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The beneficial effect of aerobic exercise on a healthy adult's perceived stress level

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THE BENEFICIAL EFFECT OF AEROBIC EXERCISE ON A HEALTHY ADULT’S
PERCEIVED STRESS LEVEL
BY
SHANA KONGSJORD
MASTER’S PROJECT
Submitted in partial fulfillment of the requirements for the degree of Master of Science in
Nursing, The College of St. Scholastica, May, 2010.
Master’s Project Committee
Catherine Miller, DNP, RN, C-NP
Chair
Kathleen Niska, CSJ, PhD, RN
Date
March 23, 2010
Sally Fauchald, PhD, RN
Chair, Department of Graduate Nursing
UMI Number: 1474662
All rights reserved
INFORMATION TO ALL USERS
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a note will indicate the deletion.
UMI 1474662
Copyright 2010 by ProQuest LLC.
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© Shana Kongsjord 2010
ii
Abstract
This literature review presents a practical assessment of the relationship between aerobic
exercise and perceived stress level in a healthy adult. Stress related to nursing and burnout is a
popular topic that must be addressed. Aerobic exercise is a means for people to reduce stress,
release endorphins, and develop self-esteem. Individuals can either work out by themselves and
participate in an activity that has meditative properties or exercise with a friend at a moderate to
high intensity; both these forms of exercise prove to have beneficial effects on stress reduction.
Studies show the more frequently one participates in physical activity, a lower level of perceived
stress is experienced. Furthermore, if one regularly engages in aerobic exercise, his or her body
is better equipped to handle the physical changes the body endures during times of stress; thus,
he or she is able to recover more quickly from stressful feelings. Clinical implications are vast
with studies revealing that advance practice nurses and other healthcare providers who partake in
regular exercise are more likely to counsel patients in the importance of physical activity for
their physical and mental health.
iii
Table of Contents
Abstract ....................................................................................................................................... iii
Introduction .................................................................................................................................. 1
Psychological Effects ................................................................................................................... 4
Regular versus Episodic ............................................................................................................... 5
Neurotransmitters ......................................................................................................................... 6
Mindful Walking.......................................................................................................................... 7
Support ......................................................................................................................................... 7
Benefits for Acute and Chronic Disease ...................................................................................... 8
Self-Regulation Theory................................................................................................................ 9
Clinical Implications .................................................................................................................. 11
Limitations ................................................................................................................................. 12
Recommendation ....................................................................................................................... 13
Summary .................................................................................................................................... 14
Conclusions ................................................................................................................................ 14
References .................................................................................................................................. 15
iv
1
The Beneficial Effect of Aerobic Exercise on a Healthy Adult’s Perceived Stress Level
Introduction
Today nurses report higher levels of stress than ever before. Patient acuity and the
demand on the nurse have increased over the years while the number of nurses on staff has
remained largely the same. Recent research examining the reasons that nurses leave the
profession found that of the 289 registered nurses who partook in a study, 26% stated stress and
burnout as the number one reason for leaving (“Unemployed RNs,” 2005). With over one-fourth
of the nurses exiting their careers due to feelings of stress, it is no wonder that this is a popular
topic of debate and research. When one uses the search phrase “stress in nursing” on the Internet,
over 4,100 hits are available.
In the 21st century, the word “nurse” encompasses a menagerie of careers ranging from
staff and homecare nursing to nurse practitioners, certified nurse midwives, and beyond. The
necessity of nurse practitioners is growing. Fewer and fewer physicians are entering family
practice while the need for primary care providers remains. Nurse practitioners, especially in
rural areas, are beginning to fill this void. A study of rural physicians found that over 50% had
considered leaving rural practice (Gardiner, Sexton, Burbridge, & Garrard, 2004).
Unfortunately, today’s nurse practitioners share the stress and burnout that registered
nurses have experienced for years. One study that examined job satisfaction of nurse
practitioners found that 72% were minimally satisfied to satisfied with the profession. This
leaves up to 30% contemplating a career change. Job satisfaction is found to be the greatest in
the first two years of practice and then subsequently decreased thereafter (Kacel, Miller, &
Norris, 2005). These statistics in combination with the dire need for quality primary care
providers can markedly affect health care in America.
