Moral Choices and Responsibilities: The Home-help Service at the Borderland of Care Management When Older People Consider Relocation to a Residential Home

ABSTRACT

The aim of this article is to reveal how care workers in the home-help services handle the process when older people’s relocation to a residential home is under consideration. Since the care workers are engaged daily in defining care receivers’ needs and yet have no formal influence on care decisions in Sweden, the focus is on how they solve this dilemma. In this inductive study, the theoretical framework is based on occupational alliances, relationship-based practice, and discretion. Thirty-three care workers in home-help services are included in open semi-structured interviews. Prominent features in the findings are that the care workers take their stand at the borderland of care management, when they know or try to find out what is right. The conclusions drawn are that care workers find ways to informally influence the decision-making process, quite contrary to the idea of approaches referred to as purchaser/provider models. The implications for social work policy and practice are that a distinction between assessment and intervention may not benefit the field of eldercare and should therefore be regarded as an area in need of thorough reconsideration.

KEYWORDS:

• Older people
• care work
• care management

Introduction

The assignment of the home-help service is expanding in many welfare states, not only due to demographic development with more people reaching high age, but also as home-based care is socio-politically advocated in contrast to residential care (Pavolini and Ranci 2008; Schön, Lagergren, and Kåreholt 2016). In line with this development even home-based care for older people with extensive needs is supported by technological advances in health care and medical care. Symptomatically, municipal politicians reduced the number of beds and, as an example, every fourth bed disappeared from residential homes in Sweden between 2001 and 2012 (Ulmanen and Szebehely 2015). Consequently, care managers at the local level tend to reformulate the criteria for having ‘sufficient needs’ for residential care (Dunér and Nordström 2006; Phillips and Waterson 2002; Söderberg, Ståhl, and Melin Emilsson 2015b) and it is up to the providers of home-based care to turn the principle of ageing in place into practice. Since the care workers are daily engaged in defining care receivers’ needs and yet have no formal influence on care decisions in Sweden, the focus in this article is on how they solve this dilemma.

On an international level and in different welfare systems, research has previously paid attention to the consequences of New Public Management – inspired ideas aimed to increase efficiency and productivity in care services (Brennan et al. 2012; Puthenparambil 2018). It has been maintained that this changing ideological agenda is dominated by agency perspectives in assessments and responses to needs (Jordan 2004; Lloyd 2006) and that there is a risk that care managers become part of a moral order aligning with advocates of tight budgets (Lymbery 2014; Weinberg 2010). Similarly, Szebehely and Trydegård (2012) argue that a decline of tax-funded home-help services in Sweden has been caused by a complex interplay of decision-making at central and local levels, resulting in stricter municipal targeting. Furthermore within the research field, attention has been drawn to time-pressure and the undermining of the discretion and autonomy of eldercare workers (Evertsson and Johansson 2007; Strandell 2018; Trydegård 2012; Tufte, Clausen, and Nabe-Nielsen 2012). Researchers have also returned to the distinction between specific and changing person-oriented care versus task-oriented care, defined from top down and limited beforehand to certain services (Eliasson 1995; Olaison 2009; Swane 2003; Szebehely 2005). In line with this focus, it has been questioned to what extent care managers assess the needs of individual care receivers in their role of exercising authority (Dunér and Nordström 2006; Olaison 2009; Söderberg, Ståhl, and Melin Emilsson 2015a, 2015b). However, what has not been studied before and what is the focus of this article is whether and, if so how, care workers in the home-help service stretch the limits for their care assignment in relation to formal decision-making processes. The aim of this article is to reveal how care workers in the home-help services handle the process when older people’s relocation to a residential home is under consideration. The research questions were:

1. How do home-based care workers proceed when they know or try to find out what is right when older people consider relocation to a residential home?

2. What are the consequences of the care workers’ procedure for the idea of purchaser/provider models and for the care of older people?

Based on an interest in the discretion and capacity for ethical practice on the part of practitioners who have no formal decision-making responsibilities, the research questions draw attention to processes when there is not yet consensus regarding whether continuing home-based care or residential care would be the best care alternative.

