What is the role of transformational leadership, work environment and patient safety culture for person‐centred care? A cross‐sectional study in Norwegian nursing homes and home care services

Abstract Aim To examine how transformational leadership, job demands, job resources and patient safety culture contribute in explaining person‐centred care in nursing homes and home care services. Design Cross‐sectional study. Methods Healthcare professionals in four Norwegian nursing homes (N = 165) and four home care services (N = 139) participated in 2018. Multiple regression analyses were used to examine to what degree transformational leadership, job demands, job resources and patient safety culture dimensions predicted person‐centred care. Results Transformational leadership, job demands and job resources explained 41% of the variance in person‐centred care, with work pace as the strongest predictor (β = 0.39 p < .001). The patient safety culture dimensions explained 57.5% of the variance in person‐centred care, with staffing being the strongest predictor (β = 0.31 p < .001). There were small differences between nursing homes and home care. In total, transformational leadership, pace of work, staffing and factors related to communication were the strongest predictors for person‐centred care.

Organizational structures and contextual factors play an important role in patients' experience of care and can act as barriers for improvement at all levels of the system (Ocloo et al., 2020). A systematic review concludes that sound organizational and workplace cultures are associated with several patient outcomes, such as increased patient satisfaction, less falls and reduced mortality (Braithwaite, Herkes, Ludlow, Testa, & Lamprell, 2017). Similarly, the patient safety culture is related to a range of outcomes in different healthcare settings, including better patient experiences (Abrahamson, Hass, Morgan, Fulton, & Ramanujam, 2016;Najjar, Nafouri, Vanhaecht, & Euwema, 2015;Wang et al., 2014). Previous research argues for the importance of managers in creating a sound patient safety culture and quality of care (Merrill, 2015;Ree & Wiig, 2019b;Sfantou et al., 2017). The transformational leadership style is related to a range of positive organizational outcomes and processes in health care, including work environmental factors and patient safety culture (Boamah, Laschinger, Wong, & Clarke, 2018;Merrill, 2015;Ree & Wiig, 2019b). Transformational leadership can be defined as leaders that "broaden and elevate the interests of their employees, generate awareness and acceptance of the purposes and mission of the group, and stir their employees to look beyond their own self-interest for the good of the group" (Bass, 1991, p. 21).

| Background
Based on the existing literature, there are reasons to believe that transformational leadership, work environmental factors and patient safety culture influence the level of person-centred care in healthcare settings. However, no previous studies have explored these associations. Furthermore, most research is conducted in the specialist healthcare setting, and there is a need for more knowledge about person-centred care in nursing homes and home care services. Therefore, the current study will contribute with new and original knowledge about the role of leadership, work environment and patient safety culture for person-centred care in these important healthcare settings, suggesting implications relevant to nursing management.
The overall aim of this study was therefore to explore how transformational leadership, job demands, job resources and pa-

| ME THODS
This study used a cross-sectional design and is a part of the intervention project "Improving Quality and Safety in Primary Care-Implementing a Leadership Intervention in Nursing Homes and home care" (SAFE-LEAD Primary Care) Wiig et al., 2018).

| Sample
The

| Questionnaire
The questionnaire consisted of questions and instruments related to patient safety culture, work environment, leadership and personcentred care, and background information such as age, occupational status and years of employment. The instruments described below were used to explore the research questions in this study.

Person-centred care was measured with the Person-centered
Care Assessment Tool (P-CAT) (Edvardsson, Fetherstonhaugh, Nay, & Gibson, 2010). The instrument has proven to have sound psychometric properties and test-retest stability when tested in Norwegian residential units for older people (Rokstad, Engedal, Edvardsson, & Selbaek, 2012). The instrument consists of 13 statements about person-centred care, measured on 5-point Likert scales (1= "disagree completely" to 5= "agree completely"). Examples of statements were "Users are offered the opportunity to be involved in individualized everyday activities" and "We are free to alter work routines based on users' preferences." One of the items ("Residents are able to access outside space as they wish") was removed in our study as we regarded that it did not fit with the study settings, especially not home care. The wording of some statements in the home care services survey was slightly modified, such as replacing "residents" with "users," to fit the home care setting. The Cronbach's alpha in the current study was 0.836.  Cappelen et al. (2016). In the home care version, the wording on some of the items was slightly modified to fit the home care context (e.g. "users" instead of "patients" and "unit" instead of "nursing home"). The Norwegian validation study found acceptable fit for the following 10-factor solution of the scale (Cappelen et al., 2016) (Cronbach's alpha is given for the current sample): • "Teamwork" (α = 0.821), for example "Staff feel like they are part of a team" • "Staffing" (α = 0.821), for example "We have enough staff to handle the workload" • "Compliance with procedures" (α = 0.53), for example "Staff follow standard procedures to care for patients" • "Training and skills" (α = 0.656), for example "Staff get the training they need in this nursing home/unit" • "Non-punitive responses to mistakes" (α = 0.655), for example "Staff are blamed when a patient is harmed" • "Feedback and communication about incidents" (α = 0.781), for example "When staff report something that could harm a patient someone takes care of it" • "Communication openness" (α = 0.811), for example "Staff ideas and suggestions are valued in this nursing home/unit" • "Supervisor expectations and actions promoting patient safety" (α = 0.879), for example "My supervisor listen to staff ideas and suggestions about patient safety" • "Management and organizational learning" (α = 0.802), for example "This nursing home/home care is always doing things to improve patient safety" All items were rated on five-point Likert scales from 1 ("never" or "totally disagree") to 5 ("always" or "totally agree").