2
For instance, a nursing researcher performed a case study in which a charge nurse, “Jim,”
reported having difficulty with sleep and coping with the job stressors that exist when one is
responsible for an entire nursing unit. He felt that he was unable to keep up with the profession’s
demands. “Jim” believed his coworkers found him undependable and not someone they could
turn to for help. He felt like he was doing an unsatisfactory job and considered leaving the
profession due to his inability to meet the needs of his patients and staff. “Jim” experienced
burnout (Antai-Otong, 2003).
“Jim” is not the only healthcare worker to experience such feelings. The term “burnout”
is an all too familiar word in the healthcare employees’ vocabulary. Burnout is due to an elevated
workload in which healthcare workers feel they are unable to meet the needs of their patients;
therefore, they are also unable to meet their own expectations as practicing professionals
(Hurley, 2007). Burnout causes many professionals, especially nurses, to remove themselves
from the stressor (work) and explore alternative careers; many leave health care altogether.
Associate, baccalaureate, and master prepared nurses leaving the profession lead to an even
greater nursing and primary care provider shortage than the country is already facing. This in
turn leads to higher demands and more stress placed on the nurses who continue to practice their
profession. This vicious cycle of stress in nursing needs to be addressed. Since much research
has been done on the subject, it is time for nurses to take a proactive approach in stress reduction.
Even if documentation on stress is evident, each person interprets stress in his or her own
way. One’s perception of stress determines his or her stress level. Stress can be caused from a
variety of problems. Interpersonal relationships, activities, commitments, self-perception, and
work can all be considered stressful. Some individuals have a high stress threshold and can
3
tolerate a high level of stress while others’ thresholds are relatively low. The stress threshold is
determined by an individual’s resilience and his or her use of coping mechanisms.
Because each person is different, stress is managed in a variety of ways. Some use
methods that will be negative to his or her health such as turning to tobacco products, alcohol,
unhealthy eating habits, or sedentary lifestyles (Gosselin & Taylor, 1999). More positive stress
reduction techniques include talking with friends or family, listening to music, meditating, or
enjoying a hobby (Ballas, 2006). Another positive way to manage stress is aerobic exercise, the
type of exercise in which the muscles utilize oxygen from the blood. While a person participates
in a physical activity, both the heart and the lungs are strengthened. When a person participates
in aerobic exercise, the body has an increased need for oxygen. To meet this demand the body
increases the oxygen utilizing capacity of the muscle (American Heart Association, 2010).
Examples of aerobic exercise, an activity in which the body uses large muscle groups, are
jogging, swimming, walking briskly, jumping rope, dancing, biking, and rollerblading.
Countless research and numerous literature reviews have focused on the physical
advantages of aerobic exercise. Even though research on the psychological benefits has been
completed, there is a lack of synthesis of such data. The purpose of this literature review is to
determine if aerobic exercise has a beneficial effect on a healthy adult’s perceived stress level.
Because the vast majority of healthcare professionals fall between the ages of 18 and 65, this is
the age range this review is referring to when it uses the term “adult.” Health is a perceived state
of being. For this literature review, being healthy requires one to be free of disease, physical
abnormalities, and or disabilities. One also needs to be free of any mental illness such as
clinically diagnosed anxiety, depression, or schizophrenia.
4
The search was conducted using The College of St. Scholastica’s (Duluth, MN) library
databases and interlibrary loan system, as well as Abbott Northwestern Hospital’s (Minneapolis,
MN) medical library. Varieties of online databases were accessed through systems. Specific
databases included CINAHL Plus with Full-text, Elsevier/Science Direct Journal, Health &
Wellness Resource Center, Medline with Full-text, ProQuest Medical Library, ProQuest Nursing
& Allied Health, PsycINFO, and PubMed. Databases were searched using the several terms and
phrases such as “aerobic exercise,” “burnout,” “nurse practitioner job satisfaction,” “coping
strategies,” “endorphins,” “exercise,” “physical activity,” “stress,” “stress level,” “stress
management,” and “self-regulation theory.”
