Person-centred Leadership: a relational approach to leadership derived through action research

This article explores the concept of person-centred leadership in clinical nursing and its influence on healthcare relationships. It presents the findings of a three-year participatory action research study, highlighting the attributes, processes, and contextual factors that contribute to person-centred leadership. The article also offers a conceptual framework for person-centred leadership and its potential impact on self-actualization, empowerment, and well-being.

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DR. SHAUN CARDIFF (Orcid ID : 0000-0002-2557-6052)
Article type : Original Article
Title: Person-centred Leadership: a relational approach to leadership derived
through action research
Authors:
1. Shaun Cardiff MSc, Dphil, RGN, Senior lecturer
Fontys University of Applied Sciences, School of People & Heathcare Studies
Eindhoven, The Netherlands.
2. Brendan McCormack BSc, DPhil, RGN, Head of Division of Nursing,
Queen Margaret University, Edinburgh, UK.
3. Tanya McCance BSc, DPhil, RGN, Director of the Institute of Nursing and
Health Research,
Faculty of Life and Health Sciences, Ulster University, Jordanstown, UK.
Corresponding author:
Shaun Cardiff
Email: [e-mail]
Telephone: [phone]
Conflict of Interest Statement: There are no conflicts of interest to declare.
Funding statement: This work was conducted by the first author in preparation
for a doctoral degree and supported by his employer.

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Abstract:
Aims & Objectives: How does person-centred leadership manifest in clinical nursing.
Background: Person-centred practice fosters healthful relationships and is gaining increasing
attention in nursing and healthcare, but nothing is known about the influence of a person-
centred approach to leadership practice. Most leadership models used in nursing were
originally developed outside of nursing.
Design: A three year participatory action research study where participant leaders planned,
researched and learned from their practice development.
Methods: After an orientation phase, four action spirals focused on: critical and creative
reflective inquiries into leadership practice change; leading the implementation and
evaluation of a new nursing system; facilitating storytelling sessions with staff and annually
reflecting on personal leadership change. Multiple data gathering methods offered insight into
leadership development from several perspectives.
Results: Critical and creative thematic data analysis revealed a set of attributes, relational
processes and contextual factors that influenced the being and becoming of a person-centred
leader. Comparing the findings with nursing leadership literature supports a conceptual
framework for person-centred leadership.
Conclusions: Person-centred leadership is a complex, dynamic, relational and contextualised
practice that aims to enable associates and leaders achieve self-actualisation, empowerment
and wellbeing.
Keywords: person-centeredness; leadership; nursing leadership; action research
What does this paper contribute to the wider global clinical community?
 This paper offers deeper insight into clinical nurse leadership as a relational and
contextual phenomenon.
 The participatory action research methodology shows how clinical nurse leadership
can be developed and researched in practice, with practitioners.
 The conceptual framework offers clinical nurse leaders a reflective tool to support
leadership development and the development of person-centred cultures.
INTRODUCTION
With increasing concerns among service-users and practitioners about the nature, formation
and maintenance of healthcare relationships, policy-makers, administrators and scholars are
showing greater interest in the concept of person-centred practice. Berwick (2013) advises
leaders at all levels to concern themselves more with the realities of frontline healthcare and
develop cultures of learning, compassion and continuous improvement. Person-centredness
has been identified as a core value of effective workplace cultures (Manley, Sanders, Cardiff
& Webster, 2011) and person-centred practice defined as the formation and fostering of

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healthful relationships with service users and among staff, based on the humanistic values of
respect for persons, individual right to self-determination, mutual respect and understanding
(McCormack & McCance, 2017). Whilst nurse leadership has received a lot of attention in
nursing literature, the study of person-centredness in nursing leadership is still in it’s infancy.
Background
Industrial age heroic and autocratic leadership, with its hierarchical and linear thinking,
compartmentalization, surveillance and control has been criticized as new leadership styles
emerge which address complexity, whole system and meta-thinking, outcome orientation,
morality and purposefulness (Cook, 2001; Wheatley, 2006). New styles of leadership
described and researched in nursing include authentic (Avolio, Gardner, Walumbwa, Luthans
& May, 2004); servant (Greenleaf, 2003); transformational (Bass & Riggio, 2006; Kouzes &
Posner, 2007) and situational (Hersey, Blanchard, & Johnson, 2001), although none of these
originated from nursing research or the nursing context. This is of importance as, from a
Bordieusian perspective, ways of being learnt and embodied whilst a nurse will influence
leadership practice (Lalleman, Smid, Lagerwey, Oldenhof, & Schuurmans, 2015). Also,
many leadership theories, styles and research assume that leaders hold hierarchical positions
and achieve outcomes by simply applying techniques, principles and practices i.e. a
unidirectional flow of influence causing change (Cunliffe & Eriksen, 2011). However,
effective leadership in healthcare is more complex as leaders need to consider “roles,
relationships and practices that are made within contexts and through social interactions,
while learning with people who share these contexts” (Fulop & Mark, 2013: 257). Inquiring
into the work of nurses, DeFrino (2009) argues that it is through their unseen relational work
that nurses achieve positive patient and professional outcomes. Such embodied history could
flow over into nursing leadership relationships and, in contrast to task-focused nurse leaders,
relationship focused leaders have been shown to improve nurses’ working life, care
environments, productivity and patient outcomes (Cicolini, Comparcini, & Simonetti, 2013;
Cowden, Cummings, & Profetto-McGrath, 2011; Cummings et al., 2010; Wagner et al.,
2010; Wong, Cummings, & Ducharme, 2013; Lynch, McCormack, McCance & Brown,
2017). However, nursing leadership research predominantly views leadership from a
hierarchical perspective and is rarely framed within relational leadership theory.
Relational leadership theory detaches leadership from management and hierarchical roles
(Uhl-Bien, 2006) and has been defined as “a practice of caring for colleagues, enabling others
to act, acknowledging and learning from one’s mistakes and being emotionally authentic”
(Binns, 2008, p.601). How relationships and relational dynamics maintain, transform and/or
construct social structures, conventions and practices becomes the focus of study (Uhl-Bien,
2006). As a moral and dialogical practice, relational leadership is a way of “being and
relating with others, embedded in everyday experience and interwoven with a sense of moral
responsibility” (Cunliffe & Eriksen, 2011, p.1432). Several relationship-orientated leadership

