Abstract
Eldercare is facing current demands to develop due to changing demographics with increasing populations of elderly over the age of 85 combined with smaller populations of young people able to provide care and contribute to care via their taxes. The need for development of quality and safety was highlighted during the COVID-19 pandemic. Swedish government subsidies aimed at developing municipalities responsible for publicly managed eldercare have only been evaluated to a limited extent and the realisation of visions of future eldercare is shrouded in mystery. The study aims to explore the development work and strategies in Swedish municipal eldercare organisations, specifically in terms of alignment between democratic visions at political and strategic levels and operationalisation at operational levels. 28 interviews with development leaders were conducted in 14 Swedish municipality organisations between March and October 2021. The interviews focused on supporting roles and functions, responsibilities and collaborations, visions and operationalisations, and the follow-up and evaluation of eldercare development. A thematic analysis resulted in the main theme “top-down handling of unmanageable alignment” and the subthemes “shaping a high road for change;” “sticking to visions, hopes, and respect for practice;” and “self-serving focus on politics.” The quality of alignment strategies and putting the strategic vision into practice were related to organisation size and resources. A gap between strategic and operational levels was accentuated in terms of inconsistent responsibilities in following through with development projects and development being characterised by top-down initiatives and resources at the strategic level but strained implementation abilities at operational levels. Peripherally located change agents with legitimacy at multiple organisational levels are suggested to ease top-down as well as bottom-up drive, which could increase a vertical alignment of visions and practice.
1. Introduction
Eldercare services, i.e., social and health aspects of care of old adults are provided in ordinary homes or residential living, are expanding in many countries. In Sweden, public eldercare has been established as part of a welfare-system since the 50s. The current and future demographics indicate growing populations of the oldest in need of eldercare and smaller populations working. This imbalance was discussed in relation to needed reforms in a special issue of Health and Social Care in the Community [1]. Ten years later, the need to meet challenges in eldercare is accentuated in many countries due to quality and safety deficiencies highlighted during the COVID-19 pandemic, increased political intentions to meet citizens’ demands to have more influence on the social aspects of care, and difficulties in terms of recruiting and retaining skilled workers.
To speed up needed developments of quality and safety of eldercare as well as of user influence, countries may implement laws and regulations. In Sweden, there are laws regulating eldercare services considering the quality of health and social care as well as the elders’ choices of care and where to live (the Social Services Act 2001: 453, the Healthcare Act 2017: 30, and the Law on Systems of Freedom of Choice 2008: 962) as well as the Working Conditions Act (the Work Environment Act 1977: 1160) [2]. Government authorities observe compliance with regulations (Health and Social Care Inspectorate, Swedish Work Environment Authority) and have repeatedly reported serious deficiencies in quality as well as demands for development work [3]. The National Board of Health and Welfare has supported development by introducing several national training initiatives. The government has for more than three decades, especially during the pandemic, directed several financial support programmes towards municipalities (responsible for eldercare) to subsidise and incentivise, for instance, quality improvements and measures to increase competence in eldercare. Programme follow-ups show shortcomings in terms of properly evaluating programme outcomes as well as a lack of organisational perseverance and sustainability of change [4, 5]. Furthermore, the eldercare sector is the publicly governed social service with the least experience of systematic knowledge acquisition, as well as the sector with the least educated workforce [4]. Theory-driven research on organisational conditions important for development work has mostly focused on either macroperspectives of public management or microperspectives of care. These studies have not looked at the perspectives related to development work at an organisational meso-level.
Given this context, there is a need for much more systematic and independent research regarding strategies, obstacles, and possibilities for development work, in practice and from organisational perspectives. This study analyses the work and strategies in eldercare development work, especially regarding alignment between visions, needs, and practical implementations. It contributes to filling gaps in our knowledge regarding the actual work and strategies of formalised organisational functions when it comes to aligning visions to practical work in the development of eldercare.
