A concept analysis of confidence related to older people living with frailty.

Aim: To describe and define a concept of confidence in the context of older people living with frailty, which is important to the worldwide healthy-ageing agenda preventing decline in independence and well-being. Design: Concept analysis informed by Walker and Avant's eight-stage approach.
Methods: Electronic databases (MEDLINE, CINAHL and PsychINFO) from 1994-2018 were searched. Published studies exploring confidence and excerpts of papers referencing older people, frailty and confidence informed the concept analysis. Extracted attributes informed model case and additional case development. Appraisal of antecedents, consequences and empirical referents informed the final concept's construction.
Results: Three overall defining attributes of confidence were identified in this concept analysis: physical, psychological and social. A central feature is personal control, influencing internal and external factors. These control factors can be enabling factors (positive factors) or dis-enabling factors (negative factors), affecting the frail older persons overall physical health and mental well-being.

INTRODUCTION

The Cambridge Dictionary defines confidence as “the quality of being certain in your abilities, or having trust in people, plans or the future” (Confidence, 2019). In healthcare literature, loss of confidence is often allied to an ageing and older population living with frailty. The World Health Organization has predicted that the global population of those aged 65 or older will triple to nearly 1.5 billion by 2050, with the greatest consequences of this increase being seen in developing countries (World Health Organization, 2011). Many of these older people will also experience frailty, which is defined as: “a clinically recognizable state of increased vulnerability resulting from ageing‐associated decline in reserve and function across multiple physiologic systems such that the ability to cope with everyday or acute stressors is comprised” (Xue, 2011:1). For over 20 years, the idea of frailty has appeared in our healthcare literature (Clegg, Young, Iliffe, Rikkert, & Rockwood, 2013). Within this, the word confidence is noted frequently in relation to the impact of deficits, impairments and loss. However, confidence is rarely presented from the direct perspective of the older person. It is most commonly tendered via the researcher's interpretation, often prefixed with self‐. For example, self‐confidence is a component of Maslow's Esteem stage in the Hierarchy of Need (Maslow, 1943). Across the body of frailty studies, the descriptions of confidence and the context of its use are ambiguous, unclear and do not allow comparison to be made with each other. Confidence lacks acknowledgement because true conceptual bearing seems not to exist. This is despite the referenced impact, both physically and mentally, throughout these studies. Examples of these range from fall interventions trials looking at balance and strength training; evaluation of frailty in home assessments; the use of technology; through to cognitive behaviour therapy (Doughty, Lewis, & McIntosh, 2000; Henderson, White, & Eisman, 1998; Jancewicz, 2001; Kutner, Barnhart, Wolf, McNeely, & Xu, 1997; Lelard & Ahmaidi, 2015; Oliver, 2007; Parry et al., 2016, 2014).

Rahman (2019) recently presented contemporary frailty themes facing practitioners in health and social care settings and asks practitioners to be alert to the negative implications associated with the word frailty. He promotes the frailty fulcrum (Moody, 2016), a multidimensional model of the nature of frailty. Elements of this model include: social and physical environments; psychological status, which comprises specific conditions, such as anxiety, or more general feelings like confidence, fear or motivation; as well as long‐term and acute conditions. Confidence has a significant impact on the life experiences of older people and is often noted in relation to loss or lack of confidence, which affects constructs such as vulnerability and resilience, both of which have an impact on a person's health and well‐being. Frailty challenges the ability to balance these two concepts. Rahman (2019) promotes the significance of intrinsic capacity or assets connected to resilience models in tipping the balance in favour of a positive health state. These assets contribute to a multidimensional health status that encompasses physical, functional, psychological and social health, each of which are strongly connected to the healthy‐ageing agenda of public health (World Health Organization, 2017). Thus, it is in this context of frailty that the concept of confidence needs to be better understood.

