Abstract
Background and objectives Randomized, controlled trials show that regular exercise is beneficial for patients on hemodialysis. Intradialytic exercise may have additional benefits, such as amelioration of treatment-related symptoms. However, the factors that influence the implementation of intradialytic exercise are largely unknown.
Design, setting, participants, & measurements Individual semistructured interviews were conducted with a purposive sample of patients on hemodialysis who had participated in a pilot randomized, controlled trial on intradialytic exercise and dialysis staff that worked in the unit during the trial. The trial took place from July to December of 2014 and enrolled 31 patients. Interviews were conducted from April to December of 2014. Interview coding followed an inductive and broad-based approach. Thematic analysis was used to group codes into common themes, first individually and then, across staff and patient interviews.
Results Twenty-five patients and 11 staff were interviewed. Three themes common to both groups emerged: support, norms (expected practices) within the dialysis unit, and the role of the dialysis nurse. The support of the kinesiologist enhanced patients’ confidence and sense of capability and was a key component of implementation. However, the practice of initiating exercise at the start of the shift was a barrier to staff participation. Staff focused on the technical aspects of their role in intradialytic exercise, whereas patients viewed encouragement and assistance with intradialytic exercise as the staff’s role. An additional theme of no time (for staff to participate in intradialytic exercise) was influenced by its low priority in their workflow and the demands of the unit. The staff’s emphasis on patients setting up their own equipment and enhanced social interaction among participants were additional themes that conveyed the unintended consequences of the intervention.
Conclusions The kinesiologist-patient interactions and staff readiness for intradialytic exercise were important factors in the implementation of intradialytic exercise. Understanding how unit workflow and the personal values of staff can influence implementation may improve the design of intradialytic exercise interventions.
- dialysis
- end-stage renal disease
- hemodialysis
- quality of life
- exercise
- qualitative research
- Humans
- Perception
- Randomized Controlled Trials as Topic
- Sensation
Introduction
Hemodialysis (HD) treatment is characterized by low quality of life (QoL) that is comparable with that of people with metastatic cancer (1). The association between QoL, mortality, and hospitalization has been shown in ESRD (2–4), and reducing the physical, social, and psychologic effects of kidney disease is a top research priority for people with ESRD (5).
Randomized, controlled trials (RCTs) in people with ESRD show that regular exercise can improve QoL (6–8) by targeting physical functioning (9). Exercise prescribed during dialysis (intradialytic exercise [IDE]) may ameliorate treatment-related symptoms (such as restless legs) (10), may improve patients’ experience of the dialysis treatment (11), and is regarded as safe (12). Given the paucity of other interventions that improve QoL in this population (13), it is unclear why IDE remains underused.
Previous qualitative studies in people with ESRD have identified post-HD fatigue and low motivation (14,15) as barriers to exercise participation. However, few studies have explored the perspectives of dialysis staff (15,16) or the contextual factors that influence IDE uptake (17). Understanding the perspectives of both those delivering and receiving IDE can improve the design and implementation of interventions (18). Furthermore, the context of IDE implementation is complex, with variable resources, expertise, and organizational readiness for IDE; what may facilitate implementation in one setting may not work in another setting. To develop more effective IDE interventions, detailed information is needed on the intervention, the context of the dialysis unit, and the interaction between these factors (19). These aspects of IDE may be difficult to identify with quantitative methods alone.
In this qualitative interpretive descriptive study, we conducted interviews with participants of a pilot RCT on IDE and the dialysis staff working in the unit. The overarching aim was to describe perceptions of IDE, its key components, and its unintended consequences. Key components are those aspects of the intervention beyond the exercise itself that are critical to enhancing effectiveness (20). To determine whether aspects of the IDE intervention required adjustment before scaling up (21), we also aimed to understand the unintended consequences (positive or negative) of implementing IDE.
Materials and Methods
Design and Setting
This qualitative interpretive descriptive study was carried out in three phases coinciding with a single–center, pilot RCT (registration no. NCT02234232). The primary aim of the RCT was to evaluate the feasibility of two types of IDE, cycling and weights, compared with control. The setting was an outpatient dialysis unit servicing approximately 110 patients and employing 35 staff in a tertiary hospital in Edmonton, Canada. The interviews were conducted in three phases (Figure 1). A kinesiologist supervised most exercise sessions. Staff were instructed on how to assist with exercise equipment setup and trial documentation. After the trial, participants could continue IDE with assistance from the kinesiologist and staff.
Interview participant flow according to the Randomized Controlled Trial (RCT) time line. Over phases 1–3, approximately 35 unit staff were working in the unit. In phase 3, 25 of 31 participants in the RCT participated in interviews.
Our methodological approach was interpretive description (22,23). Interpretive description was developed for answering questions in health care, where the aim is to generate recommendations for clinical practice. This approach provides a systematic and inductive framework for identifying common patterns from a range of individual experiences and aims to explain these patterns in the relevant social context.
