Study design and registration

A scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology [21] and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-SCR) [22]. A review protocol was registered prospectively in the Open Science Framework (OSF https://doi.org/10.17605/OSF.IO/NYHXZ). In line with JBI guidance [21], no formal appraisal of methodological quality or risk of bias was undertaken, as the aim of the review was to map the extent and nature of the evidence rather than to assess effectiveness.

A reference group comprising patient and carer representatives, representatives from Swedish regional and municipal authorities, and the Swedish Association of Health Professionals was involved throughout the review process. One member of the reference group (JB) is also a co-author. The group contributed to refining the review scope, research questions, eligibility criteria, and presentation, interpretation and dissemination of findings.

Information sources

Systematic searches were conducted in CINAHL (EBSCO), ERIC (EBSCO), PubMed, and Scopus by an information specialist at the Gothenburg University library. Searches were initially performed on 6 May 2024 and updated on 11 February 2025.

Eligibility criteria

Eligibility criteria were defined using the Population-Concept-Context framework [21]:

• Population: People with formal leadership responsibilities (operative and/or strategic level) in health and social care organisations
• Concept: Education aiming to prepare and support leaders in guiding the transition towards person-centred care
• Context: Health and social care settings worldwide

Publications were included if they:

1. - Reported empirical data (qualitative, quantitative, or mixed methods)
2. - Focused primarily on people in formal leadership roles
3. - Described leadership education explicitly linked to the implementation of person-centred care
4. - Were indexed in the selected databases, including indexed grey literature, and
5. - Were published in English, Finnish, Swedish, Norwegian, Danish or German

Publications were excluded if they were literature reviews or conference abstracts. Language restrictions reflected the languages mastered by the reviewer team to ensure accurate interpretation without external translation.

Search strategy

The search strategy was developed collaboratively by the research team, reference group, and information specialist, guided by the Population-Concept-Context framework [21]. Controlled vocabulary (e.g., Medical Subject Headings (MeSH terms)) and free-text terms related to leadership, education, and person-centred care were combined using Boolean operators. Full search strategies are presented in Table 1.

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Table 1. Detailed search strategies used in the review.

https://doi.org/10.1371/journal.pone.0350991.t001

Although “patient-centred care” is an established MeSH term, it was not included, as the review focused explicitly on person-centred care as a broader ethical and relational care approach encompassing patients, relatives, direct care staff, and leaders across the continuum of care and organisations, rather than primarily clinical encounters [11,23]. To minimise the risk of missing relevant studies, reference lists of included publications were manually screened. No restrictions were applied regarding year of publication.

Screening and selection of publications

References were managed in Endnote, and duplicates were removed prior to screening. Title and abstract screening was conducted using Rayyan software. Following Levac et al. [24], the eligibility criteria were pilot-tested on a random sample of 25 titles and abstracts by three reviewers (ECL, JB, QL). Subsequently, two reviewers (ECL and JB or JB and QL) independently screened titles and abstracts, with discrepancies resolved through consultation with a third reviewer (EB). Publications without abstracts were forwarded directly to full-text screening. Full-text screening was conducted independently by ECL and JB, with disagreements resolved through discussion and involvement of QL.

Data extraction

Data were extracted independently by four reviewers (QL, JB, EB, ECL) using a structured Microsoft Excel form developed for this review. Extracted data included: title, authors, year of publication, country where the empirical work was conducted, study design, aims(s), context, descriptions of leadership and person-centred care, participant characteristics, key content, educational methods, summary of results, involvement of patients, relatives, or other interest holders, and knowledge gaps, including suggestions for future research and reported methodological limitations.

Although the initial plan focused on patient and public involvement, it became evident that involvement of direct care staff and other interest holders was also relevant. Data on all involvement activities were therefore extracted under the broader category of interest holder involvement, with interest holders defined according to Akl et al. [25], as persons or groups with legitimate concerns regarding health issues, including staff, patients, relatives, members of the public, and policymakers.

