Table 5.

Results

Synthesized finding	Visionary leadership and empowerment	Consistent and systematic approach for person-centered outcomes	Leadership through role modeling
Category	• Importance of clear visions and values • Empowering and enhancing staff performance	• Capability to organize and establish structure systematically • Continuous focus on person-centered outcomes	• Actively participating in care provision • Promoting a safe, supportive environment with a culture of continuous growth
Findings (Excerpts from included studies)1	The findings underline the need for a clear and coherent vision to obtain professional development and person-centered dementia care. Transformational and situational leadership, along with a clear vision defining PCC, seemed to be vital for successfully implementing PCC. Leaders have a central role in drawing up a clear and consistent professional vision. The leadership seemed to influence the nursing staff's experiences of empowerment and their ability to put the idea of PCC into action to meet the patients’ needs. Encouraging the staff as a group to be actively involved and take shared responsibility for the residents’ care is crucial, as demonstrated at the ‘highly professional’ nursing home. The staff felt empowered and trusted to make their own decisions in their daily care practice (46). The leaders described having a personal understanding and knowledge of the principles of PCC. The leaders described having a clear vision of what they wanted PCC to be, and how to integrate their vision into practice. Most managers described that talking about what person-centered care is and what it is not and having full focus on the care of the resident, was important. The managers worked actively to concretize the person-centered philosophy and to operationalize this in practice. The person-centered vision was made explicitly exemplifying and verbalising important concepts of PCC. The leaders encouraged the staff to adopt a reflective mindset. Value based issues and dilemmas were solved by turning the focus back to the resident (40). Higher levels of PCC was associated with empowering leadership, among other factors. An innovative climate was associated with PCC, describing this as taking the initiative and encouraging staff to find alternative ways to do things. The finding in the present study shows that especially “empowering leadership” is associated with PCC (47). The result of this study also empirically supports the theory of person-centered nursing confirming that leadership is a prerequisite for PCC on the unit. The impact of leadership behaviors on the psychosocial climate seemed to depend on the level of person-centeredness of care, indicating that leadership behaviors are of utmost importance for the psychosocial climate of staff and residents when the levels of person-centeredness of care are very low. On the other hand, when the person-centeredness of care is low, clinical leadership becomes more important for the overall climate, suggesting that managers need to lead the way more strongly toward excellence in environments where care is less person-centered (39). PCC was described as the organization's ethos, and improving the quality of care was the most important incentive for implementing PCCfor the leaders irrespective of management level. In the VPM, the head nurse is expected to attend each consensus meeting, supervise the staff, ensure the professional standards of the decisions, and provide recognition to the frontline staff. Doing all of this was described as difficult to accomplish but necessary (48). Staff empowerment had the most extensive benefits on resident quality of life, ranging from promoting residents’ positive experience with meal services and day-to-day care to improving psychosocial well-being (specifically dignity, autonomy, and meaningful activities (42). This study illuminates some additional factors that shape the personalized dementia care dimensions, for example, quality of care is impacted by leadership, person-centered communication of staff with residents, and the personal and social life of staff (43). The quantitative data (…) indicates that a positive staff evaluation of their leaders predicts a more positive perception of their institution as to the commitment to PCC (44). The residents who live in Household B have a great life here and our mission is to work as a team to make this vision a reality. the leader needs to be vibrant, have amazing energy to support the team, engender trust and lead on PCC… (Pat, carer in focus group with staff; time 2). The recent team building sessions have strengthened each team member's contribution to the overall team and their belief in the vision… (Mary, carer in focus group with staff; time 2). (…) they are an enthusiastic, flexible and confident team and both leaders of the household work well together showing trust and appreciation for each other and for the overall team… (reflective dialogue with Bell, care manager; time 3) (45).	