Assessing individual needs in Swedish elderly home care services: care managers’ argumentation in relation to the needs of migrant customers

ABSTRACT

The aim of the article is to analyse and problematize care managers’ argumentation of individual needs when assessing migrant customers within Swedish public elderly home care services. According to legislation, need for assistance should always be assessed individually. In recent decades of service decline, standardization of needs has been part of the distribution of elderly care services. Simultaneously, the stratum of older people has become more diverse, which means that a wider spectrum of needs is presented to the care managers. Ten interviews with care managers were analysed with a focus on their arguments regarding the care needs of elderly people with migrant backgrounds seeking assistance. The theoretical conceptions of the two perspectives of care and services were used to analyse the understanding of care managers’ arguments. Our analysis shows that the service perspective with assistance and support that are standardized for Swedes is poorly suited to people born outside Sweden and socialized into other expectations of family and society. The meaning of individual needs was imprecise and contradictory when confronted with diverse cultural codes. When general standards were used in the arguments by referring to regulations and local guidelines, immigrants’ individual needs were not prioritized. Our analysis suggests that the tension between national standards, local guidelines and individual needs has to be discussed further, where theoretical tools related to care and services may be useful in guiding care managers’ professional arguments of individual needs and cultural sensitivity in the needs assessment.

KEYWORDS:

• Individual needs
• care managers
• needs assessment
• elderly home care services
• migrant customers

Introduction

This article aims to analyse and problematize the care manager’s argumentation of individual needs when assessing migrant customers within Swedish public elderly home care services. The Swedish elderly care system is characterized by increasing numbers of older people in need of help and a shrinking budget (cf. Szebehely 2003, 2011; Meagher and Szebehely 2013). Public elderly care is the most comprehensive sector within social services. The professional group care manager is delegated by the Social Welfare Board of the municipality to administer and perform an individual needs assessment in accordance with the Social Services Act (SFS 2001:453). The care managers usually have an academic background in social work or other equivalent academic training, just like the care unit managers responsible for care provision, economy and care staff. The care manager role is, however, complex and often means collaboration with the health care sector (Forssell and Torres 2012).

Individualized or user-centred care has become dominant in national guidelines with the overarching goal of adapting all care and assistance to individual needs, placing the needs of the elderly at the centre for the needs assessment and in care work (SOSFS 2012:3; National Board of Health and Welfare 2015). How this goal is accounted for in practice is, however, not discussed. There is a theoretically interesting tension between national standards, local guidelines and individual needs, which the care managers have to handle in practice. Considering the fact that the ageing population¹ has made the diversity among elderly people more visible, a wider spectrum of care needs is also presented to the care managers when assessing the needs of elderly people, which complicates the needs assessment further. For our analysis, the critical point is how in an organization governed by legislation and guidelines the meeting between the person in need of help and the care manager can be handled.

By shedding light on how care needs can be interpreted and assessed by care managers within an organizational framework characterized by clear restrictions, we will illustrate the complexity of individual needs when general standards for care provision encounter more diverse requests by recipients in need of assistance. Our empirical material consists of interviews with care managers on their decisions of needs assessment within elderly home care services. The analysis focuses specifically on how care managers argue and relate to elderly people with a migrant background and their relatives seeking assistance. In the paper, we use the two theoretical perspectives of care and services to understand how diverse needs are taken into account within public elderly care.

The Swedish context and research on elderly care administration

In the Swedish universal welfare system, the individual is the smallest unit, not the family. The fact that the individual is the smallest unit means, among other things, that each person must have his/her own taxable income in order to fully benefit from health insurance, unemployment insurance and to receive old-age pension exceeding the basic level. The Swedish welfare goals can also be described as aiming to reduce women’s dependency on the family and making it easier for women to work and thereby gain full access to the social insurance system, policies in line with what has been described as defamilisation (Björnberg 2016).