BACKGROUND

Etymology: the origin of the word

Confidence, according to The Online Etymology Dictionary (Harper, 2001–2017), is first identified in the early fifteenth century, coming from Middle French confidence or directly from Latin confidentia to mean – “firmly trusting, bold.” It is interesting to look at the orgins of confidence related words from a centuary before ‐ diffidence, from the Latin diffidentia meaning “mistrust, distrust and want of confidence" and diffidere to mean "to mistrust or lack confidence.” A seventeenth‐century sense of the word diffidence recognizes it to mean “distrusting oneself,” but this is rarely used or heard in contemporary English language today. However, it is in both these words, that the root fidere, meaning “to trust,” may start to provide insight to its contextual meaning today (Harper, 2001–2017). Confidence is most commonly used as a noun – describing people, place and things and much less commonly expressed as an attributing adjective – confident.

A practical need to understand the concept of confidence

Understanding the true notion of confidence in the context of living with frailty is important to older people, practitioners, service providers, academics and policymakers. This is because loss of confidence has life‐changing consequences, which can lead to increasing frailty (Nicholson, Meyer, Flatley, Holman, & Lowton, 2012). Given the worldwide increases predicted in the number of older people and the impact on resources needed to manage frailty, a better understanding of confidence may help develop interventions to support older people to live healthier and more independent lives and reduce dependency on statutory services. However, there is minimal evidence capturing the meaning of confidence from the perspective of older people to inform and evaluate effective interventions (Underwood, Burrows, Gegg, Latour, & Kent, 2017). A recent metasynthesis reported the voices of older people talking about confidence and concluded that confidence reflects a sense of vulnerability. This is as follows: a fragile state of well‐being that is exposed to the conflicting tensions between physical, emotional and social factors capable of enhancing or eroding this state (Underwood et al., 2017:1,326). The authors concluded with a call for a concept analysis of confidence to progress practice developments and further research. This paper responds to that call.

Two confidence connected constructs that conflict with conceptual development

When considering the contemporary healthcare literature surrounding confidence in older people living with frailty, two substantial bodies of work exist that connect, but also conflict, with any search for conceptual clarity and certainty. The two associations are with: self‐efficacy (Bandura, 1994) and the work around balance confidence (Powell & Myers, 1995; Tinetti, Richman, & Powell, 1990). Bandura describes perceived self‐efficacy as being: “…concerned with people's beliefs in their capabilities to exercise control over their own functioning and over events that affect their lives. Beliefs in personal efficacy affect life choices, level of motivation, quality of functioning, resilience to adversity and vulnerability to stress and depression” (Bandura, 1994:13). Researchers frequently use Bandura's self‐efficacy construct interchangeably with the word confidence to the point that many may be interpreting it to mean confidence. Bandura has written about his own view on confidence: “It should be noted that the construct of self‐efficacy differs from the colloquial term ‘confidence’. Confidence is a nondescript term that refers to strength of belief but does not necessarily specify what that certainty is about. …Confidence is a catchword rather than a construct embedded in a theoretical system,” (Bandura, 1997:382). Here, Bandura clearly argues a for a fundamental separation between the two terms.

The second substantial body of work focuses on the development and deployment of a balance confidence scale. Fear of falls is a recognized phenomenon, as is its connection to confidence (Legters, 2002). The Activities‐specific Balance Confidence (ABC) scale (Powell & Myers, 1995) and the Falls Efficacy Scale (FES) (Tinetti et al., 1990) were developed to demonstrate interventional impact of studies exploring falls. Both recognized the psychological harm of the fear of falling. Regrettably, the FES was created with confidence connections to Bandura's self‐efficacy construct, as it was designed to assess perceived efficacy (Tinetti et al., 1990:239). This critique is not dismissive of these bodies of work, as value is added to academic knowledge through their existence. However, these authors, for clarity of concept construction, acknowledge their presence but cautiously put them to one side in creating this contemporary concept of confidence.

