Nurses' Shared Subjectivity on Person-Centered Care for Behavioral and Psychological Symptoms of Dementia in Nursing Homes

ABSTRACT Background Person-centered care (PCC), an approach to healthcare that focuses on the individual needs, preferences, and values of patients, is particularly important in the context of caring for residents of nursing homes (NHs) with the behavioral and psychological symptoms of dementia (BPSD). However, implementing PCC in NHs varies widely due to individual staff, NH environment, and country factors, leading to heterogeneity in person-centered approaches. Purpose This study was designed to explore and gain insight into the shared subjective perspectives of nurses on providing PCC to manage BPSD in NHs in order to elicit a deeper understanding of how nurses interpret and approach the provision of PCC. Methods Q methodology was applied to explore the subjective perspectives of nurses. Twenty-nine NH nurses with more than 3 years of experience in managing BPSD completed a Q-sorting task, categorizing 43 Q-samples into a normal distribution shape. Postsorting interviews were conducted after the participants had completed this task. The collected data were analyzed using centroid factor analysis and varimax rotation run within the PQMethod 2.35 program. Interpretation of the resulting factors was based on factor arrays, field notes, and interview data. Results Four factors from the shared subjective perspectives of nurses related to PCC were identified, including (a) sharing information focused on details to update care strategies, (b) monitoring until the true needs of residents are identified, (c) awareness of interactive cues in relationships, and (d) connecting an individual's life pattern to their current care. Conclusions/Implications for Practice The findings highlight that a one-size-fits-all approach may not be suitable for all nurses and interventions, indicating that nurses should consider the applicable subjective frames to ensure the effectiveness of planned interventions. A need for PCC education that specifically addresses BPSD management is suggested, with the findings implying that a strong organizational climate with respect to PCC in managing BPSD should promote higher job satisfaction and commitment and reduce turnover rates among nurses in NHs. Facilitating the development of PCC interventions appropriate for BPSD management that encompass the various categories and ranges of NH settings and nursing phenomena is thus recommended.


Introduction
Person-centered care (PCC) is an approach to healthcare that focuses on the individual needs, preferences, and values of patients (American Geriatrics Society Expert Panel on Person-Centered Care, 2016).Moreover, PCC involves viewing patients as whole persons and encourages patients to be treated with empathy, respect, and dignity and be involved in decisions about their care (Charalambous et al., 2012;Lusk & Fater, 2013).PCC is particularly important in the context of caring for older adults in nursing homes (NHs) who require physical, functional, and behavioral assistance in daily living due to dementia.Numerous PCC interventions involving social contact, physical activities, cognitive training, sensory enhancement, assistance with daily living, and environmental adjustments have been developed for residents with dementia in NH settings (Mohr et al., 2021).These interventions have resulted in positive outcomes for both residents (e.g., improved quality of care, quality of life, and satisfaction) and NH nursing staff (e.g., increased job satisfaction, retention, and work empowerment; Brownie & Nancarrow, 2013;Edvardsson et al., 2011;Silén et al., 2019).
In addition, PCC has been shown to be effective in managing the behavioral and psychological symptoms of dementia (BPSD), which refer to the range of noncognitive symptoms such as agitation, aggression, and wandering commonly seen in NH residents (Kales et al., 2015(Kales et al., , 2019;;Kolanowski et al., 2017;Li & Porock, 2014).The PCC approach, which helps ensure care is tailored to the unique needs and preferences of each resident, recognizes that the behavior of residents with BPSD is often a response to unmet needs or unaddressed physical or psychological discomfort (J.Y. Lee et al., 2023).Understanding and identifying the underlying problems of individual residents are important components of the BPSD care competence of NH nurses, who play pivotal roles in providing direct care to residents with BPSD (D. Kim et al., 2022).The aim of PCC interventions for BPSD such as reminiscence, music, cognitive, and multisensory stimulative therapies (K.H. Lee et al., 2022) is to provide a safe and supportive environment that promotes independence, social engagement, and meaningful activities while minimizing the use of restrictive interventions and medications (Kales et al., 2015;Sefcik et al., 2020), resulting in a reduction in antipsychotics use and the incidence of BPSD (Fossey et al., 2014;K. H. Lee et al., 2022).
However, due to the complex nature of PCC, implementation strategies vary widely among NHs and individual staffs (Dys et al., 2022;Güney et al., 2021) due to factors associated with individual nurses, differences in NH environments, and differences in national/regional norms (E.L. Brown et al., 2020).These differences contribute to significant heterogeneity in the PCC approaches employed at NHs (Mohr et al., 2021).Moreover, some studies have found that, although nurses may express support for PCC in principle, systemic and practical obstacles often prevent them from fully implementing PCC in NH practice (Güney et al., 2021; J. Y. Lee et al., 2023).Additionally, nurses often face conflicts between resident preferences and medically indicated situations or safety concerns (Kusmaul & Tucker, 2020;Parker et al., 2019) as well as common problematic issues caused by residents with BPSD (Kales et al., 2015).Despite its importance, PCC is difficult to effectively implement in managing BPSD in NHs (Oppert et al., 2018;Sefcik et al., 2020).
Understanding how nurses perceive and approach PCC in the context of BPSD management can help identify barriers to and facilitators of PCC implementation in this context.Nurses are the frontline care providers in NHs, and their perceptions and attitudes towards PCC can significantly impact the quality of care received by residents (Dys et al., 2022).Gaining insight into nurses' subjective perspectives on providing PCC in managing BPSD in NHs may elicit a deeper understanding of how nurses interpret and approach the provision of PCC as well as of the various factors that influence their ability and willingness to provide PCC in this context (Watts & Stenner, 2012).Therefore, in this article, Q methodology is used to explore the subjectivity in PCC in managing BPSD of residents of NHs.

