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Evidence-Based Practice Paper

Whitney Pavlicek, Loyal Dang, and Cara Engstrom

College of Nursing, University of Arizona

NURS 379 Scholarly Inquiry for Evidence-Based Practice

Dr. Lorre Laws

August 7, 2022
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Evidence-Based Practice Paper

Yoga therapy has been around for thousands of years, but the effects it can have on

mental health are just surfacing. Our EBP topic is the effects of yoga therapy on individuals with

chronic mental health disorders. Integrative nursing involves caring for patients as whole beings

with unique properties and characteristics and it’s a way of optimizing overall wellbeing through

living life with a whole health perspective (University of Minnesota, 2022). Integrative nursing

also looks at both pharmacological and non-pharmacological approaches to treating the

individual (Koithan, 2018). The integrative nursing principles include: (1) humans are whole

systems, (2) humans have an innate capacity for healing, (3) nature is healing, (4) IN is person-

centered, (5) IN is evidence-based, and (6) well being of caregivers (Koithan, 2018). This EBP

topic pertains to INP #4 because it looks at how yoga therapy impacts an individual’s mental

health which varies from person to person, making it a person-centered approach. Our EBP topic

also aligns with INP #2 because participating in yoga therapy is your own body working to help

itself heal (Koithan, 2018).

Our EBP topic is important because, in nursing, mental health issues can stem from other

areas such as traumatic experiences, environmental factors, and lack of opportunities. Our group

came to a consensus on selecting this EBP topic because we all know and believe how important

mental health is and how much it affects people in their everyday life. Given our clinical

observation and the evidence surrounding this topic, we will examine the advantages of yoga

therapy in patients with mental health disorders over their lifetime.

Background and Purpose

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Yoga therapy was founded on the wisdom of traditional yoga, blended with scientific

knowledge. Traditional yoga roots focus on the causes and alleviation of suffering through

purusha and prakriti techniques. Purusha refers to the spirit or the indweller and prakriti refer to

material nature (Sullivan et al., 2018). According to the National Center for Complementary and

Integrative Health (2021), one in seven adults in the U.S. practiced yoga in 2017, and one in 12

U.S. children aged four to 17 practiced yoga in 2017. Different integrative modalities, like yoga

therapy, have been proven to decrease the symptoms in individuals struggling with a decline in

mental health. Integrative modalities can support people of all ages, as every type of person can

struggle with mental health, despite age, gender, religion, etc. According to the National Alliance

on Mental Illness (2022), in 2020, 21% of adults in the U.S. experienced mental illness and in

the U.S., 16.5% of youth aged 6-17 years old experience mental illness each year. The purpose

of this paper is to critically appraise four articles to examine the utility of yoga therapy in

improving mental health status in individuals with chronic depression.

PICO Question

A PICO question is a method for creating answerable and researchable questions

(Gallagher & Melnyk, 2019). The letters in PICO all have different meanings. The (P) is for

population, (I) is for intervention, (C) is for comparison, and (O) is for the outcome (Gallagher &

Melnyk, 2019). Our PICO question is: In patients with chronic mental health disorders, what is

the effect of the use of yoga therapy on mental health compared with not using yoga therapy

within someone’s lifetime? Our PICO question is classified as intervention/therapy (Gallagher &

Melnyk, 2019).

Nurses conduct literature reviews because it provides information that is necessary for a

healthcare provider to understand their patients and the background they come from. Peer-
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reviewed sources and scientific research papers help prove theories that can be implemented into

future clinical practice. Provided information that was researched in this paper included

advanced searches of our topic from PubMed and CINAHL. Filters that were used to limit

sources to five years were human-based, population, and language. The search terms we used

were mental health, yoga therapy, and nursing.

Critical Appraisal of the Articles

Critical appraisal is the process of systematically assessing the results of scientific

research for trustworthiness, value, and relevance (Brown, 2018). We appraised four articles for

our EBP topic to dive deeper into the effects of yoga therapy on people who struggle with mental

health.

Article One

The investigators (Snaith et al., 2020) conducted a qualitative descriptive study to

examine the perspectives of mental health consumers, staff, and yoga teachers on the

characteristics of a yoga-based intervention to be developed for consumers with long-term

mental health conditions, in addition to anxiety and/or depression. Convenience sampling was

done to enroll 13 participants; x of whom were mental health consumers and y of whom were

mental health staff. Data was collected using focus group interview questions. Data was analyzed

using thematic analysis methods. The results of this study include findings about the importance

of mental health understanding and experience of the yoga teacher, and trauma-informed

approaches to environmental design, teaching, and practice. The strengths of this study were that

participants were both mental health consumers and staff and that it aligns with other studies

reporting positive findings for structured practice for persons experiencing anxiety or depression.

