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Exercise Adherence in Patients with Chronic Obstructive Pulmonary Disease: An Exploration of Motivation and Goals
Adherence to an exercise regimen is challenging. Motivation is an important factor that can enhance exercise adherence. A key component of motivation is the setting and accomplishment of specified goals. Therefore, it is important to understand the relationship between patients’ motivation and goals. Motivation and goal orientation in 14 participants with chronic obstructive pulmonary disease were assessed. Participants were also interviewed to explore their exercise and activity goals. Motivation was significantly associated with goal orientation. In addition, participants reported many explicit activity goals, but few participants had set specific exercise goals. The inconsistency between activity and exercise goals has not been reported previously. Findings from this preliminary study provide novel and relevant information that may help care providers understand factors that may influence exercise adherence in people with chronic obstructive pulmonary disease.
Chronic obstructive pulmonary disease (COPD) is characterized by reduced expiratory airflow, and it is the fourth leading cause of death in the United States (Centers for Disease Control and Prevention [CDC], 2005). People with COPD often experience poor activity tolerance and difficulty breathing that negatively affect their quality of life. Nationwide, more than 2 million people are affected (CDC, 2005). People with COPD often experience breathing difficulties and may avoid exertion, contributing to their inactivity. Inactivity, in turn, leads to reduced efficiency of the cardiovascular, respiratory, and skeletal muscles, causing more breathing difficulties with subsequent exertion (Wasserman, Hansen, Sue, Casaburi, & Whipp, 1999). Findings from controlled clinical trials of diverse exercise interventions showed promise in interrupting this vicious cycle and reducing activity intolerance (Celli & ATS/ERS Task Force Committee, 2004). These findings suggest that rehabilitation nurses may be in a position to make significant contributions toward reducing disability caused by COPD. However, to sustain exercise-induced benefits, patients need to adhere to exercise interventions well beyond the conclusion of clinical trials. Disappointingly, poor exercise adherence is pervasive. When left on their own, about 50% of people with or without COPD stop exercising in just 6 months. A 2002 survey found that 27% of women and 31%–40% of minorities and those with lower incomes did not participate in any physical activity in the past month (Graham, 2003). Therefore, improving exercise adherence is one of the main challenges facing healthcare providers working with people with COPD.
Advances in the effectiveness of interventions to motivate people to adhere to regular exercise have been limited (Dishman, Oldenburg, O’Neal, & Shepard, 1998; Wilbur, Vassalo, Chandler, Mcdevitt, & Miller, 2005).Of the studies designed to enhance exercise behaviors, those with specified theoretical frameworks had greater success in identifying positive findings and were more readily understood and integrated because these studies operated within a cohesive framework (Conn, Minor, Burks, Rantz, & Pomeroy, 2003). One of the theories relevant to health behavior promotion, social cognitive theory (SCT), appears promising in delineating important components of motivation and postulating a relationship between motivation and exercise adherence. SCT states that cognition is the initiating event of a process that will ultimately lead and motivate people to perform desired health behaviors. A key component of motivation as delineated by SCT is goal setting. Appropriate goal setting increases the likelihood that people will be successful in reaching their specified goals, thus providing motivation for them to continue behaviors that add to their success. Consequently, understanding relationships between cognitive factors of goal setting, motivation, and how they influence the exercise adherence of people with COPD warrant investigation (Bandura, 1986, 1997; Roedel, Schraw, & Plake, 1994).
Goal setting and its influence on exercise motivation of people with COPD have not been studied. Using SCT as the framework, this study was designed to explore this gap in knowledge. Besides examining specific goals set by people with COPD, we examined how goal-setting behaviors may be influenced by how motivated and goal oriented people are generally. Specific purposes of this study were to determine the relationship between motivation and goal orientation in participants with COPD and explore goal-setting behaviors of people with COPD, specifically their activity and exercise goals.
Motivation in promoting health behaviors such as exercise is a person’s intrinsic determination or self-motivation. Motivation provides the readiness to change a behavior as well as the impetus to sustain a behavior change (Gifford & Groessl, 2002). Indeed, some believe motivation is the key to health- promoting behaviors, and self-motivation may be the best determinant of exercise adherence (Dishman & Sallis, 1994; Hunt & Hillsdon, 1996). Understanding factors that influence motivation, such as goal setting, may provide healthcare providers additional knowledge to develop interventions that could reliably and effectively increase the rate of exercise adherence (Plonczynski, 2000).
