Journal of Cardiovascular Nursing

Vol. 29, No. 4, pp 324Y331 x Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Predictors of Physical Activity in

Patients With Heart Failure
A Questionnaire Study
Hui-Chin Chien, RN, MSN; Hsing-Mei Chen, PhD, RN; Martin Garet, PhD; Ruey-Hsia Wang, PhD, RN

Background: Adequate physical activity is believed to help decrease readmission and improve quality of life for
patients with heart failure (HF). Objective: The aim of this study was to explore the predictors of physical activity level
1 month after discharge from hospital in Taiwanese patients with HF. Method: A prospective research design was
used. Overall, 111 patients with HF from a medical center in Southern Taiwan were recruited. Symptomatic distress,
self-efficacy for physical activity, physical activity knowledge, and demographic and disease characteristics of patients
with HF were collected at their discharge. One month later, patients’ total daily energy expenditure (DEE), DEE for
low-intensity physical activities (PAlow DEE; strictly G3 metabolic equivalents [METs]), DEE for high-intensity physical
activities (PAhigh DEE; 3Y5 METs), and DEE for intensive-intensity physical activities (PAintensive DEE; strictly 95 METs) were
collected. Results: The mean total DEE was 8175.85 T 2595.12 kJ 24 hj1, of which 19.12% was for PAlow DEE,
7.20% was for PAhigh DEE, and only 1.42% was for PAintensive DEE. Body mass index (BMI), age, self-efficacy for
instrumental activities of daily living, and educational level were predictors of total DEE of patients with HF 1 month
after discharge. Self-efficacy for instrumental activities of daily living, gender, and BMI were predictors of PAhigh DEE.
Age, BMI, and symptom distress were predictors of PAintensive DEE. Conclusions: Taiwanese patients with HF practiced
lower intensity physical activities. Factors related to physical activity of patients with HF in Taiwan were similar to
those of Western countries. Nurses should emphasize the importance of physical activity to patients with HF who are
male, of older age, with lower educational level, or with lower BMI. Improving self-efficacy for instrumental activities
and decreasing symptom distress should be incorporated into discharge planning programs for patients with HF.
KEY WORDS: heart failure, knowledge, physical activity, self-efficacy, symptom distress

are the second leading cause of death in Taiwan.2

H eart failure (HF) is one of the most common
discharge diagnoses among patients 65 years or
older.1 Although there has been no national mortal-
The heart disease mortality rate was 67.7 per 100000
in 2011, which has been increasing over the years.2
ity rate from HF reported in Taiwan, heart diseases Heart failure is a gradually progressive disease charac-
terized by a decline in physical function. Patients with
HF often experience symptoms such as weakness, fa-
Hui-Chin, Chien, RN, MSN tigue, shortness of breath, activity intolerance, and edema.1
Head Nurse, Department of Nursing, Kaohsiung Medical University These symptoms can further decrease physical activ-
Hospital, Kaohsiung, Taiwan.
Hsing-Mei Chen, PhD, RN
ities in patients with HF.3
Assistant Professor, College of Nursing, Kaohsiung Medical Adequate physical activity is believed to help
University, Kaohsiung, Taiwan. stabilize heart rate variability,4 reduce acute exacer-
Martin Garet, PhD bations, decrease the progression of HF,5 and finally
Lecturer, Laboratory of Clinical and Exercise Physiology, Jean Monnet
University, Saint-Etienne, France.
decrease readmission and improve quality of life.6 It
Ruey-Hsia Wang, PhD, RN is suggested that patients in stable condition should
Professor, College of Nursing, Kaohsiung Medical University, perform adequate physical activity starting 1 month
Kaohsiung, Taiwan. after discharge from hospital.7 Understanding the
Ethical approval was provided by a medical center in southern predictors of physical activity of patients with HF
Taiwan (KMUH-IRB-980113).
1 month after discharge can help nurses design a
The authors have no funding or conflicts of interest to disclose.
discharge-planning program when patients are still
Correspondence
Ruey-Hsia Wang, PhD, RN, College of Nursing, Kaohsiung Medical hospitalized.
University, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan In Asian countries, especially in Taiwan, people
(wrhsia@kmu.edu.tw). usually assume that patients should do nothing but
DOI: 10.1097/JCN.0b013e31828568d6 rest while recovering from illness. This belief might

