Configurations of Care Work: Fragile Partnerships in the Co-Production of Long-Term Care Services

Abstract

Over the last decade, authorities in several Western countries have stated their ambitions to increase the share of volunteers contributing alongside professionals in the future long-term care (LTC) sector, but the introduction of volunteers as co-producers of care services is sparsely investigated. This article is based on an empirical case study in Norway and investigates how co-production is translated into practice in diverse settings. Our findings demonstrate that understandings of voluntary work were fragmented. Co-production appears as a fragile partnership with an unclear understanding of the roles, expectations, and opportunities among the various parties who had different purposes/agendas and limited knowledge. To successfully provide added value in coproducing care, agents need to understand the whole picture and context, and build a common understanding of ‘why’ coproduce.

1. Introduction

1.1. A Complex Terrain

Care work in Western welfare societies is being undertaken by an increasingly diverse group of actors [1]. This is especially true in long-term care (LTC), where services are no longer solely delivered by professional staff in public institutions, but also by a number of other welfare providers. Diversifying the delivery of care is seen as one solution to the continuous pressure on welfare states resulting from social challenges and demands for budget austerity [2,3]. The voluntary and community sector is particularly being called upon to co-produce welfare services in partnerships with the public sector, the user, the family, and the market [4]. In Norway, the government has repeatedly emphasized the need for third sector involvement in providing and co-producing welfare services at the municipal level, and official policy documents and white papers are calling for new forms of cooperation between said sectors [5,6,7]. This shift in relations between the state and other sectors has led to the emergence of what Carmel and Harlock call “disorganized welfare mixes”, which are assessed on the principle of “what works” irrespective of the sector responsible for delivering the service [4]. However, as the saying goes, “too many cooks spoil the broth”, by which we mean that as the delivery of long-term care services is becoming a terrain characterized by increasing fragmentation, so the idea of “what works” would seem to depend on the perspectives of co-producing agents as well as the various contexts they engage in. In other words, as the state’s dependency upon other stakeholders to achieve its goals increases, so does the need to find common frames and understandings between often radically different and sometimes unequal actors [8]. How is this to be achieved?

In Norway, as in other Western countries, the objectives of the government are pursued through governance. According to Røiseland and Vabo governance can be understood as an interactive non-hierarchical process through which public and private actions and resources are coordinated and given a common direction and meaning [9]. In the contemporary discourse of governance processes, there is frequent use of ‘co-concepts’, like co-design, co-creation, co-production, co-operation and co-implementation [10]. These have become catchwords in the quest for social innovation and change in the public sector and are often used to bring forth images of partnerships and joint action in the production of services. However, what is the meaning and implication of these generalized abstract concepts for individuals involved in the everyday practice of service delivery [11]? Important questions to ask include how is co-production translated into practice in diverse care settings, i.e., how are mutual goals and collaboration between co-producers secured and what ways of organizing and acting are required to ensure that the quality care is not compromised?

Picking up on these questions, we direct our attention to the use of citizen volunteers in long-term care. More specifically, we analyze two empirical cases involving actors from the voluntary sector and professional employees from public sector nursing homes and look for gaps and bridges in their perspective on and motivations for voluntary work. The aim of the article is to discuss challenges that arise when actors from different contexts are brought together to co-produce caring services and to identify conditions that must be in place for co-production to be of value. First, however, we will describe the context of long-term care services in Norway, focusing on the attempts to integrate volunteers as generic service providers in public service delivery.

1.2. Norwegian Long-Term Care and Volunteering

Long-term care services in Norway are placed within the Nordic welfare model, characterized by a high degree of governmental control, tax-financed interventions, and welfare programs [12,13,14]. Service recipients in nursing homes are increasingly frail older people characterized by multiple morbidities and cognitive failure [15]. This has led to an increased need for advanced nursing competence [16]. More time is spent on caring for the critically ill and on documentation and reporting, which leaves professionals with less time for direct social contact with residents [17]. Against this background, the quality of care has been repeatedly discussed [18,19]. It is argued that general care is at a relatively high standard, but the opportunities for physical and social activities, especially in nursing homes, are relatively scarce [20]. In response to these concerns, campaigns and policy initiatives have been launched to increase the level of social and cultural activities run by volunteers to improve the quality of care services [7].

