Capstone Project

Schizophrenia and Physical Activity Grand Canyon University MRS.-441 V-230 Professional Capstone Project January 9, 2014 Research shows that implementing physical activity into a lifestyle is a vital part of being healthy and encouraged for the general population. The importance of physical activity is a knowledge deficit for the person living with schizophrenia as the education and support needed from the treating psychiatrist and nurse is not consistently provided. An emphasis is placed on medication adherence, treatment compliance and reduction in hospital admissions.

Research also shows that a person living with schizophrenia has a higher mortality and morbidity rate. This population often has chronic illnesses such as diabetes, hypertension and cardiovascular disease which often is the cause for premature death. Therefore prescriptive physical activity prescribed by the psychiatrist with support from the assigned nurse to provide much needed education and program structured to support this change in lifestyle is a much needed service provided in the current psychiatric outpatient clinic setting.

Physical activity for patients should be seen as integrative care and art of the common practice for mental health nursing. (Happens, Plantain-Phone, and Scott 2011). Keywords: schizophrenia, physical activity, serious mental illness Capstone Project A problem frequently found in the outpatient mental health clinic, inpatient facilities and within the community is the lack of importance placed on physical activity being part of the schizophrenic patient's life.

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There needs to be a shift to encourage the mental health nurse, the treating psychiatrist and the clinical team to take the time to educate the patients diagnosed with schizophrenia on the importance of incorporating physical activity into their daily routines. The benefits of becoming physically active should be described in detail to the patient as an effort to show them how this would improve their quality of life.

For many suffering from schizophrenia it may be difficult for many reasons not to be physically active but for others it is the simple lack of understanding of how being active can impact their lives in a positive way as well as having support within the clinical team. Much education of the schizophrenic patient lies with the busy mental health nurse who fete fails to realize that this type of education is Just as important as the education given to the patient on medication compliance for management of their symptoms and treatment adherence for long term stability.

There is a need for greater access to physical activity information, opportunities, and professional standards for staff in mental health care (Wand & Murray 2008). The World Health Organization (WHO) finds that physical activity, ranging from daily walking to structured exercise regimens, is internationally recognized as a key prevention and health management strategy (2007). If physical activity is a health priority for the general population why should it not be Just as important for the schizophrenic patient?

Physical health in this group is often poor and individuals tend to die early with life expectancy reduced by up to ten years compared to the general population (Philae 2001). It is common knowledge to the nurse and psychiatrist that regular physical activity can improve several common physical ailments such as hypertension, hyperglycemia, and hyperventilation's as well as reduce the risk for developing cardiovascular disease, diabetes and cancer. In adult schizophrenic patients does implementing physical activity versus not implementing physical activity improve overall health in 1 year?

There are many factors that should be addressed in order to solve this problem. The education of the mental health nurse, treating psychiatrist and clinical team on the importance of taking the time to educate these patients with this information is a very important part of providing care. The identification of the barriers for which patients who receive this education and do not implement physical activity to their current lifestyles is also important. There is also a need for immunity based physical activities or places where a patient with schizophrenia will feel welcomed and supported.

The likelihood and reality of these patients to be accepted in general population venues for physical activities is often low due to the stigma and lack of education within society of the mentally ill. Review of Literature Education and Barriers In reviewing the articles similarities were found in a few of the articles. The importance of physical activity within all the articles was identified for the Schizophrenia patient. Each article stressed the fact that this patient population has high morbidity and mortality rate.

One that with incorporating physical activity can reduce risk factors that contribute to premature death. Physical activity is determined to be an important factor in improving the quality of life as well as quantity of life for these patients. The main point in my research was to show how the mental health nurse can influence the patient's perspective of physical health as well as support it by promoting the physical activity and assisting the patient in identifying ways to incorporate physical health in their daily routines.

In the first article the argument is made on how the mental health nurse should provide leadership in promoting physical activity even if the mental health nurse is not educationally prepared to perform this role. It also concluded that mental health nurses can provide directions in understanding physical activity for their patients by using evidence-based research and mainstream physical activity in the mental health clinic. Physical activity for patients should be seen as integrative care and part of the common practice for mental health nursing. Happens, Plantain-Phone, and Scott 2011). Two of the articles were studies that identified barriers for why patients with schizophrenia do not engage in physical activity. It is has been found that these patients self-report up to a 47% that they are sedentary but without any physical limitations. The first study included 27 patients from four community clinics that were interviewed individually using a structured questionnaire. This study used the recommended American College of Sports Medicine guidelines for weekly activity levels.