| Data analyses
We had no missing data since respondents had to answer each question before moving on to the next in the electronically survey. All analyses were conducted using IBM SPSS Statistics version 25.
Hierarchical multiple regression analyses were used to examine the impact of transformational leadership, job demands and job resources on person-centred care. We used standard multiple regression analyses to assess the explained variance of patient safety culture dimensions on person-centred care.
All regressions analyses were conducted separately for the nursing homes and home care services samples, as well as in total. The p-value was set to .05. Preliminary analyses were conducted to ensure no violations of the assumptions for conducting the regression analyses. Due to issues with multicollinearity and suppression effects (Shieh, 2006), the two dimensions "handoffs" and "management support and organizational learn- Normality of residuals was tested with a normal P-P plot, where the results indicated that the residuals were normally distributed.
Occupational status and years of employment were controlled for in all analyses.

| Person-centred care, transformational leadership, job demands and job resources
In a hierarchical multiple regression analysis of person-centred care in both nursing homes and home care, the full model with transformational leadership, job demands and job resources as predictors explained 41% of the variance in person-centred care, with work pace as the strongest predictor (β = 0.39; p < .001; Table 3). The full model explained 45.7% in nursing homes and 40.4% in home care services. Transformational leadership was the strongest predictor in nursing homes (β = 0.39 p < .001), followed by work pace (β = 0.21 p < .05). In home care, work pace was the strongest predictor (β = 0.53 p < .001), followed by transformational leadership (β = 0.19 p < .05). Of the job resources, autonomy was a significant predictor in nursing homes, while participation was a significant predictor in home care services.

| Person-centred care and patient safety culture
In a multiple regression analysis of person-centred care in both nursing homes and home care, the full model with patient safety culture dimensions as predictors explained 57.5% of the variance in person-centred care, with staffing as the strongest predictor (β = 0.31 p < .001; Table 4).

| D ISCUSS I ON
This study indicates that transformational leadership, work pace and patient safety culture dimensions related to staffing and communication are important predictors for person-centred care in nursing homes and home care services. As hypothesized, transformational leadership and job resources positively predicted person-centred care, while job demands had a negative impact. However, although the job resource autonomy was a significant predictor in nursing homes, and participation predicted person-centred care in home care services, none of the job resources had a significant impact in total. Furthermore, the job demand "work pace" was a stronger predictor for person-centred care than transformational leadership. The findings are in line with a recent mixed methods study in Norwegian nursing homes and home care, showing that lack of communication and information exchange between healthcare services, users and next of kin are among the main challenges for personcentred care (Ree, Wiig, Braithwaite, & Aase, 2020). The study also emphasizes challenges related to busy schedules and poor staffing . Poor staffing is repeatedly found being related to a range of negative factors in health care, such as workload, employee burnout, work dissatisfaction, and poor patient safety and quality of care (Cho et al., 2016;Shin, Park, & Bae, 2018), and being a barrier for person-centred care (Engle et al., 2017). Higher staffing levels and resource adequacy on the other hand are related to higher levels of person-centred care (Bachnick, Ausserhofer, Baernholdt, & Simon, 2018). Similar to our findings, Nkrumah and Abekah-Nkrumah (2019) found that leadership commitment and support were important facilitators for person-centred care, while communication challenges acted as barriers.
There is probably an interaction and mutual influence between the predictive factors work pace, staffing and communication, as poor staffing will lead to a more busy work schedule with higher work pace and higher likelihood of communication gaps (Yanchus, Ohler, Crowe, Teclaw, & Osatuke, 2017). Several studies report that work environmental factors such as feeling overworked, staff shortages, lack of time and tools, and workload are obstacles for patient-centred care (van Mol et al., 2017;Ocloo et al., 2020;West, Barron, & Reeves, 2005).  is possible to implement and practice. A number of studies show that the staff-patient relationship, having enough time to get to know the patients and good communication among employees, staff and next of kin are all key for patient-centred care (Angel & Frederiksen, 2015;Oxelmark, Ulin, Chaboyer, Bucknall, & Ringdal, 2018;Ree et al., 2020;Vennik, van de Bovenkamp, Putters, & Grit, 2016

| Strengths and limitations
The main strength of this study is its originality in being the first to explore the role of patient safety culture, transformational lead-   (Johannessen et al., 2020;Ree et al., 2019Ree et al., , 2020. Furthermore, managers should have access to and make use of support tools, for example surveys to map user experiences and opinions that can be used to inform and improve practice, ensuring that the services are aligned with the needs and preferences of the users and patients in the nursing homes and home care services.

ACK N OWLED G EM ENTS
The author wish to thank the employees in the nursing homes and home care services for participating in the study. The author would also like to thank Siri Wiig for carefully reading the manuscript and valuable input.

CO N FLI C T O F I NTE R E S T
None declared.

E TH I C S A PPROVA L A N D CO N S E NT TO PA RTI CI PATE
The Regional Committees for Research Ethics in Norway regarded the study to not be governed by the Health Research Act and was therefore not within their mandate. The study was approved by the Norwegian Social Science Data Services (NSD, ID 52324) and followed the principles from the Helsinki Declaration. All participants gave their written informed consent at the very beginning of the electronic questionnaire, where it was stated that they consented to participate by responding to the questionnaire. Participants were informed that their responses to the questionnaire were confidential and only available to the researchers.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data sets used during the current study are available from the corresponding author on reasonable request.