Health and social care context.

The study was conducted within the Swedish health and social care system, which is currently undergoing transformation towards more person-centred and integrated care across health and social care settings [26,27]. Swedish health and social care is characterised by a decentralised governance structure where regions are responsible for medical and specialised whereas municipalities are responsible for health and social care in people’s homes [28]. This multi-level governance system requires coordination and collaboration across organisational and professional boundaries to achieve person-centred and integrated care. The leadership programme under study was developed to support the ongoing transformation.

The educational programme.

The University of Gothenburg Centre for Person-Centred Care (GPCC) and the Swedish Association of Health Professionals (SAHP), i.e., the main trade union for registered nurses, midwives, radiographers, and biomedical scientists in Sweden, collaborate to deliver a six-month educational programme on person-centred leadership [15]. The programme aims to strengthen leaders’ capacity to promote and implement PCC, with a particular focus on leading and managing change processes in complex organisational contexts. It is offered to SAHP members in leadership roles, including development leaders and managers, working across a range of health and social care settings and serving diverse patient groups. SAHP members were chosen as the target group because they constitute a large proportion of middle managers in Swedish health and social care. These leaders are typically responsible for operational activities and work in close proximity to both healthcare professionals and patients. This group was therefore considered to be particularly well positioned to translate person-centred leadership into practice and thereby contribute substantially to the ongoing national transformation towards person-centred and integrated care. During the study period (2022), 80 leaders were admitted to the programme.

The programme comprised six modules covering key aspects of PCC, leadership, and ethics:

1. Foundations of PCC and person-centred leadership
2. Communication and narration: self in relation to others
3. Strategies for implementing PCC
4. Being person-centred and leading with a person-centred approach
5. Ethical dilemmas and legal jurisdictions relevant to PCC
6. Leading future care: presentation of developmental projects

A blended learning format with both digital, in-person and workplace-based learning activities was applied. The pedagogical approach was based on a flipped classroom method [29], drawing on experiences from a higher education course in PCC to stimulate learning based on person-centred principles [30]. Each module included individual preparation followed by a workshop session to promote reflective practices and experiential learning. Preparatory activities included reading course literature [31], watching two to three recorded lectures (each film 20–30 min long), and completing practical homework assignments in the workplace. These homework assignments encouraged collaboration with employees, patients, and peers. Participants also maintained reflective journals to document insights and questions, which were later discussed in the workshops. The workshops combined full-group discussions with smaller peer-support groups consisting of four to six programme participants. These activities were facilitated by a team of two management strategists and two researchers (the first and last authors). The programme’s learning activities were designed to support the development of two implementation plans: one focused on person-centred leadership and the other on PCC. The pedagogical approach emphasised initiating both plans during the programme while recognising implementation planning as an ongoing process that would continue beyond its completion. Before the programme concluded, participants selected one of the plans for further development and submitted it as their final examination assignment [15].

In the programme curriculum, various aspects of leadership, such as communication, improvement science, and team development, were combined with the GPCC’s framework on PCC. This framework comprises three routines: 1) initiating a partnership – using narratives as tools, 2) working in partnership – applying shared decision-making on ways forward, and 3) safeguarding the partnership – sharing documentation of narratives and joint decisions among involved partners [32]. In the educational programme, all learning activities were designed to integrate these three routines to support leaders in translating person-centred ethics into leadership and care practices [15]. Specifically, each activity incorporated elements of narration, shared decision-making, and shared documentation–such as collages, written summaries of agreements, and implementation plans–to illustrate how the framework could serve as a practical tool for implementing PCC in leadership practices. Further details on the programme are provided by Lood et al. [15].

Reflecting on the practice of leadership.

