Nurses are the largest professional group within the health care workforce. Several investigators in varied settings have assessed the self-reported and objective physical activity (PA) levels of nurses and shown low levels of PA (Kaewthummanukul et al., 2006; Sveinsdottir and Gunnarsdottir, 2008; Ratner and Sawatzky, 2009; James et al., 2013; Babiolakis et al., 2015; Perry et al., 2015; Reed et al., 2018). The National Survey of the Work and Health of Nurses in Canada showed that a disconcerting proportion of nurses are overweight or obese (45%) and smokers (16%); have high blood pressure (13%), high cholesterol (10%) and diabetes (3%); and, experience fair/poor mental health (6%) (Shields and Wilkins, 2006). The irrefutable evidence demonstrating the effectiveness of regular PA in the prevention and management of cardiovascular disease and associated risk factors (Warburton et al., 2006, 2010; Haskell et al., 2007; Reed and Pipe, 2016) highlights the opportunity afforded by targeted PA interventions to promote positive behavior change within this unique and large professional population.

As adults worldwide embrace modern technologies, web-based innovations may represent opportune, convenient, and cost-effective methods to target suboptimal PA levels and poor cardiovascular health of nurses. Web-based interventions that can be delivered anytime and anywhere warrant particular attention because they are accessible 24 h a day, 7 days a week which may be ideal for nurses working long (i.e., 12 h) and rotating (i.e., days, evenings, nights, weekdays, weekends) shifts. Several reviews have shown that web-based interventions can increase PA levels and reduce body mass, waist circumference and blood pressure in adults (van den Berg et al., 2007; Liu et al., 2013; Joseph et al., 2014; Seo and Niu, 2015; Direito et al., 2017; Sorgente et al., 2017).

The primary purpose of this parallel-group randomized trial was to examine the impact of a web-based intervention providing specific feedback derived from an activity monitor on the PA levels and cardiovascular health of nurses working in a Canadian cardiovascular setting. We hypothesized that nurses' PA levels and cardiovascular health would improve in response to the receipt of personalized feedback regarding their PA levels derived from an activity monitor. Further, as modern informatics capabilities enable us to harness strategies designed to initiate and support positive behavior change, the secondary purpose of this trial was to assess whether nurses' PA levels are enhanced when they work together to meet their PA goals (i.e., friend or team PA challenge) compared to when they work alone to meet their goals (i.e., individual PA challenge). We hypothesized that nurses' assigned to a friend or team PA challenge (and thus have their weekly PA levels displayed to others) would become more physically active when compared to nurses assigned to an individual PA challenge. This hypothesis is based on work suggesting that people perform better when they are in front of others than when they perform alone (Hausenblas et al., 2014). One explanation for this is based on the self-presentation theory (Leary, 1992) which suggests that the desire to enhance oneself and make positive impressions in front of others is an important motivator of human behavior. From this perspective, one might expect that nurses will increase their PA levels more if they know that others will see their levels than if no one else will see their PA levels.

This is the first randomized trial, to our knowledge, to examine the impact of a web-based intervention incorporating feedback and group features on the PA levels and cardiovascular health of nurses working in a cardiovascular setting. We observed initial increases in nurses' PA levels (i.e., weekly MVPA levels and daily steps), though these were not sustained over the 6-week intervention and few met the current PA guidelines (≥150 min/week in bouts of ≥10 min). We also observed improvements in nurses' body fat percentage and resting systolic BP. Introducing web-based group features (i.e., friend and team PA targets) for motivation did not differentially impact PA or cardiovascular outcomes.

