Discretion may challenge the formal principle of justice as it may involve unequal treatment of the same type of case. This article explores the discretionary reasoning exhibited by the frontline workers at different Norwegian Labour and Welfare offices (NAV) towards the same fictitious case. Frontline workers participate in a focus group where they are presented with a vignette concerning the case of a user with medically objective findings, that is, a severe head injury. The analysis focuses on the reasoning of the frontline workers before they come up with a suggestion as to how to proceed with the case. The findings demonstrate that while different avenues are pursued in the reasoning of the focus groups, the same conclusion is reached as to the treatment of the case. The article argues that the institutional logic which guides the frontline workers actions infers the reasoning process through a “norm of action” that states how it ought to be done.
Keywords: Discretion; institutional logic; frontline workers; unequal treatment; return-to-work
The formal principle of justice demands comparable consistency in judgements across time, space and persons (Molander 2016, p. 32). The manner in which discretion is exercised is a core interest in research on frontline workers and their practices, as it is concerned with the translation of policy to practice (Caswell, Larsen, van Berkel & Kupka, 2017; Lipsky, 1980). Frontline workers may have significant capacity for discretion within the confines of available resources and regulations due to the complex nature of their work (Lipsky, 1980). Room for discretion allows for flexibility; however, it may also lead to unequal treatment or arbitrary judgements (Lipsky, 1980; Larsson & Jacobsson, 2013; Molander, Grimen & Eriksen, 2012; Nothdurfter, 2016).
Discretion as a concept can be divided into the structural: a snpace in which the social actors have the possibility to judge, decide and act according to their own judgement, and epistemic: the cognitive activity of reasoning and judging under conditions of indeterminacy (Molander & Grimen, 2010, p. 214; Wallander & Molander, 2014). Christie (2016) argues that discretion is both a threat and a pre-requesite for equal treatment, as the categorization of cases as “the same case” already implies the use of discretion. Casewell et al., (2017, p. 192) argue that the risk of arbitrariness in the frontline workers’ discretion is real, as indicated by the variation in frontline workers’ practices. Variation in the practices of frontline workers may be due to inconsistency in the ways in which discretion is structured as a result of the background and contextual pressures under which frontline workers operate (Casewell et al., 2017, p. 191).
Frontline workers at NAV make decisions about how to help users return to work. Earlier research on frontline workers at NAV indicates that they have considerable discretionary space for making decisions (Hansen & Natland, 2016; Solvang, 2017), which implies there may be a risk of unequal treatment. Heum (2014, p. 21-23) uses examples to problematize discretion used at NAV, suggesting that this is a potential source for arbitrariness. The likelihood of arbitrariness in frontline workers’ discretion increases with the discrepancy between policy goals, and frontline workers’ perceptions of the difficulties and challenges that face their clients’ (Nothdurfter, 2016, p. 434). In other words, arbitrariness in frontline workers’ use of discretion depends on the users’ willingness (or potential) to conform to the goals of the frontline workers.
There are potentially two ways in which to explore the principle of equal treatment. First, Røysum (2013) argues that consistency may be attributed to a stronger standardization of measures, limiting frontline workers’ reflections and the possibility of them individualizing measures. In order to explore whether consistency is attributed to standardization, one needs to employ several vignette cases. In Denmark, Møller (2016) found that frontline workers used discretion differently based on stereotypes of users. Through applying three versions of a vignette, where one invoked a positive stereotype (a user with objective medical findings), one with negative stereotypes (a user with a “diffuse illness”) and a neutral stereotype, the study found that the extent to which frontline workers aligned with the wishes of the user was influenced by whether the vignette presented a positive or negative stereotype.
Second, discretion may be affected by personal background (e.g. education) and organizational context. Terum and Jessen (2015) found that frontline workers at NAV had operationalized their tasks in a way which limited the influence of the user and thus limited the potential for arbitrary decisions. However, frontline workers with a background in social work tended to involve the users to a greater extent than those with other educational backgrounds or training. Fossestøl, Breit, and Borg (2016) found that there was variation among the local NAV offices in how they approached users. Some tended to use a professional social work approach characterized by individualizing measures, while others applied a bureaucratic approach that focused on judicial rights. Thus, the same case may be treated differently depending on both the frontline worker and the local office.
This article focuses on one vignette presented at eight different local NAV offices to explore the discretionary reasoning of frontline workers. As a single vignette is employed, the article aims to investigate whether the same case is treated differently at the various offices. The next section presents the theoretical foundations of the study, followed by the method, an analysis of the data, discussion and conclusion.
