Burdens, resources, health and wellbeing of nurses working in general and specialised palliative care in Germany - results of a nationwide cross-sectional survey study.

BACKGROUND: Palliative care in Germany is divided into general (GPC) and specialised palliative care (SPC). Although palliative care will become more important in the care sector in future, there is a large knowledge gab, especially with regard to GPC. The aim of this study was to identify and compare the burdens, resources, health and wellbeing of nurses working in GPC and SPC. Such information will be helpful for developing prevention programs in order to reduce burdens and to strengthen resources of nurses. METHODS: In 2017, a nationwide cross-sectional survey was conducted. In total, 437 nurses in GPC and 1316 nurses in SPC completed a questionnaire containing parts of standardised instruments, which included parts of the Copenhagen Psychosocial Questionnaire (COPSOQ), the Patient Health Questionnaire (PHQ-2), the Resilience Scale (RS-13) Questionnaire, a single question about back pain from the health survey conducted by the Robert Koch Institute as well as self-developed questions. The differences in the variables between GPC and SPC nurses were compared. RESULTS: SPC nurses reported higher emotional demands as well as higher burdens due to nursing care and the care of relatives while GPC nurses stated higher quantitative demands, i.e. higher workload. SPC nurses more often reported organisational and social resources that were helpful in dealing with the demands of their work. Regarding health, GPC nurses stated a poorer health status and reported chronic back pain as well as a major depressive disorder more frequently than SPC nurses. Furthermore, GPC nurses reported a higher intention to leave the profession compared to SPC nurses. CONCLUSIONS: The findings of the present study indicate that SPC could be reviewed as the best practice example for nursing care in Germany. The results may be used for developing target group specific prevention programs for improving health and wellbeing of nurses taking the differences between GPC and SPC into account. Finally, interventional and longitudinal studies should be conducted in future to determine causality in the relationship of burdens, resources, health and wellbeing.

Arbeitsbedingungen von Pflegekräften in der allgemeinen Palliativversorgung in Deutschland.

Working conditions of nurses in general palliative care in Germany - A cross-sectional survey Abstract. Background: Most terminally ill people are treated within general palliative care including outpatient care, nursing homes and hospitals. In contrast, only a small number is treated within specialised palliative care. Nursing research within the framework of palliative care focuses on the latter. AIM: To investigate the working conditions of nurses working in general palliative care and to analyse potential differences between nurses in outpatient care, in nursing homes and in hospitals. METHODS: A cross-sectional survey was conducted among nurses working in outpatient care, in nursing homes and in hospitals. The questionnaire included questions about working conditions, parts of the Copenhagen Psychosocial Questionnaire and self-developed questions. Descriptive and bivariate analyses were conducted. RESULTS: 437 questionnaires entered final analyses (response rate 16.7 %). On average, nurses spend 20 % of their working time with palliative care. Every fourth nurse (n = 104) express the wish for an additional qualification in palliative care. The following demands are reported: confrontation with pain, death and dying, as well as care of relatives. 59 % (n = 249) of the nurses evaluate the quality of palliative care as good / very good. CONCLUSIONS: Nurses are faced with demands, which so far had only been a subject of discussion within the framework of the specialised palliative care. Further steps for action, in particular the additional qualification in palliative care for nurses, should be discussed.

The relationship between workload and burnout among nurses: The buffering role of personal, social and organisational resources.

Workload in the nursing profession is high, which is associated with poor health. Thus, it is important to get a proper understanding of the working situation and to analyse factors which might be able to mitigate the negative effects of such a high workload. In Germany, many people with serious or life-threatening illnesses are treated in non-specialized palliative care settings such as nursing homes, hospitals and outpatient care. The purpose of the present study was to investigate the buffering role of resources on the relationship between workload and burnout among nurses. A nationwide cross-sectional survey was applied. The questionnaire included parts of the Copenhagen Psychosocial Questionnaire (COPSOQ) (scale 'quantitative demands' measuring workload, scale 'burnout', various scales to resources), the resilience questionnaire RS-13 and single self-developed questions. Bivariate and moderator analyses were performed. Palliative care aspects, such as the 'extent of palliative care', were incorporated to the analyses as covariates. 497 nurses participated. Nurses who reported 'workplace commitment', a 'good working team' and 'recognition from supervisor' conveyed a weaker association between 'quantitative demands' and 'burnout' than those who did not. On average, nurses spend 20% of their working time with palliative care. Spending more time than this was associated with 'burnout'. The results of our study imply a buffering role of different resources on burnout. Additionally, the study reveals that the 'extent of palliative care' may have an impact on nurse burnout, and should be considered in future studies.