The limitations of this study were that recruitment was difficult across the participant types due
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to schedule conflicts and the reliance on staff to recruit consumers. This study is relevant to this

EBP paper because it gives insight into the effectiveness of yoga therapy in patients who have

chronic mental health diseases.

Article Two

The investigators (Kishida et al., 2018) conducted a qualitative descriptive study to

understand the impact yoga therapy has on individuals’ relationships with themselves and others.

Using purposive sample methods, 107 yoga practitioners were enrolled and provided data via in-

depth interviews. Data were analyzed using content analysis of the open-ended responses and a

constant comparison approach of verbatim interview responses. Four themes emerged: Yoga

generates calmness, mindfulness, compassion for one’s self and others, and a sense of

connectedness. These four themes led to the idea that yoga first causes positive intrapersonal

change and then leads to positive change in interpersonal relationships. The strengths of this

study were a large sample size for the surveys and 12 in-depth interviews for the robust data

collection. The limitations of this study were the participants being predominantly caucasian

females of higher socioeconomic status and the participants being only volunteers, which can

lead to a lack of data from under-represented populations and involve participants who are

already highly involved in and motivated by yoga practice. This study is relevant to this EBP

paper because evaluating the effects of yoga therapy on suicide prevention aligns with the impact

it has on one’s mental health status.

Article Three

The investigators (Vollbehr, et al., 2018) conducted a systematic/meta-analysis study to

examine the effectiveness of hatha yoga treatment in response to acute or chronic disorders

related to mood and anxiety. Using a PRISMA study selection process, 18 studies met the
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inclusion criteria (x from acute, y from chronic populations). Data were analyzed using

extraction methods to assess effect sizes, Egger’s test for evaluating bias in publications within

the meta-analysis by using an asymmetrical graph, and qualitative description methods. This

stated that yoga has significant benefits among individuals with depression compared to

psychoeducation control groups. The strengths of this study were the use of two different types

of clinical populations to better determine the effectiveness of the intervention which provided

randomization to reduce the presence of bias. The limitations of this study were mainly the low

quality of studies that were found which produced insignificant results that would better prove

the effectiveness of the study. This study is relevant to this EBP paper because it approaches the

integrative property of yoga as therapy but is in need of significant evidence through more

studies and trials.

Article Four

The investigators (Uebelacker et al., 2021) conducted a qualitative analysis study to

examine adolescents’ experiences and attitudes toward yoga, with a particular focus on the

acceptability and feasibility of a yoga intervention for depressed adolescents. Using convenience

sampling methods, 22 participants were enrolled in the study. Data was collected using three

focus groups and eight semi-structured interviews. Data were analyzed using applied thematic

analysis methods. The results of this study include that yoga could be calming, relaxing, and

helpful for teens struggling with depression. The strengths of this study were that the data

collection methods returned rich data from which teen attitudes, logistics, and barriers to yoga

were identified. The limitations of this study were that there were very few boys and the use of

two different methods. This study is relevant to this EBP paper because this article showed that

practicing this type of yoga therapy helped the majority of the sample of depressed teens.
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Summary

The key findings from the critical appraisal as a whole concluded that the different types

of yoga therapy are useful and helpful for patients’ mental health. Theme #1, yoga leading to

calmness, was described in articles four (Uebelacker et al., 2021) and two (Kishida et al., 2018).

In article four, the study found through thematic analysis that hatha yoga led to a sense of

calmness in teens struggling with depression. In article two, the interview responses from the

participants showed that yoga generated calmness in the participants during the therapy. The

second theme, that yoga therapy is relationship-based, was described in articles one (Snaith et al.,

2020) and two (Kishida et al., 2018). In article one, the results of this study found that the yoga

teacher’s experience with the participants was critical to generating improvement in mental

health during the therapy. In article two, one of the main four themes included yoga therapy

helping to develop compassion for one’s self and others. It also led to intra- and interpersonal

relationship changes in the participants of article two.

