Digital Repository Doctoral Projects Fall 2022 Implementation of a Fitness Program to Supplement Mental Health Kaia Deroche Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Deroche, K. (2022) Implementation of a Fitness Program to Supplement Mental Health Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Implementation of a Fitness Program to Supplement Mental Health by Kaia Deroche A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 16, 2022 Project Consultant: Sophie Ducrocq Archibald LCSW, EHP, IMP KDeroche 12/16/22 _______________________________ ______________________________ Kaia Deroche DNP-FNP student, RN BSN Date 12/16/22 _______________________________ _____________________________ Joyce M. Barra PhD, RN Faculty Project Lead Date 12/16/22 _______________________________ ______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director Table of Contents Abstract .............................................................................................................................................. 4 IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 2 Implementation of a Fitness Program to Supplement Mental Health ................................................... 4 Background and Problem Statement .................................................................................................. 5 Diversity of Population and Project Site .............................................................................................. 6 Significance for Practice Reflective of Role-Specific Leadership ............................................................ 6 Literature Review and Framework ................................................................................................. 7 Framework ........................................................................................................................................ 7 Search Methods ................................................................................................................................. 8 Wellness ............................................................................................................................................ 8 Barriers to Addressing Wellness ....................................................................................................... 10 Types of Wellness Programs ............................................................................................................. 11 Physical Activity Therapy ........................................................................................................................................ 11 Stress and Relaxation Wellness Programs .............................................................................................................. 12 Lifestyle Interventions ............................................................................................................................................. 12 Discussion........................................................................................................................................ 13 Project Plan ...................................................................................................................................... 13 Project Design .................................................................................................................................. 13 Plan & Implementation .................................................................................................................... 14 Social Determinants of Health .......................................................................................................... 14 Stakeholders .................................................................................................................................... 15 Cost Analysis and Sustainability of Project ........................................................................................ 15 Continuation Budget ........................................................................................................................ 15 Funding Strategies ........................................................................................................................... 15 Project Outcomes ............................................................................................................................ 16 Instrument to Measure Intervention Effectiveness ........................................................................... 16 Project Implementation .................................................................................................................. 16 Project Intervention ......................................................................................................................... 17 Project Timeline ............................................................................................................................... 18 Project Evaluation ........................................................................................................................... 19 Data Maintenance and Security ........................................................................................................ 19 Data Collection and Analysis ............................................................................................................ 19 Table 1 ............................................................................................................................................ 19 Table 2 ............................................................................................................................................ 20 Table 3 ............................................................................................................................................ 20 Findings ........................................................................................................................................... 21 Strengths ................................................................................................................................................................. 