Methods
Q methodology, developed by William Stephenson, is a research technique that combines qualitative and quantitative methods to study subjective viewpoints (S.R. Brown, 1980;Watts & Stenner, 2012), using a structured procedure to explore the different subjective perspectives and experiences of participants regarding complex issues (Stephenson, 1953;Watts & Stenner, 2012).The five steps to conducting Q methodology include (a) developing a Q-population, (b) selecting a Q-sample, (c) selecting a P-sample, (d) conducting Q-sorting, and (e) analyzing and interpreting the Q-sorts.

Q-Population Development and Q-Sample Selection
A Q-population (aka "concourse") is a list of statements that encompass a broad range of a research topic (Stephenson, 1953;Watts & Stenner, 2012).The Q-population may be acquired from the literature, interviews, newspapers, and other suitable sources (S.R. Brown, 1980).In this study, the Qpopulation was acquired using semistructured interviews during which self-referent statements related to providing PCC in managing BPSD were collected.
Ten nurses with more than 3 years of experience providing BPSD care in NHs were purposively recruited for the interviews (Benner, 1982).All of the participants were female; three held a master's degree or higher, and the others held bachelor's degrees; their average age was 52.2 (SD = 8.09) years; and their average years of experience in BPSD care was 6.6 (SD = 3.27) years.The interviews were conducted during January and February 2022 via telephone or Zoom because of COVID-19 infection concerns.The interview questions were developed using a review of the literature on PCC in NHs.The participants were asked to provide self-referential statements by answering questions such as "How do you judge what references to use to provide care for residents with BPSD while considering their values, characteristics, and preferences?"and "What is important for providing PCC in managing BPSD, and why?" From the interview transcriptions, 71 statements related to PCC in managing BPSD in NHs were collected.After eliminating ambiguity and duplication, a final set of 43 clear and distinct statements were selected as the Q-sample (Table 1).Finally, two nursing professors with experience in Q methodology reviewed the Q-sample for readability and distinctiveness in representing PCC in managing BPSD in NHs.