The key findings from the critical appraisals can answer the PICO question by providing

specific information on the effects of yoga therapy on the mental health of individuals battling

poor mental health. Some of the key findings that would answer the PICO question include yoga

therapy generating calmness and improved person-centered relationships. The improvement in

person-centered relationships includes having more forgiveness and compassion for one’s self

and having more compassion for others in life. This shows a positive change in mental status that

could undeniably improve the mental health of those battling chronic mental disorders. In terms

of the finding of yoga therapy generating calmness, this can lead to improved mental health as

well.

Implications for Nursing Education, Research, and Practice

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Based on the findings from the critical appraisals, yoga therapy has many benefits in

providing individuals with mental health issues a form of relief through the least invasive

method. As such, yoga is beneficial to patients dealing with mental health, and it can also be

beneficial to individuals already diagnosed with diseases such as Parkinson’s Disease by

providing support on mobility (Kwok et al., 2019). Through education, research, and practice,

nurses can learn more about the different integrative processes needed to address the growing

population.

Nursing Education

Our EBP topic in the scope of mental health and the use of yoga therapy should be better

included in nursing education to help maximize the depends of nurses. Mental health is

important for nursing education, because of the importance of the role of a nurse or health care

professional in someone who is receiving help for their mental health. Improving the knowledge

of nurses about mental health and yoga therapy could be beneficial in helping to support patients

and better strengthen the patient-nurse connection (Mathad et al., 2017).

Nursing Research 

According to Vollbehr et al. (2018), the research that does exist on yoga therapy related

to mental health is of low quality and therefore more reliable studies are needed to make a

significant connection. Uebelacker et al., (2021) recommended more research needs to be done

that includes studies involving individuals of genders, as most research primarily involved

female subjects. This could make the results less significant for the general population, primarily

as both males and females deal with mental health struggles.

Nursing Practice
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The full benefits of yoga prove to be beneficial for patients. Not only is it an integrative

practice that patients can learn, but healthcare providers can also adopt the same practices so they

can understand it. Yoga provides relief to patients experiencing breathing difficulties, heart

issues, and depression. For example, it helps reduce risks for cardiovascular problems such as

cholesterol levels and relieve pain for patients with arthritis (Weill Cornell Medicine, 2021).

Recommending yoga therapy to patients is something that does not cost a lot of money and is

easier readable in the United States and other countries. Different forms of yoga can also prove

to be favorable for different populations such as the use of hatha yoga in the west (Vollbehr, et

al., 2018). Leaders researching and practicing yoga therapy as well as healthcare professionals

can bring forth all of the options that come with yoga therapy to help out the population whose

mental health benefits from it.

Conclusion

Given our clinical observation, and the evidence surrounding this topic, we examined the

use of yoga therapy in patients with mental health diseases over their lifetime. We learned a

number of pieces of evidence that connect with yoga therapy and mental health. This connects to

INP #2 because humans have the innate capacity to help heal themselves, just like yoga therapy

is done by oneself. The evidence from our four articles can be used to answer our PICO question

partially, as future studies are needed to fully address this topic. Yoga therapy has a significant

role in mental health compared to all other therapies that have been used. Yoga not only can

benefit a single individual or a group to find relief, but it also provides them with a sense of self

through an emotional, physical, and spiritual aspect.

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References

Brown, S. J. (2018). Evidence-based practice (4th ed.). Jones & Bartlett Learning.

Gallagher Ford, L., & Melnyk, B. M. (2019). The underappreciated and misunderstood PICOT

question: A critical step in the EBP Process. Worldviews on Evidence-Based Nursing,

16(6), 422–423. https://doi-org.ezproxy4.library.arizona.edu/10.1111/wvn.12408

Kishida, M., Mama, S. K., Larkey, L. K., & Elavsky, S. (2018). “Yoga resets my inner peace

barometer”: A qualitative study illuminating the pathways of how yoga impacts one’s

relationship to oneself and to others. Complementary Therapies in Medicine, 40,

215-221. https://doi.org/10.1016/j.ctim.2017.10.002

Koithan, J. (2018). Concepts and Principles of Integrative Nursing. In Kreitzer, M.J., Koithan,

M. (Eds.), Integrative nursing (2nd ed.) (pp. 3- 19). Oxford University Press.

https://doi-org.ezproxy3.library.arizona.edu/10.1093/med/9780190851040.003.0001

Kwok, J. Y., Kwan, J. C., Auyeung, M., Mok, V. C., Lau, C. K., Choi, K. C., & Chan, H. Y.