22 Weaknesses ............................................................................................................................................................ 22 IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 3 Discussion ......................................................................................................................................... 22 Translation of Evidence Into Practice ................................................................................................ 22 Implications for Practice and Future Scholarship ............................................................................... 23 Sustainability ................................................................................................................................... 23 Dissemination .................................................................................................................................. 23 References ......................................................................................................................................... 25 Appendix A ....................................................................................................................................... 29 Appendix B ....................................................................................................................................... 30 Appendix C ....................................................................................................................................... 34 Appendix D ....................................................................................................................................... 35 Appendix E ....................................................................................................................................... 37 IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 4 Abstract Purpose: Exercise and movement are proven to affect mental wellness positively, yet it is rarely integrated directly into our treatment plan for mental health. This project aims to create a fitness program for the counseling center clients to attend to augment talk therapy. The clients are offered a holistic experience by offering fitness classes in the same physical space as their talk therapy. Methodology: A six-week acro yoga class was held weekly and opened to all the therapists' clientele. A pre-and post-survey was given to participants to evaluate changes in overall mood and quality of life. Survey items assessed different aspects of health and mental wellness to evaluate the effectiveness of the course. Results: After the classes were completed, participants showed modest to significant improvement in strength, balance, anxiety, depression, social activities, and self-confidence. While the sample size was small, the results supported that physical fitness improves mental health. Best Practices: For best patient outcomes, ensuring that patients have access to physical fitness is imperative in treating mental health. Fitness and health status goals can be achieved by integrating the role of the counselor and the nurse practitioner and melding the parts into a physical fitness practice. The project found that the participants were pleased with the results. Keywords: Mental wellness, mental health, fitness class, fitness and mental health, wellness, the impact of physical fitness on mental health, benefits of physical activity, lifestyle diseases Implementation of a Fitness Program to Supplement Mental Health Mental health disorders, such as generalized anxiety disorder and depression, have increased significantly in the past several years. The numbers skyrocketed with the onset of a worldwide pandemic in 2020. With the advent of the Covid-19 global pandemic, depression rates IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 5 have tripled in adults in the United States (Beusekom, 2020). The National Health Interview Survey in late April 2020 showed that more than one in four adults reported symptoms congruent with mental severe distress, four times higher than in 2018 (Twenge & Joiner, 2020). Mental health disorders have a detrimental impact on physical health. Depression and anxiety interfere with individuals' ability to function in their daily activities and affect their mood and quality of life. Additionally, lifestyle diseases such as Type II diabetes and cardiovascular diseases are more prevalent in populations with little to no physical exercise. Those diagnosed with mental illnesses are less likely to be physically active than the general population (Stanley & Laugharne, 2014). Approaching mental health with an understanding of the connectedness to physical movement opens new revolutionary doors to treating mental health disorders. As the incidence and prevalence of mental illness increase, building innovative tools to help minimize the impact on their physical and psychological health is vital to the well-being of millions of Americans. Background and Problem Statement The mind-body-spirit model used in mental health coaching at the Center for Integrative and Holistic Counseling teaches the concept of holistic connectedness for healthy living. At this counseling center, patients receive psychotherapy that incorporates talk sessions with body awareness and exploration of belief models to improve outcomes related to depression, anxiety, obsessive-compulsive behaviors, and fewer flashbacks from post-traumatic stress disorder. A physical fitness program fits well within the model taught at the Center. The mind-body-spirit model introduces a triad of connectedness between the conscious and subconscious of the mind, the physical health of the body and the brain, and the spirit's intuition. Each piece of the triad plays a role in the overall mental and physical health of the person. The benefits of exercise for illnesses such as depression are becoming more widely studied and accepted in the western medical model (GWI, 2010). According to Fox's literature analysis, treating depression with physical activity produces the same effects as psychotherapy. IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 