Increasing demands and fewer resources impact stress levels, and according to the Swedish Social Insurance Agency, 2024 was a record year for the number of people on sick leave due to stress-related mental ill health.
The costs are high both in terms of human suffering and financially. In 2023, stress-related sick leave accounted for 21 per cent of total sickness benefit expenditure, equivalent to 9.2 billion Swedish kronor (€841m).
Women in welfare professions are particularly vulnerable. 34,300 of the 43,000 people on sick leave due to stress in 2024 were women, which means they made up 79 per cent of stress-related sick leave cases.
There are several reasons for this. The Social Insurance Agency’s report “Mental ill health in today’s working life” points to the double workload that remains a reality for many women.
It also says that many experience a lack of equality when it comes to unpaid domestic work and the care for children and relatives.
Another explanation is that women often work in people-oriented occupations like the care sector, education and social work, where stress-related sick leave levels are highest.
“It is clear that frontline contact occupations that do not require a university education are the ones most affected by negative stress caused by an imbalance between demands and resources,” the report says.
Part of the Work Environment Act
In March 2016, the Swedish Work Environment Act was expanded to include organisational and social work environments, often referred to as OSA in Sweden.
There is a focus on three areas – unhealthy workloads, the organisation of working hours and offensive treatment such as bullying and discrimination.
Every year, the Swedish Work Environment Authority (AV) carries out thousands of inspections and reviews workplaces’ organisational and social work environments.
Ulrich Stoetzer, a medical doctor and psychologist, is an expert at AV, specialising in organisational and social work environment issues. He believes the new regulations have been highly significant, even though they have not led to the desired reduction in sick leave levels.
“We have carried out two reviews of the regulations, which show they have had a great impact and have been well received. They put psychosocial issues on the agenda and initiate work on these issues,” he says.
He can confirm the Swedish Social Insurance Agency’s findings that mental ill health is most prevalent in the health care, education and care sectors, and also in schools.
“This is where there are far too many people on sick leave. This has been a problem for years, and there is no downward trend to be seen. The law is there to address existing risks.
“These may relate to resources, but also to demands put on employees. Research shows that mental health problems are not only linked to a lack of resources, but also to organisational barriers to how people work and prioritise,” says Ulrich Stoetzer.
There are many ways to address the risks of stress, but how to solve them is up to each individual workplace.
During inspections, it has become clear that much remains to be done to tackle work-related stress, and that efforts must continue to raise awareness among those who make decisions about resources and work organisation.
Trade unions in the welfare sector have called for the introduction of penalty fees, but Ulrich Stoetzer is hesitant about this. Dealing with stress factors within the organisational and social work environment is more complex than, for example, safety issues on a rooftop.
“Many take OSA seriously and are doing a good job, but we haven’t seen as much progress as we would like, and we do set requirements. In most cases, our demands are met, but not all.
“The regulations are a tool, and inspections take place through dialogue. Penalty fees might have a signalling effect, but they would also require great precision and clarity about what employers are expected to achieve.
“There is no exact formula that says, ‘do this and you’ll have a good work environment’. Work on OSA is a continuous process, and there is no black-and-white line defining how it should be done.”
Developing and improving the organisational and social environment is about people’s lives and health. Today, we know that stress causes illnesses that can lead to an early death.
But, points out Ulrich Stoetzer, the economic costs are huge too, and preventing and reducing work-related stress is also important for having a well-functioning welfare system and to attract labour.
Healthy professions turn bad
The trade union Kommunal knows that a large proportion of its members suffer from work-related mental ill health.
So what actually happened to one of the professions that, according to trade unions representing the welfare sector, was considered part of a “healthy sector” back in the early 1990s?
“The most important reason for the increase in stress-related sick leave is staffing, which has a direct impact on the work environment.
“Since the 1990s, there has been a drive to make healthcare and social care more efficient. Demands on employees have increased, without any corresponding strengthening of staffing levels.
“There are also extensive structural problems, with a high proportion of insecure employment contracts and involuntary part-time work, where many are not offered full-time positions even though they would like them.
Many have also left the sector because of the work environment. Taken together, this strongly contributes to the imbalance between demands and resources.
“Awareness of the health risks associated with prolonged stress has also increased, which makes it more legitimate to seek help for it,” says Maria Ahlsten, researcher at Kommunal.
Kommunal’s members include assistant nurses, many of whom work in elderly care. Theirs is also the one occupational group with the highest level of sick leave for mental ill health caused by work-related stress.
In 2024, 47 per cent of assistant nurses had at some stage been absent from work due to work-related health problems, according to the Work Environment Authority.
Older people in need of elderly care are increasingly unwell, and many remain at home for longer. The demands on staff have increased, but this has not been matched by sufficient resources in terms of vocational training and staffing levels, says Maria Ahlsten.
