What do we know about nursing practice in relation to functional ability limitations, frailty and models of care among older people in home- and facility-based care: a scoping review

Abstract

Background

Nursing practice in long-term care, must support the delivery of safe and evidence-based care, especially for older people with functional ability limitations and frailty, with the competency, knowledge and structured working modes such practice requires. Understanding, detecting and preventing these conditions is important in a context where care is given to a significant number of older people with complex care needs. Our aim was to map published literature on how functional ability limitations and frailty among older people (65 and above) in home-and facility-based care (i.e. long-term care) were described by key stakeholders, and to identify models of care (MoCs) targeting these conditions.

Methods

We followed Arksey and O’Malley’s methodological steps and the PRISMA-ScR reporting guidelines. The PubMed, CINAHL and PsycInfo databases were used to identify papers published between June 2002 and June 2022. The search was updated in May 2024. A descriptive analysis was conducted where the identified patterns were organised and categorised with the support of the Pattern, Advances, Gaps, Evidence for practice and research Recommendations framework (PAGER).

Results

A total of 18,875 unique records were identified. Of these, 26 papers were included. The findings implied a discrepancy between the older people’s subjective- and the nurses’ more objective, ‘matter-of-fact’ perspective. The older people described both conditions in terms of identity loss and an emotional struggle to remain independent. They also highlighted the importance of positive connotations in relation to their efforts to adapt and accommodate the situation to the conditions. Nursing practice targeting the conditions were predominantly described as being reactive, based on their experiences and guided by ‘intuition’. The identified MoCs mainly targeted functional ability limitations while focusing on educating nurses.

Conclusion

A point of saturation seems to have been reached regarding research focusing on older people’s descriptions of frailty in home-based care. The same cannot be said about older people’s or nurses’ descriptions concerning functional ability limitations or MoCs. Intervention studies focusing on nursing practice and the development of MoCs that target these conditions preferably in a home-based care context could substantially benefit the development of knowledge within nursing and nursing practice.

Trial registration: Open Science Framework

https://doiorg.publicaciones.saludcastillayleon.es/10.17605/OSF.IO/FNHSA.

Introduction

Among healthcare professionals, nurses, both registered and nonregistered, constitute the largest professional group (see Table 1 for operationalisations of key concepts). They are often the first point of contact, and they are also the group that spends the most time with patients. In addition, nurses are expected to provide a diverse range of healthcare services, where home- and facility-based care (i.e. long-term care) are two important arenas. One of the responsibilities and functions of registered nurses’ (RNs) clinical practice is to make clinical decisions based on a systematic process of assessments, diagnoses, plans, implementations and evaluations (i.e., the nursing process) related to the patient’s personal health needs [1, 2]. While nonregistered nurses can be conceived as the operational arm of RNs, as they carry out nursing functions under supervision and leadership from RNs [2]. Therefore, all nursing staff play a major part in delivering safe and evidence-based practice that involve detecting and establishing appropriate care actions. The latter is vital because home- and facility-based services, especially in the Nordic countries, are often described as necessitating more complex patient care, particularly for the increased number of older people presenting with chronic diseases [3].

Table 1 PICoS framework and operationalisation of core concepts

Statistics imply that the prospective number of older people in long-term care is estimated to increase from approximately 31 million (2019) to 38 million by 2050 [4]. Thus, the increased proportion of older people receiving home- or facility-based care has been well acknowledged [5]. In Norway alone, figures indicate that home-based care is the service that is increasing most rapidly [6]. The majority of older people needing these services are described as valuing their independence and, as such, preferring to remain in a familiar environment [7, 8]. Many are and will be living with multimorbidity which can be understood as the cooccurrences of two or more chronic conditions, including physical and/or mental health conditions, thus, exhibiting complex care needs [9]. Importantly, older people in need of home- or facility-based care are not a homogenous population. Instead, they are known to range from being relatively independent and in need of low-intensity care to being dependent and in need of high-intensity care [10].

In the group of older people receiving care in these contexts, it is not uncommon to present with functional ability limitations, and/or with some degree of frailty (Table 1). Additionally, we know that there is a considerable overlap between frailty and physical disability [11]. Even though more research is warranted to determine how for example physical conditions are associated with functional status (functional ability) and frailty and to determine factors that negatively influence frailty over time [12]. The latter is especially associated with several adverse health outcomes, such as falls, hospitalisation, increased healthcare-related costs, and death [13, 14]. In addition, many older people are still cohabiting with their partner and/or receiving support from them or from significant others [3, see 15]. Hence, it is fair to postulate that through them the health deterioration of older persons might be compensated for and delayed over a longer period of time, thereby masking their actual care needs, which can increase the risk of adverse health outcomes. Recognising frailty should be a vital part of nursing practice because frailty is both preventable and reversible [16]. Consequently, nurses play a vital part in ensuring that older people receive the correct interventions in relation to proactive prevention and treatment strategies. Being able to fulfil such responsibilities requires both qualified and competent professionals [17]; hence, a nursing practice characterised by systematic and evidence-based working modes. There is an undeniable need for structured working modes, such as effective models of care (MoCs), for the early detection and prevention of functional (ability) limitations and frailty among older people. The research into nursing practice implies that delivering care through distinctly articulated and defined MoCs can support nurses in working systematically towards a collectively decided set of goals [18]. However, it also aids nursing staff in their assessment and evaluation of care and supports nurses in sharing a joint foundation for care as well as sharing the same ‘picture’ of the given care. MoCs should here be understood as a map of nursing care (activities and/or interventions) aiming to safeguard that the older person with complex (care) needs receive the right care from the right person at the right time, hence outlining the best practice of care [19].

