The objective of this study was to gain understanding regarding impaired work ability, i.e on long-term sickness absence, in the context of female white-collar workers in high-level positions in Sweden. Work ability or inability is a complex issue and there are many layers of influence, such as internal factors connected to skill and context, and to interactions in the societal and organisational culture [24–27]. This complexity has been confirmed in this qualitative interview study.
In this section the results will be discussed in relation to long-term sickness absence, and the findings will be compared with earlier research in related fields and connected to theoretical models and concepts used in work health research. Methodological considerations, trustworthiness, and transferability of the findings will also be discussed in this section.
The women in the study were generally well educated and most had a final degree from a university or institute of higher education. A few had surprisingly little formal education considering their salary level and position in working life (Table 2). The informants' education and profession is not within the framework for the gender-segregated labour market which is characteristic of Swedish working life [4, 28, 29]. The women have posts that are more commonly held by men and are not horizontally segregated, i.e. in the typically women-dominated sectors and jobs on the labour market. Nor were they vertically subordinate, i.e. in jobs at the bottom of the hierarchy at workplaces. The informants were on the contrary in leading positions, either as specialists with some degree of managerial responsibility or with managerial responsibility as managers in a linear organisation.
The working environments where the women are active are male-dominated. The women indicated that this could have induced sex discrimination, role conflicts, and misunderstandings, which seems to have played an important role in their deteriorated health. Similar findings have been reported in studies since the 1970s [30, 31]. According to gender role theory, a stronger family involvement is more congruent with female gender and, accordingly, women in management positions could challenge traditional gender roles , which might entail perceptions about values and relations in the management teams or in relations between male and female managers.
Our findings are consistent with results from studies stating that competent women in male gender-typed positions can be disliked, not encouraged, and have a hard time building relations with their male colleagues, primarily because of their gender [33, 34]. Due to this, their performance in male gender-typed tasks can be devalued and their competence denied .
One feature in the informants' descriptions is duality and ambiguity, implying both negative and positive dimensions. This is apparent in the categories directly related to the women's positions in working life: "Career focus, but competence mismatching", and "Wrong workplace and colleagues". The women expressed strong agreement on succeeding in working life, but stated that there had been no competence matching in their present jobs. Despite this double-edged stance, the informants seem not to have given up on finding the right position and continuing a professional career. In some cases impaired health probably stopped a job change, which could have helped to save strength. On the other hand, their "locked in" positions could have had a detrimental impact on their health status. The informants' impaired health could also be a simple reason for not changing jobs due to "last in, first out" rules on the Swedish labour market and a striving not to compromise their present work positions. Our findings are in concordance with the results in a recent study  of almost 6,000 men and women in Sweden, where it was shown that "locked in" positions in occupation or workplace are associated with long-term sick leave.
As the women's gainful work is reported as not entirely rewarding, this could be considered a threat to work ability and well-being, addressing studies which claim that it is important to maintain a mutual balance between efforts needed for performing a job and the reward obtained [37, 38]. Not being rewarded for one's efforts or being unjustly treated have been found to be important issues in the process leading to burnout and emotional exhaustion in working life . If high work-related demands recurrently occur in combination with low rewards, it is possible that this can cause stress-related disorders and sustained strain reactions, with adverse effects on both physical and mental health [37–39]. The effort-reward imbalance model of work stress is applicable if people are exposed to heavy competition or if they are intrinsically motivated to engage in excessive work-related commitment. The informants probably overestimated their own coping resources and were not fully aware of their own contribution to the non-reciprocal exchange. Their overcommitment had been extensive and also included considerable efforts and responsibilities within the private sphere. The women had used a great deal of their resources both in family- and work roles, having had far too little recuperation to maintain their health and well-being. This can be considered a coping style, which is a psychological construct and presented as performance-based self-esteem. Self-esteem is a concept based on accomplishments that is used in burnout modelling . This is a concept, or rather an important personal trait, in high psychic distress and strain, which can lead to a failure in the balance between resources and perceived strain. It has been concluded that under certain circumstances this pattern can predict burnout and maladaptive stress reactions , which agrees with our results. Depite their strong focus on their work performance and career, it is certainly possible that the women reduced their professional efficacy due to their overcommitment and response to stressors.
Our findings are connected with the well-known job-demand-control-support model, which in several studies has been applied by showing that imbalance between psychosocial demands, decision latitude and social support, impacts health functioning and could lead to mental dysfunction [40–43]. Job demands were reported as high, and the results indicate that decision latitude was limited, despite the fact that the informants were in management positions. Their coping style could have hindered them in achieving a balance between work demands and decision latitude and thus a high degree of job control, showing that the imbalance might to a great extent be self-imposed. Compared with jobs that women usually have on the gender-divided Swedish labour market, the informants in this study had positions in working life that are not usually subordinated, but generally have a high decision latitude and opportunities to control and balance work. In earlier research, the high demand component at work has been found to predict emotional exhaustion [44, 45]. Low levels of work demands, control, and support in British civil service employees have been found to be associated with higher rates of short and long spells of absence in men, but to a lesser extent in women . However, results from a cross-sectional Swedish population study on long-term sick leave showed the highest associations with women in high-strain jobs in the private sector, which corresponds well with our results .
The failing support found in this study concerned immediate supervisors, co-workers and the organisation or workplace at large. The impact of failing social support on sickness absence from colleagues has been found in earlier studies. In a sample of the Swedish working population it was found that for long spells of sick leave, poor support from colleagues was related to long-term sick leave, and that good support from superiors, but not from colleagues did not change these factors . In a Finnish study of employees in the private sector, lack of support from co-workers increased the frequency of long sickness absence among men, but not among women .
The results from our study indicate that there was a connection between the reported restructuring and profitability problems in the women's companies and the leadership styles suggesting a lack of support from managers. Economic problems could certainly entail negative stress for the management; this in turn could contribute to a poor working climate, resulting in negative health consequences for the employees, and causing or contributing to long-term or frequent periods of sick leave . It has also been found that leadership which is based on exerting authority and not oriented towards solving problems through discussions is related to a higher level of sickness absence , while inspiring and communicative leadership, suggesting a transformational leadership style, has been shown to be related to lower rates of sickness absence .
The trustworthiness of a qualitative interview study depends to a large extent on the interaction between researchers and informants, and on the analysis of the data [19, 53]. A qualitative method was chosen for data collection in this study, with an explorative and inductive approach in analysies, in order to obtain a wide picture of the women's experience of work inability in the context of women in high-level white-collar positions in the private sector on the Swedish labour market. The qualitative method also allowed flexibility, and made it possible to study interrelations rather than to spot causes.
The interview situations were planned according to the wishes of the interviewees in order to create an unstrained setting. The outlined interview guide allowed an inductive strategy to derive the predominant themes reflected in the interview transcripts. The interview guide did not hinder this strategy, as it was very short. After sixteen interviews, the data collection seemed to be complete and appropriate for the purpose of answering our research question.
One of the most basic and important decisions in the content analysis was the selection of the meaning units and the further analysis into categories and themes, which was guided by the research question of the study. In this study the coding procedure was conducted to include those parts of the interview where the women talked about how they experienced working life and their positions, and how their family and social life was linked to this from a health and work (in)ability perspective. The credibility was strengthened through discussions between the co-researchers. Regarding transferability of the findings, we suggest that they might be transferred to similar settings and contexts: women working in high-level positions in the Swedish private sector, from similar socio-economic positions, and with similar demographics.