IntroductionDenmark and Sweden initially adopted different responses to the COVID-19 pandemic although the two countries share many characteristics. Denmark responded swiftly with many mandatory restrictions. In contrast, Sweden relied on voluntary restrictions and a more "relaxed" response during the first wave of the pandemic. However, increased rates of COVID-19 cases led to a new approach that involved many more mandatory restrictions, thus making Swedens response similar to Denmarks in the second wave of the pandemic. AimThe aim was to investigate and compare the extent to which the populations in Denmark and Sweden considered the COVID-19 restrictions to be acceptable during the first two waves of the pandemic. The study also aimed to identify the characteristics of those who were least accepting of the restrictions in the two countries. Materials and methodsCross-sectional surveys were conducted in Denmark and Sweden in 2021. The study population was sampled from nationally representative web panels in the two countries, consisting of 2,619 individuals from Denmark and 2,633 from Sweden. The questionnaire captured key socio-demographic characteristics. Acceptability was operationalized based on a theoretical framework consisting of seven constructs and one overarching construct. ResultsThe respondents age and gender patterns were similar in the two countries. The proportion of respondents in Denmark who agreed with the statements ("agree" alternative) that captured various acceptability constructs was generally higher for the first wave than the second wave of the pandemic. The opposite pattern was seen for Sweden. In Denmark, 66% in the first wave and 50% in the second wave were accepting of the restrictions. The corresponding figures for Sweden was 42% (first wave) and 47% (second wave). Low acceptance of the restrictions, defined as the 25% with the lowest total score on the seven acceptability statements, was associated with younger age, male gender and lower education levels. ConclusionRespondents in Sweden were more accepting of the restrictions in the second wave, when the country used many mandatory restrictions. In contrast, respondents in Denmark were more accepting of the restrictions in the first wave than in the second wave, implying an increased weariness to comply with the restrictions over time. There were considerable socio-demographic differences between those who expressed low acceptance of the restrictions and the others in both countries, suggesting the importance of tailoring communication about the pandemic to different segments of the population.

PurposeAt the outbreak of the COVID-19 pandemic, health care was at the centre of the crisis. New demands made existing organizational practices and services obsolete. Primary health care had a great deal of responsibility for COVID-19-related care. The pandemic demanded effective leadership to manage the new difficulties. This paper aims to explore experiences and perceptions of managers in primary health care in relation to their efforts to manage the COVID-19 crisis in their everyday work. Design/methodology/approachThe authors used a qualitative approach based on 14 semi-structured interviews with managers in primary health care from four regions in Sweden. The interviews were conducted during September to December 2020. Data were analysed using conventional qualitative content analysis. FindingsData analysis yielded three categories: lonely in decision-making; stretched to the limit; and proud to have coped. The participants felt lonely in their decision-making, and they were stretched to the limit of their own and the organizations capacity. The psychosocial working conditions in primary care worsened considerably during the pandemic because demands on leaders increased while their ability to control the work situation decreased. However, they also expressed pride that they and their employees had managed the situation by being flexible and having a common focus. Originality/valueLooking ahead and using lessons learnt, and apart from making wise decisions under pressure, an important implication for primary health-care leaders is to not underestimate the power of acknowledging the virtues of humanity and justice during a crisis. Continuing professional education for leaders focusing on crisis leadership could help prepare leaders for future crises.

Introduction:The present article aimed to investigate 1) if mental health problems (depression and burnout including the dimensions; emotional exhaustion, mental distance and cognitive and emotional impairment) differed between nurses and physicians in Sweden, 2) if any differences were explained by differences in sex compositions, and 3) if any sex differences were larger within either of the two professions. Method:Data were derived from a representative sample of nurses (n = 2903) and physicians (n = 2712) in 2022. Two scales were used to assess burnout (KEDS and BAT) and one to assess depression (SCL-6). The BAT scale has four sub-dimensions. Descriptive statistics and logistic regression were used to analyse each scale and dimension separately. Results:Results showed that 16-28 % of nurses and physicians reported moderate to severe symptoms of burnout. The prevalence differed between occupations across the scales and dimensions used. Nurses reported higher scores on KEDS while physicians reported higher scores on BAT including the four dimensions. Also, 7 % of nurses and 6 % of physicians scores were above the cut-off for major depression. The inclusion of sex in the models changed the odds ratios of differences between doctors and nurses in all mental health dimensions except mental distance and cognitive impairment. Limitations: This study was based on cross-sectional survey data which has some limitations. Conclusion:Our study suggests that the prevalence of mental health problems is prominent among nurses and physicians in Sweden. Sex plays an important role in the difference in the prevalence of mental health problems between the two professions.

BackgroundThe initial responses to the COVID-19 pandemic in Denmark and Sweden differed markedly. Balancing disparate concerns was crucial to generate trust in the COVID-19 restrictions. The aim was to investigate the extent to which there was trust in the handling of the pandemic by the Danish and Swedish governments and public health authorities in each country. A further aim was also to investigate the characteristics of those in Denmark and Sweden who expressed the lowest degree of trust.

MethodsCross-sectional surveys were conducted in 2021, using web panels that are nationally representative of the socio-demographic characteristics. The population consisted of 2619 individuals from Denmark and 2633 from Sweden, representative of the age, sex and region of residence of the populations aged ≥ 18 years. Trust in government and health authorities was captured in two separate trust questions on a 5-point Likert scale and dichotomized into low trusters and non-low trusters for analysis.

ResultsApproximately, 61% of the Danish respondents expressed moderately large or very large trust in the government’s handling of the pandemic. The corresponding proportion for Sweden was 42%. The proportion of low trusters was 11% in Denmark and 34% in Sweden (p < 0.001). Moderately large or very large trust in the public health authority’s handling was expressed by 83% of the Danish respondents and 74% of the Swedish respondents. The proportion of low trusters was 5% in Denmark and 17% in Sweden (p < 0.001). In both countries, trust was lower among men than among women. Age and education were associated with trust but differed between countries (p <  = 0.011).

ConclusionsIn this study, differences in trust between Denmark and Sweden and both overall and within socio-demographic factors were observed. However, given the limitations and bias in the study, it is difficult to determine the cause and true size of these differences. With that in mind, we still believe specific populations and subgroups within those populations have the potential to affect trust in handling of the COVID-19 pandemic, and that these should be kept in mind when developing and communicating responses to pandemics.

