Health social work with migrants: Constructing a specialist profession

Abstract

In 2016–2017, a large Swedish hospital introduced a mobile team of asylum social workers to work with asylum-seeking and undocumented patients. Based on interviews with the asylum social workers and the theoretical concepts of jurisdiction and professional discretion, this study explores how they experienced their work and developed their specialist competence and strategies for health social work with migrants. The findings show that they not only relieved staff and supported patients and relatives but also systemised the knowledge about health social work with migrants and created a professional specialty with a socially, rather than medically, defined group of patients.

Introduction

In 2015, more than one million fugitives arrived in the European Union. This gave rise to new challenges for hospital staff, partly because asylum seekers tend to turn to hospitals rather than primary care (Graetz et al., 2017). At the Karolinska University Hospital in Sweden, staff reported an increased workload, social problems and problems with the discharge planning process for the asylum-seeking patients. With support from the hospital management, the hospital’s Department of Social Work in Health (DSWH) initiated a mobile team of five ‘asylum social workers’ (ASWs), who specialise in patients with migration status, and covering all hospital clinics, supporting the ordinary health social workers (HSWs) who work within specific clinics. Between them, the ASWs spoke 10 languages. The purpose of the project, which took place from February 2016 to August 2017, was to support staff and asylum-seeking as well as undocumented patients and their relatives, and to cooperate with organisations to support a sustainable discharge process. The project was terminated after 1.5 years, partly due to closed borders for asylum seekers in November 2015, and restrictions in the immigration laws which were put in practice in June 2016, involving, for example, fewer grounds for being granted asylum, and limited opportunities for family reunification. When the project was terminated, the HSWs were recommended to use guidelines provided by the ASWs.

The aim of this study was to explore the ASWs’ experience of developing their social work with asylum-seeking patients in a medical context. We did this by analysing how they described their work with the patients and their relations with other professionals, the hospital organisation and external collaborators. We also aimed to gain a deeper understanding of how the ASWs developed their knowledge base and strategies for social work.

The Department of Social Work in Health

The Karolinska University Hospital is a multi-site organisation in Stockholm county and part of the public healthcare. It has some 16,000 employees and receives 1,600,000 patient visits annually. The ASWs served the two largest sites of the hospital. At the time of the project, about 160 ordinary HSWs were employed at the DSWH, making it one of Europe’s largest employers of HSWs. When an HSW or ASW is needed, hospital staff send digital referrals to the DSWH and these are distributed by coordinators.

Social determinants of health for migrants

Although health is defined as a human right, migrants and especially undocumented people face considerable barriers to accessing health services. Legal barriers are common, and unclear legislation and a reluctance among health professionals to deal with asylum seekers lead to healthcare not being provided (Humphries, 2006). Being excluded from social welfare and social security systems constitutes a significant barrier and the asylum process itself often has a negative impact on mental health (Carswell et al., 2011). Post-migration stress related to being denied a residence or work permit, worrying about family members still in conflict areas, problems with communication, housing and food insecurity and discrimination has been identified as the main cause of mental health problems, rather than pre-migration stress (Posselt et al., 2015; Vervliet et al., 2014). HSW tasks, such as providing accurate information about rights and welfare services and a holistic approach to reduce post-migration stress, have been shown to prevent mental health problems among asylum seekers (Fell and Fell, 2013; Johansson Blight et al., 2009).

HSW with asylum seekers and other migrants

Health social work sees health and illness as the interplay between the environment and physical, behavioural, psychological and social factors and it addresses the social determinants of health (Beddoe, 2013). Although there has been a tendency among HSWs to address, for example, psychiatric disorders among asylum-seeking patients, they have also challenged the focus on the bio-medical model and called for social work to return to its profession’s roots, promoting social justice and advocating for these patients (Fennig and Denov, 2019; Masocha and Simpson, 2012). By doing so, and avoiding medicalisation of social problems and injustices, HSWs link the individual experience of illness to the surrounding environment and contextualise people and their difficulties in social structures, circumstances and harmful policies (Fennig and Denov, 2019). As all social workers, HSWs have a strong commitment to promoting social justice and human rights for socially excluded groups such as asylum seekers and undocumented people (Craig et al., 2013; Mwenyango and Palattiyil, 2019; Pockett and Beddoe, 2017). However, this commitment is, for HSWs, constantly challenged by the bio-medical dominance of healthcare. HSWs further face difficulties because of the lack of a distinctive field of practice, formal jurisdiction, evidence-based knowledge for interventions or claims of being experts on certain patient groups (Beddoe, 2013).