Public elderly care should give all citizens 65 years of age and over access to high-quality care services according to need and not to their ability to pay (Szebehely and Trydegård 2012). Home care services in people’s own homes are the most common form of assistance and support given to the elderly and are regulated by the Swedish Social Services Act (SFS 2001:453), which is a framework law with no detailed regulation. The general and rather vague formulation of (elderly) citizens’ rights to claim assistance is formulated as: ‘if their needs cannot be met in other ways’ (Chapter 4, Section 1). The Social Services Act (SFS 2001:453) does not, however, regulate how their care needs should be met, but the assistance offered should always be adapted to the individual’s situation/circumstances. A reasonable standard of living according to needs (skälig levnadsnivå) is intended without any further specification. These vague wordings have resulted in local interpretations of assistance and support by the elected politicians, which are often translated into written local guidelines for care managers to follow in the needs assessment. Thus, how care needs are assessed varies between the 290 Swedish municipalities, depending on aspects such as the political governance and budgetary level of the municipality (cf. Erlandsson 2018).

Generally, social workers differ from many other professions in that their clients within social services are often surrounded by several people such as family members who also are affected by the activities offered. This becomes especially clear in elderly care services, as it is very much about supporting the continuity of everyday life. According to a change in the Social Services Act from 2009, the social board of the municipality should offer support to facilitate for the family and relative carers in cases of long-term illness (SFS 2001:453, chapter 5, section 10). One such support is next-of-kin employment on monthly salary. There are other support from the National Social Insurance on temporary basis, but in this article we refer to a monthly salary for not time limited social support, and to people who often have no employment. This support has to be assessed by a care manager who has to follow legislation and the local guidelines in the municipality. For the assessment, the circle of carers around an elderly person, such as families or relatives, have a legally unclear position (Ulmanen 2013). The silence regarding family care and paid family care of elderly relatives, has in a political context been seen as a threat to women’s employment in the labour market. From a tradition in which a woman was expected to provide care voluntarily and without pay, there is now a shift towards greater governments interest in supporting family care. This interest would seem to assume increased financial support for family care in practice, but Ulmanen (2013) finds rather the opposite. Taken together, the legislations are contradictory, and there are gaps where care managers must find their own solutions.

A needs assessment starts with an application for assistance from the elderly person, and then the care manager assesses the person’s right to assistance. This often means a negotiation between the care manager and the applicant (cf. Blomberg 2004; Olaison and Cedersund 2006; Andersson 2007; Dunér 2007; Olaison 2009; Söderberg, Ståhl, and Emilsson 2015). In the needs assessment, the Swedish care manager operates from multiple and sometimes conflicting perspectives of care and services when individual needs are interpreted. In a simplified sense, ‘according to individual needs’ could just mean the actual needs assessment that takes place between the care manager and the elderly person at an individual meeting, although the assessment might rest on standards of available services and care in the municipality.

On the assessment level, the care managers also have to follow principles and legislation to promote equality regardless of gender, class, and cultural and ethnic background (Dir 2015:72; National Board of Health and Welfare 2015), of which the Discrimination Act (SFS 2008:567) constitutes important guiding legislation. Research shows, however, that to get help services the applicant also has to express their needs in a convincing manner (cf. Olaison 2009). Furthermore, this indicates that those who do not master the Swedish language or perhaps are unfamiliar with the system run the risk of being disadvantaged in the needs assessment process. Also, older migrant people use public elderly care to a lesser extent than those who are Swedish born (Forssell and Torres 2012). Research on care managers’ experiences of cross-cultural needs assessment meetings shows several challenges relating to communication and language barriers as well as different demands and expectations from older immigrants, which caused feelings of insecurity in needs assessment meetings (Forssell, Torres, and Olaison 2015). The inclusion criteria for the target group then becomes unclear. Care managers with limited time for the assessment showed more insecurity and difficulties in reconciling the client’s needs with the local guidelines (Olaison, Torres, and Forssell 2018).

Within elderly care services other and parallel legislation will further complicate our efforts in defining the need for care and assistance individually. Legislation takes the help from family members for granted without any reflection on their autonomy, and how cultural circumstances may affect the definition of individual needs is not considered. The lack of clarity becomes evident in public elderly care, as one question is whether the needs could be met in any other way than by assistance from public care services. This includes that fact that the legislation emphasizes individual autonomy and the person’s independent position in the family and in society.

