Swedish politicians’ perspective on civil servants’ collaboration, financial resources, and contextual knowledge in eldercare: A qualitative study

ABSTRACT

Swedish municipalities are the main employer for the staff in eldercare, a sector where sick leave rates are high and work environment deficiencies are reported. This qualitative grounded theory study aimed to explore how the politicians accountable for eldercare in Sweden perceived their collaboration with civil servants, their understanding of the financing of eldercare, and views regarding their own existing knowledge of their assignment within eldercare. The study comprised interviews with 41 politicians from municipalities across Sweden. Three categories emerged: (1) holding a position of power, (2) lacking finance of eldercare, and (3) wanting to increase their knowledge base. The strongest finding showed that the civil servants can be viewed as holding a position of power in relation to the politicians. Politicians relied on the civil servants to gather and present information regarding eldercare so they could make accurate decisions; at the same time, they were aware that information might be incomplete. Most of the accountable politicians believe that the financial resources allocated for eldercare were insufficient. The politicians also believed they needed to increase their own knowledge base and expressed a desire to learn more about eldercare and the employees’ work environment. Further studies should explore the role of the first line managers of staff in the eldercare organization and their work environment, and how they perceived their collaboration with civil servants and the accountable politicians.

KEYWORDS:

• Civil servants
• eldercare
• human service organizations
• municipality politics
• work environment

Introduction

The municipalities of Sweden are the main employer in the eldercare sector, with about 275 000 employees,239 600 of whom are women (Arbetsmiljöverket 2019). While these employees aim to provide good care to the elderly, stress is common and can affect care quality and the support provided (Daly and Szebehely 2012; Nilsson and Nilsson 2017; Åhlin, Ericson‐Lidman, and Strandberg 2021). Lack of time to deliver desired care can also negatively affect employee health (Daly and Szebehely 2012). Stress of conscience is observed when staff (Åhlin, Ericson‐Lidman, and Strandberg 2021) cannot provide the desired care for their eldercare recipients (Alkrisat and Alatrash 2016; Glasberg et al. 2006). Additionally, high emotional pressure is common among nurses in eldercare, with psychological exhaustion felt during their spare time (Josefsson 2012).

Sick leave due to mental health problems is prevalent among staff working in eldercare (Försäkringskassan (Social Insurance Agency) 2020; SKR 2019; SKL 2017). A literature review shows burnout is a significant problem (Harrad and Sulla 2018). Research on nursing assistants and elderly residents shows that a healthier perceived psychosocial work environment among staff can lead to higher satisfaction among the elderly receiving care (Lundgren et al. 2020). First line managers in eldercare find satisfaction in their work but perceive it to be complex and lack organizational support. Their jobs can reflect strained financial situations and the responsibility for many employees (Hagerman et al. 2019). This finding is consistent with other public sector managers who also experience a lack of organizational support; this in turn affects their willingness to stay in their role (Cregård and Corin 2019).

In Sweden, three laws regulate care of the elderly and the staff: The Health Care Act, the Social Services Act, and the Work Environment Act. The Health Care Act states that medical care should be provided to those in need (HSL (Hälso- och sjukvårdslagen) 2017).

The Social Service Act specifies that the elderly should be able to live a dignified life, have wellbeing, and that municipalities should work to ensure that older citizens can live independently, in safe conditions, with an active and meaningful existence in community with others. When needed, elderly should receive support and care either at home or in special housing (SFS 2001:453).

The municipalities in Sweden are required to provide special housing for elderly with that need and services for those needing help and support in their own home. The special housing, health care and support needed are provided based on an individual decision (SFS 2001:453). Special housing for the elderly in Sweden is provided on the basis of renting an individual apartment within a dedicated building.

The Work Environment Act specifies that employers are accountable for the physical and psychosocial work environment of their employees, and for eliminating or mitigating risks causing ill health due to the work environment (Arbetsmiljöverket 2019; Ahlberg 2018; Ericson 2019).

Democratically elected politicians govern Swedish health and eldercare at three levels: The Government (i.e. national), 21 regions (i.e. county council), and 290 municipalities (i.e. local level). The Government sets the overall agenda for healthcare (HSL, 2017), while the regions are responsible for delivering the healthcare (Kommunallagen, 2017), and municipalities are responsible for providing eldercare services along with other areas of responsibility.

