Table 3 Data extraction Q2_Frailty
Author, year, country | Aim/research question(s) | Setting and participants | Design, data collection and analysis, categories/themes | Findings | Sorting of findings1 (Breaking down the text, inspecting and searching for patterns, assigning an identifier) | Categories |
|---|---|---|---|---|---|---|
Bjerkmo et al. [50] Norway | To explore how single-living frail older adults experience living with frailty in everyday life in rural Arctic areas | Home-based care Home care services in two rural municipalities in the northernmost county of Norway 8 older people, identified as frail (age range = 82–93 years,♀ = 6) | A qualitative longitudinal design A series of interviews Inductive thematic analysis Theme: Frailty as a phenomenon Theme: Frailty as part of old age with the sub-themes; Physical and mental decline; Letting go; Accepting the need for help; Being alone Theme: Frailty in a rural Arctic context with the sub-themes; Climate; Long geographical distances; Societal changes | The participants’ experiences of frailty varied over time. Becoming increasingly frail was partly a result of changes in health conditions. The participants shared experiences of “being almost in the reach of death” and then coming to life again. Many participants tried to adapt to the changing circumstances, while others found it more challenging. However, the findings are in line with that frailty is not a state of inevitable, “one-way”, progressive decline. Rather, they experienced “frailty” as dynamic state and as something they had to cope with, balancing losses and capacity in everyday life. Some described being frail for a shorter or a longer period of time, for example in connection to a fracture, where they could experience being frailer afterwards. Some associated frailty with having to accept more help. Their stories concerned tasks or skills that they had mastered but also those that they eventually had to let go of. Physical changes caused limitations in their everyday lives. Several participants made a distinction between physical frailty and mental frailty. Some linked frailty primarily to bodily changes and others to mental changes. Participants’ stories also concerned being alone. Not having someone to talk to was experienced as a loss, while others had come to terms with what life had become. The findings demonstrated that frailty cannot be understood solely as an individual trait or condition. Rather, shifts in the balance point (of frailty) result from an interplay between age, health related changes, contextual challenges, as well as the physical and social environments. The participants, in varies degrees, considered the experienced changes (frailty) to be a result or a part of increased age. Several tried to adapt to the changes, while others found it more challenging to accept the limitations that growing older had created. The findings showed that the rural Arctic environment affected the participants’ experiences of frailty (snow, distances, etc). Changes in society also contributed to their experiences of frailty, such as the closing of the local bank and transition to digital solutions made the participants dependent on others to perform tasks that they had previously mastered. The participants also acknowledged that their own frailty limited their social interaction. Several participants expected that they would have to move from their own homes in the future as a consequence of increased care needs and the need for social contact. However, most participants wanted to continue living in their own homes and communities for as long as possible, despite challenges | Frailty was by the older people experienced as a dynamic state where they had to balance losses and capacity in their everyday life. There were differences in the ability to adapt. Physical challenges, together with contextual, societal changes and the physical and social environment produced limitations in the older people’s everyday life. However, despite challenges, most older people wanted to live at home, simultaneously expecting to have to move. The older people experienced being alone as challenging in different degrees, some experienced it as a loss, while others had reconciled with the changes. Their own frailty was recognised to limit their social life [Descriptive label: Frailty, a constant process to defy, defeat conquer] Several older people made a division between types of frailty, connecting frailty to physical changes or mental changes. The older people’s experiences described frailty not as exclusively an individual trait or condition, but rather as an interplay between age, health related changes, contextual challenges, as well as the physical and social environments. Frailty was experienced as connected to increasing age in different degrees by the older people. Some adapted to these changes, while other found it difficult to accept [Descriptive label: Frailty and its relation to functional ability] | Implications—Everyday life Notions—Justifications |
