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. 2021 Jul 3;50(5):1802–1810. doi: 10.1093/ageing/afab109

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

Frazer Underwood 1,2,3,, Jos M Latour 4,5, Bridie Kent 6,7,8
PMCID: PMC8437059  PMID: 34228775

Abstract

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.

Keywords: confidence, older people, frailty, intermediate care, phenomenology

Key Points

  • – Confidence is a concept central to the UK's intermediate care policy, but exists without clear definition in the context of older people living with frailty.

  • – This study found that the lived experience of confidence to be an interdependent and multidimensional phenomenon; centred around four dimensions: social connections, fear, independence and control.

  • Confidence impacts on the individual's resilience and vulnerability making it of interest to practitioners and researchers when using and exploring interventions that have an effect on older people living with frailty.

Introduction

Worldwide, the range of rehabilitation services that sit between an older person’s primary health provider and acute hospital services goes by different names and is delivered by a variety of providers. In the UK, this is no different, where over the last 20 years, a tier of services known as intermediate care has evolved. England’s Department of Health states: Intermediate care should…encompass a wider preventative role, aiming to promote confidence building and social inclusion, thus avoiding the need for institutional care or intensive home care at a later date [1: 11].

England’s National Health Service (NHS) Long Term Plan [2] recently committed to grow this tier of services over the next 10 years. The National Institute of Health and Care Excellence reinforced the connection between confidence and intermediate care service delivery in their guideline [3]. They recommended that intermediate care practitioners:…build the person's knowledge, skills, resilience and confidence, with reablement…aiming…to help [older people] recover skills and confidence and maximise independence [3: 5 and 17].

Unfortunately, little is found in the current evidence base to inform practitioners’ understanding of what confidence means in the context of older people living with frailty. Recently, asset models that focus on physical health and mental well-being have been promoted as recognising characteristics of successful ageing that connect resilience to confidence [4], as opposed to the more negative focus on frailty and vulnerability that are predominantly cited in connection to the cumulative deficit models in the literature [5]. A reported meta-synthesis of very few published accounts of older people speaking of their confidence in the qualitative literature tentatively concluded that confidence was reflected as a sense of vulnerability [6: 1,326]. The authors called for better clarity to inform practice through more research. A concept analysis of confidence that drew on a wider literature review was undertaken and developed the first concept of confidence in an attempt to try and close the gap between policy and evidence [7]. This highlighted three interconnected attributes of confidence: physical, psychological and social, with a strong central feature influencing them all, identified as personal control. Despite this clear conceptualisation, the true voices of older people remained mostly absent.

This paper reports on research undertaken to capture and analyse these absent voices using phenomenological enquiry to bring meaning and understanding to the notion of confidence through the lens of older people living with frailty. The study aimed to strengthen the conceptual understanding of confidence for this oldest-old population in society to better inform and direct intermediate care services and their practitioners with effective interventions and utilisation of resources.

Methods

Study design

The phenomenological enquiry followed the methodological structure for human science research set out by van Manen [8,9]. This method has an important philosophical context but is also acknowledged for its practical orientation that generates meaningful characteristics of the studied phenomenon [10]. In this interpretive phenomenological approach, there is a search to identify what gives itself ‘as’ lived experience through a three-stage approach to analysis:

  • individual interview analysis; describing the phenomena through a process of listening, writing and rewriting of the experience and in creating incidental themes.

  • meaning and understanding review; identifying statements and phrases that illustrate the incidental themes.

  • guided existential enquiry; requiring further comprehensive reading of the interviews to identify how the lived experience is revealed across dimensions of spatiality, corporality, temporality, rationality and materiality [8,9].

The outcome sees essential themes developed from the incidental themes and richly written materials emerge to describe the phenomena, which are able to evoke its sense, or essence in others.

This study is reported in line with consolidated criteria for reporting qualitative research (COREQ) [11].

