- Email: [email protected]
Improving Exercise Prescribing in a Rural New England Free Clinic
BRIEF REPORT
Improving Exercise Prescribing in a Rural New England Free Clinic Patricia Thompson Leavitt, DNP, FNP ABSTRACT
This quality improvement project was undertaken to improve exercise prescribing frequency and quality in a rural New England free clinic. Prescribing guidelines from the American College of Sports Medicine and the American Academy of Family Physicians were used. Following a provider education program and workgroup-implemented documentation changes, overall exercise prescription frequency increased significantly from 34.6% in the pre-intervention group to 65.0% in the post-intervention group (P < .05). The use of some prescription elements (frequency, intensity, and timing) improved significantly (P < .05). Further study from the patient perspective is warranted. Keywords: exercise prescription, FITT-PRO mnemonic, free clinic, inactivity, quality improvement, rural Ó 2016 Elsevier Inc. All rights reserved.
INTRODUCTION Background Knowledge
T
he World Health Organization (WHO) identifies inactivity as the fourth leading cause of mortality, accounting for 6% of deaths worldwide.1 This places inactivity behind only high blood pressure (13%) and tobacco use (9%) as causative factors for mortality and is equal to high blood glucose (6%). Although obesity logically follows from a sedentary lifestyle, inactivity is a risk factor for abdominal adiposity and coronary heart disease independent of body mass index (BMI).2 Multiple factors and antecedents contribute to inactivity, including lack of time or motivation, increasing use of technology for work and recreation, and lack of knowledge.3 For lower income persons, barriers to daily exercise exist in terms of money, time, and access to exercise equipment, yet most intervention studies have not accessed disadvantaged populations.4,5 Barriers to exercise notwithstanding, research findings suggest that advice from respected health care professionals can have a positive impact on exercise rates.6,7 Despite evidence supporting the benefits of exercise, providers use exercise prescribing on a limited basis. In 2010, only 9.2% of provider office visits in the United States included counseling patients to participate in regular physical activity.8 One reason for providers’ failure to prescribe is lack of time, www.npjournal.org
even when structured programs are in place to assure consistency and follow-up.9-12 Provider knowledge deficits about the specifics of exercise prescribing and confidence in prescribing abilities also play a role.13 Providers are most adept at utilizing the first 2 elements of the “Ask-Advise-Agree-Assist-Arrange” model used for change coaching12; they are not as comfortable at assessing readiness to change (“Agree”) or providing follow-up (“Assist” and “Arrange”). Ackermann et al14 found that providers were more likely to prescribe exercise for patients who were in the contemplation stage of change. In addition, providers are generally more inclined to target activity prescribing for obese individuals or those suffering from chronic disease.8,15 The American College of Sports Medicine (ACSM) has published recommendations for exercise prescribing in all populations.6 The prescribing mnemonic “FITT-PRO” (Frequency, Intensity, Type, Time, and PROgression), as described by the American Academy of Family Physicians guideline, instructs the provider to consider each type of exercise (aerobic or endurance, flexibility, strengthening, and balance) and develop a prescription.16 For example, a provider may create a prescription that reads: “Aerobic activity such as walking (Type), daily (Frequency) for 30 minutes per day (Timing). Exercise hard enough so that you cannot sing but are still able to talk (Intensity). Start The Journal for Nurse Practitioners - JNP
e1
with 10 minutes per day as tolerated; increase by 5 minutes every 3 days until you reach 30 minutes daily” (Progression). Local Problem
As part of ongoing quality improvement (QI) efforts before this project, gaps were identified in addressing leisure time physical activity with each patient. The Leavitt’s Mill Free Health Center (LMFHC) patient baseline activity rates (36%) and documentation of provider exercise prescribing (32%) were comparable to national statistics for similar populations (N ¼ 50).8,17 Intended Improvement
The aim of this QI project was to improve exercise prescribing frequency and improve exercise prescribing quality at LMFHC by implementing the ACSM exercise prescribing guidelines and the prescribing mnemonic FITT-PRO from the American Academy of Family Physicians.6,16 The target for improvement was to double exercise prescribing rates from baseline. METHODS Ethical Issues
Approval for this project was granted by the institutional review board of Simmons College and the board of directors of the LMFHC. Potential bias by the project investigator, who also served as the health center’s director, was safeguarded by the use of graduate assistants who managed all primary data and de-identified data before analysis.
