Prerequisites for empowerment: a study of procurement documents for the provision of care in Swedish nursing homes

ABSTRACT Public sector reforms have expanded the number of subcontracted nursing homes in Europe. In Sweden, municipalities contract out nursing homes to various providers through procurement documents, while simultaneously striving for equality in care. This has placed increasing demands on caregivers, in hope of improving care recipients’ empowerment and well-being. Consequently, this study has two aims: first, to investigate the prerequisites for empowering care recipients and caregivers in Swedish nursing homes, as expressed in procurement documents; second, to compare procurement documents between municipalities, to determine whether they are (dis)similar based on the objective of care equality. In total, we collected 7 procurement documents, with attachments, from three Swedish municipalities, from 2015 to 2020. Deductive content analysis, based on empowerment theory regarding care recipients and caregivers, was used to analyse the documents. The results indicated an emphasis on empowering the care recipients. The procurement documents placed multiple demands on the caregivers but barely touched on staff empowerment. The municipalities differed in how the providers competed to win the procurement. The result highlights a problematic aspect of the marketisation of nursing homes, namely combining the objective of equality with competition between providers.


Introduction
Recent decades have witnessed extensive reforms in health and social care in Europe. One reformed area is the care of older people, with the private sector increasingly taking over service provision (Harrington et al., 2017). The reforms have created the prerequisites for 'marketisation', meaning that care recipients are regarded as consumers with the ability to choose among different care providers (Hartman, 2011). The marketisation of eldercare has led to an increase in the number of eldercare providers and alternative ways of organising eldercare (Harrington et al., 2017). A recent joint report by the European Commission and the Social Protection Committee highlighted gaps in access to long-term care all over Europe, partly due to the changes in household and labour structures (European Commission, 2021). In Sweden, nursing home care has transitioned from public monopoly to market provision and consumer choice (Målqvist et al., 2011;Moberg, 2017). Sweden follows the Nordic welfare model, in which municipalities have historically been responsible for the care of older people (Moberg, 2017;Szebehely & Trydegård, 2018). With the marketisation of nursing homes, municipalities started to contract out nursing home provisions to private providers via procurement documents. These documents specify certain conditions and demands, determined by each municipality. Private providers must ensure that they meet the stated conditions to retain the provision of care for a specified period, usually around three to five years, which can be extended (Feltenius, 2017;Hartman, 2011). Furthermore, these reforms have brought about structural changes, sometimes with negative outcomes, such as reduced resources available for staff and residents (Storm & Stranz, 2018).
Since the marketisation of eldercare began, the number of privatised nursing homes has increased in the Nordic countries (Szebehely & Meagher, 2018;Szebehely & Trydegård, 2018). In Sweden, approximately every fourth nursing home bed has been eliminated since 2000 (Ulmanen & Szebehely, 2015) and over 20% of providers are now private actors (Andersson & Kvist, 2015). Swedish nursing homes are said to offer care based on each older individual's needs (National Board of Health and Welfare, 2018). The Swedish Social Services Act (SFS, 2001:453) states that eldercare should provide a reasonable standard of living as well as equality in living conditions. The introduction of consumer choice among nursing home service providers may threaten the goal of equality in the living conditions of older people (Jönson & Szebehely, 2018). If providers vary in quality based on differences between municipalities and in the conditions specified in municipal procurement documents, then it is difficult to consider the care provided to be equal. Older people needing nursing home care have limited opportunities to make active choices. A systematic review and meta-analysis concerning the reasons for applying to nursing homes found that the most common reason was a diagnosis of dementia (Toot et al., 2017).