P-Sample Selection
In line with Q methodology, the participants were asked to sort a set of statements or items based on their subjective perspective (Watts & Stenner, 2012) in a process known as "Q-sorting." The participants who performed the sorting were the "Psample" (S.R. Brown, 1980;Stephenson, 1953), which is a variable of analysis in Q methodology for which a small size is sufficient to make clear distinctions among intraindividual differences (S.R. Brown, 1980;Watts & Stenner, 2012).Half of the number of the Q-sample in this study (i.e., 21) was the recommended minimum size of the P-sample (Stone & Turale, 2015;Watts & Stenner, 2012).In this study, participants were recruited through NH directors, who served as 10.The resident's daily condition determines how their day will pass, so I first identify the condition and atmosphere of individual residents every day.Statements and Factor Arrays of the Q-Sample, Continued 27.With the goal of establishing a sense of personal trust with residents, I listen carefully to whatever they have to say.
28.The interaction between residents with BPSD and myself is a delicate relationship that requires sensitivity to even small changes, so I am mindful of my words and actions to maintain consistency.

The Journal of Nursing Research
Dayeong KIM et al.
gatekeepers.An informative letter was distributed to explain the research purpose and procedures.To ensure sample variance, five NHs with resident capacities ranging from 49 to 320 were selected.For the P-sample, 30 NH nurses with more than 3 years of experience in providing direct care to residents with BPSD were purposively recruited.

Q-Sorting
Q-sorting includes a card sorting activity and postsorting interviews.In this step, the participants (P-sample) classified cards into three clusters of "disagree," "neutral," and "agree" with regard to the statement written on each card.Questions were given to the participants to facilitate sorting, such as "Place cards that you disagree with on the left, agree with on the right, and put neutral statements in the middle." The participants then placed the cards on a preestablished Qsort grid in the form of a quasi-normal distribution by putting the ones they most disagreed with on the −4 section and most agreed with on the +4 section (Figure 1).After sorting was completed, a postsorting interview was conducted with the P-sample to ask about the reasoning behind their chosen distributions, with an emphasis on the cards placed at the extremes of the grid.Among the 30 NH nurses recruited for the P-sample, one was excluded due to having contracted COVID-19.Consequently, 29 sorts were included in the analysis.The Q-sorting activity was conducted from May to June 2022 using Zoom due to COVID-19 concerns.The sorting process was video and audio recorded, and the researchers composed and shared field notes on their observations of the participants' responses.

Data Analysis and Interpretation
n Q methodology, an inverted factor analysis is used in which data are analyzed to identify the associations among participants (i.e., by person) rather than among specific traits or statements (i.e., by variable; Watts & Stenner, 2012).The aim of Q-factor analysis is to identify patterns in sorting across participants to identify patterns and clusters of similar viewpoints, which are referred to as factors and which represent shared perspectives on a particular topic (S.R. Brown, 1980;Watts & Stenner, 2012).PQMethod 2.35, a statistical program designed for Q-factor analysis, was used to derive the factors in this study (Schmolck, 2021).Following centroid factor analysis and varimax rotation, four factors were determined using the criteria that each had earned eigenvalues higher than 1, maximized defining significant statements, and had more than two defining sorts (Watts & Stenner, 2012).
Whereas analysis is quantitative, factor interpretation is a qualitative process in the Q methodology.Factor arrays (Table 1); a crib sheet, which is a tool designed for assisting in the detailed interpretation of the identified factors by listing the cards located at the extremes of the grid; distinguishing statements; and consensus statements for each factor were utilized (Watts & Stenner, 2012).Moreover, the postinterview data and P-sample's demographic data were included in factor interpretation.Finally, the labeling of each factor was completed after a discussion was held regarding the representativeness of factors in distinguishing the viewpoints among NH nurses on PCC in managing BPSD.

Ethical Considerations
This study was approved by the institutional review board of the university (KUIRB-2020-0234-02).All participants were given written consent forms that included comprehensive information about the research and guarantees of their confidentiality.

