Gendered Norms at Work: New Perspectives on Work Environment and Health (Aligning Perspectives on Health, Safety and Well-Being) 3030777332, 9783030777333

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Aligning Perspectives on Health, Safety and Well-Being

Britt-Inger Keisu Susanne Tafvelin Helene Brodin   Editors

Gendered Norms at Work

New Perspectives on Work Environment and Health

Aligning Perspectives on Health, Safety and Well-Being Series Editors Stavroula Leka, University College Cork, Cork, Ireland Aditya Jain, Nottingham University Business School and Centre for Organizational Health and Development, University of Nottingham, Nottingham, UK Gerard Zwetsloot, University of Nottingham, Centre for Organizational Health and Development, Nottingham, United Kingdom, TNO InGerard Zwetsloot Research & Consultancy, Amsterdam, Noord-Holland, The Netherlands

Raising awareness of the interdisciplinary and complementary relationship of different research perspectives on health, safety and well-being is the main aim of the book series Aligning Perspectives on Health, Safety and Well-being. Combined research approaches on health, safety and well-being are becoming more and more popular in several research disciplines across and between the social, behavioural and medical sciences. Therefore, Aligning Perspectives on Health, Safety and Wellbeing stimulates the publication of interdisciplinary approaches to the promotion of health, safety and well-being. Recognizing a need within societies and workplaces for more integrated approaches to problem solving, the series caters to the notion that most innovation stems from combining knowledge and research results from related but so far separated areas. Volumes will be edited by expert authors and editors and will contain contributions from different disciplines. All authors, and especially volume editors are encouraged to engage in developing more robust theoretical models that can be applied in actual practice and lead to policy development. Editorial Board: Professor Johannes Siegrist, University of Dusseldorf, Germany Professor Peter Chen, University of South Australia Professor Katherine Lippel, University of Ottawa, Canada Professor Nicholas Ashford, MIT, USA Dr Steve Sauter, NIOSH, USA Dr Peter Hasle, Aalborg University, Denmark

More information about this series at http://www.springer.com/series/10757

Britt-Inger Keisu • Susanne Tafvelin • Helene Brodin Editors

Gendered Norms at Work New Perspectives on Work Environment and Health

Editors Britt-Inger Keisu Department of Sociology Umeå University Umeå, Sweden

Susanne Tafvelin Department of Psychology Umeå University Umeå, Sweden

Helene Brodin Department of Social Work Stockholm University Stockholm, Sweden

ISSN 2213-0497 ISSN 2213-0470 (electronic) Aligning Perspectives on Health, Safety and Well-Being ISBN 978-3-030-77733-3 ISBN 978-3-030-77734-0 (eBook) https://doi.org/10.1007/978-3-030-77734-0 © Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG. The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Contents

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On Equal Terms? Gendering Labour Markets, the Organisation of Work, and the Well-Being of Employees . . . . . . . . . . . . . . . . . . . Britt-Inger Keisu, Helene Brodin, and Susanne Tafvelin

Part I 2

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Working Conditions

Classification of Work: An Approach to the Exploration, Understanding, and Prevention of Gender Differences in Working Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Annika Härenstam and Anna Nyberg Psychosocial Working Conditions for Women and Men in Industries with Different Types of Production and Gender Composition: Sweden, 1991–2017 . . . . . . . . . . . . . . . . . . . . . . . . . . Anna Nyberg, Annika Härenstam, Gun Johansson, and Paraskevi Peristera A Multilevel Approach to Understanding Job Demands and Resources in Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anne Richter, Marta Roczniewska, Henna Hasson, and Ulrica von Thiele Schwarz Managing Care Work in Times of Austerity: Gendered Working Conditions for Managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Klara Regnö

Part II

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Organisation of Work

Invisible Workers: On Digitalisation in Home Care Work from a Gender and Technology Perspective . . . . . . . . . . . . . . . . . . . . . . . . 105 Charlotte Holgersson and Britt Östlund

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Contents

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Organising Auditing, Person-Centred Care and Competence in Swedish Residential Care Homes . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Palle Storm and Anneli Stranz

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Gender Differences in the Impact of Work Hours on Health and Well-Being . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Philip Tucker

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The Interplay Between Gendered Norms and New Public Management Strategies in the Shaping of Homecare Services’ Work Environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Annika Vänje

Part III

Violence and Conflicts

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‘Don’t Let It Get to You.’ Gendering Workplace Violence in Disability Services in Sweden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Helene Brodin and Sara Erlandsson

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The Concept of Intragroup Conflict in Relation to Gender and Well-Being in Women-Dominated Work . . . . . . . . . . . . . . . . . . . . . 197 Britt-Inger Keisu and Susanne Tafvelin

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

Chapter 1

On Equal Terms? Gendering Labour Markets, the Organisation of Work, and the Well-Being of Employees Britt-Inger Keisu, Helene Brodin, and Susanne Tafvelin

1.1

Introduction

We are writing this book during one of the biggest crises of our time—the COVID19 pandemic. Although no one at this point knows when this pandemic will end or how the outcome will affect our societies, it has already been described as one of the greatest challenges facing the planet since the Second World War (e.g. UNDP, 2020). Women are at the centre of the fight against the crisis caused by the COVID-19 pandemic (OECD, 2020a). Across the globe, women make up 70–90% of workers in the sectors critical to tackling the pandemic, such as healthcare and long-term care (LTC) (OECD, 2020b). This also puts women working in these sectors at high risk of being exposed to the virus. Concurrently, women are underrepresented in top management positions within healthcare and LTC and, in most countries, employment and working conditions in these sectors are insecure and strained for women located at the bottom of the job hierarchy (Montgomery et al., 2020). This is particularly true for the LTC sector, where about half of employees work part time or are employed on temporary contracts, even in the Nordic countries, which are otherwise known for their generous labour-market schemes and high employment security (OECD, 2020b). In this context, it is also important to

B.-I. Keisu (*) Department of Sociology, Umeå University, Umeå, Sweden Umeå Centre for Gender Studies, Umeå University, Umeå, Sweden e-mail: [email protected] H. Brodin Department of Social Work, Stockholm University, Stockholm, Sweden e-mail: [email protected] S. Tafvelin Department of Psychology, Umeå University, Umeå, Sweden e-mail: [email protected] © Springer Nature Switzerland AG 2021 B.-I. Keisu et al. (eds.), Gendered Norms at Work, Aligning Perspectives on Health, Safety and Well-Being, https://doi.org/10.1007/978-3-030-77734-0_1

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emphasise the ongoing racialisation of the female workforce in the LTC sector in Western countries. An increasing percentage of the workforce located at the bottom of the job hierarchy in the LTC sector consists of immigrant women, whose weak bargaining position forces them to take jobs characterised by low status, low pay, and insecure terms of employment (Williams & Brennan, 2012). Recently, arduous employment and poor working conditions in the LTC sector have also been highlighted as one of the main obstacles to the effective coordination of measures to prevent the further spread of the COVID-19 virus (OECD, 2020a; Szebehely, 2020). Against this critical setting, this book sets out to explore the relationships between the work environment, health, and gender in women-dominated work organisations. More specifically, the book aims to analyse the interplay between occupational segregation in the labour market, occupational health and safety, and the organisation of jobs in women-dominated sectors. We are interested in the health effects that the work environment generates for employees in women-dominated work organisations, and we seek to determine the ways in which gender is important in these organisational processes. Accordingly, one general theme explored in the book concerns how norms of gender shape the work environment in women-dominated work organisations. Another central theme concerns how the organisation of jobs affects health and measures for preventing ill health in women-dominated sectors.

1.2

Empirical Approaches to Gender, Work Environment, and Health

The book takes Sweden as its main empirical case to explore the relationships between gender, work environment, and health in women-dominated work organisations. Hence, one additional theme explored in this book relates to the ways in which Sweden differs, or not, from other countries when it comes to this interplay between occupational segregation on the labour market, occupational health and safety, and the organisation of jobs in women-dominated sectors. We present three reasons why Sweden is an interesting case to illuminate the interplay between occupational segregation, health and safety at work, and the organisation of jobs in women-dominated sectors. Firstly, one central characteristic of the Swedish labour market is the ideological gender-egalitarian premise that men and women are equally involved in both paid labour and unpaid care work (EspingAndersen, 1999; Korpi et al., 2013). This approach is labelled the Earner–Carer Model, sometimes articulated as the Dual Earner/Dual Carer Model. Depending on how welfare-state policy structures divide into earner/carer for women and men within the labour market, it will support either women’s paid work or the traditional division of labour. The traditional male breadwinner/female full-time homemaker ideal of family life was dominant in Western welfare states throughout the twentieth century, although it became less evident during the second half of the century due to

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women’s increased participation in the labour market. During the 1970s, the Swedish egalitarian state approach led to expansions in areas that affected unpaid care work; specifically, public day-care for children, the expansion of care services for older people, and the individualisation of income tax so that, irrespective of incomes, families could afford the dual-carer model. Furthermore, generous parental leave for both men and women was introduced. However, because of the historically binary constructions of gender, the Swedish labour market remained gender segregated when unpaid care work was transformed into paid labour in the public sector, a sector that also became largely occupied by women. These historical traits have produced inequalities, because the public sector offers few career paths, and the salaries are low in comparison to jobs occupied by men in the private sector. Hence, secondly, although Sweden is renowned for its high level of gender equality, including having one of the world’s highest employment and education rates for women, the Swedish labour market is highly gender segregated, even more so than in the rest of the EU (European Commission, 2017, 2018). Gender segregation comes in different forms. The most basic form is horizontal gender segregation, which means that men and woman have different occupations and employers, and work in separate industries and workplaces. Vertical gender segregation implies that, in systematic ways, women are not promoted as far in their careers as men are, and this is reflected in the under-representation of women in higher managerial positions. Finally, internal gender segregation refers to processes whereby men and women within the same occupation are assigned different tasks or specialise in different areas and therefore perform different jobs, even though they may have the same occupational title (Acker, 1990; SOU, 2004). As presented in Chap. 2, and later analysed in Chap. 3, the gender-segregated labour market also comes with a number of consequences, in terms of arduous working conditions and higher levels of ill health in women-dominated sectors. Finding ways to understand the reasons for these differences is important if we wish to resolve them, and here the highly gendersegregated Swedish labour market appears to be a fruitful case to further explore this issue (see FORTE, 2016 for a review). Thirdly, as has happened in other welfare states, the publicly funded welfare sector in Sweden has undergone substantial changes in recent decades due to policy reforms associated with New Public Management (NPM). Indeed, as noted by Hood (1995), by the 1980s Sweden was already somewhat of an extremist in its acceptance of the international wave of NPM. The consequences of NPM have been most clearly visible in the women-dominated healthcare and LTC sectors (Meagher & Szebehely, 2013, 2018). In these sectors, policy reforms inspired by NPM have in general involved the introduction of market practices drawn from the private sector, including competition and choice between public and private service providers, and/or work organisation models, such as lean production, aiming to maximise user satisfaction and minimise waste in service production (Dellve et al., 2015; Meagher & Szebehely, 2013). In addition, in Sweden as in many other countries, these reforms have been implemented within a context of austerity, with the specific aim of reducing public spending on welfare services (Ranci & Pavolini, 2015; Theobald & Luppi, 2018). Although austerity, market practices, and private business

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organisational models continue to affect and reshape the work environment in healthcare and LTC in various countries, a burgeoning literature has found that these policy-driven changes often involve the time-and-task reorganisation of work assignments; that is, a sort of re-Taylorisation of the organisation of work (Hayes & Moore, 2017; Meagher et al., 2016). Studies indicate that the consequences of this re-Taylorisation have had negative impacts on the work environment, due to the combined effect of increased monitoring of the time spent on various services and decreased decision-making latitude in relation to how to conduct services (e.g. Brodin & Peterson, 2019; Hayes & Moore, 2017; Meagher et al., 2016; Strandell, 2019). Undesirable consequences of this development for job satisfaction have been particularly noticeable in the Swedish LTC sector (Meagher et al., 2016). One reason for this is that Sweden has maintained its high ambition of universal coverage and high-quality services while simultaneously the time and money available for performing these services have been continuously reducing (Ranci & Pavolini, 2015). Hence, in Sweden, policy reforms associated with NPM have severely undermined the preconditions for delivering high-quality services, even as the responsibility for doing more with fewer resources has fallen upon female care workers located at the bottom of the job hierarchy. Against this backdrop, developments in the women-dominated healthcare and LTC sectors in Sweden may serve as illustrative examples of how gender norms interact with the work environment, the organisation of jobs, and the prevention of ill health (or lack thereof). Altogether, we consider that these tensions between the ideological premises of gender equality and a strongly horizontally segregated labour market on the one hand, and high political ambitions for welfare services alongside deteriorating working conditions in women-dominated jobs in the public sector on the other, makes Sweden a striking case for exploring how norms of gender shape the work environment and employee health in women-dominated work organisations. In this vein, we also think that other countries might learn from Swedish developments. Although Sweden is often considered to be one of the leading countries in terms of gender equality policies, these policies do still reproduce the overall gender order, placing the masculine gender in production in the private (and higher paid) sector and the feminine gender in reproduction in the public (and lower paid) sector. We do not pretend to have the answer to how to break down this reproduction of the gender order; however, we hope that the chapters presented in this book might serve as inspiration for further discussions. In this context, we would also like to emphasise that, as an employer, the public sector is expected to provide a decent environment for its workforce and to serve as a model employer (cf. Bishu & Alkadry, 2017; Frederickson, 2010; Llorens et al., 2008). Failing to do so not only adds to the problem of hypocrisy (Brunsson, 2002) in politically governed organisations, but also undermines the ability to deal with upcoming crises, such as that caused by the COVID-19 virus discussed in the introduction to this chapter. After all, it is the workers in publicly funded sectors, such as healthcare and LTC, who constitute the backbone of contemporary welfare states (OECD, 2020a). Consequently, neglecting proper terms of employment and

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healthy working conditions for public sector workers—of whom the vast majority are women—also means ignoring the future of our welfare states.

1.3

Theoretical Perspectives

In this anthology, the authors draw upon extensive empirical studies and findings and it is our belief that social change cannot be achieved solely by deconstructing identities, subjectivities, and discourses. According to post-deconstruction and new materialism, which have inspired us, there is a need to redirect attention towards socio-economic conditions, economic and political processes, and their materiality (Kantola & Lombardo, 2017). We believe that the progress towards gender equality, at a societal level, needs to start here, by acknowledging the materiality of gendered inequalities on the labour market, including the marks that these inequalities leave on individual workers’ bodies and minds in terms of occupational injuries, exhaustion, and ill health. In this vein, we seek to explore how the material underpinning of women-dominated sectors is entrenched in norms of gender and the bodily effects these relationships produce upon workers in these sectors. We interpret the concept of materiality widely, by including aspects other than pay, such as the work environment, the organisation of jobs, and general employment and working conditions. By utilising this analytical approach, we seek to add an account of how occupational segregation is entangled with broader socio-political processes of materiality to the burgeoning literature on the gender pay gap, welfare state regimes, and women’s employment outcomes (e.g. Bishu & Alkadry, 2017; EspingAndersen, 1999; Ferragina, 2020; Hassard & Torres, 2021; Korpi et al., 2013; Koskinen Sandberg, 2018; Mandel & Semyonov, 2006). In addition, by focusing on current developments, this anthology contributes to a much-needed update on the impact of the thoroughgoing socio-political changes that have occurred since 2010 (Ferragina, 2020). While feminists have criticised classifications of welfare states for leaving out the experiences of women as workers and mothers (e.g. Borchorst & Siim, 2002; Lewis, 1992; Sainsbury, 1996), Black, lesbian, and postcolonial feminists have pointed out the one-dimensional understandings of the categories of ‘women’ and ‘gender’ underlying feminist scholarship (e.g. Crenshaw, 1988; hooks, 2000; Mohanty, 2003). The feminist movement’s endeavour to achieve gender equality has tended to centre on the experiences of white, middle-class, and heterosexual women, and hence has excluded the diversity embedded in the category of ‘women’. For example, in her classic text, Crenshaw (1988) challenged white, middle-class privilege and visualised how multiple processes of domination and subordination are embedded in the category of ‘women’ and the materiality of these intersections in terms of discrimination, segregation, and violence. This implies a need for intersectional approaches to welfare regimes and the structuring of labour markets that can and do consider the diverse circumstances of different groups of women.

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Theoretically and empirically, this book focuses on work environments and health in women-dominated sectors. However, as the case of the racialisation of the workforce in the LTC sector illustrates (Williams & Brennan, 2012), this focus includes other processes of domination and subordination as well as gender. Following Acker (2006), we see different dimensions of power, such as gender, race, age, disability, and sexuality, as constituting each other within work organisations, and we therefore acknowledge the ambivalence and impossibility of using binary categorisations in the analysis of gender. Concurrently, throughout the book, we use the term women-dominated sectors and the category of gender to explore the health effects of the work environment on employees in women-dominated work organisations and the ways in which norms of gender are important in these organisational processes. In this context, however, we use the concepts of women-dominated sectors and gender to cast light on how the welfare state, by acting as an employer of the category of ‘women’, has also created subordinated positions for various groups of women in the labour market (cf. Koskinen Sandberg, 2018). Consequently, although our primary analytical focus is on women and gender, the empirical data in this anthology includes and explores the diverse circumstances and experiences of workers and managers in women-dominated sectors and the materiality underpinning these various positions.

1.4

Chapters in This Volume

The introduction in this first chapter refers to contemporary problems for individuals, organisations, and society, and this illustrates the ambition of the book. We argue in favour of the need for empirical research, and we believe the strongest aspects of this book are the use of different methods, both quantitative and qualitative, presented together with empirical facts and findings. The theoretical approaches in relation to gender and women-dominated work differ between the chapters. The breadth is visible as two chapters make a theoretical contribution—one argues for classification by industries at the labour-market level (Chap. 2) and then tests the proposed model in an empirical study (Chap. 3), and in another chapter the authors argue for a multilevel approach when analysing healthcare (Chap. 4). Furthermore, one chapter applies gender role theory to the understanding of gender differences (Chap. 8), whilst several others apply gender theory to investigate gendered norms and power inequalities (Chaps. 5, 6, 7, 9, 10, and 11). These empirical analyses reveal how gendered norms at work are preserved rather than produced and, in the analysis of NPM, they are observed, together with gender, to have a major impact on how work is organised, on the work environment, and, consequently, on the individual worker’s health. We have mentioned in this introduction that an increasing proportion of the workforce in LTC sectors are immigrant women. In several chapters of the book, these workers are part of the workplace environment and/or included in the dataset, hence analysed by the authors, even though they may not be explicitly mentioned or

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discussed (Chaps. 3, 5, 6, 7, and 9). This implicit rather than explicit approach to how other power dimensions—for example, class—structure and organise working conditions and the work environment in women-dominated sectors is also present in other chapters discussing the interplay between horizontal and vertical segregation, and/or the materiality underpinning such hierarchies at work. After this introductory chapter, the book is divided into three parts: Working conditions, organisation of work, and violence and conflicts, consisting of ten chapters altogether. In the first part, entitled Working Conditions, four chapters scrutinise gender differences and working conditions on the labour market and within organisations, illustrating how gender segregation and gender norms are interwoven and affect employees’ and first-level managers’ working conditions and health. Two chapters are theoretically driven (Chaps. 2 and 4) and the other two are empirical chapters (Chaps. 3 and 5). The second chapter, Classification of work: An approach to the exploration, understanding, and prevention of gender differences in working conditions, is written by Annika Härenstam and Anna Nyberg. In this chapter, the authors propose a classification by industry type when surveying, analysing, and reporting results regarding the work environment within organisations. Given the fact that the labour market is to a large extent gender segregated, this classification may be helpful for identifying processes that contribute to inequality at work. Chapter 3, Organisational and social working conditions for women and men in industries with different types of production and gender composition: A comparative study of the development in Sweden between 1991 and 2017, is written by Anna Nyberg, Annika Härenstam, Gun Johansson, and Paraskevi Peristera. In this chapter, the classification of working life by type of industry proposed in Chap. 2 is illustrated with an empirical example. The analysis of the work environment, using Swedish data, reveals how organisational factors differ between industries and how social factors are dependent on gender composition. The text of Chap. 4, A multilevel approach to understanding job demands and resources in healthcare, is written by Anne Richter, Marta Roczniewska, Henna Hasson, and Ulrica von Thiele Schwarz. In this chapter, the authors argue for the benefits of analysing the work environment, in terms of job demands and resources, by using a multilevel approach including the individual, team, and organisational levels. They also suggest that in order to improve the work environment, which is particularly important in the women-dominated healthcare sector, interventions also need to be designed using a multilevel perspective. Chapter 5, Managing care work in times of austerity: Gendered working conditions for managers, is written by Klara Regnö. Based on 12 in-depth interviews with first-level managers in publicly funded and organised elderly care and disability care, Regnö shows how NPM has increased the pressure on managers to comply with budgetary constraints, regardless of the consequences for the users and workers whom they are responsible for and supervise. In addition, NPM has contributed to individualising managers’ responsibility for care operations. Altogether, this decreases managers’ room to manoeuvre, and puts them in a highly vulnerable position within the overall municipal organisation.

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In the second part of the book, Organisation of Work, four chapters illustrate how different ways of organising work: through new technologies, by NPM techniques, or by working non-standard hours, shape and impact upon the work environment and employees’ health. Furthermore, the chapters address differences in gender roles and biology (Chap. 8), as well as theories on gender norms (Chaps. 6, 7, and 9), in their explanations of how inequalities are preserved due to health and working conditions. The sixth chapter, Invisible workers: On digitisation and gender in homecare work from a gender and technology perspective, is written by Charlotte Holgersson and Britt Östlund. In this chapter, the authors explore the interplay between technology and gender, and how the digitisation of homecare services for older adults has contributed to reshaping working conditions in the sector. The authors show that although home-care services have always included technology, homecare workers are invisible when new technology is being developed, procured, and/or implemented due to the low status of homecare work. In Chap. 7, Organising auditing, person-centred care, and competence in Swedish residential care homes, the authors Palle Storm and Anneli Stranz scrutinise how residential care homes have responded to the new requirements and conditions introduced by NPM techniques, and how this affects different aspects of everyday care work. The authors find that care workers often perceive the three dimensions of auditing, person-centred care, and competence with ambivalence, and that the relational and emotional aspects of care work are made invisible and unrecognised. In the eighth chapter, Gender differences in the impact of work hours on health and well-being, Philip Tucker reviews the evidence for whether women and men have different experiences of working non-standard hours. He uses a gender-role perspective, together with a biological and organisational perspective, to understand the mechanisms that might explain why men and women may experience shift work and flexible working hours in different ways. The ninth chapter, The interplay between gendered norms and new public management strategies in the shaping of homecare services’ work environments, is written by Annika Vänje. The aim of this chapter is to provide new insights into how social values regarding gender and NPM strategies shape homecare services’ physical and organisational work environments. The author also seeks to identify what kinds of changes are needed in order to create more sustainable work environments for employees. The analysis reveals that, in different ways, gendered expectations around femininity support the performance ideologies advocated by NPM. Furthermore, Vänje shows that work environment problems are resolved at an individual level and that emotional burdens are placed on top of each other, without being visualised or assessed. In the anthology’s third part, entitled Violence and Conflicts, the voices of employees and first-level managers are brought to the centre of the analysis of the work environment, job security, and health in two empirical chapters. The tenth chapter, ‘Don’t let it get to you’: Gendering workplace violence in disability services in Sweden, is written by Helene Brodin and Sara Erlandsson. They explore the gendered subtext of workplace violence in Swedish disability care

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services. In addition, they illustrate how an individualised perspective on workplace violence, blaming either the violent client or the workers, re-creates the problem. An organisational perspective, in contrast, can be used as a driving force for changing both the work environment and ethics, through the perspectives of the clients. In the 11th and final chapter, The concept of intragroup conflict in relation to gender and well-being in women-dominated work, Britt-Inger Keisu and Susanne Tafvelin explore how conflicts are perceived and the impact they have upon the wellbeing of workers. In three different workplaces—a social services office, a school, and a geriatric hospital ward—the authors find that, despite stereotypical discourses of gender in society, the empirical analyses reveal no differences between the ways in which men and women perceive or practise intragroup conflict. The authors also show that although all conflicts trigger emotions that are difficult to handle, such as anger, stress, and exhaustion, only relationship conflicts are damaging to well-being.

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Frederickson, H. G. (2010). Social equity and public administration: Origins, developments and approaches. M. E. Sharpe. Hassard, J., & Torres, L. D. (2021). Gender, work, and health: Some introductory thoughts. In J. Hassard & L. D. Torres (Eds.), Aligning perspectives in gender mainstreaming: Gender, health, safety, and wellbeing (pp. 1–18). Springer. Hayes, L. J. B., & Moore, S. (2017). Care in a time of austerity: The electronic monitoring of care workers’ time. Gender, Work and Organization, 24(4), 329–344. Hood, C. (1995). The ‘New Public Management’ in the 1980s: Variations on a theme. Accounting, Organizations and Society, 20(2–3), 93–109. hooks, b. (2000). Feminist theory: From margin to center. Pluto Press. Kantola, J., & Lobardo, E. (2017). Feminist political analysis: Exploring strengths, hegemonies and limitations. Feminist Theory, 18(3), 1323–1341. Korpi, W., Ferrarini, T., & Englund, S. (2013). Women’s opportunities under different family policy constellations: Gender, class, and inequality tradeoffs in Western countries re-examined. Social Politics, 20(1), 1–40. Koskinen Sandberg, P. (2018). The corporatist regime, welfare state employment, and gender pay inequity. NORA – Nordic Journal of Feminist and Gender Research, 26(1), 36–52. Lewis, J. (1992). Gender and the development of welfare regimes. Journal of European Social Policy, 2(3), 159–173. Llorens, J. J., Wegner, J. B., & Kellough, J. E. (2008). Choosing public sector employment: The impact of wages on the representation of women and minorities in state bureaucracies. Journal of Public Administration Research and Theory, 18(3), 397–413. Mandel, H., & Semyonov, M. (2006). A welfare state paradox: State interventions and women’s employment opportunities in 22 countries. American Journal of Sociology, 111(6), 1910–1949. Meagher, G., & Szebehely, M. (2013). Marketisation in Nordic eldercare: A research report on legislation, oversight, extent and consequences. Department of Social Work, Stockholm University. Meagher, G., & Szebehely, M. (2018). Nordic eldercare: Weak universalism becoming weaker? Journal of European Social Policy, 28(3), 294–308. Meagher, G., Szebehely, M., & Mears, J. (2016). How institutions matter for job characteristics, quality and experiences: A comparison of home care work for older people in Australia and Sweden. Work, Employment and Society, 30(5), 731–749. Mohanty, C. T. (2003). Feminism without borders: Decolonizing theory, practicing solidarity. Duke University Press. Montgomery, A., van der Doef, M., Panagopoulou, E., & Leiter, M. P. (2020). Connecting healthcare worker well-being, patient safety and organisational change: The triple challenge (pp. 1–10). Springer. OECD. (2020a). Women at the core of the fight against COVID-19 crisis. OECD Publishing. https://www.oecd.org/gender/. OECD. (2020b). Who cares? Attracting and retaining care workers for the elderly. OECD Publishing. https://doi.org/10.1787/92c0ef68-en. Ranci, C., & Pavolini, E. (2015). Not all that glitters is gold: Long-term care reforms in the last two decades in Europe. Journal of European Social Policy, 25(3), 270–285. Sainsbury, D. (1996). Gender, equality and welfare states. Cambridge University Press. SOU. (2004). Den könsuppdelade arbetsmarknaden. [The gender-segregated labour market]. Betänkande av Utredningen om den könssegregerade svenska arbetsmarknaden SOU 2004:43. Fritzes. Strandell, R. (2019). Care workers under pressure: A comparison of the work situation in Swedish home care 2005 and 2015. Health and Social Care in the Community, 28(1), 137–147.

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Szebehely, M. (2020). COVID-19 reveals serious problem in Swedish long-term care: LTC responses to COVID-19: International long-term care network. Retrieved May 14, 2020, from https://ltccovid.org/2020/05/08/covid-19-reveals-serious-problems-in-swedish-long-termcare/. Theobald, H., & Luppi, M. (2018). Elderly care in changing societies: Concurrences in divergent care regimes – a comparison of Germany, Sweden and Italy. Current Sociology Monograph, 66 (4), 629–642. UNDP. (2020). COVID-19 pandemic. Retrieved May 14, 2020, from https://www.undp.org/ content/undp/en/home/covid-19-pandemic-response.html. Williams, F., & Brennan, D. (2012). Care, markets and migration in a globalising world: Introduction to the Special Issue. Journal of European Social Policy, 22(4), 355–362. Britt-Inger Keisu is an associate professor in Sociology and employed as a senior lecturer at Umeå University. Currently she work as head of the department at Umeå Centre for Gender studies. Her main research interests involves gender-organisation and leadership theory. Helene Brodin holds a PhD in Economic History and is associate professor in Social Work at Stockholm University. Her main areas of research are eldercare and disability care with a special focus on how gender and ethnicity interact with the organisation and distribution of care services. Susanne Tafvelin has a PhD in psychology and is an associate professor at Umeå University. Her research focus on how leaders and the work environment impacts on employee well-being as well as on transfer of leadership training.

Part I

Working Conditions

Chapter 2

Classification of Work: An Approach to the Exploration, Understanding, and Prevention of Gender Differences in Working Conditions Annika Härenstam and Anna Nyberg

2.1

Introduction

Gender segregation in working life and gender differences in working conditions and work-related health are generic patterns observed over time and all over the world (World Economic Forum, 2017; European Commission, 2009; EIGE, 2017). In spite of all efforts to improve gender equality in working life, gender differences in work environments and in work-related health still exist. In short, when comparing women and men as groups, psychosocial working conditions and stress-related ill health are worse for women and work-related physical risks and accidents are more prevalent among men (Kauppinen et al., 2003). As the contexts for women and men differ, there are many factors that have an impact on causes of gender differences, which complicate exploration, interpretation, and prevention. In this chapter, we argue for an approach concerning gender that primarily focuses on context, that is, the industry where work is performed. To do so, a classification model that takes gender into account is needed. The chapter is structured as follows: First, we describe the development of areas reporting and analysing gender differences in working conditions and work-related health, which include labour statistics and research on occupational health, gender, and work. In the second section, we suggest

A. Härenstam (*) Department of Sociology and Work Science, University of Gothenburg, Gothenburg, Sweden Department of Psychology, Stockholm University, Sweden e-mail: [email protected] A. Nyberg Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden Karolinska Institutet, Solna, Sweden e-mail: [email protected] © Springer Nature Switzerland AG 2021 B.-I. Keisu et al. (eds.), Gendered Norms at Work, Aligning Perspectives on Health, Safety and Well-Being, https://doi.org/10.1007/978-3-030-77734-0_2

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a theoretical and methodological approach for how inequalities in working life can be explored, particularly when using labour statistics and surveys. In the third section, we present a classification system and illustrate it using Swedish data. This system has also been applied for industry comparisons of psychosocial working conditions for women and men respectively in Chap. 3. Finally, we discuss how industry-specific knowledge on working conditions can be applied in order to promote gender equality in working life.

2.1.1

Labour Statistics

Labour statistics is an important resource for describing the world of work, especially when it comes to gender issues. These statistics are necessary for monitoring how the economy is performing and developing. Also, for social reasons, such as job creation, planning education systems, identifying occupational health risks and vulnerable groups, labour statistics are important. Work environment and health are thoroughly surveyed at an individual level, and large databases have been available for decades. Most countries have statistics bureaus, and international organizations such as European Union, United Nations, International Labour Organization (ILO, 2017) produce labour statistics regularly. Users of labour statistics include policymakers, employers, managers, unions, and experts with the power and authority to design organizations and jobs for the production of goods and services. It is important that labour statistics reflect reality in a meaningful way in order to meet the demands of their users. The production of labour statistics involves choosing indicators and then collecting, classifying, and systematizing the data in databases that users have access to. How these different steps are performed influence the possibilities of interpreting, analysing, and reporting the information. There are many perspectives and objectives to take into consideration. Most official individual-based statistics have recorded information on sex. But this does not mean to imply that labour statistics are constructed and used with gender as a primary concern (Greenwood, 1999). The implementation of gender-separate data started a transition period in research and policy from ‘gender blindness’ to visualizing women’s conditions in working life, nationally and internationally (Hedman et al., 1996). In Sweden, gender-separate statistics and reports on gender comparisons have been available since 1984. Gender equality in working life has become a big issue in many countries as well as in international institutions. During the last decades gender mainstreaming has been implemented at several levels of society, meaning that planned policy actions such as legislation and action programmes might have different implications for women and men, and therefore must be addressed. The International Labour Organization implemented a gender mainstreaming policy in 2008 (ILO, 2012).

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Occupational Health Research

When it comes to occupational health research and epidemiological studies, the data sources are based on official labour statistics, registers, surveys, and questionnaires. The main approach in analyses of such data is to produce decontextualized assessments on risks and consequences. Variations between groups, multicollinearity, and possible confounding and mediating contextual factors are more or less disguised in this type of research (Susser, 1999). This means that the influence of contextual and structural factors on gender differences are difficult to identify (see Härenstam, 2009; Bolin & Olofsdotter, 2019). Established theoretical models in occupational health research, particularly of psychosocial factors such as the Job Demand Control model (Karasek & Theorell, 1990), suggests that job design at the organizational level has an impact on the quality of work at the individual level. Despite this, organizational factors and organizations as analytical units have been very rare in research (Bolin & Olofsdotter, 2019; MacDonald et al., 2007; Härenstam, 2017). The different disciplines have been specialized and divided in universities, conferences, and scientific journals (Barley & Kunda, 2001). Organization researchers are mainly found in business schools with outcomes other than work conditions, such as productivity or organizational behaviour. Occupational health research on the other hand often excludes the workplace and the organizations as analytical units in populationbased samples. Instead, information on class and occupation as proxies for structural conditions are often applied, presuming that all individuals with the same occupation, sex, and class share the same context (see, e.g., Ekenvall et al., 1993; Messing & Östlin, 2006).

2.1.3

Gender Studies of Working Conditions

In occupational health research, studies specifically on gender started to be seriously undertaken in the 1980s (Östlin et al., 2001). Three phases and approaches to advance knowledge can be tracked. First were those with their focus on women’s situations, aimed at adding knowledge to the male-biased view (Thurén, 2003). The second approach was to compare women and men in order to visualize women’s situations in relation to that of men´s and to focus upon gender equality (Thurén, 2003). In fact, most gender studies of working conditions are based on the binary categories of woman and man, often without reflecting on the binary as such (Kelan, 2010). When differences are found, explanations are often sought either in a ‘counting bodies’ tradition, such as token theory (Kanter, 1977), or in traditional individual-oriented psychologically or biologically rooted gender-role behaviour and aspirations theories (see, e.g., Morawski, 1997). Sometimes gender differences are not commented upon at all, as it has been seen as an explanation per se (Yoder & Kahn, 2003).

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Health care Education Nonprofit Media& communication Public administration Legal Corporate Services Real Estate Finance Software & IT services Energy & Mining Manufacturing 0%

20% Women

40%

60%

80%

100%

Men

Fig. 2.1 Female share of employment by industry. Source: Linked in data featured in the Global Gender Gap report 2017, figure 16 (World Economic Forum). Chart prepared by the authors

A third research tradition reflecting on gender differences in working conditions is based on gender order theory (Hirdman, 1990) and gender inequality theories (Acker, 2006; Connell, 2006), and these contend that gender is a social structure enacted at many levels in society. Gender is created and recreated as social practices in interactions in daily life, particularly in organizations. The prevailing tradition before the 1980s was to view organizations as gender neutral (Britton, 2000). Joan Acker’s seminal work on gendered organizations (1990) opened up research into gender and organizations. Important mechanisms in the creation of inequality are segregation and hierarchy, that is, devaluation of women in relation to men. The horizontal gender segregation is a very stable pattern all over the world (Fig. 2.1). Still, most women work in ‘people-oriented’ jobs and men in ‘thing-oriented’ jobs (Kohn & Schooler, 1983; Lippa et al., 2014). The vertical segregation, that is, that women are underrepresented in higher positions, is still evident but has decreased slowly as many more women have entered many high-status jobs (Barabaschi & Mussida, 2016; Lippa et al., 2014; Mustomäki et al., 2017). Another mechanism is the immanent structure of the gendering process that makes gender differences difficult to reveal and change (Westberg-Wohlgemuth, 1996). Most important and a reason why gendering in working life is difficult to explore is the recursive function of the gendering process. ‘People have a gender, and their gender rubs off on the jobs they do. The jobs in turn have a gender character that rubs off on the people that do them’ (Cockburn, 1988). In this tradition, there is a focus on doing and undoing gender, that is, creating and performing the structures, processes, and symbols that shape, restore, and change what is labelled as male/masculinity-coded and female/femininity-coded activities (Deutsch, 2007; West & Zimmerman, 1987). Also, ‘doing gender’ theory is built on

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the image of how gender, as two categories, is enacted in organizations. However, among intersectionality scholars, the use of sex as a binary category has been criticized (Martinsson et al., 2016) as it disguises the complexity of identity, and it simplifies how power and status are distributed and exercised. The fact that women and men in general are found in different types of occupations, positions, industries, and sectors, as well as that they report different working conditions and have different occupational health risks, demands explanation. In the next section, theories are presented that aim to explain how inequalities between groups in working life are created.

2.2

A Contextual and Multilevel Approach to Explore How Inequalities in Working Life Are Created

Gender is a multilevel phenomenon enacted at interpersonal, organizational, and societal levels (cf. Yoder & Kahn, 2003). This means that when working conditions for women and men are compared, it is the consequences of how work is organized and governed in a chain of agency at several levels that are assessed (Härenstam, 2008). Working conditions are said to mediate the effects of structural factors at societal and organizational levels on the health of workers, and they are also restricted and modified by the contexts where they exist (Bolin & Olofsdotter, 2019; Martikainen et al., 2002; Rousseau & Fried, 2001). In a contextual and multilevel approach, individuals’ behaviours, attitudes, performances, and health are endpoints of series of events starting from the societal and institutional level (see Fig. 2.2) (Bliese & Jex, 2002; Bolin & Olofsdotter, 2019; Society Industries Organization Work place Division of labour Job tasks Working conditions

Gendering

Health, motivation, performance

Fig. 2.2 A multilevel and contextual approach to how gender differences in working conditions are enacted at many levels in society

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Härenstam, 2009; Kozlowski & Klein, 2000). If, for example, there is an economic crisis, or general trends like globalization, new technology or new institutional regulations, organizations respond to these contextual changes, for example, by changing divisions of the production process and outsourcing, which in turn leads to their employing other categories of workers and/or separating work process and matching jobs and individuals differently. When it comes to the workplace and group levels, working conditions, like social interaction as well as job demands, influence over work, and job security, might change. Actions at each of these levels can be done in a gendered way. Occupational health research has advanced tremendously in recent decades in terms of knowledge regarding risk factors at various job task levels. There is great consensus in science concerning what is healthy and unhealthy work. However, mainstream research does not produce knowledge on the arenas where inequalities are enacted, that is, the industry, organization, and workplace where jobs are performed. In the next section, we present structuration theory and inequality regime theory (Tilly, 1999; Acker, 2012), which explain how inequality is created and preserved by linking structures at societal, industrial, and organizational levels to agency. We argue that these theories are helpful in the choice of methodology for analyses of gender inequality in working conditions.

2.2.1

Structuration and Inequality Regime Theories

Structuration theory is about the interaction between actors, agency, and social structure (see e.g., Giddens, 1984). The perception of social reality is maintained by meaning shaping and acting simultaneously as social structure both enables and restricts acting. The agents are not only governed by structures, they can also change them. Structuration theory has been applied in organization research to explore how social structures of power are manifested in daily practices (Lounsbury & Ventresca, 2003). According to the organization scholars who apply this theoretical perspective and structures at the societal level, such as patriarchal norms, shape what is perceived as natural and what creates shared meaning in organizational life. For example, who is supposed to work full time, who is suitable for certain types of tasks, invited to meetings, promoted, and rewarded? As long as such actions are perceived as meaningful, they will go on following the same logic and the same power structures will remain. Furthermore, it is argued that applying scientifically framed descriptions of women and men as natural groups may contribute to keeping a biased gender order intact (Klysing, 2020). Structuration theory has been applied by the sociologist Charles Tilly (1999) to describe how inequality in working life is constructed as a process. The first step is to classify individuals in distinct categories. The categories are in the second step associated with certain tasks or objects. In the third step, the production of goods or services is separated, vertically and/or horizontally, which means that those who perform different tasks are separated. Finally, the separation in time and space means

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that the work can be valued, governed, and organized, and can also be allocated resources, differently. The result can be very different working conditions in terms of health. Inequality between categories of workers who perform the separated work, such as women and men, is thus created and even found natural as it is more or less immanent. Cecilia Ridgeway wrote: ‘That is, when a difference becomes a status difference, it becomes a separate factor that generates material inequalities between people above and beyond their personal control of resources’ (2014, p. 4). That is why it is so important to compare settings for work rather than categories of workers. It is when contexts are compared that we can find knowledge on differences in ‘upstream’ conditions that are involved in creating inequality (see Fig. 2.2). In gender and organization research, Joan Acker has been very important for advancing knowledge on how inequality regimes in organizations can be explored. She defined inequality regimes as ‘loosely interrelated practices, processes, actions, and meanings that result in and maintain class, gender, and racial inequalities within particular organizations’ (2006, p. 443). Acker’s approach to exploring how inequality regimes create gender differences in organizations has mainly been applied in the qualitative method tradition. Although her work mainly focuses on organizations, Acker also sees organizations as embedded in social contexts. When there is external pressure for change, inequality regimes can be changed, as when new legislation change organizational policies and practices (Acker, 2012). A recent example in Sweden is the new work environment act on social and organizational conditions, AFS 2015:4 (Swedish work environment authority, 2015), which seems to have increased efficiency in addressing the large work environment problems in public welfare services (Steinberg, 2018). Acker’s inequality approach has also been applied in intersectionality studies that imply that sex is intertwined with other social categories such as race and class, which also must be considered when analysing inequalities in working life (see Bolin & Olofsdotter, 2019). Both structuration theory according to Charles Tilly and Acker’s theory on inequality regimes suggest that we need to explore the arenas where processes, practices, and meanings are enacted, rather than starting by comparing women and men. This means that the principal motivation of research should be to explore characteristics in settings in working life where good and bad working conditions are created.

2.3

An Alternative Classification of Work

To summarize, there is a gap, not only in science but also in practice between those who have the power and knowledge to design jobs and workplaces and those who are supposed to prevent ill health and gender inequality. There is a need for another approach that targets and links knowledge of how to create healthy work and gender equality with knowledge of designing the production of goods and services. Most important would be to use workplaces as analytical units in relation to the

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microlevel, that is, the working conditions and health of individuals. Such an approach has been argued for, and it has also been tested and found to be very relevant (Bolin & Olofsdotter, 2019; Härenstam, 2008, 2017; Bolin et al., 2008). However, this strategy is not useful in population-based labour statistics and surveys, as it is difficult to link data on individuals to data on the organizations where they work (Dhondt, 2003). Instead, it is a matter of using available labour statistics intentionally to compare contexts with a gender concern. A very stable pattern is the gender horizontal segregation of work. Work objects, tasks, and production technologies are gendered, although there are historical examples that occupations can ‘change gender’ over time (Britton, 2000; Gonäs et al., 2001, p. 9). For example, clerical work in the nineteenth century was a male-typed occupation, and nowadays it is performed almost solely by women (Davies, 1982). On the other hand, milking was performed by dairy maids before the 1930s, but as machines for doing the work were introduced these tasks came to be performed by dairymen (Sommestad, 1992). Veterinarian is also an occupation that has ‘changed’ gender in most countries (Irvine & Vermilya, 2010). Before the 1950s, only a few percent of veterinarians in Sweden were women, and now the number is at over 80%. Technology-intensive production and services traditionally have a male connotation, both with regard to the symbolic meaning of the products linked to masculinity and the bodies performing the jobs (Wajcman, 2011). Activities involving meeting the needs of others have traditionally had female connotations, both with regard to the symbolic meaning of femininity and the bodies of those who do the work (SahlinAndersson, 1994; Selberg, 2012; Simpson, 2009). Other types of service and administrative services are not evidently gendered without adding information on specific positions and occupations (Härenstam, 2017; Kohn & Schooler, 1983). By classifying production by how it is gendered, we find a meaningful linkage between gender research, occupational health research, policymaking, and parties in the labour market. As production processes with differently gender-typed work are often separated in time and space, it is easy to assign different statuses to femaletyped and male-typed jobs without expressing openly that women and men are valued differently (Ridgeway, 2014). According to Charles Tilly (1999), it is the work object and the technology applied that restrict how the work is defined, divided, standardized, governed, and controlled. This means that the work object and the technology have great impact on how work is organized. Melvin Kohn and Carmi Schooler (1983) wrote that freedom from close supervision, the complexity of the task, routinization, and standardization are decisive for how work is valued and manned. This is in correspondence with exploitation of and opportunity hoarding that Tilly describes as important mechanisms that are involved in the creation of inequality between groups (Tilly, 1999). This view facilitates understanding how female-typed jobs are lower valued than male-typed jobs. There are reasons to believe that organizations with industrial production differ in organizing and managing from companies dealing with human services or with symbols (Marshall et al., 1997; Kohn & Schooler, 1983). Many organizations within the same type of industry act under the similar technological, jurisdictional, cultural, and economic preconditions (Giertz, 2000; Härenstam & the MOA Research Group,

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Working with Working at high tight deadlines Enough time Handle angry speed (3/4 of the (3/4 of the time to do job clients (3/4 of Disruptive +) time +) (never/ rarely) the time +) interruptions EU28 Other Services Health Education Public Administration Financial Services Transport Commerce and hospitality Construction Industry Agriculture

33 30

10

36

9

35

34 18

36

34

44 48

9

39

43

11

32

27

14

9

8

20 9

20

8

39

22

19

11

35

26 17

17

8 37

39

26 22

10

29 30

16 15

14

24

20

16 13

15

12

15

7 6

16 8

Fig. 2.3 Components of some of the work intensity dimensions by sector, EU28 (%). Source: Eurofound and International Labour Organization (2019). Chart prepared by the authors. Red columns are female-dominated sectors, and blue columns are male-dominated

2005). They share similar driving forces on global, regional, and local markets. Furthermore, analyses of EU policy documents on growth and innovation have showed that sectors, industries, organizations, disciplines, and innovations have been favoured in a gendered manner (Lindberg, 2017). A technological rather than social focus on industries and innovation have prioritized mainly male-dominated sectors, with men as actors and what have been perceived as masculine activities. Furthermore, organizations within the same field, such as type of industry and the same set of environmental conditions, tend to be more and more alike due to what is called ‘isomorphism’, according to new institutional organization theory (DiMaggio & Powell, 1983). We should therefore expect systematic differences in work environment and health risks between industries, particularly in factors related to tasks, technologies, and organization of work in time and space (such as job demands, influence). Some studies confirm this hypothesis (Bolin et al., 2008; Härenstam et al., 2004a). A new categorization of organizations that attend the question of what is produced, the position at the market, as well as the needs of knowledge and technology was developed in Sweden and applied in an investigation of productivity (Giertz, 2000). This classification system was adapted and applied also in studies of the distribution of ‘good’ and ‘bad’ jobs and exploring effects of lean organization (Härenstam et al., 2004b). Similar classification grouped by the type of economic activity they are involved in, occupation and hierarchical position has been applied in large comparative surveys like the European Working Conditions Survey (Eurofound, 2020). Also, in global policy documents, comparisons of industries are reported. Figure 2.3 below shows means of employee reports on work intensity dimensions between several large industries in 28 EU countries in 2019. These comparisons illustrate that there are different patterns between industries.