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models and frameworks are described in nursing literature. Transformational leadership is a
popular choice and frequently found in person-centred practice literature (e.g. McCormack &
McCance, 2010; Beckett et al., 2013). However, neither Bass and Riggio’s (2006) nor
Kouzes and Posner’s (2007) leadership models were developed within a nursing or healthcare
context. Also, hierarchical power could be a means of aligning staff values, beliefs and
behaviour to that of the organisation or the leader self. Measurement tools for these models
do not reveal outcomes achieved through manipulation, destruction and/or exploitation
(Hutchinson & Jackson, 2013). In their critique of transformational leadership in nursing,
Hutchinson and Jackson (2013) conclude that there is still much to be explored in nursing
leadership, and ethics and values should be given greater attention. Uhl-Bien (2006) also calls
for richer methodologies that study the processes involved in the emergence of leadership
relationships within the workplace.
THE STUDY
Aims
The aim was to study changes in clinical nurse leadership when approached from a person-
centred perspective.
Method
The chosen method was participatory action research (PAR), a rich methodology seldom
used in leadership research, but one that longitudinally studies change by and with
participants through processes of consciousness raising, collaboration and empowerment.
Action researchers (AR’ers) collaborate with practitioners, as co-researchers, to collectively
inquire into their past, present and future practice and context, with an intent of bringing
about change for the good of all and generating scientifically and practically adequate
knowledge (Winter & Munn-Giddings, 2001; Kemmis, 2008). In their natural setting,
facilitated by an external AR’er, clinical nurse leaders in this study systematically researched
changes to their leadership practice as they individually and collectively reflected on a
person-centred approach. Working with principles of collaboration, inclusivity and
participation also meant that the study design emerged across time as it responded to
individual, community and contextual (need) changes.
Context, participants and participation
The PAR fieldwork was conducted in one unit of a Dutch urban general hospital between
2009-2011. A general study design was collaboratively agreed with the unit team before the
orientation phase and again before the action spirals were started. Initial participant co-
researchers were the unit nurse manager (UM Betty) and two charge nurses (CNs Anne and

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Loes) who responded to an article describing the AR’ers (first author) interest in studying
person-centred leadership. During the study, one CN became the unit clinical nurse specialist
(CNS Anne), a new CN was internally recruited (CN Fleur), and two primary nurses (PNs
Chloé and Tess) joined the group in action spiral 2. Proposed research activities were
presented in planning meetings, with the AR’er and co-researchers dialoguing until details
were collaboratively agreed. Each co-researcher self-determined the degree to which they
would be active as a subject and/or researcher, per activity. The emergent and responsive
nature of PAR also accommodated self-determined involvement of staff in various research
activities throughout the study, for example, being interviewed post leader observation or co-
interpreting results obtained in action spiral two.
Data collection during the study
PAR generally begins with an orientation phase, the outcomes of which inform core action
spirals of planning, acting, observing and reflecting (Kemmis & McTaggart, 1988). Data
collected and analysed during the orientation phase was aimed at generating a deeper
understanding of existing relationships and the context. This was achieved through: a culture
workshop with the care team, AR’er participant observation of context and nurse leadership
by the CNs and UM, and narratives of care (n=24) and leadership (n=11) collected from
patients, staff and a physician (see table 1). Results were presented in a poster gallery event
where, after viewing, the team shared claims and concerns about the unit, collectively
identified issues for development and suggestions for action. The action research group used
these claims, concerns, issues and suggestions to co-design action spirals aimed at
collaboratively becoming aware of, and empowered to, lead from a person-centred approach.
The action phase design (see figure 1) was structured with a central action spiral influencing
and being influenced by three other action spirals (see table 1 for goals and data gathering
activities).
Action spiral one consisted of biweekly, two hourly critical and creative reflective inquiries
(CCRI) (Cardiff, 2012), held across the two years. During CCRI’s participant leaders
supported each other in sharing recent leadership narratives and collectively reflecting on
them using Mezirow’s (1981) model of critical reflection. Resultant insights influenced future
leadership practice and subsequent observations incorporated into new inquiries. Audio-
transcripts and photographs of the creative expressions in each session were used for post-
fieldwork data analysis.
Action spiral two entailed the design and implementation of a new nursing system based on
the principles of primary nursing (c.f. Manthey, 2002). Development of the system and
enactment of the PN role offered deeper insight into clinical leadership. The CN’s adopted a
dual CN/PN role and two new PNs were internally recruited. To generate a shared vision on
primary nursing, participant leaders engaged in a creative workshop and conducted semi-

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structured interviews with members of the care- and medical team as part of a second
workshop on the PN role. Participant observation of the leaders in practice was conducted by
the AR’er shadowing participant leaders at and away from the bedside. Observations sessions
ended with a post-observation leader interview, sometimes accompanied by an interview with
those being led during the session. This offered insight into individual leader intent as well as
follower perceptions. The PNs also held regular meetings evaluating the implementation
process and invited staff contributions via various methods, such as, an evaluation journal
kept in the staffroom. They used Guba and Lincoln’s (1989) claims, concerns and issues
framework to structure and document evaluations.
Staff perceptions on culture and leadership change were collected using various methods.
Qualitative data on culture and practice change were gathered in a creative culture workshop
with the care team. Quantitative data were obtained in a leader designed Likert scale staff
questionnaire, the items of which were based on concerns identified in the (pre)orientation
phase: care continuity and coordination, informed families, workload, work satisfaction, unit
atmosphere, student supervision and PN leadership of care from admission to discharge. Staff
perceptions of received leadership were collected during a workshop facilitated by an
external university researcher with no ties to the study and anonymised transcripts member-
checked before sharing with the action research group.
In action spiral three the CNs facilitated weekly 20 minute storytelling sessions where
nursing staff could share narratives and reflect on their care using McCormack and
McCance’s (2010) framework for person-centred nursing. CN experiences of facilitating
these sessions were collected in post-observation interviews, initially by the researcher and
later by each other. These too were audio-taped and transcribed.
Whilst action spiral one created reflective space for daily leadership practice, annual
reflective inquiries in action spiral four provided space to evaluate and reflect on personal
growth. Individual creative expressions of leadership and growth were critically peer
reviewed and findings compared to those of the previous annual inquiry. Whilst the PNs and
CNS chose not to participate in these sessions, they did participate in a mid-term evaluation
workshop on the research project. Having re-defined leadership during a CCRI as “a (non-
)hierarchical relationship where one person supports individuals and groups in achieving
common goals”, participant leaders felt that the AR’er was also engaging in (person-centred)
leadership. As critical (self-)reflection by an action researcher enhances research credibility
(Trondsen & Sandaunet, 2009), it was agreed that the traditional researcher ‘facilitator’ role
(c.f. Winter & Munn-Giddings, 2001) would be viewed as a ‘leader’ role. Data from the
AR’ers annual inquires, alongside the AR’er journal, audio-recorded supervision sessions and
notes from his own action learning set, therefore contributed to the data pool. The AR’ers
leadership was also evaluated by participant leaders in a workshop facilitated by the external
researcher.

