Frailty, often described as a state of increased vulnerability resulting from age-related decline across multiple physiological systems, significantly impairs an individual’s ability to cope with stressors.1 This condition elevates the risk of adverse health outcomes,2–5 necessitating a careful reconsideration of treatment strategies, including renal replacement therapies, particularly when frailty is evident.
Patients with chronic kidney disease (CKD) face a heightened risk of physical dysfunction, cognitive decline, and frailty.6 As populations age and frailty becomes more prevalent, treatment approaches for CKD are evolving.7–10 Consequently, individuals with both CKD and frailty often encounter intricate decisions regarding their care options.
The routine identification of frailty presents valuable opportunities to improve our understanding of its impact on patient-centered outcomes, thereby enriching the medical decision-making process at the point of care.11 Cognitive impairment, a significant contributor to frailty, underscores the importance of detecting memory loss, as it profoundly influences how patients and healthcare providers navigate complex medical choices and adhere to demanding treatment plans.12 In such instances, involving family members becomes crucial to ensure treatment understanding and compliance.
To address the growing need for standardized, evidence-based decision-making in the context of frailty, the Palliative and Therapeutic Harmonization (PATH) process was developed.13 PATH is designed to bridge the care gap for frail older adults who are not imminently dying but whose fragile health compromises the effectiveness of standard treatments. By employing comprehensive assessment tools to align care options with frailty levels and patient preferences, PATH empowers patients and their families to make informed decisions that optimize their health journeys.
The Frailty Assessment for Care Planning Tool (FACT) serves as the initial step in the PATH process.14,15 This user-friendly frailty screening tool is designed for non-geriatricians to effectively identify patients who would benefit from a full PATH assessment. FACT was created to overcome common obstacles in frailty identification and utilizes descriptors from the Clinical Frailty Scale (CFS).16 Key advantages of FACT include its reliance on collateral reports and the integration of validated cognitive screening tests, as detailed in Table 1. The tool’s benefits extend to pinpointing specific areas driving frailty, utilizing a refined ordinal scaling approach across four crucial domains: mobility, social situation, function, and cognition.
A recent study17 evaluated the reliability of the FACT method against the CFS, which depends on clinician’s overall judgment, using the Frailty Index as the benchmark.18 The FACT demonstrated stronger correlation with the Frailty Index (Pearson r=0.72 for FACT versus r=0.56 for CFS) compared to the CFS. Importantly, unlike the Frailty Index, FACT identifies the specific clinical factors contributing to frailty in each patient, which is invaluable for guiding decision-making. The FACT method was subsequently chosen for a qualitative 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 evolved after routine screening implementation; and 3) identify factors influencing the adoption and administration of frailty screening tools in specialized clinical environments.
Renal PATH Clinic: Integrating FACT into Practice
To effectively identify and address frailty in CKD patients, the Nova Scotia Health Authority’s Central Zone Renal Clinic adopted the PATH program’s methodology and developed the Renal PATH clinic. Patients identified as frail through FACT screening are referred to this clinic for in-depth assessment and guided decision-making, utilizing a comprehensive PATH frailty assessment and a structured approach to patient and family communication. Renal PATH enables healthcare providers to thoughtfully consider appropriate treatment options and supports patients and families in making choices aligned with their individual frailty status and circumstances.13
A nephrology nurse practitioner, trained in PATH and leading the Renal PATH clinic, served as a clinical champion and co-investigator in the study.
Study Participants and Setting
The research was conducted at the Renal Clinic of Dalhousie University, serving a large outpatient nephrology referral base in Nova Scotia, covering a population of 800,000. Nurses from the Renal Clinic were invited to participate, with inclusion criteria including: 1) Renal Clinic nurses; 2) FACT screening tool training; 3) participation in FACT screening since project inception for 24 months; and 4) English proficiency. All participants provided informed consent, and the study received ethics approval from the Nova Scotia Health Authority (File number 1015588).