The study that was the basis of this article was conducted within the framework of a post-doctoral project at Linnaeus University, Sweden. The overarching aim of the project was to reveal how care workers and their superiors in home-help services handle the process when older people consider relocation to a residential home. Previously, the author has studied this process from the perspectives of older people, their family members, care managers (Söderberg, Ståhl, and Melin Emilsson 2012, 2013, 2015a, 2015b), and hospital nurses (Söderberg 2018). This series is hereby expanded by an article based on the perspective of care workers in the home-help services.

Home-help services in Sweden

In Sweden the care of older people, including long-term medical care, has been a municipal responsibility since a nationwide reform in 1992, influenced by revised legislation reinforcing municipal independence (SFS 1991:900). Organisationally, the care of older people was placed under the Social Welfare Services Department governed by the Social Services Act, thereby positioning eldercare in the field of social work. Prominent values in the Social Services Act (SFS 2001:453) are respect for human self-determination and integrity. Furthermore, it is stated that the aim of eldercare is to ensure older people a dignified life and a sense of well-being (national code of ethics). However, tensions have been found in the performance of care between care receivers’ autonomy and protection in formal needs assessments (Jordan 2004; Olaison 2009; Söderberg, Ståhl, and Melin Emilsson 2015a, 2015b), and between an older person’s self-care and the risks of negligence (Eliasson 1995; Swane 2003). In this regard, the care of people with dementia has been described as especially complex (Lundberg 2018).

Care management has been introduced in the implementation of community care in Sweden, as for instance in England and Wales (cf. Department of Health/Social Services Inspectorate 1991), inspired by New Public Management with the introduction of purchaser/provider models (Blomberg 2008; Phillips and Waterson 2002). Thus municipal care managers in Sweden decide the content of the service for individual care receivers and the scope of time needed for the service. Furthermore, in recent decades the public care of older people has been exposed to the idea of competition with partial privatisation, and programmes are introduced with the intention of increasing individual choice and control (Szebehely and Trydegård 2012). However, even though customer-choice (voucher) models have been encouraged in the Swedish national policy (SOU 2014:2), not all municipalities support it (SALAR 2018), and where it is supported not all care receivers make an active choice. In such circumstances other distribution routines are applied (Szebehely 2011). Thus in some of the Swedish municipalities, there are publicly provided and a selection of privately run eldercare services available to give the care approved by a care manager. The services approved by a care manager are almost entirely funded by taxes. For services not approved by a care manager, there may be no other choice than to turn to family members or to the market, especially in times of austerity (Ulmanen and Szebehely 2015). Since this article focuses on the perspective of practitioners in publicly financed home-help services, the aspect of privately paid services without needs assessments is not further developed.

Theoretical framework

This article is written in a time characterised by an ongoing redefinition of responsibilities in welfare services, and by a promotion of a new vision of constructive social work practice emerging out of moral choices rather than rationality alone (Parton and O’Byrne 2000; Weinberg and Banks 2019). In this context, it is of particular interest to study the approach of care workers, who are daily involved in defining care needs and yet have no formal influence on care decisions. In theoretically challenging the distinction between providing and purchasing care, the theoretical framework is based on Molander and Grimen’s (2010) thoughts about discretionary powers of professionals, mainly what is called the epistemic aspect. This refers to discretion as a kind of reasoning under conditions of indeterminacy, ending up in conclusions such as about what is right. Schematically it could be illustrated by the formula [description of a situation + norm → action (or conclusion)].

As previously stated, the care workers have no right to make formal care decisions. Considering this, the theoretical framework includes Selander’s (1989) theory of alliance strategy, as the care workers could be perceived as an occupational group in an intermediate or subordinate position, mainly in relation to the care managers. Thereby the care workers have the possibility of allying themselves with others in order to strengthen their own position.

Finally, in theoretically following up the care workers’ interactions with the care receivers, there is a focus on how the care workers apply an effective relationship-based practice characterised by ‘professional use of self’, empathy and ‘front-line’ knowledge (Trevithick 2003) and how they engage in what is considered to be ethically right (Weinberg and Banks 2019). As practitioners, the care workers are restricted by structure, but still they are highly involved in how concepts such as self-determination and integrity as well as justice, autonomy and rights, are conceptualised and understood (Lloyd 2006). Thereby the care workers face a range of possibilities in developing their own normative interpretations.