Participant selection

To avoid participant selection bias in understanding the phenomena of confidence, only those who spontaneously spoke of their ‘confidence’ triggered consideration for study inclusion. Therefore, older people (65 years or older) living with frailty (clinical frailty scale score of 5 or greater [12]) with no significant cognitive impairment (score of 7 or greater on abbreviated mental test score (AMST) [13]) who directly spoke of their confidence to a registered healthcare professional were approached to participate in the study. Eligible participants had the study explained verbally and were given a written participant information sheet. Those willing to participate were asked permission to be referred to the study team. Potential participants were visited by the primary researcher (FU) to describe the study further and seek permission to be contacted, following their discharge from hospital, to arrange an interview. Participants did not know the researcher; however, they were aware he was a senior clinical nurse and a PhD student. All participants provided written informed consent prior to interview. Fourteen participants identified and approached to participate early in the study did not proceed to interview (Table 1). The main reasons for non-participation were not wanting to be involved in research when at home, or family members refusing researcher access to the individual once at home. The study protocol was therefore adjusted and following further ethics approval enabled interviewing of participants in hospital. All participants were asked if they wished to receive a summary of the study’s draft findings to check resonance in respect to their lived experience (member checking).

Table 1 .

Details of non-recruitment and non-participation to the study

•  Declined to participate further in the study once at home n = 6

•  Family declined access/participation once at home n = 2

•  Uncontactable once at home n = 1

•  Unable to recall the use of the word confidence n = 3

•  No mental capacity to consent n = 2

Setting

Recruitment occurred in one of three older people’s post-acute and intermediate care wards in two hospitals in the South West of England.

Data collection

Data were captured through interviews with older people, conducted between May 2017 to March 2018 in either hospital, waiting for discharge home (n = 12), or in the participant’s own home (n = 5) by FU. Two interviews conducted in participants’ homes had a family member present (P01 and P03). Interviews were semi-structured, principally using recall of the trigger word ‘confidence’ in a conversational style interview [14]. The interviews were digitally recorded. Interview duration ranged from 22 to 56 minutes. These were transcribed for analysis. Reflective field notes were made following each interview. The checking for the emergence of any new ideas following the first 10 interviews and each interview thereafter confirmed final sample size [14].

Data analysis

Phenomenological analysis used van Manen’s three-stage approach: individual interview analysis; meaning and understanding review; and guided existential enquiry [9]. Analyses were conducted by FU, paying attention to the phenomenological epoché-reduction (awareness of their suspension of judgement and openness to the exposure of the phenomena), constantly being recorded in field and later analysis notes. The outcome of data analysis for each participant was an individually written, first-person confidence narrative (Table 2), presented alongside emergent incidental themes of their confidence experience. The incidental themes were cross-referenced with supporting text from their interview transcript to provide evidence of contextual meaning and understanding, before final consideration against the five existential elements to explore and understand how the phenomena were exposed (see Supplementary Data, Appendix S1, available in Age and Ageing online for a detailed example of data analysis). These analyses were checked, challenged and confirmed by J.M.L. and B.K.

Table 2 .

Data extract from an individual interview analysis—describing the phenomena of confidence (Participant 11)

Communication has a central role to play in how your confidence is experienced and lived. In exploring frailty, even when your confidence is good, it exists in a delicate and fragile state. However, this balance can easily tip by being let down by poor communication. In these cases your confidence lowers, you can become easily intimidated and unable to defend yourself. You become more vulnerable and fragile. Poor communication can cause a mental torment that connects to your confidence and erodes it away. This personal, internal weakness is hard to admit to. Frailty feels like not being able to defend yourself, it makes you angry and this anger leads to frustration and disappointment. This frailty and lack of confidence is like being out-of-control, a helplessness, it can open you up to abuse. It comes on and goes slowly, it also has an accumulative effect and links to other factors, like physical weakness and loneliness. Fear, however, overrides all of this and has a destructive affect to your confidence. You need to fight fear to overcome low confidence. You must fight to say what you want to say. If you cannot defend yourself, you cannot have confidence.
Coming into hospital is a most frightening time, it is always linked to losing your confidence. In hospital you struggled to communicate, to be understood, to be listened to. Sometime when in hospital you are not in the right state of mind—delirium—it’s like a mental stroke—you have strong, uncontrolled raw emotions, it feels like you are out-of-control, it is horrific. You might be in tremendous pain, but not able to get through to those around you—you lose confidence in them and the situation you are in…
…Good communication is confidence giving, but it is rare to truly find.