The social norm of independency

As in most western societies and not least in Sweden, human independence and autonomy is valued highly. This striving for autonomy is fundamental in every sphere of life and also within social elderly care. Historically, old age as dependency was viewed as a rather respected status, but in modern times it has shifted towards the ideal of independence and autonomy through the course of one’s life (Daatland and Biggs 2007). One way of maintaining independence through the life course can be seen in the fact that elderly people in Scandinavia have preferred help from public services rather than becoming dependent on family members (Daatland 1990).

Today, the dominant ideology of ageing in place in Sweden includes the value of independence, which influences the encounter with the care manager (Söderberg, Ståhl, and Emilsson 2013). Even in the Swedish Social Services Act, the active, independent, elderly citizen is emphasized; the rights to assistance should be organized to maximize the individual’s possibilities leading a life of independence (SFS 2001:453, Chapter 4, Section 1; for an overview of the social policy development, see Ulmanen 2013).

The societal norm of independence complicates the relationship between the care manager and the person in need of assistance. If you are expected to live independently, difficulties will occur as soon as you express a need for support. What might have been encouraging and have given elderly people the tools to fend for themselves leads in practice to stigmatizing processes (Söderberg, Ståhl, and Emilsson 2012). Older people may also develop strategies to hide their needs for assistance, as showing dependency becomes shameful. Family members also adapt to those strategies and this also influences their interaction with care managers (Söderberg, Ståhl, and Emilsson 2012). These strategies can be seen as being fuelled by the ideas of successful ageing, representing positive ageing and healthy lifestyles, and even improving or reversing disabling problems and dependency by individual volition (Katz and Calasanti 2015). What was once described by representatives of the care perspective as a genuine reciprocal relationship (Noddings 1984; Wærness 1984) where both the carer and the cared for accepted the asymmetric condition has now given way to a more balanced negotiating position where both parties have an interest in not emphasizing the state of dependency (Söderberg, Ståhl, and Emilsson 2015). The caregiver must convince the applicant of the benefit of receiving help because the right to privacy can mean the individual right to neglect help.

Taken together, the ideology of independence becomes problematic in relation to the needs assessment concerning how to define the target group. Who are the elderly people in need of care and assistance? Researchers who have discussed support from a care perspective or a service perspective have usually had people from the same cultural circle in mind. The needs of the ‘stranger’ might thus remain unknown (Noddings 1984, 47). Within this frame, the elderly migrant seeking assistance may hold important information when it comes to answering our questions about care needs and entitlements, because their care needs may be seen as unknown and outside the general standards of assistance. Research shows that limited social networks, language problems and isolation are problems among migrants that might be a hindrance for expressing their needs and thus prevent them from being given support when the needs are assessed (Johansson 2015).

Theoretical frame of reference – care versus services

We will analyse data on needs assessment from two theoretical perspectives, here called the care perspective and the service perspective (see Table 1). Both perspectives have inherent problems. The relation between the carer and the cared for has been discussed vigorously over the years as based on asymmetry and reciprocity in caring (Noddings 1984, 48 ff; Wærness 1984; Wᴂrness and Christensen 2017). One difference between the two perspectives concerns what the ideal relationship between the assistant and assisted should be on a scale between personal/intimate and impersonal/distanced. In the care perspective, the core component will be the unique and personal relationship between the assistant and the recipient. In the care perspective, other problems occur when help is formulated by rules. Personal dignity, important within the care perspective, can be violated when the care manager offers types of help other than what is preferred. The concept of asymmetry is in this perspective used to underline the fact that it is help to somebody that the recipient is not able to achieve by themselves due to the loss of some function(s). In order to make the meeting dignified this ‘advantage’ of the assistant must be balanced as a part of the caring relationship. The care perspective also includes being able to distinguish between what Wærness (1984) categorizes as ‘care’, which is about helping people who cannot undertake the tasks themselves, and ‘services’ that can also be given to people who are able to perform those tasks themselves. In the care perspective, some form of reciprocity must exist and impersonality must be avoided. Quality is defined by how rewarding the relationship could be for the assistant and the recipient (Brechin 1998). A caring relationship is by this definition personal (person-related).