Methods

Previously the author has been part of a research programme called ‘Changing Place of Living in Old Age’, partly at the School of Social Work, partly at the interdisciplinary Centre for Ageing and Supportive Environments (CASE) at Lund University, Sweden. The research programme was approved by the Regional Ethical Review Board (Dnr 2009/16). Within this context, she wrote a doctoral thesis about the process when older people consider relocation to a residential home from the perspectives of older people, family members, and care managers (Söderberg, Ståhl, and Melin Emilsson 2012, 2013, 2015a, 2015b). In an independent article based on interviews with hospital nurses, another perspective was added to this series supported by the University of Gothenburg (Söderberg 2018). Thereafter, the view of care workers in the home-help service has been identified as yet another important perspective. The study that was the basis of this article was conducted within the framework of a post-doctoral project called ‘The role of home-help services when older people consider relocation to a residential home’ at Linnaeus University, approved by the Regional Ethical Review Board (Dnr 2016/494-31).

Data collection and context

The data collection was carried out in 2017–18 among care workers in publicly financed, publicly or privately provided home-help services. Initially for the participant recruitment the author contacted superiors at home-help services providing both household and care services, since this study is mainly related to the care of older people with extensive needs. The choice to include publicly financed, publicly or privately provided, home-help services was made in order to follow up the aim of the study and yet broaden the empirical data, even though no further attention is paid to this distinction in the analysis. The home-help services were situated in the south of Sweden and in municipalities of different sizes: a large, a medium, and a small one. One of the private providers (company A) was established in both the large and the medium-sized municipality. For more information about the participants, see Table 1.

Table 1. Participants in the empirical data.

Municipality A (large), approximately 90,000 habitants	Municipality B (medium), approximately 30,000 habitants	Municipality C (small), approximately 20,000 habitants
7 municipal care workers (including 2 superiors)	6 municipal care workers (including 1 superior)	5 municipal care workers (including 1 superior)	18 municipal care workers
5 private care workers (including 1 superior, 1 founder, 1 coordinator) in company A 3 private care workers (including 1 superior) in company B	3 private care workers (including 1 superior) in company A 4 private care workers (including 2 founders/superiors, 1 coordinator) in company C	No privately provided home-help service in the municipality	15 private care workers in company A, B + C
15	13	5	Total: 33

The participants consisted of care workers in the home-help service. However, since superiors/founders and coordinators had long working experience in the eldercare field and frequently expressed themselves on the basis of their own caring experience, they were partly included in the data, even though priority was given in the quotations exclusively to the care workers. In all, the participants consisted of 30 women and 3 men. The care workers had between 1 and 40 years of working experience of the home-help service, and for a few care workers, residential care was part of their present and/or former work experience.

The author met each of the participants once in an open semi-structured interview carried out in a separate room at the office of the home-help service. Each interview was booked beforehand to last 30–40 min, based on the high work-load and strict schedules of the care workers. Initially project information was presented verbally, whereupon the participants signed a formal letter of consent containing the corresponding information in writing and the principles of research ethics. The request to record the interview was accepted by all the participants. With an inductive starting point, a thematic interview guide was applied at the interview sessions together with questions flowing from the immediate context, as in informal conversational interviews (Patton 2002). The areas of questions focused on the decision-making process related to a potential relocation to a residential home, its causes, and the care workers’ interactions with care receivers, their family members, and other eldercare workers. In their answers, the care workers themselves chose to refer to general observations as well as to specific experiences.

Since in this article there was an interest in how care workers handle a multifaceted process, it is possible that references to complex relocation processes are overrepresented in the data. It is also possible that the participants’ responses were adapted to the interview situation. The interviews were transcribed verbatim, but minor details in the quotations were changed in order to ensure confidentiality, such as the care workers’ names and localities.

Data analysis

After the author had transcribed all the interviews, the transcripts were read reiteratively and a thematic analysis was initiated (Braun and Clarke 2006). In the coding system, the aim and research questions of the article guided the analysis, and the interpretations were made in close interplay between data, previous research and a successively expanding theoretical framework. The theoretical framework consists of perspectives related to the care workers’ discretion, occupational alliances, and relationship-based practice. In an approach with careful comparison and scrutiny of data instances, three themes were finally formulated. The process of analysis was influenced by an increasing research interest in how care workers in the home-help service ethically solved the dilemma of being daily engaged in defining care recipients’ needs and yet had no formal influence on care decisions. This means that, as it is expressed in hermeneutics, the data were influenced by the cultural context in which they were created, as well as by the cultural context in which they were subsequently interpreted (Patton 2002).

