Table 3.

Global themes, TDF domains and exemplary quotes

Subcategories	TDF domains	Quotes
Category 1: knowledge, skills and expectations
Risks and benefits for staff and patients Most believed IDE was associated with a variety of health benefits A few expressed doubts over benefits Many raised concerns over risk of injury	Beliefs about consequences Knowledge	‘So, I say you get more energy, more flexibility. Your legs move better, you know. You can go up the stair without feeling like you climb a mountain, you know’. – Marlena, patient ‘And so I think if they could get in an exercise program and hopefully get stronger in order to better prepare them for transplant I would be excited for that patient’. – Anne, MD ‘So intradialytic exercise has been shown to improve certain patient symptoms like restless legs, for example. That’s the one that I believe may be true. There’s a bunch of other stuff that intradialytic exercise has been named to improve, like in terms of outcomes like depression, blood pressure, ultrafiltration, but I’m not sure I believe any of those other stuff, so maybe restless legs’. – Sam, MD ‘Because when you’re on the machine you get very sick and you get lightheaded and your blood pressure drops and, you know, it’s not easy, trust me, it’s not an easy thing. Yeah it’s very rough. Yeah so I wouldn’t want to take a chance’. – Sandra, patient ‘Yeah the only issue that I see with that is in the off chance of an emergency, you know, your blood pressure bottoms out or because you’re pedalling and everything your heart rate will be a little bit higher, right’. – Ian, patient
Insufficient skill and knowledge to create and oversee exercise plans Staff questioned what factors precluded exercise Staff believed they lacked the necessary skill and training to oversee exercise plans	Skills Knowledge	‘I think just the plan…what the expectations would be in terms of the exercise? So how they’re gonna progress the first few weeks or what the intention is?…what’s an absolute contraindication to the study? What’s something that we can modify? We would certainly need that information’. – Trish, RN ‘And it’s not just randomly pedalling without a clear goal or expectation. I think that’s the part where nurses, technicians and doctors even nephrologists don’t really have a lot of expertise in. And so, you know, if you just bring pedals to a unit and you say here you go that’s where you’re likely gonna fail because we lack that ability to really assess and tailor the programs to patients individually’. – Justin, MD
Assumptions about patient eligibility Staff raised questions regarding eligibility criteria and contraindications Both staff and patients believed people who were older, frail and with limited mobility were unlikely to be eligible for IDE One staff participant believed assumptions about eligibility may lead to missed opportunities	Beliefs about consequences Knowledge	‘It depends on the patient but I think if I had a patient that I knew was having a lot of angina or I needed to intervene with and do ECGs on a regular basis I’d probably say that’s somebody I don’t think should exercise. But is that really true?’ – Molly, RN ‘Usually the mobile patient is offered first, right, the people, the patients that walk in. The people that come in in wheelchairs and so forth are, you know, assessed by physio and, and that sort of thing. And then the ones that we know that tend to drop their blood pressure during dialysis are not offered. But usually the ones that walk in, you know, independently the younger patients’. – Susy, RN ‘It depends on their health state and depends on their age too. Age matters if you are very old, some people are very old there so I don’t believe those people can do the exercise’. – John, patient ‘Sounds great but I think the crowd that I’m with, a lot of them come in walkers. Some come in the little carts so, in my personal view, if you got 20% of us you did very well’. – Robert Redford, patient ‘Yeah I think your biggest challenge, on the medical side, your challenge is making sure that we don’t, that doctors or nephrologists don’t make patients ineligible when in fact they might stand to benefit. I think that’s the biggest risk from a medical standpoint’. – Justin, MD
Assumptions about patient interest Staff and patients believed few eligible patients would be interested in IDE	Beliefs about consequences	‘I think for certain patients who are keen to do it and are going to do it on an ongoing basis… unfortunately I don’t think there’s a lot of them…’. – George, MD ‘People just want to come in either turn on the TV or come in and have a nap. So, it’s a smaller percentage of patients that really want to participate while they’re on dialysis’. – Jane, manager ‘Oh I think the exercise thing is awesome but I think it will be a bit of a challenge to get some patients to agree. There’ll be patients there’ll be a handful of patients that will be quite willing, but there’ll be some patients that we’ll need to persuade a little bit … But it’ll be challenging for sure looking at our group’. – Shelby, RN ‘So you’re coming in there with an exercise machine into an environment that is not used to it you’re gonna have a very big uphill battle. For me personally it’s wonderful, but for my surrounding people, my peers, I think you’re gonna have a terrible time’. – Callie, patient ‘I don’t think there’s anybody that would like to bother them about exercise…’. – Jennifer, patient
Identifying potential candidates Some staff relied on patients to self-refer Some patients preferred to be approached by staff	Social and professional role Knowledge	‘I guess if I saw value in it I would suggest it to a patient like patients who feel that they have restless legs or patients complain of other things, like being bored. I might say why don’t you try the cycling program? Typically, though, the patients ask us. I have to admit I’m probably not as good at suggesting it as I am at supporting it if someone asks’. – Molly, RN ‘So for now it’s still on a voluntary basis so if any patients see the other patients exercising they can approach me or the nurses. Otherwise sometimes the doctors will refer them to me’. – Tina, exercise professional ‘If they have someone that would ask you if you want to do exercise rather than waiting for you to ask them, it might motivate more people’. – Lola, patient
Category 2: human, material and logistical resources