The concept of discretion may be divided into epistemic and structural. While both these dimensions focus on discretion, they are concerned with different aspects of this. The structural dimension explores the space in which social actors have the possibility of using discretion, while the epistemic dimension focuses on the cognitive aspect of reasoning (Wallander & Molander, 2014). This article uses the epistemic dimension in order to explore frontline workers’ discretionary reasoning. Epistemic discretion refers to how social actors reason and make judgements in accordance with the aims and goals set forth by the delegating authority (Wallander & Molander, 2014, p. 3). There are three components to epistemic discretion, based on Toulmin’s (1958) general model of argumentation: a description of a situation, a “norm of action” and a course of action (Wallander & Molander 2014, p. 3). The epistemic dimension operationalizes discretion as for the reasoning that takes place during a process from the description of a situation to deciding on a course of action, inferred by the “norm of action”. The epistemic dimension of discretion guides our attention towards the norm of action (how things ought to be done).
In order to explore the underlying rationale of the frontline workers reasoning, a theory of institutional logic is applied. Institutional logic is a set of presumptions and perceptions that guide the actions of the social actors who are embedded in a field (Thornton, Ocasio & Lounsbury 2012, p. 114). As such, institutional logic provides these social actors with identities, goals, and schemas for focusing attention, accessing knowledge and guiding decision-making processes (Thornton et al., p. 91-95). Through triggering identities, goals, and schemas, institutional logic guides what the social actors “ought to do” by setting legitimate rationales for reasoning and decision-making. In other words, institutional logic constitutes an important influence on the norm of action which in turn influences the perception of a “description of a situation” and impacts on the reasoning which takes place in order to reach a “course of action”.
Through guiding social actors in the field, institutional logic provides an institutional framework that influences the “norm of action”, which in turn guides the reasoning of frontline workers. Institutional logic legitimates certain rationales above others through reliance on institutionalized knowledge on which frontline workers reflect when making decisions. As certain aspects are taken for granted, it is probable that these aspects do not receive due attention since humans have limited cognitive resources allocated to information processing (Thornton et al., 2012, p. 88-89). However, this does not mean that frontline workers’ decisions are determined by institutional logic, but rather guided by it.
The current study shows that norms of action are based on the discretionary reasoning that takes place between the description of a situation and course of action. However, frontline workers use certain measures to increase the information available and thus add to the description of a situation. For example, if a frontline worker uses a measure aimed at evaluating the user’s medical problems, a course of action will not in itself lead to that user accessing work, but rather add to the case information; this is then further considered upon as part of the process of reaching the final goal of returning the user to the labour market.
In order to explore the reasoning among frontline workers employed at different offices, eight focus groups at local NAV offices were conducted The data are comprised of these focus group discussions about the vignette case and took place in 2015. The participating offices ranged in size from ten to 180 employees with 27 focus group participants in total. The moderator of each focus group was either myself or another researcher with a background in social sciences.
Recruiting the informants entailed first obtaining permission from the central directorate and the regional administration to contact local offices. The selection of local offices was based on data received from two rehabilitation hospitals, indicating which local offices had had recent experience with a user with similar injuries and symptoms to the one described in the vignette. However, it was not stipulated that the focus group participants had to have had experience with such cases.
Table 1 shows that no single profession is present in all the focus groups, the most prevalent being social workers who are present in five out of the eight focus groups.
Table 1.