Table 1. Perspectives of care and service: a comparison (Johansson 2016)

Perspective:	Care	Service
Original role models	Family/informal relations.	Professional relations.
Definitions	Assistance specially tailored according to individual needs.	Universally designed uniform service packages.
Guiding principles	Do good/avoid harm.	Autonomy.
Ideals	Dignified treatment with personal presence.	Entitlement to fair but impersonal standard help.
Relationships	Asymmetry between the assistant (independent) and the recipient (dependent).	The assistant and the customer are perceived as autonomous parties.
Moral aspects	Core issue.	Not a core issue.
Governance	Not regulated, unorganized one-caring.	Governed by rules and standards.
Identified risks	When lack of personal presence (reciprocity and recognition) it can be difficult to distinguish between the social norm and the individual’s immediate needs with a risk of impersonal and overprotecting solutions; Formal relationships are not theorized.	The idea of an autonomous customer becomes problematic when the power exercise in decision making is not problematized: Risk to neglect important individual needs not expressed in line with general standards.

In the alternative perspective, which we call the ‘service perspective’, the person receiving assistance may not want or need to build a relationship with their assistant. The assistant and the recipient, often referred to as the customer, are here defined as two independent parties. The medical ethicist Helga Kuhse (1997) is a good representative of the service perspective. Kuhse values respect for personal privacy highly and a service relationship is by this definition task-related and quality is measured by the outcome, for example in terms of customer satisfaction. The service perspective is easier to apply in a rule-governed needs assessment. In the service perspective, the voice of the independent customer is decisive for the help offered, something that can become a problem when the customer cannot express their needs. When the customer cannot express their needs, the dilemma between violation of personal integrity and neglect may arise. The care managers’ have to balance this dilemma in the needs assessments, being empathetic enough to identify the care needs without neglecting to respect the individual assistance that they are entitled to.

The formal organization, where rules and regulations are important parts, plays a third part in the needs assessment, in addition to the care manager and the applicant. Care has been presented in contradiction to rules and regulations. The genuine meeting is according to those theorists undermined by strivings for the polite and confidential interaction, and sometimes also by recognition of the importance of calculating time and energy savings. The care ethicist Nel Noddings (1984) argues that organizations can never act according to caring ethics. Assistance formulated by rules is excluded by definition. The care managers work within an organization, and accordingly follow the professional context.

Individual attributes, striving for independence as well as the cultural identity and family norms of those who apply for assistance are mostly unknown to the care manager at the time for the needs assessment. From the service perspective this is trouble-free. Needs, either higher or lower than accepted standards, are formulated by a presumed autonomous person, and the care manager for the assessment does not need any contextual knowledge of the customer. In the care perspective, personal as well as contextual knowledge of the recipient is necessary so as to individualize the assistance, and the care manager is expected also to search for latent needs that the recipient is not able to formulate in their present situation. We are interested in how this appears in the needs assessment.

In a reciprocal caring perspective, several interpretations might appear of what individual needs means goes beyond what is usual. Especially if the argument for assistance falls out of the ordinary. In Noddings (1984, 47), conceptions of the stranger, the stranger’s needs and requests risk remaining unknown and neglected. ‘The independent customer’ must thus be reconsidered in relation to individual family norms and personal experience of whom you can trust. And needs of assistance in performing tasks not included in the list of services will fall outside the negotiation.

Methods – analysis of interviews with care managers

The empirical material comes from a research project consisting of surveys and qualitative interviews with politicians, care managers, elderly people with home care services, care workers and their supervisors. The project’s data was collected between 2009 and 2011 in a large municipality in central Sweden (Andersson 2010, 2013a, 2013b; Andersson and Johansson 2010). The investigated municipality had implemented market principles according to the ‘Act on System of Choice in the Public Sector’ (SFS 2008:962). A new language was adopted by shifting from ‘care recipient’ to ‘customer’ and this is also the term we use in this article.

Our previous analysis of the interviews shows that the care managers’ views of elderly migrants were rather homogenous and stereotyped (Andersson 2010; Andersson and Johansson 2010). This made us interested in analysing the material in relation to the frame of care and services and how individual needs are interpreted within this context. For this article, all the projects’ ten qualitative interviews with care managers is used to illustrate arguments when relating to assessments made with migrant customers and their relatives. By doing this the strong thematic focus on diversity in the project could be explored further. The aim is to explore and interpret how the perspectives of care and services are illustrated by the managers’ reasoning in needs assessments when expressed needs should also interact with rules and regulations. The collection of data was made some years ago, but the issues discussed in the data material are still highly relevant for our theoretical purpose (SOU 2017:21 p 586 ff). Furthermore, there are lack of knowledge on issues of cultural and ethnic diversity within gerontological social work (cf. Forssell and Torres 2012).

