Reflection 2

RESEARCH ARTICLE Open Access

Burdens, resources, health and wellbeing of
nurses working in general and specialised
palliative care in Germany – results of a
nationwide cross-sectional survey study
Elisabeth Diehl1* , Sandra Rieger1, Stephan Letzel1, Anja Schablon2, Albert Nienhaus2,3,
Luis Carlos Escobar Pinzon1,4† and Pavel Dietz1†

Abstract

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.

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* Correspondence: [email protected]
†Escobar Pinzon Luis Carlos and Dietz Pavel are authors contributed equally
and shared senior authorship.
1Institute of Occupational, Social and Environmental Medicine, University
Medical Center of the Johannes Gutenberg University Mainz, Obere
Zahlbacher Str. 67, 55131 Mainz, Germany
Full list of author information is available at the end of the article

Diehl et al. BMC Nursing (2021) 20:162
https://doi.org/10.1186/s12912-021-00687-z

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.

Keywords: Stress, Strain, Burnout, Depression, Intention to leave the profession, Prevention

Background
Due to demographic changes, western European soci-
eties are faced with numerous challenges and changes.
Higher life expectancy, in particular in older age groups,
is related to more patients with incurable and life-
threatening diseases [1]. The Federal Statistical Office in
Germany predicts an increase of persons being in need
of care from 3.4 million in 2017 up to 4.1 million in
2030, and to 5.4 million in 2050 [2]. In the past, primar-
ily cancer patients have benefitted from palliative care,
but today and in future, people with non-oncological
diseases, multimorbid patients [3] and patients suffering
from dementia [4] should also benefit from palliative
care. Over the course of these developments, palliative
care will become more important in the care sector.
The World Health Organization (WHO) defines pal-

liative care as “an approach that improves the quality of
life of patients and their families facing the problem as-
sociated with life-threatening illness, through the pre-
vention and relief of suffering by means of early
identification and impeccable assessment and treatment
of pain and other problems, physical, psychosocial and
spiritual” [5]. The implementation of palliative care in
Europe differs widely, as the European Association for
Palliative Care (EAPC) Atlas of Palliative Care in Europe
2019 demonstrates [6]. In Germany, palliative care is di-
vided into general palliative care (GPC), sometimes also
called general outpatient palliative care, and specialised
palliative care (SPC). The majority of patients are treated
within GPC in outpatient care, in nursing homes or in
hospitals within the contractual healthcare system [7].
According to the German Society for Palliative Medicine
(DGP), around 90% of approximately 850.000 dying
people in Germany are in need of palliative care, but
only 10% of them are in need of SPC [8, 9]. SPC is for
dying people who need a particularly complex treatment
and the medical support of them is more demanding,
such as a complex pain management. SPC includes the
specialist outpatient palliative care (SAPV), the inpatient
hospices or palliative care units in hospitals and is con-
ducted through interdisciplinary teams (see additional
Table 1). Palliative care should be made available at dif-
ferent levels, so that the aims and objectives of all insti-
tutions are different. Palliative care units for example
should improve or stabilise the condition of individual

patients in order to discharge them, if possible, to their
own homes. SAPV-teams in contrast should enable a
dignified death in familiar surroundings. Moreover, the
‘Charter for the Care of the Critically Ill and the Dying’
in Germany published by the German Association for
Palliative Medicine (DGP), the German Hospice and Pal-
liative Care Association (DHPV) and the German Med-
ical Association (BÄK) formulated recommendations as
the basis for a national strategy. Dying, death and grief
are part of life and all human beings have a right to a
dignified death. Further, all critically ill and dying people
have a right to

– comprehensive medical, nursing, psychosocial and
spiritual care that takes into account their individual
situation and palliative/hospice care needs.

– appropriate, qualified and, if required,
multiprofessional care.

– care based on best practice.
– benefit from care that takes into account

internationally recognised and adopted
recommendations and standards regarding the
delivery of palliative care [10].

Further information on palliative care in Germany can
be found in the statement of the German National Acad-
emy of Sciences Leopoldina and the Union of German
Academies of Sciences and Humanities from 2015 [11]
and the EAPC Atlas of Palliative Care in Europe 2019 [6].
Numerous international studies have shown that pal-

liative care is demanding [12]. For example, organisa-
tional framework conditions such as many
administrative tasks [13] or insufficient personnel to
handle workloads [14], quantitative demands such as
time pressure [15], demands resulting from nursing care
such as therapy-resistant pain or lifting and carrying of
patients [16], and in particular confrontation with illness,
suffering and death of patients and their families showed
to be demanding [13, 15, 17, 18]. Nevertheless, studies
do not report higher levels of stress or demands of pal-
liative care nurses compared to nurses in other disci-
plines [15, 17]. Within an extensive literature review,
Mary Vachon (1995) summarized that only the first early
studies in the field of palliative care observed higher
stress levels of palliative care nurses, but later studies

Diehl et al. BMC Nursing (2021) 20:162 Page 2 of 16

did not. She hypothesised that the early recognition of
the potential stress in the field of palliative care lead to
the development of appropriate organisational and per-
sonal coping strategies to deal with the stressors of this
field [19]. According to previous studies, palliative care
nurses seem to have a wide range of resources. For ex-
ample, organisational resources such as the meaningful-
ness of work [16, 20] or supervision [18] as well as social
resources such as the team, were reported to be very im-
portant resources [18, 21, 22]. In addition, personal re-
sources like resilience [23, 24], humour, self-care [22, 25,
26], hobbies [21], physical activity [27], spirituality [21,
22] or empathy [18], a special personality [28] and socio-
demographic factors like age and professional experience
[19] might help to cope with work demands and pro-
mote nurses’ health. Overall, it seems that palliative care
nurses are satisfied with their work [27, 29, 30] and re-
port low levels of burnout [13, 15, 17, 31]. In contrast,
studies outside the palliative care setting reported con-
sistently of an increasing workload with high burdens
and a high intention to leave the profession of nurses
[32–34]. Further, a recent literature review also suggests
that healthcare professionals in GPC experience more
symptoms of burnout than those in SPC settings [35].
Healthy and satisfied nurses are of enormous import-