Britton [51] England | To explore the experiences of community nurses in assessing frailty and planning interventions around frailty | Home-based care Community service provider in West of England. 6 community nurses [age/sex not specified] | Qualitative design Semi-structured interviews Thematic analysis Themes: Aspects of frailty; Frailty as an emerging concept; Lack of confidence with assessment tool and lack of certainty around frailty; Nursing knowledge and intuitive knowing; Barriers to assessing frailty within community nursing; Suggestions going forward | Participants discussed several key aspects associated with frailty such as appetite, medication and polypharmacy, past medical history and long-term conditions, social and family support, cognition, environment, and equipment use. One key characteristic raised in all interviews was mobility. Participants discussed that they routinely look at patients’ mobility and walking pace, using opportunities, such as when a patient answers the door, to assess walking. Generally, participants linked frailty with older age. Some participants discussed an intuitive feeling, intuitive knowing, that patients are frail and while they discussed some key aspects of frailty, they were not able to comprehensively verbalise the rationale behind this ‘feeling´. Some uncertainty around the concept of frailty and its definition was noted and some called for more in-depth training. Participants had a growing awareness of frailty in practice, but challenges such as time pressures, described their job as ‘busy, short staffed’ and ‘high pressured’. Participants linked time constrains with difficulty in assessing frailty. Participants discussed that more staff and more time would make frailty assessment more achievable. The Rockwood frailty scale was used within practice, but it was perceived to lack validity within the community setting. It was also discussed that nurses sometimes perceived some gaps within services, preventing them from referring on. Comments regarding patients ‘slipping through the net’ | Described key-aspects used for observation and assessment by the nurses [Descriptive label: Frailty and its “simple” description] Professionals experienced an uncertainty around frailty and its definition [Descriptive label: Frailty and its ambiguity] Lack of knowledge and calls for in-depth training [Descriptive label: Frailty and the lack of nursing knowledge] Frailty equals older age [Descriptive label: Frailty and its negative connotations] Nursing practice focusing on the detection/identification of frailty was guided by an intuitive feeling without nurses having the ability to verbalise the rationale behind this feeling [Descriptive label: Frailty and its intuitive nursing practice] The nurses’ ability to assess frailty was negatively influenced by organisational issues such as time pressure and lack of staffing and gap in services, but also by the instrument meant to be implemented for assessment which were experienced as not being relevant for their setting [Descriptive label: Frailty and organisational challenges] | Notions—Justifications Notions—Uncertainties Notions—Deficiencies Notions—(Pre)conceptions Implications—Nursing Practice Implications—Nursing Practice |
Lloyd et al. [52] United Kingdom | To understand the changing experiences of frail older people through the stories that they told | Home-based care Community-dwelling older people recruited from a medical day hospital 13 older people (age range 76–92 years, mean 86 years, ♀ = 8) [5 participants died during the study, ♀ = 4] 13 informal caregivers 8 case-linked professionals: 2 care workers 5 general practitioners 1 occupational therapy assistant [age/sex not specified] | Qualitative longitudinal approach Interviews (individually or jointly; older person and informal carer) Analysed using The Voice Centred Relational Method Three distinct forms/patterns: Narratives of stability and coping; Narratives of struggle and unbalancing; Narratives of becoming overwhelmed Result heading (not specified as a theme/category): Bringing the narratives together | The frail older people told stories of their experiences that revealed three distinct patterns. These were either stable, unbalancing or overwhelmed and related to how the person managed to adapt to increasing challenges and losses, and to reintegrate their sense of self into a cohesive narrative. Frailty was described as both biographically anticipated yet potentially biographically disruptive as older people may struggle to make sense of their circumstances without a clear single causative factor. The experience of living with frailty involved increasing losses which disrupted, and progressively restricted, the everyday lives of older people. This involved disruption of the taken-for-granted aspects of the physical body, of daily life and relationships with the self and others, where the person experienced a shift from their normal expected life trajectory that undermines self-identity. Varying degrees of fear and anxiety over what the future may hold was described | Described three distinct patterns of frailty: stability, unbalancing or overwhelming [Descriptive label: Frailty and its “simple” description] Frailty was expected but the experience of living with frailty was that frailty was expected but included varying degrees of adaption to growing difficulties and losses which disrupted, and progressively restricted, the everyday lives and relationships of the older people as well as a struggle to reintegrating their sense of self in this process. Living with frailty was described as involving varying degrees of fear and anxiety related to what may be in store for the future [Descriptive label: Frailty, a constant process to defy, defeat conquer] The older people also experienced a shift from their normal expected life trajectory that undermined their self-identity [Descriptive label: Frailty and its discord] | Notions—Justifications Implications—Everyday life Implications—Individual level |
