Frailty, in a medical context, is recognized as a condition where an individual becomes increasingly vulnerable due to the natural decline associated with aging across various physiological systems. This decline reduces their ability to effectively manage and recover from acute health stressors.1 Research consistently shows that frailty significantly elevates the risk of adverse health outcomes.2–5 Consequently, when frailty is identified, the balance between risks and benefits of standard treatments, such as renal replacement therapies, must be carefully reconsidered to ensure patient-centered care.
Patients suffering from chronic kidney disease (CKD) are particularly susceptible to physical impairments, cognitive decline, and frailty.6 As populations age, the growing occurrence of frailty is reshaping how CKD treatments are approached.7–10 For individuals with both CKD and frailty, treatment decisions become more complex, necessitating tools that can aid in personalized care planning.
Identifying frailty routinely is crucial for understanding its impact on patient-relevant outcomes and for making informed medical decisions at the point of care.11 Cognitive impairment, a significant contributor to frailty, further complicates care planning. Recognizing memory loss is essential for tailoring treatment approaches and ensuring patient and family involvement in complex medical decisions and treatment regimens.12 In such cases, family participation is vital to ensure treatment understanding and adherence.
To address the increasing need for standardized, evidence-based decision-making for frail individuals, the Palliative and Therapeutic Harmonization (PATH) process was developed.13 PATH is designed to bridge the care gap for older adults who are frail but not terminally ill, whose health status limits the effectiveness of typical treatments. By utilizing comprehensive assessment tools to align care options with frailty levels and patient values, PATH empowers patients and their families to make well-informed decisions that aim for the best possible results.
The Frailty Assessment For Care Planning Tool (FACT) is a cornerstone of the PATH process.14,15 FACT is designed as an accessible frailty screening tool for healthcare providers outside of geriatrics, helping to determine which patients would benefit from a full PATH assessment. FACT was created to overcome common obstacles in frailty identification and uses the descriptions found in the Clinical Frailty Scale (CFS).16 Key features of FACT include its reliance on reports from caregivers or family members (collateral report) and the integration of validated cognitive screening tests, as detailed in Table 1. The benefits of FACT include its ability to pinpoint the primary factors driving frailty across four key domains: mobility, social situation, function, and cognition, using a refined ordinal scaling approach.
A recent study17 evaluated the reliability of FACT against the CFS, which depends on a clinician’s overall judgment, using the Frailty Index as a benchmark.18 FACT demonstrated a stronger correlation with the Frailty Index (Pearson r=0.72) compared to CFS (r=0.56). Importantly, unlike the Frailty Index, FACT identifies specific clinical drivers of frailty for each patient, which is invaluable for guiding healthcare decisions. This advantage led to the selection of FACT for a study investigating frailty screening in a nephrology clinic.
This study aimed to: 1) explore nurses’ experiences administering FACT in a specialized renal outpatient setting; 2) assess how their understanding of frailty changed after implementing routine screening; and 3) identify factors influencing the adoption and use of frailty screening tools in specialized clinical environments.
Methods: Implementing FACT in a Renal PATH Clinic
To proactively manage frailty in CKD patients, the Nova Scotia Health Authority, Central Zone Renal Clinic, adopted the PATH program methodology, establishing their Renal PATH clinic. Patients identified as frail via FACT screening are referred to this clinic for comprehensive assessment and guided decision-making, utilizing a more detailed PATH frailty assessment and a structured patient/family communication approach. This process allows healthcare providers in the Renal PATH clinic to carefully consider appropriate treatment options and support patients and their families in making informed choices tailored to their individual frailty and circumstances.13
A nephrology nurse practitioner, trained in PATH and operating the Renal PATH clinic, was designated as the clinical champion and co-investigator for this initiative.
Study Participants and Setting
The research was conducted at the Renal Clinic of Dalhousie University, which serves a large outpatient nephrology referral area in Nova Scotia, covering a population of 800,000. Nurses from this Renal Clinic were invited to participate if they met specific criteria: 1) being a registered or licensed practical nurse in the Renal Clinic; 2) being trained in and using the FACT screening tool; 3) having participated in FACT screening since the project’s inception for 24 months; and 4) being English-speaking. All participants provided informed consent, and the study was approved by the Nova Scotia Health Authority Research Ethics Board (File number 1015588).
