The meaning of confidence for older people living with frailty: a qualitative systematic review

The meaning of confidence from the perspective of older people living with frailty: a conceptual void within intermediate care services

Background

Confidence is a cornerstone concept within health and social care’s intermediate care policy in the UK for a population of older people living with frailty. However, these intermediate care services delivering the policy, tasked to promote and build confidence, do so within an evidence vacuum.

Objectives

To explore the meaning of confidence as seen through the lens of older people living with frailty and to re-evaluate current literature-based conceptual understanding.

Design

A phenomenological study was undertaken to bring real world lived-experience meaning to the concept of confidence.

Methods

Seventeen individual face-to-face interviews with older people living with frailty were undertaken and the data analysed using van Manen's approach to phenomenology.

Results

Four themes are identified, informing a new conceptual model of confidence. This concept consists of four unique but interdependent dimensions. The four dimensions are: social connections, fear, independence and control. Each is ever-present in the confidence experience of the older person living with frailty. For each dimension, identifiable confidence eroding and enabling factors were recognised and are presented to promote aging well and personal resilience opportunities, giving chance to reduce the impact of vulnerability and frailty.

Conclusions

This new and unique understanding of confidence provides a much needed evidence-base for services commissioned to promote and build confidence. It provides greater understanding and clarity to deliver these ambitions to an older population, progressing along the heath-frailty continuum. Empirical referents are required to quantify the concept’s impact in future interventional studies.

A concept analysis of confidence related to older people living with frailty

Aim

To describe and define a concept of confidence in the context of older people living with frailty, which is important to the worldwide healthy-ageing agenda preventing decline in independence and well-being.

Design

Concept analysis informed by Walker and Avant's eight-stage approach.

Methods

Electronic databases (MEDLINE, CINAHL and PsychINFO) from 1994-2018 were searched. Published studies exploring confidence and excerpts of papers referencing older people, frailty and confidence informed the concept analysis. Extracted attributes informed model case and additional case development. Appraisal of antecedents, consequences and empirical referents informed the final concept's construction.

Results

Three overall defining attributes of confidence were identified in this concept analysis: physical, psychological and social. A central feature is personal control, influencing internal and external factors. These control factors can be enabling factors (positive factors) or dis-enabling factors (negative factors), affecting the frail older persons overall physical health and mental well-being.

"She doesn't want to go to hospital. That's one thing she hates": Collective performativity in avoidable nursing home to hospital transfers

Older people who live with a combination of conditions experience fluctuations over time, which others may interpret as a need for medical attention. For some nursing home residents, this results in transitions in and out of hospital. Such transfers may be arranged without expectation of improved quality of life, can be associated with significant morbidity and mortality, and may preclude end-of-life preferences. Factors affecting avoidable hospitalization for nursing home residents are not well understood. I aim to explore potential drivers, moving beyond deficit explanations relating to funding, training, and resources. I use a framework of analysis that firstly considers medicalization of frailty, as a state of vulnerability that provides focus for others' action. I then draw on Judith Butler's theory of performativity, to explore nursing homes as sites of identity work for staff, residents and families. I consider ways subjectivities can be effected through reiterative practice that is compelled by normative conventions. Trouble may arise when citational practice of health care staff, and performative acquiescence of residents and families, culminates in an inevitability of hospitalization when navigating grey areas of assumed clinical risk. Principles of coproduction could present a disruptive opening, to rework power asymmetries, and move toward aspirations for residents and their relatives to be at the centre of decisions about care.