Social and health care top managers’ perceptions and aims of strategic work ability management in the midst of change

1.1Work (dis)ability management

Work ability as a concept is essential for many sciences and actors related to working life. The origins of the commonly used work ability model are in the early 1980’s in Finland, when there was a social need for a new, positive approach [1]. However, there is no unified interpretation that is unanimously accepted by, e.g., insurance and rehabilitation institutions, occupational health care, or researchers representing different disciplines [2, 3]. Although there is no single definition, there exists a consensus that work ability is defined by one’s work, work environment and societal context [1, 3–5].

Regarding management of work ability, the international literature usually refers to the concept of “work disability” and “ work disability management”, instead of the “work ability” point of view. Over the past 30 years, research has mostly focused on themes related to organizational challenges for the employer, such as facilitating a return-to-work after the acute onset of illness or injury, enabling staying-at-work for workers with chronic conditions, decreased work ability or recurring symptoms, and providing effective workplace accommodations and support for workers with disabilities [6]. Work disability management has proven to be effective in reducing sick leave, increasing retirement age, and reducing the costs of disability [7–11]. However, the previous literature has usually focused on individual rather than organizational level actions [12] and organizations’ operational rather than strategic level actions.

1.2Strategic work ability management

To our knowledge, there is no previous research on strategic work ability management (WAM) and it does not have a general definition. Therefore, we refer to strategic management, which is an approach to identify and address challenges. It is a set of concepts, processes, procedures, tools, techniques, structures, and practices that must be drawn on selectively and adapted thoughtfully to specific contexts to be able to help produce desirable results. Strategizing means merging goals and capabilities, thus making sure that goals can be achieved [13]. Top managers are the decision makers and create knowledge and values to the decision-making process [14–16].

According to Jasper and Crossan [17], the features of strategic management are 1) the process of organizational leadership, recognizing and involving the whole workforce; 2) envisioning and responding to the future through fostering anticipation; 3) providing processes for coping with change and organizational development, with a focus on performance and achieving organizational strategic objectives; and 4) facilitating and communicating consistent decision-making. Thus, strategic management requires goals [13, 17–19] and strategy itself links together capabilities and objectives of the organizations and thus helps to achieve the goals [13].

While strategic management has developed across disciplinary boundaries, little has yet been reported of its specific nature in healthcare management theoretical perspectives [17] or on how organizations can and wish to implement strategies to promote a healthy and sustainable working life [20].

1.3Background of the study

In Finland, the public health and social service sector has been under nationwide reorganization and changes for many years. The municipalities and hospital districts have been responsible for organizing health and social services. From the year 2023 onwards, the responsibility will be on larger wellbeing services counties [21]. These kinds of reforms may require changes in organizations’ values, structures, and processes [22]. This study is based on the “Strategic work ability management in the social and health care reform (2019–2022)” project. The aim of the project was that health and social care organizations adopt WAM as part of strategic management, which creates the prerequisites, operating methods, and monitoring tools for maintaining and developing the personnel’s work ability in changes [23, 24].

In the above-mentioned project and in this study, we have defined work ability from a multidisciplinary point of view including employees’ competence, motivation, values, health, and functional capacity [1]. WAM includes all activities that are planned and followed in the organization itself and in cooperation with other specialists, such as occupational health care providers, to promote and maintain occupational safety, work ability and health, and to support staying at work [25]. Too often, the disability point of view may have taken the focus away from work ability as a resource. This may be because to obtain disability compensation, it is obligated to demonstrate the severity of disability [26]. Concerns about labor availability and aging workforces, the aim to control social and health care costs and extending working careers, understanding how to develop and maintain employees’ work ability is even more important [4, 22].

To our understanding, for WAM to be strategic, it must be part of daily management and the organization’s strategy, vision, and values, and it should be done in collaboration with occupational health care service, other specialists, rehabilitation, social insurance, and authorities. Currently it has also been highlighted that workplaces should integrate WAM into their management practices [27].

Top management is responsible for the organization’s strategy, including human resource management [14] and WAM as part of it. We aim to support and strengthen the concept of work ability instead of the concept of work disability. Our research contributes to the previous findings that the way top management define and understand WAM may influence measures and processes aimed to support personnel’s work ability and how these are implemented in the organizations [3, 4, 28]. In addition, top managers’ perceptions have an impact on organizations’ strategic choices and success [15]. As far as we are aware, there is a lack of studies concerning WAM from this point of view. In this paper, our aim was to find out how top managers define WAM, what were their aims for WAM, and whether the aims were on a strategic level.

