Systematic searches were conducted in the databases CINAHL and PubMed. A specialist librarian was consulted during the development of the search strategy and carried out the searches to ensure rigor. Keywords and MeSH terms were used in various combinations with Boolean operators. The search included terms related to: •

Leadership (e.g., leader*, situational leadership, attitude of health personnel, staff attitude)

The study adheres to the PRISMA guidelines for systematic review (33). The inclusion and exclusion criteria are presented in Table 1.

The year 2012 was selected as the starting point for the review because healthcare systems have undergone substantial changes over recent decades (34). Studies across diverse healthcare systems with different financial systems are included in this review, as the focus is on leadership dynamics that facilitate the adoption and maintenance of person-centered practice, independent of health policy structures or cultural contexts. We did not restrict inclusion to studies using a specific theoretical framework (e.g., McCormack and McCance's Person-centred Practice Framework). However, studies were only included if they explicitly referred to person-centeredness. Figure 1 presents the PRISMA flow diagram of the study selection process.

The quality of the included articles was assessed by two authors (ACLL and CB) using the appropriate JBI Critical Appraisal Tool based on the study design: (i) JBI Critical Appraisal Checklist for Qualitative Research or (ii) JBI Critical Appraisal Checklist for analytical cross-sectional studies. Each author conducted assessments independently and then compared their results. Minor disagreements arose but were resolved through discussion until consensus was achieved. No established parameters exist for weighting qualitative studies (35). In this review, all criteria were deemed of equal importance. A study was classified as high quality if it achieved a score above 70%, moderate quality if it scored between 50% and 70%, and low quality if it scored below 50%, as outlined by Dijkshoorn et al. (36). Only high and moderate-quality studies were included in the final synthesis. Two studies were excluded due to insufficient quality.

The JBI QARI data extraction form for interpretive and critical research (32) served as our tool for data extraction, as outlined in Table 3. Data extraction was conducted for both qualitative and quantitative studies (32, 37). From qualitative studies, we extracted the authors' interpreted findings, such as thematic categories or subthemes, along with supporting interpretations and illustrations. For quantitative studies, we followed the approach described by Lizarondo et al. (37), in which narrative descriptions of results reported by the study authors are extracted and, where appropriate, rephrased or condensed to ensure clarity and relevance to the review objective. This allowed us to integrate quantitative data with qualitative findings by transforming them into textual representations, a process known as qualitization (37). Data extraction was initially conducted by the first author (CAH) and subsequently reviewed by co-authors LBO and IF to ensure accuracy and consistency. No disagreements arose that required further resolution.

JBI's convergent integrated synthesis approach (32, 37) was used to synthesize data from the included primary studies. The synthesis process is summarized in Table 2, which provides a schematic overview of how the JBI convergent integrated approach was applied. The table outlines the steps from compiling primary data to generating synthesized findings.

Thematic categories were developed through an inductive analysis of the extracted data, which included authors' interpretive themes, subthemes, and supporting quotations from qualitative studies, as well as qualitized narrative findings from quantitative studies. During the process, findings were grouped based on similarity in meaning, with attention to recurring concepts, language, and underlying assumptions about leadership and person-centeredness. Contrasting perspectives were also explored to ensure a nuanced interpretation. Initial coding and categorization were performed independently by three reviewers (CAH, IF, LBO), followed by collaborative discussion to refine and consolidate categories.

Subsequently, one researcher (CAH) led the synthesis process by analyzing the descriptive categories for overarching patterns and integrating them into synthesized findings. This interpretive synthesis was carried out in ongoing dialogue with the co-authors (IF and LBO), ensuring that the final themes were grounded in the evidence and represented both convergence and variation across included studies.

The search yielded 1,570 potentially relevant papers. The papers were imported into EndNote software and subsequently transferred to Rayyan (38) for deduplication. Five members of the review author team independently screened the studies by title and abstract (CAH, LBO, LH, AKH, IF). For a paper to be considered relevant, it needed to include the terms “management” and “nursing home,” or their synonyms, in the text, in addition to adhering to the inclusion and exclusion criteria. The reviewers then divided into two groups and compared their results, identifying 39 articles. In the following screening phase, the five review authors independently assessed the full text of the 38 articles for final inclusion. Any discrepancies in selection during the review process were resolved through discussion.

