An Integrative Review of Registered Nurses' Understandings of Organisational Culture and Cultures of Care in the Aged Care Sector.

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Learn more: PMC Disclaimer | PMC Copyright Notice J Adv Nurs . 2025 Sep 8;82(5):4800–4826. doi: 10.1111/jan.70200 Search in PMC Search in PubMed View in NLM Catalog Add to search An Integrative Review of Registered Nurses' Understandings of Organisational Culture and Cultures of Care in the Aged Care Sector Deborah Magee Deborah Magee 1 School of Nursing, Paramedicine and Healthcare Sciences, Charles Sturt University, Bathurst, New South Wales, Australia Find articles by Deborah Magee 1, ✉ , Karen Francis Karen Francis 1 School of Nursing, Paramedicine and Healthcare Sciences, Charles Sturt University, Bathurst, New South Wales, Australia Find articles by Karen Francis 1 , Holly Randell‐Moon Holly Randell‐Moon 2 School of Indigenous Australian Studies, Charles Sturt University, Dubbo, New South Wales, Australia Find articles by Holly Randell‐Moon 2 , Samantha Jakimowicz Samantha Jakimowicz 1 School of Nursing, Paramedicine and Healthcare Sciences, Charles Sturt University, Bathurst, New South Wales, Australia Find articles by Samantha Jakimowicz 1 , Marguerite Bramble Marguerite Bramble 1 School of Nursing, Paramedicine and Healthcare Sciences, Charles Sturt University, Bathurst, New South Wales, Australia Find articles by Marguerite Bramble 1 Author information Article notes Copyright and License information 1 School of Nursing, Paramedicine and Healthcare Sciences, Charles Sturt University, Bathurst, New South Wales, Australia 2 School of Indigenous Australian Studies, Charles Sturt University, Dubbo, New South Wales, Australia * Correspondence: Deborah Magee ( [email protected] ) ✉ Corresponding author. Revised 2025 Aug 18; Received 2025 Feb 28; Accepted 2025 Aug 26; Issue date 2026 May. © 2025 The Author(s). Journal of Advanced Nursing published by John Wiley & Sons Ltd. This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made. PMC Copyright notice PMCID: PMC13069259  PMID: 40922490 ABSTRACT Aim The aim of this integrative review was to explore registered nurses' understandings of organisational culture and cultures of care in aged care. Design Integrative literature review. Methods A literature search was conducted of Medline (OVID), CINAHL Plus with Full Text, Scopus, Proquest Nursing and Allied Health, and Informit databases in June 2024. In October 2024, a search for grey literature was conducted focusing on Google Scholar, the Analysis and Policy Observatory (Australia), Australian Government websites, European Union Institutions and Bodies, and usa.gov . The inclusion criteria were Australian and international literature published in English between 2004 and 2024. The inclusion criteria were amended to focus on literature published from 2014 to 2024. Results Seventeen research studies met the inclusion criteria for the review. Four primary themes were identified: competing hierarchies of power; the multifaceted role of nurses in long‐term care settings; standing still is not an option; and implications for culture change strategies in practice. Conclusion Registered nurses in aged care are pivotal to evolving clinical and administrative practice and creating organisational cultures that affirm the rights of older people, including providing a supportive workplace for those who care for them, in an environment focussed on developing and sustaining quality care. Viewing the complex relationships at different organisational levels through the prism of Foucault's ideas on disciplinary power generates new insights into the role of registered nurses in aged care settings. This review also underscores that research on organisational culture in aged care is at a formative stage. There is potential for future research that fosters a robust evidence base to support the development of organisational cultures that nurture a person‐centred environment ultimately leading to improved care and staff experience. Implications for Policy and the Profession Registered nurses in aged care settings are advocating for a transformative shift in organisational cultures that prioritises inclusivity, compassion and person‐centred care. Empowering nurses through clinical and administrative leadership roles is crucial for cultivating person‐centred organisational cultures in aged care settings. It is essential that policymakers invest in the development of registered nurses who can excel in clinical and operational roles at management and executive levels. Policy changes that promote frameworks that facilitate nursing leadership are essential for establishing and maintaining person‐centred workplace cultures. Reporting Method Prisma extension for scoping reviews (PRISMA—ScR). Patient or Public Contribution This study did not include patient or public involvement in its design, conduct, or reporting. Keywords: aging, change management, discourse analysis, leadership, long‐term care, management, organisational behaviour, residential facilities, workforce issues 1. Introduction Globally, nurses are the largest occupational group in the health sector and therefore significantly influence organisational and workplace cultures in primary, secondary and tertiary health environments (World Health Organisation 2025a ). In the long‐term care sector, which encompasses residential and community‐based care for older people, nurses comprise only 28% of the workforce, but are responsible for case management, supervision of staff and coordination of care and therefore also have the capacity to significantly shape how people think and behave in the workplace (Organisation for Economic Cooperation and Development 2020 ). Organisational culture is described by culture change strategists Cameron and Quinn ( 2011 , 19) as ‘the taken‐for granted values, underlying assumptions, expectations and definitions that characterise organisations and their members’. Sociologists Schein and Schein ( 2017 , 6) centre their definition of organisational culture on shared learning and problem solving related to external adaptation and internal integration. Braithwaite et al. ( 2017 , 2) conclude that from a theoretical perspective, culture ‘is a composite, complex construct which changes dynamically over time, but there are enduring behavioural and cognitive patterns to its manifestation…’. Like Schein and Schein ( 2017 ), Mannion and Davies's ( 2018 , 1) definition of organisational culture in healthcare focusses on ‘the shared ways of thinking, feeling and behaving’. Råholm and Heggdal ( 2017 , 296) expand the definition of organisational culture in healthcare to include values, habits, collective memories, customs, rituals and routines. In healthcare, workplace cultures may consist of subcultures discernible in clinical units or departments, or of groups of health professionals such as nurses or allied health professionals (Mannion and Davies 2018 ). While workplace cultures may share ways of thinking, feeling and behaving, there is also the potential for discord through divergent perspectives (Braithwaite et al. 2017 ; Gillin et al. 2017 ; Leep‐Lazar and Stimpfel 2024 ). Closely linked to organisational culture and workplace culture is the concept of ‘cultures of care’, which is described by Greenhough et al. ( 2023 , 2) as ‘norms of caring behaviour, practices of care and modes of relating which promote and enable effective care and implicate the display and exchange of what are seen as ‘appropriate’ affect and responses for a particular social group’. In aged care, a foundation of caring culture is described as the relationships between team members at different levels of the organisation based on respect, kindness, collaboration and a sense of belonging (Miller et al. 2020 ; Rafferty et al. 2017 ; Wei et al. 2020 ). However, in considering the values that underpin a positive culture of care in aged care, the influences of power relations, inequality and the availability of resources must be considered (Greenhough et al. 2023 ). When analysing cultures in the healthcare setting of aged care, three levels of organisational and workplace cultures should be examined (Mannion and Davies 2018 ). The first layer, the visible manifestations of culture, includes the social mores that govern relationships, the activities that consist of how people are cared for, and the policies and procedures that underpin these. This level of culture also includes quality and safety, risk management, infection control and implementation of evidence‐based practice (EBP) (Mannion and Davies 2018 ). The second layer of organisational culture in the healthcare setting of aged care is the shared ways of thinking. Shared ways of thinking relate to, for example, ideas about resident autonomy and expectations about the clinical performance of staff (Braithwaite et al. 2017 ; Mannion and Davies 2018 ). The third layer of organisational culture in the context of aged care comprises the unconscious, uncritiqued thoughts of staff related to daily work practices (Mannion and Davies 2018 ). An example of these deeper assumptions is the relative power of groups of health professionals within particular contexts to affect change. It is this layer of organisational culture that is most difficult to access and least amenable to alteration. These unconscious, uncritiqued thoughts remain so for reasons such as health professionals lack of awareness of their nature and impact and also lack of safe spaces to give voice to and explore these thoughts (Mannion and Davies 2018 ). Organisational and workplace cultures directly impact the experience, satisfaction and health outcomes of a patient or resident in all health settings, including long‐term aged care, specifically a reduction in falls, facility‐acquired infections, medication errors and other failures in care delivery such as pressure areas (Braithwaite et al. 2017 ; Churruca et al. 2023 ; Ku and Yu 2024 ; Pavithra 2022 ; Råholm and Heggdal 2017 ; Tate et al. 2023 ). Organisational culture has also been identified as impacting nurse retention, the prevalence of workplace bullying, absenteeism and adherence to organisational guidelines (Choi and Park 2019 ; Leep‐Lazar and Stimpfel 2024 ). Leep‐Lazar and Stimpfel ( 2024 ) undertook a dimensional analysis of ‘unit culture’ or ‘ward culture’ from a nursing perspective. Unit or ward culture can be considered a sub‐set of organisational culture and is created through employees working in close proximity who identify as being part of a group and usually share a common set of problems or concerns (Leep‐Lazar and Stimpfel 2024 ). Twenty‐four articles published between 2005 and 2023 were analysed. The analysis concluded that unit culture is distinctive from organisational culture and influences every aspect of the working life of nurses and the health outcomes of those they care for (Leep‐Lazar and Stimpfel 2024 ). Unit culture is influenced by leadership, working conditions, policies and procedures, and the characteristics of the nurses employed within the unit. This study identified that research that seeks to understand how unit culture could be changed in order to facilitate improvement in patient outcomes and nurse well‐being is required (Leep‐Lazar and Stimpfel 2024 ). Råholm and Heggdal ( 2017 , 84) included eight papers from 2000 to 2014 in a qualitative systematic review that aimed to describe ‘the core of the concept’ of organisational culture in the care of older people