Using saliency and tacit knowledge for person-centred care: a two-phased qualitative study on patient and family involvement in residential care

Abstract

Background

As workforce shortages increase, collaboration between residents, their informal networks and care professionals (triad) must intensify to ensure person-centred care. Such care, which aligns with personal preferences, needs and values, requires saliency and sharing of tacit knowledge among those involved. Saliency is the ability to recognise a significant signal in a given situation that demands attention because it appears to be relevant to a person’s care and well-being. Tacit knowledge is knowledge gained through experience, is difficult to articulate, and often guides action without conscious deliberation. This two-phased study (2022, 2024) explored (1) how saliency based on tacit knowledge of the personhood of a care recipient informs person-centred responses of care professionals and (2) how a person-centred learning culture can be fostered in which tacit knowledge is shared within triads.

Aim

To effectively facilitate a learning culture in which tacit knowledge is shared and applied, to achieve optimal person-centred care.

Methods

Both phases took place on residential wards for people with dementia and somatic care. Narratives of successful examples and best practices of using tacit knowledge were collected through observations and interviews. Based on these insights and in co-creation with all stakeholders, an innovative supportive tool was developed. This consists of a seasonal calendar and a questioning game, enriched with eight elaborated practical examples. The tool facilitates dialogue and reflection and encourages the use of tacit knowledge in the daily lives of residents.

Results

Across two phases, we identified a three-step process in which residents, family members and professionals within the care triad recognise saliency, surface tacit knowledge and translate it into person-centred actions. This process, illustrated in eight triadic examples, informed a supportive tool that structures shared reflection and learning in daily practice, strengthening person-centred care despite task-oriented routines and time pressure.

Conclusion

Saliency and using tacit knowledge of parties cooperating in a triad are essential for person-centred care. Facilitating dialogue and reflection strengthens such collaboration. Concrete examples of best practices and narratives of successful communication support a learning climate that optimises person-centred care.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12877-026-07927-4.

Introduction

Population ageing worldwide is accelerating the demand for long-term care services, presenting complex challenges for healthcare systems already strained by workforce shortages and financial constraints [1, 2]. This demographic shift particularly impacts care for older adults living with dementia, older people with multimorbidity or older people having both. These conditions are associated with greater care needs and the requirement for person-centred, continuous care [3–5].

Person-centred care (PCC) is internationally recognized as a foundational approach to healthcare that enhances quality of life and health outcomes by respecting the unique preferences, values, and needs of individuals [6]. PCC is a way of delivering care that is built on creating and maintaining positive, supportive relationships among professionals, service users, and the people who are important in their lives. It is guided by dignity and respect, individuals’ rights to make their own choices, and shared understanding and mutual respect. It also depends on an empowering organisational culture that supports ongoing learning and continual improvement of practice [7, 8]. Similar values and supportive factors also underpin dementia care models, such as Brooker’s VIPS framework, which emphasises valuing people, individualised care, a positive social environment and supportive relationships [9, 10]. This definition highlights the importance of supportive relationships, respect, autonomy, and a culture of continuous learning for achieving PCC.

While the principles and values underlying PCC are well articulated, their operationalization in day-to-day care remains challenging, particularly within residential care settings for people with dementia. An essential but underexplored enabler of PCC is the use of tacit knowledge. Tacit knowledge refers to an experiential and intuitive understanding that often occurs implicitly and guides care actions without conscious deliberation. Saliency, on the other hand, denotes the noticing and interpretation of subtle behavioural, emotional, and contextual cues that stand out as meaningful in a specific situation [11, 12]. This contextual and often unconscious knowledge supports timely, on-the-spot adjustments in care that align with the person’s changing condition and preferences and better tailored value-driven care in general. This concerns experiential knowledge that stems from personal experiences of all people involved in care, including residents themselves, their family members, informal carers and care professionals.

However, several barriers limit the effective use and sharing of tacit knowledge within residential care teams. Prevailing task-oriented workflows, workload pressure, and limited time for reflection or dialogue impede knowledge exchange and collaborative decision-making [12, 13]. These challenges are further complicated in care triads, comprising the resident, family members, and professional, where coordination and communication deficits can hinder truly person-centred interactions.

To address these issues, there has been growing interest in co-creative and narrative-based interventions that aim to make tacit knowledge explicit and shareable [14, 15]. These interventions foster a culture of continuous learning within care teams by encouraging shared reflection, mutual understanding, and collaborative problem-solving. For example, life story work and shared narrative practices have been shown to enhance relational care quality and strengthen family members and informal network involvement in dementia care [16]. Also, implementing PCC in practice requires alignment not only at an individual care professional-recipient level but also within the organizational culture. The participating care organization in this study therefore operationalizes PCC through a similar conceptualization by focusing on four interconnected dimensions: seeing a person beyond the disease, knowing what truly matters to them, enabling self-determination, and mobilizing social networks as resources for support and engagement. The alignment between PCC and organizational commitment is essential for sustainable PCC delivery [17, 18].

Despite the promise of person-centred approaches, robust empirical evidence on their implementation, effectiveness, and sustainability is limited. Few studies have systematically investigated how tacit knowledge-sharing interventions can be integrated into person-centred practice within residential care settings, nor how these can be tailored to meet the complex cooperation of all participants of a triad. Conducted in residential facilities, this study employed a two-phase qualitative design. The first phase involved gathering narratives of successful use of saliency and sharing of tacit knowledge through observations and interviews to capture real-world best practices, and drafting a practical, supportive tool for care professionals. Based on these insights, the second phase co-developed an extension of the tool combining a seasonal calendar and questioning game designed to stimulate dialogue, reflection, and knowledge exchange within the triad of residents, families, and professionals. Ultimately, the study’s goal is to understand how a learning culture facilitating tacit knowledge sharing can be fostered effectively to enhance optimal person-centred care.

Methods

This study consisted of two connected phases, which are described in detail below. Both phases employed a combination of design-based research and appreciative inquiry. In addition, the research approach was structured to enable continuous consultation with the relevant stakeholders. In the phases of appreciative inquiry, the analysis of good examples guided the identification of effective practices [19]. Design-based research also follows an iterative process to arrive at solutions.