Planning the Intervention
Needs assessment interviews and educational session. After receiving informed consent, clinic staff (n ¼ 9) were interviewed to ascertain their comfort and knowledge about exercise prescribing and advising. The data from these interviews formed the basis of the 90-minute educational intervention. The educational session was provided, which included a brief overview of current evidence regarding exercise benefits and the principles of exercise prescribing using the ACSM exercise prescribing guidelines, and the FITT-PRO mnemonic.6,16 Specific information was offered regarding the particular absolute and relative contraindications to an exercise prescription. Strategies for incorporating the FITT-PRO elements of a complete exercise prescription were presented with an emphasis on timing and progression, components unfamiliar to this group of providers. QI workgroup. Monthly staff meeting/QI workgroups began in the first month of the project and continued throughout the 7 months of the project. The focus of the staff QI workgroups involved systems improvements such as documentation tools, patient resources, and workflow changes. Standardized exercise prescription forms (basic and advanced) were adopted from the Veterans Administration’s MOVE! website.18 The forms were paperbased using a check-box format for “Frequency, Intensity, and Timing” and requiring free text entry for “Type and Progression.” Initially, the forms were made available for use in a central cabinet, but the QI group soon recommended they be placed on the chart to cue providers at the annual wellness visit.
Setting
The setting for this project, LMFHC, is a nurse-managed, rural free clinic located in southern Maine. With an active patient roster of 250, LMFHC has served over 1,700 patients in its 12-year history. The majority of patients are working adults living at or below 250% of the federal poverty level. Six part-time volunteer primary care providers and 3 part-time nursing support staff form the patient care team. Patient care documentation is paper-based, with selected patient statistics and visit data maintained in an encrypted database. e2
The Journal for Nurse Practitioners - JNP
Data Collection and Analysis
Patient records were audited using a convenience sampling method. Records of the most recently occurring history and physical were audited pre-intervention (n ¼ 52) and post-intervention (n ¼ 42). Chart audit data elements included: patient age and gender; body mass index (BMI); chronic illnesses/comorbidities; baseline leisure time physical activity; and documentation of exercise prescribing and inclusion of the FITT-PRO elements. Data from chart audits were analyzed using chi-square testing to detect differences. Volume
-,
Issue
-, -/-
2016
www.npjournal.org
Date: _______________________________
Frequency
-long process. Use the handouts and Go4Life! Booklet and DVD video to help create a plan that will work for you. Most of all - have fun!
Intensity
The relative success of this quality improvement project adds some practice-based evidence to knowledge about improving exercise prescribing in a primary care environment. Clinic system changes in this project included the revision of the discharge form to emphasize healthy lifestyles and the implementation of the exercise prescription forms. Overall, the use of the forms improved adherence with guideline recommendations for documentation of recommended exercise frequency, intensity, and time (duration), but fell short in capturing discussions about exercise types and progression of the exercise plan. One factor that likely contributed to this discrepancy was the openended nature of the Type and PROgression sections of the form, as compared with the forced-choice check-boxes supplied for the FIT section of the form.
Figure. Physical Activity Prescription form.
□ □
3-
□
6-
□
Light -
□
Moderate -
□
Vigorous and cause a large sweat). You should not
□
Endurance or Aerobic: such as walking, jogging, bicycling, swimming, or dancing bands) or core strengthening
□
Type
DISCUSSION
Since the conclusion of this project, the exercise prescription forms have been revised to simplify the process. The basic and advanced forms were collapsed to one “Physical Activity Prescription” form (see Figure). Checkboxes were inserted to clarify the prescription elements of type and progression. This QI change has not yet been studied formally but has met with informal approval from provider and staff members. The QI workgroup successfully provided oversight for the project. For example, the workgroup recognized early in the improvement process that cueing the prescribers by placing the prescription form on the chart for completion increased the likelihood of exercise prescriptions being written as part of the encounter. The use of physical and visual cues to change human behavior, whether directly for patients or in terms of provider behavior, has been supported in a number of studies.19-21 The deep commitment of the staff, their caring, and immersion in the needs of the population may
□
Flexibility: such as stretching, or Yoga
□
Balance: such as balance exercises or Tai Chi
□
5 - 10 minutes per session
Time
Overall, there were no significant differences (P < .05) in the demographic profiles of the preand post-intervention audited charts. Achievement of practice improvement goals was variable. Overall, the frequency of provider exercise prescribing closely approached the target improvement goal, with the overall frequency of prescribing improved from the previous level of 34.6% to 65.0% (c2 ¼ 8.365, P ¼ .004). Documentation of all 5 of the FITT-PRO elements as targeted in the project goals did not improve as dramatically. Statistically significant (P < .05) improvements were gained in frequency, intensity, and time. However, the inclusion of specific exercise and progression remained at low levels. Documentation of specific exercise type deteriorated and there was no improvement in the use of progression in exercise prescription from pre-intervention to postintervention. No significant differences in exercise prescribing frequency in the post-intervention group were noted when correlated with age, BMI, or chronic illness burden. An increase in prescriptions for female patients was noted, but this could be correlated with providers who only have women in their panel.
