This study was part of a project investigating the acceptability and effectiveness of a 12-week progressive, individualized, supervised intradialytic resistance training intervention on muscle function among patients undergoing hemodialysis. The study was an ancillary qualitative substudy conducted within the overarching framework of project NCT03511924 (ClinicalTrials.gov) [63]. Although the intervention resulted in moderate to large improvements in muscle function, the acceptability of intradialytic exercise and the sustainability of its benefits remained low [64,65]. In the current study, we used a 2-step qualitative design to explore and categorize health care providers’ attitudes and expectations regarding IEG among patients undergoing hemodialysis. In the first step, we explored health care providers’ perspectives using inductive thematic analysis (guided by [66] of data collected from participants’ interviews. In the second step, we deductively classified the identified codes and themes using a SWOT analysis approach (as outlined [59].

We recruited participants from 2 dialysis centers located in Slovakia. Training assistants, nurses, nephrologists, and managers were eligible to participate if they had been employed or actively involved at the dialysis center for the entire duration of the 3-month intradialytic exercise intervention and were at least 18 years of age. This criterion ensured that participants had direct experience with the implementation of intradialytic exercise in routine clinical practice and were able to provide hypothetical insights into factors influencing the initiation and implementation of IEG. Furthermore, nurses, nephrologists, and managers were required to have a minimum of 2 years of professional experience in their respective roles. All available health care providers from 2 dialysis centers were prescreened based on their age, sex, and professional experience, including the total number of years worked in both current and previous health care positions and roles. While all participants had experience with the previously implemented intradialytic exercise intervention, none had prior experience with IEG. To ensure diversity within the sample, individuals of different ages and professional backgrounds were purposefully selected and invited to participate in the study via an email sent by 2 members of the research team (AZ and IMS). Health care providers who accepted the invitation received oral and written information about the study, provided written informed consent, and had their interview date and time scheduled. We continued to include participants until we reached sufficiency of information for all studied topics. This occurred when responses to questions from successive participants became repetitive and no longer provided new, unique insights to the outcome of the study [67].

Individual, in-person, semistructured interviews with health care providers were conducted using an interview guide (Multimedia Appendix 1). The interviews began in June 2019, approximately 1 month after the completion of the intradialytic exercise intervention study. Members of the research team (AZ, IMS, and DK) developed the interview guide using the Patient-Centered Access to Health Care framework [68] and the Biopsychosocial Model of Responsiveness to Physical Activity [69] as conceptual frameworks. Three senior members of the research team (JR, ZDV, and AMG) evaluated the initial interview guide and proposed adjustments to enhance its clarity. Further minor adjustments were made following a pilot interview with one dialysis center health care provider. During the interview process, the researchers continually adjusted the guide to delve into areas of specific interest, aligning with best practices for qualitative data collection [70].

The final interview guide covered 4 scope areas (detailed in Multimedia Appendix 1). The first 3 areas explored (1) the perceived benefits of physical activity for dialysis patients in general, (2) the perceived benefits and risks of intradialytic exercise, and (3) experiences with implementing exercise interventions in clinical settings. Findings from these 3 areas were presented in a separate article [65]. The fourth area focused on participants’ perspectives on variations in intradialytic exercise interventions, with particular emphasis on IEG. Participants were asked about their opinions and suggestions on alternatives to intradialytic exercise interventions, as well as their attitudes and expectations regarding IEG. Data from this area served as the basis for the current article. The open-ended questions in the interview guide allowed participants to share their attitudes and expectations regarding IEG, enabling interviewers to probe deeper into individual perspectives. Participants were encouraged to elaborate and highlight issues they deemed important. The research team facilitated verbal expression and logical thought development, taking field notes when necessary.

