Received: 24 May 2018 | Revised: 5 August 2018 | Accepted: 26 August 2018

DOI: 10.1111/nuf.12296

CONCEPT ANALYSIS

How is exercise different from physical activity? A concept

analysis

Nancy A. Dasso MSN, FNP‐C

School of Nursing, University of Texas at

Tyler, Tyler, Texas Abstract
The aim of this study is to clarify the concept of exercise using Walker and Avant13
Correspondence
Nancy A. Dasso, University of Texas at Tyler, concept analysis method. The author offers a definition of exercise, including its
Tyler 75799, TX. distinction from physical activity and how the two terms are not the same and should
Email: ndasso@patriots.uttyler.edu
not be used interchangeably. In the traditional concept analysis format will be used.
Exercise is a subcategory of physical activity that is planned, structured, repetitive,
and purposefully focused on improvement or maintenance of one or more
components of physical fitness. Physical activity is any bodily movement produced
by skeletal muscles that require energy expenditure. Sample cases are provided. A
clear definition of exercise allows health care providers to speak to patients about
improving their physical activity, particularly given that physical inactivity is a leading
but very modifiable risk factor for a wide range of diseases. One of the urgent goals of
nursing should be getting people to become more active. This means communicating
in clear terms with patients. Sometimes that will mean exercise, and sometimes that
will mean simply moving more daily. Researchers of behavior change need to be
precise in their definitions and the methods need to be provided in detail to be useful
and reproducible.

KEYWORDS
concept analysis, exercise, physical activity

1 | INTRODUCTION clarification to ensure consistency in meaning and understanding.7

Physical inactivity has been identified as the fourth leading risk
factor for global mortality1 and is one of the most modifiable risk
2
factors for a wide range of diseases. Exercise and physical activity
have been shown to increase quality of life and decrease the risk for
many diseases (eg, diabetes mellitus, hypertension, cardiovascular
(CV) disease, osteoporosis, and several types of cancer1,3,4). Helping
people to become more active has become a focus for many
organizations, including the Centers for Disease Control and
Prevention (CDC) and the World Health Organization (WHO). Often
the terms exercise and physical activity have been used inter-
changeably in the nursing and medical literature, but the meanings of
5,6
these terms are different. A clearly defined concept can help
provide a mental image of the term and allow for analysis and
Concepts used within a scientific discipline require a more specific or
narrow definition, so the concept can be used the same way with the
same meaning every time.8 Terms such as physical fitness and
exercise are perceived and interpreted differently by people in
differing classes, sex, and sociocultural factors.9 Corbin et al10 state
that in the physical fitness field there have been considerable change
in the definitions of terms and it is necessary to define them
especially when they are used as variables in research. Nurse
scientists need to use terms consistently, so their research is
reproducible. Interpretational framework for comparing studies that
relate physical activity and exercise needs consistent definitions and
concepts.11 It is very important for health care providers to use
consistent terms in assessing levels of exercise or physical activity
and encouraging the appropriate one for it in patients. Challenges

Nurs Forum. 2019;54:45-52. wileyonlinelibrary.com/journal/nuf © 2018 Wiley Periodicals, Inc. | 45

