The role of leadership in the implementation of person-centred care using Dementia Care Mapping: a study in three nursing homes

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1 Journal of Nursing Management, 2015, 23, The role of leadership in the implementation of person-centred care using Dementia Care Mapping: a study in three nursing homes ANNE MARIE MORK ROKSTAD RN, MHS 1,SOLFRIDVATNE RN, PhD 2,KNUTENGEDAL MD, PhD 3 and GEIR SELBÆK PhD 4 1 PhD Candidate, Ageing and Health, Norwegian Centre for Dementia Research, Education and Service Development, Oslo University Hospital, Oslo, 2 Professor, Molde University College, Specialized University in Logistics, Molde, 3 Professor and Research Manager, Ageing and Health, Norwegian Centre for Research, Education and Service Development, Oslo University Hospital, Oslo and 4 Research Director and Psychiatrist, Centre for Old Age Psychiatry Research, Innlandet Hospital Trust, Ottestad, Norway Correspondence Anne Marie Mork Rokstad Ageing and Health, Norwegian Centre for Research, Education and Service Development, Department of Geriatric Medicine Oslo University Hospital Bygg 37 Ullevaal 0407 Oslo Norway anne.marie.rokstad@ aldringoghelse.no ROKSTAD A.M.M., VATNE S., ENGEDAL K. & SELBÆK G. (2015) Journal of Nursing Management 23, The role of leadership in the implementation of person-centred care using Dementia Care Mapping: a study in three nursing homes Aim The aim of this study was to investigate the role of leadership in the implementation of person-centred care (PCC) in nursing homes using Dementia Care Mapping (DCM). Background Leadership is important for the implementation of nursing practice. However, the empirical knowledge of positive leadership in processes enhancing person-centred culture of care in nursing homes is limited. Method The study has a qualitative descriptive design. The DCM method was used in three nursing homes. Eighteen staff members and seven leaders participated in focus-group interviews centring on the role of leadership in facilitating the development process. Results The different roles of leadership in the three nursing homes, characterized as highly professional, market orientated or traditional, seemed to influence to what extent the DCM process led to successful implementation of PCC. Conclusion and Implications for Nursing Management This study provided useful information about the influence of leadership in the implementation of personcentred care in nursing homes. Leaders should be active role models, expound a clear vision and include and empower all staff in the professional development process. Keywords: dementia, Dementia Care Mapping, focus-group interviews, leadership, nursing homes, person-centred care Accepted for publication: 18 January 2013 Introduction Leadership is important for the implementation of nursing practice. However, the empirical knowledge of positive leadership in processes enhancing the person-centred culture of care in nursing homes is limited. In this study, Dementia Care Mapping (DCM) was used as a structured method to implement personcentred care (PCC) in dementia care practice. Person-centred dementia care was first described by Kitwood (1997), who suggested the need for a new culture of care that would preserve personhood in the course of the development of the dementia disease (Kitwood 1997). Based on this, Brooker (2007) DOI: /jonm

2 A. M. Mork Rokstad et al. presented the following four main components in the performance of PCC: valuing people with dementia; using an individual approach that recognizes the uniqueness of the person; making an effort to understand the world from the perspective of the person; and providing a supportive social environment (Brooker 2007). Additionally, McCormack and McCance (2006) developed a framework for person-centred nursing comprising four constructs: prerequisites focusing on the skills of the nurse; the care environment; person-centred processes as shown in the care practice; and the expected outcome (McCormack & McCance 2006, McCormack et al. 2010). Strategies for the clinical delivery of PCC for persons with dementia include the incorporation of knowledge of the person s history, the conduct of reminiscence sessions, providing validation therapy, prioritizing well-being ahead of routines and care tasks, simplifying and personalizing the environment and performing activities that promote a good life for the resident (Edvardsson et al. 2008). The DCM method is based on the use of standardized observation by a trained professional, which identifies the well-being and behaviour of the patients and the interactions between care staff and the patients. The results of these observations are discussed in a feedback session with the care staff. Based on this feedback, actions to improve care practice for the residents are defined and put in the care plans (Brooker & Surr 2005, British Standard Institution (BSI) 2010). Good leadership plays a key role in developing nurses understanding of patients needs and values and the acceptance of new innovations to obtain successful change and a positive care culture (Rycroft- Malone et al. 2004, Scott-Cawiezell et al. 2005, Gifford et al. 2007, Laschinger et al. 2007, Brady & Cummings 2010, Jeon et al. 2010). By strengthening the leadership skills of nursing home leaders, it may be possible to