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Data analysis
Data gathered in the orientation phase was analysed before action spiral planning. Data on
(the growth of) person-centred leadership was gathered and sometimes analysed during the
action phase as data interpretation during field work is inherent to PAR. Researchers and
participants reflect on recent observations and narratives to inform change (Winter & Munn-
Giddings, 2001). Two years of action spirals yielded 250+ hours of audio-recordings, 23
participant observations and documents from various workshops. To reduce the data corpus
to a size feasible for post-fieldwork analysis the whole was divided into two data sets. The
primary data set (see table 2) was used for the initial thematic analysis. The remaining
collected data was used to support and/or challenge themes emerging from primary data set
analysis.
A six phased thematic analysis (see box 1) was conducted by the AR’er, based on the
analysis frameworks of Braun and Clarke (2006) and van Lieshout and Cardiff (2011).
Transcripts from the primary data set were used for phases 1-5. Transcripts from the
secondary data set were included during phases 4-5 in order to expand the scope of evidence
supporting or challenging emerging themes.
Ethical considerations
The study was approved by the ethics committee of the university supervising this doctoral
study. The study aims and plans were presented to the whole unit team for critical dialogue
before fieldwork commenced and after the orientation phase. The co-researchers gave
informed written consent at the beginning, all data gathering was overt and individual
informed verbal consent obtained before commencing data gathering activities. Participation
was voluntary and care taken to respect confidentiality and anonymity. As researchers
investigating their own leadership practice there was a concern for the wellbeing of others
and self. Posing ‘how to behave’ questions to self and one another became common practice.
In line with McCormack’s (2003) framework for person-centred research, the orientation
phase and weekly presence of the AR’er was conducive to researcher socialisation within the
setting; regularly held dialogical spaces helped prepare and engage people and boundaries
were (re)negotiated; research activities were planned with participants so as not to disrupt
patient care or unwillingly impinge on private time and member-checking all written
documentation ensured authentic representation of participant voice.
Findings
Thematic analysis of the data revealed themes and sub-themes for the ‘being’, ‘becoming’
and outcomes of person-centred leadership (see figure 2). ‘Being’ a person-centred leader
entailed a set of six leader attributes and seven processes. ‘Becoming’ a person-centred leader
was influenced by four developmental and four contextual themes and eight outcomes were
identified. Person-centred leadership was defined as a style of leadership in which a leader

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tries to enable associate coming into own whilst working towards a shared vision/common
goal. Participants chose to replace the traditional term ‘follower’ with ‘associate’ as they felt
this better reflected the humanistic values guiding their practice.
Attributes for being a person-centred leader: Essentially, participants felt that leaders need
to want to become person-centred and should be authentically other-centred and caring.
CN Loes: “… you can’t learn them all. You have to want to be other-
centred … Others have their ‘feelers’, don’t they? That authenticity must
be felt by the other. ” (CCRI 4)
Although they felt this could not be learnt, self-awareness emerging from reflecting and
working with one’s own values, beliefs and preferences fostered relational connectedness, as
did daring to show one’s own vulnerability. Vulnerability could be professional and/or
personal. For instance, one CN who initially believed that leaders should be a constant pillar
of support for staff, discovered that daring to show vulnerability, whilst grieving the death of
her father, can foster reciprocal support.
Being open, patient and optimistic fostered a sense of tranquillity as leaders listened
attentively to associates, seeing them as valued and distinct individuals moving collectively
towards a common goal. Students, like staff, also experienced equity when working alongside
CN’s and PN’s.
Student Joanne: “… a bit like an equal really, not as if I’m just another
student. No, very honest, very open, explaining things thoroughly, and
letting me talk first and then looking at, “Yes, that’s right,” or not.”
(Post-observation interview)
Reflexivity, reflecting with moral intent, on large and everyday small dilemmas required
inquisitiveness, analytical thinking, heeding and questioning intuition, as well as considering
(potential) consequences. Leaders used their interpersonal intelligences to move through
different levels of engagement and share rather than sell or impose their vision. Examples
included inviting associates to share their views/narrative before responding, and matching
offers of task participation with associate desire and ability. CN Loes articulated this
movement between nearness and distance without loss of connectedness, in a narrative about
a staff nurse who was failing to progress whilst on sick leave.

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CN Loes: ”You also have to be careful that you don’t get sick of it,
because then we’d be doing her an injustice … you have to be
sympathetic, but not lose your objectivity, and you have to keep trying to
see the bigger picture.” (CCRI 9)
Processes in being a person-centred leader: The leader attributes manifested in all
processes of person-centred leadership. Core processes of sensing, balancing,
contextualising, presencing and communing were identifiable in all situations, at different
moments, in different configurations and intensity. Engagement generates information,
helping the leader position themselves in relation to associates (stancing). Creating safe and
critical (learning) spaces also aided the creation of shared visions and/or goals.
Sensing was the continuous engagement of the senses to gather information about self,
associates, performances and context. Alternative information sources, such as accounts from
other staff members, personnel records or a leader’s history with the person, sometimes
supplemented what was being sensed, but verifying interpretations was important.
CN Fleur: “…I saw that she wasn’t coping well. I saw it on her face and
in her eyes … I asked, “How are you coping?... You come across as
being a bit muddled … I noticed it again in you.” And she said, “Yes, it’s
not my morning this morning.” But, she didn’t want to take it any
further.” (Post-observation interview)
Contextualising was the process of seeing associates as more than colleagues or nurses. Each
person has their own narrative, including social roles and contexts outside the workplace
which influence their being and performance within the workplace. Recognising this,
alongside contextual factors such as policy, time and resources, meant that leaders constantly
found themselves balancing needs.
CN Loes: “I have to do something… It’s not good for anyone… She isn’t
really going to get any better under these circumstances… we need to
look critically at where we can help her… Are we doing the right thing?
because it really is something if you have to say to someone, “You’re not
functioning adequately, so, you’ll have to leave here.” (CCRI 14)
Communing with associates entailed communicating at a more intimate level to find a
common ground, shared vision and/or collectively deciding how to act. Conflict situations in
particular revealed how destructive an authoritative stance, or use of hierarchical power,
could be for relationships. Lifting discussions to a higher level of abstractness helped identify