Another aspect of the outsourcing of eldercare is that staff members may have to change their work routines if the new provider has alternative ideas about care provision and staff leadership (Trygged, 2020). Similarly, a systematic review, which included 15 European studies, highlighted that contracting out ownership of public service led to worsened working conditions, salaries, and reduced job satisfaction for public service staff. The authors concluded with a call for more studies concerning country-specific variations of contracting out ownership (Vrangbaek et al., 2015). Further, this is also important considering that staff members' empowerment and well-being affect care quality, as rated by the care recipients and/or staff (Engström et al., 2021;White et al., 2019). Previous research has demonstrated that to enhance the odds of resident well-being and adequate nursing home staffing, labour policies and equal working conditions among districts are important (Chen, 2014). Consequently, differences among providers due to procurement processes may be critical for the empowerment and well-being of both care recipients and caregivers.
Social workers have a crucial role in caring for older people by fostering a holistic approach to their quality of life and by helping caregivers understand the social aspects of care (Chong, 2007;Hardy et al., 2020) so that they can supply individualised care and empower older people (Roos et al., 2016). In our study, all staff members involved in the direct care of older persons are called caregivers. Social workers can collaborate with older people to ensure ageing-friendly policies and promote human rights, dignity, and freedom (IFSW, 2008). Social workers in Sweden are vital in ensuring reasonable standards of living and social services for older people, based on the Social Services Act (Forssell & Torres, 2012), as the care provided in Swedish nursing homes is usually a form of social care rather than health care (Melin-Emilsson, 2009). Furthermore, social workers such as care managers (biståndshandläggare) play a decisive role in determining whether or not care recipients can access a nursing home (Beaulieu, 2021;Dunér, 2013). Regardless of the organisation, caregivers in nursing homes must follow routines that affect the care recipients' autonomy (Alftberg, 2021).
According to the National Board of Health and Welfare (2014), an individual care plan should be formulated for each care recipient. The care plan is used to navigate and structure the caregiver's involvement in how and when the support should be provided to the care recipient. The care plan also addresses the care recipient's security, participation, mobility, and independence. However, individual care plans differ in scope, the richness of detail, and emphasis. Relatives are involved in developing the plans, which allows them to affect the care recipients' lives (Sjölund, 2013). Social workers, in the role of care managers, make assessments about what support older people can receive from the municipality, and those assessments are the foundation of the specifics of the individual care plans (Beaulieu, 2021). Little research has investigated the possible consequences for both caregivers and care recipients of the contracting out of care provision (Szebehely, 2011). This raises the question of how procurement documents are structured and whether they cover factors such as empowering the care recipients and caregivers in nursing homes. Freedom to choose among nursing home providers may not necessarily be equivalent to empowering older people, since there may be differences between the conditions specified in different procurement documents. If the procurement documents differ between municipalities, then the care providers may also differ, creating dissimilarities between care recipients and staff in different locations.

