Participation in and Satisfaction With an Exercise Program for Inpatient Mental Health Consumers Perspectives in Psychiatric Care
ISSN 0031-5990
Participation in and Satisfaction With an Exercise Program for Inpatient Mental Health Consumers Robert Stanton, BHMSc (Hons), Trish Donohue, NUM B Hlth Sci, MMH, Michelle Garnon, B Ex Sport Sci, and Brenda Happell, PhD Robert Stanton, BHMSc (Hons), is a Lecturer in Sport and Exercise Sciences, School of Medical and Applied Sciences, Central Queensland University, Rockhampton, Queensland, Australia; Trish Donohue, NUM B Hlth Sci, MMH, is the Director of Nursing, Archerview Clinic, Hillcrest Private Hospital, Rockhampton, Queensland, Australia; Michelle Garnon, B Ex Sports Sci, is an Exercise Scientist, Archerview Clinic, Hillcrest Private Hospital, Rockhampton, Queensland, Australia; Brenda Happell, PhD, is Professor of Nursing, and Executive Director, Research Centre for Nursing and Midwifery Practice, University of Canberra, Faculty of Health and ACT Health, Canberra Hospital, Woden, Australian Capital Territory, Australia
Search terms: Exercise, group activity, inpatient ward, mental illness Author contact: [email protected], with a copy to the Editor: [email protected] First Received October 2, 2014; Final Revision received December 11, 2014; Accepted for publication January 29, 2015. Conflict of Interest Statement None to declare.
PURPOSE: This study examines attendance at, and satisfaction with, a group exercise program in an inpatient mental health setting. DESIGN AND METHOD: Thirty-two inpatients completed discharge surveys to evaluate group activities. Data were analyzed for participation and satisfaction. FINDINGS: More inpatients (n = 16, 50%) rated exercise as “excellent” compared with all other activities. Nonattendance rates were lowest for cognitive behavioral therapy (n = 2, 6.3%), highest for the relaxation group (n = 6, 18.8%), and 12.5% (n = 4) for the group exercise program. PRACTICE IMPLICATIONS: Group exercise programs delivered by highly trained personnel are well attended and achieve high satisfaction ratings by inpatient mental health consumers.
doi: 10.1111/ppc.12108
It is well accepted that people with serious mental illness (SMI) have poorer physical health outcomes and exhibit poorer physical health behaviors, compared with the general population (Bressington et al., 2014; Scott, Happell, Strange, & Platania-Phung, 2013). In particular, people with SMI participate in considerably less exercise compared with the general population (Bonsaksen & Lerdal, 2012) and few meet the recommended minimum level of physical activity for health of 150 min per week (Jerome et al., 2009). As a result, people with SMI have below-average physical capacity compared with the general population (Vancampfort et al., 2014). Exercise has been shown to benefit people with mental illness, although the magnitude of benefit and the mechanism by which exercise may exert its potential are not fully understood (Rosenbaum, Tiedemann, Sherrington, Curtis, & Ward, 2014; Zschucke, Gaudlitz, & Ströhle, 2013). Despite potential benefits, people with SMI experience significant barriers to exercise participation, including the side effects of medications and physical comorbidities (Glover, Ferron, & Whitley, 2013). These barriers are compounded by low 62
motivation, low confidence, financial disadvantage, social isolation, and low educational status (Ussher, Stanbury, Cheeseman, & Faulkner, 2007; Vancampfort, Probst, Knapen, Carraro, & De Hert, 2012). Mental health consumers hospitalized because of mental illness may be further disadvantaged by the extent of their illness and limited access to resources. However, a recent review concluded that, although the evidence is limited for some conditions, exercise programs delivered in the inpatient setting appear safe and effective for a range of SMIs, including schizophrenia, depression, and anxiety disorders (Stanton & Happell, 2013). However, uptake and adherence to exercise programs delivered in inpatient mental health settings is often poor (Bonsaksen, 2011). The development and delivery of lifestyle interventions in general, and exercise interventions specifically in mental health settings, is hampered by organizational and personal barriers such as limited resources, prioritization of other tasks and clinicians’ attitudes toward mental health consumers regarding the uptake of exercise programs (Happell, Platania Phung, & Scott, 2011; Harding, 2013). This is in spite of high Perspectives in Psychiatric Care 52 (2016) 62–67 © 2015 Wiley Periodicals, Inc.
Participation in and Satisfaction With an Exercise Program for Inpatient Mental Health Consumers
levels of satisfaction with general care among inpatient mental health consumers (Chastin & Shapiro, 1987; Kuosmanen, Hatonen, Jyrkinen, Katajisto, & Valimaki, 2006). Overall, published accounts of consumer ratings of satisfaction with group exercise and comparisons with other therapies in inpatient mental health settings are sparse. Therefore, the purpose of the present study was to report the outcomes of an anonymous discharge survey of inpatients in a private mental health facility in regional Queensland, Australia. Methods Setting Data collection took place in an inpatient mental health ward of a private hospital in regional Queensland, Australia. The ward is a 12-bed facility attached to a medium-sized private hospital. The average occupancy rate on the mental health ward is 77.5%. Mean length of stay is 22.4 days. The inpatient ward is staffed by six full-time nursing staff and seven parttime nursing staff, and utilizes the services of hospital allied health staff as required. The inpatient ward offers a number of group activities for inpatients designed to assist with recovery, including cognitive behavioral therapy, creative expression, relaxation, reflection/discussion, and exercise. Table 1 shows the frequency, duration, and delivery of these group activities. The cognitive behavioral therapy group sessions are delivered by a psychologist, nurse unit manager, or occupational therapist. The creative expression group includes activities such as cardmaking, music therapy, and art therapy, delivered by an occupational therapist, art teacher, and music teacher. Relaxation groups are psychologist-led and targeted toward reducing anxiety and improving mindfulness. Reflection/discussion groups, led by a clinical nurse psychotherapist, allow and encourage participants the opportunity to bring forward and examine more closely life’s hidden
or traumatic incidents in a safe and structured setting. This assists the client to develop insight, build resilience, and potentially draw on resources of which they may not have previously been consciously aware. The group exercise program is led by an experienced qualified exercise specialist with more than 20 years’ experience. This exercise specialist was employed by the clinic for the sole purpose of providing an exercise program. Inpatients typically perform a combination of aerobic exercise and resistance training. The aerobic exercise component includes approximately 20 min of aerobic exercise performed on a treadmill or stationary cycle at moderate or self-selected intensity. Resistance training comprises approximately 20 min of bodyweight or resistance band exercises performed for two to three sets of between eight and 15 repetitions at a self-selected intensity. The program is individualized to meet the needs of the patient within the group setting, and the instructor provides constant support and feedback to encourage ongoing participation, rather than progression and performance. Sample All inpatient mental health consumers who were discharged between January 2014 and March 2014 were considered eligible for participation in the present study. The evaluation survey was completed anonymously to minimize the potential for patient concern regarding the impact that negative responses might have on future admission or treatment. Therefore, patient demographics were not available for the present study. Measures Participation in group activities and level of satisfaction with each activity were obtained from anonymous evaluation surveys completed by inpatients on discharge. Satisfaction
Table 1. Details of Group Activities
Group type
Frequency offered
Duration of each session
Cognitive behavioral therapy
10 sessions per week
60 min
Creative expression
2 sessions per week
60–90 min
Relaxation Reflection/discussion
2 sessions per week 1 session per fortnight
50 min 60 min
Exercise
2 sessions per week
50 min
Perspectives in Psychiatric Care 52 (2016) 62–67 © 2015 Wiley Periodicals, Inc.