Background information on the focus groups and background of participants
|
Office |
Participants |
Municipal size |
Office Size |
Background |
|---|---|---|---|---|
|
1 |
3 |
City District, 48000 inhabitants |
53 Employees |
1xSociology 1xPolitical Science 1xSocial Worker |
|
2 |
5 |
Suburban municipality, 60000 inhabitants |
40 Employees |
1xLaw 1xSociology 1xUpper Secondary Education 1xEconomy and Administration 1xSocial Worker |
|
3 |
4 |
Rural municipality. 10000 Inhabitants |
10 Employees |
1xEconomy and administration 1xUpper Secondary Education 2xSocial Worker |
|
4 |
5 |
City, 80000 inhabitants |
180 Employees |
1xHealth Sciences 1xTeacher 2xSocial Worker 1xSociology |
|
5 |
2 |
Rural municipality, 13000 inhabitants |
28 Employees |
2xLaw |
|
6 |
3 |
City in Rural district, 30000 Inhabitants |
65 Employees |
1xNurse 1xUpper Secondary education 1xCriminology |
|
7 |
3 |
City, 50000 inhabitants |
80 Employees |
1xSocial Worker 1xSociology 1xHealth Sciences |
|
8 |
2 |
City District, 45000 inhabitants |
70 Employees |
1xHealth Sciences 1xUpper Secondary Education |
The aim of the focus group was to promote discussion among frontline workers in order to access strategies, reasoning and approaches that aligned with their real practice. Following Morgan’s (2012, 2010) approach, the focus groups were regarded as two overlapping phases: “sharing and comparing” and “categorising and conceptualising” (Morgan, 2012, p. 169). The first phase allows the focus group participants to share and relate to each other’s experiences and knowledge, while the second phase generates abstract knowledge on the subject matter (Morgan, 2010). The focus group participants were invited to discuss amongst themselves how they would approach the case, and explain the rationale behind said approach. This setting allowed for an exploration of frontline workers’ shared understandings, which constitutes a “NAV-approved way” of reasoning.
The interview guide was organized around five main questions: 1) How do you approach a person such as the one described in the vignette? 2) Can you reflect on your approach to the character in the vignette? 3) What are your limitations in helping them? 4) What do you think is their biggest problem? 5) Would they be eligible for a Work Assessment Allowance (WAA), and why is that? The follow-up questions focused on giving the frontline workers the opportunity to further reflect on their answers.
The vignette case (see appendix A) revolved around a 34-year-old carpenter with a wife and two young children, who had an accident that resulted in a traumatic brain injury caused by cerebral haemorrhage. The symptoms included paralysis in the left extremities, which was the main cause for rehabilitation in this case. In addition, he had severely limited balance, as well as minor symptoms such as headaches, slight depression and a lack of energy, and lacked the motivation to return to work. His general practitioner (GP) had declared him 100 percent disabled pro tem. In addition, the vignette described the recommendation from health personnel that further rehabilitation would be advantageous. The accident was set 12 months prior to the focus group session, the point at which frontline workers are required to stop sick-leave benefits and approach the crossroads of either disability benefit or the WAA. The WAA is a benefit given to users whose work capacity is being tested and evaluated in order to determine if they are capable of work or require a permanent disability pension. Constructing the vignette was a collaborative effort between myself, researchers with medical training, and a panel of representatives from various user associations. Several of the frontline workers indicated that the vignette amply mimicked information they usually received about a case.
The design of the vignette aimed to stimulate discussion among the frontline workers by using the vagueness connected with head trauma and the difficulty of forming a prognosis. Vagueness helps to capture interpretations and thus the principles on which frontline workers reason; however, it may also encourage diverging views in the different interviews through shifts in focus (Morrison, Stettler & Anderson, 2004).
The data collected were transcribed verbatim and thematically coded using NVivo 11. During coding, particular attention was paid to the reasoning the frontline workers used when talking about the vignette. The coding of the data followed each group’s reflections on the measures suggested as a course of action for the character in the vignette. This reasoning is explored in the next section.
The analysis focused on exploring the epistemic aspect of discretion and the reasoning that takes place in the focus group interviews. Some of the focus groups had limited discussion about social measures (supporting the family); however, these measures were considered in relation to the municipality’s available resources. The analysis showed that frontline workers discussed three types of measures: medical measures (measures recommended by health personnel), evaluative measures (measures aimed at testing the functionality of the user in a work-related setting) and return-to-work (RTW) measures (measures aimed at returning the user to ordinary paid employment). This is an iterative process, where frontline workers continuously went back and forth between suggesting evaluation measures and considering RTW measures and expanding the description of a situation. However, the reasoning related to these different measures is analysed separately in order to have a stringent and clear analysis.
The medically objective findings of the user depicted in the vignette may have given the case the appearance of simplicity because there was little discussion about the user not qualifying for WAA. In all the focus groups, the initial focus was on whether the medical information determined if the user was eligible for WAA: all focus groups concluded he was. However, even if the medical findings are objective, the diagnosis does not provide a clear prognosis. Thus, the analysis focused on the frontline workers’ reasoning about the application of measures.
The frontline workers’ discussions on the evaluative measures and the RTW measures overlapped to some degree. This overlap is probably because the goals of these measures tend to focus on work participation. Several evaluation measures that were considered test a user’s capacity to work, similar to the RTW measures. An RTW measure that did not lead to work was often perceived as an evaluation measure since it gave the frontline workers additional information expanding on the description of a situation, which then initiated a new reasoning process.
