A limited physical capacity, increased stress and increased need of rest were the main health problems that made it difficult to manage work. The participants described an imbalance between their reduced resources due to their health problems and the work-related demands, which were physical work demands, psychosocial work demands and work-organizational demands. Influence of work on health varied. While several participants perceived great difficulties due to increased pain and other symptoms, others did not feel that their health problems were influenced by work.
Work ability can be seen as a balance between a person´s resources and the demands of the work that she performs [10
]. Both physical and mental resources were found to be limited among participants in the present study. Some participants used their maximal capacity to manage their work, describing how their pain could at times increase to such a level that it led to emotional exhaustion, which was expressed in irritation, depression, aggression or a loss of clarity of thought. The participants appeared to be aware of causes and consequences of overload and tried to handle them in the workplace. Our findings confirm those of previous studies that report impaired physical capacity [6
], cognitive dysfunction [15
] and decreased work ability in FM [9
], and provide a detailed description of the patient’s perspective of how physical overload progresses to cognitive overload. It appears to be important to identify situations that lead to cognitive overload, both for the employer and the employee. Greater control of work and better self-efficacy and self-confidence might put a limit to this type of overload and its consequences.
Here, an unclear definition of work tasks was a common element of the psychosocial workload, and it is probably a common characteristic of many occupations in the areas of service and care. The high level of psychosocial stress described by the participants agrees with earlier research that has shown that time pressure, poor control and unclear work roles lead to stress and low work satisfaction [16
An interesting finding was that a shortening of the workday from eight to four hours did not always result in a lesser workload, which is commonly expected by the physician and the employee. The interviews showed that if high psychosocial work demands remained, such as unclear content and the number of work tasks, psychosocial stress did not diminish when the work day was cut to four hours. Furthermore, once the stress level had increased, it appeared to maintain for the rest of the day. This indicates the importance of defining clear work roles and individual responsibilities.
In this context, the importance of the supervisor’s attitude is understandable. Our sample claimed that the supervisor had the main influence in terms of how work was scheduled and how work tasks were defined, which either broadened or limited the ability of the participant to control her work situation. This confirms earlier studies of the importance of feedback and social support given by supervisors and colleagues at work for continuing to be healthy and able to work [17
A previous five-year longitudinal study of working women with short-term FM showed that work did not prevent a decline in health status over time [8
]. On the basis of our results, it is likely that person who experiences heavy physical or psychosocial workload risks deterioration in her health and work ability. The participants in our study who had succeeded in adjusting their work tasks and the pace of work to their daily symptoms and abilities appeared to have the best possibilities for maintaining their health and employment. These findings confirm previous reports that indicate that the individual´s work ability is dependent on such factors as coping strategies, work climate, work demands, attitudes and values [19
Rest and relaxation appeared to be the primary strategies used to recover for the next workday, and the ability to find the time to rest was in part dependent on factors related to the family, such as having responsibility for small children or sick parents and whether they received support from their significant others.
From a health promotion perspective, it appears that employers, employees with FM and health care professionals should cooperate to develop the work environment by adjustments of the work demands. The interviews indicated that many persons with FM were able to take an active role to improve their work ability. Workers with FM who had an opportunity to vary their work positions and work tasks during the day and to take short breaks managed their work better. These changes would also enhance “pacing”, which is an often recommended strategy for patients with FM to be able to manage daily tasks [20
] but which was seldom possible to apply in work situations, as described by our sample. To adjust the work situation to match the ability of persons with FM, the heavy physical tasks, frequent carrying and lifting, static movements, dynamic repetitive work and eccentric muscle work need to be limited, as has also been reported previously [9
]. Adjusting work hours from day to day and modifying work tasks according to the person’s actual resources appear to be helpful strategies for patients with FM so that they can continue to work in the long term. Besides these factors, the life situation as a whole and the physical and psychosocial work environment may determine whether a person can remain at work.
Selection of the study population aimed to reach homogeneity based on shared experience of FM and being active in work life, while variations in age, pain impact, occupations and work hours brought variations of experiences and perspectives. Heterogeneity of the study population was found to enrich the discussions. Selection of the study population is assumed to strengthen the credibility of the data analyzed. Focus-group interviews was a suitable method for data sampling, as the participants openly shared their experiences and reflections with each other during relaxed discussions, also found in previous studies using the same method [21
]. Measures to achieve consistency of data collection included a short data gathering period (four weeks), standardized start and completion of the interview session, use of the interview guide, and the role of the co-moderator. The standardization allowed possibility to deepen the interviews of the topics discussed. These methodological aspects are supposed to strengthen dependability, an aspect of trustworthiness in data collection.
The first author acted as moderator in all the focus groups, while the second author based her analysis solely on the transcribed interviews. This methodology brought different perspectives on the analysis. The interviews were analysed separately and jointly by the two authors, moving back and forth through coding and categorization [14
]. The independently developed codes and categories were very similar, which is expected to increase the credibility of the interpretations, an aspect of trustworthiness of the analysis.
A limitation of the qualitative research approach is the fact that the results cannot be generalized. It is possible that gainfully employed women with FM in other settings and with other living conditions have experienced other barriers for professional work. There is always a possibility that new categories might be identified in an interview with a new study population. As authors we consider that the results are relevant when planning rehabilitation for women with FM or other long-lasting pain disorders, but transferability of the results to other contexts has to be judged by the reader [14