Caring about competition in eldercare? Staff groups, nursing homes, and Swedish market-inspired reforms

ABSTRACT

During the past 30 years, Swedish eldercare has undergone extensive reforms featuring, among others, far-reaching efforts to construct municipal markets characterised by competition between nursing homes for service provision. Our aim in this paper is to develop new knowledge about how eldercare professionals currently approach the role of competition after it has been present for three decades as a key idea throughout Sweden’s market-inspired reforms. To address that aim, we build on insights from organisational theory, and conduct a study consisting of 39 interviews with professionals working as frontline or management staff in publicly or privately operated homes. Our findings show how competition was similarly perceived across public and private nursing homes: eldercare professionals regarded it as a phenomenon primarily affecting their work in relation to tendering periods. Important differences, nonetheless, existed between staff groups in homes. Thus, the findings of our study also indicate that perceptions of competition ranged from a more employment-focused and episodically occurring phenomenon among frontline staff, to a more visibility-focused and continuously occurring phenomenon among management staff. We finish by discussing competition as a central and peripheral phenomenon in nursing homes, and by highlighting the relevance of our findings for additional eldercare contexts across Europe.

SAMMANDRAG.

Svensk äldreomsorg har under de senaste 30 åren genomgått omfattande reformer som, bland annat, har innehållit långtgående ansträngningar att konstruera kommunala marknader karaktäriserade av konkurrens mellan äldreboenden. Vårt syfte med detta papper är att utveckla ny kunskap kring hur äldreomsorgsanställda i dagsläget ser på rollen av konkurrens efter att det har varit ett genomgående fenomen under Sveriges tre decennier av marknadsinspirerade reformer. Vi tar oss an detta syfte genom att använda organisationsteori som bakgrund till en studie bestående av 39 intervjuer med anställda på frontlinjen eller inom styrning bland privata eller offentliga äldreboenden. Våra resultat visar hur konkurrens sågs på liknande sätt bland privata och offentliga boenden: anställda närmade sig konkurrens som ett fenomen vars huvudsakliga påverkan upplevdes i förhållande till upphandlingsperioder. Stora skillnader fanns samtidigt mellan yrkesgrupper inom äldreboenden. Våra resultat visar också att förståelser av konkurrens sträckte sig från ett mer arbetsfokuserat och episodiskt närvarande fenomen bland anställda på frontlinjen till ett mer synlighetsfokuserat och kontinuerligt närvarande fenomen bland anställda inom styrning. Vi avrundar genom att diskutera konkurrens som ett centralt och perifert fenomen inom äldreboenden, och genom att understryka relevansen av våra resultat för ytterligare äldreomsorgskontexter runtom Europa.

KEYWORDS:

• Eldercare
• reforms
• Sweden
• markets
• competition

NYCKELORD:

• Äldreomsorg
• reformer
• Sverige
• marknader
• konkurrens

Introduction: considering market-inspired reforms 30 years later

Market-inspired reforms in public sectors across Europe constitute one of the most important developments affecting eldercare throughout the past three decades. Such reforms can be seen in Western, Eastern, and Southern Europe (Bettio & Verashchagina, 2010; Lyon & Glucksmann, 2008), although they are particularly noticeable within traditional welfare state bastions, like the Nordic countries. In these countries, deep-rooted ideas about centralisation and standardisation as public sector steering principles have gradually become blended with new-fashioned notions of delegation and customisation taken from private sector management models (Anttonen & Meagher, 2013; Blomberg et al., 2000; Theobald et al., 2018). A key aspect throughout this blend has been the introduction of competition as means with which to allocate eldercare resources. In a Nordic context, Sweden stands out because its politicians and bureaucrats have, since the early 1990s, expended recurring and far-reaching organisational efforts to construct local markets for eldercare services. These efforts primarily encompass attempts at creating competition between public actors and private actors for the provision of services to eldercare users in Swedish municipalities (Blomberg, 2008; Hagbjer & Krohwinkel, 2018; Ulmanen & Szebehely, 2015). Politicians and bureaucrats at the municipal and national level have often taken a positive approach toward competition between providers, claiming it is set to raise resource efficiency, fuel service innovation, and increase user influence (Svensson & Edebalk, 2006; Szebehely, 2011).