Participants
Participants were purposively selected from those affected by IDE: renal program administration, patients in the study unit, trial participants, and dialysis staff. This manuscript presents findings from interviews with staff and trial participants (phases 2 and 3). Staff (registered nurses, licensed practical nurses, technicians, and service workers) were eligible to participate if they had worked in the unit during the trial. This study was conducted in a satellite dialysis unit where nephrologists are not generally present; therefore, nephrologists were not interviewed. After trial participation was complete, patients were approached for interviews by an investigator (S.T.); participation was voluntary. The Health Research Ethics Board at the University of Alberta approved this study, and all participants gave informed consent.
Data Collection
Staff participants were interviewed by telephone by an experienced qualitative researcher not involved with the trial. Staff interviews lasted 10–20 minutes. Patient interviews took place either face to face at the hospital site or by telephone according to individual preference. Patient interviews ranged from 15 to 45 minutes and were conducted by S.T., who had established a relationship with the participants during the trial. The interviews followed a semistructured format (Supplemental Table 1). All interviews were audio recorded and transcribed verbatim. The transcripts were verified against the audio recordings. Field notes were made after each interview.
Data Analyses
Data collection and analyses were conducted concurrently so that new concepts could be explored in the remaining interviews. S.T. is a nephrologist who was not involved in the clinical care of the patient participants, but she had an understanding of the contextual factors.
S.T. independently coded the interviews using a broad–based coding scheme (open coding). Codes were revised and reviewed for each individual interview and grouped into common themes. Themes were then compared across interviews. Codes were annotated to show the inductive reasoning process. To confirm that the beginning conceptualizations were consistent with participants’ experiences, preliminary themes were distributed to the participants (separately for staff and patient participants). Several staff and approximately one half of the patients responded. All respondents agreed that our thematic conceptualizations were consistent with their experiences. Theoretical saturation was reached.
Results
We interviewed 11 staff in phase 2 and 25 of 31 trial participants in phase 3 (Figure 1). Staff were primarily white women who were registered nurses (Table 1). The median age of staff was 42 years old (interquartile range [IQR], 30.0–52.0). The median age of patients was 57.5 years old (IQR, 49.2–68.0). Patient participants were predominantly white men: 88% had hypertension, and 52% had diabetes. The median age of the six nonparticipants was older (69.8 years old; IQR, 49.5–85.0); four patients were white, one was Asian, and one was Indian.
Characteristics of staff and patient participants
Interview Themes and Subthemes
Three main themes were common to staff and patient interviews: support, the role of the dialysis nurse, and norms within the unit. No time (to support IDE) and patients getting their own exercise equipment were unique themes in the staff interviews. Social interaction was an additional theme from the patient interviews. Themes with associated subthemes and exemplar quotes are shown in Tables 2–7.
Exemplar quotes from staff and patients on the theme of support
Exemplar quotes from staff and patients on the theme of the role of the dialysis nurse
Exemplar quotes from staff and patients on the theme of norms in the dialysis unit
Exemplar quotes from staff on the theme of no time to assist with intradialytic exercise
Exemplar quotes from staff on the theme of patients getting their own equipment
Exemplar quotes from patients on the theme of social interaction
Support
After hearing of the benefits of IDE from their patients, staff agreed that the exercise program was valuable for patients (quote 1 [Q1]). However, systemic factors may have influenced staff perspectives of IDE. Changes to staffing ratios on the unit were to take effect in several months (unrelated to IDE but coinciding with initiation of the clinical exercise program). The knowledge that staffing was going to be “cut back” conveyed a lack of support from management (Q2). Several staff expressed uncertainty about the need for these changes and concern over how workflow in the unit might be affected (Q3). One staff suggested that these changes could be detrimental to patient care overall and expressed doubt in their capacity to consistently participate in IDE delivery (Q4).
Participants identified the staff and the kinesiologist as the main sources of support during the study. Several patients expressed that the staff encouraged their participation in IDE typically through simple words of encouragement (Q5 and Q6). One participant could not define how support had been conveyed to her, but the staff’s reaction to IDE had given her a sense of esteem (Q7).
It was more common for patients to comment on the inconsistency of the staff’s involvement. Many participants described lack of support in the form of inconsistent help with the exercise equipment (Q8); several participants attributed this variability to the nurse (rather than situational factors; Q9). For some patients, the staff were perceived as inaccessible for help (Q10). Another participant expressed frustration with the staff’s lack of accountability, explaining that asking for equipment from particular staff members was such a “struggle” that he did not participate in IDE when those staff members were working (Q11).
