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Work and health conditions of nursing staff in palliative care and hospices in Germany.

Aims of this representative study were to assess the relevant differences between the work and organisational characteristics as well as the subjective resources and health status of nurses occupied in hospice care, compared to nurses from palliative stations. Further, the assessment of the predictive correlations between the work situation of this nurses as a factor influencing their health and perceived strains was also a leading intention. Method: In a written survey conducted in Germany in 2001, 820 nursing staff of 113 palliative stations and stationary hospices were included. A qualified diagnostic procedure for the assessment of health promoting work was implemented. In order of obtaining a secure comparison, a sample of 320 nurses working in 12 homes for old people in Saxony was also considered. Results: The nurses referred generally to favourable working conditions, still they informed about deficiencies in the perceived participation, organizational benefits and experienced gratification. Hospice nurses experienced overall more favourable work conditions than palliative nurses or than the staff of homes for old people (regarding identification with the institution, organizational benefits, accurate gratification and little time pressure during work). Hospice personnel were psychologically and physically healthier than the staff of palliative stations. Important predictors for health stability that could be assessed by multiple regression analysis were: positively evaluated work contents, the identification with the institution, little time pressure and a positive working atmosphere. Conclusions: The assessed organisational framework is generally more favourable in the institutions of professional terminal care than in common hospitals and homes for old people. Therefore, the conditions in hospices could have a modelling function for the inner-institutional work organisation and for the anchorage of the intrinsic motivation of nurses in the health care system.

experienced overall more favourable work conditions than palliative nurses or than the staff of homes for old people (regarding identification with the institution, organizational benefits, accurate gratification and little time pressure during work). Hospice personnel were psychologically and physically healthier than the staff of palliative stations. Important predictors for health stability that could be assessed by multiple regression analysis were: positively evaluated work contents, the identification with the institution, little time pressure and a positive working atmosphere. Conclusions: The assessed organisational framework is generally more favourable in the institutions of professional terminal care than in common hospitals and homes for old people. Therefore, the conditions in hospices could have a modelling function for the inner-institutional work organisation and for the anchorage of the intrinsic motivation of nurses in the health care system.

Zusammenfassung
In einer repräsentativen Untersuchung sollten erstens relevante Unterschiede zwischen den Arbeits-und Organisationsmerkmalen, zwischen den subjektiven Ressourcen und zwischen den Gesundheitsmerkmalen von Pflegekräften der Tätigkeitsbereiche stationäres Hospiz und Palliativstation erfasst werden. Zweitens ging es um die Ermittlung prädiktiver Zusammenhänge zwischen Bedingungsvariablen der Arbeitssituation und Gesundheits-und Belastetheitsmerkmalen dieser Pflegekräfte. Methode: Dazu wurde im Jahre 2001 eine deutschlandweite schriftliche Befragung durchgeführt, die 820 Krankenpflegekräfte von 113 Palliativstationen und stationären Hospizen einbezog. Als Messinstrument kam ein qualifiziertes Diagnoseverfahren zur gesundheitsförderlichen Arbeit zum Einsatz. Für einen absichernden Vergleich wurde eine Introduction Numerous publications repeatedly refer to an accumulation of known stressors and negative health parameters for care personnel in medical institutions [1], [5], [8], [11], [31]. Here, qualitatively and quantitatively excessive demands (e.g. constant closeness to dying patients under an excessive pressure of time) and general working factors with a negative influence on health such as few action possibilities, organisational troubles, unprofessional handling of patients, few career opportunities, shiftwork and job uncertainty are noticeable [2], [3], [9], [17]. Stress studies also made clear that when demands are made with adequate skills and corresponding resources as well as the work motivation present at a time, they can succesfully be managed and contribute to the development of personality [25]. Studies with health care personnel pointed out that a convenient care environment regulates the medical condition of the personnel in a great manner [7], [13], [16], [19], [23], [29]. Therefore work and organizational conditions can provide freedom in handling those demands made to the nursing staff by the structure and by patients [14], [17], [27], [30]. The conceptual implementation of the hospice philosophy and the corresponding principle of a multidimensional (physical, psychological, social and spiritual) care of dying patients generated worldwide two different institutional types which dedicate to the care of terminal and dying patients, based on the medical approach of mitigation of symptoms. Hospices sponsored by charity or private funding and palliative stations covered by school medicine relate to each other in Germany as equal partners [24] with different legal and social statuses. Stationary hospices commonly are independent social institutions, which attend critically ill persons (most of them suffering aids or cancer) whose dying process has already begun and who reject (renounce to) invasive medical procedures. The nursing and psychological care of these patients, who do not need hospital care but also can not be taken care of at home, is the most important task in this institutions. Palliative stations (lat. "pallium" mantle that covers the pain) on the other hand, are special health units dedicated to the care of the terminally ill, fully integrated in hospitals and regulated by the state. Their medical focus lies on the enhancement of quality of life in the remaining lifetime of their patients. A strong supply of stationary hospices and palliative stations in Germany could be established only during the past decade. Resultant deficiencies in the accompanying scientific research especially in the international comparison, specifically concern the situation of the staff, who have to respond to the mentioned high demands of the caring (nursing) profession generally, and to specific strains of nursing dying patients as well, and therefore should be studied. The positive relationship between the satisfaction of the patients and the satisfaction of the staff [21] also justifies the scientific research of the personnel's strain in this area under ethical considerations. Due to the fact that palliative stations and hospices emerge from different structural concepts, the comparison of both institution forms permits important insights in the experience and evaluation of institutional demands and resources, including the resulting health related consequences. Aims of this study are: • Description of the level of work and organisation characteristics, subjective resources and health aspects in the field of activity of hospices and palliative units; • Analysis of the differences between both institution types regarding the organisational and health related variables; • Assessment of predictive relationships between the organisational variables of work and the health and strain characteristics.