324

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 Physical Activity in Heart Failure Patients 325

limit physical activity of patients with HF in Taiwan. pitalization.16 Symptom distress is defined as the degree
Understanding the predictors of physical activity of of perceived physical or mental upset, anguish, or suf-
patients with HF in Taiwan could provide more knowl- fering from the specific symptom being experienced.17
edge about the physical activity of patients with HF in Patients with HF often experience symptoms of lack
different countries. of energy, dry mouth, shortness of breath, and drowsy
feeling. The greater the degree of symptom distress,
the lower the performance of physical activity of
Background patients with HF.13,18
Physical activity is defined as any bodily movement Personal characteristics also affect physical activity,
produced by skeletal muscles. Such movement results and self-efficacy is often strongly correlated with en-
in different levels of energy expenditure (EE). Physical gagement in physical activity. Self-efficacy is the belief
activity requires extra EE above the basal metabolic in one’s ability to perform a task and is considered
rate.8 Physical activity can occur during work at an in- important to predict individual behaviors.19 Patients
dividual’s occupation and during domestic tasks, sport, with HF with better exercise self-efficacy had higher
and leisure time physical activities.9 levels of physical activity.13,20 Self-efficacy for physical
The metabolic equivalent (MET) is used to measure activity was positively correlated with physical activ-
EE. Physical activity can be categorized into 5 levels: ity level both at discharge and 6 months after dis-
sleep (1 MET), sedentary activity (about 1.5 METs, charge among patients with HF.21 Knowledge affects
ranging from 1.0 to 2.9 METs), moderate activity both an individual’s behavior and whether he/she will
(about 4 METs, ranging from 3.0 to 5.0 METs), perform behaviors suggested by others.22 Patients
strenuous activity (about 6 METs, ranging from 5.1 with HF who had better knowledge had better physical
to 6.9 METs), and intense activity (about 10 METs, activity.23
Q7.0 METs).10 Many previous studies have examined the factors
Garet et al11 investigated the daily EE (DEE) of related to physical activity of patients with HF by cross-
105 French patients with HF and New York Heart sectional design. Longitudinal designs often provide a
Association (NYHA) classes from I to IV. They found better estimation of the predictive ability of patient char-
that patients with HF spent most of their time in acteristics for some desired outcome. Thus, the pur-
the low physical activity level, with 22.55% of total pose of this study was to explore important baseline
DEE below 3 METs, 12.71% of total DEE between predictors of physical activity 1 month after discharge
3 and 5 METs, and only 1.01% of total DEE above of patients with HF in Taiwan.
5 METs. Another study of 39 French patients with
HF also demonstrated that patients with HF had
low levels of physical activity.4 Only 9.63% of total Methods
DEE was spent in physical activities between 3 and 5
Design and Sample
METs, and 0.7% of total DEE was spent in physical
activities above 5 METs. A prospective research design was used. We collected
Few studies have explored the physical activity of demographic and disease characteristics, symptom
Asian patients with HF. By using the Seven-day Phys- distress, self-efficacy for physical activity, and physical
ical Activity Recall questionnaire, the total DEE of 193 activity knowledge on the discharge day of patients
Taiwanese patients with HF was approximately with HF. Patients were then followed after discharge
7998.01 T 2709.73 kJ 24 hj1.12 Taiwanese patients and the researcher collected data about physical ac-
with HF had relatively low physical activity levels as tivity after patients had been discharged from the
compared with French patients (11127.52 T 3051.83 hospital for 1 month. Data were collected when pa-
kJ 24 hj1).12 tients visited the clinic for follow-ups. For those who had
Demographic characteristics might affect the phys- not visited clinics within 7 days after they had been
ical activity of patients with HF. For example, younger discharged for 1 month, the researcher contacted them
age,11,13 higher educational level, and male gender12 and interviewed them by telephone. All data were
are associated with higher levels of physical activity collected by 1 researcher. Data were collected from
level. Marital status14 and body mass index (BMI) July 2009 to February 2010.
also are related to physical activity levels.15 Patients with HF were recruited from the Depart-
Similarly, clinical characteristics affect physical ment of Cardiology of a medical center in southern
activity level. Functional status, as measured by the Taiwan. Inclusion criteria included (a) being 75 years
NYHA classification, was negatively correlated to or younger; (b) having a diagnosis of HF as deter-
physical activity level.13 Left ventricle ejection frac- mined by cardiologists according to the Framingham
tion (LVEF) was found to be positively correlated with criteria (simultaneous presence of at least 2 major cri-
physical activity at the third and fifth days of hos- teria or 1 major in conjunction with 2 minor criteria)

