The structure versus process approach to quality of care presented by Donabedian is one of the most cited ever. However, there has been a paucity of research into the empirical validity of this framework, specifically concerning the relative effects of structure and process on satisfaction with elderly care as perceived by the older persons themselves. The current research presents findings from a national survey, including a wide range of quality indicators for elderly care services, conducted in 2012 at the request of the Swedish National Board of Health and Welfare in which responses from 95,000 elderly people living in 324 municipalities and districts were obtained. The results revealed that the only structural variable which significantly predicted quality of care was staffing, measured in terms of the number of caregivers per older resident. More interestingly, process variables (e.g. respect and access to information) explained 40% and 48% of the variance in satisfaction with care, over and above the structural variables, in home care and nursing homes respectively. The findings from this large nationwide sample examining Donabedian's model suggest that quality in elderly care is primarily determined by factors pertaining to process, that is, how caregivers behave towards the older persons. This encourages a continued quality improvement in elderly care with a particular focus on process variables.

Maximizing satisfaction among the older persons is the goal of modern individualized elderly care and how to best achieve this is of relevance for anyone planning and providing for elderly care services. Purpose of the study: What predicts satisfaction with care among older persons can be conceived as a function of process (how care is performed), and the older person. Inspired by the long-standing person versus situation debate, the present research investigated the interplay between person- and process aspects in predicting satisfaction with elderly care. Design and method: A representative nationwide sample was analyzed, based on a questionnaire sent out to 95,000 individuals using elderly care services. Results: The results showed that person-related factors (i.e., anxiety, health, and loneliness) were significant predictors of satisfaction with care, although less strongly than process-related factors (i.e., treatment, safeness, and perceived staff- and time availability). Among the person-related factors, loneliness was the strongest predictor of satisfaction among older persons in nursing homes. Interestingly, a path analysis revealed that safeness and treatment function as mediators in linking loneliness to satisfaction. Implications: The results based on a large national sample demonstrate that the individual aging condition to a significant degree can be countered by a well-functioning care process, resulting in higher satisfaction with care among older persons. 

Purpose – Care process quality (i.e., how care is enacted by a care worker toward a client at the interpersonal level) is a strong predictor of satisfaction in a wide range of health care services. The present research aims at describing the basic elements of care process quality as user-oriented care. Specifically, the questions of how and why quality in user-oriented care varies were investigated in the context of elderly care.

Design – Two municipalities were selected for in-depth field studies. First, in each municipality, we interviewed and observed care workers’ interactions with the older persons in both home care and nursing homes during two weeks (Study 1). Second, in an attempt to gain a deeper understanding of why process quality in terms of user-oriented care varies, we conducted interviews with care workers and care unit managers (Study 2).

Findings – A new taxonomy for categorising process quality variation, the Big Five of user-oriented care (Task-focus, Person-focus, Affect, Cooperation, and Time-use), is proposed. In addition, the perceived reasons for process quality variation are reported in our own developed Quality Agents Model, suggesting that variations in care process evaluations may be explained from different perspectives at multiple levels (i.e., older person, care worker-, unit-, department-, and municipality-level).

Value – The proposed taxonomy and model are useful for describing user-oriented care quality and the reasons for its variations. These findings are of relevance for future quality developments of elderly care services, but also may be adapted to applications in any other enterprise employing a user-oriented approach.

Purpose – Previous research has shown that user-oriented care predicts older persons’ satisfaction with care. What is yet to be researched is how senior management facilitates the implementation of user-oriented care. The present study set out to investigate the organizing principles and management climate characterizing successful elderly care organizations.

Design – The care organization in one highly ranked municipality was selected and compared with a more average municipality. On-site semi-structured in-depth interviews with managers as well as participatory observations at managers’ meetings were conducted in both municipalities.

Findings – The results revealed three key principles for successful elderly care: 1) organizing care from the viewpoint of the older service user, 2) recruiting and training competent and autonomous employees, 3) instilling a vision for the mission which guides operations at all levels in the organization. Furthermore, using climate theory to interpret the material, in the highly successful municipality the management climate was characterized by affective support and cognitive autonomy, in contrast to a more instrumental work climate primarily focusing on organizational structure and doing things right characterizing the more average municipality.

Value – We suggest that guiding organizing principles are intertwined with management climate and that there are multiple perspectives that must be considered by the upper management, i.e., the views of the older persons, the co-workers, and the mission. The results can guide future care quality developments and increase the understanding of the importance of organizational climate at the senior management level.