from the perspective of family members, physicians, nurses and care providers. Four themes were identified. Organisational culture reflecting firstly a commitment to care, reflecting distress and security, reflecting value conflicts and lastly the impact of leadership on organisational culture. Råholm and Heggdal ( 2017 ) concluded that the dignity, well–being and health of residents and health personnel is dependent on a safe and caring organisational culture and that further research of the characteristics of a caring culture would benefit staff and residents. An integrative review by Churruca et al. ( 2023 ) aimed to identify how organisational culture is being studied in residential aged care facilities, to explicate the results of previous studies and establish what interventions are being employed to improve organisational culture. Three studies from 2013 to 2020 focussed on describing organisational culture in residential aged care and another 11 studies exploring links between organisational culture and phenomena such as the use of psychotropic medication and antibiotic prescribing. It was noted that only 25% of the included studies used a conceptual framework or reference to a theory about organisational culture. The review concluded that further research is required with a strong theoretical framework in order to understand perceptions of organisational culture in aged care, how the values that underpin organisational culture influence the standpoint of staff in aged care have in relation to their work and how culture change can be achieved (Churruca et al. 2023 ). The extant literature includes a dimensional analysis of organisational culture from the perspective of nurses working in diverse contexts (Leep‐Lazar and Stimpfel 2024 ), and a conceptual analysis of organisational culture in the care of older people from the perspective of multiple stakeholders (Råholm and Heggdal 2017 ). An integrative review by Churruca et al. ( 2023 ) evaluated diverse studies focusing on organisational culture in aged care facilities (Churruca et al. 2023 ). While there is a link in the literature between poor organisational culture and the provision of substandard care, the understandings of gerontological registered nurses regarding these concepts are unclear. In distinction from these reviews, this manuscript focuses exclusively on registered nurses employed in aged care contexts, encompassing both residential and community care settings. 2. Aim The aim of this integrative review was to explore registered nurses' understandings of organisational culture and cultures of care in aged care. The purpose of using an integrative review framework was to synthesise and evaluate diverse perspectives from the literature to attain a deep understanding of the phenomena of concern (Torraco 2005 ). The results of this review informed a PhD study on the topic of organisational cultures and cultures of care in the aged care sector. 3. Methods/Methodology 3.1. Design An integrative literature review seeks to analyse and synthesise past empirical and theoretical research. The inclusion of a wide range of methodological approaches and a focus on generating new insights positions integrative reviews to positively contribute to evidence‐based practice (EBP) in nursing (Whittemore and Knafl 2005 ; De Souza et al. 2010 ). While an integrative review has the capacity to bring together different ‘conversations’ from a range of research paradigms, the methods used should be systematic and rigorous to ensure that the literature search is comprehensive, data extraction is accurate, and data analysis strategies are precise (Cronin and George 2023 , 169). To this end, a PRISMA Extension for Scoping Reviews (PRISMA—ScR) checklist was submitted with this manuscript (Tricco et al. 2018 ). This review was guided by the four‐stage framework developed by Whittemore and Knafl ( 2005 ). The stages are similar to those reported for systematic reviews. The first stage is the identification of the focus and purpose of the review, including variables of interest and the type of research and theoretical literature included. The second stage, the literature search strategy, should be documented explicitly and clearly. Data evaluation, stage three, should consider indicators of overall quality such as authenticity, methodological quality and informational value. The final stage, data analysis, required the codification, categorisation and the creation of a conclusion about the research focus or question that is synthesised and integrated (Whittemore and Knafl 2005 ). 3.2. Search Methods No existing review protocol or review on the topic was located in Open Science Framework or Figshare. The Population, Concept, Context (PCC) framework was used to develop the search terms, whereby Population = registered nurses, Concepts = organisational culture including workplace cultures and cultures of care, Context = residential and community‐based aged care settings. An initial limited search of Medline (Ovid) and CINAHL Plus with Full Text was conducted to source articles on the topic. The text words in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used by reviewer one (DM) to develop a full search strategy. An experienced research librarian provided feedback on the development of search strings for Medline (OVID), CINAHL Plus with Full Text, Scopus, Proquest Nursing and Allied Health, and Informit databases. Search strings were trialled extensively prior to a search of all databases undertaken on 6 June 2024. A search for grey literature was undertaken on 16 October 2024 focussing on Google Scholar, the Analysis and Policy Observatory (Australia), Australian Government websites, European Union Institutions and Bodies and usa.gov . To conform with the PRISMA—ScR checklist (Tricco et al. 2018 ) the search strategy for CINAHL Plus with full text used in the final search on 6 June 2024 is detailed in Table 1 . TABLE 1. Search strategy for CINAHL plus with full text. Population Registered nurse MH (nurses+) OR AB (‘Nurse manager*’ OR ‘clinical nurse consultant*’ OR ‘registered nurse+’ OR ‘nurse practitioner*’ or ‘advanced practice nurse*’ OR ‘residential care manager*’ OR ‘nurse educator*’) AND Concept Organisational Culture MH (‘organisational culture’ OR ‘organisational culture’) OR AB (‘organisational climate’ OR ‘workplace culture’ OR ‘workplace values’ OR teamwork OR ‘team culture’ OR leadership OR values) AND Context Residential and community based aged care exp Independent Living/OR exp. Homes for the Aged/OR exp. Nursing Homes/OR exp. Health Services for the Aged/OR Respite care/OR AB (gerontology Or ‘nursing home’ OR ‘long‐term care’ OR ‘residential aged care’ OR ‘residential care’ OR ‘Community care’ OR ‘Community dwelling’ or ‘community residing’ OR ‘community reintegration’ OR ‘home based’ OR ‘home dwelling’ Or ‘age in place’ OR ‘aging in place’ OR ‘unsupported living’ OR ‘aged care’ OR ‘independent living’ OR ‘homes for the aged’ OR ‘transitional care’) Open in a new tab 3.3. Inclusion and Exclusion Criteria The review included Australian and international literature published in English, including quantitative, qualitative, mixed methods studies and grey literature published between 2004 and 2024. Editorials, expert opinion and commentary, discussion papers, conference papers and all types of literature reviews were excluded from the review. The inclusion and exclusion criteria are in Table 2 . TABLE 2. Inclusion and exclusion criteria. Inclusion criteria Exclusion criteria The paper focusses the understanding of registered nurses (population) in relation to, ▪ organisational cultures including workplace cultures and cultures of care (concepts) ▪ in the aged care sector (context) Quantitative research papers Qualitative research papers Mixed methods research papers Published from 2004 to 2024 (note that this was altered during the full text screening process to 2014–2024). Grey literature Published in English Australian literature International literature The paper does not focus on the understanding of registered nurses (population) in relation to, ▪ organisational cultures including workplace cultures and cultures of care (concepts) ▪ in the aged care sector (context) Editorials Expert opinions Commentary Discussion papers Conference papers Scoping reviews Systematic reviews Integrative reviews Other types of literature reviews Open in a new tab 3.4. Search Outcome Following the completion of the database searches, all articles ( n = 1767) were imported into Covidence for screening. 731 duplicates were removed. Title and abstract screening of 1036 papers was undertaken by DM and MB, excluding a further 782 papers from the review. Two hundred and fifty‐four full text studies published from 2004 to 2014 were assessed for eligibility. Prior to commencement of the full text review, 10 papers were reviewed separately by DM and MB to ensure that the inclusion and exclusion criteria were being applied consistently and to provide an opportunity for refinements and clarification. Divergent opinions on the inclusion/exclusion of articles were resolved at team meetings, with KF having the deciding vote. During the full text screening process, 238 papers were excluded. The reasons for exclusion are noted in the PRISMA flowchart [Figure 1 ] (Page et al. 2021 ). During the full text screening process, the team reviewed the literature published from 2004 to 2014. The papers published from 2004 to 2014 were excluded as they were deemed not reflective of current service delivery or the positioning of registered nurses in the aged care sector. The review therefore focused on contemporary and relevant research from 2014 to 2024. FIGURE 1. Open in a new tab Prisma Flowchart. A four person team with the first author as project lead worked closely at all stages of the data screening process to ensure that the articles selected for inclusion were directly aligned with the topic of the review. While numerous studies present data that incorporates nurses from different designations, and/or the understandings of other groups of health professionals working in aged care contexts, the team felt that the understandings or perceptions of RNs could be sufficiently discerned in these studies to justify inclusion. Other articles focused on closely related topics such as leadership but did not sufficiently contribute to the central topic of the review to warrant inclusion. The 17 studies included in the review focused on registered nurses' understandings of: organisational culture, organisational climate, workplace culture or culture of care organisational culture influencers including workplace values, teamwork, team culture and leadership culture of care influencers including ethical distress, troubled conscience in the context of organisational culture and culture of care. An additional paper was found through citation searching. Data was extracted from 17 full text papers by DM, MB, KF and HRM using a custom data extraction tool. The data extraction template in Covidence was adapted to record the key features of the articles and facilitate a critical appraisal of the studies. The key features included research design, results, key points from the discussion, and conclusion and recommendations. The efficacy of the data extraction tool was trialled by all team members by comparing the data extracted from three papers. The results were discussed, and minor refinements to the data extraction tool were made. Covidence requires two reviewers to extract the data from each paper and a third reviewer to perform consensus. 