46 | DASSO
arise when there is a miscommunication between patients and nurses
when a patient is asked how much they exercise, but what is needed
12
is how much physical activity is engaged each day. Inconsistencies
are caused when self‐report of movement is under or over reported
because the terms are not thought of in the same way by all
individuals involved.9 Therefore, this study seeks to clarify exercise
as a concept and define its use in nursing.
2 | AIM
The aim of this study is to provide an in‐depth analysis of the concept
of exercise using Walker and Avant13 method. Furthermore, the
terms of physical activity and exercise are distinguished so the two
terms are understood as distinct, unique concepts and not
interchangeable. The definition of exercise is provided first, followed
by the data sources used to find the relevant literature. A discussion
of antecedents and definitive attributes is followed by consequences
and empirical referents of exercise. Constructed cases of the exercise
are offered to illustrate both a positive and a negative example. An
illustration of how the antecedents, attributes, and positive and
negative consequences interact within the concept of exercise is
provided in Figure 1.
3 | D E S IG N
The first step in analyzing the concept of exercise is to formally
define the term. Using the Merriam Webster Online Dictionary,14
exercise is defined as “an activity requiring physical effort, carried
out to sustain or improve health and fitness.” The Dictionary offers
FIGURE 1 Relationship among the antecedent, attributes, and consequences of exercise [Color figure can be viewed at wileyonlinelibrary.com]
the correctly defined example of “exercise improves your health.”
The CDC15 defined exercise as a subcategory of physical activity that
is planned, structured, repetitive, and purposive, in the sense that the
improvement or maintenance of one or more components of physical
fitness is the objective. WHO16 attempted to differentiate the terms
physical activity and exercise by defining physical activity as any
bodily movement produced by skeletal muscles that result in energy
expenditure. Physical activity can be categorized into occupational,
sports, conditioning, household, or other activities.11 Based on these
definitions, the term exercise is not synonymous with physical
activity; rather, it is a subcategory of physical activity.11,16
4 | REVIEW METHODS
The use of the terms exercise and physical activity are currently used
interchangeably in nursing literature, which is a problem as they are
not the same. For instance, using the term exercise for a study in the
elderly population may not be appropriate; however, increasing their
physical activity has been shown to improve health. Many studies
show cumulative activity adds up to better health, but the purpose of
this paper is to show exercise is a very specific type of physical
activity, and the two terms do not mean the same thing. For nursing
practice and research, the terms should be clearly defined. Therefore,
a search was conducted for the extant literature.
The data sources included CINAHL, Google Scholar, SPORTDiscus,
and MEDLINE using the key words exercise, physical activity, definition,
and concept analysis. Google search was used for finding the WHO and
CDC information on the scope of the problem regarding lack of exercise
or physical activity and the dictionary definition of exercise. The search
was limited to the years 1975 through 2017 and to the English
DASSO
T A B L E 1 Definitions of antecedents for exercise
Antecedents Definition in relation to exericse
Ability To exercise, an individual must have the ability to tolerate exercise without physical discomfort or compromise.
Environment Having a safe place to exercise is primarily important; considerations include accessibility of facilities, opportunities for activity,
weather, safety, and esthetic attributes.
Motivation Motivation means the general desire or willingness of someone to do something. Exercise needs motivation to both start and
adhere to a regular exercise program.
language. This search yielded most of the articles reviewed. Additional
searches specific for exercise antecedents, attributes, empirical referents,
consequences, and measurement was also conducted to gain a thorough
understanding of the concept of exercise.
5 | RES U LTS
5.1 | Antecedents
Walker and Avant12 define antecedents as those events or incidents
that must occur or be in place before the occurrence of the concept.
The antecedents of exercise are ability, environment, and motivation.
