There is agreement on the usefulness of defining frailty in clinical settings as well as on its main dimensions. However, additional research is needed before an operative definition of frailty can be established.

This is the unspecified version of the paper.This version of the publication may differ from the final published version. The social gerontological literature suggests that constructs of frailty are diverse. Gilleard and Higgs (2010b) posit that culturally those deemed frail have few self-empowering narratives. They argue that frailty is held within a social imaginary as a black hole, a socially void space into which older people are sequestrated away to decay and die. Thus within a social imaginary frailty, like a black hole, is both unknowable and a space from which there is no return. Permanent repository link 4Hockey and James (2003) argue that social identities in late old age can be conceptualised as liminal. Liminality (after Turner (1974)) is a threshold space, a transitional point between social structures. Such spaces are fluid, allow for the potential redefinition of self-identity and can even be a position of power. Thus although older 'liminal' individuals are placed in an uncertain outsider status this social positioning can provide a space from which "weak" elders exert power. The vulnerability of old age can expose the very decline and dependency from which wider society seeks to distance itself. Thus identities are not fixed nor necessarily related to dominant understandings of a declining body. Grenier (2006bGrenier ( , 2007 develops this thesis in her work on the subjective experience of older frail people. She and others (Becker, 1994;Kaufman, 1994) argue that frail elders themselves differentiate between being and feeling frail. The label of frailty is actively resisted as elders distinguish between the body one is (selfidentity) and the body one has -a physical, vulnerable, and objectified social identity.Within Western welfare policy and practice frailty is increasingly used as a means of classification, to prioritise and fund care. Indeed, clinically frailty is often used as a This paper draws on findings from a longitudinal study of the subjective experience of being a frail older person living at home. The aim of the study was to understand the experience of home-dwelling older people living with frailty over time in order to develop the empirical evidence base for this group and to consider more fully how narratives of frailty can shape person-centred care provision. MethodsTo capture the dimensions of social, psychological and physical frailty, the research design used a combined qualitative psychosocial method. Psychosocial research conceptualises experience as a constant and dynamic communication between internal psychological and external sociological dimensions manifest through unconscious or feeling states, and conscious communication (Hollway, 2004;Roseneil, 2006 Trust. All participants received written and verbal information about the study and informed consent was confirmed at each cycle of data collection. All were assured of confidentiality and that pseudonyms would be used in all research reports. Data collectionTwo psychosocial narrative approaches; the Biographic Narrat...

BackgroundInternationally, key health care reform elements rely on improved integration of care between the primary and secondary sectors. The objective of this systematic review is to synthesise the existing published literature on elements of current integrated primary/secondary health care. These elements and how they have supported integrated healthcare governance are presented.MethodsA systematic review of peer-reviewed literature from PubMed, MEDLINE, CINAHL, the Cochrane Library, Informit Health Collection, the Primary Health Care Research and Information Service, the Canadian Health Services Research Foundation, European Foundation for Primary Care, European Forum for Primary Care, and Europa Sinapse was undertaken for the years 2006–2012. Relevant websites were also searched for grey literature. Papers were assessed by two assessors according to agreed inclusion criteria which were published in English, between 2006–2012, studies describing an integrated primary/secondary care model, and had reported outcomes in care quality, efficiency and/or satisfaction.ResultsTwenty-one studies met the inclusion criteria. All studies evaluated the process of integrated governance and service delivery structures, rather than the effectiveness of services. They included case reports and qualitative data analyses addressing policy change, business issues and issues of clinical integration. A thematic synthesis approach organising data according to themes identified ten elements needed for integrated primary/secondary health care governance across a regional setting including: joint planning; integrated information communication technology; change management; shared clinical priorities; incentives; population focus; measurement – using data as a quality improvement tool; continuing professional development supporting joint working; patient/community engagement; and, innovation.ConclusionsAll examples of successful primary/secondary care integration reported in the literature have focused on a combination of some, if not all, of the ten elements described in this paper, and there appears to be agreement that multiple elements are required to ensure successful and sustained integration efforts. Whilst no one model fits all systems these elements provide a focus for setting up integration initiatives which need to be flexible for adapting to local conditions and settings.

