Working women’s psychological ill health made worse by uneven structures

“Working environment issues are hotter than ever. Employers and politicians are very worried about the rising cost of sick leave. There is also a daily debate on competence provision and a severe strains on welfare. It is very important to be an attractive employer, and that is when the working environment becomes an important component,” said Caroline Olsson, head of the working life section at the Swedish Association of Local Authorities and Regions. She was introducing the seminar ‘How do organisations and leaders create a sustainable working environment?’ held in March 2016.

The conference highlighted the current fears in Sweden for work-related psychological ill health. It is one example of how politicians, researchers and civil servants are furrowing their brows over how to break the rapidly rising level of psychological ill health in the workplace. Some days later new regulations in the Working Environment Act came into force, introducing new demands for good social and organisational working environments – not least in the link between demands and control.

This particular conference, organised by Swedish municipalities and county councils, several trade unions and research institutions like the Stress Research Institute, wanted to draw attention to the importance of leadership for the working environment. The aim was also to look at leaders’ own working environments, not least leaders in frontline jobs, who are often forgotten. It is after all they who are closest to the work and who handle many of the problems which can arise in the meeting with customers regardless of whether they are students, older people in need of care, pre-school children and their parents or patients. 

Not a women’s issue but a structure issue

Two thirds of working women now work in the so-called contact occupations – typically in the healthcare, education and care sector. These are the worst hit by sick leave as a result of a psychological diagnosis. The number of long term illness with a psychological diagnosis more than doubled between 2009 and 2014. It is a broad term – it could be about stress, exhaustion, worry, anxiety, but it is a diagnosis which often results in long term sick leave. 

The fact that female dominated sectors like health, education and care are worst hit means the issue is often addressed as if it were a women’s problem. This makes one of Sweden’s most senior working life research professors speak up.

“It makes me angry when you talk about women’s working environments, when in fact it is structural issues which create a bad working environment. It is equally bad for the men who work there as for the women,” says Annika Härenstam, Professor Emeritus of work science at the University of Gothenburg. She is currently a lecturer and researcher at the Stockholm University’s Department of Psychology.

There are complex reasons behind the worrying development of psychological ill health in female dominated occupations. One factor is the expansion of the public sector in the 1970s. Before then most care took the form of unpaid work at home, and few women were full time providers during an entire working life. Then society was organised in a way which would allow women to combine work and family life. 

“The public sector was not created for the professional full time employee. You were not given status but was viewed as interchangeable secondary labour. It was meant to be possible to change jobs in order to adapt to the family’s needs, and you were not irreplaceable because it should be possible to take parental leave. 

“But both the tempo and demands were high. The idea was also that you should not spend all of you time in the care sector. It is only now that we see the effects of working full time for an entire working life in that sector. It is an accumulated strain,” says Annika Härenstam and adds:

“The organisations which were built were flat, they were made up of women and women have been in those positions ever since.”

The problem with measuring care

For a long time things went well. Until the early 1990s jobs like nursing and teaching were considered to be so-called healthy occupations. There were economic resources available and also more resources to support for example janitors, cleaners, nursing assistants and secretaries. There was also less control. 

Then came the crisis in the 1990s. Public sector costs had run wild and politicians wanted to regain control. Many assistant nursing positions and supporting jobs like secretary and janitor disappeared, companies and departments were merged and many companies had to make severe cuts. Last but not least came the introduction of New Public Management, modelled on the business sector. This meant tougher and more detailed control from the top. 

As an example of today’s reality, a modern manager of a care institution for the elderly needs to master up to 22 computer programs, in addition to all the legislation and regulations covering the health, education and care sector. New demands are constantly added, but rarely come with additional support. 

“The change was driven by the desire to save money, but also by the decision-makers’ desire to remove power from professionals. The result was large and unprofessional cuts,” says Annika Härenstam. 

There was also no-one at hand when the sectors were being measured to explain the difference between measuring a hard business compared to measuring a so-called soft business. Working with people is limited to a time and a place, you often get immediate feedback – good or bad – and you use yourself as a tool. That makes the work difficult to measure and difficult to streamline. 

At the same time many who work in the education, health and care sector feel it is meaningful and enriching, which could have contributed to a culture where it was not considered right to compare people with numbers.

Different worlds for technical and care administrations

Eight years later nobody called these occupations the healthy ones. Working environments in the health, education and care sector led to a sharp rise in sick leave numbers. With a few exceptions the numbers have risen year on year since then, and a psychological diagnosis is by far the most common cause.    

