Healthcare is moving away from the acute setting into the community, accompanied by an ever-increasing focus on health promotion and disease prevention. Physical activity is an area of health promotion in which nursing has yet to find a voice. Currently, an opportunity exists for clinical nurse specialists to lead nursing in meeting our social and professional responsibilities. Failure to get out in front of this growing demand now will likely result in other providers filling the void.
Over a decade ago, Healthy People 2010 identified physical activity as the first of 10 leading health indicators. With the advent of Healthy People 2020, physical activity was designated 1 of 4 health determinants, defined in the document as individual behaviors that determine health outcomes. Unfortunately, although the multiple health benefits of physical activity are well recognized, data from Healthy People 2020 demonstrate that less than 50% of US adults achieve recommended levels of physical activity.1
Healthcare professionals are increasingly being asked to provide counseling regarding the benefits of regular physical activity. Although most professional nurses are familiar with the health benefits of regular physical activity, knowledge of its benefits does not directly translate to understanding of and competency in education and coaching about safe and effective physical activity behaviors. Indeed, how physical activity is implemented is poorly understood by approximately 75% of the general population,2 and it is unlikely that this trend is exceptionally different among healthcare providers.
By definition, physical activity is an umbrella term that includes regular low to moderate intensity activities of daily living as well as formal exercise. Exercise, as a subset of physical activity, consists of vigorous activities at the higher end of intensity. Although risks may occur, especially with more vigorous activities, it is generally recognized that the benefits of appropriately prescribed physical activity far outweigh the possibility of adverse outcomes.3
To be most effective, physical activity should be prescribed in a similar way to prescription of medications. Because the complexities of safe physical activity prescription mirror those of prescription of medication, population-level expertise is needed. For this reason, prescription of physical activity should fall within the scope of advanced practice registered nurses, including clinical nurse specialists, who are multifaceted, expert clinicians skilled in teaching/coaching and consultation. Clinical nurse specialists are ideally placed to assume responsibility for expanding physical activity prescription by nursing colleagues.
The elements of physical activity prescription should include frequency, intensity, time, and type of activity. The acronym FITT can be used as a framework for recommendations. For frequency, general recommendations are that every person should be physically active on all or most days of the week. However, activities should vary based on individual prescriptions. For intensity, moderate exertion (5-6 on a 10-point scale) is sufficient for many health benefits, whereas for others, higher levels of exertion (7-8 on a 10-point scale) are needed.
Current physical activity guidelines for time (duration) of activity vary somewhat by population. Children and adolescents should be physically active at least 60 minutes a day, whereas for adults and older adults, a range of 150 to 300 minutes per week is recommended. Finally, the type of activity chosen should be based on personal preference and health goals. For example, maintaining cardiorespiratory and musculoskeletal health is a commonly identified goal. Activities ranging from brisk walking to running provide significant cardiorespiratory benefits. Non-weight-bearing activities such as swimming and cycling also provide benefits in this area. By comparison, for musculoskeletal health (ie, maintenance of muscle and bone strength), it is necessary to engage in more vigorous activities such as running or weight lifting. However, the amount of time needed for vigorous activities that are often perceived as burdensome is much less than is needed for moderate-intensity activities.
In fact, an important educational point for many adults is that to a certain extent duration can be exchanged for intensity. For example, 15 minutes of running can provide the same dose of activity as 30 minutes of brisk walking. In essence, there is a direct and negative association between intensity and duration-as intensity increases, the need for duration decreases. Alternately, individuals who, for reasons of personal preference or physical limitations, are unable or unwilling to engage in activities at the higher end of the intensity spectrum can accrue many comparable health benefits by extending the time that they engage in activities of low to moderate intensity.
There are excellent resources available to assist clinical nurse specialists in developing their knowledge regarding physical activity needs and recommendations. The US Department of Health and Human Services provides free electronic access to the 2008 Physical Activity Guidelines for Americans at http://www.health.gov/paguidelines/guidelines/default.aspx. The guidelines are evidence-based and specifically developed for use by health professionals as an educational resource. Target populations include children who are at least 6 years old, adolescents, and adults of any age.
For older adults, the National Institute on Aging provides population-specific guidelines at http://www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide/. This site is designed for the general public and provides "how to" information for individuals wishing to begin a physical activity program. Sample exercises and recommendations are contained in the NIA publication, Exercise & Physical Activity: Your Everyday Guide, which can be downloaded free of charge from the Web site.
The Exercise Is Medicine Web site at http://exerciseismedicine.org/ contains information not only for the general public, but also for health professionals, including guidance on patient counseling and development of individualized activity prescriptions. The Health Care Providers' Action Guide contains "how to" information for prescribing the appropriate dose of physical activity to meet health needs. To assist with education, the site also contains educational resources such as exercise-related videos and brochures.
Finally, to assist with self-awareness and promote safety during exercise, the EASY tool is a simple, 6-question self-assessment tool available online. Individuals can access the tool through the Exercise and Screening for You Web site at http://easyforyou.info/. Use of the EASY tool prior to beginning an exercise program can provide valuable education and guidance regarding preexisting risks and readiness for physical activity. Furthermore, by encouraging completion of the self-assessment, clinical nurse specialists may incorporate results into the prescription process.
Currently, there is a void in healthcare surrounding physical activity prescription. An opportunity exists for clinical nurse specialists to step forward and assume responsibility for this area of practice. Their foundation in evidence-based practice and population-based assessment and care, and expertise in education and consultation make them uniquely qualified to provide recommendations and guidance regarding physical activity to individual patients and to lead efforts in nursing to expand nursing practice in the area of activity prescription. Using the multiple resources available for healthcare providers, nurses can safely prescribe the correct dose of activity, including frequency, intensity, time, and type. Clinical nurse specialists are strategically placed to fill the void surrounding physical activity prescription. It is time to step up to the challenge.
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