ance worldwide, because their health may have an effect
on the quality of the services offered by the health care
system [36]. Studies from Germany investigating pallia-
tive care aspects exclusively refer on SPC [16, 18, 37,
38]. For example, with focus on the resource ‘team’,
Müller et al. (2009, 2010) reported that the team itself
was ranked as the most important protective factor of
nurses working in hospices [38] and palliative care units
[18]. This finding was confirmed by Diehl et al. (2018)
for SAPV-teams, inpatient hospices and palliative care
units in hospitals [30]. Gencer et al. (2019) compared
the working conditions, such as the overall stress level of
nurses working in palliative care units and SAPV-teams,
showing that, for example, the stress level is higher for
nurses in palliative care units [37].
To the best of our knowledge, a study comparing the

burdens, resources, health and wellbeing of nurses in GPC
and SPC in Germany has not been performed so far. There-
fore, the aim of the present study was to address this gap
by identifying and comparing the burdens, resources, health
and wellbeing of nurses in GPC and SPC in Germany. This
information may be relevant and could be used for develop-
ing target group specific prevention programs in order to
reduce burdens and to strengthen resources of nurses in
palliative care. Furthermore, a comparison of the working
situation of GPC and SPC nurses may contribute to new
findings, which could have relevant implications for devel-
oping interventional studies, with the goal of improving the
health status of nurses and enhancing job satisfaction.

Methods
Study design
A nationwide cross-sectional empirical study was con-
ducted in 2017. Ethical approval to perform the study
was obtained by the ethics committee of the State
Chamber of Medicine in Rhineland-Palatinate (Clear-
ance number 837.326.16 (10645)).
Data among nurses of GPC were collected from a 10%

sample (3278: 1190 nursing homes, 1961 outpatient care,
127 hospitals) of the database from the Institution for
Statutory Accident Insurance and Prevention in Health
and Welfare Services in Germany. Due to data protec-
tion rules, this institution communicated with the health
facilities of which 126 (3.8%) had agreed to participate in
the survey.
Because there is no national register for nurses work-

ing in SPC nor specialised palliative care institutions,
first, all medical facilities in the specialised palliative care
were identified (950: 358 SAPV institutions, 343 pallia-
tive care units, 249 inpatient hospices) by an internet
search. Secondly, an institution-related sample was
drawn. Out of 532 institutions in the sample, 246 were
willing to participate (46.2%).
As described, the present study focused firstly on med-

ical facilities. The participating health facilities of GPC
and SPC informed the study team about the number of
nurses (nurse, geriatric nurse, nursing assistant or nurse
in training and carrying for patients) and if they pre-
ferred to answer a paper-and-pencil (with a franked re-
turn envelope) or an online-questionnaire (with an
access code). The participation was voluntary and an-
onymous. Table 1 provides information about the
amount of questionnaires send to the different health fa-
cilities in GPC and SPC.

Questionnaire
The questionnaire addressed four major issues. I) Basic
sociodemographic characteristics (gender, age, etc.) and
characteristics on current profession. II) Questions about
occupational burden, III) questions on organisational,
social and personal resources, and IV) questions con-
cerning health and well-being. Since the specific job-
related conditions between GPC and SPC are somewhat
different, some questions were slightly adapted. The
questionnaire contained questions from standardised, re-
liable and valid instruments:

– Copenhagen Psychosocial Questionnaire (COPSOQ)

Parts of the German standard version of the COPSOQ
version II [39] were used. The COPSOQ is a valid and
reliable questionnaire to assess psychosocial work envir-
onmental factors and health in the workplace [40]. The
subscales used for the present study were ‘quantitative

Diehl et al. BMC Nursing (2021) 20:162 Page 3 of 16

demands’, ‘emotional demands’, ‘demands for hiding
emotions’, ‘meaning of work’, ‘workplace commitment’,
‘satisfaction with life’, ‘self-rated health’, ‘burnout’ and
‘intention to leave the profession’. The COPSOQ scales
mostly consisted of several items and were collected
with a five-point Likert scale (categories ranging from
e.g. never to always). The ‘satisfaction with life’ scale was
collected with a 7-point Likert scale (categories ranging
from do not agree at all to fully agree) and the ‘self-rated
health’ scale as well as the ‘intention to leave the profes-
sion’ scale were collected with a single question (Table 2).
The single items of the COPSOQ scales were trans-
formed to a theoretical range from 0 (the lowest possible
amount of the aspect under investigation) to 100 (the
highest possible value). The transformation of the cat-
egories into point values is a standardised procedure and
was also used in the German validation study [40].

– Patient Health Questionnaire-2 (PHQ-2)

The PHQ-2 is the short version of the Patient
Health Questionnaire-9 (PHQ-9), which is a valid and
reliable instrument to measure depression [41]. The
present study used the German version of the PHQ-2
questionnaire to collect information on the frequency
of anhedonia and depressed mood during the last 2
weeks [42]. The question is: ‘Over the last two weeks,
how often have you been bothered by the following
problems?’ and the two items are ‘little interest or
pleasure in doing things’ and ‘feeling, down, de-
pressed, or hopeless’ with the response options ‘not at
all’, ‘several days’, ‘more than half the days’, and
‘nearly every day’. They are scored as 0, 1, 2 and 3,
thus the PHQ-2 score can range from 0 to 6 (Table
2). The recommended cut off value of ≥3 was used to
classify depressive disorder.

– Resilience Scale (RS-13) Questionnaire

The RS-13 questionnaire is the short 13-item version
of the original 25-item Resilience Scale which was devel-
oped by Wagnild and Young (1993) [43]. The German
version of the RS-13 was developed by Leppert and col-
leagues (2008) and measures resilience, i.e. the ability to
successfully adapt to critical life situations, on a 7-point
scale with answer categories ranging from I do not agree
to I fully agree. These categories were transformed to a
score ranging from 13 to 91 (Table 2). A score between
13 and 66 was defined as low, a score between 67 and
72 as moderate and a score between 73 and 91 as having
high resilience [44].

– Question about back pain from the health survey
conducted by the Robert Koch Institute

The question about back pain was selected from the
health survey conducted by the Robert Koch Institute
[45]. The question is: ‘In the last 12 months, did you had
almost daily back pain, which persisted 3 months or lon-
ger?’ with three answer categories (yes, no, I don’t
know).