□
10 - 30 minutes per session
□
30 or more minutes per session
gression
OUTCOMES
□
Add _________(#) sessions per week, every _________(#) weeks
□
Add _________(#) minutes per session, every _________ (#) weeks
□
Other: ____________________________________________________________________
□ ________________________________________________________________________ □
Provider signature: ________________________________________________
The Journal for Nurse Practitioners - JNP
e3
contribute to the discrepancy of the results of this project in comparison to other studies. These providers did not appear to selectively prescribe exercise to those with higher BMI, lower or higher chronic disease burden, or lower or higher pre-prescription activity levels, in contrast to earlier research.15 Limitations
This project had a number of limitations. Due to time constraints and low clinic volume, the chart audit was small. The project design included only 1 formal measurement of change. Ideally, several Plan-DoStudy-Act (PDSA) cycles should be included to provide incremental measurement of organizational change.22 As this was a provider-based project, patients were only indirectly involved. Ideally, patients would participate in the design of the intervention. Further, the project design did not include gathering data to ascertain patients’ adherence to the exercise prescription. Implications
The results of this project form a practical framework for the implementation of basic clinic support items, which can improve exercise prescribing practices. Although many primary care practices do not rely on paper-and-pencil forms, the revised exercise prescription template is well suited to the electronic environment by the use of check-boxes. Few nurse practitioners report that they utilize clinical guidelines in practice,23 but implementation of easy-to-follow templated guidelines that could be embedded into an electronic medical record system could encourage adoption of the exercise prescribing guideline. This project reinforces the value of time spent working with patients on encouraging lifestyle changes that are low cost and effective. By providing evidence of the success of such a project, and its minimal impact on the cost of care, policymakers can be further encouraged to support and incentivize primary care providers’ inclusion of health promotion activities. The increase in exercise prescribing at LMFHC was an encouraging finding. However, patientcentered research is needed to assess the impact exercise prescription and dispensing of the printed materials had upon patient readiness to exercise or e4
The Journal for Nurse Practitioners - JNP
actual activity levels. An area of future research should include measurement of patient change in all FITT-PRO elements via chart audits, focus group interviews, or surveys. Most studies have concluded that primary care interventions involving intensive follow-up, personal attention, and social interaction are important factors in promoting positive changes in physical activity levels among community-dwelling adults.24 Some studies have shown that the use of technology, such as text messaging, has potential as an adjunct in improving exercise rates.25,26 It would be useful to know patients’ perceptions regarding healthy lifestyle adoption and what additional interventions are warranted to improve physical activity levels in this population. CONCLUSION
This small-scale, reproducible QI project resulted in a positive practice change through implementation of national guidelines for exercise prescribing in a primary care environment. Engaging patients to improve physical activity levels offers numerous patient health benefits and aligns philosophically with nurse practitioner practice. The FITT-PRO exercise prescription model provides a practical approach to brief intervention in a primary care environment. References 1. World Health Organization. Facts on physical activity. http://www.who.int/ features/factfiles/physical_activity/facts/en/. Accessed September 2016. 2. Chomistek AK, Henschel B, Eliassen AH, Mukamal KJ, Rimm EB. frequency, type, and volume of leisure-time physical activity and risk of coronary heart disease in young women. Circulation. 2016;134:290-299. 3. Knight JA. Physical inactivity: associated diseases and disorders. Ann Clin Lab Sci. 2012;42(3):320-337. 4. Cleland V, Grenados A, Crawford D, Winzenberg T, Ball K. Effectiveness of interventions to promote physical activity among socioeconomically disadvantaged women: a systematic review and meta-analysis. Obes Rev. 2013;14:197-212. http://dx.doi.org/10.1111/j.1467-789X.2012 .01058.x. 5. Orzeck KM, Vivian J, Torres CH, Armin J, Shaw SJ. Diet and exercise adherence and practices among medically underserved patients with chronic disease: variation across four ethnic groups. Health Educ Behav. 2012;40(1):56-66. http://dx.doi.org/10.1177/1090198112436970. 6. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334-1359. http://dx.doi.org/10.1249/MSS .0b013e318213fefb. 7. Orrow G, Kinmonth AL, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and metaanalysis of randomised controlled trials. BMJ. 2012;344:e1389. http://dx.doi. org/10.1136/bmj.e13892012. 8. Office of Disease Prevention and Health Promotion. Healthy People 2020. https://www.healthypeople.gov/2020/data-search/Search-the -Data#objid¼5056/. Accessed September 2016. 9. Lobelo F, Stoutenberg M, Hutber A. The exercise is medicine global health initiative: a 2014 update. Br J Sports Med. 2014;48:1627-1633. http://dx.doi. org/10.1136/bjsports-2013-093080.