The final stage of data analysis was the development and description of the phenomena’s essential themes [9]. Here incidental themes are grouped together where commonality is clearly seen. Confirmation of an essential theme reflects the view that, if it were to be excluded, the phenomenon would no longer be what it is; van Manen calls this free imaginative variation [8: 107]. Finally, essential themes are supported by narrative descriptions to evoke the sense of the phenomena for the reader. The process of writing and rewriting the descriptions of confidence, referring back to interview data and existential exposure of the phenomena, was guided by van Manen’s own writing and publications [8,9,15]. Participants had the opportunity to comment on developing themes, since these were included as topics within subsequent interviews as the study progressed. Half of the study participants agreed to comment on the draft findings, and three returned feedback comments (via post) concurring congruity with their lived experience.

Results

Demographics

Seventeen older people participated in the study. Their age range was between 70 and 95 years old and levels of frailty ranged from 6, moderate frailty to 8, very severe frailty on the clinical frailty score (CFS) scale (Table 3) [12]. One participant reported ethnicity as White European, while all others were White British.

Table 3 .

Characteristics of study participants

Participant number Gender Age CFS Admission trigger Interview location
P01 Female 95 8 Fall at home Home
P02 Female 90 6 Fall at home Home
P03 Female 80 6 Fall at home—fractured pubic rami Home
P04 Male 70 6 Fall at home—alcohol related Home
P07 Female 87 6 Fall at home Home
P08 Female 84 6 Fall at home Hospital
P09 Female 86 6 Fall at home Hospital
P10 Female 85 6 Fall at home—fractured humerus Hospital
P11 Female 74 7 Pulmonary embolism Hospital
P12 Female 85 6 Pulmonary oedema Hospital
P13 Female 79 6 Fall at home and haematuria Hospital
P15 Female 80 7 Fall at home and bilateral septic leg ulcers Hospital
P18 Male 90 7 Shortness of breath Hospital
P19 Female 80 6 Community-acquired pneumonia Hospital
P20 Male 86 6 Discitis and duodenal ulcer bleed Hospital
P21 Male 87 7 Fall at home Hospital
P22 Male 82 7 Cardiac arrest—hyperkalaemia Hospital

Participant withdrawal post-study commencement means numbering is not sequential

Key findings

Four essential themes emerged from the phenomenological analysis to form four dimensions of confidence.

These are presented below, by dimension title and description, followed by a selection of their incidental themes and direct quotations from participants that shaped these final findings.

All individual interview analysis of confidence and incidental themes are referenced in Supplementary Data, Appendix S2, available in Age and Ageing online.

The four dimensions of confidence:

  1. The interpersonal impact on confidence through social connections with others: a social dimension.

The social connection of others to an older person’s confidence is as unique as the individuals themselves. This interpersonal connection is relational. It is a social association between them and the significant other(s) in their life and then their confidence. This dimension takes countless forms and characters. It appears as a social bond that forms and shapes their confidence. These social bonds, or connections can be with family (partners, husbands or wives, with daughters and sons, or with siblings and their children), friends (neighbours or carers), with health professionals in hospital or in the community or with a religious faith and spiritual being. In turn, these social bonds, which are the personal, social connections to confidence, can be strong or very fragile. In strength, the connection with family, friendship and companionship give confidence, hope and optimism. However, if this bond to others is broken, either permanently or temporarily such as through loss of a spouse or abandonment of friends or to the fleeting trust held in the carers supporting them, this broken connection leaves a person holding on to a frail or vulnerable confidence.

This explanation is reflected in incidental themes, including:

Being a burden on others affects your confidence.

‘…you get up and go when you have got confidence and I’m afraid I’ve not been able to do that for a long time. I just think, well I am a nuisance to my son [becomes upset and cries].’ (Participant 12, starts line 28).

Social isolation and loneliness are linked to confidence loss.

“I think [having the fall,] that’s the start of somebody becoming isolated, you know, because they don’t have the confidence to do these things. They stay in and think, ‘Well, I’ll not go out in case this or that happens’. So, you could, through a lack of confidence, become very lonely. You could be sitting in your house feeling relay miserable, you know, you haven’t got the confidence and then somebody might come in and say, ‘Arh, come on, I’ll come with you, we’ll go down so-and-so, you’ll be alright’. You know, unless you are really bad, you would say, ‘I’m not going’. If you got the chance you would go. I think that’s boosts your confidence again, you see. So, in a way, you start off again. But, its whether you get that, because as you get older you haven’t got the mobility to get out and speak to people, yet you have got to wait for them to come to you really, particularly if you are on your own.” (Participant 13, starts line 80).