Sample
From January to April 2001 the palliative stations and stationary hospices listed in the palliative guide 2000 [20] were informed about the study and asked for cooperation of their staff with the planed German wide survey. Altogether 113 of the 134 institutions that had opened until then, agreed on taking part in the study. The service centres of these institutions informed us about the number of staff they occupied. After a phone notice and motivation, according to the information gained before, 1378 questionnaires (gross sample) were sent together with addressed and stamped envelopes directly to the management of the care department or to the stations' direction of each institution. They were asked to transmit to the nurses a short message containing the aims of the study, which were summarized on a short letter, to motivate their staff to participate on the study and to hand out a questionnaire with an envelope to every nurse. By August 2001, 357 palliative care and 463 hospice nurses sent us completed and analysable questionnaires. 820 completed questionnaires correspond to a rate of return of 60%. Due to the anonymity regarding the centres, an assessment of rate of return/participating institution could not be made, nor could an analysis of non-respondents take place. Furthermore, the distribution in consideration of gender could not be assessed due to the fact that the gender ratio in nursing staff is 9:1 in favour of female employees [3] and that in palliative stations or hospices the average staff is 10 nurses. Therefore considering gender would not have permitted to guarantee the anonymity of participants.

Instruments
The needed data were collected throughout a quantitative survey. The Diagnosis of Health-Promoting Work (DigA; [6]) is a well proven and representative instrument for the assessment of work-related health, which possesses high instrumental validity and was developed especially for the analysis of organisational deficiencies or potential. This questionnaire consisting of 55 items in 15 scales makes it possible to identify job stressors and job resources. Further, it gives account of different fields of responsibility (on the own job level, on a management level and also beyond the organisation). With the aim of identifying stressors, the scales job insecurity, time pressure, disturbances and monotony are included. On the other hand, the scales identification with the institution, working atmosphere, information and participation, work organisation, organisational care, career opportunities, gratification according to job performance, work content, decision making, open conflict management, feedback from superiors and communication assess job related resources. Every item is designed in a five-step rating format (0=does not apply, 1=applies a little, 2=partly applies, 3=probably applies and 4=applies totally). The discrimination power of the items to the scales ranges between .67 and .93 with a mean of r = .82 and therefore are above the minimum (r ≥ .30) according to the standards of Guthke, Böttcher & Sprung [10]. The internal consistency of the scales (Cronbachs Alpha) lies between .69 and .85. The scales for the assessment of health indicators contained in this questionnaire (somatic complaints, psychological exhaustion, testiness and joy at work) are characterised by a mean item difficulty of .51, a mean discrimination power of r = .80 and by a Cronbachs Alpha between .70 and .85 which corresponds to the required psychometrical criteria. Regarding the content of each scale, the scale somatic complaints assesses the amount of muscle and skeleton troubles, gastrointestinal illness and cardiovascular diseases. In opposition to the scale psychological exhaustion, which is used to determine short term psychological complaints such as tiredness (fatigue), the scale testiness assesses medium-term impairments. Besides the focus on the non-appearance of symptoms, indicators of the well being and positive health of the nurses were included in order of assessing the general health status. The scale joy at work reflects positive emotions related to work (joy and pride about the own occupation).