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
326 Journal of Cardiovascular Nursing x July/August 2014

and being in NYHA class I, II, or III24; (c) being able The possible total scores for SE-BADL ranged from
to verbally communicate with healthcare providers; 0 to 20; those for SE-IADL ranged from 0 to 32.
and (d) not readmitted to the hospital during the
1-month follow up period. The sample size was de-
termined based on the correlation coefficient between Physical Activity Knowledge Scale
the variables with an effect size of 0.3,13 a power of A 10-item Physical Activity Knowledge Scale devel-
0.80, and an ! of .05.25 A sample size of 95 was ade- oped by the authors was used to measure physical
quate. Assuming an attrition rate of 10%, a sample activity knowledge in participants. The responses were
size of 105 was required. In total, 115 patients were yes, no, or don’t know. If the answer was correct,
recruited, of whom 2 died of pulmonary infection and 1 point was scored; if not, 0 points. The total scores
2 could not be approached. Finally, 111 patients with ranged from 0 to 10, with a higher score indicating
HF completed the study, with a response rate of 96.5%. better physical activity knowledge.

Instruments Daily Activity Questionnaire in Heart

Failure Scale
A questionnaire was used to collect data. The content The Daily Activity Questionnaire in Heart Failure
of the questionnaire is as follows. Scale (DAQIHF), developed by Garet et al,11 was used
to assess the DEE of physical activity in each par-
ticipant. The DAQIHF has been proven reliable, sen-
Memorial Symptom Assessment sitive, and valid for DEE estimation in patients with
ScaleYShort Form HF.11 The DAQIHF included 82 items to measure
The Memorial Symptom Assessment ScaleYShort 7 dimensions of physical activities in daily life with
Form (MSAS-SF), developed by Portenoy et al,26 added specific consideration for autonomy and/or per-
was used to assess the symptoms that participants ex- ceived exertion. The 7 dimensions were sleeping and
perienced in the last 1 week. Originally, the MSAS-SF resting periods, basic everyday activities (eating, toilet),
assessed 32 physical and psychological symptoms. One housework activities (chores, repair, child bearing), lei-
symptom, ‘‘I don’t look like myself,’’ was deleted in sure time physical activities, physical activities at work
this study as suggested by experts. Physical symptoms or other ways of being occupied, social activities, mov-
were rated on a 5-point Likert scale, where 0.8 = not at ing about, and miscellaneous activities.15 Activities in
all, 1.6 = a little bit, 2.4 = somewhat, 3.2 = quite a bit, the previous 1 week (including weekend) were reported
and 4.0 = extremely. Psychological symptoms were by participants. The participant self-reported time spent
rated on a 4-point Likert scale, where 1.0 = hardly ever, on each activity, the number of times the activity was
2.0 = occasionally, 3.0 = often, and 4.0 = almost always. done in a week or a day, and whether it required as-
If participants had no symptoms, the score was rated 0. sistance or was interrupted during practice of said
Initially validated and tested for reliability in cancer physical activity. The developer of the DAQIHF calcu-
patients, the MSAS-SF has been validated also in lated the DEE (kJ 24 hj1) by multiplying the intensity
patients with HF.27,28 The item mean score was of the activity (J minj1 kgj1) by the duration of the
calculated by summing the scores of individual items activity (minutes per day) for this study. The DAQIHF
divided by the total numbers of items. A higher item identifies 5 dimensions of DEE from total DEE. There
mean score indicated a higher symptom distress. are DEEs for waking period, for rest (sleeping, naps,
doing nothing), for low-intensity physical activities (PAlow
DEE, strictly G3 METs; eg, housework, chores), for high-
Self-efficacy for Physical Activity Scale intensity physical activities (PAhigh DEE, 3Y5 METs;
The Self-efficacy for Physical Activity Scale developed eg, sports, gardening, housework, leisure), and for
by Liou et al29 was used to measure self-efficacy for intensive-intensity physical activities (PAintensive DEE,
physical activity. The scale measured self-efficacy for strictly 95 METs). In this study, we identified the total
basic activities of daily living (SE-BADL) (5 items) DEE, PAlow DEE, PAhigh DEE, and PAintensive DEE of
and instrumental activities of daily living (SE-IADL) each participant.
(8 items). Basic daily activities included eating, dress-
ing, bathing, and transferring. Instrumental activities
included walking, climbing stairs, doing housework, Demographic and Disease Characteristics
shopping, using transportation, fast walking, and jog- Demographic characteristics included gender, age,
ging.29 Response of each item was rated from 0 (not spouse (with or without), educational level, and BMI.
at all confident) to 4 (extremely confident). A higher Clinical characteristics included NYHA functional sta-
score indicated better self-efficacy for physical activity. tus classes and LVEF. The NYHA class was evaluated

