Oct 01, 2013
Prescription for physical activity: A survey of Canadian nurse practitioners
Although nurse practitioners are well placed to counsel patients about getting enough exercise, little is known about their attitudes and practice in this area of health promotion. The authors used a self-administered Internet-based questionnaire to explore how Canadian NPs perceive their competence in prescribing physical activity and the importance they ascribe to doing so. Participants were asked to identify factors that most commonly prompt physical activity prescription. Overall, the respondents felt fairly competent in their ability to prescribe physical activity (mean score 4.49/6.0, SD = .90) and felt that this function was important (mean score 4.82/6.0, SD = .85). Competence in prescribing physical activity and a perception that this intervention is important were both positively correlated with frequency of prescribing. The most commonly reported barrier to prescribing physical activity was a lack of time. On average, respondents prescribed physical activity to 59 per cent of their patients. The patient factors that most commonly prompted physical activity prescription were overweight or obesity, type 2 diabetes, hypertension and cardiovascular health. The lack of specific education in preventive medicine (e.g., obesity prevention, physical activity, nutrition) reported by 63 per cent of respondents points to the need for a physical activity prescription curriculum within nursing education to equip future NPs to respond to the high prevalence of physical inactivity in Canadian society.
Many Canadians do not engage in physical activity of sufficient frequency, intensity or duration to achieve the well-documented health benefits of regular physical activity. Given the importance of health promotion to their professional role, nurse practitioners (NPs) are well placed to counsel patients about physical exercise (Peterson, 2007). However, little is known about NPs’ perceptions and practice with regard to prescribing physical activity. We undertook this study to explore how Canadian NPs perceive their competence in this area, the importance they ascribe to prescribing physical activity and how commonly they do so. We also wanted to identify the factors or circumstances that most commonly prompt NPs to prescribe physical activity.
Data collection. We collected cross-sectional data from Canadian NPs, using the online survey platform SurveyMonkey. Invitations to participate were sent through nursing associations, nursing regulators, NP interest groups, and national NP electronic mailing lists. To protect the confidentiality of membership and mailing lists, the invitations were sent directly by the participating groups; the actual number of invitations sent and received is therefore not known. The invitation contained a link to the online survey form. A reminder was sent one week after the initial invitation. Consent was implied by completion and submission of the questionnaire.
Measures. Socio-demographic information was gathered by means of survey questions concerning the respondent’s age, sex, body mass index (BMI), years in practice as a registered nurse and NP, and previous education in preventive medicine (e.g., obesity prevention, physical activity, nutrition).
The respondents’ level of physical activity was assessed using a modified Leisure Score Index (LSI) from the Godin Leisure-Time Exercise Questionnaire (GLTEQ) (Godin, Jobin, & Bouillon, 1986; Godin & Shephard, 1985). The LSI assesses the average frequency and duration of mild, moderate and strenuous exercise during leisure time over a typical week. The validity of the GLTEQ is well established (Jacobs, Ainsworth, Hartman, & Leon, 1993). From these data, we calculated the average weekly physical activity of each respondent and the overall average for the study sample.
The degree of involvement in physical activity counselling was assessed with an open-ended question that asked respondents to specify the percentage of their current patients to whom they prescribed physical activity. The respondents’ perception of their competence to provide such counselling and the importance they ascribed to this aspect of their practice were assessed using the Exercise and Physical Activity Competence Questionnaire (EPACQ) (Connaughton, Weiler, & Connaughton, 2001) The EPACQ is a 17-item questionnaire originally designed to assess the perceptions of deans and medical school directors with regard to the competence of medical students in exercise prescribing (Part A), the importance of exercise prescription (Part B) and the medical school curriculum related to exercise prescription (Part C). For the purposes of our study, we adapted the 12 items that comprise Parts A and B. In part A, respondents rated their competence using a 6-point Likert scale (1 = not competent; 6 = very competent) in the following skills with respect to screening and advising healthy adults: (1) conducting a physical exam to approve the patient to begin a physical activity program; (2) determining the maximum heart rate — the point at which a person is ‘straining’ during physical activity; (3) determining daily caloric and nutritional needs; (4) determining BMI; (5) calculating the aerobic training heart rate range; (6) designing a physical activity prescription, including frequency, duration and intensity. In Part B, respondents again used a 6-point Likert scale (1 = not important; 6 = very important) to rate the importance they ascribed to being able to perform the six skills presented in Part A. Items for these two scales were drawn from the ACSM Guidelines for Exercise Testing and Prescription (Connaughton et al., 2001).
Open-ended questions were used to assess the respondents’ beliefs with regard to prescribing physical activity; specifically, they were asked to identify the main advantages and disadvantages of prescribing physical activity and the factors they thought would make it easier or more difficult to prescribe physical activity.
Statistical analyses. Statistical analyses were performed using SPSS version 20 (SPSS Inc., Chicago, IL). Means and percentages were calculated for the socio-demographic variables. To test for the strength of any correlations between the dependent variables (beliefs about competence and importance) and the independent variables (socio-demographic characteristics), we calculated Pearson’s r, a measure of the strength of a relationship between two variables. We then conducted a multivariate analysis of variance (MANOVA) for independent variables shown to have a statistically significant association with the composite scores for perceived competence and perceived importance.
Responses to open-ended questions were categorized by theme.
One hundred forty-eight NPs completed the survey; 97 per cent of respondents were women and 61 per cent were master’s prepared. Eleven provinces and territories were represented; the largest proportion of respondents (23%) were from Saskatchewan. Approximately 87 per cent of respondents were working full time at the time of the study. With respect to work setting, 34 per cent of respondents reported that they worked in a community health centre. Approximately 74 per cent of respondents identified their primary area of responsibility (i.e., patient group) as “family/all ages.”
