Abstract
In the wake of welfare sector reforms and the increasing marketisation of eldercare services, nursing home first-line managers (FLMs) are confronted with escalating work demands within streamlined organisations. Given this background, the aim was to investigate FLMs’ perceptions of their psychosocial work environment and of differences between nursing home ownership types. Nineteen managers from three Swedish municipalities from municipal, outsourced, and private nursing homes participated in semi-structured interviews focused on job demands, job resources, and ownership differences. The FLMs’ perceptions were interpreted as forming two themes. Navigating challenges: striving to cope with demands highlighted various challenges, including recruitment, workload, and lack of organisational support. Key stressors encompassed personnel struggles, time constraints, and complex interactions. Influence of ownership dynamics on the work environment explored variation across ownership types. Private nursing home managers enjoyed more decision-making autonomy but faced more scrutiny than did municipal ones. FLMs in outsourced homes described unique stressors, notably uncertainty and increased workload due to the procurement process. These findings underscore the potential need for tailored systemic changes across different ownership types. The policy implications include enhancing communication and support in municipal homes, reducing the span of control in private homes, and revising the procurement process in outsourced homes. These insights suggest that further research outlining differences between ownership types, particularly private and outsourced nursing homes, is warranted. Such research could aid in formulating specific strategies tailored to each ownership type in order to enhance the psychosocial work environment for FLMs in nursing homes.
1. Introduction
Eldercare has experienced significant reforms and financial cutbacks, leading to the “marketisation” of this part of the welfare sector, emphasising competition and for-profit actors in nursing home services [1–3]. High voluntary managerial turnover in the public sector has been attributed to work environment issues and unmet expectations [4–6]. Eldercare managers face increased work demands due to slimmed-down organisations, conflicting employee-focused values, and financial control priorities [7, 8]. Managers in eldercare often struggle with an imbalance between high job demands and inadequate resources [9], greater than those in other municipal services [10]. This imbalance may be influenced by the span of control, in which managers with a smaller span of control (i.e., fewer than 30 employees) reported less stress and more structural empowerment [11]. The gendered landscape of eldercare may amplify these issues, as managers tend to have fewer resources, reduced support, and broader control spans than in masculinised services [12].
Swedish Government Official Reports [13] have called for greater clarity regarding the work environment of first-line managers (FLMs) in eldercare. Work demands [14], work-related stress, and job satisfaction have been linked to turnover intentions among registered nurses [15], a pattern that may extend to managers in similar environments. Nursing home managers often find their work meaningful but face challenges related to administrative tasks and balancing staff and resident needs [16]. Previous research has primarily focused on the municipal sector or municipal eldercare. Our study, however, explores the psychosocial work environment of FLMs across different ownership types: non-profit, outsourced, and private for-profit nursing homes. Prior studies present a complex picture of for-profit nursing homes. They report better resources for managers [17] but also higher staff turnover intentions [18] and neglect of care [19]. Moreover, Simmons et al. [20] found that working conditions in the long-term care sector were worse in Sweden than in Austria, suggesting that Sweden’s larger for-profit setting contributes to this disparity. By distinguishing between outsourced and private ownership, our study addresses a knowledge gap, shedding light on the global marketisation processes within communities in Sweden.
This study focuses on nursing homes, i.e., long-term residential care for older adults with access to around-the-clock care. FLMs are considered the managers closest to the care workers and who are responsible for employee assessment meetings. In the Swedish context, it is important to note that around 80% of nursing homes are primarily operated by municipalities or non-profit providers. The remaining 20% are run by for-profit providers [21]. For-profit providers can be divided into outsourced and full-ownership private providers, a distinction that might vary internationally due to differences in financing, regulatory regimes, and ownership mixes [1, 22]. Outsourced ownership, which began as a result of the marketisation of care, involves municipalities outsourcing care to private providers through procurement documents. These providers then compete on price or quality with other private providers or the municipality, typically securing contracts for about five years [22, 23]. Conversely, full private ownership involves private providers building their own nursing homes and attracting residents.
Changes in ownership models may influence organisational structure and leadership [17]. Subsequently, the type of ownership might play a role in influencing the psychosocial work environment, affecting the demands and resources experienced by FLMs and care workers. For-profit incentives have been associated with reduced staffing levels [24] and worse working conditions [25, 26], and Lindmark et al.’s [18] systematic review highlighted the potential benefits for staff of non-profit ownership.
Given this background, this study aimed to investigate FLMs’ perceptions of their psychosocial work environment and of differences between nursing home ownership types.
