https://orcid.org/0000-0001-9682-2225
ABSTRACT
Purpose
Clinical guidelines call for the inclusion of exercise interventions in every patient’s dialysis session, but these recommendations are rarely adopted. Healthcare providers play a key role in this. Therefore, the aim of this study was to explore how healthcare providers perceive the benefits, risks and barriers of intradialytic exercise (IDE).
Methods
We conducted 21 individual, semi-structured interviews with 11 nurses, 5 nephrologists, 3 training assistants and 2 managers from two dialysis centres in Slovakia. Verbatim transcripts of digitally recorded interviews were thematically analysed using MAXQDA®.
Results
Participants reported the benefits of IDE as improvements in patients’ physical and psychosocial functioning, independence and self-efficacy, clinical profile and quality of therapy. As risks of IDE, they most frequently reported exercise-related damage to vascular access, insufficient individualization of training and musculoskeletal injuries. The presence of psychological problems among patients was reported as a major barrier for initiating and maintaining patients’ exercise. Other reported barriers included limitations in financial and personnel resources of haemodialysis care.
Conclusions
Safe and sustainable implementation of IDE, which might improve a patient’s well-being, need to be prescribed in alignment with the patient’s clinical profile, be delivered individually according to the patient’s characteristics and requires adjustments in the available resources.
1. Introduction
Chronic kidney disease stage 5 is one of a main preventable public health problems worldwide (Bikbov et al., Citation2020; Thurlow et al., Citation2021). The disease itself along with renal replacement therapy generates enormous direct and indirect economic and healthcare system costs (Golestaneh et al., Citation2017; Li et al., Citation2021). It is therefore necessary to identify achievable goals and preventable strategies to minimize these burdens (Luyckx et al., Citation2017; Thurlow et al., Citation2021). Sarcopenia reduces haemodialysis patients’ muscle performance, physical capacity, mobility, self-efficiency and quality of life (Giglio et al., Citation2018; Lopes et al., Citation2019) and has been identified as an independent risk factor for patients’ poor clinical outcomes, hospitalization frequency, mortality (Carrero et al., Citation2016; Giglio et al., Citation2018; Isoyama et al., Citation2014; Ye et al., Citation2022) and enormously increasing healthcare expenditures (Darvishi et al., Citation2021; Janssen et al., Citation2004; Ye et al., Citation2022).
Physical activity is a major non-pharmacological therapy to suppress sarcopenia and dynapenia in patients with chronic kidney disease (March et al., Citation2022; Mayes et al., Citation2022; Roshanravan et al., Citation2017). Regular, adequate and individualized physical activity, including aerobic, resistance or combined exercise, attenuates inflammation and protein-energy wasting (Arazi et al., Citation2022; Bogataj et al., Citation2019; Saitoh et al., Citation2016), improves dialysis efficiency, renal functions and dialysis-related symptoms (Hargrove et al., Citation2021; Ma et al., Citation2022; Shlipak et al., Citation2022; Zhang et al., Citation2022), and reduces musculoskeletal, cardiovascular and metabolic comorbidities among haemodialysis patients (Deligiannis et al., Citation2021; Kang et al., Citation2017; Kouidi, Citation2001; Rabajdova et al., Citation2021). Despite the strong evidence on the benefits of physical activity, haemodialysis patients are mostly sedentary, and implementing an exercise intervention is not yet a routine in general practice and care (Lee et al., Citation2012; Wilkinson et al., Citation2021). To increase patients’ physical activity it is recommended that exercise should be incorporated into standard dialysis care (Painter & Johansen, Citation2006; Parker, Citation2016).
Counselling dialysis patients on intradialytic exercise (IDE) requires not only evidence-based recommendations for the prescription of individual training sessions but also a strategy for its safe and sustainable implementation into routine dialysis care (Capitanini et al., Citation2014; Johansen et al., Citation2003; Wilund et al., Citation2020). For the creation of such implementation strategies, evidence on the perceptions and experiences of IDE is crucial. Several studies have reported the perspectives of haemodialysis patients on the benefits, facilitators, risks and barriers of physical activity. Benefits included improvements in general health and quality of life, enjoyment connected with exercise, an increase in social interactions, better physical well-being and a higher degree of self-confidence (Clarke et al., Citation2015; Kendrick et al., Citation2019; Song et al., Citation2019). Regarding risks, patients reported exercise-related fatigue and injury and disease deterioration (Kontos et al., Citation2007; Song et al., Citation2019). Poor general health (Clarke et al., Citation2015), the presence of comorbid conditions (Kendrick et al., Citation2019), fear of injury, physical exhaustion and further aggravation of a physical condition (Clarke et al., Citation2015; Kontos et al., Citation2007; Song et al., Citation2019) have been reported as barriers to patients’ exercise. Only one qualitative study highlighted patients’ psychological limitations as a barrier to exercising (Kontos et al., Citation2007).
