Development and assessment of an educational intervention to improve the recognition of frailty on an acute care respiratory ward.

BACKGROUND: Frailty is a robust predictor of poor outcomes among patients with chronic obstructive pulmonary disease yet is not measured in routine practice. We determined barriers and facilitators to measuring frailty in a hospital setting, designed and implemented a frailty-focused education intervention, and measured accuracy of frailty screening before and after education. METHODS: We conducted a pilot cross-sectional mixed-methods study on an inpatient respiratory ward over 6 months. We recruited registered nurses (RNs) with experience using the Clinical Frailty Scale (CFS). RNs evaluated 10 clinical vignettes and assigned a frailty score using the CFS. A structured frailty-focused education intervention was delivered to small groups. RNs reassigned frailty scores to vignettes 1 week after education. Outcomes included barriers and facilitators to assessing frailty in hospital, and percent agreement of CFS scores between RNs and a gold standard (determined by geriatricians) before and after education. RESULTS: Among 26 RNs, the median (IQR) duration of experience using the CFS was 1.5 (1-4) months. Barriers to assessing frailty included the lack of clinical directives to measure frailty and large acute workloads. Having collateral history from family members was the strongest perceived facilitator for frailty assessment. The median (IQR) percent agreement with the gold-standard frailty score across all cases was 55.8% (47.2%-60.6%) prior to the educational intervention, and 57.2% (44.1%-70.2%) afterwards. The largest increase in agreement occurred in the 'mildly frail' category, 65.4%-81% agreement. CONCLUSIONS: Barriers to assessing frailty in the hospital setting are external to the measurement tool itself. Accuracy of frailty assessment among acute care RNs was low, and frailty-focused rater training may improve accuracy. Subsequent work should focus on health system approaches to empower health providers to assess frailty, and on testing the effectiveness of frailty-focused education in large real-world settings.

Studying delays in breast cancer diagnosis and treatment: critical realism as a new foundation for inquiry.

PURPOSE/OBJECTIVES: To examine how delays in breast cancer care currently are conceptualized and to introduce philosophical and theoretical tenets of critical realism as an alternative approach. DATA SOURCES: Health and social sciences literature. DATA SYNTHESIS: Diagnostic and treatment delays in breast cancer most frequently are conceptualized as patient, provider, or system related. The approach has limited utility in guiding explanatory analysis because it does not acknowledge the social context in which the delays occur. The philosophical tenets of critical realism and two related theoretical approaches are an alternative. They illustrate how an individual's biologic, social, and material resources may undermine or support structural inequities in access to breast cancer care. CONCLUSIONS: Critical realism provides a useful framework for analysis of links between social inequalities and delays in breast cancer diagnosis and treatment. IMPLICATIONS FOR NURSING: Access to breast cancer care could be better understood and conceptualized by basing future research and theoretical endeavors on a critical realist perspective.