Navigating the gap between policy and practice: frontline and second-tier management perspectives and strategies in offering vocational and educational support to young adults with mental health problems

ABSTRACT

Mental health problems among young adults often lead to obstacles to completing higher education and becoming established in the labour market. It is important to offer support that can help these individuals realize educational and vocational goals in order to become self-sufficient and achieve social inclusion. Individual Placement and Support (IPS) and Supported Education (SEd) are two methods developed for supporting people with mental health problems in attaining competitive employment and reaching educational goals. These methods have not been widely implemented in Sweden, therefore making it interesting to study management perspectives in organizations offering IPS/SEd. The study aimed to explore the reasoning and strategies managers described in offering vocational and educational support to young adults with mental health problems. This study is based on 12 qualitative interviews with managers from six units in Sweden offering support through IPS/SEd. Results show a variety in interpretation of legislation and responsibility for young adults with mental health problems. The managers were positioned between policy and practice, having to navigate between the organizational restraints and their professional assessment in offering this support and pushing traditional boundaries in prioritizing long-term individual goals over short-term economic and political considerations. These managers demonstrate the possibilities for how IPS/SEd can be implemented and made to fit different organizational contexts, even within a highly sectorized welfare system as in Sweden. However, the methods might need to be adapted and adjusted to not only fit local organizational restraints, but also to fit into the Swedish welfare system.

KEYWORDS:

• Young adults
• mental health
• individual placement and support
• supported education
• social work management

Introduction

In the transition from youth to adulthood, higher education and employment might be considered natural pathways to gaining independence and self-sufficiency. For young adults with mental health problems, there may be obstacles in completing higher education and becoming established in the labour market. Such failures to establish themselves can also contribute to a perceived reduction in quality of life (Areberg and Bejerholm 2013), and without the right kind of support in the transition to adulthood it can have long-lasting consequences (Helgesson et al. 2018). Mental health problems are costly for society in terms of the need for support, but also in individual suffering and marginalization. For these young adults, it is especially essential to offer support that can help them reach educational and vocational goals to be self-sufficient and achieve inclusion in society. To choose, get and, keep work is also an important factor in recovery from mental health problems (Hofstra et al. 2021) and many who have dropped out of education have a desire to complete their studies to increase their chances of becoming employed, as well as for their own personal development (Corrigan et al. 2008; Knis-Matthews et al. 2007).

Individual Placement and Support, IPS, is an evidence-based method focusing on vocational support based on the motivation and circumstances of the individual. IPS is based on a place-then-train model (rather than train-place) with eight principles; a) competitive employment is the goal, b) eligibility is based on the individual´s choice, c) rapid job search, d) support is guided by individual preferences, e) individualized support for as long as needed, f) personal counselling on finances, g) integration of vocational support with mental health care, h) systematic recruitment of job opportunities and engagement with employers (Bond et al. 2022). Studies show that IPS is more effective than traditional vocational rehabilitation, with IPS for example achieving, in a broad European study, a 55% success rate compared with traditional vocational rehabilitation, 28% (Bond et al. 2022). According to this method, people with mental health problems, given the right support, are competent to work in competitive employment. So far, most studies have focused on adults but there is evidence that the effects also apply to a younger population (Bond et al. 2024). However, for people with mental health problems to maintain a sustainable work-life there might be a need for additional support to complete their education, thereby increasing their chances of a sustainable work-life (Hillborg et al. 2021). Supported Education, SEd, is a method focusing on educational support, developed for people with mental health problems. It has been suggested that SEd can be used as a complement to IPS, giving individuals support to achieve their educational goals (Killackey et al. 2017; Manthey, Goscha, and Rapp 2015). This could also reflect the tendency for young adults to move between educational and vocational goals in finding their long-term career path (Bond et al. 2022).

Study objective and aim

This study builds on a previous project which sought to develop knowledge of and describe integrated models, where IPS and SEd services were jointly offered (Hillborg et al. 2024). In the previous work, which focused on the strategies and structures of providing SEd services in an integrated fashion with IPS vocational services, it became clear that many of the challenges to adapting and providing these services had their roots in organizational structures.