The ten female care managers had varying lengths of work experience as care managers, but all of them had at least five years of work experience within elderly care, as care manager, care unit managers or other position within social care. Their academic background varied from a 3½-year social work education to social care education (a 3-year non-academic training which was more common before year 2000). The four younger managers were trained social workers, and the others were trained in social care. However, there were no differences in their argumentation in relation to educational background.

The qualitative interviews lasted between 45 minutes and 90 minutes in length, and the interview guide was focusing on their experiences within elderly care as well as meetings and dilemmas in relation to ethnicity and gender. Other themes concerned elderly people’s rights and equality and future perspective of care. The interviews were transcribed verbatim so as not to leave out important arguments (Poland 1999). All the care managers gave their consent to participation in the interviews and were all ethically informed of the project (Kvale and Brinkmann 2009).

Each interview was read through comprehensively in order to capture the sense of the care manager’s reasoning. The interview sections that included their arguments and discussions of the migrant customer were then identified, coded and analysed regarding topics and the argument strategy that became salient. Furthermore, the analysis focused on the theoretical perspectives of support from a care or a service orientation. The analysis resulted in three overarching themes presented below.

Findings

In the following sections we present our analysis of the care managers’ arguments: i) in relation to the migrant customers and their relatives, and ii) how they commonly compared their arguments with Swedish-born elderly, and finally iii) how these arguments can be seen as a confusion of the perspective of care and services.

The care managers’ arguments regarding the migrant customers and their relatives

A recurring topic among the care managers was that older people with migrant backgrounds sought to replace the care workers with relatives employed to perform the care, as a so-called next-of-kin employment. Compared with other forms of support for next-of-kin this is desirable due to the salary per hour corresponding to that of an auxiliary nurse or care assistant from the municipality. Given that the salary of the care assistant is low and that the next-of-kin-employed do not usually work full-time, it can be difficult to make a living out of such an arrangement in the short term. In addition, the salary is low, which will reduce the future pension. In other words, the long-term effects are poor. According to the care managers, the municipality investigated had established local guidelines against next-of-kin employment, even though in some cases they approved of this. These arguments were raised above all concerning elderly people with an immigrant background and their families. Compared with native-born Swedes, the elderly immigrants and their relatives were by the care managers regarded as misusers of the welfare system: ‘they exploit the system’ and ‘they do not want to have home care services’, and ‘they see themselves as older and sicker than they are’. Elderly Swedish people and their relatives made no similar statements about misuse of the system, according to the care managers. Making such stereotypical statements about migrant customers shows that, by arguing from the perspective of service-orientation and ethically focusing on justice rather than seeing the individual’s needs and considering next-of-kin employment is as far from a care perspective as one can get. In fact, the general consensus among the care managers interviewed was that elderly people’s desire to have their relatives employed had to be resisted at all costs (cf. Andersson 2010; Andersson and Johansson 2010). There were various arguments against this:

Firstly, the elderly become quite dependent on their families. It may well be difficult for us to see that the care provided is not the best … That they do not have the same knowledge of and training in care work at all (care manager, C0019).

Here the manager’s major argument is related to becoming dependent on one’s family. This quote reveals that the norm of independency is clearly visible (Daatland and Biggs 2007). The quality of the care is also brought into the argument by emphasizing individual needs of the elderly by questioning the relatives’ ability to provide care. This also reveals that the care managers see the relatives as having hidden motives for getting employed, not because they want the best for their older relatives.

This rather deviant view of the migrant customer needs to be contextualized and understood in comparison with Swedish-born customers, fostered into the ideology of successful ageing striving for autonomy and independence in later life (cf. Daatland and Biggs 2007; Katz and Calasanti 2015). As we have already noted, Swedes prefer assistance from public services (Daatland 1990). By putting the migrant background in focus, the problem of the service perspective becomes clear. The services one can offer are those on the list defined beforehand as local guidelines. The service perspective goes together with ideals of autonomy and independence as well as ideals of gender equality.