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the common opinion/goal and from here they could gradually work down to concreter details
and tackle divergences in opinion as they emerged, one-by-one. Self-awareness aided this, as
unearthing own expectations and identifying shared understandings/goals reduced
defensiveness and persuasion.
CN Loes: “What I have learnt from this is that my own stance, my own
insecurity, can come across as aversion and that in doing so I maintain
her [hierarchical] stance… On the other hand, I have to find a way to
build a collaborative relationship [with her] and I could achieve that by
agreeing a common goal, among other things, and by stating beforehand
that I want to discuss the common goal. I need to be aware of that myself
[own goal] and to discuss that with her.” (CCRI 7)
Observations and narratives of presencing showed a move from participant leader
doing/resolving issues ‘for’ associates to being and thinking ‘with’ associates. Attentive
listening and sympathetic/non-judgemental understanding preceded offering alternative
perspectives, hope, shared responsibility, plausible explanations or practical and concrete
advice. This was creatively expressed in a CCRI about a staff nurse who was experiencing
difficulties balancing her work-home responsibilities.
CN Loes: “It shows an opposing
balance to the loneliness depicted
in the other pictures, that there is
someone there who puts an arm
around you and says, ”You’re not
alone. We want to think with you
and help.” That doesn’t mean to
say that you can completely take
the despondency away …
sometimes just listening and
showing understanding is enough
and people then undertake action
themselves to resolve a problem.”
(CCRI 4)
These processes helped leaders decide how to position themselves in relation to associates
(stancing), each moment anew. Four basic stances were identified: leading from the 1) front,
inviting leader role modelling or ‘doing for’ associates; 2) side-line, offering instruction or
reminders; 3) alongside, balancing challenge with support to enable action; 4) behind,
stepping back and observing when comfortable with associate ability or enabling experiential
learning. Initially, participant preferred/habituated stances were to lead from the front or side-
line and more directive than invitational. The invitational approach proved to be effective in
respecting self-determination and leaders became more responsive, moving reflectively and
fluidly through different stances in any situation. Leading from behind was the most alien and
challenging, requiring calculated risk-taking at times.

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UM Betty: “I tried to connect with where she was at … where she is in
her role, so to speak, but, I didn’t take over. A year ago I would have
taken over and it would have been long sorted … now I think, “Ok, that
is a choice you have made, that’s possible. May also be a good thing, or
at least there may be some good elements to it.” So, I pick it up more
easily, where she is at, in that moment, in her situation … and I can
continue from that point … I also intervene now and again, to give them
the feeling that they are not left swimming [alone] either.” (Post-
observation interview)
Leadership had been nurturing associate dependency on leader direction, but focusing on
enabling associates to come into their own nurtured reciprocity. The idiomatic expression
was frequently used to describe leaders wanting to help associates feel good, reach their
potential, become more active and self-determinate. In time, they started to experience
reciprocity and feel good themselves, that things were right and working life was becoming
easier.
CN Loes: “I notice a difference. I must say I’m calmer now … I think
that I do it [leadership] better now, that I’m more confident about the
things that I do … I’m accepted and people understand that my choices
are often reflected upon and it’s easier … I’m myself now … I have
chosen for myself to stay as charge nurse for the time being. And I like
that.” (Post-observation interview)
Engaging in this AR exposed participant leaders to new ways of learning. They started to
experiment in creating safe and critical (learning) spaces where multiple perspectives could
be shared, horizons broadened, interpretations balanced, as well as shared power and
responsibility nurtured. The PN’s, in particular, started to see and capitalise on learning
opportunities around them, matching opportunities with associate need and readiness to learn.
PN Chloé: “I think she comes into her own because she said that she
wanted to do it [administer medication] a few times under supervision.
And then I created the space, so that we make sure she feels safe …”
(Post-observation interview)
Developmental processes in becoming a person-centred leader: When asked
for advice on becoming and/or researching person-centred leadership, participant
leaders unanimously replied: “take the time needed to ensure sustainable change”.

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It required constantly working around/with existent structures, processes and
workloads to foster participation and build safe, trusting relationships.
CN Loes: “… despite our enormous work pressure we took time to listen
to what people were saying, to really hear the team … and adjust
yourself to them first. Look at where there is a need and try to focus on
that … So, take your time … and look at the tempo they can work at.
Some are quicker than others.” (Midway evaluation with CN’s and UM)
Engaging in research activities enabled them to become acquainted with the researcher and
re-acquainted with one another. Creating safe, critical and creative communicative spaces,
one of the AR’ers philosophical principles, enabled deep and sometimes challenging self-
inquiry. These spaces supported change momentum, honest and critical debate, living with
uncertainty, problem resolution, perspective transformation and group cohesion. Working
creatively was catalytic in opening minds and explicating thoughts and feelings which may
otherwise have been suppressed, or emerged later in disguised/deconstructive ways.
UM Betty: “Feeling uncertain about things has actually helped me
change … I now believe in collectiveness, which has come from being
open … We were open, but now that we explicitly ask each other to say
what we’re thinking, it’s more [in the] present! … The challenging
discussions help me think how to move forward …” (Participant leader
annual reflection)
There was a strong preference for experiential learning and leaders only engaged superficially
with the literature offered. By role modelling how he used theory to explain experiences the
AR’er triggered curiosity, as did re-presenting the person-centred nursing framework
(McCormack & McCance, 2010) in the form of a Dutch windmill.
CN Loes: “… it’s only now that I feel that I’m starting to understand it [
person-centered nursing framework] for myself … it was too abstract
and far off for me … now I’m starting to notice and feel what we’re
doing, that it’s great what we’re doing, and the windmill is starting to
come to life, and I’m starting to use it more often and can stick more
things on it and name them by myself.” (Midway evaluation with CN’s
and UM)