However, evidence regarding the perceptions and experiences from care providers who are personally involved in implementing IDE is limited and, as far as available, mostly regards the perceptions and experiences regarding patients’ habitual physical activities (Hannan & Bronas, Citation2017). Therefore, we conducted this study to explore how healthcare providers (training assistants, nurses, nephrologists and dialysis centre management) perceive the benefits, risks and barriers of IDE implementation in haemodialysis patients.
2. Materials and methods
2.1. Study design
This qualitative study was conducted at two dialysis centres (out of in total 77 nationwide) in Slovakia (although both private, they are reimbursed by all Health Insurance Companies; people have free choice to visit them). We approached them after implementation of an interventional, clinical trial primarily focused on the effectiveness of IDE regarding a patients’ muscle function. In this clinical trial, IDE was provided by training assistants in cooperation with nurses and nephrologists. Currently, IDE is not provided to patients as a part of routine dialysis therapy in Slovakia. The study protocol and conditions for participation in the study were explained to all subjects before the interviews took place. Written informed consent was obtained from all study participants. The Ethics Committee of the Pavol Jozef Safarik University in Kosice reviewed and approved the study protocol (approval no. 14N/2017). We report the study following the consolidated criteria for reporting qualitative research (COREQ) (Tong et al., Citation2007).
2.2. Participants
Assistants were medicine and psychology university students exclusively assigned to dialysis centres for three months of IDE intervention activities. They were eligible to participate if they were older than 18 years and worked in the dialysis centre throughout the entire IDE implementation period. Nurses, nephrologists and managers were eligible if they had a minimum of two years of experience in their position and worked in the dialysis centre throughout the entire IDE implementation. Eligible subjects were pre-screened regarding age, gender and professional experience (years in current and previous positions). Based on this, we purposively selected and invited subjects with high variation in age and professional experience. We included more participants until a thematic saturation of all the studied topics was achieved, i.e., when responses to questions in successive participants were identified as repetitive and did not yield relevant new codes regarding care providers’ perceptions (Saunders et al., Citation2018).
2.3. Development of conceptual framework
We used the patient-centred access to health care (PCA) (Levesque et al., Citation2013) and the biopsychosocial model of responsiveness to physical activity (TMR) (Thiel et al., Citation2019) as conceptual frameworks to guide the interviews and data analyses. The PCA model identifies healthcare needs that are crucial for seeking, reaching, obtaining and using healthcare services from the perspective of patients, caregivers and providers. We chose this model because the implementation of exercise intervention in standard dialysis care is conceptually related to patients’ access to health care and interfered with diverse dimensions of health care. The TMR model describes dimensions of responsiveness to being exposed to exercise, taking physiological, epigenetic, motivational, affective and body image-related aspects into consideration. We chose this model because the implementation of exercise interventions is causally related to individual dimensions of a patient’s responsiveness to exercise and interfered with the patient’s physical activity history and current behaviour. For the creation of interview content and subsequent data analyses, we combined the PCA and TMR dimensions to cover all important topics regarding the benefits, risks and barriers of IDE implementation.
2.4. Measures and procedures
Research team members (AZ, IS, DK and ZDV) compiled an interview guide (presented in Appendix A) to achieve a detailed understanding of the benefits, risks and barriers of IDE from insights of training assistants, caregivers and management. The interview guide contained questions covering these thematic topics: benefits, risks and barriers of IDE, pros and cons for exercise during dialysis, personal experience with IDE, and suggestions for better applicability of IDE.
2.5. Data collection
Individual, semi-structured, audio-recorded interviews with participants took place at two dialysis centres that have previously participated in the clinical trial as experimental centres for the implementation of a 3-month, intra-therapeutic, progressive, resistance training interventional programme. Before the start of the interviews, AZ (PhD.; young researcher, male), IS (MSc., PhD. student, female) and DK (Bc., master’s student, female) were instructed regarding optimal design and conduct of qualitative research interviews and screened for their professional background and possible personal biases, assumptions, reasons and interests regarding the interviews dimensions by ZDV (assoc. prof, senior researcher, female) (DeJonckheere & Vaughn, Citation2019; Jamshed, Citation2014; McGrath et al., Citation2019). Interviewers (AZ, IS, DK) did not have professional or personal relationships with participants prior to study commencement.