– Other parameters

To assess palliative care specific working conditions,
the questionnaire was extended by further questions,
which were based on qualitative interviews with experts
from palliative care [46] and a cross-sectional pilot study
conducted in the specialized palliative care in
Rhineland-Palatinate in Germany [16, 30]. Questions re-
garding ‘burden due to organisational framework condi-
tions’, ‘emotional burden due to death’, ‘burden due to
care of patients’, ‘burden due to nursing care’, ‘burden
due to care of relatives’ as well as questions regarding
the resource ‘good working team’ were summarized to
scales. The scale ‘burden due to organisational frame-
work conditions’ consisted of 7 items and were collected

Table 1 Number of questionnaires send out to the health facilities and response rates

Question-
naires
send out

GPC SPC

Outpatient care Hospitals Nursing homes SAPVs Hospices Palliative care units

Send Return Rate
(%)

Send Return Rate
(%)

Send Return Rate
(%)

Send Return Rate
(%)

Send Return Rate
(%)

Send Return Rate
(%)

Paper 327 80 24.5 160 29 18.1 1777 315 17.7 749 254 33.9 1160 500 43.1 864 405 46.9

Online 329 16 4.9 0 389 31 8.0 429 88 20.5 206 45 21.8 131 34 26.0

Total 656 96 14.6 160 29 18.1 2166 346 16.0 1178 342 29.0 1366 545 39.9 995 439 44.1

Send Return* Rate (%) Send Return** Rate (%)

Total Paper: 2264 Paper: 445 Paper: 19.7 Paper: 2773 Paper: 1171 Paper: 42.2

Online: 718 Online: 52 Online: 7.2 Online: 766 Online: 200 Online: 26.1

Total: 2982 Total: 497 Total: 16.7 Total: 3539 Total: 1371 Total: 38.7

Note. Rate = response rate, *26 questionnaires (21 x paper-and-pencil, 5 x online) no identification to type of institution possible, **45 questionnaires (12 x paper-
and-pencil, 33 x online) no identification to type of institution possible

Diehl et al. BMC Nursing (2021) 20:162 Page 4 of 16

Table 2 Sources and variables of the questionnaire

Source Number
of items

Example of items Outcomes of variables

Burdens

Burden due to organisational framework
conditions

pilot
study

7 How strong is the burden due to the care of to many
patients?

scale 0–100, high =
negative

Quantitative demands COPSOQ 4 Do you have to work very fast? scale 0–100, high =
negative

Emotional demands COPSOQ 3 Is your work emotionally demanding? scale 0–100, high =
negative

Demands for hiding emotions COPSOQ 3 Does your work require that you hide your feelings? scale 0–100, high =
negative

Emotional burden due to death pilot
study

9 How strong is the burden due to patients dying a
painful death?

scale 0–100, high =
negative

Burden due to care of patients pilot
study

6 How strong is the burden due to depressive patients? scale 0–100, high =
negative

Burden due to nursing care pilot
study

5 How strong is the burden due to lifting and carrying of
patients?

scale 0–100, high =
negative

Burden due to care of relatives pilot
study

12 How strong is the burden due to relatives cause unrest? scale 0–100, high =
negative

Resources

Organisational

Meaning of work COPSOQ 3 Do you feel that the work you do is important? scale 0–100, high =
positive

Workplace commitment COPSOQ 4 Do you enjoy telling others about your place of work? scale 0–100, high =
positive

Meaningfulness of work pilot
study

1 How much do the following help you to handle the
workload?

not/little helpful vs. quite/
very helpful

Gratitude of patients/relatives pilot
study

each
case 1

How much do the following help you to handle the
workload

not/little helpful vs. quite/
very helpful

Recognition through supervisor/
colleagues/ patients/relatives/ social
context/ salary

pilot
study

each
case 1

Do you receive recognition for your work from …? disagree/slightly disagree
vs. slightly agree, agree

Social

Good working team pilot
study

4 I get help and support from colleagues in emergencies. scale 0–100, high =
positive

Family pilot
study

1 How much do the following help you to handle the
workload?

not/little helpful vs. quite/
very helpful

Friends pilot
study

1 How much do the following help you to handle the
workload?

not/little helpful vs. quite/
very helpful

Personal

Satisfaction with life COPSOQ 5 In most ways my life is close to my ideal scale 0–100, high =
positive

Positive thinking/ professional
attitude/dissociation/ hobbies/ sport/
religiosity/spirituality/ self-reflection/
self-care

pilot
study

each
case 1

How much do the following help you to handle the
workload?

not/little helpful vs. quite/
very helpful

Resilience RS-13 13 I can accept it when not all people like me scale 1–91, 13–66 = low,
67–72 =moderate and
73–91 = high resilience

Health and Wellbeing

Self-rated health COPSOQ 1 If you evaluate the best conceivable state of health at 10
points and the worst at 0 points: how many points do
you then give your present state of health?

scale 0–100, high =
positive

Burnout COPSOQ 6 How often do you feel emotionally exhausted? scale 0–100, high =
negative

Diehl et al. BMC Nursing (2021) 20:162 Page 5 of 16

with a five-point Likert scale (‘no burden’, ‘very low bur-
den’, ‘low burden’, ‘high burden’, ‘very high burden’).
The scales ‘emotional burden due to death’, ‘burden due
to care of patients’, ‘burden due to nursing care’ and
‘burden due to care of relatives’ consisted of several
items and were collected with a six-point Likert scale
(‘does not apply’, ‘no burden’, ‘very low burden’, ‘low
burden’, ‘high burden’, ‘very high burden’). The scale
‚good working team’ consisted of 4 items and was col-
lected with a 4-point Likert scale (categories ranging
from disagree to agree) (Table 2). The self-developed
items of the scales were prepared according to the COP-
SOQ guidelines. The answer category ‘does not apply’
was assessed as ‘no burden’. Furthermore, single categor-
ical questions to resources were added, which showed to
be of crucial importance within the pilot study [16, 30].
The categorical variables regarding resources were di-
chotomized (example: not helpful/little helpful vs. quite
helpful/very helpful).
Table 2 provides an overview of the themes and

sources of questions, as well as examples for the ques-
tions and variable outcomes.