This article draws on theories of normative control and critical management studies to investigate caseworkers strategies in correspondence to a new leadership philosophy in the Swedish Public Employment Service called self-leadership. Based on 43 interviews and observations at two local offices, we find that managerial models are arbitrary and cause uncertainty at the local level as caseworkers both comply and resist managerial talk of self-leadership. Based on a distinction between types of and grounds for strategic responses, we identify four subject positions defined as "personal embracement", "personal detachment", "professional recognition" and "professional dismissal". The study shows that newly employed comply through practices of personal embracement, while senior employees resist based on professional dismissal. The article concludes that caseworkers are not docile bodies, who adjust to managerial talk, but derive their identity, engagement and esteem linked to a shared-work identity as organisational professionals. This demonstrates the relevance of closing the gap between street-level bureaucracy and critical management studies to further explore the tension between governing "employees" or "professionals" in contemporary public welfare governance

Purpose Activation policies and efforts to reduce sick leave rates has influenced sickness insurance systems in Western countries, which has led to social security being more connected with work and attempts to expose malingering among the sickness absent. The aim of this study was to explore how power and trust are expressed by clients and stakeholders within the Swedish sickness insurance system. Methods This was a longitudinal qualitative study based on semi structured interviews and case files from 31 clients on sick leave in Sweden. Data was analyzed using a thematic analysis. Results The main theme Acts of power and distrust illustrates how stakeholders express suspicions towards each other, and how clients need to demonstrate desire and efforts to return to work which other stakeholders verified. Conclusions The clients desire to prove themselves able to contribute to society was prominent in this study and power relations need to be acknowledged, in particular between client and the SIA. Further, to preserve citizens trust in the system, the system needs to demonstrate trust also in the clients.

Aim The aim of this study was to explore lessons from the pandemic by registered and assistant nurses in Swedish primary health care (PHC) of potential relevance for the future operation of PHC. Methods Twenty-one semi-structured interviews were conducted with registered and assistant nurses. We used a purposeful sampling strategy to achieve a diverse sample with regard to size and location of PHC centres. Data were analysed using qualitative content analysis. Results Analysis yielded two categories: lessons from the pandemic pertaining to PHC personnel and patient behaviours (adaptability of the personnel; importance of hygiene and maintaining physical distance; and importance of being attentive to illness symptoms) and lessons from the pandemic related to primary healthcare work routines (effectiveness of digital job meetings; advantages of digital patient consultations; importance of keeping infectious patients separate from other patients; and the need to allow only pre-booked patient appointments). Conclusions The seven sub-categories represent seven lessons from the pandemic. The lessons generated both instrumental knowledge, which the nurses could apply in work-related decisions, and conceptual knowledge which yielded improved understanding of problems and potential solutions for PHC.

Drawing on ethnography in the Swedish Public Employment Service, this article compares caseworkers’ and local managers’ perceptions of changes towards increasing digital self-services for clients. Findings reflect a conflict of interest between different service ideals: vulnerable subjects in need of personalized guidance (caseworkers) versus competent subjects ready to manage their own unemployment via digital self-services (local managers). As we argue, the dislocation of responsibility via digital self-services serves to reinforce responsibilization, thus turning the client into her own caseworker. This development runs the risk of pushing vulnerable groups even further away from employment than they already are.

Objective The aim of this study was to explore how the COVID-19 pandemic changed the working conditions of physicians in Swedish primary healthcare. Design This is a descriptive, qualitative study with individual semistructured interviews. Data were analysed using inductive content analysis. Setting Swedish primary healthcare units in both rural and urban areas. Participants A total of 11 primary care physicians fulfilled participation. Results Two main categories emerged: work organisation and routines and psychosocial work environment, containing three and five subcategories, respectively. The pandemic enforced changes in work organisation and routines. Increased flexibility, including more patient-oriented delivery of care, and novel means of interorganisational and intraorganisational interactions were perceived as positive by physicians. The pandemic also caused several changes in physicians psychosocial work environment. Increased workload, information overload, as well as ethical considerations and feelings of uncertainty made the work environment stressful for physicians. Conclusions The COVID-19 pandemic affected the working conditions of physicians in Swedish primary healthcare in numerous ways. The pandemic enforced changes in work organisation and routines for physicians in primary healthcare. Further research is needed to investigate how the pandemic will affect primary healthcare in the longer term. Learning from the pandemic is important because this will not be the last crisis that primary care and its healthcare professionals will face.

Bakgrund: Aktiveringspolicy och teorier om moral hazard har influerat utformningen av sjukförsäkringssystem i flera delar av västvärlden. Detta har lett till att sjukpenning blivit allt svårare att erhålla, mer kopplat till arbete och aktivitet, samt insatser för att genomskåda fusk bland sjukskrivna.

Syftet med studien var att utforska hur makt och arbetsmoral uttrycks av sjukskrivna och andra aktörer i sjukförsäkringssystemet.

Metod: Detta var en kvalitativ longitudinell studie baserad på intervjuer och akter från 31 sjukskrivna som varit på en försäkringsmedicinsk utredning. Data analyserades genom tematisk analys.

Resultat: Resultatet visar hur olika aktörer misstänkliggör varandras agendor och kompetens, samt hur olika maktmedel används för att rättfärdiga deras slutsatser. Det framkom även vissa allianser mellan aktörer där dessa präglas av samsyn och samarbete mot gemensamma mål i sjukskrivningsprocessen. Primärt ses dessa allianser mellan sjukskriven och sjukskrivande läkare, men även i enstaka fall mellan handläggare och sjukskrivande läkare i de fall läkaren förespråkar aktivering. De sjukskrivna personerna uttryckte en stark vilja och försök mot arbete eller aktivitet, och deras arbetsmoral verifierades ofta av andra aktörer.  

Slutsats: Maktspel förekommer på olika sätt inom sjukförsäkringssystemet och de medel som användes i den här studien gavs olika betydelse beroende på vilken aktör som använde dem (exempelvis tolkningen av en försäkringsmedicinsk utredning). Den här studien kan ifrågasätta vissa antaganden om moral hazard och simulering bland sjukskrivna då personerna ofta presterade över sin förmåga under en försäkringsmedicinsk utredning i förhoppningen om att i någon mån visa sig förmögen att bidra till samhället, vilket även verifierades av andra aktörer.