  1. The relationship of fear to confidence exposes a powerful and emotive effect: a psychological dimension.

Fear (also referred to as dread, anxiety, fright, panic or worry) is tethered to the confidence for older people living with frailty. Whether triggered by an incapacitating fall, an illness such as delirium or through the treatment or care received, fear can powerfully erode a person’s inner confidence. This fear resides in the person’s mind, playing psychological games. For some, they can speak to the confidence inside and try to bargain and rationalise with it, in some convincing way. These internal conversations attempt to overcome fear’s ability to wear or tear away at the person’s confidence. For others, it completely disables their desires, leaving them helpless and hopeless, and for some, it makes them completely mentally debilitated and depressed. For them, confidence is consumed by fear.

To illustrate this are the incidental themes:

Confidence is connected to fear.

‘…the fear in that [describing her experience of delirium and confidence loss] is terrible because you can’t do anything to get through [to others]. …Fear is something different, something awful erm, its much worse that frailty … fear is a real stopper.’ (Participant 11, starts line 166).

Another participant thinking about fighting fear stated:

“…you got to acknowledge you can fight the fear because without that confidence to fight the fear you won’t fight it. That’s what I feel, ‘Why can’t everyone feel confident?’, ‘Why do they have to become frail?’ and er, vulnerable and, that’s life isn’t it.” (Participant 11, starts line 233).

A further incidental theme was:

Being fearful of falling knocks your confidence.

“Like in my case, I’ve had several horrendous falls, you know, … I have a dog and I go walking but I find that my confidence has been knocked by these falls, so when I’m walking I always keep my elbow crutch with me, erm, but, it takes your confidence as though, you’re sort of walking along and I’m thinking, ‘I mustn’t fall, I mustn’t fall down’ or anything like that. So, sometimes when things like that happen you can say that knocks your confidence.” (Participant 13, starts line 7).

  1. Physical independence is a stimulus to confidence: a physical dimension.

The determination to be independent is a physical driver for confidence. Confidence’s connection to physical functioning is one that is important to maintain. The person’s body, as well as its physical strength, is important in sustaining his or her independence and overcome the limitations the person living with frailty increasingly faces in later life. Confidence is often undermined or lost as a result of the physical effects of accident, injury or ailment. Quickly the person’s ability to physically look after himself or herself, to self-care, can be affected. For some, a growing dependency appears to sit beside a fading confidence—an uncomfortable and sometimes painful companion. For others the desire to physically overcome a feeling of frailty lays witness to a growing confidence.

A contributing incidental theme was:

Confidence is connected to being independent.

“If you lose your confidence, you can’t do much then. It [confidence] means get up and go. You got to, you can’t always rely on others, … you got to do somethings yourself. Not sit in a chair and say, ‘I’m not going to do anything’, [say,] ‘I AM GOING TO DO IT’ [laughs]” (Participant 08, starts line 51).

Another:

Frailty and ill health are connected to confidence.

[“Its] just to have confidence to do things, you know, before I never thought twice before doing anything. Now I think, ‘I don’t know whether I can do that’. You know … [these leg ulcers have been debilitating, significantly affecting my mobility] … it does affect your confidence. You’re not sure about anything. On whether I’ll do that or not. Before, you’d just get on and do it you know.” (Participant 15, starts line 5).

  1. The control of confidence is fundamental but not always achievable. Control exists at the crux of vulnerability and resilience: a control dimension.

The control individuals have over their confidence is variable. Some older people living with frailty have a natural belief in the control they have over their confidence. These people often refer to their experiences of confidence over their life course, a confidence that has been shaped not only by themselves but also often by others. This confidence carries forward into older age. However, as frailty becomes recognisable in their bodies and minds, the vulnerability of control over their confidence may falter and they become hesitant. This vulnerability is influenced by a reliance on other social, psychological and physical factors. For example, social connections (family, friends, healthcare professionals, neighbours or carers) in older peoples’ lives can be control givers or control removers. A strong connection to a social group, to family and friends, can liberate a person’s control over a vulnerable confidence. The opposite sees loneliness and isolation limiting control and removing their resilience and then their confidence. Mental or psychological control over matters of confidence helps some people, but mental fragility removes this control quickly and can rapidly take confidence away. Regarding physical factors and independence, strength building and activities such as goal planning and target setting to regain mobility and self-care capabilities help give control back. For others, their control over confidence in physical matters will always be a struggle, overwhelmingly influenced by complex health problems, impairments and disabilities. There is a constant tension between the person’s internal control over his or her confidence and external control or controlling factors that affect his or her inner confidence.