The frontline workers, in general, viewed the measures as part of a whole. One frontline worker, when asked about how they would approach the case, expressed this as a “cogwheel sort of thinking, where you combine treatment with evaluation and RTW measures” (Male frontline worker, background in law, Office 5). This “cogwheel sort of thinking” relies on the combination of several measures:
[We] need to find ways to combine [measures]. We try to back him up. Off course he will have his [medical] treatment. Nevertheless, how to combine it all? (Female frontline worker, background in nursing, Office 6)
The anamnesis outlined in the vignette contained too little information on the prognosis and potential of the person in question, according to the frontline workers. They explained that such a lack of information is common so the first step for them would be evaluating the resources and obstacles facing the user for retaining their job or finding a new one.
Initially, the frontline workers’ focused on the medical information provided in the vignette, and identified that the user met the regulatory demand of 50% reduced work capacity, so that he would “know where the next pay-check is coming from” (Female frontline worker, background in social work, Office 7). However, as the frontline workers are not health experts they are dependent on medical information and advice from health personnel.
After identifying the user’s eligibility for benefit, the frontline workers mapped the user’s resources and hindrances as a starting point for their reasoning in order to arrive at a course of action. The course of action, they contended, should focus on returning the user to the labour market: “You should work with the body you have” (Female frontline worker, background at the National insurance, Office 3).
One frontline worker stated “there is almost no limit when it comes to what you can spend in order for a person to gradually re-integrate into the labour market” (Female frontline worker, Sociology education, Office 7). The statement comes after the frontline worker listed the measures available to them to return a user to the labour market. The listing of possible measures may be perceived as creating the discretionary space in which frontline workers can reason—the structural dimension of discretion. While this is beyond the scope of this article, the statement underlines an important assumption among many of the frontline workers; that they have access to measures that allow them to re-integrate almost any user into the labour market given ample time.
We see that he has the potential for a long work life, and it is easier to get a job when you are 34, even if the person requires a lot of facilitation at the work place. (Female frontline worker, sociology education, Office 7)
The frontline workers viewed the person portrayed in the vignette as a priority who needs access to ample resources from them. This reasoning is based on the “priority list of NAV” as well as the underlying notion that younger people are easier to return to the labour market despite hindrances, and that they have a longer expected time in the labour market.
The character in the vignette was viewed by most of the frontline workers as being in need of medical treatment before focusing on work.
It doesn’t seem like he is ready for anything work-related, at least yet. (Female frontline worker, Work sociology education, Office 1)
Frontline workers have access to limited medical measures that focus on a return to work as illustrated by this frontline worker:
We have some measures that are specifically related to medical treatment—psychologists and physical therapists with closer follow-up. We try to use it as often as we have the means. (Female Frontline worker, Sociologist, Office 4)
The initial evaluation consisted of gathering medical documentation in order to clarify the prognosis, as well as talking to the user in order to access his own experience of his situation. “None of us know how much improvement there will be [of the vignette person]” (Female Frontline worker, background in nursing, office 6). The frontline workers reasoned that there was potential for improvement through continued rehabilitation, following the medical advice in the vignette.
I never focus on the 100 per cent disabled for work before I have done an evaluation … and gone through the possibilities for continued training together with the rehabilitation unit, since rehabilitation continues for a long time, including follow-up. (Female frontline worker, background in social work, Office 7)
The GP has to be on our team, tell us what is possible. I am very interested in why the GP thinks he is a 100 percent disabled for work […] Still, our focus has to be on returning him to the labour market! (Female frontline worker, background in social work, Office 3 and Male frontline worker, background in economy and administration, Office 3)
Both of these quotes point to the frontline workers’ somewhat ambivalent relationship with the medical information received from health personnel. The first quote points out that the frontline worker wishes to attempt to activate the user. The second quote indicates two aspects about which frontline workers reason; first, the frontline workers’ perception of the GPs as important for the goal of returning users to work, and their perception of GPs.
One of the frontline workers was vocal in her reliance on health personnel being able to choose the right medical measure for the character in the vignette:
It is important to not just sit and read the medical information, but to be in dialogue [with the user and medical personnel]. We cannot just sit and make up everything ourselves! We need contact with specialized health personnel. (Female frontline worker, background in nursing, Office 8)
This sentiment can be found, although less explicitly, in the other focus groups, exemplifying the frontline workers’ reliance on communication with health personnel to make an informed choice regarding medical measures.