achieve and sustain improvements that are essential to promote a better quality of life for the residents (Harvath et al. 2008). This study is about the value of leadership in a structured process aimed at implementing PCC in nursing home settings. Literature review Implementation is the aggregation of processes needed to get an intervention into use within an organisation on a daily basis (Rabin et al. 2008). It is a social process modified by the context in which it takes place (Davidoff et al. 2008). Engaging the team members who are involved in an implementation process is often overlooked, and therefore a leadership strategy to accomplish this is necessary (Pronovost et al. 2008). According to Northouse s definition, leadership is a process whereby an individual influences a group of individuals to achieve a common goal (Northouse 2004). Nursing leaders have to take actions to achieve a preferred future situation (Cummings 2011), provide guidance for solving complex problems (Smith et al. 2006) and create structures that will facilitate the implementation of useful processes for delivering nursing care (Anthony et al. 2005). Four types of leaders, who have the responsibility of engaging the staff involved, have been identified by Damschroder et al. (2009): (i) opinion leaders, who are individuals within the organisation who have formal or informal influence on the attitudes and beliefs of their colleagues; (ii) formally appointed internal implementation leaders for example, team leaders or project leaders; (iii) champions, who dedicate themselves to supporting, marketing and overcoming resistance to change within the organisation; and (iv) external agents of change with the formal role of influencing or facilitating the process in a desirable direction (Damschroder et al. 2009). Previous research shows that nursing leadership styles, focusing on people and relationships such as transformational leadership are associated with improved job satisfaction for nurses (Cummings et al. 2008, 2010), increased levels of intention to stay in their current positions (Cowden et al. 2011) and better patient outcomes (Anderson et al. 2003, Wong & Cummings 2007, Tomey 2009). Transformational leadership is the process by which leaders and followers raise one another to higher levels of morale and motivation. The main goal for transformational leaders is to establish a shared vision and to bring followers up to the level where they can succeed in accomplishing organisational tasks without any direct leading interventions (Burns 1978). Factors that motivate nurses to perform well are identified as: autonomous practices; working relationships; resource accessibility; individual nurse characteristics; and the leadership style (Brady & Cummings 2010). A study exploring the differences in leadership behaviour in high- and low-performing nursing homes (Forbes- Thompson et al. 2007) concluded that the creation of clear, explicit and coherent goals, giving a strong sense of mission in the organisation, was important. In addition, the leaders should be willing to help out on the floor, promoting strong lateral decision-making as opposed to the traditional top-down method. The need for communicated goals and visions has been 16 Journal of Nursing Management, 2015, 23, 15 26

3 Implementation of PCC in nursing homes using DCM pointed out as crucial to sustaining a high quality of care in several previous studies ((Morgan et al. 2005, Stolee et al. 2005, Scalzi et al. 2006). Closely related to transformational leadership is authentic leadership, described as leading by example. Authentic leadership is leader behaviour grounded in positive psychological capacity and sound ethical standards (Avolio & Gardner 2005, Walumbwa et al. 2008), and it has the potential to provide healthy working environments for care staff and to optimize patient outcomes (Wong et al. 2010). Authentic leaders are clear and open about their perspectives, their actions are consistent with their expressed values, they share information and feelings appropriate for the situation with their employees, and their self-awareness is demonstrated in their understanding of their own strengths and weaknesses (Gardner et al. 2005). Based on a person-centred nursing framework (McCormack & McCance 2006), a conceptual model of transformational, situational leadership in nursing homes has been presented by Lynch et al. (2011). This model integrates person centeredness with leadership thinking in order to impact effectively on the performance of the staff in delivering PCC. Situational leadership claims that there is no one leadership style that works in all situations and outlines four sets of leadership behaviour: directing (the leader uses oneway-communication to give detailed instructions), coaching (the leader listens to and takes in to consideration the followers feelings, ideas and suggestions), supporting (the locus of control for day-to-day decision-making shifts over to assistants) and delegating (the assistant is given the responsibility for decisions and the implementation of actions) (Hersey & Blanchard 1993). Combining the key components of situational leadership and the person-centred nursing framework, Lynch et al. (2011) delineates four central approaches for leadership: (i) developing a shared vision of person centeredness and identifying