Aim
The aim of the study was to investigate the prerequisites for empowering both care recipients and caregivers in Swedish nursing homes.
1. What considerations for empowering care recipients are specified in procurement documents? 2. What considerations for empowering caregivers are specified in procurement documents? 3. Are there differences between the conditions for care recipients and caregivers specified in the municipalities' procurement documents and, if so, what do these differences indicate in terms of the objective of equality?

Empowerment as a theoretical framework
Empowerment theories focus on how organisations (Minkler et al., 2008;WHO, 2021) and individuals can gain power by identifying patterns of inequality (Askheim et al., 2007;Hutchison, 2015).
There are differences between empowerment for individuals (to exert control over their own lives) and for communities (to change society) (Naidoo & Wills, 2016). Laschinger and Finegan (2005) shed light on the importance of empowerment for caregivers in the hospital context, as well as in nursing homes (DeCicco et al., 2006), and on its relationship with job satisfaction and organisational commitment. Laschinger et al. (2010) found that nurses' structural empowerment in hospitals (e.g. good working conditions) was related to psychological empowerment such as autonomy, job satisfaction, and the possibility to affect the organisation. For caregivers in nursing homes, structural empowerment has also been found to be related to psychological empowerment (e.g. staff-rated job satisfaction, stress), and care quality (Engström et al., 2011;Silén et al., 2019). Laschinger et al. (2010) based their reasoning on Kanter's (1977) theory of structural empowerment and further developed the theory of empowerment to take into account the caregivers' experience of structural empowerment, including access to information, support, resources, opportunities to learn/grow, and informal and formal power, all of which affect their behaviour and attitude in the workplace. We followed Laschinger et al. (2010, p. 9) interpretation of Kanter's theory of structural empowerment which describes informal power for care recipients as 'establish partnerships with families, promote strong alliances between patients and members of the health care team'. Examples of formal power for care recipients are: being visible and available for their needs, allowing them to decide when to eat, drink, and which activities to participate in, and refraining from using dominant poses or talking down to them during visits. Informal power for caregivers is instead networking opportunities and encouraging collegiality, while formal power is for example increased role recognition for nurses or defined staff outcomes that are aligned with organisational goals. Caregivers experience empowerment when the workplace facilitates it. An empowering environment was found to generate higher work satisfaction among caregivers, who performed more effectively in the workplace and delivered higher-quality care (Laschinger et al., 2010). Empowered caregivers are more likely to empower the care recipients as well. The caregivers' work entails giving care recipients enough information, support, and resources to enable them to promote their health and experience of empowerment. As a result of their empowerment, care recipients also have opportunities to gain experience and grow (Laschinger et al., 2010). Laschinger et al. (2010) based their reasoning on the assumption that the same factors facilitate empowerment for both caregivers and care recipients. The empowerment of caregivers relates to the empowerment of care recipients, and these two agents' experiences of empowerment affect each other. However, in the theoretical framework developed by Laschinger et al. (2010), care recipients exist within a health care context, and for this study, the focus is specifically on care recipients in nursing homes.
Many nursing-home residents have dementia and do not have the same opportunities for empowerment (Toot et al., 2017). McConnell et al. (2019, p. 9) defined empowerment among persons with dementia as: 'A confidence-building process whereby persons with dementia are respected, have a voice and are heard, are involved in making decisions about their lives and have the opportunity to create change through access to appropriate resources'. Caregivers at all levels in organisations must work with policy documents about empowerment to establish their knowledge and skills to empower care recipients (Adams & Adams, 2008). One study of long-term care for care recipients with dementia in the Netherlands (Willemse et al., 2015) found that empowering the care recipients in terms of their identity, attachment, and inclusion improved their overall well-being.

Materials and method
The object of the analysis was seven procurement documents, with 10 attached documents, concerning Swedish nursing homes. One of the seven documents was a report, which contained summarised information concerning two procurement processes in one of the municipalities. The six other procurement documents contain information that specifies the nursing home being contracted out, the eligibility requirements for the procurement process, and how the municipalities will assess the proposal submitted by each provider. These documents normally comprise 20-40 pages and form the basis of the agreement with the winning providers. The collected documents included attachments such as tender dossiers and quality requirement forms, covering 20-100 quality requirements that the municipalities evaluate for each actor trying to win the procurement process. The municipalities evaluate and grade factors such as resident meaningfulness and empowerment, care quality, meal plans, leadership, and the number of competent and educated staff. See Table 1 for more details concerning the documents collected.

Selection of municipalities and documents
Procurement documents, which are publicly accessible in Sweden, were collected from three municipalities differing in size (number of town inhabitants), how many years they had contracted out nursing home care, and the number of for-profit providers in the municipality. The names of the municipalities were blinded for integrity purposes; instead, the municipalities were named 'Smalltown' 'Midtown' and 'Bigtown'. The objective was to collect two or three different procurement documents from each municipality; additional documents would be collected if further data were needed for the analysis. Differences between procurement documents were also considered, for example, in terms of the year of the contracting-out process or what private organisation won the process.