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Issue
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10. Carroll JK, Winters PC, Sanders MR, Decker F, Ngo T, Sciamanna CN. Clinician-targeted intervention and patient-reported counseling on physical activity. Prev Chron Dis. 2014;11:130302. doi, http://dx.doi.org/10.5888/pcd11 .130302. 11. Goodman C, Davies SL, Dinan S, Tai SS, Iliffe S. Activity promotion for community-dwelling older people: a survey of the contribution of primary care nurses. Br J Commun Nurs. 2011;16(1):12-17. 12. Carroll JK. Evaluation of physical activity counseling in primary care using direct observation of the 5As. Ann Fam Med. 2011;9:416-422. http://dx.doi.org/ 10.1370/afm.1299. 13. Dacey M, Arnstein F, Kennedy MA, Wolfe J, Phillips E. The impact of lifestyle medicine continuing education on provider knowledge, attitudes, and counseling behaviors. Med Teacher. 2013;35(5):e1149-e1156. http://dx.doi. org/10.3109/0142159X.2012.733459. 14. Ackermann RT, Deyo RA, LoGerfo JP. Prompting primary providers to increase community exercise referrals for older adults: a randomized trial. J Am Geriatr Soc. 2005;53(2):283-289. http://dx.doi.org/10.1111/j.1532-5415.2005.53115.x. 15. Patel A, Schofield GM, Kolt GS, Keogh JWL. General practitioners’ views and experiences of counselling for physical activity through the New Zealand Green Prescription program. BMC Fam Pract. 2011;12:119-119. http://dx.doi. org/10.1186/1471-2296-12-119. 16. McDermott AY, Mernitz H. Exercise and older patients: prescribing guidelines. Am Fam Phys. 2006;74(3):437-444. 17. National Center for Health Statistics. Lack of leisure-time physical activity: adults. Health Indicators Warehouse. http://www.healthindicators.gov/ Indicators/Leisure-time-physical-activity-none-percent_1313/Profile/Data. Accessed November 18, 2012. 18. Veterans Administration MOVE! Reference tools. http://www.move.va.gov/ ReferenceTools.asp#MOVE!23. Accessed September 2016. 19. Bellicha A, Kieusseian A, Fontvieille AM, et al. A multistage controlled intervention to increase stair climbing at work: effectiveness and process evaluation. Int J Behav Nutr Phys Activ. 2016;13:47. http://dx.doi.org/10.1186/ s12966-016-0371-0. 20. Marteau TM, Hollands GJ, Fletcher PC. Changing human behavior to prevent disease: the importance of targeting automatic processes. Science. 2012;337(6101):1492-1495. http://dx.doi.org/10.1126/science.1226918. 21. Rozin P, Scott S, Dingley M, Urbanek JK, Jiang H, Kaltenbach M. Nudge to nobesity I: Minor changes in accessibility decrease food intake. Judgm Decis Mak. 2011;6(4):323-332. 22. Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco: Jossey-Bass; 2009.
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23. Facchiano L, Snyder CH. Evidence-based practice for the busy nurse practitioner: Part one: Relevance to clinical practice and clinical inquiry process. J Am Acad Nurse Pract. 2012;24:579-586. http://dx.doi.org/10.1111/j .1745-7599.2012.00748.x. 24. Neidrick TJ, Fick DM, Loeb SJ. Physical activity promotion in primary care targeting the older adult. J Am Acad Nurse Pract. 2012;24(7):405-416. http:// dx.doi.org/10.1111/j.1745-7599.2012.00703.x. 25. Fjeldsoe BS, Miller YD, Graves N, Barnett A, Marshall AL. Randomized controlled trial of an improved version of MobileMums, an intervention for increasing physical activity in women with young children. Ann Behav Med. 2015;49:487-499. http://dx.doi.org/10.1007/s12160-014-9675-y. 26. Buchholz SW, Wilbur J, Ingram D, Fogg L. Physical activity text messaging interventions in adults: a systematic review. Worldviews Evidence-Based Nurs. 2013;10(3):163-173.
Patricia Thompson Leavitt, DNP, FNP, is executive director of the Leavitt’s Mill Free Health Center in Bar Mills, ME, and an assistant professor at the University of Southern Maine School of Nursing in Portland. She can be reached at patricia. [email protected]. The author gratefully acknowledges the contribution of the University of Southern Maine’s Graduate Assistant Program for providing funds to support 2 graduate assistants for the duration of this project. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.