Aims and purpose of this concept analysis

By drawing on contemporary healthcare literature, this concept analysis aims to identify antecedents, attributes, consequences and present a definition of the confidence concept that will add to the understanding of its use in health and social care in particular, the importance to the worldwide healthy‐ageing agenda of preventing decline in independence and well‐being. Using Walker and Avant's procedure for concept development, the purpose will be to disseminate the construct to practitioners, service providers, academics and policymakers. By sharing the conceptual meaning of confidence for older people, research activity exploring its measurement to inform interventional studies will evolve. Longer‐term aims will be to use the concept to maintain and grow the physical and mental well‐being of older people living with frailty. In turn, such interventions will address the growing social dependency frailty brings to the oldest old in our societies worldwide.

DESIGN

Walker and Avant's eight‐stage technique was used to guide this concept analysis (Walker & Avant, 2014). These iterative stages are (i) select a concept, this is set out in the introduction section; (ii) determine the aims or purpose of analysis, of which is set out in section 1.4; (iii) identify all uses of the concept that you can discover; (iv) determine the defining attributes; (v) construct a model case; (vi) construct borderline, related and contrary cases; (vii) identify antecedents and consequences; and (viii) define empirical referent.

METHOD

A literature search was undertaken to address stage (iii) of the concept analysis method. Using the search words older* OR elder* AND/ OR people OR person*; AND frail*; AND confidence NOT "confidence interval*", the databases CINAHL, MEDLINE and PsycINFO were searched going back 25 years, as this was when the formative Rockwood, Fox, Stolee, Robertson, and Beattie (1994) paper was published. This was the first paper to present a concept of frailty. Only English language articles were included. Inclusion criteria echoed the Walker and Avant (2014) call to not limit the search to the word used to formulate a concept. Therefore, inclusion criteria were as follows: older people focused on those aged 60 and older; frailty was interpreted using the clinical frailty scale definition of mildly frail (a score of 5) and over (Rockwood et al., 2005) (sometimes the word frailty used in an article was included to keep the search open); and confidence was sought in the context of direct or associated description in relation to the above two criteria. There were no exclusion criteria, beyond not meeting the inclusion parameters.

Analysis followed the outstanding stages (iv)–(viii) of the concept analysis technique (Walker & Avant, 2014). These are detailed in the results section below.

RESULTS

The search recovered fifty‐six articles that met the inclusion criteria, after removing duplicates. Following title and abstract review, 21 were considered for full review. The main reason for rejecting 35 articles was that confidence was not directly contingent to older people; rather, it was related to either the confidence of healthcare professionals or carers supporting older people. Reviewing referenced materials, 14 additional papers were included for further review, bring the total to 35 articles. These articles were read and re‐read, as defining attributes were extracted from them. These are explored in the concept analysis section below. Following identification of all usages of the word confidence, an iterative analysis of the material collected was undertaken (Walker & Avant, 2014).

Defining attributes, antecedents and consequences to establish a concept

Using the findings of a systematic review (Underwood et al., 2017), defining attributes associated with confidence clustered around physical, psychological and social domains, where attributes are defining characteristics to support the concept's construction. The most frequently appearing attributes give the broadest insight into the concept (Walker & Avant, 2014). From the literature analysed, these attributes were as follows:

Physical – falls associated; strength gaining; activity based, mobility reducing, independence growing, poor balance specific; function losing.

Psychological and emotional – mental frailty connected; memory loss related; creating low esteem, embarrassment and being shamed; anxiety provoking; grounded in psychological well‐being; stimulating motivation, body‐image affecting.

Social – isolating; engagement with others; connected; community focused; family concern related; orientated to classes, groups and positive involvement. (see Table S1 in Supporting Information: studies included, extracted findings and attributes revealed)

Figure 1 illustrates the concept of confidence. The concept of confidence is defined through the three dynamic domains of confidence: physical, psychological and social. Each individual domain rises and falls in response to the emphasis the individual places on their confidence at any one time. The cross‐cutting domain of control directly influences the individual's physical health and mental well‐being.