Statistical analysis
All scales (COPSOQ and self-developed) were prepared
according to the COPSOQ guidelines. Scale values were
computed as the average of the values of the single items
of a person, if at least half of the single items were an-
swered [47]. The proportion of missing values for the
single items of the scales was below 2% in SPC and
below 3% in GPC. Scale values are presented as mean
values. To assess the internal consistency of the scales,
the Cronbach’s Alpha was used. Values > 0.7 were
regarded as acceptable [48]. Descriptive statistics (abso-
lute and relative frequencies, means, standard deviations
(SD)) were used to describe the data. The independent
samples t-test was used to compare the mean scale
values of GPC and SPC nurses. Further, a difference of
at least 5 points in the mean value of a scale demon-
strates a relevant difference between groups, thus the
mean values of the scales of nurses working in GPC and
SPC were compared. This method is regularly used in
COPSOQ studies because a difference of 5 points in the
mean value represents a small to intermediate effect size

[Cohen’s d] of 0.2–0.35 [49]. Only results being statisti-
cally significant and fulfilling the difference of at least 5
points in the mean value were interpreted as relevant
differences. For comparisons between categorical vari-
ables, the chi-square test of homogeneity was used to
determine whether observed sample frequencies in GPC
and SPC differed significantly from expected frequencies.
Effect sizes were computed (Phi for 2 × 2 contingency ta-
bles and Cramer’s V for larger tables), where values be-
tween 0.10 and 0.30 represents a small to medium effect
size and values of 0.50 represents a large effect size [50].
The significance level was established at p < 0.05 (two-
tailed).
Statistical analyses and graphical representation were

performed using SPSS version 23.5 and Microsoft Excel
2016, respectively.

Results
Descriptive analyses
For GPC, 2982 questionnaires were sent out and 497
(16.7%) returned. For SPC, 3539 questionnaires were
sent out and 1371 returned (38.7%). Due to low GPC
participation in hospitals, these were excluded from the
analysis (Table 1). After data cleaning, n = 437 nurses
form the GPC and n = 1316 nurses from the SPC were
included into further analyses.

Characteristics of the study sample
A summary of the sample characteristics is given in
Table 3. Nurses in SPC were little older than nurses in
GPC (mean 46.1 vs. 42.8 years, p ≤ 0.001). Furthermore,
GPC and SPC nurses differed in age structure, in par-
ticular in the lowest and highest age groups. More
nurses in SPC reported higher rates of graduation and
levels of education than nurses in GPC.
78.7% of nurses in GPC worked in nursing homes and

21.3% in outpatient care. 40.9% of nurses in SPC worked
in hospices, 33.5% in palliative care units and 25.6% in
SAPV institutions. SPC nurses had more professional ex-
perience. More SPC nurses reported an additional quali-
fication in palliative care than GPC nurses. On average
(median), GPC nurses reported spending 20% of their
time in the care of palliative patients. SPC nurses experi-
enced more deaths of patients in the last month than

Table 2 Sources and variables of the questionnaire (Continued)

Source Number
of items

Example of items Outcomes of variables

Intention to leave the profession COPSOQ 1 How often in the last 12 months have you thought
about giving up your profession?

scale 0–100, high =
negative

Chronic back pain RKI 1 In the last 12 months, did you had almost daily back
pain, which persisted 3 months or longer?

yes, no, I don’t know

Depression PHQ-2 2 Over the last 2 weeks, how often have you been
bothered by the following problems?

score 0–6, score≥ 3
major depressive disorder

Diehl et al. BMC Nursing (2021) 20:162 Page 6 of 16

Table 3 Participant characteristics

GPC
(n = 437)

SPC
(n = 1316)

Difference between GPC and SPC, p-
value

Effect
size

Sociodemographic characteristics

Age grouped, no. (%) ≤ 0.001 0.161

< 30 76 (17.4) 109 (8.4)

30–39 104 (24.4) 233 (18.1)

40–49 92 (21.6) 366 (28.4)

≥ 50 154 (36.2) 582 (45.1)

Sex, no. (%) 0.201

Female 388 (89.6) 1119 (87.3)

Male 45 (10.4) 163 (12.7)

Education and Graduation

Education, no. (%) ≤ 0.001 0.202

Without school-leaving qualification/other qualification 11 (2.5) 16 (1.3)

Secondary school leaving certificate 58 (13.4) 56 (4.4)

Qualification intermediate school-leaving certificate 239 (55.3) 674 (52.5)

Entrance qualification for studies at universities of applied sciences 73 (16.9) 216 (16.8)

General qualification for university entrance 51 (11.8) 322 (25.1)

Grade, no. (%) ≤ 0.001 0.521

Nursing/geriatric nursing assistant 79 (18.7) 196 (15.2)

Nurse 75 (17.7) 835 (64.8)

Geriatric nurse 196 (46.2) 136 (10.6)

University diploma 10 (2.4) 96 (7.5)

Others (in training, other education, no education) 64 (15.2) 25 (2.0)

Working specific aspects

Working area, no. (%)

Nursing home 344 (78.7)

Outpatient care 93 (21.3)

Palliative care unit 441 (33.5)

Hospice 538 (40.9)

SAPV 337 (25.6)

Professional experience grouped, no. (%) ≤ 0.001 0.275

0–15 years 259 (61.5) 401 (30.8)

16–30 years 125 (29.7) 616 (47.4)

31–50 years 37 (8.8) 283 (21.8)

Professional experience in specialised palliative care in years, mean
(SD)

6.5 (4.8)

Additional qualification in palliative care ≤ 0.001 0.579

No 329 (76.2) 196 (14.9)

Current qualification 17 (3.9) 69 (5.3)

Yes 86 (19.9) 1049 (79.8)

Extent of palliative care in percent, median (range) 20 (0–
100)

Death of patients grouped, no. (%) ≤ 0.001 0.487

0 62 (15.6) 45 (3.8)

1–3 218 (54.9) 173 (14.6)

Diehl et al. BMC Nursing (2021) 20:162 Page 7 of 16

GPC nurses. 17.9% of SPC nurses served in an advisory func-
tion only, meaning that they did not engage in any practical
nursing activities. More SPC nurses reported a part-time-job
than GPC nurses and more SPC nurses worked in health fa-
cility with publicity-owned or independent fund.

Scales and single items
Table 4 presents the means and standard deviations of
the scales reported in GPC and SPC. All scales achieved

satisfactory values of internal consistency. Only the scale
‘workplace commitment’ in the field of SPC had a Cron-
bach’s Alpha of 0.677. Furthermore, it is specified
whether a difference in the mean value of scales is given
between GPC and SPC. In order to achieve transparency,
we show the distribution of the response items of each
self-developed scale for GPC and SPC in the supplemen-
tary material (see additional Figures 1, 2, 3, 4, 5 and 6).