“Voluntary work” signifies the work a person does within voluntary organizations for others than family and close friends without receiving regular payment [21,22]. While the general participation in voluntary organizations in Norway is high [23,24], recent studies show that voluntary work in the LTC sector is modest [25,26]. This might indicate that the above-mentioned strong call for increased contribution from volunteers on the one hand is inconsistent with the relatively stable low prevalence of volunteers in LTC on the other. Recent studies also discuss the fact that several important issues seem to be undebated in the call for volunteers, e.g., which roles and responsibilities should volunteers have and how should their effort be coordinated and shared with professional care workers [27,28]. International studies have raised similar concerns demonstrating role ambiguity and blurred boundaries between professionals and volunteers [29,30]. As is pointed out by Merrell, ‘ambiguities and uncertainties are fundamental to volunteers’ participation in formal organisations and cannot altogether be eliminated” [29] (p. 101).

1.3. Co-Production

In the public management/administration (PMA) literature, co-production has been defined as ‘…the mix of activities that both public service agents and citizens contribute to the provision of public services. The former are involved as professionals, or ‘regular producers’, while ‘citizen production’ is based on voluntary efforts by individuals and groups to enhance the quality and/or quantity of the services they use’ [31]. Pollitt and Hupe, as well as Dudau et al., see co-production as belonging to a group of omnipresent concepts frequently used in public administration called “magic concepts”. Magic concepts are characterized by their overwhelmingly positive connotations, which make them hard to oppose; they are therefore effective in overcoming conflicting interests and logics. Another important aspect of such concepts is their ability to facilitate new orientations, frameworks, and coalitions [32]. In short, “magic concepts” point the way forward to developing better and more innovative public solutions, irrespective of social context. Nevertheless, their ubiquity makes them hard to define and they require a lot of work to translate into specific practices. According to Nabatchi, Sancino, and Sicilia co-production is a term that has been applied to a wide range of areas and activities involving multiple actors, but it has neither been used consistently nor been applied in ways that make it clear what it does and does not do [33]. A hallmark of co-production is generally understood to be the creation of reciprocal relationships between actors and ensuring the contribution of everyone involved [34,35]. More specifically, co-production locates users and communities as central actors in decision making, planning, managing, and delivering a service [11]. However, empirical studies of the actual processes and practices of co-production are scarce, as are the tools necessary to analyze such practices [36].

1.4. Public Value

Public service providers, such as municipalities, are concerned with the production of public value. Public value is an ambiguous concept and therefore difficult to define in an unequivocal manner [37]. Here, we follow Moore (2013, p. 469) in understanding public value in the narrowest sense as “public policy commitments to use governmental assets to achieve particular purposes” [38]. It may also be understood as providers of public services seeking to find ways of articulating and meeting the needs of their citizens, for example care needs [39,40]. Ultimately, public service delivery is about outcomes in terms of the value that is created for service users and society. Co-production can be understood as a way to remodel public service delivery with the aim of realizing public values [40]. However, the public management/administration (PMA) literature where the concept has its roots has been criticized for focusing more on production than on the creation of value [41,42], which means that tensions between different forms of value, for example the distinction between public and private value, have received less attention [41,42,43].

Recently, however, scholars writing from a public service dominant logic perspective have merged the discourse on co-production with the discourse on value creation using concepts such as value co-creation and value co-destruction [39,40,41,42]. These concepts provide tools for analyzing the outcomes of co-production empirically.

As co-production invariably implies the involvement of multiple actors at different levels [44,45,46,47], studying the interaction between them is a complex task. In the following, we attempt to achieve this by analyzing two cases of organizing voluntary activities in long-term care of the elderly. Studying ruptures and bridges in the interaction between co-producing actors, we aim to identify if and how values are realized or obstructed in the co-production of services in long-term care.