6 Furthermore, a meta-analysis of ten randomized control trials found that resistance training and aerobic exercise effectively treat depression (Fox, 1999). Diversity of Population and Project Site At the Center for Integrative and Holistic counseling, clients are male, female, and middle to upper-class patrons (generally nurses, providers, emergency response personnel, and firefighters). The therapists treat numerous health illnesses, such as post-traumatic stress disorder, anxiety, obsessive-compulsive disorder, and religious trauma. Confidence, body image, and social support gained in physical exercise assist in developing tools and abilities to combat mental illness (Fox, 1999). The founder and owner of this counseling center are Sophie Archibald, a Licensed Clinical Social Worker (LCSW), Existential-Humanistic Psychologist (EHP), and Integrative Medicine Practitioner (IMP). Therapy from the Existential-Humanistic perspective guides clients through acquiring a greater sense of self-awareness to provide a more meaningful existence (Psychological and Educational Services, 2021). The Center also employs three other independent licensed social workers. The presence of a yoga room, the current use of yoga classes as a supplement to mental health therapy at the Center, and the mind-body-spirit model make the Center for Integrative and Holistic Counseling advantageous for hosting a physical fitness program. Significance for Practice Reflective of Role-Specific Leadership Interprofessional collaboration between the Doctor of Nursing Practice (DNP) student and the LCSW puts the sixth DNP essential into practice, improving patient outcomes by collaborating with disciplines (AACN, 2006). Similarly, the Institute of Medicine's competency and interdisciplinary teamwork endeavor to unite different expertise areas to create better healthcare for populations served (IOM, 2010). The treatment and prevention of lifestyle diseases and mental illness rests in the hands of future healthcare providers; innovation and creativity are IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 7 brilliant tools to use. Adding the DNP to mental health integrates patient care's medical and psychological sides, creating a holistic model for well-rounded care. Literature Review and Framework This literature review explores exercise for better outcomes in mental health therapy to gather evidence to build a program that supplements mental health with physical fitness. Themes noted from the literature review to assist in the creation of the program include the following: (a) wellness is an active state of being and is approached differently by each individual (Global Wellness Institute, 2010); (b) physical activity is tied directly to health (Berry et al., 2010); (c) personal beliefs and attitudes shape outcomes for physical and behavioral change (Champion & Skinner, 2008); and (d) mindfulness is strengthened through the mind-body connection. The framework used for this program is the Health Belief Model. Framework The health belief model provides a framework for assessing perceptions about susceptibility, benefits, barriers, and beliefs about self-efficacy. Understanding a person's view of vulnerability to a condition can help direct education and structuring of an individualized wellness program. Self-efficacy directly impacts whether or not a person will take action; if they believe they cannot accomplish their goal, they may not even try. Similarly, if they believe in their ability to succeed, they will do so (Champion & Skinner, 2008). Hayes & Ross (1986) found that a high sense of psychological well-being was linked to being young, unmarried, and well-educated, leading to higher exercise rates. Those married, less financially secure, and poorly educated did not attribute their well-being to being fit or active; being overweight is more socially acceptable in these circles. Exploring and understanding the person's motivation, what aspects of wellness are important to them and why builds a relationship with the patient and IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 8 places them in control of their health. Adherence to a program is greater when the patient is actively engaged in creating it (Department of Veterans Affairs, 2020). Search Methods Search terms used in collecting data for this project include wellness programs, the growing problem of mental health, fitness and mental health, wellness, the impact of physical fitness on mental health, benefits of physical activity, and lifestyle diseases. Databases were CINAHL, PubMed, Elsevier, Google Scholar, OneSearch, and Google. Wellness A systematic review of 198 full-text articles on mental illness found that patients with mental conditions, such as depression, schizophrenia, and bipolar disorder, are more likely to have comorbidities such as diabetes and cardiovascular disease and have higher mortality rates (Vancampfort et al., 2015). An analysis of life expectancy in schizophrenia showed that life expectancy was an average of 14.5 years less than those without schizophrenia (Hjorthøj et al., 2017). The literature indicates that mental and physical health are highly connected (Stanley & Laugharne, 2014; Vancampfort et al., 2015). Increasingly, in today’s medical world, more practitioners are shifting to a holistic model in healthcare delivery, with a greater understanding that the mind, body, and spirit are connected, and each aspect plays a role in health and wellness (Gonzales et al., 2000). Wellness is a concept that varies significantly between differing perspectives and has few clear markers clinically defining what constitutes a "well" individual. The Global Wellness Institute [GWI] (2010) defines wellness as "the active pursuit of activities, choices, and lifestyles that lead to a state of holistic health" (para. 2). The GWI views wellness not as a goal to be reached but as an active continuum that incorporates a proactive lifestyle, caring for the body, and living according to health promotion rather than disease treatment. The categories that define IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 