Some ethical considerations emerged during the research process. At a local level, initially the study was approved by the superiors of the home-help services and they also had a crucial role in the recruitment phase. Thus, from an ethical point of view this procedure may have reinforced expectations on individual participants to accept being interviewed. It was hard to know to what extent such circumstances may have influenced the data. In order to deal with this potential influence, at the beginning of the interview every participant was reminded that participation was voluntary and that they could choose to stop the interview at any time (cf. Swedish Research Council 2017).

Findings

Prominent features in the findings are that the care workers took their stand at the borderland of care management, when they knew or tried to find out what was right. Mainly inspired by the epistemic aspect of discretion according to Molander and Grimen (2010), three main themes were developed as the care workers’ actions (or conclusions). They have been designated Making it work, Encouraging reconsideration, and Promoting change. In the process of analysis, these actions (conclusions) were based on how the care workers perceived their own performance and in what context (norm), and what the care workers said they did (description of a situation). An overview of the findings is presented in Table 2.

Table 2. Overview of the findings.

Action (conclusion): Making it work	Action (conclusion): Encouraging reconsideration	Action (conclusion): Promoting change
Prominent norm: Adaptation to the care receivers’ self-determination	Prominent norm: Concern for the care receivers’ self-determination	Prominent norm: Negotiation of the care receivers’ self-determination
Description of a situation: Confirmed the care receivers in their desire to remain in ordinary housing despite a heavy workload Were part of informal promises about life-long home-based care Took measures to reduce anxiety and sadness Investigated different home-based care solutions by involving different occupational groups	Description of a situation: Stressed the importance of listening several times to what the care receivers really wanted Made family members aware of how they formulated their questions to their old relative Conveyed to the family members what their older relative wanted Referred to the importance of keeping the care receivers well-informed about the full range of home-based care	Description of a situation: Emphasised the advantages of residential care for the care receivers Built up a positive image of residential care if the family also promoted relocation  Recommended the care receivers to at least apply for residential care

Making it work

In line with prevailing legislative guidelines in social work ethics, the care workers referred to the importance of adapting to the care receivers’ self-determination. Of 33 care workers, 33 referred to their own experiences of making extra efforts to meet the care receiver’s desire to remain in ordinary housing as far as possible. Margarethe stated:

We may have an opinion […], but it is the desire of that person. We have just finished one such case, where there was a lot, but no. Then when you’re there and you see the joy of being at home, well then no. We did let it be. We know it’s for a while and we do it this time, because it’s worth a lot for the care receiver.

In an interpretation of the quotation, the care workers shared the care receiver’s joy of being at home, as in a relationship-based practice, and the closest colleagues were determined to make the home-based care work despite a heavy workload (Trevithick 2003). In this process they used their front-line knowledge and ended up concluding what they considered to be the only right thing to do. Thereby they strengthened their own position in the working group, without explicitly allying themselves with other eldercare workers (cf. Selander 1989).

Presumably influenced by the well-known restricted access to residential care, more care receivers remain in ordinary housing until the end. Laila expressed it like this:

Now that it has been introduced it somehow feels like, that ‘I want to end up at home. I can live here because you will take care of me.’ ‘We will definitely do that,’ we say then. So it has become much more like that now, because it’s much harder to enter residential care.

In the quotation it was made clear that more and more people in recent years actually ended their lives at home and that it had not only become more common but also more accepted. Similarly, Regina shared the following example:

In my group we have two gentlemen with dementia, who clearly expressed when they were healthy that ‘I want to live at home. I don’t want to relocate'. So that’s the desire we have to adapt to, even though frequently it’s difficult.

According to the quotations above, occasionally the care workers meet care receivers who want to be reassured that they will be taken care of in their own homes until the end, and who subsequently are given such promises. The quotations could be interpreted as expressions of informal promises about life-long home-based care, somewhere between an informal agreement and a system based on care management. From an ethical point of view such promises could be profoundly problematic, as there were no guarantees that the promises would be kept due to circumstances such as available resources, and the course of the disease. The duty of respecting civil rights and individual choices would have to be weighed against the sometimes conflicting duty of ensuring the care receivers’ safety and well-being. Furthermore, the application of ethics situated in the care work would have to be weighed against regulatory codes of ethics situated in organisational rules backed by legislation (Lundberg 2018).

