Mid Sweden University

We compared online distributed information provided to patients with cancer in Scandinavian countries through the lens of governmentality. A secondary comparative qualitative analysis was conducted. Discourses in online patient information showed differences in governmentality techniques across the countries: Norway used a paternalist approach, Denmark an educative approach, and Sweden an individualistic approach and expected the patients to make the “right” decisions. Online information for patients with cancer in Denmark and Norway showed high professional and health care system involvement, whereas in Sweden, there was high patient involvement. There was almost no use of the person-centered approach among the online discourses

This chapter reports on the work activities, time-use patterns, and stress patterns of ten health care managers in Sweden. The qualitative and quantitative evidence reveals the fragmentation in their nine-hour working days where each activity, on average, lasts only ten minutes. The time-use patterns vary individually though some patterns are related to position and unit type. Activities deal with the coexisting and competing logics of employeeship, administration, and strategy and risk handling. None of the managers’ approaches for handling the multiple legitimation processes and delimiting their workload boundaries really challenges the complexity of the coexistence of the multiple logics or the boundlessness of their working hours. Using biophysical measures, the research finds that stress reported by the managers is caused by (a) interruptions during challenging tasks and (b) personal situations such as private dilemmas and conflict-loaded or ineffective meetings. It is important to acknowledge managers’ fragmented working situation and to recognize that management should be seen as collective process, or as part of an administrative system.

Background: Campus-based clinical learning centres are used for practice and learning in nursing students' education and can be arenas in which to enhance students' awareness and competence in social justice issues. Norm-critical approaches can be used as pedagogical tools in these centres to prepare students for hands-on caring situations in which social norms can bias the outcome. Objectives: To describe nursing teachers' conceptions of learning norm-critical approaches and implementing them in a clinical training centre. Setting and participants: The study is based on interviews with 10 teachers at a Swedish university college. Methods: The data was analysed using a phenomenographic approach. Results: Five categories of description emerged in the analysis that described conceptions related to norm-critical approaches. These categories were: personally developing and meaningful; easily integrated with established nursing concepts; highlighting surrounding power; something to lean on when letting students take the first steps in norm-critical initiatives; and helping implementation in teaching and education. Conclusions: Teachers who are facing the task of providing norm-critical, practical education to nursing students in campus-based clinical learning environments are ambivalent towards the core principles of norm criticism, which they conceive as natural and provoking, at the same time. We therefore need to un-dramatise norm criticism and better prepare teachers in how to use it. Teachers would benefit from follow-up activities and formal collaborations regarding norm-critical teaching, so that they are given context to discuss, reflect, and learn from each other. 

The aim of this study was to analyse how the patient is constructed and socially positioned in Swedish patient information. Corpus-assisted critical discourse analysis methodology was utilised on a sample of 56 online patient information texts about cancer containing a total of 126,711 words. The findings show an overarching discourse of informed consent guided by specific features to produce a patient norm that we name “the reasonable patient”, who is receptive to arguments, emotionally restrained and makes decisions based on information. Through the discourse of informed consent, the norm of the reasonable patient emerges, apparently to even out the imbalance of power between patient and professional, but in reality, more likely to construct a patient who is easily controlled and managed. When the self-responsibility towards health is incorporated into the everyday domestic spaces via digital health technologies, the ideas and concepts of the patient role need to be reconsidered based on these new conditions. We conclude that it is important for nursing researchers to broaden the research on patients to include the relationship of power created through language. This study demonstrates both methodological and empirical possibilities to do so

Nursing education is in the process of incorporating critical thinking, social justice, and health inequality perspectives into educational structures, aspiring to help nursing students develop into professional nurses prepared to provide equal care. Norm criticism is a pedagogical philosophy that promotes social justice. This qualitative case study aimed to gain an understanding of and elaborate on an educational development initiative in which norm criticism was incorporated into the composition of a new campus-based clinical learning environment for nursing education. By analyzing documents and interviews with the help of reflexive thematic analysis three themes were generated: “Intention to educate beyond nursing education,” “Educating in alliance with society,” and “The educative ambiguity of the Clinical Learning Centre.” The case study indicates that the incorporation of norm criticism into a campus-based clinical learning environment may encourage nursing students to evolve social skills for nursing practice that support health equality within healthcare. By collaborating with society, nursing education can considerably improve its educational frameworks in alignment with societal demands. However, the inclusion of norm criticism in a setting such as a campus-based clinical learning environment entails a clash with established institutionalized norms and being perceived as too proximate to politics. 