Welfare services are guided and governed by different laws, regulations and areas of responsibility where regions and municipalities in Sweden also have great autonomy in local decision-making. Local politicians and top-level managers set the overall organizational objectives and provision of resources, creating the organizational conditions, while managers closest to practice often make the operative decisions on how to construct the services (Bäck et al. 2020). This can pose organizational challenges and create tension between organizational structure and implementation on the operative level, as suggested by studies in other Nordic countries (e.g. Bakkeli 2023; Storgaard Bonfils 2022). Since IPS/SEd services have not been widely implemented in Sweden it is of interest to investigate the managerial perspectives on responsibility for young adults with mental health problems. Examining their reasoning and strategies in offering this support is of importance to helping these young adults to a sustainable career, better mental health, and social inclusion.

The aim of the study was to explore the reasoning and strategies frontline and second-tier managers described, in offering vocational and educational support to young adults with mental health problems.

Vocational and educational support in the Swedish welfare system

While the Swedish welfare system is considered generous, with emphasis on the individual´s rights, it is also characterized by sectorization and decentralization where different welfare actors have diverse areas of responsibility (Markström and Lindqvist 2015). Support for young adults with mental health problems includes different stakeholders at the governmental, regional (county council), and municipal levels. While national legislation and guidelines for providing evidence-based services are central in Swedish welfare policy, county and municipal councils have great autonomy and are largely self-governed by elected politicians, directly involved in decisions regarding what services to offer. Services to this group may therefore vary between the 20 healthcare regions, and the 290 municipalities where social service agencies provide social support. The Social Services Act, SSA (SFS 2001: 453) provides regulations regarding social services promoting economic and social security, equality, and social inclusion. The SSA is devised as a framework law with few specified supports, thereby allowing each municipal flexibility in organizing social support.

The education system in Sweden is tax-funded and free of charge from pre-school through university. The Education Act (SFS 2010: 800) requires that students from pre-school to upper-secondary school should have access to student health services at no cost. There are no such requirements in municipal adult education. University students however have access to Student Health Services and Disability Services provided by the university. The University Disability Services are linked to the Discrimination Act (SFS 2008: 567), promoting equal rights for students with disabilities. The potential support system for students with mental health problems is further complicated by the fact that student health services are organizationally separate from those providing social and psychiatric support and have little experience in collaborating around mental health issues (Lövgren et al. 2020).

While many municipalities, and some regions, in Sweden, offer vocational support for people with mental health problems, it is still mostly in the form of traditional vocational rehabilitation, even though evidence shows that IPS leads to higher employment rates (Bond et al. 2022; Frederick, VanderWeele, and Pompili 2019). Despite IPS being ranked as having the highest priority by the National Board of Health and Welfare guidelines, NBHW [2011] 2018 for persons with schizophrenia and similar conditions since 2011, only a third of Swedish municipalities offer the method (NBHW 2022).

Whereas IPS has a large body of empirical evidence, SEd has not reached the same level. Explanations include a lack of rigorous studies and the diversity of settings and populations (Hillborg et al. 2021; Hofstra et al. 2021). However, integrated IPS/SEd models have developed, particularly regarding young adults as they navigate between education and employment (Hillborg et al. 2024). Studies focusing on implementing IPS report that there are difficulties in collaborating with other welfare actors including mental health care services, the Social Insurance Agency, and the Public Employment Service (Bejerholm et al. 2015). The division between social and medical support poses specific challenges for implementing methods like IPS, since as opposed to the US for example, these services are not integrated organizationally (Markström and Lindqvist 2015). These challenges have also been reported in Denmark (Storgaard Bonfils 2022) with a similar welfare system to Sweden.