3.5. Quality Appraisal The Mixed Methods Appraisal Tool [MMAT] (Hong et al. 2018 ) was used for the appraisal process and was integrated into the data extraction tool in Covidence. The MMAT (2018) is suitable for the appraisal of quantitative, qualitative, and mixed methods studies. The appraisal tools relevant to the study types were chosen from the MMAT (2018). All the papers included in the review were of sufficient quality and rigour to justify inclusion in the review. The results of the critical appraisal are in Appendix 1 : Tables A1 , A2 , A3 , A4 . Dewar et al. ( 2019 ), a paper utilising a multimethod approach, was appraised using qualitative criteria. The quantitative data collected was participant demographics and pre and post survey results expressed as percentages. The qualitative data, collected from group discussions, provided a richness and depth to the results, and thus a qualitative appraisal was undertaken. 3.6. Data Analysis and Theming The final 19 articles were again reviewed by at least two authors within the team. Qualitative, quantitative and mixed methods studies were examined separately and then comparisons made across the three groups (Whittemore and Knafl 2005 ). In this part of the review, all authors were asked to extrapolate concepts using a process of inductive thematic and narrative analysis, and data comparison, enabling a flexible method to analyse and report on identified themes and patterns in the data from the articles selected (Dwyer 2020 ). These concepts were summarised as ‘Key Findings’ and ‘Relevance to Nursing and Organisational Culture’ (See Table 3 : Review Matrix). The primary themes were then broadly aligned with the key aspects of Foucauldian theory, and the sub‐themes provided specificity to the research question. In this part of the review, the team focused on extrapolating key themes or concepts worth noting as significant to: Nurses' understandings and perceptions of their roles in aged care organisational culture The multifaceted role of nurses in the development of organisational culture and cultures of care in long‐term care settings Implications for policy, practice and research in gerontology across aged and health care TABLE 3. Primary themes and subthemes. Primary theme Subtheme Competing hierarchies of power Unique nursing roles Shared understanding, mutual knowledge The multifaceted role of nurses in long‐term care settings Nurse Managers, Practitioners, Educators, Specialists, Researchers Nursing leadership facilitates change Standing still is not an option The need for culture change Different ‘culture of care’ worlds Implications for culture change strategies in practice Integrating differing values into core practices ‘It's one thing to hear it. It's another to live it’ Understanding the larger sociopolitical context Open in a new tab The primary themes and sub‐themes are summarised in Table 3 and are further explored in the following sections. 4. Results 4.1. Included Study Characteristics The majority of papers included in the review ( n = 15) focused on registered nurses working in residential aged care. Two papers (Vendel Petersen et al. 2019 ; Winqvist et al. 2023 ) included the perspective of registered nurses employed in community settings caring for older people. A total of 17 peer reviewed journal articles were included in the review: 12 papers reported on qualitative research (Cloutier et al. 2016 ; Debesay et al. 2022 ; Greason 2020 ; Hamiduzzaman et al. 2020 ; Helgesen et al. 2014 ; Marriott‐Statham et al. 2018 ; Øye et al. 2016 ; Sahay et al. 2022 ; Scerri and Presbury 2021 ; Vendel Petersen et al. 2019 ; Wagner et al. 2014 ; Winqvist et al. 2023 ), three reported on quantitative research (Banaszak‐Holl et al. 2015 ; Trybou et al. 2014 ; Yafa et al. 2016 ) and two mixed or multimethod studies (Dewar et al. 2019 ; Frey et al. 2016 ). Four papers were from Australia (Hamiduzzaman et al. 2020 ; Marriott‐Statham et al. 2018 ; Sahay et al. 2022 ; Scerri and Presbury 2021 ), two were from Canada (Greason 2020 ; Wagner et al. 2014 ), two from the United States (Banaszak‐Holl et al. 2015 ; Cloutier et al. 2016 ), three from Norway (Debesay et al. 2022 ; Helgesen et al. 2014 ; Øye et al. 2016 ), one paper from Israel (Yafa et al. 2016 ), Belgium (Trybou et al. 2014 ), Sweden (Winqvist et al. 2023 ), New Zealand (Frey et al. 2016 ), Denmark (Vendel Petersen et al. 2019 ), and Scotland (Dewar et al. 2019 ). 4.2. Review Matrix TABLE 4. Review matrix. Reference; Country Research design & aim Theoretical or conceptual framework Sampling/Population Key findings Relevance to nursing and organisational culture Considerations for practice change 1. Banaszak‐Holl, J., Castle, N. G., Lin, M. K., Shrivastwa, N., & Spreitzer, G. (2015). The role of organisational culture in retaining nursing workforce. The Gerontologist , 55 (3), 462–471. https://doi.org/10.1093/geront/gnt129 ; United States (Michigan) Quantitative survey design. ‘We examined how organisational culture in nursing homes affects staff turnover, because culture is a first step to creating satisfactory work environments’. Competing values framework Turnover rates were provided for registered nurses (RNs), licensed practice nurses (LPNs) and nursing aide (NA) staff. The administrators of 419 nursing homes provided data on both facility culture and staff turnover. Facilities with stronger market values had increased turnover of Registered Nurses (RNs) and Licensed Practice Nurses (LPNs) Facilities emphasising hierarchical internal processes had lower RN turnover. More flexible organisational culture values were important for LPN staff only, whereas unexpectedly, greater emphasis on rigid internal rules helped facilities retain RNs. Organisational culture had differential effects on the turnover of RN, LPN and nursing aide (NA) staff that should be addressed in developing culture change strategies. 2. Cloutier, D., Cox, A., Kampen, R., Kobayashi, K., Cook, H., Taylor, D., & Gaspard, G. (2016). A Tale of Two Sites: Lessons on Leadership from the Implementation of a Long‐term Care Delivery Model (CDM) in Western Canada. Healthcare (Basel, Switzerland) , 4 (1). https://doi.org/10.3390/healthcare4010003 ; United States (Nebraska) Qualitative analysis ‘To explore the question: How did leadership style influence team functioning with the implementation of a new care delivery model (CDM)?’ Not stated Interviews conducted with residential care coordinators (usually RNs), clinical nurse educators and direct care staff, including RNs, licensed practice nurses (LPNs), health care aids and allied health therapists at 2 residential aged care facilities. Nurse leadership style had profound impact on CDM implementation. Facility A supported staff each step of the way in culture change, compared to Facility B where staff were caught in cycle of powerlessness. ‘It's the little things that count’ such as small scale events and ‘it's the people and not the model’ – leaders play a bridging role between facility management and direct care staff. In the longer term, effective nurse leaders can foster more stability among their teams if objectives for care are underlain by common value systems, and under conditions that offer safety, support and empowerment. Servant leadership style better supports culture change. Broader implications for nurse leadership during culture change and change management need to be explored, such as providing a foundation of solid, supportive, empowering relationships, and recognising and responding to perceptions of loss during change. 3. Debesay, J., Arora, S., & Fougner, M. (2022). Organisational culture and ethnic diversity in nursing homes: a qualitative study of healthcare workers' and ward nurses' experiences. BMC Health Services Research , 22 (1), 1–14. https://doi.org/10.1186/s12913‐022‐08184‐y ; Norway Qualitative hermeneutic‐phenomenological approach. ‘To explore how a multicultural workplace is experienced, through the accounts of HCWs and leaders in nursing homes’. Not stated Ward nurses, nurses, auxiliary nurses were included in the study, a total of 16 participants from 4 nursing homes. Six themes emerged from interview data: Increased understanding of diversity through shared norms & multicultural experience. Greater flexibility by challenging traditional norms in a multicultural workforce. Increase language proficiency, reduce exclusionary practices Positive perceptions of the role of the ward nurse. Acknowledge prejudices among patients. Most study participants found working in a nursing home ward with colleagues of different nationalities both exciting and instructive. Nursing homes should promote inclusion, which strengthens the internal cohesion of the organisation. Need for increased knowledge and awareness of how multicultural work communities in nursing homes function. Instances of racism directed to towards staff by patients can have significant consequences for staff well‐being and must be addressed proactively. 4. Dewar, B., Barrie, K., Sharp, C., & Meyer, J. (2019). Implementation of a Complex Intervention to Support Leadership Development in Nursing Homes: A Multimethod Participatory Study. Journal of Applied Gerontology , 38 (7), 931–958. https://doi.org/10.1177/0733464817705957 ; Scotland Multimethod—Quantitative questionnaires & qualitative group discussions. ‘To examine the learning and perceived impact of the My Home Life (MHL) intervention has made to leadership development and nursing home practice, from the perspectives of the participating managers’. Contribution analysis theory Data were collected from 119 nursing home managers, 93 of whom had a nursing background. Understanding of how to improve culture of care increased as a result of the MHL intervention. Positive changes in managers' perceptions of their self‐awareness, leadership communication and relationship skills, and development of positive cultures. Supporting nurse managers to develop leadership capability in the current context of health and social cultures of care is crucial if the vision of MHL to enhance the lives of those living, dying, working, and visiting nursing homes, is to be achieved. Expand on co‐creating data with staff, relatives, and residents to complement the managers' perspectives, improve cultures of care and achieve consistency with the participatory and appreciative ethos of the program. 5. Frey, R., Boyd, M., Foster, S., Robinson, J., & Gott, M. (2016). What is the diagnosis? Organisational culture and palliative care delivery in residential aged care in New Zealand. Health & Social Care in the Community , 24 (4), 450–462. https://doi.org/10.1111/hsc.12220 ; New Zealand Explanatory sequential mixed‐methods design (Creswell & Clark, 2011). ‘To explore both the perceptions and the reality of organisational culture within New Zealand Residential Aged Care (RAC) facilities’. Not stated Forty‐six managers of RAC facilities, encompassing directors of nursing, care managers and clinical managers. Also included were smaller numbers of managers, CEOs, owners and others ‘Clan culture’ was the preferred organisational culture of RAC managers. Clan culture emphasises ‘cohesion, participativeness, individuality and a sense of ‘we‐ness’. Hierarchical culture was also a preference for some managers. This is characterised by formality, structure and stability, and respect for position and power of leaders. Families felt a greater affinity for Clan culture, which is compatible with a staff/family partnership in caring for a resident, and it is noted as being philosophically compatible with Maori tikanga. Resource limitations have repercussions for the functioning of a Clan culture and the capacity to deliver a high quality palliative care service. Interventions to optimise organisational culture should be context appropriate. Initiatives should facilitate ‘hallmarks’ of a clan culture such as improved communication, teamwork and collaboration. 