Objectives: We aimed to investigate resource use and its association to cognitive impairment, activities of daily living, and neuropsychiatric symptoms in residents of Swedish nursing homes.

Methods: Data were collected in 2014 from a Swedish national sample of nursing home residents (n = 4831) and were collected by staff in the facility. The sample consists of all nursing homes in 35 of 60 randomly selected Swedish municipalities. Demographic data and data on resource use, cognitive and physical function as well as neuropsychiatric symptoms were collected through proxies. Descriptive statistics and regression modeling were used to investigate this association.

Results: We found that cognitive impairment, activities of daily living, and neuropsychiatric symptoms were associated with 23 hours per week increase in total resource use versus cognitively intact persons. This was also the case for being dependent in activities of daily living. Being totally dependent increased the amount of resource use by 25 hours per week. The sex of a resident did not influence the resource use. Annual costs of resource use with no functional dependency were 359 685 SEK, and in severely cognitive impaired resident, the cost was 825 081 SEK.

Conclusion: Being cognitively impaired as well as functionally dependent increases the resource use significantly in nursing homes. This has implications for differentiation of costs in institutional settings in health economic evaluations.

Long-term care (LTC) reflects a growing emphasis on person-centered care (PCC), with services oriented around individuals' needs and preferences. Addressing contextual and cultural differences across countries offers important insight into factors that facilitate or hinder application of PCC practices within and across countries. This article takes an international lens to consider country-specific contexts of LTC, describing preliminary steps to develop common data elements that capture contextual differences across LTC settings globally. Through an iterative series of online, telephone, and in-person sessions, we engaged in in-depth discussions with 11 colleague experts in residential LTC and coauthors from six countries (China and Hong Kong, England, Sweden, Thailand, Trinidad and Tobago, and the United States). Our discussions yielded rich narrative describing a vast range in types of LTC settings, leading to our development of a working definition of residential LTC. Scope of services, funding, ownership, and regulations varied greatly across countries and across different residential LTC settings within countries. Moving forward, we recommend expanding our activities to countries that reflect different stages of residential LTC development. Our goal is to contribute to a larger initiative underway by the WE-THRIVE consortium to establish a global research measurement infrastructure that advances PCC internationally.

Aims and objectives: To explore the association between nursing home managers' leadership, job strain and social support as perceived by direct care staff in nursing homes.

Background: It is well known that aged care staff experience high levels of job strain, and that aged care staff experiencing job strain are exposed to increased risk for adverse health effects. Leadership styles have been associated with job strain in the literature; however, the impact of perceived leadership on staff job strain and social support has not been clarified within nursing home contexts.

Design: This study had a cross‐sectional design.

Methods: Participating staff (n = 3,605) completed surveys which included questions about staff characteristics, valid and reliable measures of nursing home managers' leadership, perceived job strain and social support. Statistical analyses of correlations and multiple regression analysis with interaction terms were conducted.

Results: Nursing home managers' leadership were significantly associated with lower level of job strain and higher level of social support among direct care staff. A multiple regression analysis including an interaction term indicated individual and joint effects of nursing home managers' leadership and social support on job strain.

Conclusions: Nursing home managers' leadership and social support were both individually and in combination associated with staff perception of lesser job strain. Thus, nursing home managers' leadership are beneficial for the working situation and strain of staff.

Relevance to clinical practice: Promoting a supporting work environment through leadership is an important implication for nursing home managers as it can influence staff perception of job strain and social support within the unit. By providing leadership, offering support and strategies towards a healthy work environment, nursing home managers can buffer adverse health effects among staff.

Background: Swedish nursing home managers, who constitute the empirical focus of this thesis, hold overall operational responsibility for the nursing homes, which includes the care of residents, direct care staff and work environment. Aged care organisations are also expected to provide person-centred care. Working towards a person-centred approach poses new demands and leads to challenges for leaders, and there is currently limited knowledge of what characterises leadership that promotes a person-centred approach. In addition, an ongoing demographic shift in the aged care workforce entails further challenges, as the proportion of professional workers is decreasing. Leading a healthy work environment is therefore important for ensuring and protecting staff health. Based on this, it is important to explore nursing home managers’ leadership in relation to person-centred care and the work situation of staff.

Aim: The overall aim was to explore leadership in relation to person-centred care and the work situation of staff in Swedish nursing homes.

Methods: This thesis is based on data from two data collections. First, it includes cross-sectional baseline data from a national inventory of health and care in Swedish nursing homes (SWENIS) collected in 2013-2014. The SWENIS dataset consists of a sample of staff n=3605 from 169 nursing homes in 35 municipalities, and nursing home managers n=191. The second data collection consists of 11 semi-structured interviews with 12 nursing home managers in highly person-centred nursing homes that already participated in SWENIS. Data were explored via descriptive statistics, simple and multiple regression analyses, and qualitative content analysis.

Results: Leadership was positively associated with person-centred care and psychosocial climate. Highly rated leadership behaviors’ among nursing homes managers was characterized by experimenting with new ideas, controlling work closely, relying on his/her subordinates, coaching and giving direct feedback, and handling conflicts constructively. Leading person-centred care can be outlined by four leadership processes: embodying person-centred being and doing; promoting a person-centred atmosphere; maximizing person-centred team potential and optimising person-centred support structures. Leadership was also positively associated with social support and negatively associated with job strain. Further, the variation in leadership was to a very small extent explained by the nursing home managers’ educational qualification, operational form of the nursing home and the number of employees in a unit.