When asked questions relating to the medical information contained in the vignette, several of the frontline workers pointed out that one of the reasons for the focus on the reduced work capacity is due to GPs’ lack of knowledge of the measures that frontline workers have access to.
It is a shame that the GPs do not know all the measures we have. When we ask for a statement from the GP about the user, they often think that the user needs to go straight back to work, which is a high threshold, but we have many low-threshold measures also. (Female frontline worker, background in law, Office 2)
Frontline workers’ creative institutional work towards GPs for creating common grounds for cooperation is further explored in Håvold, Harsløf and Andreassen (2018).
In all the focus groups, the frontline workers clearly stated that they needed more information than was provided in the vignette to make an informed decision on the user’s prognosis and the possibility of returning to work.
We need to ask the employer and those that treat him: How is it going? Does it work? Or doesn’t it work? Compare this to the user’s wishes. What is realistic is what becomes important. (Female frontline worker, background in the National Insurance, Office 6)
The key function of the evaluative measures is to gather more information on which to base the discretionary judgement. The frontline workers often used the term “mapping” when evaluating the user. The intention, according to the frontline workers, was to identify the user’s opportunities and limitations in order to choose the correct facilitating measure(s) for a RTW process.
What is the plan for treatment? At the same time, our focus is what is needed to get a person back to work; we need to map [his resources]. (Male frontline worker, background in economy and administration, Office 3)
Initially in this phase, the frontline workers aimed to map the formal and informal resources available to them. Formal resources include education, work-experience and medical documents about the diagnosis and prognosis, while the informal relate to social aspects, such as family and other social networks, psychological aspects, interests and aspirations.
That is what the early mapping is all about, figuring out if he should be left alone [to continue medical treatment]? The medical treatment may be enough for now … but we can talk to him about that [i.e., work] as soon as it is appropriate. We should have it as a subject, incrementally move the dialogue towards work, but it is too early now. (Female frontline worker, background as schoolteacher, Office 4)
As we can see, this frontline worker makes a point about the user currently having health issues that are too severe and therefore possibly being “left alone” to focus on regaining his health. Two main ideas underline the frontline worker’s reasoning here: that the user is not in adequate health to return to work, and that the user should in the future return to work.
What is his current condition, and what is his prognosis? Is he still being treated? We should do a WCA if it has not been done already by [another focus group member] and have a conversation with the user to map [his resources]. So when they are granted WAA they are put in suitable measures ASAP. (Female frontline worker, background in National Insurance, Office 8)
The frontline workers reported that a reoccurring problem was that the information received from the health sector focused mainly on the limitations of the user. Therefore, when evaluating the user the focus was on identifying the user’s strengths. In the process for users with injuries such as those outlined in the vignette, a WCA was an important tool for guiding the user towards the correct benefits and for engaging the user in a return-to-work process.
[This is what] the WCA is supposed to help us figure out. What kind of work experience does he have? How can he continue to use this experience in another type of work? (Female frontline worker, background in nursing, Office 8)
In evaluating the user, the frontline workers initially created an overview of the resources and hindrances of the user based on available information. In the aftermath of the initial evaluation, more evaluative measures create a more detailed picture of the resources available to the user.
First we need to find some more … well here [pointing at the vignette] it says a lot about limitations … so I would find his competences and work experience and such in order to build on that. (Female frontline worker, background in social work, Office 4)
In approaching the vignette, the frontline workers said that evaluative measures were important for finding the correct way to reintegrate the user into the labour market. The frontline workers wanted more knowledge on how the person functions, meaning what he could and could not do. In so doing, the different offices used a range of different measures.
I’m not thinking about work right now, but about mastery of skills, and when the mastery of a skill comes along, then you can focus on the other things around [the vignette]. (Female frontline officer, background in social work, Office 7)
You can test his work capacity right … to see if he can actually do the job with his physical and psychological problems. (Female frontline worker, background in social work, Office 2)
We should focus on the employer, since it’s possible that he shouldn’t work as a carpenter, but maybe get a bit more education to do more administrative work. (Male frontline worker, background in economy and administration, Office 3).
One frontline worker suggested adopting an evaluative course of action to test the user so that he might re-evaluate his own career. This reasoning relates to the frontline workers’ perception that the person may be unwilling to consider a different career, despite the physical effects of his injuries.