Social distancing measures have been a key component in government strategies to mitigate COVID-19 globally. Based on official documents, this study aimed to identify, compare and analyse public social distancing policy measures adopted in Denmark and Sweden regarding the coronavirus from 1 March 2020 until 1 October 2020. A key difference was the greater emphasis on laws and executive orders (sticks) in Denmark, which allowed the country to adopt many stricter policy measures than Sweden, which relied mostly on general guidelines and recommendations (sermons). The main policy adopters in Denmark were the government and the Danish Parliament, whereas the Public Health Agency issued most policies in Sweden, reflecting a difference in political governance and administrative structure in the two countries. During the study period, Sweden had noticeably higher rates of COVID-19 deaths and hospitalizations per 100,000 population than Denmark, yet it is difficult to determine the impact or relative effectiveness of sermons and sticks, particularly with regard to broader and longer-term health, economic and societal effects.

BACKGROUND: Studies of the social validity of work ability evaluations are rare, although the concept can provide valuable information about the acceptability, comprehensibility and importance of procedures. 

OBJECTIVE: The aim of this study was to explore clients’ perceptions of social validity of work ability evaluations and the following official decisions concerning sickness benefits within the Swedish sickness insurance system.

MATERIALS AND METHODS: This was a longitudinal qualitative study based on interviews with 30 clients on sick leave, analyzed through deductive content analysis. 

RESULTS: Clients’ understanding of the evaluation was dependent on whether the specific tests were perceived as clearly related to the clients’ situation and what information they received. For a fair description of their work ability, clients state that the strict structure in the evaluation is not relevant to everyone. 

CONCLUSION: The work ability evaluations indicate low acceptability due to lack of individual adaptation, the comprehensibility varied depending on the applicability of the evaluation and information provided, while the dimension ‘importance’ indicated as higher degree of social validity. The official decision about sickness benefits however was considered unrelated to the evaluation results, lacking solid arguments and sometimes contradictory to other stakeholders’ recommendations indicating poor social validity.

Background Many problems with primary care physicians psychosocial working conditions have been documented. Many studies on working condition have used the Effort-Reward-Imbalance (ERI) model, which posits that poor health and well-being may result from imbalances between the level of effort employees perceive that they put into their work and the rewards they receive. The model has not been used in qualitative research or applied to investigate primary care physicians working conditions. The aim of this study was to apply the ERI model to explore the perceived efforts and rewards by primary care physicians in Sweden and approaches they take to cope with potential imbalances between these efforts and rewards. Methods The study has a qualitative design, using semi-structured interviews. A purposeful sampling strategy was used to achieve a heterogeneous sample of primary care physicians who represented a broad spectrum of experiences and perceptions. We recruited 21 physicians; 15 were employed in public health care and 6 by private health care companies. Results The analysis of the interviews yielded 11 sub-categories: 6 were mapped to the efforts category, 3 were attributed to the rewards category and 2 were approaches to coping with effort/reward imbalances. Many of the statements concerned efforts in the form of high workload, restricted autonomy and administrative work burden. They also perceived resource restrictions, unpredictability of work and high expectations in their role as physicians as efforts. Three types of rewards emerged; the physicians found their job to be stimulating and meaningful, and the work climate to be supportive. The physicians coped with imbalances by means of job enrichment and using decisional latitude. Conclusions Primary care physicians perceive numerous types of efforts in their job, which is consistent with research concerning work stress and associated consequences, such as poor subjective health and well-being. There are also rewards according to primary care physicians, but the findings suggest a lack of reciprocity in terms of efforts and rewards although firm conclusions cannot be drawn since the study did not investigate the magnitude of the various efforts and rewards or the effectiveness of the approaches the physicians use to cope with imbalances. The ERI model was found to be useful to explore physicians primary care work and working conditions but its applicability likely depends on the type of work or professions being studied.

Background

Health care organizations are constantly changing as a result of technological advancements, ageing populations, changing disease patterns, new discoveries for the treatment of diseases and political reforms and policy initiatives. Changes can be challenging because they contradict humans’ basic need for a stable environment. The present study poses the question: what characterizes successful organizational changes in health care? The aim was to investigate the characteristics of changes of relevance for the work of health care professionals that they deemed successful.

Methods

The study was based on semi-structured interviews with 30 health care professionals: 11 physicians, 12 registered nurses and seven assistant nurses employed in the Swedish health care system. An inductive approach was applied using questions based on the existing literature on organizational change and change responses. The questions concerned the interviewees’ experiences and perceptions of any changes that they considered to have affected their work, regardless of whether these changes were “objectively” large or small changes. The interviewees’ responses were analysed using directed content analysis.

Results

The analysis yielded three categories concerning characteristics of successful changes: having the opportunity to influence the change; being prepared for the change; valuing the change. The interviewees emphasized the importance of having the opportunity to influence the organizational changes that are implemented. Changes that were initiated by the professionals themselves were considered the easiest and were rarely resisted. Changes that were clearly communicated to allow for preparation increased the chances for success. The interviewees did not support organizational changes that were perceived to be implemented unexpectedly and/or without prior communication. They conveyed that it was important for them to understand the need for and benefits of organizational changes. They particularly valued and perceived as successful organizational changes with a patient focus, with clear benefits to patients.

Conclusions

Organizational changes in health care are more likely to succeed when health care professionals have the opportunity to influence the change, feel prepared for the change and recognize the value of the change, including perceiving the benefit of the change for patients.

Purpose: The purpose of this study was to investigate how communication within the Swedish sickness insurance system differs between cases of sick leave and how this may affect clients’ cases.

Materials and methods: This was a document study using 30 client files from the Swedish Social Insurance Agency (SIA). The clients included had been on a work ability evaluation during their sick leave spell and were aged 32–64 years. The material was analyzed using qualitative document analysis.

Results: The results show different approaches to communication, characterized by emotional argumentation, matter-of-fact driven argumentation and information exchange, which have diverse success in affecting official decisions. Arguments characterized by emotions such as frustration or desperation are to a larger extent neglected by the authorities compared to those characterized by a matter-of-fact driven approach and referring to regulations and medical certificates.