Such claims about the positive effects of competition have, however, been met with agnosticism in extant eldercare literature. This literature shows that competition has impacted the external relationships between eldercare providers in substantial, but rather unintended, ways. Competition has generally fragmented Sweden’s eldercare, making it difficult to oversee and coordinate. A select number of private actors have, nonetheless, merged into large-scale providers that primarily offer their services throughout metropolitan areas (Anttonen & Meagher, 2013; Szebehely, 2011). While eldercare literature offers insights about the impact of competition on external relationships, these insights tell us little about the ways in which competition has impacted the internal activities of providers. To begin grasping how such activities may be impacted, we must consider that eldercare providers are organisations populated by professionals whose work is grounded in trust and autonomy, and governed through implicit norms and tacit knowledge bases (Dellgran & Höjer, 2005; Kamp, 2016). This is an important consideration because professionals are portrayed in extant eldercare literature as those employees who should be most affected by market-inspired reforms that tend to introduce new elements of control and accountability, including results-centred management models, which impinge on trust and autonomy (Noordegraaf, 2007). But how professionals themselves perceive they have been impacted by competition is, however, an open question that has received scant attention. These perceptions thus merit further attention because, according to the famous Thomas theorem, ‘if [wo]men define situations as real, they are real in their consequences’ (Thomas & Thomas, 1928, p. 572). The question of how professionals perceive they have been affected by competition becomes challenging when we also consider that most reforms do not fulfil what reformists had originally planned, but instead engender a mix of intended and unintended outcomes (Brunsson, 2009). Competition, which politicians and bureaucrats often associate with positive effects, has, for long, been a core idea throughout Swedish market-inspired reforms, but professionals may come to perceive this idea in various ways as it meets the internal activities of eldercare providers. We can, as such, not assume competition pans out in those ways Sweden’s politicians and bureaucrats had originally planned.

Our aim in this paper is to develop new knowledge about how eldercare professionals currently approach the role of competition after it has been present for 30 years as a key idea throughout market-inspired reforms. Based on professionals talking about their daily work, we explore how competition is perceived to impact the internal activities of organisations providing residential care in nursing homes. Our empirical material comes from 39 semi-structured interviews conducted during 2018 and 2019 with frontline and management staff in homes operated by public actors and private actors throughout two Swedish municipalities. We use classic and recent organisational theory to analyse how professionals approach the role of a core idea in market-inspired reforms that have been shaped and defined far from the quotidian work inside Sweden’s nursing homes. Our subsequent findings show how, across homes operated by public actors and private actors, competition was mostly talked about as a phenomenon that affected daily work in connection to tendering procedures. We noted certain differences among our interviewees, however. Frontline staff tended to focus on employment uncertainties generated during tendering periods, as that was when the responsibility for operating homes could switch between multiple actors providing eldercare services. This staff group navigated potential switches by approaching eldercare as a call and an ethos that was anchored in loyalty to users and places, rather than in identification with providers. Management staff instead tended focus on marketing and branding matters during, but also between, tendering periods. This staff group perceived marketing and branding as central tools for communicating favourable images that would secure the attention of stakeholders, and, by extension, the flow of users and resources to homes. Our findings thus point at the ways perceptions of competition can range from an employment-focused, episodic phenomenon to being perceived as a branding-focused, continuous phenomenon when we examine different staff groups in Swedish nursing homes.

The rest of our paper is structured as follows. After this introduction, we present our theory and context. Then, we describe our methods. In the next section, we flesh out our empirical analysis. And, finally, we round off by discussing our findings and suggesting future research avenues.

Theory and context: grasping competition after Sweden’s eldercare reforms

Classic organisational theory tells us that reforms consist of decisions through which reformists seek to alter existing orders in social life (March & Simon, 1958). A central argument running through this body of theory points at an inherent risk for gaps between the stipulated goals and the materialised outcomes of reforms. One situation in which such gaps may arise concerns the entry of reforms into organisations. This is because decisions associated with reforms can be received in various ways by organisational members. Indeed, studies of mines, high schools, railway companies, and electric utility corporations show that reforms, once they enter organisations, are often decoupled (Brunsson & Olsen, 1993; Meyer & Rowan, 1977), implemented in symbolic ways (Edelman, 1992; Oliver, 1991), and/or faced with tough opposition from powerful groups (Gouldner, 1954; Selznick, 1949). These studies suggest that reforms seldom reach the goals originally planned by decision makers. Instead, most reforms appear to generate a mix of intended and unintended outcomes (Brunsson, 2009). Reforms tend to be launched as rather hopeful decisions, but reforms can, at the same time, also be understood as rather hopeless decisions, not least after they have entered organisations.