I would try testing him out somewhere, almost put it as a term that he is required to do some sort of trial at working. Then he would go to that competence centre which we often refer people to, because they have a practical work test, and they will often advise individuals to try another career after such a test. (Female frontline worker, Political science education, Office 1)
One frontline worker explained that they could not sit and wait for 12 months, the length of time that the user is entitled to health benefits, to do a WCA. The assessment should be done as soon as possible to see if the user requires several and complex measures. They reasoned that in the multitude of measures they had available, some measures would help them recognise whether the user required assistance from them. If this assistance was not required, frontline workers could gain important information for evaluating the user’s probability of re-integration into the labour market, or, whether they needed to start focusing on re-education at an early stage (Female frontline worker, background in nursing, Office 8).
In some cases, the frontline workers used the evaluative measures to keep the user active. One frontline worker reasoned:
If his physical and psychological health has improved, we should do more vocational rehabilitation. Because it is dis-favourable to be idle and inactive for too long. Then you slide further away from working life and the road back will be so much longer. So it is very important to follow-up this person very closely. (Female frontline worker, background as a schoolteacher, Office 4)
The foundation of the rationale in this quote seems to be that a lack of activity on the part of the character in the vignette would cause a relapse and hinder further improvement, both physically and mentally in relation to returning to the labour market. According to another frontline worker, the character was likely to get back into the labour market:
He would get information that when you get the WAA, as a user you are required to be active to assess your work capacity and to get back to work. A few times, there is no work capacity left, and you need to apply for permanent disability benefit, but that is a long process of assessing the user. I would think that he would get better when he gets therapy from the psychologist and his motivation to work would get better. We would keep the subject of work “warm” and talk about his possibilities. (Female frontline worker, background at the National Insurance, Office 8)
The requirement for activity in the above quote shows the duality of the evaluation measures, where the primary goal is to evaluate and motivate the user, while at the same time keeping the subject of work “warm”. As the frontline worker reasons, the evaluative measure keeps the user closer to the labour market and provides frontline workers with information on the user’s progress.
All the measures aim at returning the user to the labour market, but in this section the analysis focuses exclusively on the measures aimed at the final leg of the return-to-work process, meaning the active measures to reintegrate the user into the workforce. The choice of RTW measures depends on the assessment of the user’s work capacity, which can be tricky.
We are supposed to evaluate according to any job they can do, but it still cannot be any job. You have to take into consideration what kind of background a person has, and the illness and what it does to the work capacity … and then the person’s wishes and interests, so it’s very complex when you try to evaluate a person, but we need to be realistic. (Office 4, Sociology)
It’s a dilemma—making each user responsible and … user involvement right … when should we do it, especially since we think it is important that everyone is accountable. Still we should see that in some cases the user is not capable of doing it … hum … so … it is always a dilemma. (Office 5, Law)
These two quotes exemplify the difficult balancing act, which the frontline workers are faced with when attempting to find the correct RTW measures to implement.
The primary target for the frontline workers is the employer of the user, focusing on different measures available to help facilitate a continuation of the user’s current employment. A good example from the data is when one frontline worker states, “We need to talk to the employer about which possibilities they have put measures in place to facilitate [for the vignettes injuries]” (Male frontline worker, background in economy and administration, Office 3).
Since all the focus groups focused initially on the return of the user to the same employer, this indicates strongly that this is a type of default reasoning. One focus group explained why this was best for all parties. Further, they reasoned, “problems with balance, headaches, bad memory … I doubt he can continue as a carpenter” (Female frontline worker, background at the National Insurance, Office 3). One of the arguments for returning the user to the same employer as the best course of action was that brain injury and side effects, such as depression, would make it harder for the user to create new relationships in a completely new work environment (Female frontline worker, background in nursing, Office 6).
If the user did not want to go back to the same employer, even in a different job, or the employer did not have the possibility (or economic means) to facilitate the user, one would have to approach the user about a return to work in a different career. In order for the user to get a different job, most of the frontline workers focused on short-term courses as the way to do this.
It used to be called re-education [short-term courses], it is important that we have that conversation with the user at an early point in the process, and figure out what his needs are so that he can start a [re-education] process, not sit around waiting for 12 months to pass. (Male frontline worker, background in law, Office 5)
When considering longer courses, the frontline workers were generally more reluctant to implement these.