2. Materials and Methods

A qualitative study combining site visits and in-depth interviews was organized in eight municipalities in various parts of Norway. We selected cases with activities run by volunteers in nursing homes that required communication and coordination between volunteers and professionals and left out activities where volunteers operated autonomously. We prioritized the inclusion of activities that had been in operation for more than a year in order to gain insights of experience. The activities included in this study consisted of cultural, social and physical activities offered to residents in nursing homes.

In total, twenty-one qualitative interviews were carried out with front-line managers in long-term care and coordinators and activity leaders from voluntary organizations responsible for organizing the activities. We selected interviewees who were involved in the activities on a daily or weekly basis and had firsthand knowledge of the people involved and content of the activities. The managers put forward their own thoughts and opinions in response to the questions as well as the views of their staff and volunteers that had been shared with the managers in both formal and informal meetings. The interviews took place at the premises of the relevant voluntary organizations or coordinators, or in the workplace of the front-line managers, and lasted from 45 to 80 min. Interviews were conducted by the first author and followed a structured set of topics with probing questions to ensure comparability between the perspectives of the different agents. Adhering to a qualitative methodology, the interviewer was keenly aware of the participant’s voice and reasoning [48]. All respondents allowed the interview to be recorded provided they remained anonymous in any written reports. All interviews were audio-taped and transcribed verbatim and consisted of approximately 200 pages.

A thematic analysis [49,50] was applied through five interconnected stages: (i) familiarization; (ii) generating initial codes; (iii) generating themes; (iv) reviewing themes; and (v) defining and naming themes. Data were initially analyzed within the eight cases and then between cases. Themes related to frictions, co-ordination and cooperation challenges between long-term care managers, professional care workers and volunteers were identified. While engaging with the data, we realized that the value of volunteering was a central but implicit theme in the interviews. In this paper, we chose to share empirical data from two of the eight cases in the study to further illustrate and explore how partnerships and collaboration are initiated and organized in practical terms, and what experiences occur in the process. By selecting and focusing on two cases, we wish to present more in-depth empirical details and shed light on how partners respond in collaborative situations. We selected these two cases because although they organize their partnerships differently, they both struggle to produce value. The first case concerns a partnership organized from the top down (municipal coordinator pushing volunteers on a nursing home). The second case represents a bottom-up approach (a nursing home that despite solid preparations fails as the volunteers only stay in their roles for a short time).

2.1. Ethics

This project was registered and approved by the Norwegian Centre for Research Data (reference number 43928). All informants who participated in the study consented to the recording of the interviews. We have omitted information that can be traced back to the participants to safeguard their anonymity.

2.2. Findings

A common point of departure for the informants in the two cases was that they referred to government documents, white papers and national guidelines that encourage more voluntary work in long-term care services. However, the process of translating these political ambitions into practice was not always straightforward. The focus was on how volunteering was initiated, who was involved, what their motivations were and finally what challenges they encountered.

2.3. Case 1: Pushing Volunteers on a Reluctant Nursing Home

Case 1 unfolds in a municipality in Southern Norway. The municipality has an active local government that has advocated increased voluntary work in the community over the past five years. In the strategic plans for the municipality, references are made to national directives encouraging more voluntary work in health and social care, as well as in other fields. To facilitate increased volunteering, the municipality allocated funds to employ a coordinator in a part-time position. The appointee was given free rein when it came to shaping the job.

When interviewed for this study, the coordinator of the volunteers said that he thought he was hired because of his great understanding of ordinary people and that he got along well with people due to being a clergyman. Prior to his current role, he had experience from leading several voluntary activities and he was an active spokesperson from both the local church and a voluntary organization in the municipality. The coordinator began his new job by arranging several public meetings to encourage and mobilize people in the community to become volunteers. People from a range of municipal sectors, such as adult learning facilities and health and social services were invited, as well as voluntary organizations and the Norwegian Labor and Welfare Administration (NAV). In addition, a well-known motivational speaker was invited to give a talk. The coordinator’s approach to recruiting volunteers was, he said, to connect people:

‘It was important for me to connect with several people and agencies in order to increase volunteering. At the public meeting, we made a list of people who were interested in doing voluntary work. We got them together on a course about the basics of volunteering, an evening of teaching and then we were up and running. There were all kinds of people at the meeting, but mostly pensioners and several persons with minority backgrounds.’