We leverage insights from organisational theory to start approaching the context of market-inspired reforms that were launched in Sweden’s public sector during the early 1990s. As for eldercare, all ageing citizens in need, irrespective of income, insurance, or any other personal circumstances, are entitled to comprehensive medical and social services with full financing from public sector resources (Stolt et al., 2011). Swedish eldercare has traditionally been governed through public sector-based steering principles, such as centralisation and standardisation, that channel responsibility to the state for providing equal services among ageing citizens. Eldercare in Sweden gradually came into contact with market-esque ideas that were fuelled by ideological developments throughout the 1980s, but three closely connected reforms during the early 1990s marked a historical inflection point of sorts. These reforms, which we describe below, pushed private sector-like management models, such as delegation and customisation, to the forefront of Swedish eldercare (Anttonen & Meagher, 2013; Blomberg et al., 2000; Theobald et al., 2018).

In 1991, a broad-spanning ‘Local Government Act’ (Swe. Kommunallagen (SFS 1991:900)) shifted most responsibility for public sector services from the state to Sweden’s newly created 290 municipalities. Moreover, in 1992, another wide-ranging ‘Act on Public Procurement’ (Swe. Lag om offentlig upphandling (SFS 1992:1528)) introduced tendering procedures through which municipalities should outsource their service provision among multiple public actors and private actors that would be awarded contracts on the basis of quality and efficiency criteria. Finally, also in 1992, an additional ‘Elderly Reform Statute’ (Swe. Ädelreformen (prop. 1990/91:14)) implied that Swedish municipalities, following the above-mentioned Local Government Act, became responsible for all eldercare services. These three reforms can, altogether, be understood as concerted organisational efforts to construct local markets characterised by competition between public actors and private actors for eldercare provision in municipalities.

And such efforts seem to have brought about changes in eldercare. By the end of 1992, four municipalities in and around Stockholm were already outsourcing certain eldercare services to private actors through tendering procedures. A year later, 10 percent of Sweden’s municipalities variously used these procedures to outsource eldercare provision (Svensson & Edebalk, 2006). During the 1990s and 2000s, tendering procedures would be implemented in a growing number of municipalities. By the mid-2000s, these procedures were being utilised as bases for purchaser-provider systems throughout 80 percent of Swedish municipalities, although many only allowed eldercare outsourcing to other public actors (Anttonen & Meagher, 2013). Further organisational efforts to reinforce the construction of local markets included an ‘Act on System of Choice in the Public Sector’ (Swe. Lag om valfrihetsreformen (SFS 2008:962)) that gave municipalities additional tools with which competition could be created (Moberg, 2021). As such, it is perhaps most useful to consider that, by the late 2010s, public actors provided eldercare services alongside private actors in almost half of Sweden’s 290 municipalities. In municipalities within which both actor types operated, approximately one fifth of all residential care was being outsourced to private actors (Jönson & Szebehely, 2018).

Looking at the figures above, considerable competition for service provision appears to have developed in Swedish eldercare. That is at least how this development would be understood in light of many dominant economic perspectives on competition. Such perspectives typically picture competition as a uniform and semi-automatic phenomenon, which arises between social entities wherever and whenever resource demands exceed resource supplies (Dennis, 1975; Hirschman, 1982). While dominant, these economic perspectives are slightly problematic for our paper because they tend to gloss over many important nuances and deviations that may surface as competition unfolds among and within organisations. We thus draw on insights from recent organisational theory on competition (Arora-Jonsson et al., 2020; Cattani et al., 2017) as a way of further honing our approach to those market-inspired reforms that have been launched in Sweden’s public sector since the early 1990s. This recent theory tells us that competition, far from being a uniform and semi-automatic phenomenon, is a socially constructed and contextually bounded phenomenon. Such emphasis on social and contextual aspects not only underscores the nuances and deviations that may emerge as competition unfolds. Such emphasis also underscores the multiple consequences competition may generate and, perhaps most crucially for our paper, the different perceptions competition can engender.

These social and contextual aspects will be particularly important when we explore how eldercare professionals perceived that competition affected their daily work in Swedish nursing homes three decades after the launch of market-inspired public sector reforms. Before doing so, however, we describe our method for collecting and analysing empirical material.

Methods: studying perceptions of competition in nursing homes

The material for our paper comes from 39 interviews conducted during 2018 and 2019 with two different staff groups at seven nursing homes, which were operated by public actors and private actors providing residential eldercare services in two municipalities throughout Sweden. We collected this empirical material as part of a larger research project that has received approval from the pertinent regional ethical review board.¹

Our research design was motivated by potential variations in how competition may be perceived to affect the activities of nursing homes. We took several steps to capture such variations. When it came to sites, we identified ‘Alpha’ as a large and largely metropolitan municipality, and ‘Beta’ as a small and mostly rural municipality.