Figure 1

High‐level illustration of the concept of confidence in older people living with frailty

This figure presents a fundamental feature drawn from the literature, that of the negative (−) and positive (+) aspects associated with each attribute, each of which influence the element of control, which in turn affect the dominance of the three core components. The published research studies focused on interventions that, in part, recognize the impact or consequences of confidence on the older adults. For example, Parry et al. (2016) focused on the psychological interventions of cognitive behaviour therapy to reduce the fear of falling. This sits predominantly within the psychological domain of confidence conceptualization. Lelard and Ahmaidi (2015), however, solely review the evidence surrounding physical activity interventions to prevent falls. Both papers do acknowledge the wider multifactorial dimensions of falls and as such any concept of confidence must recognize each domain. However, importantly, there may be a greater emphasis on one or more domains. For example, a positive perspective study states: “Many of the participants reported that their confidence grew, they felt better physically, their mood improved and they had better concentration.” (McNamara, Rosenwax, Lee, & Same, 2016:34). Whereas Parry et al. (2014:1) present negative circumstances associated with confidence “Many older individuals suffer from a variety of adverse psychosocial difficulties related to falling including fear, anxiety, loss of confidence and subsequent increasing activity avoidance, social isolation and frailty.” This pattern was repeated across the studies reviewed. Words such as motivation, gaining and growing were connected to a positive inference of confidence, while words such as frailty, concern and loss were seen to be negatively associated.

Goal setting and goal attainment were identified in three studies associated with confidence building (Tung, Cooke, & Moyle, 2013; Wallin, Talvitie, Cattan, & Karppi, 2007; Yardley, Donovan‐Hall, Francis, & Todd, 2006). All were found to be positive, confidence growing, attributes. Furthermore, confidence‐building attributes were also linked to encouragement and trust (Parry et al., 2016; Sandberg, Jakobsson, Midlov, & Kristensson, 2014).

Walker and Avant (2014) suggest that attributes should be refined to a point where the fewest number exist, but they are still able to differentiate the concept. Acknowledging this, the concept of confidence is contextualized against the fluctuating physical, psychological and social domains (the columns connected to a range of attributes). The cross‐cutting characteristics of negative or positive inference features “control of physical and mental well‐being.” This control factor, or perceived control, be it explicit or implicit, appeared in several contemporary studies (Claassens et al., 2014; Parry, Steen, Galloway, Kenny, & Bond, 2001; Underwood, Kent, & James, 2015; Wallin et al., 2007; Yardley et al., 2006). It also was referred to indirectly in other studies referencing control associated perspectives within their text, using words such as participation, engagement, independence, self‐belief, knowledge, skills and security (Beesley, White, Alston, Sweetapple, & Pollack, 2011; McDougall & Balyer, 1998; B. McNamara et al., 2016; Sandberg et al., 2014).

Antecedents and consequences

Walker and Avant suggest antecedents and consequences are often ignored or dealt with lightly in concept construction (Walker & Avant, 2014). As reading and rereading took place to identify defining attributes (stage iv), these antecedents and consequences (stage vii) became clearer and shaped the emerging concept. This process revealed that fear often appeared as a precursor to loss of confidence (Kutner et al., 1997; Lelard & Ahmaidi, 2015; McDougall, 2000; Tavakolan, Xiao, & Menon, 2011; Tung et al., 2013), for example: “In the frailest older individuals, fear of falling is a pre‐dominant characteristic, which seems to be the main factor in determining loss of autonomy […and confidence]” (Lelard & Ahmaidi, 2015:365). Another antecedent was trust (Sandberg et al., 2014; Skymne, Dahlin‐Ivanoff, Claesson, & Eklund, 2012). However, fear also had a presence as a consequence, stimulating anxiety and subsequent confidence loss (Oliver, 2007; Parry et al., 2016), for example: “…fear, often but not always occasioned by a fall, is maintained by avoidance of activity, leading to loss of confidence, physical weakening and more fear of falling” (Parry et al., 2016:7). Other consequences of confidence include the creation of personal barriers, for example stopping a social activity and creating mental challenges to overcome, such as setting personal achievement goal (Beesley et al., 2011; Claassens et al., 2014; Doughty et al., 2000; Lelard & Ahmaidi, 2015; McDougall, 2000; Peduzzi et al., 2007; Resnick, 2002; Skymne et al., 2012; Tung et al., 2013). All these contributed to a very complex analysis. Walker and Avant (2014) recognize this and suggest creating illustrations by using a range of examples to support a more definitive definition of the concept (stages v and vi). This takes the form of a presentation of a model case alongside other cases (Table 1).