Conclusion: There are differences regarding how clients and stakeholders communicate the clients’ needs and pre-requisites, and how this affects official decisions. Further research must be carried out in order to establish social insurance literacy, initially for individuals on sick leave within the sickness insurance system, and whether there are differences between diverse groups that could lead to injustices.

• Implications for rehabilitation

• Within a social insurance context, professionals need to provide clients with adequate and individually adapted information in order for procedures to be perceived as comprehensible and manageable by the clients.

• The support from stakeholders such as the treating physician and/or employer can affect clients’ sick-leave process.

• Clients’ treating medical professionals can contribute to ensuring that clients rights are met by communicating the clients’ needs to other stakeholders in a formal way.

Background Digital consultation with primary care physicians via mobile telephone apps has been spreading rapidly in Sweden since 2014. Digital consultation allows remote working because physicians can work from home, outside their traditional primary care environment. Despite the spread of digital consultation in primary care, there is a lack of knowledge concerning how the new service affects physicians psychosocial work environment. Previous research has focused primarily on the patients point of view and the cost-effectiveness of digital consultation. Hence, there is a paucity of studies from the perspective of physicians, focusing on their psychosocial work environment. The aim of this study was to investigate primary care physicians perceived work demands, control over working processes, and social support when providing digital consultation to primary care patients. Methods The study has a qualitative design, using semi-structured interviews conducted in Sweden in 2019. We used a purposeful sampling strategy to achieve a heterogeneous sample of physicians who represented a broad spectrum of experiences and perceptions. The interviews were conducted by video meeting, telephone, or a personal meeting, depending on what suited the participant best. The interview questions were informed by the Job Demand-Control-Support (JDCS) model, which was also used as the framework to analyze the data by categorizing the physicians perceptions and experiences into the three categories of the model (Demand, Control, Support), in the deductive analysis of the data. Results Analysis of the data yielded 9 subcategories, which were mapped onto the 3 categories of the JDCS model. Overall, the participants saw numerous benefits with digital consultations, not only with regard to their own job situation but also for patients and the health care system in general even though they identified some shortcomings and risks with digital care. Conclusions This study has demonstrated that physicians perceive working with digital consultation as flexible with a high grade of autonomy and reasonable to low demands. According to the participants, digital consultation is not something you can work with full time if medical skills and abilities are to be maintained and developed.

Social distancing policies to ensure physical distance between people have become a crucial strategy in the battle against the spread of the coronavirus. The aim of this project is to analyze and compare social distancing policies implemented in Denmark and Sweden in 2020. Despite many similarities between the two countries, their response to the coronavirus pandemic differed markedly. Whereas authorities in Denmark initiated mandatory regulations and many severe restrictions, Swedish authorities predominantly promoted voluntary recommendations.

Officials in welfare state bureaucracies face the challenge of negotiating their role identities in the context of changeable organizational priorities and managerial styles. Previous studies have found that the professional values may mediate top-down demands and enable the preservation of professional autonomy also under public management reforms. But how do street-level bureaucrats who lack a common professional or occupational training respond to shifting organizational demands? Based on comparative ethnography, the present article investigates how caseworkers’ role identities are conceived and practised in two of the largest state bureaucracies in Sweden, the Social Insurance Agency (SIA) and the Public Employment Service (PES). The article identifies two radically different agency cultures, resulting in rather opposite caseworker role identities. These role identities affect how front-line staff respond to organizational demands, either by focusing externally on client-related outcomes (PES) or internally on organizational output (SIA). The analysis suggests that agency culture may shape caseworker responses to governance in patterned ways, also in the absence of joint professional training or strong occupational communities.

INTRODUCTION: Previous studies show differences regarding which clients receive sickness benefits as well as which clients are questioned or not within the sickness insurance system. There are indications that the characteristics of communication can have an impact on the sick leave process, which motivates this study with the following purpose.

PURPOSE: The purpose of this study was to investigate how communication within the Swedish sickness insurance system differs between cases of sick leave and how this may affect the clients’ case.

MATERIALS AND METHODS: This was a document study using thirty client files including the correspondence between clients, their case-manager at the Swedish Social Insurance Agency (SIA) as well as other stakeholders. The clients included had been on a work capacity evaluation during their sick leave spell and were aged 32-64 years. There were twenty women and ten men in this study, with a variety of the degree of sickness absence, disability pension and part time work. The material was analyzed using qualitative document analysis.

RESULTS: The results show different approaches in communication, characterized by emotional communication, matter-of-fact driven communication and information exchange, which have diverse success in affecting authority decisions. Arguments characterized by emotions such as frustration or desperation are to a larger extent neglected compared to those characterized by a matter-of-fact driven approach and referring to regulations and medical certificates. There are also differences in how information about the client is interpreted by different professionals.

CONCLUSION: There are differences regarding how clients and stakeholders communicate the clients’ needs and prerequisites, and how this affect the SIA. Further research must be carried out in order to establish social insurance literacy, initially for individuals on sick leave within the sickness insurance, and whether there are differences between diverse groups that could lead to injustice in the system.

PURPOSE: To study social validity and perceived fairness of a new method for assessing general work ability in a sickness insurance context. Assessments are based on self-reports, combined with examinations by physicians, and, if needed, occupational therapists, physiotherapists and/or psychologists.

MATERIALS AND METHODS: Interviews with 36 insurance officials, 10 physicians, and 36 sick-listed persons, which were analysed through a qualitative content analysis.

RESULTS: Insurance officials and physicians considered the method useful and that it facilitated benefit decisions. The experiences of persons who had undergone the assessment differed, where the dialog with insurance officials seemed to have had an influence on experiences of the assessment and the decisions it led to.

CONCLUSIONS: The perceived fairness and social validity of the assessment depended on how it was carried out; organisational conditions and priorities; communication skills; and decision outcomes. Professionals have an important pedagogical task in explaining the purpose and procedure of the assessment in order for the sick-listed to perceive it as fair rather than square, i.e., too standardised and not considering individual conditions. If the assessment could be used also for rehabilitative purposes, it could possibly be perceived as more acceptable also in cases where it leads to denied benefits. Implications for rehabilitation The perceived fairness of work ability assessments is dependent on procedures for the assessment, communication with the person, and the outcome. What is considered fair differs between assessing professionals and persons being assessed. Professionals may influence the perceptions of fairness through their way of communication. Assessments need to be coupled with rehabilitation measures in order to perceived as relevant and acceptable.