Our argument was, by extension, that these two municipalities could provide us with empirical breadth to explore different conditions in Swedish eldercare (cf. Theobald et al., 2018). In terms of providers, we contacted and visited three nursing homes operated by public actors, as well as four such homes operated by private actors. These seven homes all offered both general and dementia-focused services. Our inclusion of public actors and private actors was meant to reflect how eldercare provision in Alpha and Beta, as well as in many other Swedish municipalities, is structured today (cf. Jönson & Szebehely, 2018; Moberg, 2021). And, when it came to participants, we engaged 39 individuals originally educated as nurses, care assistants, or physiotherapists.² When we interviewed these individuals in 2018 and 2019, 25 of them worked as frontline staff, and 14 of them as management staff. Their experience in eldercare ranged from six months to 35 years. Our argument was that this broad variety of participants could help us capture perceptions across staff groups about contemporary conditions in Swedish eldercare (cf. Dellgran & Höjer, 2005).

Table 1 below contains an overview of our research design and empirical material.

Table 1. Overview of research design and empirical material

Municipalities	Service providers (homes visited)	Staff groups (individuals interviewed)
Alpha	Public (2)	Frontline (8) Management (3)
	Private (3)	Frontline (9) Management (7)
Beta	Public (1)	Frontline (3) Management (2)
	Private (1)	Frontline (5) Management (2)
Total	7	39

During our interviews, which ranged between 40 and 120 min, we sought to understand how different staff groups approached the role of competition as participants talked about their daily work in nursing homes three decades after market-inspired reforms were launched throughout Swedish eldercare. What is competition perceived to imply among staff in homes today? And how is competition perceived to affect the quotidian work of different groups? Our interviews were conducted following a semi-structured pattern of questions that afforded considerable possibilities for spontaneous queries. We took pains to build rapport with our participants, primarily by promising anonymity and confidentiality, but notably also by formulating all questions and queries with caution so that they would not be understood as evaluations of any sort.

We analysed our interview transcripts through an abductive coding technique that consisted of moving back and forth between empirics and theories (Swedberg, 2014). This technique gradually took us from narrower and more empirically grounded toward broader and more theoretically anchored codes. To begin, we searched for first-order descriptions that were closely related to the terms and phrases utilised by our interviewees when they talked about competition. In the next step, we merged and abstracted our numerous first-order descriptions into focused second-order themes. Finally, after repeated iterations, we placed our second-order themes under third-order dimensions that conceptualized how different staff groups approached competition as a socially constructed and contextually bounded phenomenon. Our analysis was greatly facilitated by MAXQDA software.

That said, we are now ready to flesh out the full findings from our analysis of how competition was perceived in nursing homes three decades after market-inspired reforms were launched in Sweden’s eldercare.

Findings: dealing with episodic and continuous competition in daily work

When we commenced this study, our belief was that, in terms of perceptions about competition, a dividing line would surface between nursing homes operated by private actors, on the one hand, and nursing homes operated by public actors, on the other hand. We believed the role of competition as an efficiency-driving, innovation-pushing, and influence-encouraging phenomenon would be quite ingrained and accepted among staff in private homes (as these nursing homes have their ownership backgrounds in a sector that has traditionally been characterised by competition). And, concomitantly, we also believed the role of competition would be rather contested and denigrated among staff in public homes (because these homes have their backgrounds in a sector that has historically not been characterised by competition). As our study progressed, however, we revised our belief. When it came to perceptions about competition, we found no clear dividing line between private homes and public homes. Instead, we found a relatively pronounced line between frontline staff, on the one hand, and management staff, on the other hand. Perceptions about competition in nursing homes thus appeared to be more associated with staff groups than with ownership backgrounds. We leverage this dividing line between groups to show how competition was variously approached as an episodic and continuous phenomenon.

Frontline staff: competition episodes and employment uncertainties

Certain nurses, care assistants, and physiotherapists working as frontline staff emphasised how competition between homes could inspire and motivate. This frontline staff approached competition as an incentivizing phenomenon that spurred nursing homes to improve their services by, for instance, offering a broader number of lunch options, communal events, or outdoor verandas than before. Such emphases and approaches were, however, not very common among frontline staff. The great majority of this staff group underscored that competition between homes did not affect daily work within homes in any significant ways.