Who delivers the session Psychologist Nurse unit manager Occupational therapist Art teacher/music teacher Occupational therapist Psychologist Nurse psychotherapist Psychologist Qualified personal trainer/exercise science student
Compulsory or voluntary participation Voluntary
Voluntary Voluntary Voluntary Voluntary
63
Participation in and Satisfaction With an Exercise Program for Inpatient Mental Health Consumers
with each activity was rated using response choices of “excellent,”“very good,”“good,”“fair,”and“poor.”A“did not attend” option was provided for those who did not participate in any given group activity. While this scale may be biased toward favorable responses, scales of this nature have been frequently used in Australian healthcare settings (Pearse, 2005). Data were collected from patients discharged between January and March 2014. Statistical Analysis As this is a cross-sectional, single-site evaluation, data are presented as frequencies and proportions. Responses were weighted using the following numerical values: 5 for excellent, 4 for very good, 3 for good, 2 for fair, 1 for poor, and 0 for did not attend. Friedman’s test with post hoc Wilcoxon signedranks test and Bonferroni corrections was used to examine the between-activity differences in satisfaction scores. All statistical analyses were conducted using Statistical Package for the Social Sciences Version 20.0 (IBM Corp, Armonk, NY, USA). Ethical Clearance Approval for the access and analysis of the data presented in this article was received from the health services ethics committee. Results A total of 37 inpatients were discharged during the data collection period. Completed discharge surveys were obtained from 32 inpatients, representing 86.5% of inpatients discharged during the data collection period. Mean ranks for inpatient group activities and responses regarding the level of satisfaction with inpatient group activities are shown in Table 2. A greater proportion of inpatients (n = 16, 57.1%) rated exercise as “excellent” compared with all other activities. Nonattendance rates were lowest for cogni-
tive behavioral therapy (n = 2, 6.3%) and reflection/ discussion (n = 2, 6.3%) groups and highest for the relaxation group (n = 6, 18.8%). Friedman’s test showed a statistically significant betweenactivity difference in mean ranks for satisfaction scores (χ2[4] = 42.0, p < .001). Post hoc Wilcoxon’s signed-rank test with Bonferroni corrections revealed a statistically significant differences in satisfaction ranking between exercise and relaxation (Z = −3.900, p < .001), creative expression and relaxation (Z = −3.606, p < .001), reflection/discussion and relaxation (Z = −3.771, p < .001), and between reflection/ discussion and cognitive behavioral therapy (Z = −3.207, p < .001). Discussion The purpose of the present study was to evaluate the selfreported participation in, and satisfaction with, therapeutic activities undertaken by inpatients in a private mental health facility in regional Queensland, Australia. The major finding of this study is that satisfaction with exercise was ranked more highly than other group activities, and significantly higher than satisfaction with relaxation. While demographic data were not available for direct comparison, studies of mental health consumers in the same geographic region report a high prevalence of obesity and poor cardiometabolic health (Happell, Stanton, Hoey, & Scott, 2014), a finding that is consistent with those reported internationally (Lassenius, Åkerlind, Wiklund-Gustin, Arman, & Soderlund, 2012; Sugawara et al., 2013). Exercise is well established as a strategy to improve physical health outcomes (Garber et al., 2011). Therefore, interventions that promote exercise and contribute to improved physical health outcomes for people with mental illness are essential. Studies comparing patient satisfaction between group activities in inpatient mental health settings are sparse. Lim, Morris, and Craik (2007) evaluated the views of 64 inpatients regarding their views of occupational therapist delivered activities across 10 inpatient settings in the United Kingdom. Sports and cooking classes were ranked as the most helpful
Table 2. Self-Reported Attendance and Satisfaction With Inpatient Group Activities Responsea Group type
Mean rank
Excellent
Very good
Good
Fair
Poor
Did not attendb
Cognitive behavioral therapy (n = 30) Creative expression (n = 27) Relaxation (n = 26) Reflection/discussion (n = 30) Exercise (n = 28)
2.63 3.23 2.04 3.50 3.60
7 14 8 14 16
16 8 9 10 7
6 3 7 5 4
1 2 1 1 1
0 0 1 0 0
2 5 6 2 4
(23.3) (51.9) (30.8) (46.7) (57.1)
(53.3) (29.6) (34.6) (33.9) (25.0)
(20.0) (11.1) (26.9) (16.7) (14.3)
(3.3) (7.4) (3.6) (3.3) (3.6)
(0.0) (0.0) (3.6) (0.0) (0.0)
(6.3) (15.6) (18.8) (6.3) (12.5)
a
Responses are number of responses and proportion of those who attended that activity. bResponses are number of responses and proportion of total respondents (n = 32).
64
Perspectives in Psychiatric Care 52 (2016) 62–67 © 2015 Wiley Periodicals, Inc.