FACT Training for Nurses
The FACT tool14,15 is designed for easy administration by non-geriatric specialists to reliably identify and stage frailty in older patient populations across clinical settings. While using staging descriptors similar to the CFS,16 FACT incorporates collateral reporting and validated cognitive screening tests, the Mini-Cog19 and the Brief Cognitive Rating Scale memory axis[20](#ref20], to establish baseline health and cognitive status. The Mini-Cog assesses cognition through three-word recall, clock drawing, and recall after drawing. The Brief Cognitive Rating Scale (memory axis) evaluates recall of current events, the US president, and names of family members. Mobility, function, and social circumstance scores are based on caregiver reports of the patient’s baseline status.
Renal Clinic nurses underwent two one-hour training sessions on frailty, its clinical significance, and the FACT screening method. The PATH program coordinator provided ongoing support, conducting check-ins with the nurses, gathering feedback, assisting with problem-solving, overseeing data collection, and promoting adherence to guidelines throughout the study.
Research Design and Data Analysis
The study employed a descriptive design and modified constructivist grounded theory to analyze core themes emerging from the nurses’ experience with FACT administration. Grounded theory, a leading qualitative method in health research, uses inductive and deductive approaches to build theory from unstructured data.21,22 Constant comparative analysis identifies relationship patterns and overarching categories leading to theoretical outputs.23 This method is well-suited for healthcare settings to understand common experiences and variations logically.
Semi-structured interviews guided focus group discussions, with questions developed from literature review and research questions. These probes aimed to gain insight into 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?”. The 24-month integration of FACT into the Renal Clinic was explored, from initiation to future directions.
Interviews were transcribed verbatim, and data analysis was conducted by three research team members. Following grounded theory guidelines,[24](#ref24] transcripts were analyzed line-by-line to identify significant excerpts, breaking raw data into conceptual headings. Emerging themes were identified, and an open coding framework was developed using Atlas.ti 6.2 software.
Direct quotes and statements from focus groups were used to support and personalize data, de-identified and edited for clarity.
Study Results: Four Key Themes Emerged
Five nurses (4 registered nurses, 1 licensed practical nurse), representing the entire Renal Clinic nursing staff, participated in the focus group. All participants 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”), further detailed in Table 2.
Theme 1: Hesitancy (“We Were Skeptical”)
Nurses initially expressed hesitation towards the FACT frailty screening initiative, describing their initial reactions.
The Unknown: Structured frailty screening was a novel approach, not part of their prior training or experience. The program’s goal—nurse-led frailty identification—initially seemed secondary to their role. Hesitation stemmed from uncertainty about how frailty knowledge would impact patient care and discomfort with frailty assessment, considered outside their “comfort zone.” FACT’s structured approach contrasted with their ad hoc, gestalt frailty assessment (“eyeball test”). Engaging patients and caregivers as required by FACT (objective cognitive testing and collateral reports) was perceived as “unusual.”
The Challenges: Perceived challenges varied, including: 1) difficulty gaining physician support, and 2) feasibility constraints during implementation. Some felt team members initially misunderstood the initiative’s purpose. Obtaining collateral informant input seemed overly burdensome to some. Despite progress, challenges persisted, particularly in consistently securing collateral history, crucial for FACT’s standardized process, as cognitively impaired individuals often overestimate their abilities.25 Nurses regularly phoned ahead of appointments to encourage collateral historians to attend.
Building Support: Initial efforts focused on educating nurses about frailty’s importance. A key initial challenge was nurses’ perception of nephrologists’ lack of support for FACT and understanding of its rationale. Nurses observed limited physician engagement and inquiries about FACT results.
Nurses voiced concerns about the initiative’s impact and questioned its value:
[…] are we going to put all of our time and effort and energy into this and there’s going to be nothing done with it? Is this going to be another one of these ‘make work’ projects?
Another nurse echoed this: “If it involves people’s time, there has to be some perceived benefit for it, because if not, it’s a hard sell”. To address this, the protocol stipulated that patients screening positive for frailty (mild or above) would be referred to the Renal PATH clinic for further assessment and frailty-informed treatment and care planning.