Aim: The aim of this article was to introduce Fairclough's critical discourse analysis (CDA) in caring and nursing science, to provide a guide on how to perform such an analysis, and to describe the wider context of discourse epistemology. Design: The article is designed as a methodological paper, including (a) epistemological roots of discourse analysis, (b) an overview of discourse analytical research within caring and nursing science which points out an increased trend, and (c) a guide to conducting a CDA. Analysis: It is important that discourse analysis is available and accessible to nursing and caring researchers. Through the process of encircling discourses, valuable insight is given into fields that otherwise would be lost or would not be available. Conclusion: Our summary stance is that discourse analysis as it is presented in this article is strongly advisable for use in nursing and caring sciences. 

Purpose

The paper aims to compare and discuss the findings of discursive constructions of patients in legal texts from the three Scandinavian countries. Since traditional welfare state systems in Scandinavia are being challenged by new governance systems, new questions are being raised about patient positions and agency, carrying with them potential ethical dilemmas for healthcare professionals.

Design/methodology/approach

The methodology of the paper is inspired by critical discourse analysis. Comprehensively analysing the findings of previous discourse studies on how "the patient" is constructed in central policy texts, this study compares the position of the patient in Norway, Sweden and Denmark.

Findings

The paper reveals ideological struggles across the Scandinavian countries, operating at a political level, a legislative level and a healthcare level. It is shown that national governance systems still exert hegemonic power by strongly influencing patients' degree of choice and autonomy. The discursive struggle between welfare state governance and other governance systems in Scandinavia indicates a shift towards a commercial healthcare market although a traditional welfare model is advocated by professionals and researchers

Research limitations/implications

Because of the specific conditions of Scandinavian healthcare policy, the findings lack generalisability. The research approach should therefore be explored further in additional contexts.

Practical implications

The findings of this study can inform policymakers, professionals and patients of the ideological values underlying seemingly objective shifts in national policy.

Originality/value

A comparative critical discourse analysis can expose patterns in the Scandinavian approaches to patient rights.

In this article, we explore the core concepts of norm-critical pedagogy developed in Sweden and only recently applied to nursing education praxis. These concepts, norms, power, and othering, are defined and demonstrated with exemplars from recent nursing education research. The theoretical model illustrates the ways in which these elements articulate in relationship to each other in nursing education praxis in ways that are dynamic, interlocking—like the gears of a clock—and resistant to interruption. We discuss the potential of a structurally oriented critical reflexivity—an equal and opposite force to the motion of the gears—to interrupt their motion.

Studies have reported that men’s uptake of sexual health services is low, that these services make them feel vulnerable, and that they experience sexual healthcare (SHC) as stressful, heteronormative, potentially sexualised and “tailored for women”. They also suggest that healthcare professionals (HCPs) working in SHC view masculinity as problematic, and situated in private relationships. This study aimed to explore how HCPs construct the gendered social location in SHC, specifically in terms of masculinity and a perception that masculinity is situated in relationships. Critical Discourse Analysis was used to analyse transcripts from seven focus group interviews with 35 HCPs working with men’s sexual health in Sweden. The study found that gendered social locations were discursively constructed in four ways: (I) by problematising and opposing masculinity in society; (II) through discursive strategies where a professional discourse on men and masculinity is lacking; (III) by constructing SHC as a feminine arena where masculinity is a visible norm violation; (IV) by constructing men as reluctant patients and formulating a mission to change masculinity. The discourses of HCPs constructed the gendered social location of masculinity in society as incompatible with SHC, and saw masculinity in SHC as a violation of feminine norms. Men seeking SHC were constructed as reluctant patients, and HCPs were seen as agents of change with a mission to transform masculinity. The discourses of HCPs risk othering men in SHC, which could prevent care on equal terms. A shared professional discourse on masculinity could create a common foundation for a more consistent, knowledge-based approach to masculinity and men’s sexual health in SHC. 