Theoretical framework

The functioning of organizations and their practitioners are determined by internal and external influences. Institutional theory focuses on the reciprocal dependence between social and cultural factors, the organization, and its surroundings. This approach has been used in research regarding IPS as it may explain the systems in which the support is offered as well as the conflict between innovations and institutional configurations (Bakkeli 2023; Storgaard Bonfils 2022). The literature states that the success of an organization and its survival are dependent on being viewed as legitimate (Meyer and Rowan 1977). Legitimacy is subject to socially constructed norms and general assumptions on how an organization should work, and striving for legitimacy is seen as the driving force rather than the organization reaching efficiency (Long and Driscoll 2008; Meyer and Rowan 1977). Intra-organizational dynamics, how institutional pressures are perceived and interpreted and how they affect practice, may also be of interest when attempting to understand the introduction of evidence-based methods, EBM (Boxenbaum and Strandgaard Pedersen 2009). In this context, the concept of translation can be valuable as it occurs as organizations make contextual adaptations, revising ideas and methods to fit their unique organizational context (Eriksson-Zetterquist, Kalling, and Styhre 2012). Diverse interests and actors translate the same idea in different ways, thus positioning them as mediators of institutional pressures on organizations (Boxenbaum and Strandgaard Pedersen 2009). Actors who attempt to develop innovative services may find themselves being constrained, in street-level bureaucracies, by organizational rules as well as norms for occupations and practices. However, rules or regulations are not only constricting but may offer opportunities for discretion in the spaces in between them (Lipsky 1980).

Method

Study design and context

The present study had a qualitative design and included six IPS-units located in cities of varying size and geographical areas in Sweden. They were already part of the larger research project, five units located within municipal social services and one in county-based specialized psychiatric health care. Units in this article refers to the actual IPS/SEd services. These belonged to different departments, within the larger organization, the social service or health care service. The respondents were selected through purposeful sampling, representing a sample of organizations working with IPS and SEd in Sweden, having a unique perspective on possibilities for implementation. Inclusion criteria were managers (1) for an IPS-unit offering vocational and educational support and (2) that to some extent had the mandate to influence the organization´s development strategies and activities. Since the IPS fidelity scale focuses not only on the role of the team supervisor (direct practice manager) but emphasizes the importance of the ‘agency’ having a focus on IPS principles and methods, we decided to include a broader management perspective with the two levels closest to practice, having the most insight into the service delivery of IPS/SEd and its implementation at the operational level. Respondents were recruited by staff from the six participating IPS-units. In total, 12 respondents agreed to participate. The managerial hierarchy varied by organization with managers having different amounts of autonomy and discretion as well as varying titles. Due to this, they are grouped together as Frontline managers (team supervisors with direct personnel responsibility of the work-/study specialists) and Second-tier managers (responsible for frontline managers as well as other units) based on definitions previously used by Shanks et al. (2014). At the time of the interviews, the informants had been in their current position for a varied amount of time (Table 1).

Table 1. Overview of participants.

	Frontline n = 6	Second-tier n = 6	Full sample N = 12
Organization type Municipality social service Psychiatric health care	5 1	5 1	10 2
Years in current position < 1 year 1–10 years 11–20 years 21–30 years	2 2 1 1	1 3 1 1	3 5 2 2

Data collection and analysis

Data was collected with semi-structured interviews with individual managers. An interview guide was created based on the themes: IPS and SEd within the organization, Organizational fit, and Responsibility for the target group. All interviews were conducted digitally due to geographical distance, time constraints of the managers, and recorded with both video and audio. Two researchers were present in all interviews, (MH + VL: 7, MH + DR: 5). The interviews were conducted between June 2022 and January 2023 and lasted between 34 and 78 minutes.

Qualitative content analysis was used with an inductive approach (Graneheim, Lindgren, and Lundman 2017). All interviews were transcribed verbatim and read several times before the coding process, and memos were written to capture initial thoughts and reflections. Each transcript was coded utilizing the software MAXQDA focusing on relevant meaning units for the aim of the study. In the initial stage of coding, data guided the codes for preliminary labels which were reviewed and redefined throughout the analysis process. Coded data were grouped together in categories mainly expressing the manifest content, keeping close to the text (Graneheim, Lindgren, and Lundman 2017). The categories were refined as they evolved during the process without preconceived categories imposed on the data to be as objective as possible. During the initial stages of the analysis MH and HH discussed codes and categories to ensure a critical perspective and view and address possible bias. In the final stages of constructing categories and themes, all authors were involved to enhance validity and quality of the analysis. The final themes and categories are shown in Table 2.

Table 2. Final themes and categories.