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Physical Activity in Heart Failure Patients 327

on the day of the patient’s discharge, whereas LVEF correlation coefficient was used to calculate test-retest
data were collected from echocardiography records. reliability. The intraclass correlation coefficients for
each scale were as follows: symptom distress, 0.78; SE-
Ethical Considerations BADL, 0.99; SE-IADL, 0.98; physical activity knowl-
edge, 0.78; and DAQIHF, 0.99. Thus, each scale used
This study was reviewed by the institutional review in this study had acceptable validity and reliability.25
board of a medical center in southern Taiwan (KMUH-
IRB-980113). All patients with HF had the aims of
the study and their rights explained and were asked to
sign an informed consent form. Results
The Distribution of Demographic and
Data Analysis Disease Characteristics, Symptom Distress,
Self-efficacy for Physical Activity,
Data were analyzed using SPSS for Windows 12.0.
Physical Activity Knowledge, and Physical
An independent t test was used to examine the as-
Activity Level
sociation between gender, spouse (with or without),
and physical activity level. One-way analysis of var- The demographic and disease characteristics of par-
iance was used to assess the association of educational ticipants are summarized in Tables 1 and 2. The mean
level and NYHA functional status class with physical T SD scores of symptom distress, total self-efficacy for
activity level. Pearson product-moment correlation co- physical activity, SE-BADL, SE-IADL, and physical ac-
efficient was used to analyze correlations of age, BMI, tivity knowledge are summarized in Table 2.
LVEF, symptom distress, self-efficacy for physical ac- The mean total DEE of participants 1 month after
tivity, and physical activity knowledge with physical their discharge was 8175.85 T 2595.12 kJ 24 hj1.
activity level. Furthermore, 19.12% of total DEE was for PAlow
Stepwise multiple regression analysis was used to DEE (1562.90 T 601.27 kJ 24 hj1), 7.20% of total DEE
identify important predictors of physical activity level. was for PAhigh DEE (588.96 T 1199.58 kJ 24 hj1),
Gender (0 = women, 1 = men), spouse (0 = without, 1 = and only 1.42% of total DEE was for PAintensive DEE
with), educational level (0 = illiteracy and elementary, (115.74 T 306.12 kJ 24 hj1). About 72.26% of total
1 = above or equal junior high), and NYHA class (0 = DEE was for sleeping and resting.
class I and II, 1 = class III) were coded as dummy
variables. Left ventricular ejection fraction, age, BMI, The Relationships Between Demographic
symptom distress, SE-BADL, SE-IADL, and physical and Disease Characteristics, Symptom
activity knowledge were used as continuous variables. Distress, Self-efficacy for Physical Activity,
Physical Activity Knowledge, and Physical
Validity and Reliability Activity Level

