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


Background
Due to demographic changes, western European societies are faced with numerous challenges and changes. Higher life expectancy, in particular in older age groups, is related to more patients with incurable and lifethreatening 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, primarily 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 palliative care as "an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention 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 divided 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 conducted through interdisciplinary teams (see additional Table 1). Palliative care should be made available at different levels, so that the aims and objectives of all institutions 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 Palliative Care Association (DHPV) and the German Medical 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 Academy 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 palliative care is demanding [12]. For example, organisational 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 palliative care nurses compared to nurses in other disciplines [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 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 personal 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 example, organisational resources such as the meaningfulness of work [16,20] or supervision [18] as well as social resources such as the team, were reported to be very important resources [18,21,22]. In addition, personal resources 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 sociodemographic factors like age and professional experience [19] might help to cope with work demands and promote nurses' health. Overall, it seems that palliative care nurses are satisfied with their work [27,29,30] and report low levels of burnout [13,15,17,31]. In contrast, studies outside the palliative care setting reported consistently of an increasing workload with high burdens and a high intention to leave the profession of nurses [32][33][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 importance 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 palliative care aspects exclusively refer on SPC [16,18,37,38]. For example, with focus on the resource 'team', Müller et al. (2009Müller et al. ( , 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  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. Therefore, 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 developing 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 developing interventional studies, with the goal of improving the health status of nurses and enhancing job satisfaction.

Study design
A nationwide cross-sectional empirical study was conducted in 2017. Ethical approval to perform the study was obtained by the ethics committee of the State Chamber of Medicine in Rhineland-Palatinate (Clearance 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 protection 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 working in SPC nor specialised palliative care institutions, first, all medical facilities in the specialised palliative care were identified (950: 358 SAPV institutions, 343 palliative 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 medical 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 preferred to answer a paper-and-pencil (with a franked return envelope) or an online-questionnaire (with an access code). The participation was voluntary and anonymous. Table 1 provides information about the amount of questionnaires send to the different health facilities 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 concerning health and well-being. Since the specific jobrelated conditions between GPC and SPC are somewhat different, some questions were slightly adapted. The questionnaire contained questions from standardised, reliable and valid instruments: 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 environmental factors and health in the workplace [40]. The subscales used for the present study were 'quantitative 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 profession' scale were collected with a single question ( Table 2). The single items of the COPSOQ scales were transformed 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 categories 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, depressed, 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 developed by Wagnild and Young (1993) [43]. The German version of the RS-13 was developed by Leppert and colleagues (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 longer?' 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 regarding 'burden due to organisational framework conditions', '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 framework conditions' consisted of 7 items and were collected 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 paperand-pencil, 33 x online) no identification to type of institution possible  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 categorical questions to resources were added, which showed to be of crucial importance within the pilot study [16,30]. The categorical variables regarding resources were dichotomized (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 questions 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 answered [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 (absolute 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 demonstrates 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 [49]. Only results being statistically significant and fulfilling the difference of at least 5 points in the mean value were interpreted as relevant differences. For comparisons between categorical variables, 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 tables and Cramer's V for larger tables), where values between 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 (twotailed).
Statistical analyses and graphical representation were performed using SPSS version 23.5 and Microsoft Excel 2016, respectively.

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 particular 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 experience. More SPC nurses reported an additional qualification 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 experienced more deaths of patients in the last month than  GPC nurses. 17.9% of SPC nurses served in an advisory function 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 facility with publicity-owned or independent fund.      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. Additionally, Table 5 presents the proportion of nurses agreed to having gained recognition through, which were reported by the nurses in both fields. SPC nurses reported 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 depressive disorder is likely. Both, chronic back pain as well as a major depressive disorder, were reported more frequently from nurses of GPC (chronic back pain: difference 13.8%, x 2 (1) = 25.098, p < 0.001, Phi = 0.121; major depressive disorder: difference 8.3%, x 2 (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 6 ↑) and GPC nurses reported chronic back pain more often, higher values on the burnout scale and the intention to leave the profession more often (Table 6 ↑). Furthermore, a major depressive disorder is more likely in GPC nurses (Table 6↑).

Discussion
The aim of the present study was to identify and compare 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 differences in sociodemographic data as well as professional 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 dealing 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 scientific discussion [51]. There were studies which revealed that high age has a negative effect on the health status [52] or work ability [53] of nurses. A study conducted in the field of end of life care found higher burnout 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 communication and work overload may make younger nurses or nurses with less professional experience more apprehensive, anxious and afraid of making mistakes [54]. Furthermore, there are studies which assessed no correlations [55] and studies which assessed diverse connections between different age groups and job-related factors and health [56]. The latter also has to be considered 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 important 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 qualification, which covers an 160 h course in palliative care, is not obligatory for all SPC nurses. According to recommendations 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]. Palliative care experts from around the world considered the education and training of all staff in the fundamentals of palliative care to be essential [58]. A study conducted 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 regarding the care of relatives [16]. In future studies, it is therefore 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. Regarding 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 elements 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 demands scale showed the greatest difference in the reported 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 explained 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-patientratio 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 underlined 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 regarding personnel requirements. The greater emotional demands and greater burdens due to care of relatives of 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 resources 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, gratitude of patients, recognition of salary, family, friends and the personal resources satisfaction with life and resilience. The highest differences in the frequencies were assessed regarding meaningfulness of work, recognition through patients and relatives, a good working team, religiosity/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 healthcare workers become important [72][73][74].
Various studies identified the team as an essential resource 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 American Association of Critical-Care Nurses (AACN) published AACN Standards for Establishing and Sustaining Healthy Work Environments, in which meaningful recognition 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, appeared to be less important [80]. Noticeable in this context 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 efforts 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 recent 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 analysis 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 resources have, not only on job satisfaction but also on health.

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 included mostly valid and reliable instruments, such as the COPSOQ. Furthermore, it included additional selfdeveloped 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 developed to address palliative care specific working conditions 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 medical facilities. Only the participating facilities reported the number of staff members. The low participation and response rate of GPC nurses raises the possibility of selection 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 underestimated. Additionally, because of the two samples, only exploratory and no confirmatory data analysis was possible and the results presented are based on comparisons of means and sample frequencies. The crosssectional 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 support causality in the relationships of burdens, resources, health and wellbeing.

Conclusions
This is the first nationwide study in Germany to compare 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 several 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 resources, 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 differences between GPC and SPC into account. While SPC nurses for example often reported self-care as a resource, 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 participants' 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 research 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 studies, 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 personal requirements, but simultaneously the strengthening of organisational, social and personal resources. 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).