1.1. Developing Public Eldercare
Eldercare development work in ageing societies includes elders’ right, quality and safety, and the attractiveness of working conditions. Countries have adopted approaches regarding governance mechanisms to modernise the modalities of organisations [1]. Their drivers of change and main obstructive conditions were identified in terms of controlling costs and services [6, 7], increased administrative control through standardisation [1, 8], fragmented politics [9], increased informal care, and a lack of professionalisation [10, 11]. However, there is limited knowledge concerning how strategies and identified obstacles affect eldercare quality and working conditions over time. Nevertheless, development work involves some fundamental similarities irrespective of the kind of organisation with regard to risks and support. According to the comprehensive review by Westgard and Winkel [12], inclusive management, organisational support, and resonant communication with operational levels are all important to avoid creating risks in working conditions during change.
Change management research describes development work in various ways: as a step-by-step procedure where the organisation “defreezes” itself to mould to then “refreeze” into a better version [13], as a single entity change evolving through a natural logic cumulating and maturing over time, or a multientity change where counterparts challenge each other’s theories of change and end up in a compromise on how to proceed with change [14]. Kotter’s [15] progress perspective of change itself is dissected into a step-by-step recipe for how to proceed with a change effort to reach a desired goal and is then compared to other change theories and summarised by the study of [16]. The most important strategies and steps for conducting changes are known as follows: (a) establish a sense of urgency for change, (b) form a powerful coalition to drive change, (c) create and communicate a vision, (d) craft an implementation plan and develop enabling structures, (e) involve people and be honest, and (f) monitor and adjust strategies in response to problems in the change process [16].
One of the most reported obstacles when implementing development work (generally and in healthcare) is a deficient practical operationalisation of visions [17–19] and thus a lack of alignment within organisations. While horizontal alignment is understood as employees being aware of their own responsibility and which actions to take to contribute to the goals of their unit, vertical alignment means that each management level is in sync with the upper and lower level to contribute to reaching the organisation’s goals [20]. Challenges in terms of managing vertical alignment are frequently demonstrated in healthcare organisations, e.g., [21, 22]. Key reasons for poor vertical alignment have been related to conflicting institutional logics in development work in healthcare [23] and in public eldercare [24]. Specifically, challenges regarding vertical alignment in public eldercare are seen in, for example, failed broader implementations of welfare technology due to a lack of resources, know-how, and follow-up in the implementation process [19, 25]. Also, vertical alignment as depending on the organisation’s ability to follow through during implementation tends to be affected by multiple simultaneous eldercare development projects managed simultaneously without coordination and, possibly, without proper evaluation [26].
1.2. Work and Strategies for Alignment in Developing Public Organisations
In healthcare and social care, it is common to organise and assign development leaders and functions supporting change at different levels. Change research in emergency healthcare describes change agents as resources when acting upon a vision and operationalising it at operational levels in the organisation [22, 27, 28]. Change agents support keeping the vision in sight and assuring that operational activities and approaches to change are aligned with the vision and organisational goals [29]. Methodological know-how, contextual knowledge, and legitimacy within the organisation, as well as acting as a link that packages messages and serves as a communication bearer between organisational levels represent key features for these roles in order to contribute to a drive for change [29]. Change in Norwegian public social care (e.g., eldercare) is described as driven by first line manager change agents [18]. Despite the power in their managerial position, the change agent role was affected by resistance from employees, feelings of being caught between two worlds, and a lack of managerial discretion [18]. Public management is proposed to be developed towards a public service logic using a value star model where value is cocreated in networks rather than following a value chain logic [30]. Development work pursued in this way centres around the patient through a network of municipality, primary care, and hospital care representatives led by a coordinator [30]. The key characteristics of the coordinator include having insight, presence, and legitimacy at multiple managerial levels while not serving as a manager but working as a facilitator for fruitful relationships and trust within networks as well as codriving change with participating organisations [30].
