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This article develops a framework for understanding how the design of administrative judicial review can circumscribe the discretion of different bureaucratic actors. The framework proposes that bureaucratic discretion is limited to a great extent if courts can (i) overturn bureaucratic decisions on substantive grounds, (ii) review decisions associated with high economic costs, and (iii) issue detailed instructions for how rulings are to be implemented. Applying the framework to the Swedish case, we first show that the legislative design of the judicial review process allows administrative courts to greatly limit the discretion of senior officials and street-level bureaucrats. Second, we show that Swedish courts defer to the expertise of bureaucratic actors in the welfare sector by sparingly overturning decisions. However, when courts actually overturn decisions, they frequently limit bureaucratic discretion by issuing detailed judgments in high-cost cases, possibly undermining the conditions for good governance.

To understand patient and public involvement (PPI) and its potential impact in the healthcare services more comprehensively, the social science literature on public participation in governing public services must be integrated with the health science literature. To facilitate planning and evaluation of PPI-activities, the aim of this article is to review conceptual discussions of involvement/participation and impact, and summarize and integrate these in a way that advances the conceptual understanding of impact of PPI in healthcare services. Based on the review, we present a conceptual integration chart of impact areas, categories and types. There are three overarching areas: (i) impact on individuals; (ii) impact on the health system; and (iii) impact on decision-making processes and society. The overarching areas contain the categories: (i) citizens, patients, and decision-makers; (ii) service provision, and public health; and (iii) decision-making, policy and state, and public and society. Under these categories, the most commonly encountered impact types are presented.

Local self-government and rights legislation: On the division of power and responsibility between national and local governments This article investigates the tension between the ideal of national equality in wel-fare policy and the principle of local self-government emphasized in the Swedish Instrument of Government (Regeringsformen). We do this by analyzing the rights legislation – an overlooked instrument through which the national government can influence the actions of the local governments in welfare matters. The aim is to shed light on how administrative judicial review of local government decisions concerning individuals’ right to welfare works in practice and to discuss the impli-cations this has for local self-government. To achieve the aim, we set out to answer two research questions: (i) Do the administrative courts’ decisions concerning indi-viduals’ right to elderly care limit the discretion of local governments, and if so, within which aspects? (ii) Is the discretion of local governments limited to the same extent by all administrative courts, or are there regional variations in this regard? By developing a theoretical framework, we show that three aspects of the court’s powers are particularly decisive for the municipalities’ discretion: the grounds or scope of court review, the policy content of the court review, and the type of rem-edies or judgment. The empirical results show that Swedish administrative courts overturn municipal decisions to a comparatively low degree (23%), which indicates that judicial review of welfare rights does not necessarily challenge the discretion of local governments. However, when the administrative courts actually overturn decisions, they use their formal powers to limit the local governments’ discretion to a great extent, both in terms of the content of eldercare services provided and resource allocation. The results also show variation in approval rates between the Swedish administrative courts. This finding indicates that the administrative judi-cial review of the Social Services Act’s rights clause affects the discretion of some local governments more than others.

Background

Having more registered nurses (RNs) leave their workplace, with a shortage of RNs in healthcare as a consequence, might pose a risk to patient safety. According to the Job Demands Resource model, social support is a resource that can enhance work motivation, and if RNs are motivated at work, their willingness to remain in the workplace may increase.

Objective

The aims were to explore (1) differences in RNs' experiences of social support from their immediate manager and co-workers between different healthcare settings, (2) associations between RNs' experiences of social support and aspects of work motivation, and (3) if these associations differed in strength between healthcare settings.

Design

A cross-sectional study design.

Methods

A stratified population of Swedish RNs, n = 2290, working in either hospitals, primary care, or home healthcare, responded to a survey in 2022. Chi-squared tests and linear and logistic regression analyses were used to analyze the data. Interaction was measured by adding an interaction term to the fully adjusted regression models. The findings' generalizability was strengthened by including calibrating weights in all analyses.