Both the regions and the municipalities have decision-making power over how to govern health and social care (HSL, 2017). The municipality councils choose the boards, committees, and the areas of responsibility, and therefore board and committee structures can vary between municipalities (Kommunallagen, 2017; SKR 2021).

An important aspect of the political assignment is to set goals, priorities and quality standards for the delivery organizations and to ensure that staff have a good work environment, including good leadership (Arbetsmiljöverket 2019; SKR 2018). In Swedish municipalities, the accountable politicians represent the municipality as employers. Therefore, they have the overall responsibility for the work environment of staff in their area of accountability (SKR 2018). In the Swedish democratic system, politicians and civil servants work collaboratively; the civil servants’ primary duty is to implement political decisions (Christensen and Opstrup 2018; SKL 2012). Decision material for boards and committees is delivered by the civil service administration and must be factual, objective and politically impartial (Christensen and Opstrup 2018; SKL 2012). The heads of administration are responsible for ensuring that organization of work is conducted in accordance with the formulated goals and guidelines, and that budget frameworks are kept (SKL 2012).

Nevertheless, shortcomings in the collaboration have been observed where politicians perceive that civil servants may withhold information (Falkenström and Höglund 2019; Werntoft & Edberg, 2015). Furthermore, the collaboration between politicians and first-line managers in eldercare may be impacted by a lack of clear goals, structure, and fragmented organization (Carlson et al. 2014).

The current study was conducted among municipality politicians accountable for Swedish eldercare with the aims to explore politicians’:

• perceptions of their collaboration with civil servants

• understanding of eldercare financing

• views of their own knowledge regarding their assignments within eldercare.

Materials and Methods

Data collection took place between the autumn of 2020 and spring of 2021. The municipalities’ websites were used to identify potential participants. These politicians were contacted by email and provided with information regarding the study. If they agreed to participate, an invitation was sent over a digital platform (i.e. Zoom or Teams). Participants were given verbal information and an opportunity to ask questions before the interview began. Four interviews were partly or fully executed over the phone because of technical problems with the digital platform, however those interviews were consistent with the study results.

Interviews were digitally recorded and lasted 35–140 minutes. Demographic questions included age, academic background, and the participant’s political career. The author developed a semi-structured interview guide with open-ended questions related to the study aims (Appendix 1).

The interview questions started out general in character with the intention of keeping the researcher’s own assumptions and theories in the background. Questions that were more specific were included as the data collection proceeded to test emerging categories (Charmaz 2014). Two pilot interviews were performed to test the interview guide, and minor changes were made e.g. the order of the questions. The data from the pilot interviews are not part of the result in this article. The present article is part of a larger study of Swedish municipality politicians’ mental health literacy with a specific focus on eldercare.

Analysis

Following the process of executing grounded theory according to Charmaz (2014), four main steps were followed in collection and analysis of the data: initial sampling, theoretical sampling, focus coding, and theoretical coding. Initial sampling was used to select the first two politicians included in the study from each of the Social Democrats and the Moderates as two of the largest parties in Sweden on different parts of the political spectrum. Both interviews were promptly transcribed and analysed through line-by-line initial coding, e.g. actions were labelled in the text to understand the data, stay close to the transcribed data material and locate tentative theories. Theoretical sampling involves continuing the data collection through seeking to elaborate and explain the tentative categories and to create an analytical meaning. The data collection and analysis process were executed simultaneously in an interactive process. The theoretical sampling process includes participants gradually and allows the researcher to modify questions to explore a specific area that has developed during the analysis. This procedure of feeding the initial results back to the data collection by adding questions is an important part of grounded theory. Theoretical saturation is considered to be reached when no new theoretical insights can be developed in relation to the emerged categories. The next step was focus coding during which the most frequently occurring initial codes were used to categorize the data. The final stage was theoretical coding, during which the categories are given an analytical explanation. The author used memo writing during the entire analysis process to reflect on and validate the categories and codes. Negative cases were included (i.e. results that contrasted with the main findings). The analysis process was supported using Open Code software (v. 4.03).

Ethics

The present study was approved by the Swedish Ethical Review Authority (Dnr. 2020–05409). The research was conducted according to the Declaration of Helsinki ethical guidelines for research on humans (WHO, 2001). Participants provided written consent for participation and digital recording. Participants were guaranteed confidentiality and could end their participation at any time without providing a reason. All the data material, including the audio files, are stored within a secure area at Malmö University and accessed only by the researchers in the project, all of whom are employed at Malmö University. The transcribed interview materials were given a code. No names, locations, workplaces, or other identifying information that could potentially be linked to the participants were included in the transcribed material. All the interviews were executed by the author who has extensive experience with qualitative studies.