Differences between samples
Data were analysed to obtain a comparison between nurses of palliative stations and nurses working at hospices regarding their age, marital status, education, attended further training, working experience and period of employment. Both institutions differ in the variables "age", "working experience" and "attended further training". Hospice nurses were ordinarily older (χ² [3, n=787] =26.72; p < .001), had fewer practical working experience (χ² [3, n=788] =18.76, p < .001) and attended less further training units of several days' duration (χ² [3, n=786] =9.60, p < .05).

Job stress and resources
The differing organisational structures of both institutions hospices and palliative stations knock down on evaluation differences. These differences are especially noticeable in the evaluation of the work and organisational conditions on the own workplace level. Nurses working at hospices evaluated more favourably almost every organisational resource of their workplace than nurses of palliative units (t-test for independent samples). Table 1 summarizes the evaluated work and organisational conditions both generally, and also specified according to the institution type. The majority of nurses appear not to be threatened by a general job insecurity and pending job losses. Considering the assessed characteristics on the management level it is evident that the scale "identification with the institution" has the highest values. Hospice staff report a very high personal identification with their institution. They strongly agreed to the statements that their hospice has a good future (90%) and holds a good reputation between the public (96%). Staff from palliative stations did not agree to this statements as much (65% and 78% respectively). The working information and participation (propagation of the information to the staff members, participation of the staff in making important decisions for the institution) is described much higher in hospices. Only 49% of the nurses in palliative stations, opposed to 70% of the respondents occupied in hospices, considered themselves well-informed about upcoming changes and decisions and stated to have some "rights to say" at the own working field. Career opportunities were rarely mentioned by the nurses, but they nonetheless were very satisfied with their own professional situation. Missing chances for promotions therefore did not appear to be generating conflicts since this situation was not perceived as frustrating. The working atmosphere perceived by the nurses was estimated to be rather positive by the majority of respondents. The high sum score of this scale can be taken as a sign for a general satisfaction of the staff with the organisational aspects of the social atmosphere. The most significant differences between both institution types can be found in the perceived organisational care. Nurses working in hospices evaluated the social service offerings made by their employer more favourably (50% opposed to 23% of the nurses in palliative stations) and accentuated that their employer gives great importance to the well being of his employees (61% in opposition to 29% in palliative stations). The accurate gratification of the own working performance is the characteristic of the organisation that was most negatively evaluated. The recognition of work, especially in palliative stations, was stated to be "almost not" or just "partly" fair corresponding to the performance. 62% of the interviewed nurses stated not to be satisfied by the acknowledgment their work receives. This aspect was also considered to be important in hospices, but 34% negative answers constitute an evaluation that is just half as frequent as in palliative stations. The actual conditions at the working place -which could represent a relief in the work process if they are convenient -were evaluated by the respondents in the upper area of the scales and therefore estimated to be positive. Regarding the assessed characteristics, the job content was most positively evaluated . 85% of the respondents experience their work to be interesting, varied, and appreciate the learning opportunities they get through their job. Respondents stated that they "mostly" could make free decisions (decision making at work) about the order in which they would fulfil the work-steps and also about the way of doing their job. A good relationship to colleagues and helping each other in the team were the single statements mentioned on first place. Cooperation and open conflict management in the teams (open conflict management) was mostly considered constructive. Criticism regarding performance made by superiors was stated by most respondents to be justifiable; positive feedback made by superiors was considered to be frequent. More critical appears to be the evaluation of the way job deficiencies are reflected by superiors. The answers of 20% of the interviewed nurses lead to the conclusion, that not only pertinent judgments, but also person-related criticism flows in the evaluation of the job performance made by superiors. Stressors at work (time pressure, disturbances and monotony) were described by respondents as relatively rare. Negative characteristics of regulation interferences associated to health such as time pressure and disturbances during work were stated to be less frequent in hospices. Interruptions by persons and telephone calls affected 32% of the hospice nurses, and up to 52% nurses from palliative stations. 18% of the respondents occupied in palliative stations perceive time pressure "mostly" or "totally"-compared to 5% of the hospice nurses.
In order of evaluating the condition and strain profiles in specific occupations, broad comparisons between institutions can be helpful (so called bench marking). Figure  1 shows the positioning of selected working and organisational characteristics of the studied hospices and palliative stations in relationship to a similar sample of 12 "homes for the elderly" (n=320), collected in 2003 in Saxony [18]. It becomes evident that the occupation conditions in palliative stations and homes for the elderly are partially similar (e.g. information, care, gratification). Regarding job uncertainty, identification with the institu-tion, job content and time pressure on the other hand, the homes for the elderly come off clearly worse. Thereby the favourable conditions of operational conditions in hospices is confirmed.