Result
Twenty-nine NH nurses participated in the Q-sorting procedure.Four factors were found to explain 76% of the total variance (Table 2).Also, 27 of the Q-sorts (93.1%) were  significantly loaded on a single factor ( p < .01),whereas two of the Q-sorts did not load significantly on any factor.The general characteristics of the participants and each factor are presented in Table 3.After reviewing the factor arrays, crib sheets, postinterview transcriptions, and demographic data, the following four subjective frames for PCC in managing BPSD by NHs nurses emerged: "sharing information focused on details to update care strategies," "monitoring until the true needs of residents are identified," "being aware of interactive cues in relationships," and "connecting an individual's life pattern to their current care." Factor 1: Sharing Information Focused on Details to Update Care Strategies Factor 1 accounted for 59% of the total variance and earned an eigenvalue of 16.99.Ten of the participants significantly loaded on this factor.The Q-sample that this factor significantly agreed with included Statements 37 (+4) and 36 (+3), indicating that sharing information about residents' conditions is a priority factor involved in PCC in the context of BPSD management.The participants prioritized closely assessing residents with BPSD and sharing new information with other staff to establish a standard for providing personalized care (Q-sample 14, hereafter referred to as Q-14) and maintaining trusting relationships with residents (Q-38).Participant 18, whose sort had the highest load on this factor, spoke about how updating residents' information through collaborative conversations with other staff members is important for consistent and effective PCC: It is necessary to understand the resident's latest condition based on shared information rather than relying solely on my own thoughts and judgments to provide an appropriate personalized approach.Since it is not possible to be with residents 24 hours a day, it is essential to share various attempts and experiences concerning BPSD care strategies by identifying and communicating the symptoms and conditions of residents at different times, environments, and spaces.
However, the participants tended to perceive understanding the feelings (Q-22) and identifying the emotional needs (Q-20, Q-22) of residents as less important.Rather than focusing on providing emotional stability, the participants who loaded on this factor tended to focus on integrating the perspectives of other staff to make better decisions.Participants emphasized that PCC for BPSD in NHs should take an interprofessional approach because NHs are where residents will live for the rest of their lives with support from multiple healthcare professionals, including nurses, social workers, physical therapists, and nutritionists.Participant 28, who weighted second highest on this factor, said: If I believe that I'm the only one responsible for providing good care to the resident.True personalized nursing cannot be achieved.I think that providing stable and consistent care, where all NH staff possess the right information and practice in the same direction, is essential for personalized BPSD nursing so that the resident doesn't become confused.

Factor 2: Monitoring Until the True Needs of Residents Are Identified
Factor 2 included four significant Q-sorts of NH nurses, accounting for 7% of the total variance and earning an eigenvalue of 2.13.On average, the participants who loaded on this factor were younger in age (mean age is 49.0 [SD = 9.8] years) and had less NH working experience (mean is 4.8 [SD = 1.7] years) than the overall P-sample (52.3 ± 8.4 and 6.3 ± 3.0 years, respectively).
The statements that this factor strongly agreed with reflect the subjective prioritization of gaining a genuine understanding of residents and their needs by taking the time to monitor NH residents' daily conditions and expressions (Q-9, Q-10) to identify underlying needs (Q-22).This viewpoint is illustrated in the following statement from Participant 13, who had the highest weights on this factor: Residents with BPSD have diverse hidden needs and ways of expressing emotions.Thus, observing them with interest is an essential aspect of personcentered care.Daily rounds are performed to gain a person-centered perspective by assessing each resident's condition and attitude through observations such as facial expressions, quality of sleep, and appetite.
As part of understanding residents and their needs, these participants valued respecting residents (Q-40) and maintaining relationships with them (Q-19, Q-26).Despite sorting them under less agreement (+1), these participants made efforts to respect residents through careful listening (Q-27) and observing their words and actions with an open mind (Q-16, Q-24).The distinguishing feature of this factor was leveraging relationships with residents as a better tool to identify their needs and conditions.
However, the distinguishing statements indicate the participants who loaded on this factor disagreed with the collaborative approach (Q-33) and regarded PCC as a difficult approach to use to manage BPSD (Q-35).These participants considered PCC unhelpful to establishing a close relationship with residents (Q-17), providing safety and stability to residents (Q-43), and relieving BPSD (Q-6).Participant 11 explained that, although PCC may be the best way to manage residents with BPSD, in the real world, this approach is difficult to implement due to heavy workloads and staffing shortages.
Providing person-centered care is unlikely to be practicable in NHs with insufficient manpower.It is difficult to meet the needs of many residents with a small number of staff, and the reality is that individual care cannot always be provided.While it is important to understand and address residents' individual needs and reduce BPSD, it may not always be feasible to provide fully personalized care throughout the entire NH.