Design-based research is a cyclical, context-specific process in which researchers work with stakeholders to design, test and refine interventions aimed at solving practical problems [20]. We used the Double Diamond model (Fig. 1) to structure this process into four phases – Discover, Define, Develop and Deliver – in which there is a two-stage interplay of divergence (broad exploration or generating many potential solutions) and convergence (clearly defining and selecting problems or solutions). The model is particularly well-suited for co-design with patients and professionals in complex healthcare contexts [21, 22].

Fig. 1.

Model appreciative inquiry [23]

Appreciative inquiry (Fig. 2) is a strengths-based, participatory approach to organizational learning and change that systematically elicits and amplifies “what works” by collecting and analysing narratives of successful practice, rather than starting from deficits or problems [24, 25]. In this study, appreciative inquiry was used as an overarching, social-constructivist lens to identify and explore best-practice examples of saliency and tacit knowledge in daily care by engaging residents, family members and professionals in valuing successful triadic interactions. These examples were used as generative material for co-design within the Double Diamond cycles [24, 26].

Fig. 2.

Double diamond model [27]

The core research team consisted of nurse researchers and social scientists with substantial experience in dementia, person-centred care and qualitative research, which facilitated rapport with participants but also required reflexive attention to preconceptions about PCC and tacit knowledge. The study is reported in accordance with the COREQ checklist for qualitative research (Supplementary File II) [28].

PHASE 1- identification of success stories of tacit knowledge (2022)

Goal and focus

The first phase investigated how care providers use distinctive characteristics and share their implicit knowledge to improve person-centred care for people with dementia. Based on this, the first draft of a support tool for care providers was developed. The emphasis was on the question: How can successful experiences with the use of tacit knowledge in healthcare be made explicit and transferable?

Research design and approach

The research consisted of a combination of appreciative inquiry and design-based research [15, 27]. Both research approaches are characterised by a design in which continuous coordination with the relevant stakeholders is central. In the phases of appreciative inquiry, analysis of good examples is essential to arrive at effective working methods. Design-based research also follows an iterative process to arrive at solutions.

Setting and participants

The study was conducted in a long-term care organisation in the northern Netherlands that adopts an explicit organisational framework for person-centred care. The organisation has multiple nursing home locations providing both somatic and psychogeriatric care. In this phase, we included two residential wards where older adults with moderate to advanced dementia reside permanently. Participants were residents living on these wards and nursing staff members providing daily care to these residents. Individual demographic data, including age, were not systematically collected, as this phase focused on healthcare professionals’ practices rather than resident characteristics. Residents of Dutch care home residents are predominantly aged 80 or older; the average age is approximately 84–86 years for women and 82 years for men, and around 69% are women [29]. The majority lives with advanced dementia; in somatic wards, this often involves multimorbidity with high care needs. Eligible staff received written and oral information from the local project lead and were invited to participate during team meetings; residents and family members were approached by ward staff and a researcher. The care staff in the teams had European Qualification Framework (EQF) Level 3 qualifications as care assistants, and each team had one EQF Level 4 nurse. These are experienced teams, most of whom have been working in elderly care for at least five years. We excluded volunteers and non-nursing staff.

We used purposive sampling to recruit ten direct-care nursing professionals (nurse assistants, vocational and bachelor nurses) who were directly involved in day-to-day residential care. For each professional, between three and seven observations of care situations were collected, resulting in a total of 47 structured observations, each followed by a Think-Aloud interview focused on surfacing tacit knowledge used during the observations. Moments of interaction within care triads were included whenever family members were present during routine care (e.g. visits or joint activities), these moments also were explicitly addressed in the subsequent Think-Aloud interviews.

Data collection methods

Data collection involved several complementary methods. The study started with structured observations using a specially developed observation tool (Appendix A) that focused on attentive behaviours and person-centred interactions, guided by an instruction manual (Appendix B). Observations recorded both formal care moments and informal interactions, which were all systematically documented with this observation tool [30]. Think-Aloud interviews were conducted immediately after observations, using a semi-structured interview guide (Appendix C). The purpose of these interviews was to surface tacit knowledge used during observed behaviours and decision-making processes [31]. To validate findings and explore collective understanding of successful practices, two focus groups were held in which 7 care professionals in total participated; each focus group lasted 1.5 h. Observations and Think-Aloud interviews in Phase 1 were conducted by trained student-researchers in collaboration with two experienced members of the research team, thus closely supervising all student-led data collection.

PHASE 2- sharing tacit knowledge in the triad (2024)

Goal and focus

In the second phase, the goal was to extend the collection of narratives of using tacit knowledge in the triad to further develop the supportive tool for broader use. The exact form of the extension for such a supportive tool was left open; the focus was on identifying, formalising and sharing tacit-based knowledge within daily care interactions in the context of the triad.

Research design and approach

We combined appreciative inquiry with design-based research in an iterative, stakeholder-focused process. We began by collecting “good” and “promising” examples of tacit knowledge within the triangle; this was followed by co-creation cycles (sessions within the learning network) to develop a prototype for the expansion of the support tool. The learning network consisted of healthcare professionals, residents’ representatives and residents.

Setting and participants

The research was conducted at the same organisation, but one ward for dementia patients was replaced by a somatic ward. Most residents in somatic wards have multimorbidity, and often also have mild cognitive impairment and require a high level of care. The size of the ward and the level and experience of the care staff were comparable.

We convened four multi-stakeholder learning networks (two per ward: one ward for residents with dementia and one ward for residents with somatic illnesses). Each network included nursing staff, at least one resident and one family member (often a client council representative), and co-developers (designers and researchers), so that existing care triads (resident–family–professional) from each ward were represented in learning activities. We held six meetings per network each lasting on average 1.5–2 h. These meetings provided a structured forum to share practice narratives, jointly reflect on “good” and “promising” examples of tacit knowledge in triadic interactions, and iteratively refine requirements and prototypes of a supportive tool. During this phase, we did not involve volunteers or non-healthcare personnel in data collection.

