Legitimizing incapacity: discursive choices in Norwegian sickness certificates

Abstract

Background: In Norway's welfare system, General Practitioners (GPs) issue sickness certificates (SCs) to document patient's inability to work. These documents serve a dual role as medical evidence and as a basis for social welfare decisions. The language used in SCs can shape how non-medical stakeholders perceive a patient's work capacity. This study examines how SC language constructs narratives of work ability, focusing on how it portrays patients' limitations and prospects for recovery.

Methods: We conducted a qualitative discourse analysis of 155 SCs written by Norwegian GPs for patients under 35 years old with common mental health conditions. We focused on certificates issued around week 39 of the patient's sick leave. Using discourse analysis techniques, we examined linguistic features that convey the patient's work capacity and functional limitations.

Results: SCs predominantly emphasized incapacity and the necessity of work absence through discursive choices such as definitive language, amplified descriptions, and rhetorical strategies reinforcing limitations. Recovery potential was presented with tentative language, reflecting uncertainty in prognosis, while the temporal dimension of treatment was frequently framed as a barrier to returning to work. Additionally, the use of specialized terminology, generalized label, and elliptical constructions placed a significant interpretative burden on non-medical readers. Furthermore, SCs largely lacked explicit recommendations for workplace accommodations or interdisciplinary collaboration, limiting their utility in facilitating structured return-to-work strategies.

Conclusions: Time constraints, administrative pressures, and the dual roles of GPs as clinicians and bureaucrats shape the entire production of SCs. In turn, these discursive choices often reinforce narratives of incapacity. Enhancing SC relevance through structural modifications and interdisciplinary collaboration, including employer involvement in evaluating workplace accommodations, could improve welfare assessments and support tailored reintegration strategies. Positioning SCs as collaborative tools - rather than standalone assessments - may better align clinical evaluations with workplace realities and foster shared accountability for recovery and return-to-work efforts. SCs seem to place a disproportionate burden on GPs to translate medical conditions into work-related recommendations, often without the support or expertise required for such interdisciplinary evaluations.

Keywords: Discourse analysis; General practitioners; Mental health; Norway; Patient work ability; Sickness certificates; Welfare assessments.