Analytical process
The first author and the second author analysed the documents separately, and the findings were jointly discussed by all authors. The gathered documents were analysed using deductive content analysis, structured based on our understanding and interpretation of Laschinger et al.'s (2010) categories of empowerment for care recipients and caregivers. First, a categorisation matrix was constructed based on these empowerment categories: 1) access to information, 2) access to support, 3) access to resources, 4) access to opportunities to learn and grow, 5) informal power, and 6) formal power. The entire material was read repeatedly to discern meaning units related to the study aim and to gain an overview of the content (see Graneheim et al., 2017). The text was sorted into two tables, one concerning the care recipients and the other for the caregivers. Relevant passages in the documents were identified and then condensed to form meaning units. Relevant passages were information related to the care recipients and the caregivers, for example, statements concerning meal plans or social activities and statements concerning the work environment. The condensed meaning units were coded and grouped into categories and sub-categories based on the mentioned framework. The material was carefully processed to ensure that no substantial part of the meaning units was lost or neglected.

Ethical considerations
A research ethics application to the Swedish Ethical Review Board (Dnr-number 2021-00121) was approved.

Results
The following section presents the results of the deductive content analysis, using two categorisation matrixes: one for the text concerning the care recipients (Table 2) and another one for the caregivers (Table 3).

Differences between the studied municipalities' procurement documents
There were differences in how the municipalities rated the incoming tender documents. Bigtown and Midtown graded them according to how the private providers described their services for the care recipients. The most critical factors of the grading process were: Bigtownmeals, activities, values, and rehabilitation approach, and Midtowna meaningful life, care, staffing and skills, and meals. Two different procurement strategies were identified. Smalltown graded incoming tenders according to the lowest price but also had the most comprehensive procurement documents regarding residents' right to participate in the nursing homes (e.g. choice of activities and meals). This could be because the incoming tenders were competing by price and not by quality, unlike in the other municipalities, possibly necessitating higher and more clearly formulated quality requirements in the documents regarding the care. The documents for the municipality of Midtown were not as detailed as the ones in Smalltown. Like all municipalities, Midtown saw the national and local ethics documents for eldercare as essential steering documents for resident treatment in the nursing homes. According to Laschinger et al. (2010), power is an essential aspect of empowering care recipients. However, only Smalltown emphasised the importance of exposing the power differences between caregivers and care recipients and ensuring that the caregivers are aware of those differences.

Discussion
We aimed to investigate the prerequisites for empowerment among care recipients and caregivers in Swedish nursing homes. The studied documents emphasised the care recipients' well-being and empowerment. Based on our results, the care recipients should have sufficient information and support allowing them to participate in their daily lives, as determined by the support needs assessment conducted by the care managers. Moreover, the caregivers should treat the care recipients based on the human rights stipulated in the procurement documents, and consider all care recipients as unique and deserving of treatment with dignity regardless of their abilities. In terms of the caregivers' empowerment, there were a few mentions of access to information, opportunities for growth, and formal power in statements concerning work environment regulations. The caregivers must have full competency, sufficient time, and sufficient resources to facilitate all dimensions that provide a good life for the care recipients. Most of the information concerning the staff concerned job requirements (e.g. education) to provide services for care recipients and language abilities. Give care recipients opportunities to complain about the care and follow up on quality (e.g. concerning activities, meals, care, and staff).
Give care recipients/relatives opportunities to give feedback on the care.
Give care recipients/relatives opportunities to express their views on the care and follow up on nursing home quality (e.g. concerning meals and activities). Give care recipients rights to privacy, integrity, and self-determination through individual care plans (regularly updated). Involve care recipients in formulating care plans.
Give care recipients opportunities to influence the support regulated in individual care plans (regularly updated).
Concretise the needs assessment in individual care plans together with the care recipients.
Notable difference: Give care recipients the right to privacy, integrity, self-determination, and participation.
Give care recipients opportunities to change nursing homes.
Regularly update the care plan. Midtown did not mention anything about participation in the organisation of care, such as meetings for service user representatives. Respect the wishes of relatives so they can represent care recipients with reduced capabilities.
Listen to the care recipients.
Have user council meetings with the residents every year.
Work for the care recipients' privacy, the integrity of body self-determination, and participation. Meet service user representatives at least twice a year.
(Continued) Involve care recipients/relatives in planning the care.
Have good relationships with relatives and respect their knowledge of the care recipients.
Offer a contact person as a link between caregivers and the care recipient/ relatives, with the possibility of changing the contact person.
Offer a contact person as a link between caregivers and the care recipient/relatives, with the possibility of changing the contact person.
Use a contact person, guarantee that the care recipient can change the contact person, and strive to find a contact person who speaks the same language as the care recipient.
Offer a contact person for regular meetings with caregivers/organisers, with the possibility of changing the contact person if needed.
Notable difference: Bigtown emphasised that the nursing homes should strive to offer a contact person who speaks the same language as the care recipient.