Participants

The study inclusion criteria included Swedish municipality politicians who were actively accountable for eldercare and had at least one year of accountability. Included politicians were elected to a board or an equivalent commitment with accountability for eldercare in their municipality. The politicians had to be 18 years or older and able to read and understand Swedish. One female participant from the Swedish democrat party was included who had only 6 months of accountability as she fulfilled central diversity criteria. Study characteristics are shown in Table 1.

Table 1. Characteristics of study participants (N = 41).

Characteristics		n	Female/Male
Sex			18/23
Mean age in years (range)	61.7 (27–79)
Education level in years	Upper secondary >16	8
	University >18	33
Professions n= 51^a	Nurse/Midwife	6/2
	Medical doctor/Physiotherapist	1/1
	Nursing assistant	3
	Psychologist/Social worker	1/2
	Engineer/Finance	3/6/
	Legal/Mathematician /Statistician	1/1/1
	Military/Police	1/1
	Head teacher/Teacher	3/1
	Special educator/Caseworker Social Insurance Agency	3/1
	Environmental inspector/Fire inspector	1/1
	Health science/Political science	1/1
	Agriculture/Humanities	1/1
High school education^b	Technology/Social science/Natural sciences	5/1/2
Political assignment with responsibility for eldercare	Board chair	13	3/10
	Board vice & deputy vice chair	6	5/1
	Board member	17	8/9
	Deputy board member	1	1/0
	Committee chair	1	0/1
	Committee vice chair	1	1/0
	Committee member	2	0/2
Mean years politically responsible for eldercare (range)		6.8 (0.6–25)
Mean years politically engaged (range)		17.3 (2–55)
Education in work environment (yes/no)		30/11
Own experience of working with elderly individuals (yes/no)		21/20

^aParticipants could state one or more professions or education.

^bProfession not specified.

Information about the study and a request to participate were sent by email to 456 municipality politicians from the 290 municipalities in Sweden who met the study inclusion criteria. Of contacted potential participants, 41 (9%) agreed to participate (Table 1). Diversity was sought regarding gender, political affiliation, and governing mode (i.e. in the majority or opposition, Table 2). Of those politicians included in the study, 37 of 41 were also members of another board with accountability for other social care areas (e.g. substance abuse treatment, young people in need of care and support). Four of the participants worked as full-time politicians and 37 worked part time. The politicians in this study referred to themselves as employers for the staff working within eldercare in their municipality. The term ‘civil servant’ refers to those in professional roles across eldercare organizations, for example the head of administration, the head of operations, and the head of social services. First line managers in eldercare are not included in the definition of civil servant. References to special housing in the results and discussion sections cover all forms of accommodation provided by the municipality for elderly individuals who obtain care and support from professional staff where the individual is renting accommodation from the municipality.

Table 2. The participants political party and governing mode N = 41.

Political party	n	Female/Male	Governing Mode	n
The Social Democrats Party	13	7/8	Majority/Minority Government Coalition/Opposition	3/2 6/2
The Moderates Party	8	3/5	Majority/Minority Government Coalition/Opposition	3/1 2/2
The Christian Democrats Party	3	2/1	Coalition	3
The Centre Party	4	0/4	Coalition /Opposition	2/2
The Liberal Party	3	2/1	Coalition/Opposition	1/2
The Swedish Democrats Party	3	2/1	Opposition	3
The Left Party	2	1/1	Opposition	2
The Green Party	3	3/0	Opposition	3
Local Independents Parties	2	1/1	Coalition	2

Quotations below provide the politicians’ governing mode as either in the majority or opposition. Politicians in the majority included both absolute majorities and governing in coalition with other political parties. While a broad range of political affiliations was sought during the data collection phase, the affiliation of the politicians was not a factor driving categories, neither was gender.

Results

Three categories related to the study aims emerged (Table 3): holding a position of power, lacking finance knowledge of eldercare, and wanting to increase their knowledge base. The strongest category was holding a position of power.

Table 3. Collaboration, resources, and contextual knowledge in the Swedish eldercare.

