On average, 20% of American adults, or roughly 50 million people, experience a mental illness annually.1, 2 For U.S. residents under age 45, mood disorders are the third leading cause of hospitalization (after pregnancy and birth).3 Psychiatric comorbidities are common and may contribute to increased length of stay and cost.2, 4, 5
Patients admitted with psychiatric illness are often placed in highly controlled, locked environments.6 Whether hospitalized voluntarily or involuntarily, these patients experience stress, anxiety, and frustration due to feelings of confinement, the perceived violation of their personal rights, and rules they often view as unpredictable.7
Given that these patients require interventions to address both their mental and physical health,2 there is a clear need to prioritize evidence-based practice (EBP) in attending to their complex needs. Ideally, treatment would involve both psychotherapeutic and psychiatric (medical) interventions, but such services are not consistently available.2 To date, there is a dearth of literature describing care for hospitalized patients with a combination of acute medical and psychiatric disorders. This article adds to the understanding of how nurses can use yoga with meditation as a complementary therapy to improve care for these complex patients.
BACKGROUND
Evidence synthesis. Working with the health science librarian at our academic medical center, we conducted a comprehensive literature search of the CINAHL, EBSCO, Cochrane, ProQuest Central, and PubMed Central databases, using the search terms mindfulness, yoga, sense of well-being, yoga as therapy, yoga in inpatient psychiatric units, yoga and mental illness, conscious meditation, stress, anxiety, therapeutic yoga, and benefits of yoga. We then reviewed the identified articles for relevance and to guide the design of our proposed EBP practice change and evaluation.
Yoga-based treatments are one of a group of complementary or alternative emerging therapies recognized as beneficial for people with various psychiatric disorders, including depression, anxiety, posttraumatic stress disorder (PTSD), and attention deficit-hyperactivity disorder, in addition to schizophrenia and other psychotic disorders.2, 8-10 Such treatments are recognized by the National Institutes of Health's National Center for Complementary and Integrative Health as a form of complementary and alternative medicine.11
Yoga includes the following features12:
* asanas (physical poses and movements, consisting of bending, standing, and stretching, to improve balance and strength)
* pranayama (breath control)
* dharana (mindfulness)
* dhyana (meditation)
It's been suggested that the various practices of yoga (a Sanskrit word often translated as "to unite" or "to attain the unattainable"13) work synergistically to produce yoga's therapeutic effects.12
While the study of yoga's clinical utility may be complicated by variation in yoga techniques and evaluation measures, there is strong evidence supporting yoga's beneficial physiological and psychological effects for patients with behavioral health issues.
Benefits of yoga. Physiological benefits of yoga include positive changes in heart rate, blood pressure, cortisol levels, and inflammatory proteins.12 Psychological benefits include improved emotional regulation and cognitive function that enhance a sense of well-being through a calming effect that reduces anxiety, stress, and depression, thus improving mood and relationships.12 Cognitive benefits of yoga include improved attention, memory, body awareness, and emotional awareness.12, 14 Increased acceptance, adaptability, and improved functioning resulting from yoga practice often aid patients in their transition to home.
Long-term benefits. The beneficial effects yoga produces are potentially long term because, working by way of the hypothalamic-pituitary-adrenal axis, yoga stimulates the parasympathetic nervous system, increasing levels of the neurotransmitter [gamma]-aminobutyric acid (GABA) in the thalamus and generating changes in the brain.9, 13 These changes include an increase in the volume of gray matter, which processes sensory signals, as well as changes in the hippocampus, amygdala, and prefrontal cortex-which play a role in regulating stress reactivity, mood, and emotion-by reducing inflammatory biomarkers and responses that contribute to mental illness and increasing levels of GABA.9, 12, 13, 15-19
The regulation of stress reactivity is particularly important for patients hospitalized with psychiatric illness because these patients experience considerable stress, and thus yoga is believed to be a good adjunctive therapy for them.6, 12 Yoga appears to be beneficial and feasible, with few adverse effects.10, 20 Even patients experiencing acute psychiatric symptoms have been able to learn mindfulness techniques.21, 22 Having a qualified yoga instructor available to provide close supervision further reduces the risk of minor adverse events, such as strains or sprains.23
Purpose. The purpose of this 12-week EBP pilot project was to use structured yoga sessions as a means of providing stress relief, promoting relaxation, reducing anxiety, and improving quality of care for male and female adult patients (ages 18 years and older) hospitalized in a locked medical-psychiatric unit within our academic medical center for treatment of both acute medical and acute psychiatric conditions.