The interviews were conducted in the Slovak language at isolated meeting rooms in dialysis centres (nurses and nephrologists) or an office located at the authors’ workplace (assistants and management staff). Written informed consent and a short personal questionnaire summarizing the socio-demographic characteristics (age, gender) and professional experiences (years in previous and current job position) of participants were obtained prior to the interviews. All interviews were conducted individually in the presence of one or two research team members (AZ, IS, DK) and lasted 20 to 60 minutes. During the interviews, the research team members strongly encouraged the participants regarding verbalization, logical derivation and development of their thoughts and experiences. If necessary, research team members wrote field notes during the interviews. No repeat interviews with participants were conducted.
2.6. Data handling and analysis
After completion of all semi-structured interviews with participants, we explored how healthcare providers perceived the benefits, risks and barriers of IDE implementation in haemodialysis patients in two phases. Regarding data handling, we transcribed and anonymized, i.e., removed all personal data of participants, the audio recordings of the interviews. The verified transcripts and audio recordings were then uploaded into the MAXQDA® standard platform (VERBI Software, Berlin, Germany) and processed by consensual qualitative analysis. We then familiarized ourselves with the audio and transcript forms of the data and performed the initial coding, code grouping, themes searching, themes defining and final analysis of domains, core ideas and cross-evaluations, as described by Braun and Clarke (Citation2006) and Hill et al. (Citation2005).
Next, for the data analyses, two research team members (IS and AZ) individually generated codes and then exchanged coding outputs for cross-checking the coding quality. In the case of disagreements or appeals to re-code, members initiated coding meetings and discussed problematic codes until consent in the final output of coding was achieved. Thematically similar codes were associated into groups and sub-groups regarding benefits, risks and barriers of IDE. The final output of the coding process and thematic code grouping was approved by the analysis auditor (ZDV). Afterwards, we extracted core themes, subthemes, contexts and quotations regarding perceived benefits, risks and barriers of IDE implementation. Additionally, we calculated the percentage rates of code occurrences regarding the identified subthemes in the participants’ professional positions only to illustrate ranges in reported perceptions across professional positions.
3. Results
3.1. Characteristics of the study participants
We included 3 training assistants, 11 nurses, 5 nephrologists and 2 members of the management from two cooperating dialysis centres. Another 3 care providers (1 nurse and 2 nephrologists) invited to the study refused to participate due to privacy concerns and high workloads. We conducted 21 semi-structured, individual interviews from June 2019 through November 2019. One quarter of the participants were over 50 years of age, a third were males, a third were academic nephrologists and half had over 15 years of professional experience. Characteristics of the participants are presented in .
Table I. Participants’ socio-demographic and professional characteristics by position.
3.2. Quantification of the codes, subthemes and themes regarding benefits, risks and barriers of intradialytic exercise
We identified 1280 codes and categorized them into 16 subthemes and three core themes related to perceived benefits, risks and barriers of IDE. Identified themes, subthemes and percentage rates of code occurrences in the participants’ professional positions are presented in .
Table II. Summary of the identified themes and subthemes regarding benefits, risks and barriers of IDE; the number of identified codes per theme and subtheme regards the number of times mentioned per profession as percentage of the total number of professionals of that background.
3.3. The benefits, risks and barriers of intradialytic exercise
We identified three core themes related to perceived benefits, risks and barriers of IDE. Benefits were categorized in six subthemes, i.e., improvements in a patient’s physical and psychosocial functioning, clinical profile and independence, alterations in time perception and distractions of patients. Identified risks were categorized in five subthemes, i.e., damage of vascular access, individualization of training, musculoskeletal injuries, a patient’s clinical conditions and the timing of IDE intervention. Identified barriers regard five subthemes, i.e., limitations in a patient’s psycho-social dispositions, work capacities of care providers and organization of a patient’s therapy, lack of financial recourses and personnel capacities and insufficient patient support during the IDE intervention.