Baserad på en etnografisk studie av styrningen av handläggarna inom sjuk-försäkringen reser denna artikel ett antal kritiska frågor om konsekvensernaav den informella styrningen inom Försäkringskassan. Trots självbilden aven formell organisation som fattar ”korrekta” beslut i försäkringsärenden vi-sar studien att den informella styrningen – genom sociala normer, grupptryckoch legitimerande organisationsberättelser – är påtaglig i det dagliga arbetetoch riskerar leda organisationen i en annan riktning är den parlamentarisktbeslutade. Artikeln påtalar att följsamhetsnormen och duktighetskultureninom myndigheten riskerar hota – och inte stärka – rättssäkerheten

Background

Implementation of evidence-based practices in health care implies change. Understanding health care professionals’ change responses may be critical for facilitating implementation to achieve an evidence-based practice in the rapidly changing health care environment. The aim of this study was to investigate health care professionals’ responses to organizational and workplace changes that have affected their work.

Methods

We conducted interviews with 30 health care professionals (physicians, registered nurses and assistant nurses) employed in the Swedish health care system. An inductive approach was applied, using a semi-structured interview guide developed by the authors. We used an analytical framework first published in 1999 to analyze the informants’ change responses in which change responses are perceived as a continuum ranging from a strong acceptance of change to strong resistance to change, describing seven forms of change responses along this continuum. Change response is conceptualized as a tridimensional attitude composed of three components: cognitive, affective and intentional/behavioral.

Results

Analysis of the data yielded 10 types of change responses, which could be mapped onto 5 of the 7 change response categories in the framework. Participants did not report change responses that corresponded with the two most extreme forms of responses in the framework, i.e., commitment and aggressive resistance. Most of the change responses were classified as either indifference or passive resistance to changes. Involvement in or support for changes occurred when the health care professionals initiated the changes themselves or when the changes featured their active input and when changes were seen as well founded and well communicated. We did not identify any change responses that could not be fitted into the framework.

Conclusions

We found the framework to be useful for a nuanced understanding of how people respond to changes. This knowledge of change responses is useful for the management of changes and for efforts to achieve more successful implementation of evidence-based practices in health care.

Bakgrund: I det svenska sjukförsäkringssystemet utförs försäkringsmedicinska utredningar av särskilda enheter inom hälso- och sjukvården på uppdrag av Försäkringskassan. Dessa utredningar ligger sedan till grund för handläggares beslut om sjukskrivnas rätt till sjukpenning. Studier av social validitet är ännu ovanliga inom försäkringsmedicin och folkhälsa men kan bidra med kunskap om vad som främjar eller hindrar att metoder uppfattas som godtagbara, begripliga och betydelsefulla.

Syfte: Att utforska sjukskrivna personers upplevelse av social validitet för försäkringsmedicinska utredningar och påföljande myndighetsbeslut avseende sjukpenning inom sjukförsäkringen.

Metod: Detta var en kvalitativ longitudinell studie baserad på telefonintervjuer med 30 sjukskrivna som varit på en försäkringsmedicinsk utredning, samt delvis deras akter från Försäkringskassan. En deduktiv innehållsanalys användes.

Resultat: Sjukskrivnas förståelse för utredningen var beroende av huruvida de specifika testerna var tydligt relaterade till personernas svårigheter eller ej och vilken information de hade fått. De anser att den standardiserade strukturen inte är relevant för alla och att bristen på individanpassning förvårar möjligheten att få en rättvis bild av deras arbetsförmåga. 

Diskussion: Social validitet utforskades för försäkringsmedicinska utredningar och myndighetsbeslut i termer av godtagbarhet, begriplighet och betydelse. Utredningarna indikerar en låg social validitet i termer av godtagbarhet på grund av bristen på individanpassning, även om vissa delar är mer socialt valida än andra. Vidare varierade utredningarnas begriplighet beroende på deras applicerbarhet och den erhållna informationen, medan dimensionen betydelse indikerar en högre grad av social validitet. Handläggarens påföljande myndighetsbeslut ansågs däremot orelaterat till utredningens resultat, sakna konkreta argument och ibland motsägande andra aktörers rekommendationer, vilket indikerar en låg social validitet i termer av både godtagbarhet, begriplighet och betydelse. 

Slutsats: Social validitet finns för delar av utredningarna men är låg för det påföljande myndighetsbeslutet.

The academic debate on NPM has been running high for several decades, but more recently addressing governance and administrative steering ‘beyond NPM’. The Swedish government recently announced tillitsstyrning as a way to develop a different form of welfare governance that should allow ‘the professionals to be professional’.

The paper analyses the Swedish PES, which from being an agency highly governed by NPM ideals, has initiated comprehensive reforms to reduce management by numbers, detailed steering and result oriented control. Models of self-leadership are put forward as ways to promote new professional ideals and practices.

Inspired by discussions on governmentality, we analyse governance techniques of self-leadership at central level and what type of personal behavior and characteristics that are required from front-line workers. The paper explore how front-line workers act and react upon models of self-leadership – how they support and resist organizational pressure to think and act as a self-leader.

The paper draws upon an ethnographic study with observations and interviews with officials at the head office, caseworkers and managers in local offices of PES.

The Swedish Social Insurance Agency (Försäkringskassan – SSIA) and its frontline staff have a key role in the implementation of activation policy. Drawing on ethnographic research conducted at local offices, this article investigates how the transparency ideal, as an integral part of the organizational governance of the activation policy, is negotiated and enacted in the everyday life of a welfare bureaucracy. The analysis shows the central role that the transparency ideal plays in the alignment of frontline staff with the normative regime of the agency. While the transparency ideal is central to the internal organizational life of the SSIA, the analysis shows how transparency is much less salient in relation to clients and other relations with the outside world.

In this chapter, we review the development of the activation concept in Swedish sickness insurance during the 2000s, by analyzing how it is conceptualized in government reports and translated into policy and practice. At different times, policy has been informed by different types of knowledge, where the conceptualization of activation has developed from focusing on individual responsibility for rehabilitation and promoting return to work through restricting access to benefits, towards a systems perspective, where return to work is considered a multistakeholder endeavor. We offer a critical analysis of the use of evidence in policy development and its practical consequences.