Table 3 Participant characteristics (Continued)

GPC
(n = 437)

SPC
(n = 1316)

Difference between GPC and SPC, p-
value

Effect
size

≥ 4 117 (29.5) 965 (81.6)

Exercise of nursing activities, no. (%)

No 233 (17.9)

Yes 1071 (82.1)

Extent of employment, no. (%) ≤ 0.001 0.116

Part-time job 175 (40.4) 667 (53.7)

Full-time job 258 (59.6) 575 (46.3)

Fund, no. (%) ≤ 0.001 0.317

Private 189 (44.7) 209 (16.4)

Publicly-owned 28 (6.6) 338 (26.4)

Independent 206 (48.7) 731 (57.2)

Note. Valid percentages, missing values GPC: age (n = 11), sex (n = 4), education (n = 5), grade (n = 13), professional experience (n = 16), additional qualification (n =
5), death of patients = 40; extent of palliative care = 121, extent of employment (n = 35), fund (n = 14), missing values SPC: age (n = 26), sex (n = 34), education (n =
32), grade (n = 28); professional experience (n = 16), professional experience in palliative care (n = 30), additional qualification (n = 2), death of patients = 133;
exercise of nursing activities (n = 12); extent of employment (n = 74), fund (n = 38)

Table 4 Scales – Means, standard deviations and differences between GPC and SPC

Scales GPC SPC Difference in mean p-value Difference ≥ 5

Burdens M SD M SD

Burden due to organisational framework conditions 46.5 21.2 45.0 19.8 1.5 0.180 no

Quantitative demands 55.4 20.8 42.7 18.5 12.7 < 0.001 yes

Emotional demands 58.6 20.1 65.6 17.9 7.0 < 0.001 yes

Demands for hiding emotions 41.4 26.7 36.5 21.3 4.9 0.001 no

Emotional burden due to death 48.2 27.0 48.3 20.6 0.1 0.976 no

Burden due to care of patients 49.9 22.7 49.1 20.5 0.8 0.516 no

Burden due to nursing care 47.6 23.2 57.5 20.8 9.9 < 0.001 yes

Burden due to care of relatives 44.5 23.3 50.6 19.2 6.1 < 0.001 yes

Resources

Meaning of work 82.2 18.8 88.3 13.3 6.1 < 0.001 yes

Workplace commitment 56.3 22.0 60.8 18.7 4.5 < 0.001 no

Good working team 70.5 22.5 77.7 18.0 7.2 < 0.001 yes

Satisfaction with life 66.9 19.4 71.5 17.4 4.6 < 0.001 no

Health and Wellbeing

Self-rated health 61.9 19.7 72.9 16.9 11.0 < 0.001 yes

Burnout 48.8 20.3 41.4 17.6 7.4 < 0.001 yes

Intention to leave the profession 20.7 24.9 12.9 19.2 7.8 < 0.001 yes

Note. M Mean, SD Standard deviation

Diehl et al. BMC Nursing (2021) 20:162 Page 8 of 16

Table 5 presents results of single items regarding
resources.

Burdens
GPC nurses reported higher values on the quantitative
demands scale than SPC nurses, whereas SPC nurses re-
ported higher values on the emotional demands scale,
higher values on the burden due to nursing care scale
and higher values on the burden due to care of relatives
scale. The highest difference in mean values concerned
the quantitative demands scale. The lowest difference
was assessed regarding the emotional burden due to
death scale, where GPC and SPC nurses gave nearly the
same results (Table 4).

Resources
SPC nurses reported higher values on the meaning of
work scale and the good working team scale than GPC
nurses (Table 4). Furthermore, 27.5% of GPC nurses had
low resilience, 17.2% had moderate resilience and 55.3%
had high resilience. In SPC, 28.8% of nurses had low re-
silience, 21.3% had moderate and 49.9% had high resili-
ence. Regarding the latter, there was no significant
difference between GPC and SPC nurses.
Table 5 presents the frequency of resources mentioned

by GPC and SPC nurses according the difference in the
frequency of being mentioned. SPC nurses reported

significantly more often religiosity and spirituality,
meaningfulness of work, self-reflection, sport, self-care,
hobbies, professional attitude/dissociation, gratitude of
relatives and positive thinking as being helpful in dealing
with the demands of their work than GPC nurses. Add-
itionally, Table 5 presents the proportion of nurses
agreed to having gained recognition through, which were
reported by the nurses in both fields. SPC nurses re-
ported significantly more frequently gained recognition
from social contexts, from supervisors, from colleagues
and from patients/relatives than GPC nurses.

Health and wellbeing
Regarding health, on average nurses in GPC scored
lower on the self-rated health scale and higher on the
burnout scale than SPC nurses (Table 4). 52.1% of GPC
nurses and 38.3% of SPC nurses reported chronic back
pain. 3.2% of SPC nurses and 11.5% of GPC nurses
exceeded the cut-off value of 3, where a major depres-
sive disorder is likely. Both, chronic back pain as well as
a major depressive disorder, were reported more fre-
quently from nurses of GPC (chronic back pain: differ-
ence 13.8%, x2(1) = 25.098, p < 0.001, Phi = 0.121; major
depressive disorder: difference 8.3%, x2(1) = 43.044, p <
0.001, Phi = 0.159). Further, GPC nurses reported a
higher value on the intention to leave the profession
scale (Table 4).

Table 5 Answers to single items – Resources and recognition

GPC SPC

% % Difference in % X2-statistics p-value Effect size

Resource is quite/very helpful

Religiosity/spirituality 25.5 47.0 21.5 60.997 < 0.001 0.188

Meaningfulness of work 77.1 91.5 14.4 63.527 < 0.001 0.191

Self-reflection 72.4 86.7 14.3 46.043 < 0.001 0.164

Sport 44.2 57.7 13.5 23.469 < 0.001 0.117

Self-care 76.4 86.5 10.1 24.256 < 0.001 0.119

Hobbies 77.5 86.8 9.3 21.034 < 0.001 0.111

Prof. attitude/dissociation 81.3 90.6 9.3 26.967 < 0.001 0.125

Gratitude of relatives 85.4 92.7 7.3 20.657 < 0.001 0.109

Positive thinking 82.2 88.3 6.1 10.344 0.001 0.078

Friends 84.3 87.4 3.1 2.655 0.103

Gratitude of patients 90.5 92.5 2.0 1.797 0.180

Family 87.4 87.8 0.4 0.057 0.812

Recognition gained through

Patients/relatives 84.7 98.3 13.6 125.515 < 0.001 0.269

Colleagues 81.9 90.9 9.0 25.905 < 0.001 0.122

Supervisor 61.8 68.0 6.2 5.406 0.020 0.056

Social context 83.6 89.3 5.7 9.712 0.002 0.075

Salary 30.0 26.7 3.3 1.757 0.185

Diehl et al. BMC Nursing (2021) 20:162 Page 9 of 16

Summary
Table 6 presents a summary of the items analysed in this
study. In 4 of 8 reported burdens there was no difference
(Table 6 ↔) between nurses in GPC and SPC. SPC nurses
reported higher values three times and GPC nurses re-
ported higher values once (Table 6 ↑). Concerning re-
sources, in 7 out of 22 items, there was no significant
difference (Table 6 ↔). In 15 items, SPC nurses reported

significantly more often resources that were helpful in
dealing with the demands of the work (Table 6 ↑). Regard-
ing health and wellbeing, SPC nurses reported a better
self-rated health (Table 6 ↑) and GPC nurses reported
chronic back pain more often, higher values on the burn-
out scale and the intention to leave the profession more
often (Table 6 ↑). Furthermore, a major depressive dis-
order is more likely in GPC nurses (Table 6↑).