Before this project was initiated, the average length of stay on the unit was 19.9 days and readmissions averaged 12.6 days. Common behavioral diagnoses included major depressive disorders, bipolar disorder, schizophrenia, general anxiety disorder, substance use disorders, and PTSD. Common medical conditions included metabolic syndrome, suicide attempts requiring medical intervention, delirium, encephalopathy, alcohol or drug withdrawal, altered mental status, seizure disorder, acute kidney injury, liver failure, anemia, neuroleptic malignant syndrome, and bacteremia. The project was designed to offer stress relief and improve quality of care for patients in this local setting. It was not designed as research, and was determined not to be human subjects research, thus institutional review board approval was not required.24
PRACTICE CHANGE AND IMPLEMENTATION
Process. The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Healthcare (available at https://uihc.org/evidence-based-practice) was used as a guide to the EBP process.25
Yoga was a good fit for EBP because of its clear patient benefit and the substantial research supporting it. Teamwork was supported through the EBP internship program for staff nurses at our medical center, which was created to assist nurses in executing and evaluating an EBP practice change.26 Because of acute exacerbation of their medical and psychiatric conditions, patients receiving care on the medical-psychiatric unit have limited access to the traditional group therapy sessions available on regular psychiatric units.
In addition to nurses, the team consisted of unit leaders; occupational, rehabilitation, and recreational therapists; psychiatrists; the department executive for internal medicine and psychiatry; and nurse scientists with EBP expertise. To facilitate the work, a recreational therapist obtained funding from the volunteer office to purchase workout clothing, mats, blocks, and music.
The nurse manager arranged staffing to manage costs. Total full-time equivalent nurse positions on the unit were and remained at 17.65. Staffing ratios were maintained by arranging patient participation in the yoga groups and patient presence on the remainder of the unit to accommodate staffing needs. Roles and schedules were adjusted so that the charge nurse covered patient assignments, and the unit secretary and transport aides cross-covered roles during sessions. This allowed improved care to have a zero-budget impact.
Practice change. Yoga was selected as a relaxation method for the mind and body to appeal to inpatients with emotional dysregulation and to provide a transportable skill for long-term use at home. The certified yoga instructor consulted with nursing as well as with the medical staff, psychiatrists, and the recreational therapist to determine patients' interest, ability to participate, and clinical condition. Patients were screened for the following prerequisites for participation in the program:
* medical stability
* ability to maintain balance
* normal vital signs
* ability to follow instructions
* physical ability
After screening, eligible patients were invited to participate and offered appropriate clothing.
Sessions were called "relaxation groups" because the word "yoga" elicited disinterest from some patients, though patients were provided an explanation of the inclusion of yoga practice with mindfulness. The unit had a large dining room with a door that could be closed to control environmental distractions. Soft lighting and music produced a calming ambiance. Sessions were offered one day a week for 30 to 60 minutes, depending on patient preferences and ability. The pilot project was planned for 12 weeks.
Introductory instruction informed patients they had permission to leave the session or request that the session stop at any time. Sessions began with the gesture of namaste, a respectful greeting often used in the practice of yoga to create a sense of inclusion and interconnectedness.
The sessions used classic yoga with breathing awareness and moved sequentially through warm-up, active poses, cooldown or stretches, and meditation or conscious relaxation. Poses typically required getting on the floor with a yoga mat but were modified for chair practice or even individualized for patients in a hospital bed. Poses were easily modified to patients' abilities and when working around catheters, injuries, and chronic medical issues.
Patients' inability to concentrate required additional creative adaptations, such as providing one-on-one classes when possible. Patients were placed in groups according to their psychiatric diagnoses, preferences, and abilities. Multiple classes were offered to address patients' preferences, safety, clinical conditions, need for same-sex sessions when inappropriate behavior in a mixed group was anticipated, or when a patient had concerns about practicing yoga in front of others. The top priorities for designing classes were patient safety and creating a relaxed, comfortable environment.
Implementation. Implementation of the practice change and early planning for sustainability were inspired by the Implementation Strategies for EBP framework from the University of Iowa Hospitals and Clinics.27 A Precision Implementation Approach28 was used for data-driven selection of strategies across four implementation phases (see Figure 127, 29).