Försäkringskassan har sedan 2010 utvecklat en metod, aktivitetsförmågeutredning (AFU), för bedömning av arbetsförmåga i relation till normalt förekommande arbete på arbetsmarknaden. Utredningen tar sin utgångspunkt i individens självrapporterade förmåga och involverar en bedömning av särskilt utbildade läkare, och vid behov även arbetsterapeuter, fysioterapeuter, och psykologer. AFU har testats i begränsad skala sedan 2011, vilket sedan stegvis har utökats.

I denna studie har 300 utredningar analyserats kvantitativt i relation till registerdata från Försäkringskassan, och 30 ärenden har analyserats kvalitativt genom aktanalyser. Därtill har intervjuer genomförts med handläggare, läkare och sjukskrivna. Studien har granskat utredningar genomförda under perioden 2013–2014.

Sammantaget tyder resultaten från de olika delstudierna i denna rapport på att AFU som bedömningsmetod oftast är i linje med den sjukskrivnes egen bedömning, och att inga skillnader i fortsatt sjukskrivning efter AFU finns beroende på kön eller ålder. Läkarens bedömning i AFU tycks inte predicera framtida sjukskrivning, vilket däremot individens självskattning gör.  Handläggare och bedömningsläkare (dvs. den läkare som utför AFU) anser generellt att AFU är en bra metod som ger relevant och användbar information. Dock används metoden sparsamt, vilket huvudsakligen tycks bero på ofullständig implementering. Utvidgade undersökningar uppskattas av handläggare och läkare då de ger ett bättre underlag. Dock finns det inga skillnader i fortsatt sjukskrivning mellan dem som fått utvidgad undersökning och övriga ärenden.

AFU leder till olika typer av utfall beroende på ärendets karaktär, där vissa får fortsatt sjukpenning eller sjukersättning, medan andra nekas fortsatt sjukskrivning. Utredningen spelar en mera central roll i ärenden där Försäkringskassan beslutar att neka sjukpenning, då den bidrar till att legitimera beslutet. I ärenden där sjukpenning beviljas bekräftar AFU huvudsakligen innehållet i tidigare underlag och får därmed en mera underordnad roll i kommunikationen med den sjukskrivne. Sjukskrivnas upplevelser av AFU skiljer sig åt, och inte enbart beroende på om utredningen lett till beviljad eller nekad sjukpenning. Försäkringskassans bemötande och handläggarnas dialog med de sjukskrivna tycks ha stor betydelse för hur sjukskrivna uppfattar utredningen och de beslut den leder till. Såväl handläggare som bedömningsläkare och andra inblandade vårdprofessioner har ett pedagogiskt ansvar i att förklara syftet med utredningen och de ingående momenten för att inte den sjukskrivne ska uppleva bedömningen som alltför standardiserad där individuella faktorer inte tas hänsyn till.

The expansion of ”audit culture” in public sector governance is well documented, including its implications for caseworkers whose performance is constantly monitored. Transparency is an inherent part of the audit culture, yet there are fewer studies researching how the ideal of the transparent organization plays out in everyday life in welfare bureaucracies. Drawing on ethno-graphic research in five local offices of the Swedish Social Insurance Agency, this article investigates how the transparency ideal is enacted on an everyday basis in this agency. The analysis reveals how the transparency ideal penetrates the organizational life in a much more pervasive way than is usually acknowledged in the audit society literature. Special attention is given to the relevance of a horizontal dimension of transparency. It is argued that the horizontal dimension of transparency is a central aspect in relation to goal achievement and the normative governance of the caseworkers. However, even if the transparency ideal is central to the internal organizational life of the Swedish Social Insurance Agency, transparency is much less salient in relation to clients and the outside world. The article explores this organizational regime of visibility, as established in every-day social interaction as well as in organizational routines.

A critical task of sickness insurance policy in most Western welfare states during recent decades has been to reduce the economic burden on society due to sick leave, by stimulating and enforcing labour market participation. In Sweden, strong activation requirements have been implemented in the health insurance in the past decades. Currently, this orientation is reflected in the politically set objective to reduce the sickness absence rate in Sweden; the center-left government in 2016 stated that “the sickness benefit rate may not exceed 9.0 days per individual and per year in 2020”. Furthermore, it was stressed that “newly granted disability pension shall not exceed 18 000 per year during the period 2016-2020”. In achieving these targets, the Swedish Social Insurance Agency (SSIA) and their frontline staff have a key role. This paper explores the organizational mediation of ’welfare to work’ policy by investigating the organizational governance and modes of operating set in place in local SSIA offices in order to fulfill the political objectives and reach these targets. More specifically, the paper focuses on one dimension of the local governance of ’welfare to work’ policy, namely the role that transparency plays in the alignment of frontline staff with the normative regime of the agency as well as its effects on caseworker subjectivity.  

The paper is based on an ethnographic study consisting of participant observations (mainly at work meetings with caseworkers, managers and insurance physicians/specialists) and qualitative interviews in the SSIA head office as well as five local offices. In total 57 interviews have been conducted and 37 meetings observed during 2015-17. Inspired by institutional ethnography (D. Smith) as well as ethnomethodology, the paper conceives of institutional settings as creating specific environments for the management of responsibility and accountability. Transparency is here key.

The paper shows how the transparency ideal is an integral part of the organizational governance in the agency, and implemented through tools, technologies, infrastructures, teamwork, and socio-spatial governance. The analysis reveals how the transparency ideal penetrates the organizational life in a much more pervasive way than is usually acknowledged in the ’audit society’-literature (following Power 1997), colouring not only case management but also the relations between colleagues and between management and staff. As an internalized ideal, transparency affects caseworker subjectivity, lending the welcoming of audit as a way to self-improvement along with the improvement of organizational performance. However, transparency is much less salient in relation to clients and the outside world. Thus this everyday regime of visibility, as established in social interaction as well as in organizational routines, is at the same time part of an organizational politics of visibility designed to facilitate the organizational performances and the smooth implementation of welfare-to-work policies in the health insurance.