On a daily basis, various measures could be taken to confirm and support the care receivers in certain care situations. Efforts were devoted, for instance, to paving the way for the care receivers’ experience of the home as a safer place. Margarethe gave the following description:

We are always keen on telling them that we are locking the door […]. There is liquid and they have the alarm clock […], to tell them that we are coming back at 1 pm […] so that they know that they are not forgotten […]. It’s worth it […], so that you don’t rush, ‘No I don’t have time, I can’t talk', and leave. Then we have created a busy night or day.

In previous research attention has been drawn to the rush in the home-help service (Evertsson and Johansson 2007; Strandell 2018). Judging by the quotation above, however, there were moments when pauses in scheduled tasks were regarded as ethically right. Thus, certain initiatives were developed in the care offered beyond the service formally specified by care management, yet crucial for continuing home-based care. Similarly, Betty stated: ‘To leave someone who is really sad, you don’t do that. Then you may postpone what you have [planned], and give some minutes extra.' Thus like an expression of ‘professional use of self’ (Trevithick 2003), there was a readiness to combat anxiety and sadness. On the one hand the care workers were involved in initiatives based on specific and changing needs of individual persons such as anticipating anxiety and sadness, on the other hand they were assigned to carry out task-oriented care purchased from top down, and limited beforehand to certain services (cf. Eliasson 1995; Olaison 2009; Swane 2003; Szebehely 2005).

Discussions about the situation of individual care receivers regularly took place in working groups consisting of the closest colleagues. Such discussions could be about how to meet specific and changing needs in the best possible way, not least for care receivers living with dementia. Mindy referred to the discussions going on like this:

It’s getting worse now, because many more live with Alzheimer’s and all this […]. But usually we first talk in the group and then with my superior […]. We discuss pros and cons and then maybe we contact the occupational therapist and the physiotherapist, so that they go and check a little […], if there is anything to do in order to make it easier.

The procedure was also referred to by Mindy like this: ‘So first it’s us [in the group] you know, then all others, nurses and then it’s the boss who finally makes a decision that we have done everything we can'. In this quotation it is indicated that there were alliance strategies with the occupational therapist and the physiotherapist for investigating various solutions for continuing home-based care (cf. Selander 1989). It is noteworthy that the care managers were not mentioned in the quotation. The initiatives could be interpreted as established expressions of discretionary powers, where the care workers, as part of their care work, took initiatives to try to optimise the use of available resources before relocation was seriously considered.

Encouraging reconsideration

Of 33 care workers, 30 care workers referred to the importance of encouraging the care receivers’ reconsideration in the decision-making process and thereby strengthening the prerequisites for a well-grounded care decision. Mary made the following statement:

I think you should listen to the person several times before making the decision. They can be tired and they may be affected by medicine. You should probably ask several times. ‘What do you really want?’ and all this and not just listen once and then make the decision. That’s what I think.

Mary indicates in the quotation that the care receiver’s desire had to be confirmed several times and at different times. The quotation could be interpreted as a normative statement emerging out of the care receiver’s self-determination and of the maintenance of good ethics in caring (Molander and Grimen 2010; Weinberg and Banks 2019). However in addition to the statement, Mary added: ‘That’s what I think.' The supplement indicates that Mary was not convinced that this practice was a common practice in the working group. Nevertheless, it was perceived as the right thing to do.

Even though the care receivers’ self-determination could be regarded as a core ethical value, its practical implication was not always easy to capture when prevailing needs were defined in different ways by the parties involved. There were examples of circumstances when the care receivers wanted to remain in ordinary housing, while residential care was promoted by family members. Susan expressed it like this:

Sometimes they really don’t want to come to a residential home but they really want to stay at home and then […] often there are family members who are pushing or the like […]. You can talk with the family members and say, sort of, tell a little about what their elderly relative tells me.

Susan drew attention to the possibility that the family members’ standpoint was not in accordance with the care receiver’s desire. Susan maintained that in such circumstances, the care workers could convey to the family members that their elder relative really wanted to stay in ordinary housing, as in an effective relationship-based practice (Trevithick 2003).