We used purposive and convenience sampling focused on composing multi‑stakeholder learning networks on each ward. Nursing staff, residents, family members (including client council representatives) and co‑developers (designers and researchers) were invited to ensure a mix of perspectives within each triad and across networks. Residents and family members were eligible when they were part of an active care triad on the ward and able to participate in group discussions. Within these networks, additional participants for observations and mini‑interviews were approached opportunistically during routine care and contact moments, provided they met the inclusion criteria and consented to participation.

Data collection

The research started with observation (‘fly-on-the-wall’) of formal (e.g. care plan meetings) and informal interactions within the triangle comprising the resident, their family members and the care professional. The observations were conducted using a structured observation tool based on the observation tool from the first phase of the study, which was adapted to the objective so that three perspectives were described. Immediately after observation Think-Aloud interviews were conducted with one or more members of the triad, to clarify the reasoning, perceptions and implicit considerations behind observed actions/decisions, using a semi-structured guide adapted to the triadic focus [31]. Subsequently, focus groups were organised as a learning network in two phases per location: (a) revisiting and exploring good/promising examples in greater depth; (b) assessing successive prototypes of the supportive tool extension using practice development methods such as Claims, Concerns and Issues (CCI) [19]. Value Clarification to reveal expectations and considerations and Role Clarification. The learning networks consisted of nine participants in total: one resident, two family representatives (client representatives) and six healthcare professionals from the participating wards. We aimed to include existing resident–family–professional care triads in each network; however, due to scheduling constraints and varying availability of family members, complete triads could not always be present simultaneously, so some networks included near‑complete triads or representatives of residents and families not yet involved in a triad. Learning network meetings were facilitated by experienced researchers. Next, we tested the prototypes during routine work, with notes from the facilitator to support design iterations. Finally, we also tested the tool in other organisations.

Data analysis (both Phases)

All qualitative data (observations, Think‑Aloud and mini‑interviews, and focus groups) were audio‑recorded, anonymised and transcribed verbatim. For Phase 1, transcripts of observations and Think‑Aloud interviews were first openly coded in Atlas.ti by trained student‑researchers, resulting in a multi‑level coding tree. The research team subsequently reviewed and refined this coding tree, clustering categories into overarching themes that captured how saliency and tacit knowledge informed person‑centred responses in daily dementia care. Building on this, Phase 2 transcripts (observations, Think-Aloud-interviews and learning network meetings) were thematically analysed by three senior researchers. This analytic process led to the identification of eight illustrative triadic examples and a three‑step process model (recognising saliency, surfacing tacit knowledge through probing, and translating this into person‑centred actions and agreements). Throughout both phases, preliminary findings were member‑checked and refined with project and learning network participants, enhancing credibility and face validity of the analysis.

Rigor and trustworthiness

To enhance trustworthiness, we addressed key criteria for qualitative research, including credibility, transferability, dependability and confirmability. Credibility was supported through methodological triangulation, combining observations, Think-Aloud interviews, and systematic desk research, and by discussing preliminary interpretations within the research team. In this study, desk research referred to a structured review of existing scientific and practice-oriented literature on attentiveness and person-centred dementia care, conducted using predefined search strategies in PubMed and Google Scholar; these findings were used to build the theoretical framework, refine the research questions, inform the design of the observation tool and interview guides, and to compare emergent themes from Phases 1 and 2 with existing evidence.

Member checking was used to verify whether the interpretations resonated with participants’ experiences, consistent with its use as a strategy to support credibility in qualitative research [32]. In practice, preliminary themes and triadic process steps were repeatedly fed back to participants in learning network meetings (including focus groups) and project meetings on each ward, where care professionals, residents and family members were invited to confirm, nuance or challenge these interpretations based on their own experiences.[file:6][file:1] Their feedback led to refinement of the coding tree in Phase 1 and of the three-step process model and illustrative examples in Phase 2, thereby strengthening credibility and face validity of the analysis.

Transferability was supported by providing a detailed description of the context, participants, and procedures. Dependability and confirmability were strengthened through a transparent analytic process, documentation of coding decisions, and reflexive attention to the researchers’ role. The study was reported in line with the COREQ checklist to promote transparency in qualitative reporting [33].

Results

Identification of success stories of tacit knowledge

An analysis of observations and ‘Think-Aloud’ interviews conducted in Phase 1 revealed six main themes that describe how care professionals applied tacit knowledge in person-centred dementia care. Together, these themes demonstrate how professionals continuously observed residents’ behaviour, interpreted subtle cues and adapted their actions to residents’ changing needs, preferences and comfort levels. The findings below are therefore not abstract categories in themselves, but practice-oriented observations and experiences of how person-centred care was applied in the daily practice of residential care.

The first theme, ‘Getting to know the resident’, focused on how care staff used detailed knowledge of each resident’s life, capabilities and vulnerabilities to make day-to-day decisions. This knowledge included known preferences, such as food, clothing and routines, but also more situational and personal aspects of the resident, such as hearing problems, mood swings and how a resident typically reacted when feeling insecure or tired. One participant described this as a conscious habit of checking things rather than making assumptions.

“I always ask him. He can express himself very well in what he wants… I find that important because, even though we sometimes need to guess what residents want, asking it supports self-management as far as possible.” (Care professional).

This illustrates how knowledge of the resident was used as a practical resource in interaction: professionals combined prior familiarity with direct questioning to preserve autonomy and adapt care to the resident’s immediate response.

The second theme, ‘Making contact based on residents’ behaviour,’ showed how care professionals used residents’ verbal and non-verbal behaviour as cues for initiating and maintaining person-centred contact. Across observations, staff reacted to signs such as disorientation, staring, searching gaze, anxiety, and disengagement by adjusting their manner of approach in the moment. These responses were often small but deliberate, and they were closely linked to the resident’s immediate reaction.

One participant described how, in advanced dementia, connection could still be created through touch and eye contact:

“Often she is so far into her dementia but touch, stroking, holding her hand, and eye contact are what you can still use to connect.” (Care professional).

This quote shows that staff did not rely on verbal communication alone, but combined knowledge of the resident with what was visible and possible in the interaction. In practice, this meant that care professionals used touch, personal attention, humour, or gentle redirection to re-establish contact when a resident appeared unsettled or withdrawn. In one observed pattern, a resident who seemed disoriented or anxious became visibly more relaxed after such a response, suggesting that these micro-actions were not incidental but part of a recurring cue–response–effect dynamic.

