The Frailty Matters Project

Older people with frailty or complex multiple conditions need proactive health and social care. They require support that anticipates changes in their conditions and offers tailored early intervention by a range of professionals and community partners, which will enable them to stay independent and healthy for as long as possible at home or in the place they call home (British Geriatrics Society and the Royal College of General Practitioners, 2015). This requires a shift from care that is reactive, fragmented, episodic and hospital-facing to proactive and personalised, which focuses on what matters to the individual and is well coordinated and grounded in a strength-based approach (Caiels et al, 2021)

Healthcare professionals (HCPs) working in the community are key in identifying those at risk of developing frailty and in prompting early intervention. As part of their role in care coordination between various professionals and services, nurses, in particular, need to have certain skills in order to ensure the care and support they provide to older people is of the highest quality. Such care must enable the older adults to live well and stay healthy at home. Research evidence indicates a need to increase the understanding and confidence of nurses to manage frailty (Britton, 2017; Windhaber et al, 2018; Papadopoulou et al, 2021).

This article reports results from a collaborative project that aimed to enhance the knowledge, confidence and capability of community nurses to manage frailty in a community setting.

Materials and methods

Study design and methodological approach

The project followed principles of participatory action research (PAR) (Chevalier and Buckles, 2013) and was conducted in three phases from February 2019 to August 2021: 1) mapping and co-design of the coaching and educational programme; 2) programme delivery; and 3) evaluation and dissemination. Results of phase 1 of the study have been reported elsewhere (Papadopoulou et al, 2021). During the co-design and delivery phase of the project (phase 2), participants and citizen co-coaches provided feedback that helped shape the content of the combined coaching and educational sessions. At the beginning and end of each session a reflection and planning for the next session was carried out.

Sample

We aimed to recruit a maximum of 12 community nurses with a responsibility for leading a local team. Each nurse had to be able to attend face-to-face and online sessions for the potential duration of the intervention and participate in a one-to-one end of study interview. We also aimed to recruit members of the public with experience of living with frailty; they were identified via the HCPs’ local arrangements for public involvement. The public co-coaches were invited to participate in the four face-to-face workshop sessions. Ultimately, nine community nurses and two co-coaches participated in the project.

Coaching and educational intervention

Due to the COVID–19 pandemic, the programme was revised mid-way. We held three face-to-face sessions, each lasting 6 hours, followed by six consecutive 90-minute sessions using Microsoft Office Teams (Table 1). The face-to-face sessions included two components: a coaching session in the morning and an educational session on a frailty component in the afternoon. An educational open access blog was created to house the teaching and coaching materials utilised in the interactive sessions. Every second week throughout the programme, materials on a new topic of relevance to the management of frailty within the community was posted. The blog also served as a team-teaching resource for the team leaders.

At the end of each interactive session participants and co-coaches were asked to consider a number of questions (Table 2). This exercise allowed the project team to tailor each blogging piece and interactive session to address participants’ requests, leading to some minor changes in the flow of the programme. Participants also had the opportunity to keep a personal log of their reflections (also see Box 1).

Box 1.Reflective questions after each session

• What has gone well?
• What has been more difficult?
• How could the coaching and education be improved?
• What have you learned about yourself, your patients, carers and team?
• What is different for you now in the day to day?
• What would you like to be different in the future?
• How would you like to be different in the future?

Evaluation strategy

A revised multi-source evaluation strategy was devised in order to manage restrictions placed by the COVID-19 pandemic. We conducted end of study telephone interviews (one-to-one and focus group; n=6) with participants. Due to limited capacity for staff to engage, we expanded our evaluation strategy to include feedback from other professional sources. We sought views of non-participant district nurses (DNs) (focus group interview; n=3) after they had access to the materials from the programme and the educational blog for a month. These were a group of experienced DNs from across Central Scotland who were participating in the Specialist Practitioner District Nursing and Graduate Diploma Integrated Community Nursing programmes being delivered in the hosting institution. Finally, we shared the aims of the project, an introduction to the ‘Frailty House’, the outline of the full programme and the link to the educational blog, with a convenience sample (n=21) of stakeholder workforce leads from a range of disciplines in 10 health and social care partnerships (HSCPs) and national organisations with an interest in frailty management (Scottish Care, Community Hospitals Association, and the Scottish Ambulance Service) (written feedback via email). The stakeholders were asked to provide answers in a qualitative survey, and send them back via email.