The data showed that two-thirds of the participants were inactive and almost a third of the participants minimally active. Only two participants met the criteria of active which is described as having moderate intensity activity or walking for at least 30 minutes for 5 days per week. The study identified four barriers: limited experience of physical activity, impact of illness and the medication, effects of anxiety and the influence of support networks. It concluded that physical activity may need to be more individualized with case management approaches by health care providers.

The development of physical activity programs should include professional and peer support which would facilitate physical activity and program adherence. Moonstone, Nicola, Donated, and Laurie, 2009). The second study explored the perceived barriers and benefits to physical activity in people with serious mental illness. A total of four focus groups were held with a total of 34 patients from two program sites which included 16 men and 18 women. The data showed that barriers to physical activity were identified as mental illness symptoms, medications, and weight gain from medications, fear of discrimination and safety concerns.

The benefits were identified as the program offered a feeling of belonging, program offered comfort and support, physical activity was viewed costively, they were able to link being active to improved health. The conclusion of this study was that these patients did value physical activity and were aware of its health benefits. The report of fear of discrimination and relying on the staff to plan and initiate physical activities also contributed to their inactivity.

The recommendation is that any program implemented should include independent initiation of activity as a method of improving one's health as this would assist the serious mentally ill patients in becoming more active and increase program compliance. McDermott, Snyder, Miller and Wilbur 2006). Lifestyle Factors and Activity Five articles, two of which were randomized studies that emphasized the importance of physical activity in relation to mortality rate, quality of life and identified activity interventions for the Schizophrenia patient. They also identified the importance of lifestyle factors such as diet, alcohol consumption and smoking.

All of the studies in this section supported the fact that a poor diet can be identified in this population and should be correlated with chronic illnesses such as Diabetes and Cardiovascular disease. The first study identified a lack of physical activity participation and impaired functional exercise capacity compared to healthy controls contributed to health related quality of life. Patients diagnosed with Schizophrenia (n=60) and health controls (n=40) completed the SF-36 Bake Physical Activity Questionnaire and performed a 6 minute walk test.

The results were significantly lower in patients with Schizophrenia compared to those of matched healthy controls. The activity scores indicated that patients with schizophrenia were significantly less' active during their leisure time and less involved in sports activities. The participants walked a shorter distance on the 6 minute walk test (19. 3%) and reported more symptoms of despise after the 6 minute walk test (28. 3%). This data suggests that patients with higher IBM might also be limited in completing daily life activities such as walking as a sedentary lifestyle correlates with a higher IBM.

This study recommends that patients should be made aware that increased body weight and physical inactivity are modifiable risk factors. Educational programs should focus on these risk factors as they are key for both treatment and prevention of disease. Bancroft, Probes, Eschews, Marriages, Sewers, Knap, and De Here, 2011). The second study evaluated evidence of physical activity with or without having diet counseling on creditability parameters in people with schizophrenia.

It is well documented that people with schizophrenia have a reduced life expectancy of 20-25 years in comparison to the general population related to premature cardiovascular disease. They also have twice the normal risk of dying from cardiovascular disease. This study reviewed 13 articles that addressed physical activity with or without diet counseling. The conclusion was that physical activity with or without diet counseling is effective in reducing weight and improving creditability risk factors in people with Schizophrenia.

It is recommended that clinicians assess and monitor cardiovascular risk factors as well as refer patients to a physical health programs. It was noted in the study that without the support of clinicians, people with schizophrenia exercised sporadically and dropout rates were at 90% after 6 months. (Bancroft, Knap, De Cert., Van Winkle, Deck, Marriages, Puddles, Simons and Probes 2009). The third article focused on the impact of poor hysterical health in relation to the mortality rate of patients with schizophrenia.

This study summarized lifestyle factors such as poor diet, low rates of physical activity, increased weight, smoking, lack of dental care, social isolation, limited to no family involvement and unemployment which can all be considered underlying causes of increased mortality in this population. This article found patients with schizophrenia have the inability to provide self-care which also places this population at greater risk for premature death. This article emphasis the need for health education that retrofires physical health as an effort to improve mortality and morbidity of people with serious mental illness.