The leaders described being embedded in PCC in all their day-to-day activities. Leading PCC involves being able to maximize the potential of the team. The leaders reminded the staff about the objectives and goals connected with a approach. These managers also expressed that they wanted to see the person-centered philosophy integrated in all aspects of care and expressed that care routines were also re-directed from intuitional-like care to person-centered care. Assessing and calibrating the extent that staff was integrating PCC into practice was described as important since PCC was perceived as somewhat difficult to maintain. A PCC approach could easily fall off the track, they had to work actively to steer back on track, and it was necessary to hold on and not let go. The leaders applied innovative solutions when organizing work to adapt the organization to the needs and requests of the residents. The managers described the importance of clarifying different team roles and positions of their staff for enhancing PCC. By knowing the individuals in the staff group, the managers could identify different roles in the group and designate different positions so that the group's combined qualities and competencies were utilized to promote person-centered care. The managers explained that identifying and utilizing their staff's unique areas of knowledge and skills enabled the possibility of creating different areas of responsibility for the staff, making it possible for staff to share their skills amongst the team members and residents. The managers explained that identifying relational competencies between staff and residents was central to building and enhancing person-centered relationships. An important aspect for the leaders was to optimize person-centered support structures. Having a clear structure for care planning, as well as routines for evaluating PCC was described as important for development and maintenance, and new forums were developed, and existing forums were optimized and changed to facilitate this. The managers described that they created new forums to lead staff toward engaging in PCC. For example, some managers used existing quality registers for nursing interventions or as baseline tools to evaluate initiatives. The leaders organized and attended care meetings, and being involved in creating care plans based on the residents’ needs provided a clear structure to follow. The managers described changing existing forums to facilitate PCC. For example, it was described that ordinary workplace meetings were used as forums to raise person-centered issues, as well as to follow-up on person-centered interventions (40). Stability in the unit was necessary in order to develop the competence and skills required to execute the functions of the VIPS practice model: [It is important] that the turnover is low, that people know what the primary tasks are, that they can document things, simply a well-driven unit. You need to sort out any chaos before you can implement something that requires professionalism and structure because you need structure to make it work. Upholding the new routines for the consensus meeting was highly dependent on the head nurses. In fact, their engagement was described as pivotal: It is the head nurse who makes the difference . . . a leader who schedules the meetings and organizes the time to hold them. The new systematic way of working also meant that interventions should be adjusted if necessary. The head nurse reminded the staff to be alert and make observations: I tell the frontline staff ‘You need to document it [how the interventions work], then we can discuss it. You need to observe it and look into it before the consensus meeting when we are evaluating it’. To manage to conduct the consensus meetings regularly in the units, the meetings were all planned ahead regarding time and participants: For things to work, you need leaders who create structure, structure with fixed meeting times, and full-time employees [present]. They made schedules, so staff could be prepared for the meetings: We planned the next meeting early on; they [the frontline staff] knew 14 days in advance. It gives them time to process it in their heads (48). The consistent and systematic pursuit of effectiveness and service was perceived as conflicting with the values of PCC (46). This leader carefully mapped which residents shared things in common with each other and with staff members and carefully planned for the ‘right matching’ and also, for the gradual implementation of the decision-making model. (44). A flamingo looking at its own reflection in the water represents the importance of getting the balance right between compliance and the culture of PCC. It constantly changes… sometimes the ripples make the reflection bigger…when a HIQA inspection is due…compliance seems heavier than person-centeredness…constant emphasis on paperwork. Having a consistent team helps to keep the balance… the images of the flamingo are equal then… (Maggie, staff nurse in focus group with staff; time 2 (45).	The staff felt leaders appreciated, supported, and encouraged their efforts for the residents and felt supported in delivering quality care. Participation from leaders in the nursing practice was considered crucial by the staff. In one of the nursing homes, the leaders were present on the ward daily making the staff feel supported and engaged. In another nursing home, the leaders could not be present at the ward and take part in tasks, which seemed to result in frustrated leaders and resigned staff. The leaders saw themselves as role models for the care staff. Leaders have a central role in being continuously supportive of the care staff and taking an active part in the care practice as role models (46). The impact of leadership behaviors on the psychosocial climate seemed to depend on the level of person-centeredness of care, indicating that leadership behaviors are of utmost importance for the psychosocial climate of staff and residents when the levels of person-centeredness of care are very low (39). Leading PCC involves providing individual support to care staff, within a trustful and innovative atmosphere. The leaders reported by being present in the unit on a daily basis and making own assessments, and taking control of the care situation, if necessary, the extent of PCC delivered was assessed. The leaders reported that