However, in the opposite case, when care workers considered that the home-based care no longer could meet prevailing care needs while family members did not find it so, it could occur that the care workers made family members aware of how they formulated their questions. Paula referred to the following example:

Then they [family members] can ask questions that are like the answer they want. ‘Do you want to live at home?’ ‘Yes’. Then it will be ‘yes’, but with older people you can ask the question in another way. ‘How does it work at home?’ Maybe a little … that you proceed softly and check a little.

By applying yes-or-no questions, it was regarded as a risk that family members got the answer they wanted at the cost of their elder relative’s self-determination. This way of handling the process could be interpreted as an application of ‘a professional use of self’, empathy and ‘front-line’ knowledge, as in the quotation it was maintained that ‘with older people you can ask the question in another way’ (cf. Trevithick 2003).

The care workers could encourage reconsideration regarding different care alternatives also by providing information about the breadth of the supply of home-based care. Betty put it like this:

Many older people do not fully understand that they can get quite a lot of help before they have to relocate. Nor does everyone know that we are not only there to help them and clean a little and so, but we have cases where we visit like eight times a day and do pretty much everything.

Based on the quotation, a lack of information could jeopardise well-founded care decisions, including the risk that residential care was promoted on incorrect grounds. Betty stated that the care workers’ area of responsibility had increased and that home-based care workers do pretty much everything. On the one hand such alternatives could be interpreted as a measure to strengthen the position of the care workers as an occupational group. On the other hand it could be problematised in the sense that the information provided could interfere with the power of authority formally given to the care managers, to whom the care workers are in an intermediate or subordinate position (cf. Selander 1989).

Promoting change

According to the idea of purchaser/provider models, the care workers should only provide services specified and approved by care managers. However of 33 care workers, 33 referred to the possibility to promote change, when they considered it to be right. Sandra reasoned in this way:

I don’t want to be the one saying ‘I think you should do so and so’. Instead it’s a choice they have to make themselves. In that case what you can do, if you notice yourself that it might be time to live somewhere else, then you try to emphasize the advantages of relocation in that case.

In the quotation, Sandra made clear that she did not want to influence the care receiver’s relocation decision too much. However when she noticed that it might be time to live somewhere else, she could make the care receivers aware of the advantages that residential care would bring. Similarly, Ann referred to the following possibility to influence the decision indirectly in the context of care receivers living with dementia:

Sometimes the care receivers themselves may not know that they need to get away, if they live with dementia and the like. So then you may try, not to persuade, that we can’t do, you know. We can only tell them what is available and so, but I mean you can speak in the right direction, so to speak.

Ann drew attention to the fact that the care receivers’ decreased cognitive capacities could contribute to the need to promote residential care. On the one hand it was maintained that it was not ethically right to engage in persuasion. On the other hand there was a possibility to ‘speak in the right direction’. Especially in dementia care, this practice could be ethically challenging, as it may potentially influence the consent competence of the individual (Lundberg 2018).

The possibility of indirectly promoting residential care was also referred to as a measure that could be influenced by the desire of family members. Margarethe said:

We should stay a little neutral. We should not really say either one thing or the other, but you can try to tell them […]. You notice if the family wants it as well, and then we start too, when you are in the ordinary housing, that ‘wouldn’t it be nice to get there now?' […] ‘You [the care receiver] wouldn’t have to buy groceries and cook and you get to meet people'. You build up a positive image. You ‘feed it’ so that it turns out well.

Even though Margarethe stated that the care workers were expected to be neutral in the relocation decision, she also said that occasionally they could get involved in the process, especially when family members promoted residential care too. Thereby, the quotation could be interpreted as an expression that the care receivers’ self-determination could be negotiated (cf. Lloyd 2006). Additionally, it indicated a discrepancy between their assignment to provide care and their informal discretion in promoting change in their reasoning, under conditions of indeterminacy (Molander and Grimen 2010). From yet another perspective, and given the limited access to residential care, such initiatives could be interpreted as striving to ‘act ethically’ in an ‘unethical climate’ (Weinberg and Banks 2019).