HSWs have described their moral distress and inability to respond to the needs of asylum seekers and undocumented people because of immigration policies (Fronek et al., 2017). HSWs are however described to operate within the context of immigration policies to overcome barriers of social exclusion and marginalisation, providing emotional support with concerns for medical issues, deportation, as well as practical support with childcare, financial assistance and advocacy in accessing social welfare payments and housing, maintaining a multitude of contacts, for example with pharmacies, primary care, hospitals, the Migration Agency, social services and nongovernmental organisations (NGOs) (Foreman and Hawthorne, 2007; Svärd, 2014a). Primary care counsellors have also described attempts to compensate for societal neglect and discrimination, acting as social workers to organise resources, thus shifting their normal mode of therapeutic work (Century et al., 2007).

Masocha and Simpson (2012) have proposed a model for HSW in mental health, in which four dimensions of practice are identified: advocacy, networking, therapeutic and practical work. They also argue that working with these dimensions should take place at three levels: with individuals, communities and at the policy level. While there is a lack of empirical studies about how HSWs can develop a professional work with asylum-seeking patients in medical settings, the professionalisation in this field is sometimes suggested as important both for patients and for staff. Robinson (2013) suggests that a key recommendation for improving the health and social workers’ work environment, promoting their well-being and rewarding effective practice would be to provide specialist social work that protects the human rights of patients and informs decisions relating to policy, management and practice in working with asylum seekers and refugees.

Theoretical framework

The day-to-day work of any profession can be understood as negotiated in relation to the situations and needs at hand as well as in relation to organisational and societal frameworks and constraints. For professions with a low degree of formal jurisdiction, such as HSWs, these negotiations are often informal and implicit (Abbott, 1988). The work of HSWs is often diverse and, when compared with other forms of social work, characterised by a general absence of exercise of public authority and a wide but seldom enunciated discretion which highlights its informal character (Sernbo, 2019).

We use the concept jurisdictional work, as elaborated by Sjöström (2013: 65), to analyse the ASWs’ experience of developing their work: ‘an interaction that has a processual and negotiative character’, both internally within a profession or a professional subgroup and externally in relation to other professions and organisations. Sjöström (2013) defines how this jurisdictional work can take on an aposematic character among HSWs by standing out from the environment, highlighting the profession’s particularity, or it can have a mimetic character by trying to blend into the bio-medical context. Sernbo (2019), who has further elaborated these terms, has shown how the daily jurisdictional work of HSWs can become either submissive, secretive and conflict-avoiding or active and open, depending on how the HSW interprets their professional discretion, the needs and inter-professional context of the situation at hand. Jurisdictional work is thus understood as an activity, allowing an analytic focus on how the ASWs describe how they developed their work and their strategies, in relation to how they understood these conditions.

Methods

Two semi-structured interviews were conducted with each of the five ASWs, one during their first week of employment and one when they ended their employment in the project. The first interview focused on their previous experience of working with asylum seekers and undocumented people, and how they perceived their new function, their upcoming work as ASWs. They were also asked to describe which professional approach they expected to be important. The interview guide was modified for the second interviews in order to capture how they experienced their assignments, function, approaches and ways of working and the organisational prerequisites and barriers in their work. They were also asked to comment on whether their understanding of the work had changed since the first interview.

The interviews lasted between 36 and 55 minutes, were tape recorded and transcribed verbatim. In presenting the results, we have anonymised descriptions and quotes and given the ASWs fictitious names. The participants consented to the publication of anonymised responses.