2.1Data collection

The project on which this research is based was carried out in five large Finnish joint municipal authorities for social and health care organizations. As part of the project, interview data were collected, e.g., to get an understanding about the state of WAM and to support the development work. The current research utilizes top management’s semi-structured interviews, which were conducted during June and October 2019, January 2020, and September 2021.

According to Graebner et al. [29], qualitative methods are useful for generating theory when the phenomenon being studied is new or there are no previous studies. Qualitative method and phenomenological approach were chosen to enable interviewees to discuss their own experiences and interpretations [30, 31]. We considered it important to focus on top managers as key stakeholders to facilitate the strategy and decide about the resources. To achieve credibility, it is crucial to find participants who probably have experiences of the phenomenon under study [32]. Inclusion criteria for the participants were that they had to be a member of their organization’s executive team. The interviewees were found with the help of project actors, such as work ability coordinators working in the joint municipal authorities for health and social services, who provided a list of their organizations’ top managers. The interviewees were contacted and invited to the interview by email which included an information letter about the current research and the project behind the study. No one refused to participate in the interviews. Out of a total of 16 interviews, 14 were conducted face to face at the interviewees’ workplace, and due to the COVID19-pandemic, the last 2 via remote connection. No other persons were present besides the interviewers and the interviewees. The interviewed top managers represented the Finnish joint municipal authorities for social welfare and healthcare from five different geographical areas and different sectors (e.g., services for the disabled or for the elderly). All participants had long experience in the social and health care sector. The data consists of 10 group and 6 individual interviews in Finnish. The total number of interviewees was 28 (18 females and 10 men) (Table 1).

2.2Interviews

All interviews were conducted by two researchers of the project group, at least one of which was an expert in WAM or in qualitative research and had a PhD degree. The interviews were conducted by the first author (female, MSc, researcher), the second author (female, PhD, senior specialist), senior specialist (female, PhD) and specialist Doctor of Occupational Health (male, DMedSci) from Finnish Institute of Occupational Health (FIOH).

There were no relationships established between the researchers and the interviewees before the study. The interviewees had no prior knowledge of the researchers and they introduced themselves in the beginning of the interviews (name and position at the FIOH). The researchers had previous knowledge about WAM and its successful implementation, but no previous knowledge about the interviewees and their perceptions of WAM. The interviewers did not identify prior assumptions or biases that would have influenced the interviews.

The research questions were guided by the objectives of the core project and previous research on successful WAM [9, 25]. The interviews were conducted using a semi-structured protocol. Interview themes focused on the importance of WAM and perceptions of its strategy (e.g., is WAM considered to be on a strategic level), processes (e.g., what practices are used in supporting work ability), roles, responsibilities (e.g., top managers’ own role in WAM), leading with knowledge (e.g., whether the organization collects anticipative data about work ability) and collaboration (e.g., between organization and occupational health care). All participants were asked follow-up questions for clarification when necessary. No questions were provided in advance, no pilot testing conducted, and no repeated interviews were carried out.

The interviews were audio-recorded and transcribed verbatim. The transcriptions were not returned to the participants. No field notes were written during the interviews. The duration of the interviews varied from 43 minutes to 1 hour 23 minutes. Two members of the research team listened to each interview, verified all transcribed data for accuracy and pseudonymized the transcribed data to protect confidentiality.

2.3Analysis

The familiarity required for the thematic coding was ensured by multiple readings of the transcripts in an active way searching for meanings and patterns [33, 34]. The analysis proceeded following the six-step framework by Braun and Clarke [33], starting with reading through the transcribed data (Table 2). To understand the top managers’ perceptions and the aims of WAM, an inductive thematic analysis was used. The strategy of inductive analysis does not presuppose in advance what are the relevant dimensions in the data and the researcher allows them to emerge from the patterns found in the cases under study. Inductive analysis begins with specific observation and builds toward general patterns [30].

