The ALLIANCE Frailty Matters 2021 review

A reflection on the Frailty Matters research project which concluded in 2021.

The Frailty Matters action research project concluded in August 2021. Funded by Burdett Trust for Nursing, this project was a collaboration between the University of the West of Scotland, the Health and Social Care Alliance Scotland, NHS Ayrshire & Arran, the International Foundation for Integrated Care, and the Queen’s Nursing Institute Scotland.  Details on the project team are available here.

The study, conducted in three phases from February 2019 to August 2021, aimed to understand the learning needs and enhance the knowledge, confidence and capability of community nurses to manage frailty. District Nurses (DN) have deep knowledge and understanding of the needs of their patients, and of family carers, and are ideally placed to identify those at greatest risk of frailty and to prompt earlier intervention to prevent or delay functional decline. With DNs, we developed a combined coaching and educational programme supported by online educational resources in response to their learning needs about caring for people living with frailty. The programme was co-delivered with older people living with frailty, deepening empathy and mutual respect, and providing valuable insights into how to empower and support them to manage their conditions to live the lives they want to live.  Sessions were initially face to face but moved online through COVID-19 restrictions.

Community nurses reported that they viewed frailty as vulnerability, loss and complex comorbidity but did not identify frailty as a long term condition with potential for prevention, early intervention and self-management. They indicated that their current practice was largely reactive, influenced by professional judgement and intuition, with little systematic frailty-specific screening and assessment. More details of our mapping and analysis of learning needs can be found in our published paper (this link will take you away from our website).

Participants identified a need for a conceptual framework and education to use in their nursing and interdisciplinary practice. We co-created the Frailty House to illustrate the key requirements for education on frailty. This was inspired by Scotland’s House of Care – an established person centred framework for collaborative care and support planning for people with long term conditions:

• The foundation includes elements of person centred coaching and leadership, active listening, reflection and action planning to facilitate change and improvement.
• The house is framed by the ethos of Realistic Medicine (this link will take you away from our website).
• The ‘building blocks’ are based on what the community nurses and co-coaches consider are important to support people living with frailty to stay well.

We sense checked the developing framework through two workshops with members of the ALLIANCE network.

Genuine co-production requires mutual respect, attention to emotional and physical wellbeing, and support to enable digital participation.

Around 50 participants from across Scotland and beyond joined an end of project celebration event in September 2021. Read the flash report and policy brief here.

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