Factor 3: Awareness of Interactive Cues in Relationships
Factor 3 comprised seven significant Q-sorts of the NH nurses and accounted for 6% of the total variance, earning an eigenvalue of 1.67.Significant statements that were agreed upon included that the goal of PCC in managing BPSD is to enhance residents' comfort (Q-41) by building a reliable relationship with them (Q-24) even when they have poor cognitive function due to dementia (Q-19).The participants prioritized paying attention to interactive cues and reflecting the words and expressions of each resident consistently in their interactions with them (Q-28), as inconsistency in care may cause BPSD (Q-25).Participant 17, whose sort had the highest load on this factor, explained that a personalized approach in managing BPSD includes focusing on identifying and maintaining resident-specific interaction patterns: I aim to establish a comfortable, family-like relationship with each resident so that they can accept the facility as their own and maintain emotional stability.It's important to note that even if the same problematic behavior is observed in multiple residents, the words and actions used to address the issue should vary for each individual while the nurse maintains a consistent demeanor.
Factors earning lower levels of agreement included interactions with other staff members (Q-37) and residents' families (Q-29) to promote consistent relationships and care procedures.Participant 2, who weighted second highest on this factor, expounded on the importance of applying PCC to accommodate variations in resident responses: When a resident communicates with another staff member, their reactions and contents may differ slightly, and their response can vary depending on the staff member's capabilities.Therefore, it is beneficial to apply PCC to discern the subtle differences in how a resident communicates with different staff members.
Factor 4: Connecting an Individual's Life Pattern to Their Current Care Factor 4 accounted for 4% of the total variance, earning an eigenvalue of 1.22.Six of the participants significantly loaded on this factor.On average, this group of participants had the longest NH work experience (8.2 ± 4.4 years) of the four factor groups.
The Q-statements that this factor strongly agreed with reflected the perspective that PCC connects residents' lives to current BPSD care strategies.To better understand residents and to plan the direction of BPSD care, these participants investigated residents' past life events and BPSD care methods used prior to their NH admission (Q-1, Q-18).They perceived that the best approach to personalized BPSD management must relate significantly to the values and priorities of residents, for example, family, friends, and routine behaviors and habits.Participant 8, who had the highest weights on this factor, said: I believe that life experiences are embedded in a resident's thoughts and words, and it can be challenging to change or break old habits.By identifying various aspects of what the resident has done before and the environment they were in, such as likes and dislikes, it can be helpful in forming trust and cooperation for personalized care.Using past photos and attachments can prevent residents from feeling separated from their families and can encourage them to participate more actively in their care process.
Participants viewed the families of residents as an important source of information, asking them about the resident's life story (Q-2) and informing them about the care process (Q-29), which encouraged family participation in the overall care process (Q-39).Participant 26, who weighted second highest on this factor, explained how nurses involve a resident's family in personalized BPSD care: It is really important to consider the resident's BPSD care environment and strategy experiences prior to entering the NH…specifically, how their symptoms were managed.We can learn from past successes in BPSD management and modify ineffective methods.Families who have been with the resident know them best, so their participation is invaluable.
On the other hand, the participants who loaded on this factor disagreed with the ideas of staying with residents (Q-30) and listening carefully to what residents say to establish a trusting relationship (Q-27).They also placed less importance on taking care of the resident's social relationships with other residents and staff (Q-37, Q-38).