Granting a benefit for him to study may backfire. He [the character from the vignette] may function well while studying, but may not function in a new job. [ … ] It is important that you grant a new career opportunity, not a study in itself. (Male frontline worker, carpenter and social work background, Office 1)
What is the purpose of the education? Often new education does not increase the work capacity at all, so in general we are very strict at granting such a measure. There has to be a purpose! (Male frontline worker, background in nursing, Office 7)
The frontline workers considered a three-year bachelor’s degree as too demanding on resources for the user particularly with the injuries he had: “I would not grant a bachelor degree!” (Female frontline worker, Background in Nursing, Office 8). Several of the frontline workers explained that due to the user’s head injury and the lack of prognosis from the doctor, they were unwilling to offer a three-year degree course to a user with cognitive impairment either at this or at a later time.
If it is a three-year bachelor in a subject, which requires a lot of concentration, then we will wait and see, because he has very bad cognitive function. It also depends on his motivation for study, since he is depressed as well. Will he manage to complete such an education … ? Since he has work experience, maybe the best course of action is to get him back to the labour market, and then perhaps start talking about more education. In this case, I believe it is too early to talk about education. (Female frontline worker, background in economy, Office 2)
The RTW measures are cooperative by nature, and the frontline workers explained that it is imperative for the final leg of the process at NAV that they have a good relationship with the employer, if reduced work capacity is identified.
We need to check if there are possibilities for [the user] finding another job. Normally we use an external re-integration company to help us with long-term measures. He should test out working, just to see what he actually can do, and afterwards we try him out at a local business … . Nevertheless, we see he has reduced work capacity, so we could refund the employer part of the wage, since he does not meet the requirements for a permanent disability pension. This requires having a good relationship with the employer, so we need to focus on that relationship. All the time! (Female frontline worker, background in nursing, Office 6)
Several of the frontline workers suggested wage subsidies as a possible means for helping the character in the vignette to reintegrate into the labour market. Wage subsidies pay part of a user’s salary due to reduced work capacity. However, as several of the frontline workers indicated, there is a resource issue regarding both the number of frontline workers and cash available in the system, indicating a limitation in the structural discretionary room available. According to the frontline workers, the lack of resources meant that they could not sufficiently follow up employers and employees, therefore limiting the total number of wage subsidies an office could support.
According to Christie (2016), discretion may be perceived as both a threat and a pre-requisite for equal treatment. The Frontline workers at NAV have considerable discretionary space when making decisions (Solvang 2017, Hansen & Natland, 2016). Regarding the process of returning the user to the labour market, the frontline workers accepted the medical recommendations concerning treatment. The focus groups differed in their views on these recommendations; some groups wanted to do a work capacity assessment before they made a choice, while others accepted the medical recommendations without much reflection. The focus groups that first wanted to do a work capacity assessment were also those that claimed GPs lacked knowledge about return to work measures and the labour market. While both office one and seven decided that the character in the vignette was not ready for work, they nevertheless wanted to carry out a work capacity assessment. On the other hand, office three wanted to evaluate the user for work as early as possible, possibly indicating a different understanding of the vignette or a stronger adherence to the principle of work as beneficial to health despite hindrances.
The frontline workers’ reasoning around the evaluative measures focused on gaining enough information to make a decision about the user’s prognosis and the probability of his returning to the labour market. The evaluative measure thus expands on the “description of a situation” in order to better inform the frontline workers decision on a “course of action”. The evaluative measures involved complex assessments of the user’s competences and wishes that were deemed realistic and purposeful by the frontline workers. In the data, all eight focus groups wanted to map the user’s resources, and then to deal with obstacles to prevent him slipping further away from the labour market. However the groups’ perceptions of how to achieve this goal differed, as office seven wanted to use therapy (i.e. a psychologist), and office four preferred vocational rehabilitation. The medical and the evaluative measures seemed to be aimed at creating a more comprehensive description of the situation, which, as Christie (2016) points out, suggests that it is the description of the situation inherent in the vignette that is being reasoned on by the focus groups.
The RTW measures revolve around three main subjects, options for returning to the current employer, options for embarking on a new career path through re-education and options for integration into work through wage subsidies. Re-education, beyond short-term courses, was rejected by most offices. Two offices indicated that they may consider a longer education or training course at a later date, providing that there is a clear purpose for the course and it is likely to lead employment. Wage-subsidies were discussed, however, these measures require the availability of sufficient financial resources in the NAV system, and depend on the user showing gradual improvements in his work capacity. Several of the frontline workers pointed out that at this stage of the process, more of their attention turned towards the user’s employer, as cooperation and a good relationship was imperative for successful reintegration into the labour market. In addition, the emphasis on the possibility of wage-subsidies at some offices as a RTW measure bears witness to the importance of cultivating a relationship with the employer. The process of reasoning seems to operate iteratively between the evaluation and the RTW measures, expanding on the ‘description of a situation’ to make a more informed decision on the correct RTW measures to implement. If successful, the RTW measure returns the worker to the labour market (or permanent disability benefit), and the frontline worker may close the case.