Feasibility: Time constraints were a universal concern, especially initially. Nurses reported FACT administration taking significantly longer (15 minutes) than the initial 6-minute training estimate. Integrating it into busy clinic schedules posed a challenge. One nurse commented:
[…] time is of the essence […] the physicians are knocking on the door, they’re ready, they don’t want any holdups in clinic. So, you’re trying to get the assessment done so they can get in there. Or, you need to go in and do it afterwards if you have time.
Not Knowing: Lack of frailty knowledge, program direction, and overall purpose contributed to this theme. Nurses were unsure of the program’s outcomes and desired more guidance. Similar to perceived lack of support, one nurse asked, “I’m going to do this, but what’s going to happen with it? Where are we going to go with it […]?” These concerns were most prominent in the program’s early stages.
Theme 2: Adaptation (“We Made It Work”)
This theme describes how Renal Clinic nurses adapted to integrate, support, and implement the FACT frailty screening initiative.
Adapting to Change: The initiative’s rapid introduction required quick adaptation. It fostered collaboration, necessitating relational behavioral changes. One nurse observed:
We share a lot of information […] it’s nice that you might point out that they [the patient] didn’t do well on the frailty [FACT screen] […] so we’ll see if there’s anything more to it. That’s the nicest thing, we’re such a small group, and such small numbers that we can actually communicate and help each other.
“Cooperation” and “flexibility” were emphasized. Nurses also made minor practice modifications to ease FACT application.
Gaining Support: Nurses felt compelled to “cheerlead” for FACT, promoting it to staff and physicians. As they recognized frailty’s prevalence and significance in their patient population, they became advocates for continued use. Their efforts were largely successful, gaining support from many nephrologists and administrators, recognizing that “Some will take more of a keen interest than others”.
Patient/Caregiver Experience: Nurses prioritized patient and caregiver understanding. They took time to introduce the screening tool and answer questions. One nurse noted, “I think it depends on whether you’ve had previous interactions with the patient or caregiver […] if it’s a new patient, it’s often more challenging”. Discussing frailty assessment outcomes with caregivers was delicate, though one nurse mentioned, “most people aren’t surprised” [by frailty identification]. With experience, nurses developed appropriate conversation strategies, agreeing that frailty communication “is not one size fits all”.
Theme 3: Development (“We Learned How”)
This theme highlights nurses’ didactic development, learned approaches, and increased confidence stemming from educational gains.
Developing Approaches: Despite the Renal Clinic’s fast pace, nurses adapted to FACT screening. Routine changes were established within months. One nurse stated:
Once you get comfortable […] you always kind of do a little meet and greet […] it’s amazing how much information you can gather once you know what to say. But I think we all had to learn that […].
Nurses modified patient/caregiver dialogues to streamline FACT within usual care, exchanging score and outcome information for learning. They acknowledged FACT implementation was “very different nursing” from their customary approach.
Measuring Frailty: Nurses repeatedly called the initiative “eye-opening,” recounting “unexpected” assessment results and surprise at FACT’s effectiveness in detecting subtle frailty, previously overlooked. Post-FACT implementation, one nurse reflected:
And then you kind of think, oh my God, we’ve been doing this [standard Renal Clinic nursing assessment] for a long time, what’s wrong with me because I’m missing this?
Tasked with measuring frailty, nurses took ownership of FACT and learned to appreciate frailty as a vital health indicator. One nurse said, “I think we’ve always looked at frailty primarily from a physical point of view”. Others agreed, stating they now “perform deeper assessments,” particularly cognitive, rather than “assume.”
Implementation: Initially, nurses hesitated to seek FACT tool clarification, relying on training materials. FACT tool clarity improved mid-initiative by refining frailty stage definitions. Nurses felt regular updates reduced “uncertainty” in FACT implementation.
Building Confidence: As nurses grew comfortable with frailty screening, their confidence in FACT implementation and results interpretation increased. High frailty prevalence in patients aged 75+ reinforced their certainty, and they began noticing subtler frailty aspects. Sixty-seven percent of screened patients were frail: 44% mildly, 17% moderately, and 6% severely. One nurse noted:
If we’re wondering about a patient, even if they don’t meet age inclusion criteria [for screening], we’ll often do the FACT along with our assessment so we can quantify their level of frailty.