Patients commonly viewed the kinesiologist as the primary source of support for IDE. Some participants perceived support from the kinesiologist in the form of technical instruction and trusted her expertise and knowledge (Q12). For most patients, the kinesiologist’s technical instruction was interpreted as having emotional meaning. Patients expressed that they gained confidence in their physical capabilities from training with the kinesiologist. The caring and esteem conveyed in the actions of the exercise specialist enhanced patients’ body confidence, sense of capability, and feeling like an individual (Q13–Q15).
The Role of the Dialysis Nurse
Although staff recognized the benefits of IDE, they commonly expressed that assisting with IDE was not a nursing responsibility. One staff member indicated that it was the exercise (rather than assisting with a study) that was inconsistent with their role (Q16). Another staff member explained that tasks, such as IDE, were left to them by default (Q17). Although staff did not express safety concerns with IDE, one person expressed concern whether patients were “doing [the exercises] right” and commented that staff could not monitor it (Q18).
Staff frequently described their involvement in IDE in technical and procedural terms (getting equipment and documentation), and their role in encouraging patients was not commonly described. In the interview when encouragement was discussed, the staff members commented that patients would find encouragement to exercise more effective if it came from physicians, suggesting that staff may not appreciate their role in patients’ decision to exercise (Q19). Understanding of IDE could also influence staff interaction with patients. Several staff were surprised that the elderly patients had the physical capacity for IDE, whereas other patients, perceived as more suitable, were not interested (Q20). One staff member expressed that many patients in the unit were too immobile and sick to participate in IDE (Q21).
Because patients commonly viewed IDE as beneficial, many expressed that staff involvement in IDE was consistent with their role as caregiver and advocate (Q22). Patients described the staff’s role as providing encouragement and assistance with the equipment (Q22 and Q23). Most patients were aware that the staff saw IDE as “extra work”; however, many patients believed that staff participation in IDE was feasible (Q23 and Q24). One patient expressed resignation about the situation, because he viewed systemic factors as a limitation to their involvement (Q25); other patients viewed staff involvement as nurse dependent (Q26). Several patients viewed the more physically active staff as more interested in participating in IDE (Q27).
Norms within the Dialysis Unit
Many of the staff expected that, before asking for help with IDE, dialysis-related tasks at the start of the shift were completed (Q28). Initiating IDE at the start of the shift was challenging, and some staff expressed frustration about how to effectively communicate with patients about the timing of exercise during dialysis (Q29 and Q30). One staff member indicated that negotiating aspects of HD delivery with patients was a preexisting issue, suggesting that IDE may have been an additional pressure (Q31).
Patients described aspects of the unit’s social structure that were barriers to receiving assistance with IDE. Some participants were concerned that IDE would disrupt the “routine” of the unit (Q32). The existing processes for obtaining help from staff (ringing the bell) were viewed as inappropriate for IDE (Q33). One patient expressed concern that using the bell for help with exercise could have negative consequences when help was urgently needed. For one patient, not being a “bother” by asking for things was important to the role of the “good patient” (Q34).
No Time
Many staff members commented that there was “no time” to assist patients with IDE. The expectation that staff had the time to participate may have negatively influenced some staff’s attitudes toward IDE (Q35). For some staff, “no time” also meant that IDE was a low priority in their workflow and that IDE was seen as “extra work.” One staff member questioned the appropriateness of exercise for the dialysis unit (Q36). Another attributed their lack of time to the unpredictability of staffing and patient acuity. Staff often expressed that, because of the demands of the unit, the situation was irremediable (Q37).
Patients Getting Their Own Equipment
There was agreement among dialysis staff that IDE would be more sustainable if patients set up their own exercise equipment (located in the unit) before treatment. Although several staff expressed that they could help frailer patients with their equipment, other staff commented that this was not feasible (Q38). Getting one’s own equipment was valued for “saving [staff] time.” More commonly, this task was valued as a sign of the patients taking responsibility for their care (Q39).
Social Interaction
Many participants described enhanced social interactions with other IDE participants. Several of the men discussed instances when they were competing with other trial participants. These interactions were perceived as positive and promoted a sense of camaraderie and normalcy within the unit (Q40 and Q41). One participant said that IDE was a positive topic for patients outside of the unit and that she thought it had improved spirits (Q42). Another participant explained that IDE fostered a more positive common identity (Q43).
Discussion
Despite the promising results of RCTs, IDE remains underused. By identifying the key components and unintended consequences of IDE, we address an important gap on the transferability of research findings to practice. Our study provides insight into what aspects of IDE enhance its effectiveness when adapted to different contexts (24). Detecting positive unintended consequences of IDE could increase perceptions of its value. It is also important to identify the negative consequences of IDE before scaling it up.
