Frailty knowledge, training and barriers to frailty management: A national cross‐sectional survey of health professionals in Australia

To understand Australian health professionals' perceptions of their knowledge and previous training about frailty, as well as barriers to frailty assessment and management in their practice.


| INTRODUCTION
Frailty is a complex syndrome characterised by vulnerability to precipitous declines in physical and cognitive health and function. 1Frailty is associated with adverse health outcomes 1 and can lead to falls, functional dependence, institutionalisation and increased mortality. 2Affecting approximately 21% of Australians older than 65 years, 3 frailty increases with age, thereby, with an ageing population, identifying an increasingly large group of high-risk older adults. 2 Identification of frailty allows management aimed at alleviating its progression and complications, whilst focussing on shared decision-making to minimise exposure to inappropriate or harmful interventions. 4 Traditional models of health care typically have an organ-or disease-specific approach, meaning that they are generally not adequate for the needs of frail older adults. 5t also means that frail adults are managed not only by staff with specialist geriatric expertise, but also across most disciplines in the health-care system, for example, when they require specialist cardiac or surgical care.Therefore, knowledge, confidence and competence in managing frailty are required by most health professionals.
][8][9][10][11] Despite an increasing recognition of the importance of frailty competence across the multidisciplinary team and across specialities, little is known about frailty education at various levels (undergraduate, postgraduate, workplace and continuing professional development).
The Australian and New Zealand Society for Geriatric Medicine has published guidelines on the pathogenesis and prevention of frailty, 12 but there are no Australian guidelines advising on frailty education for the medical, nursing or allied health workforce.A recent systematic review found that there are very few frailty training programs, with only nine programs identified in the published literature. 13Importantly, only one of these programs was from Australia, 14 suggesting a frailty training gap for Australian health professionals.
To meet the needs of an ageing population, we must understand the degree of frailty knowledge and training amongst health professionals.This will help plan appropriate education and training to equip all health professionals to provide appropriate care.Additionally, to inform the development of future tailored interventions, it is important to understand the barriers of including frailty assessment and management in clinical practice.The aim of this survey of health professionals in Australia therefore was to understand health professionals' perceptions of their knowledge of, and previous training about, frailty and its assessment, as well as barriers to frailty assessment and management in their practice.

| Study design
A cross-sectional online survey, created and administered using Qualtrics platform (Qualtrics), was conducted from 29 March 2022 to 10 May 2022 and is reported in compliance with the Consensus-Based Checklist for Reporting of Survey Studies (CROSS). 15Ethics approval was granted by the University of Queensland Human Research Ethics Committee (Approval 2021/HE002158).

| Questionnaire development
As no existing survey instruments were identified through an initial literature review, a questionnaire was developed for the purpose of this study.The Capability, Opportunity, Motivation (COM-B) model of behaviour 16 was used to underpin the survey (Table S1).The survey was developed by the authors, a team of researchers and clinicians with frailty expertise in the disciplines of geriatric medicine, nursing, pharmacy, dietetics and behavioural science, who all participated in an iterative process of early question development (guided by COM-B), refinement and pretesting to ensure content validity and appropriate scope.Ordinal scales were used with a balance of positive and negative response options.Effort was made to avoid questions with agree/disagree response options as much as possible based on their potential lower quality compared with item-specific questions. 17Discussion between the researchers enabled consensus agreement on the original version.The original questionnaire was then pilot-tested with a group of five health professionals not part of the study team (medical n = 1, nursing n = 1, allied health n = 3) who met inclusion criteria for the study to assess readability, face validity and completion time.Pilot participants were also asked to identify any potentially missing questions or responses.The questionnaire was revised based on the feedback from piloting (e.g.question

Practice Impact
This is the largest study reporting Australian health professionals' knowledge and training about frailty and barriers to including frailty assessment and management in their practice.Our findings suggest there is a lack of training regarding frailty for Australian health professionals and high interest in online multidisciplinary frailty education programs.rewording, additional response items of unsure/not relevant) and was finalised in discussion with all members of the research team.

| Final questionnaire
The online questionnaire started with a short section on respondents' current field of practice to confirm eligibility and identify years of practice.The main body of the survey consisted of five sections, seeking health professionals' views on: 1. frailty training and perceived knowledge; 2. confidence in recognising and managing adults with frailty; 3. the importance and relevance of frailty; 4. barriers to assessing and managing frailty in practice; and 5. interest in further training on frailty.
The survey also included six questions related to demographics including age, gender, employment location, practice area and initial training location.
The questionnaire mainly included multiple-choice responses, with six free-text questions.The final version of the survey can be found in Table S1.

| Population and sampling
The population of interest was health professionals (medical, nursing and allied health) engaged in clinical practice in Australia at the time of the survey, including those trained in Australia or overseas.Convenience and snowball sampling techniques were used for recruiting participants.A total of 15 professional associations and clinical networks, as listed in the Acknowledgements section of the manuscript, helped distribute the online questionnaire to their members, with a reminder email sent approximately 3 weeks later to encourage further dissemination and responses.The link for the survey was also distributed through professional and social media networks of the research team and their colleagues.