9 and encompass wellness include mental, spiritual, physical, social, emotional, and environmental (Global Wellness Institute, 2010). Wellness is defined as "the quality or state of being in good health, especially as an actively sought goal" by Merriam-Webster (n.d.) versus "a state of complete physical, mental and social well-being, not just the absence of both physical and mental disease" as defined by the World Health Organization (2021). The health continuum is corrective, treating, and curing illness already occurring within the body. Wellness focuses on preventing disease and making individual choices to maintain and improve health (GWI, 2010). Wellness is approached individually by each person. The perception of health is viewed differently by individual persons. The health belief model explains that the individual's view of a health problem and perceived barriers affect how they approach and deal with their health. For example, they are more likely to act if they believe they can change and that change will positively affect them. Similarly, if the perceived barriers are more daunting than the benefit received, they are less likely to take steps towards a change (Champion & Skinner, 2008). What Impacts Wellness Physical activity directly influences wellness; in a study by Berry et al., 57% of participants who received expert physical training and cardiac rehabilitation were downgraded from high-risk health indicators to low-risk status after completing a 6-month exercise program. The study participants were not cardiac patients; however, they received the benefits of completing a cardiac patient regimen (2010). In addition, healthy behaviors affect wellness; Sabia et al. (2012) defined healthy behaviors as "never smoking, moderate alcohol consumption, physical activity (>2.5 hours a week moderate physical activity or >1 hour per week vigorous physical activity), and eating fruits and vegetables daily" in their study on successful aging (p.1). Sabia et al. define successful aging as "good cognitive, physical, respiratory, and cardiovascular functioning, in addition to the absence of disability, mental health problems, and chronic disease" (p. 1). IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 10 Diet and nutrition are also integral parts of wellness and brain function. Five specific nutrients increase and preserve brain cognition as people age. These nutrients, polyunsaturated fatty acids, carotene, lycopene, vitamin B, and D, are found in fruits and vegetables (Women's Nutrition Connection, 2019). The Centers for Disease Control (CDC) recommends fruits, vegetables, whole grains, lean meats, and fat-free milk to maintain a healthy weight. In addition, focusing on healthy eating habits and minimizing sugar, sodium, and fat intake help reduce weight problems, heart disease, and other lifestyle diseases (CDC, 2021). Barriers to Addressing Wellness Kelly et al. (2016) sought to discover barriers and facilitators people faced when pursuing healthy behaviors. In a review of 16,426 titles, the common obstacles were the "lack of time due to other life obligations, transport, finances, beliefs and thoughts about exercise and ability, environmental restrictions, low socioeconomic status, and knowledge deficit" (pp.1-2). Facilitators include a "focus on enjoyment, health benefits including healthy aging, social support, clear messages, and integration of behaviors into a lifestyle" (p. 2). According to Champion and Skinner, 2008, using the health belief model, even if a person knows that certain behaviors will improve their health, if they perceive that the steps to get there are too timeconsuming or complicated, they will not engage in healthy behaviors (pp. 47-49). Even though physical activity is highly recommended as an adjunct therapy for physical and mental health issues, it is not widely used as routine care for patients with these complications. Furthermore, researchers cannot pinpoint exactly why that is, other than implementation is complex and individual issues make for slow and problematic progress (Czosnek et al., 2019). IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 11 Types of Wellness Programs Programs that target disease prevention before it occurs are defined as primary wellness programs (Tjoa et al., 2012). A health risk assessment (HRA) completed before any fitness regimen targets the individual's specific needs and ensures safety (Berry et al., 2010). HRA's include biometric screenings, cholesterol levels, blood pressure checks, weigh-ins, body mass index, and a lifestyle survey. Tailoring care to the results of the HRA can result in more accurate programs and solutions for the patient (Berry et al., 2010). Physical Activity Therapy According to the National Heart, Lung, and Blood Institute (NHLBI), there are four types of physical activity; aerobic activity, which increases the heart rate and improves endurance; muscle-strengthening, which improves muscle tone, bone-strengthening, and stretching. Examples of physical activity include running, swimming, walking, stretching, dancing, gardening, tennis, and more (National Heart, Lung, and Blood Institute, n.d.). One specific physical activity program is Basic Body awareness therapy (BBAT). This program utilizes movement and grounding techniques to connect the mind and body through stability and balance, creating an awareness of self and emotions. The expected outcomes of this type of therapy are to increase self-awareness, build personal relationships, and teach coping skills for stress management. A study by Lundvik Gyllensten et al. (2019) analyzed the experiences of 34 physical therapists from 13 countries on using BBAT in their professional, adult, and mental health care practices. These practices ranged from general to private, hospital, and outpatient care settings. Six focus groups were arranged with 3-9 participants in each group, and each group was asked open-ended questions about their experiences of the clinical effects of BBAT. The participants described the typical impact of patients' ability to contact themselves, create stability and balance, and become aware of their