The coordinator had a strong wish to connect volunteers with “the old and lonely residents in nursing homes” by way of a visiting scheme, and for this, he thought that “our new citizens” with refugee or minority backgrounds would be well suited:

‘Every resident in nursing homes needs both care and professional help you know… so we have several people who are caring and philanthropic who can help with the caring part… At the “kickoff” and through the Adult Learning Centre we got hold of persons who were very caring, with minority backgrounds. They are so caring you know! So many great people and they had so much love for the residents of the nursing home.’

The coordinator also recruited several members of his congregation. He thought that his call to get involved particularly appealed to people who were religious as they:

‘See this as a natural part of being a Christian… not to preach, but be a fellow human and empathetic, compassionate…’

When the coordinator had recruited 8–10 volunteers, he arranged a three-hour afternoon course assisted by a social worker from the community. The course addressed why volunteers were needed and provided practical information about what volunteers could and could not do. Shortly thereafter, the volunteers were introduced to a nursing home with a ward for people with dementia, where the volunteers were encouraged to socialize, sing, entertain, or take the residents for walks.

At the nursing home, a nurse was appointed by management to be the “contact person” for the volunteers. The nurse had previously been active in a voluntary organization, she was popular among the staff and seen to be very empathic. However, in the interview she explained how she felt she lacked the necessary tools to fill the role she was appointed:

‘I got this assignment randomly… no one else wanted it… but I have previously been involved in voluntary activity myself, and worked with care groups… I have no education in coordinating volunteers. Although I have been assigned the task of being a contact for the volunteers, I have no time allocated to coordinate or organize anything around the volunteers. It’s something that has been put on top of everything else.’

The nurse also felt that the voluntary scheme was “the baby” of the coordinator and nothing that she felt any great sense of ownership for:

‘This was his project, and he has been really keen, maybe a little too keen… You see, I have other things to do but…. (laughter). There are eight residents to a ward, and we are only two employees per ward, and I am needed everywhere. There are limits to how much I can get involved!’

After the scheme had operated for a few weeks, it turned out that most of the volunteers had a difficult time in the nursing home, especially the volunteers with refugee backgrounds who had problems speaking and understanding the Norwegian language. The original idea of the coordinator was that the volunteers with refugee backgrounds would be able to practice their language skills by visiting residents, but the staff did not see it the same way and complained to the manager:

‘…He [the volunteer coordinator] had a dream to get all these foreigners in here with us! He thought it was a very nice way to integrate them, but not all our staff agreed ... (laughter). It’s a nice thought he had but... I don’t think the patients suffering from dementia… well… that they are suitable for this. One must speak clearly to these residents, and one must understand some of the reactions and behaviour characteristics of the illness. In addition, you must understand how the service works.’

After many discussions with the nursing home, the coordinator had to admit that it had turned out to be difficult for the volunteers with refugee backgrounds to talk to residents. He also had to “call back” volunteers who did not get along with the staff. In the end, only a few volunteers were left, who had previously been employed in the nursing home before retirement.

2.4. Case 2: Mobilizing for Short-Term Involvement—Different Views on the Value of Volunteering

A manager in a nursing home in a major city contacted a voluntary organization asking for volunteers to help arrange activities for the residents. The nursing home had allocated funding for a part-time position as coordinator for volunteers. The coordinator who was hired had formal education in management and third sector involvement. The coordinator was responsible for recruiting volunteers, offering training and organizing the activities run by the volunteers. The coordinator was also an active member in a voluntary organization working to introduce more cultural activities in nursing homes. The nursing home was recognized for its innovative approach, such as facilitating several social and cultural activities run by volunteers. The manager claimed that the voluntary activities were a success, and that a key for success was to involve staff in the process:

‘When we established contact with volunteers, we had a get-together for the staff where we had a full day talking about volunteering. We had all our staff on a one-week trip overseas that was dedicated to working on the development of our institution…we have also had a lot of teaching ... we gather the staff and have courses two to three times a year. And I have regular meetings with ward leaders every week, where we discuss voluntary work.’