3.3.1. The benefits of intradialytic exercise
3.3.1.1. Improvements in patients’ physical functioning and musculoskeletal structure
All participants expressed one or more benefits related to improvements in muscle strength or muscle mass. Three-quarters believed that IDE increased patients’ muscle strength, and one-quarter expressed benefits related to gains and maintenance of muscle mass volume. A minority reported improvements in muscle endurance, flexibility and fine motor skills.
3.3.1.2. Improvements in patients’ psychosocial functioning
Nearly all participants believed that IDE positively affected patients’ psychosocial functioning. In their view, patients in standard dialysis regimens are highly vulnerable, resigned, self-regretful, depressive, grieving, wrathful, beaten inside and socially isolated. Participants expressed that IDE could change patients’ self-perception, make patients happier, less stressed, depressed and anxious, and contribute to positive attitudes and co-activation.
3.3.1.3. Improvements in patients’ clinical profile and quality of therapy
The majority of participants believed that IDE could improve (to a certain and individual extent) the clinical profile of haemodialysis patients. The most frequently reported benefits were improvements in glucose metabolism, better cardiac and vessel health, a decrease in overhydration and lower morbidity and mortality of patients due to improvements in their nutritional status.
3.3.1.4. Improvements in patients’ independence and self-efficacy
Most participants believed that IDE could improve patients’ self-efficacy in activities of daily life, decrease their dependence on help with basic needs from caregivers and family members and improve the level and safety of patients’ mobility.
3.3.1.5. Alterations in patients’ perception of time spent in dialysis treatment
According to most participants, haemodialysis patients qualify time spent on dialysis as “boring”, “useless” and “tiresome and endless”. Half of the participants stated that IDE could alter patients’ perceptions of dialysis time and thus relieve their stereotypic feelings about the dialysis routine.
3.3.1.6. Distractions of patients’ minds from feelings of physical and psychological discomfort
One-third of participants believed that IDE led to the distraction of patients’ negative thoughts about nephrology diseases, causes and causality of their health problems and further consequences during disease progression. Examples of quotations for themes regarding benefits of IDE are presented in Supplementary file 1.
3.3.2. The risks of intradialytic exercise
3.3.2.1. Exercise-related damage of vascular access and injury to the adjacent anatomical area
Three-quarters of participants believed that IDE could cause vascular access damage or malfunction and could injure the adjacent anatomical areas. The most frequently reported concerns regarded piercing and rupture of fistula, and pulling out the catheter and needles during haemodialysis therapy.
3.3.2.2. Insufficient individualization of IDE progressivity regarding patients’ physical condition
Half of the participants believed that insufficient individualization of training progress could increase the health risks of IDE and discourage patients from further exercising. They are worried that improper control and management of IDE could worsen their nephrology, cardiovascular, endocrine, neurology or neuromuscular diseases. Participants stated that the rate of progressivity should be individual and highly depended on the patients’ physical functioning, chronological and biological age, gender and other specific health conditions.
3.3.2.3. Exercise-related injuries of musculoskeletal apparatus
One-third of participants expressed concerns that IDE could contribute to musculoskeletal injuries in haemodialysis patients. They believed that exercise during dialysis could contribute to tendon and/or muscle injuries. Furthermore, participants expressed the opinion that a combination of training-related injury with dialysis- and exercise-related fatigue could increase risks of falls and injuries in patients.
3.3.2.4. Insufficient understanding of patients’ clinical conditions and health-related risks
Some participants believed that insufficient consideration of patients’ actual clinical conditions by training assistants could increase health-related risks during IDE. Participants reported that patients are generally affected by musculoskeletal, cardiovascular and infectious disease risks and frequently experience acute clinical deterioration. They expressed that insufficient review and consideration of patients’ actual conditions prior to exercise session could negatively affects manifested diseases or hidden health risks in patients.
3.3.2.5. Application of IDE early after initiation of haemodialysis therapy
A minority of participants believed that IDE could be risky for patients with acute kidney injury and patients early after initiation of maintenance dialysis. This could imply that these patients would be emotionally and physically overloaded by additional activity during the haemodialysis therapy. Participants preferred a cautionary approach to these groups of patients and postponement of IDE until the patient had established a dialysis regimen. Examples of quotations for themes regarding risks of IDE are presented in Supplementary file 2.