Table 6 Summary – Comparison of the burdens, resources, health and wellbeing of nurses in GPC and SPC

Variable GPC SPC

Burdens Burden due to organisational framework conditions scale ↔

Quantitative demands scale ↑

Emotional demands scale ↑

Demands for hiding emotions scale ↔

Emotional burden due to death scale ↔

Burden due to care of patients scale ↔

Burden due to nursing care scale ↑

Burden due to care of relatives scale ↑

Resources Organisational Meaning of work scale ↑

Workplace commitment scale ↔

Meaningfulness of work single item ↑

Gratitude of patients single item ↔

Gratitude of relatives single item ↑

Recognition through supervisor single item ↑

Recognition through colleagues single item ↑

Recognition through patients/relatives single item ↑

Recognition through social context single item ↑

Recognition through salary single item ↔

Social Good working team scale ↑

Family single item ↔

Friends single item ↔

Personal Satisfaction with life scale ↔

Positive thinking single item ↑

Professional attitude/dissociation single item ↑

Hobbies single item ↑

Sport single item ↑

Religiosity/spirituality single item ↑

Self-reflection single item ↑

Self-care single item ↑

Resilience single item ↔

Health and Wellbeing Self-rated health scale ↑

Burnout scale ↑

Intention to leave the profession scale ↑

Chronic back pain item ↑

Depression single item ↑

Note. ↔ observed sample frequencies in GPC and SPC not differed significantly from expected frequencies or scale difference < 5; ↑ observed sample frequencies
in GPC and SPC differed significantly from expected frequencies or scale difference ≥ 5 (p < 0.05)

Diehl et al. BMC Nursing (2021) 20:162 Page 10 of 16

Discussion
The aim of the present study was to identify and com-
pare the burdens, resources, health and wellbeing of
nurses working in GPC and SPC in Germany. The key
points of this comparison can be summarized as follows:
First of all, nurses working in GPC and SPC showed dif-
ferences in sociodemographic data as well as profes-
sional aspects. Secondly, 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. Thirdly, SPC nurses
reported more often resources that were helpful in deal-
ing with the demands of their work and fourthly, SPC
nurses stated a better health status and a lower intention
to leave the profession than GPC nurses.

Sociodemographic characteristics
SPC nurses were comparatively older than GPC nurses
and reported higher professional experience. However,
the relationship between age, professional experience
and job related factors and health is not clear in the sci-
entific discussion [51]. There were studies which re-
vealed that high age has a negative effect on the health
status [52] or work ability [53] of nurses. A study con-
ducted in the field of end of life care found higher burn-
out scores in younger nurses with less professional
experience. The authors of this study assumed that the
obligation to be empathically available for patients and
families as well as a lack of preparation in communica-
tion and work overload may make younger nurses or
nurses with less professional experience more apprehen-
sive, anxious and afraid of making mistakes [54]. Fur-
thermore, there are studies which assessed no
correlations [55] and studies which assessed diverse con-
nections between different age groups and job-related
factors and health [56]. The latter also has to be consid-
ered when further implications for future projects are
made. An analysis based on data of the nurses’ early exit
study (NEXT study) showed that older nurses had a
worse state of health than younger nurses and that for
younger nurses, leadership quality seemed to be an im-
portant component for preservation of a good health
status. For older nurses, a good collaboration with the
supervisor was important [52].
In connection with professional experience, a further

aspect has to be considered. In the present study SPC
nurses reported higher graduation levels and degrees of
education and additional qualification in palliative care
than GPC nurses. In Germany, this additional qualifica-
tion, which covers an 160 h course in palliative care, is
not obligatory for all SPC nurses. According to recom-
mendations of the National Association of Statutory
Health Insurance, all nurses in SAPV institutions should
have an additional qualification to invoice for palliative

care services from health insurance companies [57]. Pal-
liative care experts from around the world considered
the education and training of all staff in the fundamen-
tals of palliative care to be essential [58]. A study con-
ducted in Italy revealed that professional competency of
palliative care nurses was positively associated with job
satisfaction [59]. We assessed a positive effect of the
additional qualification within the pilot study in SPC in
relation to organisational demands and demands regard-
ing the care of relatives [16]. In future studies, it is there-
fore necessary to consider whether and to what extent
an additional qualification should be required for all
nurses in palliative care.
SPC nurses reported having a full-time job respectively

working in institutions with a private fund less often
than GPC nurses. This may have an impact on their
working conditions, their health and well-being. Regard-
ing nursing homes in Germany, a study reported the
highest burden in publicly-owned nursing homes and
the lowest in independent nursing homes [60].

Demands
SPC nurses reported higher emotional demands, greater
burdens due to nursing care and greater burdens due to
the care of relatives, while GPC nurses reported higher
quantitative demands. Quantitative demands are ele-
ments of the work environment, related to the amount
and the time conditions of work to be done [61]. Among
the different subscales of burdens, the quantitative de-
mands scale showed the greatest difference in the re-
ported scale mean. SPC nurses reported a comparatively
lower value (M = 42.7 vs. M = 55.4). COPSOQ reference
data presents mean values of the scale ranging from
M= 50.4 for occupations in the health sector [62], M =
51 for geriatric nurses, and M = 60 for nurses [63]. The
relatively low mean value of the SPC nurses can be ex-
plained by the fact that SPC nurses, e.g. in palliative care
units in Germany have fewer patients to care for than
nurses in other fields [64] and that 18% of SPC nurses
did not engage in any practical nursing activities. For
years, minimum legal standards for the nurse-to-patient-
ratio in Germany have been discussed. The Registered
Nurse Forecasting Study (RN4CAST), one of the largest
nurse workforce studies conducted in Europe in which
12 countries participated revealed, that the average ratio
of patients to nurses across hospitals ranged from 5 in
Norway, over 7 in the Netherlands to 13 in Germany
[65]. The Federal Government in Germany has under-
lined current efforts with the Nursing Workforce
Strengthening Act (Pflegepersonal-Stärkungs-Gesetz
(PpSG)) [66] to improve working conditions for nursing
care in hospitals and nursing homes for example regard-
ing personnel requirements. The greater emotional de-
mands and greater burdens due to care of relatives of