Table 1 shows this pattern: residents who appeared disoriented were approached with a smile, personal attention, and touch; residents who were disengaged were invited into the group; and residents who were searching or anxious were redirected or moved along with in a calm, responsive way. Taken together, the data show that making contact was not a general social skill, but a situational practice in which tacit knowledge helped professionals recognise what each resident needed at that moment.

Table 1.

Observations of non-verbal signals, care professional’s response, and effect on the resident

Situation description	Care professional’s response	Effect on resident
Resident appears disoriented	Care professional smiles at the resident Gives the resident personal attention Contacts the resident through touch	Resident is relaxed
Resident is disengaged in the group	Care professional involves the resident in the group	Resident responds enthusiastically
Resident looks around searching/questioningly	Shows the resident the way / gives direction Redirects the resident (e.g., by dancing/walking)	Resident compliments the care provided
Resident claps around them	Care professional entertains the resident	Resident is entertained Resident enjoys the music
Resident stares ahead	Engages the resident in care activities Gives the resident a task	Resident responds enthusiastically Resident “perks up” / becomes more animated
Resident stares ahead	Addresses the resident by (first) name Uses humour	Resident is cheerful
Resident is anxious	Moves along with the resident (dancing)	Resident is relaxed

The third theme, ‘Anticipating known behaviour’, showed how care professionals used tacit knowledge and repeated observation of residents’ emotional states to anticipate difficult situations before they escalated. Rather than reacting only after problems became visible, staff adjusted the environment and their own behaviour in advance, for example by reducing stimulation, changing seating arrangements, or offering diversion when they expected tension or agitation. One participant described this anticipatory practice as follows:

“I rearranged seating, because this resident must not be seated opposite one of the other residents, it does not work well.” (Care professional).

This quote illustrates how prior knowledge of relational triggers was translated into a concrete preventive action, with the aim of avoiding conflict or distress before it emerged. In observed practice, such anticipatory work often depended on knowing which combinations of residents, settings, or stimuli were likely to create problems, and then making subtle adjustments to maintain calm and continuity in care. In this way, tacit knowledge functioned not only as a way of understanding behaviour, but also as a way of shaping the situation so that escalations were less likely to occur.

The fourth theme, ‘Intuitive action and empathy’, showed that caregiving was often guided by spontaneous, embodied, and partly unspoken judgments about what would feel right for the resident in that moment. Care professionals described these actions as “gut feeling” or intuition, but the data also show that such intuition was grounded in prior knowledge of the resident and a deliberate concern to choose the most appropriate form of care. In other words, intuition here was not random: it reflected accumulated familiarity with the person combined with an immediate, empathic response. A participant explained this as follows:

“I think that’s normal. I know there are quite a few things he likes. Sometimes he manages to say what he’d like. Today it was more of a babbling, so I give him something I know he likes.” (Care professional).

This quote illustrates how the professional used knowledge of the resident’s preferences together with an empathic self-positioning to decide what to offer. The quote also shows that intuition was linked to responsiveness under conditions of limited communication: when the resident could not clearly express a wish, the professional relied on tacit understanding and on a moral orientation toward kindness and appropriateness. In observed practice, this often meant choosing an action that felt personally and relationally fitting, rather than simply technically correct.

The fifth theme, ‘Conscious use of knowledge to support autonomy and self-respect’, showed how care professionals deliberately combined tacit knowledge of residents’ preferences with formal dementia care knowledge to preserve dignity in everyday situations. Rather than using knowledge only to solve practical tasks, staff used it to shape care in ways that supported residents’ identity, autonomy, and self-respect. This was especially visible in small decisions about daily routines, including music, clothing, and how choices were offered.

One participant described how a resident’s known musical preference could change the atmosphere immediately:

“She loves that kind of music, so when we put on that record, she sort of dances a bit in her chair” (Care professional).

This illustrates how knowledge of a resident’s interests was used proactively to create moments of pleasure and engagement, rather than simply to complete a care task. A second example showed how knowledge of personal appearance and identity informed dressing choices:

“She has always been a person wearing nice clothes, because we know that we try to cloth her as best as possible” (Care professional).

Together, these quotes show that tacit knowledge was used consciously to maintain continuity with who the resident had been before and still was in the present. In practice, this meant offering care that protected autonomy where possible and expressed respect through small but meaningful adaptations in daily care.

The sixth and final theme, ‘Awareness of effects of professional nursing’, showed that care professionals closely monitored residents’ responses and interpreted them as signs of emotion, need, or comfort, which then guided how they adjusted care. Staff also emphasised the importance of balancing structure in the day with enough flexibility to create small but meaningful moments of enjoyment for residents. These moments were not described as extras; they were presented as part of what made care feel worthwhile and person-centred.

One participant explained this through small everyday pleasures:

“I see her enjoying it, a small glass of port wine, or I get her some fish and chips or pastry. Those are moments of real happiness.” (Care professional).

Another linked residents’ visible reactions directly to their own motivation:

“When I see a resident’s eyes light up, it gives me energy; those are the silver linings.” (Care professional).

Together, these quotes show that professionals did not only act on tacit knowledge in the moment but also became aware of the effects of their actions through residents’ emotional responses. This awareness reinforced their sense of purpose and confirmed that even small, tailored interventions could improve quality of life. In that sense, the theme captures a feedback loop in which residents’ visible enjoyment strengthened staff motivation to keep delivering flexible, person-centred care.

Understanding the successful practices

Focus groups conducted in two wards for residents with dementia confirmed that the six themes identified in Phase 1 underpinned care professionals’ accounts of successful practice. Participants described key relational skills such as being salient, attentive, listening actively, and showing compassion, which helped them notice small behavioural changes and underlying needs in everyday care. These skills enabled them to adapt professional knowledge and try out new approaches in practice rather than applying care routines mechanically. One participant captured the importance of relationship-building as follows:

“You have to invest in forming bonds with residents; that investment is the key strength.” (Care professional).