3.3.3. The barriers to intradialytic exercise
3.3.3.1. Limitations related to psychosocial dispositions of patients
All participants believed that patients had a minimal history of regular physical activity and remained inactive during their lives with nephrology disease. Their sedentary lifestyle and beliefs that physical activity is not important for their lives were identified as major barriers on the patients’ side for initiating IDE. Participants expressed their opinions that these attitudes resulted from patients’ frustration, passive negativism, shame, introversion, social isolation, closure personality, self-pity, “self-abandonment” and resignation on nearly everything. The minority reported that patients were deeply depressed with minimal “self-initiative” efforts for any exercise behaviour change.
3.3.3.2. Lack of financial resources for personnel capacities
One of the most dominant subthemes was related to financial resources for the implementation of IDE. Most of the participants expressed their uncertainties about covering direct costs, especially those connected with financing personal capacities. Even in a minimalistic setting, IDE needs to be supervised, controlled and reported by one additional person in the care-providing team in every dialysis session. Participants believed that these costs could be covered by funding from health and research government authorities or health insurance companies. However, most of the participants were sceptical about the actual will for systematic change in reimbursement of health care. The only hope reported was an initiation for adding exercise intervention into the categorization system of nephrology medical services in the Slovak Republic. The majority of the participants believed that material resources for IDE were negligible and could be covered directly by internal financial recourses of dialysis centres.
3.3.3.3. Limitations on the work capacity of care-providing teams at dialysis centres
Half of the participants reported that the implementation of IDE by training assistants produced minimal or no distraction of care-providing personnel and patients. Three-quarters of participants believed that nurses were not able to implement IDE due to their already high workload in monitoring and surveillance of patients during dialysis therapy. In their view, any additional task for nurses could negatively affect the quality of provided medical care. These participants also believed that IDE could be provided by other personnel of dialysis centres or as an external service for dialysis centres.
3.3.3.4. Lack of support, information, motivation and guidance
One-third of participants reported that insufficient support from family is a barrier in IDE. About a quarter reported missing support from caregivers. In both groups, low accessibility to IDE-related information for caregivers, families and patients, and lack of motivation and guidance for patients was frequently mentioned as the barrier.
3.3.3.5. Limitations related to the organization of patients’ therapy at dialysis centres
Some participants reported different barriers related to the “work culture” at dialysis centres. These subjects believed that IDE in a dialysis centre setting could be time- and space-limiting for patients and care providers. If IDE is performed shortly after dialysis starts, it could collide with nurses and nephrologists communication with patients. If performed late, it could postpone patients’ disconnection from the dialysis device. Space limitations were linked to patients’ privacy and quiet environment needs. Participants reported that a specific group of patients preferred to be more isolated during exercise, while other non-exercising patients might perceive IDE during dialysis as “noisy” and “sleep-disturbing”. Examples of quotations for themes regarding barriers to exercise and IDE are presented in Supplementary file 3.
4. Discussion
Despite the broad evidence of exercise benefits for dialysis patients, sustainable IDE programmes are implemented only rarely. The aim of this study was to explore the perceived benefits, risks and barriers of IDE according to healthcare providers at dialysis centres in Slovakia. We identified key subthemes regarding IDE benefits and yielded several substantial subthemes on patient- and clinical-related risks, resource management and organizational barriers for IDE. These might be prevented, controlled and managed to improve the clinical applicability of IDE interventions.