In some cases, managers argued that this was a gender trap for women carers, who would run the risk of becoming trapped in the private sphere instead of entering the labour market. By the use of guiding principles, the managers’ view of the relatives as ‘misusers’, next-of-kin employment was seen as a way of supporting them when they could not find work in the regular labour market:

[T]hey only talk about how many hours; this time is not enough, ‘I cannot manage on less than half-time work’. It is not our duty to discuss how they will cope on their pay; it is their parents’ needs (care manager, C0013).

‘Family members believe that you can stay in Sweden and care for your parents and get paid for it forever – that is wrong’ (care manager, 0018). Here the relatives are seen as a very calculating group, which view needs to be argued against by focusing on the societal expense and costs in relation to next-of-kin employment, not on individual needs. The managers also felt that compared to elderly Swedish people many of the elderly people with migrant backgrounds and their families had different requirements.

Furthermore, they know the law really well, he says, they tell you “I have a right to this”. I have even received threats, “if you do not grant my mother this, I will report it as discrimination” (care manager, 0018).

What the above quotes reveals is that elderly people with a migrant background, represented by their relatives, put forward individualized needs, something that the care managers interpret in a generalized way, although they are fully aware that there are cultural variations; by arguing that ultimately everyone wants a next-of-kin employment.

Arguments of migrant customers’ individual needs in comparison with Swedes

When the care managers relate to elderly people with migrant backgrounds, they constantly refer to them as a homogeneous group that claims the same needs and makes the same demands. The tendency to categorize them and assign them certain characteristics was stronger than the tendency to draw on individual variation. The care managers compared elderly people with migrant backgrounds to Swedish-born elderly people, who, according to the care managers, never required special efforts. On the question of how they perceived differences between men and women regarding needs and demands, the women were mostly into managing by themselves, while the elderly men were more grateful to get some help. ‘If you look at couples, they sometimes goes too far without help, and now I am referring to the Swedes’ (care manager, D0014). She continues to argue for the diverse approaches to help needs, while the Swedes want to manage on their own.

Looking at the other nationalities, they want more help than the need requires. And when I say this, I do not want to generalize; there are of course differences here, too, but you can see a slight tendency that elderly people with other nationalities build their need for assistance in relation to the somatic diseases and contact with doctors. (care manager, D0014)

If we take a step back and instead interpret this statement in relation to the Swedish-born, whom the managers obviously define as the customer, the Swedish-born can be seen as even more incongruous, as they seem to be typically adaptive to the norm of independence; not even illnesses and diseases should limit independence (cf. Katz and Calasanti 2015). The care managers also argued that ageing comes much sooner among immigrants, perhaps about ten to fifteen years earlier, when they expect assistance compared to elderly Swedes. ‘They think they have the right to step back and be pampered. And these are the cultural issues that they bring with them from their home country, so to speak’ (care manager, D0016).

A final illustration of the care managers’ arguments shows that they do not stick to one single argument of individual needs when referring to the elderly migrant customers, but rather interpret their and their relatives’ wishes as a shift of responsibility as regards what is considered to be a societal or an individual responsibility.

Swedish families are accustomed to go with their parents to the hospital without being paid … [He] thought it was shameful (his son) ‘that my father had to go out alone and walk’, and he fell twice because his sister did not have enough time allocated to her … and we tried to talk, but where is his own responsibility? He knows that he is a bit unsteady at times, so must he go out? (care manager, C0013).

The opening phrase of the quote reveal that Swedes have been socialized into the view of ‘voluntariness’, with the helping family members or rather ‘the invisible working daughters’ (Ulmanen 2013), supporting their family members voluntarily. Here, the care manager by comparing with Swedes strongly emphasizes where the line between individual and societal responsibility lies. In this sense, individualization strictly means taking individual responsibility for one’s well-being, in line with the ideology of successful ageing (Katz and Calasanti 2015). She further argues that this is how Swedish society works: ‘it is not society’s responsibility if I go out and fall over’, which further illustrate the societal norm of autonomy and independence.

