Implementing "What Matters to You" in a Geriatric Care Pathway – a Researcher-In-Residence study:

doi:10.21203/rs.3.rs-4673614/v1

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Implementing "What Matters to You" in a Geriatric Care Pathway – a Researcher-In-Residence study:

https://doi.org/10.21203/rs.3.rs-4673614/v1

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Background

To help people with frailty develop adaptive strategies to maintain their sense of identity, integrity, and wellbeing, health and care services must respect what is important to them. Training healthcare practitioners to ask frail patients “What Matters to You” (WMTY) instead of “What is the matter with you?” at every clinical encounter is expected to enable person-centred care (PCC) and provide these benefits. Asking WMTY may reduce formal complaints, improve health outcomes, and staff wellbeing, promote more efficient healthcare delivery, and reduce service costs. However, there is a lack of clarity regarding what 'mattering' is and barriers to effectively implementing WMTY. This paper explores the barriers and facilitators to implementing WMTY and its capacity to enhance meaning in life.

Methods

This Researcher-In-Residence (RiR) study embedded a researcher with clinical teams to facilitate learning and iterative feedback on WMTY implementation. All teams showed a willingness to integrate WMTY into their workflows. The researcher made handwritten notes with a participant observation tool in eight different locations (e.g., acute wards and community teams) and two matrons’ meetings; the observations were conducted for approximately 39 hours over nine months. The NASSS-CAT and Com/b frameworks facilitated qualitative data analysis.

Results

The study identifies that an every-encounter WMTY approach creates significance in the healthcare system rather than just aligning care plans with objects that matter to patients (e.g., loved ones, hobbies, home). It highlights that poor interoperability of hospital records hampers WMTY's effectiveness in guiding care plans. Additionally, illness-related challenging behaviours in reactive care settings may render WMTY inappropriate, necessitating tailored judgement calls based on patient and staff abilities.

Conclusion

Working culture and professional values may not always support PCC. Systems need better data capture to support a spectrum of structured person-centred conversations, from immediate functional goals to abstract discussions on Meaning in Life (MIL).

Person-centred care

frailty

What Matters to You (WMTY)

patient wellbeing

interoperability

Meaning in Life

healthcare delivery

functional goals

system pressure

qualitative analysis

barriers to implementation

Frailty is traditionally defined as a loss of physical functions (the phenotype model) [1] or an accumulation of multiple deficits (the cumulative deficit model) [2]. Both models predict the many adverse outcomes associated with frailty, which include falls [3], comorbidity [4], worsening disability [5], lower quality of life [6], loneliness [7], depression [8], cognitive decline [9], hospitalisation [10], nursing home admission [11] and mortality [12]. However, these deficits and adverse outcomes need to be balanced by an explicit strengths-based approach which, by supporting resilience, acceptance, and coping, can improve older adults' capacity for self-care, maintenance of social roles and the development of psychological and physical strategies to help them to manage their frailty better [13].

Advocates of person-centred care (PCC) argue that it helps develop strength-based strategies by holistically attending to physical needs, spiritual and personal beliefs and desires for social activity, and self-care [14]. Practically, healthcare professionals (HCPs) can choose to do this via shared decision-making, which helps the patient develop an awareness of treatment options and outcomes and involves them. Second, perhaps with input from friends and family, they create individualised care plans that reflect their values, circumstances, and longer-term life projects [14, 15]. Third, these care plans can be utilised by a multi-disciplinary team across multiple care settings. This potentially improves patient satisfaction, treatment adherence, and clinical outcomes, and helps them retain a sense of identity, integrity and wellbeing [16, 17].

PCC might also reduce the fragmentation of services needed to address this group's multidimensional needs. The British Geriatric Society, Age UK and Royal College of General Practitioners report argued that a more proactive, person-centred, and coordinated community-based response to frailty is essential. This approach may help reduce emergency admission and lower the demand for acute services [18]. In this sense, PCC is key to high-quality and efficient frailty care.

To this end, scholars and healthcare systems have increasingly advocated that HCPs ask, ‘What Matters to You?’ (WMTY) instead of 'What is the matter with you?' as a method of embedding the principles of PCC into frailty care. Studies indicate that WMTY helps positively reorient Health Care Practitioners (HCPs) towards a patient's priorities, needs and wishes in ongoing care planning [19]. It also improves patients' ratings of HCPs' attention to their emotional needs and the quality of their HCPs’ communication and reduces concerns and complaints [20, 21]. NHS Scotland also reported a 46% reduction in falls using WMTY [22]. Other studies have suggested that WMTY-type questions can improve health outcomes, ensure efficient healthcare delivery, and reduce service costs [23, 24]. However, these studies have yet to outline the facilitators and barriers they overcame to ensure successful implementation.

Previous research has also noted the difficulties of implementing techniques and methodologies, including WMTY, that enable PCC. Studies find that even when hospital managers advocate for the individualisation of care at a micro-operational level, there is a tendency towards standardisation [25]. This tendency is particularly acute when organisational conditions exert pressures that prioritise patient flow, reducing the time for patient engagement [26, 27, 28]. Studies encouraging care plans centred on WMTY found problems regarding the interoperability of these plans and how care continuity affects PCC implementation [24]. HCPs may lack formal education on PCC [29] or avoid engaging in PCC conversations due to difficult requests, compassion fatigue and concerns regarding perceived unfair treatment of patients [30]. Finally, HCPs may experience that patients' willingness or ability to engage in person-centred care varies [29], with some preferring a focus on their medical needs [24]. These studies identify potential difficulties in implementing WMTY. However, further research is needed to demonstrate how contextual barriers can be overcome.

