Ratings, rankings and managing numbers: Professionals' perspectives on user surveys in Swedish nursing home care.

Public sector services are audited, measured and ranked in order to improve quality and transparency and to prompt organizations to conform to normative definitions of quality. In Swedish eldercare, a nationwide user survey distributed by the public authorities to all eldercare users, designed to gauge user satisfaction, is a prominent example of this form of soft governance. The aim of the present study is to investigate nursing home representatives' meaning making of the user survey and its function. The findings from 24 qualitative interviews suggest that despite professional scepticism about flawed measurement procedures and tools and thus the validity of the survey results, organizations adjust the care they offer in order to improve low scores. External pressure and the risk of shame and a bad reputation may explain their willingness to let survey results guide their organizational improvements. The article concludes that practitioners may rely on their professional knowledge to dismiss the validity of normative external demands on one level but still manage such demands by making organizational changes on another level for the sake of good reviews. Moving between these levels makes it possible for respondents to be simultaneously critical and compliant. As an organization will need to appeal to external assessors of quality if it is to manage its reputation by achieving high scores, the audience's perceptions risk overriding care users' voices—the very voices the survey is intended to listen to. [ABSTRACT FROM AUTHOR]