The coordinator explained that her role was to initiate, recruit, organize and communicate with volunteers on a regular basis, emphasizing that voluntary work in nursing homes had to be organized and communicated in a clear and concise manner. For example, her role was to form a structure that would give an overview of the volunteers, who was coming and when, and to keep a record of the visits. On arrival, a notebook was made available by the staff for the volunteers to sign themselves in. They also wrote when they planned their next visit. The notebook was intended as a tool to commit the volunteers, and at the same time inform the staff about what could be expected from the volunteers. Their experience was that the most unfortunate situations arose when staff were unaware that the volunteers were coming:

‘If you are entering a nursing home eager to help and make a difference… and no one meets you, no one greets you, and when you are leaving nobody thanks you… well, then you don’t really feel like coming back’.

The manager in the nursing home said that voluntary work was on the agenda in every morning meeting and the staff agreed how to share the responsibility for meeting and greeting the volunteers. They organized both primary and secondary responsibility for the volunteers on each shift, which was easily done when routines were put in place.

According to the coordinator, the volunteers needed to have information about the residents before they initiated any activities. She regularly held courses for the volunteers and gave advice on how to handle different sorts of situations that were likely to arise. An important aspect was information sharing and cooperating with staff:

‘…The volunteer will be given key information about the resident they are to visit and the resident’s background (history), so that there is a smooth transition. This means that the staff member accompanies the volunteer, introduces them and includes them in the conversation in a safe and warm atmosphere.’

She also told the volunteers what to expect as volunteers in a nursing home. One issue was to explain the often unpredictable mood swings and changing health conditions among the residents:

‘It can be a difficult day, or the residents’ health is poorer than the volunteer was expecting, or the volunteer struggles with communication with the resident. And some of the volunteers are dependent on getting feedback constantly, and they do not necessarily get that from the residents that they are visiting. So, clarifying these things [expectations] is really important!’

Despite the overall success with organizing volunteers and making voluntary work part of the daily routine, a “new” type of volunteer caused concern. The coordinator was increasingly having to deal with volunteers who approached the nursing home individually with varying motives for wanting to become volunteers. Some had lost their jobs; others were looking for work or language training or simply wished to “polish” their CV’s so that they seemed to be active and involved. The coordinator gave an example to illustrate the situation:

‘…I had a lady here recently in her fifties… Very resourceful woman. She had worked as a manager in a company and lost her job. She came here and wanted to volunteer as a visitor friend. We had great faith in her because she was so resourceful. She came twice ... and then she said she had got a new job that was paid. Then she stopped! We have other similar episodes of resourceful people who have lost their jobs. When they get a new job, we suddenly hear no more’

The coordinator felt that this was very problematic. Not only had she and the nursing home invested a lot in training and informing the volunteers, but the residents had become used to the volunteers and got attached to them. The coordinator pointed out how the volunteers saw their effort as of little value, but for the residents, their presence was of great importance:

‘Some volunteers do not take the task very seriously. Some may be serious, while others say they are “just” voluntary, so they don’t bother… They may think “I don’t mean that much”. I think they feel “just” voluntary and that they won’t be missed… but actually, they will be sorely missed!’

According to the coordinator there is a contrast between the wishes of the volunteers and the wishes of the nursing home. The volunteers often want something they can display, especially when they try to find a job, and are not necessarily so involved in the volunteerism itself. She stated:

‘They are looking for something for themselves, and what do we do about it? It is a bit on the side of volunteering because we want continuity for residents and staff. We want the volunteers to stay on for as long as possible… it takes a lot of dedication and effort to integrate a person in a ward and together with the residents and staff…’

The coordinator concluded that volunteers are a differently composed group of people. Previously, her experience was that for the volunteers, their own well-being and becoming part of a social group in addition to contributing to others’ lives was a secondary motive. However, more recently, she experienced that many volunteers were busy and had neither the time to take courses offered to them or come together socially with other volunteers.