Consequently, this study aims to outline the assumptions that guide advocates in choosing WMTY as a preferred method of implementing PCC, and then consider how these assumptions guide its implementation, influence its adoption by HCPs, and shed light on solutions to enable its implementation. The aim is subdivided into three key objectives. First, we explore the assumptions of WMTY useability, its capacity to enable cultural change and its positive impacts on patients. Second, we document how these assumptions intersect with HCPs' contextual experience of providing PCC, thus identifying potential barriers and facilitators. Third, given the strong value proposition of a person-centred, strengths-based, compassionate approach to guiding clinical decision-making, we explore viable solutions that could be implemented to ensure that WMTY is transparent and practically implementable within a highly challenged health and care system.

Setting

This paper draws on service evaluation observations. As part of the NHS New Hospital Programme (NHP), the hospital is developing integrated care pathways to address current challenges and prepare for the future. WMTY was identified as a key aspect of cultural change that enables a multi-disciplinary approach to frailty care that reflects patient preferences and ensures efficient deployment of resources. Key trust strategists developed WMTY training to encourage a WMTY conversation at every point of care. This paper reports on key findings of this implementation process in the Health Care for Older People (HOP) teams during 2022–2023.

A Researcher in Residence study:

Evaluation data were collected by a Researcher in Residence (RiR) with an honorary contract with the NHS trust. The aim was to understand the barriers and challenges of implementing future-orientated innovations in regions where Integrated Care Boards (ICBs) are in National Oversight Framework level 4, which indicates a need for intensive support due to significant concerns about system performance and financial balance. The RiR is embedded within a team to support the innovation of WMTY by collecting and analysing real-time data in ways that directly impact the design, development, and implementation process [31]. The benefit of the RiR model is that it produces context-specific knowledge and provides an alternative way to achieve service change. Rather than being a separate process, the coproduction and utilisation of research evidence are merged into complex, iterative, and socially situated processes. Knowledge is created, adapted, used and reiterated in the context in which it is needed and through partnerships between different actors [32, 33]. Thus, embedding researchers to mobilise knowledge is complementary to developmental evaluation.

Data collection

The hospital's strategic management asked the RiR to explore the impacts of implementing WMTY training on the quality and person-centeredness of care, as well as the effectiveness and efficiency of care pathways (e.g., by responding to patients' desire to be cared for at home). Key champions introduced the RiR to appropriate team leaders interested in receiving training on WMTY. Team leaders invited the RiR to observe strategic meetings and shadow patient-clinician interactions.

Consequently, the RiR ran 22 internal participant observations, often including informal interviews and small talk, between November 2022 and August 2023. This consisted of one observation in the Emergency Department (ED) with a Health Care for the Older Person (HOP) team, two in an acute medicine ward, ten in four HOP/Frailty wards, five with two intermediate care teams, two in community hospitals, and two meetings with hospital matrons. This amounted to approximately 39 hours of observations over nine months.

Participants' observations were key to this RiR study. These observations allow the RiR to familiarise themself with the spaces, strategists, activities, events, goals and feelings of teams [34]. This familiarity helped the RiR understand the contextual day-to-day barriers and facilitators to person-centred care and afforded the acquisition of the language used by teams [35]. Through these interactions, the RiR created opportunities for informal interviews, which helped unpack the normative complexities around implementing WMTY [36]. Through observation, ad-hoc exploration, and reflection on PCC literature, the RiR deepened their understanding of the barriers and facilitators to implementing WMTY.

The RiR created a printable observational tool, a simple two-column table, that facilitated guided handwritten observations during strategic meetings or shadowing. The left column had a series of themes and questions developed around the Non-Adoption, Abandonment, Scale-up, Spread, Sustainability (NASSS) [37], Theoretical Domains Framework (TDF) [38] and the CARE tool [39]. Questions from NASSS and TDF explored the interaction of macro, meso, and micro contexts and mechanisms that shape implementation and influence HCP behaviour. For example, they examined whether spaces were busy, if HCPs had time to ask WMTY, and whether wider system factors such as staffing, technologies, and information interoperability supported PCC [37, 38].

Using CARE, the tool asked how patients respond to WMTY, whether they are active participants, if the outcomes of PCC were documented and if HCPs had the necessary skills to have WMTY conversations [40]. In the right column, there was space for the researcher to answer the tool’s questions. This consisted of handwritten related statements outlining events they experienced and attempts to derive their meaning [41].

Data Analysis:

The RiR then compiled these emerging insights with existing data and insights on WMTY implementation frameworks. All notes were imported into NVivo 12 and analysed using a combination of NASSS [37] and the Com/B to create a consolidated coding framework substantiated through deductive and inductive aggregation [40]. The five aspects of NASSS offered the main codes. For example, within the 'Adopters' section, several subcodes explored the physical and psychological capability to provide WMTY, "automatic" and "reflective" motivation to provide WMTY and finally, the social and physical opportunities to provide WMTY. All the observations were then run through this coding framework to provide insights into the key areas affecting the implementation of WMTY.