Concerns about workload Participants believed an IDE intervention would significantly increase staff workload and would be difficult to prioritize Perceptions of workload may be influenced by past experiences Many believed nursing staff would be resistant to more work A few believed workload may lessen	Beliefs about consequences Beliefs about capabilities Environmental context and resources Goals	‘…so they’re like all over the place trying to cover each other and stuff like that. So I’m just wondering how that’s gonna affect somebody coming in to just stay with me while I do those exercises…’. – Guinea Pig, patient ‘The other thought though is the impact on the staff. Because someone on the staff has to bring the bike put it in place, move it away, and depending on what the mechanics and logistics are that’s an added workload for the staff and that’s got to be factored in for sure’. – Sheldon, patient ‘I think that staff are already very, very busy and to throw something else at them I think will get an emotional response. There’ll be resistance based on workload’. – Penelope, manager ‘…all you need is one of those patients to have a line that doesn’t work, a fistula that’s acting up or somebody that’s unwell and your whole day goes to hell in a handbag. So having to drag somebody’s physio equipment on top of it, you know, it’s just kind of one more thing to a never-ending list. But in that particular instance it’s not gonna get done because the priority is the sick patient, a line that doesn’t work’. – Amy, RN ‘…while the patient’s actually dialysing there is downtime so that’s there’s opportunity for the staff to step in there and set up the equipment have the conversations with the patient. So I can’t really see it being an extra workload for anybody’. – Elizabeth, manager
Need for exercise professionals Many participants believed exercise professionals should take responsibility for IDE to address workload concerns One participant shared how nursing staff were resistant to IDE even when an exercise professional was present	Social and professional role Environmental context and resources	‘Yeah that model [with physiotherapists] would be I think the better than just leave it for the nurses if there’s just one person comes and set it up and it would be some, it would be some resource accessible to the nurses too. They’re just not leaving the nurses with some kind of extra work to be done yeah’. – Sarah, RN ‘And I think that somebody with exercise expertise who could transmit that and then you get into the champions idea so that there are people who know who have a better understanding of what’s going on. I think that would work best’. – Sue, MD ‘Well the advantage of the physiotherapist was guidance’. – John Doe, patient ‘So I think there was a lack of knowledge from the beginning on the nursing staff and a lot of resistance. So, you know, the fact that I was touching their patients I think that was a huge issue at the beginning’. – Tina, exercise professional
Space and equipment Units differ in space requirements for bike storage and movement Biking equipment must fit dialysis chair/beds and be easy to move, use, maintain and clean	Environmental context and resources	‘…if we have several bikes that are being used at a time it creates more equipment that could be tripped over or if we have someone who’s unstable and we had to call a code it’s just more equipment that could be in the way’. – Maddie, RN ‘We’d have to wait until all the patients are on because the nurses are moving around and patients are coming and going and we don’t want anything on the floor to be in their way. So we’d have to wait until they were all on’. – Stephanie, unit aide ‘[And] the cleaning of those things too. Like okay, if this thing comes off you can just put this thing back in or if this thing is loose you can tighten it from here or if this thing is making noise we can put oil here. So, those are some small things we need to know and that way we can run this program smoothly’. – Afim, unit aide ‘The nurses don’t like having to move that bike around so they don’t encourage it.…the nurses don’t because frankly they don’t like having to lug it out and move it around. That’s my honest impression. [laugh]’ – Brian, MD ‘I think the biggest trouble that I’ve had is logistics… is the right patient on the right bed for their session?…if you’re on the wrong bed I can’t bike with you’. – Edward, exercise professional ‘I’ve been back on dialysis for over two years and there’s nothing… nobody seems to know where there’s a bike’. – Marie, patient
Category 3: social dynamics of the unit
Champions Champions are important enablers of IDE Nephrologists were believed to be instrumental in supporting practice changes Nurse champions were seen as necessary for supporting practice changes at the bedside and encouraging patients to cycle, though many suggested it would be difficult to recruit nurse champions Patient champions were believed to encourage other patients, though not all patients would welcome a peer champion	Social influence	‘…it would need to be the physiotherapist and somebody from the administration side …then one of the physicians as well. So having at least one physician champion would be very helpful as well’. – Nurse, manager ‘And having the physicians onboard too and maybe them coming to talk to the staff about it is another one’. – Veronica, RN ‘Just maybe the staff pushing a little bit more, you know, just trying to talk you into it without being too pushy. You know, just reminding you that the equipment’s there and how good you felt when you were on it’. – Bandit, patient ‘I think it’s a good idea. But I don’t know… Just like from my time as charge nurse and then the coordinator saying, you know, get somebody on this, get somebody on this and never would you have anybody volunteering for things’. – Lou, RN ‘Well it can only be a positive thing, because you have a champion helping you, encouraging you that’s got to be a positive thing’. – Susy, patient ‘I think the staff going to patients and saying that we think…the cycling program is for you and it will help you. Patients would react to that a certain degree more so than if oh these three people are involved…’. – Timbo Slambo, patient ‘Speaking only for myself, I think I’d find it an unnecessary pressure’. – Sheldon, patient
Patient stories to ignite motivation Patient stories and experiences are highly influential and can motivate staff and patients to engage in IDE	Social influence Goals	‘And then the other side would be patient stories. Any patients that have had the intradialytic exercise and what it means to them and the benefits of it…. If you’ve got some of that I think that would help’. – Polly Anna, manager ‘I guess the feedback from the patients that they’re enjoying it. If it becomes important to the patient, then it becomes important to me’. – Lou, RN ‘…if the patient’s excited about it it’s gonna be a lot harder to say no we’re not doing that for you’. – Trish, RN ‘This lady in the article, she was the one who was biking back then. I don’t know what year that was when her picture was taken…. And she was in there and I thought if she can do it I can do it’. – Canadian Kidney Girl, patient