Nicholson et al. [53] United Kingdom | To understand the experience of home-dwelling older people living with frailty over time | Home-based care Community-dwelling older people recruited through an older persons’ intermediate care team 17 older people (age range 86–102 years, ♀ = 12) | Combined qualitative psychological method In-depth interviews using the Biographic Narrative Interpretative Method (BNIM), Free Association Narrative Interview Method (FAINM) and psychodynamic observations Analysed using a modified BNIM analysis and cross-case analysis Main themes: The dynamics of physical and psychosocial frailty; Sustaining connections within the home; Connecting with death dying | In the findings of this study frailty is presented as a persistent liminal state. The dynamics of physical and psychosocial frailty details the persistent state of uncertainty and loss experienced as a result of progressive physical and psychosocial changes. To retain anchorage in this state of imbalance, frail elders work actively to develop and sustain connections to their physical environment, routines, and social networks. The study also reveals the problematic nature of finding shared meanings between older people and health and social care professionals within the continual and shifting state of frailty. Important note, nobody in the study used the term ‘frail’ to describe themselves or their situation | Frailty was experienced as a persistent state signified by uncertainty and losses due to physical and psychosocial changes, to remain anchored older people worked to develop and sustain connected to routines, their environment and social networks [Descriptive label: Frailty, a constant process to defy, defeat conquer] Frailty was not used by the older people as a concept to describe themselves or their situation [Descriptive label: Frailty and its discord] | Implications—Everyday life Implications—Individual level |
Nicholson et al. [54] United Kingdom | To understand the experience of home-dwelling older people with changing states of frailty | Home-based care Community-dwelling older people recruited through an older persons’ intermediate care team 15 older people (age range 86–102 years, ♀ = 10) | Combined qualitative psychological method In-depth interviews using the Biographic Narrative Interpretative Method (BNIM), Free Association Narrative Interview Method (FAINM) and psychodynamic observations Analysed using a modified BNIM analysis and cross-case analysis Main themes: Losses and disconnects within frailty; Sustaining connections; Creating connections | Frailty was understood in terms of potential capacity—a state of imbalance in which people experience accumulated losses whilst working to sustain and perhaps create new connections, as well as creating everyday routines. This process was overlapping and multifaceted. The participants demonstrated capacity to overcome or find others to overcome their physical, emotional, or social vulnerabilities. However, participants did all speak of loss over time, loss of physical capacity, social status, friends, and family. For most the opened discussions around dependency, finitude and their experiences of barriers related to societal and welfare systems. The narratives suggest that the balance between (loss of) autonomy and dependence and changing roles is complex. Nobody used the term ‘frail’ to describe themselves or their situation. The older peoples extraordinary work of relating their ordinary world in a different way does not equate to the predominant stereotypical image of frail older people which focus on vulnerability | Frailty was understood (experienced) as a state of imbalance where losses accumulated whilst the older person was working to sustain and creating everyday routines whilst still demonstrating capacity to overcome losses [Descriptive label: Frailty, a constant process to defy, defeat conquer] Frailty was not used by the older people as a concept to describe themselves or their situation. Instead, older people’s experiences and their capacity to handle the accumulated losses did not equate to the stereotypical image of frail older people which focus on vulnerability [Descriptive label: Frailty and its discord] | Implications—Everyday life Implications—Individual level |
Obbia et al. [55] Italy | To explore the views and experiences of primary care professionals working with older people on of the concept of frailty Research questions: • What are the views held by primary care professionals regarding frailty in older people? • What are their experiences regarding the early detection of frailty among their older clients? • What are their experiences of introducing preventive interventions in practice with older people showing signs of frailty? | Home-based care Four local health agencies in one middle-sized town, one rural area, one affluent urban area, and one deprived urban area, in Piedmont, Italy 33 practitioners: 11 district nurses 8 home care workers 6 social workers 4 physiotherapists 4 GPs (mean age = 48, ♀ = 29) | Qualitative descriptive phenomenological design Focus group interviews; N = 4 Phenomenological analysis Theme: The psychosocial nature of frailty with the sub-themes; Loneliness; Financial issues; Family and community networks; Psychological distress; Hidden cognitive problems; Loss of independence Theme: Late detection Theme: The enablers/barriers to preventive interventions with the sub-themes; Support and related outcomes; Lack of awareness and fear of being labelled; The wall of bureaucracy; Access to the care network; Integration of care | Frailty was considered a constituent part of the ageing process, and the term frail was confused with the presence of known disability and multimorbidity and no clear distinction was made between the term’s frail, multimorbidity and/or disability. Implying the presence of a skills gap related to the detection of the early signs of frailty. The professionals experienced difficulties in identifying