ESRC IAA - A Feasibility Project to Develop the First Mindfulness Training Framework for Exercise Referral Practitioners to Implement Mindful Exercise During Exercise Referral Classes

Description of impact

This project will build a partnership between Bangor University and Gwynedd Exercise Referral Unit to jointly develop a new training framework that will allow exercise referral practitioners to deliver group-based mindful exercise sessions, i.e., the implementation of mindfulness during physical exercise, to patients in exercise referral settings.

The present project will be the first of its kind to assimilate mindfulness and traditional exercise into one intervention. This will be achieved by extending the existing mindfulness teacher training framework in Gwynedd via the development of an ancillary training stage that focuses specifically on the development of specialized practitioners in mindful exercise. This development, conducted alongside Gwynedd exercise referral practitioners, will create a platform for these referral practitioners to implement the first mindful exercise sessions in exercise referral settings anywhere in the world. Hence, paving the way for Gwynedd to become the first location to adopt this unique concept.

Accordingly, on completion of this project it is anticipated that the formation of this partnership and training framework will generate pathways to enhance quality of life in referral patients, will benefit Gwynedd Exercise Referral Scheme via enhanced patient adherence, and will forge immediate opportunities for novel research and impact activities for Bangor University.

The first aim of this project is to create a novel training framework designed to focus on the development of specialized mindful exercise practitioners. This will be achieved by expanding the existing mindfulness teacher training framework, delivered by the Centre for Mindfulness Research and Practice (CMRP), through the addition of a bespoke extension following Mindfulness Teacher Training Level 1. In mutual collaboration with practitioners from Gwynedd Exercise Referral Unit, the development of this bespoke teacher training extension will focus specifically on the implementation of mindful practice during exercise in exercise referral settings.

The second aim of this project is to develop two existing Gwynedd exercise referral practitioners so as they are able to competently deliver mindful exercise during exercise referral classes. This will be achieved by first training these practitioners to Level 1 mindfulness teacher training standard and then working in conjunction with the CMRP to create the bespoke mindful exercise teacher training extension to cultivate the competencies necessary for these trainers do develop and deliver their mindful exercise practice to referral patients.

The third aim of this project is to maintain an ongoing partnership between Bangor University and Gwynedd Exercise Referral Unit to support these newly trained mindful exercise practitioners in implementing the concept of mindful exercise in their 16 week exercise referral settings. This will firstly be achieved in conjunction with Gwynedd Exercise Referral Unit and a cohort of end users (i.e., exercise referral patients) through a joint 4 week mindful exercise pilot intervention that will be used as the basis for a mutually agreed and tailored 16 week mindful exercise programme that will be implemented at the end of the project in at least one Gwynedd Exercise Referral Scheme.
Having already formed a partnership with Gwynedd Exercise Referral Unit, two practitioners from this referral unit, who have already registered an interest in this mindful exercise training process, will be recruited to undergo mindful exercise practitioner training.

The first steps towards this training will be in accordance to the UK Network for Mindfulness-Based Teachers good practice guidelines. First, these two exercise referral practitioners will attend an 8 week mindfulness based stress reduction course in Bangor to orientate themselves with the basis of mindfulness and to develop their personal mindfulness practice.

On completion of this 8 week course, these practitioners will then attend a one week mindfulness Level 1 teacher training retreat to train them in the practicalities of delivering mindfulness as a practitioner.

After obtaining a firm knowledge of the practicalities of delivering basic mindfulness, these exercise referral practitioners will work in conjunction with exercise and mindfulness based researchers from Bangor University to develop an ancillary framework for the mindfulness teacher training process that will focus specifically on the development of practitioners to deliver mindful exercise.

On completion of this process, Researchers from the School of Sport, Health and Exercise Sciences, and the CMRP at Bangor University will, together with the trained mindful exercise practitioners, design a 4 week pilot delivery of mindful exercise in exercise referral to obtain end user (i.e., exercise referral patient) input. A review of this pilot (i.e., semi-structured interviews with patients, adherence, initial self-report, number of additional independently performed mindful exercise sessions, and quality of life based outcomes) will then form the basis for the design of a 16 week mindful exercise referral programme. The design of this 16 week programme and an agreement regarding the number of mindful exercise referral schemes that will be implemented in the first instance to ensure ongoing collaboration, will represent the end of the project.

Corresponding outputs from this will therefore include a new mindful exercise training protocol for staff (with week by week instruction) that will be developed as a bespoke extension to the present mindfulness practitioner training framework; a unique 16 week mindful exercise referral programme with accompanying workbooks and home practice CD’s, and feasibility data from the 4 week pilot.