1.3. Aim
The aim is to explore the development work and strategies in Swedish municipal eldercare organisations, specifically in terms of alignment between democratic visions at political and strategic levels and operationalisation at operational levels.
2. Methods
2.1. Study Design
This study uses an abductive approach, starting from previous research, i.e., healthcare and eldercare development work and theories (alignment and change management) and aiming to gain a deeper understanding and more fine-tuned theorising regarding the rather unknown phenomena explored in the study [31]. Development work in 14 random selected municipalities was observed through interviews with development leaders and via organisational documents. The qualitative methodology and the abductive approach steered the data analysis towards thematic analysis [32].
2.2. Participants
The selection of municipal eldercare organisations was carried out stepwise as part of a research programme. First, a random sampling of 30 of Sweden’s 290 municipalities formed a variety of contexts regarding, for instance, geographic location and size. The municipalities varied in population from 2,400 to 975,000 [33] and were classified according to structural parameters (i.e., demographic and population patterns) [34]. The selected municipalities belonged to 8 of these 9 municipality classifications and did not include large cities. Therefore, one of the three large cities in Sweden was also included.
Second, a strategic selection of municipalities (based on size and representation in the research programme) were contacted. Initial contact was sought with the municipality director, the director of development, or the director of social services. Contacts were established via e-mail with 17 municipalities. Among these, three were not interested in participating in the study due to current high pressure in their organisations.
Interviews with development leaders and documents regarding eldercare development work regarding safety, influence, and working conditions in 14 municipalities formed the basis of the study. The principles for selecting development leaders to interview were described to the initial contact as being a manager of development or another function in charge of supporting developments in eldercare with a focus on: (a) the safety of eldercare users and the possibility to influence their care, (b) employee influence and sustainable working conditions, and (c) both (a) and (b) in synergy. All but one higher management contact referred to other colleagues in the organisation to find the right development leader with insights into eldercare with regard to these matters.
Among the 14 municipalities in this study, the population in the smallest was about 6,000 and about 580,000 in the largest. The population sizes of the sample in relation to the population sizes of Swedish municipalities, as well as the respective proportion of elderly (aged 75 and above) in the sample [35] can be seen in Figure 1. The sampled municipalities are numbered 1–13. However, to increase the figure’s readability, the largest municipalities with populations larger than 350,000 including the largest in the sample (organisation 14) with 7% of its population being aged 75 and above were excluded from the figure. Thus, the figure shows 13 of the study’s included organisations in relation to 288 Swedish municipalities.
28 interviews were conducted with development functions at all organisational levels to indicate alignments. Thus, interviewees represented first line (unit level, closest to the eldercare employees), second line (department level, representing a number of units), third line (highest administrative civil service level, closest to the political level in smaller organisations), and fourth line (highest administrative civil service level, closest to the political level in larger organisations) (Table 1). A majority of interviewees were organisationally located in the third line from the eldercare operational units; although some worked close to and had insight into operational work.
The interviewees’ backgrounds varied from working in different positions within the same or another similar organisation within various fields in social care for several years to having a background in behavioural or political science and industrial managerial work.
2.3. Data Collection
The in-depth interviews lasted for 27–69 minutes (47 minutes median and 46 minutes mean) and were conducted and audio recorded between March and May 2021, followed in October 2021 by four additional interviews with referred interviewees from four municipalities. The interview guide focused on work, functions, and roles involved in development work [22]. Questions concerned (a) the functions themselves (i.e., competence and experience, placement in the organisation, job description, and collaboration with managers and employees) and (b) municipality development work (i.e., division of responsibilities for projects, follow-up and evaluation of projects, continuous improvements, and quality assurance).
2.4. Analysis
The first 24 interviews were transcribed verbatim. These interviews were read several times while taking notes. The analysis of the text was carried out in an abductive and iterative manner, partly theoretically driven by findings in previous research but still open and data-driven to account for the richness of the interview data [32]. The data were coded, and these codes were arranged into themes. Going back and forth between the themes and the raw data in the transcriptions, the analysis resulted in latent themes describing relations within and between themes [32]. The four additional interviews conducted in October 2021 were played back several times while taking notes. These interviews did not add anything new or additional but confirmed the previous analysis of the 24 interviews. Hence, saturation was considered as having been reached.