important outcomes; (ii) focusing on the impact of the context and identifying situational conditions that influence the delivery of patient care in practice; (iii) matching leadership style to the development level of the assistant using directive or supportive behaviour; and (iv) changing the leadership behaviour flexibly so as to take the assistant through the levels from beginner to competent and committed carer (Lynch et al. 2011), or what we may call an empowered carer. Kane-Urrabazo (2006) concludes that leaders need to put support systems into place that allow the staff the opportunity to empower themselves. Empowerment is described as the process of enabling others to do something, to make them feel free to act on their own judgement and trust their own decisions. The principle of empowerment contributes to each carer s sense of worth (Covey 1991) and stimulates nurses to reach a higher standard (Spence Laschinger 2008). Several previous studies have been made on structural empowerment, defined as the presence of social structures in the work place that enable employees to accomplish their work in meaningful ways (Kanter 1993). These studies indicate that the presence of structural empowerment results in: improved levels of job satisfaction (Laschinger et al. 2001, 2004, Manojlovich & Spence Laschinger 2002); better organisational recruitment and commitment (Laschinger et al. 2001, 2009); more organisational trust, justice and respect (Laschinger et al. 2001, Laschinger & Finegan 2005); and an enhanced quality of patient care (Spence Laschinger 2008). Additionally, among the staff, lower levels of job strain, less burnout and reduced turnover intentions have been reported (Laschinger et al. 2003, Spence Laschinger et al. 2009a). There is a link between work-place empowerment and engagement with the task. Nurses who engage positively in their work with vigour and dedication can make a difference to the quality of care by inspiring colleagues and making the work setting attractive (Spence Laschinger et al. 2009b). The aim of this study was to investigate the role of leadership in the implementation of PCC in nursing homes using DCM. The main areas of investigation were: how the leaders prepared and supported the care staff during the development process; and what the staff thought about the experience of taking part in this process. To answer this, we compared three nursing homes. Methods Design The study had a qualitative descriptive design using focus-group interviews to answer the main research question. DCM was used as a method of implementing PCC over a 12-month period. Sample and settings The leaders and staff of three nursing homes called NHA, NHB and NHC were recruited from three different parts of Norway. Trained DCM users, working as supervisors in departments of geriatric Journal of Nursing Management, 2015, 23,

4 A. M. Mork Rokstad et al. psychiatry, selected, contacted and asked the nursing homes for their participation. The researcher (A.M.M.R.) planned the DCM process in collaboration with the DCM users, and was otherwise not directly involved with the nursing homes in the DCM process. The researcher planned and carried out six focus-group interviews with the formal leaders and the care staff at the participating nursing homes. Separate focus groups were formed for the staff and the leaders at each nursing home. The care staff, who participated in the focus groups, consisting of both registered and auxiliary nurses, were all experienced members of the nursing team. The leaders were head managers and charge nurses. In NHC there was only one responsible leader for the participating ward, and she was interviewed individually. Table 1 shows the number of participants from each nursing home in the focus-group interviews, nursinghome characteristics and the characteristics of the nursing staff. There were some differences in size, organisation and the structure of leadership. NHA had 50 residents, a continuous budget and one head manager of the nursing home. Additionally, there were one charge nurse in each ward housing 24 and 26 residents and about 50 care staff members on each ward. NHB had 127 residents, activity-based income and a temporarily appointed head manager of the nursing home. Two charge nurses were each responsible for one ward including 34 residents and about 70 care-staff employees. There were also informal leaders in each of the wards. NHC had 64 residents and a continuous budget. There was no head manager present at this nursing home as it was organised as part of a group of nursing homes in the municipality with one manager responsible for all the institutions. There was a charge nurse in the participating ward and informal leaders. All the leaders were on duty throughout the study period except for one nurse in charge of one of the wards in NHB. The nursing staff characteristics (Table 1) reveal that most of the care staff members were women. NHB had the highest number of staff working in their current job for several years. Nearly half of the staff had been there for more than 15 years. NHC was opened 3 years before the project started and the whole staff had been employed at the nursing home since the beginning. NHB had the highest number of staff employed for at least 75% of their time and also the highest percentage of staff having additional