Conclusions: All findings point in the same direction: that leadership, as it is characterized and measured in this thesis, is significantly associated with person-centred care provision as well as with the work situation of staff. This suggests that nursing managers have a central leadership role in developing and supporting person-centred care practices, and also in creating a healthy work environment. The results also highlight five specific leadership behaviours that are most characteristic of highly rated leadership, thereby adding concrete descriptions of behaviours to the literature on existing leadership theories. The findings also include four central processes for leading towards person-centred care in nursing homes. Taken together, it seems important for managers to translate the person-centred philosophy into actions and to promote an atmosphere pervaded by innovation and trust, in which cultural change is enhanced by positive cultural bearers. Utilizing the overall knowledge and competencies among staff and potentiating care teams was also considered important for leading person-centred care, along with optimising supportive structures for supporting and maintaining person-centred care. If aged care organisations are to be committed to person-centred care, an important implication seems to be to organise nursing homes in a way that allows nursing home managers to be close and present in clinical practice and actively lead towards person-centred care. The findings of this thesis contribute to our understanding of leadership in relation to person-centre care and the work situation of staff. These findings can be used in leadership educations and nursing curriculum. Longitudinal studies would be valuable for following leadership, person-centred care and the work situation of staff over time.

Aim: To identify characteristics of highly rated leadership in nursing homes. Background: An ageing population entails fundamental social, economic and organizational challenges for future aged care. Knowledge is limited of both specific leadership behaviours and organizational and managerial characteristics which have an impact on the leadership of contemporary nursing home care. Design: Cross-sectional. Method: From 290 municipalities, 60 were randomly selected and 35 agreed to participate, providing a sample of 3605 direct-care staff employed in 169 Swedish nursing homes. The staff assessed their managers' (n = 191) leadership behaviours using the Leadership Behaviour Questionnaire. Data were collected from November 2013 - September 2014, and the study was completed in November 2016. A two-parameter item response theory approach and regression analyses were used to identify specific characteristics of highly rated leadership. Results: Five specific behaviours of highly rated nursing home leadership were identified; that the manager: experiments with new ideas; controls work closely; relies on subordinates; coaches and gives direct feedback; and handles conflicts constructively. The regression analyses revealed that managers with social work backgrounds and privately run homes were significantly associated with higher leadership ratings. Conclusion: This study highlights the five most important leadership behaviours that characterize those nursing home managers rated highest in terms of leadership. Managers in privately run nursing homes and managers with social work backgrounds were associated with higher leadership ratings. Further work is needed to explore these behaviours and factors predictive of higher leadership ratings.

Social occupations have been described as meaningful occupations, and a determinant of health in old age. With ageing populations, and increased need for nursing home care, it is therefore important to support participation in social occupations in nursing homes. However, the limited evidence on factors that may have an impact on nursing home residents’ participation in social occupations makes it difficult to know how and when to support their participation and who to target. Therefore, the aim of this study was to explore the impact of symptoms, resident characteristics and features of nursing homes on residents’ participation in social occupations. In a sample of 4,451 nursing home residents, the average number of social occupations participated in during the week preceding data collection was 5.8. Additionally, participation in social occupations was positively influenced by fewer symptoms of cognitive impairment, female sex, shorter length of stay, and living in a dementia specific care unit. The study thereby contributes with knowledge on populations at risk for occupational deprivation, and implications for understanding who to target with interventions to promote social occupations and when. However, very little is known about how to design interventions to support nursing home residents’ occupational opportunities, and what occupations they desire and need. Further research is therefore needed to identify nursing home residents’ occupational opportunities, wishes and needs in relation to environmental barriers, individual characteristics, and individual choice.

The aim of this article is to describe the Umeå ageing and health research programme that explores person-centred care and health-promoting living conditions for an ageing population in Sweden, and to place this research programme in a national and international context of available research evidence and trends in aged care policy and practice. Contemporary trends in aged care policy includes facilitating ageing in place and providing person-centred care across home and aged care settings, despite limited evidence on how person-centred care can be operationalised in home care services and sheltered housing accommodation for older people. The Umeå ageing and health research programme consists of four research projects employing controlled, cross-sectional and longitudinal designs across ageing in place, sheltered housing, and nursing homes. The research programme is expected to provide translational knowledge on the structure, content and outcomes of person-centred care and health-promoting living conditions in home care, sheltered housing models, and nursing homes for older people and people with dementia.

Aim: To explore the association between leadership behaviours among managers in aged care, and person‐centredness of care and the psychosocial climate.

Background: Theory suggests that leadership is important for improving person‐centredness in aged care, however, empirical evidence is lacking.

Methods: A cross‐sectional design was used to collect data from Swedish aged care staff (n = 3661). Valid and reliable questionnaires assessing leadership behaviours, person‐centeredness of care and the psychosocial climate were used. Data were analysed using multiple linear regression including interaction terms.

Results: Leadership behaviours were significantly related to the person‐centredness of care and the psychosocial climate. The level of person‐centredness of care moderated the impact of leadership on the psychosocial climate.

Conclusions and implications for nursing management: The leadership behaviour of managers significantly impacts person‐centred care practice and contributes to the psychosocial climate for both staff and residents in aged care. This study is the first empirically to confirm that middle managers have a central leadership role in developing and supporting person‐centred care practice, thereby creating a positive psychosocial climate and high quality care.