2.5. Ethical Considerations
Informed consent to participate in the study was applied to all interviews as well as consent to record the interviews. Ethical principles have been taken into account. The study did not require ethical approval since the focused research questions, according to Swedish legislation (2003: 460) and did not include collecting sensitive data (e.g., regarding criminal records, ethnic origin, political opinions, religious or philosophical beliefs, health, and genetic data).
3. Results
3.1. The Storyline
The municipal eldercare organisations focused on quality in terms of the elders’ safety, influence, and participation in their own care as well as on the working conditions of employees.
A main theme in the results describes the role of development leaders and the strategies used when leading eldercare development work: top-down handling of unmanageable alignment by enduring, attempting, hoping, and self-service at strategic levels. The role of development leader is conceptualised as caged at strategic levels as project managers are at a distance from supporting implementation and follow-up at operational levels. Development work was foremost project-driven and focused upwards in organisations to meet visions and decisions raised at the strategic level and not based on needs and challenges raised at operational levels. Alignment was characterised by severe challenges and almost no evaluation of the operationalisation. Conceptualised qualities of alignment strategies to put strategic decisions into practice were related to the organisation’s size and available resources. The organisation’s size formed the need for and ability to structure development work, while available resources in terms of personnel, competence, and finances formed the alignment strategies. The analysis revealed three categories of strategies where size, resources, and structure played an important role: shaping a high road for change; sticking to visions, hopes, and respect for practice; and self-serving focus on politics (Figure 2). The pandemic accentuated these strategies and the described visionary focus, loyalty, and respect within the organisation and the operationalisation of development work at operational levels. Thus, the gap between the strategic level and the intense work at the operational level was legitimised even more.
In the following text and Figure 2, the categories of the work carried out by development leaders and the development strategies are described.
3.2. The Caged Development Leaders: Project Managers with an Upward Focus
The role of development leader was conceptualised as caged in project management with a strong upward focus and limited opportunities to reach the practical level and observe whether planned changes were implemented or were successful in practice. The development leader’s own responsibility to align democratic visions at the political and strategic levels with operationalisation was not expressed by any development leader. In their caged role, they expressed lacking competence and a drive for change at operational levels, and their frustration in terms of this was obvious.
There were heavy expectations on first line managers as a form of change agent to implement changes in practice. This despite obvious impracticalities when transferring projects to operational levels. No one trusted the operational level to have the working conditions or the competence to drive developments in practice.
Alignment was characterised by severe challenges and almost no evaluation of the operationalisations. The work of development leaders involved a clear upward focus on political and strategic decisions. They drove change through project management in terms of planning, control of resources, and time to stick to the plan. Work and responsibilities focused on the steps from initiative to handing over for implementation. The implementation phase was more or less described as the stage in the project where the operational level “simply follows the instructions on what to do to reach the goal of the project.” The development leaders shared no details on actions facilitating behavioural change, motivation, and endurance among the managers, and employees are expected to drive the implementation. Furthermore, no reflection was shared regarding ways of easing or modifying the transfer of a project from the planning to the implementation phase. In rare cases, there were some kinds of method supporters at operational levels struggling to facilitate behavioural change, but with little alignment with, support, or follow-up from higher management levels.
3.3. Shaping a High Road for Change
Larger organisations with personnel, competence, and financial resources had an organisational structure based on years of reorganisations in attempts to improve efficiency and quality. These organisations had a history of collaborative partnerships with academia, other organisations, and the region in development work, organising, and evaluation. With the right resources in place, the organisation had overarching strategic support functions specialised in fields such as finances, IT, and administration. These specialists provided support within their field, which constituted preconditions for development work. This enabled shaping a high road for change. The high road itself was described by one development leader as a road with lines to avoid ending up in the ditch but without a fixed goal.