These health education strategies would include education of lifestyle factors to intervene before a serious health problem is established. As well as secondary interventions which include health screenings to aid in the early detection and management of high risk factors for diabetes and cardiovascular disease. (Pack 2009). The fourth article was also study that was based on assessment of the metabolic profile for individuals with schizophrenia in relation to dietary and physical activity habits.

This study interviewed 130 patients diagnosed with schizophrenia from the outpatient clinic. The data from these 130 patients and another 250 participants of the 2005-2008 ENHANCES were analyzed by using SPAS version 17. 0 for Windows. The data showed that less than half of the sample reported moderate physical activity and few individuals reported any vigorous physical activity. The controlled group showed a higher frequency of moderate physical activity but no difference in vigorous activity.

Previous studies have found that 40% of patients with Schizophrenia report no moderate physical activity and 75% port no vigorous physical activity. This study found that household income did correlate with moderate activity and did impair participation in physical activity for those patients who had a lower income. The conclusion of this study is that interventions should combine education and physical activity as a form of outreach that would be more appropriate for the serious mentally ill patient who has limited knowledge of the benefits of exercise.

Health care providers should offer increased opportunities for physical activity for patients with Schizophrenia as this may improve treatment outcomes and ease the burden of disease. Rattail, Palmers, Returnee, Lisbon, Grill, Take 2012). The objective of the fifth and final study was to evaluate the association between a sedentary lifestyle and psychiatric symptoms in obese and overweight adults with schizophrenia or specification disorders. This was a randomized study which included weight assessment and intervention in schizophrenia treatment.

The data was collected during 2005-2008 in an outpatient setting and included 55 patients. Sedentary behavior has been shown to be an independent risk factor for mortality in the general population and may be a factor hat is increasing the risk of common co-morbidity's in adults with schizophrenia or specification disorder. This study found in regards to physical activity that patients who were monitored spent 13 hours per day practicing sedentary behaviors and that physical activity was very limited.

Physical activity was primarily light physical activities 17% of the monitoring time and moderate to vigorous activity was 2% of the monitoring time. Self-reported sedentary behavior was found to be associated with psychiatric symptoms such as negative symptoms, depression, cognitive symptoms ND extramarital side effects to psychotropic medications. This study suggests that public health campaigns and mental health providers should focus on decreasing sedentary behaviors as an effort to reduce the risk of co-morbidity's which are often experienced by adults with schizophrenia or specification disorder. Ann., Gauguin, Richardson, Hellman, Tang, Caules, and Karakas 2013). There is much evidence to support the fact that the mental health nurse should spend time educating, promoting and possibly even facilitating the programs within the clinic that support the schizophrenia patient with the lifestyle change to incorporate physical activity into their lives to increase their quality and quantity of life. It would be realistic to set a goal for the patient to be able to incorporate 30 minutes of physical activity into their routines at least three times per week.

Physical activity teaching and support should include topics that deal with barriers to physical activity, poor diet and their influence as factors that contribute to the development of Diabetes and Cardiovascular disease. Implementation Plan In the current outpatient clinic setting such as Partner's In Recovery decisions about NY change that will affect the patients care are made not only at the administrative level but the patient level as well. There is an identified Advisory Council which is made up of volunteers which consists of patients, clergy and community members.

Prior to any proposal for change or new program within the clinic to be brought before administration the information must be presented to the Advisory Council at one of their monthly meetings. Once approval is obtained from the council then the information would be presented to the patients for their input and approval. Moving onto administration will be the tough part. The presentation will have to include physician approval, URN endorsement and willingness to adapt teaching to their current practice, patient testimony on the importance of having physical activity ordered by the physician as part of their treatment plan.

As well as the patients currently participating in a walking program for 30 minute intervals two to three times per week. This presentation would be given by the URN with self-identified patients who would help facilitate and share their personal experiences. In order for administration to be on board with a change the buy in would have to be monstrance at the patient level with a few patients willing to go the extra mile and advocate for this change to happen. A presentation for the patients would be developed and presented to the patients in the current onsite classes.