Description of the underpinning research

The health benefits of exercise are well documented in clinical populations. Accordingly, exercise referral schemes are recommended in primary care to individuals with health disorders for which physical activity would be beneficial (Pavey et al., 2012). In such referral schemes however, adherence to exercise can be disrupted due to psychological issues such as catastrophizing, involving exaggerated negative evaluations of a particular symptom (Lukkahatai & Saligan, 2013), and also fear-avoidance (Vlaeyen & Linto, 2012)). In Wales specifically, exercise adherence is relatively low, ranging from 44% - 62% (Edwards, 2013). Interventions to enhance exercise adherence would therefore contribute positively to individual health in Welsh exercise referral. Mindfulness based interventions (MBI’s) are also beneficial in clinical populations. Pertinently, low mindfulness has been shown to predict catastrophizing (Shutze et al., 2010) and MBI’s can reduce catastrophizing and increase quality of life in patients experiencing back pain (Shutze et al., 2014), and Rheumatoid Arthritis (Davis et al., 2015). Furthermore, MBI’s have been shown to facilitate illness acceptance and worry reduction in individuals with Coronary Heart Disease (Keyworth et al., 2014) and to aid weight reduction among obese individuals (Dalen et al., 2010). The addition of mindfulness to exercise referral settings may therefore deliver many benefits for exercise adherence and overall mental well-being, Though MBI’s are suggested to represent a valuable addition to primary care, barriers to their implementation also exist, for instance adequate room size and sufficient delivery time. This is unfortunate given the health benefits of mindfulness, and its potential to elicit illness acceptance and worry reduction. Furthermore, it is surprising that no initiative has yet instigated the simultaneous delivery of traditional exercise and mindfulness in primary care in the form of mindful exercise; particularly given that MBIs directly address the common psychological barriers to exercise such as avoidance and catastrophizing. One reason for this might be because the existing framework for mindfulness practitioner training (Crane et al., 2011) currently lacks a pathway to develop the competencies necessary to deliver mindfulness and exercise in conjunction. Considering the potential benefits of mindfulness during exercise it is crucial that this gap is addressed and a framework developed to train practitioners to deliver this innovative concept during exercise referral. This present project will therefore develop a framework to support referral practitioners with the skills to implement a 16 week mindful exercise referral intervention designed to enhance patient adherence and quality of life in primary care. Adherence to exercise referral schemes in Wales is relatively low at between 44% - 62% (Edwards, 2013). Mindfulness has been shown to relive some of the psychological symptoms that may act as barriers to exercise adherence in clinical populations, such as fears regarding pain, and worry surrounding illness (Keyworth et al., 2014; Shutze et al., 2014). Though mindfulness has been advocated as a beneficial addition to primary care, few strategic plans to implement mindfulness in this setting presently exist (Crane & Kuyken., 2012). Barriers to this may include constraints on sufficient room size to initiate such schemes (Demarzo et al., 2015) and little strategic and managerial support to deliver classes in clinical time (Crane & Kuyken, 2012). Given the positive role that mindfulness can play in some of the barriers to exercise participation in clinical populations, it is surprising that an initiative to combine traditional exercise and mindfulness in one simultaneously delivered intervention (i.e., mindful exercise) does not exist; particularly given that combining these two approaches would resolve the aforementioned barriers to the implementation of mindfulness in primary care. One reason for this might be the that the existing framework for mindfulness practitioner training (Crane et al., 2011) currently lacks a pathway to develop the practitioner competencies necessary to deliver exercise and mindfulness in conjunction. In recognition of this, the present project will address this gap by first working alongside current exercise referral practitioners to develop such a practitioner training framework, and then working with these practitioners and also end users (i.e., exercise referral patients) to develop a 16 week mindful exercise referral programme that will be implemented in at least one Gwynedd exercise referral unit on completion of the project.

Beneficiaries and reach of impact

Present 16 week Wales National Exercise Referral Schemes utilize motivational interviewing, goal setting, and group based exercise sessions. It is hoped that completion of this project may assist in the expansion of the existing policy of Wales National Exercise Referral Scheme to also incorporate access to mindfulness through the medium of exercise, in the form of mindful exercise, for its patient populations.

On its most fundamental level this empirically grounded project will generate societal impact by developing a novel approach to health, wellness, and adherence in local exercise referral schemes. Via increased adherence and quality of life (exercise referral report) to these exercise referral schemes for participating patients.

In addition, the project will form the first empirically documented initiative to extend the existing mindfulness teacher training framework to include specialized training for mindful exercise practitioners. As this present mindfulness teacher training framework is adopted nationally, on completion of this project it is possible that the current concept and framework may enjoy substantially wider reach than its present regional local authority targets.

On developing the ancillary framework for mindful exercise practitioner teaching, the present project will also become the first to train existing exercise referral practitioners in the delivery of mindful exercise. Hence developing new training opportunities for existing staff and forging a pathway for further opportunities to train staff in greater numbers on a regional or national level.

Impact status	Ongoing
Impact date	1 Oct 2016 → 30 Sept 2017
Impact level	Benefit