Nurses reach a large proportion of the population making them a critically important element of the health-care workforce. Nursing practice is physically and psychologically demanding (Chin et al., 2016). Physical inactivity and cardiovascular disease have been shown to be related to lower ability to work and a greater incidence of absenteeism (Burton et al., 2014; van den Berg et al., 2017). Improving the lifestyle and overall well-being of nurses is important in order to permit optimal patient care. E-health broadly refers to the use of emerging information and communication technology to improve or enable health and health care (Government of Canada, 2010). E-health encompasses a wide range of services or systems, including electronic health records, e-prescribing, telemedicine (e.g., online and telephone coaching), consumer health informatics (e.g., on demand educational content), wearable devices (e.g., Tractivity™, Fitbit™) and real-time monitoring of user health and behavioral data. Evidence has suggested that e-health interventions may improve the PA levels and health outcomes of adults (Beratarrechea et al., 2014; Joseph et al., 2014; Direito et al., 2017). Providing web-based feedback from wearable devices is acceptable and can increase the PA levels of inactive overweight and obese women (Cadmus-Bertram et al., 2015a,b). Our work extends these findings to nurses and provides support for the use of e-health interventions to target PA and cardiovascular outcomes in nurses working in a cardiovascular setting as revealed by the good compliance with the intervention and initial effects on behavior and health outcomes.

We found that web-based feedback from an activity monitor resulted in immediate increases in nurses' PA levels (i.e., weekly MVPA levels and daily steps). Yet, consistent with other web-based PA interventions demonstrating short-lived increases in PA levels (Vandelanotte et al., 2007; Kernot et al., 2014; Fjeldsoe et al., 2015; Joseph et al., 2015), nurses' PA levels decreased mid-way through the current intervention. Our 6-week intervention was relatively short in duration and incorporated a limited range of motivational strategies, namely group features. It could be argued that a longer intervention that combines feedback with additional strategies (e.g., social support, autonomy support, offering value-based rationales for PA) within the web platform is needed to achieve and sustain improvements in PA levels, particularly for those who are not meeting current PA guidelines. Whether web-based interventions that encompass more strategies that can intrinsically motivate PA are more effective in sustaining nurses' PA levels requires further investigation.

We attempted to assist nurses in achieving PA targets by having participants share data with other nurses to motivate the initiation and maintenance of PA; this appeared to lack sustained appeal. We chose friend and team PA challenges based on research showing that: (1) the act of self-monitoring can improve PA levels (Michie et al., 2009); (2) social factors (e.g., social learning, comparison, normative influence, facilitation, cooperation, recognition) can be a powerful tool for increasing the effectiveness of web-based interventions (Matthews et al., 2016); (3) social competition via the web can motivate participants to become more physically active when compared to self-monitoring only (Prestwich et al., 2017); (4) gamification can have a positive impact on behavioral and health outcomes (Johnson et al., 2016); and, (5) the desire to enhance oneself and make positive impressions is an important motivator of human behavior (Leary, 1992). The integration of technological-mediated group features did not, however, impact nurses' PA levels or cardiovascular health when compared to those who did not have access to these features. One explanation for the null finding is that the anonymity of nurses within the groups prevented social support and relatedness between participants. It is possible that nurses would have accumulated greater PA levels if the friend and team challenge conditions allowed them to feel connected and accountable to their friend or team members. It is also possible that this type of group feature is insufficient to change PA unless cash or prize incentives are provided. Finally, feedback may have undermined nurses' intrinsic motivation to perform PA because providing social pressures and rewards can give rise to extrinsic motivation (Deci and Ryan, 2012; DeSmet et al., 2014). Strategies which foster intrinsic motivation (e.g., when the behavior is done for enjoyment and personal satisfaction) may better promote behavior change and maintenance (Teixeira et al., 2012; Hancox et al., 2017; Quested et al., 2017). Future research developing and testing strategies to motivate nurses and engage them in PA is warranted.

We observed statistically significant improvements in body fat percentage (−0.8%), yet no changes in body mass, BMI or waist circumference. These latter findings were not surprising given that increases in nurses' PA levels were short-lived over the 6-week intervention and likely produced minimal, if any, deficits in energy expenditure (Reed et al., 2013). We also observed a significant improvement in resting systolic BP (−2.6 mmHg). Strong evidence from a meta-analysis of randomized controlled trials of exercise training in healthy adults (5,223 participants: 3,401 exercise training participants and 1,822 sedentary controls) suggests that resting systolic BP is reduced (−3.5 mmHg) after endurance exercise (Cornelissen and Smart, 2013). The decrease (−2.6 mmHg) we observed may not be clinically significant, yet the direction of change is nevertheless favorable and associated with reduced cardiovascular morbidity and mortality (Hansson, 1996; Padwal et al., 2016). Our findings contrast those of a pedometer-based PA program for nurses in a Canadian multi-site health care center which reported no changes in resting systolic BP (Lavoie-Tremblay et al., 2014). This study, however, used self-reported BP measures which have been shown to have moderate agreement with measured BP (Taylor et al., 2010) and did not observe significant increases in PA levels.

