Abstract
This article aims at exploring how community home care of older people is provided and organized at night. In times of welfare decline, organizational changes, and an increasing aged population, questions arise about home care and support for older people. In Sweden, as in many other Western countries, “ageing in place” is a guiding principle in care provision for older people, which put increasing pressure on home care services. Still, nighttime care represents a research gap within health and social care research, nationally and internationally. This telephone interview survey examines 41 operations managers’ perceptions of organization and care provision and how they account for the goals and work of home care at nighttime in a selection of 37 Swedish municipalities. The analysis was inspired by thematic content analysis where three central themes were categorized: organizational context of nighttime care, working conditions, and challenges of nighttime care. Our results reveal that organizational context varied depending on the demography and size of the municipality. The work situation was characterized by constantly unforeseen events to manage. Multiple challenges were identified on societal and political levels, as were limited resources and recruitment problems. In conclusion, our analysis has identified unpredictability as a core feature of nighttime care work. The complexity of the provision of nighttime care was not recognized as important for the municipal organization. To provide high-quality care at night in ordinary housing, there is a need both to focus on organizational aspects and to have sufficient resources and time.
1. Introduction
This article sheds light on a knowledge gap in Swedish social research on the care of older people that considers organization and provision of community home care at nighttime. In fact, nighttime home care is more or less a blind spot in international health and social care research [1–4]. In the last few decades, Sweden and other Nordic countries have been suffering from the consequences of new public management (NPM) reforms of health and social care for older people [5]. We have been confronted by several changes, including an increasingly aged population, welfare decline, and organizational transformation towards marketization [6–12]. Nationally as well as internationally, this period prior to the COVID-19 pandemic is characterized with greater instability in the funding of care provision and has increasingly shifted back to the domestic and family setting. In addition, care has become a matter of a growing global care market with increasing inequalities in gender, class, and ethnic background [13, 14].
From an international perspective, however, the Swedish welfare system and the care of older people may still be seen as generous and well established, with several public opportunities available for assistance and care [15]. As older people live longer and live in their own homes with severe disabilities and vulnerability, the pressure on community home care services will increase—as will the pressure on home care at night.
Historically, care for older people has been a public responsibility in Sweden ever since the beginning of the 20th century, benchmarked by the 1913 pension reform [16, 17]. The development of care provision for older people has progressed from old-age homes to home care in ordinary housing with assistance and support from the municipality, an ideology with roots in the 1950s welfare reforms that organized public care for older people as home care services [16, 18]. This “ageing in place” norm has in the last decade also become an international guiding principle for the care of older people [12, 19]. The care receivers in need of assistance from community home care services have gradually become more vulnerable, and the needs of those receiving care and assistance have constantly increased, while public support has decreased cf. [20].
The Act on System of Choice in the Public Sector (in Swedish: Lagen om valfrihetssystem (LOV)) [21] was introduced in January 2009, legislation which came to affect public care provision for older people. Each municipality decides whether they want to implement said legislation; today about half (158 out of 290; 54%) of Swedish municipalities have implemented the system of choice [22]. The Act was introduced to allow municipalities to expose their publicly provided care services to market competition and to enable users to choose their providers [23]. Thus, the logic of competition and customer choice reframe older users as becoming active consumers or customers of care [10, 24].
Changes in care provision for older people can be related to the complex interplay between decision-making on national and local levels, and especially at the local level, many municipalities have been affected by economic pressures [15]. Furthermore, an increase of local variations and differences regarding the organization and provision of care for older people between the 290 Swedish municipalities has been observed [15, 25, 26]. This trend towards local variation would most certainly also apply to home care services given at night.
1.1. Aim and Research Questions
Based on the research gap in nighttime care provision, the aim of this article is to explore how community home care is provided and organized at nighttime. A telephone interview survey directed to operations managers (OMs), the professional group responsible for planning and provision of nighttime home care, was conducted in a selection of 37 Swedish municipalities. Research questions addressed are as follows: How do OMs perceive the organization and provision of nighttime home care? How do OMs account for working situations and goal descriptions of nighttime home care?