6. Greason, M. (2020). Ethical Reasoning and Moral Distress in Social Care Among Long‐Term Care Staff. Journal of Bioethical Inquiry , 17 (2), 283–295. https://doi.org/10.1007/s11673‐020‐09974‐x ; Canada Qualitative—Seven interdisciplinary focus groups using vignettes focused on ‘difficult decision‐making’. Document analysis—to explore how ethical reasoning aligned with declared organisational philosophies. ‘The goal of the research is to gain a better understanding of how long‐term care staff reason ethically in a social care context’. Empirical ethics Twenty‐one frontline care staff comprising 10 RNs, 6 licensed practical nurses, three resident attendants and one nurse practitioner from four long‐term care facilities. Staff perceived the organisational environment as dominated by: hierarchy of power and lack of staff autonomy staffing restrictions and a task‐oriented environment concern about liability 4. family power superseding that of the resident 5. financial inequality. To manage these experiences of moral distress in practice, staff rely on four strategies to make ethical decisions: comply with being told what to do out of fear of consequences defer decisions to family ‘have a meeting’ adopt and defer to existing workplace culture. Further exploration to better understand ethical reasoning processes of staff, and the interaction between frontline practice and organisational policy. Determine the impact public policy has on the development of ethical cultures and thus decision–making environments for frontline staff. 7. Hamiduzzaman, M., Kuot, A., Greenhill, J., Strivens, E., & Isaac, V. (2020). Towards personalised care: Factors associated with the quality of life of residents with dementia in Australian rural aged care homes. PloS one , 15 (5), e0233450. https://doi.org/10.1371/journal.pone.0233450 ; Australia (Queensland and South Australia) Qualitative focus groups and individual interviews (part of mixed method ‘Harmony in the Bush’ study). ‘We aim to explore the factors that shape the dimensions of personalised dementia care in rural nursing homes’. Multidimensional theoretical model There were 104 participants from five rural aged care homes including clinical managers, RNs, enrolled nurses, and care workers. Organisational and workplace cultures are crucial to the implementation of personalised care for people with dementia. Current service delivery focusses on general nursing care rather than the provision of specific person‐centred care. Findings highlight the importance of staff retention and recruitment is critical in improving the quality of person‐centred care for people with dementia. Rural care homes require additional commitment from policy makers to achieve resource stabilisation and improvement in personalised dementia care. 8. Helgesen, A. K., Larsson, M., & Athlin, E. (2014). Patient participation in special care units for persons with dementia: A losing principle? Nursing Ethics , 21 (1), 108–118. https://doi.org/10.1177/0969733013486796 ; Norway Qualitative grounded theory design (Corbin & Strauss). ‘To explore the experience of nursing personnel with respect to patient participation in SCUs for persons with dementia in nursing homes, with focus on everyday life’. Not stated The participants were 11 nursing personnel: four RNs, four ENs and three unskilled assistants from three nursing homes. Patient participation in decisions about everyday life ranged from ‘letting the residents make their own decisions’ to using force, particularly in situations where resident wellbeing and dignity was seen to be at risk. The level of participation was adjusted primarily to suit the different conditions, and secondly to the resident's needs and wishes. Findings highlight the need to create care cultures in special care units with visible nurse leaders who give priority to patient participation. Reflection should be a component of the care culture, with nurses given space to discuss questions around the meaning of patient participation in the context of people with dementia. More research focussed on a better understanding of the complex and sometimes paradoxical phenomenon of patient participation in the SCU context. 9. Marriott‐Statham, K., Mackay, M., Brennan, N., & Mackay, J. (2018). Empowering aged care nurses to deliver person‐centred care: Enabling nurses to shine. Nurse Education in Practice , 31 , 112–117. https://doi.org/10.1016/j.nepr.2018.05.014 ; Australia Participatory Action Research (PAR)–initial phase ‘To empower registered nurses to positively influence the health care workplace culture within a residential care home by raising consciousness about their own practice’. Person‐centred framework underpinned by critical social science There were six participants in the study, including RNs, a facility manager, care manager, quality assurance officer and nurse educator from one residential care home. To create a person‐centred culture in the residential care home, all residents, including those in the hostel, must be included. Practice issues must be more openly discussed in a safe environment, such as through handovers. A shared understanding of the role of the registered nurse in the aged care setting is fundamental in enabling them to feel empowered to lead their team and contribute positively to the workplace culture. Individuals and organisations need to intentionally move from moments of person‐centredness to a culture of person‐centredness. This includes the transition from a facility with distinct sections to one cohesive residential home that offers care across the aging continuum. 10. Øye, C., Mekki, T. E., Jacobsen, F. F., & Førland, O. (2016). Facilitating change from a distance–a story of success? A discussion on leaders' styles in facilitating change in four nursing homes in Norway. Journal of Nursing Management , 24 (6), 745–754. https://doi.org/10.1111/jonm.12378 ; Norway Qualitative Multi‐site comparative ethnography. ‘To examine the influence of leadership when facilitating change in nursing homes’. Promoting Action on Research Implementation in Health Services (PARIHS) framework Interviews with 9 nurse leaders, 8 nurses who were not in leadership roles, 19 nursing auxiliaries, Four assistant nurses, one social educator and one assistant occupational therapist from 6 nursing homes. Nurse leadership involvement in Evidence‐based practice (EBP) bunning related to use of restraint is a key factor in facilitating change. Leadership does not need to be fully democratic and inclusive for successful implementation of EBP. Organisational culture is one of three influencing factors, alongside leadership and evaluation, to facilitate change in nursing homes. As a minimum, a leader's presence is necessary to facilitate change in EBP. Future research required to understand the complex social processes involved in team cultures. 11. Petersen, H. V., Foged, S., & Nørholm, V. (2019). ‘It is two worlds’ cross‐sectoral nurse collaboration related to care transitions: A qualitative study. Journal of Clinical Nursing , 28 (9/10), 1999–2008. https://doi.org/10.1111/jocn.14805 Qualitative ‘To explore how registered nurses in hospital and in home care talk about and experience cross‐sectoral collaboration related to transitional care of frail older patients’. Not stated There were 79 participants, either working in the hospital setting or home care service. Nurses working at the hospital were all RNs. RNs also featured at the home care service as well as healthcare staff with 1–2 years of education and practical training. Hospital and home care are described as ‘two worlds’ with separate cultures and professional identities. Cross‐sectoral collaboration between nurses is challenged by different definitions of nursing Cross‐sectoral collaboration. between nurses should be perceived as interprofessional rather than intra‐professional collaboration. Two ‘culture of care’ worlds: At the hospital, nursing included all aspects of care related to the patient's acute needs. The home care nurses' main tasks included coordination of care and specialised nursing tasks, e.g., medication, palliative care and wound care. Further research on underlying cultural and organisational systems should be undertaken to support policy and planning related to cross‐sectoral nurse collaborative systems. 12. Sahay, A., Willis, E., Kerr, D., & Rasmussen, B. (2022). Nurse leader agency: Creating an environment conducive to support for graduate nurses. Journal of Nursing Management , 30 (3), 643–650. https://doi.org/10.1111/jonm.13561 ; Australia Qualitative exploratory descriptive. ‘The aim of the study was to gain insight on how nurse leaders manage a culture of safety for graduate nurses in hospital and aged care settings’. Giddens structuration theory Interviews were conducted with 24 ‘nurse leaders’. The scope of positions was nurse unit manager, associate nurse unit manager, nurse educator, team leader, clinical nurse specialist, aged care facility manager and hospital nurse manager. Nurse leaders identified a range of cultural norms and values, decision‐making processes, philosophies, strategies and operational procedures to foster patient safety. Mentoring of graduate nurses includes building formal structural practices such as handover, teamwork, medication protocols and care plans. Patent safety extends to the very culture of a ward or aged care setting and should align with the clinical governance framework. Nurse Leaders who foster an environment of support and a ‘just culture’, enable the delivery of safe clinical care. Nurse leaders' capacity and legitimacy hinge on agency to practice and aspects of an organisation's social structure. More research required to understand implications for maintaining a patient safety culture. 13. Scerri, M. A., & Presbury, R. (2021). Contextual factors influencing talk in Australian residential aged care. Journal of Health Organisation and Management , 35 (5), 643–658. https://doi.org/10.1108/JHOM‐04‐2020‐0106 ; Australia Qualitative exploratory multiple case study. ‘To explore contextual factors that influence carer‐to‐resident talk in Australian residential aged care’. Service theory model Data were collected during 21 interviews with RNs, Assistants in nursing (AINs) leisure and lifestyle officers or coordinators, general managers and care managers from three residential aged care homes The care teams worked closely on shared goals to reduce pressure on individuals. A supportive organisational and team culture, combined with resources are required to enable culture change towards person‐centred care. In view of current policy reform, findings support formal strategies for communication management and person‐centred care. This includes staff training and cultural change interventions. 