Goals that are explicitly and consciously set (cognized goals) are important components of motivation (Bandura, 1997). Goals can be motivating because they serve as personal standards that one uses to direct one’s actions to reach self-satisfaction. Goal setting involves identifying and establishing successive goals that are realistic yet challenging so that achieving these goals will lead to a target behavior such as exercise adherence (Nies & Kershaw, 2002). Without goals, behaviors are unstructured and lack purpose and direction, resulting in ineffectual and unrewarding outcomes. This may contribute to the extinction of exercise adherence (Hardeman, Griffin, Johnston, Kinmonth, & Wareham, 2000). Furthermore, challenging goals elicit more interest and effort than easily attainable goals. In a study examining the effect of physical activity on weight loss, participants who were given higher exercise goals increased physical activity twice as much as did those with lower exercise goals and lost more weight over time (Jeffery, Wing, Sherwood, & Tate, 2003).
One aspect of appropriate goal setting is to identify and develop the use of concrete behavioral skills that can be adopted, practiced, and perfected. For instance, people with asthma may be taught self-management through specific skills such as using a peak flow meter and an action plan that addresses their most compelling priorities (Gifford & Groessl, 2002). The purposeful evaluation of results provides feedback to direct future action and possibly a source of motivation to continue the behavior (Bandura, 1997). However, if goals are unrealistic, poorly defined, or distal, motivation weakens. A goal that is not clearly stated or is broadly stated is less motivating. For example, “My goal in life is to be happy” does not provide clear direction in how to achieve happiness (Resnick, 2002; Stock & Cervone, 1990).
Significance of Rehabilitation for People with COPD
COPD is a progressive condition. Standard medical treatments do not reverse the underlying pathophysiology of COPD and may offer limited relief for activity-induced shortness of breath. Findings from well-controlled studies have shown that rehabilitation of cardiopulmonary and musculoskeletal systems in people with COPD, using various exercise interventions to reduce shortness of breath, improved physical function and quality of life (Celli & ATS/ERS Task Force Committee, 2004; Lacasse, Maltais, & Goldstein, 2004). Therefore, maintaining gains from rehabilitation has particular importance in this population. However, it is not clear what motivates people with COPD to initiate and continue their participation in these exercise interventions. A key function of exercise adherence for people with COPD is to improve the overall physical stamina needed to perform activities that are important to them as part of daily living. Therefore, goal-setting behaviors of people with COPD may be important for determining their exercise motivation and adherence.
This was a prospective, cross-sectional study designed to explore the relationship between motivation and goal orientation in participants with COPD and to describe their specific goals related to activity and exercise. A convenience sample of participants with a diagnosis of COPD, based on the American Thoracic Society’s disease severity criteria (Miller, Hankinson, & committee members, 2005), was recruited from the community, pulmonary clinics, and rehabilitation centers over a 6-month period. People 40 years of age or older with a diagnosis of COPD were invited to participate. Participants had to be able to walk unassisted on a flat surface and have no contraindications for exercise. All those who met inclusion criteria were invited to participate in this study. Everyone invited gave informed consent, in accordance with the institutional review board’s approval of this study. Each subject completed a demographic questionnaire and questionnaires that assessed their motivation and goal orientation. Participants were also interviewed to explore specifically their activity and exercise goals.
Motivation was measured with the Self-Motivation Inventory (SMI), a 40-item questionnaire that measures a person’s behavioral tendencies to persevere. The SMI has demonstrated good reliability, Cronbach’s (alpha) = .91, test–retest r = .76–.92, and evidence of construct validity in adults (18–70 years old) and cardiac rehabilitation patients (Dishman & Ickes, 1981; King, Humen, Smith, Phan, & Teo, 2001; Merkle, Jackson, Dishman, & Zhang, 1998; Moore, Dolansky, Ruland, Pashkow, & Blackburn, 2003).
Goal orientation was measured with the Goals Inventory, a 10-item questionnaire that measures how goal-oriented people are in general (Annesi, 2002; Roedel et al., 1994). The Goals Inventory has also demonstrated good reliability, Cronbach’s (alpha) = .75–.80, test–retest r = .73–.76, and evidence of construct validity in adults (Nietfeld & Enders, 2003).
A trained interviewer familiar with SCT met with participants individually, in a quiet and private setting. Interviews were audiotaped at the consent of the participants. The discussions were semistructured with open-ended questions to explore participants’ activity and exercise goals. The interviewer did not provide any suggestions on types of activity or exercise goals. All participants were free to elaborate in their answers.
Descriptive and correlational statistics were used to characterize the sample and to look for associations between participants’ motivation and goal orientation (SPSS 12.0). Taped interviews were transcribed verbatim, with all identifiers omitted (Microsoft Word). Words and phrases relevant to descriptions of participants’ exercise and activity goals were identified and analyzed. Because this was an exploratory study, a power analysis of sample size for hypotheses testing was beyond its scope.