emotions. Participants also experienced IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 12 an increased capacity to refocus and learn to cope and a greater sense of self. A more profound capability to relate to others, build healthy relationships, and use grounding techniques in their daily lives. These elements emerged from the discussions in the focus groups as the framework for how BBAT is utilized within the clinical practice to assist patients. Stress and Relaxation Wellness Programs Specific wellness programs are built to decrease stress and teach techniques for relaxation and connection of mind and body. Techniques for meditation, muscle relaxation, cognitive/behavioral skills, biofeedback, and any combination commonly used in these programs. Outcomes sought are mood stabilization, decreased blood pressure, decreased muscle tension, and better health management (DeFrank & Cooper, 1987). One highly recommended program to reduce stress is yoga. Yoga, a religious practice based in Hinduism that dates back to 800-600 before common era (BCE), uses asanas or postures and movements to control the mind and the body in the pursuit of finding moksha, or unity with God (Hindu American Foundation, 2020) commonly is used in this style of program. Yogabased wellness programs use the connection of mind, body, and spirit to improve blood pressure and flexibility effectively, lose weight, and improve quality of life (Thomley et al., 2011). Yoga can be modified to fit each body's ability, and a large part of the lesson is to focus the attention inward, eliminating or minimizing the comparison to others. Lifestyle Interventions Lifestyle interventions combine behavioral, dietary, and physical activity interventions to help the person change lifestyle behaviors to manage their health. These consist of a certain number of sessions for the person, individually or in a group, to discuss and support healthy eating habits and exercise, and encourage discussion of successes and growth areas. IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 13 Individualized programs personalize the progress, and the support network adds social context for the individual attempting to lead a healthy lifestyle. A support network can be vital to those making lifestyle changes; a network of people supporting healthy behaviors creates a positive feedback loop toward a wellness-driven lifestyle (Department of Veterans Affairs, 2020). Discussion Preventative medicine is the pathway to wellness; programs encouraging physical exercise, healthy eating habits, stress reduction, relaxation, and mindfulness solve the growing problems of lifestyle diseases (Dickover et al., 2014). The first step in the wellness journey is assessing readiness and motivation; no progress can be gained without the patient's willingness. Discussing their beliefs and perceptions about health and their ability to make changes will help direct education and information where the patient needs it most. Then, to achieve greater adherence and engagement, target the program's outcomes to the patient's individual goals (Champion & Skinner, 2008; Department of Veterans Affairs, 2020). Managing wellness as a continuum, recognizing that physical and mental health are inextricably linked, and supporting patients in healthy habits before they succumb to lifestyle diseases will shape and guide our future generations (GWI, 2010). Using the health belief model to help educate and manage thoughts about wellness and health will build a foundation for future generations to build healthy lives. Project Plan Project Design The program's overarching goal is to improve the population's overall mood and quality of life over six weeks. By adding a fitness program directly tied with their talk therapy, the participants will improve their mood and quality of life. Through acro-yoga, the participants will build community, strength, and trust. IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 14 Plan & Implementation This project consists of a six-week course of weekly, hour-long classes starting in January 2022 at the Center for Integrative and Holistic Counseling. The classes were structured similarly; the participants gathered in a circle, and each introduced themselves and answered a discussion question. After a short discussion, the participants were led in warm-up exercises and subsequently taught a short acro-yoga sequence. Acro-yoga is a partner-based style of yoga with a base and a flyer. The base is the foundation for the poses and lifts the flyer, moving them in different ways using balance and strength to achieve the poses. The participants were welcomed but not required to bring a partner with them for the class. Each participant created a personal identification number to track the number of classes they attend in a GoogleDoc. The individual names of participants were not kept for privacy reasons. All data is stored on a password-protected computer. Needs Assessment/Gap Analysis of Project Site and Population The Center for Integrative and Holistic Counseling is a small practice in Kaysville, Utah. The practice employs three Licensed Clinical Social Workers (LCSW). Sophie Ducrocq, LCSW, EHP, IMP, is the owner. Also included under the umbrella of the Center are Bernice Tenort, RN, LCSW, and Alice Dughi, LCSW. In addition, the building has a yoga room that is a dedicated space for the clients of the practice. Social Determinants of Health This DNP project will address the social support available within the mental health framework. Depression and anxiety can lead to isolation and further compound depression (Klein, 2020). By building a community of individuals and teaching them to interact with one another through acro-yoga, they have the opportunity to create a support system and build resilience. Positive relationships have been shown to build resiliency and bolster psychological IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 15 well-being (Suttie, 2017). This project aims to unite people and build support, trust, and healthy behaviors. Stakeholders The main stakeholders in this project are Center Director and Owner Sophie Ducrocq