14. Trybou, J., Gemmel, P., Pauwels, Y., Henninck, C., & Clays, E. (2014). The impact of organisational support and leader‐member exchange on the work‐related behaviour of nursing professionals: the moderating effect of professional and organisational identification. Journal of Advanced Nursing , 70 (2), 373–382. https://doi.org/10.1111/jan.12201 ; Belgium Quantitative ‘To examine relations between perceived organisational support, the quality of leader–member exchange, in‐role and extra‐role behaviour, professional identification and organisational identification among registered nurses’. Social exchange theory A total of 153 RNs and nursing assistants from a convenience sample from five Belgian nursing homes participated. A positive relationship exists between perceived organisational support, the perceived quality of social exchange with the head nurse and extra‐role behaviour. Organisational and professional identification positively moderates the relationship between perceived organisational support and extra‐role behaviour. Findings demonstrate the importance of organisational support and social exchange in healthcare organisations. Perceived organisational support results in RNs ‘going the extra mile’. Further exploration as to why, at the interpersonal level, RNs who perceive a high quality of social exchange with their head nurse or manager are more likely to show extra‐role behaviour. 15. Wagner, L. M., Huijbregts, M., Sokoloff, L. G., Wisniewski, R., Walsh, L., Feldman, S., & Conn, D. K. (2014). Implementation of Mental Health Huddles on Dementia Care Units. Canadian journal on aging = La revue canadienne du vieillissement , 33 (3), 235–245. https://doi.org/10.1017/S0714980814000166 ; Canada Qualitative Phenomenology/Participatory Action Research ‘To introduce the huddles concept into the long‐term (LTC) care setting to help direct‐care staff interact more effectively with dementia care residents’. Not stated The study population incorporated RNs, registered practical nurses, personal support workers and housekeeping staff from one long‐term care home. Huddles provided LTC staff with the opportunity to collaborate and discuss strategies to optimise resident care. 2. Safety culture dimensions. Huddles can improve workplace culture by supporting relational care, improving mental health care, improve resident and staff safety and increase quality of care. Knowledge translation strategies, in addition to further research on what is needed to support a culture change to person‐centred care, could be used to develop a strong theoretical basis for huddles. 16. Winqvist, I., Näppä, U., & Häggström, M. (2023). Quality of care during rural care transitions: a qualitative study on structural conditions. BMC Nursing , 22 (1), 262. https://doi.org/10.1186/s12912‐023‐01423‐5 ; Sweden Qualitative ‘The aim of this study was to explore RNs' perspectives on structural conditions that promote or hinder good quality care during transitions from hospital to HHC in rural areas’. Old age and chronic illness are positively associated with receiving home health care Social constructivism The participants were 21 RNs from Northern Sweden experienced in care transitions from hospital to home healthcare RNs have insufficient knowledge of conditions crucial to maintaining quality of care during transitions, namely: Distance and inaccessibility Competence of the actors Levels of organisational governance. Transition care represents a multi‐organisational health system with different patient safety cultures. These aspects are critical in a rural context due to geographical challenges. Each organisation should develop a holistic view of the physical, social and symbolic environment, simultaneously affecting their quality of care, and inter‐organisational collaborations. 17. Yafa, H., Dorit, R., & Shoshana, R. (2016). Gerontological nurse practitioners (GNPs) for the first time in Israel: Physicians' and nurses' attitudes. Journal of the American Association of Nurse Practitioners , 28 (8), 415–422. https://doi.org/10.1002/2327‐6924.12343 ; Israel Quantitative descriptive survey. ‘The objective of this study is to examine the attitudes among gerontological physicians and nurses towards the scope of practice and effects on healthcare quality of the new role of gerontological NPs (GNPs)’. Not stated There were 148 participants among whom 88% were senior nurses (chief nursing officers, charge nurses and clinical supervisors) from 8 geriatric care facilities. The remaining 12% of participants were physicians. Overall attitudes of physicians and RNs positive to the NP role. Attitudes of physicians and RNs differ on the scope of NP roles. Transfer of tasks from the medical to the nursing domain creates uncertainty. This impedes development of the NP role. Organisational obstacles to development and implementation of the NP role include organisational culture, failure of physicians and staff to understand the role and lack of long‐term resource planning. Successful implementation of the GNP role depends on substantive research that identifies positive contributions to treatment outcomes, cost–benefit ratios, and increased effectiveness in responding to the patients' need. Open in a new tab 5. Themes From the Literature The search results from the included studies were summarised in Table 4 , then synthesised to identify themes that contribute to a new understanding of the phenomenon from the perspective of Registered Nurses (from here the term ‘nurses’ is used). The primary themes are identified as: competing hierarchies of power. the multifaceted role of nurses in long‐term care settings. standing still is not an option; and. implications for culture change strategies in practice. 5.1. Primary Theme: Competing Hierarchies of Power The primary theme ‘Competing hierarchies of power’ provides the backdrop to how nurses might understand dominant organisational cultures in aged care, their ‘unique nursing roles’ within those organisations, and the importance of ‘shared understanding, mutual knowledge’ to sustain quality of care. 5.1.1. Subtheme: Unique Nursing Roles As reflected in the broader international literature, there is very little understanding globally of how nurses perceive their roles in organisational culture in aged care. Part of this is due to the uniqueness of nursing roles in the context of aged care, and partly due to the misalignment that has developed between organisational philosophies and nurses' perceptions of the culture in which they work (Dewar et al. 2019 ; Greason 2020 ). Whilst it is assumed that organisational culture in healthcare settings is based on a foundation of shared ways of thinking, feeling, and behaving, for nurses, flattened hierarchical team processes and a multi‐level team approach as defined by the nursing culture of care and profession are perceived as more appropriate to achieve clinical and care aims (Banaszak‐Holl et al. 2015 ; Cloutier et al. 2016 ; Frey et al. 2016 ). Nurses find that these values are often competing or in conflict with the hierarchies shaped by the dominant culture of an individual aged care organisation, which often is framed by a hierarchical performance culture driven by corporate or market values (Banaszak‐Holl et al. 2015 ). Nurses felt they should have more significant roles in management and leadership, such as in developing formal communication strategies to support person‐centred care in the context of the organisation's culture (Banaszak‐Holl et al. 2015 ; Scerri and Presbury 2021 ). However, for the position of nurse manager to be legitimate in aged care, nurses recognise that they must have the power, both in terms of authority and resources, and to be able to speak to their power (Sahay et al. 2022 ). Strategies to raise consciousness about nurses' ability to positively influence health care workplace culture and the uniqueness of their role as managers and leaders would empower nurses at all levels in residential care homes (Marriott‐Statham et al. 2018 ). Nurses in the long‐term environment of residential care described how hierarchies of power within an organisational culture often dominate relationships and ethical reasoning processes of staff, rendering them powerless (Greason 2020 ). Market and hierarchical cultures within organisations were perceived by directors of nursing care, care managers, and clinical managers as impacting negatively on the quality of care provided to residents due to issues such as a task‐oriented environment and a lack of collaboration between managers and staff (Frey et al. 2016 ). Nurses recognised that cultures of care within their organisation can be negatively shaped by a number of factors, including lack of autonomy and ability to influence care staff who may have a narrow understanding of ethical responsibilities, staffing restrictions, family power superseding that of the resident, and families not understanding the ‘bigger picture’ complexities of the long‐term environment (Greason 2020 ). Nurses felt that all of these factors influence the culture of care by impacting their ethical decision‐making and ability to care for residents, thus contributing to experiences of moral distress (Dewar et al. 2019 ; Greason 2020 ; Hamiduzzaman et al. 2020 ). The exception to this was a study by Banaszak‐Holl et al. ( 2015 ), which concluded that hierarchical internal processes positively assisted in retaining staff through creating a stable work environment. Nurses found that working in an organisation with a common vision, purpose, and shared goals facilitates teamwork and reduces negative behaviours associated with an environment that is resource constrained and dominated by competing hierarchies (Cloutier et al. 2016 ; Frey et al. 2016 ). How an organisation values staff's contribution and cares about their well‐being can be an important influencer of nurses' perceptions of oneness as a professional group in health care (Trybou et al. 2014 ). In particular, the safety culture within each organisation was seen as valuable in influencing staff to report incidents such as medication errors and falls, and the value of doing so is significant (Winqvist et al. 2023 ). 5.1.2. Subtheme; Shared Understanding, Mutual Knowledge Nurses identified the importance of sustaining a culture that creates a sense of shared purpose and mutual knowledge for staff, hence developing a genuine ‘ownership’ of ideas and trust and ensuring knowledge needs are met (Greason 2020 ). This includes mentoring of graduate nurses, fostering an environment of support and a ‘just culture’ and aligning with clinical governance principles (Sahay et al. 2022 ). A servant leadership style and clan culture leadership were seen to better support a system of shared values, motivating change that is person‐centred and emphasising larger considerations than performance or tasks (Cloutier et al. 2016 ; Frey et al. 2016 ). In the studies situated in residential care, nurses consistently discussed organisational culture within the unique context of care homes, and the crucial role nurse managers play in setting the culture of care (Cloutier et al. 2016 ; Dewar et al. 2019 ; Greason 2020 ). Similarly, for residents with dementia in residential aged care, nurses highlighted the importance of staff relationships based on shared values and decision‐making as the key to practising holistic care. Holistic, person‐centred care for residents with dementia also extended to relational, shared decision‐making between staff and family members regarding their ‘service’ with a focus on the physical environment and safety (Hamiduzzaman et al. 2020 ). Nurses identified negative influences on care for the resident with dementia as hierarchical authorisation and authoritative leadership. Both of these were felt to discourage innovation such as the implementation of a new model of care and secondly increase strained relationships among staff both horizontally and vertically (Hamiduzzaman et al. 2020 ). Nurses felt that the approach of the individual nurse to residents with dementia profoundly impacts staff decision‐making and participation, with more educated nurses encouraging participation as well as involvement of families. Furthermore, cultures of care in which the concept of resident and family participation is a commonly accepted goal, and the nurse leader is visible and one of the team, seemed to stimulate high levels of patient participation (Helgesen et al. 2014 ). Wagner et al. ( 2014 ) evaluated the use of ‘huddles’ similar to those used in mental health, in dementia care units. Huddles are short meetings that occur ‘just in time’ to manage for example, physically expressive behaviour by residents. Nurses considered that the introduction of huddles as an innovative approach for fostering shared knowledge, ideas and insights (Wagner et al. 2014 ). In conclusion, nurses felt that in a supportive organisation where there is mutual understanding of their myriad roles and open knowledge sharing, they have the power to positively influence the culture by empowering staff and improving practice. 