Participants expressed that having the opportunity to contemplate their own leadership in the context of person-centred principles was both fulfilling and beneficial for their self-leadership development. In the fast-paced environment of health and social care, such opportunities for self-reflection were rare and the programme created space for participants to assess and review their leadership approach and their capacity to lead in a person-centred way. Self-reflection was also described as essential for recognising that others may perceive situations differently, underscoring the importance of examining one’s own assumptions and perspectives to improve interactions with others. As one participant articulated:

You get the chance to pause and reflect in a way that you don’t usually do. And to reflect on precisely this: How am I as a leader? Am I person-centred? Do I see my employees? Am I working to get to know them? (Interview 10)

Throughout the programme, participants immersed themselves in profound reflection on their leadership practices, particularly in relation to person-centred ethics. This process, anchored in self-leadership, combined individual reflection with peer dialogue. Through various reflective exercises, they were prompted to critically examine their roles, responsibilities, limitations, and strengths. These exercises were both challenging and empowering, leading to meaningful insights that supported self-leadership development. One participant shared their thoughts on the impact of this reflective process:

It’s as if I’ve reflected in sync and worked on myself, associating things that we’ve had in the training. Bringing them together with my organisation and connecting them. What I’ve learned, how it is in reality, and how I work. (Interview 1)

Adopting a language for person-centeredness.

Participants experienced notable enhancements in their ability to communicate the principles of PCC to other leaders and employees. They recognised that interpretations of PCC and person-centred leadership can vary considerably, and that clearly articulating their own understanding was essential for effective leadership. Through the programme, their self-leadership was developed through greater confidence and precision in expressing their perspectives, acknowledging that defining key concepts was a vital part of advancing as person-centred leaders. As one participant noted:

It’s about using words without defining what we mean by those words. So, when we say, ‘person-centred leadership’ or ‘person-centeredness’, before doing much more and working together, we need to define what we mean here in this context. It became very clear that we had somewhat different perspectives on it. (Interview 5)

Another participant highlighted that they regularly shared insights from the programme with their employees and involved them in assignments between sessions. This helped facilitate the adoption of a shared language for person-centredness in practice and demonstrated a proactive approach to self-leadership:

So, I thought like this, ‘Now, let’s incorporate a person-centred approach in a small, at least in a small part, of this big project.’ [...] I’ve talked about person-centred care at almost every monthly team meeting and [about] what I had learned from the training. They got to learn from me each time I learned something new. (Interview 11)

Integrating person-centred principles into one’s leadership style.

Throughout the programme, participants experienced a transformation in mindset, reshaping their understanding of leadership, moving towards a more person-centred approach. This transformation was an important aspect of their self-leadership development, as it involved critical reflection on their own values, behaviours, and assumptions. By dismantling internal barriers and broadening their perspectives, participants were able to develop innovative solutions to complex challenges in their leadership practice. The programme ignited a profound understanding of, and appreciation for, employees as persons, reinforcing the importance of becoming more person-centred leaders, as one participant expressed:

That would probably be it, that I try more and more to think about who I have in front of me. It facilitates things. It also helps privately sometimes when one tries to understand. ‘Why does this happen or...?’ (Interview 12)

As described by the participants, the programme further provided them with valuable opportunities to apply their knowledge in real-world situations, which promoted both personal and professional growth. Even those with significant experience in PCC found the programme to be both challenging and affirming. Engaging in reflective processes was central to their self-leadership journey, as it encouraged them to critically assess their leadership practices and previous assumptions. As one participant described:

Now, you have really been able to challenge yourself in certain things, and some things may have been a confirmation of what you already know. […] I feel that, yes, we have been in this, although we haven’t thought about it as systematically as we do today, and neither have I. […] I feel that I have received a lot of support in the programme because I didn’t quite think like that before. (Interview 10)

Leading others with courage and confidence.