Diehl et al. BMC Nursing (2021) 20:162 Page 11 of 16

SPC nurses can be explained by the different structures
and aims of the health and palliative care institutions.
SPC nurses care for patients whose nursing care is more
complicated. Further, SPC not only concentrate on the
patient but also on the families. A fact which has to be
considered in evaluating the working situation of nurses
in palliative care, and which was long disregarded in the
research [16]. The burden due to nursing care scale
which was used in the present study describes the most
stressful nursing care situations of SPC nurses, which
were reported in the pilot study [16, 30, 46]. This can
explain why the burden due to nursing care in this study
is higher for nurses in SPC. Consequently, various other
possible demands of nurses, particular of nurses working
in GPC, were not collected. In order to gain a deeper
understanding on how the level of nursing care differs
between GPC and SPC nurses, further research is
needed.
The lowest difference between nurses in GPC and SPC

was identified regarding emotional burden due to death.
This was surprisingly, because nurses in SPC reported
many more deaths of patients than nurses in GPC.
Nevertheless, the experienced burden was nearly the
same. There are different possible explanations for this
aspect. Firstly, SPC nurses were comparatively older, had
more professional experience and reported an additional
qualification in palliative care more frequently than
nurses in GPC, as already discussed. Secondly, nurses in
SPC stated more frequent that they have various re-
sources which were helpful in dealing with the demands
of their work. Thirdly, death and dying is demanding,
but other factors play a more important role. In the pilot
study, nurses in SPC reported that the death and dying
is not of crucial importance for the perceived burden,
but rather weather the patient received good care or not
[16]. Finally, working in SPC is an active choice made by
every nurse. Nurses are aware of the demanding care for
palliative care patients and their families, but this care
also seems to be enormously rewarding [67].

Resources
SPC nurses reported more often organisational, social
and personal resources than GPC nurses. No differences
were found according to workplace commitment, grati-
tude of patients, recognition of salary, family, friends and
the personal resources satisfaction with life and resili-
ence. The highest differences in the frequencies were
assessed regarding meaningfulness of work, recognition
through patients and relatives, a good working team, re-
ligiosity/spirituality, self-reflection, sport and self-care.
Self-care is broadly defined as self-initiated behaviour
that people choose to incorporate and promote good
health and general well-being into everyday life [68].
Further, it is about being healthy but also about

incorporating coping strategies in life to deal with work
stressors. Self-care can sustain well-being and resilience
[23, 69]. The importance of self-care is deeply rooted in
SPC. Self-care trainings [70] or self-care plans [71] are
offered in SPC. Particularly with regard to the COVID-
19 pandemic, self-care and self-care trainings for health-
care workers become important [72–74].
Various studies identified the team as an essential re-

source in the field of palliative care [16, 18, 75, 76] or
support from co-workers and supervisors in the nurse
setting [77]. Recognition through patients and relatives
was already described as a key element in creating and
sustaining healthy work environments [78]. The Ameri-
can Association of Critical-Care Nurses (AACN) pub-
lished AACN Standards for Establishing and Sustaining
Healthy Work Environments, in which meaningful rec-
ognition represents one from six standards needed to
create a healthy work environment [79]. Although a
study which concentrated on the work motivation of
nurses assessed that extrinsic rewards such as payment,
promotion and fringe benefits were the basic sources of
motivation and intrinsic reward, such as recognition, ap-
peared to be less important [80]. Noticeable in this con-
text is that the majority of nurses in both GPC and SPC
do not feel to gain recognition through their salary. In
Germany, the Federal Government underling current ef-
forts with the already mentioned Nursing Workforce
Strengthening Act (Pflegepersonal-Stärkungs-Gesetz
(PpSG), which also affects higher salaries for nurses. As
our study indicates, future efforts should concentrate on
the balance of extrinsic and intrinsic rewards in the
nurse setting, in order to achieve the best balance to
promote the health and satisfaction of nurses.

Health and wellbeing
GPC nurses stated in all elevated aspects worse values
than SPC nurses. They reported a worse self-rated
health, higher burnout levels, more frequent chronic
back pain, more frequent major depressive disorders and
greater intention to leave the profession. Regarding the
latter, SPC nurses reported a lower value on the scale
(M = 12.9), other studies from Germany reported higher
values (M = 19 (t1) and M = 15 (t2) [52], M = 18 [81] and
GPC nurses reported the highest value (M = 20.7). The
results relating to burnout matches the results of a re-
cent published review where healthcare professionals in
GPC experience more symptoms of burnout than those
in specialised palliative care settings [35].
In the light of demographic developments, future ana-

lysis of the data is needed to find out why SPC nurses
seems to be more satisfied with their work than GPC
nurses and which impact the single burdens and re-
sources have, not only on job satisfaction but also on
health.

Diehl et al. BMC Nursing (2021) 20:162 Page 12 of 16

Limitations
The results of the comparison of the working situation
of nurses working in GPC and SPC in Germany must be
interpreted with caution due to the different structures
and aims of the health and palliative care institutions [7,
11]. Additionally, the present study compared the data
of GPC nurses, which represent the merged data of
nurses working in nursing homes and outpatient care,
with the data of SPC nurses, which represent the merged
data of nurses working in SAPV institutions, hospices
and palliative care units. A great deal of information
thus gets lost because the comparison is built on a
macro level, the social structures of care. In the future,
comparisons of nurses on a meso level in single areas
and institutions will follow, but this was not part of this
paper. The survey instrument of the present study in-
cluded mostly valid and reliable instruments, such as the
COPSOQ. Furthermore, it included additional self-
developed questions. The latter were not validated but
were valuable for our study as they answered certain
questions that standardized questionnaires could not. It
should be noted that the self-developed scales were de-
veloped to address palliative care specific working condi-
tions of nurses focusing on the working conditions in
SPC. Consequently, various other possible demands of
nurses working in GPC were not collected. In order to
achieve transparency, we showed the frequency of the
response items of each self-developed scale for both
areas. Further, the present study focused firstly on med-
ical facilities. Only the participating facilities reported
the number of staff members. The low participation and
response rate of GPC nurses raises the possibility of se-
lection bias. Although a random sample was drawn, this
sample was not representative of GPC due to different
response behaviours and the exclusion of hospitals. The
lower response rate of GPC could be responsible for the
differences between the burdens, resources and health
status between GPC and SPC. A comparison with
participants and no participants of this survey was
whether within GPC nor SPC feasible. It should be
noted that it is likely that nurses who experience
greater burdens were less motivated to respond to a
time-consuming survey. Therefore, it is possible that
the demands in the present study were underesti-
mated. Additionally, because of the two samples, only
exploratory and no confirmatory data analysis was
possible and the results presented are based on com-
parisons of means and sample frequencies. The cross-
sectional design of the study cannot prove causality
between burdens, resources, health and wellbeing.
Therefore, interventional and longitudinal studies at
the micro level in nursing practice are needed to sup-
port causality in the relationships of burdens, re-
sources, health and wellbeing.