they were able to coach staff in nursing interventions and also remind staff of objectives and priorities in conflict situations. Promoting a person-centered atmosphere was described to be important for enabling person-centered being and doing. An atmosphere underpinned by mutual trust, creativity, and innovation was central to providing PCC. An atmosphere of trust was described as crucial for developing PCC. Several managers described that one way of creating trustful relationships was by providing constructive and positive feedback to staff about their performance. Trust was achieved by the validation and recognition of staff competence and gradually handing over responsibility for the person-centered care to staff. The delegation was described to show that trust was in place. The managers described the importance of creating a space that encouraged staff to think outside the box and encouraged chance-taking and testing creative solutions in daily care as person-centered care was considered neither static nor standardised. Most managers described that it was important to be a role model and lead by example by being involved in the care. Also reported that they recognized, highlighted, and confirmed good examples in the clinical practice and used positive situations as a benchmark for care planning, and positive psychology seemed to be an important feature in supporting a person-centered atmosphere. Another important aspect of leading towards person-centered care was described as maximizing person-centered team potential. This was outlined as making the group function as a team, utilizing their positions, as well as competencies was considered necessary for promoting person-centered care (40). This study provides insights that leadership most prominently characterized by behaviors such as experimenting with new ideas, controlling work closely, relying on his/her subordinates, coaching, and giving direct feedback, and handling conflicts in a constructive way is positively associated with less staff stress of conscience as well as with increased PCC. The positive correlation between leadership and PCC suggests that by fostering trust, delegation, and innovation, managers can further promote this care approach (41). Leadership and organizational culture were found by the staff as key to practicing a holistic care management plan for Residents with dementia. The hierarchical leadership and relationships discouraged them to work as a team for incorporating the components of personalized dementia care in their everyday care service. Some staff stipulated that how authoritative leadership influenced their care activities. While some clinical managers discussed the difficulties in engaging the care workers into personalized care, several care workers emphasized the need to improve respect among the staff [horizontal and vertical] in order to implement a new model of care. (43). The respondents underlined that leaders at all levels in the organization had to be committed for the ethos of PCC to become a reality: We were very clear that this was not just another project; this should be the way we work, how we do things (#8). Some staff needed support from the head nurse to do this, and one head nurse said she encouraged them by stating: This is your job, and I know you can do it (#15) (48). Fostering leadership of direct care staff also showed a favorable impact on three quality of life domains including dignity, autonomy, and meaningful activities. (42). Respondents who evaluated their leaders as open and inclusive were most likely to think that their institution is committed to PCC. The leader gave freedom to staff with regard to how they organized their daily tasks, but she immediately intervened when the care work did not work out well. Leadership and staff culture appear to be pivotal factors in promoting or hindering PCC, a necessary pre-condition for confidence building initiatives in staff-patient relationships, based on PCC. Respondents who evaluated their leaders as open and inclusive were most likely to think that their institution is committed to PCC. The leadership stands out as a very important factor. As an example from the facilitator notes, in one home, the number of attendants dropped when the leader was on sick leave, from an average of 13 in the first four sessions, to five in the last 2 months when the leader was absent. How staff perceived their leaders was found to predict how staff perceived the presence or absence of PCC. By acting as internal facilitators, the leaders’ activities directly and indirectly increased the potential for success stories in terms of more person-centered and restraint- free care to happen. The ethnographic studies make clear, however, that the manner in which the leaders are involved is important for the success or lack of success of the implementation (of PCC) (44). She [the leader] treats us all like we all have star qualities—she knows the stage each of us is at. I think she works hard at getting us enthusiastic about doing the best we can …She's always supporting us to develop innovative ways to give care in a person-centered way… (Noleen, staff nurse in focus group with staff; time 2). They identified a resident, and with the resident's agreement, worked together to tailor the resident's shower, breakfast, medications and dressings all around what suited the resident—not as a series of isolated tasks, but in a smooth integrated way. The two leaders brought this change in practice to the monthly household team meeting in order to increase the staff's knowledge and understanding of PCC using the “living” example, and to help integrate the approach into their day-to-day practice. (45).