Discussion
Four subjective frames for PCC in the context of managing BPSD used by NH nurses were revealed in this study.These frames included sharing information focused on details to update care strategies, monitoring until the true needs of residents are identified, awareness of interactive cues in the caring process, and connecting an individual's life pattern to their current care.
To the best of the authors' knowledge, this was the first study conducted to explore the subjective perceptions of nurses on PCC in the context of managing NH residents with BPSD.The diverse perceptions and subjective alternatives provided by these findings may facilitate the further development and verification of practice-based nursing theory (Yeun, 2021) and potentially provide a basis for developing more-effective PCC interventions for residents with BPSD.PCC is grounded in the idea that each person has their own life story, needs, and desires and that the provision of care should reflect this uniqueness (Charalambous et al., 2012;Lusk & Fater, 2013).Thus, nurses who bring their own subjective experiences and perspectives to their care should be better enabled to provide higher levels of personalized care to residents with BPSD.
Q methodology was employed in this study to explore how nurses in NHs structure their subjective frames for providing PCC in the context of BPSD management.This does not imply that NH nurses are classified into types but rather that four factors coexist within the shared subjectivity of NH nurses.These factors reflect the need to provide PCC in a manner that considers each resident's individuality and uniqueness while effectively managing their BPSD in different NH environments.
The first factor, sharing information focused on details to update care strategies, accounted for 59% of the total study variance, indicating it was the main perspective held by the nurses in this study with regard to providing PCC to manage BPSD.This suggests that NH nurses emphasize strongly the importance of having detailed and up-to-date information in providing effective care for residents with BPSD.This factor has been reported to be a key component of competent BPSD care education (D.Kim et al., 2022).Although close assessment and collaboration with other staff to achieve a comprehensive understanding of their residents has been identified as essential for the effective provision of PCC (Güney et al., 2021;E.-Y. Kim & Chang, 2022b), the participants who loaded on this factor prioritized the personcentered approach in BPSD care by adopting an interprofessional approach.As perceptions of PCC vary among staff members, promoting collaborative practices that integrate various perspectives to facilitate decision making that is congruent with the perspectives of all staff members is necessary (Dys et al., 2022).
Because they are responsible for directly assessing and monitoring changes in resident conditions, the understandings and perceptions of nurses also influence how PCC is applied in BPSD care (Richter et al., 2022).For example, nurses who understand the meaning of PCC and are aware of residents' conditions have been found to provide better personalized care, leading to higher resident satisfaction and autonomy (E.-Y.Kim & Chang, 2022a).In this study, participants assigned to Factor 2, "monitoring until the true needs of residents are identified," valued understanding residents and their needs by taking the requisite time to monitor their conditions and expressions daily to discern their underlying needs.The finding that those who loaded on this factor had the least amount of work experience suggests that nurses with less experience in NHs place more weight on discerning the true needs of residents with BPSD.
The participants who loaded on the fourth factor had most work experience in NHs and emphasized the importance of investigating a wide range of information on the life history of residents and connecting this into current care plans to make these plans best fit resident needs.Residents prefer continuous care from nurses who understand their life history and provide personalized care (E.-Y.Kim & Chang, 2022a).However, the subjective experiences of nurses with regard to PCC may not sufficiently reflect the importance of keeping residents informed about their care process and plans due to the challenges posed by the communication limitations associated with BPSD.Nonetheless, the third factor, awareness of interactive cues in relationships, emphasizes the significance of fostering trusting and consistent relationships with residents.The participants in this study who loaded on the third factor tended to emphasize the significance of fostering positive relationships and respecting the dignity of residents through PCC in the context of BPSD management.The importance of close relationships, a fundamental concept of PCC, in NHs has been consistently highlighted in prior studies (Güney et al., 2021;E.-Y. Kim & Chang, 2022b; J. Y. Lee et al., 2023).The findings of this study further support the importance of fostering these relationships in the BPSD care context.
The findings of this study further revealed the diversity in perspectives of nurses regarding the provision of PCC in the context of BPSD management in NHs.Although all of the participants recognized the importance of PCC, the participants who loaded on Factor 2 went further by acknowledging the presence of realistic barriers to PCC implementation (e.g., unstable organizational factors such as time and work pressures) in NH settings (Richter et al., 2022).In addition, although the participants recognized the importance of PCC, a gap was found between theory and practice in PCC provision.Despite the desire of nurses to align their work with established PCC strategies, the dominance of taskoriented care, routines, and organizational issues pose barriers, particularly to BPSD management, which already poses a burden on nurses, indicating the need for additional education tailored to PCC in the context of BPSD management (Güney et al., 2021;Kales et al., 2019).A strong organizational climate that values PCC in the management of BPSD will help regularize the practice of PCC, elevating job satisfaction, promoting affective commitment, and reducing turnover (Dys et al., 2022;Edvardsson et al., 2011;Silén et al., 2019).
Several limitations of this study should be considered.First, although efforts were made to recruit participants from five different NHs to adequately capture the variability among NH environments, the full scope of variability may not be represented in the sample used.Second, the use of purposive sampling may have introduced selection bias and limited the generalizability of the findings.However, the primary goal of Q methodology is elucidating the subjective meaning of a phenomenon for those individuals who experience it rather than generating findings with broad generalizability.