Care managers’ arguments in relation to immigrants: a confusion of perspectives of care and services

The care managers said that they almost never denied anyone home care services, but in the case of those elderly people who claimed special needs (mostly immigrants), mainly as next-of-kin employment, this was never granted. According to the care managers, the relatives often argued against home care services, pointing to the intimate situation it would mean to receive intimate care from a stranger. At the same time, the care managers argued in defence of the relatives, who they identified as relatives with a migrant background. ‘Of course, you can feel sorry for the daughters and the grandchildren who have to take care of their relatives’ (care manager, C0013). In many cases, the care managers said that many of the relatives were very young people, perhaps 18 to 20 years of age, who had to care for their grandparents or even their own parents: ‘according to their cultural background it is their duty to care for their relatives’ (care manager, D0016), and the manager’s main argument was that it makes it difficult for them to live their own lives and receive an education: ‘they are bound up seven days a week’.

Perhaps these arguments can be seen as representing a caring attitude towards the relatives who are seen as being tied by cultural background and exploited by the elderly person. Simultaneously, the latter manager in the interview, also referred to relatives who systematize next-of-kin employment by circulating the care work among several relatives, although the salary is given to the relative who applied for the employment. This was in her view not the right way to handle next-of-kin employment.

In contrast to this, there were also other ways of relating to next-of-kin employment by emphasizing individual choice:

There should be some opportunity for the family to make their own choice and when they have need of assistance of around 160 hours a month, then it is not so expensive. The relative might be unemployed anyway. If you see it like that, they would get money from the government anyway through unemployment benefits. I do not find it wrong. I think it is a good alternative (care manager, C0023).

By arguing for individual choice, this may be seen as a sign of focusing on the care perspective by emphasizing an individual solution, as in the above example. Here, the relative is taken into consideration when arguing in favour of next-of-kin employment. This could be seen as accounting for a socialization into a system were the family is defined as the smallest unit and not the individual (cf. Sand 2017). However, it is not very convincing that the care manager has the individual needs of the relative in focus. It rather seems as if it is society’s interest and cost that is being argued for. Contrary to this example, another care manager argues in favour of always trying to meet the individual’s needs:

Personally, I believe that we should accommodate all their needs and wishes as far as possible. But then again, the catch is, of course, the political guidelines in the municipality that we cannot ignore. [W]hen it comes to services like special cultural cooking, such as Persian, when it takes eight hours to cook a meal, those needs cannot be met. And they think that the staff are hired by the family and use them as waitresses (care manager, D0014).

Here, the manager tries to show a fair view of the migrant customer and their relatives, but once again the service perspective with general standards and guidelines comes through as more dominant than the individual’s needs in favour for the care perspective. How can we interpret this turn towards guidelines? By giving an extreme example of cultural cooking that takes eight hours, these and other individual needs can be dismissed as absurd.

Perhaps there is no possible way for the care managers to act in a care-oriented way. At least not when it comes to the migrant customer and their relatives, even though there seemed to be arguments in favour of care orientation when they took the relatives’ possible grievances into account. It seems as if, as long as the needs assessment departs from standard guidelines, there is no way of finding arguments relating to the care perspective.

Discussion

Individual needs meet general standards and local guidelines

Universalism, the cornerstone of Swedish social policy, means that basic social benefits and services are designed for all citizens, and in practice a large majority of citizens use these benefits and services. The benefits and services are uniform rather than tailored to specific groups (Sainsbury 1996). When the stratum of elderly people has become more diverse – and a wider spectrum of needs have to be met – the universalism will become problematic. The conceptual meaning of individual needs tends to be biased when confronted with diverse cultural codes. The target group seems to be the Swedish-born person socialized into Swedish welfare norms. Researchers (Jörgensen and Thomsen 2016; Crepaz and Damron 2009) have identified what they call welfare chauvinism, mechanisms legitimized through eligibility criteria such as contribution and is often used with reference to the need to protect the welfare system for all. In our material, we have found that the social norm of independency, in parallel with the welfare norm, has often overshadowed the foreign-born individual’s requests. We found that elderly people born outside Sweden could induce unknown or not articulated aspects of Swedish universal welfare.

Regarded superficially, the care managers’ arguments seem to be guided by the service perspective rather than by the care perspective. Our analysis shows that the service perspective, with relief efforts that are standardized for Swedes, is poorly suited to people born outside Sweden and socialized into other expectations on family and society. Neither a relationship to nor trust in public arrangements could be expected from those who are socialized into other family traditions and have no experience of the state as a helper. A guiding theory was missing and care managers were forced to come up with their own arguments and analysis concerning the right to employment as family carers. Here, neither general standards nor local guidelines could guide the care managers in the needs assessment.