We found that perceived benefits towards IDE reported by healthcare providers were related to improvements in the patients’ physical and psychosocial functioning, clinical profile, quality of therapy, independence and self-efficiency. This mostly aligns with previous evidence from clinical trials that analysed the effectiveness of IDE on patient outcomes (Bündchen et al., Citation2021; Hatef et al., Citation2020; Hu et al., Citation2022; Intiso, Citation2014; Kirkman et al., Citation2019; Malini et al., Citation2022; Zelko et al., Citation2022; Zhou et al., Citation2023) and studies focused on perceived exercise benefits among haemodialysis patients and care providers (Clarke et al., Citation2015; Clyne & Anding-Rost, Citation2021; Ghafourifard et al., Citation2021; Heiwe & Tollin, Citation2012; Hull et al., Citation2021; Jayaseelan et al., Citation2018; Kendrick et al., Citation2019; Li et al., Citation2021; Lightfoot et al., Citation2021; Molsted et al., Citation2022; Regolisti et al., Citation2018; Song et al., Citation2019; Sutherland et al., Citation2021; Wodskou et al., Citation2021). However, other authors reported providers to also observe exercise benefits regarding preservation of mobility, balance improvements, less physical fatigue, higher energy levels, improved sleep and better cardiovascular fitness (Clarke et al., Citation2015; Jhamb et al., Citation2016; Kendrick et al., Citation2019; Lightfoot et al., Citation2021; Moorman et al., Citation2019; Wodskou et al., Citation2021). A possible explanation for these differences in the perceived benefits of exercise may be that our sample of participants was experienced with intradialytic resistance training only and therefore reported their perceptions closely connected with this type of exercise. Furthermore, we found two relatively unique benefits related to the alteration of patients’ time perceptions during dialysis and positive distraction of patients during therapy. Patients described dialysis as an “anxious, frustrating and empty time” that limited their habitual activities, socialization and employability (Gullick et al., Citation2017; Hall et al., Citation2020; Russ et al., Citation2005; Shahgholian & Yousefi, Citation2015). Psychological, music- and art-based interventions have been suggested to alter patients’ time flow during therapy and distract patient from negative thoughts (Carswell et al., Citation2020; Griva et al., Citation2018; Wu et al., Citation2021). It could thus be argued that supervised IDE might fill therapy time with a meaningful activity, draw patients’ attention and possibly increase their interactions with care providers and other patients.
Healthcare providers reported safety concerns about IDE-related damage of vascular access, musculoskeletal injuries and insufficient individualization of IDE regarding patients’ physical and clinical conditions. These findings are consistent with other evidence provided by patients and care providers, who emphasized the paramount priority of vascular access protection and avoidance of any additional health complications (Baker et al., Citation2022; Jhamb et al., Citation2016; Kontos et al., Citation2007; Lambert et al., Citation2022; Lightfoot et al., Citation2021; Song et al., Citation2019; Wilund et al., Citation2021; Wodskou et al., Citation2021). Our study uncovers possible contextual relationships between IDE risks reported by care providers. In general, application of insufficiently supervised, controlled and progressed IDE in poorly conditioned patients might increase risks of vascular access damage, musculoskeletal injuries and disease deterioration. Additionally, we identified risks related to the application of IDE soon after haemodialysis therapy is initiated. This remarkable evidence, addressed in a limited way in the existing literature, might reflect participants’ previous experiences in the transition process from pre-dialysis to maintenance dialysis care. To reduce these risks and complications, it might be effective to introduced physical activities as a part of therapy in non-dialysis patients before initiating dialysis therapy (Wilund et al., Citation2020).
Care providers’ perceived barriers included limitations in the psychosocial dispositions of patients, the lack of financial resources, limitations on the care providers’ work capacities, a lack of support and limitations related to organization of patients’ therapy. This finding is in contrast to the findings of other authors, who found other barriers for exercising reported by care providers, i.e., a lack of material and personnel resources, poor healthcare providers’ competencies, insufficient communication skills, general resistance to changes in dialysis health care) (Jhamb et al., Citation2016; Thompson et al., Citation2016; Wang et al., Citation2020; Wodskou et al., Citation2021; Young et al., Citation2015). An explanation for these discrepancies may be that these authors focused their interview much on barriers of general exercise and physical activities and did not ask participants specifically about barriers related to the intradialytic setting of exercising. Another explanation may be that authors collected data regarding barriers of IDE through surveys using questionnaires comprising established scales which did not identify minor and less-frequently reported themes and subthemes.
4.1. Strengths and limitations of the study
This study has several important strengths. First, using a pre-screening, we could select a wide variety of participants to ensure high diversity regarding the age, gender and professional experience of the study sample. Second, all participants in our study had expertise, as they had previous experience with and were personally involved in the implementation of IDE in clinical practice. Third, we included professionals covering various hierarchical levels of dialysis centres’ supportive, medical and leadership positions, starting with training assistants, thorough nurses and nephrologists, and ending with management.