In this study, we explore the psychosocial work environment of FLMs through the interplay of the job demands-resources (JD-R) theory and the concept of social capital. The JD-R theory posits that every job involves demands and resources. A stable psychosocial work environment requires balancing job demands with job or personal resources [27, 28]. Excessive job demands and insufficient resources may lead to stress and other adverse consequences. Conversely, copious resources can counterbalance high demands, fostering work engagement [29]. Past research has predominantly applied the JD-R theory in quantitative studies of care workers’ psychosocial work environments [30–32]. Applying the JD-R theory in a qualitative approach can help assess whether managers rate job demands and resources as similar under different ownership types.
Social capital is a complex concept critical to social interactions and structures, encompassing elements of trust, shared norms, and networks that facilitate information exchange and coordination [33]. Within the workplace, organisational social capital consists of associability, i.e., the willingness and capacity to engage in collective tasks, and trust between staff members, managers, and colleagues [34]. Social capital can foster horizontal and vertical networks in an organisation [35]. As a resource within the JD-R theory framework, social capital has been found to mitigate job demands, occupational stress, and turnover intentions [36, 37]. Previous studies have linked social capital to job satisfaction and reduced intentions to leave among healthcare professionals [38–40]. Thus, social capital may be a crucial resource for nursing home managers.
2. Methods
2.1. Methodological Approach
This study was structured using a descriptive design with a qualitative approach, utilising Graneheim and Lundman’s [41] content analysis method. The research focused on understanding and describing the psychosocial work environment of FLMs in nursing homes across varying ownership structures. The decision to use a qualitative approach was made to facilitate in-depth exploration and understanding of the managers’ perceptions, which were considered essential in order to capture nuances of job demands, job resources, and potential differences relating to the type of ownership. In order to ensure the rigour and quality of our research, we followed the Standards for Reporting Qualitative Research (SRQR) guidelines, which is provided in the supplementary materials (available here).
2.2. Sample and Setting
The study was based on purposive sampling from three municipalities in Sweden, distinguished by their size, prevalence of for-profit nursing homes, and geographical area. To ensure a consistent comparison between ownership types, we targeted three private providers operating in all selected municipalities and contacted all their nursing homes in each location. In total, we contacted managers from 28 nursing homes: 12 in a large municipality, 11 in a medium-sized municipality, and five in a small municipality. In the public sector, the sample comprised all nursing homes willing to participate. We aimed to have a balanced sample by including a similar number of municipal homes as private ones. Non-profit homes not operated by the municipality were excluded due to their scarcity in Sweden.
The managers closest to the care workers, who had staff responsibility and held employee assessment meetings, were regarded as FLMs. We decided to prioritise FLMs in charge of employee assessment meetings to get concrete answers concerning the care workers’ psychosocial work environment. In most nursing homes, the FLMs were operations or unit managers, depending on the organisational structure. Two participating FLMs served as group leaders and were not in charge of economic decisions but were closest to the staff and conducted the assessment meetings.
Nine managers declined to participate due to being new in the role of FLM, lack of time, or only temporarily holding the position of FLM. Nineteen interviews were conducted with FLMs from 17 nursing homes.
The setting included managers from nursing homes with three different types of ownership: public sector, full private ownership (i.e., for-profit organisations that had built the nursing homes), and nursing homes that had been outsourced from public to private care through procurement processes. This diversity provided a comprehensive outlook on managerial experiences across different structures. The sample consisted of 89% women, which is representative of Sweden, where 86% of eldercare managers were women in 2016 [42]. Further demographic and professional details about the participants are provided in Table 1.
2.3. Data Collection
Data were collected in interviews using a semi-structured guide between December 2021 and November 2022. Thirteen interviews were conducted remotely and six in person. The interviews were between 33 minutes and 1 hour and 15 minutes.
The JD-R theory inspired the interview guide. It included questions about the managers’ perceptions of their psychosocial work environment, for example, concerning what job demands were challenging and what resources they utilised to cope with or manage the demands. Additional questions explored managers’ well-being and trust in their immediate superiors and the organisation/municipality. The interview guide also contained questions about how managers built social relations with care workers and handled conflicts. Lastly, it contained questions about their perceptions of different ownership types. All managers were asked about specific elements unique to each ownership type, such as profit incentives for those with private sector experience, procurement processes for those familiar with outsourced homes, and multi-tiered organisational structure for those with experience in municipal settings. The interview guide also had questions about the managers’ perception of staff work environment and well-being, which will be addressed and published separately. The first author (TL) conducted and recorded the interviews with participant consent.