Health and intention to leave the profession of nursing - which individual, social and organisational resources buffer the impact of quantitative demands? A cross-sectional study.

BACKGROUND: The aim of this study was to analyse the buffering effect of individual, social and organisational resources on health and intention to leave the profession in the context of burden due to quantitative job demands. METHODS: In 2017, a cross-sectional survey was carried out anonymously among nurses in palliative care in Germany. One thousand three hundred sixteen nurses responded to the questionnaire (response rate 38.7%), which contained, amongst others, questions from the German version of the Copenhagen Psychosocial Questionnaire (COPSOQ). Moderator analyses were conducted to investigate the buffering effect of different resources on health ('self-rated health' and 'burnout') and 'intention to leave' in the context of quantitative demands. RESULTS: 'Self-rated health' was significantly buffered by the resources 'recognition through salary' (p = 0.001) and 'good working team' (p = 0.004). Additionally, buffering effects of the resources 'workplace commitment' and 'good working team' on 'burnout' (p = 0.001 and p = 0.006, respectively) as well as of the resources 'degree of freedom', 'meeting relatives after death of patients', 'recognition from supervisor' and 'possibilities for development' on 'intention to leave' (p = 0.014, p = 0.012, p = 0.007 and p = 0.036, respectively) were observed. CONCLUSIONS: The results of our study can be used to develop and implement job (re) design interventions with the goal of reducing the risk of burnout and enhancing job satisfaction among nurses in palliative care. This includes for example adequate payment, communication training and team activities or team events to strengthen the team as well as the implementation of some rituals (such as meeting relatives after the death of patients). As our study was exploratory, the results should be confirmed in further studies.

[Burdens and resources of nurses working in the specialist palliative care: an explorative cross-sectional study]. / Belastungen und Ressourcen von Pflegekräften der spezialisierten Palliativversorgung.

Burdens and resources of nurses working in the specialist palliative care: an explorative cross-sectional study Abstract. Background: For Germany, there are no studies so far which compare the burdens and the resources of nurses working in the specialized palliative care settings. AIM: The aim of this study was to analyse and compare burdens and resources of nurses working in palliative care wards, inpatient hospices and in specialized outpatient palliative care services. METHOD: In 2015, nurses from the referred settings in Rhineland-Palatinate were invited to complete a self-developed questionnaire on burdens and resources. Contingency tables, Kruskal-Wallis tests and regressions were calculated. RESULTS: 149 nurses (response rate: 34.5 %) participated in the survey. Nurses working in palliative care wards indicated higher values in all types of burdens than nurses working in hospices and specialized outpatient palliative care. Nurses in palliative care wards and hospices reported emotional burdens as the most stressful factor, while nurses working in specialized outpatient care services expressed the highest levels of burdens in patient-related areas. An association between the experienced amount of burdens and having acquired an additional qualification in palliative care was determined (adjusted Odds Ratio (aOR) for burden due to organizational conditions: 2.56, CI: 1.06 - 6.19; aOR for burden due to support for family members: 2.99, CI: 1.06 - 8.46). The three settings in our study differ in terms of the availability of the resources family, group supervision and additional qualifications. CONCLUSIONS: This study provides an insight into the burdens and the resources of nurses working in palliative care wards, hospices and specialized outpatient palliative care services in Rhineland-Palatinate, Germany. Future preventative measures should be tailored to the respective settings.

Improving end-of-life care in hospitals: a qualitative analysis of bereaved families' experiences and suggestions.

OBJECTIVES: To explore and document the experiences and expectancies of bereaved family members concerning the end-of-life (EOL) care of their deceased relative in a general hospital setting. METHODS: Cross-sectional study using a questionnaire that included open-ended questions. Free-text answers were evaluated with qualitative content analysis. A total of 270 family members provided information about improvements in inpatient care. RESULTS: Families described structural deficiencies. Furthermore, they requested a more holistic patient health care beyond medical treatment and expressed the wish for more professional support for families. DISCUSSION: The view of bereaved families confirmed the need for improvement in general hospital EOL care. The results underline the importance of a more holistic EOL care. The application of communication skills training, structured family meetings, and integrated pathways is recommended.