Health care professionals’ (HCPs) notions about gender may influence the provision and quality of care. If care-seeking men are met by HCPs holding idealized and stereotypical notions of masculinity, this could reinforce barriers to adequate care. This study explored notions about men and masculinities among HCPs working with men’s sexual health in Sweden. Focus group interviews with 35 HCPs from primary health and sexual health clinics were analyzed using qualitative content analysis. The analysis resulted in three descriptive themes: (a) Contradictory masculinity—elusive but clear. Notions of masculinity as a phenomenon or concept were elusive, but masculine and un-masculine traits, behaviors, and qualities were clear. (b) Sexual health care is a social place where men and masculinities can be challenging. Male patients were associated with unwanted sexual tensions. Masculinity could challenge professionality. Seeking sexual health care was perceived as doing un-masculinity. (c) Regarding masculinity as irrelevant—a difficult ambition to achieve. Participants strived for gender-neutrality by regarding patients as humans, individuals, or patients rather than as men and masculine. The analysis also identified a theme of meaning: Notions of masculinity are situated relationally. HCPs situate masculinity in real and hypothetical relationships. Romantic and sexual preferences were used to define preferred masculinity. This study identified themes that showed how HCPs balanced professional and private notions of men and masculinity in their patient encounters. Increased gender awareness and training are needed to professionalize the management of gendered notions in encounters with men who seek care for sexual health problems.

Background

This dissertation takes a critical look at norms and normality in healthcare education, focusing on the specific case of a nursing education programme at a Swedish university college. The concepts of norms and normality have a long history in healthcare professions, and have become important for many aspects of social life. A norm-critical perspective is central to the studies, as it exposes constructions of power and privilege related to norms and normality. It may also be useful in revealing underlying assumptions and matters which healthcare professionals take for granted, and which may result in failure to provide equitable care for all.

Aim

The overall aim of the dissertation is to describe and scrutinise norms and normality in a healthcare education context from a norm-critical perspective. A further aim is to explore how a norm-critical perspective on nursing education can contribute knowledge to existing fields of critical inquiry.

Designs

The four studies were designed using qualitative approaches to written and spoken text, as well as a number of different approaches to an instrument development process.

Methods

In study I, document analysis was underpinned by thematic analysis, while critical discourse analysis was used to analyse focus group discussions in study II. Study III analysed written responses to open survey questions using a discursive approach. Instrument development and factor analytic techniques were used in study IV.

Findings

Study I revealed the occasional use of politically correct rhetoric in curricular documents and literature, in parallel with a number of outdated views in terms of identity and normality. In study II, three discourses were identified in nursing teachers’ talk, all with norm-critical potential, though criticism of norms was not strong enough to form a discourse of its own. Study III showed how nursing students used more or less politically correct or reflexive approaches to construct images of norms and normality. Study IV developed and validated the Norm-critical awareness scale.

Conclusions

This dissertation expands knowledge about norm-critical perspectives in healthcare contexts. It exposes constructions of normative, taken-for-granted aspects within healthcare education, and concludes that the apparently desirable concept of tolerance needs to be problematised more fully in relation to norms, privilege and power. Norm criticism as an educational and intellectual tool can increase awareness of the norm-related mechanisms underlying healthcare encounters, even if awareness is only a first and necessary phase of change, and is not in itself sufficient to bring about change.