The author examined many different study designs, purpose statements, sample sizes, and
demographics to determine if the participants met the author’s description of healthy adult. In
addition, the author analyzed the statistical significance of the results to determine the strength of
the research findings. Sample sizes ranged from 45 to 1,093 subjects, the majority of which were
under 100 participants. Correlational studies were most readily utilized, likely because stress is a
subjective experience. Questionnaires, surveys, and interviews were the most popular research
tools implemented.
Psychological Effects
Nurses are caretakers by nature. They enter the profession because of their desire to care
for others, yet this often comes at their own expense. Although healthcare professionals are
continually encouraging their patients to participate in stress reduction activities, they often do
not listen to their own advice. Healthcare workers are familiar with the positive effects that
exercise has on one’s physical health, but they rarely consider its effect on mental health. A
study by Plante et al. (2007) showed a positive correlation between improved mood and
5
decreased stress when one engages in physical activity. People who engage in aerobic exercise
have been found to have lower levels of perceived stress. They are also more likely to
incorporate other constructive coping mechanisms into their daily routines (Kelsey et al., 2006).
Not only do regular exercisers experience stress relief while participating in physical
activity, but they also are more likely to avoid the high levels of anxiety often experienced by
their sedentary counterparts. It has been shown that people who frequently participate in aerobic
exercise recover more quickly from stress (Brugman, 2002). Researchers believe this is due to
the increase in pulse rate and blood pressure that is experienced both during periods of exercise
and during periods of stress. If the body has adapted to recovering from an increased blood
pressure and pulse after exercising, it is then better equipped to deal with these increases during
times of stress (DeBenedette, 1982).
Healthcare professionals are well versed in the physical benefits of aerobic activity and
many are aware of the psychological advantages as well. Despite this knowledge a large portion
of those in health care are not involved in regular physical activity. Interestingly, the number one
reason people do not participate in regular physical activity is that they feel that they do not have
time, yet this is a very common misconception. One does not need to work out for 30 minutes
every day to reap the stress reducing benefits. Physical activity can be broken up into three tenminute activities throughout the day (Gosselin & Taylor, 1999). One can take the stairs instead
of the elevator, meet friends for a walk instead of dinner, or ride bikes to the local deli.
Regular versus Episodic
Research has shown a strong correlation between regular exercise and stress reduction.
Participation in a three-month exercise program has been shown to reduce feelings of anxiety
and stress (Gosselin & Taylor, 1999). Salmon (2001) demonstrated that those who frequently
6
join in aerobic activities experience the greatest decrease in feelings of anxiety and perceived
stress. Although participating in aerobic activity on a regular basis is the most beneficial, a onetime dose of exercise can also produce results. Taking a break and walking briskly are proven to
decrease stress levels (Mobily, 1982). Gosselin and Taylor found that one episode of physical
activity lasting over 20 minutes can reduce anxiety and help provide a quicker recovery from the
feelings of stress.
Neurotransmitters
In addition, several chemicals are released in the brain when one engages in an aerobic
activity. Endorphins are one of the most well known neurotransmitters that are most often
released by the pituitary gland. Endorphins are the neurotransmitter responsible for a “runner’s
high,” the feel-good feeling one experiences after exercising at a particular level of intensity. It
has been reported that after exercising at a moderate to high intensity level, one can feel
euphoric, decreased pain, increased energy, a sense of pride and accomplishment, and inner
peace. Some researchers postulate that the increase in endorphins during physical activity helps
prevent a person’s respiratory system from becoming exhausted during the exercise. Endorphins
decrease the body’s ventilatory demand; thus, a person breathes easier while working out
(Grossman & Sutton, 1985). Researchers discovered impromptu physical activity increases
endorphins within the body, and the more one engages in aerobic activity the quicker the body
responds to releasing the feel-good endorphins (Salmon, 2001). The more exercise is part of
one’s weekly or preferably daily routine, the more that person will benefit from the positive
effects of exercise.