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Reflecting on evaluations and observations of leadership practice assisted participant
growth. Evaluative data from staff was fed back to the leaders and the AR’er consciously
tried to role model being person-centred as he worked alongside in reflecting on the
evaluations. The use of post-observation interviews also raised leader awareness to their
being and context, something left unexplored beforehand.
CN Fleur: “I have never really had to reflect on what I was doing with
someone really watching what I was doing … It’s an eye opener and a
development that is really great to experience. Shadowing is very direct,
the questions afterwards and the evaluation.” (Post-observation
interview)
Contextual influences on becoming a person-centred leader: Leader development was
influenced by personal factors and commitment, organisational culture and the crises
encountered en route. Each leader arrived with a personal history, ability, values and
beliefs, some of which were conducive to person-centred leadership, whilst others
underwent transformation. For instance, having led the unit for longer and through some
difficult periods, CN Loes’ values and beliefs about leadership underwent significant
change. In contrast, CN Fleur was a staff nurse on the unit during the orientation phase and
applied to become CN as she believed in the concept of person-centredness. Her person-
centred leadership was quickly observed and acknowledged by staff.
“More than the others she radiates warmth … you experience the
engagement … Fleur can feel what people mean, put her finger on the
salient point … She’s also comfortable admitting when mistakes have
been made or that the situation is difficult. In doing so, you feel
acknowledged when you raise an issue.” (Staff evaluation workshop on
unit leadership)
The hospital organogram showed two operational managers of equal status per unit: a UM
for the care team and medical manager (MM) for the physician team. However, traditional
professional status and power was evident in the organisational culture. Despite invitations,
the MM and physician team did not actively participate in the study. They were kept
informed via UM-MM meetings, but, as change within the nursing system and culture
emerged so did MM resistance. The changing nurse leadership was viewed negatively: “too
many people involved in decision-making processes and too much sharing of
responsibility”. This culminated in the MM expressing a lack of faith in the UM’s
managerial competency, despite a lack of concrete examples of poor performance and a
positive, independent, formal competency assessment. Finding herself in conflict with no

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support from higher management, the UM decided to resign. Her departure heightened
awareness among the remaining leaders to the role tradition and power play in
multidisciplinary contexts.
CN Fleur: “… With Clive [MM] I notice as well that I’m easily talked
around to his way of thinking and afterwards I think, “It wasn’t
supposed to happen like that.” That means that I’m still susceptible to
power and hierarchy.” (Halfway evaluation, March 2010)
Events such as this were initially perceived as crises, but, not necessarily detrimental to
leader development. For instance, UM Betty’s decision to move her office away from the
unit, or Anne’s decision to be CNS instead of CN, created new spaces for others to come
into their own, do things differently and take on new roles and responsibilities.
CN Loes: “ … the real breaking point came for me when Anne left. On
the one hand I thought, “How are we going to do this now?” But, on the
other hand I thought, “Now I can be myself.” I started to change … I
learnt more about myself then …” (Midway evaluation with CN’s and
UM)
As the participant leaders experienced the benefits of person-centeredness, so did their
commitment to the research activities. This was further helped by comparisons of self to
others in similar posts within the hospital. Participant leaders were evolving in a direction
they self-choose and found rewarding.
Outcomes of being and becoming a person-centred leader: With commitment came
outcomes at a personal, relational and cultural level. All participants described personal
changes, feeling transformed, proud of what they had achieved and embodying their new
leadership style.
CN Loes: “… it’s [person-centred leadership] under your skin … you
can’t be any different, you’ve become so.” (Final evaluation with CN’s)

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A positive leadership change was experienced by the nursing team who now saw five
individuals leading from within, rather than from above/outside the team. They felt strategic
decisions were well thought through and supervised support was balanced with freedom to
experiment. Where the leaders were parental, protective and directive, they moved from
managing to leading staff, becoming focused on ‘doing the right thing’ rather than ‘doing
things right’. The leaders themselves experienced more self-worth, relaxation and work
satisfaction, as well as relational reciprocity and equity.
CN Fleur: “The more we lead like this, the more we get back. The more
person-centered we are the more person-centered they are to us …”
(Participant leader annual reflection)
Workplace culture change emerged alongside relational changes. Leaders described greater
collaboration, inquiry and less resistance to change. There was greater staff willingness to
take on more responsibility and/or become involved in decision-making. There was a
noticeable decline in call-bells, response time and greater tranquility on the unit. The
evaluation questionnaire revealed that staff tended to agree that there was a better
atmosphere on the ward, better continuity and coordination of care, better mentoring of
students and improved work satisfaction, despite no changes in workload/pressure or
staffing levels. Photos from the culture workshop supported these findings, and expressed
improvements in being caring yet critical and transparent towards one another.
Participant observations revealed leaders using the same strategies and processes of the
research in their daily practice. For example, narrative interviewing skills when communing
with staff, or the claims/concerns/issues framework to structure evaluations. Leader
reflectivity was evident as the acted on intuition combined with cognition, connecting their
‘thinking’ with their ‘doing’ and articulating the ‘why’.
CN Fleur: “I don’t just act from gut instinct now … The gut feeling is
usually OK, it’s just that you need to be able to reason it and place it
somewhere. Gut feeling alone is not enough.” (Annual reflection, July
2010)
Discussion
Whilst the thematic analysis framework of this study could be interpreted as a linear flow of
attributes, processes and influences causing outcomes, the thematic descriptions reveal how
complex person-centred leadership is in clinical practice. For instance, supervising a staff