Three members of the research team (AZ, IMS, and DK) conducted interviews from June 2019 through November 2019. Prior to the interviews, written informed consent was obtained from participants, along with a brief personal questionnaire summarizing their sociodemographic characteristics (age and sex) and professional experiences (years in previous and current job positions). The interviews were held in Slovak language, either in private meeting rooms at dialysis centers (for nurses and nephrologists) or in an office at the authors’ workplace (for assistants and management staff). All interviews were conducted individually, involving only the participant and 1 or 2 members of the research team (AZ, IMS, and DK). The researchers conducting the interviews had no prior personal or professional relationships with the participants. Before the interviews began, ZDV instructed the researchers on optimal design and conduct of qualitative research interviews and assessed their professional backgrounds, potential biases, and personal interests related to the interview topics. To enhance confirmability, the research team comprised members with diverse theoretical and professional backgrounds, including Sports Sciences, Occupational Therapy, Health Psychology, Nursing, Digital Health, and Clinical Nephrology. Furthermore, team members were actively involved in all stages and levels of the data analysis process. This facilitated critical reflection on emerging interpretations, ensured consideration of multiple perspectives, and helped maintain a close connection between the findings and the participants’ accounts while minimizing the influence of individual researcher biases. All interviews were audio-recorded with the participants’ consent. The interview transcripts were not returned to participants for comments or corrections, and no follow-up interviews were conducted.

During data handling, AZ and IMS transcribed all interview audio recordings verbatim and anonymized them, ensuring the removal of all personal participant data. AZ and IMS manually reviewed all transcriptions, comparing them to the audio recordings to verify the accuracy and authenticity of the transcripts. The authenticated transcripts and audio recordings were subsequently uploaded to the MAXQDA® standard platform (VERBI Software).

We analyzed the collected evidence of health care providers’ perspectives regarding IEG in 2 steps. In the first step, we used Braun and Clarke [66] thematic analysis to inductively explore and identify codes, themes, and their patterns, specifically related to participants’ attitudes and expectations. Two members of the research team (AZ and IMS) repeatedly read the original Slovak transcripts to familiarize themselves with the data (Phase 1) and then independently generated codes for the entire dataset (Phase 2). Quotations included in the paper were translated from Slovak into English by 2 members of the research team (AZ and IMS), and translation accuracy was reviewed by a senior member of the research team (ZDV). Outputs of initial coding were exchanged between 2 members (AZ and IMS) for coding quality cross-check. Four coding meetings (2 online, 2 in-person) were initiated to discuss problematic codes, disagreements in coding, and appeals to recode until consensus in the coding output was achieved. Through iterative discussion and reexamination of the transcripts, codes were refined and, where necessary, recoded until consensus was reached. Both researchers then associated thematically similar codes into groups and subgroups regarding attitudes and expectations on IEG (Phase 3). These themes were subsequently cross-referenced with the raw data to ensure they accurately represented the participants’ experiences (Phase 4). The final output of the coding process and thematic code grouping was reviewed, discussed, validated, and approved by 3 senior members of the research team (JR, ZDV, AMG; Phase 5). At the end of the first step of data analysis, the entire research team documented their findings and collectively summarized health care providers’ attitudes and expectations regarding IEG (Phase 6). Using this procedure, we identified 139 codes and categorized them into 54 subthemes and 5 overarching themes.