Table 1

Model, borderline, related and contrary cases of confidence

	Model case	Borderline case	Related case	Contrary case
Confidence	Mrs. P. is 87 years old and lives with multiple morbidities. Six weeks ago Mrs. P. had a fall. She was frightened of having a further fall and this quickly affected her psychological well‐being, she became quite anxious, not wanting to go out the house. She was promptly assessed at home by community healthcare staff who provided assistive devices and gave instruction and coaching on how they can be used to prevent further falls. As trust built in knowledge and use, so her mental well‐being and physical health grew. Mrs. P was supported to attend strength and balance exercise classes in her local community centre She enjoys getting out now to these social activity events in the community and meeting others. She actively takes part in physical strength and balance classes; she particularly enjoys her Tai Chi class. This benefits her physically, but also her psychological well‐being is boosted	Mr. Q. he is 89 years old. He lives with multiple morbidities and like Mrs. P fell six weeks ago. This fall shook him. He was assessed and received some assistive devices to maintain his independence. For a short period of time he received in‐home support to help him practice strength and balance exercises. He was given information about local exercise groups he could join Mr. Q. gets out socially to regular community activities and events now. Mr. Q. suffers with mild memory problems and sometimes his mood is low. This restricts his social interactions with others, but he benefits physically from the exercise classes	Mrs. R.is 92 years old she too lives with multiple morbidities but despite never falling, she is fearful of falling and this does have the potential for adverse psycho‐social effects. It can impair her self‐efficacy – “the self‐perception of ability to perform within a particular domain of activities resulting in activity avoidance, social isolation and increasing frailty” (Parry et al., 2014:2). “Beliefs in personal efficacy affect life choices, level of motivation, quality of functioning, resilience to adversity and vulnerability to stress and depression” (Bandura, 1994:13)	Mr. S.is 65, he has just retired and describes his physical and mental health as good. He takes tablets to control hypertension, he monitors this himself and records the results online, he has not seen his General Practitioner in the last five years. Six weeks ago, he went on his first cycling holiday abroad, to the mountains of Spain. Mr. S is an active member of a local cycling club, regularly cycling in excess of 100Km a week.

The Model case for confidence

An example of the use of the concept of confidence was developed (Table 1). For Mrs. P., the concept's antecedent is a fear of falling, following a previous fall see Figure 2, which illustrates the dynamic properties of the concept derived from Mrs P’s fears and concerns. Therefore, the physical, psychological and social domains have been adjusted to reflect a dominance in the psychological attribute. Furthermore, the negative elements of the attribute are reflected by the physical fall, the associated worry and anxiety and resulting isolation. Following intervention from the community team (which included equipment provision supported by exercise training, coaching and reconnecting socially), improvements were seen in her physical health and to her mental well‐being. These shifted confidence to a positive position. Central to the concept is level of control.

