate with a bachelor’s degree in nursing facilitated all
intervention sessions, in consultation with a doctorally prepared gerontologi-
cal social worker. Facilitators had no previous relationship with participants.
Following introduction of the PATH Program in the first weekly session, sub-
sequent sessions focused loosely on one of the five domains of self-transcen-
dence, followed by activities to reach closure in the final 2 weeks. Each
weekly session was organized similarly and included mindfulness practices
followed by group discussions, then a creative activity. Sessions ended with
instruction in the at-home activity.
Mindfulness practices, including deep breathing and relaxation, combined
with a brief body scan and guided imagery, focused on the weekly theme and
were used to quiet and calm participants, create an open and engaged attitude
throughout the rest of the session, and reduce the stress of participating in an
unfamiliar activity. Group processes included open-ended discussion ques-
tions where the discussion was allowed to proceed without implicit direction
by facilitators. Creative experiences included art projects, writing stories,
poems, prayers or songs, and journaling, and introduced a fun, social element
to promote trust and bonding. Finally, independent at-home practice included
deep breathing and body scan exercises, readings, listening to music, remi-
niscing, and writing. Each of the primary elements were previously described
in detail (McCarthy, Bowland, et al., 2015; McCarthy, Ling, et al., 2015), but
are briefly discussed here.
Instruction in mindfulness practices was initiated with a simple deep
breathing and relaxation exercise; then, guided imageries developed by the
research team were added, each focusing on the topic of that week. Group
discussion followed the mindfulness exercises, when participants were
relaxed, focused, and open, with the facilitator introducing an open-ended
McCarthy et al. 11

question related to the weekly topic. For instance, in the week focused on
introspection, the question was, “How did you get to be the person you are
today? Do you believe other people see the ‘real’ you?” Follow up questions
were available if needed to stimulate group discussion but were rarely used
as the group generally responded without additional prompting. It is impor-
tant to note that the purpose of the group discussion was not to cover speci-
fied content but to allow participants to direct the discussion in a way that
was meaningful and relevant to the group, discovering for themselves obser-
vations and feelings rarely considered in the rush of everyday life and result-
ing in a sense of trust, acceptance, and bonding within the group (McCarthy,
Bowland, et al., 2015; McCarthy, Ling, et al., 2015).
Creative projects followed each group discussion, helping to relieve any
residual tensions after discussions and continuing to build acceptance and
bonding by introducing a sense of playfulness and laughter. Creative projects
were designed to be easily completed within the available time by all mem-
bers of the group. Although examples of each project were displayed in
advance, along with basic instructions, the facilitators strongly emphasized
there was not one “correct” way to complete the project but that the purpose
was for participants to enjoy experimenting and expressing themselves by
creating their own unique outcomes. An ample supply of various art and
crafts materials allowed participants to create their own personal versions of
each project. Examples of projects included decorating a “Reflection Box” in
which to store small items used in at-home activities, constructing a rainstick,
or designing the cover of a personal journal (McCarthy, Bowland, et al.,
2015; McCarthy, Ling, et al., 2015).
Finally, at-home activities were intended to reinforce the effect of activi-
ties learned in group sessions and to encourage participants to adopt one or
more activities to continue after the intervention concluded if desired.
At-home activities included deep breathing and relaxation; meditations and
guided imagery recorded on CDs; journaling and writing personal narratives,
poems, or stories; and taking time to reflect on music, images of nature, or
readings selected at group sessions. Reading materials were obtained from a
wide variety of sources at various reading levels and were selected to be
inclusive of multiple cultural and religious traditions. Some readings were
serious and some humorous, some spiritual and others secular, some a single
sentence and a few two or three pages. Each participant selected one or more
readings each week which she found personally interesting or meaningful. At
home, after a deep breathing and relaxation exercise, the participant experi-
enced music, images, or readings and then sat quietly for a few minutes
reflecting on her own responses or writing about her responses in her journal
(McCarthy, Bowland, et al., 2015; McCarthy, Ling, et al., 2015).
12 Western Journal of Nursing Research 

Given the prevalence of sensory and motor limitations in the older adult
population and the variety of education and income levels, accommodations
were made to allow full participation by all group members. CD players were
provided for all participants, as were all CDs, readings, or other materials.
Readings were in large font sizes with sharp contrast between text and back-
ground, and magnifying glasses were available. Audio recorders were avail-
able for journaling if a participant’s ability to write was limited. In group
sessions, a research assistant was available to help with creative projects if
desired by the participant.
An important aspect of the PATH Program was that participants were encour-
aged to join discussions, share feelings, or take on creative projects and to prac-
tice at home as much—or as little—as was comfortable to each individual.
Rather than being directed through set, standardized discussions or activities,
discussions were directed by the group, and participants were encouraged to
make personally meaningful choices from a wide range of options for readings,
music, guided imagery CDs, art supplies, and journaling topics to individualize
experiences in ways that seemed appropriate and useful to each participant.