1555-4155/16/$ see front matter © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2016.09.014
The Journal for Nurse Practitioners - JNP
e5
Improving Exercise Prescribing in a Rural New England Free Clinic Patricia Thompson Leavitt, DNP, FNP ABSTRACT
This quality improvement project was undertaken to improve exercise prescribing frequency and quality in a rural New England free clinic. Prescribing guidelines from the American College of Sports Medicine and the American Academy of Family Physicians were used. Following a provider education program and workgroup-implemented documentation changes, overall exercise prescription frequency increased significantly from 34.6% in the pre-intervention group to 65.0% in the post-intervention group (P < .05). The use of some prescription elements (frequency, intensity, and timing) improved significantly (P < .05). Further study from the patient perspective is warranted. Keywords: exercise prescription, FITT-PRO mnemonic, free clinic, inactivity, quality improvement, rural Ó 2016 Elsevier Inc. All rights reserved.
INTRODUCTION Background Knowledge
T
he World Health Organization (WHO) identifies inactivity as the fourth leading cause of mortality, accounting for 6% of deaths worldwide.1 This places inactivity behind only high blood pressure (13%) and tobacco use (9%) as causative factors for mortality and is equal to high blood glucose (6%). Although obesity logically follows from a sedentary lifestyle, inactivity is a risk factor for abdominal adiposity and coronary heart disease independent of body mass index (BMI).2 Multiple factors and antecedents contribute to inactivity, including lack of time or motivation, increasing use of technology for work and recreation, and lack of knowledge.3 For lower income persons, barriers to daily exercise exist in terms of money, time, and access to exercise equipment, yet most intervention studies have not accessed disadvantaged populations.4,5 Barriers to exercise notwithstanding, research findings suggest that advice from respected health care professionals can have a positive impact on exercise rates.6,7 Despite evidence supporting the benefits of exercise, providers use exercise prescribing on a limited basis. In 2010, only 9.2% of provider office visits in the United States included counseling patients to participate in regular physical activity.8 One reason for providers’ failure to prescribe is lack of time, www.npjournal.org
even when structured programs are in place to assure consistency and follow-up.9-12 Provider knowledge deficits about the specifics of exercise prescribing and confidence in prescribing abilities also play a role.13 Providers are most adept at utilizing the first 2 elements of the “Ask-Advise-Agree-Assist-Arrange” model used for change coaching12; they are not as comfortable at assessing readiness to change (“Agree”) or providing follow-up (“Assist” and “Arrange”). Ackermann et al14 found that providers were more likely to prescribe exercise for patients who were in the contemplation stage of change. In addition, providers are generally more inclined to target activity prescribing for obese individuals or those suffering from chronic disease.8,15 The American College of Sports Medicine (ACSM) has published recommendations for exercise prescribing in all populations.6 The prescribing mnemonic “FITT-PRO” (Frequency, Intensity, Type, Time, and PROgression), as described by the American Academy of Family Physicians guideline, instructs the provider to consider each type of exercise (aerobic or endurance, flexibility, strengthening, and balance) and develop a prescription.16 For example, a provider may create a prescription that reads: “Aerobic activity such as walking (Type), daily (Frequency) for 30 minutes per day (Timing). Exercise hard enough so that you cannot sing but are still able to talk (Intensity). Start The Journal for Nurse Practitioners - JNP
e1
with 10 minutes per day as tolerated; increase by 5 minutes every 3 days until you reach 30 minutes daily” (Progression). Local Problem
As part of ongoing quality improvement (QI) efforts before this project, gaps were identified in addressing leisure time physical activity with each patient. The Leavitt’s Mill Free Health Center (LMFHC) patient baseline activity rates (36%) and documentation of provider exercise prescribing (32%) were comparable to national statistics for similar populations (N ¼ 50).8,17 Intended Improvement
The aim of this QI project was to improve exercise prescribing frequency and improve exercise prescribing quality at LMFHC by implementing the ACSM exercise prescribing guidelines and the prescribing mnemonic FITT-PRO from the American Academy of Family Physicians.6,16 The target for improvement was to double exercise prescribing rates from baseline. METHODS Ethical Issues
Approval for this project was granted by the institutional review board of Simmons College and the board of directors of the LMFHC. Potential bias by the project investigator, who also served as the health center’s director, was safeguarded by the use of graduate assistants who managed all primary data and de-identified data before analysis.