The transcribed data were downloaded to Atlas.ti software program (version 9) which was used to manage the data and for coding. The data was categorized and named inductively while reading. The aim was to identify patterns in the data that are interesting in relation to the research question [35]. All researchers participated in the first steps of the coding process to familiarize themselves with the data. The researchers conducted reflective writing in Atlas.ti -program using memos and comment tools while coding the data. In addition, they wrote down thoughts about what the coded data extracts mean and how they interpret them. This supported the next stages of the analysis and the trustworthiness of the study [34, 36]. Thereafter, the first author performed coding of the whole data. To establish trustworthiness and address dependability [30, 32], the codes and themes derived from the data were discussed in the meetings within the research group (peer debriefing). The researchers reviewed the coded data extracts and sub-themes to gain mutual understanding. Disagreements in the data analysis were resolved and changes made, if necessary, for example if a sub-theme did not have enough data to support the theme [34]. The participants were not provided feedback on the findings.

3.1Top managers’ definitions of WAM

The top managers considered WAM an important issue, part of daily management, and it should be understood more comprehensively in their organizations instead of approaching it via a narrow concept of work ability. In some organizations WAM was discussed using different concepts, such as competence or occupational health management. WAM was also defined through the concept of work ability. WAM was understood as being not only individual measures, but also proactive actions, part of good management of the organization, and that all actors have responsibility for it.

The strategic nature of WAM was seen to require systematicity, clear goals, and that it should be measured and followed. However, the organizations were not yet at this level, and the interviewees described that WAM is still in its infancy and has not necessarily been included in the organization’s strategy. Some of the interviewees mentioned that, especially during organizational changes, there is a lot of discussion related to WAM at the executive board level.

3.2Top managers’ aims of WAM

Two main and seven sub-themes were identified to describe what top managers aim for with WAM. Firstly, WAM was understood as managing and supporting work ability at the individual level, and secondly, at the organizational level. In the following, we present the results concerning the main themes followed by the subthemes. Examples of citations are presented in Figs. 1 and 2.

Fig. 1

Top managers’ aims of WAM at the individual level with illustrative quotes.

Fig. 2

Top managers’ aims of WAM at the organizational level with illustrative quotes.

4.1Individual level aims to support work ability

The individual level aims of WAM were anticipating the decrease of health and functional capacity, supporting workers with decreased health and functional capacity, developing competence, and managing the effect of changes on work ability. Only one interviewee, interviewed individually, considered WAM as solely reacting to changes in work ability, others saw also the anticipative dimensions of WAM. One interviewee participating in a group interview also saw WAM mainly as competence management. Although the interviewees themselves considered anticipation to be important, the common goal in the organizations seemed to be the decrease in sickness absences. This is in accordance with previous research where actions often target work disability [6].

Top managers’ own understanding of what is or should be aimed for with WAM may differ from the organization’s written goals [39], as was observed also in our study. The top managers’ understanding of the importance of proactive actions in supporting work ability is encouraging and hopefully will guide the strategic aims of the organization in the future. In the social and health care sector personnel’s workload has been much discussed, and managers may be more aware of the importance of WAM than in other industries.

Positively, top managers included competence development as part of WAM. Especially, in the constantly changing work environment also competence demands may change quickly. If the top managers did not think competence management through organizational measures important, it could be difficult for employees to cope with the changes [38]. On the other hand, limited resources may be an obstacle to offer possibilities to develop professional skills [40].

4.2Organizational level aims to support work ability

The organizational level aims of WAM were improving labor availability and personnel retention, ensuring the flow of work, and increasing trust and creating shared values. The ongoing changes seemed to affect especially the aims at an organizational level. Constant changes had caused uncertainty and mistrust among personnel and the top managers emphasized the importance of bringing back confidence. Also, Jasper and Crossan [17] have noticed that the cultural beliefs and values of personnel have an impact on the development and implementation of the successful strategy. We found that the labor shortage had increased workload and WAM was recognized as a means to ensure sufficient personnel resources. This is in accordance with the findings of Eriksson et al. [41] on the importance of the health promoting leadership as a part of developing an attractive workplace.

Managers aimed to secure employees’ capability to provide high quality services despite the ongoing changes and lack of personnel. This could refer to top managers consideration of employees being not only a resource, but a prerequisite for the organization’s success. Productivity was also the main issue as an outcome of work ability in the study of Jansson et al. [28]. The employees’ work ability has been regarded as a tool in production and not a goal itself [28, 41].