7
Mindful Walking
Although moderate to high intensity workouts may lead to an increase in endorphins, one
does not need to participate in strenuous physical activity to experience stress reduction. A new
trend in health care is the holistic culture, the belief in mind, body, and spirit. Holism is the belief
that every entity is connected and people are not made up of a series of parts, but rather a single
unit working together (Zimmerman, 2005). One focus in holistic health care is meditation.
Mindful walking is a form of meditation that requires walkers to be fully aware of each step that
is deliberate and precise in its delivery. The meditating walker coordinates his or her breathing
with every step. Mindful walking demands the participant to focus only on what he or she is
doing at that very moment while the rest of the world and stressors fade away during the mindful
walking activity. This activity can be done at any pace, ensuring that it is tailored to the
participant (Jane, 2004).
In addition, mindful meditation is an excellent, independent activity that can be
performed anywhere at anytime. No gym membership is required and a shower is not needed
after one finishes. It may also prove invaluable to those who cannot participate in a rigorous
physical fitness routine due to pre-existing health conditions. Aerobic exercise done individually
is the most convenient, but working out with a friend has many stress relieving benefits too.
Support
Just as mindful walking causes a distraction from the day’s stressors, working out with a
friend also has positive rewards. Physical activity with a friend can be a time to catch up with
one another’s lives and to provide support. Working out with a good co-worker can help one sort
out the feelings he or she experiences during the workday. Each person can provide mutual
support and advice and let the other person know that he or she is not alone in feelings of being
8
overwhelmed, overworked, and unable to meet the expectations of the job. Those who participate
in physical activity with others reported feeling more calm afterward compared to those who
worked out alone (Plante, Coscarelli, & Ford, 2001). Working out with a friend also is very
motivating. It has been found that individuals who work out with a friend are more likely to
adhere to their physical fitness regime than those who work out alone (Gosselin & Taylor, 1999).
Benefits for Acute and Chronic Disease
The stress reducing, mood-enhancing benefits do not stop at the healthy adult. They
expand to all ages and populations including those with acute and chronic conditions.
Yoshida and colleagues (1999) found that those who participate in cardiac rehabilitation
following an acute myocardial infarction had less anxiety and depression than those who did not
join the rehabilitation program. A heart attack is a frightening and life altering experience, which
is generally accompanied by anxiety. These apprehensive feelings can have serious effects on
recovery if they progress. Those experiencing depression and anxiety have rates of subsequent
morbidity and mortality (Worcester & LeGrande, 2008; Yoshida et al.). Regular physical activity
most often in the form of a cardiac rehabilitation program hastens recovery from the negative
psychological effects. Cardiac rehabilitation decreases patients’ fears about resuming activity
after their myocardial infarction by demonstrating the appropriate activity level for their
condition. This in turns gives control back to the patients (Worcester & LeGrande). These
beneficial effects on anxiety and depression can have a lasting impact. One study found
reduction in anxiety and depression continued more than eight months following the completion
of a rehabilitation program (Michie, O’Connor, Bath, Giles, & Earll, 2005).
Cancer is another area in which exercise can be psychologically advantageous. A new
surge of research has focused on the promising effects of physical activity in breast cancer
9
patients and survivors. Studies show those who regularly join in physical activities have
decreased stress levels and an improved quality of life (Blanchard, Courneya, & Laing, 2001;
Kirshbaum, 2006). Not only does the physical activity release endorphins, but it also fosters
feelings of self-confidence in the breast cancer survivor (Blanchard et al.).
Due to advances in highly active antiretroviral therapy (HAART) which has led to the
prolongation of HIV patients’ lives, HIV is now viewed as a chronic condition. Over 80% of
HIV patients suffer from depression and anxiety (Ciccolo, Jowers, & Barholomew, 2004).
Studies have found that those who participate in an exercise program had decreased negative
psychological symptoms and an improved sense of well-being (Ciccolo et al.; Dudgeon, Phillips,
Bopp, & Hand, 2004). In addition to physical activity improving one’s mood, it may also
improve HIV prescription drug adherence. Those with depression are more likely to falter on
their scheduled medication regime (Dudgeon et al.).