Identification of possible risk factors for alcohol use disorders among general practitioners in Rhineland-Palatinate, Germany.

QUESTIONS UNDER STUDY: Research on alcohol use disorders among physicians has been scarce in Germany. The aim of our study was to identify possible risk factors for alcohol use disorders among general practitioners (GPs) working in the outpatient sector in the federal German state of Rhineland-Palatinate (RP). METHODS: An anonymous survey was carried out between June and July 2009. 2,092 practice-based GPs in the federal German state of RP were asked to take part in the cross-sectional study via postal mail. The CAGE screening tool was used in its German version (CAGE-G) to screen for alcohol use disorders (AUD). Moreover, possible risk factors such as work stress (effort-reward imbalance), stress experienced in the leisure time and personality characteristics (Type D personality, resilience) were included in the questionnaire. RESULTS: 808 GPs participated (response rate 38.6%), n = 790 were eligible for the analysis. The frequency of AUD according to the CAGE-G was 18.9% (n = 149). Moreover, nearly one in four general practitioners reported consuming alcohol on a daily basis (23.0%, n = 182). In the logistic regression analyses, stress experienced in the leisure time was positively related to the occurrence of AUD, whereas resilience was negatively associated. CONCLUSIONS: AUD as screened for by the CAGE-G was frequent in our sample of German GPs. Approaches to reduce their occurrence could comprise actions helping physicians to relieve stress in their leisure time. Furthermore, measures to increase physicians' resilience by improving coping strategies might prove useful.

Dying in Germany--unfulfilled needs of relatives in different care settings.

CONTEXT: The integration of family members in the dying process and the recognition of their special needs are important factors for the development of high-quality palliative care. OBJECTIVES: This study aimed to explore important needs and personal experiences of relatives at the end of life, and to detect differences in these needs and experiences for various care settings. METHODS: Our cross-sectional survey was based on a random sampling of 5000 inhabitants of Rhineland-Palatinate (Germany) who died between May 25 and August 24, 2008. Relatives of these randomly drawn deceased persons were interviewed by a written survey. RESULTS: A total of 1378 questionnaires were completed (response rate 36.0%), with 1337 eligible for our analyses; 81.5% of the bereaved totally/partially agreed that the information received from physicians was comprehensive and sufficient; 7.5% neither agreed nor disagreed; and 11.0% partially/totally disagreed. Of the respondents, 54.1% totally/partially agreed to having received emotional support by physicians, 14.2% neither agreed nor disagreed, and 31.7% partially/totally disagreed. Physicians in nursing homes and standard hospital wards were rated less favorably. Whereas the professionals' lack of time was strongly associated with the unfulfilled needs for emotional support, many relatives also lacked this type of care when physicians seemed to have enough time. CONCLUSION: The high rates of unfulfilled needs of relatives across all care settings and all types of diseases reinforce the necessity of a comprehensive palliative care approach. An increased awareness of the psychological vulnerability of caregivers should lead to dedicated efforts to improve deficits in the German health care system.

The mental health of primary care physicians in Rhineland-Palatinate, Germany: the prevalence of problems and identification of possible risk factors.

BACKGROUND: The generally high job-related stress level among physicians may lead to various health impairments in the long run. Apart from job-related stress, stress during leisure time and certain personality traits might be risk factors for health impairments. However, very little research on the health situation of primary care physicians (PCPs) in Germany is available. Therefore, the objective of the present study was to systematically assess the stress experience and the health situation of German PCPs. One main focus was on mental health. METHODS: In 2009, a state-wide survey among practice-based PCPs in the federal German state of Rhineland-Palatinate (cross-sectional study, n = 2092) was carried out in order to assess stress and strain as well as the health situation. RESULTS: 790 participants (37.7%) were eligible for the analyses. One in four PCPs exceeded the cut-off value ≥ 3 for depression in the PHQ-2 (PHQ, Patient Health Questionaire). Moreover, approximately one in six PCPs stated that he or she had used psychotropic drugs or other psychoactive substances at least once in the preceding year. Stress during leisure time, type D personality and low job satisfaction were associated with the presence of mental health impairments in the binary logistic regression analyses. CONCLUSION: All in all, it appears that mental health impairments are a common health problem among the PCPs. Target-group-specific measures should be taken in order to reduce the subjective stress level, and to foster mental hygiene. Furthermore, the development of favorable personality profiles and the corresponding behavioral patterns should be supported.