In summary home- or facility-based care services, for older people with complex care needs require strategies to detect signs and symptoms as well as prevent deterioration. This fits well within the remit and range of RN authorisation, responsibilities and function (professional scope of practice). However, the identified reviews imply that research within the area has focused mainly on screening tools and the effects of interventions [20,21,22,23,24,25]. Few of them have identified nurse-initiated or -led interventions. Furthermore, we argue that to be able to develop applicable frameworks organising and outlining nurses’ scope of practice (MoCs) related to these conditions, it is essential to gain in-depth knowledge about both conditions, hence advancing beyond our medical understanding. Therefore, the present study aimed to map published literature on how functional ability limitations and frailty among older people in home- or facility-based care were described by key stakeholders, and to identify models of care targeting these two conditions.

Methods

Our scoping review followed the five steps of Arksey and O’Malley’s methodological framework [26], which is appropriate for broad and complex questions. In accordance with this framework, we have mapped our findings and identified gaps in published research. The PAGER (patterns, advances, gaps, evidence for practice and research recommendations) framework [27] was used for the visualisation (patterning) and reporting of the findings. The review is the first strand in a tier of four consecutive project strands [28], where the two upcoming strands will inform the development of an intervention targeting nursing practice related to functional ability limitations and frailty in the long-term care context, which will be tested in a fourth and final strand. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist [29] (Additional file 1) and is registered (https://doiorg.publicaciones.saludcastillayleon.es/10.17605/OSF.IO/FNHSA) and preceded by a study protocol [30].

Stage 1: identifying the research question

In agreement with the framework [26], we formulated our questions to the literature utilising PICoS—population, phenomenon of interest, context and study design to align them with our main search terms (Table 1). Based on experiences from the published protocol [30], the increased familiarity gained during the limited initial scoping search and on recommendations, we refined wording(s) and the core concepts. For example, long-term care was replaced by home- and facility-based care, functional decline was replaced by functional ability limitations, and our operationalisation of MoCs was simplified. The revised questions were as follows:

• Question I (Q1): How is the condition of functional ability limitations among older people in home-or facility-based care described by key stakeholders?

• Question II (Q2): How is the condition of frailty among older people in home- or facility-based care described by key stakeholders?

• Question III (Q3): What models of care (nursing activities and/or interventions) can be identified as targeting functional ability limitations or frailty in relation to older people in home- or facility-based care?

In addition, we considered (I) by whom the questions were answered, (II) in which context(s), (III) in relation to whom or what, and (IV) which research design(s) was utilised.

Stage 2: identifying relevant studies

Systematic searches were conducted in PubMed, CINAHL and PsycINFO. The search strategy was tested and evaluated with the support of an information specialist (Additional file 2). PubMed was used to develop our search strategy, which was then customised to each individual database. The first author (IRF) developed the first draft of the strategy and conducted an initial limited scoping search. The strategy was subsequently evaluated together with the last author (GB), yielding some minor adjustments. An iterative process preceded the final strategy. Search blocks were developed and included thesaurus terms, MeSH and keywords, including synonyms. These were combined via the Boolean operators AND/OR [38]. Limits were set to include English peer-reviewed primary research published during the last approximately 20 years (June 2002–June 2022). An updated search was conducted covering the date from the last search up to 27.05.2024.

Stage 3: study selection

The identified records were transferred to EndNote [39]; here, we removed duplicates before entering them into Rayyan [40] for title–abstract screening. All the authors (IRF, ERG, AJE and GB) conducted a joint title–abstract screening test guided by the PICoS determinates (Table 1). The records were screened by two independent reviewers to ensure agreement on selection. The first (IRF) and last author (GB) thereafter conducted a stepwise title–abstract screening, ‘sifting’ through eligible records [41] (Fig. 1 [42]). Disagreements were resolved through discussion and, if necessary, by consulting a third reviewer. Papers meeting the inclusion criteria were read in full text, and those with unclear relevance were assessed by two reviewers [43]. The reference lists of the included papers were screened, and no new papers were identified.