“I think that if you set a fixed goal, you can easily fail if that goal is too complex and hard to reach. And, that is often the case in development. But if you set a direction, you are allowed to wobble a little to the sides without failing 150 times but stay on track on the high road nevertheless. So, the direction can be a bit more open (…)” (strategic level development manager, organisation 14).
Development work started with prestudies or pilot cases that preceded a wider implementation at operational levels. The development leaders at strategic levels acted as project managers inviting and coordinating the abovementioned specialists according to needs identified in the prestudies. One could say this setup of development leader accompanied by the right specialists laid the groundwork for change and basic instructions for implementation. A larger organisation also had development leaders at the operational level, often placed close to second line management. There was a well-considered idea of collaboration between development leaders at different organisational levels to be bearers of strategy and structure in development work and to increase the alignment of the political vision and operationalisation at operational levels.
With a general strategy and resources in the form of specialists in place, the organisation of strategic level development leaders could fluctuate over time without challenging the high road. However, the conditions for the operational level to stay on the strategic track were somewhat disturbed during reorganising efforts when newly formed organisations tended to end up in a patchwork of new strategic structures but where culture and habits remained at the operational level. The expectations of clarity were especially raised by operational level development leaders asking for a clear development strategy and structure to align with the strategic level and get on track to the high road for change.
In larger organisations where the communication between development leaders at different levels did not fully work, there were risks of parallel “high roads and tracks.” But these risks were seen as worth taking instead of having the strategic level codriving the change together with the operational level and the operational level being too well-served and perhaps becoming passive in the development work.
“In previous organisations, but not yet in this setting, I have seen that there is a risk that the operational level has a perception that development work is taken from them. The strategic level has taken over the sector development drive and has, so to speak, replaced the local operational development drive, and we must not end up there. I think that this is almost worse than if there happen to be parallel development tracks. That is not good either, but having a passive operational level expecting someone else to take care of it (the development work) is even worse” (strategic level development manager, organisation 14).
3.4. Sticking to Visions, Hopes, and Respect for Practice
In organisations where resources were more scarce, both in terms of finances and people, development work was above all driven by the strategic level development unit. The development unit coordinated prestudies to provide well-prepared implementation plans for the operational level. Strategic level development leaders were well-informed and active in participating in networks with other organisations, ran projects up to date with regional and government demands related to implementing welfare technology and eldercare digitalisation, and always sticking to the organisation vision. Operational level development leaders were placed close to second line management, provided support to managers regarding quality measures, and had set tasks (e.g., being responsible for quality management). The operational development leaders also collaborated with strategic development leaders in providing metrics for prestudies and/or preparing the implementation phase at operational levels. Sometimes, operational development leaders prepared metrics for the political level on a regular basis. Development work was dominated by a top-down focus. There was a desire to keep ideas for improvement and communication within the organisational silo, which was seen by some as a way for the strategic level to maintain control over the finances. Strategic development leaders took pride in working as links between the political and the operational level and hopes were high to succeed if only the right operational resources were in place. DLs, especially at the operational level, had respect for operational level constraints preventing first line managers and employees from engaging in development work. A lack of personnel was seen as one of the main constraints affecting how development work could be prioritised and realised.
“I seldom feel that I manage projects or development work that includes a need for economic resources and that we are negotiating that. Instead, it has to do with a need among people from different parts of the organisation who need to be involved in the project and be part of a project group. And, we have many development projects running simultaneously that often are in need of including the same competence and the same individuals, which forces us to prioritise. So, human resources are often an obstacle, and that is a tough factor to handle” (strategic level development leader, organisation 9).
Competence among managers and employees was another lacking resource in implementation and change in line with development plans. Some saw this lack as related to the organisation of management levels or a lack of development leaders. However, one development leader was sure that adding development leader resources would only add to managers’ frustration that the organisation was adding resources to “extra functions” instead of adding them to the core operational work.