Participation in and Satisfaction With an Exercise Program for Inpatient Mental Health Consumers
group activity, although participation rates in these group activities were substantially less than other group activities such as arts and crafts, community meetings, and relaxation therapy. This finding is in contrast to that of the present study where nonattendance to the relaxation program was higher than that for the creative expression and exercise groups. The findings of the present study concur with those of Lim et al. (2007), showing that satisfaction with exercise was markedly higher than that of relaxation or creative expression groups. Differences in the content and delivery of the activities may partly explain the differential results from the Lim et al. study. In the present study, the exercise program was delivered by a highly experienced and qualified exercise professional. These qualities have been identified as essential to the successful delivery of exercise interventions generally (Warburton et al., 2011), and are recommended in mental health settings specifically (Stanton & Reaburn, 2013) to maximize consumer uptake, outcomes and continuation following discharge. Other studies have also reported high levels of satisfaction with physical health interventions by inpatient mental health consumers. For example, in an analysis of discharge surveys from 313 Finnish inpatients, Kuosmanen et al. (2006) reported mean patient satisfaction scores for physiotherapy services was 4.0 on a 5-point Likert scale (5 = very good, 1 = very poor) and 3.8 for occupational therapy services. However, there are difficulties with interpreting these outcomes. Firstly, details of the physiotherapy and occupational therapies are not reported, and secondly, a statistical comparison of satisfaction between treatment interventions was not performed. Group and one-on-one therapies are often viewed differently by people with mental illness. For example, Haahr et al. (2012) reported the level of treatment satisfaction for individual therapies such as individual psychotherapy was consistently rated more favorably, compared with group activities such as multifamily group therapies. Notably, this study was not undertaken in an inpatient unit and did not include evaluation of exercise or similar physical therapy interventions. Nonetheless, these findings suggest that an individual approach to exercise prescription, perhaps based on preference or prior experience may be worthy of consideration in the development and implementation of inpatient exercise programs. Recent qualitative examinations of satisfaction regarding participation in physical activity and exercise during inpatient stay focus on the healing aspect of inclusion, highlight the need for leadership qualities of the therapist, and the inclusive, nonjudgmental nature of the activity (Thibeault, Trudeau, d’Entremont, & Brown, 2010). Although highly valued by both inpatients and mental health nurses, and critical to successful treatment outcomes, the therapeutic relationship is difficult to quantify (McAndrew, Chambers, Perspectives in Psychiatric Care 52 (2016) 62–67 © 2015 Wiley Periodicals, Inc.
Nolan, Thomas, & Watts, 2014). In the present study, the consumer acceptance of the exercise program delivered by the highly experienced, qualified trainer, may, in part, be the result of an effective therapeutic relationship and arguably warrants further investigation. It may not be the“exercise”per se, rather the experience of the consumer, which contributes to recovery during inpatient stay. This might be particularly important in this setting since the exercise program was consistently delivered by the same individual, whereas other activities were delivered by multiple clinicians. Limitations The finding of the present study must be interpreted with caution. Since the discharge survey is completed anonymously, and a 100% completion rate was not achieved, we are unable to report the diagnostic, medication, or admission history of the respondents. Data were collected at a single site and over a small data collection period, resulting in a small sample. Participation in all group activities including the exercise program was voluntary and the associated selfselection bias may have influenced the outcomes. Therefore, the findings of the present study may not be able to be generalized to other inpatient mental health settings, which offer other group activities. The patient satisfaction rating scale favors positive responses, and does not identify what aspect of each therapeutic activity may be responsible for reported level of satisfaction. As previously described, scales of this nature are frequently used in the Australian healthcare setting. While more complex and detailed surveys may offer additional information, this needs to be balanced against survey completion rates. In the present study, satisfaction with group activities was assessed with a single item. While calls have been made for the use of validated, multidimensional satisfaction of psychiatric treatments scales (Crosier, Scott, & Steinfeld, 2012; Gros, Gros, Acierno, Frueh, & Morland, 2013), they remain general in nature and do not allow the comparison of different therapeutic activities in an inpatient setting. Practice Implications Studies such as the one presented here may be of significant interest to health services and inform both research and practice. The findings suggest that individualized exercise, delivered in an inpatient group setting, by a trained exercise professional is well accepted by inpatient mental health consumers, with satisfaction ratings exceeding that of wellestablished inpatient therapeutic modalities. Future studies that address the limitations outlined above are needed to confirm these findings. Despite these limitations, these novel data aid in our understanding of the development and delivery of exercise interventions in the inpatient setting. Treatment satisfaction surveys and the views of consumers are 65
Participation in and Satisfaction With an Exercise Program for Inpatient Mental Health Consumers
increasingly important in mental health. They allow the views of the consumer to be acknowledged and respected. Given the benefits of exercise for mental health consumers, exploring data on the inclusion of exercise in inpatient mental health settings is justified.