This statement shows that success was understood not as a single technique, but as something that emerged through sustained relational work overtime. A participant added that person-centred care could not look identical in every interaction:

“There are many roads to Rome; not everyone can do things the same way, nor should they.” (Client council member).

This quote highlights the idea that both residents and care professionals bring individuality to the relationship, and that good care depends on fitting the approach to the person and situation rather than following one fixed formula.

Learning from colleagues emerged as another important theme. Participants described how tacit knowledge was shared through observation, verbal exchange, and guidance during onboarding, especially when new staff needed concrete examples of what works in practice. One participant explained:

“I tell new colleagues, ‘Just sit with her, bring her food first, and give one-to-one attention.” (Care professional).

Such examples were often shared during handovers, between shifts, and in care plans, although participants noted that tacit knowledge remained difficult to transfer because it was embedded in context and experience. To strengthen this exchange, participants suggested practical ways of making good practice visible, including collecting and sharing “moments of joy,” using dementia-related theatre performances to stimulate discussion, and holding reflection sessions after shifts.

The focus groups also refined the Phase 1 findings into a three-step process for eliciting tacit knowledge in the triad of resident, relative, and care professional. First, saliency had to be recognised in a daily situation or remark made by one of the triad members. Second, probing questions were needed to surface tacit knowledge and clarify what mattered in that moment. Third, once tacit knowledge had been articulated, it had to be translated into action. In the examples, this process was visible when a participant expressed a wish to remain active:

“Yes, but then I want to walk again for a bit, and I think I can do the dishes too… You see, I want to keep moving.” (Resident).

The resident’s own words signalled both saliency and a desire to remain engaged, which provided an opening for shared understanding and action. A participant then contributed additional tacit knowledge by explaining a hearing-related communication issue:

“I know she does not hear everything well; it’s not deafness but filtering information is hard for her, so clear communication is important.” (Relative).

Here, the relative’s contribution clarified why communication was difficult and how care could be adjusted accordingly. In another example, probing corrected an assumption about loneliness when a participant responded:

“Lonely? No-I’m just bored.” (Relative).

This exchange showed how a question could uncover a more accurate understanding of the resident’s experience. Participants then also demonstrated step 3 by acting on tacit knowledge, for example through tailored reassurance:

“She often feels sad when the children leave. I offer a listening ear and reassure her that they will come weekly, then try to distract her.” (Care professional).

Taken together, the focus group data show that successful practice depended not only on knowing residents, but also on relational skills, colleague learning, and the ability to move from recognising saliency to acting on newly surfaced knowledge.

The focus groups also provided clarity on how tacit knowledge came to light within the triangular relationship between the resident, a family member and the care provider. As summarised in Fig. 3, this process consists of identifying relevant aspects, asking probing questions to bring tacit knowledge to light, and translating that knowledge into person-centred action. In the following paragraph, this process is illustrated using concrete examples from this triangular relationship.

Fig. 3.

Three step process

Sharing tacit knowledge in the triad

Fly-on-the-wall observations, Think-Aloud interviews, and learning network meetings yielded eight detailed examples of tacit knowledge sharing in the triad. These examples covered mobility, nutrition, daily activities, social contact, emotional distress, and coping with limitations, showing that tacit knowledge surfaced across a wide range of everyday situations. Analysis of these examples revealed a three-step process: recognising saliency, probing to surface tacit knowledge, and translating that knowledge into action. Figure 3 summarises this process.

In step 1, saliency became visible in ordinary remarks or behaviours that signalled what mattered to the person at that moment. One participant, for example, expressed a wish to remain active:

“Yes, but then I want to walk again for a bit, and I think I can do the dishes too… You see, I want to keep moving.” (Resident).

This statement shows how a resident can signal what matters to him in a direct and everyday way, creating an opening for person-centred support.

In step 2, tacit knowledge was surfaced when family members or care professionals clarified what lay behind a resident’s behaviour or communication. One participant explained:

“I know she does not hear everything well; it’s not deafness but filtering information is hard for her, so clear communication is important.” (Relative).

These exchanges show how asking further questions can reveal a more accurate understanding of the situation and prevent care from being based on assumptions.

In step 3, care professionals translated tacit knowledge into concrete action, for example by offering tailored reassurance:

“She often feels sad when the children leave. I offer a listening ear and reassure her that they will come weekly, then try to distract her.” (Care professional).

This example shows how the professional used knowledge of the resident’s emotional vulnerability to shape a response that fit the situation.

Taken together, these examples show that successful tacit knowledge sharing depended on recognising saliency, probing carefully, and responding in a way that matched the resident’s situation. The next section builds on these examples by showing how they align with the organisation’s broader person-centred care framework and what they reveal about good and promising practice in the triad. Our findings are consistent with recent work on dementia care triads, which shows that people living with dementia, their relatives and healthcare professionals often hold only partially overlapping perspectives, and that early and structured involvement of families is critical to integrate these perspectives into care decisions in hospital, primary care and community settings [34–36]. Empirical studies of triadic encounters in general practice, diagnostic and treatment trajectories for dementia, and advance care planning similarly demonstrate that the way knowledge is exchanged and decisions are negotiated strongly depends on the extent to which professionals actively invite, structure and support the contributions of both the person with dementia and their relatives, and on whether consultation structures provide sufficient space for shared dialogue [34, 35, 37]. Against this backdrop, the three-step process we identified – recognising saliency, using probing questions to make tacit knowledge explicit, and jointly formulating person-centred actions – can be understood as a concrete micro-level mechanism within our empirical material, derived from residential long-term care. Conceptually, this three-step process aligns with broader analyses of person- and relationship-centred dementia care, which emphasise relational, experiential and context-specific knowing-in-practice as central to high-quality care for people living with dementia [8, 35, 38].

Relation to PCC frameworks

These examples were categorised under six domains of positive health: bodily functions, mental wellbeing, meaningfulness, quality of life, participation, and daily functioning. They also aligned with the organisation’s PCC themes: seeing the person, knowing what truly matters, empowering client decisions, and valuing social networks. This suggests that the examples were not isolated anecdotes, but concrete illustrations of how person-centred care was enacted through everyday triadic interactions.