Five experts, including 1 cardiovascular physician, In terms of total DEE, participants who were male,
1 sports medicine specialist, and 3 nursing profes- without a spouse, or with higher educational level had
sionals, examined the validity of the scales for patients significantly higher total DEE than others did (Table 1).
in Taiwan. These experts evaluated the appropriate- Participants of younger age, higher BMI, better SE-
ness of the items of scales from ‘‘very appropriate’’ BADL, better SE-IADL, or better physical activity knowl-
(4 points) to ‘‘inappropriate’’ (1 point). In each scale, edge had higher total DEE (Table 2).
the number of items rated from 3 to 4 by the experts In terms of PAhigh DEE, women had significantly
was divided by the total number of items, and this higher PAhigh DEE than men did (Table 1). Partici-
was taken as the content validity index. The content pants with younger age, higher BMI, better SE-BADL,
validity index for each scale was as follows: symp- or better SE-IADL had higher PAhigh DEE (Table 2).
tom distress, 0.93; SE-BADL, 0.98; SE-IADL, 0.99; In terms of PAintensive DEE, participants without spouse
physical activity knowledge, 0.92; and DAQIHF, or with lower NYHA classes had higher PAintensive
0.91. Modifications were made according to the sug- DEE (Table 1). Participants with younger age, higher
gestions of the experts. BMI, lower LVEF, lower symptom distress, better SE-
Cronbach ! was calculated for each scale using BADL, or better SE-IADL had higher PAintensive DEE
data for all participants in the study. The Cronbach (Table 2).
! for each scale was as follows: symptom distress,
Important Predictors of Physical Activity
.89; SE-BADL, .89; SE-IADL, .90; physical activity
knowledge, .86; and DAQIHF, .82. We performed a Because there was no significant association between
test-retest reliability test within 2 weeks in 10 patients independent variables and PAlow DEE, we did not ex-
with HF who met the inclusion criteria. The intraclass plore important predictors of PAlow DEE. Collinearity

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328 Journal of Cardiovascular Nursing x July/August 2014

TABLE 1 Distribution of Demographic and Disease Characteristics and Their Comparison on Physical
Activity (N = 111)
Variables n (%) Total DEE PAlow DEE PAhigh DEE PAintensive DEE
Gender
Men 69 (62.2) 8523.74 T 2391.47 1588.90 T 613.58 315.89 T 372.68 132.09 T 304.80
Women 42 (37.8) 7604.31 T 2836.36 1520.18 T 585.25 1037.57 T 1816.24 88.88 T 310.06
t value 2.32a 0.58 j2.54a 0.72
Spouse
With 80 (72.1) 7765.61 T 3114.16 1530.41 T 543.18 575.85 T 1181.05 62.24 T 167.99
Without 31 (27.9) 9234.54 T 2254.85 1646.74 T 733.86 622.77 T 1265.50 253.80 T 491.89
t value 2.20a 0.80 0.18 2.12a
Education
1. Illiteracy 26 (23.4) 6399.94 T 1677.21 1538.34 T 443.65 388.44 T 387.46 23.61 T 70.87
2. Elementary 37 (33.3) 8188.31 T 2350.03 1569.63 T 512.59 549.80 T 873.13 123.77 T 338.25
3. Above junior high 48 (43.3) 9090.94 T 2728.56 1570.35 T 733.71 724.39 T 1627.77 157.37 T 346.91
F value 10.34b 0.03 0.67 1.61
Scheffé method 39291
NYHA class
Class I and II 88 (79.3) 8387.64 T 2696.91 1588.99 T 644.47 652.88 T 1300.40 137.15 T 331.05
Class III 23 (20.7) 7365.52 T 2011.17 1463.07 T 389.86 344.39 T 654.79 33.81 T 162.14
t value 1.57 1.18 1.10 2.12a

Data are presented as mean T SD.