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We suggest a classification of industries grouped not only by type of economic activity but also taking gender into account. In the text box below, the details are described in this classification applied to Swedish data. Classification of industries of the Swedish work force The industry variable is based on the Swedish Standard Industrial Classification (SNI) (SCB, 2007), a system that follows the recommendations of the statistical classification of economic activities in the European Community (NACE), allowing for comparisons of data at the national and international level, and over time. The main criteria for the classification of the main SNI group concern characteristics of the economic activities regarding the produced goods or services; the area of use of the products; and the characteristics of the input, the production process, and the technology used (SCB, 2007). All establishments (the lowest unit in the Swedish business register, SCB) have a SNI classification, based on the main economic activity performed there, that is, the activity that contributes most to value added to the output. An establishment is defined as an address, building, or group of closely located buildings, where the economic activities are performed. A company can have several establishments with the same or different SNI codes. Through the establishment, all employees can be linked by register to a SNI code. The SNI was last revised in 2007. The SNI 2002 and 2007 have 15 and 19 categories, respectively, applicable for paid work. These categories were grouped into seven new categories adding gendered characteristics of the activity and according to two principles: (1) the type of work conducted in each industry, and (2) the proportion of men and women employed in each industry. However, as we argue for a production logic that will be reflected in differences in organizational factors, it is not relevant to merge all technology-intensive industries into one male-gendered group. We suggest separating industries where work is mainly place-bound activities in factories or mines, from industries that are mainly performed in different places and still utilizing the machinery and vehicles that has male connotations. We label these two groups as ‘Goods and energy production’ and ‘Machinery operations’. Similarly, we separate the two SNI main categories Education from Health and Social Care. Both these industries employ a large proportion of mainly the female workforce. The three gender-mixed categories encompass activities with varying job orientations: handling Things, Data, and People (Kohn & Schooler, 1983). Service and administration activities are not easily gendered. These main SNI groups have been merged into what is labelled as labour-intensive and knowledge-intensive services, that is, they have more class than gender connotations. Within these main groups, we find very gender-typed activities. One of the main SNI categories, public authorities, (continued)

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could not easily be classified into any of these groups and was consequently remained as a separate category. Public authorities contain both knowledgeintensive public administrations as well as the activities like the military, the police, and the fire brigades. In order to test the relevance of the classification with regard to gender, we explored the gender composition within each category. As shown in Table 2.1, Table 2.1 Industry classification based on work object and gender connotations. The proportion of women in each industry in 2017 in the Swedish Labour Force Survey (n ¼ 4,389,100) is given in the last column (ref)

Industry Health and social care Education Public administration Labour-intensive services

Knowledgeintensive services

Goods and energy production

Machinery operations

SNI 2007 category and code • Human health and social work activities (Q) • Education (P) • Public administration and defence; compulsory social security (O) • Wholesale and retail trade, repair of motor vehicles and motorcycles (G) • Accommodation and food service activities (I) • Arts, entertainment, and recreation (R) • Other service activities (S) • Administrative and support service activities (N) • Information and communication (J) • Financial and insurance activities (K) • Real estate activities (L) • Professional, scientific, and technical activities (M) • Mining and quarrying (B) • Manufacturing (C) • Electricity, gas, and air conditioning supply (D) • Water supply; sewerage, waste management, and remediation activities (E) • Agriculture, forestry, and fishing (A) • Construction (F) • Transportation and storage (H)

Main job orientation People

Proportion of women in the Swedish Labour Force Survey in 2017 78%

People People and data

71% 57%

People Things Data

50%

Data

41%

Things

23%

Things

14%

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two categories—goods and energy production—employs more than 70% men, and two categories—education and health services—employ more than 70% women. Public authorities, knowledge-intensive services, and labour-intensive services employ between 40% and 60% of each sex. Altogether, 28% of the total workforce in Sweden work in female-coded industries and 24% in male-coded industries. The rest, that is, 48% work in industries that are not generally gender coded without adding class- or workplace-level data in order to visualize the gender order. For example, within labour-intensive services, there is the retail trade, where selling cars and electronics have male connotations and trading aesthetic products like clothes and hygiene and beauty products have female connotations (see, e.g., Pettinger, 2005). We will therefore expect that when using this classification, there will be more variation with regard to working conditions in the three mixed groups than in the four very gendered groups of industries. Gender-stratified analyses show that 13% of all men work in female-dominated industries and 11% of all women work in male-dominated industries. Thus, the classification applied can be regarded as a proxy for female- and male-dominated and gender-mixed industries. The classification system has been found valuable when comparing groups of industries regarding development trends over time in psychosocial working conditions for women and men (Cerdas et al., 2019; see also Chap. 3). Methodological considerations Note that within each type, all occupations working at each establishment is classified in the same category based on the main economic activity. This means that, for example, the working conditions of a secretary (i.e., a femaletyped job) is classified as having the same situation as the factory worker in goods production if she works at the same address as the production unit. And a male director of a hospital is classified as having the same situation as nurse assistants in health and care industries. On the other hand, when stratifying by sex, all women are classified as having the same working conditions, independent of type of work. We argue that it is more relevant to aggregate data by type of industry in the first place, and then stratify by gender. Such knowledge is much easier to understand and apply in preventive actions and the design of jobs and work environments. Such marks have been made also by policy makers. Official statistics on work environment should prioritize industrybased statistics and secondly identify vulnerable groups. Identity-based statistics, such as gender, ethnicity, and similar categorizations, may increase polarization and segregation of groups (Sedlatschek, 2017).

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Analysing Strategy in Search for How Inequalities Are Created

In order to use industry classifications like the one suggested here for comparisons of working conditions and explorations of inequality, we need a strategy for analyses. In accordance with structuration theorists, we suggest that the main principle for comparisons are industries (or if available, organizations within industries). Comparations as a method in research and interventions helps to visualize differences and similarities, which facilitates reflections and allows for solutions to problems (see Denk, 2010; Mills et al., 2006). If systematic variations between industries are found, the next step would be to explore whether there are also differences when stratifying by categories of workers in order to find out whether there are certain groups that are at risk in industries with poor quality of work. It is important not to ‘adjust’ statistical analyses for sex, class, ethnicity, etc., as that would disguise the stratification process as good and bad jobs by distributing jobs in a systematic way. The challenge is to search for patterns of changed structures, processes, and agency at societal, institutional, industrial, and organizational levels that can shed light on observed changes at the endpoints, that is, in working conditions, health risks, and performance. This means that information on structural changes over time is needed as such changes precede changes in work environment. Such a strategy based on structuration and inequality regime theories would help to fill the gaps of knowledge on how differences in working conditions are created.

2.4

How Industry-Specific Knowledge on Gender and Work Environment Can Be Applied

The focus on prevention and interventions should be the context where work is performed that requires context-specific knowledge on what characterizes healthy and gender-equal workplaces. Psychosocial risks seem to affect men and women similarly, according to a recent review (Sverke et al., 2016). This means that there is little support for directing preventive actions specifically to men and women, respectively, in the workforce. Instead, a gender mainstreaming policy is suggested (EU-OSHA, 2003), which includes such directives, for example: • • • •

Avoid assumptions of who is at risk. Look at real work situations. Match jobs, equipment to real people. Incorporate into a holistic approach.

In addition to that many industries are very gender-segregated, they have different preconditions that frame production, organization, and job design. This means that they have different challenges to meet in order to achieve a healthy work environment independently of who is performing the jobs.

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Industry-specific knowledge of the work environment is useful at all societal levels. At an institutional level, it is possible to identify processes that might lead to differences between gender-coded industries. It has been argued that work environment laws are ‘sexistic’ (Steinberg, 2011). Both at the EU level and the national level, changes in work environment laws have led to deregulation in the welfare sector and increased regulation in construction and manufacturing industries (ibid). This means that the law is less protective in female-dominated elderly care, health care, and education than in many other industries, an observation that can be addressed if it is made visible. There is also a need for knowledge of how industries, positions, and jobs are manned in order to avoid some groups being systematically exposed to unhealthy working conditions. The work environment laws are general and encompass all workers (Lewis & Mathiesen, 2013). This means that when risks are identified, and it is determined where in the labour market they are prevalent, it is important to explore whether there are groups more exposed than others to unhealthy jobs. This is a matter for labour market policies at the institutional level and for recruiting practices and divisions of labour at the organizational level. By comparing industries and how they are manned, it is possible to detect what groups are at higher risk, rather than merely assuming that it is women who are less favoured in all industries. For example, in Great Britain, many jobs caring for the disabled and elderly have been taken from working-class women by migrant men (Hussein & Christensen, 2015). This is an example of jobs that can change gender but still preserve a hierarchical order. Also, at an industry and organizational level, there are several groups that would benefit from industry-specific work environment knowledge. Technicians, business administrators, and management consultants who design production systems and plan physical environments are examples of such groups. Also, politicians and strategic managers need industry-specific knowledge as a basis for decisions. They are also responsible for planning and purchasing new business models and production systems and technologies, for example, within process industries, transport, and health care. If industry-specific knowledge is lacking, there is a risk that ideological and market considerations will determine the development of organizations with possible negative consequences for the work environment. Another group that bears influence on work environments consists of experts of different kinds. Digitalization and artificial intelligence are increasing and seen as a solution to many problems such as lack of a competent labour force, particularly in health and social care. However, there is now evidence that IT technologies that are not adapted to the needs and conditions of specific operations lead to inefficiency, frustration, and stress (Corin & Björk, 2016; Noir & Walsham, 2007; Stadin et al., 2016). It is very important that knowledge from specific industries and operations are taken into account in the development of new technology and IT systems. At the workplace level, there is also a need for knowledge that is relevant for organizing healthy work environments in specific workplaces. It is in workplaces that social structures are enacted in actions, interactions, and practices by supervisors and employees. Furthermore, it is in workplaces that changes and work environment interventions are implemented. Legal responsibility is placed here, and it is at the

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workplace level one finds the local knowledge on the work environment. This means that the best prerequisites to create healthy working conditions are found at the operational level. However, knowledge on how to create healthy work environments adapted to specific types of production are needed in order to create healthy work in all parts of the labour market, independent of who the worker is.

2.5

Conclusions

Based on structuration and gender inequality theories, we conclude that it is more beneficial for the creation of gender equal and healthy work to primarily explore and compare working conditions by industries than to compare women and men. In this chapter, we have presented a classification of settings in working life that is suitable for comparisons in order to find and explain gender inequalities in working conditions in terms of preceding changes of structural conditions. This means that the starting point is the context where gender and power are enacted, not the binary category sex. ‘As long as it is common sense of a stable binary gender, gender needs to be done’ (Kelan, 2010). Gender will cease to be enacted when the binary gender category loses importance (West & Fenstermaker, 1995). The second advantage of comparing contexts rather than categories of workers is that the knowledge that is attained directly corresponds to the type of knowledge that the actors with power and responsibility over working conditions are familiar with, that is, at the production level and in the arenas where work is performed. By following laws and regulations on work environment and discrimination, and by focusing on industry and workplace characteristics and not on the workers, we argue that it is possible to organize work in ways that contributes to equality in work life. This is in accordance with Charles Tilly, who argued that breaking the connection between organization of work and categorization in gender, age, class, ethnicity should reduce the overall inequality significantly (1999, p. 169). The gender scholar Sylvia Gherardi (1994) expressed that although gendering is seen as an inescapable social practice that functions as differentiating women and men, this does not mean that equality in working conditions cannot be achieved.

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Chapter 3

Psychosocial Working Conditions for Women and Men in Industries with Different Types of Production and Gender Composition: Sweden, 1991– 2017 Anna Nyberg, Annika Härenstam, Gun Johansson, and Paraskevi Peristera

3.1

Introduction

Since the 1990s, women have had higher sickness absence rates than men in Sweden (see Fig. 3.1). Two hypotheses for this gender difference have been proposed. According to the exposure hypothesis, women are more exposed to stressors and strains than men, due to their occupying different jobs and social roles. According to the vulnerability hypothesis, health differences arise because various exposures have stronger negative effects on women than on men (Mastekaasa & Melsom, 2014). According to the exposure hypothesis, the increased gender differences in sickness absence rates could be related to a worse development of psychosocial working

A. Nyberg (*) Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden Karolinska Institutet, Solna, Sweden e-mail: [email protected] A. Härenstam Department of Sociology and Work Science, University of Gothenburg, Gothenburg, Sweden Department of Psychology, Stockholm University, Sweden e-mail: [email protected] G. Johansson Centre for Occupational and Environmental Medicine at Stockholm County Council, affiliated with the Institute for Environmental Medicine at Karolinska Institutet, Stockholm, Sweden e-mail: [email protected] P. Peristera Department of Psychology, Stress Research Institute, Stockholm’s University, Stockholm, Sweden e-mail: [email protected] © Springer Nature Switzerland AG 2021 B.-I. Keisu et al. (eds.), Gendered Norms at Work, Aligning Perspectives on Health, Safety and Well-Being, https://doi.org/10.1007/978-3-030-77734-0_3

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Women´s and men´s average days of sickness absence 1991-2019 30 25 20 15 10 5 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

0

women

men

Fig. 3.1 Average days of sickness absence among men and women in Sweden between 1991 and 2019. Data: Swedish Social Insurance Agency (2020)

conditions in the human services, where many women work. In the following chapter, we illustrate the development of several psychosocial working conditions for men and women in differently gendered industries. Since 2005, mental illness has increasingly come to dominate as the leading cause of sickness absence in Sweden in both genders. However, poor mental health explains a higher proportion of women’s than men’s sickness absence days (Swedish Social Insurance Agency, 2020). In 2018 and 2019, about 50% of women’s sickness absences and 40% of men’s were due to poor mental health. The exposure hypothesis (Mastekaasa & Melsom, 2014) proposes that women and men have different working conditions in the gender-segregated labour market and that these different working conditions may explain gender differences in health. Thus, the increase in sickness absence due to mental diagnoses could partly be due to deteriorated working conditions, particularly in the human services. However, there are few analyses of the development of sick leave with regard to differently gendercomposed industries. Figure 3.2 below shows the development of sickness absence in different labour market sectors in Sweden between 1990 and 2018. Before 1990, employees in municipalities and county councils had sick leave rates similar to employees in other sectors. However, since then higher proportions of sickness absence have been observed among employees in municipalities and county councils than among privately employed and civil servants. Although there are variations in sick leave in all sectors over time, the increase is steeper in municipalities and county councils than in the other sectors, particularly in the late 1990s and the start of the 2000s. A recent report from the Swedish Social Insurance Agency shows that the relative risks of sick leave over 14 days was higher in education (preschool up until high school)

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8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0

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Fig. 3.2 Sickness absence in Sweden as percent of the time the employees have been away from work sick with regard to sector 1990–2018. Data: Labour Force Surveys (LFS), Statistics Sweden

and health care compared to all other industries (Swedish Social Insurance Agency, 2018a). How can we understand these figures? As reports on sick leave rates and health differ not only between women and men, but also between work contexts like sectors and industries, it is reasonable to search knowledge on contextual factors. Working and organizational conditions in human service industries deserve particular attention because large structural and organizational changes were implemented in these industries in the early 1990s (cf. Hasselbladh & Bejerot, 2017; Szebehely & Trydegård, 2012). The overall aim of this chapter is to contribute to the understanding of increased gender differences in work-related health by comparing psychosocial work factors for women and men in differently gendered industries in Sweden.

3.1.1

Psychosocial Working Conditions in a Gendered Context

Working conditions are embedded in structures and processes in workplaces, establishments, industries, and sectors. All these levels of organizing working life are gendered contexts (Acker, 1990, 2012; Yoder & Kahn, 2003). By ‘gendered contexts’, we mean that work contexts are differently gender composed and the type of service or production that is carried out has male or female connotations (Britton, 2000; Westberg-Wohlgemuth, 1996). A number of multilevel studies have shown that the organizational context has significant importance for understanding how job demands and control (Bolin, 2009; Härenstam et al., 2004), social support (Bliese & Britt, 2001), wages (Kim, 2018), and health (Bolin et al., 2008) vary between

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employees. However, individual gender should also be considered, according to token theory (Kanter, 1977). Being the minority gender in a workplace implies higher vulnerability than belonging to the majority group. This means that contexts in working life can be gendered both by whether the type of work have female or male connotations and by the composition of men and women in a work group, in which individuals can belong to the minority or majority. In this chapter, we study several well-established work factors in relation to gendered industries. We also discuss structural changes from the same period, particularly in education, health, and social care industries that can help to understand the development of psychosocial factors for the employees. Furthermore, we argue that different aspects of working conditions require different theoretical explanations. First, we expect that dimensions that are linked to the organization of the type of work performed vary between industries and not by gender, both with regard to levels of exposure and to development trends. Secondly, we expect that factors that are related to close interactions with managers and colleagues should not vary systematically between industries, but rather be determined by factors at workplace level that are not analysed in the present chapter.

3.1.2

Work Factors Expected to Vary by Industry

Job demands and job control are the most established psychosocial work factors in research on health consequences (cf. Bolin & Olofsdotter, 2019). These factors have, for example, been established to be associated with symptoms of depression (Theorell et al., 2015) and burnout (Aronsson et al., 2017). The factors in the job demand–control model are theoretically expected to be related to the organization of work (Karasek & Theorell, 1990). This means that they are expected to vary between workplaces, industries, and sectors as well as by gendered type of work, as discussed above, but not between men and women in the same context. Job demands and decision authority are explored here as indicators of work organization, and threats and violence and harassments from clients are explored as indicators of exposures associated with the type of production of the industry. These work factors are influenced both by demands for competence from the type of technology applied, how work is governed and controlled, and also on whether the jobs involve meeting other people’s needs, handling machines, or technological or administrative work (Kohn & Schooler, 1983; Giertz, 2000). Because sick leave rates are higher and have increased more in human services compared to other sectors, we expect all these working conditions to be worse in human services for both women and men during the period studied here.

3 Psychosocial Working Conditions for Women and Men in Industries with. . .

3.1.3

39

Work Factors Expected to Vary by Gender and Gender Composition

Social interaction with managers and workmates is another often studied factor at work. Such interaction can be positive, such as good social support, and negative, such as bullying, as well as gender-based and sexual harassment. These aspects of the psychosocial work environment should be more affected by the culture and climate of the workplace (cf. Bliese & Britt, 2001) and are thus not expected to vary systematically by type of industry. For poor social support from managers and colleagues, bullying and gender-based and sexual harassment between people within the organization, we expect that women are more exposed in male-dominated contexts and men in female-dominated contexts. There are at least two theoretical propositions supporting this notion. First, according to token theory we expect that being in minority at the workplace is associated with more often being exposed to ‘bad relationships at the workplace’ (Kanter, 1977). Another mechanism could be negative reactions from others when breaking traditional gender roles. According to gender role theory, men are, to a greater extent, expected to be competence providers and women to be relational providers (cf. Davies, 1995; Eagly & Steffen, 1984), leading to different reactions from others if the expected gender roles are broken (Klysing, 2020; Rudman et al., 2012). Both these hypotheses could be studied by comparing differently gendered contexts in gender-stratified analyses. As the horizontal gender segregation of work is strong, we do not expect that the quality of social relationships for employers and colleagues have changed over time systematically by type of industry. However, there is one exception. We expect an increase in reported sexual harassment, as there is reason to believe that the tolerance level in the younger generations has decreased and the tendency to report sexual harassment increased, paving way for the rather strong #MeToo movement in Sweden.

3.2

Aim

The overall aim of this chapter is to contribute to the understanding of increased gender differences in work-related health by comparing psychosocial working conditions for women and men in differently gendered industries in Sweden. The specific objectives are as follows: 1. To estimate if psychosocial working conditions differ between differently gendered industries among women and men. 2. To explore how psychosocial working conditions have developed between 1990 and 2017 in differently gendered industries.

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Data Material and Analytical Strategy

The present study is based on 117,758 participants who have responded to the Swedish Work Environment Surveys (SWES) between 1991 and 2017. Demographic variables and information on industry were drawn from register data. Information on industry was measured according to the Swedish Standard Industrial Classification (SNI). In this study we make an empirical analysis of the classification of industries presented in Chap. 2. They include Education and Health and Social Care (female-dominated); Goods and Energy Production and Machinery Operation (male-dominated); and Services, Knowledge-Intensive Services and Public Administration (gender-mixed) industries. Figure 3.3 below shows the distribution of men and women working in each of these industries. In our sample, there is a large representation of men and women in the age group 36–55. Almost half of the sample has completed 12 years of education, and about one-third of the women and one-fifth of the men have completed 3 years or more of university studies. Variables: Job demands and decision authority were measured as indicators of the organization of work. Threats and violence as well as sexual harassment from people who the work organization provides services for (e.g. clients, patients, pupils, etc.) indicated type of production. Social support from managers, social support from co-workers, bullying by managers and colleagues, and gender-based and sexual harassment were included as indicators of social relations at the workplace (more information on the study variables can be found in the Appendix). Analytical strategy: For the first research objective, to estimate if psychosocial working conditions differ between differently gendered industries among women

MEN

Machinery operations Goods and energy production Knowledge Intensive Services Labour intensive services Public administration Education Health and social care

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Fig. 3.3 Distribution of women and men in the seven groups of industries, ordered by proportion of men in the Swedish labour force, from machinery operations to health care (see Table 2.1 for more information)

3 Psychosocial Working Conditions for Women and Men in Industries with. . .

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and men, we used pooled data from the most recent and available SWES waves, 2013–2017. We conducted logistic regression analyses, adjusted for age and education, estimating the average marginal effects (AME) of being exposed to each work factor in each industry, using knowledge-intensive services as the reference category. Results of these analyses are presented in a table in the Appendix. Knowledgeintensive services is used as reference because they are often associated with good working conditions. The industry is gender integrated and includes mainly whitecollar workers in the private sector. The average marginal effects are the average change in probability (0–1) of reporting exposure compared to the reference group. For the second research objective, to explore how psychosocial working conditions have developed between 1990 and 2017 in differently gendered industries, we calculated the proportion of men and women who reported to be exposed to each work factor each year that the work factor was available in SWES.

3.4

Results

Below are the results presented, stratified by gender and structured according to (1) factors expected to vary by industry, and (2) factors expected to vary by gender and gender composition of the industry.

3.4.1

Work Factors Expected to Vary by Industry

The seven industries are categorized according to work object and gender composition of the industry, and the data is presented separately for men and women. For more information on the classification, see Chap. 2. The labels in the figures below are abbreviations for groups of industries compared: MO ¼ Machinery Operation GEP ¼ Goods and Energy Production LIS ¼ Labour-Intensive Services KIS ¼ Knowledge-Intensive Services PA ¼ Public Administration Edu ¼ Education HSC ¼ Health and Social Care

3.4.1.1

High Job Demands

As expected, both women and men employed in the educational industry show higher probabilities of reporting high job demands than employees in knowledgeintensive services during the period 2013–2017 in Sweden (see Table 3.1,

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Fig. 3.4 (a) Women and (b) men. Proportions reporting high job demands by industry between 1991 and 2017

Appendix). Among women employees in health and social care also show, as expected, higher probabilities for high job demands, and women in labour-intensive services show lower probabilities for reporting high job demands during this period. The data in Fig. 3.4 suggest that the percentage reporting high job demands has decreased in later years for both men and women in all industries. A larger proportion reporting high job demands has been seen in the education industry across time, a trend that is particularly clear among women. Among women, the percentage reporting high job demands is also greater in the health care industry than in most other industries across time, whereas the pattern among men in this industry is more fluctuating across time.

3.4.1.2

Poor Decision Authority

In our statistical analyses of differences between industries, we find that among men, poor decision authority is reported at a higher probability in all industries compared to knowledge-intensive services (see Fig. 3.5). Probabilities are particularly high in health and social care and the educational industry. Women in the reference category, knowledge-intensive services report a lower level of decision authority compared to three of the other industries. Similar to the case for men, it is the education and health care industry that show particularly high probabilities of low decision authority for women. Figure 3.5, displaying proportions among men and women in different industries, shows that the proportion reporting poor decision authority has increased over time among women in the health care and education industries. The percentage reporting poor decision authority among men in the health care sector has been high for some time periods, although the percentage appears to have decreased in recent years.

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Fig. 3.5 (a) Women and (b) men. Proportions reporting to have poor decision authority by industry between 1991 and 2017

3.4.1.3

Exposure to Threats and Violence

Our analyses of differences between industries in exposure to threats and violence by people that the organization provides services for show that both male and female employees in health and social care, but also in public administration and the educational industry, have high probabilities for such exposure. This was in line with what we expected. Exposure to threats and violence appears to have been stable across time in most industries. The exception is that among men there appears to have been a peak in experienced threats and violence in health and social care and in public administrations in the late 1990s. Among women it furthermore appears that threats and violence have increased somewhat in the education sector in recent years, whereas they have decreased somewhat in recent years among men (Fig. 3.6).

3.4.1.4

Sexual Harassment from Clients and Others

Sexual harassment by people who the organization provides services for is common in health and social care for both genders and also among women in labour-intensive services. There are lower probabilities for women in goods and energy production to report sexual harassment by costumers, clients, patients, etc. than the reference category, knowledge-intensive services. Sexual harassment of this kind was not particularly common in the education industry, which is contrary to what we had expected. There has been a negative development over time such that more women and men continuously report exposure to sexual harassment from clients and others within health and social care from 1991 and onwards, although there has been more of a fluctuation in percentages over time among men. There has also been an increase

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Fig. 3.6 (a) Women and (b) men. Proportions reporting to be exposed to threats and violence by industry between 1991 and 2017

of women reporting exposure to sexual harassment in labour-intensive services, an increase that was particularly steep between 2011 and 2017 (data not shown).

3.4.2

Work Factors Expected to Vary by Gender and Gender Composition

3.4.2.1

Poor Social Support by Managers

In accordance with our expectations, there are higher probabilities for women in machinery operations to report poor social support by managers, and there are lower probabilities for men in public administration to report poor social support by managers compared to the reference category, knowledge-intensive services. We also observe that many men in the gender-integrated sector public administration have good social support by managers. One striking result in Fig. 3.7 is the decrease in percentage of men in most industries reporting poor support by managers (Fig. 3.7b).

3.4.2.2

Poor Social Support by Colleagues

Higher probabilities of poor social support by colleagues are reported by men in machinery operations compared to men in knowledge-intensive services. Lower probabilities of low social support are reported by men and women in education, and by women additionally in health and social care and public administration

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Fig. 3.7 (a) Women and (b) men. Proportions reporting poor support from managers by industry between 1991 and 2017

compared to the reference category. These results do not agree with our expectations, since a larger proportion of both men and women appear to enjoy good support from colleagues in the female-dominated sector health and social care. A relatively large proportion of men in the male-dominated sector machinery operations, furthermore, appears to have poor social support from colleagues. There is no clear trend in development over time between industries (data not shown).

3.4.2.3

Sexual Harassment by Managers and Colleagues

Among women, sexual harassment by managers and colleagues was less common in health and social care and more common in machinery operations as compared to the reference category, which is according to our expectations. Among men, no statistically significant differences between industries were observed, which was unexpected. Among women, the high percentage reporting sexual harassment by managers in machinery operations started several years before #MeToo. Yet, the industry stands out at several measurement points as an industry in which a large proportion of women report being sexually harassed by managers and colleagues. In goods and energy production, another male-dominated industry, the percentage that reported being exposed sharply increased in 2017 compared to previous years. There is also a more continuous increase from 2013 up until 2017 in women reporting exposure in the gender-integrated industry of labour-intensive services. Among men we see, as expected, the opposite pattern. It is particularly in female-dominated health and social care that men report being more greatly exposed to sexual harassment by managers and colleagues, as compared to other industries. There does, however, not

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Fig. 3.8 (a) Women and (b) men. Proportions reporting exposure to sexual harassment by managers and colleagues by industry between 1991 and 2017

appear to be a clear development over time in percentage reporting to be exposed to sexual harassment among men (Fig. 3.8).

3.4.2.4

Gender-Based Harassment

Higher probabilities for reported exposure to gender-based harassment in 2013–2017 were observed for women in goods and energy production and lower probabilities in health and social care and education. Among men, higher probabilities were observed in the female-dominated industries health and social care and education compared to the gender-integrated industry of knowledge-intensive services. This pattern supports our expectation that both men and women are more exposed in work situations dominated by the opposite sex. This pattern also appears to be rather stable across time in accordance with our expectations. However, it appears that a continuously higher proportion of women reported exposure to gender-based harassment from 1999 to 2013 in goods and energy production (Fig. 3.9).

3.4.2.5

Bullying

Higher probabilities of reporting being exposed to workplace bullying were observed in men in health and social care, public administration, and goods and energy production. No statistically significant differences between industries were observed among women. These results are not in line with what we expected. On the other hand, there is no clear trend in development over time between industries (data not shown), which is in line with our expectations.

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Fig. 3.9 (a) Women and (b) men. Proportions reporting exposure to gender-based harassment by industry between 1991 and 2013

3.5

Discussion

The main results showed, in line with our expectations, that the psychosocial work factors job demands, decision authority, and workplace violence by people the organization provides services for varied by industry and were worse for both women and men in the female-dominated education, health and social care industries in comparison to other industries. That the psychosocial work environment is poorer for both genders in female-dominated industries where sickness absence rates are high indicates that the exposure hypothesis is relevant to studies of reasons for gender differences in sickness absence rates. Gender-based and sexual harassment, on the other hand, show a pattern between gendered industries and gender combined, such that more harassment occurs for men in female-gendered industries and for women in male-gendered industries. There was also some support for the expectations that other aspects of the relation to colleagues and managers showed different patterns for women and men in differently gender-composed industries. However, social support showed a different pattern, as there were similar results for women and men in that area. By applying a gender perspective and a contextual approach in the analyses and interpretation of the results, our study contributes indications of how structural changes may have different consequences for women and men in the gendersegregated labour market. Such studies based on gender theory are rare and have been called for (Härenstam, 2009; Mustosmäki et al., 2017; Vänje, 2015). Contextualization in organizational research has been requested in order to increase the applicability of the results in working life and can occur in several phases of the research process (Rousseau & Fried, 2001). In our study, this was done by comparing industries rather than by gender and as a supplement to information on structural changes when interpreting the results. Our data and statistical analyses do not

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provide statistical evidence that sick leave rates are linked to structural changes in industries mediated by changes of specific working conditions. However, we suggest that the contextual approach contributes to a deeper understanding of why sick leave rates differ between women and men as groups, and it varies differently over time. Below we discuss the results in light of structural and organizational changes, particularly in the education and health and social care industries that might increase our understanding of why these female-dominated industries have both worse sick leave rates and worse working conditions than many other industries.

3.5.1

Work Factors Expected to Vary by Industry

3.5.1.1

High Job Demands in the Female-Dominated Education, Health, and Social Care

The proportion reporting high job demands increased considerably during the 1990s, particularly in the education industry, and the number stayed high among women in this industry up until the mid-2010s. Also, women in health and social care report high job demands significantly more often than women in other industries do. Job intensification in health and social care since the 1990s has been observed in many other studies (Cerdas et al., 2019; Rasmussen, 2004; Strandell, 2020). This observation raises the question of what happened in these industries at that time. During the first half of the 1990s, an economic crisis hit the public sector hard, with major cuts of resources in human services (Nyberg, 2014). More than one in three nursing and medical assistants disappeared from the workforce between 1993 and 1999 (Eliason, 2011; Landstingsförbundet, 2002). Many secretaries, assistants, and caretakers were dismissed, and the tasks were placed on more qualified groups such as teachers, doctors, and nurses, possibly affecting the working conditions in these professions. Furthermore, studies of elderly care have shown that a home care assistant in Sweden visited an average 4 elderly patients in the 1980s (Stranz & Szebehely, 2018), 9 in 2005, and 12 every day in 2015 (Strandell, 2020). At the same time, the health status is worse today among those who receive these services, due to large cuts in the number of beds both in residential homes for the elderly and in hospitals, as well as to tightened eligibility criteria for obtaining access to elderly care services (Szebehely & Trydegård, 2012). As nurse assistants in caring services is the most common occupation for women in Sweden (SCB, 2020), it is possible that systematic structural deficiencies in organizing and planning resources in care services affect the job demands for a large number of women in Sweden, as well as the small number of men (9%) in the same type of work. Another structural change implemented in public sector services during the 1990s was the introduction of new management principles. For example, with the introduction of purchase–provider split models and privatization of many elderly care organizations, it has been suggested that through standardization and fragmentation the caring work was transformed into ‘care products’ (Stranz & Szebelehy, 2018).

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Another characteristic of the new public management principles was the increased measurement of results and the use of audits, which demanded more administration. It was expected that new digitalized technology would reduce workloads. Instead, the increasing numbers of administrative tasks were carried out by more highly qualified groups, such as physicians (cf. Aronsson et al., 2012) and other human service workers and their immediate managers in the public sector (Björk et al., 2013; Björk & Härenstam, 2016). Why it is particularly among women in the education industry that we see an increased proportion reporting high job demands can be explained by several factors. As a consequence of new curriculum and deregulating reforms in the 1990s (Jacobsson & Sahlin-Anderson, 1995), there has been increased emphasis on responsibilities for socializing children in addition to focus only on reaching knowledge targets (Stenlås, 2009). This could be a demand that is more pronounced in schooling of younger children, where many female teachers work. It could also be that female teachers, to a greater extent than male teachers, are expected to be responsible for caring tasks, expectations that may come from children, parents, and managers, creating an even greater burden. Another explanation could be that the lack of support for administrative tasks are particularly pronounced in the parts of the school systems where many women work. Our results support the idea that job intensification and increased job demands might have a mediating effect between structural changes and employees’ health (cf. Andreeva et al., 2017; Kivimäki et al., 2000).

3.5.1.2

Poor Decision Authority in Female-Dominated Education, and Health and Social Care

In line with our expectations was that poor decision authority was reported more often in female-dominated education, and health and social care, in both genders, than in the reference category, knowledge-intensive services. The proportion reporting poor decision authority in our study appears to have increased in the female-dominated industries, particularly among women, which could be explained by the different occupations men and women hold in these industries. Also, women more often occupy lower positions in the organizational hierarchy than men. These observations may thus indicate that it is particularly in functions with close contact with clients that the decision authority has decreased over time. It has, in a recent Swedish report, been stated that occupational level is important in explaining doctorcertified sickness absence rates in Sweden, alongside the industry level where the prerequisites for psychosocial working conditions are often created (Swedish Social Insurance Agency, 2018b). Thus, it seems that a contextual perspective on changes of decision authority should consider both industry-specific structural changes as well as the division of labour within the industry. The changes of management systems in the public sector from the 1990s implied that measurement of quality and results increased with the support of new technology and valuation shifts in the form of freedom of choice, competition, and

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transparency (Williamson & Colley, 2018). It has been suggested that a consequence was a shift in power from the professionals in human service activities such as school, health, and social care, to citizens, their political representatives and regulatory authorities (Bejerot & Hasselbladh, 2013; Johansson et al., 2016) as well as a devaluation of the work and the workers (Gonäs & Tyrkkö, 2015). Structural changes, for example, that the responsibility for education up to university level was shifted from the state to the municipalities in 1991, have been said to lead to lower status in teaching (Stenlås, 2009). Elderly care changed government from county councils to municipalities in 1992. One consequence was that many elderly care workplaces were merged into large units under the same manager (Stranz & Szebeheley, 2018), with limited authority over resources (Björk & Härenstam, 2016). Having many employees under the same manager means, for example, that the time in which to be a present and supporting leader is lacking. Because the prevalence of work-related ill health is high in these industries, one would have expected that each manager had fewer employees to care for, not the opposite (Regnö, 2016; Vänje, 2015; Williamson & Colley, 2018). It is difficult to understand why there were changes that meant lower status in the female-gendered services without going back to the 1970s, when the foundations were laid for how these activities were organized and to be manned mainly by women (cf. Ohlander, 2001). There is research showing that these services were standardized so that the employee became interchangeable when she needed to be on parental or sick leave (Gonäs & Tyrkkö, 2015; Peetz, 2015; Mandel & Shalev, 2009). Standardization was done either through demands for formal education (one teacher or nurse could be replaced by another), or because the work was considered unqualified with low demands for education or introduction at the workplace, as for example, in elderly care. Perhaps it was not until the economic crisis and the introduction of new management principles in the beginning of the 1990s that the working conditions were negatively affected. The standardized forms of organization with many temporary and part-time workers and short training periods in the workplace, as well as large groups of employees with the same manager, characterize school and care organizations even today (Björk & Härenstam, 2016; Forsberg Kankkunen, 2014; Stranz & Szebeheley, 2018). Short training times in the workplace are especially common where many women work, indicating that the service has low status (Grönlund, 2012). It is noteworthy that in the current pandemic of Covid-19, the situation is particularly problematic in elderly care. It has been suggested that working and employment conditions in elderly care, with many employees meeting the clients, unsatisfactory management support, lack of information and education, as well as a lack of protective equipment, are important causes of high dissemination of the virus and thus an important cause of the high death rates.

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51

Exposure to Violence and Sexual Harassment by Service Users

With regards to threats and violence, the results were in line with our expectations. Many employees, particularly in health and social care, but also in public authorities and the education industry, report exposure to threats and violence. It should be mentioned that in public administration, workplaces associated with the police, criminal justice divisions, fire brigades, and other public authorities with contact with other people are included in this group of industries. The educational industry has not been particularly well researched when it comes to exposure to threats and violence, but the high prevalence of threats and violence in health and social care as well as in protection workers across time has been well established in the international literature. A lot of research has also been conducted on workplace violence in the area of health and social care (e.g. Konttila et al., 2018; Lanctot & Guay, 2014; Nikathil et al., 2017; Pompeii et al., 2013). The negative impact of threats and violence on mental health in health and social workers has recently been presented in a literature review of prospective and longitudinal studies (Nyberg et al., 2020). Reports of sexual harassment by clients, etc. is, as expected, more common for both men and women in health and social care than in knowledge-intensive services, which we used as the reference category. This supports data presented in previous research (Friborg et al., 2017; Nielsen et al., 2017). It is also more common for women in labour-intensive services (including, e.g., hotel and restaurant workers), which is expected, since they too work with customers. Why we do not see this among men in labour-intensive services could perhaps once again be explained by the types of occupations that men and women have within this industry. However, why men are exposed in health and social care, like women, but not in labourintensive services, unlike women, deserves more research. The proportions reporting exposure to sexual harassment increased in recent years for both men and women within health and social care and for women also in labour-intensive services. This may either indicate that an increasing number of people sexually harass workers that they are given services by or that attitudes towards sexual harassment are changing in the younger generation, with increasingly lower acceptance of such behaviours. More research on the health consequences of sexual and gender-based harassment is needed to clarify its potential role in explaining increased risks of ill health and sickness absence in health and social care (Nyberg et al., 2020).

3.5.2

Work Factors Expected to Vary by Gender and Gender Composition

In accordance with our expectations, a very different pattern was found regarding differences between industries in the social factors. In two of the studied variables— sexual and gender-based harassment—the expected patterns were found, that is, men and women in minority in industries dominated by the opposite sex fare worse.

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However, men and women reported social support similarly, and it seems as though gender composition has something to do with the results. The pattern among both men and women when it comes to harassment based on sex is that an individual is more exposed in an opposite-sex work setting, which is in line with our expectations. This pattern is found among women regarding both sexual and gender-based harassment and among men for gender-based harassment. That there are no statistically significant differences between industries in exposure to sexual harassment among men could partly be explained by the fact that the percentage exposed is very low. This overall pattern of exposure in opposite-sex work settings has been reported previously (Campbell Quick & McFadyen, 2017; Willness et al., 2007). Women, in particular, were exposed to sexual harassment by managers and colleagues in machinery operations. These data confirm that women are often exposed in male-dominated professions of low socio-economic status, which has been reported previously (Campbell Quick & McFadyen, 2017; Muhonen, 2015; Bergman, 2003). Regarding social support from managers and colleagues, we found, as expected, that the best situation seemed to be gender-mixed industries, particularly public administration, and secondly, the reference category, knowledge-intensive services. Thus, it seems that where men and women meet daily in working life, social behaviour seems to be better. There is also research showing that the number of sickness absences is lower at gender-mixed workplaces (Bryngelson et al., 2011). The other observation is that the male-dominated machinery operations seem to be problematic for both women and men. Men had the lowest prevalence of support from managers, and women had the lowest support from colleagues. Thus, it seems that being in the majority is not helpful in this industry. A possible explanation might be that social support from managers and colleagues is a consequence of how the industry is organized and manned, just as what was to be expected for job demands and control. This group of industries includes construction and transport, which have been exposed to large structural changes due to, for example, deregulation of EU rules, which has led to increased outsourcing in chains of employers, hiring of temporary workers and increased self-employment. It has been argued that the increasing prevalence of serious accidents in these sectors is a consequence of these structural changes (Arbetsmiljöverket, 2019; Frank, 2013). It is reasonable to believe also that support from colleagues and managers has similar explanations. Many of these employees work alone, driving machines or vehicles large parts of their working day. These industry-specific characteristics imply that it is difficult to have closer and long-lasting relationships to colleagues and managers. Moving to bullying, as we expected, the proportions exposed to bullying did not appear to change over time, but bullying did not follow a pattern of gender, and gender composition of the industry was not in line with what we expected. In sum, regarding the factors that we expected to vary by gender and gender composition, we can conclude that this expectation was largely confirmed regarding exposure to harassment based on sex, but not for social interaction not based on sex, such as support and bullying.

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Implications for Research and Practice

How work is organized is important to address in order to create healthy workplaces and prevent hazardous jobs. Employers bear the responsibility of the work environment, gender equality, and prevention of the work-related ill health of their employees. However, to fulfil this responsibility, they have a need for knowledge and advice that is adapted to different contexts such as industries with different types of production. We therefore want to encourage working life and gender equality researchers to focus to a greater extent on how working conditions and health are related to the context in workplaces, in line with what was the recommendation in a recent knowledge review of the health care sector (Vänje, 2015). Within research of implementation of interventions in general and in work, the notion of ‘one fits all’ is challenged. Instead, tailoring both intervention and the way it is implemented to the context is proposed (Härenstam et al., 2019; Nielsen & Randall, 2015). Knowledge related to context may therefore be a necessary tool used by employers, occupational health actors, and others in tailoring primary interventions aimed to improve working conditions and health.

3.7

Conclusion

We have shown that work conditions differ between different gendered industries and have also developed differently. This different development may therefore explain the increased gender difference in work-related mental health that has been evident in Sweden the last decade. The results here also show the importance of studying work conditions, gender differences, and health in relation to contextual factors such as industry and gender composition, where health hazards may originate.

Appendix A.1 Variables Job demands were measured with four items: (1) does not have time to talk or even think of anything other than work; (2) the work requires undivided attention and concentration; (3) have to skip lunch, work late, or take work at home; (4) have far much to do. Response options for items 1–3 for both demands and decision authority ranged between 1 ‘almost the whole time’ to 6 ‘no, not all’. The fourth item was scaled as 1 ‘too much to do’ to 5 ‘too little to do’. Respondents were classified as having high job demands if they reported at least two of the following: at least half of the time, item 1; nearly all the time, item 2; at least once every week item 3; and agree fully to some extent for item 4 (Cronbach’s alpha 0.64).

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Four items were also used to create a score for decision authority: (1) have possibility to set the work tempo; (2) decide when to do your work; (3) decide how to do your work; (4) have to little influence at work. Response options for items 1–3 ranged between 1 ‘almost the whole time’ to 6 ‘no, not all’. The fourth item was scaled as 1 ‘little influence’ to 5 ‘big influence’. Respondents were classified as having low decision authority if they reported two of the following: mostly not or never for item 1; mostly not or never for item 2; never or mostly for item 3; and agree fully or to some extent for item 4 (Cronbach’s alpha 0.63). Violence at work was measured through one question that investigated how much individuals on a seven-point Likert scale were subject to violence or threat of violence at work. The variable sexual harassment at work due to others was measured on a seven-point Likert scale and investigated if the respondents were subjected to sexual harassment at work from other persons (e.g. customers, patients, clients, passengers, etc.). For both variables we created a dummy variable indicating no violence/no sexual harassment due to others if they answered ‘not at all the last 12 months’. Information on support from both managers and colleagues were collected with one question of whether support was given when work becomes troublesome. Respondents were on both questions classified as having poor support if they reported that mostly never or never had such support. Information on sexual harassment from managers, sexual harassment due to gender, and bullying were each collected with one question where all three questions had the same response options on a seven-point Likert scale: 1 ‘every day’ to 7 ‘not at all the last 12 months’. The respondents were categorized as not having experienced sexual harassment or bullying if they answered ‘not at all the last 12 months’. Information on age and highest degree of education were controlled for. Both were collected from the Lisa database. Age was divided in five groups: 16–25, 26–35, 36–45, 46–55, and 56 or more years old. For each person registered in Sweden, the highest level of education is recorded each year. Education is classified according to the Swedish Nomenclature of Education (SUN), which is adjusted to the International Standard Classification of Education (ISCED). SUN has six different educational levels, of which two are pre-secondary (education shorter than 9 years or equal to 9 years), one secondary, and three post-secondary (shorter than 2 years, longer than 2 years, and doctoral). Here education was divided into five categories (maximum 9 years of school, gymnasium, university or equivalent less than 3 years, and university or equivalent 3 years or more).

A.2 Tables Below are the average marginal effects (AMEs) of the organizational factors high job demands and poor decision authority and the social factors threats and violence and sexual harassment by people that the work organization provides services for. AMEs are presented for men and women in each industry using knowledgeintensive services as the reference category.