Participants emphasised how the educational programme significantly strengthened their skills to lead their teams. They felt empowered to create space for others by adopting a person-centred approach to both leadership and care. This shift was underpinned by a growing sense of confidence and clarity in their roles as leaders of their teams. They described a transformation in their leadership style, from previously uncertain to more grounded and assured, thanks to the programme. One of the participants expressed their empowerment as follows:

I felt empowered in the sense that I’m doing the right thing. I’m on the right track. I have the feeling that if I hadn’t taken that leadership training, maybe I would have faltered along the way, quite simply. (Interview 8)

Participants also shared a revitalised sense of self-assurance and stability in leading their teams. By integrating new tools and perspectives, they experienced a deeper sense of calm and control. Although some had previously doubted their team-leadership abilities, they now felt the courage to recognise and acknowledge their strengths. The programme equipped them with a fresh perspective on how to empower their teams, promoting a more inclusive, collaborative, and confident leadership environment. As one participant articulated:

Now I have a few more tools in my little toolbox that I can use, and I don’t get so nervous or worried if I find myself in situations where I feel like, ‘No, I don’t know. I have no solution for this today.’ Without knowing how to act. I might not have an answer, but I’ll come back. I believe that the training, combined with other factors, has made me feel more confident as a manager, absolutely. (Interview 4)

Exploring curiously without preconceived assumptions.

Participants noted that one of the most significant changes they experienced following the programme was the development of a more curious and open-minded approach to team-leadership. This shift in mindset marked an essential counterbalance to their prior practices, where they frequently assumed they understood the needs of employees, patients, and relatives. Such assumptions had previously limited their ability to lead in a truly person-centred way. Through the programme, participants learned to cultivate curiosity as a core team-leadership skill, asking questions rather than relying on assumptions. This change enabled them to better understand the unique perspectives and needs of those they lead. One participant reflected:

I often say it is intriguing that we, as care professionals, think we know what patients and relatives need and have a pretty good idea about it. But when you speak to patients and relatives, you see that... sure, some things are entirely correct, absolutely. But there’s also so much that is individual-dependent, which is not at all what we assume. (Interview 5)

Participants also found it challenging yet immensely rewarding to engage in conversations without steering them too much. This required them to listen with full attention and to suspend their own preconceived judgements and expectations. The quotation below highlights how they experienced active listening as a both demanding and enlightening practice that deepened their ability to lead with presence.

And then I tried to let them just speak for themselves. I find it difficult because it’s easy for me to... that I want to try to control it [...] You also got to hear what they do, things you don’t see when they’re working. They were supposed to give examples of when they worked in a person-centred way, and it was great because a lot of things came up, things they do here on weekends when I’m not here, and so on, so it was fun. But maybe I should dare to let them speak even more instead of trying to steer a little. (Interview 12)

Setting the stage for reciprocal meetings.

During the programme, participants described how they deepened their understanding of their own leadership strengths by actively engaging employees in tasks and discussions related to PCC. A key area of team-leadership development was their ability to foster more meaningful and reciprocal interactions with their teams. They recognised the importance of being more prepared to invite employees to scheduled meetings and of being fully present during conversations, as highlighted in the quotation below.

I’ve thought about many things there that I’ve changed or tried to work on, especially my presence in a meeting. How I’m present when I meet my employees and other people. In hindsight, I’ve reflected that I was often maybe somewhere else or far ahead in my thoughts. Now I try to be more present in the meeting. (Interview 1)

Participants further expressed that they uncovered valuable insights by altering their approach to conversations and meetings. They gained deeper insights into both operational dynamics and employee well-being. Engaging with employees in their daily work, prior to performance reviews, allowed for more grounded and informed discussions. Scheduled meetings became opportunities to tackle important topics in more innovative and impactful ways. Moreover, many participants observed that they had become better at encouraging others to actively engage in conversations. This shift towards a more inclusive dialogue came about through reflection and growth during the programme, as illustrated in the following quotation:

This exercise allowed me to reflect on how I invite people to conversations. What are the effects depending on how you organise the conversation or how you invite someone? [...] it gave me insight into what I should do to get sincere answers and a sense of how they think and [what they] believe, and so on. Not to be too authoritarian, perhaps. (Interview 7)

Recognising uniqueness and using all competencies.

