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

Underwood, Frazer; Kent, Bridie; James, Allyson

JBI Database of Systematic Reviews and Implementation Reports: July 2015 - Volume 13 - Issue 7 - p 62–71

1Royal Cornwall Hospitals NHS Trust, United Kingdom

2Centre for Innovations in Health and Social Care: an Affiliate Center of the Joanna Briggs Institute; Plymouth University, United Kingdom

Corresponding author: Frazer Underwood

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Review question/objective

This review poses the following question:

What is the meaning of the term “confidence” from the perspective of older people living with frailty?

The objective of this review is to explore from the older person's perspective the meaning of confidence through synthesis of the qualitative evidence relevant to older people living with frailty, in order to inform health and care practices, service delivery and policy.

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Worldwide, the number of people aged 65 or older is projected to nearly triple, from an estimated 524 million in 2010 to nearly 1.5 billion in 2050, with most of the increase occurring in developing countries.1 In many countries, the oldest old (those aged 85 years and older) are now the fastest growing part of the total population.1

In the UK, over the next 50 years, the number of people aged 65 and over is expected to double and those 85 years and over are set to increase at least four-fold.2 The impact of this on health and care resources is of great concern to policy makers as well as health and care service providers, as this oldest population will increasingly be living with the clinical condition of frailty: Collard et al.3 reported that one in four people aged 85 years and over currently live with “frailty”.

Frailty” is a word growing in our lexicon: in the evidence base for practice and in health and social care policy relating to older people, there has been an increase in references made to the phenomenon. Frailty can be seen as either a very physical attribute, described by Clegg et al. as the “phenotype model”: an association between five measures (weight loss, self-reported exhaustion, low energy expenditure, slow gait speed and weak grip strength).4 Alternatively frailty can be seen within a “cumulative effect” framework, a proposition that incorporates non-physical factors, such as emotional, psychological and social factors alongside the physical impact of aging. This resonates more clearly when set with in the context of Clegg et al.'s definition of frailty.4 They describe the clinical condition of “frailty” as developing due to a consequence of age-related decline in multiple body systems, which results in vulnerability to sudden health status changes triggered by minor stress or events such as an infection or a fall at home. This in turn increases the risk of adverse outcome including delirium and disability.

Connecting to and clearly understanding the notion of confidence related to maintaining mental well-being and physical health as experienced by this older population who are living with frailty is important. The impact of an individual losing their “confidence” results in additional health and care staff contact time and resources to meet a deficit between a person's “loss” and their actual or perceived need.

Despite the need to recognize loss of confidence, anecdotal evidence from practice in the UK suggests that many practitioners who are in contact with older people living with frailty, receiving care and treatments in hospitals, clinics and community care settings rarely hear such individuals talking about their “self-efficacy” or about how “confident” they are. Instead these practitioners will be acutely familiar with comments such as: “I'm feeling much less confident now” or “I seem to have lost my confidence to do that now.” Consequently, “confidence” is commonly spoken about in our care settings when in contact with older people, but as a notion, it is not clearly understood.

An individual's “confidence” is often made reference to in practice; similarly it is quite commonly commented on in the healthcare literature.5–8 There is a need to clarify more fully understanding related to this notion. Confidence and self-efficacy are often used interchangeably or they merge in explanations. For example, Wallston describes his concept of “perceived competence”, a generalized theoretical perspective of self-efficacy, as “self-efficacy reflecting one's confidence in performing goal-oriented behaviors across situations.”9(p149) Understanding how interchangeable these two concepts are when considering an individual's belief in their abilities becomes important when starting to transfer knowledge from literature into practice. It becomes important to interpret what confidence really means to an individual and what specifically can be done by health and care staff, or by the systems they work within, to maintain and grow this “confidence”, or “self-efficacy”, as we see a significantly growing number of older people living with frailty and dependency in the world.

An initial search of literature was undertaken to ascertain further clarity on what confidence is and how individuals and practitioners conceptualize and use such knowledge. No systematic reviews exploring confidence, frailty and mental well-being and physical health were located. Other studies located were qualitative in nature, such as that by Nicholson et al.10 exploring the experiences of older people living with frailty. They importantly identified “loss of confidence” as a recurrent phase being used in the context of an individual's dealings with the impact of their physical health deterioration over time on their psychological and social well-being. To ensure the widest scope in capturing qualitative studies describing the meaning of confidence, a lower age limit of 60 years will be deployed in the search criteria.

Like Nicholson et al.,10 other literature that discuss the loss of confidence make links with other losses which are discussed next.