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nurse (SN) during a phased return to work after sickness, in a context/organisational culture
pressing for reduced sickness rates, CN Fleur’s leader attributes (interpersonal intelligence,
self-awareness and reflexivity) supported her engagement in relational processes (sensing
how the SN was coping, being mindful of the SN’s difficult home context, balancing needs of
the SN to feel functional with patient safety needs) from which she decided which stance(s)
would most likely enable the staff nurses’, and her own, coming into own. Consequently, she
frequently led from alongside, encouraging and supporting the SN’s engagement and
perseverance in nursing care. At times she also led from behind, to show acknowledgement
and trust in the SN’s growth, and observe her progress. Person-centred leadership now
becomes a complex relational and contextualised practice. As a relational practice, leader
attributes support relational processes, which inform stancing aimed at enabling associate and
leader coming into own. As a contextualised practice, contextual structures, practices and
conventions influence leader-associate relating. Activation of leader attributes and relational
processes, as well as contextual factors, is particular and dynamic. This means that each
leader-associate relationship is unique and in a constant state of flux.
The (sub)themes show congruency with a person-centred practice theory. Being authentically
other-centred, caring and reflexive, engaging in relational processes such as presencing and
communing, as well as being focused on the coming into own of associates and self,
demonstrate the enactment of the humanistic values (mutual) respect, right to self-
determination and understanding. As well as portraying relational leadership as a moral and
dialogical practice (c.f. Cunliffe & Eriksen, 2011), the themes resonate with Binn’s (2008)
description of relational leadership as an authentic, caring practice that enables others to act
whilst acknowledging and learning from one’s own actions. The findings thereby contribute
to knowledge on relational leadership theory in nursing. However, the process of leader
development was relatively long and contained to leaders on one unit. When the study
started, besides the person-centred nursing framework (McCormack & McCance, 2010),
there was also no conceptual framework or model for person-centred leadership. This has
encouraged the development of a conceptual framework for person-centred leadership (see
figure 3) where thematic findings and compared to existent nurse leadership literature.
A conceptual framework for person-centred leadership
The conceptual framework for person-centred leadership offers a graphic and narrative
representation of clinical nursing leadership as person-centred relationships that are healthful
(McCormack & McCance, 2017) and growth-fostering (Jacobs, 2014). It contains themes
from the findings, inductively ordered and supported by propositions to describe relationships
between the themes. The framework is circular with a relational and contextual domain
separated by a permeable border (dotted line). This represents leadership as a constantly
evolving phenomenon emerging from intrapersonal, interpersonal and contextual interactions.
The findings show how leaders were consistently and increasingly aware of self, self in

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relation and context. They developed and used attributes for relational being, and core
processes for relational connectedness. Knowledge derived from being and relating
influenced stancing, intended to foster associate and leader coming into own. The assumption
here was that when people felt good at work, optimal performance and commitment were
likely to follow. This is in line with Cummings et al.’s (2010) finding that relationship-
focused leadership has greater positive influence on the nursing workforce and nursing
environment than task-focused leadership.
The relational domain: The relational domain of the framework holds leader attributes and
core processes informing leader positioning of self (stancing) in relation to associates. Nurses
want honest, positive, receptive, moral and facilitative leaders (Anonson et al., 2013; Wieck,
Prydun, & Walsh, 2002; Stanley, 2006). Being authentic, other-centred and caring, the
leaders respected unicity and sought meaning in “I-Thou” relationships with associates.
Leader authenticity has been shown to aid subjective well-being at work among public
organisation managers (Ménard & Brunet, 2011) and self-reported vitality among nurses
(Mortier, Vlerick, & Clays, 2015). The caring disposition so familiar among nurse leaders,
requires intra- and interpersonal intelligence and can lead to ad hoc or fragmented work if
not balanced with an investigative stance (Lalleman, 2017). Reflexivity and willingness to
show vulnerability helped the leaders balance the caring and investigative dispositions as they
acknowledged their fallibility and tried to understand first, second and third person
perspectives in context. Studying intergenerational leadership, Wieck et al. (2002) also
conclude that today’s leaders need to be aware of differing needs in order to respond
appropriately. Whilst nurses value decisive leaders in times of crisis (Anonson et al., 2013),
they also need to trust leaders. Avolio et al. (2004) use the term commensurability (the
sharing of self-aspects in dyads) to explain the building of such trust. The reciprocity
experienced by the person-centred leaders in this study, is indicative of trust emerging from
relational connectedness.
The leader attributes support continuous engagement in the five relational processes
providing a constant flow of information to guide stancing. Sensing (using one’s senses to
gather information about associate being, and verifying interpretations) is described in
nursing (Bundgaard, Nielsen, Delmar, & Sorensen, 2012; Sellevold, Egede-Nissen, Jakobsen,
& Sørlie, 2013; Martin, O' Connor-Fenelon, & Lyons, 2012), but not leadership research.
Hersey et al. (2001) describe leader assessment and diagnosis of ‘follower’ competency and
willingness, but this is a more reductionist (task-orientated) than holistic (whole person-
orientated) approach. Contextualising (understanding how associate embeddedness within
differing contexts, past and present, can influence present and future being) is also a concept
not described in leadership literature but was demonstrated by the leaders as they, for
instance, lead associates reintegrating into work life after sick leave. In contrast, balancing
needs and communing (action-orientated dialogue) are frequently described in nurse
leadership literature. However, where publications on leader communication skills usually