3. Discussion

The first case demonstrates an uneasy relationship between the central actors and an uncoordinated process where there was incomplete negotiation and alignment of motives and goals. Being part of the local community external to the nursing home and having a different professional background, the coordinator lacked insider knowledge of the nursing home and importantly, knowledge of the degree of poor physical and cognitive health that characterized the residents the volunteers would encounter. Rather than aligning the motivations for his actions with the needs and motivations of the nursing home, he made the recruitment of a certain type of volunteer his priority. The resultant mismatch between the recruited volunteers and the staff and residents at the nursing home inevitably caused tensions that adversely affected residents and staff, as well as the volunteers themselves. Lack of attention to local contextual needs and the suitability of the volunteers made the construction of a shared collaborative field, central to co-production, difficult to achieve in this case. At the level of discourse, co-production holds great promise, infused as it is with positively valued notions of inclusion, empowerment, active citizenship, collaboration, deliberate democracy, and better services [32,39,51]. At the level of everyday practice as shown in this case, however, there are grounds for disenchantment, especially regarding the assumption that co-production necessarily leads to positive outcomes in terms of public value. Steen, Brandsen, and Verschuere (2018) make the point that the normative tendency towards optimism can end up masking potential pitfalls [52]. Recently, research has explored the dimension of quality or value brought forth by co-production, and critical perspectives have emerged in relation to the co-creation of value perspective [52,53,54]. Expressions such as “the dark side of co-production” [52] and concerns about the destruction of value for one or more actors that are in direct interaction with each other [55,56] are brought forward. Rather than talking of value co-creation in co-production, Plé [56] suggests that we talk of value processes in order to acknowledge that value is not always co-created but can also be co-destroyed. Looking at the first case in terms of value, it created little in the way of positive value for service users (residents), service providers or volunteers. Immigrants and refugees were recruited as volunteers to co-create what we might call dual value: the volunteers by offering the residents at the nursing home social activities, and the residents by providing the immigrant volunteers with language training. However, neither the residents nor the volunteers were able to fulfill this promise and consequently they both lost out. Furthermore, the service professionals who worked to accommodate the volunteers, sometimes on top of an already heavy workload, obtained a poor return for their efforts.

Our second case also illustrates, albeit in a different way, that the alignment of motivations and goals of co-producing actors can be difficult to achieve. Professional providers in long-term care have extensive clinical and local knowledge that will shape their views on volunteering and their expectations of volunteers. These will not necessarily be shared by volunteers, however, which gives rise to contradictions that are not easily solved. In this case, volunteering was a bottom-up initiative, and a coordinator with relevant professional background was employed to organize volunteering and plan for the inclusion of volunteers in the daily activities with residents and staff. Despite putting much effort into recruiting, preparing, and retaining volunteers, the coordinator found that the stability of the volunteers was poor. According to her, volunteers were a mixed group of people that increasingly had self-interested motivations for volunteering. Regardless of the work that was put into planning, organizing, and preparing them for engaging with the residents, they saw their input as of little consequence and their commitment was consequently short lived.