Implications for Practice and Research
This study emphasized the importance of support and training for nurses in implementing PCC in the management of BPSD.Ongoing education and training in NHs promote a shared understanding and approach to PCC, including the development of a BPSD-specific system, increased staffing, and supportive work environment.Involving residents, families, and staff in care planning enhances consideration of unique needs and preferences, fostering shared understanding among care providers.The findings and recommendations of this study provide a foundation for future research on nursing staff perceptions of PCC in the context of BPSD management and inform the development of tailored interventions in diverse NH settings to enhance personalized care based on residents' interactive cues and life patterns.

Conclusions
The findings of this study support the importance of considering nurses' shared subjective frames in providing PCC in the management of BPSD in NHs.Interventions should be tailored to the subjective frames of nurses to ensure effectiveness.Understanding the diversity in subjective perspectives of nurses can guide researchers and healthcare providers in supporting and promoting person-centered practices among NH nurses.
Providing personalized care has nothing to do with respecting the dignity of the resident.Residents cannot be directly involved in determining the direction of individualized care throughout nursing planning and intervention.In a situation where the resident refuse to do so, I make it a more important criterion to keep the direction of the nursing plan than to respect the autonomy of the resident.on what I aware about the resident, I set a safe standard for the individual resident to accept BPSD without any intervention.think NHs are a place where person-centered care can be effectively provided by focusing on personality and characteristics rather than labeling the resident by diagnosis or symptom name.Rather than the words and actions of the residents, it is necessary to restrict them to act as I see and judge on them.I believe that making an effort to establish a close relationship with resident results in understanding their personal values and preferences.give the feeling that I know the residents well, I try to investigate past life events or information about residents in advance and understand their words and actions based is impossible to maintain a true trust relationship with individual residents because they have poor cognitive function due to dementia.if I am usually kind to the residents, they may not feel that I truly understand their personal identify and solve the underlying emotional needs of individual residents, I observe and act the same way the residents behave.Focusing on the cause of BPSD rather than understanding what is important to the residents and recognizing their needs in advance is less important in providing person-centered care.
a person who can better understand and explain the needs of the residents than their family is the most important thing in personalized BPSD care.treat the residents kindly and open-mindedly with the aim of becoming a person who can personally talk and express what they need at any time.am always careful about my behavior and attitude and maintain the same mood and appearance every time because the words or actions I inadvertently say can be interpreted differently by individual residents and may lead to BPSD.believe that BPSD can be alleviated if residents feel a sense of belonging to our facility, so I actively think of ways to foster positive relationships among residents.

Figure 1
Figure 1Example of a Completed Q-Sorting Grid (Participant 1)

Table 1
Statements and Factor Arrays of the Q-Sample

Table 1
I don't think there is a need to involve the family in the process of person-centered care because the participation of the family does not help the residents relieve BPSD.
a It's irrelevant to planning and effectively implementing personalized care to inform the residents or their family members of the current BPSD status and the direction of care.a I don't think sitting next to the residents without any special conversation or activity affects my relationship with the individual residents.a To provide proper person-centered care, I think it is important to be good to the residents rather than to cooperate with other staff.a While other staff members may have a different perspective, I don't think that understanding residents and their BPSD requires considering all viewpoints.a Person-centered care is only possible for the resident with mild dementia or without dementia, but it is practically difficult for the resident with BPSD. a a I don't think the personalized approach in managing BPSD is related to the resident feeling our NH is safe and stable.Note.BPSD = behavioral and psychological symptoms of dementia; NH = nursing home.a Reversed statements.*p < .05. **p < .01.

Table 2
Eigenvalues and Total Variances, by Factor

Table 3
General Characteristics of the P-Sample