Nurses identified local needs through completing a pre- and post-pilot questionnaire. Table 1 reports the sequential steps used to meet those needs: first is the questionnaire item, then the pre-pilot data, next is the key implementation strategy selected to meet the local needs, and last is the resulting post-pilot data.
Awareness and interest in the yoga sessions/EBP project were generated through staff meetings, and via a unit newsletter that shared their anticipated impact and publicized the yoga equipment. The nurse manager provided support by promoting yoga during interprofessional meetings, spotlighting patient stories, and arranging staffing.
Knowledge and commitment were fostered through group and one-on-one educational sessions, which provided additional background information and resource materials.
Action and adoption were promoted by reminders and signs posted in key locations and in patient rooms, raising patient awareness of sessions and available equipment, encouraging attendance, and providing follow-up to encourage self-directed practice.
Adoption was further supported by nurse documentation in the electronic health record, where nurses noted any changes in a patient's condition after yoga sessions. Pre-pilot data indicated that documentation could be easier, so the documentation template was updated. Nurses further identified a need to better understand their role, so staff were able to participate in yoga sessions when scheduling permitted. Participating in yoga sessions helped build nurses' appreciation for yoga and allowed them to observe the benefits yoga offered their patients.
Integration and sustained use. Based on the clear patient benefits of yoga, a preliminary plan for sustaining the EBP project was developed. Post-pilot data provided an opportunity to reinforce the use of yoga. The interprofessional screening of patients to participate continued and patients were encouraged to attend yoga sessions. Additional planning for sustaining patient improvement occurred using post-pilot data and internal reporting.
RESULTS
Process and outcome data from both patients and nurses captured knowledge, attitudes, behaviors, and outcomes using existing tools.30 Patients were given a questionnaire before and after yoga sessions to evaluate their effectiveness. Questionnaires were adapted from other established surveys, including the Hospital Anxiety and Depression Scale,31, 32 the Who-5 Well-Being Index,33 and the Beck Depression Inventory,34 so as to be applicable and feasible for assessing patients' current affect and mood using the fewest possible items.
Nurse evaluation. Staff nurses, nursing assistants, and unit managers provided feedback. Nurses provided input before and after pilot testing (n = 40 pre-pilot; n = 20 post-pilot) using a two-part questionnaire to evaluate their knowledge and attitudes. Participation was voluntary and identifiers were not tracked, so individual follow-up was not possible. Of note, of those nurses completing the pre-pilot questionnaire, 75% had experienced yoga, yet only 3% of them practiced regularly.
Nurses' responses to the knowledge items indicated that most nurses were aware of the benefits of and screening considerations for patient participation in yoga sessions (pre = 88%; post = 84%). Response options to the attitude items consisted of a four-point Likert-like scale (ranging from 1 = strongly disagree to 4 = strongly agree) and responses showed positive change across the board. Nurses reported feeling more supported to promote yoga (pre = 3.2; post = 3.4), knowledgeable about their role (pre = 2.55; post = 2.75), that documentation was easy to complete (pre = 3.15; post = 3.43), and that they had easy access to needed supplies (pre = 2.78; post = 3.21). (For more details on nurse responses, see Table 1.)
Patient evaluation. Over a 12-week period, 39 patients participated in one or more yoga sessions (n = 39, pre-yoga; n = 38, post-yoga). They completed questionnaires that consisted of statements describing their mood with response options of yes, somewhat, or no. Patient responses were also positive. After participating in the yoga sessions, 76% (29 of 38) of patients responded "yes" to being calm and relaxed, compared with just 23% (nine of 39) pre-yoga. In addition, compared with their experience pre-yoga, patients reported feeling less anxious, tense, or on edge post-yoga. Feelings of anxiety decreased from 41% (16 of 39 respondents) pre-yoga to 5% (two of 38 respondents) post-yoga. Fewer patients reported having difficulty relaxing after participating in the yoga sessions (pre-yoga = 41%; post-yoga = 16%). (For more details on patient responses, see Figure 2.) A few patients who were diagnosed as experiencing a manic or psychotic episode or with severe intellectual disabilities chose to leave sessions or requested that a session stop; they were not included in the evaluation.
