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National Board of Health and Welfare claims that the quality of elderly care services differ considerably between municipalities in Sweden. This study aims to analyze to what extent these variations can be accounted for by the older person’s municipality affiliation (i.e. receiving elderly care in a certain municipality).

Addressing this issue, national survey data from 78,538 older respondents receiving elderly care services in Sweden were analyzed using multilevel modeling (MLM).

The results showed that municipality affiliation only marginally explained the variance in satisfaction with care, i.e. its variations were larger within than between municipalities. Instead, user-oriented care accounted for the variation in satisfaction with care. Specifically, the way the care workers behave toward the older person proved to be much more crucial for satisfaction with care than municipality affiliation. Moreover, random effects analyses revealed that the effects of user-oriented care on satisfaction with care varied across municipalities. Care setting (i.e. home care or nursing home) only marginally accounted for its variance.

Developing care quality should start and primarily be discussed at the interpersonal care level, and not, as is customary, at the municipality level.

The present research is the first in its kind to quantitatively investigate the sources of variation in perceived quality of Swedish elderly care using MLM.

Previous research has shown that user-oriented care predicts older persons’ satisfaction with care. What is yet to be researched is how senior management facilitates the implementation of user-oriented care. The purpose of this study is to investigate the organizing principles and management climate characterizing successful elderly care.

The department in one highly ranked municipality was selected and compared with a more average municipality. On-site in-depth semi-structured interviews with department managers and participatory observations at managers’ meetings were conducted in both municipalities.

Results revealed three key principles for successful elderly care: organizing care from the viewpoint of the older person; recruiting and training competent and autonomous employees; instilling a vision for the mission that guides operations at all levels in the organization. Furthermore, using climate theory to interpret the empirical material, in the highly successful municipality the management climate was characterized by affective support and cognitive autonomy, in contrast to a more instrumental work climate primarily focusing on organizational structure and doing the right things characterizing the more average municipality.

The authors suggest that guiding organizing principles are intertwined with management climate and that there are multiple perspectives that must be considered by the management, that is, the views of the older persons, the co-workers and the mission. These results can guide future care quality developments, and increase the understanding of the importance of organizational climate at the senior management level.

Care process quality (i.e. how care is enacted by a care worker toward a client at the interpersonal level) is a strong predictor of satisfaction in a wide range of health care services. The purpose of this paper is to describe the basic elements of care process quality as user-oriented care. Specifically, the questions of how and why quality in user-oriented care varies were investigated in the context of elderly care.

Two municipalities were selected for in-depth field studies. First, in each municipality, the authors interviewed and observed care workers’ interactions with the older persons in both home care and nursing homes during two weeks (Study 1). Second, in an attempt to gain a deeper understanding of why process quality in terms of user-oriented care varies, the authors conducted interviews with care workers and care unit managers (Study 2).

A new taxonomy for categorizing process quality variation, the Big Five of user-oriented care (task-focus, person-focus, affect, cooperation, and time-use), is proposed. In addition, the perceived reasons for process quality variation are reported in our own developed Quality Agents Model, suggesting that variations in care process evaluations may be explained from different perspectives at multiple levels (i.e., older person, care worker-, unit-, department-, and municipality level).

The proposed taxonomy and model are useful for describing user-oriented care quality and the reasons for its variations. These findings are of relevance for future quality developments of elderly care services, but also may be adapted to applications in any other enterprise employing a user-oriented approach.

User-oriented care, defined as individualized assisting behaviors, is the dominant approach within elderly care today. Yet, there is little known about its conceptual structure. This paper proposes that user-oriented care has a bi-partite structure which may be decomposed into the two dimensions of task and relation.

Care workers were “shadowed” (i.e. observed) at their work (n=391 rated interactions). User-oriented care was assessed along ten process quality indicators targeting the acts of caregiving (i.e. task focus, relation focus, involvement, time-use, body language, autonomy, respect, warmth, encouragement, and information) in two elderly care settings, i.e. home care and nursing home. Observations added up to 45 hours.

Principal component analyses confirmed the proposed two-factor structure of user-oriented care. Specifically, the user-oriented care indicators loaded on two distinct factors, i.e. task and relation. The underlying structure of user-oriented care revealed to be invariant across the two settings. However, the results revealed interesting structural differences in terms of explained variance and the magnitude of factor loadings in the home care and nursing home settings. Differences also emerged specifically pertaining to the indicators of autonomy and time-use. These findings suggest that user-oriented behavior may to some extent denote different acts of caregiving and what may be called task- and relation-orientation may be loaded with different meanings in these two care settings.

This is the first study investigating user-oriented behavior in the context of elderly care using a quantitative observational approach. The authors propose that the observed differences between the two care settings are primarily not due to better elderly care work in home care, but due to some inherent differences between these two contexts of care (e.g. better health and living at home).