2.4. Data Analysis
The data were analysed using qualitative content analysis. This analytical method was selected considering that both the subject and context were essential for addressing the research aim [41]. The analysis followed Graneheim et al.’s [43] guidelines and focused on interpreting the latent content, as described by Lindgren et al. [44]. Initially, the first author (TL) transcribed all interviews verbatim, after which the material was reread for a deeper understanding. At first, meaning units, i.e., text segments directly related to the research aim, were identified at a manifest level, condensed, and labelled with codes. The co-authors then reviewed these codes for validation. All co-authors read a subset of the transcribed interview data for a comprehensive understanding of the data. The first author sorted the codes according to their relevance to two predefined elements: the general psychosocial work environment and the influence of ownership type on the psychosocial work environment. Codes within these elements were further categorised based on similarities and differences, involving increased interpretation and abstraction. All authors discussed and refined these categories, ensuring a thorough understanding and interpretation of the data. The latent meanings of the categories under each element were then synthesised into one theme each. These latent meanings captured the underlying implications or interpretations beyond the explicit content. During the interpretation process, the authors examined the data for similarities and differences among managers from the perspectives of different types of ownership. All authors contributed to the latent interpretations.
2.5. Ethical Considerations
The Swedish Ethical Review Authority approved the study (Reg. no. 2021-00121). Participants received oral and written information about the study before the interviews, including assurances that participation was voluntary and that withdrawal was possible at any time. Written consent was obtained from all participants. The data gathered were deidentified and securely stored.
3. Results
Nursing home FLMs reported coping with numerous challenges. Their perceptions were interpreted as constituting two main themes with categories (Table 2). Each manager is referred to as “FLM” followed by a number, with the ownership type indicated as “M-NH” (municipal), “O-NH” (outsourced), or “P-NH” (private).
3.1. Navigating Challenges: Striving to Cope with the Demands
The FLMs described struggling with numerous complexities, including recruitment issues, heavy workloads, and leadership challenges. They described a gap between political aspirations and available resources, resulting in inadequate support from higher decision-making levels. They described striving to derive strength from positive interactions, supportive workplace resources, and personal coping strategies to help them deal with the demands. These positive interactions can be seen as a form of social capital, building trust and shared norms among staff and managers, thereby acting as a buffer against job demands. While some of these challenges and resources were universal across various ownership types, subtle differences based on ownership were noticeable. The managers expressed the need for practical improvements in their work environment.
3.1.1. Recruitment and Personnel Challenges
The FLMs described several challenges regarding the recruitment and competence of staff. For instance, one noted that:
The most difficult thing is getting competent nursing home staff … To get educated, not just educated, but also the right personnel. We can see that it is getting worse. (FLM 4, M-NH)
They also reported skill shortages among staff, language barriers affecting interactions and documentation, and concerns about the high reliance on hourly workers disrupting residents’ continuity of care. One latent interpretation was that municipal managers were more critical of the reliance on hourly workers than their counterparts in other ownership types:
Overall, the whole concept of hourly workers is like, well, there is such widespread misuse of the system … Currently, it is the hourly workers who are keeping the long-term care sector in Sweden alive … we need permanent staff. (FLM 10, M-NH)
The managers reported that residents’ care needs had increased over time, requiring more resources and time, yet staffing levels remained unchanged. A few managers who had transitioned from private or outsourced care to municipal settings noted that staffing levels in private or outsourced care tended to be slightly lower than in municipal settings. Personnel conflicts arising from diverse cultures, attitudes, and personalities added to their workload.
3.1.2. Workload and Time Constraints
The FLMs described heavy workloads and time constraints affecting their health and interactions with staff, residents, and relatives. One municipal manager even attributed stress-induced ulcers to the constant demands of the role. The managers sometimes felt overwhelmed by the number of tasks they had to handle. As one manager put it, “I could work two hundred percent, and it would not be enough sometimes” (FLM 9, O-NH). Responsibilities outside their designated roles, such as writing error reports about physical leaks, added to their workload. Interaction with residents’ relatives, who were sometimes demanding and had high expectations, introduced another layer of complexity. Some managers from municipal and outsourced nursing homes described this as the most challenging part of their job.