Another round of analysis involved carefully reading all the codes in each branch and inputting them into a Word document. The primary researcher then drew out key themes and points under each code, such as motivation, and provided observational evidence for each theme. These themes were then considered to determine what aspect of the TDF they reflected. Importantly, a critical friend reviewed the primary researcher’s coding choices. For example, there are 14 key themes for motivation, 19 under psychological and physical skills and 12 under social and physical opportunities, ensuring a rigorous coding process.

This process of coding and recoding yielded five themes, which we outline below. These themes raise questions about whether some tensions encountered in implementing WMTY stem from a lack of clarity about the underlying philosophies and definitions of mattering, particularly the difference between person-centred and patient-centred care. The thematic analysis also identifies key practical barriers to the effective implementation of WMTY, which we will address in the discussion.

Theme 1: Hopes & Assumptions:

Assumptions behind Implementation:

The NHS trust's guidance advocates for WMTY at every point of care, aligned with the national Make Every Contact Count (MECC) framework [42]. This approach assumes WMTY conversations are quick, simple, and capable of capturing relevant information for PCC. Some HCPs believed that addressing what mattered to patients required minimal support and caused minor disruptions to clinical workflow. Examples included patients wanting a shower at a specific time or desiring a swift return home to family and pets. Thus, WMTY facilitated quick and easy person-centred care in high-pressure acute settings.

Clinical Hopes for WMTY:

Some HCPs members utilised WMTY to shift their practice from a 'fix-it' mentality to fixing things that matter, integrating people's values, preferences, and interests into clinical decision-making. This was particularly noticeable in a high-pressured ward environment. The WMTY conversation helped co-develop a care that met acute medical needs and nonmedical desires such as comfort, peacefulness, and staying in a place where one feels connected to family, friends, and home.

Examples:

"I spoke to a staff member today, and she told me, 'Working out what is best for a patient… can be time-consuming. However, asking what matters could help staff in a high-pressure ward quickly transition from a fix-it mentality to attending to the health concern most essential to a patient." (Observational Note 1)
"[HCPs] hope that WMTY can unearth expectations around hospital discharge and tailors people care plans to meet their nonmedical goals, particularly because of the high risk of deterioration in hospital" (Observational Note 2)

In this sense, some HCPs recognised that for frail patients with several comorbidities, asking WMTY helped quickly shift their role from attempting to meet various complex medical needs to prioritising medical and nonmedical needs aligned with the patient's priorities, facilitating quicker discharge and improving patient flow [43, 44]. They also believed that this approach to PCC was easier than collecting person-centred data via telephoning family, friends, and nursing home staff.

Theme 2: Understanding What Matters Takes Time:

Against this, effectively determining and documenting a person's preferences, fears, values, and goals in a short, clinically focused encounter is challenging. Good WMTY conversations will sometimes require input and information from family, carers, and nursing homes, making the responses case-specific and not always straightforward.

"The family remarked how positively the patient responded to the staff members' care and attention. However, it took around 30 minutes, with a family member present, by the bedside, to fill out a "This is Me" form [a document associated with what matters to Dementia patients]. The HCP had overrun for lunch by 15 minutes by the end of it". (Observational Note 3)
"The HCP listened empathetically to the patient for around 10 minutes. The patient was bored and suffering from loneliness in the hospital and care home. After listening, the HCP provided him with exercises. The patient was happy to do them, giving him something to help alleviate his boredom." (Observational Note 4)

This data illustrates that HCPs can provide person-centred care and personalised functional goals that improve patient satisfaction. Listening to what matters can also help by responding to nonmedical concerns, allowing patients to feel heard and significant in the healthcare system, which is important for their wellbeing. Nonetheless, one should not underestimate that it is likely the unhurried gift of a HCPs time and skill, along with input from family and carers, that affords these improvements in patient satisfaction and feelings of significance. We observed HCPs taking the time to actively listen and then creatively interpret and respond to patient's concerns, and such responses may not appear as obvious to busy HCPs. In essence, WMTY as a fast method of PCC may be less effective.

Consequently, in more under-pressure teams and contexts, such as the emergency department (ED) or a very busy acute ward, asking WMTY may also appear less valuable.

Example

"An older man has had a fall. Staff feel a simple change of medication reduces the likelihood of future falls. They asked what mattered to him. The patient proceeded to provide a lengthy variety of information regarding his family and past. I noticed the ED staff trying to wrap the conversation up. I got the sense that they struggled to see how the conversation was a good use of their time." (Observational Note 5)

Trying to understand what matters may lead to a time-consuming conversation with large sums of person-centred information. In time-pressured clinical encounters, where several patients need to be seen, particularly if the medical solution is also simple (e.g., a medication change), HCPs may consider WMTY unhelpful. This is because, in time-limited environments, lengthy what matters conversations, which appear irrelevant to care planning, are likely to be considered by HCPs as reducing their capacity to effectively care for all patients. Consequently, while being listened to may make patients feel significant, the perceived value of WMTY for HCPs may be reduced if it does not quickly lead to actionable goals. This likely affects the adoption of an every-encounter WMTY approach.

If hospitals are to encourage the adoption, it is crucial to acknowledge how effective WMTY requires HCP time, skill, creativity and perhaps family input, which, even in a less pressured context, may lead to HCPs missing breaks. Therefore, in high-pressure contexts, such as ED or hospitals regularly in Operational Pressures Escalation Level 4, where there is an increased potential for patient care and safety to be compromised, without sufficient time and headspace, it may appear as negatively impacting efficiency and productivity [27]. This potential for poor reliability across the acute setting suggests effectively translating WMTY into care plans may require intensive and therapeutic discussions beyond the scope of routine clinical encounters. Consequently, an every-encounter approach in the acute setting might wish to anchor the conversation into something immediately actionable, such as where a patient should transition next - to a home or an intermediate institution.