All the offices decided that the most prudent course of action would be to attempt to return the user to his current employer. Much of their argument was based on the user’s cognitive limitations, which according to frontline workers would make a change in the environment difficult for him. While the different focus groups came up with alternative solutions as described in the previous paragraph, the similarity in the perceived best course of action for returning a user to the labour market may indicate a strong norm of action, and thus an institutional logic.
Returning users to the labour market is the stated goal of NAV, and while the frontline workers discussed the user’s injuries in the vignette case, they appeared to believe that the user will at one point return to work. The frontline workers statements bear witness to this goal as it frames their rationale. The “norm of action” which seems to underline their rationale is that work is beneficial, even to those with disabilities.
Following Christie (2016), it would be advantageous to do further research on the discretionary reasoning among frontline workers at NAV by exploring the initial understanding of the vignette further. This study had limited potential for exploring this initial understanding due to the focus group design; this restricted the time spent on discussions pertaining to the original vignette.
The similarities in the courses of action suggested by the focus groups highlight a possible limitation in discretionary reasoning of frontline workers, and thus a potential problem for the principle of justice. In other words, do frontline workers practice discretion, or do they simply comply with policy demands? The stated goal of NAV is to return users to work, with which the focus groups clearly comply; however, the variation in the frontline workers’ approach to gaining more information and expanding the description of a situation indicates discretionary reasoning that takes into account the contextual influences. The variation in approaches could be due to the different initial categorization of the vignette, leading to somewhat different descriptions of the situation. This indicates that the norm of action influences not only the course of action, but the description of a situation as well.
The reasoning process expressed by the frontline workers at NAV has some similarities to how they perceive the information contained in the vignette. The initial response was to build motivation for work, as suggested by not wanting to rush the user back into work, but rather to use the available measures to evaluate his potential, and thus expand on the information in the description of the situation. The frontline workers did not suggest permanent disability benefit and suggested that returning to the current employer was the best course of action. The similarities among the frontline workers in the data suggest that they are guided by an institutional logic which follows the principle that work is beneficial to health despite hindrances.
The study presented in this article is part of the Project “Transitions in rehabilitation. Biographical reconstruction, experiential knowledge and Professional expertise” funded by the Norwegian Research Council, Project number 229082. I wish to thank the Project Group and the project’s user panel for fruitful discussions and comments to the article. I want to express my gratitude to the Norwegian Labour and Welfare Administration and especially the focus group participants at the local offices who have shared their thoughts and ideas.
Admitted: xxx Printed: xxx (3-week rehabilitation stay)
Doctor: xxx xxx
Male, 34, married, 2 children (2 and 4 years). Carpenter with a certificate, 12 years of experience, currently on sick leave. Wife on 50% leave without pay and serves as support and caregiver at home.
Admitted due to treatment of previously diagnosed balance problems due to an accident 12 months ago with traumatic brain injury and paralysis in left extremities. A hip and multiple rib fractures well healed. Light / moderate depression diagnosed after injury.
Recovered function in left extremity, some impaired strength and problems with everyday functions due to lack of dexterity in the hands. Intensive care treatment, primary rehabilitation carried out at University Hospital. Recommended further rehabilitation for dizziness and dexterity in specialized rehabilitation hospitals. Currently on the waiting list. Offered placement after 5 weeks. Conversation therapy due to depression conducted by a psychologist. Throughout the stay experienced balance problems, as well as problems with dexterity. He complains of not remembering and strong headaches in addition to lack of energy to help at home and with the children. He expresses a strong desire to have enough energy to play with the children. CT of head—unchanged. Neuropsychological testing identified a limited cognitive failure with limited memory retention. He describes the wife as a good support.
Both balance and dexterity improved after training. Physiotherapist and occupational therapist recommends follow-up and training. Neuropsychologist further recommends cognitive therapy for memory problems. Medical treatment for headaches as needed. Lacks motivation to work. GP states that his lack of work capacity is currently at a 100%.