Our study also has some limitations. First, despite our strong efforts, not all groups of participants in specific professional positions reached optimal sample sizes (6–8 participants). We included 11 nurses, 3 training assistants, 5 nephrologists and 2 members of management. We have reached full thematic saturation in nurses, training assistants and nephrologists, but may have reached only partial saturation for managing positions. However, we found a high level of agreement in themes and subthemes reported by managers and by respondents in other positions, supporting the idea that we mostly covered their perspectives, too. Second, all participants were recruited from two dialysis centres, representing dominating nephrology healthcare networks in Slovakia. We assumed that thematic content of perceived benefits, risks and barriers might be affected by socio-economical, demographic and cultural variables of target groups of participants. Therefore, the generalizability of our findings to all dialysis settings deserves further attention in particular, if relevant characteristics of the healthcare-providing system are different. Third, inclusion criteria for participants in our study required different minimal durations of professional experience for training assistants and other professional positions. We designed these criteria because of the unavailability of assistants with extensive professional experience and because we wanted to prevent misleading evidence from insufficiently experienced nurses, nephrologists and managers. However, differences in minimal experience requirements (between professional positions) may have led to a missing of the experiences in the first two years of work for the other types of professionals.
4.2. Implications
Our results highlight that healthcare providers are adequately aware of the benefits of intradialytic exercise among dialysis patients. However, they reported considerable concerns and deficiencies in the safety and applicability of IDE that needed to be addressed for efficient and sustainable incorporation of exercise therapy in dialysis treatment. To avoid or minimize major IDE risks, our participants suggested the following safety and monitoring actions:
Risks of vascular access damage: fixation and strict avoidance of exercising with body areas used for vascular access during IDE,
Risks of insufficient individualization of IDE: assessments of physical functions before and during IDE intervention,
Risks of exercise-related injuries: close monitoring of patients and provision of support during IDE by training assistants,
Risks of insufficient understanding of patients’ clinical conditions: organization of a short team briefing before every IDE session to review patients’ clinical profiles.
To counteract the barriers of IDE implementation in clinical practice, our participants suggested these supporting and enabling actions:
Lack of financial resources for personnel capacities: calls/initiatives for systematic changes in the categorization system of medical services and additional financing for implementing IDE as standard dialysis healthcare service,
Limitations on the work capacity of care-providing teams: request for additional personnel capacities for IDE implementation, optionally as an external service for dialysis centres,
Lack of support, information, motivation and guidance: application of specialized education and promotion of IDE awareness among patients and their families, encouragement and motivation for patients by the positive example of other patients’ performing IDE,
Limitations related to organization of patients therapy: changes in the organization of patients’ therapy and work culture at dialysis centres.
5. Conclusions
Care providers reported a diverse spectrum of perceived IDE benefits that represent sufficient collective awareness about the positive aspects of IDE for dialysis patients. Regarding IDE risks and barriers, they were mostly concerned about vascular access safety during ID, health-related risks of inappropriately managed exercise interventions, a lack of financial resources and work capacities and limitations related to organization of patients’ therapy. Besides generally known and expected perceptions, healthcare providers considered the beneficial roles of IDE in the alteration of patients’ time perception during dialysis and positive distraction of patients during therapy. They also reported safety concerns for application of IDE too soon after initiation of haemodialysis therapy and pointed out limitations in patients’ psychosocial dispositions as possible barriers for IDE.
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Supplementary material
Supplemental data for this article can be accessed online at https://doi.org/10.1080/17482631.2023.2287597
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Notes on contributors
Aurel Zelko
Aurel Zelko is a junior researcher at the Department of Health Psychology and Research Methodology, Faculty of Medicine, Pavol Jozef Safarik University in Kosice and a Ph.D. candidate in the Faculty of Medical Sciences, University of Groningen. His Ph.D. project focuses on the effectiveness and applicability of intradialytic exercise in chronic kidney disease patients.
Ivana Skoumalova
Ivana Skoumalova is a senior researcher at the Department of Health Psychology and Research Methodology, Faculty of Medicine, Pavol Jozef Safarik University in Kosice. Her main research interests are patient safety and the second victim phenomenon; and qualitative research activities for DIPEx (Database of Individual Patient Experiences).
Denisa Kravcova
Denisa Kravcova is a research fellow at the Department of Health Psychology and Research Methodology, Faculty of Medicine, Pavol Jozef Safarik University in Kosice.
Zuzana Dankulincova Veselska
Zuzana Dankulincova Veselska is an associate professor of social psychology dedicated to building research in the field of social determinants of health of vulnerable groups of the population (currently especially adolescents with emotional and behavioural problems).