The final sample comprised ten studies: six qualitative and four quantitative (Figure 1). Four of the studies were conducted in Norway, three in Sweden, one in Australia, one in Ireland, and one in the USA. Perspectives from both formal leaders (nursing home managers and head nurses) and non-managerial staff (e.g., registered nurses, enrolled nurses, and nursing assistants) were represented. The quality assessment of the included studies is presented in Table 4.

The data synthesis led to three synthesized findings: (i) Visionary leadership and empowerment; (ii) Consistent and systematic approach for person-centered outcomes; and (iii) Leadership through role modeling. These findings were arrived at through the use of the JBI's convergent integrated synthesis approach, as described earlier (32). Table 5 presents the results of the data synthesis following the convergent integrated approach (37), in which findings from included studies were grouped into thematic categories and further integrated into three overarching synthesized findings. The structure aims to illustrate how multiple qualitative findings were converged through interpretive analysis into higher-order syntheses, supported by excerpts from the primary studies.

The results in this synthesized finding highlight how the leaders had clear and shared visions for person-centered practice through the following categories: (i) Importance of clear visions and values, and (ii) Empowering and enhancing staff performance.

In this synthesized finding, the importance of having a systematic approach and a structured plan in the workplace to achieve person-centered goals is highlighted. In addition, the importance of maintaining focus on the goal was emphasized. The synthesized finding is reflected in the subcategories (i) Capability to organize and establish structure systematically, and (ii) Continuous focus on person-centered outcomes.

A recurring topic was the importance of the leaders leading by example. The importance of role modeling was emphasized both by the leaders and by the employees. The synthesized findings are divided into the following categories: (i) Actively participating in care provision, and (ii) Promoting a safe and supportive environment with a culture of continuous growth.

The findings underscore the necessity for nursing home leaders to possess a cohesive vision and set of values aligned with person-centered principles, ensuring these visions transcend superficial policies and resonate with leaders' core beliefs (39, 40, 45–48). These findings align with previous research indicating that leaders who deeply understand and embody person-centered principles are better positioned to implement them effectively in practice (30). Earlier studies also support the importance of a shared vision as an essential feature of leadership behavior. Martin et al. (49) found that vision provides orientation and meaning for leaders and their teams, helping them focus their energies and engage in the transformation of practice. A 2022 systematic overview of reviews by Feldthusen et al. (50) describes numerous prerequisites for facilitating person-centered practices in healthcare, including the formation of a vision.

The correlation between empowered staff and person-centeredness underscores the significance of effective leadership in fostering staff empowerment through support, autonomy, and opportunities for agency (45–47). Prior research (51) corroborates these findings, suggesting that empowering staff improves outcomes for nursing home residents and enhances staff motivation and job satisfaction. Additionally, Ta'an et al. (52) found that highly empowered nurses displayed higher performance than less empowered nurses in hospitals. Conversely, Feldthusen et al. (50) found that a lack of influence over policies, procedures, and practices contributed to feelings of disempowerment among healthcare professionals. These factors, coupled with rising workloads and insufficient support, adversely impacted their psychological well-being and their ability to deliver PCC (50).

The findings indicate that fostering person-centered practices requires systematic approaches and structured planning from leaders (40, 48). For instance, one nursing home in the study implemented systematic review meetings to evaluate care plans and PCC practices, which were deemed crucial for developing and maintaining person-centered practice (40). This finding aligns with international literature, where previous research supports the necessity of a systematic approach and regular evaluation to sustain high-quality person-centered practice (11, 53). These findings suggest that nursing home leaders should prioritize the development of structured care planning and evaluation routines to ensure consistent and high-quality PCC.

