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Activating the Sick-Listed: Policy and Practice of Return to Work in Swedish Sickness Insurance and Working Life
Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences.
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

A critical task of social policy in most Western welfare states during recent decades has consisted of reducing the economic burden on society due to sick leave, by stimulating participation in the labour market. Many jurisdictions have introduced activation policies, based on the premise that work “per se” has a therapeutic effect on sick-listed workers. People are expected to be “active”, rather than “passive”, recipients of financial benefits. However, there is limited knowledge of how activation policies focusing on return to work (RTW) are carried out in local practice. Against this background, the overall aim of this thesis is to study the local practice of activation policies by analysing how they are received, implemented and experienced by welfare state organizations, employers and sick-listed workers. The analysis has been influenced by theories concerning organization fields, individualization, street-level bureaucracy and organizational governance.

In this thesis, the overall aim is investigated in four interrelated papers. In Paper I, the aim is to analyse the perspectives of stakeholders (i.e. welfare state actors and employers) on work ability by studying multistakeholder meetings. Paper II sheds light on activation policy, focusing on early RTW in the context of modern working conditions; the aim is to analyse RTW practice in local workplace contexts, in relation to Swedish early-RTW policy. The third paper focuses on employers, with the aim of analysing their role and activities regarding RTW, in local workplace practice. In Paper IV, the aim is to analyse sick-listed workers’ experiences of the sickness insurance system in their contact with the Swedish Social Insurance Agency (SSIA) and their front-line staff.

The empirical material comprises two empirical studies: 1) audio-recorded multi-stakeholder meetings from regular practice (n=9) and 2) semi-structured interviews with sick-listed workers and their supervisors in 18 workplaces (n=36). The analyses of the material have been performed in accordance with the principles of qualitative content analysis.

Main findings of the papers reflect strong organizational boundaries in the implementation process of activation policies. Welfare state actors and employers appear to be governed by their own organizational logics and interests, so the actors involved fail to take a holistic view of sick-listed workers and do not share a common social responsibility for individuals’ RTW. This thesis illustrates how current activation policies focusing on RTW are based on a rather idealized image of the standard workplace. There is an explicit or implicit assumption that employers and work organizations are able to welcome sick-listed workers back to work in a healthy way. However, the intensity of modern working life leaves limited room for accommodating people with reduced work ability, who are not considered to have a business value to the workplace. In several cases, findings indicate that the SSIA’s focus on activation and early RTW clashes with the financially oriented perspective of employers. Economic considerations regarding their business take precedence over legal and ethical considerations, and employers have difficulty taking social responsibility for RTW. Sick-listed workers are encouraged to adjust to new workplace settings and environments to meet the demands of the workplace, and, if RTW is not possible, to the demands of the labour market. The findings also show that sick-listed workers experience that contacts with the SSIA are ‘standardized’; i.e., they perceive that the officials are loyal  to demands in their organizations rather than being involved actors who support workers’ individual needs. Sick-listed workers clearly experience that measures in Swedish activation policies have a strong focus on demanding aspects (financial work incentives) and less on enabling aspects (investments in skills).

Overall, this thesis illustrates an emerging social climate where sick-listed workers are positioned as active agents who must take responsibility for their sick leave and their RTW process. In a Swedish context, RTW is a matter of activating the sick-listed rather than activating the workplace.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2014. , 71 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1421
Keyword [en]
Activation policies, return to work, social policy, sickness insurance, working life, employers, street-level bureaucracy, individualization
National Category
Occupational Therapy Public Health, Global Health, Social Medicine and Epidemiology Political Science Sociology Work Sciences
Identifiers
URN: urn:nbn:se:liu:diva-112400DOI: 10.3384/diss.diva-112400ISBN: 978-91-7519-232-1 (print)OAI: oai:DiVA.org:liu-112400DiVA: diva2:765944
Public defence
2014-12-19, Aulan, Hälsans Hus, Campus US, Linköpings universitet, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2014-11-25 Created: 2014-11-25 Last updated: 2014-11-26Bibliographically approved
List of papers
1. Policy and Practice of Work Ability: A Negotiation of Responsibility in Organizing Return to Work
Open this publication in new window or tab >>Policy and Practice of Work Ability: A Negotiation of Responsibility in Organizing Return to Work
Show others...
2012 (English)In: Journal of occupational rehabilitation, ISSN 1053-0487, E-ISSN 1573-3688, Vol. 22, no 4, 553-564 p.Article in journal (Refereed) Published
Abstract [en]

Purpose In welfare policy and practical work it is unclear what the concept of work ability involves and assessments may be different among involved actors, partly due to a lack of theoretical research in relation to regulations and practice. Based on theoretical and legal aspects of work ability the aim of the study is to analyze stakeholders’ perspectives on work ability in local practice by studying multi-stakeholder meetings.