Fig. 1

PRISMA flow diagram

Stage 4: charting the data

To facilitate systematic charting of the data, the first author (IRF) and last author (GB) developed a data extraction sheet (Tables 2, 3, 4); this was independently tested on six included papers [44]. Our testing resulted in minor changes related to the layout and level of charted detail. The first author (IRF) was mainly responsible for extracting data, whereas the last author (GB) randomly checked the accuracy and level of detail of the extracted data. The following information was extracted:

• Author(s), year of publication, country of origin

• Aim(s) of the study

• Context (home- and/or facility-based care)

• Study population (registered and nonregistered nurses; older people; significant others)

• Methodology (design, data collection and analysis)

• Models of care (nursing- activities and/or interventions targeting functional ability and/or frailty)

• Vital findings, i.e., answering our questions to the literature

  Table 2 Data extraction Q1_Functional ability limitations

  Table 3 Data extraction Q2_Frailty

  Table 4 Data extraction Q3_Models of Care

The majority of the included papers were quality assessed by the first author (IRF), whereas the second author (ERG) and last author (GB) independently and randomly supported the assessment. Our quality assessment aimed to identify gaps in the literature related to high-quality research and determine areas not requiring further investigations [cf. 71]. The Critical Appraisal Skills Programme (CASP) checklist for qualitative [72] and randomised controlled trials [73] was used. The appraisal tool for cross-sectional studies (AXIS) [74] was used for cross-sectional designs, and the Johanna Briggs Institute Critical Appraisal Tool was used for quasi-experimental designs [75]. The ethical quality of the papers was assessed as recommended by Weingarten et al. [76] and inspired by Westerdahl et al. [77] (Table 5). We chose our appraisal tools based on their common usage in health service research and the high level of familiarity they offer. None of the critical appraisal tools recommended the use of scores. However, to be able to offer a clear map of the paper’s quality and its ethical considerations we decided to calculate the number of ‘yes answers’ for each tool (Table 5). The total number of ‘yes’ answers was then divided into quartiles (q), where q1 and q2 represented low quality, q3 represented medium quality and everything above q3 represented high quality. Our approach felt acceptable as no papers were excluded and no evidence was weighted based on these procedures.

Table 5 Patterning chart: Design and critical and ethical appraisal Q1–Q3

Stage 5: collating, summarising and reporting the results

In this stage our choice of summarising via a descriptive approach appeared to be the most appropriate. Thus, we utilised concepts such as coding and categories whilst excluding the final stage of abstraction as described in most recommended approach—content analysis [79, 80]. Our rationale was twofold: (i) the concept of ‘summarising’ [26, 44, 71, 79] are still enigmatically described, (ii) Morse’s [81] definition of a theme (sc. thematic analysis) as the ‘essence’ that runs through the data (a red thread) and of a category (sc. content analysis) as a set of similar data that have been sorted together. Despite choosing the latter we have opted to not label our procedure as thematic- nor as content analysis. Instead, we offer a thorough presentation of our process of analysis below.

Our process began with a careful reading of the findings of the included papers by the first author (IRF). The pertinent text that was evaluated to answer our questions was extracted (Column 5, Findings) into the extraction sheet (Tables 2 and 3), and the text was then broken down into smaller parts, making it possible to inspect and understand the individual parts while searching for patterns in the data, i.e., analysis [82]. In the third phase, the sorting and categorisations [81] of all the acknowledged patterns were given an identifier, that is, a tentative descriptive label that resulted in 17 descriptive labels (Column 6, Sorting of findings). Next, in phase four, to create an overall pattern of our sorting of the text excerpt, a patterning chart (Table 6) for Q1 and Q2 was created. This phase was inspired by Waigwa et al. [83] and the visualisation of their findings. Our work with the patterning chart resulted in the identification of constructs representing two categories, ‘implications from the states’ for nursing practice, everyday life and the older individual and several descriptive and experiential ‘notions of the state’, such as justifications, (pre)conceptions, uncertainties and deficiencies. The patterning chart composed, supported the visualisation of the findings to gain a logical structure of the narrative results. The whole process was characterised by an iterative process going back and forth between the parts of the text. In these phases, the last author (GB) randomly inspected the thoroughness and relevance of the work conducted on a regular basis. Team meetings were held regularly to ensure the rigour of the process. For Q3, the extracted data were shortened and compiled into brief narrative descriptions (Table 4).

Findings

Our search resulted in 18,875 potentially relevant records after the removal of duplicates. After title–abstract screening, 76 papers were read in full text, resulting in 26 papers being included and 50 excluded; approximately 68% of them were assessed as not answering any of our questions, whereas the remaining were assessed as not meeting our inclusion criteria.

Descriptive findings

Twenty-six papers were evaluated to answer our questions. Q1 and Q2: How are the conditions of functional ability limitations and frailty among older people in home- or facility-based care described by key stakeholders? Q3: What models of care (nursing activities and/or interventions) can be identified as targeting these two conditions? The majority (77%) answered our first two questions. Of these, 19% covered functional ability limitations, and 58% covered frailty. Moreover, 23% of the papers covered MoCs targeting these two conditions. Four focused on functional ability limitations, and two focused on frailty. The papers represented research from Nordic countries (n = 9), Europe (n = 13), North America (n = 2) or Oceania (n = 2) (Table 5).