Planning the Intervention
Needs assessment interviews and educational session. After receiving informed consent, clinic staff (n ¼ 9) were interviewed to ascertain their comfort and knowledge about exercise prescribing and advising. The data from these interviews formed the basis of the 90-minute educational intervention. The educational session was provided, which included a brief overview of current evidence regarding exercise benefits and the principles of exercise prescribing using the ACSM exercise prescribing guidelines, and the FITT-PRO mnemonic.6,16 Specific information was offered regarding the particular absolute and relative contraindications to an exercise prescription. Strategies for incorporating the FITT-PRO elements of a complete exercise prescription were presented with an emphasis on timing and progression, components unfamiliar to this group of providers. QI workgroup. Monthly staff meeting/QI workgroups began in the first month of the project and continued throughout the 7 months of the project. The focus of the staff QI workgroups involved systems improvements such as documentation tools, patient resources, and workflow changes. Standardized exercise prescription forms (basic and advanced) were adopted from the Veterans Administration’s MOVE! website.18 The forms were paperbased using a check-box format for “Frequency, Intensity, and Timing” and requiring free text entry for “Type and Progression.” Initially, the forms were made available for use in a central cabinet, but the QI group soon recommended they be placed on the chart to cue providers at the annual wellness visit.
Setting
The setting for this project, LMFHC, is a nurse-managed, rural free clinic located in southern Maine. With an active patient roster of 250, LMFHC has served over 1,700 patients in its 12-year history. The majority of patients are working adults living at or below 250% of the federal poverty level. Six part-time volunteer primary care providers and 3 part-time nursing support staff form the patient care team. Patient care documentation is paper-based, with selected patient statistics and visit data maintained in an encrypted database. e2
The Journal for Nurse Practitioners - JNP
Data Collection and Analysis
Patient records were audited using a convenience sampling method. Records of the most recently occurring history and physical were audited pre-intervention (n ¼ 52) and post-intervention (n ¼ 42). Chart audit data elements included: patient age and gender; body mass index (BMI); chronic illnesses/comorbidities; baseline leisure time physical activity; and documentation of exercise prescribing and inclusion of the FITT-PRO elements. Data from chart audits were analyzed using chi-square testing to detect differences. Volume
-,
Issue
-, -/-
2016
www.npjournal.org
Date: _______________________________
Frequency
-long process. Use the handouts and Go4Life! Booklet and DVD video to help create a plan that will work for you. Most of all - have fun!
Intensity
The relative success of this quality improvement project adds some practice-based evidence to knowledge about improving exercise prescribing in a primary care environment. Clinic system changes in this project included the revision of the discharge form to emphasize healthy lifestyles and the implementation of the exercise prescription forms. Overall, the use of the forms improved adherence with guideline recommendations for documentation of recommended exercise frequency, intensity, and time (duration), but fell short in capturing discussions about exercise types and progression of the exercise plan. One factor that likely contributed to this discrepancy was the openended nature of the Type and PROgression sections of the form, as compared with the forced-choice check-boxes supplied for the FIT section of the form.
Figure. Physical Activity Prescription form.
□ □
3-
□
6-
□
Light -
□
Moderate -
□
Vigorous and cause a large sweat). You should not
□
Endurance or Aerobic: such as walking, jogging, bicycling, swimming, or dancing bands) or core strengthening
□
Type
DISCUSSION
Since the conclusion of this project, the exercise prescription forms have been revised to simplify the process. The basic and advanced forms were collapsed to one “Physical Activity Prescription” form (see Figure). Checkboxes were inserted to clarify the prescription elements of type and progression. This QI change has not yet been studied formally but has met with informal approval from provider and staff members. The QI workgroup successfully provided oversight for the project. For example, the workgroup recognized early in the improvement process that cueing the prescribers by placing the prescription form on the chart for completion increased the likelihood of exercise prescriptions being written as part of the encounter. The use of physical and visual cues to change human behavior, whether directly for patients or in terms of provider behavior, has been supported in a number of studies.19-21 The deep commitment of the staff, their caring, and immersion in the needs of the population may
□
Flexibility: such as stretching, or Yoga
□
Balance: such as balance exercises or Tai Chi
□
5 - 10 minutes per session
Time
Overall, there were no significant differences (P < .05) in the demographic profiles of the preand post-intervention audited charts. Achievement of practice improvement goals was variable. Overall, the frequency of provider exercise prescribing closely approached the target improvement goal, with the overall frequency of prescribing improved from the previous level of 34.6% to 65.0% (c2 ¼ 8.365, P ¼ .004). Documentation of all 5 of the FITT-PRO elements as targeted in the project goals did not improve as dramatically. Statistically significant (P < .05) improvements were gained in frequency, intensity, and time. However, the inclusion of specific exercise and progression remained at low levels. Documentation of specific exercise type deteriorated and there was no improvement in the use of progression in exercise prescription from pre-intervention to postintervention. No significant differences in exercise prescribing frequency in the post-intervention group were noted when correlated with age, BMI, or chronic illness burden. An increase in prescriptions for female patients was noted, but this could be correlated with providers who only have women in their panel.