Figure 2

The concept of confidence – illustration of Mrs. P. (Model case)

Other cases

Additional cases were created to allow for defining attributes to be clearly associated with the emerging concept of confidence. This gives transparency to the model case through defining what it is not (Walker & Avant, 2014). In Table 1, three alternative cases are presented, headed as Borderline, Related and Contrary. The Borderline case is that of Mr. Q, which contains most, but not all, of the defining attributes of the Model case. This case's difference reflects the studies suggesting an association between confidence, memory perception and low mood. Mr. Q’s memory disables and isolates him from the social connection column of the concept seen in Figure 1. Bensadon (2011) writes of memory anxiety and the impact on self‐confidence, and McDougall and Balyer (1998) explore depression linked to memory confidence. Mood connections were identified in other studies that connect to socially isolating factors (McNamara, Chen, George, Walker, & Ratcliffe, 2013; Oliver, 2007; Parry et al., 2016). This discrete difference in the Borderline case emphasizes the importance of social connectedness as a key attribute in the Model case and the need to keep all three domains present and balanced. Of course, opportunities for Mr. Q to socialize can be created. However, it highlights how intrinsic factors (e.g. mood and memory problems) can hinder participation, as well as the confidence‐boosting benefits of social participation. The Related case of Mrs. R. brings to this concept analysis the construct of self‐efficacy (Bandura, 1994). Related cases do not contain all the defining attributes of the Model case but reflect its connection to any concepts surrounding it. These cases are useful for presenting ideas that are similar to the main concept, but differ when closely examined (Walker & Avant, 2014). The two quotes for this case in Table 1 illustrate connections to physical, psychological and social domains of the concept. However, these are from a contradictory view on the foundations of self‐efficacy theory. The final case is the Contrary case of Mr. S. This concept of confidence from the perspective of the frail older person is clearly not demonstrated in the description of the healthy and active cyclist. Walker and Avant (2014) present Contrary cases as examples of what the concept “is not.”

Empirical referents

Stage (viii) of the Walker and Avant (2014) concept analysis technique focuses on the identification and recognition of empirical referents to capture and measure the concept. This is often the final step in analysis and asks: what if the concept was to be measured in the real world? As discussed in the introduction, measures of confidence have been academically explored including the FES and ABC Scales. These are established measures of falls self‐efficacy and balance confidence. They may provide an adjunct into the exploration of falls related confidence or the fear of falling. They focus on physical function, acknowledging they are implicit measures to social connectedness (e.g. walk in a crowded mall) and mental well‐being. However, they are not explicit in measuring these latter domains and as such they do not capture all aspects of the concept of confidence. In the absence of measurement tools, Walker and Avant (2014) advocate identifying defining characteristics, or attributes, of the concept to support future instrument development, which can then be used in practice. This concept analysis has generated a wide range of attributes from the literature that could inform such developments. However, it needs to be recognized that, as this is an emerging concept (Morse, Hupcey, Mitcheam, & Lenz, 1996), further explorations of attributing factors are required to define and develop a robust instrument to measure this concept.

DISCUSSION

The need to explore the concept of confidence as perceived by older people living with frailty is enhanced due to the growth in numbers of the oldest old worldwide, many of whom who will live with frailty. This is further reinforced by the legitimate aim of seeking interventions to reduce the dependency burden on the individual and wider society. Confidence is a concept that, for this population, has not been defined and described until now. Etymological exploration of the word confidence identified the old connected word – diffidence – meaning “distrusting oneself.” In the contemporary literature review, this is captured by Parry et al. (2016) as they postulated that activity avoidance (in respect to distrusting oneself) can lead to social isolation and increasing frailty. Skymne et al. (2012) explored how frail older people experience and adapt to assistive devices to support their independence. They analysed confidence in the context of knowledge and experience. For their study participants, this meant trusting the experts providing the devices and trusting themselves in knowing they needed an assistive device to support them. Trust is present in another paper (Sandberg et al., 2014). This qualitative study explores complex case management interventions from the perspectives of older people and their case managers. Trust is reported as being an essential component of the mutual confidence built during such interventions, highlighting its importance in maintaining constructive relationships between patients and caregivers (Sandberg et al., 2014). The dictionary definition of confidence also reflects this element of trust: “…having trust in people, plans, or the future” (Confidence, 2019). Indeed, a meta‐analysis of trust in healthcare professionals and health outcomes revealed a positive correlation (Birkhäuer et al., 2017), with greater trust being associated with better health outcomes.