Preference for place of death in Germany.

BACKGROUND: Dying in the preferred place is considered a key requirement for a "good death." The aims of our study were to explore preferred places of death of deceased people and their bereaved relatives in Rhineland-Palatinate (Germany). We further wanted to assess the congruence between preferred and actual place of death. METHODS: The cross-sectional study was based on a random sample of 5000 inhabitants of Rhineland-Palatinate (Germany) who died between May 25 and August 24, 2008. Relatives of these deceased persons were interviewed by a written survey. RESULTS: After removing duplicates, 4967 questionnaires were sent out, 3832 delivered, and 1378 completed, yielding a response rate of 36.0%. Regarding the deceased, 93.8% wanted to die at home, 0.7% in a hospital, 2.8% in palliative care, 2.4% in a nursing home, and 0.3% elsewhere. The figures for the relatives were 80.7%, 4.3%, 7.5%, 7.1%, and 0.5%, respectively. Of the deceased 58.9% and of the relatives 59.1% had their wish fulfilled. Logistic regression analysis revealed that living in a rural municipality (adjusted odds ratio [aOR]: 1.88; 95% confidence interval [CI]: 1.02-3.43), rural town (aOR: 2.30; 95% CI: 1.17-4.49) or small town (aOR: 1.95; 95% CI: 1.04-3.68), having a nonworking relative (aOR: 1.79; 95% CI: 1.16-2.76), and living together with a relative (aOR: 2.28; 95% CI:1.57-3.32) increases the probability to die in the preferred place. DISCUSSION: Because the availability of a relative was the most important factor to die in the preferred place, relatives of dying people should be supported in providing informal care. The introduction of palliative home care teams should allow more people to die in their preferred place by easing the burden of informal carers.

Factors influencing place of death in Germany.

CONTEXT: Knowledge about factors influencing the place of death may be very useful for the planning of public health strategies to improve the situation of terminally ill patients. OBJECTIVES: The aim of our study was to determine where people died in the German federal state of Rhineland-Palatinate in 2008. We further wanted to detect which factors had an influence on the place of death. METHODS: Our cross-sectional survey was based on a random sample of 5000 inhabitants of Rhineland-Palatinate who had died between May 25, 2008 and August 24, 2008. Relatives of these randomly drawn deceased persons were interviewed by means of a written survey. RESULTS: After removing duplicates, 4967 questionnaires were sent out. In total, 3832 questionnaires were delivered and 1378 completed, leading to a response rate of 36.0%. Of this group, 38.2% of the deceased died at home, 39.3% in a hospital, 13.4% in a nursing home, 7.5% in a palliative care facility, and 1.6% elsewhere. Suffering from cancer (adjusted odds ratio [AOR]: 1.30; 95% confidence interval [CI]: 1.01-1.68), social support (AOR being married: 1.33; 95% CI: 1.04-1.70; AOR having a nonworking relative: 1.71; 95% CI: 1.28-2.29), a high care level (AOR Care Level II: 2.79; 95% CI: 2.06-3.79, AOR Care Level III: 4.96; 95% CI: 3.40-7.24), and living in a rural municipality (AOR: 1.36; 95% CI: 1.01-1.84) were major factors favoring home death compared with institutional death. CONCLUSION: Compared with other European countries, home death is still a frequent event in the federal state of Rhineland-Palatinate. Regional health policy should consider the actual distribution of place of death and corresponding predicting factors when establishing specialized palliative care home services as designed by recent German health legislation.

End-of-life care in Germany: Study design, methods and first results of the EPACS study (Establishment of Hospice and Palliative Care Services in Germany).