Our study has several strengths. It is the first to examine the impact of web-based feedback from an activity monitor on the PA levels and cardiovascular health of nurses working long and rotating shifts in a cardiovascular health center. This is particularly important as innovative interventions are needed to address at-risk nursing populations (Reed et al., 2018). Second, we integrated technologically-mediated social participation into the web-based intervention to increase participants' motivation, although this did not impact PA levels or cardiovascular health indicators. Third, nurses' PA levels were objectively measured in 1-min increments throughout a baseline week and 6-week intervention using a valid activity monitor. Fourth, we observed a low dropout rate of 5% (n = 4/76). A review of internet- and web-based PA interventions in which the majority of participants were women revealed a dropout rate of 21% for interventions <6 months in duration (Joseph et al., 2014). Further, a pedometer-based PA program for nurses in a Canadian multi-site health care center reported a response rate of only 55% (Lavoie-Tremblay et al., 2014).

Several limitations warrant discussion. First, the generalizability of our findings to male nurses is limited as 97% of our sample were female—characteristic of the Canadian nursing population (Shields and Wilkins, 2006). Second, the generalizability of our findings to older nurses and those working nights only is limited given most of our nurses were middle age and working days only. Third, this was a single-center study. Replication of this study across several hospitals is needed to confirm our findings. Fourth, we recruited 19% of nurses from the hospital (total nursing population = approximately 400 nurses); it is possible that nurses interested in participating in a PA and health study may be “healthier” and more active than average, thus limiting the impact of a PA intervention to improve PA and cardiovascular health. Finally, we cannot affirm that participants did not disclose their group assignment to one another, and consequently contaminate the group effects. No differences in PA or cardiovascular outcomes were, however, observed between groups.

Web-based PA interventions may be effective in initiating, but not sustaining optimal PA levels among Canadian nurses working in a cardiovascular setting. Improvements in nurses' body fat percentage and resting systolic BP were observed following the intervention. Embedding technologically-mediated social participation did not appear to impact nurses' PA levels or cardiovascular health. Nurses working in a cardiovascular setting do not appear to be meeting PA guidelines. Future larger multi-site randomized controlled trials are needed to confirm our findings. If our findings are replicated, alternative novel and multi-faceted interventions are needed to address the low PA levels and poor cardiometabolic health of at-risk Canadian nurses.

The growth in e-health interventions is occurring rapidly. It is foreseeable that new technologies (e.g., global positioning systems, smart watches, video games) will provide additional means of improving and or maintaining PA which is a known modifiable risk factor of cardiometabolic health. Consumers will be able to monitor their time spent in MVPA, daily steps and bouts of sedentary time. The cost of such technologies will, in all likelihood, continue to decrease as companies strive to provide competitive, accessible and affordable products for consumers. Future work is needed to synthesize all available data regarding the effectiveness of e-health interventions in improving PA levels and cardiometabolic health in adults, particularly in women as over half of women lack knowledge of cardiovascular disease risk factors and the majority are uninformed when it comes to their own level of risk (McDonnell et al., 2014; Reed et al., 2015).

JR: Conceptualized and designed the study; JR: Performed the analyses and interpretations of the data, drafted the initial manuscript, and revised and approved the final manuscript as submitted; CC and MZ: Assisted with the acquisition of data, drafting and revising the manuscript; JB: Assisted in drafting and revising the manuscript; HT, HS, RR, and AP: Assisted in designing the study, selecting outcome measures, and provided critical revision of the manuscript.