“This is a balancing act … when we get to be too many support functions in development. When we are too many not working with the core operational work but instead on developing it. (…) I have also thought about if I was a unit manager I would have thought: “they have to quit adding new people to develop my unit” (operational level manager, organisation 11).
There seemed to be a matter of finding the right person or the ultimate recipe to engage crucial stakeholders at different organisational levels to follow through with implementation all the way out to the elderly. In several organisations, project ownership was seldom transferred properly from the strategic to the operational level, as intended in the implementation phase.
“But many times, it ends up in a unit: “well, what about this now? How do we solve this? Who takes care of this? Well, it is not a prestudy anymore so no one is a project owner.” Then, it somehow sort of ends up in no man’s land” (operational level manager, organisation 11).
The respect for practice was seen in some operational development leaders being somewhat burned by previous failed implementation efforts (e.g., the operational level refusing to transfer a project from the strategic to the operational level or employees misreading instructions and implementing their own version of change completely missing the project goal).
Even though operational development leaders were eager to have good relations with managers and employees, they were themselves constrained to jump in and support implementation, often due to certain set tasks serving the strategic level or new projects taking their time. It varied whether the organisations performed process evaluation or merely followed implementation results, such as comparing longitudinal outcomes in customer satisfaction and/or employee surveys. There was broad criticism of their own organisation’s routines regarding follow-up and evaluation; in particular, a lack of learning from mistakes or disseminating good results within the organisation.
Respect for constraining working conditions at the operational level kept operational development leaders from facilitating local change initiatives. Development leaders rather stayed close to their second line managers and waited to be called upon by first line managers, resulting in very few collaborations with first line managers. Still, the development leaders had high hopes that many smaller and local development initiatives would be taken by first line managers and employees, andthe development leaders simply were not sufficiently involved to be able to present examples.
3.5. Self-Serving Focus on Politics
In smaller organisations, having the finances in balance was on everyone’s lips. Development work was highly visionary, and full-time development leaders were placed at the strategic level, often responsible for either serving the whole organisation or the social sector (not exclusively eldercare). The choice to have central development leaders placed at the strategic level, as well as keeping change initiatives from the operational level from going up in the hierarchy via the line managers was seen as a way to control the finances.
Strategic development leaders seldom had insight into initiatives taken locally at the operational level, since their mission was strictly to support the strategic level (sector manager or the political level).
Prioritising development work in smaller organisations was always carried out from a financial point of view, with a lack of structure and clarity for the people involved in development. Lacking communication between strategic and operational levels could result in uncertainty at the strategic level as to how financial resources for development work had been used at the operational level.
“Well, now a couple of million is coming in from the government subsidies, but its…. (laughing) There’s no process for… no process for how to work with development and how to pursue it” (operational level development leader, organisation 8).
The work of strategic development leaders was characterised by preparing/having store-fronting documents in place presenting the organisation’s goals and the intended organisational culture supposed to support reaching these goals. Having steering documents in place was especially important when elections were coming up. There was criticism among strategic development leaders regarding the organisation’s short-sighted priorities.
“I think it is a challenge, considering … it has to do with both culture and competence in development work at all levels, which has been lacking for so many years. Um … the priority has been to keep the budget in balance and then focus on making cuts instead of perhaps thinking about what could lead to better quality and cut costs in the long run. Instead, it’s very much here and now…” (Strategic level development leader, organisation 6).
Politically driven projects were handed over to first line managers for implementation, but implementation was only very rarely preceded by benefit realisation analysis, nor was it evaluated. Thus, organisational sharing and learning from the results was not possible. Financial controllers were sometimes more involved in development projects than the development leaders themselves.
The perceived low success rate of development work was said to be the result of employees and managers not possessing, for instance, the competence and/or maturity for digitalisation, understanding core principles of implementation work, and sometimes even lacking basic healthcare competence to implement aspects such as hygiene routines. Some talked about a culture among employees only focusing on the core tasks of eldercare and having both a certain fear of change mixed with exhaustion following years of continuous change.