Theme 3: Documenting and Sharing WMTY:

The administrative load of documenting WMTY information collected during clinical encounters and ensuring its interoperability may hinder its adoption. Some HCPs raised concerns about the quality of notes and the time taken to write them. This load would increase with an every-encounter WMTY approach.

Examples:

"I have now observed three HCPs who stated they would like to reduce the amount of time they spend on writing notes so they can maximise patient engagement, which they preferred." (Observational Note 6)
"An elderly woman has been asked WMTY in Accident and Emergency (A&E) by staff, to whom she indicated that she wanted to die. The HCP used this information to begin developing a new care plan. In our follow-up encounter, realising her medication changed because of her indication of wanting to die; the woman discussed how she did not want to die but felt like a burden on the NHS and her family, who would be better off without her." (Observational Note 7)

Some HCPs stated that the current administrative load was affecting their time with patients, which may reduce motivation for an every-encounter WMTY approach. This might be because WMTY required more time with patients and writing notes afterwards. Further, difficulties may arise when writing up and sharing the nuances of what matters, such as trying to truthfully capture the complex web of thoughts and feelings that inspire ‘what matters’ to patients. This complexity often results in patients and carers sharing information multiple times, contributing to a workload burden on HCPs.

Theme 4: Mistrusting WMTY:

The observations of WMTY conversations occurred during a highly stressful time for the NHS, with waiting lists burgeoning and junior doctor strikes mounting [45, 46]. Within this context, some frontline HCPs expressed concerns that not all discharged patients were medically fit, citing incomplete discharge plans and assessments. This context and resulting risk aversion in working culture may have shaped HCPs’ attitudes towards WMTY. For example, some HCPs suspected that WMTY would be used to legitimise far earlier discharge of patients than would have happened previously.

"I said that managers wanted to encourage what matters to you. HCP initially responded that they wanted to treat the patients like cattle. She asked, ‘Can we still blame Covid?’ the other lady stayed quiet and kept to herself. She turned back to me and said, ‘There is much pressure from above to get people to move out’." (Observational Note 8)

As previously stated, WMTY conversation may intend to unearth a person's desire to return home and be close to family, friends, and pets. While this can justify faster discharge, some HCPs may question whether these conversations could lead to the uncareful prioritisation of patient desires over acute medical needs, thus reducing the quality of care and increasing hospital readmission.

A HCP requested the research team compare readmission data for those kept, against their wishes, for a few days extra to ensure they were properly mobile to those allowed to go home, regardless of a perceived risk of falling.

(Observational Note 9)

This request for further research highlights concerns that a tool for quickly aligning medical needs with a patient's preferences could be misused to achieve a hospital's goals of improving patient flow at the expense of gold-standard patient care.

Theme 5: Patient Behavior and HCPs Personality Variety

The findings below pertain to the HCP's difficulties navigating the values and preferences of patients who are capable of coherent and consistent decision-making. These preferences sometimes challenge professional opinions of best practice. During the observations, tensions were observed between the expressed desires of patients and their families and the (professional) opinions of HCPs regarding the appropriate care package.

"A nurse describes two types of patients from her experience. Firstly, 'the stoic' does not come into the hospital until it's almost too late, and they need extra support and to be told they need extra time in the hospital. On the other hand, the 'functional dependent' refuses to do anything for themselves, requiring others to feed them despite having the capacity." (Observational Note 10)
"An HCP stated, in response to us discussing behaviours that affect PCC, that in the case of one older man, things escalated to the point that he would rather 'top himself' than receive support from the nurses." (Observational Note 11)
"Staff noted (perhaps controversially) that families were quick to absolve the responsibility of their loved ones onto the NHS system, expecting them to solve various nonmedical issues that could have been much more easily solved with the support of the family." (Observational Note 12)

In some instances, HCPs know that what matters to a patient or their family is not in the best interests of the patient or the health system. What matters to a 'stoic' patient may be to deny their need for help to maintain their 'independence'; for others, it is to depend wholly on HCPs for care. For their families, a recent visit to the hospital may be seen as an opportunity to ensure their loved one is cared for in a residential home. However, from experience, HCPs may understand that these paths may lead to poorer outcomes. This creates tensions as HCPs struggle to help patients understand the importance of accepting and co-developing an appropriate care plan, which they believe to be gold-standard support.

Observing the consequences of these patients' actions, HCPs may also conclude that what matters to these people is to make their lives more difficult. Consequently, HCPs may be dissuaded from asking and facilitating what matters at every encounter because it requires navigating complex and unhelpful motivations that may complicate their job.

WMTY can provide Meaning in Life (MIL)

The thematic analysis presented above leads to several insights about barriers and enablers to meaningful, practical, and impactful support for PCC through strategies such as WMTY. In summary, HCPs may hope that asking “What matters to you” at every encounter can provide a quick and simple method to create care plans that align with patients' nonmedical needs. However, our observations indicate that effective WMTY conversations take time and skill to complete. They were often limited in their capacity to reliably facilitate and improve care planning in pressure environments. Further, the increased administrative load and the variable interoperability of these notes may demotivate adoption. Finally, motivation to adopt WMTY may also be reduced by mistrust that WMTY is primarily a tool to enable discharges too early and that HCPs are sceptical regarding patients' and families' motivations behind their stated priorities.