A stable workforce was identified as critical for achieving systematic organization and structure, ensuring a well-coordinated department, and promoting expertise development among staff (48). Stable staffing allows for continuity of care, which is essential for building trust and understanding between residents and caregivers. When staff members are familiar with the residents and their specific needs, they can provide more personalized and effective care (5). However, research by Moore et al. (54) suggests that consistent leadership may be even more critical. Consistent leadership provides direction, stability, and a clear vision, which are vital for sustaining person-centered practices (22). These findings underscore the importance of maintaining a stable workforce and ensuring continuity in leadership roles to effectively implement and maintain person-centered practice.

A recurring theme was the profound impact of leaders actively modeling person-centered behaviors (40, 43, 45, 46). By serving as visible role models, the leaders reinforced the importance of person-centered values and inspired staff to adopt similar practices. Numerous studies have underscored the leader's role as a model for expected behaviors (49, 54–57). However, what sets this context apart is that leaders also serve as role models in their execution of daily patient care, as evidenced in the study by Rokstad et al. (46), where staff regarded leader participation in nursing practice as crucial. While leader involvement in daily care can enhance understanding and presence, several challenges may emerge. Challenges such as role confusion, time pressure, insufficient clinical competence, and inadequate resource allocation can impede effective leadership and optimal care. Of particular concern is the potential lack of clinical competence among leaders. Although many leaders possess healthcare backgrounds (58), their clinical skills may not be as current as those of staff who work with patients daily. Moreover, Kirchhoff and Karlsson (59) found that first-line nurse managers frequently face role conflict or feel 'squeezed' by the competing demands of their responsibilities as registered nurses and leaders. This dual pressure can result in significant stress, emotional exhaustion, and an inclination to resign from their leadership roles.

A key finding was that the majority of the included studies emphasized the importance of adopting a person-centered approach not only for residents but also for treating staff according to the principles of person-centeredness (40, 41, 43, 44, 46, 48). Such findings illustrate the paradigm shift from the traditionally PCC, which primarily focuses on the patient as the sole important person in the relationship, to person-centered practice, which encompasses all individuals in the relationship, including healthcare professionals (7). Buetow (60) refers to this shift as viewing patients and healthcare personnel as “moral equals,” indicating that to provide effective PCC, healthcare professionals must also feel that their personhood is respected and recognized.

Backman et al. (39) discovered that the influence of leadership behaviors on the psychosocial climate was contingent on the degree of PCC, suggesting that leadership behaviors are critically important for the psychosocial well-being of staff and residents. Furthermore, Jacobsen et al. (44) found that staff perceptions of their leaders were indicators of the presence or absence of PCC in the nursing home. These findings align with research by Seljemo et al. (23) and Zonneveld et al. (24), who emphasize that the significance of leadership behaviors, rather than just leadership styles, is crucial in nursing home care.

The data from all included studies underscore the extensive and multifaceted expectations placed on leaders in nursing homes (39–48). Beyond ensuring the implementation of person-centered practices, leaders are tasked with a wide range of responsibilities, including administrative tasks, role modeling, and direct involvement in care activities (40, 43–46, 48). Persistent challenges in nursing home leadership, such as understaffing, financial constraints, limited resources for staff development, and blurred work-life boundaries, further exacerbate expectations (58, 61, 62). Such demands mirror the traditional “heroic” model of leadership, where leaders are expected to manage and resolve all organizational issues independently (63). This model raises questions about its feasibility and sustainability in the context of modern nursing homes.

There is an apparent contradiction between the expectations placed on leaders and the principles of person-centered practice, which advocate for shared responsibility and collaborative approaches (5). A disconnection between expectations and the support provided to leaders can lead to burnout and reduced effectiveness in leaders (59, 62) and diminish their ability to foster a person-centered culture. This issue highlights the need to rethink traditional leadership models in nursing homes.