From the FLMs’ responses, it became evident that the challenge of overseeing an extensive number of care workers also shapes their work environment. Some managers in private nursing homes pointed out that the work environment and leadership challenges were significantly influenced by the number of staff they had to manage. Consequently, high workload and time constraints were evident job demands that directly influenced managers’ stress levels and work engagement.
3.1.3. Challenging Leadership Roles
FLMs described challenges that affected their ability to provide effective leadership. Balancing leadership with escalating administrative tasks posed a significant challenge, diverting attention from their leadership role:
We have a lot more administration … We have many systems to handle … So, the administrative part, I think, complicates close leadership. I find that there is a tendency for it to be extremely important to one’s leadership to be a natural leader … At the same time, many distractions arise. These are difficult to combine. (FLM 11, M-NH)
In municipal settings, FLMs struggled with managing decisions on finances and recruitment that were made without their input but still fell under their responsibilities. Those with experience in both private and public settings reported a stronger sense of leadership control in private nursing homes. In outsourced settings, it was implicitly understood that having an operations manager above the FLM enabled more time for hands-on leadership on the floor.
This limited time and autonomy could gradually diminish their leadership-based social capital, as increasing administrative demands hinder their capacity to build trust and sustain effective leadership.
3.1.4. Unclear Communication and Support from Higher Management
FLMs struggled with challenges regarding interactions with higher decision-making levels and the support they received. They encountered difficulties due to the gap between political aspirations and actual resources:
Now comes the third requirement from politics that we should reduce our hourly employees … it is an enormous challenge … they have put this on us, the first-line managers, to solve. But no, we do not have resources. (FLM 18, M-NH)
Municipal managers found organisational support systems lacking in active engagement, leading to poor communication and support from higher levels. In contrast, private and outsourced FLMs did not describe as many issues with their support systems. Instead, they characterised their work as more autonomous, possibly suggesting fewer support functions to turn to. Some managers also described feelings of isolation, particularly during the pandemic, when they had to make decisions without adequate support. Similarly, some described neglect of managers’ well-being, contributing to high turnover rates:
People often focus on the lack of nurses or healthcare personnel. But there are not enough unit managers either … Many managers feel very bad. There is also a high turnover rate there. (FLM 19, M-NH)
Moreover, managers voiced frustration with the focus on measurement and reporting, which did not necessarily improve care quality. One manager stated:
We are in a time when everything must be measured … But we are not measuring the right things … there are so many things we need to report that do not address the core of the problem. (FLM 13, P-NH)
These issues affect the managers’ work engagement, from miscommunication to misaligned priorities. Furthermore, inadequate support and higher-level communication can weaken organisational social capital, impacting horizontal and vertical networks.
3.1.5. Support and Resources within the Workplace
FLMs underlined the importance of workplace support and resources in managing their roles. They drew joy and strength from interactions with residents and colleagues: “I love working with caregiving … The staff bring joy to work, and the residents bring joy to work” (FLM 9, O-NH).
Distributing some leadership responsibilities to staff is a key strategy of FLMs, helping free up their time and boosting team members’ growth, serving as a valuable job resource. The nature of workplace support FLMs sought differed depending on ownership type. FLMs mainly turned to assistant or operations managers in private or outsourced homes for support. In contrast, municipal managers typically relied on subordinates like coordinators and administrative staff, suggesting variations in organisational social capital possibilities. Registered nurses were also mentioned as crucial in assisting FLMs in their work across ownership types. These job resources and elements of social capital help FLMs navigate their demanding roles and maintain efficiency in their work.
3.1.6. External and Organisational Support
FLMs emphasised the significance of external and some organisational support in their roles. They appreciated trust, open communication with immediate superiors, and the clarity offered by operational functions such as HR, payroll, and quality control. One interpretation of what the managers described is that the FLMs’ closest manager seems to play a more prominent role in providing support in private or outsourced nursing homes. In municipal settings, the closest manager is viewed as supportive, but the hierarchical chain of command somewhat constrains the support they can provide.
A few managers highlighted the importance of maintaining good relationships with residents’ relatives. One manager noted: “Relatives are an incredible resource, which has been somewhat forgotten here” (FLM 10, M-NH). This sentiment underscores the view that the involvement of relatives is crucial for delivering optimal care.