Implications

In a practical sense, the findings can facilitate understanding, planning and implementation of further norm-critical initiatives in educational contexts. Where theory is concerned, the studies fill a knowledge gap by contributing to norm-critical approaches in settings where future healthcare professionals are being educated, which have barely been explored until now. The studies also add to existing research traditions involving critical, emancipatory and anti-oppressive perspectives in terms of healthcare professions.

Aim. The aim of this thesis was to deepen the knowledge concerning health care managers’ everyday work experiences and their handling of stress and balance.

Background. Health care managers’ work is characterized by daily hassles, conflicting perspectives, and unclear boundary setting. They could therefore use support in boundary and stress management.

Methods. A qualitatively driven mixed methods approach was used. Qualitative interviews, focus groups and workplace observations were used for data collection in Study I. Physiological stress indicators, stress self-assessments, workplace observations and interviewing were used in Study II. Analyses were mainly carried out on the interview data, using grounded theory methodology (Study I) and conventional content analysis (Study II).

Results. Paper I shows that a first step in managers’ boundary setting is to recognize areas at work with conflicting expectations and inexhaustible needs. Strategies can then be formed through proactive, continuous negotiating of their time commitments. These strategies, termed ‘boundary approaches’, are more or less strict regarding the boundary setting at work. Paper II shows that nonnormative, interactive feedback sessions could encourage understanding and meaningfulness of previous stress experiences through a two-step appraisal process. In the first appraisal in the study, feedback was spontaneously reacted on, while in phase two it was made sensible and given meaning. However, during the sessions, some obstacles appeared to managers’ learning about their stress, preventing a second appraisal of the feedback.

Conclusions. Awareness and continuous negotiation regarding boundary dilemmas can be effective as a proactive stress management tool among managers. Further, non-normative feedback on stress indicators may initiate key 3 processes of sensemaking which can aid managers’ stress management by increasing awareness and supporting learning about their stress. Proactive boundary awareness is a concept leading to better understanding of lower-level managers’ management of their time commitments and stress, which can be supported by continuous reflection, feedback situations and a supportive context.

Purpose – The purpose of this paper is to explore managers’ boundary setting in order to better understand their handling of time commitment to work activities, stress, and recovery during everyday work and at home.

Design/methodology/approach – The paper has qualitatively-driven, mixed method design including observational data, individual interviews, and focus group discussions. Data were analyzed according to Charmaz’ view on constructivist grounded theory.

Findings – A first step in boundary setting was to recognize areas with conflicting expectations and inexhaustible needs. Second, strategies were formed through negotiating the handling of managerial time commitment, resulting in boundary-setting, but also boundary-dissolving, approaches. The continuous process of individual recognition and negotiation could work as a form of proactive coping, provided that it was acknowledged and questioned.

Research limitations/implications – These findings suggest that recognition of perceived boundary challenges can affect stress and coping. It would therefore be interesting to more accurately assess stress, coping, and health status among managers by means of other methodologies(e.g. physiological assessments).

Practical implications – In regulating managers’ work assignments, work-related stress and recovery, it seems important to: acknowledge boundary work as an ever-present dilemma requiring continuous negotiation; and encourage individuals and organizations to recognize conflicting perspectives inherent in the leadership assignment, in order to decrease harmful negotiations between them. Such awareness would benefit more sustainable management of healthcare practice.

Originality/value – This paper highlights how managers can handle ever-present boundary dilemmas in the healthcare sector by regulating their time commitments in various ways.

The documents and literature that regulate nursing education are based on certain values and knowledge, and the underlying power in the curriculum raises the question of how health care professionals are molded during the course of their education. Norm criticism is a concept with its roots in critical pedagogy and gender and queer studies, emphasizing the origins as well as the consequences of marginalization, power, and knowledge of what is generally accepted as "normal" and "true." Norm criticism is used in this article to analyze the documents and literature underlying a nursing program in Sweden, which are shown to include a sometimes politically correct rhetoric, but one lacking a firm basis in social justice values.