The antecedents are listed and defined in Table 1.
5.1.1 | Ability
An individual must have the ability to tolerate movement without
physical discomfort before they can exercise.5 There has been an
association demonstrated between chronic disease and reduced
physical fitness due to the cumulative effects of illness, inflammation,
medications, pain, and fatigue on cardiorespiratory and musculoske-
17
letal functioning. An example of reduced ability to exercise could
be people who have the chronic obstructive pulmonary disease that
is characterized by airway obstruction, systemic inflammation, and
skeletal muscle dysfunction, which reduces physical fitness and
results in symptoms of dyspnea on exertion, muscle fatigue, and a
gradual decline in functional status.18
5.1.2 | Environment
Having a safe place to exercise is of primary importance and must come
before one can exercise. An environment such as safe neighborhoods,
parks, sidewalks, or bike trails can help make exercise more likely.19 A
lack of a safe environment makes it harder for people to find a place to
exercise. An example of how environment impedes or facilitates exercise
is the trend of rapidly increasing obesity rates in children and adolescents,
particularly in lower social‐economic status families. These families may
not have ready access to safe neighborhoods or parks, which can result in
a lack of exercise.20 Furthermore, Humpel et al21 found that weather and
accessibility of facilities impact securing a safe environment to exercise.
Some people may not have thought of alternative environments that may
offer safe places to exercise, such as public stairwells, community and
senior exercise facilities, and public swimming pools.19
| 47
5.1.3 | Motivation
Motivation means the general desire or willingness of someone to do
something. People will not exercise unless they have the desire to
start and continue to exercise. There are several behavioral change
theories that concentrate on motivation that can be used to help
people increase their exercise, such as the self‐determination
theory.2 There are two types of motivation, intrinsic and extrinsic.
Intrinsic motivation means the individual engages in the activity for
the satisfaction of the activity itself, the primary satisfaction is
usually the experience of competence, interest, and enjoyment.22
Extrinsic motivation is the individual engaging in the activity to
obtain externally provided rewards or outcomes that are separate
from the behavior; in terms of exercise an example of extrinsic
motivation might be the desire to improve appearance.22 Most
exercise participants are activated by both intrinsic and extrinsic
motives, many individuals start exercise for due to extrinsic
motivational reasons such as body‐related outcomes, but those
individuals who focused on enjoyment, competence, and social
interaction (intrinsic motivation) were more likely to show exercise
adherence.22 An example of different motivations was seen in a study
conducted by Frederick et al23 of 130 college students in which they
completed two surveys (Physical activity Measure and Sport
Enjoyment Questionnaire), and the results showed that intrinsic
motivation was a predictor of affect, perceived competence, and
satisfaction, while extrinsic motivation predicted adherence of
exercise only for men.
5.2 | Critical attributes
Identifying the defining attributes for the concept of exercise is a
necessary step to further establish how it is used in nursing and
research. Attributes are how to recognize the concept.13 The
attributes of exercise are physical activity that is planned, structured,
repetitive, and purposed for achieving physical fitness. These
attributes are described in Table 2.
5.2.1 | Planned
Exercise is a planned behavior. The CDC24 recommends 30 minutes
of exercise at least 5 days a week, plus two muscle strengthening
sessions. Without planning, exercise is very difficult for well‐
intended individuals to successfully meet this recommendation;
through planning people have a great chance of accomplishing
48 | DASSO
T A B L E 2 Definitions of critical attributes for exercise
Attributes Definition in relation to exercise
Planned Planned exercise allows for increase in physical fitness and decreased risk of not exercising. Planning entails goal setting, how to
overcome barriers and how, where, and when to exercise.
Structured Structured exercise means the parts go well with each other. Then exercise can.
Repetitive Repetition of exercise is needed to achieve physical fitness, it is built up over time but repeating an activity.