Trust and confidence are another concept combination that exist interdependently. Luhmann (2000) draws a useful distinction between confidence and trust, one dependent on perception and attribution. He suggests that if you do not consider alternatives (such as getting in a car and driving, despite a moderate cognitive impairment for example), you are in a situation of confidence. However, if you choose an action in preference to others, despite the possibility of being disappointed by this choice, you define the situation as one of trust. In the case of confidence, you will react to disappointment by external attribution. In the case of trust, you will have to consider an internal attribution and eventually regret your trusting choice (Luhmann, 2000:3). This gives important insight into the wider meaning of confidence and recognizes the importance of control. This perceived control relates to the balancing act of asset recognition of older people with advancing age and frailty (Rahman, 2019). The concept of confidence that has emerged from this concept analysis acknowledges an individual's control as an overriding factor connected to the older person's health and well‐being. This central element of the concept is influenced by a range of attributes across the physical, psychological and social domains. Crome and Lally (2011) connect frailty to immobility, instability, incontinence, intellectual impairment and iatrogenesis; all of which have a strong evidence base, from a practitioner's perspective. The three domains of physical, psychological and social connect to an intervention framework familiar to practitioners in older people's care known as Comprehensive Geriatric Assessment (CGA) (Ellis, Whitehead, O'Neill, Langhorne, & Robinson, 2011). Thus, there is now an opportunity for this concept of confidence to contribute to a range of established interventions.

Limitations

This concept analysis is limited by the core search terms used and exclusion of non‐English language studies. Although databases used were judged to hold wide bibliographical data sources, some literature may have been missed. Additionally, new literature since the study concluded in 2018 may produce further insight into the concept. It is possible that by using the adjective, confident, in the search and including other language publications, additional attributes may have emerged. Furthermore, this concept analysis clearly articulated a cautious separation from published studies connected to self‐efficacy constructs or scales for measuring balance confidence. This too may have affected the outcome of the concept analysis. However, careful consideration was taken to avoid such judgemental bias, by taking guidance from the core texts of Walker and Avant (2014:175–178).

CONCLUSION

By using the Walker and Avant (2014) eight‐stage process, a concept of confidence experienced by older people living with frailty has been defined and described. Extensive analysis identified a concept constructed of three core domains – physical, psychological and social. Each of these domains could be imagined to be rising and falling in response to the emphasis the individual places on their confidence at any one time. The cross‐cutting central domain of control the individual has over the core three domains directly influences their physical, mental and social health and well‐being.

IMPLICATIONS

Implications for practice

This concept of confidence provides nurses with a practical framework to facilitate confidence focused conversations. These can inform understanding of confidence experience with older people. As the domain of control overarches the other three conceptual domains, nurses can explore ways to influence feeling of control to improve health and well‐being outcomes. Adoption of confidence conversations should be with explored within local approaches to Comprehensive Geriatric Assessment with older people living with frailty. Finally, educationalists should help disseminate this new description of confidence to remove ambiguity and enhance understanding when listening for and responding to the word confidence in practice.

Implications for research

As no confidence measurement tools currently exist, there is now an opportunity to develop these to influence practice innovation and evaluate further research.

CONFLICT OF INTEREST

The authors declare no conflict of interest with respect to the research, authorship and/or publication of this article.

AUTHOR CONTRIBUTION

FU, JML, BK: Study design. FU: Data acquisition. FU: Primary data analysis and interpretation. FU, JML, BK: Further analysis and interpretation of data. FU: Manuscript preparation. All authors revised the paper for important intellectual content, approved the final version to be published and agreed to be accountable for all aspect of the work.

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