Olsen et al. argue that a problem with implementing WMTY conversations is that it tries to reconcile two overlapping but distinctive conceptual positions: patient-centred and person-centred care, each with somewhat different outcomes [27]. Both these models encourage empathy, communication, and a holistic focus on care. However, patient-centred care focuses on providing care that is respectful and responsive to the individual's needs and values and helps patients live a functional life, while person-centred care attempts to place healthcare into the larger frame of an individual's life project [47] to help them achieve what we would call Meaning In Life (MIL). To them, these differences in aimed care outcomes made it hard for HCPs to decide which model was most appropriate for various healthcare contexts – should they improve functionality or increase meaning in life? This confusion, they believed, affected the levels of HCP adoption.

Somewhat in agreement, this study contends that we must determine under what circumstances HCPs should aim to facilitate a significance in the system or longer-term sense of MIL. Arguing for this MIL approach to understand WMTY, we first define ‘what ‘mattering’ is, how it creates MIL and its relation to coherence and purpose. Then, we consider how both patient-centred and person-centred approaches can address people's biomedical goals and provide MIL, albeit with emphasis on one or the other. For example, the patient-centred approach may provide short-term MIL but not long-term MIL through care planning. Understanding these things may assist implementers and HCPs in better adapting WMTY, depending on the context.

Understanding what ‘mattering’ is and how it contributes to feelings of MIL helps to understand the relative roles of functional goals that can support significance in the health system and care planning that enables long-term MIL. Specifically, mattering (or feeling significant) describes the feelings that an individual's life has importance beyond trivial and momentary conditions, is worth living, and that one's actions make a difference. It results from acting positively towards worthy objects of love [48]. For example, one may feel they matter because they enjoy nursing, which works towards an objective good: healing the sick and protecting the vulnerable. A recent study shows that mattering is the most significant factor in experiencing MIL [49], a sense that our lives are more than a sum of seconds, days, and years [50]. In this sense, acting positively toward a worthy other (e.g., friend, family, career, church, sports team) gives people a sense of significance and thus MIL.

Interestingly, mattering is the precursor to two other aspects of meaning in life: coherence and purpose [49]. Coherence refers to broadly making sense of our experiences and the world - for example, whether the elderly patient has a sense of order and can comprehend their surroundings. Purpose is defined as "a central, self-organising life aim that organises and stimulates goals, [and] manages behaviours" p.242 [50]. In this sense, mattering helps us make sense of our lives and direct our energies towards a desired future [49], adding greater depth to our MIL. This may help explain why healthcare and scholarship are increasingly dovetailing around recognising higher-order goals focused on the needs, values and preferences that can help prioritise fragmented and conflicting goals in healthcare and improve achievement rates [51–54]. Using this knowledge, perhaps the key to these goals is to ensure that they incorporate something a patient enjoys that acts positively towards an object (volunteering, spending time with grandchildren, making their garden beautiful).

Drawing on this understanding of mattering and MIL, we see how a patient-centred care approach to WMTY can attend more directly to functional goals but contribute to MIL. For example, considering a person's needs and values regarding their functional outcomes may make HCPs work feel more meaningful [49], but also, as patients become objects worthy of love, they also feel more significant within the health system. This felt significance will likely provide a sense of MIL. For example, in theme 2, a WMTY-styled conversation led to the provision of bespoke exercises, validating the patient's concerns about boredom and making him feel significant [48]. However, the extent to which a patient-centred approach generates significance (mattering) beyond the confines of the healthcare system (e.g., helping them in daily life act positively towards something they love) is not properly understood. Thus, without a deliberate attempt to articulate these objects of love, affording longer-term MIL may not be as readily achieved.

Furthermore, by defining "mattering" as something deeply connected to what one loves (family, friends, and communities), we understand why WMTY conversations often lead to lengthy discussions on abstract matters rather than easily actionable goals (see Theme 2). Nonetheless, effectively utilising this information, HCPs could curate longer-term care plans that provide a longer-lived sense of MIL. For example, an HCP could co-develop a plan to spend two days weekly with friends, family or a carer outside the care home. This plan could help generate a longer-term feeling of significance, with a plan to act positively towards an object of love, improving coherence and purpose (MIL) [49], potentially reducing the fragmentation of services and increasing goal achievement rates [51–54]. However, moving beyond identifying immediate concerns (biomedical or otherwise) to finding longer-term healthcare goals that align with more abstract matters requires dedicated time and a more therapeutic-styled conversation, for which a pressurised acute environment is often not the optimum setting (see themes 2 and 3). Thus, a more patient-centred approach with a localised MIL output may be most desirable in these settings.

In this sense, difficulties in implementing WMTY are not caused merely by a conflict about whether to prioritise functionality or MIL but rather a more complex problem of when, where, and how a patient-centred or person-centred WMTY approach should be used to maximise the potential delivery of MIL. Depending on varied contextual pressures, should the HCP help patients focus on providing significance in the narrow health system or attempt to co-create and support goals targeted towards things that one loves and thus provide long-lived meaning in life? At present, it appears that long-term MIL-focused WMTY is less appropriate in busy acute hospital settings. Nonetheless, explicitly clarifying the type of WMTY and when and where they should be used might also address other issues that were surfaced by the thematic analysis, including perceived appropriateness of conversations, which might lack fittedness with any course of action that is feasible within the acute setting (theme 2) and the time implications of recording WMTY (theme 3).