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Table 3.1 Average marginal effects (AMEs) and 95% confidence intervals (CI) for psychosocial work factors expected to vary by differently gendered industries when using knowledge-intensive services as the reference category. Data: Swedish work environment surveys 2013–2017 Women AME

95% CI

Men AME

High demands Knowledge-intensive services 0.00 0.00 Education 0.60 0.42;0.79 0.05 Health and social care 0.21 0.03;039 0.06 Labour-intensive services 20.20 0.39;0.01 0.01 Public administration 0.04 0.26;0.19 0.02 Goods and energy production 0.13 0.38;0.11 0.00 Machinery operations 0.18 0.50;0.13 0.03 Poor decision authority Knowledge-intensive services 0.00 0.00 Education 0.21 0.17;0.25 0.25 Health and social care 0.26 0.22;0.29 0.27 Labour-intensive services 0.06 0.02;0.10 0.12 Public administration 0.01 0.04;0.06 0.12 Goods and energy production 0.05 0.01;0.10 0.14 Machinery operations 0.03 0.04;0.09 0.14 Threats and violence from people that the organisation provides services for Knowledge-intensive services 0.00 0.00 Education 0.25 0.19;0.31 0.23 Health and social care 0.41 0.35;0.46 0.42 Labour-intensive services 0.11 0.05;0.17 0.08 Public administration 0.25 0.18;0.32 0.28 Goods and energy production 20.11 0.16;0.05 20.04 Machinery operations 0.18 0.08;0.27 0.06 Sexual harassment from people that the organisation provides services for Knowledge-intensive services 0.00 0.00 Education 0.01 0.03;0.02 0.04 Health and social care 0.10 0.06;0.13 0.12 Labour-intensive services 0.05 0.02;0.09 0.02 Public administration 0.02 0.02;0.06 0.04 Goods and energy production 20.05 0.07;0.03 0.01 Machinery operations 0.03 0.02;0.08 0.00

95% CI

0.00;0.11 0.00;0.11 0.03;0.04 0.06;0.03 0.04;0.03 0.01;0.07

0.19;0.30 0.22;0.33 0.07;0.17 0.06;0.17 0.10;0.19 0.10;0.18

0.16;0.30 0.34;0.49 0.03;0.12 0.21;0.35 0.07;0.01 0.02;0.10

0.00;0.08 0.04;0.20 0.00;0.05 0.00;0.08 0.02;0.00 0.02;0.02

Analyses adjusted for age group, highest degree of education and year of SWES. Bold face indicates statistically significant association

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Table 3.2 Average marginal effects (AMEs) and 95% confidence intervals (CI) for psychosocial work factors expected to vary by differently gendered industries and gender-combined when using knowledge-intensive services as the reference category. Data: Swedish work environment surveys 2013–2017

Poor social support (colleagues) Knowledge-intensive services Education Health and social care Labour-intensive services Public administration Goods and energy production Machinery operations Poor social support (manager) Knowledge-intensive services Education Health and social care Labour-intensive services Public administration Goods and energy production Machinery operations

Women AME

95% CI

Men AME

95% CI

0.00 20.07 20.08 0.02 20.06 0.02 0.04

0.09;0.05 0.10;0.06 0.04;0.01 0.08;0.03 0.05;0.01 0.00;0.09

0.00 20.07 0.01 0.03 0.02 0.01 0.05

0.11;0.04 0.06;0.03 0.01;0.06 0.06;0.02 0.03;0.04 0.01;0.08

0.03;0.06 0.01;0.07 0.02;0.07 0.05;0.05 0.03;0.09 0.00;0.15

0.00 0.02 0.01 0.02 20.06 0.00 0.04

0.04;0.07 0.06;0.05 0.06;0.03 0.11;0.01 0.04;0.04 0.01;0.08

0.00 0.02 0.03 0.03 0.00 0.03 0.08

Sexual harassment (managers/colleagues) Knowledge-intensive services 0.00 Education 0.01 Health and social care 20.02 Labour-intensive services 0.00 Public administration 0.00 Goods and energy production 0.02 Machinery operations 0.04 Gender-based harassment Knowledge-intensive services Education Health and social care Labour-intensive services Public administration Goods and energy production Machinery operations Bullying Knowledge-intensive services Education

0.02;0.00 0.03;0.01 0.01;0.01 0.01;0.02 0.01;0.04 0.00;0.07

0.00 0.07 0.18 0.04 0.05 0.03 0.03

0.07;0.21 0.10;0.45 0.04;0.11 0.06;0.17 0.04;0.11 0.04;0.10

0.00 20.06 20.06 0.04 0.03 0.07 0.05

0.10;0.03 0.09;0.02 0.07;0.00 0.07;0.02 0.00;0.15 0.04;0.14

0.00 0.10 0.18 0.04 0.04 0.03 0.02

0.00;0.20 0.05;0.31 0.02;0.09 0.03;0.12 0.02;0.09 0.03;0.06

0.00 0.01

0.04;0.01

0.00 0.05

0.00;0.09 (continued)

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Table 3.2 (continued)

Health and social care Labour-intensive services Public administration Goods and energy production Machinery operations

Women AME 0.00 0.00 0.01 0.01 0.00

95% CI 0.03;0.02 0.03;0.02 0.04;0.02 0.03;0.04 0.04;0.04

Men AME 0.08 0.03 0.08 0.06 0.03

95% CI 0.03;0.14 0.00;0.06 0.03;0.13 0.02;0.09 0.00;0.06

Analyses adjusted for age group, highest degree of education and year of SWES. Bold face indicates statistically significant association

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Anna Nyberg is a licensed psychologist and associate professor in psychology at Uppsala University and Karolinska Institutet. Her research broadly concerns health effects of workplace leadership and the psychosocial work environment and she has a particular focus on work stressors associated with vertical and horizontal gender segregation. Annika Härenstam is professor emerita, Department of Sociology and Work Science, University of Gothenburg. She is now working at the Department of Psychology, Stockholm University. Her research concerns work environment, work organization and health. She has a particular interest in methodological issues with a gender perspective in working life research. Gun Johansson is PhD and epidemiologist at the Centre for Occupational and Environmental Medicine at Stockholm County Council. She is affiliated with the Institute for Environmental

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Medicine at Karolinska Institutet. Her research focuses on the relation between work and health, with a particular focus on work organization and sickness absence. Paraskevi Peristera is researcher, PhD in Statistics, at the Stress Research Institute, Department of Psychology, Stockholm’s University. Her research focuses on occupational epidemiology and applied gerontology with a special focus on robust statistical modelling of health outcomes.

Chapter 4

A Multilevel Approach to Understanding Job Demands and Resources in Healthcare Anne Richter, Marta Roczniewska, Henna Hasson, and Ulrica von Thiele Schwarz

The health and social sector is one of the biggest and fastest growing sectors worldwide, containing about 10% of all employments (OECD, 2017). About 67% of all health and social sector employees are women, and this is true across 104 countries (Boniol et al., 2019). Whereas the nursing and midwifery occupation consists primarily of female employees, the majority of physicians, dentists, and pharmacists are male (Boniol et al., 2019). When an industry’s employees are mostly one gender, this is called horizontal occupational segregation (Cohen, 2004). It is estimated that in the EU, there is about 27% occupational segregation. Even though women in Sweden are nearly as active in the labour market as men (85% vs. 89%; Statistics Sweden, 2018), the labour market is highly gender segregated: Approximately 60% of women and 64% of men work in gender-segregated occupations (Eurofound, 2013; Morner & Kruse, 2006). Whereas women are in general more represented in the caring and nurturing sectors (e.g. healthcare, public

A. Richter (*) · H. Hasson Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Solna, Sweden Centre for Epidemiology and Community Medicine, Region Stockholm, Stockholm, Sweden e-mail: [email protected]; [email protected] M. Roczniewska Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Solna, Sweden SWPS University of Social Sciences and Humanities, Warsaw, Poland e-mail: [email protected] U. von Thiele Schwarz Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Solna, Sweden School of Health, Care and Social Welfare at Mälardalen University, Västerås, Sweden e-mail: [email protected] © Springer Nature Switzerland AG 2021 B.-I. Keisu et al. (eds.), Gendered Norms at Work, Aligning Perspectives on Health, Safety and Well-Being, https://doi.org/10.1007/978-3-030-77734-0_4

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administration, or education), which are primarily found in the public sector, men often are found in technical or managerial jobs (Crawford et al., 2016; Eurofound, 2013). Not only is the pay lower in so-called female-dominated sector occupations (i.e., the gendered pay gap), but there are also wage differences between men and women in the same occupation (Morner & Kruse, 2006). Moreover, differences also exist in job security and employment forms, where women more frequently work part time and in temporary jobs (Boniol et al., 2019; Morner & Kruse, 2006). These different types of work arrangements have an impact on employees’ exposure to occupational safety and health (OSH) hazards and risks and their access to OSH services (Crawford et al., 2016). For example, part-time workers are often not consulted in risk assessments; hence, the work hazards for this group are missed (EU-OSHA, 2013). In sum, horizontal segregation exposes men and women to different working conditions and hazards that may impact their health and well-being. As a consequence, men and women experience different work-related health problems (Crawford et al., 2016; EU-OSHA, 2013). In this chapter, we argue that working conditions threaten the sustainable employability of the workforce of the femaledominated sector, that is, when employees are able to continue working in a productive, satisfactory, and healthy manner (Crawford et al., 2016). We focus on healthcare, which is one example of a female-dominated sector, and discuss the pattern of job demands and resources that constitute the work environment in healthcare, linking it to employee well-being. We propose that it is vital to study these workplace factors at multiple levels of an organization and therefore outline here the theoretical, methodological, and practical implications of a multilevel approach. Finally, we provide suggestions for designing and implementing interventions that target distinct levels of organizational life in female-dominated sectors.

4.1

Mental Health Issues and Their Relation to Work and Gender

During the last decade, sickness absence and early retirements due to mental health problems have increased in Europe (OECD, 2012). This includes sickness absence rates and disability retirement, which is as high as 12% in some of the northern and eastern European countries (Belin et al., 2016). In this group, mental health problems are particularly prominent. Even though the stigma and discrimination against people who experience mental illness are lower now than they used to be (OECD, 2012; Wittchen et al., 2011), mental health problems are still considered to be comparably unrecognized, underdiagnosed, and untreated (OECD, 2012). This trend is also mirrored in Swedish statistics. The Swedish national insurance office has reported that sick leave has been increasing over the last few decades (Försäkringskassan, 2013) and that the primary cause is psychiatric disorders (Försäkringskassan, 2016). In particular, in many of the female-dominated sectors, such as the public sector and healthcare, there is a higher risk for sickness absence

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due to the specific psychosocial work environment conditions (Försäkringskassan, 2013). Over the last few decades, work environment surveys and national representative studies have shown over and over again that women are on sick leave more frequently and longer and report higher work-related stress (European Foundation, 1997; Försäkringskassa, 2015). Long-term sickness absence, early retirement, and reduced work ability negatively affect not only the individuals (e.g. through the loss of income as well as the emotional and physical burden of ill health), but also the employers (e.g. through sick pay, costs due to staff turnover, time spent managing sickness absence, and providing occupational health services). Each case of stress-related ill health has been estimated to result in approximately 31 workdays lost (Mental Health Foundation, 2007). Furthermore, there is a risk for further absenteeism (for reviews, see Allebeck & Mastekaasa, 2004; Dekkers-Sanchez et al., 2008; Duijts et al., 2007), suboptimal performance (Nahrgang et al., 2011), production loss (Beck et al., 2011), additional costs associated with the recruitment and training of new employees (McDaid, 2007), and negative consequences of presenteeism, being at work while unwell (Aronsson et al., 2000). Presenteeism has been shown to result in five times the costs of absenteeism alone (Aronsson et al., 2000; Sanderson & Andrews, 2006). In addition, sickness absence affects society in general when the state has to pay for increasing sickness benefits and has to deal with forgone taxes and the extra healthcare costs that arise (Black & Frost, 2011). In the majority of OECD countries, the higher expenditures on disability and sickness benefits have been noted through a negative influence on economic growth (Directorate for Employment Labour and Social Affairs Organization for Economic Co-operation and Development, 2010). The cost of mental ill health in Europe has been estimated to 240,000,000,000 euros per year. Of this amount, 136,000,000,000 euros were attributed to reduced productivity and 104,000,000,000 euros to direct costs such as treatment (EU-OSHA, 2014). Hence, the welfare system needs to cover substantial costs when employees suffer from poor health and the state is responsible for paying for long-term sickness and disability benefits. Compared to other countries, Sweden spends 4–5% of its GDP on disability and sickness benefits, which is as much as twice as high as other OECD countries spend. Not only do severe mental health problems need to be considered to understand health and well-being, but the experience of stress and, in particular, the exposure to prolonged and unmanaged stress that might result in severe mental health issues also need to be focused on (OECD, 2012; WHO, 2010). To better understand the mechanisms linking the work environment’s characteristics to individual employees’ well-being and health, we invoke the job demands–resources model.

4.2

The Job Demands–Resources Model

To understand well-being and work-related stress (i.e., work demands and pressures that are not matched with knowledge ability or the ability to cope; WHO, 2003) the job demands–resources (JD-R) model can be used (Bakker & Demerouti, 2007).

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This framework includes two processes that explain the potential effects of demands and resources on well-being. The first is the health impairment process, when exposure to job demands depletes the existing resource pool, leading to negative consequences such as health impairment. Job demands refer to the physical, psychological, social, and organizational aspects of the job, such as work schedules, an adverse work group climate, organizational changes, or less favourable leadership. The second is the motivational process, where resources are utilized to fulfil employees’ needs for autonomy, competence, and relatedness. Resources are the physical, psychological, social, and organizational aspects of the job that help employees achieve goals, reduce job demands and their effects, and stimulate personal growth, learning, and development. Examples of resources include career opportunities, social support, participatory decision-making, task significance, and autonomy. Resources’ main effect can be helping employees achieve work goals or stimulating their development and growth; hence, resources increase well-being. Resources can also affect well-being through buffering the effect of existing demands; demands and resources interact. Empirically, psychosocial factors of work have been linked to major depression and less severe common mental illnesses (for reviews, see Bonde, 2008; Kuoppala et al., 2008; Netterstrøm et al., 2008), physical health problems (for reviews, see Briggs et al., 2009; da Costa & Vieira, 2010), cardiovascular morbidity and mortality (for a review, see Kivimäki et al., 2012), and diabetes (for a review, see De Hert et al., 2011). Overall, according to the JD-R model, an unfavourable working environment is one (a) with low levels of job resources; (b) with high levels of job demands, especially those of hindering character; or (c) where there is an imbalance between demands and resources such that not enough resources exist to deal with the demands.

4.2.1

Healthcare Working Conditions

Although the JD-R model has been used in various types of working populations (Bakker & Demerouti, 2007; Bakker et al., 2005; Brauchli et al., 2015), it also has been applied in the healthcare context, particularly nursing, to identify specific demands and resources relevant to this sector (Broetje et al., 2020; Keyko et al., 2016; Mcvicar, 2016). Compared to other sectors, the healthcare sector is characterized by high demands combined with low autonomy (Karasek, 1979), which has been defined from a theoretical perspective as a high-stress job and thus is associated with negative consequences. Another factor that makes the healthcare sector particularly stressful is its patient focus. Employees have to deal with acute dramatic situations and trauma while supporting patients without being able to express emotions (European Agency for Safety and Health at Work, 2010). In addition, employees frequently report experiencing adverse social behaviours such as verbal abuse, physical violence, unwanted sexual attention, humiliating behaviour, and harassment (Eurofound, 2015). A recent integrative review that summarized key demands and resources of nursing staff (Broetje et al., 2020) highlighted work overload, work–life interference, and the lack of formal rewards, supervisor support,

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authentic management and transformational leadership, interpersonal relations, autonomy, and professional resources. These conditions take a toll on individuals working in healthcare. About one-third of nurses in the United States and Europe report symptoms of burnout (Aiken et al., 2012). More than one-third intend to leave their current employer, and 9% are even considering leaving the nursing profession (Heinen et al., 2013). Simultaneously, it is a challenge for healthcare organizations to retain personnel (OECD, 2017) and to recruit employees at the rapid pace of this sector’s growth, which is caused by a continuously aging population with growing demands for healthcare. Healthcare organizations globally are facing a shortage of employees (OECD, 2017). In sum, the main reason working women suffer increased ill health more than men do is the working conditions in the female-dominated sectors (Arbetsmiljöverket, 2016). Even though job demands and resources have so far been investigated primarily on the individual level, resources and demands also are found on other levels, such as the team or organizational level. In a recent proposal for further research on the JD-R model and understanding well-being, Bakker and Demerouti (2017) recommended further examination of the effects of demands and resources, considering the multilevel design of organizational reality.

4.3

The Necessity for a Multilevel Approach in Research on Demands and Resources

Hierarchy and structure are fundamental aspects of an organization. Employees work in project groups or teams, which are further parts of units or departments, forming organizations. In the study of employee well-being, individuals are clearly the centre of focus; however, individual outcomes in the workplace are a function of complex interactions between the characteristics of the environment and the person. More importantly, when groups of individuals (e.g. nurses in wards, units, departments) are exposed to similar environmental factors, their perceptions and responses to the environment are interdependent and show similarities (Bliese & Jex, 2002). Even though researchers acknowledge this nested complexity of real organizational life, much of the research, like job demands or job resources, has focused on studying the individual level (Demerouti & Bakker, 2011). Yet in reality, workplace factors, such as demands and resources, operate at multiple levels of organizational life. Conceptually, they may be located at the level of an organization (e.g. organizational justice), a department (e.g. workload), a workgroup (e.g. team support), or a job (e.g. control). Klein et al. (1994) noted, ‘Every construct is tied to one or more organizational levels or entities, that is, individuals, dyads, groups, organizations, industries, markets, and so on’ (p. 198). Thus, the issues of levels in organizational research and practice are inescapable and should not be neglected. The complexity of working conditions has to be taken into account by applying an analysis strategy that is multifaceted and comprehensive.

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Fortunately, in recent years, research in the organizational sciences has increasingly incorporated a perspective using multiple levels of analysis. This shift towards multilevel models enabled detection of relationships that are not present at the individual level but may be evident only when a broader—that is, group—context is invoked. For instance, Keller (2001) examined the effect of team composition on team performance and revealed that functionally diverse (vs. homogeneous) teams tended to perform worse because they were more stressed, and this stress taxed their performance by impairing team cohesiveness. Thus, a group-level characteristic related to team composition was predictive of how well the team was functioning. Of interest to the topic of this chapter is that one such group characteristic could be gender composition. Multilevel models are well suited to investigate how gender composition affects individuals and interacts with other workplace factors to determine employee outcomes (Härenstam, 2009). For instance, in a recent study, Kim (2018) investigated how demographic compositions (e.g. gender) at job and workplace levels affect the wages of women and men and found that the gender wage gap within jobs is aggravated in female-dominated workplaces. Without a multilevel perspective including organizational-level data, this pattern would not have been evident in previous studies focusing only on the job or occupational level. The central advantage of applying multilevel analysis is that determinants of employee well-being can be detected on a higher level than that of an individual, for example, a unit, group, department, or organization. This provides important and necessary information to further the understanding of employee well-being and provides information on which factors and levels interventions should target. Recognizing within-group similarities and possible between-group differences creates an opportunity to treat workplace factors as group-level phenomena. Proper statistics (e.g. ICCs; Bliese, 1998) provide a better understanding of whether the variability in a phenomenon is due to individual differences in perceptions or experiences or whether group members share commonality regarding the phenomenon. Therefore, multilevel models make it possible to address questions of whether a particular workplace factor or stressor has an influence only through the lens of an individual or if the team members consistently share the experience, implying that it is a workplace characteristic rather than an individual experience of this characteristic. For example, until recently, leadership has been researched at the individual level, with scholars investigating how individual perceptions of leaders are linked with followers’ performance, attitudes, and subjective well-being. However, this research received criticism for failing to consider leadership as a group phenomenon (Yammarino et al., 2005). An increasing interest in examining the multilevel aspects of the leadership provided results suggesting, for instance, that it is vital to study leadership as a group phenomenon considering how group-level perceptions may impact followers’ well-being. Multiple studies have linked group-level leadership behaviours with important employee outcomes such as productivity (Kim et al., 2015), well-being (Mesu et al., 2015), and long-term sickness absence (Labriola et al., 2006). When individual employee data are aggregated to show group-level perceptions of a workplace factor, the factor’s characteristics can be considered more of an

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objective rating of the environment than an individual-level assessment (Bliese & Jex, 2002). This is because such aggregation can attenuate bias due to individual employee reporting tendencies. For instance, if nurses are asked to report the number of patients per shift, aggregation removes bias due to nurses’ differences in the ability to estimate this figure. However, if nurses report their own workload or levels of experienced job insecurity, aggregation may also remove the unbiased variability in individual reports. Thus, it is important to realize that individual-level reports and aggregated measures may capture different aspects of workplace factors. In that sense, an analysis including both of these levels may provide complementary information about the role of the work environment in shaping employee health and well-being. For example, an epidemiological cohort study of female registered nurses and nursing aids in France identified organizational factors at the work-unit level (e.g. poor communication) that had a direct effect on hospital workers’ depressive symptoms but also those factors that had an indirect effect through individual perceptions of an effort-reward imbalance (e.g. staffing inadequacy; Jolivet et al., 2010). Treating job demands or resources as group-level variables allows comparison of different groups’ working environments to explore how these group differences influence individual employees and processes measured at the individual level, such as links between one’s workload and stress level. Some well-established factors may have different roles for well-being depending on the context. For example, research demonstrated that although at an individual level, a proactive personality buffers one against the effect of emotional job demands on the intention to leave an organization, high team-level potency reverses this effect: In teams with shared confidence in the team’s general capability, highly proactive team members express higher turnover intentions (Loi et al., 2016). Research conducted by Chowdhury and Endres (2010) provided another example, where high patient variability in a unit (e.g. diverse psychological conditions) predicted more injury and illness incidents among staff, but this relationship was attenuated in units with a stronger climate of safety. Thus, going beyond individuals’ perceptions allows researchers to refine the understanding of processes at the individual level by answering under which organizational circumstances these relationships are true. Another advantage of multilevel models is that they provide the possibility for testing whether the relationships between two or more variables at one level are replicated at other levels of analysis. For instance, a group of Finnish researchers examined the relationships between work–family culture and work attitudes in Finnish work departments that included the domains of healthcare (Mauno et al., 2011). They showed that not only did employees in the same work department share similar perceptions of the department’s work–family culture but also that the positive effects of a supportive work–family culture on work attitudes were present at the individual and work departmental levels. An interesting example was presented by Elovainio et al. (2004), who examined how decision latitude and organizational justice are linked with hospital personnel’s health. Though latitude and organizational justice were interrelated at the individual and work unit levels, only individual perceptions of justice predicted sickness absence. This pattern emphasizes the

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importance of making a distinction between contextual characteristics and individuals’ perceptions of them. Although employees in a unit may share perceptions about workplace factors, individual perceptions of stressors may be the deciding factor between the environment and an individual’s reaction. In addition, other researchers have demonstrated that the effect of teamwork and workload among nurses seemed to be amplified at the team level, attesting to the role of shared perceptions in explaining team differences in burnout (Consiglio et al., 2014). Watanabe and Yamauchi (2018) examined the effect of overtime work on nurses’ mental health and work engagement. The results of their research demonstrated that involuntary overtime work due to workload had detrimental effects on mental health and work engagement at the ward and individual levels, whereas overtime due to conformity exerted a harmful effect at only the individual level. These results have implications for practice, because they indicate a need to deal with overtime work due to workload through structural policies within a ward, and overtime work due to conformity should probably be addressed at an individual level. Given the complexity of the organizational environment regarding the nested structures, it has been argued that no theoretical construct can be “level free” in organizational studies (Klein et al., 1994). In fact, multilevel analysis provides an opportunity to decompose variance—for example, in job satisfaction—across different levels to demonstrate where the greatest variability in the phenomenon prevails. For example, a study investigating the multilevel effects that CEOs’ leadership behaviours and top-level managers’ support have on middle managers’ performance demonstrated that over half (about 60%) of the variance in performance was explained by differences between those middle managers’ leaders (Song et al., 2014). This partitioning of variance should not be treated as a purely academic exercise. In fact, recognizing at which level (e.g. a ward rather than the hospital) the variance in well-being primarily belongs is diagnostic because it is likely that existing differences at this level (e.g. abusive leadership, excessive workload, understaffing) are responsible for the variation. For example, one study investigating the role of authentic leadership and justice in three different employee outcomes showed that the effect of nesting (i.e., employees experiencing the same work environment by being in the same workgroup) was higher on turnover intention (27% of the variability in this outcome could be explained through the workgroup) than for perceived stress (15%; Kiersch & Byrne, 2015). The fact that stress has more individual-level variability is consistent with stress theories (Folkman et al., 1986), pointing to the importance of individual appraisals of stressors for stress reactions. As a consequence, such knowledge should guide actions because it suggests the level on which work environment factors, such as demands and resources, should be reformed to have the biggest effect. Therefore, future research could investigate which outcomes are primarily explained by individual factors, whereas for other outcomes, a team or organizational level may play a more pivotal role.

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Interventions to Target Demands and Resources

As pointed out previously in this chapter, there are advantages to recognizing that factors affecting employee well-being operate at the team, group, and/or organizational level in addition to the individual level and that some factors operate across levels. This recognition implies that a basic requirement for researchers and organizations attempting to conduct interventions to improve employee working conditions and health is to recognize that interventions must target the appropriate level. This decision requires careful analysis of the level on which the factors the intervention is targeting is operating.

4.4.1

Individual Interventions

Organizations often offer their employees some health and well-being interventions, including different types of activities to support employees’ behavioural changes towards healthier habits (Oakman et al., 2018). In the literature, these interventions are often called individual-level OSH interventions. The basic idea is that individuals are the targets of an intervention, which aims to engage them in activities that can increase their resources for dealing with their working conditions and improve their well-being and health. The OSH literature contains multiple examples of individual-level interventions, of which many have demonstrated positive employee outcomes (Conn et al., 2009; Martin et al., 2009; Oakman et al., 2018; Richardson & Rothstein, 2008; Rogers et al., 2017). For instance, educational programmes and digital tools to prevent and decrease substance abuse and improve coping strategies and mental health (depression, anxiety, post-traumatic stress disorder, phobias, panic disorders, obsessive– compulsive disorder) and diet and physical activity levels are common examples of individual-level interventions. There is some evidence that interventions at the individual level are more effective than interventions on other levels, such as group, departmental, or organizational levels (Richardson & Rothstein, 2008). This is not necessarily surprising because individual-level interventions often are tailored specifically to the needs of each individual and/or group of individuals sharing specific symptoms (e.g. individual stress management interventions for individuals suffering from high stress) than are interventions at a higher level addressing a larger group, which often are more preventive in nature (e.g. surveys to identify risk factors). Thus, individual interventions are often secondary or even tertiary preventions, whereas interventions on other levels more often comprise primary prevention or health promotion activities. This implies that in studies with individual-level interventions, there is often greater room for improvement and less variation within the groups, making it easier to achieve statistically significant results.

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The upside of individual interventions—directly targeting the reasons for ill health on an individual level—also has a downside. Individual interventions are less likely to affect causes—for example, of ill health—that are found on the team or organizational level. Thus, an individual stress management intervention, for instance, may effectively improve resources in terms of individuals’ coping capacities or may influence how individuals perceive work demands but is less applicable for affecting the causes responsible for a stress experience that are shared in a team or organization. In line with this, individual-level interventions have been criticized for not addressing the root causes of work-related ill health caused by higher-level factors in organizations (e.g. how work is organized or managed). This is a significant limitation of individual-level interventions in female-dominated workplaces such as healthcare, where it is primarily the characteristics of the workplace and not individual factors that influence ill health (Härenstam, 2009). In fact, it can be argued that intervening on the individual level when the factors causing ill health are on an organizational or even societal level is not only less effective in terms of addressing the root cause but also sends an unfortunate message about who is responsible for addressing these issues.

4.4.2

Organizational Interventions

Given the potential limitations of individual-level interventions for targeting the root causes of ill health, interventions on other organizational levels (e.g. team or departmental levels) have also been evaluated (Knight et al., 2017). These interventions commonly aim to change how work is designed, organized, and/or managed and can be conducted at team, group, departmental, and/or organizational levels. Interventions on any level above the individual are frequently called organizational interventions in the literature (Härenstam, 2008). More specifically, they commonly focus on the redesign of work and management practices or changes in the physical work environment, working time, employment contract, psychosocial factors, work– life balance, and health and safety processes (LaMontagne et al., 2007). Subsequently, organizational interventions are recommended in many of the current policies for addressing root causes of ill health (Health and Safety Executive, 2007; WHO, 1995; Zoni & Lucchini, 2012). However, the empirical evidence for the effectiveness of organizational interventions is mixed (Dobson & Cook, 1980; Joyce et al., 2016; Knight et al., 2019; Montano et al., 2014; Richardson & Rothstein, 2008). There are several methodological reasons that effects are mixed. First, the complexity of organizational interventions involving many actors with potentially different needs makes the choice of intervention activities challenging. Moreover, when a wide range of intervention activities is implemented, exposure to them may vary between individuals, teams, units, and departments. Furthermore, organizational interventions often are integrated into the organizational structures and processes that many times change over the course of an intervention, making it hard to capture

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the content of the intervention and its effects (von Thiele Schwarz et al., 2016). Next, challenges are involved in recruiting an appropriate sample size on the unit level to be able to statistically detect an intervention’s effect. Last, another reason for the mixed effect could be a mismatch between the intervention level and the studied outcome. Moreover, the chosen unit of analysis has implications for the choice of intervention level and the choice of appropriate outcomes to evaluate the intervention against. This illustrates that conducting and evaluating an organizational intervention is difficult.

4.4.3

Multilevel Interventions

We propose that the main issue is not choosing between individual and organizational interventions, but rather to realize the greatest benefit from both approaches. This implies the use of multilevel interventions, that is, interventions that include activities on more than one level, for example, activities that target factors related to the individual as well as the team or organization (Montano et al., 2014). These interventions combine the benefits of individual-level interventions by targeting individual factors (e.g. increasing employee resources) with precision, along with the benefits of team- and organizational-level interventions targeting psychosocial work environment factors. A specific type of multilevel intervention targets managers. On the one hand, such interventions can be categorized as individual because they often focus on an individual’s skill building. On the other hand, a manager with improved leadership skills could also evoke changes on the team level. Thus, interventions targeting leaders may be made specifically and intentionally to facilitate changes on the organizational level (Kelloway & Barling, 2010). Leadership interventions may therefore be appropriate interventions for improving team-level factors directly, as indicated by associations between leadership style and employee outcomes, and indirectly, when leaders’ behaviours are directed towards improving the way work is organized, designed, and managed (Lornudd et al., 2015). In this way, leadership interventions are often multilevel, influencing their managers’ and employees’ health and well-being through processes at the individual, team, and organizational level. Most often, interventions targeting managers focus on first line and middle managers (Montano et al., 2014), those managers closest to the employees. Regarding the hierarchical levels of organizations, interventions targeting higher managerial levels can also be motivated. For example, some attempts, with positive preliminary outcomes, have been made to design and test an intervention to improve senior management’s capacity to provide middle managers with direction and resources (Hasson et al., 2018). Finally, there is a level above the operative senior management: the strategic leadership level. In corporations, this is the board of directors, and in public organization, such as healthcare, it is the administrative management or politicians.

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Strategic management is responsible for overseeing an organization, its performance, and its long-term survival, and as such, these managers make decisions that have substantial influence on an organization’s working conditions (Bäck et al., 2020; Lornudd et al., 2020). Despite this, the strategic leadership level is seldom the target of interventions. One reason may be that these groups may not be aware of the impact that they have on working conditions, or they do not acknowledge it as a strategic issue (Bäck et al. 2020; Lornudd et al., 2020). Concurrently, it is also important to recognize that these groups are unlikely to participate in any extensive intervention. However, it can be speculated that even a minor intervention, such as an awareness-raising lecture or discussion, could have an impact if it results in a greater understanding among this group of the impact that their decisions have on employees’ psychosocial work environment.

4.5

Interventions at Multiple Levels: Methodological and Practical Issues

We need to acknowledge at least five methodological and practical issues related to the design, implementation, and evaluation of interventions at multiple levels. First, before designing an intervention, a careful analysis on the multilevel structure of the factors causing ill health in an organization is needed. This is crucial because context is different even within an organization. Some of the root causes of ill health can differ between units, and some factors can be shared on higher hierarchical levels. An intervention needs to target the right factors at the appropriate levels. Second, involvement of employees and managers in the design and implementation of these interventions is recommended in OSH literature and in EU legislation (Zoni & Lucchini, 2012). These participatory interventions invite employees and managers to work together to improve the work environment. They typically include assessments of working conditions and joint analysis of the assessment results, followed by participatory action planning and implementation of the action plans (Nielsen et al., 2010). In this way, different organizational actors’ know-how of the organization is taken into account. From this, it follows that participatory approaches may be one way to facilitate the analysis of the level on which factors should be addressed to result in interventions that fit well within the local context (Nielsen et al., 2010). Third, practical tools are available to assist in the analysis and selection of activities and ensure that the right level is addressed with appropriate interventions. For instance, the relationship between an intervention’s activities on different organizational levels and the problem they attempt to address can be outlined in the programme logic model. The programme logic model outlines all intervention activities and thereafter the theoretical short- and long-term consequences of each activity. This can help the organization and researchers clarify the mechanisms of

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change for each intervention component as well as the potential measures necessary to evaluate the activities’ impact. The programme logic model can be employed at each organizational level, using the outcome at one level as input for the next, to show the interdependence between levels. Fourth, multilevel interventions require close evaluation of what activities have been implemented at what level and thus what exposure levels have been obtained. Different individuals are likely to receive different activities and different degrees of activities, which calls for detailed evaluation approaches that can track the different activities and the exposure to them (Hasson et al., 2012). This can be done in multiple ways. For example, paper trails of the intervention can be collected and analysed. Intervention descriptions can be collected from change agents, managers, or others who are knowledgeable about the planned activities. This information can then, for instance, be included in the design of an employee questionnaire investigating the exposure rates to the intervention activities (Hasson et al., 2014). Last, and particularly vital in the female-dominated sector, specific attention should be paid to developing interventions that target structural factors. Currently, there seems to be a disconnect between the analysis of research evidence pointing to structural factors as a central element threatening the sustainability of working conditions and the target of the interventions conducted (Härenstam, 2009). Interventions still, primarily, address individual factors or, possibly, processes and procedures but seldom address organizational structures (Macdonald et al., 2008). These structures may, for example, include types of contracts, payment structures, staffing levels, work schedules, number of managerial levels, and types of governance (Macdonald et al., 2008). Thus, we call for more interventions at structural levels. This may, for example, include more flexible work schedules or an increase in staff or staff-to-bed ratios or the size of work groups to extend first-line managers’ span of control and create a stronger alignment of leadership across the different organizational levels.

4.6

Conclusion

Male- and female-dominated sectors differ regarding not only gender distribution, but also the characteristics of their workplaces as represented by job demands and resources (Härenstam, 2009). Healthcare is one example of a female-dominated sector in which growing job demands are met with a relative scarcity of job resources. Such an imbalance has repeatedly been linked with employees’ poor performance and ill health. Importantly, as we have shown, these aspects of the job operate on multiple levels and along different planes in the workplace. Acknowledging these levels in theoretical conceptualizations and analyses mirrors the complexity of organizational reality to a higher extent. Doing so is a step towards more nuanced mechanisms that link organizational characteristics with employee outcomes. Given the above-mentioned complexities, an intervention’s design should take into consideration the level at which the problem resides and target that level.

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We conclude that understanding individual versus group perspectives should lead to the design of proper interventions that fit more closely with the challenges that female-dominated workplaces face. With an intervention at the appropriate level, individual ill health may decrease, as will long-term sickness rates, work disability, or early retirement, thereby increasing the sustainability of work in the healthcare sector.

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Anne Richter is an associate professor in psychology and works as a senior researcher at the Medical Management Centre, Karolinska Institutet, Sweden. In her research, she focuses on how work environment factors, such as stressors and leadership training, influence the health and wellbeing of employees as well as on the implementation processes, when changes are introduced at the workplace. Anne works also as senior consult in healthcare organizations. Marta Roczniewska is a researcher at Medical Management Centre (Karolinska Institutet) and an Assistant Professor at SWPS University of Social Sciences and Humanities (Poland). Her research interests relate to organizational change, person-environment fit, job crafting, and fairness perceptions. Her current projects concern organizational and individual interventions for sustainable employability Henna Hasson is Professor in implementation science and a director for Medical Management Centre at Karolinska Institutet. She has a great interest in the practical impact of her research as a Head of Unit for Implementation, Center for Epidemiology and Community Medicine at Stockholm Region. Ulrica von Thiele Schwarz is a psychologist and professor in psychology, working at the School of Health, Care and Social Welfare at Mälardalen University, and Procome, Karolinska Institutet. Her research is focused on how to design, conduct and evaluate organizational interventions so that both practical and scientific impact is maximized.

Chapter 5

Managing Care Work in Times of Austerity: Gendered Working Conditions for Managers Klara Regnö

5.1

Introduction

Despite extensive interest in management in both research and public debate, the organizational context in which formal managers operate, and how it appears in different parts of the labour market, have received minimal attention in research and idea debate in recent decades. Conceptualizations of management are seldom analysed in relation to organizational structures, requirements, and working conditions in the different parts of the labour market (Lounsbury & Ventreska, 2003; Linghag & Regnö, 2009). Gender inequality related to managerial positions is mainly discussed in terms of women’s under-representation in leadership positions and the prevailing gender pay gap, even at managerial levels. Furthermore, research on gender and management has primarily focused on managers in the business sector. As a result, research on the working conditions of female managers has largely focused on women who are in the minority in male-dominated managerial contexts. This chapter addresses another structural feature of managerial work, namely, the average number of supervised employees, so-called span of control or ‘span of management’ (van Fleet & Bedeian, 1977). It explores managers’ experiences of managing large working groups in complex operations in times of austerity. The data presented in the chapter show that managers in women-dominated operations have substantially larger areas of responsibility compared to other industries both in the EU and in Sweden. The chapter discusses how this way of organizing work is associated with New Public Management (NPM), and is an expression of the gendered structuring of the labour market. The chapter also investigates the consequences of this way of organizing on the managers’ work environment, room for

K. Regnö (*) Division of Organization and Management, School of Business Society and Engineering, Mälardalen University, Västerås, Sweden e-mail: [email protected] © Springer Nature Switzerland AG 2021 B.-I. Keisu et al. (eds.), Gendered Norms at Work, Aligning Perspectives on Health, Safety and Well-Being, https://doi.org/10.1007/978-3-030-77734-0_5

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manoeuvring, and health. The chapter begins with a brief introduction to NPM and research on gendered work organizations upon which the analysis is based. The methodology is then introduced followed by the data on span of control and, finally, interviews with managers and concluding remarks.

5.2

Gendered Work Organizations

Research on gender and organizations shows that gender is deeply embedded in organizational life (Acker, 1990). Gendering occurs in the materiality of organizations as well as in organizational cultures. Materiality concerns the way in which organizations are structured, how work is organized, tasks distributed and coordinated, how responsibilities and powers are distributed, as well as the construction of hierarchies (Acker, 1990; Mintzberg, 1979). Material conditions include gendered divisions of work, the valuation of work in the form of salaries, the location, and physical status of workplaces and buildings. Power is built into organizational structures. People’s placement in organizational hierarchies gives them different kinds of access to resources and creates different opportunities (Acker, 1990; Kanter, 1977). Gender is also present in organizational cultures and symbols that explain, reinforce, or, at times, oppose gendered organizational structures (Acker, 1990). Power works through culture as power over thought through, for example, the gender labelling of positions and tasks and artefacts in organizations that neutralizes and makes certain gender distributions or ways of organizing work seem more natural or self-evident (Acker, 1990; Yoder, 1991). People’s room for manoeuvre is negotiated in organizational processes when human interaction takes place in specific organizational settings. Here the concept of gendered room for manoeuvre is used to describe the possibilities and restrictions associated with gender in a specific context (Linghag & Regnö, 2009; Regnö, 2013). When the room for manoeuvre is negotiated, prevailing power relations are reshaped or changed. At the same time, organizational culture and materiality are re-created or altered. Uneven power relations have the consequence that people have different room for manoeuvre. Gendered individual experiences have bodily effects and create gendered components of individual identity.

5.3

New Public Management

During the 1990s, New Public Management (NPM) reforms were introduced in response to budget crises and financial austerity in Europe. NPM has had a profound impact on how the public sector across Europe is governed (Simonet, 2011). It has redefined the decision-making powers in the public sector (Hood, 1991; Lapsley, 2008; Power, 1997; see also the introductory chapter). In line with the market ideals of NPM, committees that provide social welfare services usually are organized

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according to a so-called purchaser–provider model in which a department of public servants is responsible for day-to-day operations (supply side) and a group of care administrators evaluate the applicants’ needs and decide what and how much care services they are entitled to receive (demand side) (Montin, 2007). Many of the organizational principles and practices associated with NPM, such as flat organizational structures, standardized and centralized decision-making processes, marketization, performance and quality assessments, and financial accountability at low organizational levels have been introduced to a much larger extent in women-dominated municipal operations such as social care and education compared to male-dominated technical municipal operations. Managers in male versus female operations work under different organizational preconditions with regards to, for example, resources, support, distribution of authority, and responsibilities (Björk, 2013; Björk & Härenstam, 2016; Corin, 2016; Kankkunen, 2014; Westerberg, 2000). A study comparing the work environment for middle managers in maledominated technical departments concerned with street maintenance, energy, and recreation, with women-dominated care and education operations, showed that managers, predominantly women in care and education, had higher levels of education, lower salaries, more psychosomatic reactions, lower job satisfaction, and a less satisfying psychosocial work environment (Westerberg & Armelius, 2000). Current research does not support the idea that care work is particularly suited to being organized with large groups of subordinate staff. On the contrary, care operations meet many of the criteria that have been identified when it is appropriate for managers to be in charge of small groups of employees (Andersson-Felé, 2008; Bell, 1967; Gulick, 1937; Regnö, 2016; Woodward, 1965). The differences in working conditions translate into different health risks at work. It is more common for women to risk their health due to stress caused by high demands and a low level of control (Westerberg & Armelius, 2000; Östlin, 2002).

5.4

Data and Methodology

Sweden provides publicly financed healthcare and care services for all its citizens according to their needs. Since the 1990s, the private provision of publicly funded services has grown substantially (see Chap. 7—Storm & Stranz and Chap. 10— Brodin & Erlandsson). However, municipalities still perform most care services in Sweden, and it is the working conditions of these organizations that are the focus of this chapter. The chapter is based on both quantitative and qualitative data. The quantitative data are a comparison of the average size of working groups, number of employees supervised per manager, the so-called span of control in the EU and Sweden. The Swedish data were retrieved from the Swedish Occupational Register, Statistics Sweden. The classification of occupations follows the Swedish Standard Classification of Occupations (SSYK, 2012). The classification of industries follows

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the Swedish Standard Industrial Classification 2007 (SNI, 2007).1 Statistics on the EU were retrieved from the EU Labour Force Survey (EU-LFS) and Eurostat’s database on employment and unemployment. The calculations are based on the Classification of economic activities, NACE Rev. 2, a similar classification as the Swedish classification of occupations and industries; and the international standard classification of occupations 2008, ISCO-08, comparable to the Swedish Standard Industrial Classification 2007. The average span of control for the different industries was calculated from data on the number of managers and employees in each industry. The qualitative data comprise interviews with managers in three departments of social care in two different municipalities. The material stems from a research project reported in a doctoral thesis in Swedish (Regnö, 2013). Overall, 12 managers were interviewed. They work in departments that provide home care services and residential care to older people and people with disabilities. Managers at three organizational levels have been included in the study: first-level operational managers, middle managers, and strategic executive management. Managers at the first level are in charge of two to four housing services or daily activity centres for older people or people with disabilities. Middle managers are in charge of groups of approximately six to eight first-level managers. Executive management is responsible, for example, for providing all the care for older people or the care for both older and disabled people, depending on how the municipality is organized. Managers at all levels have their own budget and are responsible for the financial results. The managers are between 30 and 60 years of age and most of them are between 40 and 60. The average duration as a manager is 12 years. Those managers with the least management experience have worked for 2–5 years. Several of the managers have held different managerial positions for more than 20 years. Each manager was interviewed at their workplace for 60–90 min and some interviews lasted 2 h. The interview questions evolved around their daily work, what they did, how they perceived their work and their relationship to colleagues at different organizational levels. The answers were analysed thematically with the help of the code-and-retrieve software Nvivo. The themes that emerged were clustered in line with the theoretical framework.

5.5

Large Working Groups: Mainly in Women-Dominated Industries

Tables 5.1 and 5.2 below show the labour market industries in the EU and Sweden sorted by size of the average number of employees supervised by each manager, that is, span of control, starting from the largest at the top of the table.

The smallest industry: A, Agriculture, forestry, and fishing is reported together with unknown industries under the heading, other/unknown.

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Table 5.1 EU-28 Year 2019, managers, employees 15–64 years, and span of control by industry. Numbers and gender distribution (%)

Q Human health and social work P Education H Transportation and storage O Public admin and defence E Water supply: sewerage, waste B Mining and quarrying C Manufacturing N Administrative support services F Construction D Electricity, gas, steam air con. G Wholesale and retail M Professional scientific and technical R Arts, entertainment, and recreation J Information and communication K Financial and insurance I Accommodation and food L Real estate activities Other/unknown Total

Gender distribution Women Men 79 21 72 28 22 78 49 51 22 78 14 86 30 70 49 51

Span of control 30 25 20 18 17 16 16 16

Managers 820,600 676,500 590,000 820,800 101,000 42,700 2,106,700 578,100

Employees 25,821,300 17,871,600 12,265,600 15,726,900 1,865,500 728,800 35,544,900 9,863,450

1,113,500 112,300 2,347,900 1,041,800

15,813,500 1,620,300 31,604,600 13,516,300

10 26 49 48

90 74 51 52

13 13 12 12

326,000

4,164,500

48

52

12

724,500

7,602,200

30

70

9

739,100 1,270,300 245,200 523,900 14,180,900

6,572,200 11,260,650 1,943,200 16,391,400 230,176,900

51 54 53 _ 46

49 46 47 _ 54

8 8 7 – 16

Source: Eurostat LFS

There is a gendered pattern in the tables. The size of the control span, with a few exceptions, particularly in Sweden, largely follows the gender distribution. The smaller the groups, the more male dominated the sector. Managers in Human Health and Social Work have the largest average working groups in the entire labour market: 30 employees in the EU and 28 in Sweden, followed by the education sector, which has an average of 25 and 27 employees per manager, respectively. On average, managers in these sectors supervise significantly larger groups of employees than managers in the rest of the labour market. The spans of control in these operations are approximately twice the average size of the labour market. The tables show an average and do not differentiate between managerial levels. First-level operational managers usually supervise larger groups than middle and strategic executive managers. Individual studies of care services show that operational first-level managers in the health and social care sectors often supervise very large groups of employees (Björk, 2013; Björk & Härenstam, 2016). The Swedish Work Environment Authority’s inspection of a large home care service in Sweden

19,529 26,349 32,772 31,514 3286 13,421 4833 14,544 5949 1315 184,088

2825 14,467 9462 13,497 1221 5255 2683 17,846 3946 698 117,311

18,676 7516 32,390 9895 2013 301,399

42,234 45,011 4507

22,354 40,816

Total 26,386 18,627 9535 10,710 10,729

Source: The Swedish Occupational Register with statistics, Statistics Sweden

Q Human health and social work P Education H Transportation and storage I Accommodation and food R+S+T+U Arts, entertainment, recreation, personal services F Construction M+N Admin. professional, scientific, technical support B+C Manufacturing, mining, quarrying G Wholesale and retail D+E Electricity, gas, steam air con. Water; sewerage, waste J Information and communication L Real estate activities O Public admin and defence K Financial and insurance services Other/unknown Total

Managers Women Men 20,303 6083 12,496 6131 2477 7058 4722 5988 5413 5316

57,291 29,156 172,567 47,475 23,621 2,207,909

128,816 253,502 12,357

32,383 237,168

140,271 41,114 123,328 46,254 36,084 2,335,809

406,346 303,344 36,944

292,119 309,057

Employees Women Men 606,925 153,806 382,371 131,009 50,327 168,239 79,990 76,852 93,960 71,042

197,562 70,270 295,895 93,729 59,705 4,501,484

492,928 556,846 49,301

324,502 546,225

Total 760,731 513,380 218,566 156,842 165,002

29 41 58 51 40 49

24 46 25

10 43

71 59 42 49 40 51

76 54 75

90 57

Gender distribution Women Men 80 20 74 26 23 77 51 49 57 43

Table 5.2 Sweden 2018, managers, employees 15–64 years, and span of control by industry. Numbers and gender distribution (%)

10 8 8 8 – 14

12 11 10

14 12

Span of control 28 27 22 14 14

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showed that 73% of first-level managers were in charge of more than 40 employees (Swedish Work Environment Authority, 2014). In the following sections the interviewed managers describe their operations, the major organizations in which they work, and the consequences of this way of organizing on their work environment.