Data analysis

A descriptive qualitative analysis was conducted in line with scoping review methodology [21]. Following data extraction, the first author organised data according to the research questions (key content, educational methods, reported results, and knowledge gaps). Text segments were coded based on manifest content and iteratively grouped into descriptive categories where appropriate to provide an overview of the scope and characteristics and scope of leadership education for person-centred care. To enhance analytical rigour and transparency, preliminary categories were discussed among all authors and with the reference group and refined through iterative dialogue until consensus was reached. As the purpose of the review was mapping rather than interpretative synthesis, no theory-building or latent interpretation was undertaken, and inter-rater reliability statistics were not calculated. Credibility was supported through reviewer triangulation and collaborative validation of categories. Data on publication and participant characteristics, interest holder involvement, and knowledge gaps were summarised narratively and presented in text and tables to provide contextual detail and support transparency.

Ethics statement

The authors have nothing to report.

Overall descriptions of the education interventions

The 20 identified leadership education interventions varied in key content, format, duration, educational methods, theoretical underpinnings, and target groups. Most conceptualised leadership education as a longitudinal, work-based learning process embedded in participants’ organisational contexts rather than short, classroom-based training. Theoretical foundations clustered around leadership and person-centredness. Three main target groups were identified: managers (n = 6), people in non-managerial leadership roles (n = 8), and mixed groups including both managers and other leaders (n = 6). Education participants were predominantly registered nurses holding formal non-managerial leadership roles, and women were overrepresented in publications reporting participant sex. Most interventions (n = 14) extended over six months or longer, particularly those aimed at broader leadership development and cultural change, whereas shorter durations were more common among interventions targeting managers or mixed leadership groups. An overview of key content, educational methods, and reported results is provided in Table 3.

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Table 3. Brief descriptions of key content, educational methods, and reported results described in the included publications, sorted by primary target group and ascending education length.

https://doi.org/10.1371/journal.pone.0350991.t003

Key content

Key content was defined as the substantive topics, competencies, and frameworks addressed within leadership education. These are described in three broad categories: 1) Leadership theories and styles, 2) Person-centredness, and 3) Facilitation skills.

Leadership theories and styles

Leadership theories and styles were identified as key content in 12 interventions and were used to frame leadership as a practice that enables cultural and practice change. Across these interventions, leadership was predominantly conceptualised as a relational, values-driven, and developmental practice. Five interventions focused explicitly on person-centred leadership, describing leadership as a dynamic and enabling process that empowers both leaders and direct care staff by nurturing trust, shared responsibility, and collaborative workplace cultures as prerequisites for person-centred care [29,31,36,37,45]. Person-centred leadership was conceptualised using several definitions. Cardiff [29] drew on Plas and Lewis [48], Cardiff et al. [36] applied McCormack and McCance’s framework [6], Lood et al. [45] used Eide and Cardiff’s definition [2], and Lynch et al. [37] referred to person-centred situational leadership as described by Lynch [49]. Jeon et al. [31] incorporated person- or client-centred leadership strategies operationalised as clinical leadership qualities [50]. Other leadership theories and styles included Theory U-based transformative leadership [51] in two interventions [41,43], transformational leadership based on Bass and Avolio [52] in three interventions [30,35,44], and ethical leadership drawing on multiple theoretical perspectives in one intervention [33]. In addition, transformational leadership was applied by Manley et al. [30], and reflective leadership by Boomer and McCormack [28], although without explicit theoretical referencing. One intervention further described leadership styles related to communication, empowerment, decision-making, operational management, and governance [44].

Person-centredness

Person-centredness was identified as key content in 14 interventions and was conceptualised using multiple established frameworks addressing care, care planning, ethics, nursing, culture, leadership, and patient participation. Most commonly, person-centredness was framed as a relational approach emphasising collaboration, dignity, and mutual respect [28,29,36,37,39,41–43], drawing on McCormack and McCance’s Person-centred nursing framework [53] or the further developed Person-centred practice framework [6]. Four interventions applied the University of Gothenburg Centre for Person-Centred Care (GPCC) framework [7], emphasising person-centred ethics, leadership, and patient participation in recognising each persons’ resources and needs [38,45–47]. Other conceptualisations included the VIPS framework for dementia care [54], described in the intervention by Brooker et al. [32], person-centred care planning [40], tailored services [30], and frameworks for person-centred care planning in services for persons with disabilities [55]. Despite conceptual variation, all frameworks shared a common focus on partnership, recognition of personhood, and integration of person-centred values into leadership and organisational practices.