Data analysis

Interviews were audio recorded and transcribed intelligent verbatim using an authorised secretarial service. Qualitative data from the one-to-one interviews as well as the written feedback from the qualitative survey with the stakeholders’ views were analysed using broad thematic content analysis (Braun and Clarke, 2013).

Results

The Frailty House

To guide discussions within the sessions, we created an educational framework—the Frailty House (Figure 1), inspired by an established framework for collaborative care and support planning for people with long term conditions (Scotland's House of Care, 2016). The Frailty House was co-developed with participants, researchers and co-coaches after the first session and underwent three iterations to reach its current version. The foundation of the Frailty House is person-centred coaching and leadership, active listening, reflection and action planning to facilitate change and improvement. The walls are based on the concepts encapsulated in the approach to shared decision-making encouraged by the Chief Medical Officer's Directorate in Scotland, known widely as the realistic medicine approach (Realistic Medicine, 2023). The bricks are based on what the participants, co-coaches, steering group, public and professional stakeholders identified as the vital components required to make improving the lives of the people with frailty a reality. On the one side there are topics on which people living with frailty and their carers require to be engaged, informed, and empowered to manage their health conditions through a self-management approach. On the other side there are topics that health and social care professionals need to understand to manage those living with frailty effectively. The floor of the house hosts the relational, social and community assistance required when planning care and support for older people living with frailty in the community.

Feedback from participants

a. Changes in clinical practices

Participants in the study identified that the programme had altered the way they assessed people with multiple conditions and that they were now more likely to make use of a formal frailty assessment tool:

‘We had this idea in our head of what frailty was to us, and if we saw patients in our care, we just automatically put them into that category by saying they were very frail. Now we’ve actually got…an actual grouping for frailty now...it's a whole different way of thinking’. Participant 3 (Focus group)

‘The assessment that I would use now…it's most definitely a more comprehensive assessment that I do, now.’ Participant 1 (Telephone interview)

The improved knowledge of frailty and its assessment led to a further improvement in nurses’ overall confidence in dealing with frailty:

‘…when you’re talking to other professionals, I suppose it gives you that more credence to say, I’m concerned about frailty, they’re sitting at this score…before, you’re saying, there's just something, I’m not quite sure what it is, but they’re getting a bit frailer. Whereas, now you can identify whereabouts they are on the frailty score, and use that as part of your assessment, so from that point of view, definitely, it's assisted.’ Participant 5 (Focus group)

A key aspect of the teaching and coaching programme was the use of resources created by several community and third sector providers. This encouraged some participants to explore what was available locally and make more use of other community support services and assets.

‘I think something that was highlighted to me was transport for individuals, how to get to groups and...to get out and about, and I think I try to do something locally with that information now.’ Participant 1 (Telephone interview)

b. Views on the programme

The presence of citizen co-coaches had a considerable impact on what participants took away from the experience. When this was mentioned, it tended to be stated alongside the value of meeting with colleagues from other teams they generally had little contact with.

‘I liked the interaction with the non-professional people that were on the group, that was very interesting hearing the other side, I really did enjoy this. I learned a lot from the girls (other DN participants) as well, about the way things are getting done in the other areas.’ Participant 3 (Focus group) ‘I was able to pass on information to the staff nurses, when they came to ask a question, I could pass this on. So yes, there was definitely a benefit there in having access.’ Participant 1 (Telephone interview)

The blog was used by participants to gain further knowledge about frailty and as a reminder of what they learned in the online live sessions. The blog had increased visit activity towards the end of the project, indicating that nurses were sharing information with their teams and accessed information (Figure 2).