FACT Training for Nurses
The FACT tool14,15 is designed for ease of use by non-geriatric specialists for reliable frailty identification and staging in older patient populations across clinical settings. While using similar staging descriptors to the CFS,16 FACT uniquely incorporates collateral reporting and validated cognitive screening through the Mini-Cog19 and the memory axis of the Brief Cognitive Rating Scale20 to establish baseline health and cognitive status. The Mini-Cog assesses cognition through a three-word recall test, a clock-drawing test, and subsequent recall of the words. The Brief Cognitive Rating Scale (memory axis) evaluates recall of current events, the US president’s name, and names of family members. Mobility, function, and social circumstance domains of frailty are scored based on caregiver reports of the patient’s usual status.
Renal Clinic nurses received two one-hour training sessions on frailty, its clinical relevance, and the FACT screening method. The PATH program coordinator served as a liaison, providing ongoing support, feedback sessions, troubleshooting assistance, data collection oversight, and adherence monitoring throughout the study.
Research Design and Data Analysis
The study adopted a descriptive design combined with modified constructivist grounded theory to analyze themes emerging from nurses’ experiences with FACT. Grounded theory, a leading qualitative method in health research, uses inductive and deductive approaches to build theory from unstructured qualitative data.[21](#ref21],22 Data analysis involved constant comparison to identify patterns and categories, leading to theoretical outputs.23 This method is well-suited for healthcare settings to capture common experiences and understand variations logically.
Semi-structured interviews guided focus group discussions using probes developed from literature review and research questions. Probes aimed to explore nurses’ opinions and experiences, not to identify relationships in data. Example questions included: “What does frailty screening mean to you?” “What was your experience implementing FACT?” “What was helpful/challenging about FACT?” “Has FACT changed your understanding of frailty?” and “What advice for FACT implementation would you give others?”. The 24-month integration of FACT into routine renal care was examined from initiation to future directions.
Interviews were transcribed verbatim and analyzed by three researchers using grounded theory guidelines.[24](#ref24] Transcripts were examined line-by-line to identify significant passages, broken into parts, and sorted under conceptual headings. Emerging themes were identified, and an open coding framework was developed using Atlas.ti 6.2 software for qualitative data analysis. Direct quotes from interviews were used to support findings, with participant quotes de-identified and edited for clarity.
Results: Nurse Experiences with FACT Implementation
Five nurses (4 registered nurses and 1 licensed practical nurse), representing the entire Renal Clinic nursing staff, participated in the focus group. All were female with over 10 years of nursing experience. Data analysis revealed four main themes: hesitancy (“we were skeptical”), adaptation (“we made it work”), development (“we learned how”), and internalization (“we understand”), as summarized in Table 2.
Theme 1: We Were Skeptical (Hesitancy)
Nurses initially expressed hesitation towards the FACT frailty screening initiative.
The Unknown: Structured frailty screening was novel, not part of their prior training or experience. The goal of identifying frailty was initially seen as peripheral to their nursing role. Hesitation stemmed from uncertainty about how frailty status would impact patient care and discomfort with frailty assessment, which felt “formal” and “structured” compared to their “eyeball test” approach. Engaging patients and caregivers in FACT’s manner (cognitive testing and collateral reports) was considered “unusual.”
The Challenges: Perceived challenges included lack of physician support and feasibility issues, especially during implementation. Some felt the purpose of FACT was not initially understood by the Renal Clinic team. Obtaining collateral information was seen as effort-intensive. Ongoing challenges included consistently getting collateral historians (family members) to appointments, requiring proactive phone calls and reminders.
Building Support: Early on, nurses perceived a lack of support from nephrologists, who seemed disengaged and rarely inquired about FACT results. Nurses questioned the benefit of their efforts, expressing concerns about it being a “make work project” and requiring time without perceived benefit. To address this, the protocol included Renal PATH clinic referrals for all patients screening positive for frailty (mild or above) to ensure frailty was considered in care planning.
Feasibility: Time constraints were a major concern, especially initially. FACT administration took longer (15 minutes) than the trained 6 minutes, adding to their hectic schedules. Nurses struggled to “fit it in” amidst physician schedules and clinic flow.