Holding a position of power	Receiving accurate information Collaboration with civil servants
Lacking finance of eldercare	Securing the right budget Cutting costs and enhancing efficiency
Wanting to increase their knowledge base	Understanding the importance of knowledge Improving knowledge of mental health and the work environment

Holding a position of power

Civil servants working in organizations delivering care for the elderly were considered essential to enabling politicians to carry out their obligations for eldercare. While most politicians viewed the collaboration positively, there were also concerns that the civil servants presented information in ways that were too complex or incomplete.

Receiving accurate information

The role of civil servants was described as providing politicians with information regarding eldercare. Politicians relied on civil servants for information necessary to make decisions regarding the budget and organizational changes. During board meetings, various professions of civil servants participate and present information about eldercare. The politicians stated that full-time civil servants could get more deeply involved compared to most politicians who worked part time. A female board member from the Green Party in opposition explained:

We expect the managers [civil servants] who do this full time to provide us with relevant material. There is a limit to how much you can ask [the civil servants]. It’s assumed that they do their job […]. Participant 25

Although the majority of the politicians believed that they were provided with accurate information, conflicting opinions were also stated. Concern was raised that the provided information could be difficult to understand, especially statistics presented in tables and diagrams. A few participants mentioned that this might be done deliberately to avoid questions. A male board member from the Swedish Democrat party in opposition gave an example of how he perceived the information given during board meetings:

[…] the consultant was appointed to make a presentation of what the civil servants had come up with that would be complicated enough for people [politicians] not to understand. Participant 22

Concern was expressed that politicians did not have enough knowledge themselves and therefore blindly trusted the civil servants and did not question the information provided. A female board vice chair from the Left Party in opposition expanded on her experiences and the importance of politicians having their own knowledge:

[…] they [civil servants] play a lot with numbers; they talk about the median and mean. Now it’s the case that I’m an incurable scientist who asks for strange things when they try to present bars, pie charts, percentages, and everything possible—when they hide things. But it does not work with me, no, no! But there are many politicians who can’t add one and one and get to two, sadly enough. For statistics, you can know how to do a lot with [numbers]. Participant 31

Another concern was raised that civil servants could avoid answering questions. One male board member in opposition from the Liberal party described his experience of questioning civil servants’ information regarding persistent budget deficits. He explained:

We ask questions. It’s not just me, but several, especially the opposition, so why is it like this again [a budget deficit]? [The civil servant answers] ‘It’s a deficit, but it is still less than it was before. It´s very difficult to get any more information if you don’t go directly to the first line managers. But if you do that, you usually get told off [by the civil servants]. Participant 33

Collaboration with civil servants

Most politicians viewed the collaboration with the civil servants as good, and a few mentioned that they visit special housing together to show staff they work as a team. Others were more concerned about the collaboration with civil servants and thought that provided information was occasionally or regularly filtered to demonstrate a more positive depiction than was the reality of eldercare. Politicians who did not fully trust the civil servants developed their own strategies for gathering information through talking directly to staff engaged in eldercare or asking the civil servants more probing questions. In some municipalities, talking directly to staff was considered to be violating the correct procedure since talking to staff was thought to be the civil servants’ role. A male board member from the Liberal party in opposition elaborated on his strategies to gather unfiltered information:

Sometimes I get the feeling that we politicians do not always find out the whole truth. There is a filter. That is why it is so extremely important to ask questions in the right way. Because if you’re clever, like a criminal lawyer, if you ask the questions in the right way, you can get through to the truth. Participant 32

Views varied on the importance of politicians having direct collaboration with the first line managers. Even though many visited special housing and talked to the managers and other staff, collaborations were more common with middle managers or the most senior level administrators. A few politicians raised concerns that even though the civil servants should be politically impartial, this was not always the case. As a male board member from the Liberal party in opposition explained:

It may be someone who thinks something on the floor, so to speak, but it never really comes out, because it is very filtered from managers and political organizations and in this city. […] how the organisation should work is very tightly controlled by the majority [party], and I think probably there is a tendency not to say anything. I think it’s a bit of a culture of silence unfortunately. Participant 33

Lacking finance of eldercare

This category represented how politicians perceived the budget for eldercare and their obligation to stay within the budget. The overall opinion was that the budget was insufficient and this profoundly affected care of the elderly. Eldercare was the area of the municipality’s responsibility where most cost cuts were made. However, some politicians did not think they were cutting costs but expressed this as working more efficiently.