Aligning WMTY with HCPs Strengths:

Understanding HCPs' values and preferences is crucial for identifying those best suited to conducting patient-centred or person-centred WMTY conversations. This section explores the importance of considering what matters to HCPs, balancing autonomy and empathy, and the relevancy of HCPs' personality traits for the future implementation of WMTY in healthcare settings.

Firstly, under theme 4, we noted low morale and high mistrust levels in a system under significant pressure. HCPs' sense of meaningfulness at work is questioned as they worry about the quality of care provided. If caring for the sick is their object worthy of love, failing to act positively towards this object will reduce their MIL: a sense of significance, purpose and capacity to make sense [49]. At worst, they may have personally experienced a morally injurious event, for example, witnessing unethical behaviour and failing to intervene. Consequently, the NHS may find itself with a more disconnected, less motivated workforce suffering from compassion fatigue [55, 56, 57]. Therefore, it is essential to ensure that HCPs across the hierarchy feel they matter and recognise the importance of their roles before they can help patients find long-term MIL effectively.

Under Theme 5, evidence suggested that acknowledging the full spectrum of patient and HCP behaviours and personal preferences is crucial. Understanding this variation and its impact can help hospitals choose people to adopt various types of WMTY. WMTY, we have argued, assumes that a patient does have a life goal or things they love that they wish to act positively towards, and that HCPs can elicit these preferences, and create a care plan that benefits patients, HCPs, and the healthcare system broadly [24]. However, many older adults, due to cognitive and functional decline or perhaps just beset by the tragedies of their ill health and life, may present to HCPs with highly challenging behaviours.

Consequently, if WMTY leads to the overrepresentation of a patient's more challenging preferences, it may leave HCPs feeling a loss of autonomy and professional compromise (see Themes 4 and 5). A substantial body of research has documented the impact of challenging behaviours on HCP's wellbeing [58, 59, 60, 61]. However, suppose WMTY leads to the overrepresentation of patient or carer preferences that HCPs believe prevent gold-standard care practices (see Theme 5). Although there are various interventions to help HCPs manage patients with challenging behaviours [62, 63], the risk remains that if their empathy towards patient preferences does not serve an objective good, it will reduce their empathy for patients and their sense of MIL [30].

Consequently, there may be a need for the management of teams to select the types of people more suited to conducting person-centred WMTY-style questions depending on the character and nature of patients and HCPs. Extraversion may be an important indicator here; studies suggest that nurses and paramedics with higher neuroticism and lower extraversion may be less suited to the profession [64]. Empathy among HCPs is positively associated with conscientiousness and agreeableness and negatively associated with neuroticism [65]. Additionally, trait neuroticism is related to HCP's burnout, while extraversion, agreeableness, and conscientiousness could help prevent perceived burnout [66].

Bagley et al. [67] further suggested different categories of nurses; first, the cheerful professionals who held higher-ranking jobs were more extroverted, agreeable, not depressed and had middle-range hardy personalities. Second were high achievers with high-ranking jobs, high extraversion and low neuroticism, higher scores on hardiness, self-esteem, and higher nursing values scores. Third, the 'soldier' experienced some burnout, more work-life stress, lower scores on agreeable personality and lower nursing value scores. Fourth, there were highly stressed potential leavers. As Mason et al. [64] also observed, these people were high in neuroticism, low in extraversion and low in hardy personality.

Reflecting on this, it can be suggested that, among nurses, at least, those most suited to person-centred (MIL-focused) WMTY are the cheerful professionals and those holding higher rank jobs. However, those with higher ranks are less likely to engage directly with patients. By contrast, the soldiers and those on the cusp of leaving the profession, with lower hardiness and lower extraversion, may find themselves with the greatest responsibility for providing long-term MIL WMTY conversations despite having less suitable personality traits [67].

Rather than creating unrealistic demands on HCPs by advocating for undifferentiated WMTY conversation at every encounter, making assumptions that all HCPs are agreeable, extraverted and conscientious [22], hospitals should tailor the type of WMTY conversations to context and the personality traits of the HCPs. For example, a person-centred approach that allows for in-depth discussions and long-term planning may be more appropriate in slower, less pressured environments by cheerful professionals and high achievers [67]. Overall, by aligning the type of WMTY conversation with both the context and the HCPs' traits, healthcare systems can optimise the effectiveness of these interactions, ultimately improving patient care and HCP wellbeing.

Infrastructural Readiness:

Finally, effective WMTY rests on an effective infrastructure. We note that (theme 3), even for HCPs who did feel comfortable engaging in WMTY conversations, the fact that key documents that contained PCC information were not being shared across settings and teams was very frustrating. To create both significance (short-term MIL and healthcare outcomes) alongside longer-term MIL, a WMTY system requires an effective means of collecting, summarising and sharing information [24]. For example, in the case of the elderly lady in A&E, PCC inputs before hospital admission might have helped HCPs understand and negotiate her feelings of being a burden. In systems that lack a comprehensive electronic patient record and indeed still rely on paper records for some services, the administrative burden on HCPs and the frustrations felt by HCPs and patients around the necessary duplication of PCC conversations must be taken seriously.