5.2. Primary Theme: The Multifaceted Role of Nurses in Long‐Term Care Settings The second primary theme, ‘The multifaceted role of nurses in long‐term care settings’ focuses attention on the breadth of their practice as ‘Nurse Managers, Practitioners, Specialists and Researchers’, and the call from nurses that ‘Nurse leadership facilitates change’. 5.2.1. Subtheme: Nurse Managers, Practitioners, Educators, Specialists, Researchers Nurses maintained that when they play a bridging role between facility management and direct care staff in the health and social contexts of residential aged care, the culture of care inevitably improves, hierarchies flatten, and a multi‐level team approach achieved (Cloutier et al. 2016 ). How they are supported influences their approach to practice and sustaining a relationship‐centred culture (Dewar et al. 2019 ). When nurses modify their behaviour as leaders to empower others, rather than being seen as the ‘fixers’, staff can more easily identify and weigh courses of action and situations, and conflict can be reduced (Dewar et al. 2019 ; Greason 2020 , 10). The legitimation of the position of nurse manager as leader speaks to their power and to the forms of communication they engage in, including the significance of their discourse. Nurses recognise that as individuals they must have the power, both in terms of authority and resources (Sahay et al. 2022 ). In this way, a positive ethical culture can be established when leaders within the organisation proactively recognise ethics as an integral component to the organisation's culture and success (Dewar et al. 2019 ). Nurses believed that supporting specialist nurses as visible leaders in the delivery of personalised dementia care in dementia special care units creates a care culture where patient participation is supported. However, they acknowledged that there are organisational obstacles to bridging the gap between the theoretical ideal of patient participation and the reality in practice (Hamiduzzaman et al. 2020 ; Helgesen et al. 2014 ). Similarly, organisational obstacles to successful Nurse Practitioner (NP) role implementation in aged care were identified, including a lack of amenable organisational culture, failure of interdisciplinary staff to understand the role, and a lack of long‐term human resource planning (Yafa et al. 2016 ). Nurses felt that more authentic involvement of nurses as role models and leaders within the organisation, as well as co‐researchers, would equalise power, create a shared voice, and develop shared values and vision. For example, in research, co‐researchers could include an academic staff member, the Facility Manager, and the Nurse Educator, and it was recognised that these were positions of power (Marriott‐Statham et al. 2018 ). 5.2.2. Subtheme: Nursing Leadership Facilitates Change Nurses consistently call for the need to facilitate culture change that focuses on transformation, inclusiveness, compassion, and caring, and recognition of roles through principles of servant leadership (Cloutier et al. 2016 ; Dewar et al. 2019 ). At a minimum, it was felt that a nurse leader's presence is necessary to facilitate internal processes in order to more successfully implement evidence‐based practice (EBP) and effective clinical governance (Øye et al. 2016 ). In a culture shaped by servant leadership, nurse leaders also identified utilising agency and aspects of social structure as factors critical to their roles and decision‐making capacity with respect to a safety culture in the workplace. For example, how individual nurse leaders support their team and mentor graduate nurses speaks to their agency, the culture they create on the ward, and their own sense of identity as a leader (Sahay et al. 2022 ). In the context of team culture, nurses recognised the need to understand the role of nursing leadership in successfully implementing EBP as a collective social process through collaboration and cooperation with staff rather than simply focusing on residents' daily needs and clinical role responsibilities (Øye et al. 2016 ; Scerri and Presbury 2021 ; Trybou et al. 2014 ). The role of nurse leaders in developing processes of critical thinking and a high quality of social exchange as a shorthand for active agency in the context of creating structure and culture of clinical governance in an organisation (also involves practices such as handover, teamwork, medication protocols and care plans) (Sahay et al. 2022 ; Trybou et al. 2014 ). In dementia care, nurses believed they are responsible for the education of frontline staff and optimising the process of learning. This includes empowering personal support workers who spend the most time with residents to participate in innovative approaches such as huddles (Wagner et al. 2014 ). The role of the Gerontological Nurse Practitioner in nurse leadership also requires further investigation in terms of improving quality healthcare provision and organisational culture (Yafa et al. 2016 ). In summary, nurses believe that in the context of organisational culture, their myriad roles in aged care are crucial to facilitating change that focuses on improving EBP, clinical governance, and a positive ethical culture. 5.3. Primary Theme: Standing Still Is Not an Option The third primary theme, ‘Standing still is not an option’ speaks to the ‘The need for cultural change’ voiced by nurses, not only to improve person‐centred care practice, but also to enhance shared knowledge and understanding of ‘Different culture of care worlds’ across aged care and acute care settings. 5.3.1. Subtheme: The Need for Culture Change Nurses generally voiced the need for culture change in their organisation/s that focuses on inclusiveness, compassion and caring, with the recognition that ‘… standing still is not an option’ (Cloutier et al. 2016 , 4). Nurses perceived their role in residential care as the linchpin in changing an organisation's culture from an embedded hierarchy, often seen as a ‘hierarchical heritage’ of nursing, to a person‐centred culture (Marriott‐Statham et al. 2018 ). The philosophy of person‐centredness includes all staff, residents and families and is underpinned by values of respect of persons, individual rights to self‐determination, mutual respect, and understanding (Marriott‐Statham et al. 2018 ). In this way a person‐centred culture is enabled by cultures of empowerment that fosters continuous approaches to practice development and leadership (Cloutier et al. 2016 ; Marriott‐Statham et al. 2018 ). Nurses also described how they play an important bridging role between facility management and direct care staff, focusing on ‘the little things’ and ‘the people not the model’. This bridging role may facilitate cultural change through open dialogue, building relationships and collaboration between management and staff (Cloutier et al. 2016 , 12). Globally, ethnic diversity has become a significant component of the healthcare workforce and can be seen as a strength in supporting inclusion of all cultures in care (Debesay et al. 2022 ). Creating shared opportunities for staff unification through a system of shared values was raised by nurses as an important context for understanding diversity experiences and for encouraging shared decision‐making between staff and family members regarding the service and preference of residents (Debesay et al. 2022 ; Hamiduzzaman et al. 2020 ). 5.3.2. Subtheme: Different ‘Culture of Care’ Worlds Nurses described collaboration across the acute and home care sectors as working in different contexts, within different cultures with divergent professional features and characteristics (Vendel Petersen et al. 2019 ). Although the goals for a safe care transition for patients were seen as shared, the values of hospital and home care cultures were perceived as distinct, shaped by each organisational system, and influencing the nursing approach to patients (Vendel Petersen et al. 2019 ; Winqvist et al. 2023 ). For example, nurses outlined their role in a hospital ward as ‘giving instructions to the patient’ or ‘knowing what is best for the patient’, whereas nursing in a home care setting was referred to as being ‘based on the citizen's need and wishes’ and ‘negotiation with the citizen towards a common goal’ (Vendel Petersen et al. 2019 , 2003). Whilst nurses recognise that transition care represents a multi‐organisational health system with different patient safety cultures, they also highlight the need for shared learning to improve cultures of care through better understanding and mutual knowledge, particularly in the area of organisational governance (Winqvist et al. 2023 ). In conclusion, nurses strongly agree that the need for culture change and continuous improvement applies not just to individual organisations within aged care but also across contexts where transitions occur between hospital and home care cultures. 5.4. Primary Theme: Implications for Culture Change Strategies in Practice The fourth primary theme ‘Implications for culture change strategies in practice’ focuses on the importance of ‘Integrating differing values into core practice’ across different organisational and care cultures in aged care. Nurses felt that for staff to have ownership of culture change it must be embedded in practice, where ‘It's one thing to hear it. It's another thing to live it’. Cultural change needs to be undertaken with consideration of the larger sociopolitical context influencing health policy. 5.4.1. Subtheme: Integrating Differing Values Into Core Practices Nurses believed that broader implications for nurse leadership during culture change and change management need to be explored, such as providing a foundation of solid, supportive, empowering relationships, and recognising and responding to perceptions of loss during change (Cloutier et al. 2016 ). During care transitions, nurse managers should be cognisant that leadership approaches have significant bearing on facilitating cultures of empowerment that foster continuous approaches to practice development, the patient safety culture and error management (Marriott‐Statham et al. 2018 ; Winqvist et al. 2023 ). In dementia care, innovations such as huddles are more successful in a culture where patient safety is a priority, change is embraced and actively includes those whom it will influence (Wagner et al. 2014 ). 