Finally, participants benefitted more from the face-to-face sessions than from the online delivery. This was reflected in the poor participation with online live sessions, albeit under very challenging circumstances during the pandemic.

‘I think the participation in the beginning was better. It didn’t work as well on Teams, I have to say, because there was the whole problem with actually getting the IT to work, because the IT infrastructure in our service isn’t good, but the times that we did manage to do it, we got quite a bit out of it.’ Participant 6 (Focus group)

Feedback from district nurses

Reflecting on the coaching programme and the online resources, all DNs were very positive:

‘I think it was quite good as well because there was lots of different things, different techniques. There were the lessons, videos and the podcast.’ DN1

All DNs agreed that a programme focusing on frailty is needed either as part of district/community nurse training or even part of the nursing undergraduate programme:

‘…in the community, where frailty's concerned, and I think now that I’ve read it (through the programme), I do recognise there's a real need for it... I’ve been in nursing for a long time and I’ve never done a frailty assessment.’ DN3

The length of the programme and the number of face-to-face/real time contacts would need to be re-examined due to time and workforce challenges. The district nurses stressed that potential participants would need to be aware in advance of the time commitment involved. Management would also need to support participants by offering opportunities to make the most of the knowledge they had gained.

Feedback from key stakeholders

All stakeholders agreed there is a need for more education on frailty across a wide range of disciplines and care settings. Respondents identified benefits for those working at many key points of healthcare delivery; planning, commissioning and regulating care services, promoting health and wellbeing, delivering long-term care and supporting care home providers, those working in community hospitals, urgent care or in new roles within primary care teams.

‘The need for education spans across all disciplines within the partnership to enhance current care provision and raise the frailty agenda within all aspects of care. Education on frailty to support professional, organisational and inter-organisational learning is the foundation for sustainable change.’ Stakeholder 1

‘This work is very transferable to a wide range of other professionals and settings.’ Stakeholder 2

Respondents also welcomed the combined education and person-centred coaching approach, including the involvement of older adults as co-coaches who are ‘experts by experience’:

‘I would be a strong advocate for this within the programme as the ‘lived’ experience would enrich and potentially accelerate the learning.’ Stakeholder 5

Finally, the Frailty House was considered to be a helpful ready reckoner or visual prompt for illustrating the complex concept of frailty.

‘I think it is a comprehensive model that is portrayed in a visual, engaging and easily understandable way.’ Stakeholder 10

Discussion

Preventing and managing frailty remains a new area for many community practitioners and for their community partners. This study has identified that the current management of frailty by community nurses in Scotland and elsewhere is largely reactive, dependent upon experience, professional judgement and intuition, with little systematic training in frailty-specific screening and assessment (Obbia et al, 2020; Papadopoulou et al, 2021). This intervention offers a framework, the ‘Frailty House’, that is intuitive, accessible and highly relevant for a wide range of community professionals and could be used to shape current best practice in care for people living with frailty. The co-designed contextually sensitive combined coaching and educational programme makes sense for managing frailty in the lived experiences of both community professionals and people living with it. Combining technical knowledge and relational skills-building with peer support and coaching was valued by all the participant DNs and other district nursing and community staff who provided feedback to the research team. All recognised the challenge of caring for people living with frailty at a difficult time and acknowledged that they would benefit hugely from further knowledge and skill development in this field.

Currently, several e-learning programmes are available for frailty, all broadly compliant with the NHS England frailty framework of core capabilities (Skills for Health, 2018). However, while self-directed e-learning can have a wide reach at relatively low cost and can be at least as effective as traditional learning approaches, and superior to no instruction at all in improving HCP knowledge and behaviour (Sinclair et al, 2016), it continues to have limited potential to address the more relational aspects of care. There is also some doubt regarding whether e-learning can achieve sustained changes in practice on its own (Martinengo et al, 2020). A person-centred coaching approach supports staff to develop skills and confidence in shared decision-making, self-management and health behaviour change. Supporting these relational aspects of care enhances staff motivation, wellbeing, and retention (Benner et al, 2011). These aspects currently need a lot of nurturing while the health and care workforce is pandemic weary, feel undervalued and may have lost the pleasure they took from work they used to generally find rewarding (Royal College of Nursing, 2020).