3.1.7. Personal Resources and Strategies
FLMs in nursing homes utilise personal resources and strategies to navigate their demanding roles. They drew motivation from the challenges of the job, stressing the need to maintain work-life balance, mainly by not bringing work home. These descriptions were similar across ownership types. They described tactics such as using lunch breaks for personal recovery or catching up on work in order to manage the demands of their roles. Some managers strongly believed in the importance of prior caregiving experience:
Almost anyone can become a manager today. If you pass some college exams, becoming a manager is no problem … I also think that is a bit wrong … I think that managers should, at the core, have some form of caregiving experience. (FLM 10, M-NH)
Such experience was viewed as an asset, providing an in-depth understanding of staff challenges and facilitating practical problem solving.
3.1.8. Improvement Suggestions for the Work Environment
The managers were asked what improvements they would like to see regarding their work environment in nursing homes. Municipal managers seemed to desire more robust organisational support and easier scheduling. Private managers frequently expressed concerns about having a broad control span and preferred smaller units. Managers in outsourced settings suggested that if they perform well, their contracts should be extended continuously rather than reopened for new bids, altering the process to reward good performance. Table 3 summarises the most frequent suggestions.
3.2. Influence of Ownership Dynamics on the Work Environment
The managers described how the dynamics of nursing home ownership shaped their work environment to some extent, with each ownership type presenting unique challenges and advantages. These differences influenced various aspects, such as employment structure, leadership style, budget control, recruitment process, work support, and overall quality expectations. Despite these variations, in some cases, the quality of care may be more closely aligned with the practices of the specific service provider rather than the type of ownership.
3.2.1. Employment Opportunities and Scheduling Difficulties
FLMs identified unique challenges and advantages across different nursing home ownership types, particularly regarding employment opportunities, scheduling, and span of control. The managers said that municipal nursing homes offered more full-time positions, while private ones employed more part-time staff, easing their scheduling complexities. One private nursing home manager noted:
Many part-time employees, very few full-time employees … and that has a lot to do with the schedule, as it is complicated to arrange the staffing schedule if many have full-time employment. (FLM 7, P-NH)
On the other hand, municipal nursing homes, despite providing the benefit of full-time employment, faced scheduling difficulties. As one manager noted, the decision to offer full-time employment in the municipal sector turned scheduling into a “nightmare.” This suggests that the flexibility of having more part-time staff in private nursing homes might facilitate scheduling. Despite the scheduling difficulties, municipal nursing homes were often deemed more attractive workplaces due to full-time employment opportunities and additional benefits, such as vacation days. Moreover, the employment structure also influenced the span of control, with private facilities typically having a higher average span of control than municipal and outsourced nursing homes (Table 1).
3.2.2. Leadership and Decision Making
Challenges and benefits in decision making and leadership were identified by FLMs, with the ownership type playing a significant role. Managers in the private sector described having shorter decision-making processes and easier access to supervisors, creating a more streamlined environment:
What I think is good about private compared with municipal [nursing homes] is that there are shorter decisionmaking processes, it is easier to get in touch, and things happen a bit faster. (FLM 7, P-NH)
They also highlighted greater decision-making autonomy: “In municipal [nursing homes], you can hardly decide anything. [laughs] There you are more rigid” (FLM 9, O-NH). These streamlined decision-making processes could be seen as a job resource, potentially boosting trust and strengthening social capital within the organisation.
In outsourced nursing homes, managers grappled with the complexity of navigating the expectations and requirements of two employers. One positive side is that they could receive support from both their company and the municipality. However, this duality sometimes posed difficulties, as one manager stated:
I thought it was more challenging, in that way, to be a manager in an outsourced nursing home. Because you had to answer to both the company’s guidelines and the municipality’s simultaneously. (FLM 1, P-NH)
Furthermore, some municipal managers emphasised their broader societal commitment compared with private nursing homes. They noted their unique focus on community collaboration and creating opportunities for those distant from the labour market, which affects their approach.
3.2.3. Finances and Budget
FLMs noted differences in budget flexibility and economic focus among nursing home ownership types. They noted that municipalities, unlike private organisations, can exceed their budgets when necessary, especially towards the end of the year. In contrast, private entities must adhere more strictly to their budgets, which could add to their job demands. This stricter adherence to the budget could also be because of a profit-driven approach despite some improvements over time:
I also know that there are private providers who are very economic [minded], just go for profit, unfortunately. But it is improving and has gotten better, but many still aim for a profit. (FLM 9, O-NH)
Some managers who transitioned from private to municipal roles cited financial inflexibility as a significant factor in their move, expressing concerns about the constant pressure to balance the budget, often at the cost of staffing. Reducing or cutting staffing levels could undermine work environment trust, weakening the organisational social capital. One manager described the experience in the private sector: “It became very time-controlled … Since they focused so much on the finances, that was one reason why I quit working for that company” (FLM 18, M-NH).