Securing the right budget

The budget for eldercare was a topic that frequently came up during the interviews. This was an area where the politicians had extensive opinions. Politicians were clear on their fiscal responsibility regarding the health care budget, and they endeavoured to secure sufficient resources through negotiations and discussions with political colleagues and civil servants. Some politicians thought the budget was adequate and that they had sufficient financial resources for eldercare. But the majority thought the budget was insufficient to cover the costs of eldercare. The politicians extensively discussed this perception of a deficient budget. One female board vice chair from the Moderate party in opposition said:

I can say this, as long as I have been on the board, we have never had the right budget. I don’t believe anyone thinks this regardless of whether you are in the majority or in opposition. The budget that we have in the whole municipality should provide for everything, so then you get upset if someone spends 500,000 SEK on a bike rack that is needed for something else […]. Participant 9

Politicians expressed the need to deliver a sufficient budget to cover the obligations of the Social Services Act. With that said, not everyone thought the law was written clearly or provided the best care for the elderly. A female board chair from the Moderate party in majority explained:

[…] we have a problem because we have no legislation that provides any legal support for it [care of the elderly] to be a certain way. Participant 37

A male board vice chair from the Social Democrats in majority explained this further and asked

The question is, rather, is the Social Services Act written so that the elderly should have it as good as possible? If the law raises the goal, we will employ more staff […]. Participant 2

Eldercare was described as receiving a large part of the total budget in comparison to other areas in the municipalities, sometimes even the largest part. When the budget was adopted, the majority explained that the calculations were based on the budget from the previous year, the tax forecast, and the central Government subsidy. It was common to compare budgets of similar municipalities to benchmark spending on eldercare. Some politicians in municipalities in northern Sweden explained that tax income had decreased as younger people moved away and the elderly population increased. This meant that they had to provide care for more elderly with a smaller budget.

Cutting costs and enhancing efficiency

Most of the politicians had implemented cost-cutting measures in eldercare to stay within the budget. A broad variety of methods were described, including reducing the number of permanent staff, decreasing hours for people who had carers at home, and using more temporary workers. However, not everything was regarded as reducing costs. For example, increasing the rent for accommodation at a special housing, charging for support equipment, or increasing food prices could contribute to reducing the burden on the budget. Reducing activities delivered in special housing by allowing charities such as the Red Cross or church groups to carry out activities was another way of saving money. A female committee member from the Moderate party in majority explained her experiences of cost reductions:

Oh my God, there are so many [cost cutting areas]! The only area where we have cut costs in recent years is within eldercare and it has mainly been on staff. Participant 37

The perception of either not knowing or struggling to know where to cut costs was raised because the budget for eldercare had been continuously reduced over many years. A few of the politicians stated that budget reductions stressed them, and some had trouble sleeping because they felt they were unable to provide good care for the elderly. A money-saving strategy was to encourage elderly people to remain in their own home for as long as possible, supported by carers, as this was less expensive than having them in special housing. Cost reductions were often unpopular among staff and the public. As one male board vice chair in majority from the Moderate party described about cutting costs in eldercare:

Absolutely, that’s when you end up in the newspaper […]. Participant 34

There were also contrary opinions about whether the budget was sufficient, or the care delivery organization needed to be more efficient. One way of improving efficiency was to instal monitoring safety cameras in the home so that the night staff did not have to make unnecessary visits.

Split shifts, i.e. working in two separate four-hour blocks, were rarely mentioned as a way to reduce costs even though it was clear that split shifts supported this objective. Most of the politicians did not support this work pattern and tried to eliminate them. The justification for split shifts was the need for more staff to cover tasks in the morning and evening. Some of the politicians said that without split shifts, staff would have to work more weekends. A female board vice chair from the Moderate party in opposition expressed this opinion on split shifts:

It’s not good, and I have tried to point this out. Split shifts would never happen in the technical administration or in other administrations; we are alone in this [eldercare]. Participant 40

Only a few of the politicians mentioned undertaking a risk assessment to view the consequences of changes prior to cost cutting decisions. In a rare example, a board vice chair from the Left party in opposition explained how civil servants in her municipality did their risk analysis and presented it to her board:

Then we have a large Excel sheet with probably 15 different columns where they have done [the civil servants] risk analysis. So, if we remove this, can something happen [in the eldercare]? If nothing can happen, then we remove it. Participant 31

Wanting to increase their knowledge base

This category concerned politicians’ perception of the knowledge they required to be able to fulfil their responsibility for eldercare. The category included areas where more knowledge was needed. Most thought they required more knowledge and believed that knowledge among the board or committee members was too low in relation to their responsibility.