| Data management
No personally identifying data were collected in the online survey.No strategies were employed to prevent 'multiple participation'.The authors deemed that multiple responses were unlikely due to the length of the survey, its topic and lack of incentive to participate.

| Consent
The survey introduction described the scope and intent of the study, and informed participants that their response to the survey implied their consent for their deidentified data to be collated, analysed and distributed in research publications and presentations.Due to the anonymous data collected, individuals could not request their survey responses to be deleted after submission.

| Statistical analysis
STATA version 17.0 (StataCorp LLC) was used for statistical analyses.The responses to survey questions were analysed using descriptive statistics.As the number of respondents completing each question varied, proportions are based on valid responses to each question.Only respondents who answered at least one question in the main body of the survey (i.e.Sections 1-5) were included in the analysis.Forced response function (i.e.where respondents must answer a question before progressing to the next question) was not used in this survey, with the exception of the questions related to participant eligibility.All responses provided were used (i.e.no case-wise deletion) and no imputation was carried out.

| RESULTS
The online questionnaire was taken by 736 health professionals, consisting of allied health (45% of sample, n = 329), nursing (35%, n = 257) and medical (20%, n = 150) professionals.An additional 46 responses were excluded due to: starting the survey but not proceeding to the main body of the survey (n = 36) or answering 'no' to the eligibility question: 'Are you a health practitioner (medical, nursing, allied health) currently practicing in Australia'? (n = 10).Table 1 displays the characteristics of respondents, who were mostly women (84%, 497/593) with more than 10 years of experience working in their field of practice (67%, 492/736).All Australian states and territories were represented in the study, with most respondents working and/or trained in New South Wales or Queensland (Table 1).Around half of the respondents (52%, 306/589) have worked in a specialist geriatric ward/team.Most participants reported currently working in a hospital (73%, 431/592).
The most relevant results of the survey have been presented below, with a full analysis of all results from questions with multiple-choice responses presented separately in Table S1.The results of the free-text questions are not presented in this paper.
Most respondents reported a 'good' (38%, 271/712) or 'fair' (40%, 285/712) understanding of frailty.Nearly a quarter of respondents reported that they were 'not at all' experienced in undertaking frailty assessment in their practice (Table S1).

| Confidence in recognising and managing adults with frailty
Respondents were 'fairly' or 'somewhat' confident with identifying frailty, talking with patients/clients and families about frailty, and in referring to/liaising with other health professionals about frailty (Figure 1).

| The importance and relevance of frailty
Many respondents felt that identifying frailty was part of their professional role (Table 2).Almost all respondents (>90%) reported that frailty impacts clinical outcomes and that assessing someone as being frail would influence their clinical decision making about care, treatment or management options (Table 2).Despite this, a similar proportion of respondents (92%) reported that there was 'always', 'often' or 'sometimes' something else of a higher priority than assessing people for frailty.They identified priority groups for frailty assessment as 'people with history of falls', 'oldest old people (>85 years)' and 'people with recent functional decline'.
Ninety per cent of respondents (569/635) agreed that there are beneficial interventions for frail people, and only three participants responded that there are 'no' beneficial interventions for frail people.Two-thirds of respondents (65%, 403/624) believed there are many medical procedures/interventions that are very harmful for frail people, while a quarter of respondents were 'unsure' if there are many or few very harmful interventions for frail people (Table S1).

| Interest in further training
Most respondents (88%, 521/595) stated they were interested in learning more about frailty, with high interest in a range of topics (Table 3).Online training modules was the preferred format, followed by webinars and printed material, with lower interest in lectures.

| DISCUSSION
This study of 736 medical, nursing and allied health professionals across Australia was the largest national survey, F I G U R E 1 Confidence in recognising and managing adults with frailty (n = 694).
in terms of both scope and population, to investigate the knowledge and training of health professionals about frailty and barriers to its assessment and management.The survey developed for this study was informed by the COM-B model of behaviour, 16 which can provide direction for future training and behaviour change interventions to improve frailty management specifically targeted towards Capability, Opportunity and/or Motivation.This survey suggest that the barriers to including frailty identification and management in practice are related to physical opportunity (i.e.contextual factors) and capability (i.e.knowledge and skills).
In terms of capability, participants reported moderateto-low levels of self-reported knowledge of frailty and experience in frailty assessment, as well as moderate levels of confidence in frailty identification and management.Consistent with other studies, 7,[18][19][20] respondents reported a lack of adequate training in frailty, with only 14% reporting specific frailty training and most frailty training being provided 'on the job' or as part of broader training programs.Our finding of limited experience in undertaking frailty assessment was consistent with other studies that have reported limited hands-on knowledge of their participants on how to perform frailty assessment, which would also act as a barrier to integrating frailty assessment into routine clinical practice. 22,23Also consistent with other studies, 8,24 lack of consensus about which frailty assessment to use was identified as a barrier in this sample.This T A B L E 2 Opinions of health professionals about frailty assessment and management in practice.