Themes	Categories
Addressing legislation and guidelines	Interpreting legislation and guidelines Acknowledging responsibility for young adults with mental health problems Aspiration of shared responsibility in the welfare system
Organizational culture and discretion	Impact of organizational culture Resource limitations and needs Emphasis on long-term perspectives Managerial commitment and strategies

Methodological and ethical considerations

Together with a query to participate, all managers received a letter with information about the study. Written consent was collected from all participants. It can be argued that the sample is relatively small but by going through the material parallel to data collection it was possible to assess saturation. Organizations in Sweden offering support through IPS and particularly SEd are few, and it was essential that the sample could provide the data needed to answer the research questions (Graneheim, Lindgren, and Lundman 2017). These managers offered a unique experience that could directly inform the research questions, since fewer than 30% of municipalities in Sweden have actually implemented these services (NBHW 2022). The managers’ professional backgrounds could have added insightful information for the analysis; however, the focus of this study was their role and perspectives as IPS managers, and few of these positions in Sweden are determined by profession. As only one psychiatric health care unit participated it was important it could not be identified in the results, therefore it was decided to apply the term service user instead of clients or patients and to emphasize that they are active agents in using the IPS/SEd services. This study was approved by The Swedish Ethical Review Authority, 2021–03763.

Results

The analysis resulted in two themes, Addressing legislation and guidelines, and Organizational culture and discretion, with corresponding categories. For each theme, the categories will be presented and explained further with illustrative excerpts from the interviews.

Addressing legislation and guidelines

This theme describes how legislation at the national level affects the organization. These nationally legislated mandates dictate the organizations general responsibilities, but due to local autonomy in governance, there is a built-in degree of flexibility leading to differences in local decision-making. This includes differences in the views of responsibility in some areas regarding the particular service organization as well as the welfare system as a whole.

Interpreting legislation and guidelines

Among the social services, there were obvious differences in how legislation was interpreted. The most evident difference regarded whether offering vocational and educational support was interpreted as mandated by the SSA or not. One manager described the need to motivate offering these supports to higher management since it was not considered as a mandated service. Another manager described that social services for mental health problems (social psychiatry) were seen as optional, meaning that reducing budgets was easier in that area. On the other hand, some managers viewed offering the support as ‘mandated by law’, as it was their obligation to work with employment support for the target group. One frontline manager expressed how their task was to work with preventing mental health problems and counteract marginalization in society, therefore considering offering these kinds of support as their responsibility.

Apart from legislation, there are national guidelines on methods recommended for both municipal and health care services. These guidelines are not mandatory, leaving it up to these service organizations to decide whether to offer the recommended interventions. Managers in two sites explicitly expressed that they had implemented IPS since it is assigned the highest priority by NBHW, one of them stating ‘I feel we have an obligation to work with what we know works. We have a responsibility to work with and try to implement the methods that are recommended in the National Guidelines’.

In the social service organizations, there were differences in the interpretation of the SSA, whether formal needs assessments were a prerequisite for support. In some municipalities, the support was only available with these formal decisions while in others the users could contact the units directly. Both frontline and second-tier managers were primarily concerned regarding the need for a formal decision and expressed that the needs assessment process might make it more difficult to respond to the service user’s initial motivation, a core principle of the method.

We have taken in people on self-registration but we aren´t allowed to do that, so from next year formal assessments will be required. We fear that some people won´t cope with that process, it will be harder. And it will take longer before you can start. … there are many regulations that aren´t customized to the method. (Frontline manager)

Acknowledging responsibility for young adults with mental health problems

Most expressed that it was their organization´s responsibility to respond to vocational and educational needs by offering services such as IPS and SEd. However, some from the municipal units voiced frustration that other welfare actors sometimes abandoned their responsibility, since the municipalities constitute the ultimate societal safety net for all citizens. On the other hand, some managers also described municipal social services as having the possibility to offer more individually tailored support compared to other welfare actors. Even those managers interviewed who did not think it was their organization´s primary responsibility to offer these services took it on for the best of the service users, concerned that if they did not, the service users would be left without vocational and educational support accommodated to their needs. A second-tier manager expressed that ‘ … we could have just let it go and say it is your responsibility, let us shut this unit down, the only thing that would happen would be that our service users wouldn´t get a job’.

In most interviews, it was articulated that a more flexible interpretation of national and local regulations would benefit both organizations and service users. One manager expressed that it would be profitable to invest in educational support for young people with severe problems, allowing financial assistance from social services while studying. Offering support to young adults in their educational pursuits was particularly seen as a long-term investment in the individual’s personal and professional development. However, in most interviews, it was articulated that the higher management stipulated that this was not consistent with the SSA.