Looking to the future: key recommendations.

How can we ensure that systems of WMTY are sensitive to context, not result in demanding time constraints and the duplication of information collection due to problems of interoperability, and ensure that staff across the hierarchy feel they matter and thus have the required level of empathy to support their patients to find their meaning effectively, and respect professional autonomy?

Critically assessing available toolkits.

Several 'toolkits' are available to support professionals in undertaking WMTY conversations. However, they do not recognise how person-centred and patient-centred approaches, which help create MIL, can be used appropriately in different contexts.

Montefiore Hudson Valley (MHV) [21] and British Columbia's (BC) health care system [68] suggest that WMTY is a patient-centred approach focused on providing functional, personalised support to patients' needs. They indicate that WMTY usually only takes 90 seconds and that around 50% of WMTY requests are quick and easy to respond to. All BC acute and community staff are encouraged to integrate these conversations into everyday care interactions [68, 21]. In this sense, the MHV and BC approach promotes the discovery of small yet meaningful actions beyond merely medical and functional needs. This may help patients feel they matter and are significant to the healthcare system. However, these toolkits do not acknowledge the potential for WMTY to require longer conversations to produce long-term MIL.

In contrast, the Institute for Healthcare Improvement (IHI) [69] created a comprehensive tool kit with a detailed process for elucidating and creating a WMTY-related care plan. This process includes conducting the pre-prepared interview, based on a review of records, by an HCP, and in a setting where a team has pre-selected as most appropriate for the patient. During the interview, WMTY questions were to identify things that make people feel significant and can be turned into actionable functional goals and healthcare activities people could self-manage (e.g., medication and testing). Interviewers were encouraged to listen actively, using health literacy tools, affirm the conversation, and incorporate this information into the care plan to document and share for future WMTY conversations. This approach demands specialist training and preparation, which may not always be feasible due to contextual challenges.

Overall, toolkits are yet to capture and distinguish between WMTY approaches effectively. Compared to the MHV and BC toolkits, the IHI toolkit describes creating healthcare goals to provide patients with MIL and recognises the importance of who, where and the time and preparation needed for WMTY. This reflects our person-centred WMTY conversation but does not capture the patient-centred approach. Similarly, the MHV or BC WMTY approach offers a patient-centred approach, creating localised significance and quickly helping to align health goals with MIL, but not long-term MIL.

Table 1

An outline of the three types of WMTY conversations with aims, examples, and desired outcomes.
Type of WMTY	Preferred context and frequency	Aim:	Example question:	Desirable outcome:
Patient-Centred WMTY	An every-encounter approach is more suited for busy acute/community healthcare environments [22]	To explore what is important to the patient in a relationship to immediate, simple medical and nonmedical needs. Detailed note-taking is not required.	• Is there anything you usually have/do at home that makes you more comfortable? • Regarding [procedure/ailment], is there anything worrying you I can help with? • What matters to you while you are in hospital with me?	Increase functionality, patient satisfaction and temporary increase in MIL
Person-Centred WMTY	The IHI method is conducted by well-trained and suitable champions in the acute and community setting or voluntary sector staff after admission or after key changes to a person's health care needs/strategy [72].	To understand the various objects an individual deems worthy of love and wishes to exist even once they are deceased. In addition, multiple strategies help people act positively towards these things. Detailed notes are required.	• What things do you love to do? • What do you want to continue after you are gone? (a church, team, family welfare) • What things could we do to help you work towards acting positively towards this? And what can we do even if our health situation worsens?	To produce a high-quality person-centred care plan that increases MIL in the long term.
A Patient-Centred Booster WMTY	These could be conducted by peripatetic HCPs every week after an older adult is discharged from the hospital or any other HCPs in primary, community or acute as part of a routine checkup.	To ensure that one's objects worthy of love remain the same and, if so, to focus on how they can continue to adapt health goals to enable an individual to work positively towards them. Updating previous notes is required.	• In a previous discussion, you highlighted that [object of love] was important to you. • Is this still the same? Have the functional things we implemented helped you act positively towards this?	Increase long-term MIL by updating functional goals.

This leads us to divide WMTY questions into three overlapping and inter-connected camps (see Table 1). The first is a patient-centred WMTY conversation, most suited to pressured environments. This type of WMTY, an every-encounter approach, may elicit small and doable functional requests that staff can do to benefit people's care immediately. The second, a person-centred WMTY, aims to outline what an object a patient loves and specific functional goals that encourage them to act positively towards it. This approach requires preparation, specialist skills, and a suitable personality; thus, it is not an every-encounter approach but requires specially trained staff, a general practitioner or voluntary sector support. The final patient-centred booster approach focuses on updating functional goals about an existing MIL-focused WMTY conversation. This could be conducted by community, primary care or acute care.

Against this background, there is a case for amending these toolkits to encourage or recognise that person-centred and patient-centred WMTY approaches are more suited to different types of staff personality, time, and hospital business. These toolkits could also identify the risk WMTY may pose to feelings of professional autonomy and methods of mitigating this. The benefits are potentially worth it. Extensive literature demonstrates the value added to frailty care by person- and patient-centred approaches [19–24]. We need to be realistic about the inputs and processes required to enable WMTY conversations that lead to increased longer-term MIL, the tensions that might arise relating to staff time and autonomy, and a wider context of limited community care. Doing person-centred WMTY requires resources beyond the health service, and if staff feel charged to have these types of conversations at every encounter, repeatability for all patients seems unlikely.