From the vantage point of frontline staff, competition was mostly perceived as a distant phenomenon that seldom came to mind when nurses, care assistants, and physiotherapists worked with elders. A nurse mentioned that, ‘oh, no, it [competition] is not something I have felt or find myself thinking much about’ (Interview 5 – Public home 2). And a care assistant similarly expressed that ‘I do not think much about that [competition] at work’, adding how ‘me and my colleagues are focused on our patients, and we want to be available for those who live here’ (Interview 12 – Private home 3). A precautionary note needs to be inserted here, and it concerns the fact that few of our interviewees worked within eldercare before Sweden’s market-inspired reforms were launched 30 years ago. Most of the frontline staff we interviewed started working within eldercare during the 2010s; this staff was, as such, not fully equipped to engage in comparisons between pre-competition and peri-competition contexts. The peri-competition eldercare context most of our interviewees were familiar with, nonetheless, led them to approach competition between nursing homes as a phenomenon that was little noticed in quotidian work.

Nurses, care assistants, and physiotherapists in frontline staff regularly downplayed competition by associating it with a long-standing characteristic of Swedish eldercare. And this is that the demand among elders for residential care services in nursing homes largely exceeds the supply of such services, despite an influx of private actors providing further rooms (Bergman & Jordahl, 2014). ‘We have’, as a nurse with more than 30 of years of experience stressed, ‘almost always had full occupancy in the homes where I have worked’ (Interview 3 – Public home 1). There were, succinctly put, seldom rooms available at homes in Alpha and Beta. Scarcity was a fact. Using rather economistic terms, Bergman and Jordahl (2014, p. 9) argued that, ‘for customer choice to provide real options … there has to be a certain overcapacity on the market. This is not always the case within eldercare’. It may, in certain respects, thus be more appropriate to suggest that users competed for homes than the other way around. Although additional nursing homes were planned within the two municipalities we studied, it was unclear if those additions would cover the existing demand for residential care services among elderly users.

The high demand for and low supply of rooms generally implied that frontline staff did not perceive other homes as competitors. Nonetheless, this staff group sensed there were specific situations when competition between nursing homes was accentuated. Such situations concerned tendering periods during which multi-year service provision contracts were awarded by municipalities to public actors and/or private actors in eldercare. We conceptualise the perceptions surrounding these situations as episodic competition to highlight how tendering can be understood in terms of ‘occasional, discrete “showdowns”’ (Barnett, 2008, p. 11). Nurses, care assistants, and physiotherapists in frontline staff stressed that tendering periods could produce considerable uncertainty, which was most noticeable when employment issues came up during our interviews. We have already mentioned that rooms in Sweden’s nursing homes were seldom available. This, in turn, suggests that most, if not all, homes would be awarded certain service volumes by municipalities so as to cover the existing demand. The uncertainty experienced by nurses was, however, related to shifts in volumes that often took place as certain nursing homes were awarded larger or smaller contracts than before. Such volume shifts could have significant employment implications within homes. Decreased service provision volumes implied that jobs were slashed, especially among frontline staff. Asked about upcoming tendering periods, a care assistant emphasised they may ‘turn out well’, but that the implications, nonetheless, ‘remain to be seen’ (Interview 8 – Private home 2). This sense of uncertainty is in line with the notion that tendering periods tend to generate ‘organisational instability’ (Stenius & Storbjörk, 2021, p. 6), and, perhaps most particularly, with the notion that ‘marketisation policies are often followed by an aggravation of the employment … situation for care workers’ (Theobald et al., 2018, p. 215).

Beyond decreased volumes, however, the greatest uncertainty was perceived in connection to nursing homes that changed operators. This was not uncommon after tendering periods, because public actors and private actors could be awarded the operation of entire homes, thus poaching them from competitors. The subsequent start-up phase for new operators was often perceived as chaotic and unruly. Faced with this resulting uncertainty, many of our frontline staff interviewees found comfort and security in what they saw as a call and an ethos that represented their devotion to eldercare (cf. Kamp, 2016). Across public homes and private homes, nurses, care assistants, and physiotherapists in frontline staff groups largely disregarded what operators they worked for. Instead, these interviewees repeatedly emphasised that they worked for their users. A care assistant illustrated this point by stating how ‘it doesn’t matter if I work for the municipality or a private provider. It is still them [the users] that I care for … To me that is very important’ (Interview 20 – Public home 3). Another assistant mentioned that ‘I haven’t worked in private care previously, so this is the first time, but I would generally say that I … don’t see any big differences’ (Interview 29 – Public home 4). When nursing homes changed operators, some frontline staff interviewees also seemed to find comfort and security in the notion of places (cf. Cresswell, 2014). Certain interviewees in this staff group expressed how they coped with changing operators by attaching to the material aspects of workplaces, such as rooms, corridors, or entire buildings. These aspects were regarded as permanent facets in the midst of competition between providers that, at times, produced great uncertainty.