The analysis distinguished between good examples, in which saliency was recognised, tacit knowledge was surfaced, and action followed, and promising examples, in which saliency was present but further probing would have been needed to complete the process. In several cases, surfacing tacit knowledge led directly to action plans, such as arranging more social activities among residents or organising personalised visits from family members who also provided informal care. Together, these examples show that tacit knowledge becomes practically useful only when recognition, dialogue, and action are connected in the triad.

Barriers to articulating and sharing tacit knowledge

The focus group revealed several barriers experienced by participants to the optimal exchange of tacit knowledge. On the one hand, healthcare professionals reported finding it difficult to initiate conversations or apply conversational techniques to access tacit knowledge. On the other hand, formal meetings, such as discussions about care plans, focus primarily on physical and logistical care, with little attention paid to getting to know the person. Also, care providers in this study prioritise physical care, and psychosocial care interventions, such as addressing loneliness, are often passed on to social workers, resulting in fragmented or one-sided information about residents. As one care professional explained:

“I will also put it to our welfare worker so that she can think about loneliness – which a relative has mentioned for a resident – and about possibilities to pay attention to that.” (Care professional).

The organisational culture and the sense of time pressure result in few informal three-way conversations, while the workload also leads to formal three-way conversations being skipped. Several care professionals described how time pressure directly limited conversational space:

“We now must arrange everything in between other activities; many hours have been taken away. We must do more in less time, so you can only do what you must do. Connecting through small talk and chatting falls away, otherwise you will not get the work done.” (Care professional).

In an exchange between a nurse and a resident, the resident explicitly linked this haste to their own experience:

“What your daughter just said to me is that you feel the hurried way in which care is done, that we are always so busy.” (Care professional) “Yes, and that chases me up.” (Resident).

In daily routines, informal moments with relatives were often missed or not used to explore what mattered to residents. One participant reflected on such a missed opportunity:

“When a relative brings a resident back to the room we continue with our work. I often do not start a conversation with a relative, but now that I think about it, that moment, when they come back from a walk in the garden carrying wildflowers, that could be a moment to connect. I could refer to those flowers and use it as a conversation starter.” (Care professional).

Consequently, residents and family members feel more like they must fit into the ways of the residential home and care providers than that they experience a personal living environment for residents with support and care from care providers. This sense of having to adapt to the institutional rhythm was voiced by both relatives and residents:

“Well, I should not ask for changes or do things differently – they are busy enough as it is.” (Relative) and “We have to adapt to the way things are done here.” (Resident).

In addition, there appears to be a great deal of miscommunication leading to unmet or misunderstood needs; especially when residents or families are less inclined to show assertiveness. One relative, for example, described repeatedly signalling a preference that was not acted upon:

“Could this be meat (looking at a tray with a meal)? But she does not eat meat. I’ve said it a hundred times: no meat.” (Relative).

Care professionals also recognised that relatives sometimes struggle:

“Sometimes the family sits looking at their phone when they visit and sit together in the living room. Family members do not always know how to spend time with the resident. As a staff member you could act upon that.” Care professional)

Development and testing of the supportive tool

To develop the tool (Box1), the research group developed design criteria which were presented to the stakeholders to check whether they adequately met their needs. Based on the design criteria, thematic analysis, and focus group outcomes, the supportive tool was developed through iterative cycles across both study phases, involving continuous input from care professionals, residents, and family members. The innovation aimed to support the three-step process: recognising saliency, surfacing and explicitly sharing tacit knowledge, and using this knowledge within the triad during daily care and living, to strengthen PCC and residents’ autonomy and self-respect. With support from designers, the tool evolved from an initial prototype into the ‘Know and Share’ Calendar and Game: a seasonal, wipeable calendar that visualises the three-step process and includes eight detailed practical examples, combined with a questioning game (Fig. 4). The game consists of reflective questions presented on cards, designed for team discussions in regular care meetings and for “on-the-spot” educational exchanges within the triad, thereby promoting the sharing of tacit, practice-based knowledge and generating concrete suggestions for action in daily routines. Feedback from focus groups and advisory boards highlighted the importance of aligning the question sets with Dementia Care Mapping (DCM) and ensuring relevance to real workplace scenarios, while also addressing feasibility issues such as embedding the tool in existing workflows and avoiding disruption to routine care. Care teams on participating wards received an introduction to the tool, followed by practical use in daily work; subsequent evaluations collected experiences and recommendations from care teams and input from client council representatives. Both phases were concluded with a final symposium to share insights, discuss implementation lessons, and support broader dissemination with participating stakeholders.

Fig. 4.

Example of the tool-summer

Box 1 The ‘know and share’ calendar and game

The ‘Know and Share’ Calendar and Game is a supportive tool designed to facilitate triadic conversations between residents, their family members, and care professionals. It is structured in three parts: conversation starters; attentiveness, such as recognising salient cues and sharing experiences; and applying these experiences to daily life. The first part encourages shared conversation by offering prompts such as seasonal associations or personally meaningful statements. The second part helps participants to identify what they have noticed, why it matters and the tacit or experiential knowledge that is being shared. The third part translates this shared understanding into concrete agreements and actions for the resident, their relative and the care professional in everyday care.

In practice, the tool is used by starting a conversation around a specific situation or theme, jointly exploring what each person notices and knows, and finally formulating practical follow-up actions. The calendar and cards help to structure the dialogue, guiding people from a shared opening to reflection on what is important and finally to person-centred action. Therefore, the tool is not primarily an information leaflet, but rather a conversation aid that supports triadic dialogue and the practical application of experiential knowledge in routine care.

Overall, participants received the tool positively and valued its role in facilitating recognition of saliency, surfacing and using tacit knowledge, stimulating reflection in and on action, and strengthening dialogue about professional behaviour, interventions, and their impact on residents. Practical recommendations included offering digital versions to increase accessibility across communal areas, simplifying or tailoring questions, and extending the tool to more explicitly incorporate family members’ tacit knowledge. Participants also appreciated the tool’s potential to deepen conversations and encourage family members’ involvement; however, concerns were raised about privacy compliance (e.g., GDPR constraints), the perception of additional workload, and the need for sustainable integration into daily routines and culture, with suggestions for digitalisation and wider dissemination to support scale-up.