those who were frail or who may become frail. Early detection and effective preventive interventions were considered complex but feasible by participants. However, this may require a systematic restructuring of primary care organisations. Important dimensions of frailty were loneliness, financial issues, family/network, comorbidity, disability, hidden cognitive problems and phycological distress while family, neighbours, or informal caregivers were seen as “protective factors”. Participants believed the older people did not want to be labelled as frail or as someone in need | Professionals could not distinguish between frail, disability or multimorbidity [Descriptive label: Frailty and its ambiguity] Lack of knowledge and training related to early detection of frailty and the prevention of frailty [Descriptive label: Frailty and the lack of nursing knowledge] Frailty was preventable but the present health- and social care system and a lack of focus hindered such work [Descriptive label: Frailty and its reversibility] Frailty equals negative connotations of being old and in need of help [Descriptive label: Frailty and its negative connotations] Staff described that older people did not want to be labelled as frail or in need of help [Descriptive label: Frailty and its discord] Described protective factors as well as important factors of frailty [Descriptive label: Frailty and its “simple” description] | Notions—Uncertainties Notions—Deficiencies Implications—Nursing Practice Notions—(Pre)conceptions Implications—Individual level Notions—Justifications |
Papadopoulou et al. [56] Scotland | To understand the perceptions of community nurses about frailty; training and use of educational materials on frailty; learning needs in relation to identification, assessment, and management of people with frailty; and their leadership role in interdisciplinary practice within community teams | Home-based care One health board area in Scotland Community nurses; N = 17 Team leaders, with formal specialist practitioner qualification, registered nurses, and clinical support workers [age/sex not specified] | Exploratory qualitative design Focus group interviews; N = 3 Individual interview; N = 1 (team leader) Thematic content analysis Theme: Concept of frailty with the sub-themes; Meaning of frailty; Process of caring for the frail Theme: Knowledge about frailty with the sub-themes; Educational needs; Building capacity in the context of adversity | The term frailty was associated with negative attributes, such as being vulnerable and old, experiencing various losses and having multiple health conditions—complex comorbidity. Loneliness and social isolation were also recognised as complicating frailty. The nurses differentiated between the inevitability of the ageing process and the potential for frailty to be reversible or preventable. They also acknowledged the potential for early interventions to prevent functional decline. Current practice was described as largely reactive, guided by experience and intuition, with little systematic frailty-specific screening and assessment rather than a systematic use of evidence-informed frailty specific screening and assessment. Thus, the nurses expressed a need for frailty-specific education, particularly around assessment | Frailty equals negative connotations of being old, and vulnerable [Descriptive label: Frailty and its negative connotations] Frailty was perceived as preventable and reversable with early interventions, but current practice was not organised to support this [Descriptive label: Frailty and its reversibility] Nursing practice focusing on the detection/identification of frailty was reactive and guided by intuition and experience [Descriptive label: Frailty and its intuitive nursing practice] Lack of knowledge about frailty and its assessment [Descriptive label: Frailty and the lack of nursing knowledge] | Notions—(Pre)conceptions Implications—Nursing Practice Implications—Nursing Practice Notions—Deficiencies |
Skilbeck et al. [57] England | To explore how older people with complex health problems experience frailty in their daily lives | Home-based care A community matron team in a city in the North of England 10 older people (age range 77–91 years, median 84 years, ♀ = 7) | Ethnographic study Participant observation (up to six encounters per participant) Semi-structured interviews Constant comparative analysis Theme: Fluctuating ill-health and the disruption of daily living with the sub-themes; Ongoing disruption; Stability and disruption Theme: Changes to the management of daily living with the sub-theme; Keeping going Themes: Frailty as fear, anxiety, and uncertainty; Making sense of changes to health and daily living | The frail older people experienced transitions in health and illness as a continual process of change, with sudden events, general decline, and periods of relative stability. Older people work hard to modify and maintain daily routines to achieve balance. Sustaining daily routines and renegotiating activities and priorities contributed to the maintenance of an older person’s identity as an independent person. This occurred even when transitions were enduring and multifaceted in nature, often pushing an older person’s adaptation to the limit and striving to construct and conserve daily routines, the older people in this study did not live up to the stereotyping associated with frailty. Episodic moments of frailty occur, where daily living becomes precarious, and their resilience is threatened. This could culminate in moments of fear, anxiety, uncertainty, and feeling frail. Bodily decline often tips this balance. The older people seemed to anticipate