□
10 - 30 minutes per session
□
30 or more minutes per session
gression
OUTCOMES
□
Add _________(#) sessions per week, every _________(#) weeks
□
Add _________(#) minutes per session, every _________ (#) weeks
□
Other: ____________________________________________________________________
□ ________________________________________________________________________ □
Provider signature: ________________________________________________
The Journal for Nurse Practitioners - JNP
e3
contribute to the discrepancy of the results of this project in comparison to other studies. These providers did not appear to selectively prescribe exercise to those with higher BMI, lower or higher chronic disease burden, or lower or higher pre-prescription activity levels, in contrast to earlier research.15 Limitations
This project had a number of limitations. Due to time constraints and low clinic volume, the chart audit was small. The project design included only 1 formal measurement of change. Ideally, several Plan-DoStudy-Act (PDSA) cycles should be included to provide incremental measurement of organizational change.22 As this was a provider-based project, patients were only indirectly involved. Ideally, patients would participate in the design of the intervention. Further, the project design did not include gathering data to ascertain patients’ adherence to the exercise prescription. Implications
The results of this project form a practical framework for the implementation of basic clinic support items, which can improve exercise prescribing practices. Although many primary care practices do not rely on paper-and-pencil forms, the revised exercise prescription template is well suited to the electronic environment by the use of check-boxes. Few nurse practitioners report that they utilize clinical guidelines in practice,23 but implementation of easy-to-follow templated guidelines that could be embedded into an electronic medical record system could encourage adoption of the exercise prescribing guideline. This project reinforces the value of time spent working with patients on encouraging lifestyle changes that are low cost and effective. By providing evidence of the success of such a project, and its minimal impact on the cost of care, policymakers can be further encouraged to support and incentivize primary care providers’ inclusion of health promotion activities. The increase in exercise prescribing at LMFHC was an encouraging finding. However, patientcentered research is needed to assess the impact exercise prescription and dispensing of the printed materials had upon patient readiness to exercise or e4
The Journal for Nurse Practitioners - JNP
actual activity levels. An area of future research should include measurement of patient change in all FITT-PRO elements via chart audits, focus group interviews, or surveys. Most studies have concluded that primary care interventions involving intensive follow-up, personal attention, and social interaction are important factors in promoting positive changes in physical activity levels among community-dwelling adults.24 Some studies have shown that the use of technology, such as text messaging, has potential as an adjunct in improving exercise rates.25,26 It would be useful to know patients’ perceptions regarding healthy lifestyle adoption and what additional interventions are warranted to improve physical activity levels in this population. CONCLUSION
This small-scale, reproducible QI project resulted in a positive practice change through implementation of national guidelines for exercise prescribing in a primary care environment. Engaging patients to improve physical activity levels offers numerous patient health benefits and aligns philosophically with nurse practitioner practice. The FITT-PRO exercise prescription model provides a practical approach to brief intervention in a primary care environment. References 1. World Health Organization. Facts on physical activity. http://www.who.int/ features/factfiles/physical_activity/facts/en/. Accessed September 2016. 2. Chomistek AK, Henschel B, Eliassen AH, Mukamal KJ, Rimm EB. frequency, type, and volume of leisure-time physical activity and risk of coronary heart disease in young women. Circulation. 2016;134:290-299. 3. Knight JA. Physical inactivity: associated diseases and disorders. Ann Clin Lab Sci. 2012;42(3):320-337. 4. Cleland V, Grenados A, Crawford D, Winzenberg T, Ball K. Effectiveness of interventions to promote physical activity among socioeconomically disadvantaged women: a systematic review and meta-analysis. Obes Rev. 2013;14:197-212. http://dx.doi.org/10.1111/j.1467-789X.2012 .01058.x. 5. Orzeck KM, Vivian J, Torres CH, Armin J, Shaw SJ. Diet and exercise adherence and practices among medically underserved patients with chronic disease: variation across four ethnic groups. Health Educ Behav. 2012;40(1):56-66. http://dx.doi.org/10.1177/1090198112436970. 6. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334-1359. http://dx.doi.org/10.1249/MSS .0b013e318213fefb. 7. Orrow G, Kinmonth AL, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and metaanalysis of randomised controlled trials. BMJ. 2012;344:e1389. http://dx.doi. org/10.1136/bmj.e13892012. 8. Office of Disease Prevention and Health Promotion. Healthy People 2020. https://www.healthypeople.gov/2020/data-search/Search-the -Data#objid¼5056/. Accessed September 2016. 9. Lobelo F, Stoutenberg M, Hutber A. The exercise is medicine global health initiative: a 2014 update. Br J Sports Med. 2014;48:1627-1633. http://dx.doi. org/10.1136/bjsports-2013-093080.