Thematic analysis was used. Initially, both authors coded each interview separately, searching for content relevant to the study’s aim. This coding resulted in suggested themes (Braun and Clarke, 2006) by each author, which were jointly discussed to reach dialogic intersubjectivity and consensus about the most important themes and strengthen reliability and validity (Castleberry and Nolen, 2018). During these discussions, the authors elaborated the theoretical framework. This resulted in a focus on the concepts of ‘professional discretion’ and ‘jurisdictional work’ for the second stage of the analysis. The analysis was refined and revisions were agreed by the authors.

Results

The analysis resulted in four themes, with several sub-themes. The first theme describes the ASWs’ Perceived functions at the beginning of the project. The second, Constructing the target group, describes how the ASWs’ understanding of their patients changed during the project. The third and fourth themes are based on the interviews at the end of the project. Relational work describes the conditions and strategies for the ASWs’ work, while Developing knowledge, competence and a professional specialty explores how they identified knowledge gaps and developed their HSW with migrants.

Perceived functions

Functions for the organisation and colleagues

At the time of the first interview, the medical context was new to most ASWs. They were instructed to shape the project in dialogue with the DSWH management, but there was no clear work description. However, they expected to relieve the workload of the HSWs and other hospital staff. Olivia describes how this function entailed being prepared to listen to the organisation and colleagues, explore the existing competence of hospital staff, and assess what gaps the project should fill in order to meet the expectations of others:

You have to listen to everyone; the care provider, what the hospital wants, what knowledge they’ve got, what I can fill in. We must somehow understand everyone’s competencies, I think. In that way, I think we can find a common path. I mean, if I come and say ‘This is best, this is what will work’, then I think we’ll lose it. As I’ve understood the project, it’s about finding a solution, a bigger solution. (Olivia)

Here, Olivia strives to blend into her surroundings, functioning as a mediator finding ‘a common path’. This approach also relates to patients:

As a mediator, I see myself as the one who on the one hand understands the context of where the person is, but also that we’ve a specific task now, trying to achieve success regarding the bed-numbers and to do so in a dignified way for the individual as far as possible. So, it’s about finding ways, so I see myself as a person in the middle who can try to find the solutions together with my [ASW] colleagues. (Olivia)

Being the ‘person in the middle’ as Olivia puts it, often characterises the HSW profession: mediating between patients, staff and external collaborators (Sernbo, 2019). Olivia is also taking on a complementary approach: contextualising ‘the individual’ as well as ‘the bed-numbers’, assessing missing or foreseen aspects of existing care and trying to find safe discharging processes when the patients’ medical treatment was completed. Many of the patients experience insecure social situations, often related to housing, which leads to difficulties in safely discharging them with regard to their medical and social needs in the after-care, as well as difficulties in admitting patients with more acute medical needs. This is a common concern for hospital staff and management in Sweden, related to decades of austerity policy resulting in great reductions in bed-numbers (McKee, 2004).

Function for the patients

The ASWs state the need to be aware of patients’ possible traumas, insecure circumstances and their need for information about how things work in Sweden. The ASWs expect to fulfil several functions for the patients, making sure they receive the right support, for example, by providing information, emotional support and assistance in contacts with authorities and NGOs. In this regard, they position themselves on the side of the patients, looking after their needs for health and social care. Stella also stresses the importance of strengthening the patients’ competence and making sure that the patients are understood, as a basis for upholding patients’ trust in healthcare. By doing so, ASWs adopt an advocacy function (Masocha and Simpson, 2012), acting on behalf of patients: guarding and protecting their rights. This approach is not new for them, but compared with previous decision-making roles in the social services, the non-authoritative HSW is described as challenging:

I think that the biggest obstacle for me is the role. Coming from this public authority role where you make decisions and come in and change people's lives and don’t just motivate. From that role, where I’ve made many important decisions for people about social assistance, housing or child welfare. Now it’s voluntary. . . I might assess what kind of help they need, but it’s nothing decisive in that way, because I’m not exercising public authority here. (Nadia)

Instead of decision-making, the ASWs describe their work as assessing patients’ circumstances and opportunities for support or alternative solutions in relation to organisational and legal conditions – typical HSWs’ work tasks (Pockett and Beddoe, 2017; Sernbo, 2019; Svärd, 2014b).