This presentation would highlight the high risk behaviors that can be modified to avoid the development of chronic illnesses such as diabetes, cardiovascular disease and cancer. It would also include the high morbidity and mortality rates found within this population which is also attributed to schizophrenia and the lack of physical activity. A healthy snack would be served to them during the presentation. Patients that were self-identified as wanting to participate in this process would be called to additional Once the patients were on board and actively walking we would move meeting. Onto the physicians and nurses. This presentation would have the same information and would be presented to them during one of the monthly clinical staff meetings with arrangements made for lunch to be served since it is normally held during their lunch hour. This presentation would focus on the importance of physical activity being prescriptive by the physician. Reinforced, supported and taught by the URN who is assigned to that patient for continuity and adherence.

It is recognized among the medical staff that serious mentally ill patients across the spectrum of diagnosis suffer from a sedentary lifestyle. Physical activity may need to be more individualized with case management approaches by health care providers. The development of physical activity programs should include professional and peer support which would facilitate physical activity and program adherence Moonstone, Nicola, Donated, Laurie 2009). This presentation would be adaptable to the audience for future reservations.

For the physicians and nurses it would have statistical data to support the change and show the positive outcome for reinforcing a lifestyle change for many of their patients. For administration it would have data to support that the quality of life would be greater and the quantity of years of life extended with the patient who is being supported to be physically active. The cost may be increased for the mental health system as the SIMI patients diagnosed with Schizophrenia will live a longer life related to implementing this change.

This small change may motivate the patient to incorporate more healthy behaviors such as quitting smoking, eating healthy and seeing their primary care physician regularly to manage their chronic illness such as diabetes and hypertension which will in turn lead to healthier more productive lives. For some, patients possibly even the opportunity to reach full recovery in which they would no longer need to be part of the mental health system. The problem at hand is that physical health in this group is often poor and individuals tend to die early with life expectancy reduced by up to ten years compared to the general population Philae et al. 001). It is common knowledge to the nurse and psychiatrist that regular physical activity can improve several common physical ailments such as hypertension, hyperglycemia, and hyperventilation's as well as reduce the risk for developing cardiovascular disease, diabetes and cancer. At the outpatient clinic level much of the patient education is provided by the busy Mental Health Nurse. Time constraints, patients in crisis needed to be triages or hospital discharges often take precedence to teaching or reinforcement of physical activity.

There is a need for rater access to physical activity information, opportunities, and professional standards for staff in mental health care (Wand & Murray 2008). The World Health Organization (WHO) finds that physical activity, ranging from daily walking to structured exercise regimens, is internationally recognized as a key prevention and health management strategy (2007). In the additional meeting these patients would be given more specifics about what their participation will mean to move this change forward to Administration for final approval to be implemented for all the patients diagnosed with Schizophrenia.

A detailed explanation of the commitment being made to themselves in become physically active. Patients would receive a pre-test and a plan would be set for implementing walking for 30 minute intervals two to three times per week as well as a log to track their participation. Patients would receive a pedometer if they were interested in seeing their walking translated into steps. Patients would return weekly to report their progress, enjoy a health snack, receive additional support and reinforcement from their assigned Nurse as well as planning the following weeks activity.

A room within the clinic would be designated or this meeting. The cost for implementing this walking program for the patients would be minimal as the clinic receives donations of food and water on a weekly basis. Often time staff is also willing to support activities such as this with donations of fruit or vegetable trays. The cost on the other hand maybe viewed differently from Administration as this program would take time from a designated URN to meet with the patients on a weekly basis which in turn would take away from clinical hours and billable patient care. The average URN at PRI makes $28-$32 per hour.

Considering one our for the patient meeting time, prep time and possible phone call allotment time may come out to three to four hours per week which would average $112-$128 per week. Not being privileged to the average billing rate for a visit with an URN for one hour in the clinic a weekly average of the loss in unable to be determined. There would also be a cost incurred with paper, ink and printing of materials. If this program was to be implemented as identified above with the physician prescribing the physical activity to the patient diagnosed with schizophrenia and the support given by the URN the outcome would be phenomenal.

Mental health nurses can provide directions in understanding physical activity for their patients by using evidence-based research and mainstream physical activity in the mental health common practice for mental health nursing. (Happens, Plantain-Phone, Scott 2011). Resources that would be needed for this program to be implemented would include the meeting room, healthy snacks, power point presentation or printed handouts, pre-test for the patients, a nurse to run weekly meetings, weekly tracking log, pedometers and a post-test to measure the increase in awareness and knowledge.