One of the key successes of the project was the involvement of the citizen co-coaches. The importance of including the public in co-designing and co-creating research has been well documented (Glasson et al, 2008; Small et al, 2021). In this study, the presence of co-coaches nurtured greater empathy and provided valuable insights into creating the conditions necessary to empower and support individuals with frailty to manage their conditions and live the lives they want to live. The co-production generated feelings of mutual respect, albeit the approach required careful attention to the emotional and physical wellbeing of the citizen co-coaches. During the pandemic, additional support was also required to ensure the co-coaches were able to manage participation.

Changing practice requires much more than knowledge. The Frailty Matters project offers a blueprint for a structured approach, helping create local learning communities that can inspire professionals to deliver the best possible care for people with frailty. Participants in future programmes could potentially become Frailty Champions. They would have skills and knowledge, which would aid them in inspiring their peers to adopt the best possible care and support for people living with frailty they encountered in practice. The creation of such learning communities and future cohorts of Frailty Champions could be an important enabler for the successful scale up of new models of people-centred integrated care for older people. This would be in line with both the UK governments’ (England, Scotland, Wales and Northern Ireland's) policy ambitions and the NHS's desire to base more care in the community and reduce unnecessary hospital admissions (NHS, 2019; 2021).

Study limitations

This study is not without limitations. We included a convenience sample of one area within Scotland. Further implementation testing is warranted with a larger sample in diverse community contexts. Conducting research over the course of the pandemic brought additional challenges relating to maintaining engagement of participants. Moving from a face-to-face to an online mode of delivery—while seeming to be viable solution towards supporting remote access—decreased engagement. The reason for this was twofold. Firstly, technological literacy and availability was variable in this group. In the future, it is important to assess technological competency of participants and mitigate potential barriers early on by incorporating training sessions that build user confidence. Secondly, the unprecedented pressure of the pandemic on the health system meant that time allocation for educational or research purposes became less of a priority for the workforce. Moving forward, as services resume and recover, it is crucial that participation in education and workforce development is safeguarded within teams.

Conclusion

Now and into the future, a wide range of primary care, community and urgent care practitioners need to be competent in identifying and managing frailty and its consequences. Many will require skills in case management, care coordination, re-ablement and rehabilitation, as well as relational skills for collaborative and person-centred practice. They will also have to work in a more integrated manner across teams, care settings, and with community partners. The pandemic has shown what can be achieved when organisations work together more creatively and with local communities: better collaboration and trust, and an ability to pivot, innovate and make changes in practice at pace has been demonstrated by many local and regional community teams across the country (NHS Confederation and NHS Providers, 2020; Rural Services Network, 2020). Concerted action is needed, now more than ever, to build resilient, fairer, healthier, and stronger communities and places that enable older people to age and live well with frailty. As we push the boundaries of what can now be achieved in the community, the ‘Frailty House’ framework and the associated coaching and educational programme could support HSCPs and their community partners to build a workforce that is integrated, capable and fit for frailty.

Key points

• Current care in the community remains reactive, influenced by professional judgement and intuition, with little systematic frailty-specific screening and assessment
• Community nurses play a key role in identifying older people living with frailty
• There is a need for a conceptual framework and education to use in interdisciplinary practice
• The Frailty House was co-created to illustrate the key requirements for education on frailty management and is aligned with the Frailty Core Capabilities
• The model offers an educational framework that is intuitive, accessible, and highly relevant for a wide range of community professionals
• Using a model like the Frailty House in the future can empower participants to cascade their learning as local Frailty Champions with the knowledge, skills and confidence and inspire their peers to adopt the best possible care and support for people living with frailty

CPD reflective questions

• What is your current practice to manage frailty in your locality?
• Have you received any education specific to frailty? Are you aware of any resources that are available in your local community?
• What steps do you think are necessary to take for your team to have a more streamlined and consistent approach to manage and prevent frailty in your community?