Nurses, care assistants, and physiotherapists working as frontline staff tended to construct symbolic boundaries (Lamont & Molnar, 2002) that bracketed and compartmentalised tendering periods. Such periods were regarded as short and compressed time lapses that interrupted, but did not form any integral part of, daily work for this staff group. The competition for service provision contracts between nursing homes during tendering periods was perceived to be so temporally concentrated that it could be separated and distinguished from quotidian work. This separation and distinction, by extension, allowed frontline staff to further downplay the role of competition. After multi-year service contracts were awarded, competition was perceived to be paused until the next tendering period (cf. Svensson & Edebalk, 2006). Such pauses implied that nurses could focus on their daily work, without having to worry about shifting volumes or changing operators.

Management staff: marketing, branding, and continuous competition

Just as frontline staff, nurses in management staff emphasised how competition between homes was not a phenomenon that affected quotidian work to any major extent. This latter staff group similarly pointed to how the demand for residential care services had exceeded the supply of such services during several decades. And, because rooms were seldom available, management staff neither perceived that nursing homes competed against one another (cf. Bergman & Jordahl, 2014).

Although daily work was not believed to be affected, nurses in management staff regularly talked about competition as a phenomenon that, more than anything else, influenced the strategic endeavours of homes. Such endeavours concerned long-term decisions that were not immediately connected to the care of elderly users. In terms of competition between nursing homes, strategic endeavours primarily encompassed business-like organising efforts to gain and maintain visibility through active marketing and branding. This type of efforts would, at first glance, appear to be directed toward elders (and/or their relatives). But, because nursing homes were not perceived to compete with one another for users, elders became secondary targets of marketing and branding efforts. Throughout our interviews with management staff, it instead became clear that most business-like efforts to gain and maintain visibility in Alpha and Beta were directed toward municipal politicians and bureaucrats, as well as toward potential employees. Politicians and bureaucrats controlled the resources financing all service provision contracts. Those resources seemed to make municipal politicians and bureaucrats central targets of marketing and branding. Moreover, in terms of potential employees, skilled nurses, care assistants, and physiotherapists are difficult to recruit because Swedish eldercare jobs have, for long, held low status. This is because jobs in eldercare are generally understood to imply stressful conditions and meagre wages (Ulmanen & Szebehely, 2015). Locating and attracting skilled nurses, care assistants, and physiotherapists for eldercare jobs was thus challenging, if anything. Such challenges made potential employees additional core targets of marketing and branding efforts by nursing homes in the two municipalities we studied. A nurse working as an operations manager summed up these efforts by emphasising that ‘we need to remain one step ahead and always be proactive toward them [politicians, bureaucrats, and employees] … We cannot relax and think that everyone knows what we are doing’ (Interview 22 – Public home 3). ‘We want to show who we are, and what we can achieve’ (Interview 30 – Private home 4), as another nurse in management staff put it.

But how did nursing homes communicate to gain and maintain visibility through marketing and branding efforts? Social media was recurrently used by homes to communicate messages about the virtues of locations, facilities, and events, and about the competences of employees (cf. Jönson et al., 2017). These messages constituted attempts at cultivating favourable images of nursing homes among elderly users and their close relatives, but also, and perhaps primarily, among municipal politicians and bureaucrats, as well as among potential employees. In terms of locations, homes stressed how they were situated close to city centres and nature trails. But, at the same time, nursing homes were supposedly also situated in familiar areas of town where many elders had lived before. Homes, in this way, framed their locations as convenient for all types of needs and wishes. As for facilities, nursing homes attempted to communicate that they consisted of more than rooms with residential care services. While such services were obviously important, homes also sought to portray their facilities as vibrant places consisting of gyms, libraries, restaurants, and other amenities stretching far beyond what is most immediately associated with residential care. Closely connected, in terms of events, nursing homes emphasised the various leisurely diversions that were offered on-site, such as yoga sessions, reading circles, and dinner nights. These events framed homes as dynamic communities within which elderly users could socialize in different constellations and through different pastimes. And, finally, when it came to competences, nursing homes highlighted the skills and merits possessed by those nurses, care assistants, and physiotherapists who were on regular duty. Along these lines, homes often underscored that their nurses had received certificates, such as the ‘Silviasyster’ specialisation for dementia care. The ways that nursing homes in Alpha and Beta appeared to mainly communicate through social media reinforce findings from previous studies. These studies show how homes expend significant marketing and branding efforts directed at various stakeholder groups (Kastberg, 2002; Svensson & Edebalk, 2006), but also how they communicate in ways that do not satisfy the needs of elders, who tend to prefer personal dialogues over compact messages when making choices among eldercare services (Hagbjer & Krohwinkel, 2018; Harding, 2021).