Results

RNs in primary care reported higher social support from their immediate manager than RNs in hospitals and home healthcare. RNs in home healthcare reported lower social support from co-workers than RNs in hospitals and primary care. There were statistically significant associations between higher levels of social support from the immediate manager and co-workers, respectively, and higher ratings in all aspects of work motivation: work engagement (manager: beta coefficient [b] = 0.08, confidence interval [CI] 95% = 0.05; 0.10; co-workers: b = 0.12, CI 95% = 0.08; 0.16), job satisfaction (manager: b = 0.24, CI 95% = 0.21; 0.27; co-workers: b = 0.22, CI 95% = 0.16; 0.28), opportunities to provide high-quality care (manager: b = 0.15, CI 95% = 0.11; 0.18; co-workers: b = 0.19, CI 95% = 0.13; 0.24), satisfaction with the employer (manager: b = 0.46, CI 95% = 0.42; 0.50; co-workers: not statistically significant) and intention to remain at the workplace (manager: odds ratio = 1.89, CI 95% = 1.69; 2.13; co-workers: odds ratio = 1.42, CI 95% = 1.17; 1.72). The associations differed in strength between hospitals, primary care, and home healthcare.

Conclusions

Strengthening social support from the immediate manager and co-workers appears to be a way to increase RNs' work motivation, including their intention to remain at the workplace. This may be important, particularly in primary care and home healthcare.

Clinical Relevance

To strengthen RNs' work motivation and willingness to stay in the workplace, it appears important for healthcare organizations to provide RN social support.

Background: A challenge in Western countries is the growing need for registered nurses (RNs') in hospitals, primary care and home healthcare. Decreasing illegitimate tasks and strengthening RNs' work motivation are some strategies to address this challenge.

Objective: Our overall aim was to explore the association between RNs' experiences of illegitimate tasks and work motivation operationalised as four dimensions: work engagement, opportunities to provide high-quality care, employer satisfaction and intention to remain at the workplace. To address this aim, three specific research questions were asked: (1) Is there an association between illegitimate tasks and work motivation? (2) Do the levels of reported illegitimate tasks differ between RNs working in hospitals and those working in primary care or home healthcare settings? (3) Do associations between illegitimate work tasks and work motivation differ with type of workplace?

Design: A cross-sectional design.

Methods: We used responses from a stratified population of RNs in Sweden, n = 2,333, working either in hospitals, primary care or home healthcare. Calibrating weights were applied in all analyses to ascertain the generalisability of the findings. Illegitimate tasks were measured with the Bern Illegitimate Tasks Scale. Data were analysed using chi-squared tests and linear or logistic regression analysis. Interaction was measured on the multiplicative scale by adding an interaction term to the fully adjusted models.

Results: Overall, approximately 25 % of RNs reported frequently experiencing illegitimate tasks. There were statistically significant associations between higher perceptions of illegitimate tasks and lower ratings in the four dimensions of work motivation: work engagement [beta coefficient [beta] = -0.14, confidence interval [CI] 95 % = -0.18; -0.10], opportunities to provide highquality care [beta = -0.46, CI 95 % = -0.51; -40] and employer satisfaction [beta = -0.60, CI 95 % = -0.67; -0.54]. Experiencing higher levels of illegitimate tasks also related to a decreased intention to remain at the workplace [illegitimate tasks: odds ratio = 0.32, CI 95 % = 0.27; 0.29]. RNs who worked in home healthcare reported higher levels of illegitimate tasks than RNs who worked in hospitals.

Conclusions: Reducing the amount of illegitimate tasks may contribute to counteracting the shortage of RNs by increasing work motivation and willingness to remain at the workplace.

This article analyzes whether, and if so, why, national inspectorates adopt different enforcement strategies when controlling the provision of welfare services, such as health care, eldercare, and the compulsory school. The findings show that the Swedish Schools Inspectorate uses a predominantly strict strategy, while the Health and Social Care Inspectorate relies on a more situational strategy. To explain this variation in enforcement strategy, the article tests four hypotheses derived from the literature on regulatory enforcement. The findings suggest that the variation between the agencies is not primarily the result of differences in resources or the authority to issue punitive decisions, as suggested by previous research. Instead, we find support for the hypothesis that the definition of quality can explain variation in adopted strategies, and partial support for the hypothesis that differences in regulatory mission can account for a variation in the agencies' formal enforcement strategies.

This article deals with the 2009 user choice reform in Swedish elderly care. It analyses  how  the  tension  between  choice  and  older  citizens’  equal access to  good  quality  care  was  dealt  with  by  the  policymakers  who introduced it.  Three  overarching  research  questions  are  addressed  in  the analysis: (i) what  role  and  responsibilities  did  the  Swedish  user  choice reform  assign to  the  users  and  how  did  the  policymakers  view  users’ ability  to  make an  informed  choice?  (ii)  How  did  the  policymakers  view the  role  and responsibilities  of  the  local  authorities  and  what  tools  were the local authorities given to ensure access to good quality elderly care for all  citizens? (iii) Can  the  new  user  choice  reform  be said  to contain  a new notion  of social  citizenship  for  older  people  in  Sweden?  The  findings suggest  that while  the  user  choice  reform  encouraged  users  to  allocate resources and make free choices between providers, it also required users to  become  more responsible  to  ensure  service  quality.  The  reform  also advocated that the local authorities should steer their elderly care sectors through  partly  new governance  tools  and  secure  quality  foremost through  the  entering  of contracts  with  authorized  providers.  The  paper argues that, because of these required new roles and responsibilities, the Swedish  user  choice  reform entails a  more  libertarian  notion  of  social citizenship,  requiring  users  to  take  on greater  responsibility  for  their own  well-being  and  protection  against  risks.

