156 Chapter 8 GENERAL DISCUSSION The overall aim of this thesis was to explore, conceptualize and operationalize the concept ’Inability to Work Fulltime’ in the context of work disability benefit assessments. This chapter summarizes and discusses the main findings of the thesis, addressing methodological considerations and implications for both practice and research, and closing with its leading conclusions. MAIN FINDINGS Research question 1: What does the concept inability to work fulltime entail, and how can this be measured? In the first part of the thesis, we aimed to conceptualize and operationalize the concept of inability to work fulltime. In Chapter 2 we further contributed to this aim by interviewing occupational and insurance physicians and representatives of patient organizations. Our qualitative study found inability to work fulltime explained as ‘inability to work normal working hours’; this concept is considered complex to operationalize -- it is strongly individually determined and variable, affected by changes over time as well as change in the underlying disease. However, we found three measurable indicators: fatigue, cognitive impairments, and restrictions in functioning in- and outside work. A combination of methods (e.g., assessment interviews, testing, and assessment in the actual work setting) and measurements at different time points were considered the most suitable way to assess inability to work fulltime in the context of work disability benefits. Our international survey study (Chapter 3) provided additional information about whether the (in)ability to work fulltime (in that study called ‘work endurance’) is also assessed in other social security systems across Europe, and if so, about the assessment procedures used. We gathered data from 16 countries; these showed that the ability to work fulltime is indeed assessed in most countries. It is considered normal when a person is able to work the standard fulltime working hours per week, ranging from 35.0 (France) to 42.0 (Switzerland). General energy deficit was reported as an important indication of limited ability to work fulltime. Our findings indicated some significant differences in definitions, operationalization, and measures. In some countries, (in)ability to work fulltime is defined as the maximum time during which a person is able to sustain specific physical activities (walking, standing, sitting) without interruption; others define it more generally, as the maximum time during which a person is able to perform suitable work. In all countries, all somatic and mental diagnoses were accepted as causes of inability to work fulltime however, countries showed inconsistencies regarding whether other factors (i.e., psychosocial and environmental factors) could
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