Purposeful Exercise needs to have a purpose to achieve physical fitness is often performed to improve cardiovascular fitness, strength, and
flexibility, balance or agility.
exercise vs simply increased physical activity.25 Planning implied
that goals will be set for exercise, which McDonald and Trost26
indicated may be an effective strategy for improving aerobic fitness.
Goals can be multileveled, for instance, an individual may have a
daily goal of 10 000 steps, but an additional goal of having one
30‐minute period where they achieve 3000 steps of those steps to
get their heart rate up for an extended amount of time.27 Planning
has been shown to bridge the gap between intentions and
making exercise a regular habit.28 Chapman et al29 found that
planning helped people in their effort to improve their regular
exercise routines. Scholz et al30 found that two types of planning
are needed for exercise to occur, one is the action planning (ie,
when, where, how) and the other is coping planning (ie, anticipating
barriers, mental simulation of success scenarios). Exercise, when
planned, can increase physical fitness. Planning also can decrease
the threat of jeopardizing the exercise routine. Though planning is
multidimensional and can be thought of in many different ways, it is
required for successful exercise.
5.2.2 | Structured
31
Exercise needs to be structured. The Cambridge Dictionary defines
structured a circumstance when parts relate well to one another. In
terms of exercise, structured means that the activity is specifically
geared toward a purpose such as improving CV fitness, strength,
flexibility, or balance and agility.32 An example of a structured
exercise program is one that was designed for older women with the
purpose of preventing falls and fractures rather than increasing
aerobic function, the program was specifically designed to improve
balance, coordination, and strength as well as cardiorespiratory
fitness.33
5.2.3 | Repetitive
Exercise needs to be repetitive to improve physical fitness. In the early
1900’s international running coach Peter Thompson wrote an article in
Athletics Weekly about the need to have “repetition training.”
Furthermore, the Nobel Prize–winning physiologist A.V. Hill (in 1923)
discussed the need for repetition in exercise to dramatically impact
physiological responses. Increasing skeletal muscle mass and creating
intracellular changes to improve physical fitness can be done by
34
manipulating repetition of exercise, as well as frequency and volume.
Increasing and maintaining flexibility takes repetition too. There is
sufficient evidence to support the effectiveness of long‐term use of
stretching to improve flexibility and athletic performance.35 According
to the Livestrong Foundation (2017) the most important thing in
becoming or remaining flexible is consistently—repetitiously—practicing
stretching.
5.2.4 | Purposeful
Physical activity that is purposefully focused on physical fitness is
exercise. Household chores can be planned, but generally are not
focused on improving physical fitness. Specifically, exercise is
performed to improve CV fitness, strength, and flexibility, balance
or agility.32 In a meta‐analysis exploring purposeful exercising using
cycling, Maitland36 found an association between CV improvement
with purposeful cycling and sports but not between gardening and
walking.
5.3 | Consequences
Consequences are defined by Walker and Avant12 as those events or
incidents that happen as the result of the occurrence of the concept.
The positive consequences of exercise include improved health,
decrease risk of many chronic diseases, increased muscle strength,
increased flexibility, and improved sleep and mood. The possible
negative consequences of exercise are injuries, dehydration, or
possibly cardiac dysrhythmias; and the negative effects of not
exercising.
5.3.1 | Positive
Exercise, if done regularly, provides many health benefits to the
individual. It may reduce total body and abdominal fat, and improve
insulin sensitivity, and reduces blood pressure.37 It may improve the
ability of the heart to pump more blood to the muscles, increasing
cardio stamina, which allows more activities to be performed over
time at different levels of intensities, while also decreasing the risk
for heart attack and stroke.38 Reduced risk for other chronic
conditions such as diabetes and osteoporosis.32 Exercise may
improve muscular strength and ability to lift heavy objects, and
increase speed and agility.32,38 It may increase muscle flexibility,
make daily activities more comfortable, and has the potential to
DASSO | 49