Methods The material comprises nine digitally recorded multi-stakeholder meetings. Apart from the sick-listed individual, representatives from the public Social Insurance Agency, health care, employers, public employment service and the union participated in the meeting. The material was analyzed using qualitative content analysis.

Results Three perspectives on work ability were identified: a medical perspective, a workplace perspective and a regulatory perspective. The meetings developed into negotiations of responsibility concerning workplace adjustments, rehabilitation efforts and financial support. Medical assessments served as objective expert statements to legitimize stakeholders’ perspectives on work ability and return to work.

Conclusions Although the formal goal of the status meeting was to facilitate stakeholder collaboration, the results demonstrates an unequal distribution of power among cooperating actors where the employers had the “trump card” due to their possibilities to offer workplace adjustments. The employer perspective often determined whether or not persons could return to work and if they had work ability.

Place, publisher, year, edition, pages
Springer, 2012
National Category
Occupational Therapy Work Sciences Public Health, Global Health, Social Medicine and Epidemiology Political Science Sociology
Identifiers
urn:nbn:se:liu:diva-73888 (URN)10.1007/s10926-012-9371-3 (DOI)000310472400012 ()
Available from: 2012-01-16 Created: 2012-01-16 Last updated: 2017-12-08
2. Early-Return-to-Work in the Context of an Intensification of Working Life and Changing Employment Relationships
Open this publication in new window or tab >>Early-Return-to-Work in the Context of an Intensification of Working Life and Changing Employment Relationships
2015 (English)In: Journal of occupational rehabilitation, ISSN 1053-0487, E-ISSN 1573-3688, Vol. 25, no 1, 74-85 p.Article in journal (Refereed) Published
Abstract [en]

Purpose Many Western welfare states have introduced early-return-to-work policies, in which getting sick-listed people back to work before they have fully recovered is presented as a rather unproblematic approach. This reflects a belief in the ability of employers and the labour market to solve sickness absence. Against this background, the aim of this study was to analyse return-to-work practice in local workplace contexts, in relation to Swedish early-return-to-work policy.

Methods Semi-structured interviews were conducted with 18 matched pairs of workers and managers. The material, comprising a total of 36 interviews, was analysed using qualitative content analysis.

Results Three main themes were identified: (1) intensive workplaces and work conditions (2) employer support—a function of worker value and (3) work attachment and resistance to job transition. The results reflected the intensity of modern working life, which challenged return-to-work processes. Managers had different approaches to workers’ return-to-work, depending on how they valued the worker. While managers used the discourse of ‘new opportunities’ and ‘healthy change’ to describe the transition process (e.g. relocation, unemployment and retirement), workers regularly experienced transitions as difficult and unjust.

Conclusions In the context of early-return-to-work policy and the intensity of modern working life, a great deal of responsibility was placed on workers to be adaptable to workplace demands in order to be able to return and stay at work. Overall, this study illustrates an emerging social climate where sick-listed workers are positioned as active agents who must take responsibility for sick leave and return-to-work process.

Place, publisher, year, edition, pages
Springer, 2015
Keyword
Social policy; Return-to-work; Sick leave; Work place; Career mobility
National Category
Occupational Therapy Public Health, Global Health, Social Medicine and Epidemiology Sociology Political Science Work Sciences
Identifiers
urn:nbn:se:liu:diva-112396 (URN)10.1007/s10926-014-9526-5 (DOI)000349971100008 ()24920449 (PubMedID)
Available from: 2014-11-25 Created: 2014-11-25 Last updated: 2017-12-05Bibliographically approved
3. Return to work or job transition?: Employer dilemmas in taking social responsibility for return to work in local workplace practice
Open this publication in new window or tab >>Return to work or job transition?: Employer dilemmas in taking social responsibility for return to work in local workplace practice
2015 (English)In: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165, Vol. 37, no 18-19, 1760-1769 p.Article in journal (Refereed) Published
Abstract [en]

Purpose: The aim was to analyze the role and activities of employers with regard to return to work (RTW), in local workplace practice.