In the second step, we used a SWOT analysis approach to organize emerging themes into strengths and weaknesses [potential internal factors], and opportunities and threats [potential external factors]. We conducted a deductive analysis using a revised SWOT model specifically adapted for health care research. The model is built on 3 foundational pillars: addressing stakeholder expectations, evaluating resource management, and considering contextual developments [59]. One member of the research team (AZ) extracted relevant parts from the results of the inductive thematic analysis and categorized them into the 4 quadrants of the SWOT framework. During this process, all codes and subthemes derived from the inductive thematic analysis were systematically examined and categorized as either internal or external factors. Internal factors were defined as those originating within the dialysis centers and directly related to their organizational structures, personnel, operational routines, and implementation processes. External factors were defined as those arising outside the dialysis centers and beyond their direct control, including health care policies, reimbursement frameworks, technological advancements, and broader societal and patient-related influences. They were then evaluated in terms of their hypothetical positive or negative effects on the initiation and implementation processes. Strengths were identified as internal benefits positively related to the IEG at dialysis centers. Weaknesses were identified as internal limitations that might negatively affect or impede the exergaming during dialysis. Opportunities were considered external factors that could positively enhance the applicability and sustainability of IEG. Lastly, threats were identified as external factors that could pose barriers to or adversely affect the implementation of IEG [71]. Afterward, members of the research team (JR, ZDV, AMG; and MA, LK, TJ serving as independent experts not involved in data collection) reviewed and validated whether the content extracted through inductive thematic analysis was appropriate and whether its deductive categorization aligned with the quadrants of the SWOT framework. Using this approach, 43 categories were generated, resulting in 2 strengths, 2 weaknesses, 3 opportunities, and 3 threats regarding IEG. The process of mapping the results of the inductive thematic analysis onto the SWOT framework is presented in the analytical flow table (Multimedia Appendix 2).

The study protocol was reviewed and approved by the Ethics Committee of the Pavol Jozef Šafárik University in Košice, Slovakia [approval no. 14N/2017]. Written informed consent was obtained from all study participants. We report this qualitative study according to the Standards for Reporting Qualitative Research and the Consolidated Criteria for Reporting Qualitative Research guidelines (Checklist 1) [72,73]. The research team comprised experts from various fields, including Sports Sciences (AZ, PhD), Occupational Therapy (MA, MSc), Health Psychology (IMS, PhD; DK, MSc; ZVD, prof; AMG, prof), Nursing and Digital Health (LK, PhD; TJ, prof), and Clinical Nephrology (JR, PhD and MD). All team members had prior experience in researching older people with chronic diseases, as well as expertise in designing, analyzing, and writing qualitative studies.

We invited 24 health care providers from 2 cooperating dialysis centers to participate in our study. Three care providers (1 nurse and 2 nephrologists) declined to participate due to high workloads and privacy concerns. We conducted semistructured, individual interviews with 3 training assistants, 11 dialysis nurses, 5 nephrologists, and 2 members of dialysis center management. Of the 21 participating health care providers, 11 were recruited from the first dialysis center (6 dialysis nurses, 2 nephrologists, 2 training assistants, and 1 dialysis center manager) and 10 from the second dialysis center (5 dialysis nurses, 3 nephrologists, 1 training assistant, and 1 dialysis center manager). Interviews lasted between 20 and 60 minutes, with an average duration of 39 minutes. One-fourth of the participants were over 50 years old, one-third were male, and half had over 15 years of professional experience. Table 1 provides the demographic and working experience characteristics for each participant’s professional position.

Using inductive thematic analysis, we identified 139 codes, which we then grouped into 54 subthemes and further organized into 5 overarching themes. These themes reflect a range of perspectives, including (1) mixed attitudes toward IEG: balancing optimism and skepticism, (2) attitudes on the acceptability and long-term sustainability of IEG interventions for patients, (3) expectations for addressing patients’ individual needs in IEG interventions, (4) expected benefits of IEG, and (5) expectations of the potential risks and barriers associated with IEG.

The SWOT analysis led to the identification and formulation of 2 strengths, 2 weaknesses, 3 opportunities, and 3 threats concerning IEG (Figure 1). (1) Strengths included (a) health care providers’ beliefs that exergaming is a safe activity to perform during dialysis, along with their (b) enthusiastic attitudes toward its integration into clinical practice. (2) Weaknesses reflected concerns about (a) the technological complexity of exergaming devices and platforms, and (b) inadequacies in patients’ access to and experiences with digital technologies. (3) Opportunities reported by health care providers included (a) uncertainty regarding alternative forms of exercise that could be implemented during dialysis, (b) calls for changes in dialysis culture, particularly to ensure better availability and greater specificity of information and support for IEG, and (c) suggestions and tips regarding the settings and modifications of exergaming interventions to facilitate their implementation during hemodialysis therapy. (4) Threats included (a) health care providers’ skepticism about the availability of financial resources, (b) factors related to patients’ behavior, personal space, and privacy, and (c) the resistance to IEG interventions among some health care providers. The overall categorization of the outputs derived from the inductive thematic analysis into the SWOT framework is presented in the analytical flow table (Multimedia Appendix 2).

