An Inquiry into Satisfaction and Variations in User-Oriented Elderly Care

The foundation for this thesis is an ongoing discussion about quality in Swedish elderly care: Which are the most important factors that contribute to elderly care in terms of satisfaction among older persons, and what are the primary reasons for their differences? Aims. The principal aim was to examine what determines satisfaction with elderly care in home care and nursing homes, using the perspective of older persons (Studies I and II). The secondary aim was to analyze why these determinants differ, using the perspective of care workers, managers, and observers (Studies III and IV). Methods. Study I analyzed aggregated statistical data from the level of municipalities and districts (N = 324) based on the Swedish elderly care quality reports “Open Comparisons”, while Study II analyzed individual data based on the original ratings in the annual, nationwide elderly surveys (N = 95,000). Study III describes field observations and interviews with care workers and managers in two municipalities, one with a high rating for user satisfaction and one with an average rating. Study IV describes investigations in these two municipalities concerning their organizing principles and departmental‑level management climate. Results. The results relating to the principal aim showed that process factors (such as respect, information, and influence) are related considerably more closely than structural factors (such as budget, staffing levels, and training levels) to satisfaction with care. Other process factors (such as treatment, safeness, staff and time availability) were also able to alleviate person factors (such as health, anxiety, and loneliness). Moreover, the results relating to the secondary aim showed that differences in user-oriented elderly care are mainly due to interpersonal factors between the caregiver and the older person. Care workers, however, reported that other factors (such as organizing principles and leadership support) influence the quality of the care process. Overall, older persons who receive home care generally report higher satisfaction with care than those in nursing homes, and feeling less safe. It may be that differences in the process of aging explain this. Value. This thesis shows that satisfaction with elderly care can be largely explained by psychological quality at the individual level. The sizes of structural resources and organizing principles at the municipal level have minimal effect (< 5%). The thesis also presents a theoretical multiple-level Quality Agents Model to explain the sources of differences in satisfaction with care, and it presents recommendations for elderly care practices. A renewed focus on the psychology of satisfaction may contribute to the development of quality in elderly care.