References Bonsaksen, T. (2011). Participation in physical activity among inpatients with severe mental illness: A pilot study. International Journal of Therapy and Rehabilitation, 18(2), 91–99. Bonsaksen, T., & Lerdal, A. (2012). Relationships between physical activity, symptoms and quality of life among inpatients with severe mental illness. British Journal of Occupational Therapy, 75(2), 69–75. doi:10.4276/030802212X13286281651036 Bressington, D., Mui, J., Hulbert, S., Cheung, E., Bradford, S., & Gray, R. (2014). Enhanced physical health screening for people with severe mental illness in Hong Kong: Results from a one-year prospective case series study. BMC Psychiatry, 14(1), 57. doi:10.1186/1471-244X-14-57 Chastin, P. B., & Shapiro, G. E. (1987). Physical fitness program for patients with psychiatric disorders: A clinical report. Physical Therapy, 67, 545–548. Crosier, M., Scott, J., & Steinfeld, B. (2012). Improving satisfaction in patients receiving mental health care: A case study. Journal of Behavioral Health Services & Research, 39(1), 42–54. doi:10.1007/s11414-011-9252-0 Garber, C. E., Blissmer, B., Deschenes, M. R., Franklin, B. A., Lamonte, M. J., Lee, I.-M., & Swain, D. P. (2011). Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Medicine and Science in Sports and Exercise, 43(7), 1334–1359. doi:10.1249/MSS.0b013e318213fefb Glover, C. M., Ferron, J. C., & Whitley, R. (2013). Barriers to exercise among people with severe mental illnesses. Psychiatric Rehabilitation Journal, 36(1), 45–47. doi:10.1037/h0094747 Gros, D., Gros, K., Acierno, R., Frueh, B. C., & Morland, L. (2013). Relation between treatment satisfaction and treatment outcome in veterans with posttraumatic stress disorder. Journal of Psychopathology and Behavioral Assessment, 35(4), 522–530. doi:10.1007/s10862-013-9361-6 Haahr, U., Simonsen, E., Røssberg, J. I., Johannessen, J. O., Larsen, T. K., Melle, I., & McGlashan, T. (2012). Patient satisfaction with treatment in first-episode psychosis. Nordic Journal of Psychiatry, 66(5), 329–335. doi:10.3109/08039488.2011.644808 Happell, B., Platania Phung, C., & Scott, D. (2011). Placing physical activity in mental health care: A leadership role for mental health nurses. International Journal of Mental Health Nursing, 20(5), 310–318. doi:10.1111/j.1447-0349.2010.00732.x Happell, B., Stanton, R., Hoey, W., & Scott, D. (2014). Cardiometabolic health nursing to improve health and primary care access in community mental health consumers: Baseline
66
physical health outcomes from a randomised controlled trial. Issues in Mental Health Nursing, 35(2), 114–121. doi:10.3109/01612840.2013.842619 Harding, S. L. (2013). Direct care staff perspectives related to physical activity in mental health group homes. Journal of Psychosocial Nursing and Mental Health Services, 51(12), 38–43. doi:10.3928/02793695-20130827-01 Jerome, G. J., Rohm Young, D., Dalcin, A., Charleston, J., Anthony, C., Hayes, J., & Daumit, G. L. (2009). Physical activity levels of persons with mental illness attending psychiatric rehabilitation programs. Schizophrenia Research, 108(1–3), 252–257. doi:10.1016/j.schres.2008.12.006 Kuosmanen, L., Hatonen, H., Jyrkinen, A. R., Katajisto, J., & Valimaki, M. (2006). Patient satisfaction with psychiatric inpatient care. Journal of Advanced Nursing, 55(6), 655–663. doi:10.1111/j.1365-2648.2006.03957.x Lassenius, O., Åkerlind, I., Wiklund-Gustin, L., Arman, M., & Soderlund, A. (2012). Self-reported health and physical activity among community mental healthcare users. Journal of Psychiatric and Mental Health Nursing, 20(1), 82–90. doi:10.1111/j.1365-2850.2012.01951.x Lim, K. H., Morris, J., & Craik, C. (2007). Inpatients’ perspectives of occupational therapy in acute mental health. Australian Occupational Therapy Journal, 54(1), 22–32. doi:10.1111/j.1440-1630.2006.00647.x McAndrew, S., Chambers, M., Nolan, F., Thomas, B., & Watts, P. (2014). Measuring the evidence: Reviewing the literature of the measurement of therapeutic engagement in acute mental health inpatient wards. International Journal of Mental Health Nursing, 23(3), 212–220. doi:10.1111/inm.12044 Pearse, J. (2005). Review of patient satisfaction and experience surveys conducted for public hospitals in Australia. St. Leonards, NSW, Australia: Health Policy Analysis Pty Ltd. Rosenbaum, S., Tiedemann, A., Sherrington, C., Curtis, J., & Ward, P. B. (2014). Physical activity interventions for people with mental illness: A systematic review and meta-analysis. Journal of Clinical Psychiatry, 75, 964–974. doi:10.4088/JCP.13r08765 Scott, D., Happell, B., Strange, S., & Platania-Phung, C. (2013). Investigating self-reported health behaviors in Australian adults with mental illness. Behavioral Medicine, 39(3), 60–65. doi:10.1080/08964289.2012.726289 Stanton, R., & Happell, B. (2013). Exercise and mental illness: A systematic review of inpatient studies. International Journal of Nursing Studies, 23(3), 232–242. doi:10.1111/inm.12045 Stanton, R., & Reaburn, P. (2013). Exercise and the treatment of depression: A review of the exercise program variables. Journal of Science and Medicine in Sport, 17(2), 117–182. doi:10.1016/j.jsams.2013.03.010 Sugawara, N., Yasui-Furukori, N., Sato, Y., Saito, M., Furukori, H., Nakagami, T., & Kaneko, S. (2013). Body mass index and quality of life among outpatients with schizophrenia in Japan. BMC Psychiatry, 13(1), 108. doi:10.1186/1471-244x-13-108 Thibeault, C. A., Trudeau, K., d’Entremont, M., & Brown, T. (2010). Understanding the milieu experiences of patients on an
Perspectives in Psychiatric Care 52 (2016) 62–67 © 2015 Wiley Periodicals, Inc.
Participation in and Satisfaction With an Exercise Program for Inpatient Mental Health Consumers
acute inpatient psychiatric unit. Archives of Psychiatric Nursing, 24(4), 216–226. doi:10.1016/j.apnu.2009.07.002 Ussher, M., Stanbury, L., Cheeseman, V., & Faulkner, G. (2007). Physical activity preferences and perceived barriers to activity among persons with severe mental illness in the United Kingdom. Psychiatric Services: A Journal of the American Psychiatric Association, 58(3), 405–408. doi:10.1176/appi.ps.58.3.405 Vancampfort, D., Probst, M., Knapen, J., Carraro, A., & De Hert, M. (2012). Associations between sedentary behaviour and metabolic parameters in patients with schizophrenia. Psychiatry Research, 200(2–3), 73–78. doi:10.1016/j.psychres.2012.03.046 Vancampfort, D., De Herdt, A., Vanderlinden, J., Lannoo, M., Soundy, A., Pieters, G., & Probst, M. (2014). Health related
Perspectives in Psychiatric Care 52 (2016) 62–67 © 2015 Wiley Periodicals, Inc.