Formal power
Take enough time to listen to and talk with the care recipients.
Listen to the care recipients, but if the care recipients are confused, the caregivers must protect them from dangerous situations.
Give care recipients opportunities to influence the time of outdoor, social, and healthy activities, and to choose in line with their interests.
Notable difference: Give the care recipients opportunities to participate in activities that are meaningful to them.
Give care recipients opportunities to join activities outdoors and join in group sessions.
In Smalltown and Bigtown, caregivers should listen to the care recipients, giving them opportunities to participate in meaningful activities and influence what they eat. Ensure that care recipients' preferences regarding food, drink, and mealtimes are considered.
Allow care recipients to influence what they want to eat, taking into account religion, culture, and health, and to choose between different types of food In Midtown, caregivers must listen to care recipients but balance that against protecting them from harm.
Caregivers must consider that the care recipients are dependent on them. The caregivers must be aware of the unequal power relationship between them and the care recipients/relatives.
Smalltown emphasised that caregivers must consider the unequal power relationship between them and care recipients. At takeover, hold information meetings for staff, residents, and relatives.
Describe how the takeover will take place for the personnel.
Notable difference: Only Midtown emphasises the importance of informing the staff about requirements in procurement documents. Access to support Access around the clock to someone on staff who can support, supervise, and guide the other staff members.
The nearest manager must be available daily for employees. Support and guidance in rehabilitative work methods must be given to the staff by a physiotherapist and occupational therapist.
All municipalities had principles concerning access to support in daily work.
The person who leads the daily work must be physically close to the staff and be a pedagogical leader. According to Laschinger et al. (2010), caregivers should have enough information, support, resources, and power to help them empower the care recipients. The workplace should be structured to support the caregivers in their efforts to empower both themselves and the care recipients (Laschinger et al., 2010). The reviewed documents emphasised that the caregivers should apply a rehabilitation approach, to make the care recipients as autonomous as possible. Care recipients in nursing homes usually have severe disabilities (Toot et al., 2017). This may be important for social workers and especially care managers to consider, given that the caregivers' well-being and empowerment affect overall care quality, including missed care (Engström et al., 2021;White et al., 2019). If the caregivers' empowerment is low, this may limit the care recipients' empowerment as well (Laschinger et al., 2010). Social workers and primary care managers can play an important part in ensuring that the Social Services Act requirements concerning reasonable standards of living and Guarantee that the employees are offered collective agreementlike conditions in terms of holidays, working hours, and wages.
Notable difference: Ensure that the employees have the freedom to report misconduct without retaliation and counter-investigation to harass the employee.
As far as possible for the business, offer the employees the right to full-time employment.
Smalltown did not specify that the employees should be offered fulltime work whenever possible, which the other municipalities did.
social care for older people are considered in each individual care plan (Forssell & Torres, 2012). No paragraph in the studied procurement documents describes the social workers' role in nursing homes, except that the individual care plans mention that care recipients need support in nursing homes (National Board of Health and Welfare, 2014;Sjölund, 2013). This finding should be highlighted, considering that The European Commission (2021) calls for further collaboration in nursing homes from allied professions such as social workers. The support needs assessment conducted by care managers (mainly social workers) is the first step in developing an individual care plan (Beaulieu, 2021). Currently, the care recipients' needs are considered, but it may not always be possible to empower them in their daily life due to caregivers' lack of time. There must be some preconditions for the caregivers in nursing homes to be able to strengthen the empowerment of care recipients and implement the individual care plans, for example, having enough time and knowledge to work according to the needs assessment and not just the most urgent daily routines. Nursing home managers can sometimes be