Psychological health
Short term exhaustion states, especially tiredness and nervousness, were reported by 70% or 59% of the nurses to happen from "every day" to "every two or three weeks". 59% of all respondents stated to take "every day" or up to "every two or three weeks" work problems home ("not to be able to disconnect"). Within physical complaints, muscle or skeleton diseases appear on first place; more than 60% complained about neck and back pain from "every day" up to "every two or three weeks". Irritable behaviour was named much less by respondents. In some areas, a higher percentage of palliative nurses (P) feel strained, when compared to hospice nurses (H). Palliative Single statements lead to the assumption that palliative stations' personnel suffer more tiredness, higher nervousness, as well as more stomach and digestion complaints, more back pain and more blood pressure problems. Joy at work (a principal health aspect within the salutogenic concept) was reported to be very high among the interviewed nursing staff. 82% of the nurses reported to feel glad about their work almost every day, 70% were mostly proud of the work

Work stress/resources and psychological health/disease
The chosen methodological approach permitted assessing relationships between occupational conditions and health related variables. As an example, the regression relationship between work conditions (independent variables) and the health variables "joy at work" and "psychological exhaustion" will be presented in following. All assessed work and organisational conditions were included in the regression model as independent variables. Table 2 summarizes the results for the criteria "joy at work". The relevant influencing factors are presented in the rows. The weighting (beta) shows the strength and direction of the impact. The higher the beta coefficients are, the more important is the impact of the variable. Positive weighting marks a positive connection, whereas negative weighting indicates an opposite connection. The presented variables explain to 47% the joy of the nurses about their work. Especially positive evaluated job contents, the high identification with the institution and also a good working atmosphere appear to be relevant for the experience of joy at work. Perceived time pressure reduces significantly the joy at work. Table 3 summarizes the regression analysis to the dependent variable "psychological exhaustion". The predictors presented in Table 3 explain up to half (49%) the variance of the scale emotional exhaustion. The scale time pressure is the most important predictor for states of emotional exhaustion of the respondents, according to the regression model. In opposition, the cooperative management of problems and conflict in the team as well as interesting and varied job contents have a reducing effect on emotional exhaustion tendencies. Regarding the coping strategies, to give up predicts a high emotional exhaustion of the personnel.