decrease fat while increasing lean muscle.38 In addition to the
physical improvements exercise may provide, it can positively
influence mood, increase the feeling of wellbeing,39 and improve
quality of sleep while reducing stress.32
5.3.2 | Negative
Exercise can have negative consequences. Grice et al 40
reported
most exercise injuries were sport specific, and more common in men
than in women; in the short term can result in pain, absence from
work, loss of time training, and associated financial costs but have the
long‐term risk for development of osteoarthritis or disability. Often
the injuries can be avoided by warming up correctly, getting fit over
time, having proper fitting equipment, and using proper exercise
training techniques.41 Another possible negative consequence to
exercise can be dehydration. This is worse if exercising in the heat. To
prevent dehydration, optimum fluid replacement strategies will
depend on the exercise task, the environmental conditions, and the
individual athlete’s physiological characteristics. Additionally, manip-
ulation of pre‐exercise body temperate (ice vests) may be a strategy
that can be used by athletes in stressful environments.42 There is
some controversy over the role of strenuous exercise and atrial
fibrillation. There have been some studies showing both that exercise
may cause atrial fibrillation but other studies with contradictory
findings that found exercise does not play a role in atrial fibrillation.43
Evidence confirms the beneficial effects of regular, moderately
intense, and progressive exercise, and its role in maintaining CV
health in the majority of people, showing that screening is the best
43
way to prevent this negative consequence. The last negative
consequence to be discussed will be the cost of exercise. Structured
exercise programs can be expensive.44 A cost‐effectiveness analysis
was done using two hypothetical groups of 1000 men at age 35, one
group that exercised and one that did not. The authors compared the
cost of exercise, injury, and value of time spent doing the exercise vs
the cost of coronary heart disease (CHD) and estimated that there
were 78.1 fewer CHD events, and 1138.3 quality‐adjusted life years
gained over a 30‐year period, but no economic saving were found.45
There are also negative consequences to not exercising or getting
any physical activity. Baseline activity is doing activities of daily life,
such as standing, walking slowly, and lifting light objects, people who
only do these things are considered physically inactive.15 Booth et al3
define physical inactivity as levels less than those required for
optimal health and prevention of premature death. The conse-
quences of not exercising are well described in the introduction and
include but are not limited to increased risk for type 2 diabetes, CV
disease, and many causes of premature death.1,3,19
5.4 | Empirical referents
Empirical referents are used as the basis for measuring and observing
the concept.7 They are listed and described in Table 3.
There are multiple devices available to monitor activity but are
unable to capture the intensity of the movement. Accelerometers, like
Fitbit, have improved in accuracy and ability to capture large amounts
of data. They detect movement in up to three orthogonal planes and
translate that into metrics of interest.46 Pedometers count number of
steps taken; they are simple and relatively low cost.46 Both devices are
very useful but are unable to measure exercise.
There are measurements for exercise that capture the intensity
of the physical activity or the result of planned, structured activity.
Self‐report questionnaires are the most commonly used method of
exercise assessment; these rely on participants’ recall ability, so
validity is inconsistent, but they are cost effective and easy to
administer.46 Another referent is direct observation, which is when
an independent observer monitors and records exercise, however,
the major disadvantage is that it has a high cost in time and energy.46

