Gegenstand der Arbeit ist die Beanspruchungssituation des Pflegepersonals im Krankenhausbereich. Es wird der Frage nachgegangen, mit welchem Verhaltens- und Erlebensmuster Pflegepersonen ihren Anforderungen gegenübertreten und wie sie über die Art und Weise der persönlichen Auseinandersetzung mit den Anforderungen ihre Beanspruchungsverhältnisse mitgestalten.<br><br>Den theoretischen Ausgangspunkt der Arbeit bilden salutogenetisch orientierte Ressourcenmodelle, insbesondere Beckers Modell der seelischen Gesundheit (Becker, 1982, 1986). Nach ihm hängt der Gesundheitszustand einer Person davon ab, wie gut es ihr gelingt, externe und interne Anforderungen mithilfe externer und interner Ressourcen zu bewältigen. Hier knüpft das in der Arbeit im Mittelpunkt stehende diagnostische Instrument AVEM (Arbeitsbezogenes Verhaltens- und Erlebensmuster; Schaarschmidt & Fischer, 1996, 2001) an, das die Erfassung interner Anforderungen und Ressourcen der Person sowie deren Zuordnung zu 4 Verhaltens- und Erlebensmustern gegenüber der Arbeit unter Gesundheits- und Motivationsbezug ermöglicht.<br><br>Mit den Hypothesen wird angenommen, dass in Anbetracht der problematischen Arbeitsbedingungen in der Pflege eine Zurücknahme im Engagement bzw. eine Schutzhaltung vor nicht gewollten und als unangemessen empfundenen Anforderungen sowie wenig beeinflussbaren Bedingungen im Vordergrund stehen. Dort, wo zumindest partiell gesundheitsförderliche und als herausfordernd erlebte Arbeitsbedingungen anzutreffen sind, sollten günstigere Musterkonstellationen auftreten. Wir vermuteten, dass sich die ungünstigen Tendenzen bereits in der Berufsausbildung und in frühen Berufsjahren zeigen. Musterveränderungen in gesundheits- und persönlichkeitsförderlicher Hinsicht sollten durch gezielte Intervention herbeigeführt werden können. Schließlich nahmen wir an, dass die Tätigkeit und die mit ihr verbundenen Anforderungen und Ausführungsbedingungen musterspezifisch wahrgenommen werden.<br><br>Zur Beantwortung der Fragen werden Ergebnisse aus verschiedenen Quer- und Längsschnittuntersuchungen herangezogen, die in Wiener Spitälern und Krankenpflegeschulen, aber auch in deutschen Krankenhäusern durchgeführt wurden. Zu Vergleichszwecken werden Befunde anderer Berufsgruppen dargestellt. Neben dem AVEM wurden weitere Fragebögen zu folgenden Inhalten eingesetzt: Arbeitsbezogene Werte, Erleben von Ressourcen in der Pflegetätigkeit, Belastungserleben und Objektive Merkmale der Arbeitstätigkeit.<br><br>Die Ergebnisse bestätigen die Hypothesen in allen wesentlichen Punkten. Im Vergleich mit anderen Berufsgruppen fallen für die Pflegekräfte deutliche Einschränkungen im Arbeitsengagement auf. In Bezug auf die gesundheitlichen Risikomuster nimmt das Pflegepersonal eine Mittelstellung ein. Die Musterdifferenzierung in der Pflegepopulation lässt die stärksten Unterschiede in Abhängigkeit von der Position erkennen: Je höher die Position, desto größer ist der Anteil des Gesundheitsmusters und desto geringer ist die Resignationstendenz. Die meisten Risikomuster zeigen sich bei den Pflegekräften mit der niedrigsten Qualifikation. Für Pflegeschüler ist ein zeitweiliges starkes Auftreten von resignativen Verhaltens- und Erlebensweisen sowie eine kontinuierliche Abnahme des Engagements kennzeichnend. Dieser Trend setzt sich nach Aufnahme der Berufstätigkeit fort. Nur gezielte intensive personenorientierte Interventionen erwiesen sich als geeignet, Musterveränderungen in gesundheits- und persönlichkeitsförderlicher Hinsicht zu erreichen. Die Tätigkeit und die mit ihr verbundenen Anforderungen und Ausführungsbedingungen werden musterspezifisch wahrgenommen, wobei Personen mit eingeschränktem Engagement bzw. mit einer Resignationstendenz wesentliche Tätigkeitsmerkmale, denen persönlichkeits- und gesundheitsförderliche Wirkung zugesprochen wird, für sich als wenig wichtig beurteilen und sich mehr Defizite im Verhalten gegenüber Patienten bescheinigen.