a situation where independence may decrease and the ability to exercise personal agency is reduced, led older people to contemplate their ability to continue living at home, their own ageing and mortality. Older people were aware of what they could not do for themselves and how this fluctuated. However, they focused on continuing to engage with daily living and in doing so they defined themselves in relation to what they could achieve | Frailty was experienced as an ongoing process of transitions of health and illness characterised by general decline and relative stability which forced older people to work hard to maintain their daily life and achieve a balance to continue their identity as independent while they continued to focus on what they could do. When this process failed and the adaption was pushed to the brink the older people experienced fear, anxiety, uncertainty and feeling frail [Descriptive label: Frailty, a constant process to defy, defeat conquer] | Implications—Everyday life |
Strømme et al. [58] Norway | To develop knowledge about homecare professionals’ observational competence in early recognition of deterioration in frail older patients Research question: • How can homecare professionals’ practices and experiences with early recognition of deterioration in frail older patients be described? | Home-based care Two home-care districts in two municipalities in western Norway; city, urban and rural areas. Focus group interviews; N = 30 Registered nurses, skilled health workers and assistants [age/sex not specified] | Explorative, qualitative mixed methods design Participant observation; 62 h Focus group interviews; N = 6 Qualitative content analysis Theme: Patient-situated assessment of changed clinical condition with the sub-themes; Knowledge of the patient; Changed physical and mental function; Basic understanding of vital signs Theme: Organisational environment with the sub-themes; Focus on planned practical tasks; Collaboration, and collegial support | Awareness of, and ability to recognise signs of deterioration varied and was at times quite low. No clear difference was found between the RNs, skilled health workers and assistants in noticing early signs of deterioration. Monitoring and measuring patient’s vital clinical signs were not a priority among staff. Thus, vital signs were in general measured infrequently. When a patient’s situation was vague or critical, vital signs were measured more frequently. In situations where nonspecific signs and symptoms were the only indicators of a patient’s decline the HCPs emphasised the importance of knowing the patient. Many found it difficult to visit unfamiliar patients and assess their clinical conditions. In a few situations, changes in physical and mental functioning led to the HCPs communicating with the patient and monitoring certain vital signs. However, in most instances, HCPs described relying on intuition and feeling a sense of concern to pinpoint signs of decline. The organisational environment influenced their practices, their routines were described in detailed workplans which affected their assessments of the patients’ decline. The HCPs expected actions and tasks during home visits to be part of the detailed work plans | Lack of knowledge and skills in early recognition of deterioration among both RNs and other Health Care staff. Both groups did not show visible differences related to how they noticed early signs of deterioration [Descriptive label: Frailty and the lack of nursing knowledge] Nursing practice of early recognition of deterioration were guided by the HCPs intuition and sense of concern and monitoring or measuring vital signs were not prioritised [Descriptive label: Frailty and its intuitive nursing practice] HCPs practice, actions/tasks were described as controlled by set workplans not supporting early recognition of deterioration and the non-specific signs and symptoms aggravated the HCPs ability for early recognitions. Early recognition of deterioration demanded knowledge about the patient [Descriptive label: Frailty and organisational challenges] | Notions—Deficiencies Implications—Nursing Practice Implications—Nursing Practice |
Søvde et al. [59] Norway | To explore the lived experiences of frail home-dwelling older people Research question: • How do home-dwelling older people experience frailty? | Home-based care Two geriatric outpatient clinics 10 home-dwelling older adults (age range 72–90 years old, ♀ = 7) | Hermeneutical phenomenological study In-depth interviews Hermeneutic phenomenological Theme: Frailty as being in the borderland of the body with the sub-themes; The body shuts down; Living on the edge; Not giving up | The experience of frailty is described as an ambiguous experience of balancing frailty, strength, and an altering body. Given the findings of this study, frailty might be experienced as a downward spiral of losses of physical functioning, social engagement and a pervasive risk of injury when performing daily activities. Participants even started questioning their capability to walk on stairs without falling or get to the door when the doorbell rang without tripping over their feet. The findings show that participants experienced that they could not escape or recover from frailty, and some had to give up meaningful activities, which was a big loss. Still, participants adjusted previous activities to keep up meaningful activities, and still being independent, this strengthened their feeling of being themselves. They used past experiences of overcoming life challenges to endure and to hold onto what was most important for them. Participants described fear of being left with a meaningless everyday life with nothing to fill the days | Frailty was described and experienced as a downward spiral of losses from which they could not escape or recover from, still using past life experiences and adjustment of their daily activities supported them to experience independency and being themselves. The spiral of losses meant that frailty could be accompanied by a fear of being left with a meaningless everyday life [Descriptive label: Frailty, a constant process to defy, defeat conquer] | Implications—Everyday life |