“Much depends on the management team, what they focus on, drive, and consider to be essential. But of course, if it goes on for many years and you cut down on training opportunities and such, then it becomes a culture also among employees that you do what you have to do…” (Strategic level development leader, organisation 6).
Too much was often expected by the development leaders in too little time, and new projects took over as soon as older projects came to an end, before having had time to evaluate or think old projects through and with no opportunity for collective learning.
“No, but that’s also a lack we have talked about, that when something is finished, it is finished. You don’t evaluate. You don’t share, project results. (…) We talk a lot about not having a culture of joint learning in our organisation.” (Strategic level development leader, organisation 5).
Another way of controlling the finances was to not have full-time dedicated development leaders but instead place strategic development responsibility on a strategic manager or a specialist role such as medically responsible nurse or similar. This constellation put the (part-time) specialist/development leader in a role stuck in-between levels and formal tasks associated with the respective role. They were drawn to the operational level but pulled back up again by the strategic level. This situation caused a certain amount of strain for individuals prone to run at every ball thrown up in the air and where there was no clear strategy or structure to lean on when prioritising work tasks. Nevertheless, the setup may well be beneficial for a vertical alignment of development work if working conditions at the operational level enable projects to be transferred from the strategic to the operational level for implementation.
4. Discussion
This study unveils a fraction of development work in Swedish public eldercare. It discusses the likelihood of reaching alignment between strategic and operational levels in organisations with complex goals and work, while having limited resources. The key conditions forming development work in eldercare were related to the size and competence of organisations, the absence of change agents in practice, and the need to make use of known knowledge regarding sense-making and sense of urgency at all organisational levels.
4.1. Size and Competence
The study identified strategies in development work failing to support aligning strategic level visions and implementation plans into operational level practice. Larger organisations were in a better position to enhance vertical alignment by using development leaders at several managerial levels, as links packaging and translating messages between levels [22, 29]. Trust-based leadership, tolerance towards failure, and organisational learning were considered keys by strategic levels. The middle-sized organisations struggling with manager turnover, a lack of resources or competence in place to align vision with practice focused on enduring, with the highest respect for obstacles in the work environment at the operational levels. Smaller organisations with scarce finances focused on keeping up with legislative requirements and making sure that they had control over what was possible to control. Despite short distances in the smaller organisations, the strategic level preferred to stay strategic, while leaving vertical alignment to operational managers. Something all organisations had in common was that the strategic level did not fully trust the operational level to have neither the working conditions nor the competence to drive development. Change agents with a clear responsibility to align democratic visions at the political/strategic level with the operationalisation could not be identified. No doubt, several studies have already highlighted the importance of increased knowledge regarding eldercare development [36], but size is seldom included or considered. Previous studies on size have focused on the size of units and challenges shaping the operational work of managers with large numbers of employees [37]. This study shows the importance of size when it comes to gathering resources for development work in a poor sector when it comes to shaping a high road for development work that may suit different contexts, and also that knowledge concerning contextual conditions among development leaders is poor.
4.2. Where Are the Change Agents in Eldercare?
This study shows how eldercare organisations lean on traditional views on change as a linear process [16], used development leaders as project managers assigned to a certain managerial level, preparing a project at one level and handing it over to the next level for implementation, often without follow-up or evaluation. The projects moved through the organisation in a chain of “middle hands” without securing vertical alignment, thus risking losing momentum and a slight change in the message at each handover. Change agents can act as a link between organisational levels and working in close collaboration with steering groups, thus forming powerful coalitions with change champions [22, 29]. This study indicates that eldercare organisations more seldom have change agents in the sense of having one key function securing a project’s journey from the strategic level (prestudy/pilot) and following through to implementation at the operational level (i.e., change in culture and behaviours). In an organisation without operational development leaders or with strategic development leaders without operational level insight, the first line manager was expected to serve as the “end post” of a project. The first line manager was expected to take on a combined role of project manager and change agent in the implementation phase, thereby running the risk of working as an island of its own without alignment between strategic and operational levels [29] and thus (if time was available) focusing solely on driving bottom-up development [38]. However, if the first line manager would be more aligned with the strategic level, the proposed value star model [30] with synchronous top-down and bottom-up change drive would be realised. In line with results from Håkansson [24], this study indicates mistrust regarding operational level competence. This mistrust seemed to be based on the strategic level’s lack of insights into the specific conditions and needs of the operational level.