Patient comments were recorded in the comments section of the questionnaire. After participating in a yoga session, one patient reported, "I feel good, I feel ok, I feel just good all over," and another stated, "I feel my mind is calm and my body is relaxed." Another patient, who had such severe paranoid schizophrenia that he had caused his own blindness from self-harm and had daily command hallucinations, had said prior to yoga, "My mind races all the time, and my body is tense all the time." After his one-on-one yoga session, he said he intended to do yoga at home after discharge, and he was given a mat to take home with him. In response to patient feedback, the nurse manager arranged staff schedules to allow the nurse-yoga instructor four hours per week of nonpatient care time in order to offer more one-on-one yoga sessions.
Nurse documentation of patients' moods occurs routinely on every shift, and more often if indicated, though it is not specifically associated with the yoga sessions. Nurses chart using a list of mood descriptors, making quantitative analysis difficult. However, we could use these descriptors to categorize a patient's mood as showing improvement, no change, or deterioration from before to after the yoga sessions. Nurses documented positive mood changes in 45% of patients, no mood change in 39% of patients, and negative mood changes in 5% of patients. Four charts were missing documentation. The timing of documentation after yoga varied and the proximity of charting to the yoga session may explain some of the differences in mood. On average, documentation of positive mood changes occurred 3.7 hours after yoga, documentation of no change in affect occurred 4.9 hours after yoga, and documentation of negative mood changes occurred 9.75 hours after yoga.
Yoga sessions were intended to provide immediate benefit and had the potential for a longer-term impact with continued practice both during and after hospitalization. Patients identified a desire to continue using yoga, saying "I will do this when I go home to keep my body healthy and my mind," and "I will do yoga instead of drinking and doing drugs to stop the voices in my head because this is the only thing that works."
INTEGRATING AND SUSTAINING YOGA SESSIONS
This EBP pilot project was reported within the organizational shared governance of the academic medical center to promote its integration and sustain support.35 Nurse executives were interested in the program and a business plan was created for integration and rollout of the yoga sessions. The plan described a schedule and a budget for offering yoga classes on all behavioral health inpatient units, and led to immediate funding of a 50% position for the nurse-yoga instructor to sustain and add sessions. This built on the limited relaxation sessions that were already provided to the more stable patients on other units.
Expansion of the yoga program. Yoga classes are now offered on all inpatient behavioral health units at least three times per week. The new position of certified yoga instructor was upgraded to a 100% full-time equivalent position through the rehabilitation department, and rehabilitation therapists became certified yoga instructors. Additional evaluation to establish a return on investment is being planned.
Patients have been so enthusiastic about how they feel after yoga sessions that they have asked for more access. Videos were made for yoga practice in bed, in a chair, and on a mat and added to the hospital's educational television channel. At the patients' request, yoga mats were provided for use in the hospital, and some were distributed at discharge. Some patients asked for written yoga instructions to take home. The nurse-yoga instructor gave each person a chance to review the instructions, take notes, and ask questions.
Patients asked the nurse-yoga instructor for free videos and were taught how to access them on the internet, but they wanted access to this familiar instructor and her approach, so she created short videos and posted them for free on YouTube.36 Patients were also given additional information on other free sources for yoga videos.
Lessons learned. Yoga was feasible and effective, yet practice sessions needed to be tailored to meet each patient's needs. An interprofessional approach to patient screening and project implementation was helpful. Patients with hypomania were able to do a full hour session if it contained a more physical component. Patients with mania were able to participate but were often unable to finish the sessions, though they were grateful to be able to attend. Leadership support is important to enable access to certified yoga instructors and to arrange staffing.
CONCLUSION
This EBP practice change explores the use of yoga and mindfulness relaxation to improve the care of inpatients who have a combination of acute physical and acute psychiatric disorders. Health and well-being are paramount for this vulnerable and complex patient population with mental or behavioral health issues. Patients who participated in the yoga sessions reported benefits for both mind and body. In addition to medication and psychiatric care, yoga and mindful relaxation can have a positive impact on patients with behavioral health issues, as our project demonstrated.
Patients with a combination of medical and behavioral conditions have complex needs. Nurses caring for this vulnerable population are highly committed to improving the care they provide. The EBP internship program created an opportunity for staff nurses to learn EBP and apply the process to address a clinical priority. The Iowa Model outlined the steps in the EBP process for the team to follow. Implementation of the EBP pilot project was uniquely focused on meeting local needs by using the Precision Implementation Approach to create implementation strategies that promote the adoption of yoga as a complementary intervention. Using a systematic process generated the results needed to create a business case and garner executive leaders' support to roll out the program on additional units.
REFERENCES