Procedure
The study was approved by the university Institutional Review Board.
Participants were recruited at the senior centers after research staff explained
the purpose of the study at scheduled community center activities. Gift cards
worth a total of US$100 were offered in appreciation of participants’ time and
to cover transportation. After the purpose of the study and the PATH Program
was explained, eligible participants gave written informed consent. A set of
questionnaires was completed by participants at both Center A and Center B
1 week prior to delivering the intervention to participants at Center A. One
week following completion of the intervention at Center A, both groups again
completed questionnaires. Some aspects of the intervention were revised and
the intervention was then delivered to participants at Center B. Revisions
made before implementing the intervention at Center B included slight
refinement of the guided imageries and minor changes to discussion ques-
tions. Significant revisions were made so that at-home activities were more
appealing and less confusing to participants, and to simplify the process of
instructing participants on how to practice at-home activities.

Data Analysis
Descriptive statistics were used to characterize the study sample. Means and
standard deviations were used to describe all continuous variables and
McCarthy et al. 13

frequencies and percentages were used to describe all categorical variables.

To examine differences in baseline characteristics and measures between the
intervention and wait-list control groups, independent two-sample t tests and
chi-square tests were conducted for continuous and categorical variables,
respectively. To assess the effects of the intervention within each group,
paired t tests were used. Standardized mean differences (Cohen’s d) were
calculated for effect sizes. Separate linear mixed models were developed for
each measure to examine the effect of the intervention over time. Each model
included group (intervention vs. wait-list control), time (baseline vs. postint-
ervention), and a Time × Group interaction. All data were analyzed using
Statistical Analysis System Version 9.4 (Cary, North Carolina). Due to the
pilot nature of this study, the alpha level was set a priori at .10.

Results
Baseline Characteristics of the Sample
There were no significant differences in demographic characteristics between
the two groups at baseline. The mean age of the sample was 72.4 years (SD =
7.6), the majority were White, non-Hispanic (95%), and most had some col-
lege or post–high school certification (40%). Other than one participant who
had never married, about one third of the sample was married, another third
divorced or separated, and the remainder widowed. Seventy-five percentage
of the sample reported perceived income as adequate or better. The mean
self-transcendence score for the entire study sample was 3.3 (SD = 0.4) and
did not differ between the intervention and wait-list control groups at base-
line (3.3 vs. 3.4, p = 0.14). In addition, there were no group differences in any
of the other measures at baseline.

Comparison of Intervention Group (Center A) and Wait-List

Control Group (Center B)
Linear mixed models were conducted to examine differences between the
two groups over time to see whether the intervention had an effect on the
study outcomes (Table 1). For self-transcendence, there was no significant
Group × Time interaction. In addition, the groups did not differ over time on
any of the other outcome variables.

Pre- and post-test comparison of intervention group and wait-list control

group.  Table 2 presents a comparison of baseline (Time 1) and postinterven-
tion (Time 2) measures for the intervention group at Center A and the
14 Western Journal of Nursing Research 

Table 1.  Linear Mixed Model Results for Each Outcome With Adjusted Means by
Group and Time (Centers A and B; n = 18).
Adjusted M (SE)a F, df (p Value)

Wait-List
Intervention Control
Outcome Group Group Group Time Group × Time

Self- 3.2 (0.1) 3.4 (0.1) 2.57, 18.1 (.13) 0.01, 17.2 (.91) 0.05, 17.2 (.82)
Transcendence
Philadelphia 11.0 (1.5) 11.0 (1.5) 0.00, 18.0 (.99) 0.14, 17.1 (.72) 0.54, 17.1 (.47)
Geriatric
Morale Scale
Life Satisfaction 46.4 (3.0) 45.4 (3.0) 0.06, 18.0 (.81) 9.05, 17.2 (.01) 0.01, 17.2 (.92)
Index
Acceptance and 48.8 (2.8) 49.8 (2.7) 0.07, 18.2 (.80) 7.16, 17.4 (.02) 0.44, 17.4 (.52)
Action
Proactive Coping 40.6 (2.2) 43.2 (2.2) 0.68, 17.8 (.42) 0.67, 17.0 (.42) 1.41, 17.0 (.25)
Geriatric 3.5 (1.2) 3.5 (1.2) 0.00, 18.0 (.99) 1.89, 17.1 (.19) 1.63, 17.1 (.22)
Depression
SF-20 61.9 (7.2) 67.1 (7.2) 0.25, 18.0 (.62) 0.03, 17.0 (.86) 0.26, 17.0 (.62)