Not Knowing: Lack of frailty knowledge, program direction, and overall purpose contributed to uncertainty. Nurses felt a need for more direction regarding program outcomes and next steps after screening. These concerns were stronger in the initial program phases.
Theme 2: We Made It Work (Adaptation)
This theme highlights how nurses adapted to integrate and support the FACT initiative.
Adapting to Change: The rapid introduction of FACT required quick adaptation. A collaborative approach emerged, with nurses emphasizing relational behavioral changes. Information sharing within the small nursing group facilitated mutual support and problem-solving. Cooperation and flexibility were key interpersonal strategies. Minor practice adjustments made FACT application smoother.
Gaining Support: Nurses became “cheerleaders” for FACT, promoting it to staff and physicians as they recognized frailty’s prevalence and significance. Their advocacy was largely successful, gaining support from nephrologists and administrators, although some remained more interested than others.
Patient/Caregiver Experience: Commitment to patient and caregiver understanding was central. Nurses introduced FACT before administration and addressed questions. New patient interactions were more challenging. Discussing frailty outcomes with caregivers was delicate, though “most people aren’t surprised” by frailty findings. Experience helped nurses develop conversation strategies, acknowledging “not one size fits all” approaches to frailty discussions.
Theme 3: We Learned How (Development)
This theme focuses on nurses’ learning and growing confidence through FACT implementation.
Developing Approaches: Despite the Renal Clinic’s fast pace, nurses adapted routines within months to accommodate FACT. They refined their patient/caregiver interactions to streamline FACT administration during usual care. Regular information exchange about scores and outcomes facilitated learning, acknowledging FACT implementation as “very different nursing” from their usual approach.
Measuring Frailty: FACT screening was “eye-opening,” revealing unexpected assessment results and subtle frailty often overlooked previously. Nurses realized they had been “missing this” despite long-term standard assessments. Measuring frailty led to ownership of the FACT initiative and a deeper appreciation of frailty as a key health indicator. Their understanding of frailty expanded beyond physical aspects to include cognitive dimensions.
Implementation Improvements: Nurses initially hesitated to seek clarification on FACT use, relying on training materials. Wording adjustments to frailty stage definitions midway through the initiative improved clarity. Regular updates reduced “uncertainty” in FACT implementation.
Building Confidence: Increased comfort with FACT led to confidence in administration and result interpretation. High frailty prevalence among patients over 75 (67% frail) reinforced their confidence. They started noticing subtler frailty aspects. FACT was even used for patients outside screening age criteria to quantify frailty levels. Personal growth and self-assurance were positive outcomes, changing their overall perspectives in unexpected, immeasurable ways.
Theme 4: We Understand (Internalization)
Reflecting on their FACT adoption experience, nurses reached a point of “understanding.” This theme highlights recognizing frailty as crucial to health and FACT’s value in their roles.
Recognizing Frailty: Nurses developed a deeper appreciation for frailty, recognizing their earlier “observations” as less informed. FACT provided a unique frailty perspective, enhancing their clinical skills. Their thinking shifted from stereotypical “frail person with the cane” images to deeper considerations of frailty’s meaning and scope. They became more attentive to subtle cues during FACT administration and clinic visits, promptly acting on observations and discussing complex cases as a team. They realized frailty knowledge guides personalized care planning.
Value Added: Nurses unanimously viewed FACT as highly valuable, citing numerous examples of its benefit to their expertise. FACT improved their assessment and understanding of frail patients, benefiting patients and families long-term. Frailty scores were considered “significant” for overall assessment and care planning. Nurses affirmed continued FACT use if it enhances patient care.
General Perceptions of Frailty Screening: Nurses described FACT as “structured,” enabling “prioritization,” “communication,” and requiring “training.” Using collateral historians was beneficial for accurate baseline information and nurse-caregiver interaction. FACT prompted earnest family conversations, with some family members realizing their loved one’s frailty more clearly. Standardized FACT language improved staff communication about patient frailty. Objective cognitive testing was valued for efficiently gauging cognitive capacity. Straightforward FACT protocols allowed self-paced learning and adaptation, contributing to a shift in overall perspective beyond kidney-specific health to “the whole picture.”