Purpose: Healthcare professionals' conscious or unconscious norms, values and attitudes have been identified as partial explanations of healthcare inequity. Norm criticism is an approach that questions what is generally accepted as "normal" in society, and it enables professionals to identify norms that might cause prejudice, discrimination and marginalisation. In order to assess norm-critical awareness, a measurement scale is needed. The purpose of this paper is to develop a scale for measuring norm-critical awareness. Design/methodology/approach: The scale-development process comprised a qualitative item-generating phase and a statistical reduction phase. The item pool was generated from key literature on norm criticism and was revised according to an expert panel, pilot studies and one "think aloud" session. To investigate the dimensionality and to reduce the number of items of the scale, confirmatory factor analysis was performed. Findings: The item-generation phase resulted in a 46-item scale comprising five theoretically derived dimensions revolving around function, consequences, identity, resistance and learning related to norms. The item-reduction phase resulted in an instrument consisting of five dimensions and 20 items. The analyses indicated that a summary score on the scale could be used to reflect the broad dimension of norm-critical awareness. Originality/value: The Norm-critical awareness scale comprises five theoretically derived dimensions and can be used as a summary score to indicate the level of norm-critical awareness in educational contexts. This knowledge is valuable for identifying areas in greater need of attention. © 2019, Emerald Publishing Limited.

Education is important in shaping professional identity, including how one approaches norms and normalisation. In the analysis presented in this study, nursing students' own constructions of norms and normality from the outlook of their education are highlighted and problematised. To deepen the understanding of these matters, the aim of this study was to explore constructions of norms and normality among students in nursing education. Students studying in a nursing department at a Swedish university college were approached and asked to consider open survey questions targeting their views on norms and normality; 154 of them replied. After a discourse analytic approach to the data, we could see how the students constructed norms and normality as (a) instrumental instructions, consisting of easy-to-digest statements grounded in the profession's obvious moral and ethical values, (b) limiting and frustrating obstacles for personal freedom that were important to challenge, (c) rules to be obeyed for the stability of society and (d) a matter of reflection, with each individual being responsible for understanding differences in norms, perspectives and opinions. We conclude that nursing education would benefit from norm-critical perspectives, problematising students' own positions to norms, power and privilege.

This paper describes the discourses underlying nursing teachers’ talk about their own norm-critical competence. Norm criticism is an approach that promotes awareness and criticism of the norms and power structures that exert an excluding effect in society in general and in the healthcare encounter in particular. Given the unequal relationships that can exist in healthcare, for example relationships shaped by racism, sexism and classism, a norm-critical approach to nursing education would help illuminate these matters. The studied empirical material consisted of focus group interviews. Nursing teachers discussed their norm-critical competence based on the university course "Norm-Aware Caring" in which they had recently participated. Through a critical discourse analysis, three discourses were identified in their talk, all of which had the potential to disrupt traditional, normative nursing education. However, in all three discourses there was an underlying discourse of normality, clearly positioning the teachers as exemplifying the "normal." The binary constructed between normality and otherness contradicts a basic tenet of the norm-critical approach and may hamper the development of genuine norm-critical competence in nursing education. © 2016 John Wiley & Sons Ltd.

Background: Nursing education in Sweden generally lacks norm-critical perspectives, even though this could help unveil normative judgements of patients in nurses’ daily work. To pursue work-integrated learning about norm criticism for nursing teachers at a small university college in Sweden, all teachers involved in nursing education were offered the course Norm-Aware Caring.Aim: To describe how norm criticism in nursing education is constructed by nursing teachers’ discussions.Methods: After the course Norm-Aware Caring, 20 of the participating 33 nursing teachers were interviewed in five focus groups about their reflections on their new knowledge. The interview transcripts were analyzed on the basis of Fairclough’s discourse analysis, in which words and social practice are seen as mutually constituting each other.Results: Discursive constructions related to teaching, caring and learning were seen in the text. Norm critical teaching was constructed as a practice of much consideration not to insult any student. Norm criticism as a basic caring value was closely related to person-centered care. Their own, personal learning was expressed as fear to use their new knowledge in a wrong way. The teachers themselves considered norm-criticism as something to learn in order to improve the understanding of people who does not fit into majority norms. This perspective of tolerance was consistent in the construction of all discourses.Discussion: It appears that the teachers’ social practice is influenced by a perspective that divides the “normal” from the “deviant”. This may prevent an internalization of norm-critical knowledge, a perspective that aims to question categorizations of normality. Therefore, it is important to continuously scrutinize and reflect over the role of social norms as part of work-integrated learning for nursing teachers.