[…] if you are young, you still have dreams and wishes, an education is often needed and gives these people more self-esteem and security. So even if it [financial assistance for educational support] is not usually offered I think it is positive to do so. (Second-tier manager)

All managers described a focus on young adults and young adults in the organization, with a particular focus on reducing future support needs and reducing risks for marginalization from society.

Aspiration of shared responsibility in the welfare system

There was congruence that the society and welfare system have a shared obligation to cater to their citizens and that welfare actors should cooperate for the best of the individual. One manager expressed that even though they as municipal actors have a great responsibility for these young adults, collaboration with other welfare actors is essential, and that support should be given at an early stage. However, the managers expressed a general feeling that other welfare agencies were not offering support adapted to individuals with mental health problems. Further, most experienced difficulties cooperating with other agencies.

[…] we have tried different ways, could we have a person employed in your team or can you employ someone in our team, can we work together? It has been very hard. (Second-tier manager)

There were a few examples of successful cross-organizational collaborations. One social service unit had a close collaboration with a psychosis unit where they had been able to develop a sense of shared responsibility for service users by discussing cases in scheduled meetings. Another unit had formed a collaboration with the local departments of national Social Insurance and Employment authorities to improve cooperation.

Organizational culture and discretion

This theme focuses on internal organizational factors that affect the possibilities for offering vocational and educational support through IPS/SEd. These include the degree of willingness to facilitate working with the methods and how priorities from higher management affect the practice. Support from higher management was seen as essential to keep the units and develop them further, both by offering an environment that encouraged forward thinking as well as allocating enough resources.

Impact of organizational culture

Differences emerged in how the managers described their respective organizational cultures and to which degree the organization was willing to make changes in relation to IPS/SEd. All expressed legitimacy for the methods, but that specific interest and knowledge regarding the methods varied among the higher management. Some described the methods as well-established, while others said they had to continually persuade higher management to maintain the support. In organizations where IPS/SEd was well-established, managers on both levels explicitly expressed that working with evidence-based methods was a priority for the organization.

I feel like in [city] there has been an interest in evidence-based methods and working together with [other agency] with different interventions. There has been a great interest in what is current and functional, and what interventions are good for the users. (Frontline manager)

There was a connection between a facilitating organizational culture and expressed importance in offering evidence-based support. One way of facilitating was to lower the threshold for formal needs assessments, making it easier for the service users to access vocational and educational support. One unit made alterations in the age range to make the support more accessible for young adults with mental health problems from the age of 18 instead of 20 years old.

We have tried to focus especially on young people the last few years since there is a feeling of increased mental ill health and complexity, that they get support early to not lose footing and get caught in a world of care. We think that is very important. (Second-tier manager)

Resource limitations and needs

Many expressed not having enough financial resources concerning the need they saw for vocational and educational support for the service users. For some managers, this resulted in a feeling of necessity to apply for external funding for projects as their organization did not allocate financial resources for developing the units or implementing earlier successful projects. When the organizations made budget cuts, their units were often affected and they expressed that resources were prioritized in other areas within the organization.

In the organization they [local politicians] are happy to allocate more resources for assessment officers, but as far as resources for practitioners working directly with service users with mental health problems, it lags behind. Nothing is coming to those actually carrying out the work. (Frontline manager)

Several managers described how they had been in danger of shutdown due to budget cuts and how this had made it necessary to prioritize which service users would be eligible for the support. In many cases this led to prioritizing young adults and was expressed as preventing future marginalization in society and promote self-sufficiency.

Almost half of the staff was let go … So we can´t be as generous anymore, we have to prioritize and higher management wanted us to focus on young people. … We try to work towards that young people with psychosis won´t have to be in a situation that they can´t finish their education or get a job. (Frontline manager)

Most managers described that they had to find ways to redistribute the existing resources, using their discretion in prioritizing and organizing within their unit. One frontline manager stated ‘Nothing is invested and financial aid from the government ends up in other places. So, I have rearranged my resources. This is a group we have responsibility for anyways, so I have moved around … ’

Not being able to take in all users due to queues caused by lack of resources was expressed in several interviews as troublesome in relation to the principles of IPS/SEd. They described that the long wait made it more difficult to maintain the service user’s willingness and motivation.

