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 person-centred 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) 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.
‘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 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 one-way-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. 2009b). 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.