training. The implementation of PCC using DCM In the DCM process, observations of the residents were made over 6 h and altogether there were three observations at 6-months intervals in each ward. During the observations the care staff were encouraged to carry out their daily practice as usual. The mappings were followed by feedback sessions with the staff, run Table 1 Sample and settings characteristics NHA NHB NHC Total Focus group interview participants Number of staff members interviewed Number of leaders interviewed Nursing home characteristics Participating wards (number of patients on the wards) 2 ( ) 2 ( ) 1 (24) 5 (118) Number of residents in the nursing homes Nursing staff characteristics* N = 24 N = 23 N = 7 N = 54 Female gender (%) 22 (92) 21 (91) 7 (100) 50 (93) Years in current job (%): <1 year 5 (21) 2 (9) 0 (0) 7 (13) 1 5 years 10 (42) 5 (23) 7 (100) 22 (42) 6 15 years 9 (37) 5 (23) 0 (0) 14 (26) Over 15 years 0 (0) 10 (45) 0 (0) 10 (19) Staff working at least three-quarter time (%) 17 (71) 21 (91) 4 (57) 42 (78) Occupation (%): Unskilled care workers 3 (13) 3 (13) 1 (14) 7 (13) Auxiliary nurses 13 (54) 11 (48) 3 (43) 27 (50) Registered nurses 8 (33) 9 (39) 3 (43) 20 (37) No additional training (%) 19 (91) 11 (61) 6 (86) 36 (78) *Nursing-staff characteristics were collected by means of a self-report questionnaire. 18 Journal of Nursing Management, 2015, 23, 15 26

5 Implementation of PCC in nursing homes using DCM by the trained external DCM users. The care staff were requested to participate actively in the feedback session and to share reflections on the observed findings and their implications for their care practice on a daily basis. Based on these discussions, action plans could be made for each resident. The actions would be evaluated by means of the repeated DCM observations. Interviews and analysis The focus-group interviews were made after the second DCM observation at 6 months and repeated at the end of the implementation time. They were based on a semi-structured interview guide (Freeman 2006, Krueger & Casey 2009, Kvale & Brinkmann 2009). The main question to the leaders was: How did you reflect and act as a leader in the preparation and the developmental phases of using DCM? The nursing staff were asked to say how they were involved and stimulated by their leaders in the process of implementing person-centred care in their daily nursing practice. Both leaders and staff were asked to share their experiences with the DCM method and how it influenced their care practice from day to day. The interviews were tape recorded, transcribed and cross-checked by listening to the taped interviews. A qualitative content analysis with a conventional approach was used to analyse the interviews. The analysis was not informed by a theoretical framework (Graneheim & Lundman 2004, Hsieh & Shannon 2005, Zhang & Wildemuth 2009). Initially, each interview was analysed separately. The text was sorted into content areas, and was read through several times to obtain a sense of the whole. Then, the text was divided into meaning units that were condensed and labelled with a code using NVivo 8. A scheme consisting of main categories and subcategories was constructed. The text was further organised and put into a matrix making it possible to compare the three nursing homes. The information was analysed at the group level, and the interaction within the focus groups was not emphasized. Based on the preliminary analysis, a subsequent interview was made with each group. In this interview the participants were given the opportunity to validate or/and supplement their statements made in the first interview and confirm or deny the temporary interpretations made by the researchers. No interpretations were denied. The next step in the content analysis was to identify prominent themes based on the interpretation agreed by the participants. To address the research question, descriptions of both the context and the prominent themes were identified. The matrix and comparisons between the nursing homes were made in collaboration with the second author (S.V.). Results Context The context in which the implementation of PCC took place was different in the three nursing homes, as described below. Vision and purpose In the focus-group interviews, the leaders spoke about the development of their vision and their main goals for the home and the staff commented on how these had influenced their daily practice. NHA had a clear professional vision ahead of the DCM process, and during the implementation project the vision was extended and put into action by a group of 12 staff members in collaboration with the leaders. NHB also had a written vision statement, made 5 years earlier, which consisted of 13 sentences pin-pointing the goals of the institution. However, the staff found it difficult to remember all the points. The nursing home leader at NHC knew there had been a vision for the nursing home, but she did not remember the content of it and wanted to create a new vision. There was no exact plan for this process and nothing happened during the project in NHC. Professional development The focus on professional development in the three institutions was different. NHA had chosen to focus on the development of psychosocial interventions and PCC, and the leaders were fully aware of the need to see the development