Abbreviations: DEE, daily energy expenditure; NYHA class, New York Heart Association classification; PAhigh, physical activity from 3 to 5 metabolic
equivalents; PAintensive, physical activity strictly above 5 metabolic equivalents; PAlow, physical activity strictly below 3 metabolic equivalents.
a
P G .05.
b
P G .01.

diagnostics were assessed by examining tolerance study, total DEE of Taiwanese patients with HF was
(range, 0.72Y1.00) and variance inflation factor (range, 8175.85 T 2595.12 kJ 24 hj1. Compared with limited
1.00Y1.33) before stepwise multiple regression. There studies in Western countries, the total DEE of Taiwanese
was no collinearity among independent variables. As patients with HF is lower than that reported for French
shown in Table 3, important predictors of total DEE patients with HF (11127.52 T 3051.83 kJ 24 hj1).11
were BMI, age, SE-IADL, and educational level, which Taiwanese patients with HF spent 19.12% and 1.42%
explained 72.4% of the total variance of total DEE. Im- of DEE for PAlow DEE and PAintensive DEE, respectively.
portant predictors of PAhigh DEE were SE-IADL, gender, The results are similar to those in the study of French
and BMI, which explained 29.5% of the total variance patients with HF, which are 22.55% and 1.02% of total
of PAhigh DEE. Important predictors of PAintensive DEE for PAlow DEE and PAintensive DEE, respectively.11
DEE were age, BMI, and symptom distress, which ex- However, Taiwanese patients with HF spent only
plained 19.1% of the total variance of PAintensive DEE. 7.20% of total DEE for PAhigh DEE, which is only
one-half of that of French patients (12.71%). Physi-
cal activity at the level of 3 to 6 METs is recommended
Discussion for patients with HF.30 Enhancing practice of high-
Few studies have addressed the physical activity level intensity physical activity should be emphasized for
of patients with HF, especially patients in Asia. In this patients with HF.

TABLE 2 Correlations Among Age, Body Mass Index, Left Ventricle Ejection Fraction, Symptom
Distress, Physical Activity Self-efficacy, Physical Activity Knowledge, and Physical Activity (N = 111)
Variables Mean T SD Total DEE PAlow DEE PAhigh DEE PAintensive DEE
a b
Age 63.20 T 11.50 j0.57 j0.10 j0.20 j0.32a
BMI 25.70 T 4.93 0.66a 0.17 0.31a 0.30a
LVEF 48.90 T 16.4 j0.05 j0.04 0.12 j0.18b
Symptom distress 0.90 T 1.26 j0.07 j0.09 j0.13 j0.21b
SE-BADL 17.97 T 0.16 0.32a 0.02 0.27a 0.21b
SE-IADL 18.16 T 0.51 0.51a 0.01 0.40a 0.25a
Physical activity knowledge 6.32 T 0.01 0.20b j0.06 0.13 0.14

Abbreviations: BMI, body mass index; DEE, daily energy expenditure; LVEF, left ventricular ejection fraction; PAhigh, physical activity from 3 to 5
metabolic equivalents; PAintensive, physical activity strictly above 5 metabolic equivalents; PAlow, physical activity strictly below 3 metabolic
equivalents; SE-BADL, self-efficacy for basic activities of daily living; SE-IADL, self-efficacy for instrumental activities of daily living.
a
P G .01.
b
P G .05.