5.6

Large Working Groups and Minimal Administrative Support

Each of the studied departments employs between 700 and 900 people and has a budget equivalent to 50–100 million EUR. Furthermore, they are flat organizations with few management levels, meaning that managers at all levels have large areas of responsibility and first-level managers in particular are in charge of large groups of employees. They supply many care services and the work involves responsibility for budget, staff, business development, and day-to-day operations. Managers state that their work is stimulating and that they regard it as a strength to be able to manage such complex and demanding tasks. They state that they take pride in their work and find it stimulating to develop operations in collaboration with colleagues. I like to improve the public sector, to explain the assignments [to my staff]. I find this kind of strategic work very rewarding. I like to be where things happen. I like to be involved and have a say, otherwise I would not have chosen this job.

However, large working groups entail a heavy workload for the managers. Furthermore, many care operations operate 24/7, which requires the scheduling of employees’ working hours. This is a task that some of the managers describe as timeconsuming. Many of the practices associated with NPM have also increased the administrative burden for both managers and employees. Despite a heavy workload, the managers report that they receive very limited administrative support. When the department has to save money, it is administrative support that is usually rationalized first. A first-level operational manager in the study describes how, in addition to other managerial tasks, she administers wages and pays invoices. I do all the administrative work myself, including the wages. I currently have 45 employees, so it takes a lot of time. We have no HR department. We handle everything ourselves, pay all the invoices, handle all the finances. It is administrative work that runs parallel with other managerial tasks.

The manager in the quote below describes how administrative support has decreased during her time as a manager. Today, administrative tasks take a significant amount of her time. Like the managers in the quote above, she also handles the

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administration of wages and all administration related to service users, as well as the work schedule. It’s a lot of administration. We handle all the wages ourselves. When I started here, we actually sent the lists [of the working hours of each employee] to the payroll department. That was many years ago now. There [in the computer system] you have to do everything from hiring to payments. You register the number of hours a person has worked, and do the scheduling and everything.

The managers have to meet the demands and expectations of many different stakeholders within and outside of the organization. They have to meet the expectations of citizens, politicians, senior managers, their own staff, as well as service users and their relatives. A first-level manager typically meets with their own managers, managerial colleagues at the same organizational level, politicians, employees, service users and their relatives, healthcare representatives, and other stakeholders who are involved in the care. Consequently, managers spend a lot of time attending meetings. In the quote below a middle manager describes how her weeks are structured around meetings. There are many meetings, rather too many. [. . .] I meet the executive group once a week and plan, work more strategically and develop the operations. [. . .] Then I meet with the firstlevel management and communicate what came out of the meeting with the executive group and I support and direct them in their work. Now and then I am contacted by citizens or relatives of our customers. [. . .]. I also participate in many meetings that are not directly related to elderly care but rather concern the municipality as a whole. [...] I also meet with my management group every other week and we discuss what is going on in our operations. It could be problems or just everyday questions. We talk about leadership and discuss what’s going on in the municipality at large.

The care operations described by the managers are the result of decades of restructuring that have resulted in flatter organizations and reduced administrative support functions. This has led to an administrative burden for both managers and employees (Andersson-Felé, 2003; Hjalmarson et al., 2004). This way of organizing has been a way to save money, but there were also hopes that less hierarchical and more flexible organizations could meet the changing needs of the public in a more optimal way. Instead, in many cases, the organizations became too lean. Consequently, the burden on those who worked in these organizations became very heavy (Andersson-Felé, 2003; Cerdas et al., 2019; Rasmussen, 2004, see also the introductory chapter). During cost-saving periods, it is easier for politicians to decrease the number of administrative staff than the number of employees directly involved in care. As a result, it is the budget rather than the managers’ needs that determine the extent to which the manager receives administrative support (Kankkunen, 2009; Hjalmarson et al., 2004). Previous studies show that broad spans of control have negative effects on the working conditions for managers. It increases stress and creates an excessive workload. Control over work and job satisfaction decreases (Stewart, 2009; Wallin et al., 2013; Wong et al., 2015). Wide spans of control entail, for example, that the number of administrative, strategic, and personnel-oriented tasks increase in a way

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that makes it difficult to balance different tasks and requirements (Andersson-Felé, 2008; Wallin et al., 2013).

5.7

Autonomous Working Groups

First-level managers are usually responsible for multiple operations in different parts of the municipality, for example, different residential care homes for the old or disabled people or home care. The geographically dispersed operations shape the managers’ work environment and relationships to their employees. The way in which the operational managers’ own workplace is physically organized differs between the departments in the study. Some of the managers have an office in the main municipal administrative building and travel to the different units during the week. Other managers have their base at one of the units, for example, a room in one of the residential care facilities. It is also common for managers to share a room with the staff. Work becomes fragmented for managers who are in charge of geographically dispersed operations. The manager in the quote below describes her situation. I have an office that I share with my staff. I don’t have my own office. The office I share has some locked cabinets with documents and that’s my base. I’m bouncing back and forth between my units all the time. [...] I’m in four different places in a week. It was ages since I spent a whole day in my office. It doesn’t happen. It doesn’t look like that. [. . .] My units are quite scattered. [...] I spend a lot of time in my car driving back and forth. That’s what it looks like.

The fact that many of the first-level managers are responsible for operations that operate 24/7 means that issues involving a manager can arise at any time. It can be difficult to anticipate care needs, and the situation can change rapidly when unexpected things occur. One of the managers described this situation. I can never go home and say that we are closed now. Now it’s quiet at work. Now I have locked the door. This is not possible. I can receive a phone call anytime. Something urgent may have happened. Even though we have managers on standby and should be protected from receiving calls outside of office hours, operations operate 24/7 and this is, of course, a very special situation.

The large working groups in combination with minimal administrative support and geographically dispersed operations shape the managers relationships to the staff. The managers are not able to attend the daily operations and state that a good manager should not intervene too much because employees are expected to work independently. I believe a good manager should be able to delegate. Employees should be able to work independently. That is the kind of relationship I have with my manager. You [the manager] should not interfere with everything but rather give the employees more responsibility, I believe this makes them feel more needed and the work becomes more enjoyable.

The size of the working group affects a manager’s ability to interact with their employees and be present at and involved in their work. As a result, employees are

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expected to work independently. Even with autonomous working groups, managers still have to carry out many traditional tasks related to hiring, introducing new employees, performance assessment, and salary, as well as various types of documentation related to the employees. High levels of stress are reported by managers who feel that they almost never have enough time to carry out all their tasks (Meyer et al., 2011; Wolmesjö, 2005).

5.8

Frequent Restructuring Under Public Scrutiny

The departments in the study are characterized by recurring restructuring. Operations are complex and care needs are changing and difficult to anticipate. As a result, some care operations may have to expand, and others close. However, according to the managers, cutbacks in funding, and a changing political majority are the main causes of restructuring. The managers emphasize that working in a politically governed organization means that the circumstances under which they work can change rapidly. When you work in a politically governed organization, the circumstances can change quite quickly and all of a sudden you are expected to do things differently. Then we have to adjust. That is the nature of this profession.

At the time of the interviews, two departments had recently been restructured. However, this proved to be only the most recent restructuring. One of the managers stated that operations had been restructured every other year since she had started her job 6 years previously. Although the managers emphasize the importance of flexibility, they find the constant changes challenging, particularly when they feel that the current way of operating works well and they see no obvious need for a new organizational structure. It was ok then [before the last restructuring] and it works well now. It’s a give and take situation. But I think there’s a great risk that the managers will not cope.

The managers state that they feel that it does not matter how well they perform or how good their results are. Their operations will be restructured, anyway. All these changes take a lot of energy and it is demotivating to feel that their commitment to running a high-quality operation still results in restructuring, even though it was running well. The constant changes negatively affect the work environment. The managers stress that it takes time for them to adjust the operations to the new circumstances. They also find it difficult to motivate their own staff when the working conditions are constantly changing. This is madness. The great results we have delivered! Are they worth nothing? Now it is time to divide the working groups again. What credibility do we have in the eyes of our employees?

Not only do the managers have to motivate their own staff when their operations are restructured, they also have to explain and defend their operations publicly. The

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managers report that the media often contacts them and that they really prioritize media contacts. It is important to be ready to explain and give the correct image of their operations. We try to ensure that we are very accessible when the media wants to talk to us. This means you might be late for a meeting because you have to call a journalist. [...] Usually, someone is dissatisfied because they have not received the help they required, or they make a request that we may not be able to meet. This is probably the most likely scenario. It is quite common to then contact a journalist. [...] If we are not quick to respond, they can write just about anything they like.

The managers think that the fact that care services receive a lot of negative media attention negatively impacts the work environment. When the focus is on care services, it is usually about scandals or neglect. Negative images in the media make it harder for employees to feel proud of their work and may make them reluctant to tell other people that they work in care services. Negative media reports also negatively affect status. When there are negative reports about care for older people, no one wants to mention that they work in care operations.

The managers find it strange to be confronted with such a negative image of care services when they themselves find the work meaningful and stimulating. They point out that it is not possible to run their operations without being knowledgeable and committed. The manager in the quote below states that she has chosen her job and that she is proud to work in care. Despite this, she feels that her work is classified as a ‘bad job’. This image negatively affects everyone who works in the organization. I have always worked in care services. It’s the best work I know. I am proud of my job and I enjoy it. There is no other job I would rather have. Still, for some reason, it is classified as a ‘rubbish job’.

Previous studies show that recurring restructuring led to loss of skilled employees and minimal time for training and supervising new employees (Andersson-Felé, 2003; Hjalmarson et al., 2004). Moreover, the increased demand for transparency associated with NPM has resulted in increased critical scrutiny of care operations in the media. Most commonly, the operations are portrayed in a negative light. Consequently, managers must be prepared to explain and defend their operations publicly (Lloyd et al., 2014; Wilmar et al., 2019).

5.9

Top-Down Communication

The interviewed managers report minimal personal contacts between the various strategic levels. Communication mainly takes the form of written evaluation and feedback. Communication becomes one-way, top-down. The operational managers state that the dominant attitude is that the instructions from the strategic management and the politicians must be implemented. This means that, to a large extent, the role of middle management and operational first-level managers is to pass on information

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from higher levels to their employees and work together with them to implement business plans, salary policies, risk analyses, quality plans, gender equality plans, and integration programmes, for example, as described by the manager in the quote below. We receive lots of tasks. They always come from the top: Can you deliver this? Can you deliver that?

The first-level manager below states that she does not always feel that executive management understands what it takes to run the operations. She receives a lot of different tasks from executive management that she has to carry out together with her employees at short notice. She stresses that her staff have limited time they can attend meetings. They need to care for the old people. I can feel resistance if there are many tasks coming from the top that we are expected to carry out within a short time frame. I think: When are we supposed to take care of our old people? They [top management] sometimes lack the understanding that the staff cannot sit for hours working on a specific task. I could, of course, do the tasks myself, but we are supposed to work in a collaborative manner with our quality plans and action plans and such like. [. . .]. It’s not possible for us all to sit down in the afternoon when we have groups [of care users on the premises].

In the studied departments, the distance between the operational level and strategic executive management appears to be small. However, flat organizations have proved to create distance between organizational levels (Kankkunen, 2009, 2014). The large size of the working groups implies that very little personal contact and dialogue takes place between different levels of hierarchy. Instead, large departments are governed by written information, evaluation, and feedback. The operations are measured and assessed, and control is exercised through steering documents such as various plans and key indicators. This way of governing has been particularly highlighted in large departments with a flat organizational structure and few managerial levels (Kankkunen, 2014).

5.10

A Balanced Budget: The Top Priority

In line with NPM reforms, each operational unit in the studied departments has its own budget and is responsible for the financial results. Executive management has the authority to determine budgetary constraints. Financial responsibility is at the level of operations management. Recurring cutbacks decided at higher organizational levels create a difficult situation for operational first-level managers and their staff, who are expected to maintain the same services with less resources. The budget becomes very much in focus. What is clearly stated by the municipality is that the budget must be balanced. You may have succeeded with your operations but if your bottom line is in the red, it is considered a failure, anyway.

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This does not mean that managers do not attempt to put forward information on the political level about the amount of time and other resources needed to provide good quality care. The manager in the quote below describes this situation. However, if her request is not taken into consideration, it becomes the responsibility of the operational manager to carry out the tasks, anyway. My job is to ensure that they [the employees] are able to do what the politicians tell them to do. In order to do so I have to communicate upwards to higher managerial and political levels that we need this and that in order to deliver. And if we don’t get what we need, then we can’t deliver. Then there will be certain consequences. [. . .] But if my manager tells me to do this anyway, then I just have to carry on with the job and deliver.

In line with NPM reforms the revenues are based on a standardized calculation of the number of hours needed to perform a specific task. The managers describe that this cause problems because the standardized allocation of resources determined by the care administrators is not always consistent with the care users’ actual needs. The middle manager in the quote below states that she must devote a lot of time and energy to describing what is needed in order to run the operations properly. With regards to the budget, there is sometimes a gap between what is calculated and the reality of care work. [. . .] If a user is granted a number of hours and these hours are just enough for one person to help the care user and the care user needs two people to help him or her. The administrators sometimes have no understanding of these situations.

The budget is fixed and managers are financially responsible for operations but cannot fully control the revenues. Each care user provides an income, and when they fall ill or are unable to participate in day care activities, for example, this means that the operations are losing revenue. This creates a culture in which it is up to the manager to sort out difficult situations. The operational managers and their employees have to manage the conflict between the demand to maintain highquality care and a balanced budget. The manager in the quote below describes this situation. I run a day care centre and our system is such that we get no money when they [care users] are not physically in place. The reason they don’t show up could be that the special transport service was not working, or the home care service didn’t come, or they’re ill.

To minimize the risk of budgetary deficits, the managers state that they increase the number of service users in their operations and thereby the workload for their employees. However, doing this is no guarantee that they will escape further cutbacks. Instead, if the manager demonstrates that it is possible to run the operations at a lower cost, further reductions may be implemented. The manager in the quote below describes how she has worked hard to get her budget in balance only to find that the budget for the next year was reduced. I have been in charge of this unit. In August it will have been two years and we still have a balanced budget. I had a balanced budget last December, with the result that there were cutbacks in the new budget. [...] I was upset and angry. I mean, we had really worked [to balance the budget]. It had been a tough year.

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Previous research highlights that a consequence of NPM reforms is that accountability for the operations has been shifted downwards in the organizations, while financial restrictions have increased. Thus, responsibility and authority become separated in the organizations. First-level operational managers are responsible for the organizational results, while they have little ability to influence strategic decisions such as resource allocation and staffing (Andersson-Felé, 2003; Kankkunen, 2009; Montin, 2007).

5.11

Room for Manoeuvre: High Level of Personal Responsibility, Stress, and a Culture of Positivity

The managers report that politicians and senior managers generally do not accept that the budget is exceeded. The managers state that they risk being transferred to another position if the budgetary requirements are breached. This creates a mindset in which the directives from politicians are not possible to change and must be implemented in the operations, regardless of their implications. These working conditions create a culture in which having a professional approach means carrying out the tasks at hand within the given budget. As the responsibility for maintaining a proper service is delegated to lower management levels, the focus becomes on the individual manager’s ability to carry out the assigned tasks within the given budget. The managers in the study assume great personal responsibility for the care operations. The inability to maintain operations and meet the budgetary requirements is interpreted as personal failure, not that the task of maintaining the same level of services on a lower budget was impossible. If the managers are unable to live up to the expectations, they state how they are ready to take responsibility for this through, for example, seek employment elsewhere. I take this work very seriously, much too seriously. Because this is my job and my mission and if I do not accomplish it, then I will have to do something else. This work is very important to me.

The high level of individual responsibility for the operations makes is difficult to discuss the working conditions, both with colleagues and senior management, since exceeding the budget is not an organizational concern but instead casts a shadow on the individual manager’s ability. The working conditions and expectations on managers create a ‘culture of positivity’. Managers are expected to be positive and accept all work tasks without expressing any dissatisfaction, no matter how challenging these tasks may be. This makes is difficult for them to mention work problems or express dissatisfaction at their work situation. This vulnerable situation for individual managers makes them reluctant to talk about challenges at work. It’s very difficult to own up when you make mistakes and say that something is difficult. [...] You can’t do that because then you may become a less reliable manager and it’s very dangerous to be unreliable. We are supposed to be so competent. Everything is supposed to

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be easy and enjoyable. That’s the culture in these management groups. [...] There’s always a threat to us managers. There’s a threat that if, as a manager, you’re not perceived as running your operations properly and are not well liked, you will be transferred. There will be restructuring and then you’re transferred.

NPM reforms put an emphasis on the accountability of service providers. As a result, the economic governance model and performance outcome measurements are increasingly common (Power, 1997). Since standardized steering instruments only capture certain measurable aspects of care, human care activities, although very diverse and complex, are perceived as more uniform than what they actually are. It is considered that measurable facts will provide an accurate picture of the entire organization. The image of the operations as uniform will, in turn, be possible to maintain when senior management has minimal contact with operational managers and staff. When operations are perceived as homogeneous, personal contact with managers at lower levels is not deemed necessary. When operations management has few options to discuss the consequences of cutbacks with strategic management, it is not possible to create a congruent image of the operations. Instead, strategic management may have a completely different idea of how the operations are doing compared to the employees and the operational managers. Senior management and politicians can maintain the idea that good quality operations can continue with fewer resources. Executive management believes that it is possible to carry out all care activities regardless of the size of the budget, while front line managers and their personnel struggle to provide a proper service on a tight budget (Kankkunen, 2009). When executive and operations management and their employees have a different perception of what services can be maintained within a given budget, executive management can decide on budgetary cutbacks while operational managers and their employees become responsible for trying to maintain satisfactory care within this budget. Some of the tasks in social care are emotionally stressful and raise existential questions about life and death. Conflicts between professional considerations and a lack of resources occur when first-level managers and their employees feel that they cannot help the care users in the way that they should. These situations can be very hard to deal with and create a stress of conscience characterized by a sense of inadequacy and powerlessness (Hjalmarson et al., 2004; Juthberg, 2008; Montin, 2007).

5.12

Concluding Remarks

This chapter discusses the fact that many of the organizational structures and practices associated with NPM such as flat organizations, marketization, performance, and quality assessments have been introduced to a much larger extent in women-dominated municipal operations such as care and education compared to male-dominated technical municipal operations. Furthermore, managers in the care and educational sectors have the largest spans of control in the entire labour market, both in Sweden and the EU. These sectors employ many women, which means that a

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high number of women, both managers and employees, face challenging working conditions. This is also apparent in health statistics. Sickness absence as a result of stress and burn out is much more common in women than in men. The working conditions are gendered in the sense that the way that work is organized differs in male compared to women-dominated operations. This means that individual women and men in the same workplace largely encounter the same organizational conditions, for example, expectations of having a balanced budget. The different behavioural patterns of managers in different operations can be related to gendered working conditions, rather than to the gender of the individual person. The gendered material conditions of the studied departments are that they are major organizations that provide many different care services. Furthermore, they are flat organizations with few management levels, meaning that managers at all levels have large areas of responsibility. Their work comprises responsibility for the budget, staff, and day-to-day operations. Operations are geographically dispersed. First-level managers are usually responsible for several different operations in various locations. Some of the operations comprise different forms of residential care that are open 24/7. Managers, particularly first-level managers, are responsible for large groups of staff and, despite this, they received very little or no administrative support. In some cases, the managers lack their own personal office and move between three and four different units during a working week. Each operational unit has its own budget and is responsible for the financial results. Operations are measured and assessed continuously. All managers have experienced cutbacks. The departments are restructured at regular intervals. The organizational structure leaves little room for dialogue between the different levels of the hierarchy. There is minimal personal contact between the various strategic levels with control taking place via evaluation and feedback. Responsibility and authority are separated in the organizations. Economic responsibility is at the level of operations management while the authority to determine financial expenditure lies with the executive management and politicians. The organizational culture that results from such material conditions is constituted by notions of the operations themselves and by expectations on managers and employees. Operations are perceived as uniform and are believed to be able to fully describe and govern via written directives, measurements and evaluations. Furthermore, operations are governed by the idea that it is possible to standardize care needs for different categories of care users. The expectations on managers and employees are that they will work independently and keep a balanced budget. They are also expected to be flexible and adaptable and deliver under changing circumstances. There is also a culture in which it is difficult for a manager to mention work-related problems or express dissatisfaction about their work situation. These expectations lead to the creation of a ‘culture of positivity’ within which managers are expected to be positive and accept all work tasks, no matter how challenging these tasks may be. The structure and culture of the studied organizations constitutes the room for manoeuvre for the managers in the sense that it encourages certain ways of being and

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acting, while other actions are associated with social costs. For example, that the managers are aware that budget requirements are at the core and if the budget is exceeded it may come at a high personal cost. There is a risk of being transferred and of being regarded as incompetent. It is first-level managers and their personnel who are responsible for maintaining a proper service. The managers attempt to maintain a decent service, even when it means that their working situation becomes so onerous that it leads to poor health and sickness absence.

References Acker, J. (1990). Hierarchies, jobs, bodies: A theory of gendered organizations. Gender & Society, 4(2), 139–158. Andersson-Felé, L. (2003). Hur många direkt underställda kan en chef ha? Om kontrollspann i vård och omsorg. [How many employees be in charge of? On spans of control in human care service]. Socialstyrelsen. Andersson-Felé, L. (2008). Leda lagom många: om struktur, kontrollspann och organisationsideal. [To manage a fair number: On structure, span of control and organizational ideals]. Göteborgs universitet. Bell, G. D. (1967). Determinats of spann of control. American Journal of Sociology, 37(1), 90–101. Björk, L. (2013). Contextualizing managerial work in local government organizations. Göteborgs universitet. Björk, L., & Härenstam, A. (2016). Differences in preconditions for managers in genderdized municipal services. Scandinavian Journal of Management, 32(4), 209–219. Cerdas, S., Härenstam, A., Johansson, G., & Nyberg, A. (2019). Development of job demands, decisions autority, and social support system in industries with different gender composition – Sweden. 1991-2013. BMC Public Health, 19, 758. Corin, L. (2016). Job demands, job resources, and consequences for managerial sustainability in the public sector: A contextual approach. Göteborgs universitet. Gulick, L. (1937). Notes on the theory of organizations. In L. Gulick & L. Urwick (Eds.), Papers on the Science of Administration. Institute of Public Administration, Columbia University. Hjalmarson, I., Norman, E., & Trydegård, G-M. (2004). Om man ska vara stöttepelare åt andra måste man stå stadigt själv: en studie om äldreomsorgens chefer ochderas förutsättningar. [If people depend on you, you need to stand on firm ground. A study of managers in care for old people and their preconditions]. Stiftelsen Stockholms läns äldrecentrum. Hood, C. (1991). A public management for all seasons? Public Administration, 69(1), 3–19. Juthberg, C. (2008). Samvetsstress hos vårdpersonal i den kommunala äldreomsorgens särskilda boenden [Stress of consciousness among care personnel in municipal residential care for old people]. Umeå university. Kankkunen, T. F. (2009). Två kommunala rum: Ledningsarbete i genusmärkta tekniska respektive omsorgs- och utbildningsverksamheter. [Two municipal spaces: Managerial work in genderized municipal technical and human services]. Acta Universitatis Stockholmiensis. Kankkunen, T. F. (2014). Access to networks in genderdized contexts: The construction of hierarchical networks and inequalities in feminized, caring and masculinized, technical occupations. Gender Work and Organization, 21(4), 340–352. Kanter, R. M. (1977). Men and women of the corporation. Basic Books. Lapsley, I. (2008). The NPM agenda: Back to the future. Financial Accountability & Management, 24(1). Linghag, S., & Regnö, K. (2009, February). What is gender in organizations? Paper presented at ‘Feminist Research Methods. An international conference’. Stockholm University.

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Lloyd, L., Banerjee, A., Harrington, C., & Jacobsen, F. (2014). It’s a scandal! Comparing the causes and consequences of nursing home media scandals in five countries. International Journal of Sociology and Social Policy, 34(1/2), 2–18. Lounsbury, M., & Ventresca, M. (2003). New structuralism in organizational theory. Organization, 10(3), 457–480. Meyer, R., O’Brien, L., Doran, L., Streiner, D., Ferguson-Pare, M., & Duffield, C. (2011). Frontline managers as boundary spanners: Effects of span and time on nurse supervision satisfaction. Journal of Nursing Management, 19, 611–622. Mintzberg, H. (1979). The structuring of organizations: A synthesis of the research. Prentice-Hal. Montin, S. (2007). Moderna kommuner. 3 uppl. [Modern Municipalities]. Liber. Östlin, P. (2002). Gender inequalities in health: The significance of work. In S. P. Wamala & J. P. Lynch (Eds.), Gender and social inequities in health: A public health issue. Studentlitteratur: Lund. Power, M. (1997). The audit society: Rituals of verification. Oxford University Press. Rasmussen, B. (2004). Between endless needs and limited resources: The gendered construction of a greedy organization. Gender, Work and Organization, 11, 5. Regnö, K. (2013). Det osynliggjorda ledarskapet. Kvinnliga chefer i majoritet. [Invisible leadership. Women Managers in Majority]. Kungliga Tekniska högskolan. Regnö, K. (2016). Chefer i välfärdens tjänst. En forskningsrapport om hur personalgruppens storlek påverkar kvalitet och hälsa. [Managers in welfare services. A research report in how the size of working groups affects quality and health]. Simonet, D. (2011). The New Public Management Theory and the Reform of European Health Care systems: An international comparative perspective. International Journal of Public Administration, 34, 815–826. SNI. (2007). SNI 2007 Swedish Standard Industrial Classification 2007. Standard för svensk näringsgrensindelning 2007. Statistics Sweden. SSYK 96. (2012). Swedish Standard Classification of Occupations 1996. Standard för svensk yrkesklassificering 1996. Statistics Sweden. Stewart, A. (2009). Span of control and stress: The nurse manager’s perspective. D’YouvilleCollege. Swedish Work Environment Authority. (2014). Inspektioner av kvinno- och mansdominerad kommunal verksamhet, hemtjänst och teknisk förvaltning. Rapport 2014:3. [Inspections of female and male dominated municipal operations, home care service and technical services]. Arbetsmiljöverket. van Fleet, D. D., & Bedeian, A. G. (1977). A history of span of management. The Academy of Management Review, 2(3), 356–372. Wallin, L., Pousette, A., & Dellve, L. (2013). Span of control and the significance for public sector magagers’ job demands: A multilevel study. Economic and Industrial Democracy, 0(0), 1–27. Westerberg, K. (2000). The important activity: Work, tools and tensions of municipal middle managers in elder care. Umeå universitet. Westerberg, K., & Armelius, K. (2000). Municipal middle managers: Psychosocial work environment in a gender-based division of labor. Scandinavian Journal of Management, 16(2), 189–208. Wilmar, M., Jacobsson, W., Ray, C., Dellve, J., & Låstad, L. (2019). Under crtitical scrutiny, a normal task for Swedish Executive Municipal HealthCare Managers. Journal of Social Science Research, 14(2019).

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Wolmesjö, M. (2005). Ledningsfunktion i omvandling: om förändringar av yrkesrollen för första linjens chefer inom den kommunala äldre- och handikappomsorgen. [Management in tranformation: Om changes in managerial work for first line managers in municipal vare for old and disabled people]. Lunds universitet. Wong, C. A., Elliot-Miller, P., Laschinger, H., Cuddihy, M., Meyer, R. M., Keatings, M., Burnett, C., & Szudy, N. (2015). Examining the relationships between span of control and manager job and unit performance outcomes. Journal of Nursing Management, 23, 156–168. Woodward, J. (1965). Industrial organization: Theory and practice. Oxford University Press. Yoder, J. D. (1991). Rethinking tokenism looking beyond numbers. Gender & Society, 5(2), 178–192.

Klara Regnö, is a Senior Lecturer at Mälardalen University, affiliated researcher at Örebro University, Center for Feminist Social Studies and an Equal Opportunities Strategist at Karolinska Institutet. Her research interest is organization, management and gender studies, with a specific focus reproduction and change of power structures in organizations.

Part II

Organisation of Work

Chapter 6

Invisible Workers: On Digitalisation in Home Care Work from a Gender and Technology Perspective Charlotte Holgersson and Britt Östlund

6.1

Introduction

Taking care of older people in need of help is something that has historically taken different forms in different communities and cultures. A general feature through all times is that the work in this sector is mainly performed by women. Today, home care is a growing need due to aging populations, but the differences are large between home care provided by public welfare and home care as unpaid work that is still expected to be performed as part of the household work (Abdelrazek et al., 2010; Meagher et al., 2016). Reviewing published literature shows that in large parts of the world, home care work is viewed as unskilled and simple, something that women can do part time in parallel with the work at home in their own household (Andersson, 2012; Vänje, 2015). During the expansion of home care in modern welfare societies, technology has played a central role in communication and in the distribution of various types of services (Östlund and Frennert, 2021). A common argument for the introduction of new technology in home care has been to bring about change and increased efficiency. However, studies indicate that work conditions have deteriorated in the Swedish home care sector (Strandell, 2020). In order to meet the need for a deeper understanding of how gender and technology interplay and effect home care work, this chapter provides a theoretical reflection based on a gender and technology perspective.

C. Holgersson (*) Department of Industrial Management and Organisation, KTH Royal Institute of Technology, Stockholm, Sweden e-mail: [email protected] B. Östlund Department of Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Stockholm, Sweden e-mail: [email protected] © Springer Nature Switzerland AG 2021 B.-I. Keisu et al. (eds.), Gendered Norms at Work, Aligning Perspectives on Health, Safety and Well-Being, https://doi.org/10.1007/978-3-030-77734-0_6

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The chapter draws on questions raised within the research project How to improve the working environment in home care – participative change in practice funded within the Swedish Research Council for Health, Working Life and Welfare (FORTE) program on Working environments in female-dominated sectors 2016. The project is a collaboration between the Faculty of Engineering, Faculty of Medicine and Faculty of Social Sciences at Lund University, the KTH Royal Institute of Technology, the trade union Kommunal and four municipalities in the southern region of Skåne in Sweden. It has its point of departure in the challenges that the Swedish home care sector is facing, with an increasing aging population, high and rising sickness rates, high staff turnover and difficulties in recruiting competent staff. The purpose of the project is partly to compile available knowledge about interventions to improve the work environment in the home care sector, and partly to evaluate interventions in Swedish municipal home care. This chapter problematizes a central and recurring question that has arisen within the framework of the project, namely the role of gender and digitalisation in relation to the problems and changes that take place in home care work. The literature review was carried out during the first project year and the data collected during the interventions revealed that stress and other problems were associated with gender or the way in which the technology was organised and used. However, the awareness and the ability to discuss the role of gender or technology was low both in research literature and in practice (Rydenfält et al., 2020; Östlund et al., 2018). The literature review reveals that only 16 publications concerned organisational changes in home care work while 2715 concerned nursing (Rydenfält et al., 2020; Östlund et al., 2018). Second, the survey to union members and publications from municipalities reported on interventions involving organisational change, education and training, digitalisation and scheduling were mainly concerned with changing specific behaviours or with new single technological applications rather than tackling complex issues such as sick leaves, stress or gender inequalities. The chapter begins with an introduction to the methodology upon which we base our discussion. We then proceed to briefly sharing insights from research on the gendered nature of care work before we present the context of home care work in Sweden and the ongoing digitalisation in home care. In the final two sections, we discuss the consequences of digitalisation for home care workers, both in relation to their lack of control over time and lack of influence over the design and implementation of digital technology.

6.2

Methodology

As authors of this chapter, we come from different disciplines. Britt Östlund is a scholar in science and technology studies (STS), specialising in technology in health care; and Charlotte Holgersson is a scholar in gender and organisation. We are both interested in understanding how gender and technology interact in (re)producing and possibly also in challenging inequalities faced by home care workers.

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Our discussion on how gender and technology interact in home care has its point of departure in two main bodies of literature: research on gendered work organisations and STS. Our common point of departure is that gender and technology are social constructions. We share an understanding that work and work organisations are inherently gendered. This means that organisations constitute arenas where gender relations are accomplished through dialectic processes between individuals and organisational structures and cultures (Acker, 1990, 2006). These gender relations are intertwined with other power relations such as race/ethnicity, class and sexuality (Acker, 1990, 2006; Holvino, 2010; see also Chap. 1). In organisations, gendered divisions are not only rationalised and legitimised, and thus reproduced, but also challenged, through the agency of individuals. Simultaneously, this agency is conditioned both materially and discursively by organisational structures and cultures. We also share a view on technology as socially constructed. Technological products and systems and society are mutually constitutive (Latour, 1991; Woolgar, 1991; Oudshoorn & Pinch, 2003a; Bijker, 2010; Joyce & Loe, 2010; Mol et al., 2010; Oudshoorn, 2020). Dominant understandings of technology are nevertheless shaped by a technical/social dualism which is mutually reinforced by a masculine– feminine dualism resulting in the (re)production of perceptions of technology as masculine and sociality as feminine (Faulkner, 2001). Since the dominant gender order attributes higher status to men, higher status is also attributed to technology (Sandelowski, 2000). Indeed, there is a ‘circuit of gender and technology’ (Cockburn & Ormrod, 1993) that is a two-way mutually shaping relationship between gender and technology in which technology is both a source and consequence of gender relations and vice versa (Faulkner, 2001). Thus, technological development involves a mutual construction of technologies and gender (among other) identities (Oudshoorn et al., 2004). By assigning specific responsibilities, skills, and tasks to users, technology contributes to constructing the identities of users, both transforming or reinforcing existing identities as well as enabling new identities (Lie & Sørensen, 1996). Moreover, the domestication process, that is, the process by which technology is transformed from being unfamiliar to familiar and becomes embedded in everyday practices, not only shapes identities but also the use and meaning of technology (Oudshoorn & Pinch, 2003a, b). Thus, our point of departure is that home care workers are not passive receivers of new technology, but active in domesticating technology, shaping its use and meaning to fit into their context (cf. Frennert et al., 2020; Fischer et al., 2019, 2020; Peine & Neven, 2019; Stokke, 2016; Kelly & Loe, 2010; Berker et al., 2006).

6.3

Care Work and Gender

In order to understand the interaction between gender and technology in the digitalisation of home care work, we need to understand the gendered character of care work. Care work, both providing direct, personal and relational care such as

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feeding a child or nursing an ill person, and more indirect care such as cooking and cleaning (ILO, 2018), is an activity that is usually carried out by women. Statistics on a global scale show that women make up 66% of workers in care occupations and 70% among domestic workers. Moreover, women provide the vast majority of unpaid care work (ILO, 2018). This gendered division of care work has been linked to the idea of separate spheres where the sphere associated with men and masculinity is linked to public life, production and paid work, while the sphere associated with women and femininity is linked to domestic life, reproduction and caring for people (e.g. Acker, 1990). This has implications for paid care work. Research reveals that occupations, qualifications and tasks that are associated with women and femininity are valued less than those associated with men and masculinity (e.g. England, 1992, 2005; Grimshaw & Rubery, 2007; Koskinen Sandberg, 2017). Acker (1990) argues that the low status attributed to women’s jobs is often justified on the basis of the association between women and domestic life. Women are associated with sexuality, childbearing, emotions, and thus in many ways assumed to be unable to conform to the demands of the seemingly neutral paid job, which in reality are shaped according to a man with no other obligations than work. Moreover, care work is highly associated with women from disadvantaged groups. As noted above, organisational hierarchies are not only gendered, but they are also classed and racialized (Acker, 2006) and organisational processes that are taken for granted and regarded as normal, reproduce specific relations of inequality and privilege (Holvino, 2010). Although there are variations depending on time and geographical context, women from disadvantaged groups, in particular women of colour, immigrant and working class women are often seen as suitable to carry out paid care work (e.g. Collins, 2000; Hondagneu-Sotelo, 2001; Duffy, 2005). The symbolic separation between women and men as belonging to different spheres also has consequences for how skills and abilities are understood and valued. Service work, including care work, does not involve any exchange of tangible goods. It is therefore difficult to differentiate between the service and the person providing it (cf. Rasmussen, 2004). For example, service work involves what has been labelled emotional labour (Fineman, 2000; Hochschild, 1983). Emotional labour is often understood as the individual skill of the person providing service and since most often women provide this service, it is seen as a natural skill of women. As Rasmussen (2004) notes, this has made it difficult for women in for example healthcare occupations to have their work recognised as professional work and not a job that can be carried out by any woman. Furthermore, as a result of the gendered hierarchy between intimacy and distance, the association of care work with the (dirty) body and its various secretions has also contributed to its association to femininity, the lack of men and subsequent low status (Twigg, 2000; Isaksen, 2002). Another result of the cultural devaluation of women’s work is the low wage levels. Scholars note that female-dominated occupations have wage levels that are lower than comparable male-dominated occupations (e.g. England, 1992; England et al., 2002; Magnusson, 2009) and highlight that there exists a care penalty, that is, that care work pays less than other occupations after controlling for individual,

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occupation and industry characteristics (England et al., 2002; Budig & Misra, 2010; Hirsch & Manzella, 2015). Research has nevertheless shown that despite the low wages, women in care occupations will do more work out of moral obligation towards care recipients (e.g. Andersson, 2007; Dodson & Zincavage, 2007). Care work is indeed understood as a mutual relationship with a strong focus on moral obligations (Andersson, 2012), especially as the consequences of care work can be a matter of life and death. Care work requires competencies such as empathy and patience (cf. Waerness, 1984), characteristics that are female gendered.

6.4

Home Care Work in Sweden

Historically, home care was not considered a real job: It was seen simply as a traditional woman’s job with no demands for formal education except for ‘a housewife’s own common sense’ (Szebehely, 1998, p. 177). Today, however, home care in Sweden is provided by assistant nurses employed by local governments or private businesses. They constitute the largest occupational group on the Swedish labour market both for women born in Sweden and abroad, 92% employed as assistant nurses are women. Assistant nurses also work in nursing homes and at hospitals, in all 136,400 people in 2019 (Statistics Sweden, 2020). To differentiate home care at the local level from home health care provided by nurses, the type of daily care and practical support named home care services (hemtjänst) is provided by assistant nurses (undersköterskor) or assistants with no formal training (vårdbiträden). One difference to note between trained home care staff and nurses is that the latter have credentials, which assistant nurses do not have. Neither assistant nurses nor assistants have any formal training in technology use and they work under the same conditions in regard to technology use. The tasks performed by the assistant nurses consist of helping with their daily hygiene and household duties, such as washing dishes, doing their laundry, cleaning, supervising the delivery of prepared food, providing health care such as changing dressings and distributing medicine and providing them with social support. The time allocated to each of these tasks is regulated in accordance with each individual person’s assistance entitlement. These entitlements form the basis of the fee that the care recipients pay to the local council for the subsidised services they receive (Hjalmarsson, 2009). The organisation of home care services has undergone many changes, from a system where care recipients paid for help assessed simply on a time basis to the present organisation where assistance entitlement is assessed both by time and through detailed regulation of its content. This way of organising home care services is, in part, a result of the demands for cost containment, efficiency and improved quality imposed on the public sector in general in Sweden following the international trend of New Public Management (NPM) (Szebehely & Trygdegård, 2012). Changes in legislation have also enabled the establishment of the private provision of home care and introduced a customer-choice model as well as tax deductions for household and care services. Moreover, NPM has resulted in the implementation of

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new management principles, increasingly predefined tasks and the introduction of various documentation systems (Erlandsson et al., 2013; see also Chaps. 4 and 9). This increased standardisation and fragmentation of work often is referred to as taylorization (England & Dyck, 2011; Szebehely & Trygdegård, 2012). Contrary to the intentions of the reforms, taylorization has limited the home care worker’s discretion and their capacity to meet the client’s needs as well as increased workload and decreased work satisfaction (Oomkens et al., 2016; Strandell, 2020). The changes in the organisation of the home care sector with an increasing focus on efficiency have been linked to many occupational health problems, such as increased risk for injuries and musculoskeletal disorders, and high levels of sick leave and staff turnover, as well as perceived stress and high workload (Dellve et al., 2003; Vänje, 2015). Björk and Härenstam (2016) note that for a long period of time in Sweden, human services such as education and health care were characterised by good working conditions and almost no gender differences in, for example, occupational health and sick leave rates. This has, however, changed since the 1980s with increasing gender differences in sick leave rates. A survey of the work situation of workers in the Swedish home care sector in 2005 and in 2015 revealed a deterioration of work conditions (Strandell, 2020). The respondents reported an increased number of clients per day, receiving less support from supervisors and having less time to discuss difficult situations with colleagues as well as having considerably less influence over the planning of their daily work. Workers in 2015 experienced increased mental exhaustion and an accumulation of work-related problems compared to workers in 2005. The analysis links these deteriorated work conditions to the increased focus on cost containment and efficiency as well as organisational reforms including technology implementation that have marked the home care sector in Sweden.

6.5

Digitalisation in Home Care

Today, technology use is an obvious feature of home care for the distribution of different types of service, for communication with caregivers and with each other, and not least for the opportunities to work mobile. Digitalisation is, as previous technological changes, policy driven, often as a way to streamline work, and often motivated as a solution to impending “care crisis” (Ertner, 2019; Stokke, 2018; Rosengren, 2018; Moser & Thygesen, 2015). It is argued that new technology offers new opportunities to improve home care and increase quality of life for care receivers. The ongoing digitalisation is more systemic and includes both old and new infrastructure and new and old applications. By digitalisation, we refer to the transformation that is underway where existing applications are being transformed from being analogue to digital, such as telephones, alarms, door keys and vacuum cleaners and where new applications are created with more or less artificial intelligence, for example wheeled robots carrying goods at hospitals or service robots for

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therapy, for example Paro or JustoCat (Gustafsson et al., 2015; Takanori & Coughlin, 2014). Digitalisation in home care is thus a continuation of a development that has been going on for several decades and increased the automation of tasks and relationships. The technological landscape in home care and its embeddedness in practices, routines and relationships, is the result of many years of technology use and the introduction of new products and systems (Cozza et al., 2019; Bygstad & Lanestedt, 2017). A fundamental and important reform to promote technology in home care was the implementation of “aging in place” policies deployed in Western countries, in Sweden known as the residency reform (kvarboendereformen) (Ministry of Social Affairs, 2015). This policy is still strongly promoted worldwide to support older people’s ability to remain in their own homes (Peine et al., 2021; WHO, 2016). Following this reform, widescale technologies were implemented to support the distribution of care and services to older people’s homes. An example of a technology that for a long time has been an integrated part of home care work is the personal emergency response system (PERS), also called social alarms or safety alarms (Pritchard & Brittain, 2015). The development of PERS reflects very well the technological development that has taken place in society in general as well as in home care, from radio networks over information technology development (IT) with an increasingly efficient transfer of images and of spoken and written information, to today’s digitalisation. The first version was implemented in the early 1970s to enable the ‘aging in place’ reform making it possible for older people at home to get into immediate contact with home care 24 h a day in case of an emergency. The alarm device placed in the home, with a switch or a pull cord to use in an emergency, transferred information over the radio network to a receiver managed by home care (Stokke, 2018). The second-generation PERS had in addition a necklace and/or a wristband with a button that the user can press when in need, which allowed for open communication between the user and the responder both inside and partly outside the home (Stokke, 2018). The third-generation PERS include a range of devices and services such as sensors for monitoring blood pressure and sleeping patterns and a variety of alarms combined with other devices such as iPads and robots. Although this technology has been in place over a long period of time and has been very much used in order guarantee the safety of care receivers, its consequences beyond the devices coming out as a result of the interplay between technology and home care work has been less discussed (Stokke, 2016, 2017). While the function of technology depends on mathematical calculations and its incentives being improvements of the working environment and increased efficiency from a managerial perspective, its use and practical significance depend on the domestication of technology into a social and cultural context. It is such a research perspective that allows us to understand what really happens when new technology is introduced into a work environment. This is where control of the work comes into play.

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Digitalisation and Home Care Workers’ Control over Work

An example of a study that explores digitalisation in home care that takes on the perspective of technology being socially constructed is Bergschöld’s (2016) analysis of the use of a vehicle route problem solver (VRP-solver) in Norwegian home care. The VPR-solver was meant to automate decision-making regarding logistics, however, the routes proposed by the VRP-solver were perceived as deficient by the home care workers who instead collectively rescheduled the routes. By rescheduling, hence redefining the role of the VRP-solver, they simultaneously produced a functional route without the VRP-solver and without the control of the manager. This shows that users are not passive or that they simply reject new technologies that they do not approve of, but that they are active in integrating the new system in a way which enables them to continue to carry out their work tasks. It also illustrates that it is impossible to judge the use and the meaning of technology outside the social context in which it is implemented. The practical function of the VRP-solver is thus also shrouded in obscurity for the manager as long as one believes that technology is a changing force outside a practical context. Similar observations have been made in other studies. For example, Day et al. (2012) argue that digital planning systems combined with digital schedules on a mobile device, can decrease home care workers’ control over their work since it enables management to monitor and reschedule without the involvement of the home care workers. Indeed, monitoring time is one of the more common reasons behind the introduction of digital systems. For example, in a study of the introduction of hand-held computers in a home care team in Sweden, Hjalmarsson (2009) reveals that the home care workers exerted resistance towards this monitoring by not using the hand-held computers as intended, neglecting to use them or tampering with registration. In a similar way, home care workers in a Norwegian study (Bergschöld, 2018) found ways of performing ‘time labour’, that is, practices that produce a sufficient amount of time to perform care, by changing the amount of time shown on the smart phone before the device was able to save the information to the external server where it would be available for managers. By doing so, it became possible for the home care workers to challenge the standardised time slots. Both Hjalmarsson (2009) and Bergschöld (2016, 2018) argue that the introduction of devices to monitor time could give home care workers more control over their time and the opportunity to assess their own work performance. However, both studies show that the devices instead contribute to the subordination of the home care workers. Hjalmarsson (2009) argues that the use of the device reproduced a twofold subordinate position of the home care workers, both as caregivers and as employees. Their position as a caregiver becomes subordinated to instrumentality. Their work is expected to be predictable which prevents them from being sensitive to the needs of the clients. The device also contributes to the reproduction of the home care workers’ subordinate position as employees since the employers’ control of both their time and content of their work increases.

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This subordination can be even stronger in contexts where time is directly linked to payment. For example, Hayes and Moore (2017) show that in the UK electronic monitoring technology has increased the capacity for local authorities and care companies to extract unpaid labour from home care workers by targeting the organisation of their work time. Home care workers are required to use landline telephones or GPS mobile telephone systems to register the minutes they spend at each care recipient’s home and it is on the basis of this time that they are paid. Hayes and Moore argue that electronic monitoring is in fact a technological driver for the degradation of employment and pay. Hjalmarsson (2009) argues that digital support systems can be understood as examples of technologies that pull home care workers away from the principles of caring practices rather than support them in moving closer to these (cf. Sandelowski, 1997). Even when efforts are made to measure time in order to make it visible, the experienced lack of time persists or even increases (Andersson, 2010). Scholars highlight that caring activities cannot be fitted into the time restrictions provided by individual digital applications, and that rationalising home care based on the same logic as in industry is problematic. Discretion, continuity and time are fundamental conditions for a care worker to provide good care (Szebehely, 1999) and such conditions are jeopardized when tayloristic principles become dominant in the governance and organisation of care work (Eliasson, 1994). Indeed, the developments where home care is increasingly divided into standardised tasks and monitored through digital devices for the purpose of efficiency is a form of digital taylorism (Gellerstedt, 2012).