Voie et al. [60] Norway | To explore how home care professionals conceptualise frailty in the context of home care | Home-based care One large municipality in Northern Norway 14 Registered nurses and certified nursing assistants home care or day care centres (♀ = 11) [age not specified] | Qualitative research design Focus group interviews; N = 4 Thematic analysis Themes: “Frail”–a term which is too imprecise to be useful; Frailty as a consequence of ageing; Frailty as lack of engagement and possibilities for engagement; Frailty as a contextual phenomenon; Frailty as potentially affected by care | The home care professionals conceptualised frailty as an individual trait but also as resulting from the interplay between individual and environmental factors. Moreover, the home care professionals conceptualised frailty diversely; representing a continuum between frailty as related to prevention and management (‘cure’), and frailty as related to ageing as natural decline (‘care’). The participants thus conceptualised frailty in accordance with the service users’ diverse health and care needs, and how they as home care professionals provide services that range from supporting people with minor tasks, such as medication delivery and domestic care, to caring for people with extensive health and care needs. Furthermore, the terms frail and frailty were considered ‘too imprecise to be useful’ while also being terms to which the home care professionals ascribed several contrasting meanings. Rather than using the term ‘frail’, the home care professionals in this study preferred to use terms they considered more ‘professional’ and specific when addressing service users’ care needs. The participants in this study acknowledged that frailty is ‘potentially affected by care’ and considered physical activity, nutritional support and social support as means to prevent or reduce frailty. The participants conceptualised frailty as both a natural age-related decline, which could be expected in very old age, and as a state that can be prevented or reduced. The results indicate that while home care professionals struggle to conceptualise frailty, they manoeuvre the continuum between cure and care in their everyday practices and in encounters with older persons with complex care needs. While the home care professionals talked about interventions to prevent and reduce frailty, statements also demonstrated that they also recognised the limits of curative models of care and that frailty is not always possible to prevent | The nurses (home care professionals) conceptualised frailty in different ways; as an individual trait or as a result of the interaction between individual and environmental factors. Conceptualising frailty on a continuum between; as related to prevention and management (‘cure’) and as related to ageing as natural decline (‘care’). The nurses (home care professionals) considered the older peoples’ (service users’) different need and the care they had to provide—from minor tasks to extensive need [Descriptive label: Frailty and its relation to functional ability] The nurses (home care professionals) preferred to use other terms than frail or frailty, which they saw as more “professional” and specifying the individual’s needs, as they considered the former terms as too imprecise and including contrasting meanings [Descriptive label: Frailty and its ambiguity] The nurses (home care professionals) saw frailty as both potentially preventable through care/interventions such as physical activity, nutritional support and social support, while at the same time demonstrating that they acknowledged that it was not always preventable [Descriptive label: Frailty and its reversibility] | Notions—Justifications Notions—Uncertainties Implications—Nursing Practice |
Wang et al. [61] United States of America | To describe HHC nurses’ understanding of and educational preparation for effective assessment of depression and frailty in older patients and to identify barriers to HHC nurses’ care related to the assessment and care management of depression and frailty in older patients | Home-based care Four home healthcare agencies in the great Nashville, TN area, USA. One private, nonprofit agency and three proprietary, for-profit agencies 10 RNs for interviews (range 25–64 years, Median = 53.5 years, ♀ = 9) 4 additional RNs for observations (age range 40–50 years, ♀ = 3) 16 older people observed (range 65 and 94 years, median 79 years, ♀ = 62%) | Qualitative pilot study Direct observations; N = 16 home visits Semi-structured interviews; N = 10 Qualitative content analysis (inductive-deductive), using an adapted SEIPS framework IBM SPSS: Descriptive quantitative analysis of data from observations Categories from interviews (SEIPS framework): Health care system; HHC agency; Technology and tools; HHC nurses; Home and community environment; Patient characteristics 14 themes in total under these categories | The nurses report a lack of education in frailty assessment, and few nurse visits incorporated such assessment, i.e., frailty was not routinely screened for in nursing practice. The nurses were familiar with the term frailty