2. Background and Previous Research
2.1. Swedish Home Care Services at Nighttime: A Blind Spot
Despite the ideological shift towards “ageing in place” and an increased aged population with severe care needs and support around the clock, we still know very little about community home care at nighttime. This is remarkable, considering that night teams or night patrols started to develop in Sweden somewhere between the 1970s and 1980s to provide support to the neediest and most vulnerable older people in their homes—nighttime care remains a blind spot. Research and official statistics on community care of older people in ordinary housing have not separated the time of day for the provision of care, which implicitly indicates that care and care work is mainly described as activities performed during the daytime and valued as similar regardless of the time of day. However, nighttime home care differs from daytime home care as it is characterized by many short visits to frail and vulnerable older people, emergency visits, and little access to management support [27]. Furthermore, there are no official statistics on frequencies of nighttime care or numbers of older people requiring assistance at night. Swedish statistics [28] offer a hint, however, by producing searchable statistics on available interventions of public care provision for older people, such as residential care, daily care activities, short-term residential care, safety alarms, food distribution, and home care services. In the latter category, it is possible to search for the number of hours per month in four time intervals (see Table 1), where “50–around the clock” is the highest interval of home care services. However, having home care services for more than 50 hours per month does not necessarily include nighttime care. Nevertheless, there are no separate frequencies for nighttime home care services, and the available statistics are very imprecise because having nighttime care is not necessarily correlated with granted hours per month within home care services.
Table 1 reveals that the lowest and the highest intervals of hours of home care are most frequently granted to the older people, meaning that almost a quarter of the total number (171,184) of people who have home care services have 50 hours or more and/or around-the-clock assistance. To complicate the picture of nighttime care frequencies, in December 2022, 220,101 people had safety alarms. This means that approximately 49,000 older people only have a safety alarm, and thus, they may have no support from night teams until they press the alarm button.
2.2. Home Care Services at Nighttime: A Unique Way of Organizing Public Services?
Swedish community care of older people is mainly provided through home care and residential care, where home care services are the most common form of care and support and are offered to older people in their own home. Despite the fact that home care is the most common support given to the older people in Sweden, the few national and international studies available on nighttime care have focused on residential care facilities with a main focus on older residents, for example, in relation to sleep quality [29, 30], and risk factors of fall accidents at night [31]. One national research study explored security among older people in home health care in ordinary housing [2]. International comparisons on welfare service organization are, however, complicated and risky, as differences are more salient than similarities between countries and within the country, as in the Swedish case (with local variation) [15, 20, 25].
The current project has been presented at international conferences, and several questions have been raised by the international audience. Some researchers wondered whether it was a pilot project or not about nighttime care, as they indicated that mobile night teams seemed to be a fictitious invention. Other researchers raised multiple questions concerning the economy and expressed curiosity and surprise as they found it hard to understand that care workers were driving around in cars at nighttime to give care and assistance to older people in their homes [3]. Older people having such extensive needs were—from an international perspective—seen as the breaking point for a move to residential care facilities. Another frequent comment referring to care recipients was “but they are asleep at night.” This is a common stereotype frequently used in different contexts in relation to nighttime care even among care staff working daytime shifts [32]. There are obviously various international solutions for nighttime care assistance, and in addition to moving to residential care facilities and family care when extensive needs for support arise, “live-in carers” may also be employed. Research from Austria reveals that there is an increase in migrant care labour in private households, so-called “24-hour care” [33, 34]. Like Sweden, Austria has limited national data on formal home care at night, and the authors raise the question as to whether 24-hour care is a substitute for or a complement to traditional formal home care [33].
2.3. Care Work at Nighttime
In the case of working conditions at night, there is international research that focuses on the dilemmas of professional registered nurses, primarily in the hospital environment and in nursing homes. Research points to poor working conditions, leadership, and access to expert support and to fewer opportunities for development and education in the profession, in relation to daytime work. Altogether, these findings indicate low status and low recognition of the complexity of night work (see, for example, [32, 35, 36]). However, there is no equivalent research on nighttime care work provided by less-qualified care workers in ordinary housing by comparison.