An incidental theme for this dimension was:

Control and ‘getting back to normal’ are linked to confidence.

[Describing confidence] ‘… well you don’t feel as if you are in control. Erm (.) and not doing things you used to take for granted and do. (.) do the best you can, …’ (Participant 15, starts line 53).

Another participant stated:

‘You feel a little bit lost and not in control of what you are doing. Er, that’s about it. (…) we hope that we get back to normal.’ (Participant 15, starts line 103).

A further incidental theme was:

Confidence is being in control.

‘[Confidence is] being in control. I think then when you get out of bed, you do need some confidence. Because everything seems to go haywire. You can’t get your balance. Your head can’t get right. Your body cannot cope, to whatever has been done. I think that is the word confidence comes into that lot.’ (Participant 20, starts line 12).

Another stated:

“Well, you just get on with it, for sure you know, I don’t know how long the confidence will take. It’s a difficult thing to say, but, erm, I want to be out of here as soon as possible now. Now I am up and at it. I have just got to keep going, to my estimation, the full recovery and all this comes when you get home. You’re in your own home, you’re in your own surroundings…” (Participant 20, starts line 53).

The four dimensions of confidence were then reimagined to create a new conceptual framework of confidence.

Conceptual design

A concept of confidence existed, based on recent published literature exposing attributes and perspectives of older people living with frailty [7]. This concept analysis highlighted three interconnected attributes with a strong central control feature. This was similar to that which emerged from this phenomenological study; however, this was now enhanced through the analyses of the unique lived experiences of these participants, providing deeper and richer personal understanding of confidence. Thus a new and rigorous conceptual framework was created. Figure 1 illustrates a comprehensive conceptualisation of confidence in older people living with frailty.

Figure 1 .


Figure 1

Conceptualisation of confidence through the lens of older people living with frailty5

Conceptual description

For an older person living with frailty, confidence sits on a continuum between vulnerability (a fragile state of well-being [6]) at one end and resilience (the ability to adapt to adversity [4]) at the other. Confidence is a dynamic and interdependent concept, directly influenced by the individuals’ perceptions and lived experiences of social connections, fear and independence. These three confidence dimensions can either be enhanced or eroded by the fourth dimension, control. The concept of confidence seems receptive to change through targeted interventions to strengthen resilience across these four dimensions.

Discussion

Study findings from this phenomenological research have enriched the conceptual understanding and meaning of what confidence means for older people living with frailty. Rich narrative descriptions of confidence have allowed the dimensions of social connections, fear, independence and control to be identified as its essential themes. This new knowledge enhances the previously higher-level descriptions of a literary-based concept analysis [7] and provides a tangible construct to inform intermediate care practice and service response.

Social connections to confidence in this study highlight the importance of social bonds to older people living with frailty, whether strong or very fragile. Directing practitioners to recognise and acknowledge the significance of social health, which includes control over life circumstances, support networks, engagement activities, social capital and social cohesion [4], is essential. The conceptual opposite of social health in the literature is social vulnerability, understood to mean the susceptibility to physical, functional and psychological health problems triggered by an individual’s social situation [16]. Here the continuum between social health (and resilience) and social vulnerability is reflected in the conceptual illustration (Figure 1). Practitioners are encouraged to strengthen social connections by working with the individual to tackle confidence-eroding factors, such as isolation, or the emotional impact from the loss of a spouse, and promote social dimension–enhancing factors.

The phenomenological analyses specifically identified a dimension of fear, but one with a broad reach and subsequent impact. Fear manifested in physical concerns and psychological illness, as well as in the torment from other dimensions such as being a burden on family (social connections) and feelings of helplessness (control). A phenomenological study exploring confidence in stroke survivors similarly identified a broadly defined theme of fear, which included worries about a further stroke, fear of stigma, going outside and the fear of falling [17]. The fear of falling phenomena is a frequently cited sequel of old age [18] and is associated with reductions in physical and social activities and quality of life consequences [19]. Fear of falling literature has long referenced confidence [20–22] but never explored its true meaning. With such prominence, practitioners must now be mindful of these new studies that present meaning and understanding of confidence. They show wider experienced fear factors, beyond an association with falls and their consequences.