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describe a unidirectional (leader-to-follower) flow of information, person-centred leaders are
more dialogically orientated, thereby lowering the potential for manipulation as they balance
needs and commune. Utilising the narrative interview skills learnt in CCRI’s helped reduce
perceived power differences and enhanced authenticity, shared understanding and shared
decision making as they engaged in communing and ordinary ‘person-to-person’
conversations (c.f. Groysberg & Slind, 2010). Also, presencing (being and thinking with an
associate) fostered relational connectedness. The presencing demonstrated and described
showed greater similarity to McCormack and McCance’s (2010) sympathetic presence
(appropriately responding to another’s cues so as to maximise coping) and Baart’s (2001)
presencing (beneficent attentiveness), than Senge, Scharmer, Jaworski, & Flowers’ (2004)
presencing as personal and contextual mindfulness. Alongside the other processes, this being
and thinking with associates helped the leaders decide on a stance they felt most likely to
enhance associate coming into own.
Whilst the process of stancing was broken down into four basic stances, observations and
narratives demonstrated that different stances occur within any leader-associate encounter,
reflecting responsiveness to own and associate being, as well as contextual changes. Leading
from the front entailed offering directive support, such as role modelling or ‘doing for’ the
associate. When leading from the side line, leaders offered instruction or advice. Leading
from alongside or behind was less directive as associates were encouraged and supported in
becoming more self-directive. Where leading from alongside showed more intense
interaction, with high challenge and high support. Leading from behind was far less
interactive as leaders stepped back and observed. These four stances could be confused with
Hersey et al.’s (2001) four modes of situational leadership, however, there are differences in
discourse and leader intent. Situational leaders are primarily concerned with follower
performance, whilst person-centred leaders focus first on associate wellbeing, empowerment
and self-actualisation (coming into own). Situational leaders ‘tell’ followers what to do in S1
mode, rather than ‘offer’ direction, ‘selling’ and/or ‘persuading’ followers to psychologically
buy in to what the leader wants in S2 rather than offering advice. In S3, situational leaders
support follower confidence and involvement in problem-solving, using praise and
compliments, and in S4 they delegate, convinced of follower task competency (Hersey et al.,
2001). Person-centred leaders may choose to lead from behind even when associate
competency is not evident. For instance, aware of the CNs’ learning needs and preferred
learning styles, the UM Betty restrained from intervening and stepped back, observing how
they solved challenging issues, thereby creating a safe learning space as she could change
stance if and when needed. Calculated/considered risk-taking is characteristic of empowering
care environments (McCormack & McCance, 2010) with benefits including heightened
associate self-awareness, empowerment, self-confidence, job satisfaction, professional
development and organisational innovation (Crenshaw & Yoder-Wise, 2013) i.e. associate
coming into own.

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Based on staff and leader positive evaluations, three concepts were associated with the idiom
‘coming into own’: empowerment, wellbeing and self-actualisation. The NHS NICE (2009)
guideline recommends that front-line leaders focus on staff wellbeing and empowerment.
Findings in the orientation phase reflected earlier research that Dutch nurses experience
leadership as hierarchical, non-communicative and increasingly ‘business-like’ (van der
Arend & Remmers-van den Hurk, 1999). However, as leadership practice changed, so did
perspectives, with coming into own not restricted to associates. Participant leaders sought and
developed their own empowerment. This is important as nurse middle-management leaders
often do not feel empowered (Patrick, Laschinger, Wong, & Finegan, 2011; Regan &
Rodriguez, 2011). Also, the relational approach to leadership meant that empowerment was
seen as something that can be enabled (not given), individually experienced and
contextualised. The person-centred approach respected that not everyone wanted the same
level of responsibility and self-determination all the time. Also, structural empowerment as
supporting access to opportunity, information, resources, support and (in)formal power
(Kanter, 1977) was accompanied by psychological empowerment as supporting self-
determination and self-efficacy in meaningful work (Conger & Kanungo, 1988). Although
not empirically measured in this study, working simultaneously with both empowerment
approaches has been shown to have a positive impact on nurses and nursing (Wagner et al.,
2010).
The contextual domain: A leader-associate relationship manifests in context, not isolation.
Whilst leadership research has tended to stay clear of studying situatedness and contextual
influences (Ashman & Lawler, 2008), this study revealed several factors influencing and
influenced by the leader-associate relationship.
Creating learning spaces enabled adult cooperative, collaborative and transformative
learning (c.f. Cranton, 1996) and opportunistic, facilitated workplace learning can be
professionally and personally empowering (Snoeren, Niessen, & Abma, 2013; Merriam,
1996). Facilitated critical and creative reflection on-, in- and before-action in action spiral 1
supported the connecting of thinking with doing, thereby influencing future ‘being’. Also, in
contrast to traditional leadership development strategies such as educational programmes, the
PAR approach provided the positives of work-based learning (self-directing and self-pacing)
without the challenges of written assignments and/or portfolio development for academic
accreditation. Utilising the development strategies they were experiencing, the leaders created
learning spaces aimed at fostering a person-centred culture. Nurses appreciate leader
facilitation of professional development (Anonson et al., 2013) and although no evaluative
data on care was collected from a patient perspective, Lynch (2015) found that nurse leaders
partnering associates from a person-centred approach fostered person-centred care.

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There is a danger that person-centredness could be interpreted too individualistically i.e. too
focused on own assumptions and the needs of one individual/group. Awareness of, and
working with ‘differing stakeholder needs’ helps balance such blinkeredness. Reciprocal
influencing between the leader-associate relationship and other stakeholder needs was evident
in the PAR, for instance: when leaders realised that absent persons could potentially be
affected by decisions/actions they made in the here and now with one individual/group, and
when PN’s started to collaborate more with colleagues each shift after hearing fears that their
range of nursing activities was declining. In contrast, the MM’s attempt to regain control over
nurses and nursing on the unit reflected an individualistic mindset and reflects Fealy et al.’s
(2011) finding that interdisciplinary relationships are a potential barrier to clinical nurse
leadership development, especially when nurses choose not to play the ‘doctor-nurse’ game
(McMahan et al, 1994). Organisational culture refers to espoused values and practices across
differing groups within an organisation (Kotter & Heskett, 1992) and whilst many believe
this determines ‘the way things are done’ within organisations, Bolan and Bolan (1994)
propose that groups and units within the organisation (idio-cultures) are both carriers and
creators of culture. That nurse leaders can be seen as minor strategic players (relative to
physicians and higher management), experience positional marginalisation and powerless
responsibility has been documented (Fealy et al., 2011) and was evident within the research
setting. However, collaborative reflection on such organisational values and practices raised
awareness and conscious action. Comparing their leadership vision and development with
colleagues of similar positions within the organisation aided this empowerment and the idio-
cultural/unit findings support the view that leadership can enable the enactment of person-
centred values in workplace cultures (c.f. Manley et al., 2011; Lynch et al., 2017).
Lastly, healthcare practices need systems of evaluation to maintain quality and safety, plus,
perceptions and leadership practices evolve in time (Krugman, Heggem, Kinney, & Frueh,
2013). Some evaluation systems monitor key performance indicators regularly whilst others
are specific and transient/intermittent. All have the potential to influence and be influenced
by leadership practice. For instance, based on primary nursing implementation evaluations,
the CN’s decided to alternate weekly between working bedside and working from the office,
so as to meet their clinical and administrative responsibilities.
Conclusion
Front-line leadership is pivotal to workplace culture evolution and with the increasing interest
in person-centred practice it is important that insight is gained into the role leadership plays.
This participatory action research study describes how a relational, person-centred approach
to leadership influences leaders, associates and context. The conceptual framework derived
from the findings portrays person-centred leadership as a complex, dynamic, relational and
contextually embedded practice that fosters healthful relationships and growth.