Understanding the importance of knowledge

Most of the politicians were clear that they did not have enough knowledge of the work environment or mental health problems among staff working in eldercare. A few politicians stated that participating in this study made them aware of issues regarding the work environment that they had not previously considered. Some said that they would now ask the civil servants more detailed questions. An area where lack of knowledge was particularly high was understanding why staff were on sick leave (e.g. due to mental health problems or physical illnesses). A few politicians thought they had enough knowledge because of their political and/or clinical background but thought that other board or committee members lacked sufficient knowledge. When politicians joined a board or committee with responsibility for eldercare, no specific knowledge of eldercare was required from the municipality when becoming responsible of eldercare as a politician. Nevertheless, it was viewed as important to learn about the field, although the level of knowledge required was not consistently articulated. Concerns were raised that politicians who lacked knowledge of eldercare did not actively participate in board discussions and did not adequately question the information provided by the civil servants. A chair from the Social Democrat party expressed his thoughts about the lack of knowledge among the board members:

Those who have been with the board for a long time speak; the others are silent and just vote with their party. They don’t know what they have actually voted for, or the consequences of [the vote]. The knowledge should be much greater; it’s too easy to end up on the board without really knowing what responsibilities one has. Participant 27

Concerns were raised that some politicians did not fully understand their assignment and one’s responsibilities for eldercare. A male board chair from the Social Democrate party stated:

[…] it is a huge area [eldercare] and there are many laws. And at the same time, you are legally and financially personally responsible and you can’t say you didn’t know, it’s one’s duty to find out […]. We are responsible for the work environment, so there is definitely a need for more education. Participant 7.

A few of the politicians had an opposing view. They thought they possessed enough knowledge for the assignment and that it was important to trust that civil servants provided them with accurate information. This was highlighted by a male board chair from the Christian Democrat party:

[…] politicians should not know too much of the area [eldercare] because why, otherwise, do we have civil servants? Participant 17

Improving knowledge of mental health and the work environment

This sub-category concerned specific areas where politicians expressed a desire to enhance their knowledge regarding eldercare, including the employees’ work environment, mental health problems linked to work in eldercare, and how to promote good health when working within eldercare. Some politicians mentioned that they were offered training at the beginning of the mandate period with general information regarding the duties and responsibilities of being on a board or a committee. Some said they were informed about the Municipality Law and the Social Service Act, while others explained they had to find that information for themselves. Few mentioned that they were given training about the Work Environment Act and their responsibilities as employers for eldercare staff. Visiting special housing and home care teams and talking to staff were regarded as good ways of gaining practical knowledge.

Opinions were divided on whether politicians should have direct clinical experience from working in a special housing or home care. Some believed it was essential, while others specified that one should not have too detailed knowledge of the work, as there was a risk of getting too involved in the operations of eldercare and that is not the politician’s role. As part of their political job, politicians were allowed to work-shadow, but few took the opportunity. Some thought there was no need to have such detailed knowledge of the clinical work, or that it was inappropriate to shadow because of privacy of the elderly. Others thought it was an ideal way to learn. A male board member from the Left party in opposition stated:

The best way to learn is practical experience. Imagine if we [politicians] had time to work in eldercare for a whole summer. Imagine what we would learn then. Participant 30

A few politicians believed they should not work shadow due to privacy of the elderly. A male board chair from the Centre party in majority explained:

[…] it’s also a question of ethics and morals. Should I go into someone’s home who has home care? That would also be wrong. So, we have chosen not to be involved [work shadow]as others [municipalities] may do. We think it would be wrong to go and look at people like they are in cages […] Participant 15

Concerns were raised that some politicians did not understand the roles of the professions working within eldercare or the work duties of different professions. The knowledge was specifically lacking concerning rehabilitation staff, i.e. the professions of physiotherapy and occupational therapy. A Left party board member in opposition stated her opinion and said how important she thought it was to understand the professional roles:

If I make decisions and it affects them [the staff], then I have to know what the hell they are doing [work duties]. It was up for discussion to remove them [rehabilitation staff] totally. Participant 31

Specific areas where the politicians expressed a need for knowledge were the Work Environment Act, mental health problems in relation to eldercare, and understanding the different professions’ roles in eldercare. A male board member from the Centre party in oppposition elaborated on the prospect of various professions presenting their responsibilities to the board:

Besides me, many of the politicians are over 70 years old and none has worked in eldercare. So that kind of knowledge would be worth its weight in gold. Participant 4.