A critical task of sickness insurance policy in most Western welfare states during recent decades has been to reduce the economic burden on society due to sick leave, by stimulating labour market participation. Activation policies have gained strong support, and activities that prevent the “disability benefit trap” are favored by international organizations such as the OECD and EU as well as national governments. A common statement in policy documents is that “the longer people are off work due to illness, the less likely it is that they will return to work”. Work per se assumed to have a therapeutic effect, leading to good health and well-being. In line with this development, the Swedish center-left government in 2016 introduced a numerical target –and a very exact one – regarding the sickness absence rate in Sweden; it is stated that “the sickness benefit rate may not exceed 9.0 days per individual and per year in 2020”. Further, it is stressed that “newly granted disability pension shall not exceed 18 000 per year during the period 2016-2020”. The targets are part of a governmental “action plan for improved health and reduced sickness absence”. In achieving these targets, the Swedish Social Insurance Agency (SSIA) and their frontline staff have a key role. The state agency is responsible for administrating the sickness insurance and decisions regarding individuals’ right to sickness benefits.

The aim of this paper is to analyze the role of numerical targets (understood as object and mobilizing symbols) in shaping caseworker subjectivity, including their emotions and relationships to clients. The study identifies central governance technologies used in the organizational shaping of the “ideal caseworker”. The paper is based on an ethnographic study with participant observations (meetings with caseworkers, managers and insurance physicians/specialists) and interviews in the head office and five local offices of the SSIA. In total 57 interviews were conducted and 37 meetings observed.

The study shows how numerical targets are loaded with positive emotions within the organization, associated with emotions such as work joy, sense of achievement, pride and belonging – but also frustration and embarrassment in relation to colleagues and other local offices with “better numbers” and results. Furthermore, the analysis shows how teamwork (in so-called self-managed teams between caseworkers) and meetings with different street-level bureaucrat experts (e.g. insurance specialists and insurance physicians) constitute central governance technologies in the shaping of caseworker subjectivity and emotions. Teamwork and the meetings have an influence on caseworkers to achieve mobilization around the target 9.0. Governing by numerical targets illustrates the SSIA’s effort to create a feeling of togetherness at the workplace and influence caseworkers to move in the same direction – as well as maintain the “work strategy” in the sickness insurance and reduce the number of people on sickness benefits.

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.

In the aftermath of the global financial crisis, people who had never before had cause to worry about losing their jobs entered the ranks of the unemployed for the first time. In Sweden, the welfare state has been radically challenged and mass unemployment has become a reality in what used to be viewed as a model case for a full employment society. With an emphasis on Sweden in the context of transnational regulatory change, Makeshift Work in a Changing Labour Market discusses how the market mediates employment and moves on to explore the ways in which employees adjust to a new labour market. Focusing on the legibility, measurability and responsibility of jobseekers, the expert contributors of this book bring together an analysis of activation policy and new ways of organizing the mediation of work, with implications for the individual jobseeker. Students and researchers of labour market policy, the organization of markets and work and society both in Sweden and abroad will find this book to be of interest. Policy makers will find the empirical examples of policy processes among employees an extremely useful and insightful tool.

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.

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.

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.

Vad är arbetsförmåga? Det är en komplex fråga vars svar beror på vem som svarar. Att fastställa en persons arbetsförmåga utifrån objektiva kriterier är mycket svårt eftersom den påverkas av många olika faktorer. Ändå görs detta av många olika aktörer i sjukskrivnings- och rehabiliteringsprocessen; för att bedöma om en person har rätt att få sjukpenning, som ett underlag för rehabiliteringsåtgärder och av Arbetsförmedlingen som en bedömning av anställningsbarheten.

Hur ska då arbetsförmåga förstås? I denna bok belyses begreppet arbetsförmåga ur flera olika perspektiv. Sammantaget bildar de olika kapitlen en illustration av den komplexa helheten, av en arbetsförmåga som är relativ och som används av olika aktörer, på olika sätt, i olika syften.

Boken vänder sig till personer som arbetar med bedömning av arbetsförmåga och med åtgärder för att främja återgång i arbete, till exempel läkare och annan sjukvårdspersonal, rehabiliteringsprofessioner, berörda inom arbetslivet och företagshälsovården.

De höga kraven i dagens arbetsliv har lett till att många personer ses som icke anställbara och allt fler arbetssökande kodas som funktionshindrade av Arbetsförmedlingen. Artikeln analyserar det bedömningsarbete som ligger till grund för funktionshinderkodningen, och där de sökandes arbetsförmåga, anställbarhet och funktionshinder upptäcks, skapas och objektifieras. Funktionshinderkodningen ska dock främst förstås i en vidare kontext kopplat till krav och förväntningar i Arbetsförmedlingens omgivning.

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.

I juli 2003 infördes ett krav i lagstiftningen att Försäkringskassan vid behov ska använda sig av ett så kallat avstämningsmöte vid bedömningen av individers rätt till ersättning och rehabiliterande insatser från sjukförsäkringen. På policynivå har avstämningsmötet presenterats som ett effektivt verktyg i lösningen på problemen med långa sjukskrivningar och hög sjukfrånvaro. Genom att samla involverade aktörer ”runt ett bord” (Försäkringskassan, den sjukskrivne, sjukvården, arbetsgivare och Arbetsförmedlingen) förväntas parterna hitta gemensamma lösningar som ska underlätta den sjukskrivnes väg tillbaka i arbetslivet.

Huvudsyftet med föreliggande studie har varit att analysera på vilka grunder involverade parter bedömer individers arbetsförmåga och möjligheter för återgång i arbete. En central frågeställning var att studera vilka aspekter av arbetsförmåga som under mötet belystes. Fokus riktades mot involverade aktörers resonemang om arbetsförmåga och hur parterna såg på sin egen och övriga aktörers roll i verksamhetsprocessen. Rapporten baseras på nio inspelade avstämningsmöten under år 2007 och 2008 i Östergötland. Det empiriska materialet har kompletterats med metodstöd från Försäkringskassan och offentliga rapporter. En innehållsanalytisk metod har använts i analysen av det empiriska materialet.