And the numbers continue to rise, to the detriment of those who are hit, to businesses and to the economy as a whole. Today the total cost of work-related psychological ill health is three to four percent of GDP in all OECD countries, and it continues to rise. This development worries politicians in Sweden and in many other developed economies. There are now plans in place in Sweden, and in other OECD countries, for how to reduce sick leave and how to stop the negative spiral of work-related psychological ill health.

Annika Härenstam believes one important measure will be to understand the basic differences between different sectors in society or within a municipality. It is not as simple as saying a bad working environment is synonymous with being a municipal employee. 

It depends on where you work, what you do and just how this work is being organised. It is important to understand this in order to make changes to the working environment to suit a particular company. As long as you compare care with care, it is difficult to make changes. Conditions are accepted in one sector which would never be accepted in another. Between 2008 and 2014 Annika Härenstam and research colleagues ran the CHEFiOS project at the University of Gothenburg.  

It looked at the working conditions for public sector leaders, and was a cooperation with three municipalities in western Sweden plus Gothenburg Water. The project showed that the conditions for a leader in a technical administration was quite different from a similar position within the health, education and health sector.

“Our systematic comparison showed worrying signs of highly different conditions for leaders depending on where they worked. Leaders for technical administrations were listen to, met with respect and considered to be experts. Leaders within the care sector have a completely different status – they do not live in the same world,” says Annika Härenstam.

”My God, is this how it is for you”

The technical administrations had clear goals, fewer subordinates, a different contact network linking to management and most had succeeded in avoiding parts of New Public Management by arguing their company was far too complex. Politicians were more interested in these companies than in the ones in the care sector, and technical leaders were treated like experts and listened to. If workloads were heavy, the leaders in technical management could approach politicians and get help with their priorities.

The research shows very different conditions within the health, education and care sector. The targets are more blurry and politicians like to think of themselves as the experts. When a leader within the care sector wants help, she – because more often than not it is a woman – is told that “you will have to reprioritise, you’re so good at that”. Leaders head large groups and it is not uncommon to have 50 or more subordinates.

“We have always distinguished between technical administrations and those of the health, education and care sector. Workplace inspectors are responsible for one or the other, and no comparisons are made. When the Work Environment Authority allows inspectors who normally visit technical administrations to go to the care for the elderly, the reaction might be: ‘My God, is this how it is for you?’,” says  Annika Härenstam.

In order to address work-related psychological ill health you need to understand the structures which create ill health, she says. That is why it is wrong to talk about women’s working environments. When measures are introduced to improve men’s conditions in the industry, you never talk about men’s working conditions. You simply talk about working conditions.

Conversational arenas

“As long as we keep talking about women’s working environments, we are maintaining the divide. Instead we should look at how it really is and learn how to organise work in a way which allows people to manage an entire working life. We need to remember that sick leave is not equal to ill health, it is about how well you adapt the demands to each individual worker’s abilities,” she says.

So how do you create a sustainable working life for leaders, and how can they in turn create a good working environment?

You need different strategies depending on the situation at the unit or workplace where you are. It is important to describe how things look and to communicate this. What is the balance between demands and resources like? How many subordinates does the boss have? There is no reason why leaders in the care sector should have three times as many subordinates as those in technical administrations. 

“Frontline leaders are enormously important for discovering ill health among staff, but if you are responsible for too many subordinates you won’t have time for that. This, I think, is an important reason for the rise in psychological ill health,” says Annika Härenstam.

The lines of communication between strategic management and businesses need to be improved and inspected. Perhaps some businesses need more support, and of course a better balance between demands and resources – which will always be central to a good working environment. 

Influence and contacts are also central for leaders to be able to run a good business, also for employees. Many also say they need support and a sounding board. You cannot change what you produce, but you can change how it is produced, and this is where politicians can change things.

“They can involve experts and listen to those who know their job. Today the care sector management operates far form the decision makers compared to the technical administrations. You therefore need to create arenas where you can meet, but also where you can develop a common language.”

To change structures you need fresh thinking, nearly a cultural revolution, thinks Annika Härenstam. But this could create a modern way of organising work which would benefit employees, users and the labour market.

“The main and nearly only perceived threat today is the future staffing in the care sector, and the costs connected to sick leave and the changeover of leaders,” she says.

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