In home care, it is also common for work to be scheduled down to the minute.
For example, only a set number of minutes is allocated to help a care recipient take a shower, regardless of how they are feeling or what their needs are on that particular day.
“The staff can see what needs to be done, but they often don’t have time to meet those needs. This leads to moral stress,” says Maria Ahlsten.
Much of the work on organisational and social work environment issues falls to frontline managers.
But these managers often lack both time and authority, which becomes an obstacle to improving working conditions, explains Maria Ahlsten. The high turnover of managers also makes the work more difficult.
“Employers often reject demands for increased staffing levels, even though adequate staffing is the most crucial resource in these sectors. To improve the work environment in the welfare sector, the government must also provide sufficient resources for these services.
“In Sweden, we have high ambitions for our welfare system, and rightly so, but more resources are needed to live up to those ambitions,” says Maria Ahlsten.
No absolute link between sick leave and work environment
Örjan Lutz has worked for 20 years analysing health and sickness trends at the Swedish Association of Local Authorities and Regions (SKR). He starts the interview by providing some nuance to the concept of “mental ill health.”
““It covers an incredible range of conditions, which is problematic. What tends to be increasing globally are primarily milder mental health diagnoses such as anxiety, worry and sleep disorders.
“In Sweden, people have been very quick to conclude that this is primarily due to shortcomings in the work environment and that these, in turn, cause sick leave – as if there were a linear relationship between the work environment and sickness absence. But that’s not the case,” says Örjan Lutz.
During his years at SKR, he has closely followed sickness absence figures and their dynamics. He notes that they have fluctuated significantly, but that there were three clear periods of decline – in 1991, 2002 and 2016.
On each of these occasions, stricter rules were introduced for how the insurance system was applied. This, in turn, often led to debates about whether the conditions for taking sick leave had become too harsh, says Örjan Lutz.
“When sickness absence rates rise, people point to shortcomings in employers’ responsibilities.
“When the rates fall, the insurance system is instead accused of being too strict in its assessments. There always seems to be a need to identify a villain in the system, and that’s problematic,” he says.
Örjan Lutz also wants to initiate a debate about the rise in stress-related diagnoses. Among women alone, cases have increased from around 7,000 in 2010 to 37,000 today – an increase of several hundred per cent over 15 years.
At the same time, there are no indications that either stress levels in working life or overall public health have deteriorated to a corresponding extent, argues Lutz.
“Are we medicalising natural life conditions? Many doctors believe we are, that patients are being signed off sick when it would actually be better for them to remain at work.
“Sick leave has long been seen as the best remedy for stress, which is not necessarily the case. At the same time, there is a very intense public debate about stress at the societal level,” he says.
Örjan Lutz sees linking stress-related sick leave directly to the work environment as a risk. He argues that the connection is not that clear-cut and that doing so could steer workplace health efforts in the wrong direction.
There are certainly workplaces with low sickness absence despite having a poor work environment, and others that work hard to improve conditions but still have high levels of sick leave.
This means there is a danger that employers who are actually doing the right things may think they need to change everything, while those doing everything wrong may believe they are on the right track.
Many factors influence sickness absence that have little to do with the work environment itself.
But regardless of how high sickness rates are explained, they are a fact – and addressing them is a major concern for SKR.
Municipalities and regions are at the heart of the challenge of securing sufficient skills and staff, a problem that is set to become even more difficult.
It is crucial to retain employees, helping them thrive and perform at their best. And when people speak positively about their work, it also makes recruitment easier, says Örjan Lutz.
“We work so much with work environment issues, especially the organisational and social aspects. The work environment is crucial to delivering high-quality welfare. In fact, it underpins the entire welfare system.
“There is no real conflict between the social partners on this, even if we may have different explanations for the high sickness rates.
“The social partners carry out most of the work on improving the work environment together, and we often share a common view on how it should be done,” says Örjan Lutz.
He describes initiatives focused on leadership, expert support from occupational health services, research, and joint organisations that work on prevention. There is an emphasis on strengthening positive factors, building on what works well and developing effective ways of organising work.
The trade unions also highlight the need for better staffing, does that mean more employees?
“Staffing levels, like pay, are of course issues where the social partners may have slightly different views, that’s only natural,” says Örjan Lutz.
“Working in the welfare sector can be demanding. Much of the work goes on around the clock, all year round, and involves caring for people.
“We know it is both rewarding and stressful, and some of the risks linked to that are, of course, difficult to eliminate entirely.
“That’s why systematic work environment efforts are so important, as well as being alert to which measures are needed to prevent employees from ending up on long-term sick leave,” says Örjan Lutz.