A elaboration or recognition of some sort for the patients who continue to practice this lifestyle change after a pre-set timeshare. This patient group would be followed by the assigned URN for one year and their progress would be reported to the Physicians, Nurses, Advisory Council, Administration and other patients suffering from serious mental illness at each quarter through the year. Another resource that may be necessary after the initial year would be to continue this program with new patients.

In the clinic setting peer support is a big deal, maybe the patients who have been successful, faced challenges and are now practicing this new lifestyle may be the ones facilitating the weekly meetings with the URN present for additional support and reinforcement. How much more effective would it be to see and hear it from your peer and your nurse to get you motivated to actually give physical activity a try? Theory There are two theories that will address the issue of increased physical activity in the Schizophrenia patient population.

The first is the Health Belief model in which the key concepts are based on the patient's perception of the threat, benefit and barriers. In this model in order for the patient to adopt the new behavior such as physical activity, their perception of the threat for chronic long-term illness, the severity of those identified illnesses and the benefits of their participation in physical activity must outweigh their perceived barriers to incorporating this activity. This theory would be one that is easy to implement and incorporate into a visit with the nurse or psychiatrist without needing additional time scheduled.

The use of this theory would facilitate the education much needed by this patient population in regards to deeding physical activity as part of their treatment plan. It is the hope that once the patient is given this information by a nurse or psychiatrist their interest in physical activity will be increased. Once there is motivation behind the interest then the patient can implement the physical activity. The second theory is the Theoretically model which entails the stages of change. In this model it is believed that a person (patient) shift in a progression though five levels related to their readiness to make a change.

The first stage is pre-contemplation in which the patient maybe thinking bout making this change. The second is contemplation in which the patient maybe more serious about making this decision. The third is preparation in which the patient is now taking steps to be able to make the change. The fourth is action in which the patient is actually doing the activity or incorporating the change into their routine. The fifth and final stage is maintenance in which the patient is implementing the activity into their routine and doing other activities to support their new lifestyle change.

This theory would be easy to include into a support group or class setting. This theory can aid in facilitating the class structure. With this theory each patient will be able to identify what stage they are in, identify what is needed to make the change and even set a date to incorporate change into their current lifestyle. This theory can be beneficial in addressing physical activity as a healthy lifestyle change that is much needed in this patient population as an effort to prolong their lifep.

The hope is that with a class structure the patient can be supported as he/she incorporates physical activity into their current lifestyle. Evaluation The methods used to evaluate the progress of implementing a walking program will be a pre and post-test (Appendix A). This walking program will be implemented as part of a Wellness program that entails enhanced patient education and consists of group walking 3 days a week for 30 minutes with the self-identified patients being treated for Schizophrenia at an outpatient psychiatric clinic.

The identified variables that will be measured throughout the year of this program will be an increase in knowledge of the participants about the importance of physical activity, increase in he amount of physician referred or prescriptive physical activity, increase in amount of referrals to the walking program (Appendix C). A long term outcome worth measuring would be the decrease in IBM, cholesterol and triglycerides in the patients who participate in the walking program for one full year (Appendix B). Dissemination Results would be disseminated first of all with Administration and the Advisory Committee in one of the quarterly meetings.

A power point presentation would outline the Journey of the implementation of the walking program as well as the outcomes. It would include the amount of physician and nurse educational sessions, physical activity weekly nurse run classes, amount of participants actively walking, amount of referrals via physician referral or self-identified participants, measurable changes in lab results for cholesterol and triglycerides, changes in IBM tracked for 1 year. Posters would be printed in colorful themes displaying the outcomes which were tracked over the year.

These posters and the power point presentation would then be shared with the referring physicians and nurses during Grand Round. Results would be shared with the patients and staff with these posters by placing them on the walls throughout the clinic. It would be the hope that these posters would build motivation and interest of other patients to encourage them to follow and start exercising. Results would be shared with all clinical staff, case managers, family and peer mentors in the monthly staff meetings with the power point presentation.

Each time the power point presentation is presented it will be given by a patient who has completed or is currently actively walking and has some personal experience with the outcomes of decrease in IBM, lower cholesterol or triglycerides so that they may share their story during this time as well. These results and personal accolades will be shared with the Arizona Department of Health Services, Behavioral Health Services Division for Mauricio County as an effort to provide education to other outpatient clinics with the same patient population.

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