Despite initial challenges, standardized frailty screening was significantly beneficial. Clinical prioritization of frailty screening was seen as crucial for teamwork and cooperation. Barriers to frailty identification included “lack of leadership,” “knowledge/understanding of frailty,” and “initiative.” These were general barriers, not specific to their clinic or FACT. Table 3 summarizes factors contributing to FACT success and barriers to adoption.
Discussion: Enhanced Efficacy and Understanding Through FACT
The renal nurses’ experience with FACT was marked by enhanced efficacy and a deeper understanding of frailty. This improvement was directly linked to the standardized frailty detection process and their team confidence in providing more appropriate care. Increased frailty knowledge was deemed important and associated with better decision-making, consistent with other nurse-led screening initiatives.26–[28](#ref28] Key factors for positive implementation included realistic goals, clear guidelines, and a visible initiative leader (Box 1).
Structured FACT implementation and ongoing support were positive factors. Unlike frailty measures like the Frailty Index[18](#ref18] or Fried Frailty Score,29 FACT includes objective cognitive ability measures. Nurses valued learning to quickly identify cognitive impairment using the Mini-cog19 and Brief Cognitive Rating Scale.[20](#ref20] However, limiting formal training to the initial phase diminished its impact; ongoing workshops were preferred.
FACT’s use of everyday experience metrics to describe frailty levels, contrasting with numeric outputs or unfamiliar metrics (grip strength), facilitated communication between providers and patients. Nurses reported more open dialogues, communicating frailty’s significance to patients and families. Clear communication enhanced collaboration within the Renal Clinic by introducing a common lexicon for discussing frailty stages and drivers.
The grounded theory approach allowed active researcher engagement, inviting elaboration and clarification.[23](#ref23] Similar nurse experience studies have used grounded theory[30](#ref30] or normalization process theory,31 though the latter is less common in nurse-focused research.
Study Limitations and Future Directions
The small focus group size is a key limitation. Experiences might differ in other clinical settings. Retrospective data on initial program stages may introduce recall bias due to the 2-year interval since inception.
Further research should compare these findings with other FACT initiatives in similar groups. Future projects could define roles more clearly, identify program champions, and engage stakeholders. Patient and caregiver experiences with FACT screening also require further study.
The nephrology clinic-PATH program partnership13 was positive, providing support for frail renal patients. This reciprocal relationship created a useful system for complex case management.
Program follow-up revealed reduced adherence and patient recruitment since interviews, despite continued operation. Sustainability challenges are consistent with literature on nurse-led programs,27,[28](#ref28] potentially due to slower summer clinic flow and the time-intensive nature of obtaining collateral history amidst busy schedules. Nurses admitted reduced clinical priority for the initiative and desired more routine contact with research staff and expert professional support. Scheduled stakeholder meetings and increased recognition were suggested motivators, alongside improved clinic environments and dedicated FACT time.
Conclusion: FACT as a Valuable Tool for Frailty Screening
This study provides valuable insights into nurses’ experiences using FACT to identify frailty in a renal outpatient clinic. Four core themes emerged: initial hesitancy, adaptation, development, and internalization. Initial challenges were overcome, and confidence grew with enhanced frailty understanding. Nurses’ frailty understanding expanded beyond physical indicators to include comprehensive assessments of frailty domains. They developed a broader “big picture” view of patient health beyond kidney-specific issues.
These findings have implications for nurse-led clinical programs. Systematic frailty screening with well-defined guidelines can succeed but requires supervision and support for long-term sustainability. Clearly prioritizing FACT for frailty evaluation may improve uptake. Focusing on training, education, and professional development, inspired by nurses’ adaptation and development experiences, is crucial to prevent FACT from being seen as just another task. Nurses’ positive attitudes stemmed from FACT’s ability to improve their patient interaction and understanding, providing clear practical benefits beyond data collection.
Acknowledgments
This initiative was funded by the Nova Scotia Health Authority Research Fund. The authors thank the Renal Clinic nursing staff for their participation. The FACT tool is copyrighted but freely accessible at www.pathclinic.ca.
Disclosure
Dr. Mallery and Dr. Moorhouse, FACT and PATH model co-creators, receive consultant fees for PATH training program delivery. No other conflicts of interest are reported.
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