References

AGENCY FOR HEALTH CARE ANALYSIS 2014. A more equal care is possible. Analysis of unmotivated differences in care, encounters and treatment. Report 2014:7. Stockholm: Agency for Health Care Analysis.

FAIRCLOUGH, N. 1989/2015. Language and power, London, Routledge.

KIRKEVOLD, M. 2009. Nursing Science – epistemological deliberations]. In: ÖSTLINDER, G., SÖDERBERG, S. & ÖHLÉN, J. (eds.) Caring as an Academic Subject: Report from a Working Conference. Swedish Association for Nurses.

VAN HERK, K. A., SMITH, D. & ANDREW, C. 2011. Examining our privileges and oppressions: incorporating an intersectionality paradigm into nursing. Nursing Inquiry, 18, 29-39.

Bakgrund. Normkritisk kompetens är en förutsättning för att kunna ifrågasätta rådande, begränsande normer som skapar ojämlikhet. Att kunna mäta normkritisk medvetenhet är nödvändigt av flera skäl, exempelvis för att kunna identifiera kunskapsbehov eller utvärdera insatser. Idag finns dock inget vetenskapligt baserat instrument för detta ändamål. Syfte. Studien syftar till att utveckla ett instrument som kan mäta graden av normkritisk medvetenhet. Metod. Utvecklingen av instrumentet omfattade två faser: (1) generering och test av items samt (2) reducering av items genom konfirmatorisk faktoranalys. I den första fasen formulerades och testades validiteten i items genom expertbedömningar, pilotstudier och samtal med studenter, vilket resulterade i 46 items. I nästa fas analyserades dessa med konfirmatorisk faktoranalys i syfte att reducera instrumentet till 20-25 items för att få ett mer lätthanterligt instrument. Resultat. Faktoranalysen resulterade i 20 items och fyra dimensioner. Dimensionerna var Normers konsekvenser, Att lära sig normer, Motstånd mot normer och Normers funktion. Det visade sig också att de fyra dimensionerna tillsammans mäter en bred dimension (normkritisk medvetenhet). Diskussion. Utvecklingsprocessen reser frågor kring styrkor och svagheter med att operationalisera och kvantifiera kvalitativa fenomen så som medvetenhet om normkritik. Det utvecklade instrumentet kan användas för att mäta normkritisk medvetenhet i olika sammanhang, exempelvis effekten av normkritiska utbildningssatsningar inom högre utbildning.  

Det nya lärandemålet i sjuksköterskeutbildningen innebär att studenter ska visa kunskap om mäns våld mot kvinnor och våld i nära relationer. Målet illustrerar behovet av att medvetandegöra och problematisera normer kring kön, makt och relationer. Med utgångspunkt i erfarenheter från Högskolan Väst föreslår vi i denna artikel normkritik som ett arbetssätt i utbildningen och formulerar handfasta råd. Undervisning om normer och makt kan förflyttas från att vara en perifer fråga driven av eldsjälar till gemensamt kollegialt ansvar med en central placering i varje kurs. Råden kan användas av ledare och lärare som vill erbjuda en sjuksköterskeutbildning där studenters förmåga att fråga, agera och ge våldsutsatta kvinnor en röst är ett centralt inslag.