Many policies promote patient and public involvement (PPI) in health research and healthcare provision. However, research points to uncertainties about its impact. The aim of the article was to compare what types of impact have been reported in reviews of PPI in health research and healthcare, respectively, and to map differences and similarities between the review studies. A review of reviews was undertaken with a search strategy based on the PCC mnemonic for scoping reviews. Four online databases were searched. Studies published in English between the years 20 0 0-2020, using a review-based method and aiming to demonstrate impact of PPI were included, resulting in sixty-one articles. More reviews of PPI impact in healthcare than in health research were found, although the latter included a larger number of empirical studies. Systematic reviews, quality assessment and quantitative studies were less common in health research. Many original studies were from the United Kingdom. In health research, reported impacts most often related to research design and delivery, while in healthcare the most commonly reported impacts were individual health outcomes/clinical outcomes. However, there is still uncertainty about the strength of evidence for PPI, in particular when it comes to collective in-volvement in healthcare, that is in policymaking and service improvement initiatives at hospitals or the like. 

Decision-makers may have to decommission services as a response to budget deficits. The aim of this study was to investigate a case of decommissioning with regard to the public's awareness and opinions. The analysis of a survey in a Swedish region that begun the implementation of an extensive decommissioning programme in 2015 shows that the majority of respondents were well or very well informed about the programme (68 %). A large proportion of the respondents thought the decision-makers to a low or very low degree had adopted appropriate measures to solve the economic problems (43 %), but together more respondents were either indifferent (39.5 %) or positive (17.5 %). Regarding the level of satisfaction with the region's healthcare system, compared to prior to the decommissioning period, 30 % were less satisfied while together more were either indifferent (48 %) or had become more satisfied (22 %). The large share of indifferent responses opens up for various interpretations or framings of the programme outcomes. Trust in the regions' healthcare system nevertheless increased during the same period. Furthermore, self-assessed health as well as age and utilization seem to be associated with healthcare system satisfaction during decommissioning. This illustrates heterogeneity in the public's responses to decommissioning, which calls for further investigation.

Background

Drawing on the literature on cutback management, this article deals with healthcare decommissioning in times of austerity. Politicians and decision-makers are typically reluctant to decommission healthcare, and if they do, the public generally reacts strongly towards reductions in service supply. Despite this, comprehensive decommissioning does take place, though empirical knowledge about its effects and economic sustainability is limited. To further the understanding of healthcare decommissioning, this paper aims to introduce the concepts of cutback management into the research on healthcare decommissioning, and apply its components to an empirical case of comprehensive decommissioning. In doing so, the study analyses whether decommissioning measures can be expected to generate long- or short-term economic payoff, and considers what other effects they might have on the healthcare system.

Method

We developed a theoretical framework that enabled us to investigate the measures through which a local healthcare system in Sweden, region Dalarna, responded to an acute fiscal crisis in 2014, and what effects these measures are likely to generate. The method used was a deductive content analysis of Dalarna’s decommissioning program, containing 122 austerity measures for saving 700 million Swedish Krona (SEK).

Results

Dalarna’s local decision-makers responded to the fiscal crisis through a combination of operational cuts (20% of undertaken measures), programme cuts (42% of undertaken measures), and structural reforms (38% of undertaken measures). The instruments most commonly used were increased patient fees and the merger of service facilities. By relying foremost on programme cuts and structural reforms, Dalarna adopted the measures most plausible to have moderate or long-term economic payoffs. Successful implementation, however, may be challenging and difficult to evaluate.

Conclusions

Healthcare politicians and decision makers have better potential to stabilize their long-term economic situation if they rely on responses such as operational cuts, programme cuts and structural reforms, as opposed to across-the-board cuts and cuts in investment and capital expenditures. However, with economics being only one important factor for sustainable healthcare systems, further studies should investigate how these measures affect important principles, such as equal healthcare distribution and access.