Constructing the target group

When talking about the patients and their needs, the ASWs primarily define the patients from a legal perspective: not knowing whether they will be allowed to stay in Sweden. Without a residence permit, patients also lack the right to subsidised healthcare, the social security system and other social rights. At the beginning of the project, Alyssa describes how these uncertainties and difficulties, rather than any medical diagnosis, defined their patient target group:

They’ve a lot of healthcare needs of course, as other people have, and they arrive here and maybe have fled, and of course, they’ve some other needs. They’re not familiar with this society, don’t know where to turn and, also, they don’t have the same right as a person who is entitled to benefits from the Social Insurance Agency, things you might be used to. (Alyssa)

Other patient characteristics are described as experience of trauma, not speaking the language and not having a social network. However, Alyssa stresses that there are variations within the group: coming from a wide range of countries and types of society, with different levels of education, and being individuals with varied needs.

Sweden’s immigration laws had changed by the end of the project, becoming much more repressive, which affected the target group:

I can see now that it’s actually a patient group, or not a patient group, let’s say a target group then, with various diseases and other stuff. But which is large and where a lot is happening around them at the societal level which we can’t control or do anything about. It is what it is, but it affects their opportunities for getting treatment and how they feel. It’s also about competence, I think, which is important at a hospital. Asylum-seekers arriving here today, how is their health?. . . What impact will the law changes have? They will have a huge impact, for sure. (Alyssa)

In this quote, the patients are defined in relation to society: they lack legal rights, which gives rise to social difficulties and ill health. All ASWs focus on these social determinants of health, rather than specific diseases. Alyssa’s hesitation about whether to describe the patients as a ‘patient group’ (usually a diagnosis group) or a ‘target group’ highlights a dilemma. Because the hospitals are organised around medical diagnoses, the ASWs become an anomaly, organised around the patients’ social circumstances, contextualising them socially rather than medically.

Relational work

Working to make relations work

The ASWs describe the social problems and the new repressive immigration laws affecting the patients negatively as difficult to deal with and necessitating multiple contacts with authorities:

I didn’t expect it to be so hard, that the asylum seekers had such tough situations. I didn’t know. . . So, when I worked with it, tried to help them – on the one hand, I didn’t feel I had the power to help them as an ASW. But yes, we tried to anyway. But I’ve seen how hard it is, even for us . . . to call the Migration Agency or other authorities, and to stand in queues and fight with them. About everything from economy to housing. (Maryam)

Work that does not include the exercise of authority results in a role that is a combination of relational work and advocacy. This is described by Maryam as fighting with the patients to improve their social situation in relation to other authorities. They also emphasise this lack of authority in relation to physicians’ decisions about whether to give patients medical care:

We have a law saying that undocumented have the right to healthcare that cannot be delayed. I think I now understand what interpretive priority our doctors have. What can wait, what cannot wait? And regardless of the doctor’s assessment, how can I convey this to the patient and be able to continue working with this psychosocial support? On the one hand you are denied healthcare, on the other hand you are welcome. (Stella)

The physicians’ power to deny patients medical care poses a dilemma for the ASWs because they still can use their professional discretion to continue to provide psychosocial interventions. Dependency on others is often referred to and Stella describes how her jurisdictional work was elaborated in relation to others:

I thought that I had a clear mission but in reality, you face different, how to put it, not challenges but . . . well our profession is based on relationships, so I understood quite early that in order to achieve this goal, whatever it might be that I and the patient set up, different factors around it have to work. (Stella)

The ASWs emphasise how surrounding factors must be taken into consideration to be able to support patients. Nadia describes being dependent on collaborating with other professionals, specifically related to the ASWs’ lack of formal jurisdiction:

Some things I can’t understand, like when I need a medical certificate and the doctor has maybe said to the patient ‘Yes you have this and that, and because of this and that’. And then, when you say like, ‘Can I have that in writing?’, it’s just ‘No’ . . . I’ve been in a discussion for an hour with a chief-nurse when they’ve refused to write a medical certificate, and I can’t quite get it. (Nadia)

When trying to collaborate and close gaps between the healthcare system and the Migration Agency, a doctor’s certificate was sometimes needed, for example, for medical priority to better housing for asylum seekers. The ASWs were also dependent on Migration Agency officers; initially they experienced difficulties in this cooperation because they lacked established relationships.

The uncertainty and unpredictability when collaborating with other professionals and authorities were caused by no one wanting to take responsibility. This affected the ability of the ASWs to obtain adequate information, decisions or certificates, preventing them from advocating for patients’ rights. In building collaborations to making things work around the patients, the ASWs were dependent on other people reaching out to them. When people failed to do this, they tried new ways of collaborating – establishing stable relationships with, for example, a head of unit and a few officers at the Migration Agency whose direct telephone numbers they obtained. The collaboration with agencies concerned individuals with an ongoing application for asylum or other form of resident permit, with the patients’ approval according to the Swedish Official Secrets Act, and was described being about, for example, visas for relatives, housing, and special allowances with regard to medical needs. Regarding undocumented people, the ASWs established collaboration with different NGOs, such as the Swedish Red Cross and Médecins Sans Frontières, who could further assist these patients. This way, the ASWs assessed each patient’s current situation and used a solution-focused approach to protect the patient’s human rights in times of restricted migration laws.

Balancing active and submissive jurisdictional work

All ASWs describe how being organised as a consulting team, for hundreds of departments and wards in two large hospital sites located miles apart, made their dependency on relationships with hospital staff particularly challenging:

At the time, I probably didn’t understand, for example, what it means to arrive at a clinic without any kind of relationship with the other care professionals there. Our HSWs have completely different conditions. They’ve met those who work at the clinic. For me, it’s been. . . It’s felt like, it still feels like I’m some kind of visiting consultant, because I’ve got to cover the entire hospital. I understood quite immediately that you probably have to exercise your social skills and introduce yourself every time you’re there, and tell people what your role is. (Stella)

As consultants, the ASWs were constantly having to introduce themselves and their functions and create new relationships. The hospital underwent an extensive reorganisation during the project, with new managers and names of wards and clinics, which further affected opportunities for getting acquainted. All ASWs remark that the challenging organisational circumstances made them feel like outsiders, being dependent on good relationships with the HSWs, who became important links between the ASWs, other staff members and patients:

The collaboration with the ordinary HSWs, I think it’s very important. Super super important, because they’ve all the other knowledge we don’t necessarily have and that . . . yes, everything from who to talk to about this, and the medical stuff we don’t always have time to acquaint ourselves with. (Alyssa)

In general, the ASWs felt that the collaboration with HSWs worked well, with clear professional boundaries and an appropriate distribution of problems and work:

I think the collaboration has been great with the different HSWs I’ve been working with. They focus on what’s related to the disease. As we can’t visit every ward and be specialists in every disease, complaint and so on, it’s felt good in those cases. Being able to focus on the migration part of it and the HSW on the other part. (Nadia)

This positive experience, shared by the HSWs according to a survey (Svärd, 2022), was however accompanied by uncertainty. Some HSWs were described as being sceptical, not seeming to welcome the project at all. Good cooperation with the HSWs was thus regarded as a necessity that could not be taken for granted. To develop and make use of their competence, the ASWs describe how they, being strategically submissive, tried to avoid confrontation with HSWs:

In the end, it’s actually about the patients. And if you have one patient and there are two . . . it shouldn’t affect the patients. That’s the most important thing. I think that’s what we’ve been dealing with. If it’s better for the patients that we take a step back, then it’s probably better for the patients. . . It shouldn’t be a battlefield between colleagues. (Alyssa)