A total of 1961 participants were represented. Older people represented 86% (1689) of the total number of participants. Registered or nonregistered nurses represented 3.3% and 9.7%, respectively, while 1% represented significant others. Included papers answering Q1 represented research conducted in facility-based care (100%), whereas 80% of the papers answering Q2 represented research conducted in home-based care. One paper answering Q2 was set in facility-based care (6.7%), whereas two were set in both home- and facility-based care (13.3%). Papers answering Q3 were equally set between home- and facility-based care (50–50%). The majority of included papers (54%) were conducted with a descriptive qualitative design [78], and 23% were conducted with a classical qualitative design [84]. The remaining 23% were conducted with a quantitative design, where 11.5% of them utilised an experimental design and 11.5% used a nonexperimental design (Table 5).

Descriptions of functional ability limitations

Five papers representing facility-based care [45,46,47,48,49] answered Q1. Two accounted for the perspective of older people alone [45, 48], whilst two accounted for both older people and nurses’ perspectives [47, 49]. One paper accounted for the perspective of significant others [46] (Table 6).

Table 6 Patterning chart: Categories for Q1–Q2

Implications from the state of functional ability limitations

The descriptive category ‘implications from the state of functional ability limitations’ mapped out descriptions of the consequences for (i) the nursing practice given and on offer, (ii) the older people’s everyday life activities and (iii) for them as individuals (Table 6).

Descriptions of the consequences of functional ability limitations for nursing practice were identified from the perspectives of all three key stakeholders in facility-based care [45, 46, 49]. Nurses’ ‘well-intended’ actions related to functional abilities affected the care that older people received [45, 49]. Regardless of older people’s functional level or degree of autonomy, nurses were perceived as replacing older people in self-care tasks [45]. When the nurses did not assess their support and actions related to activities daily life (ADLs), interventions intended to facilitate these tasks for the older people could become ineffective [49]. Despite the nurse’s close bedside presence, older people could experience more difficulties and need more assistance than the nurses realised [49]. Nursing practice was described as being affected by contextual and organisational challenges [46, 49]. For example, significant others described organisational challenges, such as a lack of resources, highlighting the ambiguity but also the necessity of their involvement and role in supporting the older person’s functional ability next to the nursing staff in their practice [46]. Contextual difficulties in nursing practice, such as the lack of formalised care plans and being chronically short staffed, were described as forcing nursing staff to work in ways contrary to what they meant was best practice. For example, replacing toileting care with the prescription of diapers, even though the older person was continent, thus increasing the risk of harm to the older person’s self-care abilities and dignity [49].

The implications of functional ability limitations for everyday life include one aspect highlighted by both older people [45,46,47] and significant others [46]: the importance of focusing on more than merely ADLs, or ‘daily chores and independence, when considering the state. Both emphasise the importance of including pleasurable activities, social relations, emotional needs and preferences in everyday life [45,46,47]. The specific context and routines inherent to the nursing home environment made maintaining autonomy and dignity related to ADLs more challenging for the older people [49]. Functional ability limitations were described as having consequences not only for older people’s everyday lives but also for them on an individual level [47, 49]. Although valuing participation, they described their struggles in doing so because of their functional ability limitations [49] as well as their struggle to withhold their independence [47]. The later was described as an important part in easing the burden for the already pressured nursing staff [47].

Notions of the state of functional ability limitations

The descriptive category ‘notions of the state of functional ability limitations’ mapped out several descriptive and experiential notions of the state, such as justifications and (pre)conceptions (Table 6).

The notion of justifications for functional ability limitations was explained mainly as being related to concepts such as capacity and independence in ADL [45, 47]. The nurses explained functional ability limitations related to ADLs as being related to activities of daily living—being dependent or independent. Alternatively, they saw it as an abstract term that included physical, social, and psychological domains, for example, standardised indicators [47]. Older people’s descriptions focused more on the different ways of coping with functional difficulties rather than on a dichotomy of independence or dependency. They explained it as a more versatile concept, including ADLs, but ranging from needing help and coping with difficulties to feeling like a burden [47]. On the other hand, explanations could also entail notions about being ‘noncapable’ without this being related to needing support in daily activities or the use of assistive devices. The older people resisted showing any signs of, for example, being incapable of walking because this was seen as a potential first sign of dependence [48].

(Pre)conceptions concerning the states described how older people struggled to resist the label of being dependent, for example, being solely a ‘care-receiver’ or being ‘noncapable’ [47, 48]. Even if they did have functional limitations, they worked hard to avoid being labelled as such because this could risk them being socially excluded and being stuck with the label permanently. Negative connotations, or discrimination against those labelled ‘noncapable’, were reflected in how the nursing staff acted [48]. (Pre)conceptions were also described concerning the power or influence that older people had on functional ability limitations themselves, with both older people and significant others believing that older people could influence their functional abilities to some extent [46, 47].

Descriptions of frailty

Fifteen papers [50,51,52,53,54,55,56,57,58,59,60,61,62,63,64] answered Q2. Twelve was conducted in home-based care [50,51,52,53,54,55,56,57,58,59,60,61], two in both contexts [62, 63] and the last one in facility-based care alone [64]. Seven of them reflected the perspective of older people [50, 52,53,54, 57, 59, 61], and the remaining eight reflected the perspective of nurses [51, 55, 56, 58, 60, 61, 63, 64] (Table 6).