Overall the opinion was that more knowledge among the politicians on boards and committees would lead to better quality decisions regarding eldercare.

Discussion

This qualitative grounded theory study aimed to explore how politicians accountable for Swedish eldercare perceived their collaboration with civil servants, understanding of the financing of the eldercare, and the politicians’ views of their own existing knowledge regarding their assignment within eldercare. Three categories emerged: holding a position of power, lacking finance of eldercare, and wanting to increase their knowledge base. The strongest category was that the civil servants were viewed as holding a position of power in relation to the politicians arising from their professional knowledge. The politicians relied on the civil servants to gather and present necessary information so they could make well-founded decisions regarding, for example, the financing of eldercare. At the same time, there were concerns that civil servants could provide politicians with filtered information or overly complicated presentations that the politicians might not fully understand. This is consistent with previous research showing that politicians may feel they are not provided with adequate information from the civil servant administration (Falkenström and Höglund 2019; Werntoft & Edberg, 2015).

The present study shows that politicians want to increase their knowledge base but can be limited by their available time since the majority also had other jobs and areas of responsibilities that needed their attention. This knowledge deficit and the limited time spent on this assignment could result in a knowledge imbalance between the civil servants and politicians, and the civil servants hold the power that can be exercised through information selection and presentation. That some politicians believed that information provided was not adequate is undeniably concerning since a core aspect of the civil servants’ role is to provide politicians with necessary and accurate information so that they can make informed decisions (SKL 2012).

One of the main duties of the municipality politicians is setting the budget for their accountable area (Kommunallagen, 2017). The politicians in this study expressed concern regarding the financial situation of eldercare. They were specifically concerned that the budget was insufficient to cover the requirements for eldercare. The politicians also had extensive experience of cost-cutting decisions to stay within budget while at the same time having limited knowledge of the consequences for staff. However, knowledge of high sickness absence rates among staff in eldercare should not be surprising (Försäkringskassan, 2020; Porter and Muhonen 2021). Research on representatives of health care management, including politicians, has shown a pressure to prioritize cost effectiveness over the ethical principle of caring for people in need (Höglund and Falkenström 2018). An employee’s workplace is a fundamental factor impacting their mental health including both the physical and psychosocial work environment (Westerberg and Nordin 2021). Employees who experience mentally healthy workplaces (OECD 2012) are more productive and take less sick leave (Harvey et al. 2014). Staff are the primary asset in providing care and support to the elderly and quality is linked to the team climate in nursing homes (Backhaus et al. 2017). Notably, previous research shows that civil servants are not always provided with sufficient financial resources to implement political goals (Audette-Chapdelaine 2016). Clearly, if budgets are persistently inadequate, these effects both the work environment and the elderly receiving care. Additionally, deficits in the collaboration between politicians and civil servants are observed; their roles and focus conflict, and they possess disparate knowledge bases (Johnston Miller and McTavish 2012).

When determining the budget, politicians use the Social Service Act (Socialtjänstlagen, 2001) to guide decisions by setting the minimum standard for what the municipality should provide for eldercare. Nevertheless, there were opinions that the law was not sufficiently clearly on how to provide the best care for the elderly. Previous research on the Social Service Act and the goal of dignified and good wellbeing for the elderly depicts a gap between policy and practice and shows the goals to be abstract and lack clear guidance (Andersson and Sjölund 2020). In the absence of other measures, a common way of determining the budget was to benchmark spending on eldercare with other similar municipalities. However, comparing a budget does not guarantee adequate resources since the comparison municipality may have a deficient budget or may not provide dignified and good wellbeing service for the elderly.

A thought-provoking result is the politicians’ awareness of areas in which they wanted to enhance their knowledge, such as the staff’s work environment. This reflects their engagement and interest in eldercare. Swedish citizens vote every four years and elect their political representatives (Sveriges riksdag, 2017). These representatives are not necessarily assigned to a board or committee accountable for eldercare because of their knowledge, but rather based on their political affiliation. This fundamental democratic principle could affect what can be expected from politicians regarding their initial knowledge. One might argue it is sufficient that the civil servants possess the necessary knowledge, and politicians should trust their capacity to inform them accurately. This author concurs with the view expressed by study participants that it is important to enhance their knowledge and asserts that increasing knowledge is necessary for politicians after they are elected to an area of accountability. This will enable politicians to request the information they need in a decision-making process, evaluate the information provided, ask relevant questions, and understand the consequences of their decisions on the elderly receiving care and the staff’s’ work environment.