Statement Response Count (%)
To what extent do you feel that identifying frailty is part of your professional role and identity?(n = 663) Very great extent 171 (26)   Great extent 272 (41) Some extent 156 (24)   Little extent 44 (7)   Very little extent 20 Generally, in your clinical care, how often is something else a higher priority than assessing people for frailty?has been highlighted in the 2018 scoping review by Theou et al., which identified 89 different frailty measures that were used in older inpatients. 25Although routine screening for frailty in older people is recommended by clinical guidelines for frailty, 26,27 the gap in the evidence base about the optimal frailty measure hinders the integration of frailty assessment in the care of older people. 4Another common barrier reported by respondents in our study was the lack of a defined protocol for managing frailty.This was also a finding of a qualitative study of Canadian health professions, 24 which identified the need to have clear 'next steps' after frailty screening to enhance the use of frailty assessment tools.High interest in training amongst respondents suggests that these capability-related barriers may be easily addressed.Online frailty training has been previously shown to be effective when combined with face-to-face training as part of graduate medical training (e.g.geriatric medicine teaching week for medical students) 28 and for practicing physicians (e.g.9-month geriatric education program for emergency physicians). 29A high preference for online training for health professionals has been reported in other studies 30 ; however, one-off training may not be enough to consolidate skills, with health professionals reporting a need for post-training support to help them implement new knowledge and skills in their practice. 30However, education and training are unlikely to be effective in isolation, given the barriers related to physical opportunity identified in this survey.In order to implement evidence-based frailtyinformed care into routine clinical practice, strategies will need to address contextual barriers identified in this study, such as competing priorities for health professionals, lack of time 18,22 and lack of multidisciplinary teams to support frailty assessment and management, 8 also reported in previous studies.In this sample, social opportunity does not appear to be a barrier to frailty assessment and management, with frailty seen to be of importance to their supervisors, peers and patients/clients and their families.
The results of this survey suggest that health professionals in Australia are likely to be motivated to include frailty assessment and management in their practice.This was evidenced through beliefs about consequences (i.e. that frailty is of high clinical importance, impacts clinical outcomes and their decision-making about care, and that there are interventions to manage frailty) and alignment with professional roles and identity.Interestingly, this is in contrast with other international studies where health professionals held beliefs that frailty was synonymous with ageing and therefore non-modifiable. 7,21Further qualitative exploration of the attitudes of Australian health professionals may provide further insight and confirmation of their motivation to include frailty assessment and management in their practice.
This study is the largest survey of health professionals' knowledge of frailty to date.The sample included health professionals from a range of disciplines, work settings and from all Australian states and territories; future secondary analysis of this data will provide further insight into the knowledge, training and barriers within specific discipline groups.Furthermore, this purpose-built survey is underpinned by a sound theoretical framework (COM-B) that provides a starting point for designing interventions to support health professionals with improving frailty management.The survey was developed through a robust process of preliminary pretesting and pilot-testing, thus maximising face validity.
This study also has limitations.Snowballing sampling technique was used to maximise the number of respondents, meaning that the response rate cannot be accurately known.Results should be interpreted carefully, understanding that they may not be representative of all Australian health professionals due to selection bias.Respondents may have self-selected such that those with more interest and knowledge of geriatric care and frailty were more likely to respond.Higher rates of missing data towards the end of the survey may indicate respondent fatigue/drop-out due to the length of the survey, and therefore further exploration of barriers to frailty management may be warranted to confirm these findings.Nevertheless, the results provide a sound 'first step' in addressing frailty knowledge gaps.

| CONCLUSIONS
The findings of this large theory-guided survey suggest that frailty is perceived to be of high importance by health professionals in Australia.Yet, several barriers, such as lack of knowledge and training, as well as time and resources, hinder the inclusion of frailty assessment and management in practice.Rapidly emerging research on assessment and management of frailty can be translated into practice through multidisciplinary frailty education programs.Our findings suggest that education on frailty and its management can address knowledge gaps and should be well-received by Australian health professionals.

F I G U R E 2
Barriers to completing frailty assessments in respondents' current workplace.T A B L E 3 Interest in further training about frailty.If interested in learning more, what are you interested to learn more about?a (n = 519) Developing an appropriate care/management plan 422 learning more, in what format would you prefer to receive training? a (n = 520) , therefore percentages add to >100%.b Other formats of trainings included: face to face training with multidisciplinary approaches, workshops, conference, in-service or ward-based education, online reading, PDF information documents and recorded webinars.

3.1 | Frailty training and perceived knowledge
Characteristics of survey respondents.