of the professionals competence as a long-term project. The nursing home leader at NHB wanted to develop the institution as a model for others and, on this basis, to ensure the funding of the institution. The leadership had developed their own dementia plan and wanted to be able to arrange open seminars for nursing homes in the local authority area. They were also open for visits that displayed what they had developed in terms of best practice in dementia care. The staff, by contrast, claimed they did not feel prepared to care for persons with dementia as a result of organisational changes in recent years. The wards had been transformed from traditional nursing home units into special care units for persons with dementia. NHC had a limited focus and no plan for Journal of Nursing Management, 2015, 23,

6 A. M. Mork Rokstad et al. staff development in general and was more based on traditional experience. The staff, however, said that they would like to learn more about dementia. The influence of the funding system NHB differed from the other nursing homes in having activity-based funding, meaning that they were financed according to reported, detailed action plans made for each resident. That means a focus on the connection between activities and funding, which is a market-orientated system. This documentation, which was time consuming and experienced as a burden on the leaders, had to be updated to release the funding. These plans gave the care staff only a limited opportunity for improvization and flexibility in their relations with the residents. This kind of influence from the funding system was not reported from the other nursing homes. Based on the findings of contextual differences in the three nursing homes (Box 1), we chose to characterize the nursing homes as: the highly professional nursing home (NHA), the market-orientated nursing home (NHB) and the traditional nursing home (NHC). Main findings Two main themes, leadership support (Box 1) and the experience of the use of DCM in the implementation of person-centred care (Box 2), were chosen to answer the research questions on how the leaders supported the care staff and how staff experienced taking part in the DCM process. The connection between the participant s quotes and the condensed meaning is shown in the matrices (Boxes 1 and 2). Leadership support (Box 1) The leaders in the highly professional nursing home took an active part in the nursing practice and they saw themselves as role models for the care staff. This participation from the leaders was considered as crucial by the staff members. They felt that their initiatives to act in the best interests of the residents were accepted and appreciated by the leaders and they felt encouraged and supported to deliver good quality care. The leaders confirmed that they admired the staff for their engagement and skills. The leaders in the market-orientated nursing home said that they had no chance of being present on the wards on a daily basis and had to lead through informal leaders on the wards. They stated that their initiatives to motivate the staff in favour of professional development were met by resistance from the staff. The staff confirmed that they experienced their leaders as only sporadically present on the ward. In contrast to the leaders experience of resistance to development, they asked for more continuous supervision. The leader in the traditional nursing home stated that she gave support to the ward staff on occasions when there were special needs. She encouraged the staff to use their individual skills in their care practice. The staff said they felt stretched to deliver good quality care. They had a good relationship with their leader but, on a daily basis, they felt alone and forgotten. The experience of the use of DCM in the implementation of person-centred care (Box 2) The leaders in the highly professional nursing home claimed that the DCM process had motivated both staff and leaders to join forces for further development. The staff felt more focused on delivering individualized, person-centred care and the leaders had the chance to see the results of the action taken in the feedback of the repeated DCM observations. Both leaders and staff at the market-orientated nursing home found the DCM feedback useful and interesting. However, the results of the mappings were not reflected in action plans to be followed up and because of this, the staff s interest in participating in the process decreased. In the traditional nursing home, the leader stated that the DCM process had raised consciousness and reflections concerning care practice. The staff claimed that the constructive feedback after the DCM observations was a good experience. To what extent the process had developed their skills in PCC they were not able to tell. Discussion The findings in this study, as illustrated in Figure 1, show major differences in the leadership in the participating nursing homes. These differences seem to influence the implementation of person-centred dementia care even although the method used (DCM) in the implementation process was the same. The role of the leadership The findings underline the importance of transformational leadership (Burns 1978, Wong & Cummings 2007, Tomey 2009, Cummings et al. 2010) and especially the need for a clear and coherent vision to 20 Journal of Nursing Management, 2015, 23, 15 26