Note. SF-20 = 20-item Medical Outcomes Study Short Form Health Survey.
a. Means include baseline and postintervention scores.
b. Alpha level set at .10.

wait-list control group at Center B. For the intervention group at Center A,

there was no significant change in mean self-transcendence between baseline
and postintervention. There was a significant decrease in proactive coping
after the intervention. There were no other differences in pre- and postinter-
vention scores for the other measures. After the intervention group at Center
A completed all intervention and data collection sessions, the wait-list control
group at Center B received a revised version of the intervention and data were
collected using the same set of questionnaires to assess changes in the out-
come variables 1 week post intervention. This group’s mean self-transcen-
dence score increased significantly from pre- to post-test. There were also
significant increases in mean Philadelphia Geriatric Center Scale scores and
the Life Satisfaction Index scores.

Discussion
Findings supported the hypothesis that the theory-based elements of the
PATH Program may increase levels of self-transcendence and indicators of
psychological well-being. Not surprisingly, given the small sample size of
this pilot study, there were no significant Group × Time interactions for any
McCarthy et al. 15

Table 2.  Comparison of Mean Baseline and Postintervention Scale Scores for the
Intervention Group and Wait-List Control Group (n = 18).

Time

Baseline Postintervention

Scale M (SD) M (SD) da tb p Valuesc

Intervention group, Center A
 Self-transcendence 3.2 (0.4) 3.2 (0.4) 0.0 0.0 0.99
  Psychological well-being 10.2 (5.5) 10.8 (5.8) 0.21 −0.62 0.55
  Life satisfaction 47.1 (13.5) 43.9 (9.6) 0.56 1.67 0.13
 Acceptance 50.7 (8.6) 47.6 (10.0) 0.53 1.59 0.15
  Proactive coping 42.6 (5.8) 40.8 (6.1) 1.13 3.41 0.01
 Depression 3.9 (3.9) 3.9 (4.5) 0.0 0.0 1.00
  Health-related QOL 58.3 (27.0) 60.1 (26.1) 0.16 −0.48 0.64
Wait-list control group, Center B
 Self-transcendence 3.4 (0.3) 3.6 (0.3) 0.74 −2.22 0.06
  Psychological well-being 11.7 (3.1) 12.9 (3.7) 0.82 −2.48 0.04
  Life satisfaction 44.1 (6.9) 48.9 (10.2) 0.87 −2.62 0.03
 Acceptance 48.8 (9.2) 49.3 (7.1) 0.19 −0.56 0.59
  Proactive coping 44.0 (8.4) 42.9 (9.8) 0.27 0.82 0.44
 Depression 3.1 (2.9) 2.6 (3.1) 0.31 0.92 0.38
  Health-related QOL 65.3 (20.3) 68.0 (17.9) 0.45 −1.36 0.21

Note. QOL = quality of life.

a. Standardized mean difference (Cohen’s d).
b. Paired t tests.
c. Alpha level set at .10.

outcome variable nor pre- and post-test differences in the intervention group.
However, following revisions of the intervention, the wait-list control group
means differed significantly pre- to postintervention on self-transcendence,
well-being, and life satisfaction. These results were congruent with findings
of a previous feasibility study as well as research supporting the efficacy of
the PATH Program (Coward & Kahn, 2005; Haugan, 2014; Matthews &
Cook, 2009; McCarthy et al., 2013; Nygren et al., 2005; Runquist & Reed,
2007; Stinson & Kirk, 2006; Upchurch & Mueller, 2005; Walsh et al., 2011).
It is likely the revisions made to the PATH Program after the intervention
group and before the wait-list control group received the intervention account
for the differences. This possibility was anticipated, but it was deemed more
important to pilot changes to the intervention suggested by the experience
with the original intervention group than it was to retain fidelity of the PATH
16 Western Journal of Nursing Research 