Overall, 63 per cent of respondents indicated that during their nursing studies they had received no formal education (such as a course or a module within a course) that specifically addressed preventive medicine. The responses to questions about the respondents’ own level of physical activity indicated that 56 per cent were meeting current guidelines for at least 150 minutes weekly of moderate or vigorous exercise in sessions lasting 10 minutes or more. On average, respondents reported that they were prescribing physical activity to approximately 59 per cent of patients seen. About 58 per cent of respondents indicated they intended, in the future, to prescribe physical activity to their patients.
The mean scores for respondents’ perceptions regarding their competence in physical activity prescribing and the importance they attached to this function are shown in Table 1. Overall, the respondents felt fairly competent in their ability to prescribe physical activity (mean score 4.49/6.0, SD = .90) and felt that it was important to discuss physical activity with their patients (mean score 4.82/6.0, SD = .85). Perceived competence was positively correlated with the number of minutes spent on exercise in a week (r = .18, p = .031), meeting guidelines for exercise (r = .23, p = .007) and current frequency of physical activity prescribing (r = .24, p = .003). Perceived importance was positively correlated with current frequency of physical activity prescribing (r = .18, p = .032). While these correlations are small, the level of significance indicates that these findings are not due to chance.
MANOVA showed a statistically significant association between meeting guidelines for exercise and the respondents’ perceptions concerning physical activity prescribing: that is, those who met exercise guidelines were more likely to rate their competence in physical activity prescribing highly and to view this function as important [Wilks’ λ = 0.955, F(2,139) = 3.311, p = 0.039]. A significant association was present only for perceived competence. NPs who met current guidelines with respect to their own levels of exercise rated their competence in prescribing physical activity significantly higher than NPs who did not meet these guidelines (Mdiff = .377, p = 0.012).
The factors most commonly reported by survey respondents as prompting them to prescribe physical activity were as follows: overweight or obesity (119 responses), type 2 diabetes (54), hypertension (44) and cardiovascular health (41). The five most commonly mentioned “disadvantages” of prescribing physical activity to patients were lack of time (46 responses), lack of patient compliance or of followup (16), lack of knowledge about prescribing physical activity (15), risk of offending patients (10) and lack of patient readiness (7). However, 37 respondents replied that there were no disadvantages. The five most commonly mentioned advantages of prescribing physical activity were an increase in the patient’s overall physical health (27 responses), prevention of chronic illness (25), achieving or maintaining a healthy weight (20), improvement with respect to chronic disease (19) and improvement in mental health (17).
To our knowledge, this is the first study to examine the beliefs of Canadian NPs with respect to physical activity prescribing and the prevalence of this function within NP practice. Our finding that NPs ascribed high importance to prescribing physical activity (mean score 4.82 on a 6-point scale) is consistent with the findings of a U.S. study in which 92 per cent of NPs surveyed perceived that exercise counselling was as valuable a component of their practice as the prescribing of medications (Tompkins, Belza, & Brown, 2009). The moderately high rating that our respondents gave to their competence in this area (mean score 4.49 on a 6-point scale) is also consistent with the results of two other U.S. studies: Grimstvedt (2011) reported an overall score for NPs’ confidence in exercise counselling of 3.7 on a scale of 5, and Vickers, Kircher, Smith, Petersen and Rasmussen (2007) reported that approximately 86 per cent of their sample of NPs were confident in counselling on health behaviours that they engaged in themselves. In the Vickers et al. study, no differences between NPs who met current guidelines for physical activity and those who did not were found with respect to their perceptions of their clinical competence in this area or their views of its importance; however, NPs’ views of their competence in prescribing exercise were strongly correlated with their own level of physical activity.
Our finding that 63 per cent of respondents had not received any specific training in preventive medicine during their undergraduate and NP education is consistent with survey findings from the U.S. In a survey involving primary care providers (physicians, physician assistants and NPs), 85 per cent of respondents said that they had no formal training in exercise prescription (Dauenhauer, Podgorski, & Karuza, 2006). In Grimstvedt’s study (2011), 75 per cent of NPs and physician assistants reported that they routinely counselled patients about physical activity, about half (51%) reported that they had received training in this area and nearly three-quarters (72%) indicated they were interested in receiving additional education in physical activity counselling. In a survey of NPs conducted by Buchholz and Purath (2007), 61 per cent of respondents said they had received no training in physical fitness counselling. NPs are ideally placed to prescribe physical activity. In view of the fact that only 59 per cent of those sampled were currently engaging in physical activity prescription, future work needs to be directed at raising awareness and improving education exposure with respect to physical activity prescription. However, the literature points to a lack of guidelines for physical activity prescription. Douglas, Torrance, van Teijlingen, Meloni and Kerr (2006) reported that the NPs they surveyed had insufficient educational materials available. NPs need consistent, evidence-based information to support their competence in this area. Further, exploration of educational tools to assist them in managing chronic illness with physical activity prescription is warranted.
The most commonly reported barrier to counselling patients about physical activity was lack of time. There is a need to ensure that NPs and other health-care providers understand that time allocated to such counselling is well invested, as it can result in positive, measurable health outcomes. Our findings also point to the need for a physical activity prescription curriculum within nursing education to equip future NPs to respond to the high prevalence of physical inactivity in Canadian society. There is still a gap between evidence-based guidelines for healthy levels of physical activity and the application of those guidelines in clinical practice.
Limitations of our study include its small sample size and reliance on self-reporting and the uneven representation across the provinces and territories. Larger studies with Canada-wide representation will help us gain a clearer understanding of the challenges faced by NPs in the realm of physical activity prescription and, ultimately, will help NPs engage in productive discussions with their patients about their physical fitness. Finally, specific interventions to promote and improve physical activity counselling should be a focus for future research.
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