7 Implementation of PCC in nursing homes using DCM Box 1 Theme: leadership support; condensed meaning units and statements from leaders and staff Leaders Care staff Nursing home with key points of context Condensed meaning unit Statement Condensed meaning unit Statement The highly professional nursing home Clear and integrated vision Long-term focus on professional development Basic funding with no direct influence on daily practice The market-orientated nursing home Five years old complicated vision Inconsistency between the leader s and the care staff s experience of professional development Activity-based funding giving detailed instructions on care practice The traditional nursing home No active vision known Professional development asked for by the staff but not put into a structured plan Basic funding with no direct influence on daily practice The leaders took part in care practice as models The leaders showed admiration and encouraged the staff initiatives for better care practice The leaders were not able to be present on the ward and had to lead through others The leaders tried to motivate the staff to participate in professional development but were met by insecure and resistant staff members The leader gave support on occasions of special need on the ward The leader encouraged the staff to use their individual skills We have to keep the idea of person-centredness warm all the time. I have been present on the ward to follow up the actions; we have decided to focus on taking part in the daily care practice. I admire the skills of my staff, and, within the aim of our institution, I encourage their initiatives and ideas for better care practice. I cannot be present on the wards on a daily basis, so I have to lead the care practice through others (nurse 1). I find this frustrating. I try to motivate and spread professional impulses but it kind of seems like they don t want it. Some of them look unsure of themselves and a little bit afraid to make their own decisions. I can be of help on the wards if there is special need and my time schedule makes it possible. I try to give the staff signals of support, and I participate in decisions concerning the residents. I try to support them and regularly tell them what a good job I think they do and I try to encourage them to use their individual skills. Staff felt motivated by the leaders Staff felt encouraged to deliver good quality care Staff stated that the leader was only sporadically present on the ward Staff asked for continuous supervision Staff felt stretched to deliver good quality care Staff loved their leader but felt forgotten from day to day It all depends on the charge nurse being there to drag us along. The more we do, the happier our leaders are; to take good care of the residents is what matters the most. I cannot remember seeing her on the ward; well, she walks through the ward now and then. I would like to have some continuous supervision. I think we stretch ourselves as best we can to meet the needs of the residents. Our leader is very pleasant and we truly love her, but on the daily basis we feel a little bit forgotten. obtain professional development and person-centred dementia care. PCC is described as a value base (Brooker 2007), and the goals for nursing practice need to reflect these values to make them normative. The highly professional nursing home seemed to manage to incorporate the values of PCC both in their written vision and in the processes implementing it. The vision of the market-orientated nursing home was more focused on terms like service and standardized best practice, and the staff seemed more distant to the meaning of PCC. The goals of effectiveness and service, thought to be incompatible with the values of Journal of Nursing Management, 2015, 23,

8 A. M. Mork Rokstad et al. Box 2 Theme: the experience of the use of Dementia Care Mapping (DCM) in the implementation of person-centred care (PCC); condensed meaning units and statements from leaders and staff Leaders Care staff Nursing home Condensed meaning unit Statement Condensed meaning unit Statement The highly professional nursing home The marketorientated nursing home The traditional nursing home The process had made staff and leaders joined forces for development Both staff and leaders found the first feedback of the DCM observations interesting but the interest decreased during the process The process raised the staff s consciousness I think the DCM process has inspired us and made us join forces in the development of our care practice because it gives us the chance to see the results of the actions we choose to take. I think the feedback was interesting and so did the staff, but at the second feedback session there were only two of the staff present. That s really disappointing. The staff members have become more aware of ethical issues and their consciousness concerning their own care practice has increased. The staff felt more focused on delivering individualized care The staff found the feedback useful but asked for concrete actions in the continuation of the feedback meeting To get constructive feedback was a good experience for the staff It (DCM) makes us focus on the residents and what to do together in a staff group to develop individualized care. The feedback was useful and made us reflect upon