33 Exploring the concept inability to work fulltime in the context of work disability assessments research, which raised some questions about the validity of self-reported disability measures for quantifying actual function in work disability settings [13, 30–32]. When used in combination, the above-mentioned measures can help to estimate and quantify the role of the specified indicators and strengthen the credibility of assessment outcomes. Additionally, as participants also mentioned, information from significant others like treating physicians, partners, employers, and occupational health physicians, as well as information based on previous assessments and re-integration during the period of sick leave, could be used. This is also in line with the Dutch guideline, which advises combining data from the assessment interview with additional data from tests like exercise tests and FCE, findings from significant others, and information about the subject’s personal and social situation in order to assess the inability to work fulltime [7]. Rugulies [13] discussed the advantages and disadvantages of using, among others, self-administered questionnaires and observer-based assessments, and also advised using a combination of methods. Repeated assessment should also be considered, given the longitudinal and variable aspects/dimensions of inability to work fulltime. Further research is needed to evaluate the measurement properties of the different assessment methods and their combinations. Strengths and limitations To our knowledge, this is the first study to follow a multi-perspective approach to conceptualize and operationalize the concept inability to work fulltime as part of disability assessment. It is promising both physicians and patient representatives made similar observations. In addition, the study included a wide variety of physicians and patient representatives, thereby providing broader insights into the characteristics, dimensions, indicators and methods of assessing inability to work fulltime. This study also has some limitations. First of all, the study included only representatives of patient organizations. Although some of them are patients themselves, it is their job to lobby for the interests of their organizations; including a wider variety of patients might have produced different data. Further, the physicians were more often male, and representatives of patient organizations were more often female, but we expect that this did not influence our study results, as congruent findings were found from both perspectives. A second limitation may be some educational bias, as our participants had all received higher education; we may thus have missed relevant responses from people with less education regarding inability to work fulltime. This may reduce the generalizability of our study findings. Finally, our interviews took place in 2014; nevertheless, we are convinced that our data are still valid, as the practice of assessment of inability to work fulltime has not changed since that time. 2
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