Viljanen et al.11 report the impact of “sensory loss” and how the fear of falling jeopardizes an individual's confidence; whilst “loss of social contact”/"social isolation"/"loneliness" is reported by a number of authors.5,12–16 Furthermore, “loss of skills”, such as driving skills, have also been identified.17 However this is discussed predominantly in the literature about “skill development” promoting confidence.18–20 “Technology's” influence in boosting confidence is reported in papers from Cattan et al.12, De and Lewin21, Skymne and Waara et al.23 Other literature identifies confidence as being impacted on by “mental health concerns” such as: “anxiety”24,25, “anxiety and depression”26 and “stress”.27,28

“Loss of confidence” is also a term prominent within falls literature, and is found alongside “loss of independence”. It is connected to “fear of falling” and “loss of balance confidence”.29–31 Such psychological and social consequences of a fall are seen as the start of a vicious cycle that leads to reduced activity, physical functioning and further increased risk of falling.32 It is recognized that periods spent on the floor, when the person is unable to get up following a fall or waiting for help, are particularly undermining to an individual's confidence.33 Yardley and Smith31 called for a better understanding of “falling-related beliefs”, but to date, this remains an area that is largely unexplored despite its impact on older people being significant. Psychological and behavioral science literature offers some insight into what this means. Psychologist Albert Bandura34 comments that “confidence” is a colloquial term: a catchword rather than a construct embedded in a theoretical system. This may account for the lack of published literature on the subject. Bandura goes on to dismiss “confidence” as a nondescript term that refers to strength of belief, not specifically about the certainty about the belief. Thus it appears to be a term that is widely used but which has minimal stated understanding.

Understanding more fully the evidence related to what “confidence” means in the context of an older person living with frailty will provide an opportunity to understand the impact of losing confidence and explore what can be done to improve it. Bandura, the originator of the social cognitive theoretical construct of “self-efficacy”, describes a self-belief paradigm of four influences: “mastery experiences” - acknowledging the idea that success builds success; “vicarious experience” - seeing people similar to oneself manage tasks and demands successfully; “social persuasion” - being told that you have the capabilities to succeed; and influences from “somatic and emotional states” - indicative of personal strengths and vulnerabilities.34 This behavior specific and situational specific view is criticized by psychologists who view self-efficacy as more generalizable.35,36 Schwarzer's Health Action Process Approach is a five principled approach when intentions foster a level of planning that translate into behavior change. Throughout, “perceived self-efficacy” interplays with the model, driving the individual to action.36 Wallston would rather move away for the word self-efficacy and talks of “perceived competency” relating this to a person's health locus of control, where one's action is responsible for one's outcome, which in turn brings about a level of “perceived control” over one's health behaviors.35 This construct around “control” offers a nexus to confidence. Walker, in describing a new theory of control, associates perceived control to a person's confidence and optimism.37 However, this level of theoretical language and complexity starts to become inaccessible to many health and care staff working in acute hospital and post-acute care, and makes translation and application to practice challenging.

A literature search has been undertaken as indicated above, and there has been no synthesis of the best available evidence that attempts to describe and explain what “confidence” means to the frail elderly. Given the growing numbers of this population world-wide, a systematic review on this topic is urgently needed since evidence-based guidance, which can be used to inform practice based support to older people who have lost confidence, or for whom it is recognized that the maintenance of confidence is crucial for their well-being, is currently limited.

The nature of the research found (highlighted above) recognizes that the term “confidence” is commonly used and referenced in this literature, more often literature that is quantitative rather than qualitative. This qualitative systematic review therefore aims to search for and examine the experiences of older people for reference to confidence from interpretive studies including phenomenology, grounded theory, ethnography, action research and feminist research, in order to develop a better understanding of the meaning of confidence for older people living with frailty.

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Inclusion criteria

Types of participants

This review will consider studies that include frail adults aged 60 years and over who are currently receiving or had experienced acute hospital and or post-acute care in the last twelve months.

Frailty will be recognized as being defined using a “pheno-type model” (bio-medical criteria such as weight loss or timed walking) or the “cumulative effect” (recognizing with the aging population mental as well as physical health vulnerability and its particular sensitivity to minor stressors, such as an acute infection).4

Phenomena of interest

This review will consider studies that describe and explore the older person's descriptions, understandings and meanings of confidence and its impact on their mental well-being and physical health as they live with their frailty, and if they have recently experienced acute hospital and or post-acute care services.

Types of studies

This review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.

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Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken, followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review. Studies published in the last 20 years will be considered for inclusion in this review. This has been identified as the most appropriate period given the expansion of research and services specific to frailty and older people.

Initial database search will be through:


Other databases to be searched will include:

AMED, British Nursing Index (BNI), Cochrane Library, EMBASE, JBI Database of Systematic Reviews and Implementation Reports, ProQuest Health and Medical Complete, PsycINFO, ScienceDirect, SCOPUS and SocINDEX.

The search for unpublished studies will include sources such as:

Dissertation Abstracts International (WorldCat/OCLC), Google, Google Scholar, MedNar, Networked Digital Library of Theses and Dissertations, OAlster, OpenGrey, Open Access Theses and Dissertations (OATD), ProQuest Dissertations & Theses Database (PQDT).

Initial keywords to be used will be:

confidence, (excluding “confidence interval[s]”), old(er) people, frailty.

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Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute's Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

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Data extraction

Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II) by the first two reviewers independently. The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives.

Authors of primary studies will be contacted for any missing information or to clarify unclear data.

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Data synthesis

Qualitative research findings will, where possible be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form.

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Conflicts of interest

The authors have no conflict of interest to declare.

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Health Education England (South West)

Royal Cornwall Hospitals NHS Trust Health Librarians

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Appendix I: Appraisal instruments

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QARI Appraisal instrument



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Appendix II: Data extraction instruments

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QARI data extraction instrument




Aged; elderly; frailty; frail; lived experience; self-concept; health and well-being; physical health; mental health; systematic review.

© 2015 by Lippincott williams & Wilkins, Inc.