3.2.4. Staff and Recruitment
Managers identified differences in recruitment processes between the public and private sectors. Private-sector managers described having autonomy in selecting employees to suit their teams, whereas public-sector managers grappled with less control and prolonged decision making. A few expressed frustrations with this process:
When working for the municipality, I could not decide what substitutes or staff I would get. Instead, I had to place an order … I thought the decision-making processes were too long. (FLM 1, P-NH).
FLMs in the public sector highlighted concerns about the quality of staff, noting that despite not being directly involved in the hiring process, they are held accountable for the hired personnel’s decisions. These descriptions suggest that private-sector managers enjoy more autonomy in recruitment, which allows for better team fit. In contrast, public-sector managers deal with longer decision-making processes, potentially resulting in mismatches between staff competence and the expectations placed upon managers.
3.2.5. Outsourcing Vulnerabilities and Long-Term Prospects
Based on managers’ perceptions, the type of nursing home ownership influenced their work, particularly concerning the vulnerabilities of outsourcing and the security linked to long-term stability. The outsourcing process in the private sector presented its own challenges, often triggering stress and anxiety due to contract uncertainties and potential changes. “I can say that that it [i.e., the outsourcing process] is the most challenging work environment factor. It is so anxiety-inducing … it is a huge stress” (FLM 17, O-NH). The handover process in outsourcing increased the workload and mental exhaustion of FLMs: “Everything falls on me as the first-line manager. So, it is not fun to do a handover … Plus, you have to deal with everything else that is on your plate” (FLM 15, O-NH).
They also noted better long-term prospects in municipal and privately owned nursing homes than outsourced ones, as decisions and improvements were made without fear of contracts ending or takeovers.
In private nursing homes, you have a contract for, what is it, 15 years, I think? You build, you own. Then you never have that stress of changing employers. You do not have that. (FLM 15, O-NH).
Drawing on the managers’ insights, it is clear that the vulnerabilities tied to outsourcing stand in contrast to the stability of municipal and privately owned nursing homes. The stability in municipal and privately owned nursing homes fosters a more consistent work environment, possibly enhancing the organisational social capital. This underlines how ownership structure can influence the psychosocial work environment.
3.2.6. Quality Expectations and Operational Disparities
Private-sector managers perceived higher quality expectations in their sector, which some viewed as a beneficial driver in maintaining standards:
Sometimes, I feel that there are higher demands on us as outsourced than on municipally owned homes … But at the same time, it is good! Because then we also have to maintain the quality we have. (FLM 2, O-NH)
However, outsourced and private managers described higher quality expectations being associated with increased scrutiny and control from the municipality and the media, creating additional job demands for the managers.
Some managers in municipal nursing homes pointed out disparities in support functions. They reported that public-sector facilities often lacked essential equipment, such as ceiling lifts, which were more common in private-sector facilities. These managers also voiced difficulties in reaching out to support functions such as HR, leading to confusion over the division of roles and responsibilities. This lack of clarity and the general sentiment that support functions did not provide sufficient assistance added to their challenges. In contrast, managers in the private sector conveyed satisfaction with their existing support functions, even though they speculated that municipalities might have more extensive support systems than private providers. These contrasting experiences suggest that the ownership structure may shape quality expectations and the efficiency of the support functions available to managers.
3.2.7. Role of Specific Provider versus Ownership Type
Some managers argued that the quality of care depended more on the specific provider than the ownership type. They could not determine whether working for a public or private organisation was better, as the work characteristics, regulations, and routines in nursing homes were similar in both sectors. However, some felt that working in a particular sector suited them better on a personal level. One manager who was initially sceptical of private care found their perceptions overturned after experiencing the support and resources provided by that specific private provider:
I have also been one of those who have been against private long-term care … But anyway, I applied for this job, and I must say that I have probably never had such a good employer. They are incredible. (FLM 9, O-NH)
3.2.8. Procurement Processes
Managers indicated the influence of procurement processes on the work environment in outsourced nursing homes. While some found adhering to quality-based procurement challenging, advocating for more practical approaches, others argued against price-based procurements due to their pressure in terms of cost-cutting, especially targeting personnel expenses.
I believe that price procurement … they must remove it … That is where they save on staff … It is better with quality procurements … You cannot go much lower in price soon. (FLM 15, O-NH)
Managers also noted the mental strain of procurement processes, with the looming risk of replacement due to lower bids or higher quality on paper, even if their performance had been good. The difficulties of procurement processes represent an additional job demand for managers in outsourced nursing homes. This highlights the need to prioritise quality over frequent procurement processes.