T A B L E 3 Empirical referents for exercise

Explanation of test
Measurement of physical activity
Accelerometers Detect movement in up to three orthogonal planes and translate that into metrics of interest.
Pedometers Count number of steps taken.
Measurement of exercise
Self‐report questionnaires Individual reports to research the amount of exercise they have accomplished. Most commonly used.
Relay on recall so validity may be an issue.
Direct observation Independent observer monitors and records exercise. High cost both time and energy.
Heart rate monitor Measures participants heart rate. Intensity can be determined based on heart rate percentages of
maximum heart rate. May be altered by external variables.
VO2 max The percentage of oxygen used during exercise. Considered gold standard of overall fitness, but can
be cost and time prohibitive.
Blood lactate threshold testing Measures amount of lactate increase build up in an individual while exercising. Effective way to
track effectiveness of training.
Improvement in specific physical activity Measuring the outcome of the activity, for example speed, time, heavier weight
50 | DASSO
The American Council of Exercise47 stated using heart rate monitors
were an effective way to monitor the intensity of exercise, using the
participant’s percentage of maximum heart rate as a reference, but
heart rate can also be altered by external variables such as heat,
humidity, and dehydration causing an inaccurate percentage at times.
VO2 max is defined as the maximal volume of oxygen that the body
can deliver to the working muscles per minute, which is a way to
measure the body’s efficiency at producing work and is considered
the gold standard of overall fitness, which is the desired outcome of
exercise,48 but VO2 max requires skilled technicians, expensive
equipment, and is time consuming so it is usually impractical.49
Lactate threshold is defined as the intensity of exercise at which
lactate begins to accumulate in the blood at a faster rate than it can
be removed, the higher the lactate threshold is, the fitter the person
is becoming because they can exercise at faster zones without
becoming sore or wanting to stop.50 Lactate threshold testing is the
most effective way to individualize training zones (planning) and
track training effectiveness (the purpose of exercise).48 When first
introduced, lactate threshold testing meant blood samples, but now
close estimates can be made on either time trials or races, which
allows tracking of improvement in lactate threshold over time as an
indicator of physical fitness improvement, and allows for estimations
of training zones.51 Other measures would be improvement in speed
(time/distance) or ability to increase the duration of exercise (time),
the increase in muscle strength (amount of weight able to be lifted).
5.5 | Constructed cases
5.5.1 | Model case
A 55‐year‐old female decided (motivated) she would like to improve her
aerobic fitness and endurance (purposeful). She was healthy and had
been on the swim team in high school (ability), so she joined a local
master’s swim team with a coach who continually changed workouts to
improve physical fitness (structured). She went to coached swim
training sessions 4 days a week (planned) for 6 months (repetitive),
resulting in an improved 100‐yard swim time by 10 seconds (positive
consequence, and a type of referent of improving physical fitness).
This example of exercise shows that she planned her behavior by
going to practice 4 days a week for a coached workout. It was a
structured swim team program that progressed her fitness level and
her masters coach made the workouts build up to improve the
duration and speed at which she could swim. Structured lap
swimming is a repetitive activity that needs constant repeating to
improve. She was very purposeful in trying to improve her fitness and
took steps to carry this out using swimming 100 yards as her way to
measure her improvement in fitness.
5.5.2 | Contrary case
A 55‐year‐old female was very busy in her life. She had two grandkids
she baby‐sat regularly, they were always active, and it took a lot of
energy to keep up with them. She did not watch television, preferring to
clean house or socialize with friends when she had time. She had sporadic
golf dates (not repetitive), but saw them purely as social outings
(pleasure, not purposefully increasing physical fitness). She was able to
travel several times a year and go to places she always wanted to visit.
She did not want a gym membership as she considered her activity
sufficient (nothing structured or planned). Her weight was steady, and
she watched her diet carefully to make sure she ate a balanced, healthy
diet, and went to annual exams for blood pressure and lab evaluation.
This is an example of physical activity, but not exercise. Her
expenditure of energy is not planned or structured and is more as it
happened, not designed for the purpose of improving her physical
fitness. Though she is active, her activity does not have any structure
and does not do anything repetitive to build up and improve her
endurance or her muscular strength.
6 | CO NCL USION
Exercise and physical activity are becoming increasingly important in
health care to prevent and improve diseases that are epidemic such as
diabetes mellitus, hypertension, and several types of cancer. The research
exploring interventions to help people adapt to healthy lifestyles will
become increasingly important in 21st century health care. In the current
research literature, there continues to be a blurring of the concepts of
exercise and physical activity, with the two terms used interchangeable.
Distinguishing between the two will enable patients to clearly understand
their own and provider expectations for either improving activity levels
or physical fitness. Improving the precision of research evaluating the
impact of physical inactivity and the subset of exercise will reap richer
rewards than continuing the confusion and potential misplaced expecta-
tions that may stymie the attributes of exercise.
Nurses need to be able to communicate clearly with their patients
about the differences in increasing physical activity or exercise, and the
resulting expectations for improving their health. For example, if a nurse
uses the term exercise, a patient may misunderstand and say they do
not exercise but may be active enough to remain healthy.
This analysis of exercise shows that the definition of exercise
should be more restricted and focused than common usage; it is a
subcategory of physical activity. Understanding the difference
between the two is critical because research needs to be precise
and nurses need to communicate with their patients. The recom-
mendation from this analysis is that the terms physical activity and
exercise should not be used interchangeably in research, and that
nurses make a clear distinction of their expectation of activity when
discussing health promotion with patients.
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