(2019). Effects of mindfulness yoga vs stretching and resistance training exercises on

anxiety and depression for people with Parkinson’s disease. JAMA Neurology, 76(7),

755–763. https://doi.org/10.1001/jamaneurol.2019.0534

Mathad, M. D., Pradhan, B., & Sasidharan, R. K. (2017). Effect of Yoga on Psychological

Functioning of Nursing Students: A Randomized Wait List Control Trial. Journal of

clinical and diagnostic research: JCDR, 11(5), KC01–KC05.

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https://doi.org/10.7860/JCDR/2017/26517.9833

National Alliance on Mental Illness. (2022). Mental health by the numbers. NAMI- National

Alliance on Mental Illness. https://www.nami.org/mhstats.

National Center for Complementary and Integrative Health. (2021). Yoga: What you need to

know. National Center for Complementary and Integrative Health.

https://www.nccih.nih.gov/health/yoga-what-you-need-to-know.

Oregon Health & Sciences Library. (n.d.). Hierarchy of evidence and study design.

https://libguides.ohsu.edu/c.php?g=693307&p=4912291

Snaith, N., Rasmussen, P., Schultz, T., & Proeve, M. (2020). The practicability and relevance of

developing a yoga intervention for Mental Health Consumers: A qualitative study.

International Journal of Mental Health Nursing, 29(4), 622–631.

https://doi.org/10.1111/inm.12694

Sullivan, M. B., Erb, M., Schmalzl, L., Moonaz, S., Taylor, J. N., & Porges, S. W. (2018). Yoga

therapy and polyvagal theory: The convergence of traditional wisdom and contemporary

neuroscience for self-regulation and resilience. Frontiers in Human Neuroscience, 12,

67–67. https://doi.org/10.3389/fnhum.2018.00067.

Uebelacker, L. A., Wolff, J. C., Guo, J., Feltus, S., Caviness, C. M., Tremont, G., Conte, K.,

Rosen, R. K., & Yen, S. (2021). Teens' perspectives on yoga as a treatment for stress and
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depression. Complementary Therapies In Medicine, 59, 102723.

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Table 1

Summary of Evidence

Author(s) & Study Purpose Design Results: Report the study results Level of Evidence
Date Sample that are most relevant to your
Setting PICO Question
The aim of the study Design: Qualitative The results of this study include: Level VI (OHSU,
(Snaith et al., was to understand the Descriptive Study findings about the importance of n.d.)
2020) perspectives of mental health understanding and
mental health experience of the yoga teacher, and
consumers, staff, and Sample: Two focus trauma-informed approaches to
yoga teachers on the groups: (n=18); mental environmental design, teaching, and
characteristics of a health consumers (n= x), practice.
yoga-based and mental health staff
intervention to be (n=y)
developed for
consumers with a
long-term mental
health condition, in Setting: South Australia
addition to anxiety
and/or depression.
(Kishida et al., The purpose of this Design: Qualitative A familiar pattern emerged from the Level VI (OHSU,
2018) qualitative study was Study themes which are positive n.d.)
twofold: (1) to better intrapersonal changes and
understand how yoga interpersonal changes. Yoga first
practitioners perceive Sample: 107 yoga causes positive intrapersonal change
intra- and practitioners and then leads to positive change in
interpersonal interpersonal relationships.
outcomes of their
yoga practice, and (2)
to develop a Setting: Pennsylvania,
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conceptual model of United States

yoga effects on intra-
and interpersonal
outcomes that may
underlie the
“relational”
influences of yoga.

(Vollbehr et al., Design: Systematic/ From the results, yoga has been
2018) This review aimed to Meta-Analysis shown to have significant changes in Level I (OHSU, n.d.)
critically evaluate the individuals with depression
effects of Hatha Yoga compared to the psychoeducation
on improving mental Sample: Eighteen control groups. The qualitative
health in acute and studies, fourteen in analysis states that hatha yoga
chronic illnesses in acute, and four in care encourages populations with chronic
patients. settings depression.

Setting: The United

States, India, Sweden,
and Germany

To understand Design: Qualitative The results of this study Level VI (OHSU,

(Uebelacker et adolescents’ analysis include that yoga could be calming, n.d.)
al., 2021) experiences and relaxing, and helpful for teens
attitudes toward struggling with depression.
yoga, with a Sample: 22 teens
particular focus on
acceptability and
feasibility of yoga
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intervention for Setting: The United

depressed States
adolescents.