quality of life, physical fitness and physical activity participation in treatment-seeking obese persons with and without binge eating disorder. Psychiatry Research, 216(1), 97–102. doi:10.1016/j.psychres.2014.01.015 Warburton, D. E., Bredin, S. S., Charlesworth, S. A., Foulds, H. J., McKenzie, D. C., & Shephard, R. J. (2011). Evidence-based risk recommendations for best practices in the training of qualified exercise professionals working with clinical populations. Applied Physiology, Nutrition, and Metabolism, 36(Suppl. 1), S232–S265. doi:10.1139/h11-054 Zschucke, E., Gaudlitz, K., & Ströhle, A. (2013). Exercise and physical activity in mental disorders: Clinical and experimental evidence. Journal of Preventive Medicine and Public Health, 46(Suppl. 1), S12–S21. doi:10.3961/jpmph.2013.46.S.S12
67
ISSN 0031-5990
Participation in and Satisfaction With an Exercise Program for Inpatient Mental Health Consumers Robert Stanton, BHMSc (Hons), Trish Donohue, NUM B Hlth Sci, MMH, Michelle Garnon, B Ex Sport Sci, and Brenda Happell, PhD Robert Stanton, BHMSc (Hons), is a Lecturer in Sport and Exercise Sciences, School of Medical and Applied Sciences, Central Queensland University, Rockhampton, Queensland, Australia; Trish Donohue, NUM B Hlth Sci, MMH, is the Director of Nursing, Archerview Clinic, Hillcrest Private Hospital, Rockhampton, Queensland, Australia; Michelle Garnon, B Ex Sports Sci, is an Exercise Scientist, Archerview Clinic, Hillcrest Private Hospital, Rockhampton, Queensland, Australia; Brenda Happell, PhD, is Professor of Nursing, and Executive Director, Research Centre for Nursing and Midwifery Practice, University of Canberra, Faculty of Health and ACT Health, Canberra Hospital, Woden, Australian Capital Territory, Australia
Search terms: Exercise, group activity, inpatient ward, mental illness Author contact: [email protected], with a copy to the Editor: [email protected] First Received October 2, 2014; Final Revision received December 11, 2014; Accepted for publication January 29, 2015. Conflict of Interest Statement None to declare.
PURPOSE: This study examines attendance at, and satisfaction with, a group exercise program in an inpatient mental health setting. DESIGN AND METHOD: Thirty-two inpatients completed discharge surveys to evaluate group activities. Data were analyzed for participation and satisfaction. FINDINGS: More inpatients (n = 16, 50%) rated exercise as “excellent” compared with all other activities. Nonattendance rates were lowest for cognitive behavioral therapy (n = 2, 6.3%), highest for the relaxation group (n = 6, 18.8%), and 12.5% (n = 4) for the group exercise program. PRACTICE IMPLICATIONS: Group exercise programs delivered by highly trained personnel are well attended and achieve high satisfaction ratings by inpatient mental health consumers.
doi: 10.1111/ppc.12108
It is well accepted that people with serious mental illness (SMI) have poorer physical health outcomes and exhibit poorer physical health behaviors, compared with the general population (Bressington et al., 2014; Scott, Happell, Strange, & Platania-Phung, 2013). In particular, people with SMI participate in considerably less exercise compared with the general population (Bonsaksen & Lerdal, 2012) and few meet the recommended minimum level of physical activity for health of 150 min per week (Jerome et al., 2009). As a result, people with SMI have below-average physical capacity compared with the general population (Vancampfort et al., 2014). Exercise has been shown to benefit people with mental illness, although the magnitude of benefit and the mechanism by which exercise may exert its potential are not fully understood (Rosenbaum, Tiedemann, Sherrington, Curtis, & Ward, 2014; Zschucke, Gaudlitz, & Ströhle, 2013). Despite potential benefits, people with SMI experience significant barriers to exercise participation, including the side effects of medications and physical comorbidities (Glover, Ferron, & Whitley, 2013). These barriers are compounded by low 62
motivation, low confidence, financial disadvantage, social isolation, and low educational status (Ussher, Stanbury, Cheeseman, & Faulkner, 2007; Vancampfort, Probst, Knapen, Carraro, & De Hert, 2012). Mental health consumers hospitalized because of mental illness may be further disadvantaged by the extent of their illness and limited access to resources. However, a recent review concluded that, although the evidence is limited for some conditions, exercise programs delivered in the inpatient setting appear safe and effective for a range of SMIs, including schizophrenia, depression, and anxiety disorders (Stanton & Happell, 2013). However, uptake and adherence to exercise programs delivered in inpatient mental health settings is often poor (Bonsaksen, 2011). The development and delivery of lifestyle interventions in general, and exercise interventions specifically in mental health settings, is hampered by organizational and personal barriers such as limited resources, prioritization of other tasks and clinicians’ attitudes toward mental health consumers regarding the uptake of exercise programs (Happell, Platania Phung, & Scott, 2011; Harding, 2013). This is in spite of high Perspectives in Psychiatric Care 52 (2016) 62–67 © 2015 Wiley Periodicals, Inc.
Participation in and Satisfaction With an Exercise Program for Inpatient Mental Health Consumers
levels of satisfaction with general care among inpatient mental health consumers (Chastin & Shapiro, 1987; Kuosmanen, Hatonen, Jyrkinen, Katajisto, & Valimaki, 2006). Overall, published accounts of consumer ratings of satisfaction with group exercise and comparisons with other therapies in inpatient mental health settings are sparse. Therefore, the purpose of the present study was to report the outcomes of an anonymous discharge survey of inpatients in a private mental health facility in regional Queensland, Australia. Methods Setting Data collection took place in an inpatient mental health ward of a private hospital in regional Queensland, Australia. The ward is a 12-bed facility attached to a medium-sized private hospital. The average occupancy rate on the mental health ward is 77.5%. Mean length of stay is 22.4 days. The inpatient ward is staffed by six full-time nursing staff and seven parttime nursing staff, and utilizes the services of hospital allied health staff as required. The inpatient ward offers a number of group activities for inpatients designed to assist with recovery, including cognitive behavioral therapy, creative expression, relaxation, reflection/discussion, and exercise. Table 1 shows the frequency, duration, and delivery of these group activities. The cognitive behavioral therapy group sessions are delivered by a psychologist, nurse unit manager, or occupational therapist. The creative expression group includes activities such as cardmaking, music therapy, and art therapy, delivered by an occupational therapist, art teacher, and music teacher. Relaxation groups are psychologist-led and targeted toward reducing anxiety and improving mindfulness. Reflection/discussion groups, led by a clinical nurse psychotherapist, allow and encourage participants the opportunity to bring forward and examine more closely life’s hidden
or traumatic incidents in a safe and structured setting. This assists the client to develop insight, build resilience, and potentially draw on resources of which they may not have previously been consciously aware. The group exercise program is led by an experienced qualified exercise specialist with more than 20 years’ experience. This exercise specialist was employed by the clinic for the sole purpose of providing an exercise program. Inpatients typically perform a combination of aerobic exercise and resistance training. The aerobic exercise component includes approximately 20 min of aerobic exercise performed on a treadmill or stationary cycle at moderate or self-selected intensity. Resistance training comprises approximately 20 min of bodyweight or resistance band exercises performed for two to three sets of between eight and 15 repetitions at a self-selected intensity. The program is individualized to meet the needs of the patient within the group setting, and the instructor provides constant support and feedback to encourage ongoing participation, rather than progression and performance. Sample All inpatient mental health consumers who were discharged between January 2014 and March 2014 were considered eligible for participation in the present study. The evaluation survey was completed anonymously to minimize the potential for patient concern regarding the impact that negative responses might have on future admission or treatment. Therefore, patient demographics were not available for the present study. Measures Participation in group activities and level of satisfaction with each activity were obtained from anonymous evaluation surveys completed by inpatients on discharge. Satisfaction
Table 1. Details of Group Activities
Group type
Frequency offered
Duration of each session
Cognitive behavioral therapy
10 sessions per week
60 min
Creative expression
2 sessions per week
60–90 min
Relaxation Reflection/discussion
2 sessions per week 1 session per fortnight
50 min 60 min
Exercise
2 sessions per week
50 min
Perspectives in Psychiatric Care 52 (2016) 62–67 © 2015 Wiley Periodicals, Inc.