6.7

Home Care Workers’ Lack of Influence in Digitalisation

It seems as if an interventionist approach characterises technology development in home care by which technology is assumed to be the primary agent of change determining how home care is done. New applications implemented in home care are described as ‘ready-made’ in the sense that they are marketed to fulfil specific functions and lead to certain effects possible to predict in advance (Bergschöld et al., 2020). The context of home care practices or already existing implemented and used technology is seldom taken into account (Ertner, 2019; Kellermann & Jones, 2013; Himmelstein & Woolhandler, 2005; Greenhalgh et al., 2004). Moreover, it seems as if home care workers are not involved in the procurement and implementation of digital technologies (Spånt Enbuske, 2019a, b). There is thus a risk that this will add to the already large number of systems that home care workers have to manage, including registration of information about the care receivers, keys, schedules and registration of certain information required by other authorities. However, as highlighted in the studies above, the way technology is used can be shaped by the home care workers themselves in a direction that was not originally intended. Thus, the use and meaning of technology is not predictable outside the context in which it is supposed to work. On the contrary, new technologies can affect both daily routines

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and underlying structures in either a conservative or liberating direction, reinforcing existing values and practices or changing them (Sandelowski, 2000). Moreover, home care workers not being involved in implementations of new technologies can be understood in relation to the multiple and intertwined hierarchies such as the hierarchy between care and technology, women and men, unskilled and skilled labour, non-white and white. The power of interpretation of the home workers’ needs is attributed to engineers and managers. Home care workers are thus cast in the role of ‘lay end users’ and “implicated users” (Saetnan et al., 2000; Clarke, 1998), referring to someone who is affected by the design of technologies but who is not involved in the process. It is, nevertheless, well-known today that participation is an important aspect of any organisational change as it ensures ‘a fit between the employees and their environment’ (Nielsen, 2013, p. 1045) as well as for improving the quality and design of products (Fischer et al., 2019). In design practice, it is widely acknowledged that designing technology benefits from understanding social practices that people perform in their daily life activities (Fischer et al., 2019; Kuijer, 2017). Recent studies also support the notion that the involvement of care workers is necessary to procure and implement new technology and not least to improve psychological empowerment and job satisfaction (Strömgren, 2017). Being involved in decisions and design can make a difference since many technologies incorporate constraints for specific groups of users, such as women, because these users are not involved in essential parts of the development of technologies (Oudshoorn et al., 2004). If home care workers confronted with demeaning design separates them from the interpretation of their own needs and preferences, then this will most probably limit their agency.

6.8

Invisible Home Care Workers in a Digitalised Workplace

In contrast to interventionist and to some extent deterministic perspectives on technology as a factor of change, this chapter intends to deepen understanding of the interplay between gender and technology in the digitalisation of home care work. We find that home care work and home care workers continue to be an invisible occupational group in research and in practice. Home care work continues to be associated with low status and ridden with technological visions based on outside perspectives. Moreover, research lacks theoretical insights in order to provide convincing explanations. Applying a gender and technology perspective, we can contribute with the following conclusive reflections: First, the low status of home care work is based on inequality regimes in society (cf. Acker, 2006) where occupations that traditionally have employed working class women have lower wages and less power in the labour process. Without more awareness and knowledge of the interplay between gender and technology, home

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care workers will remain invisible as actors in the digitalisation process, further contributing to the reproduction of their subordinate position on the labour market. Moreover, a deterministic view of digitalisation can contribute to further deterioration of the working environment with more lack of control and stress. Second, although research highlights that participation is essential for successful implementation of new technology, home care workers are not involved. Digitalisation of home care work, a female-gendered activity mainly carried out by women, is a venue for tests and introductions of (new) technology, a male-gendered phenomenon produced by a male-dominated professional category, engineers and designers, which rarely have a background in home care work. In addition, since home care workers are not consulted in the technology development and implementation process, their own ability to demand for, and influence the development of, appropriate technology is not developed. Third, insufficient theoretical understanding of what shapes technology use in practice hides the fact that home care workers are not by default rejecting new technologies and are far from passive in accepting new technologies, but are instead active in domesticating and adapting new solutions introduced into their work environment. Looking back at digitalisation in home care since the 1960s, we can assume that home care workers have the experience of using technologies and solving problems related to technologies that are not adapted to their work. Moreover, in combination with the precarious employment conditions and the increasingly tayloristic management principles that characterise home care in Sweden (and elsewhere), digitalisation results in digital taylorism instead of providing home care workers with more control and influence over their work. The few studies looking at the work environment of home care workers over the years show no improvement, in fact, statistics reveal increasing numbers of stress-related problems (Strandell, 2020). Our reflections on the impact of digitalisation on home care workers’ working conditions leads us to the final reflection that the organisation of home care services is changing, the technology is changing, but the invisibility of home care workers as actors and their subordination continue to be perpetuated.

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Chapter 7

Organising Auditing, Person-Centred Care and Competence in Swedish Residential Care Homes Palle Storm and Anneli Stranz

7.1

Introduction

Since the early 1980s, Scandinavian feminist research on care and care work has stressed that the organisational conditions of the work—time, support from managers and colleagues, flexibility and scope of discretion—are crucial for both workers’ and care receivers’ experiences of care quality (Eliasson-Lappalainen & Motevasel, 1997; Wærness, 1984). In contrast, research acknowledge the fact that above-mentioned preconditions for performing good care are a resource of wellbeing and meaningfulness at work, and the opposite—feeling inadequate—towards care recipients are connected to bodily and mental strain, as well as thoughts of leaving the job position (see f.eg. Fläckman et al., 2009; Stranz, 2013). Yet, the realities of practical care work and the fact that such work is intellectual, emotional and relational have seldom been highlighted or considered in the reform of the eldercare sector (Stranz & Szebehely, 2018). Compared, the relational and emotional aspects of care work have been challenged by New Public Management reforms, which emphasise standardised forms of work as part of a managerial control function (Banerjee & Armstrong, 2016). These changes are characterised by a purchaser–provider split, competition, and an inherent focus on standardisation, auditing and accountability as organisational core concepts to achieve a qualitative and person-centred1 care (PCC) (Anttonen & Meagher, 2013; Chap. 1). These changes have, in turn, shaped a new ‘language of care’ which places emphasis on standards that directly oppose the rationality of

1 Individualized care (IC) and person-centred care (PCC) are used synonymously in the chapter (see, e.g., Brownie & Nancarrow, 2013).

P. Storm · A. Stranz (*) Department of Social Work, Stockholm University, Stockholm, Sweden e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2021 B.-I. Keisu et al. (eds.), Gendered Norms at Work, Aligning Perspectives on Health, Safety and Well-Being, https://doi.org/10.1007/978-3-030-77734-0_7

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caring. The rationality of caring can be understood as an approach to care work that focuses on the care recipient’s needs when organising services. Several care researchers have analysed the introduction and establishment of NPM-inspired regulations in relation to its impact on working conditions for staff (Erlandsson et al., 2013; Keisu, 2017; Stranz & Szebehely, 2018). However, most of the empirical studies in this body of research have focused on the home care sector (e.g. Banerjee & Armstrong, 2016; Dahl, 2010; Roostgard, 2011; Szebehely & Trydegård, 2012). The home care sector is profoundly changed when it comes to organisational aspects and the standardisation of work tasks. Limited time frames and intensified use of various documentation systems makes the work fragmented and thus harder for the care workers to provide high-quality care (Strandell, 2020). But the impact of organisational changes inspired by NPM in Swedish residential care facilities (RCHs) is scarcely included in the research focusing on the working conditions of care workers. Drawing on observations and interviews with staff and managers in two Swedish RCHs, as well as a document study of the facilities, the aim of the chapter is to critically explore how the workers and managers experience three central aspects of their work: auditing, person-centred care and the question of care workers’ competence. Further, we aim to illuminate how these experiences shape working conditions and how gendered norms are displayed in our understanding of care practices.

7.2

Swedish Elder Care: The Case of Residential Care Homes

The Swedish welfare model is described as a universal social welfare model due to its ambitious goal of achieving equality between different groups in society. The social service sector is thus extensive and used by all citizens despite their personal economic resources (Anttonen & Sipilä, 1996). It has been debated whether this image of Nordic universalism is or ever has been accurate. However, in a broader international comparison Sweden is still one of the world’s most generous countries when it comes to public spending on eldercare (Szebehely & Meagher, 2018). While this universal ambition remains a loadstar in Swedish policies, eldercare services are less universal today than in the early 1990s. The public spending has not kept pace with the aging population, and the number of available spaces in residential care has declined and are consequently less accessible than it used to be (Stranz & Szebehely, 2018).

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Characteristics of Swedish Residential Care Homes

The initiation of the Swedish elder care policy in 1992, known as the ÄDEL reform, marked a turning point in the medical orientation of nursing homes. The reform transferred the responsibility for older seniors with extensive care needs from the county councils to the municipalities (Larsson, 2004). The reform also entailed a shift in care philosophy—from large-scale nursing homes focusing on a medicalbased model of care towards a social-oriented model of residential care for older people (Lundgren, 2000). Today, the norm in Swedish residential care settings is small-scale units with 8–10 residents living at each unit. Further, all residents have their own small apartment, with a private bathroom and often a small kitchenette (Daly & Szebehely, 2012). All common areas, such as architecture, and the interior in settings are guided by norms and ambitions of homeliness. And the overall goal is to integrate the residents’ physical and social needs as a part of good care, in order to challenge the distinction between an institution and a home (Storm, 2013; Szebehely, 2017).

7.2.2

Care Work and Work Environment

Research on care work, both Swedish and international, is characterised by the fact that eldercare is a sector where considerable organisational changes have been implemented. One major change concerns marketisation, which is primarily based on outsourcing through public tendering, competition and free choice models. In addition, an introduction of numerous methods and practices from the private sector was implemented in the public sector through NPM (Trydegård, 2012; Erlandsson et al., 2013). These reforms, with a focus on efficiency and standardisation of work, have affected working conditions profoundly (Deusdad et al., 2016). In Sweden, as in most other countries, women constitute the majority of eldercare workers (9 out of 10), but an increasing proportion of the care workforce are immigrants. One in three male care workers and one in five female workers are born outside the Nordic countries with the majority in countries outside Europe. Even if the training levels have increased over time as a result of various state initiatives, one in five of the residential care workers still lack relevant training (Stranz & Szebehely, 2018). Reflecting the increased health problems among older people in both residential and home-based care, current national guidelines stress that all care workers should have training as assistant nurses (AN), but there is an apparent gap between policy objectives and their implementation when it comes to formal training. Despite the above, in Sweden there is less differentiation in the tasks care workers with different levels of training do than in other countries. Care workers with shorter training, or none at all, such as care aides, do more or less the same tasks as those with longer training (assistant nurses) (Daly & Szebehely, 2012; Stranz, 2013).

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Table 7.1 Psychosocial working conditions in residential care; 2005 and 2015 (%) Working conditions Most often too much to do Most often feel inadequate Almost always feel physically tired after a working day Almost always feel mentally exhausted after a working day

2005 40 32 29 16

2015 50** 38{ 31*** 26***

Source: Stranz and Szebehely (2018), p 52; ns not significant; ***p < 0.001; **p < 0.01; *p < 0.05; {p < 0.10

Additionally, there is usually no specialised cleaning, laundry or housekeeping staff; instead, each care worker is responsible for most aspects of care (personal care, domestic work as well as social support) for a handful of residents. Working in Swedish eldercare has also become more and more arduous (Table 7.1). As the 2015 Nordcare study found, 50% of the responding care workers had seriously thought about leaving their position (this is a higher proportion than in the other Nordic countries) (Szebehely et al., 2017). Moreover, the results from the Nordcare study (Table 7.1) reveals that work in residential care homes have changed in a negative way. Care workers increasingly reported having too much to do and feeling inadequate in relation to their care recipients. Further, according to the Nordcare study, feelings of bodily or mental exhaustion after a work shift were more common in 2015 compared to 2005 (Szebehely et al., 2017). In line with the process of marketisation in RCHs, the proportion (not in table) of care workers answering that they do administrative tasks, such as documentation several times every day, has increased from 16% to 37% between year 2005 and 2015 (Ibid.). In the light of the problematic and worsening conditions of work in Sweden, it is important to recognise the discrepancy between time pressure in everyday work and the ambitions from the politicians to attain person-centred care and to satisfy the ‘customer’, which is usually the relatives rather than the resident. A consequence of an increasing group of residents with extensive cognitive and physical limitations (Meinow et al., 2011), those living in RCHs have become both older and sicker which leads to shorter stays (Schön et al., 2016). Additionally, the proportion of older persons with a dementia diagnosis is growing.

7.3

Feminist Ethics of Care versus New Public Management

We use the concept rationality of caring (closely connected to taylorisation), and NPM (marketisation) as two organising principles/logics to analyse the results. The concepts developed in early Nordic care research—the rationality of caring (Wærness, 1984) and taylorisation (Eliasson, 1992)—have played a central role in the criticism of the logic of wage work, which is considered to be in conflict with the

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specific features of care work. The concept rationality of care was created in a context when it was important to argue that women acted as rational actors. Rationality is often perceived as the opposite of emotionality; however, the veracity of this concept is questioned when we challenge the dichotomy of intellect and emotionality. Wærness’ (1984) empirical study showed that the female home care workers worked more than they were paid for, which traditionally was interpreted as irrational, but she showed that it could be interpreted as a rationality of care—a focus on the well-being of the care recipient. Paid care work is here perceived as situational in contrast to reach effectiveness. Further, this definition combines knowledge, experience and skill as the core of care work. According to Wærness (1984, 2005), the term rationality of care, can be used as a critical searchlight on the relationship between practical paid care work and the forms of administrative and scientific authority that determine the conditions of the work. The tension between care and work is described by Abel and Nelson in the following quote (1990, p. 4): ‘caregiving is an activity encompassing both instrumental tasks and affective relations. Despite the classic Parsonian distinction between these two modes of behavior, caregivers are expected to provide love as well as labor.’ Internationally, this thinking is part of a research tradition named ethics of care which is a central part of feminist care and welfare state studies, with the aim to integrate moral aspects of care with political theory and practice as well as interpersonal relationships (Tronto, 1993; Sevenhuijsen, 1998). In this tradition, the perspective of social policy and power is central to contextualise care and care work in different welfare regimes (Daly & Lewis, 2000). Many of the organisational transformations in eldercare have worsened the working conditions care researchers have described as necessary for caring well— time, continuity, room for manoeuvre and knowledge of the caregivers (Armstrong et al., 2008; Fisher & Tronto, 1990; Stranz, 2013). The logics of care, in the feminist tradition, focus on relational aspects due to the rationale that care work is both Care + Work. The challenge then is to recognise both aspects when transforming the conditions of care work on all levels (James, 1992; McDonald & Merrill, 2002).

7.4

Material and Method

The data for this analysis was collected within a larger international project, Healthy ageing in residential places, which aimed to identify promising practices in residential care homes for both workers and residents in six countries: Sweden, Norway, Canada, Germany, the UK and the USA. The RCHs were selected through a preliminary process that identified these homes as potentially offering promising practices in nursing home care (Storm et al., 2017; Stranz & Sörensdotter, 2016). The main methodology for the project was rapid, site-switching ethnography, which included short but intensive participant observations and interviews with care staff, managers, residents and family members (Baines & Cunningham, 2013).

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The Swedish data used in this chapter is based on observations and semistructured interviews from two Swedish RCHs, and was collected during 2014. Both homes were private, however, one was run for profit and one not for profit. Each home consisted of several units including both older persons with somatic illnesses as well as those with dementia. Both were located in a metropolitan area in Sweden. The observations were conducted by teams of two researchers working 6 h shifts, from early mornings to late evenings during one intensive week. During the week, each team conducted semi-structured interviews with care workers, residents, family members, registered nurses and care managers. The interviews, which lasted from 30 to 90 min, contained questions regarding organisation of work, working conditions and approaches to care. Each interview was audio-taped and transcribed (Stranz & Sörensdotter, 2016). All interviews and observations notes were transcribed and uploaded on a password-protected database, only available for the project members. In this chapter, we draw specifically on data from the semi-structured interviews, which includes 15 care workers (nurses’ aides and assistant nurses), 8 care managers/administration-staff, and 4 registered nurses. Furthermore, we use observation notes from the field study, government reports and official policy documents on elderly care to reflect and analyse our empirical data. Our presentation of the result is focused on similarities between the two residential care homes that emerged from the analysis of the data. Thus, many of the differences that existed between homes were excluded from the analysis (see Storm & Stranz, 2018). Further, our focus is on the care workers experiences, but we also include the care managers’ perspective to contextualise eventual tensions. Analyses were made using the instruction of a directed content analysis using theory and prior research, deriving from feminist research on care, to further investigate the area of knowledge (Hsieh & Shannon, 2005). The process of a directed content analysis means identifying and condensing meaning units, coding, and categorising, and this process was partly completed in Nvivo.

7.5

Findings

In this section, the findings are presented under the following headings: Auditing: quality or control? Person-centred care: for both workers and residents? and Formal training and caring skills in the era of marketisation: re-professionalism or de-caring? Each section starts with a short introduction to contextualise the results.

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Auditing: Quality or Control?

The introduction of NPM inspired forms of governance has led to stronger demands for auditing care by requiring the staff to document the daily work as a strategy to achieve standardised and measurable data. As Daly et al. (2016) stress, these regulations identify not only what the staff should do, but also when and how they should perform the work. Additionally, auditing is considered to be a technology for managers to secure and evaluate the quality of care (Baines, 2015; Banerjee, 2013). This increased focus on documentation a data source is not only important for the care providers internal quality work, but the data is also crucial for marketing the care facilities to attract presumptive customers (residents or relatives), and to report how the requirements set by the municipality are implemented (Erlandsson et al., 2013; Storm & Stranz, 2018). While documentation has been a part of the staff’s daily work since the reorganisation of the Swedish residential care sector in the early 1990s, the requirements and regulations on documentations are more detailed and fulfil more purposes today. This change is not perceived in the same way by different occupational groups. For instance, the managers at both homes highlighted the increased role of documentation as a necessary tool to secure the quality of care and to meet requirements regulated in the Social Service Act (2001:453): It is comprehensive, we have internal controls. We work with quality and to ensure quality through different methods. We do have contract follow-ups, when they come from the district and check us up, but we also do our own intern-controls, using our templates to structure what we are looking for [. . .] If we identify any failures, this work gives us useful indication of what kind work we must proceed to do (Manager)

The staff’s view on the impact of the increased demands of auditing—mainly in the form of written documentations—differed depending on the types and purposes of the documentation. While the documentation required by the Social Service Act was seen as an important instrument for good care, the documentation from management focusing on internal controls was viewed with a degree of scepticism. Yes, it has become more lists over time. In a way it might be good, but I don’t know what the purpose of it is [...]. You may not need to write all these lists, but we do today. We have a list when we clean the kitchen, when you clean the staff toilet you have to sign, the laundry room you have to sign, all these signatures. The most important thing for me is to do what is most important for the residents, to do all the everyday activities and to spend time with them, sit and have a coffee, not all these papers (Nurse assistant) We have been obliged with many extra checklists to be signed, there has been increased control. They [the managers] have created own checklists in order to auditing the staff (Nurse assistant)

A recurring theme in the interviews was that the internal documentation, with its focus on documenting work details, took time from everyday care. And few of the workers saw the direct connections between the documentation and the quality of the care they performed. Rather, the staff felt that this documentation was used as a tool

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by management to control the staff and reflected a lack of confidence in the workers’ ability to perform good work.

7.5.2

Person-Centred Care: For Both Workers and Residents?

In Swedish policy documents, the concept ‘person-centred care’ (PCC) is used to define an individualised, value-based approach to elder care (SOSFS, 2012:3). The goal of eldercare services is to achieve a dignified life for care recipients in home care and RCHs. This involves high-quality care and respect for privacy and integrity. Further, the care provided should be designed to promote self-determination, participation and well-being. The trend to centre on the person (Dewing, 2004) in eldercare is an international trend, but as research shows, the forms of implementation and outcomes differ across contexts of care (Stranz & Sörensdotter, 2016). A common language of person-centeredness is emerging but it is still diffuse and still somewhat of a buzzword (McCormack et al., 2015). It is generally considered to be something inherently good and requiring a culture change focusing on the person and away from institutional needs and routines (Koren, 2010). In the Swedish context, the implementation of person-centred care is more or less a top-down process, wherein workers and residents have not been active stakeholders in the process. Also, the implementation of person-centred eldercare has advanced hand in hand with the marketisation of RCHs that forces the companies to compete and attract ‘clients’ (Storm & Stranz, 2018). The concept of ‘individualised’ care is a central aspect of person-centred care. It is found in the spoken language of care workers, in the everyday organisation of their work, and additionally referred to by management. This individualised approach to care underlines the importance of the residents’ opportunities to make everyday choices. This requires supporting their self-determination and participation. Personcentred care, understood as individualised choice, can thus be very concrete and visible when it comes to wishes about, for example, when to get up in the morning or what activities a resident wants to participate in. We also found that person-centred care, when assessed and written down in a care plan, can be experienced by staff as a way to standardise the work practice because their decision latitude is reduced. The following quote shows a tension between the relational knowledge produced over time that shapes the encounter between care worker and resident, and a fixed individualisation that ‘anyone can do’: There is a positive side to this person-centred care, especially the aspect of selfdetermination [for the residents]. We all agree that it is important, but it can be puzzling because care workers do different [in the encounter with residents]. . . I get the feeling that I am replaceable, someone else can do the same things; that is a sad feeling. (Nurse assistant)

Referring to an international research tradition on working conditions in eldercare, we know that the relational and emotional aspects of work are important

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and crucial for feeling meaningful at work (Tufte et al., 2012). If the work is standardised, it is hard to be able to adapt to care recipients’ changing and individual needs, including bodily, social and psychological needs. Standardisation thus clashes with the aims of person-centred care plans. A standardised form of care work, that also needs to be followed up in documentation as ‘done’, can be interpreted as a lack of respect and trust from management. An important feature of care work is based on the workers’ personal experience and competence on how to relate to the residents. Another consequence of a stricter work situation concerns the decreasing decision latitude, a prerequisite that is crucial to sustain health and well-being for the care workers (Szebehely et al., 2017). However, it is perceived as a positive approach to care with reference to residents’ possibility to influence their everyday life. In the following quote, a nurse assistant describes what residents wish to do when they have the possibility to be outside: So in the summer we could be in the garden and we had one person, she liked to smoke and she could sit in the wheelchair and smoke. And there was another person, he is bodily fit and could play football. Then we had a resident, he doesn’t like to play but he wants to see what is happening so he often jumps up to the table and sit with the legs crossed [...] But he did not like to play. (Nurse assistant)

The group of residents are of course not homogeneous. Nevertheless, a majority, 70% of the residents in Swedish RCHs, have a dementia diagnosis which affects the practice of care workers (Government Bill, 2017:21). The staff often describe this group of residents and their care needs as unpredictable, and it is far from possible to always follow what was planned beforehand: When you work with persons with dementia, it is much more this work, you need to have great patience and being able to listen, [. . .]. Being able to think outside the framework, we do encounter many problems with people who absolutely do not want to shower, who completely have lost speech and still have their illness that they will live with all the time and there you can learn with tricks [. . .]. You have routines though you cannot follow them to the point, it is more this to capture the moment. (Nurse assistant)

The symptoms of dementia force the staff to be responsive. Working conditions must be flexible to enable care that responds to the residents’ moment-to-moment needs. A detailed care plan might be an obstruction and stressful for staff when they are not successful in performing the planned tasks. In a time when person-centred care is a guiding principle, dilemmas of participation and self-determination emerge. For example, how long can a resident wait to get a shower? The quote below gives an example from everyday work: She never wants to shower. Then a staff member who she does not recognise. They usually go to her and say: ‘I’m here now, you ordered a shower today’. It works. She doesn’t mind. ‘Well, I did! When did I do it?’ ‘It’s been three days since you did [ordered] it.’ You have to lie a lot to get her clean and washed. It’s about having tricks all the time. You have to see it as a challenge to work with dementia [person with a dementia diagnose]. (Nurse assistant)

The care situation exemplified in the quote above is observably related to the residents’ health status and ever-changing needs, as well as work practices. The care worker says in the quote that they have to ‘lie a lot’ to persuade her to take shower

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and successfully complete their work task. However, another interpretation of the situation is that it is a performance, creating self-determination in the residents’ everyday life: a core value in person-centred care. This knowledge is experience based and not well fitted to a checklist or document in a care plan that seldom gets updated (at least every sixth month) parallel to the residents present needs and wishes. Sometimes, following the care plan can prevent providing what is the best for the resident.

7.5.3

Formal Training and Caring Skills in the Era of Marketisation: Re-professionalism or De-caring?

The feminist-oriented care literature has described care work as a combination of intellectual, emotional and manual labour (Daly & Szebehely, 2012: 139). The direction towards a more science-based knowledge in care work has also been formulated by National Board of Health and Welfare (2020: 38), ‘A knowledge base health and social care should be based on best available knowledge, built on science and proven experience.’ According to Fejes (2012), there has been a growing confidence in science-based knowledge since the reconstruction of Swedish elder care in the 1990s. This confidence posits that science-based knowledge is more important or truthful then knowledge connected to emotions or which emerge from daily work. This is echoed by Moberg (2017), who suggests that changes in this period reflected political goals, with ambitions to raise the status and professionalism of the work and the largely female workforce. Underemphasising female-coded abilities, such as emotions and nurturing, can be seen as a strategy to increase professional status by ‘acquir[ing] more recognition on the premises of the established male society’ as Elwér (2013:18) notes. Further, the impact of education and the share of trained staff as a quality symbol for residential care facilities has been more evident in the era of marketisation (Storm & Stranz, 2018). All presumptive residents and their relatives can use National Board of Health and Welfare E-services ‘Open Comparison’ in order to compare the share of trained staff between all care providers in the municipality (NBHW, 2019). However, there are not yet any detailed national regulation standards on how to achieve nursing assistant competence, and thus no consensus on what actual knowledge base each individual nurse assistant actually has (Government Bill, 2019:20). Although all unit managers stressed the importance of formal training for care workers, they nevertheless defined the meaning of core words such as ‘competence’ and ‘formal education’ rather vaguely, and fluidly, compared to the more rigorous formulation of the impact of educational standards in local tender documents. There are a lot of criteria in the professional requirements, yes, there are hundreds of criteria that show that you have to be able to do this [work] There are criteria that show that this is a

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qualified job, it is not anyone who can do this work, and to be able to do this work, you must have some standards. (Manager) You can do the web-education BPSD (Behavioural and Psychological Symptoms for Dementia) at home. If they want to be employed by hour, they have to done this before they apply for a position. If you are seeking an [permanent] employment here, without this competence. . .I use to say, when they apply, I have these requirements. . .If they do not have this education, they are given time here to do it. (Manager)

From a management perspective, care education operated as some kind of base standard to employ the staff and to illustrate care work as qualified work requiring specialised skills and not an occupation ‘anyone can perform’. Both unit managers in the quotes above mention education as an ongoing process that continued at the workplace. The work of Ahnlund and Johansson (2016) indicates how care managers can have an ambivalent attitude to formal education as the only employment criteria. Instead, personal abilities and work experience were sometime valued higher among those interviewed. Recruitment problems and intense competition between care providers to attract trained staff might be one interpretation for this ambivalence, suggesting that the ambitions of managers had to be adjusted to the everyday realities. The workers in the study raised a number of concerns that illustrated the tensions between formal training and knowledge-based skills as most important to meet the residents need in everyday life. A theme that emerged was how the staff drew connections between formal training and medical knowledge. If you are educated, you are better prepared to handle situations that might occur, and you know what to do if someone [of the residents] has chest pain. To be professional, you need to be educated (Nurse assistant). Yes, education is really important, you have knowledge about diseases and techniques to protect yourself from being infected (Nurse assistant)

As the quotes above illustrates, formal education was foremost framed by the staff as an inherent prerequisite to be considered as professional and this was mainly associated with medical-oriented competence skills. Yet the bulk of the daily work for all front-line care workers are oriented towards personal care duties, such as personal hygiene, dressing, eating and social activities (Stranz, 2013). Although these tasks are central in the everyday life of residential care, they have a lower status and are less visible than medical duties. This might be one interpretation as why proper education, on behalf of relational and personal caring abilities, was a recurring theme in most of the staff interviews. Nowadays, you cannot seek for an employment if you do not have education, of course, there can be people with really good educations, who are really bad in caring, and it can be the opposite. I consider myself to be just as good as someone who has education. I have still same feeling and thinking as in my 20s. (Care assistant)

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Discussion

In the chapter we have investigated how two RCHs respond to new requirements and conditions, in an era of marketisation, and how the NPM inspired changes are perceived by staff and managers. Additionally, the focus has been on how these transformations are enacted in everyday work. By analysing qualitative data, with earlier care research as a point of departure, the results showed that three aspects of the organisation of care work in the facilities were prominent. The staff and managers perceived that auditing, person-centred care and the care workers competence are major matters that structure the organisation of the facilities and everyday care work. These areas are connected to and impelled by the focus on competition and quality control, as well as the focus on the residents’ well-being. Auditing is perceived in different ways depending on the aim of the documentation. The required documentation to comply with the Social Services Act is seen as self-evident and is focused on everyday care work. On the other hand, internal documentation that is imposed by managers is described by the care workers as a tool to control them and evidencing a lack of trust. In contrast, the managers, referring to inspections and the guidelines outlined by local municipal authorities, reason that the different kinds of checklists are necessary to achieve quality care. The increased auditing has altered the work environment in RCHs, leading staff to spend more time on documentation. This can create a struggle between different tasks and make the work more fragmented. The results reveal that the arrangement of care work in RCHs has become highly standardised with complex systems of documentation and checklists. The written and countable is valorised to a higher degree than tasks centring on the resident’s individual needs. Person-centred care is generally perceived as a positive approach with reference to residents’ increased opportunity to influence their everyday life. However, the findings reveal a tension between social policies that focus on the position of the residents gaining more influence in their daily life and the standardised care plan that risk making the relational encounter between care worker and resident unrecognisable. The results reveal a discrepancy between PPC as a policy and organisational conditions and scope of discretion to perform this kind of care in the daily work. The documented and partly standardised individualisation of care and the situation where staff can adapt to the persons’ ever-changing needs in care situations can be interpreted as two different practices relying on two different rationalities. The standardised care plan has a higher status in the organisations, and the working conditions often undermine possibilities to adapt to the residents’ individual and changing needs in the present care situation. Further, the question of formal education and the share of trained staff as a quality indicator for residential care facilities has been even more evident along with the development of a market-inspired organisation of eldercare. This change has shaped a tension between formal training and knowledge-based skills where the latter is interpreted as most important to meet the residents’ needs. A general assumption is that care given in a non-medical environment is supposed to be less routinised and

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give the care workers the opportunity to respond to the resident’s needs (Edvardsson et al., 2014). Referring to our findings, the social model is characterised by inconsistencies and several practices in the RCHs reveal difficulties for staff to respond to residents’ needs and use their competence due to an inflexible organisation.

7.7

Conclusion

The feminist approach to care—which aims to scrutinise, criticise and transform the gendered norms of care and the view of care work as low-status, low-skilled and the responsibility of women—can be used to illuminate the substantial differences social policies and politics can make in everyday work life. Further, we can use the searchlight of a rationality of caring to construct alternative understandings of care work. For example, we may develop auditing that helps staff in their work by giving them relevant knowledge of the users; make PPC a reality with the possibility for care workers to adapt to resident’s present needs and wishes; and cultivate a condition where formal education is recognised as beneficial for staff, and possible to use in their work, not just a symbol of status. There is a possibility to organise care and work in a different way without maintaining the aspects of control, standardised needs and the higher status connected to formal training as the dominant guiding principles. Care work, in the RCH we studied, is clearly standardised and controlled, and relations and trust are partly sacrificed as a consequence. This struggle can be understood as a tension between two organisational logics-rationality of caring and marketisation—where one of them, rationality of caring, is constantly devalued by the organisation but necessary in the everyday work.

References Abel, E., & Nelson, M. (1990). Circles of care: Work and identity in women’s lives. State University Press. Ahnlund, P., & Johansson, S. (2016). Omvårdnadsutbildning som mål eller medel? Om legitimitetsproblem och kunskapssyn. [Care education as a goal or as a strategy? Legitimacy problems and perceptions of knowledge]. Socialvetenskaplig tidskrift, 13(3), 212–227. Anttonen, A., & Meagher, G. (2013). Mapping marketisation: Concepts and goals. In M. Szebehely & G. Meagher (Eds.), Marketisation in Nordic eldercare. A research report on legislation, oversight, extent and consequences (pp. 203–217). Department of Social Work, Stockholm University. Anttonen, A., & Sipilä, J. (1996). European social care services: Is it possible to identify models? Journal of European Social Policy, 6(2), 87–100. Armstrong, P., Armstrong, H., & Scott-Dixon, K. (2008). Critical to care. The invisible women in health services. University of Toronto Press. Baines, D. (2015). Neoliberalism and the convergence of nonprofit care work in Canada. Competition & Changes, 19(3), 194–209.

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Government Bill. (2019:20). Stärkt kompetens i vård och omsorg [Improved competence in healthand care work]. Fritzes. Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288. James, N. (1992). Care ¼ organisation + physical labour + emotional labour. Sociology of Health & Illness, 14(4), 488–509. Keisu, B-I. (2017). Dignity: A prerequisite for attractive work in elderly care. Society, Health and Vulnerability, 8(1). Open Access. https://doi.org/10.1080/20021518.2017.1322455. Koren, M. J. (2010). Person-centered care for nursing home residents: The culture change movement. Health Affairs, 29(2), 312–317. Larsson, K. (2004). According to need? Predicting us of formal and informal care in a Swedish urban elderly population. Dissertation, Stockholm University. Lundgren, E. (2000). Homelike housing for elderly people – Materialized ideology. Housing, Theory and Society, 17(3), 109–120. McCormack, B., Borg, M., Cardiff, S., Dewing, J., Jacobs, G., Janes, N., Karlsson, B., McCance, T., Mekki, T. E., Porock, D., van Lieshout, F., & Wilson, V. (2015). Person-centredness – the ‘state’ of the art. International Practice Development Journal, 5(Suppl 1), 1–15. McDonald, C. L., & Merrill, D. A. (2002). “It shouldn’t have to be a trade”: Recognition and redistribution in care work advocacy. Hypatia, 17(2), 67–83. Meinow, B., Parker, M. G., & Thorslund, M. (2011). Consumers of eldercare in Sweden: The semblance of choice. Social Science & Medicine, 73(9), 1285–1289. Moberg, L. (2017). Marketization in Swedish eldercare: Implications for users, professionals, and the state. Dissertation, Uppsala University. NBHW. (2019). Öppna jämförelser – Äldreomsorg [Open Comparisons: Elder care]. National Board of Health and Welfare. NBHW. (2020). Vård och omsorg om äldre. En lägesrapport [Nursing and caring for older people. An actual review]. National Board of Health and Welfare. Rostgaard, T. (2011). Care as you like it: The construction of a consumer approach in home care in Denmark. Nordic Journal of Social Research, 2. Open Access. https://doi.org/10.7577/njsr. 2042. Schön, P., Lagergren, M., & Kåreholt, I. (2016). Rapid decrease in length of stay in institutional care for older people in Sweden between 2006 and 2012: Results from a population-based study. Health & Social Care in the Community, 24(5), 631–638. Sevenhuijsen, S. (1998). Citizenship and the ethics of care: Feminist considerations on justice, morality and politics. Routledge. Social Service Act. (2001:453). From June 2001. SOSFS. (2012:3). Socialstyrelsens föreskrifter. Värdegrund i socialtjänstens omsorg om äldre. [Regulations and general advice value grounds for Social Services care for older people]. Socialstyrelsen. Storm, P. (2013). Care work in a Swedish nursing home. Gendered norms and expectations. In A. Hujala, S. Rissanen, & S. Vihama (Eds.), Designing wellbeing in elder care homes (pp. 148–161). Aalto University publication series, Crossover 2/2013. Storm, P., Braedley, S., & Chivers, S. (2017). Gender regimes in Ontario nursing homes: Organizations, daily work and bodies. Canadian Journal on Aging, 36(2), 196–208. Storm, P., & Stranz, A. (2018). Äldreboendet i marknadiseringens tid: Konkurrens, organisering och vardagsomsorg [Residential care homes for older people in the time of marketisation: Competition, organization and daily care work]. In H. Jönson & M. Szebehely (Eds.), Äldreomsorger i Sverige. Lokala variationer och generella trender (pp. 169–184). Gleerups. Strandell, R. (2020). Care workers under pressures: A comparison of the work situation in Swedish home care. Health and Social Care in the Community, 28(1), 137–147. Stranz, A. (2013). Omsorgsarbetets vardag och villkor i Sverige och Danmark. Ett feministiskt kritiskt perspektiv [The everyday realities and conditions of care work in Sweden and Denmark. A feminist critical perspective]. Dissertation, Stockholm University.

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Stranz, A., & Sörensdotter, R. (2016). Interpretation of person-centered dementia care: Same rhetoric, different practices? A comparative study of nursing homes in England and Sweden. Journal of Aging Studies, 38, 70–80. Stranz, A., & Szebehely, M. (2018). Organizational trends impacting on everyday realities: The care of Swedish elder care. In K. Christensen & D. Pilling (Eds.), The Routledge handbook of social care around the world (pp. 45–57). Routledge. Szebehely, M. (2017). Residential care for older people. Are there lessons to be learned from Sweden? Journal of Canadian Studies, 50(2), 499–507. Szebehely, M., & Meagher, G. (2018). Nordic eldercare–weak universalism becoming weaker? Journal of European Social Policy, 28(3), 294–308. Szebehely, M., Stranz, A., & Strandell, R. (2017). Vem ska arbeta i framtidens äldreomsorg? [Who will work with care in the future?]. Working paper. Department of Social Work, Stockholm University. Szebehely, M., & Trydegård, G.-B. (2012). Home care for older people in Sweden: A universal model in transition. Health and Social Care in the Community, 20(3), 300–309. Tronto, J. C. (1993). Moral boundaries: A political argument for an ethic of care. Psychology Press. Trydegård, G. B. (2012). Care work in changing welfare states: Nordic care workers’ experiences. European Journal of Ageing, 9(2), 119–129. Tufte, P., Clausen, T., & Nabe-Nielsen, K. (2012). Client-related work tasks and meaning of work: Results from a longitudinal study among eldercare workers in Denmark. International Archives of Occupational and Environmental Health, 85(5), 467–472. Wærness, K. (1984). The rationality of caring. Economic and Industrial Democracy, 5(2), 185–211. Wærness, K. (2005). Social research, political theory and the ethics of care in a global perspective. In H. M. Dahl & R. Eriksen (Eds.), Dilemmas of care in the Nordic welfare state: Continuity and change (pp. 15–30). Ashgate.

Palle Storm holds a PhD in Social Work and is researcher and lecture in Social Work at Stockholm University. His research interest includes care work and the impact of gender and racialization in the everyday life of residential- and home-care settings for older people. Anneli Stranz holds a PhD in Social Work and is an assistant professor in Social Work at Stockholm University. Her research interests include care work and how working conditions and the organisation of eldercare are transformed by care recipient’s needs, policy changes and market reforms.

Chapter 8

Gender Differences in the Impact of Work Hours on Health and Well-Being Philip Tucker

8.1

Shift Work

A shift worker may be required to work so-called rotating or alternating shifts, whereby their daily work hours (start and finish times) change in a more or less regular sequence over the shift cycle (e.g. a combination of morning, afternoon and night shifts); or they may work the same hours every working day—so called permanent shifts (e.g. permanent night shifts). According to the sixth European Working Conditions Survey, about 21% of all workers in the EU work shifts, with only small differences in the proportions of men and women doing shift work (Eurofound, 2016). Shift work can negatively affect workers’ health, well-being and safety. Many of these problems stem from disruption of the shift workers’ biological rhythms (e.g. the sleep–wake cycle. See Fig. 8.1). These circadian rhythms in our bodily functions are partly driven by the internal body clock. The influence of the body clock can be seen in night workers. They may struggle to remain awake and alert during nightshifts, when the body clock is promoting sleep. They may also have difficulty sleeping adequately during the days between nightshifts, when the body clock is promoting wakefulness, adding to the sleep disturbance caused by daytime environmental conditions (e.g. light and noise). There is a prevailing view in the research literature that women tend to be less tolerant of shift work than men (i.e. they experience more problems of fatigue and health), although the evidence on gender differences in the effects of shift working is mixed (Saksvik et al., 2011).

P. Tucker (*) Psychology Department, Swansea University, Swansea, UK Department of Psychology, Stress Research Institute, Stockholm University, Stockholm, Sweden e-mail: [email protected] © Springer Nature Switzerland AG 2021 B.-I. Keisu et al. (eds.), Gendered Norms at Work, Aligning Perspectives on Health, Safety and Well-Being, https://doi.org/10.1007/978-3-030-77734-0_8

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Shiftwork

Gender-related factors moderating the impact of shiftwork: Gender roles; Biological factors; Working conditions; Shift schedules

Disturbed Body Clock

Shortened and Disturbed Sleep

Disturbed Family and Social Life

Acute Effects on Mood and Psychological Well-Being

Coping Strategies

Chronic Effects on Mental Health

Health and Safety

Fig. 8.1 A conceptual model of how gender-related factors may influence the associations between shiftwork and health, wellbeing and safety (adapted from Folkard, 1993)

8.1.1

Shift Work and Well-Being

8.1.1.1

Sleep, Fatigue and Accident Risk

According to an early review by Saksvik et al. (2011), female shift workers tend to be at greater risk of fatigue and sleepiness compared to males. However, it was noted that the evidence that female shift workers experience more sleep problems than their male counterparts was not very strong. A more recent systematic review reported that the majority of selected studies found no sex differences in the association between shift work and sleep (Booker et al., 2018). Another review

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published around the same time noted some limited evidence of higher rates of shift work disorder (SWD—a circadian rhythm sleep disorder characterized by excessive sleepiness and complaints of insomnia related to the work schedule) in males than in females (Kervezee et al., 2018). A potential consequence of disrupted sleep and subsequent sleepiness is the increased risk of accidents and injuries. Some studies have found that female shift workers, and those with children in particular, are at greater risk of work-related injuries than male shift workers (Catano & Bissonnette, 2014; Ryu et al., 2017; Smith et al., 2013; Wong et al., 2011). However, by the far the largest prospective cohort study in this area failed to find any gender differences in the association between nightwork and injury risk (Larsen et al., 2017).

8.1.1.2

Health

Besides the disruption that shift work causes to the sleep–wake cycle, it also disrupts circadian rhythms in a wide range of other physiological and psychological functions (e.g. metabolic processes, digestive processes, cellular reproduction, etc.). The extent to which shift workers health problems are due to insufficient sleep (i.e. disruption of the sleep–wake cycle) or to the disruption of other circadian rhythms can be hard to disentangle, although it can also be a combination of both, such as in the case of diabetes (Gao et al., 2020). The earlier review by Saksvik et al. (2011) noted that, besides evidence of female shift workers’ greater susceptibility to problems of sleep and fatigue, the reviewed studies also indicated that they had higher risks of disability pension, mortality and factors relating to obesity. Since then, meta-analyses have been published that have looked at potential gender differences in the susceptibility of shift workers to a range of chronic diseases. Female shift workers have been shown to be at higher risk than their male counterparts of developing metabolic syndrome (Wang et al., 2014) and the closely related condition of type 2 diabetes (Gao et al., 2020). While Saksvik et al. (2011) identified two studies showing that female shift workers had a lower risk of developing cardiovascular disease than their male counterparts, a more recent meta-analysis found no evidence that the association between shift work and cardiovascular disease differed between men and women (Torquati et al., 2018). The association between shift work and breast cancer is currently one of the most widely debated issues in shift work research. A position statement by the International Agency for Research on Cancer (IARC, 2019) concluded that shift work involving circadian disruption is probably carcinogenic to humans. Most metaanalyses in this area have reported significant associations between shift work and breast cancer (Moreno et al., 2019). However, one meta-analysis found no significant association (Travis et al., 2016). Since that publication, results from two large prospective cohort studies based on the Nurses Health Studies (Wegrzyn et al., 2017) reported that risk was primarily associated with long-term exposure to rotating nightwork during early adulthood, which may go some way to explaining the lack of association reported in the recent meta-analysis (see (Schernhammer, 2017)).

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Meta-analyses have also identified significant associations between nightwork and both prostate cancer (Rao et al., 2015) and colorectal cancer (Wang et al., 2015). Notably, the latter found an equal risk in both men and women, while a recent metaanalysis of the association between night work and all cancers also found no gender difference (Liu et al., 2018). Cross-sectional studies examining the association between shift work and sickness absence separately for men and women have also produced mixed evidence of gender differences (Catano & Bissonnette, 2014; d’Errico & Costa, 2012; Lesuffleur et al., 2014; Niedhammer et al., 2008, 2013; Slany et al., 2014). Of three longitudinal studies that have incorporated a gender perspective, the findings were an increased risk of long-term sickness (>8 week) in males only, becoming non-significant after adjustments (Tuchsen et al., 2008); an increase in musculoskeletal-related long-term sickness absence associated with shift/night work in men only (Foss et al., 2011); and no interaction between gender and work schedule in the prediction of sickness absence (van Drongelen et al., 2017). Potential causes of these inconsistencies include the different ways in which studies treat potential confounds, as well as differences in the types of shift systems studied and in the characteristics of the studied populations (Merkus et al., 2012). The possibility of an association between shift work and poor mental health has received relatively little attention in the research literature, compared to the number of studies examining physical health complaints. High-quality evidence of a link between shift work and poor mental health, in either women or men, remains relatively sparse. A systematic review and meta-analysis found that nightwork significantly increased the risk of depression in women but not in men (Lee et al., 2017). However, the reliability of that conclusion is undermined by the fact that the meta-analysis was based largely on cross-sectional studies (including conference poster presentations) and that it failed to demonstrate a dose–response relationship. Another systematic review published around the same time, based exclusively on prospective studies (Angerer et al., 2017), painted a more equivocal picture of gender differences in the association between shift work and mental health. It reported that studies of healthcare workers (mostly women) with up to 2 years follow-up mostly found either no association or a favourable association between shift work and depression (Lin et al., 2012; Nabe-Nielsen et al., 2011; Thun et al., 2014). In contrast, studies of multiple occupations that examined men and women separately, with longer follow-up, did tend to find an increased risk for women but not for men (Bara & Arber, 2009; Bildt & Michelsen, 2002). However, one of those studies found that permanent nightwork had a greater negative impact on men’s mental health (Bara & Arber, 2009), while another study found an increased risk only for men, which disappeared after adjusting for psychosocial working conditions (Driesen et al., 2011). Most recently, a systematic review and meta-analysis, based on a selection of longitudinal studies that overlapped with those included in the previous review, found that shift work predicted an increased risk of poor mental health in women but not in men (Torquati et al., 2019). The mixed picture that emerges from these studies may reflect the methodological challenges that are present when seeking to understand the relationship between shift

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work and mental health. Firstly, studies tend to use varying, inconsistent and often vague definitions of shift work. This increases the risk for measurement error and misclassification bias. Secondly, many studies rely upon the workers’ own subjective reports of their mental well-being that are subject to bias, particularly given the social stigma that is attached to mental illness. Thirdly, self-selection into and out of jobs that involve shift work (the healthy worker effect) can bias results towards underestimated effects, particularly if past exposures to shift work are not accounted for. This might occur, for example, when a comparison group of dayworkers is ‘contaminated’ by the presence of ex-shift workers who continue to experience health problems stemming from their prior exposure. In an attempt to address these problems, we drew upon data from the Swedish Occupational Survey of Health (SLOSH), a large national survey of a broadly representative sample of the working population (Hall et al., 2019). We examined the prospective effect of work schedule on antidepressant prescription rates, using objective measures obtained via linkage to national health registers, in males and females, over a 2-year period. We used detailed categories of work schedule that differentiated between dayworkers with and without a history of nightwork, between shift work that included and did not include nightwork, and between shift work and rostered work (rostered work is similar to shift work, but the sequence is more ad hoc such that the employee has relatively short notice of which shifts they will be working). Another category in the analysis was for respondents with flexible work hours. The analyses adjusted for a wide range of demographic and social covariates, as well as for prior history of depression. We found no effects of either category of shift work or rostered work on antidepressant use, either before or after adjusting for covariates. However, we found that among women, those with flexible work hours were twice as likely as those working regular hours to use antidepressants, while there was no such effect among men (results are discussed in the section Flexible Work Hours, below). The findings suggested that shift work was not a cause of clinically significant levels of depression (i.e. depression severe enough to warrant antidepressant use) over the short–medium term (i.e. 2 years), in either women or men. Nevertheless, the likelihood remains that shift work is a source of hardship and consequent distress, and that this may be more acutely felt by women than by men.