Program protocols. In addition, despite the lack of statistically significant

differences in demographic characteristics or mean levels of study variables
at baseline, both facilitators observed tensions in the intervention group at
Center A. Preexisting conflicts among a few group members, perhaps based
on differences in social status not reflected in baseline demographic data or
mean levels of variables, may have existed. Similar observations of the wait-
list control group at Center B reflected a seemingly more cohesive and toler-
ant group. Regardless, the significant findings for the wait-list control group
provide support for the effectiveness the final version of the PATH Program.
The small sample size, convenience sampling, and nonrepresentative sam-
ple limited generalizability. In a feasibility study, both men and women were
recruited and randomly assigned to intervention or control groups; by chance,
only women were assigned to the intervention group. Qualitative results later
suggested the women in the intervention group felt they would not be willing
to share personal information or discuss their identities as women in a mixed
group (McCarthy, Bowland, et al., 2015). Subsequently, the decision to limit
enrollment to women in the present study was made. In future, the interven-
tion will be tested in male and mixed gender samples.
The small sample size, although appropriate for a pilot study, did limit
options for statistical analysis which might explore the specific role of self-
transcendence, that is, as a mediator, moderator, or covariate. Effect sizes
from this study will be used in power analysis to calculate sample size with
sufficient power to avoid Type II error in future. Variability in data collection
or delivery of the intervention, while deemed acceptable in this pilot study, is
a potential limitation which will be addressed in future studies. As with any
self-report questionnaires, there is potential for social desirability bias; this
was minimized because responses on questionnaires are not easily recog-
nized as desirable. Because the study was conducted at two separate senior
centers, with no known overlap in participants, the potential for contamina-
tion was limited, but this possibility must continue to be considered in future.
The results of this pilot study support the merit of a future study to test the
revised intervention with a larger sample. A multisite study with a larger sam-
ple from a similar population of women living independently or with minimal
assistance with personal care in supportive residential communities for older
adults is planned. Although this pilot study supported the overall structure
and contents of the PATH Program, fidelity in delivery of the PATH Program
will be addressed rigorously in future studies. The principal investigator, who
was the developer of the PATH Program, was the primary facilitator of this
study. To avoid potential bias, a standardized training module will be devel-
oped for new facilitators, intervention materials will be fully standardized,
and methods of monitoring for fidelity to the intervention protocol will be
McCarthy et al. 17

identified and implemented. Finally, additional variables such as blood pres-

sure, cortisol levels, actigraphy to measure sleep, or self-care behaviors such
as adherence to recommended preventative health screenings or appropriate
chronic disease self-management may be incorporated into future studies
testing the PATH Program.
This innovative intervention is the first to use multiple elements—
mindfulness practices, group processes, and creative projects in a struc-
tured, theory-based psychoeducational program. The use of independent,
at-home practice of activities to reinforce learning and integrate activities
into participants’ lives on an ongoing basis is also innovative. The poten-
tial to train available staff to deliver this intervention for groups of eight to
10 suggests the PATH Program may be affordable and practical for use in
a variety of community settings. Although a psychotherapy group of eight
to 10 participants would be considered too large, this study involved psy-
choeducation, not psychotherapy; thus, group size seemed appropriate.
This conclusion was congruent with results that demonstrated group size
of eight to 10 was effective in providing peer support and allowing group
bonding, promoting participants’ personal growth and development
(McCarthy, Bowland, et al., 2015; McCarthy, Bowland, Nayar, Connelly,
& Woge, in press).
According to the National Center for Health Statistics, Centers for Disease
Control and Prevention, U.S. Department of Health and Human Services
(2015), in the year 1900, the average U.S. life expectancy was 47 years; today
it is 78.8 years. Both the increasing life span and the Baby Boom birth cohort
help account for the startling fact there are now 70,000 centenarians in the
United States, and, by 2050, the number of people living to age 100 is pre-
dicted to reach more than one million. Although the aging of the population
has often been viewed as a potential threat to social services, health care, and
the U.S. economy, there is growing evidence that older adults may be happier
than at any other stage of life, with the potential for greater psychological and
emotional well-being (Carstensen, Fung, & Charles, 2003). It is also true,
however, that there is great heterogeneity among the older adult population
and a significant number do not have the opportunities and resources to reach
developmental maturity.
Ultimately, this practical and affordable intervention is intended to be
implemented in a number of settings—senior centers, retirement communi-
ties, assisted living facilities, church groups, and other places where older
adults gather—using trained lay facilitators to make this a practical and
affordable program to foster optimal development of self-transcendence and
increase indicators of well-being among large numbers of older adults.
18 Western Journal of Nursing Research 

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: This study was funded by grants awarded
to Dr. Valerie Lander McCarthy by the American Nurses Foundation and the Midwest
Nursing Research Society.

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