Who delivers the session Psychologist Nurse unit manager Occupational therapist Art teacher/music teacher Occupational therapist Psychologist Nurse psychotherapist Psychologist Qualified personal trainer/exercise science student
Compulsory or voluntary participation Voluntary
Voluntary Voluntary Voluntary Voluntary
63
Participation in and Satisfaction With an Exercise Program for Inpatient Mental Health Consumers
with each activity was rated using response choices of “excellent,”“very good,”“good,”“fair,”and“poor.”A“did not attend” option was provided for those who did not participate in any given group activity. While this scale may be biased toward favorable responses, scales of this nature have been frequently used in Australian healthcare settings (Pearse, 2005). Data were collected from patients discharged between January and March 2014. Statistical Analysis As this is a cross-sectional, single-site evaluation, data are presented as frequencies and proportions. Responses were weighted using the following numerical values: 5 for excellent, 4 for very good, 3 for good, 2 for fair, 1 for poor, and 0 for did not attend. Friedman’s test with post hoc Wilcoxon signedranks test and Bonferroni corrections was used to examine the between-activity differences in satisfaction scores. All statistical analyses were conducted using Statistical Package for the Social Sciences Version 20.0 (IBM Corp, Armonk, NY, USA). Ethical Clearance Approval for the access and analysis of the data presented in this article was received from the health services ethics committee. Results A total of 37 inpatients were discharged during the data collection period. Completed discharge surveys were obtained from 32 inpatients, representing 86.5% of inpatients discharged during the data collection period. Mean ranks for inpatient group activities and responses regarding the level of satisfaction with inpatient group activities are shown in Table 2. A greater proportion of inpatients (n = 16, 57.1%) rated exercise as “excellent” compared with all other activities. Nonattendance rates were lowest for cogni-
tive behavioral therapy (n = 2, 6.3%) and reflection/ discussion (n = 2, 6.3%) groups and highest for the relaxation group (n = 6, 18.8%). Friedman’s test showed a statistically significant betweenactivity difference in mean ranks for satisfaction scores (χ2[4] = 42.0, p < .001). Post hoc Wilcoxon’s signed-rank test with Bonferroni corrections revealed a statistically significant differences in satisfaction ranking between exercise and relaxation (Z = −3.900, p < .001), creative expression and relaxation (Z = −3.606, p < .001), reflection/discussion and relaxation (Z = −3.771, p < .001), and between reflection/ discussion and cognitive behavioral therapy (Z = −3.207, p < .001). Discussion The purpose of the present study was to evaluate the selfreported participation in, and satisfaction with, therapeutic activities undertaken by inpatients in a private mental health facility in regional Queensland, Australia. The major finding of this study is that satisfaction with exercise was ranked more highly than other group activities, and significantly higher than satisfaction with relaxation. While demographic data were not available for direct comparison, studies of mental health consumers in the same geographic region report a high prevalence of obesity and poor cardiometabolic health (Happell, Stanton, Hoey, & Scott, 2014), a finding that is consistent with those reported internationally (Lassenius, Åkerlind, Wiklund-Gustin, Arman, & Soderlund, 2012; Sugawara et al., 2013). Exercise is well established as a strategy to improve physical health outcomes (Garber et al., 2011). Therefore, interventions that promote exercise and contribute to improved physical health outcomes for people with mental illness are essential. Studies comparing patient satisfaction between group activities in inpatient mental health settings are sparse. Lim, Morris, and Craik (2007) evaluated the views of 64 inpatients regarding their views of occupational therapist delivered activities across 10 inpatient settings in the United Kingdom. Sports and cooking classes were ranked as the most helpful
Table 2. Self-Reported Attendance and Satisfaction With Inpatient Group Activities Responsea Group type
Mean rank
Excellent
Very good
Good
Fair
Poor
Did not attendb
Cognitive behavioral therapy (n = 30) Creative expression (n = 27) Relaxation (n = 26) Reflection/discussion (n = 30) Exercise (n = 28)
2.63 3.23 2.04 3.50 3.60
7 14 8 14 16
16 8 9 10 7
6 3 7 5 4
1 2 1 1 1
0 0 1 0 0
2 5 6 2 4
(23.3) (51.9) (30.8) (46.7) (57.1)
(53.3) (29.6) (34.6) (33.9) (25.0)
(20.0) (11.1) (26.9) (16.7) (14.3)
(3.3) (7.4) (3.6) (3.3) (3.6)
(0.0) (0.0) (3.6) (0.0) (0.0)
(6.3) (15.6) (18.8) (6.3) (12.5)
a
Responses are number of responses and proportion of those who attended that activity. bResponses are number of responses and proportion of total respondents (n = 32).
64
Perspectives in Psychiatric Care 52 (2016) 62–67 © 2015 Wiley Periodicals, Inc.