This study aimed to explore the attitudes and expectations of health care professionals regarding the concept of IEG as a strategy to support patient self-management in the domain of physical activity. It offers novel insights into the perceived strengths, weaknesses, opportunities, and threats associated with IEG, as reported by training assistants, nurses, nephrologists, and dialysis center managers.

Health care providers identified the perceived safety of IEG, along with generally positive and enthusiastic attitudes toward its use, as key strengths. However, they also highlighted the complexity of the exergaming concept, as well as closely related issues of accessibility and user experience, as potential weaknesses that could hinder its integration into health care services. In terms of opportunities, participants expressed uncertainty regarding alternative approaches to the organization and delivery of intradialytic exercise. They emphasized the need for cultural adjustments within dialysis settings to facilitate the implementation of various proposed IEG modalities in the clinical environment. The main threats identified included skepticism about the financial and resource implications of IEG, potential patient reluctance or refusal to participate due to behavioral factors, and resistance to change among health care professionals in adopting exergaming as part of routine care.

Patients’ perceptions of safety play a key role in their decision to initiate and continue using technology-based physical activity interventions during dialysis therapy [74,75]. Our findings regarding perceived strengths suggest that health care providers generally view exergaming as a safe activity for patients undergoing hemodialysis. This aligns with existing evidence from studies monitoring patient safety, which consistently report no serious adverse events attributable to IEG [42,76-80]. From a broader perspective, research on exergaming interventions in patients with heart failure, stroke, or cancer similarly reports either no adverse events or only rare, exceptional cases [81-83]. Paradoxically, evidence from older adults and patients with multiple sclerosis, mild cognitive impairment, other neurocognitive disorders, and hypertension suggests that exergaming may raise concerns about physical safety. These concerns include fear of falls and general injuries, as well as occurrences of knee or back pain [16,84-89]. Such safety issues have been attributed to reduced awareness of the physical environment and insufficient guidance and support during exergaming activity [84,85,90]. Our participants expressed that, when properly introduced, clinically monitored, and technologically supported, IEG does not pose additional health risks to patients. They also expressed enthusiastic attitudes toward its use during hemodialysis therapy, which is consistent with existing evidence on positive perceptions among health care providers working with patients with dementia, cardiovascular conditions, stroke, and cancer [53,55,82,91,92]. Taken together, these insights into perceived strengths underscore the importance of promoting IEG by prioritizing patient safety and leveraging the enthusiastic support of health care providers. Their positive perceptions can play a pivotal role in enhancing patient engagement and long-term adherence to technology-supported physical activity during dialysis therapy.

Technological limitations and a lack of design flexibility in exergaming devices and platforms may undermine their ecological validity and hinder their transferability into clinical practice [93-95]. Our participants identified several weaknesses related to the design, installation setup, and positioning of exergaming technologies within dialysis environments, collectively referred to as technological complexities. These included limited space in dialysis centers, the need to maintain unobstructed access between the patient and the dialysis machine, and preferences for wireless, self-powered devices that can be securely yet easily attached to dialysis beds. These findings are consistent with existing evidence on the general limitations and challenges of exergaming among patients undergoing hemodialysis, particularly those arising from environmental and organizational constraints [96-99]. Importantly, other authors have noted that such complexities may present challenges not only during the integration of these technologies into clinical settings but also for health care providers and end-users [55,100-105]. Our participants also identified additional barriers to IEG, including patients’ digital literacy, sensory and cognitive impairments, socioeconomic factors, and differing views on the influence of age on user experience. These factors were seen as key challenges that may limit patients’ accessibility and engagement with exergaming technologies [16,56,97,98,100,101,103,106]. To improve the quality of implementation, particularly the transferability and accessibility of IEG technologies in clinical practice, developers and promoters should be aware of and take into account the specific conditions of dialysis environments and patient-related limitations from the earliest stages of design and development.