Self-Regulation Theory
In order to reap the psychological benefits of physical activity one must be motivated to
move because aerobic exercise is not a passive activity. It requires full participation of both body
and mind and demands an individual be accountable for his or her own success. The theory of
self-regulation (SRT) is one that has been studied, adapted, and revised countless times. SRT
was first publicly proposed by Kanfer in 1970 and then by Bandura in 1977. During a time when
theories were heavily based on extrinsic factors and an external locus of control, Kanfer and
Bandura theorized that an individual could reach within him or herself and find the ability and
reason to act. SRT is just coming to life with the majority of its revisions and application by
researchers occurring within the last twenty years (de Ridder & de Wit, 2006). Despite the
numerous spinoffs of the original self-regulation theory, all have stayed true to the basic
10
principles which include self-monitoring of behaviors, implementing goals and putting a specific
plan into place, acting on such plans, and lastly self-reinforcement (Bandura, 2005).
Self-motivation is a key ingredient in physical activity. Monitoring one’s own behaviors
helps to determine the perceived barriers to physical activity. For example, keeping a daily log of
all activity including watching TV can reveal that one spends more time in sedentary activities
than originally estimated. Self-monitoring can also be positive by demonstrating an increase in
ability in a practiced activity (Parrillo, 2009). Son, Kerstetter, Mowen, and Payne’s (2009) study
on self-regulation and physical activity reinforced the importance of self-monitoring by showing
that those who were the strongest in self-monitoring had positive outcomes in goal achievement.
In addition to self-motivation, goal setting and strategizing are very important when it
comes to physical activity. As discussed above, those who regularly exercise appear to obtain the
greatest psychological benefit from the activity. To achieve this, arranging a daily workout into
one’s schedule is an excellent goal and plan; strategizing new methods to integrate physical
activity into the day is also beneficial. During the goal setting process, it is important to be
realistic about one’s own abilities and time constraints. Setting unrealistic goals and unattainable
plans can inevitably result in failure and disappointment. Siegert, McPherson, and Taylor (2004)
feel that that self-regulation theory is an appropriate theory for physical activity goal setting,
because it recognizes that goals must be appropriate for the individual. These goals may need to
be altered over time to continually fit the individual’s capabilities.
Once a reasonable, individualized plan is in place, it is much easier to reduce the
perceived constraints to participating in regular physical activity. Acting on the set goals and
following a plan can lead to feelings of satisfaction, pride, and a sense of accomplishment
(Wallace & Lahti, 2005). These feelings are positive intrinsic self-reinforcement. Even though
11
there are built-in reinforcers, outside reinforcement is often needed as well. These can include
social supports, healthcare provider encouragement, and personal incentives (Bandura, 2005).
Clinical Implications
It is safe to say that the nursing diagnosis of physical activity deficit can be applied to
many healthcare providers. For years, these caregivers have been advising their patients to
participate in physical activity; it is time they heed their own advice and engage in regular
aerobic exercise. This would not only benefit their physical health but also their mental health as
well. Healthcare workers who experience a reduction in perceived stress are less likely to
encounter burnout. Healthcare providers act as role models for their patients. If they are having
difficulty managing their own stress, it may make it more cumbersome to care for their patients.
It also makes it more challenging to impart accurate advice regarding stress management.
Furthermore, nurses and nurse practitioners pride themselves in patient education and
illness/disease prevention. The emphasis on education and prevention are two of the qualities
that separate nursing practice from medicine. Thus, it is a nurse practitioner’s duty to educate
patients on the beneficial effect of physical activity for their physical and mental wellbeing. A
study published by Blackwell (2004) in the Journal of the American Academy of Nurse
Practitioners revealed that nurse practitioners who were involved in healthy practices such as
regular exercise were more likely to encourage their patients to do the same. If a nurse
practitioner values physical activity, he or she will find enough time in a visit to counsel patients
about the importance of regular physical activity. They are also less likely to feel as though
counseling on such a topic is hopeless and unheeded by their patients (Robbins, 2004).