Another way to proceed was to try to ease the care receivers’ agonies over the actual relocation decision. Mathilda expressed it like this:

‘You [the care receiver] can apply, at least apply and see what answer you get.’ And when I know that family members are supportive in that decision and push the matter, so to speak, then I also tell the individual that your family agrees on this. ‘And when you get the decision, then maybe you get a rejection, then you can appeal.’

From one perspective, the recommendation to become acquainted with the application system could be perceived as an initiative to try to secure the care receivers’ civil rights. From another perspective, it could be perceived as biased recommendations for residential care, strongly influenced by the desire of the family. This latter alternative could also be interpreted as a balancing act where the care receivers’ safety and well-being were weighed against the duty to uphold civil rights and individual choices (Lundberg 2018).

Concluding discussion

Many researchers have previously paid attention to the issue of discretion among decision-makers in welfare services and how it is influenced by declining welfare provisions. In Sweden, as in several other European welfare states, the supply of social services primarily tends to be a matter of finding practical support to help people cope with their everyday life, labelled ‘social care’. This means that trained social workers, such as many care managers, to an increasing extent are involved in the administrative coordination and exercise of authority (Dunér and Nordström 2006; Postle 2001) and risk management systems and structures are supplanting ideologies of meeting needs (Miller and Weissert 2000; Taylor 2006). However, what has not received as much attention is how practitioners in the field of social work formally lacking the right to exercise authority still engage in formal decisions. Proceeding from the aim to reveal how care workers in the home-help services handle the process when older people’s relocation to a residential home is under consideration, this article draws attention to the influence of moral choices and responsibilities embraced by practitioners in charge of the care of older people.

Prominent features in the findings are that the care workers take their stand at the borderland of care management, when they know or try to find out what is right. In a follow-up to the first research question, the care workers in the home-help services are found to make it work when continuing home-based care is considered to be right, they encourage reconsideration when there are question-marks regarding what is right, and they promote change when residential care is considered to be right. In a follow-up to the second research question about the consequences of the care workers’ procedure for the idea of purchaser/provider models and for the care of older people, several conclusions could be drawn. Firstly, in practice the care workers’ procedure challenges the idea of approaches referred to as purchaser/provider models. Having stated this, the question that presents itself is whether it is even possible as a care worker in the home-help service to provide care without perceiving the situation in its entirety and thereby indirectly engage in purchasing care services. Secondly, several possible consequences could be noted. On the one hand the care workers’ informal influence on the decision-making process may challenge the moral concepts associated with advocates of tight budgets. On the other hand, the care workers’ good intentions to do right may contribute to new dilemmas such as double needs assessments, parallel dialogues, promises that will not be kept, a lack of knowledge among care managers regarding existing needs, and so on. Considering that previous research indicates that municipal care managers do not only purchase services according to needs but also according to budgets (e.g. Andersson 2004; Blomberg 2008; Söderberg, Ståhl, and Melin Emilsson 2015a, 2015b), the formal and informal assignment of home-based care workers must be paid more attention. Could it even be that, despite heavy workload and time pressure, care workers fill a gap between the purchasing and the providing of care in a grey zone that could be defined as a constructive social work practice?

In Sweden, as for instance in the UK, care management is carried out in a context of declining welfare resources intertwined with core values of eldercare such as active ageing, individual responsibility, and self-determination (e.g. Lloyd et al. 2014). In the end, it is up to the care workers to turn these values into practice. This means that, on a more or less daily basis and in face-to-face interactions, the care workers catch sight of prevailing needs and search for constructive situation-based, long-term solutions. However, it is not enough to focus solely on everyday individual ethical resistance in social work. Additionally, there is a need to focus on the work of ethical framing on all levels (Weinberg and Banks 2019). The implications for social work policy and practice are that approaches referred to as purchaser/provider models with a distinction between assessment and intervention may not benefit the field of eldercare and should therefore be regarded as an area in need of thorough reconsideration.

Disclosure statement

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

Notes on contributor

Maria Söderberg is a Senior Lecturer at Lund University. She has been a post-doctoral researcher in care of older people at Linnaeus University in Sweden and has thereby been part of the multidisciplinary research group REIS – Research on Elderly in Social Sciences. In 2014 she defended her dissertation at the School of Social Work at the University of Lund. As a PhD-student she was part of the PhD-programme at the School of Social Work, as well as of the PhD-programme at a multidisciplinary centre for research on ageing and older people called CASE at the University of Lund.