Nurses reported personal growth and confidence gains from FACT screening, “in ways that we probably didn’t expect it to be, not in measurable ways […] it just changes your overall perspective”. Others validated this, describing individual benefits and a shared feeling of personal value in the initiative.
Theme 4: Internalization (“We Understand”)
Reflecting on their FACT adoption experience, nurses’ final theme, “We understand,” emerged, encompassing: 1) frailty recognition as a critical health determinant; and 2) FACT’s clear value in their healthcare provider roles.
Recognizing Frailty: Nurses developed a deep appreciation for frailty’s importance, considering their earlier “observations” less informed. They credited FACT with introducing a unique frailty perspective, enhancing their clinical practice. Nurses described a shift from identifying “[…] the typical frail person with the cane […]” to questioning “what does that really mean?” or “what does that capture?” in response to FACT descriptors. They became attentive to nuances during screening and clinic visits, acting on observations and discussing complex cases as a team:
[…] Do they need supports? Do we need to contact social work? Do we need to include family members in the process of medical decision making? Are the offered treatments appropriate in the context of frailty?
Essentially, nurses realized frailty knowledge aids personalized care plan development.
Value Added: Nurses responded positively to FACT as a systematic frailty evaluation approach, unanimously valuing the tool. They cited FACT’s improvement to their expertise as renal nurses. One remarked:
[…] personally, after doing them, I can see the benefit of how I look at the frail patient and their overall care […]. I find it helps my own assessment, which benefits the patient and their family in the long run.
Another described patient frailty scores as “significant” for overall assessment and care planning. One nurse summarized the Renal Clinic staff’s sentiment: “If we feel that using the tool adds value in enhancing patient care, then we will continue to use it”.
General Perceptions of Frailty Screening: Nurses discussed frailty detection differences before and after FACT. Prompts included “What does screening for frailty mean to you?” Initial FACT descriptors: “structured,” “prioritization,” “communication,” and “training.”
Collateral historian use, versus patient self-report, was deemed beneficial for accurate baseline information, facilitating valuable nurse-caregiver interaction. Nurses described earnest family conversations sparked by FACT:
I’ve had some family members say that it was really an eye-opener for them on how their loved one […] was a lot more frail, once we put it in those terms, than they thought.
FACT’s standardized language improved staff communication about patient frailty status. Objective cognitive testing was viewed as “interesting” and positively valued for efficiently gauging cognitive capacity. Straightforward FACT implementation protocol allowed self-paced adjustment and learning, referencing guidelines as needed. This self-directed assimilation was hypothesized to catalyze perspective shifts:
Our specialty here is kidneys, but this kind of helps us to get an idea of overall health, and how that will kind of intertwine with the health of your kidneys. So that instead of just looking at this one little picture, we’re looking at the whole picture.
Despite challenges, a structured, standardized frailty screening approach was considered significantly beneficial. Nurses agreed clinical prioritization of frailty screening was crucial for teamwork and shared goals. They outlined factors hindering frailty identification: “lack of leadership,” “lack of knowledge or understanding of frailty,” and “lack of initiative,” viewed as general barriers, not specific to their clinic or FACT.
This discussion segment was categorized into FACT success factors (nurse-identified) and adoption barriers, summarized in Table 3.
Discussion: Enhanced Efficacy and Understanding with FACT
Renal nurses’ FACT tool experience was characterized by enhanced efficacy and frailty understanding, directly linked to standardized frailty detection and team confidence in providing more appropriate care. Increased frailty knowledge was deemed important and associated with improved decision-making. Routine frailty identification has proven effective in other nurse-led initiatives.26–28 Positive implementation factors included realistic goals, clear guidelines, and a visible initiative coordinator (Box 1).