Implications from the state of frailty

In the descriptive category ‘implications from the state of frailty’, consequences for nursing practice, for older people’s activities of everyday life and for them as individuals were mapped out (Table 6).

The implications from frailty for nursing practice were accounted for by the nurses, who described that their practice regarding the identification, detection and early recognition of frailty was predominantly guided by their ‘intuition’ [51, 56, 58]. The nonspecific nature of signs and symptoms of frailty was described as hindering their practice of early recognition resulting in a sense of concern while also demanding substantial knowledge of the older person [58]. They also described an experience-based reactive practice concerning the identification and detection of frailty [56]. Several organisational challenges were described to negatively influence their nursing practice related to frailty [51, 58, 61]. Time pressure, lack of staffing, gaps in service, instruments available for identification of frailty not adapted to the setting [51], lack of standardised tools, lack of training and interdisciplinary collaborations [61] and task-oriented services [58] were described. The prevention of frailty was feasible [55, 60], but early detection and effective preventative interventions were described as requiring a systematic reconstruction of the organisation [55]. Interventions such as physical activity, nutritional support and social support were exemplified to potentially prevent frailty.

The implications of frailty for older people’s activities of everyday life include descriptions of how physical challenges, along with contextual changes, and the physical and social environment limited older people’s everyday lives. However, despite challenges, most older people wanted to live at home while expecting to have to move into facility-based care at some point in time [50]. The descriptions of a constant daily struggle to sustain and develop routines aimed at maintaining their identity as capable and independent were also identified. These struggles disrupted and restricted their everyday life while demanding varying degrees of adaptation to losses, difficulties and the physical and psychosocial changes they experienced. Frailty was described as a dynamic and persistent state of imbalance [50, 53, 54] and as a continuing downwards spiral from which individuals could not escape, causing experiences of fear, anxiety, uncertainty and a sense of a meaningless everyday life [52, 57, 59]. Frailty was also described to have an incremental effect on older people as individuals, especially on their self-image and self-worth [52,53,54,55, 62]. Despite being assessed as frail by nursing staff, older people did not identify with this concept or wish to be labelled as such, nor did they desire to be classified as needing help [53,54,55, 62].

Notions of the state of frailty

In the descriptive category ‘notions of the state of frailty’, constructs concerning a variety of justifications, (pre)conceptions, uncertainties and deficiencies about frailty were mapped out (Table 6).

The descriptive justifications related to frailty included the nurses’ rather straightforward accounts of frailty. The nurses described risk factors for frailty such as loneliness, cognitive problems, psychological distress, recent falls, psychological exhaustion and the need for mobility- or other assistance equipment, whereas having an adequate social network was described as a protective factor [51, 55, 61]. An assessment of (instrumental) ADLs was prioritised over frailty in practice, and the meaning of frailty was described by some nurses as unclear [61]. Others explained frailty as both an individual trait and interaction between individual and environmental factors. The nurses’ explanations related to the care they provided entailed descriptions of frailty on a continuum from preventative care and management, to related to ageing and a natural decline [60]. Frailty was also explained mainly as a physical state and related to physical ability [63, 64]. Some nurses explained that, in relation to their understanding of age-related complexity, the identification of the state of frailty among older people was obvious [63]. Older people explained frailty as either two separate entities, physical and mental frailty, or as one entity, but their descriptions of the possible relationships between these two types of frailty differed [50, 62]. Physical frailty was explained as more ‘real’, whereas mental frailty was related to mainly negative connotations. They described mindset, cognition and emotions as factors affecting frailty while relating frailty to loss of ability, independence (mobility) and loss of control over one’s life [62].

On the other hand, some of the older peoples’ justifications included more nuanced descriptions. Some described frailty not exclusively as an individual trait or condition but rather as an interplay between age, health-related changes, contextual challenges and the physical and social environments [50]. Frailty was also described as the following distinct patterns: stability, unbalancing and overwhelming, reflecting how the person adapts to increasing difficulties and losses and reintegrating their sense of self into a cohesive narrative [52]. The latter also entailed descriptions of social losses, depressive symptoms, anxiety and existential suffering, which could culminate in a tipping point where the older person surrendered [52]. Frailty was described as being connected to increasing age to different degrees by older people. Some adapted to these changes, whereas others found it difficult to accept [50].

Descriptions about (pre)conceptions concerning frailty represented descriptions related negative connotations, such as being old, needing help and/or being vulnerable, by both nurses and older people [51, 55, 56, 62]. Some even related personal choice to frailty, especially mental frailty [62]. Frailty could be seen as a static state that is unpreventable and unmodifiable [62, 63]. Simultaneously, frailty was also described, mainly by non-frail or prefrail community-dwelling older people, as modifiable regardless of age and as potentially affecting isolated parts of the person [62].