The physicality of frailty is dominant in the literature. Independence, the physical dimension of confidence, has synergy with the concept of self-determination that resonates in the ‘I’m going to do it!’ attitude of Participant 08. In this, older people emphasise independence and control factors, such as having the cognitive ability to make a decision or having the knowledge to act [23], and it is linked to personal motivation as an actualisation of self-care [24]. Knowledge and education are important components to greater physical independence [25] and strongly connect to the wider asset building attributes [4] that intermediate care services need to respond to.

The final dimension of confidence is control. The unifying theory of control developed by Walker [26], despite not living up to its initial hype [27], presents an insightful presentation of a theory and useful adjunct to understanding the control dimension in the context of this concept. Walker contextualises perceived levels of support and control to recognise that, when both are in their lowest state, hopelessness and helplessness exist, but when both are in their highest state (a high level of perceived support and a high level of perceived control), confidence presides [26]. Control here is fundamentally connected to support, in its social context, which reinforces the interdependent aspect of the constructs four fundamental, but individually recognisable, dimensions.

This study was triggered by the lack of older people’s informed conceptual insight and knowledge of confidence within the context of services maximising the independence of this population in response to acute illness. The findings addressed this deficit in the evidence base by presenting a revised conceptual framework that can be used to develop new models of care delivery. Thus it is now possible for practitioners working with older people, particularly in intermediate care services, to apply a pragmatic conceptual framework, directly informed by the voices of service users, to help them respond to older persons’ confidence-related issues.

Strengths and limitations

This phenomenological enquiry importantly introduced the voices of older people living with frailty to enrich a literature-based concept [7]. This has informed, changed and significantly strengthened understanding to enable the production of a practice-relevant conceptual framework, previously missing from national intermediate care policy and guidance. The framework’s limitations must be acknowledged however. The sample was drawn from a post-acute care patient population, but protocol revision meant that the majority of interviews were conducted in a hospital setting that may have influenced responses. However, it is likely that the reduced time interval between the spontaneous use of the word confidence and the interview enhanced lived experience recall, thereby adding strength. The sample was ethnically homogeneous and participant voices came from just one region of the UK, thereby potentially limiting transferability. Finally and in line with previous confidence concept development publications [6,7], this study maintained the separation from Banura’s social construct of self-efficacy [28] on the grounds that Bandura viewed confidence as a ‘colloquial term’ [29: 382], one not linked to self-efficacy in any way.

Implications for research and practice

For research, the conceptual framework provides new knowledge, and its usefulness to practice must be explored further. The development of measurement tools to quantify confidence is a priority since this will help optimise the evaluation of future confidence-related interventional studies. For practice, translation of the concept into ‘confidence conversations’, which naturally align to comprehensive geriatric assessment processes, would further optimise person-centred asset and deficit recognition to promote well-being.

Conclusion

This study has revealed new understanding about confidence in the context of older people living with frailty, a word that has not been truly understood. The emergent concept of confidence compellingly compliments existing frailty models, exposing essential well-being assets equally as well as deficits. It is important that this new evidence base is used to inform commissioned intermediate care services in the UK, and elsewhere, thereby reviewing their approach and response to confidence building and promoting activities.

Supplementary Material

aa-20-1528-File002_afab109

Acknowledgements

We are grateful to the participants of the study for sharing openly their experiences that have contributed so richly to these findings.

Contributor Information

Frazer Underwood, South West Clinical School in Cornwall, Royal Cornwall Hospitals NHS Trust, Truro, UK; School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK; University of Plymouth Centre for Innovations in Health and Social Care: A JBI Centre of Excellence, Plymouth, UK.

Jos M Latour, School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK; University of Plymouth Centre for Innovations in Health and Social Care: A JBI Centre of Excellence, Plymouth, UK.

Bridie Kent, South West Clinical School in Cornwall, Royal Cornwall Hospitals NHS Trust, Truro, UK; School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK; University of Plymouth Centre for Innovations in Health and Social Care: A JBI Centre of Excellence, Plymouth, UK.

Declaration of Conflicts of Interest

None.

Declaration of Sources of Funding

The Royal Cornwall Hospital NHS Trust funded the Doctor of Philosophy academic study costs of the first author of which this research contributed. The first author is an NIHR 70@70 Senior Nurse and Midwife Research Leader and receives funding from the National Institute for Health Research. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Ethical Approval

The study received UK Health Research Authority approval (reference number: 16/YH/0363).

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