Structured FACT implementation and ongoing training/support were positive factors. Unlike frailty measures like the Frailty Index[18](#ref18] and Fried Frailty Score,29 FACT incorporates objective cognitive ability measures. Nurses valued learning to quickly identify cognitive impairment using the Mini-Cog[19](#ref19] and Brief Cognitive Rating Scale.20 However, the educational component’s impact was diminished by limiting formal training to pre-rollout, with nurses preferring ongoing workshops.
In contrast to numeric frailty index outputs[18](#ref18] or unfamiliar metrics (grip strength), FACT uses everyday experience metrics to describe frailty levels, fostering communication between providers and recipients. Nurses reported more open, informative dialogues about frailty with patients and families. Clear communication enhanced collaboration, introducing a common lexicon for discussing frailty stages and drivers.
Grounded theory allowed researchers active data collection and engagement with nurses through interviews and elaborations.23 Similar nurse experience studies have used grounded theory30 or normalization process theory,31 though the latter is less historically evidenced in nurse-focused research.
Study Limitations and Future Directions
The primary limitation was the small focus group size. Participants from a single clinic with similar roles may have different experiences than those in varied settings. Retrospective data collection regarding initial initiative stages introduced potential recall bias due to the 2-year interval since program inception.
Further research comparing these findings with other FACT initiatives in similar clinical groups is needed for a fuller understanding.
This study suggests nurse perceptions of frailty evaluation are valuable for improving nurse-led initiatives. Future projects could benefit from clearer role definitions and program champions. Project stakeholders must be identified and integrated. While patient/caregiver factors weren’t identified as barriers/facilitators, further study is needed to understand their FACT screening experience.
The nephrology clinic-PATH program[13](#ref13] partnership was positive, facilitating PATH support for frail renal patients. This reciprocal relationship created a useful system for managing complex cases requiring additional Renal Clinic resources.
Program follow-up revealed reduced adherence to FACT guidelines and patient recruitment since interviews. Despite the program’s continued operation, sustainability challenges align with research on nurse-administered programs,27,28 citing permanency issues. This disconnect from data collection experiences was attributed to slower summer clinic flow and difficulty managing collateral historian engagement amid busy schedules. Nurses admitted reduced clinical priority for the initiative and expressed desire for routine research staff contact to review findings and discuss project trajectory, preferring expert professional support for FACT-related clarifications.
Nurses suggested process improvements like scheduled meetings among stakeholders (nursing, research, clinicians) to review progress and maintain motivation. Other suggestions included increased recognition, improved clinic environment, and dedicated FACT administration/paperwork time.
Conclusion: Valuable Insights for Nurse-Led Frailty Screening
This study provides crucial insights into nurses’ experiences using FACT to identify frailty in a specialized renal outpatient clinic. Focus group data analysis revealed four core themes: hesitancy, adaptation, development, and internalization. Initial challenges (perceived lack of support, uncertain benefit, feasibility constraints) were gradually overcome, with confidence growing through enhanced frailty knowledge. Nurses’ frailty understanding expanded beyond physical indicators to include comprehensive frailty domain assessments. They also reported a broader “big picture” health perspective, moving beyond kidney-specific ailments.
These results have implications for clinical programming, especially nurse-led initiatives. Systematic frailty screening with well-defined guidelines can succeed but requires supervision and, critically, support for long-term sustainability. Nurses consistently cited “lack of support” as an implementation challenge. Prioritizing FACT-based frailty evaluation clinically may improve uptake. Based on nurses’ adaptation and development experiences, focusing on training, education, and professional development is crucial to prevent FACT from being seen as merely another task. Nurses’ positive attitudes stemmed from FACT’s ability to improve patient interaction and understanding, rather than just data collection without clear benefit.
Acknowledgments
This initiative was funded by the Nova Scotia Health Authority Research Fund. The authors thank the Renal Clinic nursing staff for their participation and open discussions. The FACT tool is copyrighted but freely accessible online (www.pathclinic.ca).
Disclosure
Dr. Mallery and Dr. Moorhouse, FACT tool and PATH model co-creators, receive consultant fees from institutions implementing the program for PATH training. The authors declare no other conflicts of interest.
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