Descriptions by both nurses and older people of uncertainties related to frailty reflected a term lacking a specific meaning and uncertainties related to its definition [51, 55, 60,61,62, 64]. Some nurses could not distinguish between frailty, disability and multimorbidity [55]. Frailty was even seen as too unspecific to be valuable in practice working with this complex population [64], or the nurses preferred to use a more ‘professional’ term focusing on the older person’s needs [60]. Descriptions of deficiencies were identified, and the lack of knowledge related to frailty and its assessment and detection was described among nurses [51, 55, 56, 58, 61]. This lack of knowledge could, in some circumstances, result in less awareness of frailty in nursing practice [61].

Identified models of care and/or nursing interventions

Six papers were identified answering Q3 that is; what models of care (nursing activities and/or interventions) targeting functional ability limitations and/or frailty in relation to older people can be identified, where three were conducted in home-based care [65,66,67] and three in facility-based care [68,69,70]. Four papers focused mainly on older people [66, 67, 69, 70], one focused on both older people and nurses [68], and the last focused on nurses [65]. The latter represented research with a qualitative descriptive design, whereas three used an experimental design [68,69,70] and two a nonexperimental design [66, 67]. Furthermore, four targeted functional ability limitations [66, 68,69,70], and the two remaining targeted frailty [65, 67]. Four included educational interventions targeting nursing staff (Table 4).

In one of the papers conducted with a descriptive qualitative design, the intervention focused on increasing the nurses’ skills in recognising and responding to deterioration [65]. This paper revealed an alterable effect of the intervention as its delivery was described to be affected by implementation and contextual issues [65] (Table 4). Moreover, three papers presented research where different types of care models were implemented: (i) integrated care [66], (ii) a community virtual ward [67] and (iii) function-focused care [68]. All the MoCs implied positive result but without statistically significant effect related to the implemented and tested MoCs. The integrated care model [66] showed that the intervention was preferred over usual care. The difference in preference was especially related to the outcome measures; enjoyment of life, psychological well-being and social relationships and participation, while the effect on physical functioning was less pronounced. The community virtual ward [67] implied the potential to support older people in remaining at home as well as to delay or reverse the downwards trajectory of frailty, whereas the function-focused care model [68] showed increased physical activity and some improvement in physical functioning. Additionally, the latter paper indicated, a small statistical change, that nursing assistants provided more function-focused care [69]. Finally, two papers focused on interventions consisting of different forms of ADL training, but neither of these interventions had a statistically significant positive effect on ADLs [69, 70]. Both papers showed that ADLs were maintained in the intervention group, except for participants with cognitive impairment [70].

Descriptive findings from the critical and ethical appraisal

Critical and ethical appraisals were conducted (Table 5). All the papers with a qualitative design were assessed to be of a high quality [46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65]. However, only 30% of the papers addressed, to some extent, the relationship between the researcher and participants [47, 49, 57, 59, 61, 65]. Among the papers with a nonexperimental design, 67% were of a medium quality [45, 67], whereas 33% were of a low quality [66]. Two randomised controlled trials were of a high quality [68, 70], and one was of a medium quality [69]. Regarding ethical appraisal, 73% of the papers were assessed to be of a high ethical quality [45,46,47,48,49,50, 52, 54, 55, 57, 58, 60, 62, 64,65,66,67,68,69], whereas 23% were of a medium [51, 53, 56, 59, 63, 70] and 4% of a low quality [61]. Only 15% of the papers addressed the handling, storing or protection of data beyond simply stating following guidelines [58, 60, 65, 66].

Discussion

This scoping review mapped the literature on three questions: Q1 and Q2: How is the condition of functional ability limitations, and the condition of frailty among older people in home- or facility-based care described by the key stakeholders? Q3: What models of care can be identified as targeting these two conditions in relation to older people in home- or facility-based care? The following discussion is presented within the framework of PAGER: patterns, advances, gaps, evidence for practice and research recommendations [27].

Patterns

Our findings could be plotted into two categories, that is, implications and notions of the states, creating a detectable pattern (Table 6). The pattern primarily represented older people in facility-based care (75.8%). While the nurses, being in minority (13%), mainly represented the home-based care context. Our pattern revealed that the findings largely represented a Central and Northern European perspective (Table 5). The states of functional ability limitations (Q1) and frailty (Q2) were described slightly differently among the key stakeholders. The findings highlighted a discrepancy between the older people’s subjective, existential perspective and the nurses’ more objective, ‘matter-of-fact’ perspective, particularly regarding frailty as a physical state related to physical ability. The older people described the states of functional ability limitations and frailty in terms of identity loss and an emotional struggle to remain independent, challenging the stereotypical views of dependency associated with ageing. Negative connotations or ‘labels’ related to both states as being old, vulnerable and dependent [85] were rejected by the older people (Table 6). The importance of positive connotations was described in relation to older people’s efforts to adapt and accommodate their situation related to both states (Table 6). Two published meta-syntheses corroborate our findings regarding the state of frailty and the older people’s efforts to challenge this state and its negative connotations [86, 87]. Nursing practice targeting functional ability limitations and frailty were predominantly described as being reactive, which was based on nurses’ experiences and guided by their ‘intuition’ rather than as encompassing structured activities guided by MoCs. Surprisingly, the majority of the few MoCs identified (Q3) addressed functional ability limitations, even though the latter has seemed to attract relatively little attention within research into nursing compared with the state of frailty.