Facilitation skills

Facilitation skills were identified as key content in eight interventions evaluated across 10 publications [26,30,32,34,35,39,41,43,46,47]. Facilitation skills referred to the concrete competencies to support learning, enable dialogue, and create conditions for change, collaboration and reflection. In the eight interventions, facilitation skills were positioned as central to workplace learning and implementation. In one publication, facilitation was described as supporting reflective practice, problem-solving, and professional growth, enabling direct care staff and leaders to take ownership of learning and change [34]. Two interventions [46,47] explicitly linked facilitation to implementation efforts through the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework [56], highlighting facilitation as support for systematic and context-sensitive change in health services [46,47]. Facilitation skills were further described as relational and developmental, supporting shared learning, collaboration, and transformation within teams [35,39,41], and as essential for cultivating person-centred relationships and practices [39]. In one intervention, facilitation skills were operationalised through coaching and role modelling, emphasising leaders’ roles in enacting person-centred ethics in everyday practice [32].

Educational methods

Common educational methods included action learning [26,28,30,31,34–37,41,43], reflection [29,30,34,36,37,41–45], and practice-based learning [26–28,30–32,38,39,42,44–47]. All interventions utilised internal and/or external facilitation by researchers and/or appointed staff members. Additional methods included team-based learning, 360-degree feedback, coaching, and practice-based projects. Several interventions also employed participatory and emancipatory strategies to promote ethical leadership, interprofessional collaboration, and transformative change.

Reported results

Reported results encompassed both experiential accounts and evaluated effects and were synthesised into four categories: 1) Leadership practice outcomes, 2) Care practice outcomes, 3), Mechanisms of impact, and 4) Perceived challenges.

Leadership practice outcomes

Leadership practice outcomes primarily reflected changes in how participants enacted leadership following the interventions. Reported results included steps taken towards implementing knowledge gained through the interventions, that is, the “how” of leading towards person-centred care. Education participants reported improved skills in leading oneself and others, alongside greater sense of belonging and personal growth. They described finding their voice, creating safe spaces for engagement with co-workers and patients grounded in respect and a shared vision [35,43]. Reported outcomes included improved leadership effectiveness [29], relational capacity in relation to direct care staff and other leaders [29,33,36], reflexivity [33,34,36,41,43,44], heightened awareness of the importance of communication, person-centredness, advocacy, support, role modelling, and empowerment [44], and accessibility [28]. Leaders were also reported to have an increased ability to balance contextual demands with developmental needs [36], and more willing to experiment with innovative leadership approaches [32]. These outcomes were predominantly based on qualitative self-reports and reflective accounts.

Care practice outcomes

Care practice outcomes related to perceived changes in care practices and workplace culture from the perspectives of education participants, healthcare staff, and patients. The most frequently reported outcome was a shift towards a more person-centred and learning-oriented culture [26–29,32,34–40]. This was described in terms of improved teamwork [28,36,38], more positive staff attitudes towards patients and improved knowledge of diagnoses [32], increased focus on relationships rather than tasks [36], improved continuity and coordination of care [32], and greater patient involvement in care and activities [26–28,35,38]. Quantitative evaluations were limited, and statistically significant effects on patient participation were not consistently demonstrated. Nevertheless, Hurtig et al. [47] and Årestedt et al. [46], reported increased awareness of attitudes and behaviours in patient encounters, perceived as supporting alignment with patients’ agendas [46,47]. Additional outcomes included increased motivation to challenge existing practices [26,33,35,36,38], more positive job experiences [35,36], reduced dependence on leaders, and higher engagement and energy levels among direct care staff [29].

Mechanisms of impact

Mechanisms contributing to reported impact were most commonly described as structured reflection [26,29,33,35–39,41–44], active learning [26,28,29,33–35,38,39,45], a person-centred approach to learning [29,32,35–37,45], and timely feedback [30,33,39]. Reflection and reflective inquiry were identified as central to supporting leaders’ self-care and self-growth, with implications for community and practice-level impact [41]. Tailoring leadership education to specific professional groups, such as allied health leaders, was also reported to enhance the relevance and effectiveness of educational interventions [35].