4. Discussion
This study aimed to investigate FLMs’ perceptions of their psychosocial work environment and of differences between nursing home ownership types. The first theme, Navigating challenges: striving to cope with the demands, highlights the managers’ general portrayal of their psychosocial work environment. They were often confronted with multiple concurrent demands, the management of which sometimes relied more on the managers’ personal resources than on adequate resources provided by the organisation. These demands included a variety of personnel struggles, time constraints, and demanding interactions with different groups. An overwhelming number of demands can sometimes cause health and leadership issues in their managerial roles. Communication and support from higher management were described as crucial to balance the demands but were lacking in some instances. Instead, they received support and resources from within the workplace and used personal strategies to manage their roles effectively. Moreover, managers’ suggestions for improving their work environment provided insights into potentially beneficial systemic changes at various levels of nursing home operation.
The second theme, Influence of ownership dynamics on the work environment, highlights differences depending on the ownership type of the facility where the manager works. The ownership type may influence the number of staff per manager, scheduling, and decision-making autonomy. Private nursing homes appeared to allow more flexibility but also had increased scrutiny. Budget management seemed to vary, with municipal homes having more flexibility, while private homes appeared to adhere more strictly to their budgets. Differences in staff recruitment processes were reported, with managers of private homes suggesting that they had more autonomy. The structure of support functions seemed better in private organisations. The critical finding of this study may be the notable stress from the outsourcing process reported by some managers. The uncertainty of managing an outsourced nursing home was specific to that type of setting, with both municipal and private nursing homes having more secure long-term prospects. These findings underscore the complex nature of the work environment of FLMs in nursing homes and that the work environment differs slightly depending on the ownership type.
Our study echoes previous research on the challenges eldercare managers face, specifically the imbalance between high job demands and scarce resources [7, 9, 10], mirroring the JD-R theory’s counterbalancing principle [27]. Managers used personal strategies to address demands. For some managers, however, organisational resources fell short of balancing the demands. Some managers in our study described a lack of attention to managers’ health as well as high turnover, which could be related to resource deficits in balancing the overwhelming demands. This imbalance may contribute to high turnover [4, 5] and increased workloads due to streamlined organisations [7], likely attributed to marketisation and new public management ideals, which emphasise leaner structures [1, 22]. A lack of structured support indicates a possible social capital deficit among managers [34, 35]. The results may indicate that high work demands and stress lead to higher turnover rates for FLMs, a pattern similar to that for nurses in nursing homes [14, 15]. The present study’s results resemble Hagerman et al.’s [16] findings that nursing home managers find their work meaningful but struggle to balance different tasks and interactions. Looking through the JD-R lens, it is worth questioning whether the perceived meaningfulness can sufficiently offset the demands described in this study and previous ones.
Ownership type appeared to influence managers’ work environment. It influenced job demands and resources, such as the number of staff per manager, scheduling, autonomy, and budget practices. These findings expand on previous research on how for-profit incentives affect staffing and work conditions [24–26]. Private nursing home managers reported greater decision-making ease but faced more scrutiny, illustrating a complex interplay between job demands and resources. Organisational structure, potentially influenced by ownership type, might affect trust within the team, a key element of social capital [33, 35]. While increased autonomy may enhance social capital, heightened scrutiny could strain relationships. The specific advantages and challenges of different ownership types seemed complex and varied. Similarly, Lindmark et al. [18] demonstrated that the possible effect of ownership type on the staff work environment differs between studies and settings.
Our findings partly concur with Dellve and Wolmesjö’s [17] findings regarding better resources for managers in for-profit nursing homes. The private FLMs in our study reported easier decision making and better support access. However, managers in outsourced nursing homes, who have to report to two employers, encountered additional demands and stress, particularly from the procurement process. This suggests that outsourced ownership presents unique challenges not reflected in private or non-profit homes. Notably, all private FLMs in our study had over 30 subordinates each, potentially affecting their structural empowerment [16], compared to managers in municipal and outsourced homes, who generally had fewer than 30. Variations in budget flexibility and priorities may also reflect differences in financial control priorities, as depicted by Strömberg et al. [8], but in this case, depending on each ownership type. Organisational structure and ownership type may therefore influence the shaping of the psychosocial work environment.