Health care providers are central figures in the development, initiation, and long-term sustainability of innovative therapeutic approaches in clinical practice [107,108]. In relation to opportunities for IEG, participants expressed limited ability to tailor such interventions to clinical settings and individual patient needs, highlighting gaps in their awareness, knowledge, and experience. Nevertheless, they proposed several key opportunities to enhance implementation, including raising awareness among health care professionals, integrating exercise specialists into routine dialysis care, and fostering international collaboration to share best practices. Although intradialytic exercise is not yet a standard component of dialysis care in Slovakia, participants suggested feasible strategies to support its integration. These included legislative backing, cultural shifts within dialysis centers, and the availability of complementary services. Our evidence on health care providers’ expectations and proposed opportunities aligns with existing literature, which emphasizes the importance of health care providers’ competencies, the presence of support teams and services, and the need for legislative and leadership support within dialysis networks [107,109-114]. Enhancing the availability of professional competencies and providing institutional and legislative support may serve as foundational drivers for cultural change in dialysis care. Such improvements could help meet the needs and expectations of health care providers and enable broader implementation of IEG in clinical practice. A recent study highlights that implementation of innovative exercise interventions, such as exergaming, depends on addressing multilevel factors, such as patient needs, health care professional engagement, and supportive policy frameworks [105].

Underestimating external factors, particularly potential threats, during the planning of behavioral interventions can compromise their usage in clinical practice. Our participants expressed uncertainty and skepticism regarding the financial feasibility of IEG, emphasizing the need for robust evidence of its health benefits and cost-effectiveness. Patient behavior was also identified as a potential threat, with participants highlighting the importance of a personalized and sensitive approach to introducing exergaming, given the psychological, social, and environmental challenges that may influence initial engagement and long-term adherence. Additionally, some health care providers expressed resistance to the concept of IEG, favoring traditional care methods and raising concerns about technological burden, workflow disruptions in dialysis settings, and potential patient discomfort. Existing literature reflects similar concerns, with reports of uncertainty and skepticism about the availability of financial resources for exergaming [89,92,115,116], although other studies highlight its favorable cost-effectiveness and cost-efficiency [117-119]. However, cost analyses specific to IEG are currently lacking and are critically needed to inform planning and development. Patient behavior, particularly motivation, and social and emotional factors has been significantly associated with the effectiveness and adherence to exergaming interventions across diverse populations, and is recognized as both a key determinant and a potential threat [120-124]. A particularly salient concern raised by health care providers was the potential for gaming addiction, reflecting a critical awareness of unintended psychological consequences that may arise from IEG. The evidence highlighting resistant, reserved, and oppositional attitudes, as well as expectations surrounding IEG, represents a challenging yet essential insight for effective planning and development. Recommendations to overcome initial resistance include the provision of education and support from specialized professionals (eg, physiotherapists), and the active involvement of health care providers in the planning and management of the intervention [65,109,113,125]. To effectively mitigate potential risks, it is essential to conduct a thorough assessment of the resources required, prioritize individualization by addressing each patient’s specific needs, and actively involve health care providers in the planning process prior to implementation of IEG.