Perceived challenges

Perceived challenges highlighted limitations and tensions within leadership education for person-centred care. Education participants described relational challenges, including balancing leadership responsibilities with personal development and experiencing guilt relating to prioritising leadership learning [28]. They also found it more challenging than expected to remain focused on others and to ask appropriate questions at the right time to support the sharing their narratives [29,36,39]. Critically reflecting on one’s practice and letting go of traditional leadership and learning approaches was described as both challenging and beneficial [33,34,36,39,42]. Although reflective inquiry was generally viewed as valuable, some participants struggled with it, indicating a need for additional support in developing reflection skills [28]. Further challenges related to the complexity of facilitating implementation of person-centred care. While education participants valued the educational opportunities, changing workplace norms required more time and broader organisational engagement than anticipated [46]. Limited time for implementation and constrained ability to balance contextual demands with implementation needs were also reported [29,32,33,36–38,40,44,46]. Action learning was described as both enabling and constraining impact, depending on group composition, group dynamics, and the establishment of trust within learning groups [28,33,34,37].

Knowledge gaps presented in the included publications

The knowledge gaps explicitly presented in the included publications primarily concerned the practical and organisational steps of implementing leadership education for person-centred care. These included limited evaluation of organisational readiness for change [40], restricted opportunities to apply learning in practice [27,35,38,39], challenges related to intervention fidelity [47], and methodological limitations such as cross-sectional designs and a lack of validated outcome measures [44]. Additional gaps concerned unclear educational objectives and roles [27,28,30,37–39], limited organisational willingness to invest in reflective learning beyond daily routines [44], and limited diversity among education participants. Patient and relative perspectives were underrepresented [31,36,44], as were staff beyond nursing, including allied health professionals [35], home care staff [32], and other healthcare roles [34]. Although many interventions adopted participatory approaches with healthcare professionals and staff, patient and relative involvement was infrequent and typically limited in scope. Suggested directions for future research included greater focus on the practical processes of implementing change [45], clarification of workplace roles in leadership education [32], and qualitative research and evaluations conducted in real-world practice contexts [37,39].

Strengths and limitations

This scoping review has several strengths. The inclusion of a reference group comprising patient and carer representatives, regional and municipal authorities, and professional organisations enhanced the relevance, credibility, and ethical sensitivity of the review through diverse perspectives and critical input throughout the process. Additional strengths include prospective protocol registration in the OSF, collaboration with an information specialist for the literature search, systematic screening and data extraction procedures, and an updated search that captured recently published studies. To minimise bias, the first and last authors, who co-authored one of the included publications, were not involved in screening, data extraction, or synthesis of that publication. The updated search further strengthened the review by capturing recently published studies. Several limitations should be considered when interpreting the findings. The included publications were highly heterogeneous in educational design, evaluation methods, and theoretical grounding, with many interventions having small samples, qualitative or action research designs, and non-comparative approaches. Few studies employed control groups, validated outcome measures, or longer-term follow-up. Consequently, reported positive outcomes should be interpreted as indications of perceived benefit and plausible mechanisms of change rather than evidence of effectiveness or causal impact, limiting conclusions regarding sustainability, scalability, and comparative effectiveness.

In line with scoping review methodology [21], no formal quality appraisal was conducted. While appropriate for mapping the evidence base, this further restricts interpretation for practice or policy recommendations. In addition, overlap between educator and researcher roles in several publications may have contributed to social desirability bias and underreporting of negative or unintended impact. The findings should therefore be regarded as exploratory and hypothesis-generating rather than confirmatory.

Conceptual and methodological challenges also affected the review. Variability in terminology related to leadership, person-centred care, and education may have resulted in the exclusion of relevant publications using alternative concepts. Although inclusion of the MeSH term “patient-centred care” might have increased retrieval, its exclusion was a deliberate conceptual choice, supported by literature distinguishing patient-centred care from person-centred care [4,23,73], and by evidence that dominant indexing terms can obscure conceptually distinct approaches in fields characterised by overlapping terminology [73]. Finally, restricting inclusion to publications in English, Finnish, Swedish, Norwegian, Danish or German and to indexed literature may have introduced language and publication bias. While necessary for feasibility and accurate interpretation, these restrictions may have limited the global representativeness of the findings. As with all literature reviews, publication bias cannot be fully eliminated, and caution is warranted when interpreting the results.