generally, still they were unsure of the exact meaning of the term. Despite a belief that screening for frailty fell within their job role they did not feel prepared to assess or manage frailty due to lack of education and training, this was referred to others; “Physical and occupational therapy [are better suited] because they are professionals…”. Assessment of frailty indicators that was done was primarily subjective (e.g., patient weight self-report), while objective measures were related to specific medical conditions. In interviews, assessment of (instrumental) activities of daily living were reported as prioritised, yet it was not noted during any of the observations. The findings might suggest that for both frailty and disability, what HHC nurses need is a higher-level understanding about how these deficits and symptoms interact and how these interactions lead to poor health outcomes. The participants reported a focus on ensuring safety, availability of equipment as well as availability and knowledge of informal caregivers. Having a recent history of falls, multiple chronic conditions, and physical exhaustion indicate elevated risk for frailty according to the participants. Barriers, which if addressed could facilitate nursing care delivery related to frailty included insufficient training and lack of standardised protocols/guidelines, documentation burden, limited reimbursement, difficulties getting insurance approval which affects the number of visits and type of equipment provided, lack of effective interdisciplinary collaboration and high caseload affecting the possibility to develop a trusting relationship important to gather important information | Nurses were unsure of the exact meaning of frailty and calls for more training is uttered [Descriptive label: Frailty and its ambiguity] Lack of knowledge (education and training) about frailty and its assessment, leads to frailty not being a part of the nursing practice [Descriptive label: Frailty and the lack of nursing knowledge] Described key-areas of importance when working with older people with frailty and risk factors for frailty [Descriptive label: Frailty and its “simple” description] The nursing practice was affected by several barriers, which if resolved might facilitate the nursing care [Descriptive label: Frailty and organisational challenges] | Notions—Uncertainties Notions—Deficiencies Notions—Justifications Implications—Nursing Practice |
Archibald et al. [62] Australia | To understand how older people, including frail older persons in residential aged care, perceive and understand frailty | Facility- and home-based care Two aged care facilities (FBC) and one continued learning university (HBC) in South Australia. 39 older people (age range 62–99 years, mean 80.6 years, SD = 9.6) FBC; N = 17 HBC; N = 22 [sex not specified in numbers] | Interpretive descriptive qualitative design Focus groups interviews; N = 7 Thematic Analysis Theme: The old and frail: a static state near the end of life Theme: Frailty at any age: a disability model with the sub-theme; Perspectives of frailty as a dynamic state were common within the disability view Theme: Frailty as a loss of independence: control, actions and identity with the sub-themes; Frailty is seen as a loss of control over oneself and one’s environment and is closely tied to mobility; Frailty and a loss of independence is linked to identity and self-worth Additional theme describing important influencing factors (mediators) cutting across the three ways of describing frailty: Mediating factor: frailty is influenced by mental state and attitude, with the sub-themes; Within the ‘old and frail’ schema, mental state and attitude are seen as protective towards frailty but are entangled with choice and individualism; Mental frailty: attitude and mental state as a cause or type of frailty | Understandings of frailty varied significantly and despite the older people being familiar with the term frailty, it often lacked a specific meaning. Frailty was described according to three schemas for how older persons view frailty. First a model of frailty as old age, where frailty was related to the end of life and was largely unpreventable and unmodifiable. Second, a disability model where frailty was modifiable, could occur at any age and could affect isolated parts of the whole person (mostly described by the non-frail or prefrail participants living in community settings). Thirdly, an independence-focused model where frailty was seen as a static state, associated with age, loss of ability, control of one’s environment and oneself, loss of identity and self-worth. Mobility was central in this schema linked to independence, and mobility aids could be a sign of frailty. Aside from a disability model, views of frailty as unmodifiable permeated older persons’ perspectives. Still, the participants relating frailty to advanced age did generally acknowledge that not everyone becomes frail. Mindset, cognition, and emotions were discussed as important influencing factors cutting across the schema—entwined with attitude and choice and are indicated as mediators. Frailty was generally viewed negatively, often linked to end of life, and implicated with personal choice, specially related to mental frailty. Participants generally resisted self-identifying as frail and there was little correlation between the frailty assessments and participants self-identification as frail. Participants differentiated between different ‘types’ of frailty, i.e., physical, and mental frailty and discussed their relationship. Often physical frailty was perceived as “more real” and mental frailty was more associated with negative connotations | The older people understood frailty in a variety of ways and the term often lacked specific meaning [Descriptive label: Frailty and its ambiguity] Frailty equals negative connotations of being old, near the end of life and was associated with personal choice, especially related to mental frailty [Descriptive label: Frailty and its negative connotations] Frailty was primarily perceived as unpreventable and unmodifiable, but some still saw it as modifiable, occurring at any age and affecting isolated part of the person (mostly community-dwelling) [Descriptive label: Frailty and its reversibility] Frailty was a term the older people resisted identifying with them-self, even those assessed as frail [Descriptive label: Frailty and its discord] Described associated factors and mediators related to frailty [Descriptive label: Frailty and its “simple” description] Separating physical and mental frailty, with differing understanding of the relationship [Descriptive label: Frailty and its relation to functional ability] | Notions—Uncertainties Notions—(Pre)conceptions Notions—(Pre)conceptions Implications—Individual level Notions—Justifications Notions—Justifications |
McGeorge [63] United Kingdom | To explore how mental health nurses construct and operationalize the concept of ‘age-related complexity’ | Facility- and home-based care A large NHS mental health trust 13 RNs (♀ = 11) 5 working on wards 1 in care homes 1 in a general hospital 6 community psychiatric nurses [age not specified] | Constructivist grounded theory approach “Lightly structured” in-depth interviews Constant comparative method Category: Dynamic complexity. Themes: Components of complexity; Complexity as an abstract concept Theme (focus of this paper): The relationship between frailty and complexity with the sub-themes; Physical frailty versus multidomain complexity; Unidirectional frailty versus dynamic complexity; Decline versus recovery; Long-term conditions versus acute problems | Nurses in this study offered the consistent view that while frailty and complexity are related, they are neither mutually dependent nor mutually exclusive. Nurses saw the identification of frailty as straightforward or ‘obvious’. Frailty was exclusively used to describe physical states and attributes, while complexity is seen as a consequence of the interaction of needs across a number of areas. Unlike frailty, complexity is a dynamic state in which there can be movement back and forth, it emphasizes the possibility of improvement (becoming less complex) as needs are met or circumstances change | Frailty was exclusively related to physical states and attributes, and was believed to be obvious to identify [Descriptive label: Frailty and its relation to functional ability] Frailty was indirectly described as a static state with no possibility of transitioning between severity degrees [Descriptive label: Frailty, a constant process to defy, defeat conquer] | Notions—Justifications Notions—(Pre)conceptions |
Schreuders et al. [64] England | To explore care home managers’ perspectives of the term frailty, how the care of residents living with frailty is managed and whether existing frailty guidelines are useful in the care home context | Facility-based care Seven care homes in the North of England. 8 care home managers: 5 previously worked as carers 2 were RNs 1 previously worked in hospitality management ♀ = 8 [age not specified] | Exploratory qualitative design Semi-structured interviews Thematic Analysis Main themes: Frailty is not specific enough; Providing individualised care to older people is more important than categorizing residents; Supporting residents to access outside support or expertise is a key role of the care home manager | The care home managers believed that the term frailty was not specific enough in a context where many are frail and individualised care is requisite, it was not useful in providing additional information to care management. The participants did not agree on the characteristics of frailty and the findings show that care home managers do not define the term frailty in the same way as in the medical literature. Frailty was described as related to a person’s physical ability but could also be relevant for people mental and cognitive decline or difficulties. The care home managers did not like to use the term frailty as it had negative connotations which they were afraid might be harmful to the person’s identity. It was seen as not in line with their responsibility of providing individually tailored care as labelling residents as ‘frail’ was incompatible with acknowledging them as individuals with unique needs. Furthermore, they did not believe identifying the residents as frail would facilitate access to outside support, even if they experienced barriers related to receiving such support. Care home managers valued a proactive approach and discussed how they used their knowledge and experience to recognise the need for, and arrange access to, outside expertise when caring for residents with frailty | The term frailty was believed to be too unspecific to be valuable in care, did not have an agreed set of characteristics nor did the understanding fit in line with medical literature [Descriptive label: Frailty and its ambiguity] Described frailty as mostly linked to physical ability and in some degree to mental or cognitive difficulties [Descriptive label: Frailty and its relation to functional ability] Care home manager use their knowledge and experience when managing care for older people with frailty [Descriptive label: Frailty and its intuitive nursing practice] | Notions—Uncertainties Notions—Justifications Notions—Deficiencies |