Counseling patients on physical activity and acting as role models are significant
elements of a nurse practitioner position. To act as a good health role model nurse practitioners
12
must adopt their own health practices. This not only benefits the patient but also the nurse
practitioner. The health of a nurse practitioner can be easily pushed to the wayside as they
tirelessly care for others. As nurse practitioners advocate for their patients, they must remember
to be an advocate for their own health. Scheduling “me time” for physical health has the
potential to decrease stress and improve the quality of life for the nurse practitioner (Robbins,
2004). Espeland (2006) revealed that physical activity is necessary to prevent burnout and
increase job satisfaction in the healthcare professional. Taking excellent care of oneself both
mentally and physically better prepares the nurse practitioner for the daily stressors of a high
demand career.
Encouraging physical activity is a non-pharmacological way to reduce stress. Better yet,
it is inexpensive and can be done anywhere by anyone. People can participate in countless
activities by tailoring their workout routine to fit their abilities, goals, and lifestyles. Not only
does aerobic exercise improve one’s physical self, but it also enhances self-esteem, energy, inner
harmony, and decreases perceived stress level.
Limitations
The writer noted several limitations to the research studies utilized for this literature
review. First, the majority of research participants were Caucasian females. This makes it
difficult to ascertain that the beneficial effects of aerobic exercise would be similar with their
male counterparts and those of a different ethnic background. In fact, one of the studies found no
significant difference in pre- and post-exercise stress levels in males (Folkins, Lynch, & Gardner,
1972).
Second, there was a wide age range of participants for the majority of the studies. Despite
having a mean age on average of 41-45, the standard deviation on some studies was up to 15.
13
Having such a large age gap can lead to numerous confounding variables, including but not
limited to physical ability, length of time in said career, and developmental stage.
Third, stress level and the perceived relief from it is a subjective experience.
Questionnaires and self-reports were the tools of choice for most of the studies. Subjective data
are not as concrete as objective data such as blood pressure and heart rate. Another limitation is
that a significant number of the studies are correlational in nature. Correlation does not prove
causation. One cannot determine if physical activity was the single reason for a decrease in
perceived stress level or if it was an outside, unidentified, third variable that created the positive
change. Simply the act of being with another person when exercising with a friend could actually
be the cause of decreased stress level, not the exercise itself (Gosselin & Taylor, 1999).
Fourth, the vast majority of healthcare provider stress research has been performed on
registered nurses and physicians. Little information is available on burnout in nurse practitioners.
Nurse practitioners have a different role in the healthcare system than nurses and physicians.
Their daily stressors and their subsequent reaction to these stressors have the potential to be
unlike those of other healthcare workers.
Recommendation
Although there is a great deal of research and literature on the beneficial effects of
aerobic exercise on reducing stress, most of it is of a subjective nature. Further studies that make
use of quasi-experimental and experimental designs are needed to provide stronger links between
physical activity and stress. Furthermore, more research should be done to help determine which
specific activity creates the greatest relief from stress. Another area for future study would be to
examine the rate of nursing burnout in nurses and nurse practitioners who regularly participate in
14
physical activity. This would help determine if nurse practitioners who participate in regular
exercise have reduced levels of perceived stress and thus have a decreased rate of burnout.
Summary
The psychological benefits of physical activity are far-reaching. Reducing stress, anxiety,
and depression can greatly enhance one’s quality of life. People of all lifestyles with various
positions on the health ladder can take advantage of these positive psychological effects. Nurses
and nurse practitioners must act as advocates and role models for superior health practices that
include physical activity.
Conclusion
To conclude, this project confirms physical activity is beneficial to mental health. Those
who regularly engage in physical activity have proven to have lower perceived stress levels.
There is a variety of ways to reap the psychological benefits of exercise. The American Heart
Association recommends 30 minutes of moderate intensity physical activity at least five days a
week or high intensity activity for 20 minutes for three days a week to fully obtain the physical
benefits of exercise (Haskell et al., 2007). To achieve the elevated mood contribution the activity
does not need to be as frequent or intense. Simple, deliberate, mindful walking has stress
reducing properties (Jane, 2004).
Individuals can do innumerable varieties of physical activities to improve their
psychological health. Such variation makes it relatively easy to find an exercise that is suitable to
one’s physical activity level.
15
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