how we meet the patients, but no concrete action was taken to follow up the discussions from the feedback. Constructive feedback gives us the opportunity to change. To be observed and get feedback from someone outside (DCM mappers) was a great experience. PCC, frustrated both leaders and staff. In the traditional nursing home a verbal vision was set out and demonstrated by the leader in the way she acted and supported the staff but her goals were unknown to her nursing staff. These findings are supported by previous research which underlines the need of clear, explicit and coherent goals to obtain results in the quality of nursing (Scalzi et al. 2006, Forbes-Thompson et al. 2007, Cummings 2011). Situational leadership is recommended to develop a person-centred culture of care (Lynch et al. 2011). To practise situational leadership the leaders need to be present on the wards, know the skills of their employees and choose the appropriate leadership behaviour. They have to choose directing, coaching, supporting or delegating strategies to fit the nurses developmental levels and competence (Hersey & Blanchard 1993). In the highly professional nursing home, the leaders were present on the wards on a daily basis and the staff felt supported and engaged. Given the circumstances of high work pressure and many administrative tasks, the leaders at the marketorientated nursing home could not manage to take this role in the wards. This fact seemed to result in frustrated leaders and resigned staff. The leader at the traditional nursing home stated that she supported her staff on occasions of special need and participated in decisions concerning the patients. The staff felt they had to stretch themselves and manage on their own as they felt forgotten. The fact that the leader had no opportunity to be present on the wards on a daily basis and observe the nurses needs for supervision and support may have limited the effect of her good intentions to support the staff when needed. Authentic leaders (Wong et al. 2010) are role models and supervisors demonstrating their professional and ethical standards in the way they communicate openly and act consistently with their expressed values. Such leadership behaviour, as we identified at the highly professional nursing home, influences the staff s engagement, motivation and commitment (Anderson et al. 2003, Avolio & Gardner 2005, Scalzi et al. 2006). The situations at the market-orientated and traditional nursing homes were different, as the leaders were responsible for larger groups of staff and patients and had a more limited opportunity to lead by example (Avolio & Gardner 2005). An alternative 22 Journal of Nursing Management, 2015, 23, 15 26

9 Implementation of PCC in nursing homes using DCM Context Nursing home A 'Highly professional' Nursing home B 'Market-orientated' Nursing home C 'Traditional' -Clear and integrated vision -Long-term focus on professional development -Complicated vision -Inconsistent professional development -No vision -No structure for professional development -Basic funding -Activity-based funding -Basic funding The Dementia Care Mapping (DCM) process Professional supportive leadership through participation in practice care No directly supportive leadership Supportive leadership only on request Implementation of person-centred care (PCC) PCC awareness and practice PCC awareness PCC awareness and reflections on it Figure 1 The influence of context and the role of leadership in the implementation of person-centred care (PCC) using the Dementia Care Mapping (DCM) process. to this unsatisfactory situation could have been to appoint internal implementation leaders (Damschroder et al. 2009), who would be given the formal authority and responsibility as project or team leaders and enabled to be role models and supervisors on the wards. A study of barriers and enablers to a culture of change in nursing homes concluded that a critical mass of change champions appeared to have a significant influence in implementing and sustaining changes (Scalzi et al. 2006). Change champions are individuals, not formal leaders, who dedicate themselves to supporting, marketing and driving through an implementation by overcoming the resistance that the intervention may provoke (Damschroder et al. 2009). Opinion leaders having formal or informal influence on the attitudes and beliefs of their colleagues and external change agents also influence the development process (Damschroder et al. 2009). In this study, we focused on the role of the formal leaders, but studies of the influence of different types of intervention leaders would be interesting as well. Staff empowerment has been emphasized in several previous studies as a key strategy for successful professional development (Kane-Urrabazo 2006, Spence Laschinger 2008, Spence Laschinger et al. 2009b). 