Advances

Our findings seem to imply some clearly detectable advances. The findings can be positioned in the frame of the core principles of nursing, here being seen as a nursing practice departing from a humanistic and holistic perspective [cf. 88]. To the best of our knowledge, this is the first published scoping review mapping descriptions about both the state of functional ability limitations and frailty in home- and facility-based care from the perspective of nurses, older people and significant others. The same seems true for MoCs aiming to support nursing practice targeting these states. Therefore, it is notable that our findings propose a clear advancement in that the included papers explored older peoples’ perspectives of frailty in home-based care as we sparsely identified the same substantial acknowledgment in relation to the state of functional ability limitations. The descriptions from older people highlight the importance of seeing the individual in a way that is consistent with the humanistic and holistic perspective of nursing and promoting independence [cf. 1, cf. 88] rather than focusing on older people’s individual health conditions. Furthermore, challenging stereotypical views of ageing [85] seems especially relevant for strengthening older people’s self-efficacy because it is estimated that the proportion of older people living with frailty both nationally and internationally will increase substantially [cf. 89]. Despite these advancements, the perspective of older people still needs to be strengthened in the dominate understanding of frailty today. However, the same advancements cannot be said to exist related to nurses’ and significant others’ perspectives nor for descriptions of functional ability limitations. Neither has the same advancements been identified related to MoCs.

Gaps

Our findings suggest that the research into nursing may not have fully explored the state of functional ability per se or, as here, functional ability limitations among older people. A clear gap was that we did not identify similar findings for functional ability limitations as for frailty regarding notions about uncertainties or deficiencies. Instead, the descriptions and experientials seemed to justify and conceive of functional ability limitations as a ‘natural’ and intrinsic part of ‘normal ageing’ (Table 6), representing a somewhat ‘outdated’ nursing practice. Viewing functional limitations as a normal part of ageing or still using concepts such as being dependent or independent in the care of older people is, in our view, counterproductive. By adopting new perspectives on functional ability limitations and responding to the cues in older people’s descriptions, which portray a deliberate ‘fight’ against these limitations and negative labelling, we can shift the scope of nursing practice into increasing proactive thinking, functions and working modes. Instead of merely compensating for limitations, we can develop nursing interventions that emphasise older people’s ability to strive, adapt, accommodate and cope. Thus, focusing on older people’s functional abilities instead of limitations could push the here earlier described reactive nursing practice towards a more proactive and preventative nursing practice for older people in these two contexts. The latter should be prioritised as we know that the home-based care context is the fastest growing health service area for older people both in Nordic countries and Europe [4, 6]. It is here that nurses and—a relevant nursing practice—have favourable possibilities for making an impact. Despite the importance of advancing this field, this review also identified gaps related to the perspective of nurses and a lack of MoCs. Research has shown that frailty is preventable and reversible [24] and, thus, associated negative health outcomes [13]. However, early detection is vital, highlighting the need to support nurses in working effectively and systematically, especially in the demanding context of home-based care. Therefore, the lack of MoCs here is concerning.

Research recommendations

Regarding research recommendations, our findings, quality and ethical appraisal evaluations included, coupled with the recent influx of literature reviews in this field [86, 87, 90], have shown that we seem to have reached a point of saturation on the subject of older people’s descriptions of frailty in home-based care. Hence, it is safe to propose that this does not require any further exploration through qualitative research. Particularly as the majority of the included papers here clearly reflected high quality execution in the quality and ethical appraisal. Rather, what should now be prioritised is using this existing knowledge to develop and test feasible solutions to increasing early detection and prevention of frailty through (non)experimental designs. However, the latter warrants some caution regarding their methodological stance as the majority of those included in this review reflected a medium quality and, a total of 33% of them reflected low quality. Regarding the descriptions concerning functional ability, MoCs or research focusing on nurses’ perspectives related to either state our findings clearly implies the need of more well conducted studies regardless of whether the research questions imply a qualitative or quantitative design.

Regarding the state of frailty, our work further highlights the importance of embracing the multidimensional approach to frailty. The ongoing debate among academics and clinicians about the uni- and multidimensional approaches, coupled with the absence of a clear and comprehensive definition of frailty [91], has not significantly advanced the field. In addition, there is controversy over whether frailty should be considered a precursor to functional ability limitations or whether it should be considered a part of frailty (12). This suggests that, to make progress in the field, it may be necessary to address the conceptual confusion surrounding these two states, especially within research into nursing. Several researchers have advocated for a multidimensional approach to frailty, emphasising overall functioning and the potential reversibility and preventability of these states [92,93,94]. Furthermore, research implies a shift within the nursing profession where the perspective of nursing and nursing practice in relation to the state of frailty is more prominent [95,96,97]. This shift is vital because others [95, 96] have suggested that nurses in community care are exceptionally situated to facilitate assessments and management of the ever-changing phenomenon of the state of frailty in the care of older people. Considering this, we propose that it is possible that the two states of interest in this review must be explored simultaneously while testing those operationalisations and definitions available now. This might further this discussion and strengthen the related nursing practice. Our findings also indicate that further research aimed at strengthening nursing practice by developing, testing and implementing effective MoCs containing proactive preventative strategies directed at older people’s functional ability limitations and frailty is needed. This is important because we know the extent of negative health outcomes related to these conditions, which we can spare older people by preventing or reversing the states early [13].