Marketing and branding efforts to cultivate favourable images were closely associated with how nurses in management staff approached the role of competition. Earlier on, we saw how frontline staff perceived competition as an episodic phenomenon that was accentuated during tendering periods, but paused between such periods. Management staff typically extended this perception by approaching competition as a continuous phenomenon that nursing homes needed to consider both during and between tendering periods. There were, in this line of thinking, no pauses from competition. These nurses, who regarded competition as a continuous phenomenon, emphasised how homes would also be best off by approaching marketing and branding efforts as a constant task. This was, as several management staff interviewees ultimately argued, an important way for nursing homes to remain visible, and, thus, to increase their possibilities of being awarded repeated service provision contracts.

Competition for service contracts seemed to generate unintended consequences, however. Nurses working as management staff generally asserted it was beneficial for homes to be awarded multi-year service provision contracts from municipalities. Such contracts generated resources, and, by extension, stability and continuity. But service contracts did not necessarily have to be economically beneficial for nursing homes in a short-term perspective. This was particularly noticeable as contracts were believed to be associated with the visibility of homes. That is, management staff often expressed how service provision contracts functioned as ways for nursing homes to gain and maintain visibility. By accepting contracts, nursing homes presented themselves as capable and dependable organisations toward politicians and bureaucrats. Service provision contracts that were not economically beneficial in a short-term perspective could, as such, still be beneficial in a long-term perspective. This, however, meant that nurses in management staff believed their homes had to accept most, if not all, contracts awarded by municipalities. ‘We have’, as mentioned by a nurse, ‘accepted contracts that are bad business for us … But we would never say to politicians that “this does not work” … Everyone [nursing homes] wants to keep their contracts, and to be seen and look good’ (Interview 16 – Public home 3). This quote illustrates how willingly nursing homes appeared to accepted service contracts in the pursuit of visibility. This quote, as such, also illustrates how homes competed for the limited attention of politicians and bureaucrats who controlled the resources that financed municipal eldercare in Sweden.

Discussion: approaching competition as a central or peripheral phenomenon

During the past three decades, market-inspired reforms have been launched in public sectors across Europe (Bettio & Verashchagina, 2010; Lyon & Glucksmann, 2008). Sweden has arguably featured some of the most extensive reforms, which, in its case, have featured far-reaching organising efforts to create local eldercare markets. These efforts have, among others, encompassed attempts at constructing competition between nursing homes for the provision of residential care services to elderly users in Swedish municipalities (Blomberg, 2008; Hagbjer & Krohwinkel, 2018; Ulmanen & Szebehely, 2015).

In this paper, we sought to develop new knowledge about how eldercare professionals currently approach the role of competition now that it has been present for 30 years as a core idea throughout Sweden’s market-inspired reforms. Based on interviews conducted with nurses, care assistants, and physiotherapists during 2018 and 2019, the findings of our study show how competition was similarly perceived across homes operated by public actors and private actors: professionals regarded it as a phenomenon that primarily affected daily work in connection to tendering procedures. While there were no major differences across operators, we, however, found there were considerable differences between staff groups. Frontline staff seemed to focus on employment uncertainties resulting from competition, as service volumes and home operators could change swiftly during tendering periods. Such uncertainties were allegedly handled by seeing eldercare as a call and an ethos that was anchored in devotion to users and places, rather than in devotion to operators. Management staff instead appeared to concentrate on marketing and branding efforts during, but also between, tendering periods. These efforts were supposedly vital to gain and maintain visibility among crucial stakeholders, including municipal politicians and bureaucrats, as well as potential employees.