The prevailing labor shortage in the field seemed to reflect what top managers aimed for with WAM on the organizational level. This is a significant and new perspective which separates WAM from work disability management that usually targets individual level actions [6]. According to previous studies, individual level actions alone are not effective when supporting work ability [12]. In a systematic review by Montano et al. [42], the best results were achieved by multicomponent interventions.

4.3Strategic nature of the aims

In general, WAM was strongly emphasized as part of the organization’s strategy and considered important. However, WAM was not yet visible in the organizations at a strategic level or WAM wasn’t even included in the strategy. As was seen throughout the interviews, constant changes affected the discussion about WAM. Too frequent re-organizations have been regarded as an obstacle and could have a negative impact on the development of sustainable structures supporting health promoting leadership [22, 41]. Despite the tightening economy and commonly known high levels of sickness absence in social and health care sector, the pursuit of financial savings was not emphasized. This was interesting while in a review by Figueroa et al. [22] noticed that political decisions often focus on cost savings resulting financial resource constraints in the health services’ operating environment. These constraints may lead to poor human resource management and create an imbalance between service demand and supply [22]. The availability of employees and securing the flow of work were considered more important. This could indicate that for the top managers WAM is strongly related to the organizations’ values, like in the upper echelons theory (UET), in which the values of top managers’ may influence the strategic decisions [14–16].

Referring to Jasper and Crossan [17], the top managers’ aims of WAM seemed to be on a strategic level. Personnel participation, which is one of the key features of strategic management, was seen important in the midst of changes. The top managers aimed to anticipate future personnel needs. Accordingly, top managers were worried about the coping of the personnel during changes and providing processes for it. Jasper and Crossan [17] also emphasized facilitating and communicating consistent decision-making. However, this did not emerge in our data. Since top managers have an important role in facilitating goal attainment and visions of the organization and enabling personnel engagement [43], more attention should be paid to discussing the strategic aims of WAM.

This study was conducted during major changes in the social and health care sector. Regardless of the industry, both global and local changes affect working life. Therefore, WAM should always be acknowledged and considered that every decision made affects personnel’s work ability. We viewed only the top managers’ aims and did not compare them to the organizations’ written aims. The two being aligned would be essential for the implementation of the strategy. The presented findings could be useful when developing organizations’ strategic WAM.

4.4Strengths and limitations of the study

Our study has several strengths. As far as we are aware, this is the first study focusing on top managers’ perceptions of WAM. Although work ability is already understood comprehensively, studies on management and work ability support practices have mainly approached the subject through disabilities. The study material was large enough and the same patterns started to repeat themselves referring to the saturation of the data. The studied organizations represented different geographical areas and the interviewees different fields of social and health care in Finland. Our research group was interdisciplinary and reflected all findings from different point of views and had ongoing conversations to gain a mutual understanding in case of disagreements. The accuracy of illustrative quotations’ translation from Finnish to English was approved collectively.

Some limitations of the study are also worth mentioning. First, the interviews were originally conducted for the development work of the “Strategic work ability management in the social and health care reform” project. This has partly guided the interview questions. Second, the project actors of the participating organizations provided the list of top managers who could be asked to participate in the study. Therefore, it is not possible to exclude the possibility that the sample was biased. However, to achieve credibility, it is important to find participants who have experiences of the phenomenon. Third, two out of sixteen interviews were conducted online due to the COVID19-pandemic. For the interviewees it may have been more difficult to express feelings online. During the online interviews the cameras were open, but as the interviews were not recorded the researchers were not able to afterwards return to the interview situation to e.g., read body language and interpret possible non-verbal communication. However, the online interviews may be more informal and relaxed as the interviewees are able to be at their homes making them feel more comfortable to share their thoughts [44]. Fourth, the combination of group and individual interviews was chosen mainly due to limited resources and time frame in the participated organizations. The individual interviews may contain more information as one may have more time to speak than in group interview. On the other hand, group interviews may encourage to discuss more critically or express more personal opinions [45]. There seemed to be a psychological safety in the group interviews, and everyone were able to share their thoughts. Finally, the organizations involved in the project, as well as the top managers interviewed, may have had more than average interest in work ability issues and have more critical thoughts about these matters.