Jaroslav Rosenberger
Jaroslav Rosenberger is a senior researcher at the Department of Health Psychology and Research Methodology, Faculty of Medicine, Pavol Jozef Safarik University in Kosice. His medical activities are arranged in the Transplantation Department of the University Hospital L. Pasteur Kosice (and II. Internal Clinic Medical Faculty PJ Safarik University) and FMC – dialysis services Slovakia where he treats nephrological, dialysed and transplanted patients. His primary focus is on quality of life, adherence, health literacy, malnutrition, epidemiology and chronic kidney disease – mineral and bone disorder. Apart from his medical activities in the field of nephrology, his research activities are mainly focused on the quality of life in patients with several chronic diseases.
Andrea Madarasova Geckova
Andrea Madarasova Geckova is a professor of social psychology and head of the Department of Health Psychology and Research Methodology, Faculty of Medicine, Pavol Jozef Safarik University in Kosice. She is leading the research team mapping new developmental challenges of Generation Z, and another one focusing on mental health challenges associated with providing health care.
Jitse P. van Dijk
Jitse P. van Dijk is an associate professor of public health affiliated to the Department of Community and Occupational Medicine, University Medical Center Groningen, University of Groningen. He is a professor at the Palacky University Olomouc and a member of the Graduate School Kosice Institute for Society and Health, Faculty of Medicine, Pavol Jozef Safarik University in Kosice. His main research interests are social determinants of health in adolescents, on chronic disease and their participation in society.
Sijmen A. Reijneveld
Sijmen A. Reijneveld is a professor of community and occupation medicine at the Department of Community and Occupational Medicine, University Medical Center Groningen, University of Groningen. His main research interests are community medicine and its management. His expertise concerns public health and epidemiology, in particular prevention, early treatment and promotion of health-related social participation and current research concerns youth and deprived groups.
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Appendix A
– Interview guide
1.BENEFITS OF PHYSICAL ACTIVITIES FOR DIALYSIS PATIENTS IN GENERAL
Main question:
What are the benefits of physical activities for dialysis patients?
Sub-questions:
Sub-questions:
Do you think that physical activities are suitable for dialysis patients? Which benefits could physical activity induce/bring? (health, psychological, social, economic impacts)
What risks could be associated with physical activity in dialysis patients?
Why do you think some patients prefer a sedentary rather than an active lifestyle? What reasons can be given for this phenomenon?
2.BENEFITS AND RISKS OF INTRADIALYTIC EXERCISE
Main question:
Do you consider a patient’s exercising during dialysis to be appropriate? Can you justify your opinion?
Sub-questions:
Sub-questions:
Can patients benefit from exercise during dialysis? (health, psychological, social, economic benefits)
What risks could be associated with exercise during dialysis?
Do you think that exercise during dialysis could improve patients’ quality of performing habitual daily activities?
Can exercise during dialysis help patients better cope with dialysis therapy?
3.IMPLEMENTATION OF EXERCISE INTERVENTIONS IN CLINICAL SETTINGS
Main question:
What was your experience with the implementation of intradialytic exercise in the dialysis unit?
Sub-questions:
Sub-questions:
What factors could aggravate the implementation of such exercise interventions in a dialysis unit? (from a patient’s, different care-providing personnel, management, point of view etc.)
What do you think could motivate patients to exercise during dialysis?
Who should implement an intervention in a dialysis unit? Who should finance and support such an intervention? Who are the “key players” in the successful implementation of such an intervention?
If patients exercise during dialysis routinely, do you think it would add to the workload of the care-providing staff? What is your opinion about routine intradialytic exercise and the extent (level) of acceptability for such an intervention among care-providing staff?
Are you comfortable counselling patients about exercise? Do you have any training in this area? If yes, was your training sufficient for your counselling activities with patients? If not, what would help make you feel more comfortable during counselling activities?
Which patients should be recommended for exercise during dialysis? Which patients should be involved?
Why do some patients declined intradialytic exercising even when it is offered to them?
Do you think there is enough time and space in dialysis care to perform exercise during haemodialysis?
Do you think there is enough care-providing staff present in the dialysis unit to carry out such exercise interventions without affecting the dialysis therapy operations?
4.VARIATIONS IN INTRADIALYTIC EXERCISE INTERVENTIONS
Main question:
Can you imagine and explain what (other) form of exercise would be possible to implement at your dialysis unit?
Can you imagine the implementation of exercise during dialysis by computer games or exergaming?
Would patients welcome such diversification of the time spent at the dialysis therapy?
Can you identify certain barriers or risks for patients in this approach?
5.TIME AND SPACE FOR THE PARTICIPANT’S PERSONAL EXPRESSIONS
Do you want to add anything else regarding our interview?