5.4.2. Subtheme: ‘It's One Thing to Hear it. It's Another Thing to Live it’ Nurses felt that decision‐makers working at a higher level from middle management (facility level) need to do what they can to protect facilities, direct care staff, residents and their families, as well as the local leadership from facing too much change and immediate adaptation (Cloutier et al. 2016 , 14). In order to establish a positive inclusive organisational culture it is imperative that staff maintain a sense of control and ownership over their work with the aim of uniting and integrating them ‘into a shared social and cultural sphere of meaning’ (Debesay et al. 2022 , 11). 5.4.3. Subtheme: Understanding the Larger Sociopolitical Context Nurses as managers and leaders need to understand the larger sociopolitical contexts which influence public and organisational policy (Greason 2020 ). Policy implications are particularly important for resources in rural care homes, leadership and organisational culture, and physical environment and safety (Hamiduzzaman et al. 2020 ). Relevant policy across sectors should be considered, and underlying cultural and organisational systems need to be explored and taken into consideration when planning and implementing collaborative systems (Vendel Petersen et al. 2019 ; Winqvist et al. 2023 ). Nurses must pay particular attention to current policy reform and their role in policy implementation, and findings that support formal strategies for communication management and person‐centred care. For example, an application of a transformative service research approach may have value in improving organisational performance in residential aged care, including the balance of competing care demands (Scerri and Presbury 2021 ; Trybou et al. 2014 ). Finally, linking policy to research that identifies positive contributions from Nurse Practitioners related to treatment outcomes, cost–benefit ratios, and increased effectiveness in responding to the patients' needs (Yafa et al. 2016 ). To summarise, nurses believe that their leadership in empowering staff and providing a sense of ownership is integral to the process of culture change in aged care. Nurses also felt that understanding organisational culture in the sociopolitical context is critical for achieving transformation across all levels of organisations. 6. Discussion The review findings augment those from previous studies highlighting the dearth of research providing insight into nurses' understanding of their specific roles in the context of organisational culture in aged care, in particular cultures of care, and how culture change strategies can be implemented (Churruca et al. 2023 ; Leep‐Lazar and Stimpfel 2024 ). The central concepts identified from the findings to elicit change are nurses' belief in the need for organisational cultures specific to aged care, the need for an empowered nursing workforce, and strong nursing leadership. In this integrative review, the central themes are viewed and developed through the lens of Michel Foucault's ideas on governmentality and disciplinary power, with a focus on understanding the relational nature of nursing roles, where they are situated within the cultural fabric of aged care, and the capacity of bringing about practice change (Foucault 2003 , 2007 ). The application of Foucault's ideas helps to clarify the relational operation of power and how nurses negotiate organisational structures and enact forms of care within these structures. 6.1. The Tension Between Uniqueness and Homogeneity of Organisational Culture in Aged Care The findings have focused attention on nurses' perceptions that their roles in the context of aged care and organisational culture are unique. The question may then be asked: Is there a uniqueness to organisational and workplace cultures in aged care or do all organisations that deliver health services possess an inherent homogeneity? Burrell ( 1988 , 13), in distilling the dynamic, evolving views of Michel Foucault, advises that applying a reductionist method to organisational culture through ‘discourses and classification schemes’ shifts the focus from individual ‘cultures of care’ to a homogeneity that ‘reflects and reproduces a disciplinary society’. In this instance, a disciplinary society is described as a mechanism of power that regulates human behaviour through a process of ‘surveillance, examination, judgement and correction’ of the human person (Havis 2014 , 112, 111). As a result of the reductionist method, in an individual aged care organisation a hierarchical performance culture may dominate and compete with shared values associated with a person‐centred culture and workplace (Dewar et al. 2019 ; Greason 2020 ). The antidote to a reductionist approach to organisational culture is recognising that each aged care facility has a singular culture different from other aged care facilities and from facilities in other components of the health system. Nurses in aged care perceive their organisational cultures as different from other areas of clinical practice, due to the nature of the work undertaken, the structure of the aged care sector, and the relationships with residents or clients and families (Cloutier et al. 2016 ; Dewar et al. 2019 ; Greason 2020 ). In recognising organisational and workplace cultures as highly localised and context dependent, the human agency of nurses embedded in each culture can play an active role in the complex, multifaceted mechanisms of power’ (Raffnsøe et al. 2019 , 162). 6.2. An Empowered Nursing Workforce in Aged Care Critical to Change Nurses working in aged care believe that an empowered nursing workforce is critical to changing organisational culture. Human agency and empowerment are similar concepts, both centre on the capacity of a person to act intentionally, gaining control of factors that shape future outcomes (Landes and Settersten 2019 ; World Health Organisation 2025b ). Nurses working in aged care contexts see empowerment as a mechanism to bring about positive change to working conditions and the lives of older people through improving standards of care (Cloutier et al. 2016 ; Dewar et al. 2019 ; Greason 2020 ; Marriott‐Statham et al. 2018 ; Wagner et al. 2014 ; Winqvist et al. 2023 ). This speaks to Foucault's assertion that while power can be a negative and repressive force, such as in the case of political dictatorships, it is also productive and through resistance, capable of bringing about change. Mechanisms of resistance to repressive power in contemporary society include education and individual empowerment (Schirato et al. 2020 ). The apparatus of power, according to Foucault, is the relationship between people, institutions, bureaucracies and cultural fields such as the medical system, media and business (Schirato et al. 2020 , 46). Nursing itself is not neutral or apolitical, and the profession has demonstrated a capacity to employ power (and resistances to power) to bring about change from a strategic position located at the nexus of the government and the community. An exemplar of this is the role of industrial organisations in improving nurses' wages and working conditions (Holmes and Gastaldo 2002 ; Muhle 2014 ; Stanton et al. 2022 ). The role of nurses in clinical and managerial leadership is perceived as pivotal to cultures of empowerment and the implementation of evidence‐based practice, effective clinical governance, and the provision of complex care to, for example, people with dementia (Cloutier et al. 2016 ; Hamiduzzaman et al. 2020 ; Helgesen et al. 2014 ; Øye et al. 2016 ; Sahay et al. 2022 ). 6.3. Positive Organisational Cultures Depend on Strong Leadership For change strategies to be implemented in practice, nurses believe that strong leadership is integral to a positive organisational culture including cultures of safety, innovation, and evidence‐based practice, and effective clinical governance (Cloutier et al. 2016 ; Hamiduzzaman et al. 2020 ; Helgesen et al. 2014 ; Sahay et al. 2022 ; Scerri and Presbury 2021 ; Trybou et al. 2014 ; Wagner et al. 2014 ). Commencing with the acknowledgement that innovation in aged care is necessary to meet the needs of residents, clients, and an expanding regulatory framework, Davy et al. ( 2024 ) analysed 109 papers from mostly Australia and the United States, published between 2012 and 2022, to identify how to foster a culture of innovation in residential and community aged care. Leaders that recognised the expertise of staff and sought their opinions before and during the innovation implementation process promoted staff feeling empowered, trusted, and valued. Alignment between organisational vision, culture, and the proposed innovation supported the implementation process. Innovations that were not congruent with organisational vision and culture were less likely to receive support from stakeholders including staff and more likely to experience a delay in or cessation of the implementation process (Davy et al. 2024 ). Demonstrated organisational commitment manifested through the support of leadership and provision of human and material resources, education and training for staff, and adequate time to embed the change into ways of working was pivotal to success. Change should optimally occur in an environment of stability, specifically consistent ownership of a facility or organisation, with an organisational structure and leadership not subject to significant changes (Davy et al. 2024 ). Davy et al. ( 2024 , 6) acknowledges the importance and challenges of engaging with ‘key subcultures’ such as medical practitioners, allied health professionals, residents or clients, and their families when implementing innovations. Scant mentions of power in contemporary leadership scholarship focus on its mechanistic and unidirectional nature, indicating that a leader's power arises from their organisational position and personal characteristics (Ladkin and Probert 2021 ). However, this dismisses the complex and multifaceted nature of the connection between leadership and power or ‘who the leader is and how a leader is constituted by context’ (Ladkin and Probert 2021 , 5). This is illustrated by Cameron and Quinn ( 2011 ) who concluded that a successful leader in an organisation is predicated on congruence between their leadership strengths and the dominant organisational culture. As social actors who participate in interactions with others and whose actions are evaluated, leaders are also subject to relational forces such as the expectations of their ‘followers’ (Chandler and Munday 2020 ; Haugaard 2022 ). Some of these expectations are implicit in nature and arguably emerge from levels two and three of organisational culture. Leaders are also significantly impacted by the dynamics within the layers of management above them, the governance structure of the organisation and greater sociopolitical context that the organisation is embedded in (Braithwaite et al. 2017 ; Ladkin and Probert 2021 ; Mannion and Davies 2018 ). From a Foucauldian perspective, power relations, rather than power per se is the phenomena under study when considering leadership. (Harter 2016 ; Ladkin and Probert 2021 ). In aged care, leaders are further challenged by the marketisation of the aged care sector which gives primacy to discourses of efficiency, bureaucratic regulations linked to a discourse of accountability, and disciplinary power which asserts control over nurses and other health professionals (Ettlinger 2017 ). 