8.1.2

Potential Mechanisms

8.1.2.1

Gender Roles

Evidence from a number of cross-sectional studies suggests that women are more likely to suffer negative effects of shift working if they have children, due to the impact that childcare has on recovery. Several researchers have talked about the ‘double burden’ faced by women who cope with demanding work schedules in combination with a higher domestic workload than their male counterparts. Even when female shift workers do not work more hours in total (i.e. combining paid

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work hours and unpaid domestic work hours) than men, they may nevertheless lack the recovery opportunities that men have. This may be as a result of childcare activities that occur at those times of day (or night) when recovery would otherwise take place. For example, it has been found that women working rotating shifts are less likely to extend their time in bed (i.e. get up later) when working afternoon shifts, thereby missing the opportunity that men have to repay the sleep debt that is accumulated when working night shifts and/or early starting morning shifts (Clissold & Smith, 2002). Another gender difference is that female workers may be more likely than men to have spouses who work full time (Jolly et al., 2014). This means that women are more likely to be part of a family where the combined paid work hours of both parents is higher, adding to the difficulties of sharing childcare between parents. It is interesting to note a small field study that followed newly recruited police officers and found that female recruits actually experienced longer daytime sleeps between night shifts than their male counterparts, which was attributed to the females being largely younger, single and without children (Lammersvan der Holst et al., 2016).

8.1.2.2

Biological Factors

While gender roles are likely to play a part in the heightened difficulties faced by female shift workers, psychobiological factors may also play a role. In general, women report a greater need for sleep, more subjective complaints of non-refreshing sleep and higher levels of insomnia than men, although the gender disparity is not reflected in studies using objective measures of sleep (Schwarz et al., 2015). Laboratory studies have identified sex differences in the human circadian timing system, with women showing an earlier circadian phase relative to sleep time (Kervezee et al., 2018). That is to say, the psychophysiological processes that ready the body for wakefulness occur earlier in the sleep episode in women. These differences may help explain women’s greater susceptibility to developing sleep problems, such as waking too early in the morning. It may also be linked to women’s greater tendency towards morning orientation (i.e. being ‘morning types’ or ‘larks’), which may in turn reduce their ability to tolerate nightwork. Women also tend to show larger circadian fluctuations in performance and alertness, with one laboratory study finding that women experienced greater cognitive impairment (lower task accuracy) than men when working at night (Santhi et al., 2016). Given the mechanisms outlined above, it is perhaps surprising that findings of lower shift work tolerance among women are not more common and unequivocal. Methodological issues are likely to underlie the mixed picture that emerges from gender comparisons in the effects of shift work, as described above. Most studies that directly compare female and male shift workers are based on samples from multiple occupational groups. As female and male shift workers tend to work in different occupations, there is a risk that such gender comparisons are confounded by occupational factors (e.g. working conditions, shift patterns).

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Working Conditions

Stressful working conditions are an important mediator in the pathway between shift work and health (Puttonen et al., 2010). However, there has been only limited empirical research comparing the working conditions of shift workers and non-shift workers, and even less that has incorporated a gender perspective. A Danish study (Boggild et al., 2001) compared the working conditions (i.e. exposure to physical and psychosocial risk factors) of shift workers and non-shift workers separately for men and women in a large national survey. Overall, they found more differences in the male sample than in the female sample; in nearly all instances of significant difference, conditions were worse for shift workers than for dayworkers. This would suggest that if general working conditions are affecting health, the associations between shift work and poor health should be more marked among males than among females. This would be in contrast to the prevailing view that health effects of shift work are more apparent in women than in men. Building on these findings and drawing once again on data from SLOSH, we sought to determine whether psychosocial working conditions could account for prospective associations between shift work and stress-related health outcomes (Tucker et al., 2020). Working conditions are most appropriately viewed as a feature of an occupation rather than being directly associated with one gender or the other. Thus, we chose to distinguish between workers in female-dominated (FD) occupations and workers in male-dominated (MD) occupations, rather than between female and male workers. The analyses examined the prospective associations between work schedule and health indices, separately for workers in FD and MD occupations; and whether the associations remained after controlling for psychosocial working conditions. The categories of work schedule were daywork, shift work that included nightwork and shift work that did not involve nightwork; and the health indices were self-reported symptoms of depression, sick leave, self-rated health and sleep disturbance. The analyses were based on a 4-year time lag, given that our own previous findings described above (Hall et al., 2019) and others (Angerer et al., 2017) suggest that shorter time intervals may be less sensitive to some strain-related effects of shift work. As with the earlier study, we sought to limit the possibility of selection effects; on this occasion by excluding from the category of dayworks any respondents reporting prior experience of nightwork. The analyses adjusted for two sets of covariates: firstly, variables relating to the participants’ background and personal circumstances; and secondly, their psychosocial working conditions, namely, psychological and emotional job demands, job control, worktime control, social support at work, persecution at work, and threats or violence at work. We found few significant associations between shift work and health in either FD or MD occupations. However, in contrast to our previous study described above (Hall et al., 2019), we found an association between shift work that involved nightwork and depressive symptoms that was present in MD occupations but not in FD occupations. We also found that within FD occupations (but not MD

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occupations) the same type of schedule was associated with increased risk of shortterm (< 8 days) sick leave. Despite some notable differences in psychosocial working conditions between dayworkers and shift workers (e.g. shift workers in FD occupations reporting higher levels of threats and violence at work than dayworkers, and greater emotional demands; shift workers in MD occupations reporting lower levels of job control), the associations between shift work status and depressive symptoms/short-term sick leave remained significant after taking into account these differences in working conditions (i.e. after adjusting for working conditions in the statistical analysis). This suggested that the associations between shift work and health could not be accounted for by the poorer psychosocial working conditions of shift workers, in either occupational group. It is notable that the significant associations were observed only among those whose shift work schedule involved nightwork, but not among those working shift work without nightshifts. This further suggested that while the psychosocial working conditions of shift workers may not have been an underlying cause of the observed differences in the health of dayworkers and shift workers, the circadian disruption caused by nightwork may have been an influential factor. However, it also remains a possibility that the differences with respect to depressive symptoms (in MD occupations) and sick leave (in FD occupations) were instead due to other unmeasured aspects of the working environment.

8.1.2.4

Shift Schedules

An alternative explanation for gender-related differences in the effects of shift work is that women and men tend to work different shift patterns. For example, in Sweden, female shift workers are more likely than men to work split shifts (i.e. two or more periods of work within a single day) and are also more likely to experience ‘quick returns’, that is, intervals of less than 11 h between the end of one shift and the start of the next (Sverke et al., 2016). Both split shifts and quick returns are known to have deleterious effects on fatigue and well-being (Tucker & Folkard, 2012). Another possible reason that women could be more negatively impacted by shift work than men is that certain shift patterns may be less suited to women. For example, compressed work weeks (in which weekly work hours are organized into fewer, longer shifts, e.g. 12 h shifts) may be more disadvantageous for women than for men. These working time arrangements are often regarded positively by workers who appreciate the extended periods of time off and the reduced number of journeys to and from work. However, working longer days reduces the amount of time available before and after work for attending to childcare and meal preparation, that is, daily activities which, in at least some households, may be more commonly undertaken by women than by men. Thus women have been found to experience more problems with compressed work weeks than their male counterparts, due to issues around childcare and other household tasks (Tucker & Folkard, 2012). By contrast to the potential negative effects of compressed work weeks on women, as noted above there is some evidence that women’s mental health is less

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adversely impacted by permanent night work than is the case for men (Bara & Arber, 2009). The regular and predictable work hours that are a feature of permanent night shifts may be advantageous for those with childcare responsibilities (e.g. women), given the invariant nature of childcare from day to day and week to week. Such potential advantages were highlighted in an earlier cross-sectional study (Barton, 1994) which found that nurses (primarily female) working permanent night shifts reported fewer health, sleep, social and domestic problems than those working rotating shifts that included nightwork. Notably, the most positive outcomes were observed among those who had chosen to work permanent nights to suit their individual circumstances (usually domestic), rather than because it suited their personal circadian preferences.

8.1.3

Conclusions on Shift Working

The widely held view among researchers that shift work is more harmful to the health and well-being of women than it is to men has been challenged by the findings of some recent systematic reviews. In particular, the evidence of gender differences with regard to sleep, fatigue, cardiovascular heart disease, certain forms of cancer and sickness absence is equivocal. However, recent reviews seem to agree that the link between shift work and metabolic disorders may be stronger in women, and that women's mental health may be more negatively affected. Our own research has found few substantial gender differences in the health effects of shift work, although the general absence of effects in these studies, irrespective of gender, raises questions about the sensitivity of our analyses. Clearly the null findings of our own studies in this area do not constitute an ‘all-clear’ signal. Nor can the findings of systematic reviews and meta-analyses be regarded as conclusive. Further highquality studies are needed to elucidate the issue of shift work and gender, based on large representative samples, using clear unambiguous definitions of exposure and accurate unbiased measures of both exposure and outcome.

8.2

Flexible Work Hours

Flexible work hours are a working time arrangement in which the employee’s working time may vary from one duty period to the next, from week to week or from year to year. They are commonly characterised by variations in the length of the working day, the start and end times of a duty period and the days (or shifts) that are worked. These variations in work hours may be primarily at the discretion of the employer (‘employer-oriented flexibility’ or ‘variability’) or under the control of the employee (‘employee-orientated flexibility’ or ‘flexibility’; (Costa et al., 2006)). The terms ‘variability’ and ‘flexibility’ were coined in an effort to distinguish between the different health effects that are associated with each. The former tends to

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be associated with negative impacts on well-being, while the latter is more commonly associated with positive health outcomes. The sixth European Working Conditions Survey indicated that work hours flexibility was rather more common than work hours variability (Eurofound, 2016). It was reported that almost half of workers (44%) reported having some degree of employee-orientated work hours flexibility. Among the remainder who had no possibility to influence their own work hours, less than a third had changes in their work hours imposed upon them by their employer (i.e. experienced variability). There were only very small differences in the proportions of men and women having some degree of flexibility, and in the proportions of men and women reporting no possibility to influence their work hours. However, it should be noted that this lack of gender differences is in contrast to other national surveys that have found that women have lower work-time control, including studies conducted in Sweden (Albrecht et al., 2016), Finland (Ala-Mursula et al., 2004) and Japan (Takahashi, 2012), as well as in a cross-national study (Lyness et al., 2012).

8.2.1

Variability

The primary purpose of work hours variability is to promote an organization’s efficiency, performance, and accessibility to customers and clients. It can put heavy demands on employees, such as by requiring them to work long weekly work hours, at weekends, working on-call, etc. This can lead to problems for the employee such as impaired recovery and sleep, disruption of the normal balance between working life and life outside work, and difficulties planning ahead. Research studies have found that variability is associated with negative effects on subjective health, psychological well-being, sleep quality, the experience of leisure time and accident risk (Bohle et al., 2004; 2011; Janssen & Nachreiner, 2004; Martens et al., 1999; Nachreiner et al., 2019). Variable work hours have become increasingly prevalent as result of the increase in precarious work and associated working time arrangements such as ‘zero hour’ contracts, casual work and on-call work. In such situations, variability may coexist alongside flexibility in more or less equal measure. Where this is the case, the hours worked by the employee should, in theory, reflect a negotiated process of matching the requirements of employee and employer. In practise, however, variable work hours that are irregular and unpredictable are usually associated with greater work– life conflict and poorer health, for example, cardiovascular disease, fatigue and mental health (Arlinghaus et al., 2019). Nevertheless, in situations where work hours variability and flexibility do coexist, the negative effects of variability on work–life conflict and mental health have been shown to be off-set by higher levels of flexibility (Bohle et al., 2011).

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Flexibility

Work hours flexibility can take many forms. Besides being able to self-determine the start and end of their working day and which days are worked, employees with autonomy over their work hours may also be able to choose when to take breaks within the duty period (e.g. for rest or to undertake personal errands). Other forms of flexibility include flexible daily hours around a core set of hours (‘flexitime’); being able to swap shifts or duty periods with colleagues; and the interrelated concepts of ‘trust hours’ and ‘boundaryless work’, when employees are given more or less total autonomy to achieve their work-related goals (i.e. their performance is judged on the basis of output rather than input) and are able to choose both when and where they perform their work. Research has often demonstrated that flexible work hours protect employees from otherwise harmful work environments (e.g. high workload conditions) and that they are commonly associated with better health, well-being and work–life balance (Nijp et al., 2012). That said, some studies have demonstrated negative health effects, suggesting that some employees may use the autonomy to make unhealthy choices regarding their work hours. Especially when workloads are high and there are ambiguous norms about work hours, employees may feel pressured to give their personal time to engage in extra work, resulting in overwork (Kossek & Lee, 2008). Such findings highlight the importance of placing appropriate boundaries between work hours and leisure time in order to promote psychological detachment during free time and thereby facilitate recovery (Sonnentag & Fritz, 2015).

8.2.3

Potential Mechanisms

8.2.3.1

Work–Life Interference and Recovery

The mechanisms underlying the effects of flexibility and variability are not well understood. However, two likely mediators are work–life interference; and the processes of recovery from the strain and effort associated with work. Having work-time control helps people align their work commitments with their private life. Work-time control thus leads to a reduction in stress, thereby promoting better health (Albrecht et al., 2020). Conversely, being required to work irregular and unpredictable hours is likely to increase mismatches between work and non-work demands on the employee’s time, resulting in greater stress which in turn negatively affects health. Having work time control also allows employees better opportunities to recover, both while at work and outside work. Irregular and unpredictable hours, on the other hand, make it more likely that the employee will have to work at times when stress and fatigue levels, as well as the need for recovery, are already high. As a consequence, stress and fatigue are exacerbated, with potentially negative consequences for health, performance and safety at work (Nijp et al., 2012).

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Gender Roles

While few studies have explicitly studied gender differences in the impact of work hours variability, several studies report that women are especially likely to benefit from flexibility. For example, some studies have found that flexibility provides a greater protective effect for women than men with respect to work–family conflict (Byron, 2005), stress and burnout (Grzywacz et al., 2008), self-reported health issues, psychological distress and sick leave (Ala-Mursula et al., 2004). This probably reflects a greater engagement by women in domestic activities such as childcare, compared to men. According to some research, employees with children, especially women, are most likely to report that flexibility reduces work–family conflict (Ala-Mursula et al., 2004; Byron, 2005; Janssen & Nachreiner, 2004). Moreover, the positive impact of perceived flexibility is greatest among workers whose spouses are in full-time employment (Grzywacz et al., 2008), which probably also reflects the benefits of flexibility on managing childcare. However, it also seems that the existence of such gender differences is contingent on societal factors and cultural norms. A Swedish study found both women and men benefited equally from increases in work hours flexibility (Leineweber et al., 2016). This was ascribed to Sweden’s relatively high numbers of women working full time, its system of guaranteed subsidized childcare and its high levels of equality between women and men, with many men sharing responsibilities for household demands. While women are often regarded as having most to gain from flexibility, flexible work hours can also be seen as a way of putting the onus for childcare on the individual, usually women, while absolving the State of responsibility (Joyce et al., 2010). It may, therefore, result in negative consequences for some women. For example, women may end up engaging in more non-work responsibilities, rather than using the increased control and time to lower stress and strain outcomes (Hammer et al., 2005; Hartig et al., 2007). As a result, their recovery may be impaired and they may experience increased work–life conflict. This in turn may negatively affect marital relationships and parenting, thus increasing sleep problems, chronic fatigue and psychosomatic problems (Costa, 2010), with potentially negative consequences for mental health (Allen et al., 2000). Another potential disadvantage of flexible work for women is that women may use it to reduce their paid work hours as an alternative to using flexibility to take on excessive work and non-work responsibilities. This could adversely affect gender equality, since it increases the number of women in part-time employment (Plantenga & Remery, 2009). The potential negative effects for women of flexible work hours were highlighted by our study described above (Hall et al., 2019), in which women (but not men) who worked flexible hours were found to be at substantially increased risk of antidepressant use, compared with their counterparts working regular daily hours. The question in our survey about flexible working did not explicitly differentiate between variability and flexibility and so it is possible that respondents experiencing either type of arrangement (or both) would be placed in this category of work schedule.

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However, several strands of evidence suggested that employee-orientated flexibility was relatively high among respondents in this category. The proportion of respondents with managerial roles was higher than in the entire SLOSH sample and the occupational categories were those typically associated with high work time control and boundaryless working (e.g. professionals, technical and associated professionals, legislators). Thus, the study provided the first evidence of an association between boundaryless work and objectively measured mental ill health.

8.2.4

Conclusions on Flexible Work Hours

The weight of available evidence suggests that while the health effects of employerorientated flexible work hours (‘variability’) are most likely to be negative, employee-oriented flexible work hours (‘flexibility’) are most commonly associated with positive and protective health effects. Work–life balanced is thought to play a major role in these associations and hence women who take on a greater share of the domestic burden (e.g. childcare) may be most affected by having flexible work hours. Boundaryless work is a form of flexibility most commonly associated with knowledge-intensive work and where there is potential for negative effects, for example, if workers choose to take on excessive amounts of work (in and out of formal work hours). Thus, it may be important to provide employees in these types of jobs (and their supervisors) with guidance on how flexible working practises should be introduced and managed. This could include training employees about the importance of recovery and teaching techniques to promote unwinding and ‘psychologically detaching’ from thoughts about work in the evenings (Lisspers et al., 2014). Managers should promote an appropriate balance between the use of communication technologies that allow employees to be contactable 24/7 and employees’ non-work life (Field & Chan, 2018).

8.3

Long Weekly Work Hours

Working many hours per week (for instance > 48 h) reduces the amount of time available outside work (e.g. in the evenings) for rest and recovery. Workers will experience a greater need for recovery, resulting from the prolonged exposure to work stressors, together with reduced opportunity to achieve that recovery. As a result, long weekly work hours tend to be associated with shorter and more disturbed sleep (Virtanen et al., 2009). This is due to the restricted time available, not just for sleeping but also for relaxation during leisure time. Being unable to fully relax and unwind can lead to increased sleep disturbance. The impairment of recovery between workdays is also thought to underlie at least some of the health problems that are associated with long weekly work hours (Geurts & Sonnentag, 2006), such as cardiovascular disease (Virtanen & Kivimaki, 2018). According to the sixth

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European Working Conditions Survey (Eurofound, 2016), while men are more likely than women to work more than 40 h a week (31% versus 15%), men are less likely than women to work less than 35 h a week (16% versus 41%). Perhaps surprisingly, despite the often-cited double burden of paid and non-paid work that many women are said to experience, there is little clear evidence that women’s health is more negatively affected by long weekly work hours than is men’s. Systematic reviews involving meta-analyses have concluded that there are no differences between men and women with regard to associations between long work hours and coronary heart disease, stroke (Kivimaki et al., 2015), depression (Virtanen et al., 2018) or alcohol use (Virtanen et al., 2015). Given that women (in the EU) are more likely than men to work short hours (e.g. part-time work), it is worth briefly considering the potential implications for health of working part time. One of the few studies in this area to examine gender in relation to part-time working found that while women working 25 h or less per week reported significantly less need for recovery than those working 36–40 h per week, among men, those working shorter hours reported greater need for recovery (Jansen et al., 2003). This gender difference was ascribed to the different reasons that men and women work part time, with men in this category being more likely than women to be suffering long-term health problems.

8.4

General Conclusions

This review has found mixed evidence as to whether women’s health and safety is more negatively affected by demanding work hours than men’s. Nonetheless, several issues have been identified which highlight the need to pay particular attention to the well-being of women who work non-standard hours. In many societies, women still undertake the lion’s share of domestic chores such childcare and household management. Thus the ‘double burden’ of demanding work hours and domestic workload is likely to be a significant stressor for many women. Protective countermeasures with the potential to mitigate this stressor include: (1) provision of adequate childcare support (e.g. state subsidized) and other measures that promote gender equality; (2) educational programmes that raise awareness of the importance of recovery and ways of achieving it; and (3) designing work schedules according to ergonomic principles, so as to minimize disruption of sleep and circadian rhythms, minimize the accumulation of fatigue and maximize opportunities for recovery (Tucker & Folkard, 2012). Acknowledgments Thanks to Constanze Leineweber for her insightful comments on an earlier draft.

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Puttonen, S., Harma, M., & Hublin, C. (2010). Shift work and cardiovascular disease – pathways from circadian stress to morbidity. Scandinavian Journal of Work, Environment & Health, 36 (2), 96–108. Rao, D., Yu, H., Bai, Y., Zheng, X., & Xie, L. (2015). Does night-shift work increase the risk of prostate cancer? A systematic review and meta-analysis. Oncotargets and Therapy, 8, 2817–2826. Ryu, J., Jung-Choi, K., Choi, K. H., Kwon, H. J., Kang, C., & Kim, H. (2017). Associations of shift work and its duration with work-related injury among electronics factory workers in South Korea. International Journal of Environmental Research and Public Health, 14(11), 1129. Saksvik, I. B., Bjorvatn, B., Hetland, H., Sandal, G. M., & Pallesen, S. (2011). Individual differences in tolerance to shift work--a systematic review. Sleep Medicine Reviews, 15(4), 221–235. Santhi, N., Lazar, A. S., McCabe, P. J., Lo, J. C., Groeger, J. A., & Dijk, D. J. (2016). Sex differences in the circadian regulation of sleep and waking cognition in humans. Proceedings of the National Academy of Sciences of the United States of America, 113(19), E2730–E2739. Schernhammer, E. S. (2017). RE: Night shift work and breast cancer incidence: three prospective studies and meta-analysis of published studies. Journal of the National Cancer Institute, 109(4). https://doi.org/10.1093/jnci/djx002. Schwarz, J., Lindberg, E., & Kecklund, G. (2015). Sleep as a means of recovery and restitution in women: The relation with psychosocial stress and health. In K. Orth-Gormer, N. Schneiderman, V. Vaccarino, & H. Deter (Eds.), Psychosocial stress and cardiovascular disease in women (pp. 105–127). Springer. Slany, C., Schutte, S., Chastang, J. F., Parent-Thirion, A., Vermeylen, G., & Niedhammer, I. (2014). Psychosocial work factors and long sickness absence in Europe. International Journal of Occupational and Environmental Health, 20(1), 16–25. Smith, P. M., Ibrahim-Dost, J., Keegel, T., & MacFarlane, E. (2013). Gender differences in the relationship between shiftwork and work injury: Examining the influence of dependent children. Journal of Occupational and Environmental Medicine, 55(8), 932–936. Sonnentag, S., & Fritz, C. (2015). Recovery from job stress: The stressor-detachment model as an integrative framework. Journal of Organizational Behavior, 36, S72–S103. Sverke, M., Falkenberg, H., Kecklund, G., Magnusson-Hanson, L., & Lindfors, P. (2016). Kvinnors och mäns arbetsvillkor: Betydelsen av organisatoriska faktor och psychosocial arbetsmiljö för arbets och hälsorelaterade utfall. [Women’s and men’s working conditions: The importance of organizational factors and psychosocial work environment for work and health-related outcomes]. Arbetsmiljöverket [Swedish Work Environment Agency]. Takahashi, M. (2012). Prioritizing sleep for healthy work schedules. Journal of Physiological Anthropology, 31, 6. https://doi.org/10.1186/1880-6805-31-6. Thun, E., Bjorvatn, B., Torsheim, T., Moen, B. E., Mageroy, N., & Pallesen, S. (2014). Night work and symptoms of anxiety and depression among nurses: A longitudinal study. Work and Stress, 28(4), 376–386. Torquati, L., Mielke, G. I., Brown, W. J., & Kolbe-Alexander, T. (2018). Shift work and the risk of cardiovascular disease. A systematic review and meta-analysis including dose-response relationship. Scandinavian Journal of Work, Environment & Health, 44(3), 229–238. Torquati, L., Mielke, G. I., Brown, W. J., Burton, N. W., & Kolbe-Alexander, T. L. (2019). Shift work and poor mental health: A meta-analysis of longitudinal studies. American Journal of Public Health, 109(11), e13–e20. Travis, R. C., Balkwill, A., Fensom, G. K., Appleby, P. N., Reeves, G. K., Wang, X. S., et al. (2016). Night shift work and breast cancer incidence: three prospective studies and metaanalysis of published studies. Journal of the National Cancer Institute, 108(12), djw169. Tuchsen, F., Christensen, K. B., & Lund, T. (2008). Shift work and sickness absence. Occupational Medicine (London), 58(4), 302–304. Tucker, P., & Folkard, S. (2012). Working time, health and safety: A research synthesis paper. International Labour Organization.

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Tucker, P., Peristera, P., Leineweber, C., & Kecklund, G. (2020). Can psychosocial working conditions help to explain the impact of shiftwork on health in male- and female-dominated occupations? A prospective cohort study. Chronobiology International, 37(9-10), 1348–1356. van Drongelen, A., Boot, C. R., Hlobil, H., van der Beek, A. J., & Smid, T. (2017). Cumulative exposure to shift work and sickness absence: Associations in a five-year historic cohort. BMC Public Health, 17(1), 67. Virtanen, M., Ferrie, J. E., Gimeno, D., Vahtera, J., Elovainio, M., Singh-Manoux, A., et al. (2009). Long working hours and sleep disturbances: The Whitehall II prospective cohort study. Sleep, 32(6), 737–745. Virtanen, M., Jokela, M., Madsen, I. E., Magnusson Hanson, L. L., Lallukka, T., Nyberg, S. T., et al. (2018). Long working hours and depressive symptoms: Systematic review and metaanalysis of published studies and unpublished individual participant data. Scandinavian Journal of Work, Environment & Health, 44(3), 239–250. Virtanen, M., Jokela, M., Nyberg, S. T., Madsen, I. E., Lallukka, T., Ahola, K., et al. (2015). Long working hours and alcohol use: Systematic review and meta-analysis of published studies and unpublished individual participant data. BMJ, 350, g7772. Virtanen, M., & Kivimaki, M. (2018). Long working hours and risk of cardiovascular disease. Current Cardiology Reports, 20(11), 123. Wang, X., Ji, A., Zhu, Y., Liang, Z., Wu, J., Li, S., et al. (2015). A meta-analysis including doseresponse relationship between night shift work and the risk of colorectal cancer. Oncotarget, 6 (28), 25046–25060. Wang, F., Zhang, L., Zhang, Y., Zhang, B., He, Y., Xie, S., et al. (2014). Meta-analysis on night shift work and risk of metabolic syndrome. Obesity Reviews, 15(9), 709–720. Wegrzyn, L. R., Tamimi, R. M., Rosner, B. A., Brown, S. B., Stevens, R. G., Eliassen, A. H., et al. (2017). Rotating night-shift work and the risk of breast Cancer in the Nurses’ health studies. American Journal of Epidemiology, 186(5), 532–540. Wong, I. S., McLeod, C. B., & Demers, P. A. (2011). Shift work trends and risk of work injury among Canadian workers. Scandinavian Journal of Work, Environment & Health, 37(1), 54–61.

Dr. Philip Tucker is an associate professor at the Psychology Department, Swansea University and a guest researcher at the Stress Research Institute of Stockholm University. His research focuses on the impact of working time arrangements (e.g. shiftwork, overtime and work time control) on employees’ health and safety.

Chapter 9

The Interplay Between Gendered Norms and New Public Management Strategies in the Shaping of Homecare Services’ Work Environments Annika Vänje

9.1

Introduction

In this chapter, publicly provided homecare services’ work environments are explored in the light of organisational preconditions, social constructions of gender and the prevailing management concept—new public management (NPM). The context and approach is of interest as homecare services constitute a complex and vast gender-segregated work environment where the work takes place in different contexts, including private homes, during transportation and at the municipalities’ work premises. Moreover, the current demographic development and longer life expectancy calls for the expansion of this work sector. However, today we see high rates of sick absences amongst the women-dominated public sector, and the most common diagnosis for these absences are stress-related diseases. The latter can be seen as a signal of organisational and social work environment deficiencies, and calls for a need to develop more sustainable jobs in this sector (EU-OSHA, 2019). Previous research has provided us with insights about common work environment risks and what these organisational deficiencies can be about (Aronson & Neysmith, 1996; Delp et al., 2010; Denton et al., 2002). The aim of this chapter is to provide new insights, mainly from an organisational perspective, on how social values regarding gender and NPM strategies shape homecare services’ physical and organisational work environments, as well as identify what kinds of changes that are needed in order to create more sustainable work environments for employees in this work area. Data from two action-oriented research projects on homecare services undertaken in the Swedish public sector will serve as examples from practice. The results from these projects are relevant for organisations outside the Swedish A. Vänje (*) Division for Ergonomics, KTH Royal Institute of Technology, Stockholm, Sweden e-mail: [email protected] © Springer Nature Switzerland AG 2021 B.-I. Keisu et al. (eds.), Gendered Norms at Work, Aligning Perspectives on Health, Safety and Well-Being, https://doi.org/10.1007/978-3-030-77734-0_9

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context, not the least because public steering concepts and sick absence rates for women follows the same trends in the western European Union (EU) (EU-OSHA, 2019; Försäkringskassan, 2020; Pollitt & Dan, 2011).

9.2

Theoretical Framework

This section covers, the following theoretical themes: NPM from different angles, gender and gender equality in the work environment; changes in homecare service work organisations; and management of organisational shortcomings. In order to provide a holistic understanding of the concept and to place home care service work in an organisational context, examples of NPM implemented in different business orientations are given in this section.

9.2.1

New Public Management from Different Angles

NPM (Brignall & Modell, 2000; Hood, 1995) gained a foothold during the 1980s and was developed by countries such as the United Kingdom, the United States and New Zealand, out of a political wish to move away from what was seen as resource demanding planning towards a more business-like (Pollitt & Dan, 2011: 4) governance of the public sector. From an overall perspective this new way of steering was based on rationality and performance management (Keisu et al., 2016; Williamson et al., 2020), for instance implementing competition within the sector through procurements, customer-oriented strategies and follow-ups based on quantitative key figures (Pollitt & Dan, 2011: 5). NPM can be described as a management concept heavily influenced by the private engineering sector’s lean production (Pil & Fujimoto, 2007), even if that concept is not only based on rationality and saving resources but also inherited qualitative and value-oriented perspectives (Fujimoto, 2012; Pettersen, 2009; Vänje & Brännmark, 2017) aiming at organisational and individual learning. Even if NPM has the intention to include the latter, it is often neglected due to a strong focus on cutting costs and short-term business visions. Previous research on gender and NPM organised work has targeted different areas, for example higher education (Thomas & Davies, 2002), voluntary care work (Carvalho & Santiago, 2009), elderly care (Keisu et al., 2016) and public services (Williamson et al., 2020). This has resulted in knowledge on how care workers and their managers, as well as women academics, struggle with interpreting NPM in terms of good working conditions that are also grounded in established cultural factors and professional identities (Keisu et al., 2016; Thomas & Davies, 2002). Previous research about NPM in relation to gender shows that gendered stereotypes are often reproduced in NPM organisations and can coexist in the same context, meaning that a gender-segregated organisation does not necessarily have to be either feminised or masculinised (Glinsner et al., 2019). Further, Williamson et al. (2020)

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have provided us with insights to how a mismatch between an organisations’ NPM strategies and gender equality policies hinder a successful implementation. We also know that NPM in its striving for efficiency exploits workers through factors such as resources which are too limited and the fragmentation of work tasks (Baines & Cunningham, 2011). This leads to the fact that employees such as homecare service workers become exposed to more risks at work, as a result of not being able to work according to the requirements of the job nor develop their professionalism (Baines & Cunningham, 2011).

9.2.2

Gender and Gender Equality in the Work Environment

Social constructions of gender are of interest, as research and practical examples show that gender equality is a prerequisite for a healthy workplace (Hensing & Alexanderson, 2004). However, there remains a lack of scientific knowledge about gender and its relation to the work environment and workers’ health (Vänje, 2017). One reason of this knowledge gap is that research on occupational safety and health derives from the male-dominated engineering sector and its occupational health services. Moreover, due to scientific traditions (Armstrong & Messing, 2014) based in natural, technical and medical sciences, there has been little focus on the work environment as a whole, in favour of knowledge about how to work reactively on separate work environment risks. However, in order to meet the societal need of increased homecare services capacity, there is a profound need for work environment development that paves the way for gender-equal, attractive and sustainable jobs. A processual view on gender is here applied when analysing the examples from practice, meaning that social constructions of gender are seen as asymmetrical and constantly ongoing practices on macro-, meso- and micro-levels in our society and working lives (Vänje, 2005). This is an approach that opens up the space for seeing variations of gender as well as more subtle interactions between women and men, affected by organisational structures and intersections (West & Fenstermaker, 1995) such as social class and race (Nash, 2014). As highlighted in this book’s introduction chapter, as well as by Acker (2006), gender is not binary, but is constructed through constantly ongoing processes including dimensions such as age, race, social class and sexuality. The concept of gender equality is here interpreted as a result of the work for practical change to create quantitative and qualitative equality between the sexes in organisations and in society at large (Regnö, 2013). In the EU’s latest gender equality strategy, it is stated that ending gender-based violence and stereotypes, ensuring equal participation and opportunities in the labour market, including equal pay, and achieving gender balance in decision-making and politics are the goals for gender equality work from 2020 to 2025 (Commission E, 2020). This means that the distribution of power between the sexes as well as the distribution of women and men on different levels of an organisation (Hirdman, 1988) are in focus when

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discussing gender equality. Sweden is an interesting context, in the sense that despite a gender-equal representation of women and men in the government and in the labour market, it is still one of the most gender-segregated countries within the EU. This is a situation, which can be described in terms of a tension between genderequality policies and the practice of doing gender. While the state itself fulfils the policy of equal distribution of women and men in the highest decision-making level, at the same time strong gendered norms in society clearly affect images and expectations of what sectors women and men work in (Abrahamsson & Gonäs, 2014). These social constructions of gender is followed by an uneven distribution of resources, in favour of the more status-filled male-dominated technical work areas. In turn, this results in fewer resources being allocated to the women-dominated welfare sector, and is one reason why it has to find ways to reduce costs. However, it is important to keep in mind that sick absences, difficulties to recruit and poor working conditions generates costs for the individual as well as for the employer/ organisation (Sandkull, 2008), and have a negative effect on production quality (Eklund, 2000).

9.2.3

Changes in Homecare Service Work Organisations

Homecare services have undergone some major changes in the last decades, to a vast extent depending on the implementation of NPM strategies. According to Pollitt’s and Dan’s (Pollitt & Dan, 2011) meta-analysis of NPM implemented in Europe, practical steering tools used include measurements of outputs, lean inspired organisations such as Lean Healthcare, hierarchical organising and practicing of user choice mechanisms and seeing citizens as customers (Pollitt & Dan, 2011: p. 5). In line with this ideology are the neoliberal ideas of marketisation on organisational as well as individual levels. This is manifested in a bureaucracy where the organisations’ and their individual members’ performances are constantly evaluated, leading to a situation where individual employees become responsible for the outcomes. Translated into work environment management, this feeds a blaming culture where the organisations’ members are held responsible for their own health at work (Dekker, 2014). Due to neoliberal ideas as objective guiding principles and tangible performance targets, there is little room for a professionalism grounded in subjective and relational dimensions—the kinds of aspects that are important and which constitute an essential part of homecare service work at home (Benoit & Hallgrimsdottir, 2017). Accordingly, business visions are built on quantitative ideals that are implemented through strategies that leave less space to develop ‘deeper values’ that go beyond objective efficiency. A longitudinal survey from 2005 and 2015 regarding working in homecare shows that the proportion of men working in homecare has tripled, of which approximately 20% were born abroad; more have longer formal training; and that more work full time (52.9%) (Strandell, 2020: pp. 140–141). Further, the number of visits to

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different care receivers have both increased and been more fragmented during the period, and the proportion of those feeling they had too much to do was still high (40%) (Strandell, 2020). These results support previous studies highlighting that NPM increases the intensity of work at the same time as workers’ space for managing the unforeseen and emotional aspects become severely limited (Kamp et al., 2013; Twigg et al., 2011). These are the results of marketisation and neoliberal ideals, which lead to high physical and emotional pressure on concerned workers (Strandell, 2020). These changes, together with how they shape working conditions, are presented as an overall picture in this book, in the introduction (Chap. 1; Keisu, Brodin and Tafvelin), in more detail in Chap. 7 (Holgersson and Östlund) in terms of reasons for why digitalisation is not adjusted to the work environment and in Chap. 8 (Storm and Stranz) regarding how the implementation of NPM techniques such as auditing affects the mundane work in nursing homes. Another organisational change concerns the character of the work and the fact that the publicly provided household services has extended to include caregiving to multi-sick citizens in their homes. This change means that care for older people with diseases which are not too complicated is transferred from hospitals’ costly medical settings to less expensive private or residential homes (Purkis et al., 2011). This is followed by the fact that it is more common today that individuals with medical care needs are granted publicly provided homecare services in their own homes (Szebehely, 2005). To this is added that NPM-like steering strategies result in the fact that tasks such as emotional labour (Hochschild, 1990), household services and distribution of medicines have to be provided at a prior stipulated time, not taking the unexpected into account. Explanations as to why these shortcomings in the work environment arise are complex, and inherit dimensions such as gendered societal values, gendered expectations and lack of organisational values. Gendered societal values concern the fact that women’s work in private homes is still not self-evidently a profession, as it comprises work tasks which were earlier, and in some countries still are, unpaid household labour (Erickson, 2011) performed by women. Even if a majority of those working in homecare services are professionally trained assistant nurses, these values prevail. Indirectly, this leads to a situation where the work itself is not valued by the employers in the public sector according to (1) the requirements and needs of financial, material and time resources; as well as (2) necessary professional skills. The increasing amount of old people in the EU and the increasing life expectancy means that homecare services is a sector that has to expand in the near future. To complicate this further, in recent years there has been a low interest among young people to be trained as an assistant nurse. Yet, there is a tendency for change in interest today due to the Corona pandemic (OECD, 2020), which on a global level has highlighted the extensive needs of well-functioning eldercare.

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To Manage Organisational Shortcomings

The steering and organising of today’s public homecare services rest to a large extent on an idea that resembles Taylorism (Taylor, 1911), where the principle of management’s control over the work and the work process was essential. This results in a low degree of, and space for, employee participation when it comes to practices such as budgeting, work planning and scheduling of the everyday work. This occurs despite the fact that management at higher levels often have little or no knowledge of the complexity of daily routines and practical homecare service work. In Sweden, the concept of trust-based steering has been launched by the government as an answer to perceived deficiencies in the NPM system, and to counteract this low degree of participation and non-sensitivity to the complexity by providing space for trust in the management system (SOU, 2017). Trust-based steering is defined in a government publication (SOU, 2017) as giving more space for professionals’ own judgements, openness in terms of relying on colleagues and as managing your co-workers. Another item on the list of trust-based steering’s characteristics is to put the citizens in focus as customers, and to be open and responsive to their needs (SOU, 2017). In order to be able to meet future competence needs due to the demographic changes, three main strategies (Umegård, 2017) have been developed by the employers’ umbrella organisation (SKR) for the public sector and regions in Sweden: – The first strategy is labelled ‘more work more’ and it aims to increase the degree of employment of public employees by having more full-time workers. – The second is labelled ‘extended working life’ and aims to increase the retirement age by 2 years. – The third is labelled ‘use the technology’ and aims to increase efficiency at work. As can be seen, all three of these strategies aim for better efficiency in performance, leaving qualitative issues such as development of the work environment and complexities of care work behind. A vital prerequisite for creating trust in work organisations is gender equality and gender awareness, as these two dimensions open up the space for democracy and understanding power relations and power structures in organisations. Without understanding what role power and inequality regimes (Acker, 2006) play in organisations’ everyday lives, it is more or less impossible to change the organisation or value of work (Abrahamsson, 2000). By identifying who interacts with whom in an organisation, and when they do so, we can draw maps and illuminate formal and informal power relations (Acker, 1990; West & Fenstermaker, 1995; West & Zimmerman, 1987). When analysing these kinds of power structures it is important to critically reflect on issues such as what positions and gender do the participants taking part in a formal meeting have, or why some employees or managers do not take part in certain meetings or do not raise their voices at meetings. Interactions between members and between members and the

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structures contribute to the construction of gender-based expectations within the organisation (West & Fenstermaker, 1995), as well as the distribution of power. Previous research has shown that the doing of gender through interactions between individuals is also present in gender-segregated work environments (Abrahamsson & Gonäs, 2014). One reason for this is that values regarding women and men in society and in the labour market are mirrored in the workplace, which contributes to the construction of the prevailing gendered norms in organisations. This occurs as a strong norm relating to the represented gender arises, based on practices that seem to be the only option due to the absence of variations (West & Fenstermaker, 1995) of femininities and masculinities. From strong social norms follow difficulties for new groups to be seen and valued for their differences (West & Fenstermaker, 1995) in relation to the prevailing gender norms. One example is how men entering homecare services can take on a hybrid masculinity (Cottingham, 2019) in terms of balancing expected macho-like values with the personal wish to work with care and relational work. According to Cottingham (2019), this is a way to tackle prevailing organisational values and interactions with individual practices.

9.3

Data and Methods

Two different action-oriented research (Berge & Ve, 2000; Maguire, 2006; Reason & Bradbury, 2001) projects constitute the empirical basis of this chapter. The first project ran from 2013 to 2016 (Nord Nilsson & Vänje, 2018), where one aim was to identify sector-specific knowledge about publicly provided homecare services’ work environments. A 1-year-long cooperative inquiry (Heron & Reason, 2001; Van Lith, 2014) was performed in collaboration with three different municipalities within the same region in Sweden and their occupational health service. All in all, it included 12 active participants (of which a majority were women) employed as first-line managers, homecare service workers who also held a position as safety representatives, occupational health service staff and two researchers. The data from the cooperative inquiry was validated through different methods such as joint reflections on the researchers’ interpretations, which were presented live to the whole inquiry group on several occasions. In detail the data was thematically analysed on an empirical grounding (Braun & Clarke, 2006), resulting in that five common recurring patterns were recognised and came to form overarching themes. The second project was started in 2017, and was to end in 2020, and aimed to develop gender awareness in gender-segregated work environments through interand intra-organisational learning. It includes publicly provided homecare services and technical maintenance in two municipalities as well as the Swedish Work Environment Authority (SWEA). Participating actors are homecare service workers, managers on different levels in the municipalities, union representatives as well as inspectors and specialists working at SWEA. The methodological approach includes semi-structured interviews, dialogue seminars and to-date two analysis seminars (with between 32 and 50 participants on each occasion). Also in this project the

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data is being analysed thematically (Braun & Clarke, 2006) by hand or in the Nvivo Pro 12 software package, and to-date it consists of five patterns. The findings presented in this chapter are based on a merging of the in total 10 themes that have emerged in the two projects described above. The analytic procedure is consistent and can also in this case be described as thematic, using existing theories and the processed data as a basis (Braun & Clarke, 2006). More specifically the aim has here been to explore how social values regarding gender and NPM strategies shape homecare services’ physical and organisational work environments. For this, the researcher’s subjectivity in terms of being well acquainted with previous performed analysis (project one and two) can be considered an asset as it enabled in-depth understanding (Clarke & Braun, 2018). In detail, the thematic analysis can be described as organic, consisting of reading the material several times and looking for patterns, consisting of essences or stories that in some way have something in common (Clarke & Braun, 2018). In line with what Braun and Clarke (2006) stress, the theories used here contribute to set the scene for the analytic procedure, and accordingly for the presented interpretations. In this case, the analytic procedure resulted in five identified patterns which form the five labelled themes that are presented in the next section. In addition, there has been an openness to differences and contradictions concerning the essence within the different themes.

9.4

Examples from Practice

The two projects’ data about the work environments and work organisations with relevance for NPM will be presented in this section. In focus is the five emerged themes: a balancing act, doing gender and the organisational work environment, emotional labour and inadequate work descriptions, a work environment sensitive to the employees’ needs and lack of organisational values.

9.4.1

A Balancing Act

In our research cases, building trust with the care recipients and being there for them was, in both projects, a clear and articulated motivator for working in homecare services. However, the homecare service workers did not talk about what needs they had for being able to do this relational work in what would be for them a sustainable manner. Instead, they saw themselves as having to be skilled in dealing with limited resources and manage all kinds of unforeseen events that constantly occur in homecare service work. Examples from practice are not just about providing care and service to people in their homes, but also how problems with care during the winter and having to shovel snow to gain access to care recipients’ houses had to be dealt with in the moment. These are events, which takes time, and are not included in the formal time schedule.

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Women’s skills in providing care and service was in general perceived as given by nature and not obviously as professional competence. These ideas about gender in combination with NPM-inspired performance management can be said to subsidise the municipalities’ existing gender order (Keisu et al., 2016). Leading to the fact that emotional care work (Hirvonen, 2014) is not valued for its complexity, followed by limited resources and no or deficient work tools. Examples of the latter includes how cleaning devices owned by the care recipients were used, which was taken for granted even if they varied in quality and affected the possibility of doing the work properly. This can be compared with, for instance, carpenters, who always have their own tools when visiting customers. Moreover, we have seen a lack of functional work clothing as well as simple and spartan work premises. Appointed safety representatives representing homecare service workers articulated that they had not received any training for holding this formal role. Consequently, they did not know how to take measures and counteract work environment deficiencies, or work preventatively. Additionally, systematic work environment management, which in Sweden is formalised, was not on the agenda.