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10. Carroll JK, Winters PC, Sanders MR, Decker F, Ngo T, Sciamanna CN. Clinician-targeted intervention and patient-reported counseling on physical activity. Prev Chron Dis. 2014;11:130302. doi, http://dx.doi.org/10.5888/pcd11 .130302. 11. Goodman C, Davies SL, Dinan S, Tai SS, Iliffe S. Activity promotion for community-dwelling older people: a survey of the contribution of primary care nurses. Br J Commun Nurs. 2011;16(1):12-17. 12. Carroll JK. Evaluation of physical activity counseling in primary care using direct observation of the 5As. Ann Fam Med. 2011;9:416-422. http://dx.doi.org/ 10.1370/afm.1299. 13. Dacey M, Arnstein F, Kennedy MA, Wolfe J, Phillips E. The impact of lifestyle medicine continuing education on provider knowledge, attitudes, and counseling behaviors. Med Teacher. 2013;35(5):e1149-e1156. http://dx.doi. org/10.3109/0142159X.2012.733459. 14. Ackermann RT, Deyo RA, LoGerfo JP. Prompting primary providers to increase community exercise referrals for older adults: a randomized trial. J Am Geriatr Soc. 2005;53(2):283-289. http://dx.doi.org/10.1111/j.1532-5415.2005.53115.x. 15. Patel A, Schofield GM, Kolt GS, Keogh JWL. General practitioners’ views and experiences of counselling for physical activity through the New Zealand Green Prescription program. BMC Fam Pract. 2011;12:119-119. http://dx.doi. org/10.1186/1471-2296-12-119. 16. McDermott AY, Mernitz H. Exercise and older patients: prescribing guidelines. Am Fam Phys. 2006;74(3):437-444. 17. National Center for Health Statistics. Lack of leisure-time physical activity: adults. Health Indicators Warehouse. http://www.healthindicators.gov/ Indicators/Leisure-time-physical-activity-none-percent_1313/Profile/Data. Accessed November 18, 2012. 18. Veterans Administration MOVE! Reference tools. http://www.move.va.gov/ ReferenceTools.asp#MOVE!23. Accessed September 2016. 19. Bellicha A, Kieusseian A, Fontvieille AM, et al. A multistage controlled intervention to increase stair climbing at work: effectiveness and process evaluation. Int J Behav Nutr Phys Activ. 2016;13:47. http://dx.doi.org/10.1186/ s12966-016-0371-0. 20. Marteau TM, Hollands GJ, Fletcher PC. Changing human behavior to prevent disease: the importance of targeting automatic processes. Science. 2012;337(6101):1492-1495. http://dx.doi.org/10.1126/science.1226918. 21. Rozin P, Scott S, Dingley M, Urbanek JK, Jiang H, Kaltenbach M. Nudge to nobesity I: Minor changes in accessibility decrease food intake. Judgm Decis Mak. 2011;6(4):323-332. 22. Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco: Jossey-Bass; 2009.
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23. Facchiano L, Snyder CH. Evidence-based practice for the busy nurse practitioner: Part one: Relevance to clinical practice and clinical inquiry process. J Am Acad Nurse Pract. 2012;24:579-586. http://dx.doi.org/10.1111/j .1745-7599.2012.00748.x. 24. Neidrick TJ, Fick DM, Loeb SJ. Physical activity promotion in primary care targeting the older adult. J Am Acad Nurse Pract. 2012;24(7):405-416. http:// dx.doi.org/10.1111/j.1745-7599.2012.00703.x. 25. Fjeldsoe BS, Miller YD, Graves N, Barnett A, Marshall AL. Randomized controlled trial of an improved version of MobileMums, an intervention for increasing physical activity in women with young children. Ann Behav Med. 2015;49:487-499. http://dx.doi.org/10.1007/s12160-014-9675-y. 26. Buchholz SW, Wilbur J, Ingram D, Fogg L. Physical activity text messaging interventions in adults: a systematic review. Worldviews Evidence-Based Nurs. 2013;10(3):163-173.
Patricia Thompson Leavitt, DNP, FNP, is executive director of the Leavitt’s Mill Free Health Center in Bar Mills, ME, and an assistant professor at the University of Southern Maine School of Nursing in Portland. She can be reached at patricia. [email protected]. The author gratefully acknowledges the contribution of the University of Southern Maine’s Graduate Assistant Program for providing funds to support 2 graduate assistants for the duration of this project. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.
1555-4155/16/$ see front matter © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2016.09.014
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