Participation in and Satisfaction With an Exercise Program for Inpatient Mental Health Consumers
group activity, although participation rates in these group activities were substantially less than other group activities such as arts and crafts, community meetings, and relaxation therapy. This finding is in contrast to that of the present study where nonattendance to the relaxation program was higher than that for the creative expression and exercise groups. The findings of the present study concur with those of Lim et al. (2007), showing that satisfaction with exercise was markedly higher than that of relaxation or creative expression groups. Differences in the content and delivery of the activities may partly explain the differential results from the Lim et al. study. In the present study, the exercise program was delivered by a highly experienced and qualified exercise professional. These qualities have been identified as essential to the successful delivery of exercise interventions generally (Warburton et al., 2011), and are recommended in mental health settings specifically (Stanton & Reaburn, 2013) to maximize consumer uptake, outcomes and continuation following discharge. Other studies have also reported high levels of satisfaction with physical health interventions by inpatient mental health consumers. For example, in an analysis of discharge surveys from 313 Finnish inpatients, Kuosmanen et al. (2006) reported mean patient satisfaction scores for physiotherapy services was 4.0 on a 5-point Likert scale (5 = very good, 1 = very poor) and 3.8 for occupational therapy services. However, there are difficulties with interpreting these outcomes. Firstly, details of the physiotherapy and occupational therapies are not reported, and secondly, a statistical comparison of satisfaction between treatment interventions was not performed. Group and one-on-one therapies are often viewed differently by people with mental illness. For example, Haahr et al. (2012) reported the level of treatment satisfaction for individual therapies such as individual psychotherapy was consistently rated more favorably, compared with group activities such as multifamily group therapies. Notably, this study was not undertaken in an inpatient unit and did not include evaluation of exercise or similar physical therapy interventions. Nonetheless, these findings suggest that an individual approach to exercise prescription, perhaps based on preference or prior experience may be worthy of consideration in the development and implementation of inpatient exercise programs. Recent qualitative examinations of satisfaction regarding participation in physical activity and exercise during inpatient stay focus on the healing aspect of inclusion, highlight the need for leadership qualities of the therapist, and the inclusive, nonjudgmental nature of the activity (Thibeault, Trudeau, d’Entremont, & Brown, 2010). Although highly valued by both inpatients and mental health nurses, and critical to successful treatment outcomes, the therapeutic relationship is difficult to quantify (McAndrew, Chambers, Perspectives in Psychiatric Care 52 (2016) 62–67 © 2015 Wiley Periodicals, Inc.
Nolan, Thomas, & Watts, 2014). In the present study, the consumer acceptance of the exercise program delivered by the highly experienced, qualified trainer, may, in part, be the result of an effective therapeutic relationship and arguably warrants further investigation. It may not be the“exercise”per se, rather the experience of the consumer, which contributes to recovery during inpatient stay. This might be particularly important in this setting since the exercise program was consistently delivered by the same individual, whereas other activities were delivered by multiple clinicians. Limitations The finding of the present study must be interpreted with caution. Since the discharge survey is completed anonymously, and a 100% completion rate was not achieved, we are unable to report the diagnostic, medication, or admission history of the respondents. Data were collected at a single site and over a small data collection period, resulting in a small sample. Participation in all group activities including the exercise program was voluntary and the associated selfselection bias may have influenced the outcomes. Therefore, the findings of the present study may not be able to be generalized to other inpatient mental health settings, which offer other group activities. The patient satisfaction rating scale favors positive responses, and does not identify what aspect of each therapeutic activity may be responsible for reported level of satisfaction. As previously described, scales of this nature are frequently used in the Australian healthcare setting. While more complex and detailed surveys may offer additional information, this needs to be balanced against survey completion rates. In the present study, satisfaction with group activities was assessed with a single item. While calls have been made for the use of validated, multidimensional satisfaction of psychiatric treatments scales (Crosier, Scott, & Steinfeld, 2012; Gros, Gros, Acierno, Frueh, & Morland, 2013), they remain general in nature and do not allow the comparison of different therapeutic activities in an inpatient setting. Practice Implications Studies such as the one presented here may be of significant interest to health services and inform both research and practice. The findings suggest that individualized exercise, delivered in an inpatient group setting, by a trained exercise professional is well accepted by inpatient mental health consumers, with satisfaction ratings exceeding that of wellestablished inpatient therapeutic modalities. Future studies that address the limitations outlined above are needed to confirm these findings. Despite these limitations, these novel data aid in our understanding of the development and delivery of exercise interventions in the inpatient setting. Treatment satisfaction surveys and the views of consumers are 65
Participation in and Satisfaction With an Exercise Program for Inpatient Mental Health Consumers
increasingly important in mental health. They allow the views of the consumer to be acknowledged and respected. Given the benefits of exercise for mental health consumers, exploring data on the inclusion of exercise in inpatient mental health settings is justified.