9.4.2

Doing Gender and the Organisational Work Environment

The meaning of gender in our research cases also pinpointed what can be described as contempt against women, articulated by the women themselves. In practice, the female homecare service workers did not refer to female colleagues in positive terms during the individual interviews in two of the municipalities. Further, the women in one of the municipalities described their work culture as consisting of strong social norms and expectations, which meant that they felt suppressed. Male colleagues were, in the capacity of representing the minority, seen as being able to bring in new social values and by this counteract the prevailing norm. In her dissertation on female leaders in the public sector, Regnö (2013) has identified this phenomena and labels it as glorification of men. The first-line managers were in one of the research cases very clear about their position, in relation to their co-workers. One example is how they took interpretative prerogative over the homecare service workers during group presentations in a dialogue seminar. In this specific situation, the homecare service workers were articulating what they perceived as deficiencies in the work environment, when their first-line managers directly raised their voices. This hierarchy between the workers and their first-line managers was also manifested by the fact that acting managers were clear that they did not work in the care recipients’ homes after being promoted.

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Emotional Labour and Inadequate Work Descriptions

Today, according to our data there is often no time for regular work meetings where the workers have the opportunity to support each other, share experiences and exchange knowledge about the care recipients. This can be interpreted as a result of the higher management levels’ lack of insight regarding what homecare service work is really about. In practice this means that debriefing emotional burdens (Hochschild, 1990), such as from being harassed by care recipients, taking care of people with dementia or problems with addictions, in combination with not having enough time to complete the job in line with the self and one’s values, rarely occurs. Emotional burdens are therefore placed on top of one other, resulting in not just stress-related diseases and sick absences, but also allowing a hotbed of conflicts in the work environment to easily emerge due to these shortcomings (see also Chap. 11 by Keisu and Tafvelin). Not to be valued according to one’s real competence is something that has been highlighted by the homecare service workers in both of our projects. Manifested in practices such as work scheduling based on geographical key figures, and not on a match between the homecare service workers’ competence and the homecare recipient’s needs. Further, professional judgements and decisions are often made individually, based on personal values, due to this lack of common organisational values concerning gender equality. This is also confirmed by the Swedish Work Environment Authority’s evaluation of inspections of elderly care (some of the inspectors were part of our research), where one of the main conclusions was the prevalence of invisible and undefined work tasks (Arbetsmiljöverket, 2020). This lack of clarity in what is included in the job in turn leads to stressful situations and unnecessary emotional burdens.

9.4.4

A Work Environment Sensitive to the Employees’ Needs

For today’s workers and first-line managers in public homecare services, trust-based steering is something vague and far removed from their everyday working life. Instead, their daily work has for decades been characterised by NPM-inspired strategies, which has coloured the organisational culture in different ways. This became apparent during a workshop in one of the municipalities, when reflecting on the Swedish state’s wish to counteract the negative aspects of NPM by opening up the space for trust in terms of a higher degree of participation and openness for professional experiences in the organisation. A pronounced dilemma was for the participating first-line managers and homecare service workers to understand what trust meant for them in their daily work. For instance, many asked in which ways trust could be part of their interactions with their colleagues. For them, the care recipients always had and always will come first. However, at the same occasion it was articulated that there was nearly no time for exchanging experiences or

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discussing professional issues with colleagues during an ordinary workday. In this sense, trust was in practice reduced to an abstract word not easily translated into the daily work. In our cases, we have seen that citizens in the role of care-receiving customers, in the NPM-organised municipalities, really are the homecare service workers’ focus and concern, manifested in a femininity where caring of others is one of the most important aspects and where the self easily comes in second. To further reinforce the care receivers’ role as a customer by enhancing the importance of trust in those interactions would, in other words, rather reinforce the prevailing femininity, than open up the space for change and create a work environment sensitive to the workers’ and first-line managers’ needs.

9.4.5

Lack of Organisational Values

Unclear organisational values lead to a situation where individual standpoints in gender equality issues are brought into the daily work, and indirectly create individual differences in professional judgements of how work tasks should be performed. Additional examples from practice are how one work group can let care recipients decide on the sex of ‘their’ homecare service worker, at the same time as another work group have developed their standpoint regarding gender equality and are clear about how to respond to such demands. There are also examples in our research of how homecare service workers and first-line managers adjust work tasks depending on the workers’ gender.

9.5

Three Different Organisational Dilemmas

Above all, our findings disclose three different dilemmas that have to be dealt with when aiming for sustainable work environment improvements in NPM-organised homecare services (Fig. 9.1). They concern (1) organisational imbalances between the management system and the character of the work, (2) the need of going beyond the prevailing gendered norm in order to change how organisational resources are distributed, as well as (3) organisational imbalance between the NPM systems’ one-sided focus in measurable results and the need of organisational learning and work environment development. All three dilemmas can be seen as results of the interplay between organisational preconditions, social constructions of gender and NPM strategies in the shaping of the work environments. The first dilemma can be described in terms of an incoherent logic between the NPM-inspired system and the character of homecare work. Where NPM aims to rationalise the operations at the same time as homecare work needs resources for being able to conduct non-tangible tasks as caring (Husso & Hirvonen, 2012). One identified organisational imbalance that directly or indirectly has an impact on the

168 Fig. 9.1 Three different strategies that in a sustainable way contribute to counteracting the organisational imbalances and the inequality regimes that generate negative consequences in home care work environments

A. Vänje

A management system aligned to the character of the work. Including empowerment strategies and employee participation.

Structures for organisational and individual learning. To open up for development of the organisational and individual competence.

Gender awareness. To move away from traditional gendered values and open up for sustainable work environment improvements.

work environment is the coexistence of inadequate work descriptions and detailed time management. It has been evident in previous research and in practice that public homecare organisations’ blurry demands and expectations create unsustainable jobs and inadequate work environments (Denton et al., 2002; Szebehely, 2005). Unforeseen events are mundane and often solved with what can be called invisible work tasks (Messing & de Grosbois, 2001). These kinds of invisible work tasks are, due to their character, not formalised and they therefore constitute work environment risks (Vänje, 2017). In homecare services these risks are both of a physical character, such as helping the care recipient with hanging curtains or heavy lifting such as moving furniture, and of an emotional character due to difficulties in setting bodily and/or social boundaries between the private and public (Fine, 2005). These different kinds of risks have in common that they are undertaken due to rationalities such as inadequate resources and fragmentation of work tasks in NPM (Baines & Cunningham, 2011; Husso & Hirvonen, 2012). Gendered expectations such as being loyal and caring (Aronson & Neysmith, 1996; Husso & Hirvonen, 2012) to the care recipient are other explanations as to why workers and managers in homecare service carry out these informal practices even if they can be risky and are not valued by their employer. One contradiction that follows from these imbalances creates a dilemma for the first-line managers, as they are squeezed between, on the one hand, demands from upper management based on a lean organisation with continuous follow-ups of key performance indicators, and on the other hand, a wish to provide a good work environment for their co-workers and to deliver quality of care. Previous research has shown that managers with limited resources and no platform to act from are not self-evidently part of the organisation’s empowerment structures, and therefore must struggle to keep their own position and resources (Kanter, 1993). In this sense the first-line managers in our cases were stuck between, on the one hand, limited

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resources and a subordinated femininity that included being loyal to the system (Keisu et al., 2016), and on the other hand, difficulties when making demands to higher management levels for resources to improve working conditions. The business itself is time-consuming and the NPM inspired organisations rely to a large extent on these women’s emotional commitment (Fisher, 2007; Rasmussen, 2004) to the care recipients and loyalty to the employer. Resulting in that employees take individual responsibilities and tries to even the imbalances between formally available resources and care recipients’ personal needs, at the expenses of one’s own well-being. The second dilemma concerns a logic, where going beyond the prevailing gendered norm is needed in order to change how organisational resources are distributed. Interactions between the organisations’ members and, in this case, the care recipients, were coloured by individuals’ social habitus (Bourdieu, 1977) and constructions of the self (Korvajärvi, 1998; Vänje, 2005). According to Bourdieu (1977), the social habitus consists of individuals’ present and current social standing, which indirectly sets the frames for how the person in question interacts at work. In this sense, the social habitus interplays with the social constructions of gender. During the action-oriented research approaches it was obvious that the female homecare service workers had a gendered social habitus that included a subordinated standing and to be a trustful, warm and caring person (Erickson, 2011) in the interactions with care recipients. Consequently, values beyond the measurable were an important part of the daily work. Putting clear demands and ask for resources to managers would mean to not act according to what is expected from homecare professionals, and could result in that employers’ and colleagues trust in them is jeopardised. One way out of this dilemma is to develop formal organisational structures which opens up for a higher degree of employee participation (Inanc et al., 2015) in tasks as work planning and budget work. Yet, there is also a profound need for management on higher levels to learn what homecare services are about and how it can be aligned with the management system in what is for the workers a sustainable manner. The upper-level managers in our research cases were frustrated by having difficulties in what can be described as conducting a more strategic and transformative leadership (Shields, 2010), in their striving for trust-based steering. Even if first-line managers were offered possibilities to make demands and ask for resources, they clearly had difficulties in doing this. These perceived limited power resources affect not just the space for needed actions in the care and service employment sector, but also generate perceptions that it is more or less impossible to make demands for work environment improvements. The prevailing gender order (Keisu et al., 2016) and the existing gendered expectations contribute to a work culture where demands are not made; instead, the homecare service workers tend to be passive regarding the lack of resources and use their own coping abilities. This ‘demand less’ culture not only results in the fact that some of the daily work tasks are disguised and never formalised, but also that the homecare service workers become experts in dealing with inadequate resources. Examples from practice were to not question malfunctioning time schedules, and rather adjust to the difficulties it brings, resulting in individuals, including the first-line managers,

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easily becoming boundless in their striving to lubricate the organisation (Delp et al., 2010; Hirvonen, 2014). The latter can be labelled adjustment strategies (Kanter, 1993), which in a short-term perspective solve real-time problems for the workers and their managers, but not the work environment deficiencies that constitute health risks and generates lack of quality as well as extra costs for the individual and the employer (Sandkull, 2008). The third dilemma concerns the organisational imbalance between the NPM-inspired systems’ one-sided focus in measurable results and the need of organisational learning and work environment development. This was an identified imbalance that appeared in terms of a perceived lack of employee participation in work planning and budget work, which resulted in work environment deficiencies as not supporting organisational learning. Williamson et al. (2020) have described a similar dilemma where a lack of alignment between the content in gender equality action plans and crucial NPM strategies tends to hinder development work in the organisation. For publicly provided homecare work organisations, this would imply that for being able to drive work environment development successfully it has to be clearly integrated with applied NPM strategies and gender equality policies. In the work by Williamson et al. (2020), monitoring and evaluations were highlighted as such important parts. However, these researchers also raise the issue that there is lack of possibilities for managers in these organisations to develop their capability in gender equality work (Williamson et al., 2020). This in itself is a hindrance factor that can lead to that the prevailing gendered norm is easily reproduced.

9.6

Conclusions

The NPM culture is well established in the studied cases. This is described through three identified dilemmas that both constitutes parts in the shaping of the work environments, and illustrates intersections where work environment developments can take its starting points: – Organisational imbalances between the management system and the character of the work. – The need of going beyond the prevailing gendered expectations in order to change how organisational resources are distributed. – Organisational imbalances between the NPM inspired systems’ one-sided focus in measurable results and the need of organisational learning and work environment development. The prevailing norms and gendered expectations regarding femininity support the performance ideologies that NPM holds. Even if attempts of trust-based steering aims to cover up for the work environment deficiencies that follows from NPM, it is ruled out by the strong gendered expectations and practices. For being able to counteract identified power dynamics and inequality regimes that produce negative consequences in homecare’s work environments, development

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work on different levels has to be implemented (Fig. 9.1). Based on the three identified dilemmas the following measures are suggested. Firstly, the management system has to be aligned to the character of the work. This can be created through formalised structures and empowerment strategies that opens up for a higher degree of employee participation. An approach that would pave the way for realistic resources and reduce work environment risks, as invisible work tasks. Secondly, gender awareness has to be developed in the organisation in order to be able to move away from traditional values and open up for sustainable work environment improvements. Thirdly, the management system has to include structures for organisational learning and individual learning. In order to be able to create trust between colleagues as well as possibilities to develop one’s professional competence. These are all factors that constitutes crucial parts in creating a good work environment. Acknowledgements A special thanks to the homecare service workers, first-line managers and division managers in the participating municipalities, who made it possible for us to understand your work environments. I am also grateful to SWEA and their participants who have openly reflected and shared their experiences. Finally, I would like to thank my co-workers Med. Dr. Teresia Nyman at Uppsala University and PhD student Karin Sjöberg Forssberg at KTH for the help with gathering data and being active at different action-oriented seminars. AFA Insurance in Sweden financed both projects presented here.

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Annika Vänje is an Associate professor in the Division for Ergonomics, Royal Institute of Technology-KTH, Sweden. Vänje conducts research and teaching within the area of organisational change and gender. She has experiences from leading larger action research project about gender segregated work environments within the public sector.

Part III

Violence and Conflicts

Chapter 10

‘Don’t Let It Get to You.’ Gendering Workplace Violence in Disability Services in Sweden Helene Brodin and Sara Erlandsson

10.1

Introduction

The World Health Organization has estimated that approximately one-quarter of all violence at work concerns the health and social care sectors (Di Martino, 2002). Consequently, both European and American studies outline workplace violence in health and social care as an escalating problem with long-term consequences for both the victims and society (Eurofound, 2015; Philips, 2016). For the victims, workplace violence is associated with episodes of prolonged sick leave (Biering et al., 2018) and burnout (Winstanley & Hales, 2015). At the societal level, workplace violence hinders the recruitment and retention of care workers (Byon et al., 2016) and the sustainability of work over the life course (Eurofound, 2015). Less often mentioned is that workplace violence in health and social care is a highly gendered issue. Women comprise the majority of employees in both health and social care (International Labour Organization, 2017) and, therefore, are at higher risk of becoming victims of workplace violence. In Sweden, for example, two out of three reported occupational injuries caused by threats or violence at work concern women (AFA, 2018), and high-risk occupations include assistant nurses, auxiliary nurses, personal assistants and social workers (Arbetsmiljöverket, 2018; Brå, 2018). In contrast with other high-risk occupations, victims of workplace violence in health and social care usually know the perpetrator (Eurofound, 2015), because the committers of workplace violence in these sectors are mostly clients with whom the workers have an established professional relationship (Byon et al., 2016; Mueller & Tschan, 2011; Philips, 2016; Sousa et al., 2014). Many times, violent clients also suffer from cognitive impairments, psychiatric disorders, substance abuse and/or severe mental strain. Therefore, victims of workplace violence in health and social

H. Brodin (*) · S. Erlandsson Department of Social work, Stockholm University, Stockholm, Sweden e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2021 B.-I. Keisu et al. (eds.), Gendered Norms at Work, Aligning Perspectives on Health, Safety and Well-Being, https://doi.org/10.1007/978-3-030-77734-0_10

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services typically argue that the committers cannot be considered responsible for their actions (e.g. Wikman, 2012; Zelnick et al., 2013). Consequently, client-initiated threats and violence in health and social care are seldom perceived as crimes (Philips, 2016) and reported to the police (Brå, 2018). Instead, workplace violence in health and social services tends to be trivialised and normalised as part of the job and handled at the organisational level by introducing safety routines, such as twin staffing and alarm devices, or with policies aiming to reduce confrontational situations (Åkerström, 2002; Arbetsmiljöverket, 2018; Geoffrion et al., 2017). In Swedish disability services, client-initiated threats and violence usually involve shouting, insults and threats directed at the employee or their family as well as shoving, scratches, pinches, property damage (Lundström, 2006; Menckel & Viitasara, 2002) and, sometimes, sexual harassment (Wikman, 2012). If reported, these incidents are commonly defined as less serious workplace injuries (AFA, 2018). However, studies show that even incidents that do not result in physical injuries are damaging for both employees and the work organisation (Biering et al., 2018; Sousa et al., 2014; Vaez et al., 2014; Wieclaw et al., 2006). Even minor incidents can result in emotional trauma and fear of future violence, which in turn may affect both the quality of work and job satisfaction (Alink et al., 2014; Mueller & Tschan, 2011; Winstanley & Hales, 2015). Frequent incidents of workplace violence are also associated with unfavourable working conditions, such as high levels of stress, heavy workloads and poor management (Eurofound, 2015; Vaez et al., 2014). Moreover, there are indications that employees in social care avoid reporting workplace violence because of a lack of support from managers and/or fear of being blamed (Arbetsmiljöverket, 2018; Wikman, 2012; Zelnick et al., 2013). Given these circumstances, the under-reporting of workplace violence in social care services is common in Sweden (e.g. Åkerström, 2002; Wikman, 2012), as elsewhere (Byon et al., 2016), and surveys often show considerably higher prevalence than official statistics (e.g. Menckel & Viitasara, 2002; Vaez et al., 2014; Zelnick et al., 2013). Further, some studies indicate that men working in the femaledominated social care sector tend to report more workplace violence than their female colleagues (Brå, 2018; Heiskanen, 2007; Menckel & Viitasara, 2002; Wieclaw et al., 2006; Wikman, 2012). Researchers have argued that belonging to the under-represented gender is a risk factor for being exposed to workplace violence; accordingly, this could explain why men working in the female-dominated social care sector tend to report more workplace violence than women. Although previous studies indicate that gender affects workplace violence in health and social care, how gender interplays with workplace violence in different fields of services is less well explored. So far, studies on how gender affects workplace violence in health and social care have presented aggregated data (e.g. Biering et al., 2018; Brå, 2018; Eurofound, 2015; Heiskanen, 2007; Menckel & Viitasara, 2002; Vaez et al., 2014; Wieclaw et al., 2006), leaving out varieties in different fields of services. Furthermore, studies on how gender affects exposure to workplace violence in social care have primarily viewed gender as biological sex (e.g. Brå, 2018; Menckel & Viitasara, 2002; Vaez et al., 2014), and not linked

10

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representations of male and female bodies to constructions of gender within work organisations or occupational segregation (cf. Acker, 2006). This chapter aims to fill these empirical gaps by exploring how managers and employees represent workplace violence in disability services in Sweden. We compare how front-line managers and care workers perceive and explain threats and violence committed by clients in four different types of disability services (i.e. personal assistance, living support, day-care centres and group homes). Specifically, we study how norms of gender are entangled in representations of workplace violence (cf. Acker, 2006) and how this contributes to normalising workplace violence in disability services. By employing this approach, we seek to add an account of how workplace violence in female-dominated sectors is entrenched in norms of gender and the consequences this produces upon organisations to the growing field of research on workplace violence.

10.2

Swedish Disability Services

The share of women working in Swedish disability services varies from 73% to 78% (SCB, 2020). The Swedish Act concerning Support and Services for Persons with Certain Functional Impairments regulates personal assistance, day-care centres and group homes, whereas the Social Services Act regulates living support. Irrespective of legislation, all four services are provided after local authorities conduct a needs assessment. All four services are also tax-funded at the local level, but personal assistance may be co-funded at the national level by the Social Insurance Agency (i.e. assistance >20 h/week). The organisation of the services differs. Personal assistance and living support are performed in the client’s home. Whereas personal assistance includes all forms of help for the person to maintain independence in daily living (from personal hygiene to going to the theatre), living support aims to support and motivate the client to independence. Thus, people who receive personal assistance may have a variety of disabilities, whereas people who receive living support usually suffer from cognitive or psychiatric disorders and/or substance abuse. Day-care centres aim to support independence through activities reflecting work life and usually include clients with intellectual disabilities. Group homes, finally, offer both institutional and homebased care: on the one hand, group homes are residential care mostly directed to people with intellectual disabilities and, on the other, clients are defined as tenants who are free to decide over their flats. Currently, a mix of public, private and non-profit providers characterise the provision of services. This implies many parties are involved in service provision, which blurs responsibilities for dealing with and preventing workplace violence. For example, according to the Swedish Work Environment Act, it is the employer’s responsibility to prevent workplace violence. Concurrently, disability services are needs-assessed and thus vital to the physical health and/or psychological well-being of the client. Consequently, if the risks of clients becoming threatening or violent

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exist, employers must find ways to meet the needs of the client without risking the safety of the employees. However, employers have no authority to decide over the client’s home, which makes it difficult to control the work environment in homebased services, such as personal assistance and living support, and to implement policies and routines preventing threatening or violent situations. Furthermore, as disability services are tax-funded and locally provided, the ultimate responsibility for delivering services in appropriate and safe ways lies with politicians in local councils (Arbetsmiljöverket, 2018). However, Swedish politicians seldom acknowledge this overarching responsibility for the work environment. Instead, the current political response to workplace violence in the field of health and social care is the criminalisation of the perpetrator (e.g. SOU, 2018:2), which conceals how organisational problems, such as cuts in funding and reduced time slots for service delivery, affect workplace violence in these sectors (cf. Wikman, 2012).

10.3

Analytical Framework

Previous studies indicate that workplace violence in social care is related to organisational factors, such as heavy workloads, low staffing, cuts in financial resources and stress (e.g. Banerjee et al., 2012; Byon et al., 2016; Mueller & Tschan, 2011; Vaez et al., 2014; Wikman, 2012; Winstanley & Hales, 2015; Zelnick et al., 2013). Research also indicates that backing from the management is important to recover from incidents of threats or violence (Mueller & Tschan, 2011), but that many victims of workplace violence in social services in Sweden lack this support (Arbetsmiljöverket, 2018; Lundström, 2006; Menckel & Viitasara, 2002). Against this backdrop, this study examines workplace violence in its organisational setting. Here, we use Braverman’s (2002) typology to explore how organisations in disability care deal with workplace violence. Braverman outlines two ideal types of work organisations: those characterised by trust in colleagues and management and those defined by distrust. In organisations defined by trust, workplace violence is interpreted as organisational responsibilities and incidents are reported and investigated accordingly to learn how to prevent such events from happening again. In contrast, in organisations marked by distrust, workplace violence is perceived as single incidents caused by individuals (e.g. clients or employees). As a result, measures for how to deal with workplace violence are bureaucratised and employees learn to cope with workplace violence by following written procedures (Jeffcott et al., 2006). Hence, if workplace violence is explained primarily as actions caused by individual clients or employees, we define this as work organisations characterised by distrust that respond to workplace violence by using bureaucratised procedures, such as reporting. In contrast, if workplace violence is constructed as organisational problems, we define this as organisations marked by trust that respond to workplace violence by using transformative methods, such as changing work procedures.

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Table 10.1 Analytical approach based on Bacchi (2009) The WPR model (Bacchi, 2009) Q1: What’s the problem represented to be in a specific policy? Q2: What presuppositions or assumptions underlie these representations? Q3: How have these representations of the problem come about? Q4: What is left unproblematic in this problem representation? Q5: What effects are produced by this representation of the problem? Q6: How have these representations of the problem been produced, disseminated and defended?

Our analytical approach How do the informants describe causes of and organisational responses to workplace violence? What norms of gender are embedded in these different representations? Not included. What is left unproblematic in the different representations of causes and consequences of workplace violence? In what ways do the different representations challenge or maintain normalisation of workplace violence in disability care? Not included.

Furthermore, workplace violence includes a wide range of incidents. In this context, the Californian Occupational Safety and Health Administration (Cal/OSHA) has developed one commonly used categorisation (e.g. Mueller & Tschan, 2011; Philips, 2016; Sousa et al., 2014; Wikman, 2012). According to Cal/OSHA (1995), workplace violence splits into three major types based on the perpetrator: The offender has no legitimate relationship to the workplace (Type I), the committer is a user of services provided by the victim and/or the workplace (Type II), and the perpetrator has an employment–relation with the victim (Type III). Some experts also add structural violence to this last type of workplace violence (e.g. Banerjee et al., 2012; Wikman, 2012) by including actions committed by the work organisation against employees or clients that deliberately expose them to risks without their knowledge. In this study, we only focus on Type II forms of workplace violence. To explore how norms of gender are embedded in Type II forms of workplace violence in Swedish disability services, we draw upon a delimited version of Bacchi’s (2009) ‘What’s the problem represented to be?’ approach (WPR). According to Bacchi (p. 35), analysing problem representations can help reveal how discourses limit ‘what is possible to think, write or speak’. To do so, Bacchi proposes the researcher considers six questions. We have delimited our analysis to four of these questions and excluded those we considered be outside the aim and scope of this chapter (Table 10.1). To analyse how norms of gender contribute to normalising workplace violence in disability service, we use Johnson’s (Johnson, 2008) typologies of intimate partner violence. According to Johnson (2008), three types of intimate partner violence exist: intimate terrorism, violent resistance and situational couple violence. Whereas intimate terrorism describes violence occurring in relationships of coercive control, violent resistance refers to violent responses by the target of intimate terrorism.

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Situational couple violence describes incidents when arguments escalate to verbal aggression and physical violence. Gender is implicated in all three forms of violence but in different ways. Men usually are perpetrators of intimate terrorism, whereas women are the prime users of violent resistance. Situational couple violence, however, is assumed to be gender symmetric, that is, men and women are both likely to be perpetrators and victims (Johnson et al., 2014). Although Johnson’s typologies outline intimate partner violence, we find two reasons for using this model to analyse how norms of gender normalise workplace violence in disability services. Firstly, the relational aspect of workplace violence in disability services often mirrors that of intimate partner violence. Similar to intimate partner violence, threats and violence committed by clients in disability services usually target a worker with whom the client has an established relationship. Secondly, the context of workplace violence in disability services reflects that in intimate partner violence. Like in intimate partner violence, which mostly occurs in the private sphere of a home, three out of four services explored in this study are performed in the client’s home (i.e. personal assistance, living support and group homes). Altogether, these characteristics imply that workplace violence in disability care is embedded in relations and contexts that many times are comparable to those in intimate partner violence.

10.4

Data and Methods

The study reported in this chapter draws on an analysis of interviews with 96 frontline managers and employees in Swedish disability services (Table 10.2). Although we strived to include managers and employees from the same workplace, this was not always possible. About half of the interviews covered workplaces where managers and employees worked together, whereas the others included workplaces where managers and employees did not work together. Furthermore, given that disability care is a female-dominated sector, the interviews included more women than men. Further, the majority of both managers and employees worked for the public sector. This means that our interview sample is not representative of the country in general. The number of privately employed managers and employees in all four types of disability services is generally higher in Sweden than in our sample (SKR, 2020; Socialstyrelsen, 2019). This is particularly true for personal assistance, in which about 60% of all employees working more than 4 h per week are privately employed (SOU, 2020:1). These biases probably mean that we have interviewed managers and workers with better employment and working conditions than what is characteristic for the disability sector in general (Ibid). Managers were interviewed individually, and employees were interviewed either individually or in focus groups depending on the possibility to access informants for a group format. This was particularly the case concerning personal assistance, which is a service highly characterised by lone work; we were not able to arrange more than a few focus groups. Therefore, although focus groups and individual interviews

Women Men Public sector Private sector 2

0

0

Day-care centres 4 1 3

Front-line managers Personal Living assistance support 5 3 1 0 6 3

Table 10.2 Interview sample

1

Group homes 6 1 5 4

Employees Personal assistance 15 5 16 0

Living support 16 2 18

1

Day-care centres 6 3 8

0

Group homes 20 8 28

9

Sum 75 21 87

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draw upon somewhat different methodological approaches (Gubrium et al., 2012), we decided to be flexible and adjusted the interview methodologies according to the informants’ availability to participate. In total, 21 individual interviews and 11 focus groups, with two to seven participants, were conducted. All interviews were recorded and transcribed. The interviews followed a semi-structured topic guide organised around five overarching themes. This chapter primarily analyses responses to the theme of employment and working conditions, including experiences of threats, violence, racism and sexual harassment. Our analysis proceeded in five steps. First, we identified accounts of threats and violence, including causes of and organisational responses to workplace violence, and coded these independently using NVivo 12. Second, we compared our coding, revising as appropriate, to ensure the trustworthiness of the coding. Third, we used our delimited WPR approach based on Bacchi (2009) to identify problem representations emerging in coding. Fourth, drawing on Bacchi (2009), we conceptualised the identified problem representations as three different discourses on workplace violence. Fifth, we used Braverman’s (2002) and Johnson’s (2008) typologies to generalise organisational responses and the gendered subtext embedded in the suggested three discourses on workplace violence in Swedish disability services.

10.5

Gendering Workplace Violence in Swedish Disability Services

In the following, we describe the three different discourses on workplace violence emerging in our analysis of client-initiated threats and violence in disability care. The discourses are presented in this section as the violent client, the worker’s fault and organisational problems. These discourses should not be interpreted as distinct, but rather as interrelated, and informants often moved between at least two of the three discourses when they verbalised experiences and explanations of workplace violence in disability care. For example, informants could argue that threats and violence in disability care depended on both violent clients and a lack of training among care workers. All three discourses included specific gendered subtexts, which we describe at the end of each theme. Each discourse is also related to the trustful or distrustful organisation, which we discuss at the end of this chapter. To illustrate findings from the interview data, we have translated quotes in this section from Swedish to English.

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10.5.1 The Violent Client The most common discourse of workplace violence in disability care among all informants was the violent client. This discourse locates the causes of workplace violence in disabilities or illnesses that lead to frustration, impulsivity or aggression, which causes clients to behave violently. More than half of the managers and two-thirds of the employees articulated this explanation of workplace violence, regardless of employer or disability service. Predominantly, employees emphasised this representation when they verbalised their lived experiences of workplace violence. For example, one worker in living support referred to her clients’ sufferings in combination with mental illnesses to explain her frequent experiences of clientinitiated threats and violence: There are lots of threats and violence and it’s quite commonplace, and it’s probably because of what they’ve been through, and their experiences in life, everything has affected them to become violent. . ./. . . ./ But then again, some have paranoia and psychosis, and it [threats and violence] can arise from that, but we try to see it as caused by diagnoses and diseases. (Worker, woman, public sector)

Similarly, one manager in personal assistance claimed that threats and violence often relate to clients’ disabilities: Well, yes, there are both [threats and violence]. Well, usually we’ve persons with autism and it’s part of their disability. /. . ./ It’s such things that’s part of the disability, it can be a punch, this might happen, really. So, it’s quite commonplace I’d say. (Manager, woman, public sector)

As these quotes indicate, the discourse on the violent client brings an understanding of threats and violence as unintentional and the clients as unable to take responsibility for their actions. Particularly for the workers, this discourse helped them to forgive and to maintain a professional relationship with the client. However, this discourse also contributed to normalisation because it defined client-initiated threats and violence as inevitable parts of everyday work. Consequently, one man working in a group home stated that disability care workers must be able to deal with workplace violence daily, ‘We know what this job is all about, and that there are threats and violence. If you’re not able to deal with that, you should find another job.’ Not only male but also female workers replicated this perception of threats and violence as part of the job. However, women tended to articulate more empathy for the clients than the men did. For example, one woman working as a personal assistant described how her client subjected her to verbal sexual harassment and aggression regularly. Even though her client continued to be offensive after she repeatedly had told him to stop, she still showed compassion for him when she talked about her work: He can be a bit aggressive due to his mental illness; he scolds me, and he’s mean, but I feel I’ve to take it. After all, it’s an ill person and he always apologises afterwards and says he doesn’t mean it, ‘You’ve to forgive me, I get like that sometimes.’ (Worker, woman, public sector)

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As this quote illustrates, the discourse on the violent client tended to trivialise experiences of workplace violence. Therefore, inherent in this discourse were expectations from both workers and managers that the staff should tolerate and be able to handle workplace violence. For instance, one publicly employed manager for living support reported that threats and violence were just something that the staff has to cope with: There are units where it’s one [incident] every day, nearly every hour that threats and violence happen in one form or another. So, it’s absolutely things that happen and occur and you deal with it in the daily work. (Manager, woman, public sector)

Hence, the discourse of the violent client defined threats and violence as fixed problems impossible to change except in rare cases. In this context, a few managers and one worker described how their workplaces had reduced threats and violence successfully by helping clients find alternative ways to express their emotions: We work with this group to reduce violence. And when it decreases, it’s usually because the person is feeling better. We work individually with those persons. We’ve to teach them, ‘How do you do instead [of being violent]?’ Find strategies and find tools. (Worker, woman, public sector)

One plausible explanation to this more positive outlook on violent clients was organisational differences between the workplaces. Both the worker in the quote above and the managers who articulated possibilities to reduce threats and violence by changing the behaviour of clients worked with specific types of disabilities and had invested in education. This meant that the staff had knowledge of specific needs and knew how to prevent threats and violence among the particular group of clients with which they worked. This opened up the opportunity for systemic preventive measures, compared with organisations in which the clients had a variety of disabilities and the workers lacked knowledge about the special needs of the clients. The discourse on the violent client also included a specific gendered subtext that mirrored the one Johnson (2008) identified in intimate terrorism. This subtext suggests that women should undertake responsibility for violent partners and endure abusive relationships (Johnson et al., 2014). Although the relationship between the violent client and the care worker is professional and not intimate, the discourse on the violent client draws upon similar gendered connotations of women’s inexhaustible caring commitments. The ideal care worker is tolerant and forgiving no matter how violent the client is. Thus, the same subtext that hinders women from leaving abusive partners also encourages (women) care workers to stay in their job, even if they repeatedly are subjected to threats and violence. In accordance with this subtext, disability care workers may also withhold from raising complaints about threats and violence, not because of fear of retaliation from the perpetrator, as often is the case when women are victims of intimate terrorism, but because of fear of being blamed by managers and co-workers.

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10.5.2 The Worker’s Fault The second-most common discourse articulated by the informants was that workplace violence depends on the individual worker. Particularly, front-line managers emphasised this discourse, but it also appeared among the employees. One-third of the managers claimed that clients could not be blamed for threats and violence because of their disability. Instead, these managers argued that client-initiated threats and violence mostly occur because of a lack of professional approaches or professional training among the staff. Especially, publicly employed managers reproduced this discourse of blaming the staff for workplace violence, regardless of what kind of disability services they represented. For example, one front-line manager for living support organised by local authorities claimed that when clients become aggressive, staff has not followed routines and policies for how to approach clients. Her first response to client-initiated threats or violence was therefore to confront the victimised worker: As a manager, I then ask how has the person in question behaved /. . ./ That is, how did it come that you ended up in this situation, what was your approach, how was the situation /. . ./ Usually here when it’s about threats and violence or lots of shouting and screaming and things like that, then it’s typically that the staff has not followed policies. (Manager, woman, public sector)

Similarly, another front-line manager in charge of a municipal day-care centre stated that client-initiated threats and violence mostly depends on professional failings. However, this manager indicated that workplace violence could also relate to organisational problems, such as understaffing and overcrowded spaces, which might trigger some clients to behave violently: I always turn to the staff and ask what do you think caused this incident? Could you have done things differently? I’d say most threats and violent situations are not directed towards the staff but between clients. And we’ve talked about this; could it be that we’re understaffed, or not really understaffed, but on the contrary – we must have many clients in the same place? (Manager, woman, public sector)

As indicated by this quote, managers who blamed their staff could concurrently argue that it is not always the individual worker’s fault because client-initiated threats and violence are context-based and, therefore, not always possible to predict or prevent. Furthermore, the prevention of workplace violence is undermined by factors that neither managers nor employees have any possibilities to exert influence on, such as facilities where the services are provided. Among the privately employed managers, only one responsible for a day-care centre indicated that the individual worker was to blame for the occurrence of workplace violence. This manager claimed that she had practically eliminated incidents of threats and violence at her workplace by lots of training and supervision of her staff and substantial following-ups of incidents from her side. One possible explanation for these differences in discourses on blaming the staff could be the physical location of the managers. The privately employed managers interviewed in this study worked in the same facility as their staff. Hence, they interacted daily with

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their staff, and this close relationship meant that they could be in the same room as their staff when incidents occurred. In contrast, the majority of the publicly employed managers who blamed their staff for workplace violence had their offices located in other facilities and only met with their staff once a week. Consequently, these managers received reports after incidents had occurred. This physical distance between the manager and the staff could also explain why these managers took a top-down approach and simplified client-initiated threats and violence as the worker’s fault. Managers who upheld the discourse of blaming their staff for client-initiated threats and violence generally argued that low-arousal approaches were the key to eliminate workplace violence in disability services. Low-arousal approaches aim to identify triggers in various situations and promote the use of low-intensity approaches (e.g. avoiding conflicts) and the use of behaviour management strategies to reduce stress, fear and frustration among clients. Although these methods were mentioned by nearly all managers, as they are commonly used in disability services, those who blamed the individual worker for client-initiated threats and violence much more frequently returned to them as universal solutions to workplace violence in disability care. In this context, however, one manager for a privately organised group home also expressed criticism against low-arousal approaches. In her opinion, low-arousal approaches led her employees to blame themselves for every incident that happened and, therefore, contributed to normalising workplace violence: Often the problem is that they [the staff] become so used to these pinches, threats and violence that they just say, ‘No, don’t worry, I know, well, yes, it was stupid of me to stand so close because I knew [what was going to happen].’ /. . ./ Because we’ve talked so much about low arousal [approaches], it becomes so easy for them to say, ‘Well, yes, I shouldn’t have stood [there], if I just hadn’t gone into that room right there and then this would never have happened.’ (Manager, woman, private sector)

However, employees also upheld the discourse on the individual worker’s fault. Similar to managers, employees argued that client-initiated threats and violence occur because colleagues lack knowledge or training about the client’s disability or because of flaws in personal abilities. Furthermore, in the interviews with employees, representations of client-initiated threats and violence as the worker’s fault commonly appeared when they described how others had been exposed to workplace violence, but only rarely when they mentioned their own experiences. For instance, one employee at a day-care centre argued that threats and violence relate to both work experiences and personal qualities: It [threats and violence] has to do with experience. And it has a lot to do with personality, how you’re as a person. You’ve to understand that you’d just step back and not be so straightforward, even if you’re like that as a person /. . ./ Those who are calmer, more cautious, careful and listening, empathetic and attentive, they’re not as exposed. (Worker, man, public sector)

Only one worker employed as a personal assistant indicated that threats and violence were not only caused by a lack of training or professional approaches among colleagues but also by organisational problems, such as introductions that are

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too short for new employees. This meant that newcomers did not receive any information about how to respond and prevent clients’ aggressiveness: We’re extremely vulnerable in lonesome situations and it’s, how should I put it, unacceptable that the introductions are too short, and lots of times, the persons [care workers] lack knowledge of how to deal with and prevent these situations. (Worker, woman, private sector)

Similar to the discourse on the violent client, the discourse on the worker’s fault drew upon a gendered subtext. In this case, however, the subtext reflected the one Johnson (2008) identified in situational couple violence. This subtext proposes that men and women are just as likely to be perpetrators and victims, although gender is implicated in this form of violence (Johnson et al., 2014). For example, because of differences in body size, victimised women will likely suffer more from fear or injuries than victimised men will. Furthermore, as in intimate terrorism, the assignment of caregiving to women creates a context in which women are encouraged to stay in abusive relationships for the sake of others. Finally, women who are verbally aggressive prior to the incident, provoke their partner or confront their perpetrator are also likely to be blamed for causing the violence (Eigenberg & Policastro, 2016). Likewise, the discourse on the worker’s fault draws upon assumptions of gender symmetry, that is, in theory, male and female care workers are both likely to be blamed for causing workplace violence. Concurrently, this discourse conceals that because of differences in body size, female workers are more likely to suffer harm than male workers when exposed to threats or violence by clients. Additionally, as in the discourse on the violent client, the discourse on the worker’s fault omits the gendering of care work as women’s work concomitantly as it encourages (female) workers to tolerate threats and violence for the sake of the client. Lastly, as women more often are blamed for provoking violence, female care workers who refuse to put up with threats and violence committed by clients are probably more likely to be blamed than male care workers in similar situations.

10.5.3 Organisational Problems The third discourse emerging in the interviews related the causes of workplace violence in disability services to organisational problems, such as a lack of funding, understaffing, and poor management. However, this discourse was the least common among both managers and employees, even though all categories of informants occasionally articulated it regardless of what service and kind of provider they represented. Compared with the others, this discourse was also more indirect and often embedded in other topics, for instance, how work affected psychological wellbeing or preconditions for providing good care. In this context, both managers and employees indicated that organisational problems supported normalisation of workplace violence in disability services, but they approached the issue from different angles. Managers emphasised how cuts to funding and increased workloads could

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lead to workplace violence, whereas employees primarily verbalised this discourse in accounts of how managers belittled experiences of client-initiated threats and violence. For example, one personal assistant described how her client had intimidated her repeatedly during a workday, but when she reported this, her manager told her not to take the harassment personally: I don’t see any interest from the managers or anyone else to do anything about it [threats and violence], it’s more or less, ‘Well, this is how it is, so try not to take it personally.’ /. . ./ Seriously, you shouldn’t have to hear that you’re worthless for seven and a half hours at your workplace; of course not. I think it’s degrading and humiliating when managers say, ‘Don’t let it get to you.’ (Worker, woman, public sector)

Similarly, other employees articulated how they did not have any time to report incidents of threats and violence and that it was no use to report them anyway because they did not get any feedback or follow-up from their manager: Perhaps we get a reflection from him [the manager]. But nothing more. We never get any [advice], what do we do about this, are we supposed to write some sort of plan? We always have to solve our own problems. (Worker, man, public sector)

Other care workers pointed out how a lack of time and complicated procedures for documentation resulted in outdated risk assessments and care plans. Consequently, temporarily employed staff did not have access to the client’s current status or safety routines for how to prevent violence. Most workers seemed to accept these deficiencies in systematic preventive measures. However, one woman who worked in a group home objected to her colleagues’ laconic attitudes during a focus group interview: They forget that this is a work environment issue. We work here too, and we should feel safe at our workplace. And the clients are always more important because it’s like, they are the way they are. So, we have to move on [to another workplace] if we are uncomfortable. (Worker, woman, public sector)

In contrast to the employees who described how poor management undermined the reporting of incidents and downplayed experiences of workplace violence, the managers emphasised how a lack of funding and reduced time slots for performing services created stressful working conditions and work environments that trigger clients to commit violence. Hence, managers recognised their responsibility for the workers’ health and safety but, at the same time, pointed to risk factors beyond their scope of influence. For example, one manager of a privately organised day-care centre characterised her position as mission impossible. A lack of resources meant that she recurrently confronted situations involving more clients and an unchanged number of employees, which increased the risk for workplace violence: What I’m thinking is resources. That is, resources in the meaning that it should be proper resources for the mission we have. Really, at all levels, to create preconditions to run a quality service. And this is sort of associated with stress. I mean, it’s stress and then we’ve this within some disability services – threats and violence. (Manager, woman, private sector)

Not only privately but also publicly employed managers mentioned a lack of funding as increasing the risks for client-initiated threats and violence. One manager

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responsible for a municipal day-care centre reported how cuts affected her staff and how this, in the end, had consequences for the clients: Financially, it becomes tighter and tighter. /.../ And it has consequences for those we’re here for. Because when the staff doesn’t feel good, things happen with our clients, and aggressive behaviour can be one such thing, and then it doesn’t matter how skilled you are as an employee /. . ./. Because when you’re tired and worn out, then you don’t deliver the same quality. (Manager, woman, public sector)

Another organisational problem emerging in the interviews with managers was how increased burdens of administration stole time from clients. For example, one manager in charge of another day-care centre organised by local authorities claimed that she had calculated that her staff was forced to devote half of their working hours to documentation instead of being with the clients. However, the most serious organisational problem arising in the interviews with managers was how a lack of cooperation between different divisions of the local authorities increased the risk for workplace violence. Especially, publicly employed managers responsible for living support and group homes verbalised this problem and mostly concerning clients with dual diagnoses, such as mental illness and substance use disorder. These managers reported how a lack of cooperation around clients with dual diagnoses endangered their staff. Concurrently, they argued that they had little power to exert influence over the situation, as they did not perform a needs assessment for clients and, therefore, could not decide what services should be provided to the clients. For example, one manager responsible for a group home organised by local authorities described how workplace violence repeatedly occurred at one of her units, but she could not do much more than provide her staff with alarm devices and guards: It has been one place where there are adolescents and substance abuse involved. /. . ./ It has been pretty often there. Threats, I mean. Then violence, yes, it has been that a number of times also. /. . ./ They’re three people working there, and they each have one of those alarms you carry with you, and then we’ve Securitas [private company providing guards] /. . ./ We’ve had manned guarding by Securitas twenty-four-seven there sometimes. /. . ./ And then they [the staff] of course know that they immediately call the police when something happens. (Manager, woman, group home)

Like the manager in the quote above, other publicly employed managers responsible for living support and group homes who had clients with dual diagnoses reported that they had very limited means to improve the situation for their staff other than to establish safety routines, such as twin staffing, alarm devices and, in the worst case, guards. Similar to the other discourses on workplace violence in disability services, the discourse on organisational problems contains a gendered subtext. This time, however, the subtext reflects how horizontal and vertical dimensions of occupational segregation result in policies that call upon women to endure working conditions unacceptable in sectors not associated with caregiving. For example, managers in male-dominated sectors also characterised by high frequencies of workplace violence, such as transportation and storage (Eurofound, 2015), are unlikely to instruct co-workers not to let threats and violence get to them. Neither would employers in

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these sectors be able to escape penalties for neglecting the work environment, as politicians responsible for publicly funded disability services obviously do. Herein lies the problem. As long as policies and practices for preventing workplace violence omit horizontal and vertical dimensions of occupational segregation, women working in health and social care will also be exhorted to tolerate workplace violence for the sake of others.

10.6

Challenging or Maintaining Normalisation of Workplace Violence?

This chapter has discussed how different discourses on workplace violence in disability services delimit organisational responses to the problem. The discourses on the violent client and the worker’s fault both offer individual explanations to workplace violence: the clients’ disabilities or the workers’ behaviour. In contrast to the discourse on the violent client that constructs violence as an inescapable problem inherent in disability services, the discourse on the worker’s fault attributes the responsibility for threats and violence to victimised workers. Despite differences in the location of responsibility, both discourses rely upon the presupposition that professional care workers, predominantly women, always will be empathic with their clients and withstand threatening and even abusive behaviour. Thus, we claim that these discourses both trivialise exposure to threats and violence (cf. Geoffrion et al., 2017) and draw upon general discourses of intimate partner violence that encourage women to endure abusive relationships. The discourse on organisational problems challenges the individual explanations embedded in the other discourses and offers structural explanations to the occurrence of workplace violence. Hence, this discourse calls attention to problems related to the organisation of work, such as understaffing and time constraints. This discourse indicates that change is possible, but it also points to the existence of problems that cannot be solved by individual workers or managers – resources and interorganisational collaboration are needed to bring about real changes. The discourses identified in this chapter also produce different organisational responses to workplace violence. Following Braverman (2002), we argue that both the discourse on the violent client and the discourse on the worker’s fault are associated with organisations characterised by distrust between co-workers and managers. Whereas the discourse on the violent client locates the problem to disabled individuals, the discourse on the worker’s fault puts the entire blame on individual employees. In both cases, however, workplace violence is perceived as incidents caused by individuals. Consequently, both discourses produce standardised safety routines, such as twin staffing, alarms and guards, and bureaucratic measures for how to deal with workplace violence, such as reporting and offering counselling to victimised workers. Both discourses, therefore, encourage care workers to cope with workplace violence by following written procedures

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(cf. Jeffcott et al., 2006). Further, both discourses leave out how power relations within organisations, such as those between managers and workers, affect organisational responses to workplace violence in disability services. Given that women comprise the majority of workers in disability services, the discourses on the violent client and the worker’s fault not only blames female care workers for their exposure to workplace violence but also enforces the vertical dimension of occupational segregation. In contrast, the discourse on organisational problems articulates structural factors as the main cause of workplace violence in disability services. By emphasising how organisational conditions, such as poor management and a lack of funding and cooperation around violent clients, result in workplace violence, this discourse opens up the potential for preventing workplace violence by transforming working conditions. In this sense, the discourse on organisational problems reflects the trustful organisation (Braverman, 2002). Concurrently, this discourse manifests the normalisation of workplace violence in disability services. Managers downplay workers’ experiences of harassment, threats and violence, and politicians ignore how cuts to resources and a lack of cooperation between divisions of local authorities affect working conditions in the sector. Further, the discourse on organisational problems indicates that workplace violence in disability services includes more than the Type II definition of workplace violence (Cal/OSHA, 1995). A lack of support from managers and a lack of cooperation around clients with dual diagnoses imply that work organisations in disability services deliberately expose both employees and clients to risks, although this sometimes happens with their knowledge. In this vein, the discourse on organisational problems shows that workplace violence in disability services also includes structural violence (cf. Wikman, 2012). As long as this materiality underpinning workplace violence in disability services remains unacknowledged by those located at the top of the organisations, such as politicians, policymakers and employers, we unfortunately see few possibilities to overcome trivialisation and normalisation of workplace violence in female-dominated sectors, such as health and social care.