Conclusions
This is the first nationwide study in Germany to com-
pare the working situations of GPC and SPC nurses in
various settings providing a large amount of information.
Overall, the working situation of GPC and SPC nurses
were different and the nurses reported burdens in sev-
eral working areas. However, the study demonstrated
that although nurses in SPC overall reported a higher
level of burden than those in GPC, SPC nurses stated
that they had a better health status and a lower intention
to leave the profession than GPC nurses. Further, SPC
nurses differenced in the frequency of reported re-
sources, which were helpful in dealing with the demands
of their work to GPC nurses. The results of the present
study may be used to develop individual concepts for
improving health and wellbeing of nurses taking the dif-
ferences between GPC and SPC into account. While
SPC nurses for example often reported self-care as a re-
source, future interventions in the field of GPC could
take self-care as a subject of discussion into account
[82].
In the future, the demographic differences, further par-

ticipants’ characteristics as well as the differences in the
burdens and resources should be further analysed in
order to examine which have the biggest impact on
health status and intentions of leaving the profession.
Additionally, future studies should review SPC as the
best practice example for nursing care in Germany.
The implementation of palliative care differs strongly

around Europe [6] and around the world [68]. Future re-
search is needed in order to find out to what degree the
presented results can be transferred to other countries.
Nevertheless, the results of the present study could have
relevant implications for developing interventional stud-
ies, with the goal of improving the health status of
nurses and enhancing job satisfaction. This includes first
of all an improvement of working conditions like per-
sonal requirements, but simultaneously the strengthen-
ing of organisational, social and personal resources.

Abbreviations
GPC: General Palliative Care; SPC: Specialised Palliative Care;
COPSOQ: Copenhagen Psychosocial Questionnaire; PHQ-2: Patient-Health
Questionnaire; RS-13: Resilience questionnaire-13; EAPC: European
Association for Palliative Care; SAPV: Specialist outpatient palliative care
services; M: Mean; SD: Standard deviation

Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12912-021-00687-z.

Additional file 1: Additional Table 1. Palliative care in Germany.

Additional file 2: Additional Figure 1. Burden due to organisational
framework conditions (GPC: n = 437, SPC: n = 1316). Additional Figure
2. Emotional burden due to death (GPC: n = 437, SPC: n = 1316).
Additional Figure 3. Burden due to care of patients (GPC: n = 437, SPC:

Diehl et al. BMC Nursing (2021) 20:162 Page 13 of 16

n = 1316). Additional Figure 4. Burden due to nursing care (GPC: n =
437, SPC: n = 1316). Additional Figure 5. Burden due to care of relatives
(GPC: n = 437, SPC: n = 1316). Additional Figure 6. Good working team
(GPC: n = 437, SPC: n = 1316).

Acknowledgements
We thank the nurses and the institutions for taking part in the study. We
thank O. Kleinmüller, E. Muth, R. Amma and C. Kohring who were helpful in
the recruitment of the participants and data collection.

Authors’ contributions
ED, SR, SL, AS, AN, LCEP participated in the conception and design of the
study; ED, SR and AS monitored data collection; ED analysed data; ED wrote
the manuscript; ED, SR, SL, AS, AN, LCEP and PD participated in data
interpretation, drafting, and revising the manuscript. All authors read and
approved the final manuscript.

Funding
The project was funded by the BGW – Berufsgenossenschaft für
Gesundheitsdienst und Wohlfahrtspflege (Institution for Statutory Accident
Insurance and Prevention in Health and Welfare Services). The funder did not
influence the project, the analysis, the results or the present publication at
any time. Open Access funding enabled and organized by Projekt DEAL.

Availability of data and materials
The whole data set is available at the University Medical Centre of the
University of Mainz, Department of Occupational, Social and Environmental
Medicine. Contact: [email protected]

Declarations

Ethics approval and consent to participate
Approval to perform the study has been obtained from the ethics
committee of the State Chamber of Medicine in Rhineland Palatinate
(Clearance number 837.326.16 (10645)).
Participation was voluntary and anonymous. Informed consent was obtained
written at the beginning of the questionnaire.

Consent for publication
Not applicable.

Competing interests
The authors declare the following potential conflict of interest which did not
influence the project, the results or the present publication at any time. The
project was funded by the BGW – Berufsgenossenschaft für
Gesundheitsdienst und Wohlfahrtspflege (Institution for Statutory Accident
Insurance and Prevention in Health and Welfare Services). The BGW is
responsible for the health concerns of the target group investigated in the
present study, namely nurses. Prof. Dr. AN is head of the Department for
Occupational Medicine, Hazardous Substances and Health Science of the
BGW and co-author of this publication. All other authors declare to have no
potential conflict of interest.

Author details
1Institute of Occupational, Social and Environmental Medicine, University
Medical Center of the Johannes Gutenberg University Mainz, Obere
Zahlbacher Str. 67, 55131 Mainz, Germany. 2Institute for Health Services
Research in Dermatology and Nursing (IVDP), University Medical Centre
Hamburg-Eppendorf, Building W38, Martinistraße 52, 20246 Hamburg,
Germany. 3Department for Occupational Medicine, Hazardous Substances
and Health Science, Institution for Accident Insurance and Prevention in the
Health and Welfare Services (BGW), Pappelallee 33/35/37, 22089 Hamburg,
Germany. 4Federal Institute for Occupational Safety and Health (BAuA),
Nöldnerstr. 40-42, 10317 Berlin, Germany.

Received: 11 September 2020 Accepted: 23 August 2021

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