LCSW, EHP, IMP, and Kaia Deroche, RN, DNP/FNP student. In addition, the other Center's social workers are invested and will inform their clients about the fitness program. Dr. Ducrocq promotes the class to the other counselors and clients of the Center and provides the space for the DNP student to hold the class. The DNP student creates the lesson plan, teaches the course, and collects and interprets the data. Cost Analysis and Sustainability of Project If the project proves successful based on participant feedback and the Center’s agreement, permanent classes will be held at the Center for Integrative and Holistic Counseling long term. The DNP student paid the initial startup fees, $100 for yoga mats and $10 for advertisements and flyers. After the initial free introductory period, the classes will require payment for service to maintain the program. The cost is projected to be a $15 drop-in or a $50 monthly fee per person. Continuation Budget The budget would include the cost to rent the yoga room, which is yet to be determined, and the payment of the teachers. There would need to be an average of five participants per class, and permission will need to be obtained from the suite owner to continue using the yoga room to hold classes. See Appendix A. Funding Strategies The service fee will pay for the time of the teachers and the space to be rented. In the future, if the classes become popular, another strategy would be to advocate for insurance to cover fitness as a wellness benefit. IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 16 Project Outcomes The proposed outcomes of the classes are that the participants will improve their quality of life. The post-test measures changes in strength, balance, fatigue, sleep quality, cognition, anxiety, depression, social activities, and self-confidence. The program is designed to assist the participants in connecting with others in a social environment and learning to use physical activity to benefit their mental health. The pre-test measured each participant's current quality of life compared with the post-test evaluation of the same question. The pre-test also measured the current health of the participants. Ensuring confidentiality and providing a judgment-free space for those enrolled in the program will uphold social justice within the DNP project. A waiver and a confidentiality agreement assure the participants' anonymity within the program. In addition, discussions on consent and boundaries built in the program allow for the empowerment of the participants to establish their comfort level and communicate that to their peers. This safe zone addresses some participants’ fears about working in a group of their peers and the possibility of being perceived differently for being in therapy. An internal review board (IRB) approval was not necessary at the Center; IRB approval through Weber State University was granted on November 19, 2021. Instrument to Measure Intervention Effectiveness The evaluation tool to track results is a Likert scale given before the beginning of the first class. The DNP student allotted time in the final class to take the post-test. T-test analysis of the data collected will be done. The specific areas of evaluation are quality of life, current health, and overall mood. See Appendix B. Project Implementation The project was implemented at the Center for Holistic and Integrative Wellness in IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 17 January 2022 for six consecutive weeks. The classes were an hour long and held weekly on Friday evenings in the yoga room at the Center. The yoga room was an open room with hardwood floors and no furniture. The open concept made it a comfortable space to utilize for acro-yoga. The project was facilitated by the DNP student and overseen by the owner of the Center. Project Intervention The project focused on creating a fitness class, Acro-Yoga, directly tied to mental health therapy. The first step was to develop a relationship with The Center for Integrative and Holistic Health director, Sophie Ducrocq, LCSW, EHP, IMP, and establish the need for this program. The DNP student created a PowerPoint (see appendix E) and presented the information to two other counselors at the Center to explain the project and its purpose. The response of the counselors was very positive. Alice Dughi, CSW, raised concerns about how the DNP student would handle the situation if a participant was a victim of assault and experiencing posttraumatic stress disorder. The DNP student responded that the participants are always in control of their experience, and if they need a moment to process, that is always acceptable and encouraged. Next, the structure of the class and the creation of advertisements for the course began. The DNP student used a Canva template to create a flyer describing the class and the project’s purpose (see appendix D). This was distributed via email by the owner of the Center and the other counselors of the Center to their clients to encourage participants to come to the class. The recruitment process was to send out an email to raise awareness and hope that people attended the course. The flyer included an email address, and the DNP student received five emails from interested parties. Three participants of those that emailed participated in the first class, and one participant continued for the duration of the six weeks. The project was submitted for initial approval to the Internal Review Board (IRB) of IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 18 Weber State University (WSU) on November 17, 2021. Official approval was granted on November 19, 2021. The Center does not have an internal review board; no permission was needed to carry out the project at that location. In the very first class, a liability waiver and a pre-test was given to each participant for completion. The weekly class structure began with an introduction of each attendant and an information-sharing moment, consisting of a different question each week. The purpose of the question was to facilitate communication between the group participants and build camaraderie. An example of one