A national study has focused on how intimate care is provided for older people at night by care workers, which revealed that home care services at nighttime primarily involve targeted interventions, such as changing incontinence pads, providing help into bed, draining catheters, helping to go to the toilet, and visits for check-ups, as well as responding to safety alarms. Night work was also characterized by many short visits and a lot of car driving [27]. Working on the night patrol means being flexible, actionable, and always prepared to manage uncertainty [4].
3. Methods and Materials
As part of a larger project focusing on community home care services at nighttime, this study explores the organization and provision of community home care at nighttime from the OMs’ perspective. A telephone interview survey consisting of standardized open-ended questions was conducted with 41 OMs (1–41) responsible for community nighttime home care services. The material was conducted in 37 of Sweden’s 290 municipalities, covering urban as well as rural areas and smaller and larger municipalities as well as bigger cities. In total, we contacted 58 municipalities of which 21 municipalities declined because of lack of time and/or occupied with reorganizations. Before we conducted the telephone interviews, a small pilot study consisting of interviews with four OMs was performed aiming to test the telephone interview questionnaire and to further develop guiding themes. Overall, the pilot study revealed that the OMs felt that nighttime care work was often neglected and seen as an unimportant field for the organization of care provision for older people. These interviews are not included in the interview study.
The telephone interview survey consisted of standardized questions ranging between “simple” and more “complex” open-ended questions organized under four themes: (1) organization (e.g., implementation of LOV legislation, private providers, and transportation), (2) care staff’s working situation (e.g., documentation, emergency alarm, security, and cooperation), (3) provision of care (e.g., application procedure, working tasks, and use of welfare technology), and (4) goal descriptions of home care (e.g., greatest challenges now and for future, guiding documents, and how to secure safety for older people) at nighttime.
All data used in this article have been approved and obtained after informed consent and are reported from the OMs’ views of nighttime home care organization and practice. The current research has been given ethical approval from the Regional Ethical Review Board in Umeå, Sweden (Dnr 2016/55-31).
3.1. Generating Data for the Telephone Interview Survey
We looked up the OMs in the selected municipalities’ web pages for contact details and contacted them personally and informed them about the aim of the research project and a date for each telephone interview was booked. The interviews were conducted between October 2016 and December 2017 and were performed by both researchers. Most of the OMs were positive to participate in the study, as they believed that nighttime care was an important but neglected practice within the community care of older people. The role of the OM was comprehensive responsibility for planning and organizing home care at nighttime in the municipalities’ different geographic areas. The OMs’ demographic background varied (see Table 2), seven of the 41 OMs were male, and all the OMs had academic education where “social education” (social work or equivalent) and “other education” (within economy, leadership, or military) were the most common educational background. Approximately one-fifth of the OMs had “medical education,” primarily as registered nurses. The OMs’ working experiences ranged between a couple of months up to 40 years.
The telephone interviews lasted 30–80 minutes each, but the majority lasted about an hour. Two-thirds of the interviews were recorded after giving consent, but all interviews were documented by the researchers’ taking notes in the questionnaire during the interviews.
The telephone interview approach made it possible to include municipalities from different regional areas to grasp local variations of strategies to organize nighttime home care services in Sweden. Open-ended questions made it possible to invite the OMs to speak openly about their views of nighttime home care as well as to obtain in-depth descriptions of the challenges of nighttime care [37, 38]. The survey also helped us identify four representative municipalities for the project’s case study [4].
3.2. Analysis
To map the field of nighttime home care services, and to capture similarities and differences in the material, we sorted and categorized the material from the survey’s four themes inspired by thematic content analysis [39]. Interview responses from the “simple” questions helped us highlight organization and provision of nighttime care in general terms. Responses from the survey’s “complex” questions contained rich reasoning and arguments by the OMs. These two types of responses are presented jointly in our findings of the analysis as they are informed by each other. Both researchers read through all the interviews separately to get a sense of the material. In a second round of reading, keywords and notes were added in the margins and then discussed. We worked out jointly the themes and categories of the material while remaining empirically sensitive in the analysis.