“Using the questioning game encourages us to consciously reflect on what we do and why, it opens up conversations about what works well.” (Care professional).

Discussion

This study set out to understand how saliency based on tacit knowledge informs person-centred responses in daily residential care, and how a learning culture in which tacit knowledge is shared within resident–relative–professional triads can be fostered to optimise person-centred care. Our findings suggest that in this context, saliency functions as a practical trigger for person-centred care only when it is followed by deliberate efforts to surface tacit knowledge and to translate this shared understanding into concrete adjustments in care and daily life. Across both phases, we identified a three-step process, recognising saliency, probing tacit knowledge and co-constructing person-centred actions, and we showed how this process can be supported by a concrete tool that creates micro-spaces for triadic reflection in routine practice.

By conceptualising tacit knowledge as experiential, often pre-reflective, knowing that is embedded in relationships and routines, our analysis shows how such knowledge can become shareable in triads in a reflective learning culture rather than remaining implicit in individual practice. In this sense, we treat ‘tacit’ and ‘implicit’ knowledge as referring to the same experiential dimension of knowing-in-practice, and we extend predominantly dyadic accounts of tacit knowledge in caregiving to explicitly triadic interactions that include residents, relatives and professionals.

Identification of success stories of tacit knowledge

The results revealed that saliency in person-centred dementia care can be characterised by six interrelated success factors: getting to know the resident; attuning to cues; anticipating known behaviours; acting intuitively and empathetically; supporting autonomy and self-respect consciously; and monitoring the effects of professional actions. Together, these factors illustrate how micro-level saliency, small but situationally meaningful signals, is recognised and translated into personalised care responses. This supports existing frameworks that emphasise tacit knowledge and saliency as core competencies in dementia care and explains why these competencies are difficult to operationalise [39]. It also aligns with the view that tacit knowledge is experiential, difficult to verbalise, and embedded in practical judgement rather than formal instruction [11, 40]. These competencies operate at the micro-level of daily interaction, making them hard to notice, name and transfer [41]. Although care teams reported feeling motivated and energised by sharing ‘what works’, they still struggled to articulate the reasoning behind their actions, i.e. the tacit knowledge that guided their responses. In that respect, tacit knowledge in the data was not arbitrary, but grounded in familiarity with the resident and in immediate contextual interpretation. Think-Aloud interviews proved effective in bridging this gap by prompting professionals to verbalise their considerations immediately after an observation. This made tacit knowledge debatable in everyday practice language, a precondition for collective learning [42]. The use of Think-Aloud interviews therefore did not only support analysis but also functioned as a method for making tacit reasoning more explicit.

Understanding the successful practices

The focus groups confirmed that successful practice across both phases depended not only on recognising saliency, but on sustained relational investment and a team culture that made sharing tacit knowledge safe and worthwhile. This finding suggests that tacit knowledge becomes shareable when it is discussed in a reflective learning climate rather than remaining embedded in individual practice. Care professionals described this as building bonds over time, learning from each other through observation and sharing examples, and adjusting their approach to the individual rather than applying fixed care routines, a process that mirrors what has been described as narrative-based professional learning in health care contexts [42]. Using appreciative inquiry’s focus on what works, rather than what fails, created a productive space for this exchange; other studies confirm that this approach positively influences attitudes, knowledge sharing, and behaviour in nursing home settings [40]. Collegial learning through knowledge transfer, informal exchanges, and onboarding is consistent with evidence that tacit knowledge in eldercare is primarily transmitted through situated, relational channels rather than formal instruction, and that its transfer depends on whether the team culture makes sharing feel recognised and valued [43]. This also indicates that the ‘successful practices’ found in our study were not individual exceptions, but socially sustained patterns of working.

Sharing tacit knowledge in the triad

In the second phase of the study, these findings were extended to the triad, confirming a three-step process: recognising saliency; surfacing tacit knowledge through deliberate probing; and converting that shared understanding into concrete care actions and agreements. The step from recognising saliency to probing was crucial, because saliency alone did not yet constitute shared understanding. The contrast between good practices, in which all three steps were completed, and promising examples, in which saliency was present, but probing did not follow, highlights the fact that recognising saliency is a necessary but not a sufficient condition for person-centred action. Translating saliency into PCC requires micro-skills for asking open, inviting questions and routines that legitimise pausing and jointly prioritising what matters in a specific moment, in other words, embedding reflection-in-action into everyday triadic work [44]. The results also make clear that residents, family members and care professionals do not automatically treat each other’s observations as legitimate sources of knowledge for collaborative care decisions. This points to the relational and cultural preconditions that must be in place before the three-step process can operate effectively [45]. In practical terms, tacit knowledge in the triad is co-constructed rather than individually held.

Barriers to articulating and sharing tacit knowledge

The barriers identified in this study, task-oriented routines, time pressure, the delegation of psychosocial care and miscommunication, reflects a structural tension at the heart of the implementation of PCC in residential care. The main problem was therefore not the absence of relevant knowledge, but insufficient conversational space to surface it. In daily practice, the primary performance standard is completing physical care tasks. Creating space for triadic dialogue involves direct competition between professional values [46, 47] Under time pressure, care staff tends to intensify familiar routines rather than pausing to reflect, which makes reflection-in-action less likely precisely when it is most needed [44]. Another barrier relates to the professional identity of care assistants. Having detailed, personalised knowledge of residents can be a source of status within the team. However, willingness to share this knowledge depends on whether the broader culture makes sharing feel safe and valued rather than threatening [40]. The perception of family members as guests rather than knowledge partners reflects an implicit division of care responsibilities in nursing homes. Addressing this requires active renegotiation of mutual expectations through sustained, trust-based dialogue [48]. The motivational gap among care professionals, a limited sense of urgency to actively involve family members and utilise their tacit knowledge, is further shaped by contextual factors. These include residual visiting restrictions due to non-revised policies from the Coronavirus pandemic, and a professional identity in which physical assistance is perceived as the core of ‘being of value’ [49–51]. These conditions help explain why promising examples often stalled after the first step.