Accountable politicians represent the municipality as employers of the professionals working in Swedish eldercare (SKR 2018). Citizens should be able to trust that the politicians making these important decisions have accurate knowledge to perform that role.

Strengths and Limitations

Criteria for increasing trustfulness in grounded theory include credibility, originality, resonance, and usefulness (Charmaz 2014). Credibility means that the researchers achieve familiarity with the topic during data collection and the analysis process. A systematic comparison was made between the categories and sub-categories throughout the analysis process. The author repeatedly returned to the originally transcribed material and memos to assure the categories and sub-categories were grounded in the data. The results were presented within the author’s research centre and feedback was received. The author included participants from different parts of Sweden, all major parties, and genders, with the goal of including a wide range of ages. Theoretical sampling allowed gradual inclusion of participants to expand and refine categories, and to explore connections between them. The second criteria, originality, was reached since no previous research with this specific focus has been identified. Resonance reflects on whether the results can be applied to other individuals who share the same circumstances as the included participants. The aim in grounded theory is not to generalize, but to develop a conceptual model that clarifies the results through connections and possible explanations among categories and sub-categories. Therefore, the results and conclusions of this study represent only the 41 participants.

Two politicians who did not participate in the study had the opportunity to give feedback on the results. Their comments were consistent with the authors interpretations and therefore no changes were made. The two participants were a woman aged 31 from the Social Democrat party and a 45-year-old man from the Moderates. These were chosen as they represented two of the largest political parties in Sweden with different positions on the political spectrum and were asked to participate in the feedback as they responded positively after the data collection had ended.

Quotations were included to provide a more precise view of the participants’ statements and to provide transparency. Negative cases were included with the aim of presenting a broad assortment of opinions. The final criteria, usefulness, was achieved since Swedish municipality politicians with accountability for eldercare are responsible for a field where high sick leave is common. Therefore, considering eldercare from the politicians’ perspectives is important in order to be able to understand their views and knowledge of eldercare and its organization.

Limitations of the study include the relatively high mean age of the participants and that only 41 of 456 contacted politicians agreed to participate. One explanation of the lack of interest could be that data collection was executed during a peak in the COVID-19 pandemic and municipality politicians were unable to participate due to heavy workloads.

Conclusions

A deeper understanding of the perspectives of accountable municipality politicians within Swedish eldercare shows the challenges faced in their political roles. These include an inadequate budget for eldercare and challenges in acquiring adequate knowledge for decision-making. Civil servants are perceived as holding positions of power since they provide the politicians with the information needed for decision-making. The politicians were aware that provided information could be filtered or made too complicated for them to understand. The politicians were also aware of their own lack of knowledge regarding the work environment in eldercare and expressed a desire to learn more to support their political duties. With enhanced knowledge among politicians, the knowledge imbalance between civil servants and politicians might diminish, and politicians could be empowered to ask questions and make more considered decisions regarding eldercare.

Acknowledgments

The author would like to thank each of the municipality politicians who kindly contributed to this research, as well as FORTE for the research grant (2016-07220).

Disclosure statement

No potential conflict of interest was reported by the author.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

The project was financed by The Swedish Research Council for Health, Working Life, and Welfare, FORTE [grant no. 2016-07220].

Appendix 1. Interview questions

• How would you describe your collaboration with the civil servants working in eldercare?

• How would you describe your collaboration with the managers working in eldercare?

• Can you describe how decisions are made regarding which resources are to be allocated to eldercare?

• Have you been involved in cut costing decisions? If so, can you describe how these decisions are made?

• Do you feel that you have sufficient knowledge of the work carried out in eldercare? If not, what do you want to learn?

• Do you feel that you have sufficient knowledge of the psychosocial work environment in eldercare? If not, what would you like to learn in relation to your responsibilities?

• Do you have knowledge of the Work Environment Act?

• What is your opinion of work shadowing?

• Do you believe that as someone accountable for eldercare, you should know the different professional roles in eldercare?

• Is there anything else you want to add?