social workers, in which case they can contribute knowledge of the social aspects of daily life in nursing homes (Beaulieu, 2021). However, regardless of their positions, all staff should address the tender document requirements, translating them to their working reality and sharing with other staff the importance of empowering care recipients (Adams & Adams, 2008). The municipalities differed in their stated management support for caregivers, with Smalltown and Midtown having stated support requirements, while Bigtown did not. Another difference was that Smalltown operated based on price, with the quality specified in advance, while the other two municipalities allowed the providers to compete in terms of the quality offered. The fact that the municipalities compared providers on different bases may lead to differences between the municipalities in quality of care. Considering that Swedish policies emphasise freedom of choice among providers (Moberg, 2017) and the objective of equality (Jönson & Szebehely, 2018), these differences between municipal procurement documents and how providers compete may counteract the striving for equality. The juxtaposition between care choice and the objective of equality would be pointless if all providers were the same, meaning that it is difficult to see how the equality objective can ever truly be achieved. Older people living with dementia may consequently struggle to make a rational choice of provider; furthermore, the number of available providers may range from one to several depending on the municipality, causing problems in realising freedom of choice for older people.
The lack of stated resources, support, and informal power for the caregivers' empowerment and well-being is troubling, but not unexpected. For example, Vrangbaek et al. (2015) systematic review showed that contracting out public services generally led to worsened working conditions, but countries with tougher-regulated procurement documents had fewer negative outcomes from contracting out ownership. The authors argue that regulating and designing procurement documents to high standards is one key factor to safeguard the employees' working environment (Vrangbaek et al., 2015). The document's lack of staff empowerment or well-being may be one problematic aspect of marketisation and subcontracting leading to adverse outcomes. Consequently, considering the synergy effects whereby resident empowerment is dependent on staff empowerment, and one can empower the other (Laschinger et al., 2010), procurement documents could benefit by adding more psychosocial work environment aspects for staff, such as mandatory support systems from management and human resources.
Although these findings are based on procurement documents from Swedish nursing homes, the difference between how providers win the contracting process and the lack of empowering factors for caregivers may be relevant for other European countries. Considering that previous studies have illustrated that the marketisation of eldercare may be troublesome for staff and quality outcomes (Harrington et al., 2017;Vrangbaek et al., 2015), tougher regulations in procurement documents could be one step to alleviate the possible negative consequences of profit incentives. However, adding statements of empowerment or stronger regulations may not be enough. Recent studies have shown that Swedish procurement documents struggle with vague and imprecise wording (Isaksson et al., 2018), as well as accountability when providers fail to meet the specified criteria in the documents (Blomqvist & Winblad, 2022). Consequently, the marketisation of eldercare may be challenging for all countries striving for equality in nursing home care. Further research in other European countries could be beneficial to further determine the role that social work and care managers can play in nursing homes, the role of staff empowerment in the procurement documents, and possible ways to regulate and uphold standards.

Limitations
This study was based on procurement documents from the chosen municipalities. We only studied the preconditions for empowerment among care recipients and staff. We do not know for sure whether the documents convey a true picture of the actual conditions in nursing homes, but since the documents represent different priorities, there are likely differences in such conditions between municipalities.

Conclusions
. Several paragraphs in the documents referred to care recipients and their empowerment; few paragraphs besides those addressing labour law emphasised the empowerment of caregivers. The information about caregivers primarily concerned work requirements. . The municipalities have different strategies for considering price and quality when grading procurement documents. This likely reflects different quality standards despite nationwide policies calling for equality in care.