A way to avoid confrontations when HSWs did not hand over cases was to combine the submissive strategies with more active strategies, offering to relieve the HSWs’ workload with issues related to migration. Stella describes what happened when an HSW did not want to disrupt an established treatment relationship with an asylum-seeking patient by involving the ASW:

Then I said ‘I can help you just with housing’. Because that was the problem, that he was waiting for a [new organ] but didn’t get it because of his unstable housing. And then I started calling round and. . . Because they’d sent in a medical certificate, and a certificate from the HSW, and then I might start having a more demanding attitude, saying I need answers. ‘We have submitted certificates, what’s happened to them?’ . . . within three weeks he had somewhere to live here in [x-town], close to the hospital. (Stella)

This quote demonstrates how the ASW use an active strategy in the jurisdictional work, to secure the patients’ health and survival, offering the HSW help on a specific issue. The established collaboration with the Migration Agency officers enabled Stella’s influence on the officers’ decision to grant the patient a medical priority for a new housing, making the organ transplantation process possible.

Developing knowledge, competence and a professional specialty

Alyssa described how her expectations of the role changed during the project. She went from regarding herself as a complementary resource to help secure socially sustainable discharge situations, to identifying the need to work with routines and knowledge within the organisation:

But with time you also realise that there are many things you didn’t know when the project started. And like, prior knowledge about this target group wasn’t great in the organisation. When I look back it feels like maybe there wasn’t a lot of structure. (Alyssa)

Even though they were working in a role defined by others, the ASWs also developed their own understanding of the needs, using their wide professional discretion to expand the scope of their work. The lacking structure and the ‘things you didn’t know’ created a space where the ASWs had an opportunity to define the problems they encountered and develop their work, functions and strategies accordingly.

The ASWs thus took on the role of specialist consultant, which involved giving talks and information and spreading knowledge in the DSWH, all the while using a submissive, conflict-avoiding and complementary approach in relation to the HSWs:

It’s not about questioning the competence of others, but rather that there are some people who’ve been given the opportunity to specialise in this for a while. (Alyssa)

By framing the specialist competence as something they simply ‘have been given the opportunity’ to develop, Alyssa avoided presenting herself as standing out as more competent than other HSWs on migration issues. All ASWs say they spent much time advising and informing HSWs and other professionals, as a way of working with factors surrounding the patient:

We’ve had a lot of advising and consulting, they knock on the door, and you can sit there for 40 minutes or an hour, and we discuss cases, different residence permits and rights, and all of that. And people phone, without having made a referral, to consult us, like ‘what’s the patient fee for this?’ (Nadia)

This informational approach primarily concerned the interpretation of legislation and regulations, thereby promoting legal certainty. The ASWs also strived to improve knowledge and change the prejudiced ideas of medical staff about patients and their abilities – for example, when staff assumed a patient did not know how to use an ATM. The ASWs’ jurisdictional work thus included the aim of improving the competence of healthcare staff.

Similar to Alyssa, Olivia says that her view of her job changed during the project. It was now about developing a long-term specialist HSW with migrants:

I thought our function was to support medical care somehow, try to ease an acute situation. But I can see that our work has been more about specialising ourselves and understand . . . systematise. So, I think it went from being something acute, thinking ‘now let’s get in there and fix this’, to being ‘no, let’s take a long-term perspective. How can we could develop the social work around this’. I’ve noticed also, that this has really been appreciated among colleagues. (Olivia)

According to Olivia, the ASWs clarified and systemised the knowledge they needed in the fields of migration law, the rights of patients with different migration statuses, the medical and social care available from NGOs, as well as theories about migration stress, post-migration related stress, traumatisation and culture. They also emphasised the importance of being sensitive to individuals’ circumstances and having social and collaborative skills.