We identified three major themes which we labelled: organizational context of nighttime care; working conditions—unpredictability at night; and challenges of nighttime care. These themes are categorized with subheadings in our presentation of the results, which is reflected in the structure of our findings. Representative quotes from the interviews are illustrated as examples of OMs’ perceptions of nighttime home care.
4. Findings
4.1. Organizational Context of Nighttime Care
Generally, the organization of nighttime home care varied between different municipalities; for example, in large but sparsely populated municipalities, different aspects of logistics were mainly in focus of the OMs. Thus, the organizational conditions of nighttime home care in the 37 municipalities in our material varied, depending on demography and local political presumptions [15, 25, 26]. All the OMs said they used cars for transportation at nighttime, both in rural and in urban areas. During a night shift, the patrols could drive between 3,000 km and 30,000 km depending on the geographical area. In one case, a boat had to be used to enter an island in a specific local area.
4.1.1. Public or Private Providers: A Matter of Cost Efficiency
One striking finding was connected to private providers at nighttime. Even though about half (51%) of the OMs said they had implemented the Act on System of Choice in the Public Sector (LOV) [21] in their municipality, there were only five (12%) out of the 41 OMs who said they had private care providers offering nighttime home care services in their area. This means that nighttime home care is mainly provided by public welfare organizations and publicly employed home care staff in the municipalities, despite the implementation of LOV.
One reason for having few private providers at night was related to the economy, as one OM expressed: “we are bleeding money at nighttime” (OM40). The way this manager referred to the economy, nighttime care does not seem to be cost-effective for home care practice. Another example from this limited “customer choice” system at night was the fact that in some municipalities, recipients had to use the safety alarm to get help, as they did not plan for or schedule any safety visits; rather, a standardized provision of care support was applied. Taken together, this reflects that, according to LOV, “customer choice” at nighttime is not profitable [10].
4.1.2. Communication and Routine
Another central finding was connected to the organization of 24-hour home care and the establishment of routines and systems for communication work. “It is very awkward, we use fax or telephone for reporting, it is an area for improvement” (OM9). This is also an area of deficiencies that has been noticed at the national level [40].
In the cases of municipalities with many private providers, communication between day and night care staff could become specifically problematic because the documentation systems were not synchronized with each other and not fully available to night staff; “there are always problems with the private providers” (OM40). Even when there were no private providers, these challenges regarding lack of communication were described as major problems and a weak link in 24-hour home care services. Usually, the time for handovers was normally set to 10–15 minutes between day and night care staff: “the most important incidents at night will be reported within the 15 minutes handover, but sometimes we do not have the time” (OM5). There was not enough time to communicate the documentation, and several of the OMs expressed that there were documentation and communication deficiencies between night and day shifts, and this was something they needed to improve.
Other temporary disruptions in routines were related to the management of seasonal movements among older people on holiday, which increased the burden of care work at night. This often meant that summer guests in need of home care services in small cabins were not properly adapted for either the care recipient or the staff.
4.1.3. Welfare Technology and Municipal Changes
Many OMs responded that they were constantly confronted with different changes within the municipality. One such ongoing change was the implementation of welfare technology, where there was a huge variety regarding systems of technology. Some managers said they had had a pilot project under a period and then left it, while others said they continued. Web cameras were mostly used to monitor older people while they slept at night, and sometimes, this was used instead of physical safety visits by staff and was legitimized as not disturbing someone in their sleep. One OM said that the clients were sceptical: “the camera works fine, but you need to persuade your clients to accept the camera” (OM2). Other arguments were related to the local politicians and their decisions to implement welfare technology. Surprisingly, few of the OMs responded that they had routines for using welfare technology; either technology such as web cameras were being tested or they planned to start using them, but they had not yet been put into use.
Other technologies often taken for granted but always used were mobile phones, safety alarms, different digital documentation systems, and keyless locks at care recipients’ homes.
4.2. Working Conditions: Unpredictability at Night
Working situations at nighttime were, according to the OMs’ replies, mainly connected with working tasks, cooperation with other professionals, and security for care staff. They also said that they were aware of the complexity of nighttime care work and staff’s working conditions, especially regarding the unpredictability and preparedness for unforeseen things. Even though nighttime care work mostly was based on scheduled regular visits at the care recipient’s houses, the staff also had to be prepared to respond to emergency alarms if someone had fallen or become ill, for example. This also meant meeting some care recipients they never had met before and hardly knew anything about.