This paper aimed to outline the assumptions that guide advocates in choosing WMTY, how these assumptions guide implementation, impact adoption, and find solutions to boost future implementation. This study's first objective was to understand the assumption guiding advocates and its impact on implementation. We found that WMTY was perceived by implementers as a quick and easy method that all HCPs could employ to help reframe patient care needs away from merely medical solutions to what was most important to a patient. Staff believed this process could encourage discussions about earlier discharge from the hospital, improving flow and reducing potential inpatient health deterioration.

Our second objective was to document how these assumptions intersected with context and created potential barriers and facilitators for implementation. The study found that WMTY was not always simple and easy but required time, attention, internal reflection, and a mature digital infrastructure with the capacity to share these insights across an MDT effectively. Additionally, not all spaces and HCPs were suitable for person-centred WMTY. Thus, we argued, for example, that patient-centred WMTY may be more appropriate for busy hospital wards (e.g., ED) and HCPs lower in trait agreeableness and higher in trait neuroticism [67]. WMTY conversations could also threaten professional autonomy and perhaps increase the possibility of workplace burnout or decreased MIL [25–30]. In this sense, misalignment between initial assumptions around implementation and contextual complexity may be affecting implementation.

Consequently, given the strong value proposition of a WMTY in guiding clinical decision-making, the study has suggested the subdivision of WMTY conversations that prioritise patient-centred care, and functional goal creation, person-centred care, with care plans for longer-term MIL (see Table 1). The paper advocates for a patient-centred WMTY approach for everyday encounters in hospital settings, supported by a person-centred approach via suitable HCP or voluntary sector champions in less pressured healthcare settings. Finally, we suggest this person-centred WMTY should be supported by booster functional-focused WMTY that can update a person-centred WMTY with new actionable strategies.

This delineated approach is important. Existing literature outlining the difficulties in WMTY implementation highlighted a key limitation that HCPs struggled to decide whether to focus on functional outcomes or goals aimed at creating MIL [27]. However, we have argued that both person- and patient-centred approaches contribute towards MIL [51]. Additionally, our WMTY approach (see Table 1) then confronts the complexity of choosing between person- and patient-centeredness by suggesting that context and personality should inform applicability. Thus, by determining which personalities and contexts are best suited to different styles of WMTY, we can better understand how to improve its adoption, drive positive health outcomes and maximise MIL among the elderly.

Future studies may wish to complement RiR observations with semi-structured interviews with staff members that get them to reflect on the observations. This triple-loop learning method is becoming increasingly popular in health service research [70]. Such a process may help to understand how staff perceive the function of WMTY more conclusively and their capacity to conduct these conversations.

WMTY – What Matters To You

PCC- Person-Centred Care

HCP - Health Care Practioner

HCPs - Health Care Practioners

RiR- Researcher-In-Residence

MIL - Meaning In Life

HOP - Health Care for Older People

ED - Emergency Department

NASSS-CAT - Non-Adoption, Abandonment, Scale-up, Spread, Sustainability

TDF - Theoretical Domains Framework

MECC - Make Every Contact Count

A&E – Accident and Emergency

MHV - Montefiore Hudson Valley

BC - British Columbia's health care system

IHI - Institute for Healthcare Improvement

Ethics approval and consent to participate.

As a minimal risk study, conducting service evaluation observations, we followed the relevant NHS Health Research Authority guidance in using a ‘proportionate approach to seeking consent’. This included organisational endorsement and a layered approach to oral and electronic individual consent to fit the data collection opportunities. Explicit and informed consent was sought at each instance of data collection, and anonymity and confidentiality of data recorded were assured to each participant.

This study received ethical approval from the Yorkshire & the Humber – Sheffield Research Ethics Committee (REF Reference: 24/YH/0002) and the Health Research Authority. The University of Plymouth Ethics Committee (Reference: 2024-4029-596)

Consent for publication

Not applicable

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to them containing confidential patient and staff information, but they are available in an anonymised format from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This research was funded by a small fund associated with a local NHS trust in the South-West, which, for confidentiality reasons, must be kept anonymous.

Authors' contributions

KG conducted the research, wrote the draft text, and finalised the manuscript.

SA helped redraft and restructure the manuscript twice.

JD helped code the data, reviewed the manuscript, and offered a variety of suggestions for improvement, particularly in the methods and result sections.

OP reviewed the manuscript.

Acknowledgements

Thanks to Dr Felix Gradinger and Dr Julian Elston for their support throughout the research process and the management at the NHS trust that made this publication possible!

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No competing interests reported.

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You are reading this latest preprint version

Implementing "What Matters to You" in a Geriatric Care Pathway – a Researcher-In-Residence study:

Status:

Version 1

Abstract

Background

Methods

Setting

A Researcher in Residence study:

Data collection

Data Analysis:

Results

Theme 1: Hopes & Assumptions:

Assumptions behind Implementation:

Clinical Hopes for WMTY:

Theme 2: Understanding What Matters Takes Time:

Theme 3: Documenting and Sharing WMTY:

Theme 4: Mistrusting WMTY:

(Observational Note 9)

Theme 5: Patient Behavior and HCPs Personality Variety

Discussion

WMTY can provide Meaning in Life (MIL)

Aligning WMTY with HCPs Strengths:

Infrastructural Readiness:

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1