References Bonsaksen, T. (2011). Participation in physical activity among inpatients with severe mental illness: A pilot study. International Journal of Therapy and Rehabilitation, 18(2), 91–99. Bonsaksen, T., & Lerdal, A. (2012). Relationships between physical activity, symptoms and quality of life among inpatients with severe mental illness. British Journal of Occupational Therapy, 75(2), 69–75. doi:10.4276/030802212X13286281651036 Bressington, D., Mui, J., Hulbert, S., Cheung, E., Bradford, S., & Gray, R. (2014). Enhanced physical health screening for people with severe mental illness in Hong Kong: Results from a one-year prospective case series study. BMC Psychiatry, 14(1), 57. doi:10.1186/1471-244X-14-57 Chastin, P. B., & Shapiro, G. E. (1987). Physical fitness program for patients with psychiatric disorders: A clinical report. Physical Therapy, 67, 545–548. Crosier, M., Scott, J., & Steinfeld, B. (2012). Improving satisfaction in patients receiving mental health care: A case study. Journal of Behavioral Health Services & Research, 39(1), 42–54. doi:10.1007/s11414-011-9252-0 Garber, C. E., Blissmer, B., Deschenes, M. R., Franklin, B. A., Lamonte, M. J., Lee, I.-M., & Swain, D. P. (2011). Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Medicine and Science in Sports and Exercise, 43(7), 1334–1359. doi:10.1249/MSS.0b013e318213fefb Glover, C. M., Ferron, J. C., & Whitley, R. (2013). Barriers to exercise among people with severe mental illnesses. Psychiatric Rehabilitation Journal, 36(1), 45–47. doi:10.1037/h0094747 Gros, D., Gros, K., Acierno, R., Frueh, B. C., & Morland, L. (2013). Relation between treatment satisfaction and treatment outcome in veterans with posttraumatic stress disorder. Journal of Psychopathology and Behavioral Assessment, 35(4), 522–530. doi:10.1007/s10862-013-9361-6 Haahr, U., Simonsen, E., Røssberg, J. I., Johannessen, J. O., Larsen, T. K., Melle, I., & McGlashan, T. (2012). Patient satisfaction with treatment in first-episode psychosis. Nordic Journal of Psychiatry, 66(5), 329–335. doi:10.3109/08039488.2011.644808 Happell, B., Platania Phung, C., & Scott, D. (2011). Placing physical activity in mental health care: A leadership role for mental health nurses. International Journal of Mental Health Nursing, 20(5), 310–318. doi:10.1111/j.1447-0349.2010.00732.x Happell, B., Stanton, R., Hoey, W., & Scott, D. (2014). Cardiometabolic health nursing to improve health and primary care access in community mental health consumers: Baseline
66
physical health outcomes from a randomised controlled trial. Issues in Mental Health Nursing, 35(2), 114–121. doi:10.3109/01612840.2013.842619 Harding, S. L. (2013). Direct care staff perspectives related to physical activity in mental health group homes. Journal of Psychosocial Nursing and Mental Health Services, 51(12), 38–43. doi:10.3928/02793695-20130827-01 Jerome, G. J., Rohm Young, D., Dalcin, A., Charleston, J., Anthony, C., Hayes, J., & Daumit, G. L. (2009). Physical activity levels of persons with mental illness attending psychiatric rehabilitation programs. Schizophrenia Research, 108(1–3), 252–257. doi:10.1016/j.schres.2008.12.006 Kuosmanen, L., Hatonen, H., Jyrkinen, A. R., Katajisto, J., & Valimaki, M. (2006). Patient satisfaction with psychiatric inpatient care. Journal of Advanced Nursing, 55(6), 655–663. doi:10.1111/j.1365-2648.2006.03957.x Lassenius, O., Åkerlind, I., Wiklund-Gustin, L., Arman, M., & Soderlund, A. (2012). Self-reported health and physical activity among community mental healthcare users. Journal of Psychiatric and Mental Health Nursing, 20(1), 82–90. doi:10.1111/j.1365-2850.2012.01951.x Lim, K. H., Morris, J., & Craik, C. (2007). Inpatients’ perspectives of occupational therapy in acute mental health. Australian Occupational Therapy Journal, 54(1), 22–32. doi:10.1111/j.1440-1630.2006.00647.x McAndrew, S., Chambers, M., Nolan, F., Thomas, B., & Watts, P. (2014). Measuring the evidence: Reviewing the literature of the measurement of therapeutic engagement in acute mental health inpatient wards. International Journal of Mental Health Nursing, 23(3), 212–220. doi:10.1111/inm.12044 Pearse, J. (2005). Review of patient satisfaction and experience surveys conducted for public hospitals in Australia. St. Leonards, NSW, Australia: Health Policy Analysis Pty Ltd. Rosenbaum, S., Tiedemann, A., Sherrington, C., Curtis, J., & Ward, P. B. (2014). Physical activity interventions for people with mental illness: A systematic review and meta-analysis. Journal of Clinical Psychiatry, 75, 964–974. doi:10.4088/JCP.13r08765 Scott, D., Happell, B., Strange, S., & Platania-Phung, C. (2013). Investigating self-reported health behaviors in Australian adults with mental illness. Behavioral Medicine, 39(3), 60–65. doi:10.1080/08964289.2012.726289 Stanton, R., & Happell, B. (2013). Exercise and mental illness: A systematic review of inpatient studies. International Journal of Nursing Studies, 23(3), 232–242. doi:10.1111/inm.12045 Stanton, R., & Reaburn, P. (2013). Exercise and the treatment of depression: A review of the exercise program variables. Journal of Science and Medicine in Sport, 17(2), 117–182. doi:10.1016/j.jsams.2013.03.010 Sugawara, N., Yasui-Furukori, N., Sato, Y., Saito, M., Furukori, H., Nakagami, T., & Kaneko, S. (2013). Body mass index and quality of life among outpatients with schizophrenia in Japan. BMC Psychiatry, 13(1), 108. doi:10.1186/1471-244x-13-108 Thibeault, C. A., Trudeau, K., d’Entremont, M., & Brown, T. (2010). Understanding the milieu experiences of patients on an
Perspectives in Psychiatric Care 52 (2016) 62–67 © 2015 Wiley Periodicals, Inc.
Participation in and Satisfaction With an Exercise Program for Inpatient Mental Health Consumers
acute inpatient psychiatric unit. Archives of Psychiatric Nursing, 24(4), 216–226. doi:10.1016/j.apnu.2009.07.002 Ussher, M., Stanbury, L., Cheeseman, V., & Faulkner, G. (2007). Physical activity preferences and perceived barriers to activity among persons with severe mental illness in the United Kingdom. Psychiatric Services: A Journal of the American Psychiatric Association, 58(3), 405–408. doi:10.1176/appi.ps.58.3.405 Vancampfort, D., Probst, M., Knapen, J., Carraro, A., & De Hert, M. (2012). Associations between sedentary behaviour and metabolic parameters in patients with schizophrenia. Psychiatry Research, 200(2–3), 73–78. doi:10.1016/j.psychres.2012.03.046 Vancampfort, D., De Herdt, A., Vanderlinden, J., Lannoo, M., Soundy, A., Pieters, G., & Probst, M. (2014). Health related
Perspectives in Psychiatric Care 52 (2016) 62–67 © 2015 Wiley Periodicals, Inc.
quality of life, physical fitness and physical activity participation in treatment-seeking obese persons with and without binge eating disorder. Psychiatry Research, 216(1), 97–102. doi:10.1016/j.psychres.2014.01.015 Warburton, D. E., Bredin, S. S., Charlesworth, S. A., Foulds, H. J., McKenzie, D. C., & Shephard, R. J. (2011). Evidence-based risk recommendations for best practices in the training of qualified exercise professionals working with clinical populations. Applied Physiology, Nutrition, and Metabolism, 36(Suppl. 1), S232–S265. doi:10.1139/h11-054 Zschucke, E., Gaudlitz, K., & Ströhle, A. (2013). Exercise and physical activity in mental disorders: Clinical and experimental evidence. Journal of Preventive Medicine and Public Health, 46(Suppl. 1), S12–S21. doi:10.3961/jpmph.2013.46.S.S12
67