Their jurisdictional work in relation to hospital staff covered promoting a socially contextualised attitude to patients, telling professionals to safeguard patients’ rights, reducing prejudices and discrimination and giving talks and providing guidelines for the HSWs. However, while they strived to develop the function of HSW with migrants, they also identified needs and obstacles at the organisational (hospital) level which required changes that could not be brought about by them or the DSWH alone. There was, for example, a need to clarify confusions about patient fees and to implement guidelines about patients with migration status for all hospital staff. Stella describes such measures as ‘the need to develop a little more of a basis for when things happen outside of the box’, referring to the target group as often falling outside the box.

However, the obstacles the ASWs identify are primarily at a structural level: unclear legal assessments of patients’ rights to healthcare and uncertainty arising from different agencies being responsible for bearing costs depending on type of migration status. This led to the risk of patients falling outside the systems and thereby risking health, treatment, or even life. The ASWs often reflect on being asked to investigate the fundamental question of patients’ migration status; it was often unclear to staff whether they were asylum seekers, undocumented, had work permits, were seeking residence permits on other grounds or were tourists (see also Svärd (2022) for similar findings). Nadia says,

One part of the job was to develop a way of working. . . We’ve expanded our framework, and yes, in the end, maybe it indicates that there are more needs to cover, and that we shouldn’t only be called asylum social workers, or maybe something else and do more, widen [the target group] so to speak. (Nadia)

While the mission of the ASWs was to work with asylum-seeking and undocumented patients, they soon identified a great need to support professionals in their work with patients with migration status, regardless of type, because the specific status was correlated with specific legal and social conditions and rights.

Discussion

This study explores how the ASWs experienced their social work with migrants in a medical context, focusing on their work with patients and their relations with other professionals, the hospital organisation and external collaborators. The analyses focus on gaining a deeper understanding of how the ASWs, from their specialist position, developed a knowledge base and strategies for their work. By interviewing the ASWs at the beginning of the project as well as at the end, the focus of the analysis became twofold: highlighting the changing perceptions and content of their day-to-day work and looking at how they developed strategies when establishing their work, knowledge base, and the specialist team.

We found that the ASWs initially primarily strived to relieve HSWs and other staff by filling complementary and informing functions. This can be understood as using what Sjöström (2013) calls a mimetic approach in their jurisdictional work, focusing on blending into the hospital environment by filling gaps in (non)existing routines, and using submissive strategies in order to be involved in the ordinary HSWs’ patient cases. In their relational work, they also strived to fill and bridge gaps between the hospital and other organisations, and between patients and various professionals.

The mimetic approach was successively combined with an aposematic approach (Sjöström, 2013) as the ASWs articulated their own analyses and perspectives from a stand out position. Although they adopted submissive strategies when forming collaborative relationships and offering their support and specialist knowledge, they also dealt with their own lack of authority by actively trying to influence the decision-making of physicians or Migration Agency officers, by suggesting what they needed to do. This is related to how their understanding of the target group, patients’ needs and the lack of legal clarity when assessing patients’ rights changed during the project – causing the ASWs to take on an advocacy role, trying to achieve change for the patients (cf. Masocha and Simpson, 2012). As the ASWs widened their understanding of the patients and their needs, contextualising them socially rather than (only) medically, they concentrated on social determinants of health such as post-migration stress, legal matters, social resources, housing, economy and experiences of flight and possible traumas – working with the four dimensions of practice outlined by Masocha and Simpson (2012): advocacy, networking, practical and (to some extent) therapeutic work. As they formed their own understanding of what needed to be done, the submissive jurisdictional approach became more active, as the ASWs promoted their competence and skills. This involved addressing a lack of competence and other obstacles in the organisation, adding knowledge by giving talks and suggesting guidelines, aiming at changing overall structures and routines in order to strengthen patients’ rights to social and healthcare. In this process, the ASWs used their wide professional discretion to broaden their role, develop a specialist competence base and professionalise the HSW with migrants. They thus expanded from the individual to the organisational level (cf. Masocha and Simpson, 2012), trying to reduce the effects of social exclusion caused by immigration policies (cf. Foreman and Hawthorne, 2007).