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When clinical nurse leaders embody the set of attributes, and engage in the relational
processes, they become more responsive and better able to support associate and own
wellbeing. Whilst the findings are predominantly based on the leaders’ voice, many of the
attributes and relational processes affirm existent findings in nursing leadership literature.
Others, such as a willingness to show vulnerability, contextualising and communing, are new.
A new perspective of shifting leader focus from primarily aligning ‘followers’ with their
own/organisational vision, higher performance, lower turnover/absenteeism and improved
service-user evaluations to associate empowerment and self-actualisation, is also presented.
The belief being that associate wellbeing, empowerment and self-actualisation are antecedent
to the other outcomes. The framework also makes explicit the interplay between leadership
relationships and context.
The developmental journey was long, intense and restricted to the leaders on one unit.
However, the participatory action research approach demonstrated how leaders working
alongside an action researcher can be active and self-directive in both their leadership
development within the workplace and practice research. Engagement in research activities
raised awareness to their own embeddedness and helped them remain attentive to the multiple
values, needs, structures, conventions and practices influencing and/or being influenced by
their leadership relationships. A positive and valuable mindset for contemporary clinical
nurse leaders.
Relevance to clinical practice
The study supports the call for greater relationship-orientated leadership in clinical nursing. It
shows how clinical nurse leaders can develop relational leadership within the workplace.
Expert facilitators can support them in collectively, critically and creatively reflecting on
their own leadership narratives. Where the facilitator is also an action researcher, the step to
becoming practitioner researchers is also reduced. Those wishing to develop person-centred
cultures now have a conceptual framework to aid their developmental journey too. The
framework can assist the deconstruction of leader narratives into present/absent elements in
the relational and contextual domains, and help identify areas for growth and development.
Because of the relatively limited view from an associate and service user perspective, we also
recommend that these perspectives are studied more intensely in future research on person-
centred leadership development and practice.

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Table 1: Overview of research phase/action spiral goals and data gathering activities.
Phase Primary goals & activities: Participants
Orientation Goal: To gain insight into current relationships and context
(structures, conventions & practices)
 critical and creative culture workshop 22 members of staff
 participant observations of context (x5) Staff & patients
 participant observations of nurse leadership (x3) CNs / UM / staff
 narratives of care 8 patients + 16 staff
 narratives of nurse leadership 11 nursing staff +
1 physician
Action spiral
1
Goal: To gain insight into changing nurse leadership practice
 19 AR’er facilitated critical and creative reflective
inquiry sessions on 15 narratives
2CNs + 1UM + 1CNS +
2PNs
Action spiral 2 Goal: To gain insight into leading change in the nursing system
 Visioning primary nursing workshop, facilitated by the
AR’er
2CNs + 2PNs
 Primary nurse role analysis workshop, facilitated by the
AR’er
2CNs + 2PNs
 23 AR’er participant observations of leadership + post-
observation interviews with the observed leader (and those
interacting with leader)
CNs (16 sessions)
PNs (4 sessions)
UM (3 sessions)
2 staff nurse interviews
2 student interviews
1 physician interview
 4 PN implementation evaluation meetings 2PNs + 2CNs
 (Evaluative) critical and creative culture workshop,
facilitated by 1UM + 1CN
5 staff nurses
 Nurse leadership evaluation workshop, facilitated by an
external researcher
5 staff nurses
 Participatory analysis of a staff evaluation
questionnaire (n=15), facilitated by the AR’er
4 staff nurses + 1CN
Action spiral 3 Goal: To gain insight into leading storytelling sessions aimed at
fostering person-centred care
 13 post-observation interviews of CN facilitated
storytelling sessions
2CNs

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Action spiral 4 Goal: To gain insight into nurse leader growth
 3 annual reflective inquiries into individual leader
growth
2CNs + 1UM + AR’er
 19 supervision sessions AR’er + 4 supervisors
 3 AR’er experiences reflected upon during Action
Learning Set sessions with university co-workers.
AR’er ±7 set members
 AR’er leadership evaluation workshop, facilitated by
external researcher
1UM + 1CNS + 2CNs
 Midterm evaluation workshop of action research
experience, facilitated by AR’er
4 co-researchers

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Table 2: Overview of primary data set for thematic analysis
Action
Spiral
Primary data set:
1  15 critical and creative reflective inquiries = 23 hours of
transcript
2  23 observations of leadership practice + post-observation
interviews = 10 hours of transcript
 Unit leadership evaluation workshop = 1,5 hours transcript
3  8 post-observation storytelling session interviews = 4,5 hours
transcript
4  3 annual reflective inquiries = 8 hours of transcipt
 Midterm evaluation workshop of action research experience =
2,5 hours transcript
 AR’er leadership evaluation workshop
Box 1: Thematic data analysis framework
1. Familiarization and submergence: Reading and scanning data to refresh and enhance
understandings gained during the fieldwork, noting relevant events, citations and thoughts.
2. Creative expression: Intermittently working on a creative expression of the cognitive and
embodied inferences emerging from phase 1. Working on the expression intermittently
creates space for contemplation and rest whereby one returns with ‘new eyes’, reviews and
continues. Key words/concepts are then added to relevant/appropriate areas on the final
product.
3. Blending and melding: Intermittently seeking patterns and connections using the words
and imagery, clustering those that can be blended and aligning others for melding. A
tentative thematic framework emerges.
4. Indexing: Extracts and citations from the raw data are coupled with (sub)themes. New
(sub) themes may emerge from re-reading the data, or existent (sub)themes adjusted.
5. Reviewing and refining: Thick descriptions are composed for each theme, supported by
extracted data. Returning to the data set may be necessary to check the context in which
citations were made.
6. Critiquing: The thematic framework(s) are member-checked (preferably in dialogue) with
participants, and peer-reviewed, until consensus is reached.

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Figure 1: Methodological framework

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Figure 3: Conceptual framework of Person-Centred Leadership
Figure 4: Photo accompanying citation ‘CN LOES’ (CCRI 4)