Discussion
The results emerging from this study underline the importance of the assessed working and organisational conditions under the consideration of resources for disease prevention and health promotion. This applies especially for the population of nurses caring for terminally ill patients, who are usually considered a population undergoing a lot of strains from a clinical point of view. General stressors, emerging form stationary nursing such as time pressure and disturbances at work, also have a negative effect on every health indicator in this area. In opposition, organisational resources facilitate positive health characteristics and reduce both physical and psychological afflictions.
When compared to studies of other hospital stations, our respondents reported significantly fewer general stressors at work, such as time pressure and monotony [2], [3], [8], [11], [12]. The majority of nurses confirmed the existence of work related resources (an evaluation of the own occupation as interesting and varied, acceptable space for own decision making, mutual help and positive relationships between colleagues). Studies about general care have elucidated the health promoting aspects cooperation and mutual help [16], [19] which also can be seen as important support factors for coping with demands in palliative and hospice care. Nurses stated to be displeased with the remuneration of the performed activities and also with the little organisational care and social services offered. According to the model of efford reward imbal-ance postulated by Siegrist [26] this discrepancy between the perceived value of the own performance and the received remuneration can develop to a serious strain. Over a half of the respondents complained about tiredness, nervousness and sleep disorders, as well as about neck and back pain. This order (succession) of health complaints was described similarly in studies about the strain of nurses in other medical areas and can be explained partly by the demands of the nursing activity [28], [11]. The situation of nurses in the professional care of terminally ill and dying patients can be characterised by the usually high occurrence of psychosomatic complaints on one hand and by a high satisfaction with work on the other hand, which suggests a positive effect of the work content and organisational aspects of this occupation. Further, differences between the institution types could be observed. Due to the relatively large samples collected, even little differences can be statistically significant. Still, the high effect values of single variable aspects give an account of the relevance of the respective differences. Hospice nurses, as sub group in this study, reported higher institutional resources and less stressors at work, when compared to the sub group of palliative nurses. The gratification of the own activity and performance, organisational care, organisational information and participation policies as well as the identification with the institution are being more positively evaluated in hospices than in palliative stations which are a part of regular hospitals. This differences, that burden palliative stations, can partly be explained by the hierarchic organisational structure of hospital mangement. Limitations of this study emerge from the population specificity of the interviewed persons and also through the designed transversal data collection. The collected sample can be taken as representative for the population of nurses in the area of terminally ill patients. Generalisation of the results, beyond this specific population, is limited by the selective attraction of this occupation and especially because of the social and religious motivations of the nurses. Interpretations about influencing effects can only be made as predictions within the context of stochastically relationships, but otherwise suggested both by theoretical hypothesis and well proven findings on the relationship between work and health. The resulting descriptions of organisational conditions are based on an anonymous employee survey and do not reflect the "objective" aspect of conditions. Nevertheless, especially the subjective experience and evaluation qualities of an individual are of real pathogenetic of salutogenetic relevance for the demands and conditions of an occupation.

Conclusions
The general framework and resources provided by an institution (such as sufficient time reserves that make it possible to address the patients' desires) have a great influence on how the strains of nursing terminally ill pa-tients are perceived by the nurses. These general conditions are significantly more favourable in institutions of terminal care, in opposition of the "normal hospital care". Therefore, the first can be taken as a model regarding the attitudes of the personnel and structural work organisation for the social care systems in Germany, which is getting more and more tense. The relatively high variance explained by work and organisational conditions on the health condition of nurses refer to the influence possibilities of the management in health care institutions. These can contribute not only to the avoidance of diseases and absences from work, but also to the internal quality assurance of care. Social resources within health care institutions (open conflict management, working atmosphere) have become very important for the psychological stabilisation of the personnel within terminal care (e.g. through supervision) and claim for a systematic transfer and implementation in other areas of the health system. The level of identification with the institution the interviewed nurses reported, had a high impact on the health condition and especially for hospice nurses, appears to be based on the perceived meaning of their occupation. This correlation entitles to hope that a stronger ethical fundament of organisational guidelines will lead to a stronger identification and cohesion of nurses to the institution, due to an intrinsic motivation. The generally positive evaluation of the job content, which is related to health indicators such as joy at work, independently refers to a central significance of intrinsic motivation for nurses in the terminal care. The potential for intrinsic motivation can be considered already in the selection of personnel, in order of assuring the good health of the employees and the quality of care on a long term basis. Important resources for the good condition of nurses in hospice care and palliative units are not being exploited totally and also at risk of disappearing when economical difficulties arise. Especially the achieved grade of participation and information policy (e.g. the involvement of nurses in the determination of the steps to follow in their work) deserves to be maintained and further developed.