Evidence for practice

Regardless of the development of a research-based understanding, the main evidence for practice from our findings highlights the critical responsibilities of nurses in gaining a deeper understanding of older people’s experiences through their assessments and evaluations of functional ability limitations and frailty. Our findings imply that there is a distinct difference between older people’s and nurses’ perspectives of the state’s impact on everyday life and that of older individuals, with older people’s descriptions painting a more nuanced picture. To effectively implement a nursing practice that are capable of early detection and prevention of the often, subtle signs and symptoms of these states, it is essential for nurses to actively seek the perspectives of older people to provide care that is appropriately tailored to their needs. Nevertheless, our findings suggest that we still have a limited understanding, i.e., lacking knowledge, how nurses themselves view and experience functional ability limitations and frailty, particularly the former, as related or unrelated, or if they actively target them in their professional clinical practice in this context. Regardless, to be able to include the patient’s perspective into a tailored care demands systematic and evidence-based working modes. Example of the latter is models of care (MoCs) which outline, organise and guide nurses’ specific scope of practice, including their authorisation, responsibilities and functions. Thus, we suggest that MoCs need to emphasise the nurses’ clinical decision-making process—i.e., nursing process [98, 99]. Especially as it is central to all nursing practice and stresses the uniqueness of a nursing practice focusing on patients’ reactions to their health condition and their responses to treatment and nursing care rather than the patients actual medical diagnosis [cf. 100, 101]. Knowledge about the latter is essential since nurses’ clinical practice and decision-making processes are shaped by their competence and skills related to functional ability limitations and frailty. Thus, exploring nursing practice in relation to these states appears vital as more knowledge are warranted that can facilitate the development of feasible and acceptable MoCs for nursing practice in the ever-changing environments of home and facility-based care.

Currently, much practice in this context is characterised by task orientation and ‘firefighting’ rather than providing holistic care [102]. Our findings were related to a lack of formalised care plans, a lack of staffing, gaps in service, task-oriented services, time pressure, a lack of standardised assessment tools and a lack of training. These findings are also supported by previous research showing that nurses must more or less simultaneously address the factors related to the health care system, such as quality of care delivery and organisational and contextual factors [103, 104]. To address these challenges, it is crucial to develop nursing practice through both tangible clinical changes and research designed to yield appropriate, practical implications for nursing practice, in other words, research design to counteract waste of research and promote sustainable inquiry.

Methodological considerations

There is an inherent strength in following Arksey and O’Malley’s [26] methodological framework. As such, it supported our iterative processes from the development of search strategies and the inclusion of full texts to the extraction and summarisation of the findings. The implementation of the PAGER framework [27] for the visualisation (patterning) and reporting of findings could also be viewed as a strength. Regardless of this—and together with our decision to aim for sensitivity instead of specificity [38] in our search strategies—we cannot exclude that some papers might have been missed. Despite recommendations [26] to not conduct critical appraisals in scoping reviews, we decided to assess both the quality and ethical considerations of the included papers. Lately, this has become a more common trait in scoping reviews, and by doing so, important perspectives can be revealed, particularly when the PAGER framework and its individual headings for reporting (i.e., ‘gaps and research recommendations’) are implemented. Assessing the ethical considerations made in the included papers may be a priority in scoping reviews (or, in that case, in all reviews). Others have implied that relevant information and/or gaps are likely to be identified [77, 105]. Our detailed description of our systematic process in stage 5—summarising—might be seen as a strength in relation to the analysis and reporting of our findings. Having opted to label the analysis as neither thematic nor content analysis, we leave it for the readers to evaluate its credibility [106].

Implications and conclusions

The present scoping review, being the first strand in a tier of three further consecutive project strands [cf. 28], has enabled us to identify what is already well researched and where the possible gaps are, thus counteracting waste of research [107,108,109]. Together with these upcoming strands, these findings inform the development and testing of an intervention targeting nursing practice related to functional ability limitations and frailty in the context of long-term care. For example, we can conclude based on some of our findings that there is a need to develop interventions targeting nursing practice related to these conditions and that our main focus should be on RNs working in home-based care, highlighting and investigating both conditions as a central part of nurses’ scope of practice. There is also a need for the simultaneous research of functional ability limitations and frailty to achieve a more complete understanding as to develop knowledge supporting nursing practice and the nurse’s clinical competence in home- and facility-based care.