4.1. Implications for Practice
This study indicates a need for practical suggestions tailored to the unique demands and resources associated with different types of nursing home ownership. The following policy recommendations integrate our suggestions, managerial input outlined in Table 3, and recommendations from existing research. These collectively emphasise the need for lowering job demands and enhancing available resources.
Our findings highlight a disconnect between political aspirations and practical resources. Policy directives should, therefore, be aligned more closely with the resources realistically available to managers. Our findings also emphasise that the improvements recommended for care staff in prior research [18] should equally be extended to FLMs. Increasing the number of permanent care workers and reducing hourly workers could decrease job demands, benefiting managers and residents by improving the consistency and competence of staff. Furthermore, Managers expressed frustration with the current measurement and reporting systems. These systems may require revision, in line with Trygged’s [45] recommendations, to better capture the authentic work environment and quality of care provided rather than technical aspects.
Municipal FLMs described challenges due to insufficient autonomy and support functions. Improvements could involve initiatives to strengthen vertical communication channels, add administrative support, and increase managerial autonomy, which could mitigate role demands [4, 8]. Enhancing managerial social capital by improving communication networks and relationships could improve job satisfaction [38].
In private nursing homes, where FLMs handle many subordinates each, a solution might involve appointing additional FLMs or support staff. Reducing the number of subordinates could reduce stress and promote empowerment [11, 16]. Our study underscores the concerns about high staffing levels in these settings, suggesting the need for stricter staffing regulations for private providers [25, 46].
In outsourced nursing homes, our findings highlight the procurement process as a unique stressor. To address this, we recommend reshaping the procurement process by possibly extending ownership contracts and eliminating price-based procurements. Maintaining continuity of care and clear communication during the procurement transition could alleviate stress and preserve shared norms. These targeted, ownership-specific policy recommendations aim to improve managers’ psychosocial work environment and are likely to create a ripple effect benefiting staff and residents as well.
4.2. Methodological Concerns
We strove to achieve trustworthiness by adhering to Graneheim et al.’s [43] credibility, dependability, and transferability guidelines. The study’s strength was its purposive sampling from three diverse municipalities in Sweden, which reinforced the credibility of our results concerning the varying roles and responsibilities of FLMs.
However, given the specific nature of the Swedish care sector and its geographic context, there are constraints to the present findings’ dependability and transferability. In particular, the small sample size from the outsourced and private sectors could have affected the diversity of the studied experiences. Nevertheless, our results may be transferable within Sweden and potentially to other countries with similar social care and healthcare models. Our study also provides insights into the marketisation of care relevant to countries shifting towards privatised care models.
Although only one author conducted the interviews, all authors contributed to evaluating a subset of the transcribed material, interpreting latent themes, and participating in the data analysis, which enhanced the study’s dependability. Additionally, presenting multiple quotations from the manifest content strengthened the study’s credibility [41, 43]. Furthermore, applying the JD-R theory in constructing parts of the interview guide could have influenced the findings; however, doing so provided a valuable lens to view the job demands and resources of FLMs across different ownership structures.
5. Conclusions
Overall, this study expands our understanding of FLMs’ psychosocial work environment and highlights the importance, for policymakers, of considering each ownership type when evaluating and addressing implementation in order to improve managers’ work situations. By examining distinct ownership types, the study helped shed light on how the marketisation of care may have affected FLMs’ work environment. Furthermore, the study’s distinction between outsourced and private ownership types addressed a knowledge gap regarding the potential differences between ownership structures. The study also contributed to the JD-R theory’s applicability by examining social capital as a resource and utilising the framework in a qualitative setting. The study presented managers’ own ideas for possible improvements to the psychosocial work environment of FLMs in nursing homes. Further research on different private ownership types in nursing homes is vital to enhance our understanding of how ownership types may influence the work environment.
Data Availability
The qualitative data used to support the findings of this study have not been made available due to general data protection regulations (GDPR) and ethical concerns.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Authors’ Contributions
All authors contributed to the study’s conception and planning. TL collected the data and drafted the manuscript. All authors contributed to the interpretation and analysis of the data. ST and ME reviewed and revised the manuscript for significant intellectual content. The final manuscript was read and approved by all authors.
Acknowledgments
The University of Gävle supported the project. Open-access funding was enabled and organized by Bibsam 2023.
Supplementary Materials
The Standards for Reporting Qualitative Research (SRQR) checklist is included as supplementary material [47]. This checklist helps guide readers by indicating where they can find specific information about the article’s research methodology and results. (Supplementary Materials)