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 take their own decisions in their daily care practice. At the traditional nursing home the nursing staff were trusted by their leader but did not feel supported in their work on a daily basis. In addition, there were no formal delegation structures to give staff members at the unit level the power and opportunity to act as implementation leaders. They lacked knowledge of how to treat persons with dementia and asked for supervision and education. The staff at the market-orientated nursing home also felt to some extent uncertain of how to act to meet the patients needs and asked for continuous formal supervision. However, the activity-based funding gave signals on what kind of activities the residents could be offered, and the activities were even described with time limits. A paradox is the fact that, comparing the three nursing homes, the market-orientated nursing home had the highest percentage of care staff with additional training, many years of experience in the current job and the highest percentage of staff working at least 75% of full time (Table 1). Summing up, the highly professional nursing home seemed to succeed in implementing PCC in their daily practice through support from their leader. In the market-orientated nursing home, PCC awareness was achieved but did not lead to change Journal of Nursing Management, 2015, 23,

10 A. M. Mork Rokstad et al. in care delivery. The traditional nursing home also achieved PCC awareness and increased reflection among the care staff, but the influence on care practice was uncertain. These two had no support of their leaders. The differences in how much the three nursing homes succeeded in implementing PCC might have several explanations. However, transformational, situational leadership and the existence of a clear and coherent vision, clarifying the content of PCC, seemed to be important. Additionally, 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. The way the nursing homes where organised, including the funding system, seemed to have influence on the implementation process and needs to be investigated further. Additionally, research is needed on the use and influence of different kind of intervention leaders. Methodological considerations Focus group interviews were chosen as the method of finding out about the role of leadership in developmental processes using DCM. The advantages of using focus groups are that it is an efficient method of gathering the viewpoints of many individuals in a short time, and the interaction within the group may lead to richer expressions of opinion. However, there is a chance that some group participants find it difficult to express themselves in front of the group (Polit & Beck 2008). To encourage open discussion within the groups, the participants were divided into groups of staff and groups of leaders. The content of the interviews in the separated groups of staff and leaders could be compared to validate the different opinions expressed. The coding was made by the main researcher (A.M.M.R.), and the second writer (S.V.) reviewed and questioned the logic and consistency in the coding and the preliminary interpretations. The second round of interviews contributed to the validation of their previous conclusions. After much discussion, the main researcher (A.M.M.R.) and the co-writers summed up the findings and worked out the final conclusions. Conclusion This study gave useful information about the influence of leadership on the implementation of PCC using DCM in nursing homes. Leaders have a central role in drawing up a clear and consistent professional vision, being continuously supportive to the care staff and taking an active part in the care practice as role models. Structural empowerment and delegation of authority and decision making to competent implementation leaders are alternatives to consider when organisational limitations make it difficult for the formal leaders to be present on the wards on a daily basis. The effect of market-orientated leadership on the development of PCC in nursing homes should be investigated further. Source of funding The study was funded by the Norwegian Research Council and The Norwegian Directorate of Health. Ethical approval The participants gave their informed written consent and the study was accepted by the Regional Ethics Committee for medical research in eastern Norway (REK-east) and the Norwegian Data Inspectorate (NSD). As this study included only three nursing homes, it would have been possible for those included, especially the leaders, to recognize themselves in the description, and there might have been a chance that they would feel offended or embarrassed. Efforts have been made in the way the material is presented to avoid this. During the second interviews the participants had the opportunity of confirming or distancing themselves from statements in the first interviews. Nobody wanted to remove any statements from the material, and the interpretations were confirmed and to some extent amplified. The consent of the participants was confirmed prior to the second batch of interviews. References Anderson R.A., Issel L.M. & Daniel R.R. Jr (2003) Nursing homes as complex adaptive systems: relationship between management practice and resident outcomes. Nursing Research 52 (1), Anthony M.K., Standing T.S., Glick J., et al. (2005) Leadership and nurse retention: the pivotal role of nurse managers. Journal of Nursing Administration 35 (3), Avolio B.J. & Gardner W.L. (2005) Authentic leadership development: getting to the root of positive forms of leadership. The Leadership Quarterly 16 (3), Brady Germain P. & Cummings G.G. (2010) The influence of nursing leadership on nurse performance: a systematic 24 Journal of Nursing Management, 2015, 23, 15 26

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