BACKGROUND: In order to tackle the deficits in the provision of palliative home care, profound structural changes in the outpatient sector were introduced by law in Germany in 2007. The EPACS study was carried out (Research Accompanying the Establishment of Hospice and Palliative Care Services in Rhineland-Palatinate, Germany) to document the quality of inpatient and outpatient end-of-life care in Rhineland-Palatinate, Germany, before the implementation of these changes. With this article we focus on the study design and methods of the EPACS-Study. We further report first results regarding several aspects of outpatient end-of-life care. METHODS: The cross-sectional survey was based on a random sample of 5000 inhabitants of Rhineland-Palatinate that had died from May 25 until August 24 of the year 2008. Relatives of these randomly drawn deceased persons were interviewed by means of a written survey. RESULTS: The overall response proportion considering only those questionnaires that actually were delivered (n = 3833) was 36.0%. Factors influencing participation were age, sex, and marital status. 355 (25.8%) deceased persons had used professional home care in the four weeks prior to their death, but only very few persons had used a specialised palliative home care service (n = 30; 8.5%). There was a clear gap between the need for specialised outpatient care and the actual utilisation of these services. CONCLUSIONS: Satisfaction with professional home care was relatively high, but physicians were rated less favourable than nurses. There were deficits especially with respect to physicians' communicative and supportive skills. Further analyses are necessary to provide more detailed information about quality of care in different care settings and for distinct groups. Predictors of good care, as well as obstacles to it, must be further investigated. In the long run, a follow-up survey must be conducted to compare quality of home care before and after the structural changes in Germany.

Commuting accidents in the German chemical industry.

Due to accident severity and the extent of claim payments commuting accidents are a significant expense factor in the German industry. Therefore the aim of the present study was the identification of risk factors for commuting accidents in a German chemical company. A retrospective analysis of commuting accidents recorded between 1990 and 2003 was conducted in a major chemical company in Germany. A logistic regression-model was calculated in order to determine factors influencing the duration of work inability as a result of commuting accidents. The analysed data included 5,484 employees with commuting accidents. Cars (33.1%) and bicycles (30.5%) were the most common types of vehicles used by commuters who had an accident. The highest number of commuting accidents was observed in the age group under 26 yr. Accidents on the route from the work site to the worker's residence were less frequently observed, but they caused longer periods of work inability than accidents on the way to the work site. The longest periods of work inability were found in the groups of motorcyclists and older employees. The present study identifies specific groups at risk for commuting accidents. The data of the present investigation also underline the need for developing group specific prevention strategies.

Biological monitoring of welders exposed to aluminium.

To evaluate an adequate strategy for biological monitoring of aluminium (Al), a group of 62 Al welders (age in 1999: 23-51 years, median 35 years) was surveyed annually from 1999 to 2003 by determination of pre- and post-shift Al in urine and plasma. Biomonitoring was supplemented by personal air measurements of the total dust concentration. The welders' internal exposure was compared to the exposure of 60 non-exposed assembly workers (age in 1999: 21-51 years, median: 36 years) who were surveyed in 1999, 2001 and 2003. Having a nearly constant dust exposure, median concentrations of Al in urine (Al in plasma) of the welders decreased from 40.1 microg/g to 19.8 microg/g creatinine (8.7 to 4.6 microg/l). For the control group the median levels of Al in urine (plasma) ranged from 4.8 microg/g to 5.2 microg/g creatinine (2.4-4.3 microg/l) indicating a higher sensitivity for the marker Al in urine. No systematic differences have been found between pre- and post-shift internal exposure. This might be caused by the slow elimination kinetics and low systemic bioavailability of Al. A correlation analysis did not yield close relationships between dust exposure, Al in plasma and Al in urine underlining the importance of biomonitoring for assessment of Al exposure.

[EUROVIHTA Project--specific intervention program for HIV infected patients to support the coping process with this chronic illness]. / EUROVIHTA-Projekt--zielgruppenspezifisches Interventionsprogramm für Betroffene bei der Verarbeitung von HIV als chronische Erkrankung.

In this European multicenter intervention study 117 persons were examined who took part in group programs to improve coping with the HIV-infection. Psychological measures were taken at four times before, during and after the intervention. These were psychological symptoms (SCL-90-R), Coping (TSK), Locus of Control (KKG), Quality of Life (MOS-HIV), and physical health. Psychopathology (DSM-III-R) and neuropsychological deficits were assessed at baseline. The study is designed to investigate, along with the effectiveness of the intervention, differences between participating homosexual men and drug users as well as to discuss HIV as a chronic disease. The program has proven efficiency to enhance psychological and physical wellbeing and to support participants' coping with HIV. Drug users report less psychopathology and more improvement during the intervention. References for the organization of group programs with these subgroups are made.