The care managers mixed the two perspectives by using the local service directed guidelines to prohibit next-of-kin employment and then suggesting help according to the service perspective for the applicant. Simultaneously they were suggesting care services with long-term arguments that can be derived from the care perspective when they tell the prospective helpers, the women/daughters to lead their own lives and also to review their future possibilities of living independently. This responsibility sometimes leads care managers to overprotective decisions in contradiction to the preferences of the applicant and/or other people in the caring circle. The managers concern about the future of the recipient’s family members could be their attempt to implement gender equality (cf. Ulmanen 2013) and goes in line with the Nordic defamilisation project (Björnberg 2016), that aims to reduce women’s dependency within the family. According to the care perspective, no one needs to feel guilty to care and the recipient should not have to be perceived as a burden. The idea that everyone embraced the Swedish view of the family may be in conflict with the same perspective.

When a wider spectrum of needs has to be met within an organization with multi-layered objectives, the high-quality care services according to need and not the ability to pay will become problematic. In fact, according to the care perspective, a less dignified way of resolving the asymmetric relationship between the care manager and the applicant was seen, which then remains unproblematized, such as in cases when the care manager offers types of help other than what is preferred. Our analysis leads to the question of whether the assessment contains unintended and unjustified power exercise in the decision making.

In our analysis of the material, we have found that the problem occurs when the customer cannot express their needs within the existing normative framework. When the needs assessment was based on general standards with support in local guidelines rather than individual needs, the care managers perceived the migrant customers to be a rather calculating group. Thus, the migrant customers were stereotyped and seen as misusers of the Swedish welfare system and claiming special support, such as next-of-kin employment. Instead of being open to a wider spectrum of individual assistance to meet a more diverse composition of the population in their late part of life, the organizational structures represented by the care managers definitely helped to keep alive the idea of the homogeneous population structure of the elderly. This is problematic in relation to the service perspective where the care manager should not question the requests from the customer/applicant. Assuming the priorities of another person also directs our theoretical interest to the asymmetrical relationship between them. Here, theories of care and justice could after necessary adaptation to actual realties, be useful to guide needs assessments and to develop professional knowledge.

Concluding remarks

The uncertainty of how to meet and treat migrants stands out very clearly in our material about needs assessment in Swedish elderly care. Neither what we call the care perspective nor the service perspective in their present form (see Table 1) was found to provide the care managers with helpful guidance. The decisions on what is best for the individual can permit that needs are translated into ‘the best welfare outcome’ in the name of care, and important needs can in other cases and from the service perspective become neglected by employing fair rules. The balance between assessments with the risk of becoming too personal and caring and making decisions according to what seems best, or forcing the individual to adjust to services that do not fit their needs can become a real challenge. Kuhse’s (1997) argument that, in the meeting, the patient’s interest in assistance does not need to include moral aspects of doing good must be rejected (see also Pullman 1999). Our analysis shows that moral aspects are always there, but the awareness about how to handle them varies. The variation in care managers’ argumentation about how immigrants’ needs can be assessed demonstrates the desirability of comprehensive professional development work on how to act when cultural identity and social norms can shape the needs differently (cf. Forssell and Torres 2012).

Welfare as a structure that redistributes resources as fairly as possible, can from a care perspective be seen as being structured around frameworks that can lead to impersonal assessments or even to exclusions. Care managers need to reconsider their use of professional discretion if the needs assessment is to result in a reasonable living standard also for people not socialized into what might be expected in Sweden as the standard norms of the majority. The tension between universal standard norms, local guidelines and individual needs has to be further discussed in relation to professional tools and knowledge. Perhaps the ideal of universalism must be adjusted on the basis of the new conditions, so that the needs of minorities are more clearly included. Thus, there is a need to develop care managers’ own professional ethics independently of national standards and local guidelines.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

Vetenskapsrådet [2007-9620-53427-13].

Notes

1. In January 2019, 1 960 000 (19%) of the Swedish population were foreign-born (SCB statistics).