The analysis shows that promoting specialist competence required an aposematic approach, standing out from the ordinary HSWs. However, because they were organised as a consultant team at a very large hospital and because they functioned as links to other hospital staff as well as patients, the ASWs were dependent on establishing good relationships with the HSWs. The HSWs and the DSWH therefore played a vital role for the ASWs in developing their specialist profession and maintaining the opportunity to stay focused on migration issues. This dependency might explain why they, parallel with the aposematic approach to their jurisdictional work, also maintained submissive and conflict-avoiding strategies: recognising that the patients also needed the ordinary HSWs. A questionnaire study (Svärd, 2022) about the ordinary HSWs’ experience of the ASWs and their work found that the ASWs were much appreciated for relieving their workload, for improving the quality of care and encounters with patients, for securing patients’ rights and for improving the HSWs’ knowledge of migration issues. This indicates that the ASWs adopted a successful combination of strategies for the development and implementation of the specialisation.

Implications

One main facilitator of and barrier to developing and maintaining specialist competence and a specialist team is related to steering and management. It has previously been suggested that specialist social work with migrants could improve staff’s work environment, promoting their well-being and rewarding an effective practice (Robinson, 2013). When the project was terminated, the HSWs were supposed to continue using the guidelines provided by the ASWs. However, because of changing legislation and organisational circumstances, these guidelines quickly become out of date and need constant revision. Social workers are expected to have far-reaching knowledge about legislation, social security systems, social support and the competence to advocate for and promote social and human rights. However, HSWs maintain that ever-changing laws and conditions make it difficult for individual HSWs to remain up-to-date (Svärd, 2022).

One facilitating factor was the wide professional discretion, supported by the DSWH, which allowed the ASWs to define problems and decide what to work with. Constructing their target group socially rather than medically and defining the patients’ problems and needs from this social perspective allowed the ASWs to be experts in strengthening patients’ rights, in line with the general ambitions for HSW (Craig et al., 2013; Pockett and Beddoe, 2017). This has previously been found to be difficult for HSWs to achieve in medical contexts (Beddoe, 2013; Fennig and Denov, 2019). The project under study, in which ASWs implemented a specialisation for HSW aimed at a socially rather than medically defined target group, resting on a solid legal, social and psychosocial knowledge base and developed specifically from the circumstances of the target group, is unique. In healthcare, specialist positions for HSWs usually follow medical specialisations, such as oncology, neurology and neuropsychiatric disorders. Working in medical settings, often without belonging to an HSW organisation, leaves HSWs without a social work arena where they can focus on professional development in relation to the important social and legal aspects of their role. The usual model of HSWs specialising in a group of medical diagnoses rather than a social group may strengthen the collaborative and inter-professional blend of functions, making HSWs more similar to the other members of a medical specialist team (Svärd, 2014b). However, this might be at the cost of specialised social work competence which puts patients’ social and human rights first (Fennig and Denov, 2019). The ASW specialist team combined the best aspects of both positions – standing out by focusing on the social determinants of health, blending in via the submissive relation to the ordinary HSWs.

Conclusion

This study makes an important contribution to improving our knowledge about HSW with migrants, based on empirical material from a Swedish context. The ASW team was recruited to relieve hospital staff in an acute situation with a high number of asylum-seeking patients. However, the ASWs added their own aim of improving knowledge about asylum-seeking and undocumented patients within the organisation and strengthening patients’ social rights and right to medical care. In doing so, the ASW team used both mimetic and aposematic jurisdictional work to establish a new professional specialisation of HSW with migrants at the hospital. This specialisation did not blend into the usual hospital focus on medical diagnoses, but rather concentrated on the social determinants of health.

This study raises questions about how specialisations in social work may need to be combined with a generalist approach, here provided by ordinary HSWs, thereby enabling necessary relationships and personalised links to patients and other professionals and making sure that all the social and psychosocial needs of patients are properly assessed and met. However, whether or not HSWs are specialised, all HSWs must be committed to promoting social justice and human rights, not risking patients’ health and situation due to restrictive laws and policies.