Emphasis on long-term perspectives

All managers considered support through IPS/SEd as leading to a long-term gain for the organizations from a financial perspective. The general feeling was however frustration over higher managements’ investments being made on a short-term basis. It was stated that it was essential to describe the whole process in terms of total cost to the local politicians, trying to get them to understand the long-term gain. Many described the service users process as slow, making it difficult to show results within a yearly budget. One frontline manager stated: ‘Over time it would be large savings. They [local politicians] aren´t taking full responsibility, or the chance to decrease the total costs for the municipality since they do not invest long-term, the investments and perspectives are so narrow’. The managers’ main priority was the service users but they also recognized the long-term financial gain for the organization.

To get people into work or education […] and contribute to society as a taxpayer and using less support from the welfare system, it´s a win-win, even if you only see the financial gain, it will cost society less. (Frontline manager)

Some managers put great emphasis on their units offering long-term support, giving the service users support as long as needed. This was viewed as a factor that greatly accounted for the success from a sustainable perspective for both service users and the organization. One manager compared the unit with other services in the same organization and said that proof of the sustainable effects of IPS/SEd was that very few of the service users returned.

A few managers expressed that it was easier to motivate vocational support than educational, due to the more tangible and immediate benefits of employment, as in becoming a taxpayer, compared to a person studying for several years before producing a taxable income. It was evident that all managers had a strong engagement in what the support led to for the service users, more so than for the organization. One second-tier manager stated that their focus was to achieve the individual´s goal and that organizational targets were not as important. In a couple of interviews, it was conveyed that the main goal was not for the individual to become employed or finish their education but rather to improve their mental health and quality of life.

Of course, work is very good and people feel better having something to do … But even though everyone does not get work or start studying, we have seen that they feel a lot better, they have the confidence to do things they didn´t before. So that itself might lead to increased quality of life. (Frontline manager)

Managerial commitment and strategies

The managers played a large part in implementing policy, keeping within budget, and navigating through organizational restraints. This while at the same time trying to offer their employees the best prerequisites to work towards what is best for the service users. Frontline and second-tier managers in one department described that local politicians were positive to implementing an earlier SEd project if it was successful but later decided they could not afford it. However, the frontline manager was engaged in continuing their work and found strategies to implement it.

[…] the plan was, the local politicians signed an agreement that if the unit showed positive results, it was to be implemented, there was no question about it. It was very successful but still the local politicians said that ‘no, this unit isn´t needed, we can´t afford it’. But I implemented nonetheless and rearranged personnel resources, so we kept the unit anyway. (Frontline manager)

The managers stated that there was a big gap between policy and practice and described their role as the link between politically steered priorities and practice, with a mandate to make certain decisions directly affecting the unit. A big part of the role as manager was depicted as creating conditions making it possible for the work-/study specialist to work as closely as possible to the principles of IPS/SEd. This sometimes did not correspond to organizational guidelines, meaning that the managers had to find a middle-ground between the organization at large and the practice.

The need for strategies was illustrated by how some managers felt a need to forego basic principles of the methods and make adaptions in order to maintain working with IPS/SEd. One frontline manager expressed that adapting to the organization was the only way, otherwise the unit would be shut down. There were however a few instances where organizational adaptions and exceptions were made regarding educational support through SEd. One manager described a situation where a work-/study specialist had advocated for a service user who had been denied student funding and was then informed that social services-based financial assistance did not allow for studies. Despite the established criteria, they were able to work together with the financial assistance department to make it possible for this student and future students to study with support, as part of a rehabilitation plan.

Some managers described that their own commitment to the methods and personal belief in individuals’ capabilities were of great importance, exemplifying managemental support as a valuable factor in creating an environment that facilitates working with IPS/SEd.

Discussion

By exploring the reasoning and strategies managers described in offering vocational and educational support to young adults with mental health problems, this study showed the challenges managers meet in relation to legislation and organizational culture, and how they find solutions, navigating between policy and practice, in offering vocational and educational support through IPS/SEd. The study suggests that managers who strive to implement IPS do so for the good of their service users, utilizing their discretion as they face organizational structural challenges. The most common strategy expressed was to redistribute resources or apply for external funding, but some managers also described the need to forego basic principles of IPS/SEd to accommodate organizational restraints.