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 Physical Activity in Heart Failure Patients 329

TABLE 3 Hierarchical Multiple Regression of LVEF and physical activity level needs further study
Predictors of Physical Activity (N = 111) to confirm.
The phenomenon of the ‘‘obesity paradox’’ has
Variables Standardized " Adjusted R2 F
been observed in patients with HF.31 Higher BMI
Total DEE 72.98a seems to be protective of adverse outcome in patients
BMI .54 0.433 with HF.32,33 This study demonstrated that higher
Age j.38 0.673
SE-IADL .21 0.712 BMI at discharge predicts higher physical activity level
Educational j.13 0.724 1 month later. Patients with HF who had low BMI
level may be frail, which may limit their ability to engage
Constant 8.66 in physical activities. More longitudinal studies are
PAhigh DEE 16.38a needed to confirm these data.
SE-IADL .38 0.149
Gender j.33 0.250 Participants with better physical activity knowl-
BMI .23 0.295 edge had higher DEE in this study, which is consistent
Constant 3.74 with the findings of Dunderdale et al.23 Providing
PAintensive DEE 9.68a knowledge of the importance of physical activity is nec-
Age j0.27 0.093 essary during patients’ hospitalization. Consistent with
BMI 0.26 0.157
Symptom j0.20 0.191 the result of a qualitative study,34 SE-IADL was an im-
distress portant predictor of DEE and PAhigh DEE in this study.
Constant 8.95 Activities of PAhigh DEE involve activities such as walk-
ing, carrying, or lifting things, which need more ef-
Abbreviations: BMI, body mass index; DEE, daily energy expenditure;
PAhigh, physical activity from 3 to 5 metabolic equivalents; fort. It is reasonable that SE-IADL is more important
PAintensive, intensive activities strictly above 5 metabolic equivalents; than SE-BADL as a predictor of DEE and PAhigh DEE.
SE-IADL, self-efficacy for instrumental activities of daily living. A multimedia exercise intervention has been found
a
P G .001.
to increase exercise self-efficacy.35 Nurses can develop
multimedia exercise intervention to improve knowl-
Although the total DEE of men was significantly edge and self-efficacy for physical activity of patients
higher than that of women, PAhigh DEE in women was with HF.
significantly higher than that in men. This finding is Although the symptom distress of patients with HF
in line with the study of Seo et al.18 High-intensity in this study was not very high, symptom distress be-
physical activities such as household tasks are usu- fore discharge was an important predictor of PAintensive
ally performed by women, which may result in women DEE 1 month after discharge. This finding is consis-
having higher PAhigh DEE than men do. Nurses can tent with previous research findings.13,18 Interventions
encourage men with HF to perform housework or that reduce respiratory distress or sleep disorder dis-
leisure activity after they have been discharged from tress have been demonstrated to improve the physical
hospital. activity of patients.36 Nurses should identify symptom
In this study, age was an important predictor of distress in their patients with HF early and educate pa-
PAintensive DEE. Intensive activities may need more tients on how to manage their symptoms before their
muscle power. The loss of muscle mass with aging discharge.
may limit older patients’ ability to perform intensive The important predictors addressed in this study
physical activities. In line with the study of Landi et al,14 explained only 29.5% and 19.1% of the total var-
patients with spouses had lower PAintensive DEE. Spouses iance of PAhigh DEE and PAintensive DEE, respectively.
of patients with HF might assist them in performing Previous studies indicated that oxygen consumption
intensive physical activities because they are concerned per unit time15 and heart rate variability4 were im-
about the safety of having the patient perform those portant predictors of physical activities above 3 METs.
activities. Such assistance might restrict patients’ per- To more comprehensively understand the predictors of
formance of intensive physical activities resulting in de- PAhigh DEE and PAintensive DEE, we need to include
bilitation. Healthcare providers should educate spouses oxygen consumption per unit time and heart rate
of patients with HF to encourage patients to practice variability as independent variables in the future.
intensive physical activities.
We found that patients with a worse NYHA class
performed less intensive activities. Patients with a worse
Study Limitations
NYHA class have more symptoms that likely interfere This study has some limitations. The generalizability
with their practicing of intensive physical activities.3 of the study findings was limited because patients with
Patients with HF who had higher LVEFs had worse HF were recruited from a medical center in southern
PAintensive DEE in this study. However, the correla- Taiwan. Future studies need to recruit patients with HF
tion was weak (r = j0.18). The relationship between from diverse hospitals. We followed the physical activity

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
330 Journal of Cardiovascular Nursing x July/August 2014

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