Twenty-three people were screened by phone or in person. Fourteen of these people met all inclusion criteria. All 14 participants who gave informed consent completed the study (9 men and 5 women; mean forced expiratory volume in 1 s [FEV1] = 1.07 L, and mean FEV1/forced vital capacity [FEV] = 46, mean age 69.7). They were all Caucasians and former smokers (Table 1).
Motivation and Goals
Participants were moderately motivated, mean = 118.2 (+/-) 24.2, with possible scores from 0 to 200. Higher scores on SMI represent greater motivation. Goal orientation of participants was moderately high, mean = 12.1 (+/-) 5.6, with possible scores from 0 to 50. Lower scores on the Goals Inventory represent greater goal orientation. Motivation and goal orientation were significantly related, r = (-).57, p < .05 (Table 2). Higher scores of motivation indicated lower scores on the Goal Inventory or stronger goal orientation. In addition, SMI was related to age, r = .62; p < .05, and the Goals Inventory was related to body mass index (BMI), r = 0.67; p < .01. Scores on the SMI and the Goals Inventory were not significantly associated with participants’ other demographic characteristics (Table 3).
The interviews lasted from 45 to 90 minutes, during which participants talked about their thoughts and feelings on a variety of topics related to their health. For the purpose of this article, findings related to goals are presented. Taped interviews were transcribed verbatim with all identifiers omitted. Because the purpose of the interview was to explore participants’ exercise and activity goals, words and phrases relevant to descriptions of participants’ exercise and activity goals were identified from the transcribed data. These words and phrases were reduced, and categories were developed to reflect broad types of exercise and activity goals to generate an organizing framework of abstract themes (Collaizzi, 1978). To ensure scientific rigor of the data analysis, a three-member research team held periodic team conferences during data analysis and interpretation. In addition, retrievable Microsoft Word® documents and decision matrices created an audit or decision trail of the study results. Furthermore, extensive discussions by the research team during data analysis and examination of the findings during the confirmatory stage of data analysis augmented the rigor of data interpretation. Three central themes were identified in relation to participants’ activity goals:
In relation to participants’ exercise goals, three central themes were also identified:
Activities Related to Recreation
All but one participant readily listed activity goals. Some participants focused on recreational activities they did frequently in the past but are now unable to do. They expressed wanting to get back to the activities that they enjoyed previously:
Activities Related to Connection
Several participants described activities that are related to staying connected with their support network such as friends and family.
Activities Related to Independence
Still other participants focused on activities that may give them a greater sense of freedom and independence.
Explicit and Self-Directed Goals
The majority of participants had some difficulty clearly identifying their exercise goals. Only 2 of the 14 participants readily described their exercise goals. They had set explicit exercise goals and monitored their progress closely.
Vague and Other-Directed Goals
This group of participants had difficulty identifying their exercise goals. They did not set specific goals for their exercises.
Some of the participants did not have any exercise goals, nor did they see a need to set any exercise goals despite having activity goals that they would like to achieve.
Findings from this study support relationships predicted in SCT, demonstrating that motivation is linked with goals in people with COPD, suggesting that optimization of goal-setting behaviors may enhance motivation. By assessing patients’ goal orientation, it may be possible to identify those at risk and allow clinicians to intervene early. Because this is a descriptive study with a small convenience sample, generalizability of the findings is limited. In addition, the SMI and Goals Inventory had not been previously tested in people with COPD. However, to develop an understanding of the complexities associated with exercise adherence, using in-depth interviews as a component of the method was particularly helpful. Therefore, sample size was guided by the need to obtain sufficient data to clearly elucidate the phenomenon through data saturation. The presence of a significant correlation between motivation and goal orientation is noteworthy because of the small sample size. Often, small samples do not have adequate statistical power to detect modest effects. Conversely, very large samples may detect small effects that are statistically but not clinically significant. Therefore, when a small study detects statistical significance, it suggests that the effect probably is large. Given this study’s sample size of 14, significance level of (alpha) = .05, and power of .80, the effect size would need to be large for detection (.80 or greater) (Cohen, Cohen, West, & Alken, 2003; Munro, 2001). In addition, SMI was significantly related to age, indicating that older participants were more motivated. The Goals Inventory was related to BMI, indicating that those with higher BMIs were less goal oriented.