4.2.1. Working Tasks at Nighttime
The care work tasks at nighttime in the care recipients’ homes included a wide range of tasks. Apart from responding to emergency alarms, the tasks varied from helping someone into bed and/or in using the toilet, changing incontinence pads and/or catheter bags, giving medication, comforting someone with anxiety, or seeing if the care recipient was safe. One OM said: “they should give good care and the help should be performed as scheduled; for instance, help to toilet and to get into bed, and preferably they should be asleep.” (OM5). The ideal was to have sleeping recipients at night. However, the OMs’ responses oscillated between an awareness of not disturbing the recipients’ sleep and—on the other hand—arguing that they were just as sick at night as they were in the daytime.
Documentation during the night shift was also an important task both for the care workers themselves and to inform (written and verbally) staff at daytime. The OMs planned for some overlapping time of the care work between day and night, for the staff groups to meet, both before the night shift started in the evening and after the night shift ended in the morning. To document and report at night was challenging, mainly because of lack of time and as care work was so unpredictable at nighttime with unforeseen events that affected the scheduled routines.
4.2.2. Cooperation with Other Professionals
One topic which we raised in the survey was how cooperation with other professional groups appeared during the night. Most of the managers said that they were collaborating with registered nurses, palliative teams, and advanced medical home care. Some OMs also said: “we have our own direct number to 112 to contact the rescue service” (OM3). In other severe cases, the police, fire brigade, ambulance, and even locksmiths were mentioned as collaborators. One municipality had even set up a manager position on-call during nighttime to facilitate internal cooperation and to offer support to the care workers. One of the more extreme examples of collaboration came from a manager in a large but sparsely populated municipality, where they had on-call cooperation with a taxi company to answer emergency alarms from care recipients living far out in rural areas within the municipality. Some managers also emphasized internal cooperation between home care services and residential care, and others said that they were already cooperating sufficiently.
4.2.3. Responsibility for the Care Workers’ Security
Working at nighttime could mean that care staff was exposed to disturbances in the city during journeys between different care recipients. The OMs worked on risk assessments—which was a demanding task, according to some OMs. “Safety for the staff is important, if they are not safe, they cannot do their job” (OM6). None of the managers reported any serious incidents such as personal assaults on care workers, but some of them had, as a precaution, put in place assault alarms for night-care staff linked to the police or to security. Other OMs (one-third) replied that for security reasons, the staff always worked in pairs and carried their mobile phones with them. Simultaneously, one-third of the managers said that they always planned for solo night patrol while one-third had to accept solo work on certain occasions. In contrast, in some sparsely populated areas, it was a requirement to be able to work alone at night to be employed as a care worker.
Another unpredictability described was a lack of mobile coverage, especially in rural areas. This further highlights the local variation between municipalities regarding work organization of nighttime care. In addition to risks in the external environment, managers also mentioned car accidents, wildlife accidents, and drunk driving as well as slip and fall accidents among staff, especially during wintertime. The managers stressed that safety was complicated and difficult to manage at night, mainly due to darkness and small and unsafe cars. At the same time, the weather was a constant risk factor at night as were unknown spatial environments.
Taken together, the managers appeared to agree that nighttime care staff were special and accustomed to dealing with difficult and unpredictable situations, and they did not complain about safety at night, unless necessary.
4.3. Challenges of Nighttime Care
Our survey also included questions about what managers thought were the biggest challenges in nighttime care, now and for the future. Most of the identified challenges concerned recruitment problems, limited resources in care provision for older people, demographic and political changes, overall societal changes, and changes in the living conditions of older people.