As part of their workforce development efforts during the programme, participants recognised the significance of treating employees with the same level of care and respect as patients and their relatives. This shift in perspective was key to cultivate a more positive and productive workplace culture. By adopting a person-centred approach to leadership, participants described that they felt empowered to build successful teams, grounded in open communication and mutual trust between leaders and employees. A vital component of such workforce development was the recognition of each employee’s unique strengths and areas for growth. The practical exercises within the programme encouraged participants to regularly evaluate and address employees’ needs, ensuring that everyone could effectively leverage their skills in the workplace. As one participant noted:

Maybe it’s more about me thinking that way, trying to see nurses also as individuals in a different way, and actually trying to consider how their skills fit into the right context and that we are good at different things, and it’s important to incorporate everyone’s skills. I think I try more to engage in broader dialogues, perhaps more openly than I did before. But it’s not certain that it’s visible. (Interview 11)

As participants began to organise and apply their own and employees’ competencies in a more organised manner, they noticed a broader range of perspectives emerging in discussions. As the programme advanced, this led to increased employee engagement in developing the workplace. Participants realised that effective leadership does not require them having all the answers. Instead, they found it beneficial to systematically involve others early in the process, co-creating solutions with employees. As described by one participant:

Can we look at it together and see how we can improve each other’s skills? That’s also a part of it, not thinking that one must know everything, but that this is a way we could make it clearer. (Interview 13)

Power shifting through shared decision-making.

Participants shared their insights on how the programme supported a shift in their leadership approach by promoting shared decision-making as an element of workforce development. By involving employees earlier in operational decisions, participants began to feel that the workplace was more inclusive and collaborative, helping them to feel less isolated, and making the workplace feel more enjoyable. However, participants observed that altering established working methods and enhancing employee involvement in decision-making was a lengthy and challenging endeavour. It required practice and a willingness to let go of control, as exemplified by one participant:

I may have an idea, but I don’t necessarily need to present my idea; instead, I can ask, ‘Do you have any ideas on how we can solve this?’ And that’s something I’ve had to practise a lot. I am responsible for the decision, but I don’t need to make the decision without my employees being able to contribute with their own ideas. I can say, ‘If you think this is the best solution, I’ll accept it.’ (Interview 4)

Participants also noted that employees often felt uncertain about assuming responsibility, prompting them to reconsider their previous, more controlling, approaches to leadership. The programme helped them develop the ability to temper their own need for control, listen more actively and create space for dialogue between them and employees. This promoted collaborative thinking rather than leaders making decisions on behalf of employees, seen as essential for more sustainable workforce development as illustrated by the following quotation:

It’s about listening more, not thinking that you know best and have all the solutions. I’ve discussed this a lot during the training with my closest colleague, who is also very clear and direct... but we have actually changed... we have reflected and changed our approach, to listen more, to have more of this dialogue, to listen. (Interview 2)

Allowing progression together at a steady pace.

Participants found that adopting a person-centred approach to their leadership during the programme helped them to achieve a joint and steady development towards PCC at their units. They reflected on the importance of understanding their own operations, the needs of employees, and the shared purpose of their work. They also gained tools for change management, motivation and communication. Moreover, the programme introduced structured routines for PCC (initiating a partnership, working in partnership, and safeguarding the partnership), which provided a practical framework for leading change collaboratively. These routines helped participants manage change with greater clarity and calm, as one participant described:

Yes, but I’ve had this mantra, narrative, partnership, documentation. It has become a mantra for me, to say, ‘This is what we should look at and raise our gaze.’ How should one think about it at all levels? (Interview 13)

Participants also recognised the challenges of adopting new work practices and the significance of setting clear goals. The programme inspired them to reflect on and value the importance of establishing both personal and organisational goals for the progress of PCC, aligning leadership objectives with employee needs and broader organisational aims. They stressed the necessity of anchoring change efforts among all persons involved to ensure a shared understanding and commitment. As one participant stated:

Yes, that’s something I’ve struggled with a lot, so that it truly becomes the target group and the employees who decide whether it’s person-centred or not. […] It’s about them having influence, feeling that they have influence, and demonstrating that they do in some way. And we need to ask them and invite them in. (Interview 9)