Studiens resultat visar hur välfärdspolitikens fokus på arbetslinjen och aktiva insatser ställer krav på de organisationer som har till uppgift att återföra sjukskrivna i arbetslivet. Avstämningsmötet äger rum i skärningspunkten mellan organisationer med skilda regler och rutiner. Mötena utmärktes av en förhandling om arbetsförmåga och vilka aktörer som hade rehabiliteringsansvaret för individerna i fråga. Tre perspektiv på arbetsförmåga blev framträdande: det medicinska, regelverkets och arbetslivets perspektiv. Försäkringskassan argumenterade ofta utifrån sjukförsäkringens regelverk, och sjukvården betonade främst medicinska hinder för individens arbetsoförmåga, medan arbetsgivare framhöll individens fysiska nedsättningar i relation till arbetes krav. Samtidigt som perspektiven kunde knytas till specifik aktör kunde parterna växla mellan olika perspektiv på arbetsförmåga beroende på situation. I förhandlingen om den sjukskrivnes arbetsförmåga utgjorde den medicinska expertisen en ”neutral expertfunktion” som skapade legitimitet för parternas ståndpunkter. I rapporten visas hur Försäkringskassans regelverk med fokus på tidig återgång i arbete och aktiva insatser kom på kollisionskurs med arbetsgivarnas svårigheter att anpassa arbetsplatsen. Sjukskrivnas arbetsförmåga och möjligheter att återgå i arbete berodde därför inte enbart beror på den strikt medicinska bedömningen av funktionsnedsättning. I praktiken grundades bedömningen av arbetsförmåga istället på relationen mellan individens förmåga och arbetets förutsättningar. Studien aktualiserar avslutningsvis frågor om vilka förutsättningar den arbetslivsinriktade rehabiliteringen har när arbetsmarknaden idag tenderar att lämna begränsat utrymme för människor som inte anses leva upp till arbetslivets krav.

Såväl arbetsmarknadspolitiken som arbetsmarknaden präglas idag av krav och förväntningar på att människor ska kunna marknadsföra sig själva, ha rätt attityd och personlighet för att få en anställning. Mänskliga förmågor, kunskaper och färdigheter lyfts fram som centrala verktyg för att konkurrera på den moderna arbetsmarknaden och vara motståndskraftiga mot arbetslöshet och utanförskap. Detta är en utveckling som speglar en ny syn på individen som själv förväntas ta ansvar för arbetslöshet och anställning. Utvecklingen har formulerats i termer av ett ideologiskt skifte där det sociala ansvaret har kommit att förskjutas från samhälle till individ – från rätten till anställning till skyldigheten att vara anställningsbar. Samtidigt kan vi se att antalet grupper som befinner sig utanför den reguljära arbetsmarknaden blivit flera.

Detta kapitel handlar om Arbetsförmedlingens verksamhet riktad mot sökande med nedsatt arbetsförmåga. Kapitlet belyser hur byråkratiska processer leder fram till hur arbetssökande klassificeras i termer av ett funktionshinder. Hur går arbetet med att bedöma och kategorisera egentligen till? Vilka antaganden vilar arbetet på? Kapitlet belyser hur verksamheten är utformad, hur utredningsprocessen ser ut, vilka aktörer som är involverade och hur begrepp som arbetsförmåga och funktionshinder operationaliseras. Ambitionen är att ge en rikare förståelse för hur Arbetsförmedlingen på lokal nivå arbetar, organiserar och utformar verksamheten för sökande med begränsad arbetsförmåga. 

I ljuset av en förändrad arbetsmarknad där antalet människor klassificerade som funktionshindrade i arbetslivet har ökat handlar denna rapport om Arbetsförmedlingens verksamhet riktat mot sökande med funktionshinder.

Studien bygger på intervjuer med tjänstemän på central och lokal nivå inom Arbetsförmedlingen och avdelningen Rehabilitering till arbete.

Huvudsyftet är att beskriva och ge förklaringar till bedömningsprocessens utformning som leder fram till att en sökande klassificeras som funktionshindrad och därigenom berättigas särskilda arbetsmarknadspolitiska stödinsatser.

Föreliggande studie lyfter fram en tämligen etablerad och expertorienterad verksamhet inom Arbetsförmedlingen där människors förmågor, kapaciteter och resurser utgör föremål för utredning, förändring och anpassning. I arbetsmarknadspolitikens lokala praktik framkommer således en grupp närbyråkrater som agerar i rollen som experter med en central roll i definitioner av sökandes funktionshinder. Samtidigt visar sig funktionshinderbedömningen bygga på en komplex och situationsbunden process starkt kopplad till konjunkturläge och normer på arbetsmarknaden. I rapporten konstateras att expertis, medikalisering och förändringar på arbetsmarknaden förklarar bedömningsprocessens utformning. Klassificeringen av sökande som funktionshindrade ska framförallt ses som ett resultat av Arbetsförmedlingens behov av att hantera en förändrad arbetsmarknad som har kommit att lämna mindre utrymme för personer som av olika anledningar uppfattas som avvikande. När Arbetsförmedlingens huvuduppdrag har kommit att bli matchning och där stora delar av arbetsmarknadspolitiska insatser har minskat blir funktionshinderbedömningen ett sätt för närbyråkraterna och de sökande att få tillgång till "exklusivare" former av stödinsatser som lönebidrag, Samhallanställning och offentligt skyddat arbete. Dessa insatser ses som en möjlig alternativ väg för att idag få sökande i aktivitet och arbete.

To make domestic services like maids and nannies less expensive, thereby increasing the legal market for companies offering such services, tax deduction has been on the right-wing feminist/political agenda in Sweden for almost fifteen years. On the 1st of July 2007, after a successful lobby campaign, such a reform was implemented. This paper, based on interviews with actors involved in promoting the reform, describes how the law permitting tax deduction finally passed and how the market for domestic services developed the years before and after the reform. The protagonists’ arguments for the importance of tax deduction for the survival and expansion of the market are also described. Their main arguments were: a) that the tax deduction would encourage people to buy these services from legal companies instead of using illegal workers, b) that many unemployed could be offered a legal job in the sector, and c) that the equality between men and women in work life would increase when women got rid of some of their family responsibilities. Our analysis shows that by framing the question differently in different situations, the reform protagonists managed to avoid some of the conflicts regarding gender equality, working conditions, competence, immigration/ethnicity and social class inherent in their arguments. These value conflicts are outlined in the papers final section. By integrating sociological theories on intersectionality with theories on the organization of markets, we analyze the value conflicts and also discuss why the reform antagonists (left-wing politicians, feminists and parts of the trade unions) failed to organize their resistance.