Discretion in interpretations of legislation

It was notable that the flexibility in the social service legislation allows for significant differences in the interpretation of the organization’s responsibility on the local level. This was especially evident regarding whether educational or vocational support such as IPS/SEd was mandated by the Social Services Act (SSA) or not and whether support through IPS/SEd required a formal needs assessment or not. Similarly, there were differences regarding the possibility to receive support via financial assistance during studies. Since the SSA was intentionally written as a framework law, leaving room for interpretation, this can be seen as self-explanatory. However, the flexibility in legislation creates interesting discretionary challenges in local decision-making as policy is translated into practice (Evans and Harris 2004). Even though most managers expressed concern that the needs assessment process could jeopardize the service user’s initial motivation, thereby breaching one central component of IPS/SEd (zero exclusion), they had to adapt to the organization’s local routines and regulations. This is in line with previous research in Norway where IPS challenged existing organizational routines and structures (Bakkeli 2023). Potential implications of this flexibility could create social injustices, for example, different opportunities depending on where you live. It shows the importance of recognizing the political dimension that underpins discretion (Evans and Harris 2004), in this case, a politically determined gate-keeping function affecting managers’ discretion in practice. While these managers have an amount of discretion in organizing the IPS they are still subordinate to the organizational interpretation and translation of legislation and regulations made in higher management.

The different views on whose responsibility it is to offer vocational and educational support for young adults can also be linked to the possibility of flexible interpretations and translations. When asked where the responsibility should lie, all managers, both in the health care and municipal units, expressed that it should be shared between all welfare actors and society, expressing a corresponding urge to cooperate. However, most of them perceived that the primary responsibility fell to their organization since other welfare actors were not providing educational support services for young adults with mental health problems. The managers suggested that had they not implemented IPS/SEd, the service users would likely fall through the cracks of poor coordination between, and responsibility by, other actors. Their efforts to take on responsibility can be seen as examples of implementation by local champions motivated by ethical values reflecting a service user perspective.

Structural challenges and colliding logics

Our findings show that organizational culture and structure challenge practice when implementing methods like IPS/SEd. A contradiction was suggested between the organizational responsibility for providing evidence-based services and the readiness of higher management to support what the interviewed managers experience as a continuing battle to protect and develop these services. Choosing to work with evidence-based methods (EBM) could be seen as a driving force for these organizations to achieve legitimacy and quality insurance of services (Bäck et al. 2020; Boxenbaum and Strandgaard Pedersen 2009). A commitment to an EBM such as IPS, may facilitate their ability to implement these services within the organization. At the same time, challenges arise from perceived differences in focus between managers and local politicians since politicians’ power is contingent on societal norms and values as well as perceived institutional pressure (Boxenbaum and Strandgaard Pedersen 2009). If educational and vocational support is not seen as specified by law and not their primary area of responsibility, offering IPS/SEd could be viewed as challenging socially constructed norms of what services to offer. Another reason might be the development of New Public Management, NPM (Hood 1995) where managerial logic prioritizing cost efficiency dominates over professional logic which prioritizes the user’s well-being (Arman, Liff, and Wikström 2014). This would explain the managers’ perception that local politicians’ focus is on short-term results (representing managerial logic) while their focus is on long-term gain for the service users (representing professional logic).

The NBHW has however commissioned studies of the economic and organizational consequences of implementing recommended evidence-based methods. For IPS, this included the conclusion that adjustments in responsibility, regulations and financing will be necessary consequences when implementing IPS and that the short-term costs will be greater, but that savings will occur over time (NBHW [2011] 2018). Furthermore, implementing these methods as they are described based on the implementation in other welfare system contexts, may necessitate extensive adaptations when implemented in the Swedish welfare system. This would entail challenging a well-established organization with accustomed norms and routines, requiring both time and financial resources (Bertram, Blase, and Fixsen 2015) as well as transforming organizational structures and peoples’ actions (Eriksson-Zetterquist, Kalling, and Styhre 2012). This might explain the difficulties for higher management to sanction changes in adapting to fit IPS/SEd, instead trying to make them fit into the existing organizational structure.