Our study provides comprehensive evidence on Slovak health care providers’ attitudes and expectations regarding the implementation of IEG in clinical practice, systematically organized into thematic quadrants of the SWOT framework. Future research exploring perceptions of IEG, including those of patients, exergame developers, and stakeholders (particularly patients’ organizations, governmental and regulatory bodies), could enhance understanding of critical factors for strategic planning. Evidence on attitudes and expectations toward IEG from respondents representing diverse health care systems, geographical regions, and socioeconomic and cultural backgrounds could strengthen the generalizability of these findings.

This study presents several key strengths. First, the sample included professionals from all levels of the organizational hierarchy within dialysis centers, from training assistants and nurses to nephrologists and senior management, providing a well-rounded and comprehensive perspective on health care providers’ attitudes and expectations regarding IEG. Second, the use of prescreening enabled the recruitment of a highly diverse group of participants, varying in age, gender, and professional background. Third, all participants contributed relevant expertise through their direct involvement in implementing intradialytic exercise interventions in clinical practice. Fourth, we used an inductive approach to analyze health care providers’ attitudes and expectations, followed by deductive categorization using the SWOT framework. We believe this methodological strategy yielded a practical, systematically organized, and transferable overview of the SWOT associated with IEG interventions, offering valuable insights to support strategic planning and informed decision-making.

This study has several limitations that should be acknowledged. First, despite our efforts to ensure a balanced representation across professional roles, we were unable to achieve the optimal sample size of 6 to 8 participants in the groups representing dialysis center managers and training assistants. However, the strong thematic alignment between managers, training assistants, and other professional groups suggests that their perspectives were largely reflected. Second, all participants were recruited from 2 dialysis centers affiliated with leading nephrology networks in Slovakia. As a result, the findings may be shaped by context-specific factors such as socioeconomic, demographic, and cultural characteristics, which could limit their generalizability to other dialysis settings with different health care structures. Third, our inclusion criteria required varying minimum levels of professional experience across roles. This decision was made to address the limited availability of experienced training assistants and to avoid potential bias from insufficiently experienced nurses, nephrologists, and managers. Nonetheless, this approach may have excluded early-career perspectives from some professional groups. Fourthly, our study is limited by the fact that participating health care providers had no direct experience with IEG. Therefore, the findings are based on hypothetical perceptions and expectations regarding its implementation in hemodialysis care and may not fully reflect experiences or challenges associated with its actual use in clinical settings.

This study offers valuable insights into health care providers’ views on the implementation of IEG in clinical practice. They regarded IEG as safe and potentially beneficial for patients undergoing hemodialysis when supported by clinical monitoring and technological oversight. They highlighted the potential of IEG to enhance patient engagement and alleviate boredom during hemodialysis while noting weaknesses such as technological complexity and limitations on accessibility and users’ experiences. Health care providers identified opportunities such as clarifying alternative exergame options, enhancing the availability and quality of information and support for IEG, and refining available IEG settings and modifications to facilitate implementation during hemodialysis therapy.

Although IEG is not yet standard practice in Slovakia, our findings indicate that, with appropriate planning, training, and policy adjustments, it could become a sustainable component of hemodialysis care. Health care providers acknowledged its potential benefits for engagement and well-being but raised concerns about financial feasibility, long-term sustainability, and availability of support for integration into the health care system. Common threats included uncertainty over funding and skepticism about health care system readiness, alongside worries about patients’ privacy, clinical routines, staff workload, and resistance. In addition, our participants emphasized the need for a personalized approach to address patients’ psychological variability and possible discomfort in shared spaces. The findings highlight the need to address both human and systemic factors in the design, development, and implementation of IEG, indicating that successful integration will require not only technological innovation but also cultural, organizational, and legislative support.

Health care providers regarded IEG as a safe and promising option for patients on hemodialysis, particularly for boosting engagement and reducing treatment-related boredom. To make this approach feasible in practice, clear guidelines, staff training, and organizational support are essential to overcome technological and accessibility challenges. With thoughtful planning and adequate resources, IEG could become an effective addition to hemodialysis care, improving patient experience and overall well-being.