4.3.1. Societal Challenges: Politics, Demography, and Geography
A recurrent challenge for nighttime care practice was the need to expand home care at night to maintain quality and simultaneously keep to the budget, which meant a constant struggle with politicians, because older people are not a high-priority social group, according to some managers. At the same time, managers were aware of the increasing group of older people: “politicians have made decisions regarding “ageing in place,” which means that we must expand our night practice” (OM14). In line with this, there were others who responded: “Challenges due to more complex cases, for instance, those who are more demanding and know their rights, can we really execute all the decisions of care at night?” (OM39). More older people will need care at night, as many are frail and diseased, which is a challenge for the future. Sometimes, hospitals send care recipients home earlier than before, which also affects their ability to carry out care work at night.
We must invest more, it’s getting stingier and stingier, there’s no time left soon. The elderly shouldn’t be allowed to cost—it’s shameful! People are just as sick at night as they are during the day. We need to invest more resources in the elderly (OM3).
Many of the challenges identified by the OMs were of a general nature, such as limited resources, but were also associated with geographical position and season. Winter was always a challenge at night due to slippery roads, darkness, and a lot of snow on unpaved roads, especially in sparsely populated areas and in northern Sweden. At the same time, there were more and more challenges in the surrounding society, such as increased violence and car fires, especially in urban areas, which affect the ability of care staff to do their work at night.
4.3.2. Recruitment Problems and Limited Resources
One of the biggest challenges, according to managers, was recruiting care workers who were competent and well trained and willing to remain in the profession, “We need a stable staff that is careful and does not rattle at night and wake up the care recipients” (OM15). It is also important to emphasize that the managers were working on making the nighttime care work more attractive and visible to the care organization in the municipalities. Being able to recruit the right staff and get them motivated to work and stay is crucial, and one manager pointed out, however: “we are not interested in just anyone” (OM6). This can be related to a debate in Swedish politics referring to the basic character of care work for older people as an easy job that anyone can do.
In line with previous research, recruitment problems were a challenge, also in nighttime home care, and were expected to increase in the future. A Nordic comparative study shows that about half of Sweden’s care workers in home care want to leave, mainly because of poor working conditions [41]. In addition, the workload and work situations at night are particularly unpredictable, with bad cars and a lot of driving, and a risk of accidents and extreme weather, making future recruitment to night care work rather insecure and risky.
One source of recruitment problems is related to the limited resources, which have increasingly come to be discussed in connection with the need to develop welfare technologies in care provision for older people [42]. In some of the investigated municipalities, new technologies had been installed, mostly surveillance cameras for use at night. However, there were several challenges in relation to welfare technology, both in relation to the care recipients and in relation to local politicians and to managing different systems for documentation.
5. Discussion
The aim of this article was to explore how community home care services are provided and organized at nighttime. Research of organization and provision of home care at night represents a blind spot which we have highlighted from the OMs’ perspective and how they account for the goals and work. The OMs had comprehensive responsibility for the planning and provision of nighttime home care while being accountable to the municipality’s politicians. Overall, the organizational context of nighttime care differed from daytime home care as there were few private providers. The logic of competition and “customer choice” spurred by the Act on System of Choice in the Public Sector [21] seemed to be out of play at night in most municipalities. Economy seemed to be the major reason for this, as it was not cost-effective to have mobile teams at night and certainly not profitable for private providers [10]. Our analysis has shown reoccurring arguments by the OMs about how they had to struggle with limited resources in social care practice.
It also became salient that organization and provision of nighttime care varied between the municipalities due to demography and regional location. Rural areas had to find solutions for long distances and unforeseen events, often related to weather conditions and extensive car driving. In urban areas, there were more societal disturbances at night, such as violence in the street and car fires. The working situation at night was characterized by unpredictability and to manage unforeseen events, such as emergency calls and the need to comfort someone at night in cases of anxiety or falls. The unpredictability of nighttime care provision puts high demands on cooperation with numerous other professionals such as advanced medical care, palliative teams, or the police. The number and character of possible collaborators involved reflects the complexity of work and potential risks during the night.
The provision of home care at nighttime was impregnated with challenges. Some challenges involved changes and reorganizations of community home care at night, for example, the implementation of welfare technology and documentation systems. Even basic technology like having mobile coverage could be a challenge when put out of play. A major concern for the OMs was the increasing group of older people in need of care at night with complex or demanding needs. “Ageing in place” puts high demands and pressure on nighttime home care and care staff, which must be planned for. However, the OMs perceived recurrent challenges with limited resources in nighttime care and political requirements to maintain goals for quality of care.
