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Structure and Process Quality as Predictors of Satisfaction with Elderly Care
University of Skövde, School of Health and Education. University of Skövde, Health and Education. Department of Psychology, University of Gothenburg, Gothenburg, Sweden. (Social Psychology)ORCID iD: 0000-0003-0629-353X
University of Skövde, School of Health and Education. University of Skövde, Health and Education. (Social Psychology)ORCID iD: 0000-0001-7164-0433
2016 (English)In: Health & Social Care in the Community, ISSN 0966-0410, E-ISSN 1365-2524, Vol. 24, no 6, 699-707 p.Article in journal (Refereed) Published
Abstract [en]

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.

Place, publisher, year, edition, pages
John Wiley & Sons, 2016. Vol. 24, no 6, 699-707 p.
Keyword [en]
elderly care, process, quality of care, satisfaction, structure
National Category
Psychology Social Psychology
Research subject
Humanities and Social sciences
URN: urn:nbn:se:his:diva-10920DOI: 10.1111/hsc.12230PubMedID: 25809819ScopusID: 2-s2.0-84991045246OAI: oai:DiVA.org:his-10920DiVA: diva2:811490
Organisering för verksamhetskvalitet inom svensk äldreomsorg: Ett skifte i fokus från vad till hur
Forte, Swedish Research Council for Health, Working Life and Welfare, 2012–1200
Available from: 2015-05-12 Created: 2015-05-12 Last updated: 2016-12-01Bibliographically approved
In thesis
1. An Inquiry into Satisfaction and Variations in User-Oriented Elderly Care
Open this publication in new window or tab >>An Inquiry into Satisfaction and Variations in User-Oriented Elderly Care
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The foundation for this thesis is an ongoing discussion about quality in Swedish elderly care: Which are the most important factors that contribute to elderly care in terms of satisfaction among older persons, and what are the primary reasons for their differences?

Aims. The principal aim was to examine what determines satisfaction with elderly care in home care and nursing homes, using the perspective of older persons (Studies I and II). The secondary aim was to analyze why these determinants differ, using the perspective of care workers, managers, and observers (Studies III and IV).

Methods. Study I analyzed aggregated statistical data from the level of municipalities and districts (N = 324) based on the Swedish elderly care quality reports “Open Comparisons”, while Study II analyzed individual data based on the original ratings in the annual, nationwide elderly surveys (N = 95,000). Study III describes field observations and interviews with care workers and managers in two municipalities, one with a high rating for user satisfaction and one with an average rating. Study IV describes investigations in these two municipalities concerning their organizing principles and departmental‑level management climate.

Results. The results relating to the principal aim showed that process factors (such as respect, information, and influence) are related considerably more closely than structural factors (such as budget, staffing levels, and training levels) to satisfaction with care. Other process factors (such as treatment, safeness, staff and time availability) were also able to alleviate person factors (such as health, anxiety, and loneliness). Moreover, the results relating to the secondary aim showed that differences in user-oriented elderly care are mainly due to interpersonal factors between the caregiver and the older person. Care workers, however, reported that other factors (such as organizing principles and leadership support) influence the quality of the care process. Overall, older persons who receive home care generally report higher satisfaction with care than those in nursing homes, and feeling less safe. It may be that differences in the process of aging explain this.

Value. This thesis shows that satisfaction with elderly care can be largely explained by psychological quality at the individual level. The sizes of structural resources and organizing principles at the municipal level have minimal effect (< 5%). The thesis also presents a theoretical multiple-level Quality Agents Model to explain the sources of differences in satisfaction with care, and it presents recommendations for elderly care practices. A renewed focus on the psychology of satisfaction may contribute to the development of quality in elderly care.  

Place, publisher, year, edition, pages
Göteborg: Göteborgs universitet, 2015. 77 p.
, Doktorsavhandlingar vid Göteborgs universitet, ISSN 1101-718X
National Category
Psychology (excluding Applied Psychology)
urn:nbn:se:his:diva-11684 (URN)978-91-982353-9-5 (ISBN)
Public defence
2015-12-11, F1, Haraldsgatan 1, Göteborg, 18:21
Forte, Swedish Research Council for Health, Working Life and Welfare, 2012-1200
Available from: 2015-11-23 Created: 2015-11-12 Last updated: 2016-12-15Bibliographically approved

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