The literature on voluntary work points to volunteers’ motives having become more complex and varied in recent years, as have the group of volunteers themselves [57,58,59,60]. Traditionally, voluntary work is based on membership in voluntary organizations with members sharing values. However, volunteers are now less attached to organizations, and perhaps more motivated by personal development as a result. This can be understood as a “new type” of volunteer as mentioned in case 2 or as “organized individualism” [61]. Volunteers can, for example, be motivated by the need to document that they are active while waiting to get a paid job or when they are between jobs, which contradicts the logic of the nursing home and the elderly residents who seek stability and to build trust over longer time. In the second case, we have seen that the volunteers regarded their role as non-important, while the residents and staff considered it to be of great value. Danish studies have shown that co-production initiatives are mostly led by managers in public organizations and their staff [54]. They often set the premises and terms for how volunteers can contribute. Frictions are likely to arise as voluntary organizations do not wish to be controlled and monitored by the public sector [54], but want to define their own terms, and be free to enter and exit their roles at their own discretion. Moreover, volunteers constitute a large and complex group of people, which means that shared values cannot be taken for granted. As Hustinx et al. (2010) points out, volunteers and the activities they engage in “are embedded in interpersonal relationships with other volunteers, paid staff, and clients, as well as in specific organizational programs and settings, and broader societal structures and dynamics [62] (p. 425). This means that we must acknowledge that volunteering happens in multifaceted environments with actors acting to satisfy multiple and sometimes conflicting motives.

In the literature on co-production, professionals are seen as having a vital role in shaping the institutional context for co-production as well as in motivating and enabling citizens and service users to co-produce [63,64]. Our study and others show that successfully mediating between the many actors, motives and demands of co-production initiatives puts considerable pressure on professionals [28,63]. In line with Dudau, Glennon, and Verschuere et al. [39], we argue, therefore, that when it comes to value co-production, it is important to ask for whom value needs to be created: residents in nursing homes, service users in the community, professional service providers, or the municipality? The notion of value co-destruction [55] focuses on the misuse of resources and the resulting decline in well-being because of poor resource integration. Previous studies have identified that factors leading to such an outcome include a lack of transparency, the absence of information, a lack of trust, mistakes and a lack of bureaucratic competence [41]. We argue that additional factors such as poor understanding of the sector or context in which services are to be co-produced, failing to identify and comprehend the motives and concerns of the different actors involved as well as pushing new practices on unprepared agents, may also result in value co-destruction.

The two cases show that whether co-production initiatives are top-down or bottom-up, they may fail to produce positive value. In our first case, a top-down initiative failed despite the best intentions, due to poor alignment of motives and the incompatibility of goals, i.e., old people with dementia providing immigrants with language training in return for companionship. In our second case, a bottom-up initiative failed due to incompatibility between the stable relationships needed by the residents in the nursing home and the short-lived commitment of the volunteers. Consequently, considering the appropriateness of the planned initiative for the targeted services or specific groups within those services is important for its success. As Dudau et al. point out, “the assumption that the co-paradigm is not universally applicable to all public services seems more realistic than its ubiquity” [39] (p. 1590). Our cases also give cause for concern regarding the misuse of resources, especially at the municipal level. If municipalities respond to policy calls by funding initiatives in the haphazard way presented in our first case, the gains from co-production will be limited. As regards voluntary work in long-term care, recent studies have brought to light several factors that must be acknowledged for success to be possible. These factors include good relations and a high level of understanding between volunteers and professionals [65,66,67], recognizing that volunteers and service providers adhere to different logics [28,68], and recognizing that the health care needs of service recipients in long-term care are complex and often require professional care [69].

4. Conclusions

At the policy level, co-production is often presented as a visionary model for planning and delivering services with citizens as equal partners [35]. What happens at the frontline of co-production initiatives is less well known [11,39,70]. Our study of volunteering in long-term care services sheds light on challenging issues at the frontline. The analysis particularly points to the challenge of organizing a workable arrangement for volunteering in long-term care with actors who follow different logics in terms of motives, expectations, and priorities. Such contradictions must be solved for a collaborative partnership to be possible. Other studies warn against having uncritical confidence in co-production as a tool to solve challenges of quality and efficiency in the health- and welfare sector [52]. An unclear division of responsibility between public services and civil society has been reported, and co-production might lead to a transfer of responsibility from public services to civil society [53]. We argue that for successful co-production of services in the care sector to take place, initiatives must be firmly anchored in the services where the parties work together (e.g., nursing homes). The co-producers will benefit from preparing the joint effort together, planning and sharing aims beforehand as well as clarifying each other’s roles and expectations and the context in which they operate. Unless the activities are anchored and shared among all stakeholders, the co-production may lead to more frustration than value.