Working for the best of the service users

While the managers can be seen as a link between policy and practice, it was evident that their focus was on the service users. In their management role, they are expected to implement organizational policies while at the same time creating the best conditions in offering support to the service users, having to handle the organizational tensions (Bakkeli 2023; Storgaard Bonfils 2022). The managers in our study however, expressed that the primary goal was the long-term effect for the service users rather than short-term organizational goals. Interestingly, they also expressed that working or studying was not necessarily the end goal, but instead the positive effects on the individual´s well-being. The managers expressed a personal belief and conviction that offering support through IPS/SEd was the best available support for young adults with mental health problems wanting to work or study. However, within their varied management roles, they had different degrees of managerial discretion in relation to the organizational structure (cf. Evans and Harris 2004) to organize the units and distribute resources from a service user perspective. The managers additionally shared a strong commitment and engagement to finding solutions and creating conditions for the work-/study specialists to work as closely to the principles of IPS/SEd as possible. Even though they were constrained, expressing frustration in their role as managers, they developed strategies to adapt IPS/SEd to fit the needs of service users and the organizational context. As policy actors with influence (cf. Evans 2011), if financial resources did not meet the need for example, they could to some degree redistribute as they saw fit or apply for external funding. These challenges demonstrate the struggles of being in a position between policy and practice and how the engagement of lower-level management can have a central role in converting policy into practice (Bakkeli 2023).

Another strategy for implementation was to forego some of the basic principles of IPS/SEd as the only way for the unit to survive. A report on the implementation of IPS in Sweden showed that more than half of the units shut down within three years (Markström et al. 2015). This points to the difficulties in the sustainable implementation of IPS and highlights the need to develop knowledge that allows for coordination and adaptation to the method and individual needs (Hillborg et al. 2021). The managers interviewed in this study, while a select group, demonstrate that implementation is indeed possible. The variations in how they offer support through IPS/SEd in Sweden can be explained by viewing these examples as local translations of the methods to make them fit a well-established organization. The act of translation into the local context increases the chances of becoming a sustainable part of the organization, where adaptations may be necessary to fit the unique organizational context (Eriksson-Zetterquist, Kalling, and Styhre 2012; Damschroder et al. 2009). Our results suggest that there is no one formula for achieving implementation and that despite the success of these managers, organizational challenges represent a continuing threat to sustainability and further implementation.

Conclusions and implications for practice

Our study provides insights into the reasoning and strategies these managers developed in offering educational and vocational support. This demonstrates possibilities in how IPS/SEd can be implemented and adapted in different organizational contexts. In a sectorized welfare system, as in Sweden, where the national laws provide framework legislation, and reinforce local autonomy, there is a great deal of discretion in interpretations, both regarding responsibility and in what services to offer and to whom. The flexibility in legislation may result in social injustices with regard to local decision-making that create organizational obstacles or facilitations affecting the accessibility of these services. Despite challenges, it is possible to implement IPS/SEd. However, results show that the methods might need to be adapted and adjusted to not only fit local organizational restraints but also to fit into the Swedish welfare system.

Our results demonstrate a perceived discrepancy in primary focus between frontline/second-tier managers and the higher management. These competing logics position the managers between policy and practice, having to navigate between organizational restraints and professional assessment of what they believe is best for the service users. For some this meant having to seek external funding or rearranging financial resources to ensure sustainability in offering IPS/SEd, the benefits of which may take time to achieve. These managers imply that quality is not restricted to the goals of educational success and employment but includes health and well-being for young adults with mental health problems. They prioritize long-term individual goals, seeming to express resistance to the short-term cost-effective solutions promoted by NPM (Hood 1995). The managers suggestion, that they take on the responsibility, has important implications for addressing these needs at a welfare system level. They see that implementing prioritized and evidence-based methods are critical to the needs of these young adults. However, it was not evident if their views on responsibility were individual or reflected the commitment of managers representing the organization at a higher level, a differentiation requiring further research.

As the results suggest, offering this kind of support is not only an organizational challenge but also a reflection of a welfare system characterized by decentralization and sectorization where multiple factors need to be taken into consideration. Evidence-based methods may also challenge short-term economic and political considerations, since in this case the positive effects may be long-term and difficult to capture. Further research, as well as awareness by national actors, is needed as to explore what role educational support can play for the individuals´ participation in studies, entry into the labour market and their overall well-being.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The project has received funding from FORTE: Swedish Research Council for Health, Working Life, and Welfare. Grant number [2020-01363].