All but one participant described activity goals without hesitation. Depending on participants’ prior health status, their goals may vary greatly (Rockwood, Graham, & Fay, 2002; Wolpert & Anderson, 2001). Because purposeful, appropriate, and realistic goals served as motivators to influence behavior changes, it is important that clinicians clearly communicate what improvements might be possible because patients often want to return to “the way things were,” hoping for a reversal of their condition. Therefore, assisting people with COPD to set appropriate and realistic exercise goals to achieve their activity goals may provide motivation for them to adhere to exercise interventions.
Interestingly, only 2 of the 14 participants had explicit and directed exercise goals intended to help them achieve their activity goals. Although some participants spoke of wanting to increase components of their exercises, they stated these goals in a nonspecific and hesitant manner. Some participants looked to others to determine their goals. For example, some participants felt they wanted to increase their exercises but were waiting for their healthcare providers to initiate these changes (McDevitt, Snyder, Miller, & Wilbur, 2006). Other participants did not have any exercise goals. Their primary focus was to not make any changes and to preserve their current status. They appeared to be concerned with deteriorating but were also concerned with harming themselves if they were to do more. All participants indicated they had attended pulmonary rehabilitation programs (6 months to 11 years ago). However, the characteristics of each program were not explicitly measured.
Overall, participants in this study had low exercise goals or no exercise goals. Those with low exercise goals did not have a structured plan to achieve them. Only 2 of the 14 (14%) participants were goal directed and able to readily discuss their exercise goals. They set high exercise goals for themselves and expressed determination to achieve their goals. Consistent with predicted relationships of SCT, findings demonstrated that for goals to be effective motivators, they must be clearly cognized, appropriate, and challenging and follow a well-structured plan of behaviors designed to realize the goals (Bandura, 1997; Hardeman et al., 2000).
Disconnect of Activity and Exercise Goals
Another important but unexpected finding was an apparent cognitive disconnect between activity goals and exercise goals in a majority of the participants. Twelve of 14 participants listed a number of activity goals but gave no indication that they were purposefully directing their exercises to accomplish their activity goals. For instance, one participant spoke of wanting to be more independent and be able to walk more and shop yet did not set any exercise goals directed toward enhancing strength, endurance, or symptom tolerance.
Clinicians may assume that it is obvious that to be able to increase one’s activity level it would be necessary to increase one’s overall capacity for doing activities. Findings of this study suggest that a majority of participants in this sample did not make such an inference. Most participants in this study did not set appropriate exercise goals that would help them realize their activity goals. Therefore, their exercise and activity goals were unlikely to give them positive motivation to increase exercise adherence (Nies & Kershaw, 2002).
Implications for Practice
The findings of this study demonstrated that many of the participants were not setting exercise goals to achieve their activity goals. Nurses and other healthcare providers often are involved in the care of patients with COPD in a variety of settings. Nurses may also be directors of pulmonary rehabilitation programs, charged with developing education and exercise interventions and evaluating outcomes of rehabilitation. As clinicians, we have the opportunity to influence the cognition of our patients by providing education and direction.
The importance of goal setting in general is known, and clinicians may be knowledgeable about goal setting and educate patients accordingly, but what might have been taught and what was learned and implemented may not be equivalent. Prior studies did not concurrently examine both activity goals and exercise goals. Based on the findings of this study, there may be a distinction in patients’ minds between their activity goals and their exercise goals. It is possible that more emphasis is needed on identifying patients’ activity goals and educating patients on the relationship between activity goals and exercise goals. It is our responsibility as clinicians to help patients make and maintain that connection and to evaluate whether progress made is important to the patient. In other words, are the outcomes clinically significant? Because this is a small study with a convenience sample, generalizability to other people with COPD is limited. However, these findings offer new knowledge that may be useful in designing future studies in larger samples of people with COPD. Findings from this study may also inform future intervention studies with greater diversity in age, ethnicity, and randomization. Larger and more diverse samples would have greater generalizability and provide more definitive recommendations for rehabilitation nursing practice.
The author is grateful to the research participants for their contributions. The author would also like to acknowledge the directors of the pulmonary rehabilitation centers, Bonnie F. Fahy, RN MN FAACVPR; Charlotte Werpy, MS RN; RoseMary Weese, RN RRT; and Elaine Allin, BS RN, for their support of this research, and Joseph E. Davis for reviewing earlier drafts of this manuscript.
Funding sources: NIH/NINR 1 R15 NR008103-01 and the University of Arizona College of Nursing.
About the Author
Amy H. T. Davis, PhD RN, is an assistant professor at the College of Nursing, University of Arizona. Address correspondence to her at the College of Nursing, University of Arizona, 1305 N. Martin, Tucson, AZ 85721-0203 or ahtdavis @nursing.arizona.edu
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