Development and testing of the supportive tool

The ‘Know and Share’ Calendar and Game was designed specifically to address the barriers identified above by providing a low-threshold scaffold for triadic learning. Its purpose is to support, rather than replace, professional judgement and triadic dialogue. It creates structured pauses by prompting the recognition of saliency, surfacing tacit knowledge through reflective questioning, and translating insights into concrete care actions and agreements. The tool’s design aligns with evidence that tangible objects used for knowledge mediation provide a shared reference point, translating abstract concepts such as saliency and tacit knowledge into a shared understanding that can be discussed across professional and personal knowledge boundaries [52]. While this study developed the ‘Know and Share’ tool as one approach to making tacit knowledge explicit and shareable, other methods serve comparable purposes at different levels of structure and intensity. These methods include narrative care practices, life-story work, Dementia Care Mapping, and reflective supervision, indicating that organisations have a range of options to choose from depending on their context and resources [14, 53]. Participant feedback indicated that sustained acceptability depends on embedding the tool into existing workflows rather than treating it as an additional task, on achieving consensus about role clarity within the triad, and on organisational commitment to facilitate and protect micro-spaces for dialogue. These findings are consistent with broader PCC implementation evidence [40, 46]. The tool therefore functions best as a conversation aid within an enabling culture, not as a standalone intervention.

Strengths and limitations

Methodological strengths include the use of real-world success narratives, iterative co-creation with multiple stakeholders across both phases, and the staged progression from exploratory identification (Phase 1) to triad-focused development and dissemination (Phase 2). Credibility was strengthened through methodological triangulation, member-checking, and reflexive team analysis; the provision of detailed contextual descriptions supports analytic generalisation to comparable residential care settings [54]. A further strength is that the discussion can be directly traced back to the six themes and the triadic process model, which enhances internal coherence.

Limitations include the fact that not all phases of the appreciative inquiry cycle were completed in Phase 1, and that there was no systematic investigation of how consistently PCC was understood or applied across teams. Furthermore, the study focused on developing and refining a working method and supportive tool rather than demonstrating effectiveness, meaning that potential differences between residents may influence impact in ways that were not examined. There has been no systematic investigation into exactly what team members understood by PCC, nor into the extent to which it was applied consistently across different situations. In Phase 2, stronger attention to preconditions such as protected time, role clarity and sustained contact moments might have enhanced participation and implementation readiness. Finally, the study was conducted within a single care organisation in the northern Netherlands, which limits direct transferability to other settings.

Conclusion

Saliency acts as a practical trigger for PCC, but its benefits depend on deliberately surfacing and sharing tacit knowledge and converting it into concrete actions within the resident–relative–professional triad. Narrative, success-based reflection helps make person-centred competencies visible and transferable, while the supportive tool offers a pragmatic aid to structure this process in daily routines. Sustainable impact will require implementation strategies that explicitly address the urgency gap for family members’ involvement and the dominance of organisational habits, workload, and privacy constraints, by embedding triadic dialogue and reflection into existing workflows and culture.

Recommendations

Based on these findings, care organisations should embed the three-step process of recognising saliency, surfacing tacit knowledge and translating this into action within existing routines, such as handovers, care-plan meetings and brief informal encounters, rather than introducing it as an additional task. Short, practice-based training in probing questions, reflective dialogue and shared language around tacit knowledge and PCC may further support teams in using the supportive tool more consistently in daily work. To strengthen triadic collaboration in practice, wards should also actively invite and prepare relatives for participation, for example by clarifying expectations, offering practical examples and creating designated moments for dialogue, while management safeguards time, ownership and psychological safety for narrative reflection on what works. In addition, organisations should remove predictable implementation barriers by providing a usage protocol that complies with data protection regulations, clarifying who initiates the dialogue and who documents follow-up actions, and offering accessible formats of the tool, such as simplified card sets and optional digital versions. Wider dissemination should be accompanied by ongoing feedback loops and pragmatic evaluation of uptake, feasibility and perceived workload, so that the fit of the approach can be iteratively optimised across ward types and organisational cultures.

Future research should include a more systematic investigation of what team members understand by PCC and how consistently this understanding is applied across different situations, in order to align tacit knowledge-sharing more explicitly with PCC frameworks in practice. Studies across multiple organisations and ward types are also needed to examine the contextual conditions for successful implementation and to explore to what extent such a triadic, tacit-knowledge-based approach can be sustainably embedded in routine residential care.

Abbreviations

PCC

Person-centred care

Authors' contributions

MVC led the funding applications and was responsible for the effectuation of both studies. KL initiated research–practice collaboration and co-wrote funding applications. AP served as principal investigator and project lead across both studies and drafted the manuscript. The projectteam (GD, AVM, AR, GT) contributed to the execution of the research, including data collection and practical coordination; GD and GT were involved in the second project only. MVC, KL and AP jointly interpreted the findings and co-wrote and revised the manuscript. All authors read and approved the final manuscript.

Funding

This work was supported by two project grants: the first study (Succesverhalen van opmerkzaamheid in Persoonsgerichte Zorg) was funded through a SIA RAAK KIEM grant (K21.01.056), and the second study (Ervaringskennis delen, Persoonsgericht doen) was funded by the AGIS Innovatiefonds (grant 2023-29). The KIEM project included co-funding by the participating partners (NHL Stenden University of Applied Sciences, Studio Maki, and Kwadrant).

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Both subprojects were conducted in accordance with the Declaration of Helsinki and international guidelines for research ethics. Given their non-interventional nature (observations, interviews, focus groups within the usual care environment), both fell outside the scope of the Medical Research Involving Human Subjects Act (WMO) and therefore did not require METC approval. For the first study, this was formally confirmed for the first subproject by the Regional Review Committee for Patient-Related Research (RTPO) of Medisch Centrum Leeuwarden (now part of Frisius MC) the Netherlands (reference number 1137) to be on the safe side. Written informed consent was obtained from all participating employees; for residents with dementia, family members/legally authorized representatives were informed and asked to give written consent. The data was anonymized during transcription, stored on a secure institutional research drive, and retained for five years on a marked research drive in accordance with the GDPR and institutional policy

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.