The findings of this review point to the potential benefits of shifting towards a more integrated leadership model that aligns with person-centered values. In particular, distributed leadership may offer a valuable contribution by supporting a more balanced distribution of responsibilities and tasks across different organizational levels (64). In this model, administrative duties may be delegated to specialized personnel, while clinical leadership is exercised by experienced nurses closer to care delivery. By embedding distributed leadership within broader person-centered strategies, nursing homes may cultivate cultures where leadership is enacted through relationships rather than imposed hierarchically. This can enhance staff engagement and competence (62, 65) and support the sustainable implementation of person-centered practices. Moreover, person-centered leadership plays a crucial role in nurturing such practices by emphasizing staff empowerment, fostering teamwork, and aligning leadership actions with the core values of PCC (22). According to McCormack and McCance (11), the goal of person-centered processes is to create a “healthful culture”, an environment that promotes both staff well-being and quality of care. Emerging research on healthful leadership further reinforces its role in establishing supportive and sustainable workplaces (66).

By integrating the principles of person-centered and distributed leadership, healthcare organizations can enhance the well-being of both staff and leaders, ultimately improving care outcomes (11, 22, 64). Further support for this integrated approach comes from recent work by Cable, McCance, and McCormack (67), who explored how person-centered nursing leadership can be cultivated through transformative professional development. They emphasize that becoming a person-centered leader is a process of knowing, being, and becoming, an internal journey that fosters authenticity and relational depth in leadership.

Taken together, these insights suggest that developing integrated leadership models may be key to the sustained success of person-centered practices in nursing homes.

The strength of the study lies in summarizing knowledge in an area with limited existing evidence. Furthermore, the study is conducted systematically and rigorously, adhering to a recognized framework for systematic reviews. The included studies were critically appraised by multiple reviewers to enhance objectivity and reduce bias.

However, some limitations are evident in this review. The most notable is the imbalance in the distribution of findings among the included articles. Some articles contribute numerous findings, while others provide less. To ensure transparency, the details of which findings are extracted from each article are presented in the results section (see Table 5).

Of the ten included studies, seven were conducted in Norway and Sweden. This raised questions about our search terms and whether different words or concepts might be used in other countries. We extensively used various MeSH terms and examined search terms from comparable studies. Additionally, a specialized librarian conducted the searches. Despite these efforts, we acknowledge the possibility of overlooked factors. Furthermore, the review included only two databases, CINAHL and PubMed. While these databases are highly comprehensive within the scope of nursing and health services research, the use of additional databases might have yielded a small number of additional studies, and this is acknowledged as a limitation.

In our searches, we have not differentiated between professional and administrative leadership, and there might be differences in how closely these various levels work with the staff. There are also different ways of organizing nursing homes in various countries, which have not been considered in this study.

In addition to the limitations already discussed, we acknowledge potential methodological and theoretical constraints in this review. Methodologically, the search was limited to two databases (CINAHL and PubMed), which may have excluded relevant studies indexed elsewhere. Furthermore, while our inclusion criteria focused on studies that involved formal nursing home leaders, the variation in how leadership roles are defined and reported across countries and studies may have introduced some ambiguity.

Variability in study designs, populations, and outcome measures has made drawing definitive conclusions challenging, but such diversity also provides a comprehensive overview of the existing evidence and highlights areas where further research is needed.

The findings of this review highlight the need for leadership approaches in nursing homes that are actively aligned with person-centered values and enacted through everyday leadership behaviors. In practice, this calls for leaders who can articulate and embed a clear vision for care, empower staff, and lead by example through consistent engagement in care provision. Establishing such leadership requires not only structural support but also the cultivation of reflective practice, where leaders routinely assess and adapt their approaches based on feedback, values, and situational demands.

From a policy perspective, these findings point to the importance of leadership development programs that prioritize relational and values-based competencies alongside organizational skills. Policies aimed at improving care quality in nursing homes should therefore support leadership models that encourage reflection, staff involvement, and shared responsibility.

Future research should explore how leadership practices can be systematically developed and sustained over time to promote person-centered practice in nursing home settings. Longitudinal studies may help clarify how specific leadership behaviors support the creation of person-centered cultures, enhance staff well-being, and improve person-centered outcomes for residents.