Although the importance of exercise professional support in sustaining an IDE program has been recognized (25,26), how support functions to enhance the effectiveness of IDE and what may be required from those delivering IDE are unknown. We identified the support of the kinesiologist as a key component of IDE implementation. Social support is a multidimensional concept that includes emotional (communication of empathy and esteem) and instrumental support (offering assistance and information) (27). Previous publications have emphasized the technical role of the exercise specialist in IDE (25,26), consistent with instrumental support. However, it was the emotional interpretation of this technical support that seemed critical to enhancing perceptions of the intervention’s effectiveness and facilitated high acceptability of IDE. In one study in people with ESRD, higher levels of perceived social support, regardless of domain, predicted improved outcomes, such as QoL (28). Consistent with other research (27), we found that the emotional aspect was the most effective component of social support.
Maintaining norms within the dialysis unit was another key component of IDE delivery. Initiating exercise at the busiest time of the shift was a barrier to staff participation. Although patients viewed IDE as consistent with the staff’s role as caregiver, reluctance of some individuals to ask for help suggests that exercise was not an expected aspect of the dialysis treatment. In another study (29), patients perceived IDE as a potential burden to staff, but staff perceptions were not explored.
We found that IDE promoted social interaction among trial participants and promoted camaraderie and normalcy. Given that patients on HD rate the quality of their social interactions as low (30), greater social interaction could be a benefit of IDE. Because social interaction with other patients on dialysis is a positive aspect of in-center HD (31), IDE could improve outcomes, such as satisfaction with care. For staff, IDE was an opportunity for patients to increase responsibility for their care by getting their own exercise equipment. The extent to which this view was grounded in values of self-care or was simply about pitching in warrants additional exploration. Framing IDE within unit priorities, such as promoting self-care, may facilitate IDE uptake, whereas an emphasis on pitching in may exclude frailer patients needing more help.
Emphasis on the technical aspects of the dialysis nursing role is not unique to participation in IDE and has been explored in other studies (32). In one study (33), the increased workload in the unit and the resistance to take on new roles were factors contributing to technology-focused care. In our study, staff participants discussed several systemic factors that influenced their perceptions of their role in IDE. First, there was a perceived lack of support from management—expressed as a lack of adequate staffing. Second, consistent with findings from other studies on IDE (15,17), staff frequently mentioned that there was no time to assist with IDE. Given the high value placed on busyness in acute care nursing (34), the assumption that staff could accommodate IDE in their workflow may have negatively influenced its acceptability. The view that dealing with acute issues superseded staff capacity to take a consistent role in IDE also reflects the values of an acute care culture, where the urgent takes precedence over other important roles. Reconciling this acute care mentality with the competing priorities of chronic disease management is particularly germane for in–center HD units.
Consistent with previous research, despite the staff’s perspective that exercise was beneficial for patients (17,35), there was a lack of readiness for IDE (17,36). Our results extend these findings by identifying important considerations in implementation of IDE. First, it is important to recognize that structure of work and perceived value of tasks are grounded in organizational culture (37). For staff to prioritize IDE, management’s support of IDE must be evident to staff. In this context, support could be conveyed to staff by ensuring that adequate time is created in the staff’s workflow to accommodate participation in IDE. Second, at the individual level, increasing staff knowledge of who can perform and benefit from IDE may improve acceptability. Before implementing formalized education on IDE, it is necessary to increase staff motivation to engage with IDE. Some patients perceived that more physically active staff were more involved in IDE, suggesting that the role of the nurse in IDE is influenced by personal values about exercise. Because exercise is a socially desirable behavior, initiatives that concurrently encourage staff exercise may promote engagement in IDE.
Although the qualitative approach does not aim to generalize results, our findings should be considered in light of our study’s limitations. First, the specific context of the unit, including readiness for IDE, physician and administrator involvement, and organizational culture, may influence findings, and therefore, the transferability of findings to other centers, particularly those with different models of care, may be limited. Second, although it is possible that participants provided socially desirable responses in interviews, the candid responses from participants suggest that they were able to speak openly. Third, because of the lack of diversity in the demographics of our study population, we did not analyze our findings according to these characteristics.
We identified important areas for future study. It would be useful to explore the characteristics of exercise specialists and the specialist-patient interaction that are associated with improved effectiveness of IDE. Our results expand our understanding of the decisional influences on patient participation in IDE beyond individual factors to include those that exist at the contextual level. Future studies should consider how contextual factors may affect adherence to IDE rather than attributing poor adherence to lack of patient motivation.
Disclosures
None.
Acknowledgments
This work was supported through Alberta Innovates Health Solutions.
The funders had no role in the design, collection, analysis, interpretation, writing, or submission of the manuscript.
Footnotes
Published online ahead of print. Publication date available at www.cjasn.org.
This article contains supplemental material online at http://cjasn.asnjournals.org/lookup/suppl/doi:10.2215/CJN.11981115/-/DCSupplemental.
- Received November 12, 2015.
- Accepted February 23, 2016.
- Copyright © 2016 by the American Society of Nephrology
References
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