Over the past three decades, we have witnessed welfare decline and the marketization of public care provision for older people [5, 10], changes that all have affected older people in need of care and assistance in their homes, as well as care workers. This fits poorly with the “ageing in place” ideology and goals for safety and security in home care. The receivers of nighttime home care are frail and vulnerable in need of extensive care and support and cannot act as independent active customers. As our analysis revealed, “customer choice” was out of play at nighttime, which accordingly may be perceived positively. However, the nature of nighttime care work with lack of time and unforeseen events such as emergency calls violated the routines of scheduled visits and resulted in more unpredictability, also for the recipients at night. Paradoxically though, our analysis shows that nighttime care work is full of unpredictable and unforeseen events—reflecting the complexity of care work at night—and yet care work at nighttime seemed to be such an insignificant and neglected practice of care for older people in the municipalities.
5.1. Limitations
We chose to focus on organization and provision of nighttime care in the survey, and consequently, we interviewed OMs responsible for operating night care practice. It would have been interesting to hear from other professional groups as well, and not having perspectives other than those of OMs may be seen as a limitation of this study. However, the telephone interview survey functioned as guidance for our research project’s next stage, the case study, which included care workers, care recipients, and care unit managers’ perceptions [4]. This research study was performed before the COVID-19 pandemic, which means that our results might have turned out differently after the pandemic. There is reason to believe that the challenges in community home care with current underfunding, staff shortages, and increased workload would put even more pressure on nighttime care.
6. Conclusions
Our analysis of this study has revealed some important results. Not only have we explored a blind spot and a research gap in public care provision for older people, but it also reveals a neglected field of practice, partly due to low recognition of nighttime care work and general perceptions that all care recipients sleep at night. The OMs faced many challenges related to safety management and care staff’s working conditions. Our analysis has identified unpredictability as a core feature of nighttime care work, as it is loaded with unforeseen events. This is important to acknowledge when organizing care work at night. An increasing aged population and increased frailty among care recipients also put pressure on municipalities.
The ageing people are not a prioritized group for the politicians in the community, according to the interviewed OMs. There were numerous challenges connected with care provision for older people that needs to be addressed more broadly. International research has identified severe challenges of care provision for older people that has become particularly visible during the COVID-19 pandemic, affecting healthcare research of older people, the welfare policy system, and care staff’s working conditions and their own health [13, 43, 44]. Moreover, the COVID-19 pandemic has posed unprecedented care-related challenges, which necessitate the reconceptualization of care and its focus on research [13]. The pandemic has generally downgraded social care, and care work is connected to low recognition; however, this also raises fundamental questions of care and well-being of human life and how to value reproduction work. Home care must be organized with sufficient resources including time, and to be in tune with the ideology of “ageing in place” to provide good and quality care at night, now and in the future.
Data Availability
The qualitative interview data used to support the findings of this study have not been made available because of the anonymization of the respondents and the municipalities used for ethical reasons.
Additional Points
What is Known about This Topic. (1) “Ageing in place” is the norm in Swedish community home care provision for older people, and the care recipients in need of care and assistance are more vulnerable than before. (2) More than half of Swedish municipalities have implemented the Act on System of Choice in the Public Sector, which opens public care provision for older people to market competition and “customer choice.” (3) Many municipalities have been affected by economic pressure, and there are local variations and differences regarding organization and care provision between municipalities. What This Paper Adds. (1) “Ageing in place” and an increasingly aged population put high pressure on the provision of nighttime care with numerous challenges, such as organizational changes, limited resources, and recruitment problems, depending on municipalities demography and regional location. (2) Home care at nighttime was mainly provided by public providers, and thus, market competition and “consumer choice” were taken out of play at night. (3) Nighttime care work is full of unpredictable and unforeseen events which must be acknowledged when organizing and providing high-quality care at night.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Acknowledgments
The research has been funded by the FORTE, Swedish Research Council for Health, Working Life and Welfare (Reg. no. 2015-00820).