Background: Palliative care patients are often described as complex but evidence on complexity is limited. We need to understand complexity, including at individual patient-level, to define specialist palliative care, characterise palliative care populations and meaningfully compare interventions/outcomes. Aim: To explore palliative care stakeholders' views on what makes a patient more or less complex and insights on capturing complexity at patient-level. Design: In-depth qualitative interviews, analysed using Framework analysis. Participants/setting: Semi-structured interviews across six UK centres with patients, family, professionals, managers and senior leads, purposively sampled by experience, background, location and setting (hospital, hospice and community). Results: 65 participants provided an understanding of complexity, which extended far beyond the commonly used physical, psychological, social and spiritual domains. Complexity included how patients interact with family/professionals, how services' respond to needs and societal perspectives on care. 'Pre-existing', 'cumulative' and 'invisible' complexity are further important dimensions to delivering effective palliative and end-of-life care. The dynamic nature of illness and needs over time was also profoundly influential. Adapting Bronfenbrenner's Ecological Systems Theory, we categorised findings into the microsystem (person, needs and characteristics), chronosystem (dynamic influences of time), mesosystem (interactions with family/health professionals), exosystem (palliative care services/systems) and macrosystem (societal influences). Stakeholders found it acceptable to capture complexity at the patient-level, with perceived benefits for improving palliative care resource allocation. Conclusion: Our conceptual framework encompasses additional elements beyond physical, psychological, social and spiritual domains and advances systematic understanding of complexity within the context of palliative care. This framework helps capture patient-level complexity and target resource provision in specialist palliative care.

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Aims. To synthesize evidence and knowledge from published research about nurses' experiences of nurse-patient relationships with adult patients in general, acute inpatient hospital settings. Background. While primary research on nurses' experiences has been reported, it has not been previously synthesized. Design. Meta-ethnography. Data sources. Published literature from Australia, Europe, and North America, written in English between January 1999-October 2009 was identified from databases: CINAHL, Medline, British Nursing Index and PsycINFO. Review methods. Qualitative studies describing nurses' experiences of the nursepatient relationship in acute hospital settings were reviewed and synthesized using the meta-ethnographic method. Results. Sixteen primary studies (18 papers) were appraised as high quality and met the inclusion criteria. The findings show that while nurses aspire to develop therapeutic relationships with patients, the organizational setting at a unit level is strongly associated with nurses' capacity to build and sustain these relationships. The organizational conditions of critical care settings appear best suited to forming therapeutic relationships, while nurses working on general wards are more likely to report moral distress resulting from delivering unsatisfactory care. General ward nurses can then withdraw from attempting to emotionally engage with patients. Conclusion. The findings of this meta-ethnography draw together the evidence from several qualitative studies and articulate how the organizational setting at a unit level can strongly influence nurses' capacity to build and sustain therapeutic relationships with patients. Service improvements need to focus on how to optimize the organizational conditions that support nurses in their relational work with patients.

AimsTo synthesize evidence and knowledge from published research about nurses' experiences of nurse-patient relationships with adult patients in general, acute inpatient hospital settings.BackgroundWhile primary research on nurses' experiences has been reported, it has not been previously synthesized.DesignMeta-ethnography.Data sourcesPublished literature from Australia, Europe, and North America, written in English between January 1999–October 2009 was identified from databases: CINAHL, Medline, British Nursing Index and PsycINFO.Review methodsQualitative studies describing nurses' experiences of the nurse-patient relationship in acute hospital settings were reviewed and synthesized using the meta-ethnographic method.ResultsSixteen primary studies (18 papers) were appraised as high quality and met the inclusion criteria. The findings show that while nurses aspire to develop therapeutic relationships with patients, the organizational setting at a unit level is strongly associated with nurses' capacity to build and sustain these relationships. The organizational conditions of critical care settings appear best suited to forming therapeutic relationships, while nurses working on general wards are more likely to report moral distress resulting from delivering unsatisfactory care. General ward nurses can then withdraw from attempting to emotionally engage with patients.ConclusionThe findings of this meta-ethnography draw together the evidence from several qualitative studies and articulate how the organizational setting at a unit level can strongly influence nurses' capacity to build and sustain therapeutic relationships with patients. Service improvements need to focus on how to optimize the organizational conditions that support nurses in their relational work with patients.

This commentary discusses the perception of frailty by different key stakeholders-most notably older people. It considers the need to integrate predominantly medically driven understandings of frailty within a wider conceptual framework. This is imperative if the potential of frailty as a construct, around which the optimisation of health and well-being of older people can take place, is to be realised.