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Banerjee, A., Daly, T., Armstrong, P., Szebehely, M., Armstrong, H., & Lafrance, S. (2012). Structural violence in long-term, residential care for older people: Comparing Canada and Scandinavia. Social Science and Medicine, 74(3), 390–398. Biering, K., Andersen, L. P. S., Hogh, A., & Andersen, J. H. (2018). Do frequent expose to threats and violence at work affect later workforce participation? International Archives of Occupational and Environmental Health, 91(4), 457–465. Brå. (2018). Yrkesrelaterad utsatthet för brott. Brå. Braverman, M. (2002). The prevention of violence affecting workers: A system perspective. In M. Gill, B. Fisher, & V. Bowie (Eds.), Violence at work: Causes, patterns and prevention (pp. 114–131). Willan. Byon, H. D., Storr, C., Edwards, L., & Lipscomb, J. (2016). Client history and violence on direct care workers in the home care setting. American Journal of Industrial Medicine, 59(12), 1130–1135. Cal/OSHA. (1995). Injury and illness prevention model program for workplace security. https:// www.dir.ca.gov/dosh/dosh_publications/iipsecurity.html Di Martino, V. (2002). Workplace violence in the health care sector. Country case studies. WHO. Eigenberg, H., & Policastro, C. (2016). Blaming victims in cases of inter-personal violence: Attitudes associated with assigning blame to female victims. Women and Criminal Justice, 26 (1), 37–54. Eurofound. (2015). Violence and harassment in European workplaces, causes, impacts, and policies. Dublin. Geoffrion, S., Goncalves, J., Boyer, R., Marchand, A., & Guay, S. (2017). The effects of trivialization of workplace violence on its victims: Profession and sex differences in a cross-sectional study among healthcare and law enforcement workers. Annals of Work Exposure and Health, 61 (3), 369–382. Gubrium, J. F., Holstein, J. A., Marvasti, A. B., & McKinney, K. D. (Eds.). (2012). The SAGE handbook of interview research: The complexity of the craft. SAGE. Heiskanen, M. (2007). Violence at work in Finland: Trends, contents and preventions. Journal of Scandinavian Studies in Criminology and Crime Prevention, 8(1), 22–40. International Labour Organization. (2017). Violence and harassment against women and men in the world of work: Trade union perspectives and action. ILO. Jeffcott, S., Pidgeon, N., Weyman, A., & Walls, J. (2006). Risk, trust, and safety culture in UK train operating companies. Risk Analysis, 26(5), 1105–1121. Johnson, M. P. (2008). A typology of domestic violence: Intimate terrorism, violent resistance and situational couple violence. Northeastern University Press. Johnson, M. P., Leone, J. M., & Xu, Y. (2014). Intimate terrorism and situational couple violence in general surveys: Ex-spouses required. Violence Against Women, 20(2), 186–207. Lundström, M. (2006). Våld- utmaning och utmattning. Vårdares utsatthet och upplevelser i samband med våld i gruppbostäder för personer med utvecklingsstörning. Diss: Umeå University. Menckel, E., & Viitasara, E. (2002). Threats and violence in Swedish care and welfare – Magnitude of the problem and impact on municipal personnel. Scandinavian Journal of Caring Sciences, 16(4), 376–385. Mueller, S., & Tschan, F. (2011). Consequences of client-initiated workplace violence: The role of fear and perceived invention. Journal of Occupational Health Psychology, 16(2), 217–229. Philips, J. P. (2016). Workplace violence against health care workers in the United States. New England Journal of Medicine, 374(17), 1661–1669. SCB. (2020). 30 största yrkena. https://www.scb.se/hitta-statistik/statistik-efter-amne/ arbetsmarknad/sysselsattning-forvarvsarbete-och-arbetstider/yrkesregistret-med-yrkesstatistik/ pong/tabell-och-diagram/30-storsta-yrkena/ SKR. (2020). Valfrihetssystem i kommuner 2019. https://skr.se/demokratiledningstyrning/ driftformervalfrihet/valfrihetssystemochersattningsmodeller/socialomsorg/ valfrihetssystemikommunerbeslutslaget2019.29749.html

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Socialstyrelsen. (2019). Statistik om äldre och personer med funktionsnedsättning efter regiform 2018. Socialstyrelsen. SOU. (2018:2). Stärkt straffrättsligt skydd för blåljusverksamhet och andra samhällsnyttiga funktioner. Justitiedepartementet. SOU. (2020:1). Översyn av yrket personlig assistent – ett viktigt yrke som förtjänar bra villkor. Socialdepartementet. Sousa, S., Silva, I. S., Veloso, A., Tzafrir, S., & Enosh, G. (2014). Client’s violence against social workers. Tékhne, 12(S1), 69–78. Vaez, M., Josephson, M., Vingård, E., & Voss, M. (2014). Work-related violence and its association with self-related general health among public sector employees in Sweden. Work, 49(1), 163–171. Wieclaw, J., Agerbo, E., Mortensen, P. B., Burr, H., Tüchsen, F., & Bonde, J. P. (2006). Workrelated violence and threats and the risk of depression and stress disorder. Journal of Epidemiological Community Health, 60(9), 771–775. Wikman, S. (2012). Våld i arbetslivet. Utveckling, uppmärksamhet och åtgärder. Diss: Stockholm University. Winstanley, S., & Hales, L. (2015). A preliminary study of burnout in residential social workers experiencing workplace aggression: Might it be cyclical? British Journal of Social Work, 45(1), 24–33. Zelnick, J. R., Sleyter, E., Flanzbaum, B., Butler, N. G., Domingo, B., Perlstein, J., & Trust, C. (2013). Part of the job? Workplace violence in Massachusetts social service agencies. Health and Social Work, 38(2), 75–85. Helene Brodin holds a PhD in Economic History and is an Associate Professor in Social Work at Stockholm University. Her main areas of research are eldercare and disability care with a special focus on how gender and ethnicity interact with the organisation and distribution of care services. Sara Erlandsson holds a PhD in Social Work and is an Assistant Professor in Social Work at Stockholm University. Her research interests include working conditions, consequences of policy changes and market reforms, and how policies are translated into practices within disability care and eldercare.

Chapter 11

The Concept of Intragroup Conflict in Relation to Gender and Well-Being in Women-Dominated Work Britt-Inger Keisu and Susanne Tafvelin

11.1

Introduction

The starting point for this chapter is an interest in the concept of conflict in the workplace in a Swedish, women-dominated setting. The concept of conflict is understood by Lewin (1951) as a balance of counteracting forces that could both drive and restrain change. This understanding entails that conflict can be either destructive or constructive within an organisation. Scholars have shown that constructive conflicts can be energising and are a vital part of promoting the open discussion of diverse perspectives and integrating them into viable solutions (Tadorova et al., 2014; Tjosvold et al., 2014). Furthermore, it has been shown that a poor psychosocial work environment nurtures destructive conflicts that could, in the long run, lead to relational conflict, bullying, harassment and sick leave (Oxenstierna et al., 2012; Stoetzer, 2011). In previous research, three types of intragroup conflict have been identified: task, relationship and process conflicts (Amason, 1996; De Wit et al., 2012; Guetzkow & Gyr, 1954; Jehn, 1994; Jehn et al., 1999). Firstly, a task conflict arises when a group disagrees about the content or outcomes of the tasks being performed (De Wit et al., 2012; Jehn & Mannix, 2001). Such disagreements can be characterised by animated discussions or individual excitement. This type of conflict does not give rise to the negative personal feelings that are associated with the second type, relationship conflicts. These involve personality differences and/or differences in norms and

B.-I. Keisu (*) Department of Sociology, Umeå University, Umeå, Sweden Umeå Centre for Gender Studies, Umeå University, Umeå, Sweden e-mail: [email protected] S. Tafvelin Department of Psychology, Umeå University, Umeå, Sweden e-mail: [email protected] © Springer Nature Switzerland AG 2021 B.-I. Keisu et al. (eds.), Gendered Norms at Work, Aligning Perspectives on Health, Safety and Well-Being, https://doi.org/10.1007/978-3-030-77734-0_11

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values. This type of conflict often involves feelings of tension, friction and dislike. The third type of conflict is labelled process conflict and consists of disagreements about the logistics of task accomplishment, such as who is responsible for what and how much responsibility everyone has. Research on workplace conflicts has focused on how conflicts affect work performance, and one unexplored field within this research consists of studies on how intragroup conflicts affect employee well-being. Also, few studies have focused on women-dominated work. Another under-researched area is gender-theoretical perspectives on conflicts (Tafvelin et al., 2019). We revealed in a recent study that women and men in the same occupation experience the same types of intragroup conflict (Tafvelin et al., 2019). At the same time, it is common to encounter stereotypical understandings of intragroup conflicts and gender. At a societal level, discourses of women and femininity often characterise women as vague, emotional, unable to cooperate in teams, sensitive and brooding over things, talking behind other people’s backs and taking on problems (Keisu, 2009). Men and masculinity are commonly associated with the opposite, because gender is constructed dichotomously (e.g. Bergenheim, 1997; Connell, 2008, 2009; Fogelberg Eriksson, 2005; Hirdman, 2001; Höök, 2001). These binary acts produce an ordering and hierarchical device (Gannon & Davis, 2012). Hence, organisations are arenas where the production of gender upholds inequalities (Acker, 1990; Johansson, 2020). Against this backdrop, we are interested in whether and, if so, in what way, the thinking and acting related to intragroup conflicts are gendered among welfare workers in women-dominated workplaces. In this chapter, the aim is to describe and discuss research on intragroup conflicts and well-being as well as studies of intragroup conflict in relation to gender. We also aim to investigate how the concept of conflict is perceived by employees in womendominated work, and how the theory of task, relationship and process conflicts refers to these understandings from a gender perspective, that is, in what ways the welfare workers’ perceptions and practices are related to wider societal discourses of gender. We will start by describing and discussing the consequences of intragroup conflicts in terms of reduced well-being, and addressing the topic of gender differences and intragroup conflict. We will then perform an empirical analysis focusing on employees’ interpretations of the content of conflicts because we want to investigate whether the different types of intragroup conflicts identified in previous studies (i.e. task, relation and process conflicts) are found in Swedish, womendominated workplaces. These consist of a social-services office (at a national level, 84% of employees are female), a school (75% of employees female) and a geriatric ward (90% of employees female). Furthermore, we relate examples of intragroup conflicts to societal discourses on gender and conflict.

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Intragroup Conflicts and Employee Well-Being in Welfare Occupations

Previous research on intragroup conflicts have focused mainly on productivityrelated outcomes, such as group performance and effectiveness (De Dreu & Beersma, 2005), but a growing number of studies are focusing on their impact on well-being. Below, we will summarise these studies, with a focus on studies involving women-dominated work. Based on the notion that workplace conflicts may trigger negative emotions and stress that may, over time, lead to diminished mental health, a number of studies have examined the overall impact of intragroup conflict on well-being. These studies have found that such conflict increases negative affect (Ilies et al., 2011), stress (Dijkstra, van Dierendonck, Evers, & De Dreu, 2005) and depression (Inoue et al., 2010), while also having a negative effect on mental health (Dijkstra, van Dierendonck, & Evers, 2005). For example, in their study of nursing staff working in an institution for people with acute disability, such as paralysis, Dijkstra, van Dierendonck, and Evers (2005) found that workplace conflict increased feelings of helplessness and flight behaviour, which in turn increased stress and led to diminished mental health. However, given that relationship, task and process conflicts have been found to impact differently upon employee performance and productivity (De Wit et al., 2012), it is reasonable to assume that these types of intragroup conflict may also vary in how they affect well-being. Relationship conflict is the type of intragroup conflict that has been most strongly associated with reductions in well-being (Guerra et al., 2005; Medina et al., 2005; Sonnentag et al., 2013). Studies have demonstrated that the experience of relationship conflicts increases stress (Friedman et al., 2000), negative affect (De Wit et al., 2012) and, in some studies, also burnout (Jimmieson et al., 2017). For example, in a study of Dutch social-services workers, Giebels and Janssen (2005) found that relationship conflict increased conflict stress, which in turn increased perceptions of exhaustion. This negative effect on well-being has been explained in a number of ways. Based on conservation of resources theory (Hobfoll, 1989), relationship conflicts have been suggested to lead to a loss of valuable resources, such as social support, which over time may reduce well-being. Disagreements with colleagues may also represent an ego threat, which increases hostility within a team, and over time may transform into feelings of distrust, stress and anxiety (De Wit et al., 2012). Task conflicts, on the other hand, have not been as strongly related to well-being as relationship conflicts. In the most recent meta-analysis, no relationship was found between task conflict and affective reactions (De Wit et al., 2012). Studies have found task conflicts to be unrelated to emotional exhaustion (Giebels & Janssen, 2005), well-being (Medina et al., 2005), stress (Friedman et al., 2000) or burnout (Leon-Perez et al., 2016). For example, in a study at a university hospital in the USA, Friedman and colleagues (2005) found that task conflict was unrelated to stress. However, they did find an indirect relationship, whereby task conflicts increased the probability of relationship conflicts, which in turn increased stress. This suggests that

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task conflicts which remain unresolved may transform into relationship conflicts, leading to reductions in well-being. However, the lack of any direct effect of task conflicts on well-being has been debated, and is a bit surprising given that conflicts around work tasks are suggested to increase team members’ cognitive load, causing people to brood, and thereby generating dissatisfaction and stress (De Wit et al., 2012). Process conflict, which was introduced as a concept later than relationship or task conflict, has not been much studied in relation to well-being, and the few studies on the subject have produced conflicting findings. In a study of Spanish safetyinspection workers, process conflict was unrelated to burnout (Leon-Perez et al., 2016), while in a study of Dutch employees, process conflict increased negative emotions (Rispens & Demerouti, 2016). In theory, process conflicts are suggested to reduce well-being, because disagreements about issues such as task delegation or role assignment easily become highly personal and are therefore expected to trigger stress and negative emotions (De Wit et al., 2012). In a recent study, we also examined how relationship, task and process conflicts were related to well-being among three welfare occupations in Sweden: nurses, teachers and social workers (Tafvelin et al., 2019). In our study, we were interested in exploring whether workplace conflict would be related to well-being, while also controlling for demands and resources in the work environment (Bakker & Demerouti, 2007). As the high rates of sick leave in women-dominated workplaces have been suggested to be a consequence of unfavourable working conditions (FORTE, 2016), we wanted to determine whether workplace conflicts might also be a contributing factor, while also taking working conditions into consideration. Our findings demonstrated that after controlling for the levels of demand and resources at work, relationship conflict increased employees’ perceptions of stress, burnout and depression. Task conflict was unrelated to our well-being indicators, while process conflict only increased perceptions of depression, but was unrelated to stress or burnout. These findings suggest that relationship conflict is the type of conflict that hurts well-being the most in welfare occupations, regardless of how good or bad the work environment is. Therefore, managers need to take intragroup conflicts seriously, and make sure they do not become personal, because if they do, they will harm employees’ mental health. Given that research on intragroup conflict and well-being is still in its infancy, a number of issues remain unresolved and merit future research attention. For example, we still do not know why relationship conflict harms well-being, while task conflict does not. A few studies suggest that, over time, task conflicts may transform into relationship conflicts, but the mechanisms linking both task and relationship conflict to such factors as stress and exhaustion need to be identified in order for us to better understand how different types of intragroup conflict affect employees. Another issue that deserves future research attention is the potentially reciprocal relationship between the work environment and intragroup conflict; which comes first? It has been suggested that an unfavourable working environment may trigger intragroup conflicts, but it has also been suggested that intragroup conflicts may lead to a reduction in resources at work, such as social support. The dual relationship

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between conflicts and the demands and resources at work is an area where more knowledge is needed. Furthermore, so far, studies of intragroup conflict have centred on the consequences for employee performance and well-being. However, in order to help organisations prevent the emergence of intragroup conflict, more studies are needed on the antecedents to such conflicts. Factors in the work environment may play an important role, but there might also be other relevant factors, such as external pressure in terms of political decisions and organisational change, and these need to be uncovered. Finally, it would be of interest to compare how conflicts emerge and affect employees across different cultures and welfare systems. A large proportion of the studies on intragroup conflict in relation to performance outcomes have been conducted in the USA, while studies on well-being outcomes have largely been conducted in Europe. Based on Hofstede et al.’s (1990) idea that national culture plays an important role in the culture of organisations, this may also affect how employees interact and are affected by conflicts at work. In addition, different welfare systems may also play a role in different inequality trade-offs (Korpi et al., 2013).

11.3

Intragroup Conflict and Gender

Another aspect of intragroup conflict that still requires further attention is the impact of gender, how it is constructed and what effects it produces within organisations. In the welfare sector, a majority of employees are women, but studies focusing on welfare workers are scarce. Several studies, primarily in a US context, have examined gender differences in relation to conflicts at work, using quantitative methods (e.g. Boonsathorn, 2007; Davis et al., 2010; Shockley-Zalabak & Morley, 1984; Sorenson et al., 1995; Wachter, 1999; Watson et al., 2008), or examining conflict management styles related to the sex of managers (Brewer et al., 2002; Chusmir & Mills, 1989; Holt & De Vore, 2005; Korabik et al., 1993; Watson & Hoffman, 1996), and examinations of gender differences in conflict resolution in studies involving students (Brahnam et al., 2005; Sadri & Rahmatian, 2003; Watson et al., 2008). The results of these studies are often contradictory, but in a meta-study by Holt and De Vore (2005), the authors conclude that women are more likely to endorse a compromising conflict style than men, regardless of organisational or national culture. Still, a more gender-theoretical approach to gender and intragroup conflict is needed because gender and inequality are embedded in all the organisational processes of the workplace and as a constitutive element of organisational logics, while understandings of conflict are also gendered (Acker, 1990, 2012). Genderblind research or approaches taking the binary construction as given do not challenge inequalities when overlooking the impact of social constructions of femininity and masculinity on interactions in the workplace. Furthermore, besides inequality, it is of interest to examine whether relational work and intragroup conflicts affect wellbeing in different ways. One example is that welfare work involves emotional labour: being compassionate, listening and assessing the needs of others

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(Hochschild, 2012; Storm & Stranz Chap. 8). Given that, from a social constructionist perspective, girls are trained in these skills from a young age (West & Zimmerman, 1987), we can assume that, when women become involved in intragroup conflict concerning such competences at work, it becomes more of a failure in relation to gender identity for them than it would be for men. Perhaps intragroup conflicts therefore affect women’s well-being more negatively than they do men’s. Furthermore, the horizontal gender segregation within the labour market in Sweden, as well as internationally, is very consistent, even though vertical segregation has slowly decreased (Härenstam & Nyberg Chap. 5). For decades now, the welfare sector has been undergoing downsizing and transformation due to new public management (NPM), and many scholars, especially within health and social care, have reported negative consequences for the work environment (e.g. Dahl, 2012; Hayes et al., 2006; Trydegård, 2005 and introduction Chap. 1). NPM is characterised by its emphasis on managerialism and marketisation. This rationale embraces effectiveness, which may undermine the possibility of meeting the requirements for high-quality work in the welfare sector and constitute a hindrance to doing satisfactory work (Bergmark, 2008; Kamp & Hvid, 2012; Keisu et al., 2015). This is because the reforms were implemented in a context with lack of resources due to austerity which aims to reduce public spending (Keisu, Brodin, & Tafvelin Chap. 1). Additionally, women still have greater responsibility than men for unpaid household work, which means that, overall, women work more hours than men (SCB, 2018). Coping strategies and resources could thus be under more strain for women than for men. Taken together with the social construction of female gender identity and the effects of NPM, this could mean that the negative relationship between intragroup conflict and well-being is stronger for women than it is for men in women-dominated welfare occupations. In a recent study, we compared the perceptions and consequences of intragroup conflicts among women and men in the same occupation (Tafvelin et al., 2019). Our respondents worked in three welfare occupations, as teachers, nurses and social workers. The analysis showed no differences in the perceived levels of relationship, task and process conflict between women and men. We also compared whether women and men reacted differently to intragroup conflicts, but found that relationship, task and process conflicts affect well-being in the same way for both men and women. Our findings contradict previous ideas in the literature, which suggest that women would be both more prone to experiencing conflicts at work and more affected by them (Keisu, 2009). Instead, our findings suggest that men and women perceive and are affected by conflicts at work in the same way due to the poor work environment.

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Data and Methods

The study reported in this chapter consists of 26 semi-structured individual interviews at three workplaces. We interviewed four first-level managers and 22 of their employees in different welfare occupations, specifically, three registered nurses, four assistant nurses, four teachers, one teaching assistant, one school welfare officer, two social workers working as team leaders, and seven social workers. At each of two workplaces, one first-level manager was interviewed. At the third workplace, two interviews with first-level managers were conducted. Both women and men are included in the data even though the majority of both interviewees and workforce were women. The interviews were conducted on-site at the workplaces and the material was gathered between the years 2017 and 2019. The first-level managers informed their employees about the research project and contact information was supplied to those who were interested in taking part in the interviews. All professionals who expressed interest were contacted and included in the study. In the interviews, we asked about their thoughts around the concept of conflict with the question: what do you think of when you hear the word conflict? Several other questions about the interviewees’ personal experiences of conflict and whether gender has any impact on conflicts in their current workplace were asked, but for this analysis the focus is on their understandings of the concept of conflict. All interviews were recorded and transcribed verbatim. The software Maxqda11 was used to facilitate the qualitative analyses. In the analysis of welfare workers’ thoughts on the concept of conflict, which involves reading, organising and coding the transcribed text, the theories of task, relationship and process conflict were applied (De Wit et al., 2012; Jehn & Mannix, 2001). Three main codes were constructed. Each of these codes contains several examples of task, relationship and process conflicts that the welfare workers had experienced. The different types of conflict are found in the data at all of the three workplaces. The codes are presented in the findings section titled ‘The Concept of Intragroup Conflict—An Empirical Analysis’ and the quotes are translated from Swedish into English.

11.5

The Concept of Intragroup Conflict: An Empirical Analysis

In the first section, ‘Who—A Positional War between Groups of Allies’, relationship conflicts are illustrated; in the second section: ‘What—Different Opinions Leading to High-Quality Work’, task conflicts are visualised; and, finally, the third section, ‘How—The Process of Building Routines’, exemplifies process conflicts. In the section, Conflicts as Destructive Phenomena in Women-Dominated Workplaces, the relationship, task and process conflicts are summarised and further we conclude how gender is practised and perceived in intragroup conflict.

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11.5.1 Who: A Positional War Between Groups of Allies In the individual interviews, the welfare workers were asked what they thought of when they heard the word ‘conflict’. The dominant pattern of their initial responses was that the concept of conflict refers to something destructive, ‘a fight’ between individuals who do not like each other and ‘something that is not very nice’. Furthermore, they said that conflicts trigger many difficult emotions, such as anger, stress, nervousness, anxiety, fear, insecurity, dissatisfaction or exhaustion. Being part of, or nearby, this type of conflict makes individuals feel drained. The way in which the concept is described in this pattern is in line with the definition of a relationship conflict, which is defined as personality differences and differences in norms and values, with this type of conflict often involving feelings of tension, friction and dislike (De Wit et al., 2012; Jehn & Mannix, 2001). These conflicts are described as problems that often grow larger and larger over time, and interviewees stated that they are often ignored without anyone taking responsibility for resolving them. The interviewees perceived that it is difficult to end this type of conflict. Therefore, they said that it feels like having an ‘elephant in the room’, as one welfare worker explained, and people start to think: ‘it’s gone too far, it’s no idea’ to do anything, as another interviewee described it. One additional example is a welfare worker who distinguished between group disagreements as having different opinions versus the case of a ‘war of different positions’ with ‘allies’: If we think differently, then we can disagree. I think that’s a little bit different from what I perceive as a conflict... then you... get stuck, you can’t move forward, it lies there and then it grows ... and it affects the future. / ... / and then when it crosses the line ... you can’t discuss it calmly and sensibly, reasoning. It will be a war of different positions and you may start to search for allies.

A relationship conflict can manifest in different forms, for example, between individuals or between a group and an individual. During the interviews, the welfare workers reflected upon the reasons why a conflict becomes relational. Often, the characteristics or behaviour of an individual is a focus for the explanation. This is almost always a first-level manager or an (informal) leader who is described as authoritarian, aggressive, persuasive, controlling, unfair, bossy and/or a bully. These types of conflict are, in other words, produced vertically within the organisational hierarchy. However, a few welfare workers addressed the group process instead and said that a conflict becomes relational due to people’s need for safety and trust, to be united against a ‘common enemy’, as shown in the following quote: You’re so afraid of ending up outside of... [laughter] ‘the pack’. That is, we’re animals who all want to be part of the pack and we should think alike, and we should be united, eh, preferably against someone else. Because when we get a common enemy, then we unite. And if we don’t have a common enemy, the group is reconstructed until we get the unity we’re looking for. And I think it’s because of our need to feel secure.

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11.5.2 What: Different Opinions Leading to High-Quality Work During the interviews, the welfare workers also described the word conflict in terms that were in line with the definitions of a task conflict (De Wit et al., 2012; Jehn & Mannix, 2001), that is, when individuals or groups have opposing or different ideas, needs or wishes about the content or outcomes of the tasks being performed. This can be characterised by animated discussions or individual excitement but not by the negative feelings that are associated with relationship conflicts, according to the theory. The quote below illustrates an example of how the welfare workers perceived conflicts: Yes, conflict is a word, I think, that has negative connotations. Conflict is perceived as something that’s huge, an agitated fight or polarised opinions. But I don’t think it always has to be that way. A conflict can consist of differences of opinion, you could think differently, and you can meet in that.

However, when describing different task conflicts, the interviewees in our data addressed numerous emotions, such as stress, sadness, anxiety, discomfort or experiences of being offended. The welfare workers described their experience that colleagues ‘compete’ with each other, and this behaviour could reinforce disagreement about the content or outcomes of the tasks being performed. These types of conflict are horizonal and related to the division of labour. Even though the initial response from the welfare workers was characteristic of destructive conflicts when describing what they thought about when they heard the word conflict, they often changed their view as they talked, concluding that conflict can be either destructive or constructive, depending on how it is handled. Furthermore, many of the interviewees had experiences of task conflict that started in a destructive way but ended up as constructive. However, some of their initial responses to the question were that conflict is constructive and necessary for developing the work, as illustrated in this quote: At our workplace, we usually gather around a specific case. There are several people with different work positions [with different status], and in such situations I think it’s extremely important that you dare to say ‘I don’t like this, I think you’re wrong, I think like this.’ Because that’s what helps and makes us move forward. And I think it has to be that way in a workplace, even if it feels really uncomfortable sometimes [laughs].

As this quote shows, these conflicts are sometimes generated between individuals or groups with different positions within the organisational hierarchy, that is, vertically. Different opinions about how to accomplish a task, according to the welfare workers, are often connected with emotions of inconvenience, but are still a necessity for the quality of care for the vulnerable, the teaching of a student or the curing of a patient. Hence, this reveals how the welfare workers put their own emotions aside for the sake of others. When challenging and questioning one another, forcing oneself to perceive a problem from a different perspective can improve the quality of the work. If this is an integrated part of daily routines at the

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workplace, welfare workers will have the necessary requirements for handling conflicts in a constructive way. The constructive part of a conflict is that the differences become visible, as shown in the quote below: When you have a terrible problem and don’t talk about it, you get a stomach-ache and think it’s just awful. But when a conflict reaches the surface, it becomes visible. Then you have to do something about it.

According to this interviewee, a task conflict is constructive when everyone involved can distinguish between their own needs and the needs of the other: the student, the patient or the client. It is also constructive when the group and/or individuals can reach agreement on the content or outcome of a task.

11.5.3 How: The Process of Building Routines When the welfare workers were asked about how they perceived the word conflict, they also described it in a way that is in line with the theory of process conflict (De Wit et al., 2012; Jehn & Mannix, 2001). Process conflict involves disagreements about the logistics of task accomplishment, such as who is responsible for what and how much responsibility everyone has. When describing this type of conflict, the interviewees addressed emotions such as anxiety, stress, sadness, shock, insecurity, fear, exhaustion, aggression and anger, as well as stating that the process tends to erode the mind and become surreal. Furthermore, the welfare workers said that when people are too proud, the conflict sometimes ends up in a ‘power struggle’, or like volcanoes that just explode when they erupt. Often it is unclear routines, or a lack of routines, in the workplace that are the root cause of this type of conflict. However, the conflict often involves status between groups of employees or between individuals in the process. That is, an individual or group who believe they have interpretative prerogative due to their higher status. Sometimes this status is related to their position as managers within the organisational hierarchy, while other examples described by the interviewees involve individuals having an occupation with higher status. Status is sometimes a parallel explanation for why the conflict emerges. One example is when newly recruited staff (not managers), with high status and a mandate to act, do not understand the workplace routines, but instead of asking someone immediately start to complain about co-workers: ‘You can’t work here because people just don’t do what they’re asked to do. It doesn’t work’, the guy said, and I had a meeting where I gathered the staff and explained the situation. They were quite upset and sad, because they didn’t understand the problem. They were working in line with the routines we had and then, all of a sudden, this way of working became wrong.

This newcomer has high status within the organisation and thus, when he complains, it creates discomfort and other stressful emotions and confusion among the co-workers. They have little authority to respond or act upon the critique and therefore they seek support from their first-level manager, the person who recounted

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this situation. These types of conflict are produced vertically. Another example reported by our informants was a huge process conflict that began at a workplace when a popular co-worker got a position as a team leader. The new leader began to track mistakes and lack of routines and argued for the need to make changes amongst the employees. The first-level manager reflected on how he had handled the conflict and said: ‘I was, like, firefighting the whole month, really. Trying to defuse the situation.’ The employees believed that there was no reciprocity in the process of change, because this leader was controlling, diminishing their contributions and yelling at them. The staff went and talked with another team leader (i.e. not their first-level manager), who tried to support them in finding ways to take responsibility for the conflict, rather than handing it over to him. He asked them questions in order to visualise the welfare workers’ own responsibilities. In this quote, the first-level manager recounted the situation: . . .you know, . . . he’s had a couple of chats with staff where, you know, they’ve come to him and said ‘oh, I don’t like how this person’s done this.’ ‘Ok. . . did you tell her?’ ‘No.’ ‘So how could she know?’ And really, like. . . getting their psychology [laughs] really like, you know. . . and really, he is good at changing people’s. . . like, you know. . . [sighs] and asking them the question: ‘Ok, so you’ve had this conflict with the person, a disagreement. How am I gonna change it?’ I’m just thinking of one example where they said ‘mm. . . I don’t know what you can do.’ ‘So. . . can you change it?’

Despite the trouble at this workplace, both the first-level manager and the employees believed that the destructive conflict had changed the culture and that it had become better for everyone. This conflict started as a process conflict but quite quickly became a relationship conflict. The interviewee believed that high status and ‘wise guy’ behaviour is really destructive in conflicts, compared to high status combined with a respectful response towards employees with lower status. Another example of a constructive process conflict described by welfare workers was a firstlevel manager who defended the ethos of the workplace in relation to politicians and political decisions, even though this risked creating complicated relations higher up in the organisational hierarchy.

11.5.4 Conflicts as Destructive Phenomena in Women-Dominated Workplaces In the analysis of welfare workers’ understandings of the concept of conflict, the data fitted well with the theory of task, relationship and process conflict (De Wit et al., 2012; Jehn & Mannix, 2001). We did not find any new types of conflict. This is despite the fact that the theory was developed in a US context, with no focus on different distinctions between gender composition, as in our data, collected in a Nordic, women-dominated context. Furthermore, our results reveal that women’s intragroup conflicts do not differ from men’s. Both men and women are described as conducting intragroup conflict in similar ways. This contrasts with societal

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Table 11.1 The relationship, task and process conflicts experienced by the welfare workers together with their focus, characteristic and organisational level Relationship conflict Task conflict Process conflict

Focus Who What How

Characteristic Destructive Destructive and constructive Destructive and constructive

Organisational level Vertical Vertical and horizontal Vertical

discourses of gender, in which women are assumed to engage in intragroup conflicts more often and less well than men (Keisu, 2009). Lewin’s (1951) understanding of the concept enables conflicts within an organisation to be both destructive and constructive, depending on the balance of the counteracting forces involved in the process. The dominant pattern of the welfare workers’ initial response was that the concept of conflict refers to something destructive. While destructive conflicts are primarily related to relationship conflicts, both task and process conflicts are described as sometimes constructive, sometimes destructive. Hence, the analysis of the data reveals a clear pattern, which is that the experience of conflict among welfare workers is never solely constructive but is often exclusively destructive. Furthermore, our findings reveal that process and relationship conflicts are, to a high degree, related to status and power, for example, unequally distributed or connected to the organisational hierarchy and positions (see Table 11.1). Hence, both process and relationship conflicts are produced vertically. On the other hand, task conflict is produced both horizontally (between colleagues at the same hierarchical level) and vertically (between colleagues with different status). Welfare workers’ experiences of task conflicts are illustrated as both vertical and horizontal within their organisations. Constructive task conflicts are characterised by welfare workers putting their emotions aside and distinguishing between their own needs and the needs of the other (the student, patient or client). This is the core of the expectations related to the welfare workers’ professional behaviour, especially because it is a relational field of work (see Brodin & Erlander Chap. 10; Fejes, 2012; Storm & Strantz Chap. 8). This visualises welfare workers’ professional efforts to raise standards and the quality of practice at work, in the school, the social work office or the geriatric ward. Moreover, when describing all three types of conflict, the interviewees addressed emotions. This focus on relationships and how to professionally handle emotions is needed in a relational field of work and can go hand in hand with strong emotions produced by vertical conflicts attributed to status derived from the organisational hierarchy in general. Theoretically, process conflicts are suggested to reduce well-being (De Wit et al., 2012). This is in line with our empirical analysis of the concept of intragroup conflicts, in which our interviewees described how process conflicts, in term of debates about who is responsible for doing what, caused stress and anxiety among employees. Hence, we want to argue for the necessity of addressing the impact of emotions in relation to all three types of conflict, not only relationship conflicts.

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11.5.5 Limitations and Future Directions The empirical data consists of 26 individual interviews at three workplaces which each have different target groups, consisting of students, clients and patients. The three cases have different prerequisites, which might complicate the comparison. Still, what unifies them is that emotions are part of their everyday work. We therefore assume that similar and comparable results could be found at other workplaces in the welfare sector in Sweden, as well as in other countries. Given that women-dominated sectors are an under-researched area, and more specifically that the common societal discourse that women fight more and less well than men (Keisu, 2009) was not reflected in our data, it is of interest to further explore the role played by gender in workplace conflicts. For example, do our results, which find no differences in perceived conflicts between men and women based on employees in women-dominated occupations, hold up in other types of settings, such as gender-integrated or male-dominated occupations? Studies of women in male-dominated occupations have revealed that they are exposed to sexual harassment more often than their male colleagues (DiTomaso, 1996; Keisu, 2009; Wahl, 2003). Translated into intragroup conflicts, this may suggest that women in male-dominated occupations, being the minority, perceive higher levels of intragroup conflict than their male colleagues do, and therefore experience lower levels of well-being. Being in the majority or minority could produce different structures of power at work (Kanter, 1977). However, this remains to be explored in future research. Another phenomenon to take into consideration when conducting a gender analysis of intragroup conflicts is that, during our interviews, the questions about the concept of conflict were asked in a gender-neutral way, that is, without mentioning women or men, and a dichotomous view of gender was missing from the data. However, during the same interviews, when other questions that explicitly mentioned gender or sex were asked, another dominant pattern emerged. This is in line with societal discourses of gender and conflict (Keisu & Brodin forthcoming). Thus, when welfare workers talk about women/men and intragroup conflicts, the narratives are clearly marked by stereotyped understandings, and even though welfare workers describe engaging in the same types of conflict (task, relationship and process) in their everyday work, their ideas about gender depict two complete opposites, in which women and femininity are subordinated to men and masculinity. This indicates a divergence between the gender we think and the gender we do; hence, recreating the unequal power relations between men and women (Gherardi, 1994).

11.6

Conclusion

To conclude, our analysis of the concept of conflict in women-dominated workplaces suggests that conflicts are mainly perceived as destructive when related to relationship conflicts, whereas both task and process conflicts are sometimes

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perceived as constructive, sometimes destructive. Secondly, our analysis suggests that conflicts are inherently emotional. Our interviewees described a wealth of emotions in relation to all types of intragroup conflict, including anxiety, sadness, shock, fear and anger. Thirdly, our review of the literature on intragroup conflict and well-being suggests that although conflicts are emotional, not all of them affect welfare workers’ well-being over time. Only relationship conflicts seem to be hurtful to employee well-being. While, for example, task conflicts are also experienced as emotional, these emotions do not necessarily translate into increased perceptions of stress, depression or burnout over time. However, task conflicts that remain unresolved may over time transform into relationship conflicts, which makes it important to ensure that task conflicts are resolved. Fourthly, our study of gender in relation to intragroup conflict suggests that there are no differences between the ways in which men and women in welfare occupations perceive or react to such conflicts, calling into question the common discourse that women are not very good at fighting and that they fight more than men. Taking them together, this chapter suggests the need for gender awareness in research and an understanding that conflicts are a part of everyday life in women-dominated occupations, and have an impact on welfare workers’ well-being if not well managed.

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Britt-Inger Keisu is an associate professor in sociology and employed as a senior lecturer at Umeå University. Currently, she works as head of the department at Umeå Centre for Gender studies. Her main research interests involves gender-organisation and leadership theory. Susanne Tafvelin has a PhD in psychology and is an associate professor at Umeå University. Her research focuses on how leaders and the work environment impacts on employee well-being as well as on transfer of leadership training.

Index

A Accident risk, 146 Assistant nurses, 109, 123, 126, 161, 177, 203 Auditing, 8, 121–133, 161

B Binary categorisations, 6 Bullying, 39, 40, 46, 52, 54, 56, 197

C Care, 2, 24, 37, 63, 85, 105, 121, 158, 177, 202 management, 8, 50, 73, 86, 112, 115, 124–125, 128, 131, 150, 157–171, 202 work, 2, 3, 7, 8, 83–88, 95, 105–115, 121–125, 129–133, 158, 162, 165, 189 Classification, 5–7, 15–29, 40, 41, 54, 85, 86 Client-initiated violence, 178, 184, 185, 187, 188, 190 Competence, 8, 38, 39, 66, 121–133, 162, 165, 166, 171, 202 Constructive, 197, 205–208, 210 Constructive conflict, 197 Contextual approach, 19, 47, 48 Covid-19, 1, 2, 4, 50

D Decision authority, 38, 40, 42, 43, 47, 49–50, 53–55 Destructive, 197, 203, 205, 207–209 Destructive conflict, 197, 205, 207, 208

Development, 4, 5, 7, 15, 26, 28, 35, 36, 38, 43, 45, 46, 53, 65, 66, 89, 107, 111, 113–115, 132, 157, 159, 162, 167, 170 Digitalisation, 105–115, 161 Disability care, 7, 8, 180–182, 184–186, 188 Discourse, 5, 9, 181, 184–193, 198, 207, 209, 210 Doing gender, 18, 160, 164 Dual Earner/Dual-Carer model, 2, 3

E Earner-Carer Model, 2 Egalitarian, 3 Eldercare, 121–125, 128, 132, 161 Emotion, 9, 66, 108, 130, 186, 199, 200, 204–206, 208–210 Emotional labour, 108, 161, 164, 201

F Fatigue, 137–139, 144–148, 150 Female-dominated sector, 45, 64, 75, 182 Flexible work hours, 141, 145, 147–149

G Gender, 2, 15, 35, 63, 83, 105, 137, 157, 178, 198 composition, 7, 25, 35–53, 68, 207 connotations, 24, 25 differences, 6–8, 15–29, 35–37, 39, 47, 53, 110, 137, 139, 140, 142, 145, 146, 148, 150, 198, 201

© Springer Nature Switzerland AG 2021 B.-I. Keisu et al. (eds.), Gendered Norms at Work, Aligning Perspectives on Health, Safety and Well-Being, https://doi.org/10.1007/978-3-030-77734-0

215

216 Gender (cont.) ordering, 4, 18, 20, 26, 107, 165, 169 roles, 6, 8, 17, 39, 142 segregation, 3, 7, 15, 18, 39, 202 structuring, 83 Gendered context, 37–39 Gendered norms, 6, 8, 122, 133, 160, 163, 167, 169, 170 Gendered organizations, 18

H Health, 2–8, 15, 16, 19, 21–28, 35–51, 53, 55–57, 63–76, 84, 85, 87, 88, 98, 99, 106, 108–110, 123, 129, 130, 137, 139–141, 143–150, 159, 160, 170, 177–181, 190, 192, 193, 202 Healthcare, 1, 3, 4, 6, 7, 90, 140, 160 Healthy work, 21, 27–29, 159 Homecare service work, 158, 160, 162, 164, 166 Horizontal segregation, 22, 64

I Individual interventions, 71, 72 Industry, 3, 15, 36, 63, 83, 109 Industry classifications, 25, 27 Inequality, 3, 5–8, 16, 18–22, 27, 29, 83, 106, 108, 114, 162, 170, 198, 201 Intragroup conflict, 9, 197–203, 207–210

Index Marketisation, 128, 130–133, 160, 161, 202 Mental health, 36, 51, 53, 64, 65, 70, 71, 140, 141, 144, 146, 148, 199, 200 Multilevel, 7, 19–21, 37, 63–76 Multilevel modelling, 68, 69

N New materialism, 5 New Public Management (NPM), 3, 4, 6–8, 49, 83–85, 89, 93–97, 109, 121–125, 127, 132, 157–162, 164, 166–170, 202 Normalisation, 181, 185, 189, 192–193

O Occupational health, 2, 15–17, 19, 20, 22, 53, 65, 110, 159, 163 Occupational segregation, 2, 5, 63, 179, 191–193 Organisational, 2, 3, 6–9, 106–108, 110, 114, 121–123, 125, 133, 157–171, 178, 180, 181, 184, 186–193, 201, 204–208 imbalances, 167, 170 interventions, 72, 73 responses, 181, 184, 192, 193 values, 161, 163, 164, 166, 167 Organisation of work, 1–9, 192

L Labour market, 1–9, 22, 28, 29, 36, 47, 63, 83, 86, 87, 97, 109, 115, 159, 160, 163, 202 Labour statistics, 15–17, 22 Long work hours, 150

P Person-centered care (PCC), 121, 128 Power, 6, 7, 16, 19–21, 29, 50, 84, 97, 107, 114, 125, 159, 162, 163, 169, 170, 191, 193, 206, 208, 209 Prevention, 4, 7, 15–29, 53, 71, 187 Process conflict, 197–200, 202, 203, 206–209 Psychosocial, 15, 17, 26, 27, 35–53, 65, 66, 72–74, 85, 140, 143, 144, 197 Psychosocial work environment, 39, 47, 65, 73, 74, 85, 197 Public sector, 3, 4, 48, 49, 64, 84, 89, 109, 123, 157, 158, 161, 162, 165, 182, 183, 185–188, 190, 191

M Management strategies, 8, 188 Managers, 6–8, 16, 28, 38–40, 44–47, 49, 50, 52, 54, 56, 70, 73–75, 83–99, 112, 114, 121, 122, 125–127, 130–132, 149, 158, 162, 163, 165–171, 178, 179, 182, 183, 185–193, 200, 201, 203, 204, 206, 207

R Rationality of caring, 121, 122, 124, 133 Recovery, 141, 142, 146–150 Relational work, 163, 164, 201 Relationship conflict, 9, 197, 199, 200, 203–205, 207–210 Residential care homes, 8, 91, 121–133

J Job demands, 7, 17, 20, 23, 37, 38, 40–42, 47–49, 52–54, 63–76, 143 Job demands-resources model, 65–67

Index S Science and technology studies (STS), 106, 107 Sexual harassment, 39, 40, 43–47, 51, 52, 54–56, 178, 184, 185, 209 Shift work, 8, 137–145 Sickness absence, 35–37, 47, 49, 51, 52, 64, 65, 68, 69, 98, 99, 140, 145 Sleep, 137–139, 142, 143, 145, 146, 148–150 Social, 5, 16, 35, 63, 84, 106, 122, 141, 157, 177, 198 services, 9, 122, 127, 132, 177–180, 198, 199 support, 37, 39, 40, 44–45, 47, 52, 56, 66, 109, 124, 143, 199, 200 Span of control, 75, 83–88 Structural approach, 47 Structuration, 20–21, 27, 29 Structures, 2, 7, 18, 20, 27, 28, 37, 67, 70, 72, 75, 83–85, 92, 94, 97, 98, 107, 114, 127, 132, 159, 162, 168, 169, 171, 209 Sweden, 2–4, 7, 8, 16, 21–23, 26, 35–54, 63, 65, 83, 85–88, 97, 106, 109–112, 115, 122–126, 144, 146, 148, 160, 162, 163, 165, 171, 177–193, 200, 202, 209

T Task conflict, 197, 199, 200, 203, 205, 206, 208, 210 Threats, 38, 40, 43, 44, 51, 54, 55, 97, 143, 144, 177–180, 182, 184–193, 199

217 V Vertical segregation, 7, 18, 202 Victim blaming, 186 Violence, 5, 8, 38, 40, 43, 44, 51, 54, 55, 66, 143, 144, 159, 177–182, 184–193

W Welfare occupation, 200, 202, 203, 210 Well-being, 8, 9, 64–71, 73, 121, 125, 128, 129, 132, 137, 141, 144–147, 150, 169, 179, 189, 198–202, 208–210 Women, 1, 15, 35, 63, 83, 105, 123, 137, 158, 177, 198 Women dominated organisations, 2, 4, 6 Women-dominated work, 2, 4, 6, 9, 198, 199, 209 Work, 1, 37, 63, 83, 105, 121, 137, 157, 177, 197 environment, 2, 15, 39, 64, 83, 106, 123, 124, 147, 157, 179, 197 environment risks, 157, 159, 168, 171 Working condition, 1–5, 7, 8, 15–29, 35–53, 64, 66, 67, 71, 74, 75, 83–88, 90, 92, 96, 98, 110, 115, 122–126, 128, 129, 132, 137, 140, 142–144, 146, 150, 158, 160, 161, 169, 178, 182, 184, 190, 191, 193, 200 Work–life interference, 66, 147 Workplace violence, 8, 9, 47, 51, 177–182, 184–193 WPR, 181, 184