of the questions was, “Name something that you do to help you improve your mood when you are feeling down?” After the introduction and discussion, the DNP student led a short, guided warm-up. The class then learned a simple exercise that broke down the acro-yoga moves into easy step-by-step movements. The end poses could be easily achieved by breaking each activity into shorter, more uncomplicated actions. The participants each commented on how, when first seeing the moves, they did not believe they could manage them, yet each participant was able to succeed in doing the end movements. The acro-yoga class opened up new ways to achieve fitness and built confidence and self-esteem in the participants. The following five classes kept to the same format, an introduction, a brief discussion, and a new acro-yoga sequence. Project Timeline The project timeline covers the initial stages of forming the relationship with the Center’s director and progresses through the final stages of interpreting the data collected. The project began with the idea of wanting to integrate physical fitness directly into mental health. From this idea, the DNP student cold-called a local counseling center and connected with the owner of The Center. The collaboration was formed through multiple discussions, a presentation of the concept, approval of the project from the Weber State University IRB Board, and class IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 19 promotion. The classes were held at The Center in the yoga room for six weeks. See Appendix C for the timeline. Project Evaluation Five participants completed a pre-test, reported in Table 2, and two completed the postevaluation test, reported in Table 3. The tests were Likert scales with questions that addressed eight aspects of mental health and well-being on a scale from 0-3, three being “improved a lot” and zero being “gotten worse” (see appendix B). Data Maintenance and Security Surveys were initially done on paper and collected by the DNP student. All data was stripped of identifiers, and information was stored on a password-protected laptop. All paper documents were stored in a locked drawer in the home of the DNP student. Data Collection and Analysis Data were collected on paper and transferred into data tables on the password-protected laptop. Demographic data designating gender was collected. (See Table 1.) The pre-test and posttest questions differed slightly (see appendix B). Table 1 Participant Characteristics Gender N=5 - Female4 - Male1 Participants were asked on the pretest about their quality of life, current health, and how severely their mental illness affected their daily life on a scale from 0 to 10 (see table 2). A total of five participants took the pre-test, and two participants took the post-test. IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 20 Table 2 Pre-Test Questions n=5 Table 3 Post-test Questions n=2 How has your perception of these areas changed over the last six weeks since starting mental health fitness? Gotten Worse % No change % Improved a little % Improved a lot % Strength 0 50 50 0 Balance 0 0 100 0 Fatigue 0 100 0 0 Sleep Quality Cognition 50 50 0 0 (memory, concentration, etc) 0 100 0 0 Quality of Life Horrible % Bad Fair % % Good % Excellent % Current Health 0 0 20 60 20 Overall 0 0 20 40 40 Mood 0 0 40 60 0 How much does mental Not at all % Moderate Interference % Extreme Interference % health condition affect your life 20 60 20 IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 21 Anxiety/Depression 0 50 50 0 Social Activities 0 50 0 50 Self-confidence in 0 0 the ability to do exercise How would you rate your current quality of life? n=2 50 50 Best % Fair % Worst % Participants 50 50 0 How would you rate your experience with the mental health fitness program? n=2 Best % Fair % Worst % Participants 100 0 0 Findings The data show that those who completed the program enjoyed the classes; the participants gave the program a “best” rating in their personal experience. The areas that showed the most improvement were balance and self-confidence, but overall, five categories showed “a little to a lot” of improvement. One participant had a reduction in quality of sleep; it is unknown if this was related to the class or outside stressors. The response to the five open-ended questions in the post-survey resulted in five comments. Comments that were given were “the most beneficial thing was the opportunity for me to get back into my body in an interactive and social way.” Another participant stated that the most beneficial thing since starting the program was “believing I could do hard things.” IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 22 Strengths The program was a success for the two participants, showing improvement in several areas tested and enjoyed by the participants who completed the program. From the comments received, the participants grew in self-confidence and self-awareness, which highly affect mental health. Weaknesses In future studies, I would increase the advertising to multiple counseling facilities and possibly to yoga studios to improve participation. The study had low numbers, which affected the outcomes and made the study difficult to generalize to the larger population. Improvement could be made in the orientation of the therapists to help them better understand the program and promote it. It is unknown why the three participants dropped out of the study. In future research, I would make the pre and post-test questions more exact to compare the results more quickly. Discussion This DNP project implements a physical fitness regimen connected to a mental health facility to connect the mind and body for healing. The project is successful, and the outcomes of improvement in balance and self-confidence show improvement. To increase participation, future classes can be held with improved advertising and a broader audience. Translation of Evidence Into Practice Due to individual responses to interventions, treatment for diseases like depression and anxiety is difficult to narrow down and predict. Studies are increasingly proving that adding physical fitness