4.3. Sense-Making of Changes in Eldercare
The forced and ad hoc implemented changes in working methods (e.g., hygiene routines) in eldercare due to the pandemic showed that a rapid top-down implementation was possible when combined with a great enough sense of urgency and understanding concerning the point of the change (Step 1 according to Kotter [15]). The following change steps [15, 16] are harder to apply to changes following the pandemic since they were anything but planned. However, bearing in mind that operational levels could mobilise from a sense of urgency during the pandemic, the current and future challenges of eldercare need to be put in concrete terms in ways that create a sense of meaning for all stakeholders involved in providing eldercare. That means reaching out to stakeholders with different backgrounds and competencies and making sure that sense-making goes top-down as well as bottom-up to support vertical alignment [29]. Top-down means supporting operational levels’ understanding and sense-making of urgent demographic challenges facing the organisation to pinpoint how one’s own behaviours relate to the bigger picture. Bottom-up means supporting the strategic level’s understanding and sense-making of the urgency in solving strained work conditions representing barriers for motivation, participation, and behavioural change for employees [24]. Due to complexity (e.g., in terms of stakeholder backgrounds and competencies) in eldercare, the “forming of a powerful coalition to drive the change” [16] is probably a precondition for succeeding with sense-making.
5. Conclusions
Before drawing any conclusions, the methodological strengths and limitations regarding time, location, and sharing of information need to be clarified. The study was conducted in Sweden, considered as having well-developed public eldercare services organisationally similar to other Scandinavian countries. However, it was conducted during the COVID-19 pandemic in a Swedish context (i.e., in a society that was not under lockdown), which highlighted the needs for rapid improvements in development work in eldercare. The interviewees were all keen to share information and contribute to research and improvements in development work with an impact in practice.
The analysis provides a bigger picture of development work in public eldercare organisations, characterised as a “top-down handling of unmanageable alignment.” The quality of alignment strategies and putting the strategic vision into practice were related to organisation size and resources. The gap between the strategic and the operational level was accentuated in terms of lacking consistent responsibility in following through with development projects from initiative to full implementation, as well as development being characterised by top-down initiatives with resources at the strategic level but strained implementation abilities at operational levels. Organising support in the form of peripherally placed change agents with legitimacy at multiple organisational levels is suggested to ease top-down as well as bottom-up drive and increase the vertical alignment of visions and practice.
According to these results and previous research, the operational development leader and first line managers would jointly constitute a link and enhance vertical alignment, as well as horizontal alignment specifically at the operational level [29]. A peripheral placing of a change agents at the operational level would maintain trust with employees and first line managers. Development leaders placed at the strategic level were often too caught up with serving the political level, which meant that even top-down development used up little of their time. Yet, the organisations would probably benefit from having an assigned change agent with a great understanding of the operational setting as well as legitimacy at multiple levels. This could even improve analysing the use of specific eldercare government subsidies.
Data Availability
The data used to support the study are available from the corresponding author upon request.
Conflicts of Interest
The authors declare that there are no conflicts of interest.
Acknowledgments
The authors wish to thank all interviewees contributing to the study with their rich knowledge and descriptions of their work. The authors thank the Swedish Research Council for Health, Working-Life and Welfare for funding the present study (Grant no. Dnr 2020-01579).