Method: Semi-structured interviews were conducted with sick-listed workers and their supervisors in 18 workplaces (n  = 36). The analytical approach to study the role of employers in RTW was based on the three-domain model of social corporate responsibility. The model illustrates the linkage between corporations and their social environment, and consists of three areas of corporate responsibility: economic, legal and ethical.

Results: Employers had difficulties in taking social responsibility for RTW, in that economic considerations regarding their business took precedence over legal and ethical considerations. Employers engaged in either “RTW activities” or “transition activities” that were applied differently depending on how valued sick-listed workers were considered to be to their business, and on the nature of the job (e.g. availability of suitable work adjustments).

Conclusions: This study suggests that Swedish legislation and policies does not always adequately prompt employers to engage in RTW. There is a need for further attention to the organizational conditions for employers to take social responsibility for RTW in the context of business pressure and work intensification.

Implications for Rehabilitation

  • Employers may have difficulties in taking social responsibility for RTW when economic considerations regarding their business take precedence over legal and ethical considerations.
  • Rehabilitation professionals should be aware of that outcomes of an RTW process can be influenced by the worker’s value to the employer and the nature of the job (e.g. availability of suitable work adjustments). “Low-value” workers at workplaces with limited possibilities to offer workplace adjustments may run a high risk of dismissal.
  • Swedish legislation and policies may need reforms to put more pressure on employers to promote RTW.
Place, publisher, year, edition, pages
Informa Healthcare, 2015
Keyword
Activation policy, employers, sick leave, work accommodation, workplace
National Category
Occupational Therapy Public Health, Global Health, Social Medicine and Epidemiology Political Science Sociology Work Sciences
Identifiers
urn:nbn:se:liu:diva-112397 (URN)10.3109/09638288.2014.978509 (DOI)000359878700020 ()25355548 (PubMedID)
Available from: 2014-11-25 Created: 2014-11-25 Last updated: 2017-12-05Bibliographically approved
4. Activation Policies and Sick-Listed Workers’ Experiences and Trust in the Sickness Insurance System in Local Practice
Open this publication in new window or tab >>Activation Policies and Sick-Listed Workers’ Experiences and Trust in the Sickness Insurance System in Local Practice
2014 (English)Manuscript (preprint) (Other academic)
Abstract [en]

In recent welfare and labour market reforms in Europe and North America, there is a general trend towards activation, in that people (e.g. those who are sick-listed, unemployed and recipients of social welfare) are expected to be “active”, rather than “passive”, recipients of financial benefits. Meanwhile, street-level bureaucracy in many welfare state organizations has been fundamentally reformed in recent years with the implementation of New Public Management Principles which have come to influence the day-to-day work of front-line staff. The aim of this paper is to analyse sick-listed workers’ experiences of the sickness insurance system in their contact with the SSIA and their front-line staff. The data consists of semistructured interviews with 18 sick-listed workers in Sweden. The material was analysed using qualitative content analysis. The findings illustrate that sick-listed workers experienced contacts with the Social Insurance Agency (SSIA) as “standardized”; that is, they perceived that the officials were loyal to demands in their organizations rather than involved actors that supported workers’ individual needs. The SSIA was described as having a mainly administrative and controlling function during their sick leave, resulting in a distant relationship. It was also clear that sick-listed individuals experienced the activation policy as demanding, and their sick leave was characterized by insecurity and uncertainty. Overall, this paper suggests that activation policies with regulations emphasizing time limits, and enforcement of standardized work processes at the SSIA, challenge sick-listed workers’ trust in the sickness insurance system.

National Category
Occupational Therapy Public Health, Global Health, Social Medicine and Epidemiology Work Sciences Political Science Sociology
Identifiers
urn:nbn:se:liu:diva-112398 (URN)
Available from: 2014-11-25 Created: 2014-11-25 Last updated: 2014-11-26

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