Background:

The capacity to work among workers with common mental disorders (CMD) is important to understand but scarcely explored from a manager perspective, even though their views could add essential knowledge. The aim of this study was to explore and describe managers’ experience-based understand[1]ing of capacity to work in individuals with CMD.

Methods:

This qualitative focus group study used inductive manifest content analysis as analytic technique. First-line managers with experiences of employees with CMDs were recruited via organizations and networks. Eight focus group interviews with altogether 31 participants were performed.

Results:

The analysis resulted in five categories of managers’ experi[1]ence-based understanding of occupational functioning in workers with CMDs: (1) The capacity to mentally focus on work tasks decreases or disappears, with negative consequences for work output. (2) The capacity to commit to continuous and coherent tasks changes, making tasks that span over longer periods of time difficult. (3) The capacity to independently adapt to the needs of the situation decreases, causing the worker to need more guidance and instructions than usual. (4) The capacity to keep up professional appearances is reduced, meaning that the worker struggle with the profes[1]sional role. Finally, (5) the ability to interact socially and professionally decreases, which potentially causes conflicts at the workplace.

Conclusions:

This study shows managers’ experience-based understanding of CMDs in workers as severe changes and reductions of employees’ capacities needed for occupational functioning. These findings add to the understanding of the construction of the capacity at the workplace. A deeper understanding of reduced work capacity is also needed to adapt workplaces and our findings can facilitate work accommodations for employ[1]ees with CMDs.

Key messages:

• This study adds a manager perspective to the increasing knowledge about how capacity to work is influenced by CMD. 
• This study shows that managers experience that CMD in workers severely change and reduce employees’ capacities needed for occupational functioning.

PURPOSE: Understanding of the capacity to work among employees with common mental disorders (CMDs) is important, but contemporary knowledge on this issue lacks the managers' perspective. The aim of this study was to explore and describe managers' experience-based understanding of capacity to work in employees with CMD.

METHODS: A qualitative focus group study was designed. Managers with experience in supporting employees with CMD were recruited via organizations and networks. Eight focus group interviews with 31 participants took place.

RESULTS: The analysis resulted in five categories. (1) Capacity to mentally focus on work tasks decreases or disappears, with negative consequences for work output. (2) Capacity to commit to continuous and coherent task changes, making tasks that span longer periods of time difficult. (3) Capacity to independently adapt to the needs of the situation decreases, and employees need more guidance and instructions than usual. (4) Capacity to keep up professional appearances is reduced, and the employees struggle with the professional role. (5) Ability to interact socially and professionally decreases, which potentially causes conflicts at the workplace.

CONCLUSIONS: This study adds managers' perspective to the increasing knowledge on how capacity to work is influenced by CMDs. Managers understand CMDs in employees as changed, reducing the capacities needed for occupational functioning. A deeper understanding of reduced capacity to work is needed to adapt workplaces, and our findings can facilitate work accommodations for employees with CMDs.

Traditional welfare state systems in Scandinavia are challenged by new governance systems. Demands for efficiency and productivity in healthcare increase, raising questions about patients' positions and agency. This also implies ethical dilemmas for healthcare professionals. Comprehensively analysing the findings of previous discourse studies on how the patient is constructed in central policy texts, this study compares the position of the patient and the accompanying ideological struggles in Norway, Sweden, and Denmark. The purpose was to compare and discuss the findings of discursive constructions of patients in law and policy text from the three countries. We found an ideological struggle across the Scandinavian countries, operating at a political level, a legislative level and a healthcare level, with variation in how the new value-based patient care is constructed. We conclude that national governance systems still exert hegemonic power by strongly influencing patients' degree of choice and autonomy. The Scandinavian countries may all be heading towards a commercial healthcare market, despite their tradition of a welfare model of healthcare. Today, healthcare strategies move in the opposite direction, controlled by politicians' financial goals. The ideological struggle between welfare state governance and other governance systems, may exist also in other western countries in our globalized world.