significantly impacts outcomes in mental health patients (Czosnek et al., 2019). Exercise improves self-esteem, overall mood, sleep, and stress resilience (Fox, 1999). In this project, the participants show an improvement in self-confidence. The number of participants that completed the classes is n=2. Therefore, the data is not transferrable to the general IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 23 population. Further studies with larger populations will need to be conducted to discover viable conclusions. Implications for Practice and Future Scholarship In the future, these findings can help teach practitioners the importance of ensuring that patients participate in regular physical fitness. Future studies could adjust the focus on the mental health of traditional yoga practitioners. Future studies on the effects of lifestyle modifications could be to give the clients of a counseling center passes to a local gym and track the number of times the passes are used and the effect on their mental health. A way to apply this information to direct practice would be to improve family practitioners' knowledge about access to physical activity. Another application would be utilizing regular physical activity in psychiatric practitioners' care plans for their mental health patients. Sustainability Government funding would be highly effective in helping maintain sustainability. Lobbying for insurance companies to cover gym memberships under insurance coverage could help families to cover costs and improve access to fitness. Partnering fitness centers with healthcare could improve the overall health of Americans. Dissemination I will encourage each patient I see to utilize regular exercise as a part of their wellness journey. I will routinely document their reported type and duration of exercise each week. I will create a poster with the details of the study and results to present to my peers. I can submit the paper to the Global Wellness Institute for review and possible integration into practice. Conclusion Physical fitness and mental health are inextricably intertwined. Utilizing fitness to connect the mind with the body has powerful benefits for patients suffering from mental health IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 24 disorders. As shown in this small study, adding a weekly physical routine improved selfconfidence in 100% of the participants. While further research is necessary to draw more applicable conclusions, this small, short study indicates the need for increased implementation of physical activity in treating mental health disorders. 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World Psychiatry, 14(3) 339-347, https://doi.org/10.1002/wps.20252 IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 29 Women's Nutrition Connection. (2019, April). Good nutrition can help keep brain function healthy as you age. https://link.gale.com/apps/doc/A578583285/ITOF?u=ogde72764&sid=ITOF&xid=54548 207 World Health Organization. (2021). What is the WHO definition of health? World Health Organization. https://www.who.int/about/who-we-are/frequently-asked-questions Appendix A Category Quantity Estimated Expense Actual Cost Yoga Mats 5 $30 ea- $150 Room rental $100/mon IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 30 Appendix B Participant Pre-Program Survey Mental Health Fitness Program Evaluation your overall mood on a 1-10 scale? How much does your mental health condition affect your daily life? IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 31 Appendix M Participant Post-Program Survey Mental Health Fitness Participant Post-Program Survey Name (optional): _______________________________________ Date: __________________ How has your perception of these areas changed over the last 8 weeks since starting mental health fitness? Circle one per symptom: GOTTEN WORSE NO CHANGE IMPROVED A LITTLE IMPROVED A LOT Strength 0 1 2 3 Balance 0 1 2 3 Fatigue 0 1 2 3 Sleep Quality 0 1 2 3 Cognition (memory, concentration, etc.) 0 1 2 3 Anxiety/Depression 0 1 2 3 Social Activities 0 1 2 3 IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 32 Self-Confidence in the ability to exercise 0 1 2 3 GOTTEN WORSE NO CHANGE IMPROVED A LITTLE IMPROVED A LOT How would you rate your current quality of life? BEST FAIR WORST QUALITY OF LIFE QUALITY OF LIFE Form Adapted with Permission from Yoga Moves MS 9/7/21 Appendix M-Continued How would you rate your experience with the mental health fitness program? EXCELLENT GOOD FAIR BAD HORRIBLE What have you found the most beneficial since starting mental health fitness? IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 33 What do you like best about the classes? What would you like to change about the classes? Any other feedback that you would like to share? Form Adapted with Permission from Yoga Moves MS 9/7/21 Demographic Questions: NOT REQUIRED Please fill out if you choose to share your information, it would be appreciated, and if not, it will be absolutely respected. Age: _____ Gender _____________ Marital Status __________________ Occupation ___________________ Education _____________________ IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 34 Appendix C Date Task 1/20/21 Phone call with Sophie to discuss project idea 5/20/21 Meeting with Sophie to discuss project details 9/28/21 Pre/post survey tool found 10/23/21 Presentation to counselors of the Center about the project 10/27/21 Project proposal for Weber State University IRB 10/31/21 Waiver created for participants 11/2/21 Flyer created and sent to Sophie for distribution. Hung up at the Center 12/15/21 Yoga mats purchased 1/28/22 First acro yoga class held 2/4/22 Second acro yoga class held 2/11/22 Third acro yoga class held 2/18/22 Fourth acro yoga class held 2/25/22 Fifth acro yoga class held 3/4/22 Final acro yoga class held IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 35 Appendix D IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 36 IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 37 Appendix E IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 38 IMPLEMENTING A FITNESS PROGRAM TO SUPPLEMENT MENTAL HEALTH 39 • • •