6.4. Changing Organisational Culture In addition to strong leadership being pivotal to a strong organisational culture, nurses also identified that strong leadership is imperative during a process of organisational change (Cloutier et al. 2016 ; Hamiduzzaman et al. 2020 ; Marriott‐Statham et al. 2018 ; Øye et al. 2016 ; Winqvist et al. 2023 ). Mannion and Davies ( 2018 ) note two distinct perspectives on organisational culture in healthcare. Firstly, organisational culture can be assessed or measured, and change can be implemented with the aim of making improvements. An empirical approach dominates, focussing on domains of organisational culture such as safety culture, which are subject to performance targets used to gauge progress towards a stated objective (Mannion and Davies 2018 ). The second perspective, while viewing organisational culture as measurable, does not view it as a malleable construct in every circumstance. Qualitative insights prompt staff to reflect, learn, and collaborate to bring about change in a manager‐led process (Mannion and Davies 2018 ). The description of an organisational change process provided by Schein and Schein ( 2017 ) highlights that successful leadership in this context is relational, that is, contingent on the relationship between leader/s and employees. The outcome of power in this instance is the employees engagement with the change process (Ladkin and Probert 2021 ). For organisational change to occur, a process of ‘disconfirmation’ must occur, which highlights that change is necessary. Disconfirming information has four sub‐types, economic, political, social or personal, and is generally symptomatic, rather than diagnostic in nature. For change to occur, an important value or goal of the organisation must be compromised, and collective avoidance or repression of the problem must be overcome and the fear of having to adapt new ways of thinking or behaving. Leaders play a pivotal role in this process in either denying or repressing the problem or responding by implementing a process of change (Schein and Schein 2017 ). Anxiety related to change can be driven by fear of loss of power or status, fear or punishment, fear of being exposed as incompetent in developing new skills, and lastly a fear of loss of personal identity. In order to optimise the conditions for successful change, effective leaders optimise the psychological safety of employees and minimise barriers to change. It is imperative that a ‘compelling positive vision’ of the post‐change environment is provided which is clearly articulated and supported by management, who provide positive role models for adopting the specific behaviour change required. Staff engagement with the education and training process is essential to success and to creating the new cultural norms and assumptions (Schein and Schein 2017 ). 6.5. Creating a Person‐Centred Organisational Culture Creating an organisational culture that embraces a person‐centred care philosophy was a central concern of nurses in the literature and imperative to the provision of quality care to older people and their families (Hamiduzzaman et al. 2020 ; Marriott‐Statham et al. 2018 ; Scerri and Presbury 2021 ; Wagner et al. 2014 ). In evolving the concept of person‐centred care to person‐centred practice, the importance of relationships between staff characterised by mutual respect, collaboration, and inclusivity is highlighted by McCance and McCormack ( 2016 ) as necessary. In addition to positive relationships between staff, transformational leadership and a non‐hierarchical environment that fosters empowerment and innovation are pivotal to a ‘healthful’ person‐centred organisational culture (McCance and McCormack 2016 , 60; Rutten et al. 2021 ). Person‐centred practice, consistent with Foucauldian thinking, recognises power as omnipresent, relational in nature, and negotiated between individuals and within teams. In an aged care setting, the strengths and vulnerabilities of the older person are recognised in the process of negotiating power. The outcome of this process should reflect the values and beliefs of the older person and facilitate their autonomy in collaboration with residents' families (McCance and McCormack 2016 ; Villadsen 2007 ). 6.6. Strengths and Limitations A strength of this integrative review is the cohesive, supportive team that undertook the review. The team consisted of academics with expertise in gerontology, nursing workforce, research methodology, and critical discourse analysis, who provided guidance to a PhD student undertaking their first integrative review. The involvement of team members enhanced the overall rigour of the review, particularly the thematic analysis of the included papers. The methodological framework of Whittemore and Knafl ( 2005 ) amplified the rigour of the review and ensured congruence between the problem, literature search, data evaluation, data analysis, and presentation stage. The use of the MMAT Tool (Hong et al. 2018 ) to undertake critical appraisal ensured that the papers included were of high methodological quality. This review has three key limitations. Firstly, the exclusion of papers published in a language other than English. It is possible that papers in other languages exist that met the inclusion criteria but were not included. Secondly, the papers included in the review are from high‐income countries. The perspectives of RNs from countries with developing economies are not captured in this review. This review focussed on the views of RNs employed in a specific practice context. By focussing on RNs employed in the aged care sector, the themes distilled from the literature may not be generalisable to other practice contexts. RNs working, for example, in acute care environments may have a different understanding of organisational culture and cultures of care. 7. Conclusion This exploratory review of registered nurses' understandings of organisational culture in aged care has provided new insights into the conception of their role and its explication in this unique context. Findings arising from this study highlight the significant role registered nurses play in facilitating change within aged care environments. Registered nurses are pivotal to evolving clinical and administrative practice that affirms the rights of older persons to quality person‐centred care and facilitates inclusive and supportive environments for staff. As leaders and role models, registered nurses are social actors in a complex interplay of relationships where the key outcome is negotiating and sharing power that mediates how organisational change can occur. This review also underscores the formative nature of research on organisational culture in aged care and the potential for future research that fosters a robust evidence base to support the creation of organisational cultures that lead to improved care and staff experience. Author Contributions Deborah Magee: conceptualisation, formal analysis, writing – original draft, review and editing. Karen Francis: conceptualisation, supervision, formal analysis, writing – review and editing. Holly Randell‐Moon: supervision, formal analysis, writing – review and editing. Samantha Jakimowicz: supervision, writing – review and editing. Marguerite Bramble: conceptualisation, supervision, formal analysis, writing – original draft. Conflicts of Interest The authors declare no conflicts of interest. Acknowledgements Deborah Magee is the recipient of an Australian Government Research Training Program Scholarship in 2025. Special thanks to Ms. Lorraine Rose, Senior Client Services Librarian, Charles Sturt University, who provided expert consultation with the literature search strategy. Open access publishing facilitated by Charles Sturt University, as part of the Wiley ‐ Charles Sturt University agreement via the Council of Australian University Librarians. Appendix 1. Results of Critical Appraisal TABLE A1. Qualitative study methodological quality criteria. MMAT Q1 MMAT Q2 MMAT Q3 MMAT Q4 MMAT Q5 MMAT Q6 MMAT Q7 First author Study design Are there clear research questions/aims/objectives? Do the collected data allow to address the research questions? Is the qualitative approach appropriate to answer the research question? Are the qualitative data collection methods adequate to address the research question? Are the findings adequately derived from the data? Is the interpretation of results sufficiently substantiated by data? Is there coherence between qualitative data sources, collection, analysis and interpretation? Cloutier Qualitative component of a mixed methods study Yes Yes Yes Yes Yes Yes Yes Debesay Hermeneutic‐phenomenology Yes (expressed as a statement) Yes Yes Yes Yes Yes Yes Dewar Multimethod (with dominant qualitative component) Yes Yes Yes Yes Yes Yes Yes Greason Critical Discourse Analysis (Fairclough) Yes Yes Yes Yes Yes Yes Yes Hamiduzzaman Qualitative component of a mixed methods study Yes Yes Yes Yes Yes Yes Yes Helgeson Explorative grounded theory Yes Yes Yes Yes Yes Yes Yes Marriott‐Statham Nominal group technique and thematic analysis Yes Yes Yes Yes Yes Yes Yes Oye Multi‐site comparative ethnography Yes (expressed as a statement) Yes Yes Yes Yes Yes Yes Sahay Qualitative exploratory descriptive study Yes Yes Yes Yes Yes Yes Yes Scerri Qualitative exploratory multiple case study Yes Yes Yes Yes Yes Yes Yes Vendel Petersen Qualitative design using thematic analysis. Yes Yes Yes Yes Yes Yes Yes Wagner Descriptive phenomenological study Yes Yes Yes Yes Yes Yes Yes Winqvist Supplementary qualitative analysis Yes Yes Yes Yes. Yes Yes Yes Open in a new tab TABLE A2. Quantitative non‐randomised studies methodological quality criteria. MMAT Q1 MMAT Q2 MMAT Q3 MMAT Q4 MMAT Q5 MMAT Q6 MMAT Q7 First author Study design Are there clear research questions/aims/objectives? Do the collected data allow to address the research questions? Are the participants representative of the target population? Are measurements appropriate regarding both the outcome and intervention (or exposure)? Are there complete outcome data? Are the confounders accounted for in the design and analysis? During the study period, is the intervention administered (or exposure occurred) as intended? Trybou Cross‐sectional Yes, expressed as hypotheses. Yes Yes Yes Yes Yes Yes Yafa Cross‐sectional Yes, expressed as an objective Yes Yes Yes Yes Yes Yes Open in a new tab TABLE A3. Quantitative descriptive studies methodological quality criteria. MMAT Q1 MMAT Q2 MMAT Q3 MMAT Q4 MMAT Q5 MMAT Q6 MMAT Q7 First author Study design Are there clear research questions/aims/objectives? Do the collected data allow to address the research questions? Is the sampling strategy relevant to address the research question? Is the sample representative of the target population? Are the measurements appropriate? Is the risk of nonresponse bias low? Is the statistical analysis appropriate to answer the research question? Banaszak‐Holl Survey Yes, expressed as hypotheses. Yes Yes Yes Yes Yes Yes Open in a new tab TABLE A4. Mixed methods studies methodological quality criteria. MMAT Q1 MMAT Q2 MMAT Q3 MMAT Q4 MMAT Q5 MMAT Q6 MMAT Q7 First author Study design Are there clear research questions/aims/objectives? Do the collected data allow to address the research questions? Is there an adequate rationale for using a mixed methods design to address the research question? 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