Szebehely (2011) has demonstrated how tendering procedures in Swedish eldercare early on generated certain cost reductions, but that these reductions were temporary, and that they simultaneously engendered quality reductions. This is taken to suggest that the drivers behind Sweden’s market-inspired reforms have been ‘political rather than economic’ (Szebehely, 2011, p. 236), and, thus, primarily driven by ideological motivations. Our staff-centred study of competition shifts focus from motivations behind eldercare reforms to perceptions in nursing homes. We found staff groups perceived competition in various ways, and this challenges economic perspectives that picture it as a uniform and semi-automatic phenomenon (cf. Arora-Jonsson et al., 2020; Cattani et al., 2017). Our findings highlight the ways that perceptions of competition in homes could range from an employment-focused, episodic phenomenon among frontline staff to a visibility-focused, continuous phenomenon among management staff. Looking at these findings, we argue that competition simultaneously became a central and peripheral phenomenon in nursing homes. Our interviewees in frontline staff restricted the role of competition to tendering periods, during which it was approached as central for employment uncertainties. But this restricted and, thus, episodic approach to competition also meant that competition became a peripheral phenomenon between tendering periods. Our interviewees in management staff, however, expanded the role of competition beyond tendering periods, approaching it as central for marketing and branding efforts to foster visibility both during and between those periods. This approach can be understood by considering that the marketing and branding efforts of nursing homes could not constitute more than attempts at cultivating desired images (Alvesson, 2004). That is, homes were hardly able to control how the resulting images would be received by stakeholders. And this presumably expanded the efforts to foster visibility, ultimately making them almost continuous. Whether competition was approached as a central or peripheral phenomenon appeared to depend on staff groups, and, in particular, on their perceptions about what the time during and between tendering periods implied. The different ways in which frontline staff and management staff approached competition can, by extension, also be interpreted as implicit resistance or implicit acquiescence to market-inspired reforms. Although such resistance and acquiescence was not explicit, frontline staff seemed rather content with a restricted role of competition in nursing homes, whereas management staff appeared quite compliant with an expanded role of competition, and its implications, in homes.

Our paper contains limitations that benefit from being acknowledged. Here, we highlight two limitations, and emphasize that they simultaneously serve as avenues for future research on competition and other market-inspired phenomena in eldercare. First, our reliance on cross-sectional interviews could be understood as a limitation. While we used these interviews to address our aim in this paper, they do not tell us much about the ways that perceptions of competition have evolved over time. How did different staff groups in nursing homes approach the role of competition when Sweden’s market-inspired reforms were launched 30 years ago? And how have perceptions of competition evolved since then? Some of our interviewees possessed extensive experience in eldercare, and they often spoke retrospectively, but we did not envisage this paper as a longitudinal study. Future research could thus adopt longitudinal designs to explore the ways that perceptions of competition and other market-inspired phenomena in eldercare are shaped over time. Ideally, this research would combine retrospective interviews with archival documents. Second, our reliance on a single national context could be understood as another limitation. Although Swedish eldercare features certain idiosyncrasies, such as more recurring and far-reaching reforms than in most other contexts, we suggest it also features several characteristics that make Sweden comparable to other national contexts. Important characteristics still permeating Swedish eldercare, including a high governmental involvement, can similarly be found across the Nordic countries, as well as in certain parts of continental Europe, including France and Germany (Bettio & Verashchagina, 2010; Lyon & Glucksmann, 2008). Future research could thus expand on our paper by studying perceptions of competition and other market-inspired phenomena in contexts that display similarities with Sweden’s eldercare. Such research would facilitate international comparisons, which ultimately promise to enhance our knowledge about the role played by competition and other market-inspired phenomena in nursing homes across Europe.

Acknowledgements

We express our deep gratitude to the anonymous reviewers at this journal for their constructive comments and supportive suggestions.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by Jan Wallanders och Tom Hedelius Stiftelse samt Tore Browaldhs Stiftelse: [Grant Number W18-0053].

Notes on contributors

Peter Edlund

Peter Edlund is a postdoctoral researcher at the Department of Business Studies, Uppsala University, Sweden. His main research interests encompass qualitative approaches to status and competition in and between public sector organisations. Edlund’s latest book is ‘Science Evaluation and Status Creation: Exploring the European Research Council’s Authority’ (2020, Edward Elgar Publishing).

Daniel Lövgren

Daniel Lövgren is a senior lecturer at the Department of Informatics and Media, Uppsala University, Sweden. His research curiosity revolves around communication approaches to variable forms of organising, including the role of strategic communication and visibility in the public sector, and the development of small-scale food production and consumption.

Notes

1 The research project is labelled ’Mediatization of, in, and Between Organizations – Prevalence, Dynamics, and Consequences in Private, Public, and Civic Sectors’, and it has been funded by Jan Wallanders och Tom Hedelius Stiftelse (grant number P2017-0198:1). This project received ethical approval from Regionala Etikprövningsnämnden i Uppsala (approval number 2018/213).

2 We provided written information to, and received written consent from, all participants before our interviews.