<br><br>Die Ergebnisse verweisen darauf, dass im Pflegeberuf vor allem die Zurückhaltung im Engagement Anlass für eine kritische Betrachtung sein muss. Das Problem "Burnout" stellt sich in seiner Bedeutung relativiert dar. Günstigere Voraussetzungen für die Aufrechterhaltung und Förderung der Gesundheit bestehen dort, wo im konkreten Arbeitsfeld ein erweiterter Tätigkeits- und Handlungsspielraum sowie mehr Verantwortung vorliegen. Diese Befunde stehen in Einklang mit arbeitspsychologischen Ressourcenmodellen. Die Befunde zu den Pflegeschülern verweisen auf teilweise ungünstige Eignungsvoraussetzungen der Auszubildenden und legen nahe, die Angemessenheit der Anforderungen in den Krankenpflegeschulen zu hinterfragen. Hinsichtlich der Möglichkeiten der Veränderung der Muster in gesundheits- und motivationsdienlicher Weise brachten die Ergebnisse zum Ausdruck, dass verhaltensbezogenen Maßnahmen ohne gleichzeitige bedingungsbezogene Interventionen wenig Erfolg beschieden ist. Mit Blick auf die musterspezifische Wahrnehmung der Tätigkeit und der mit ihr verbundenen Anforderungen und Ausführungsbedingungen ist schließlich grundsätzlich festzuhalten, dass arbeitspsychologische Konzepte, die hohen bzw. komplexen Anforderungen und umfangreichen Freiheitsgraden in der Arbeit grundsätzlich persönlichkeits- und gesundheitsförderliche Wirkungen zuschreiben, einer Relativierung durch eine differentielle Perspektive bedürfen. Die vorgefundene Interaktion von Persönlichkeit und Arbeitsbedingungen hat zur Konsequenz, dass Verhaltens- und Verhältnisprävention in untrennbarem Zusammenhang gesehen werden sollten. / The object of this essay is the strain situation of nursing personnel in the hospital sector. We will take a look at the coping capacity of the nursing personnel, the behaviour and experience patterns with which they meet their challenges and how they co-design their present and future strain situations by means of their personal approach to these challenges.<br><br>The theoretic starting points of this work are salutogenetic-oriented resource models, especially Becker's model of mental health (Becker, 1982, 1986). According to him, a person's state of health depends on how well he or she manages to cope with external and internal demands with the help of external and internal resources. The model uses the lack of satisfaction of personal requirements as a source of extraordinary strain. This is where the diagnostic instrument AVEM (Arbeitsbezogenes Verhaltens- und Erlebensmuster [work-related behaviour and experience patterns]; Schaarschmidt & Fischer, 1996, 2001) comes into the picture, which is at the center of work and helps to determine the internal requirements and resources of the person as well as the classification into 4 behaviour and experience patterns compared to working under health and motivation aspects.<br><br>These hypotheses assume that reduced engagement as well as guarding against demands deemed unwanted and inappropriate together with hard to influence conditions are in the foreground when considering the problematic working conditions in the nursing profession.<br><br>More favourable model constellations should occur in areas with partially health-promoting and challenging working conditions. We furthermore assume that the expected unfavourable trends already become apparent during vocational training and the early working years. It should be possible to induce pattern changes from a health and personality promotion point of view by means of targeted intervention. And finally, we assumed that the profession and its related challenges and performance conditions are perceived as patterns.<br><br>In order to answer these questions, we will refer to results from various cross-section and panel studies performed in hospitals and nursing colleges in Vienna but also in German hospitals. The results obtained in other profession groups will be presented for comparison. Besides the AVEM, we applied additional questionnaires dealing with the following contents: work-related values, experiencing resources in the nursing profession, experiencing strain and objective professional features.<br><br>The results confirm the hypothesis in all essential points. Compared to other profession groups in Austria, the nursing profession shows clear restrictions when it comes to work engagement. With respect to the health risk patterns, the nursing profession takes a medial position. The pattern differentiation in the nursing population shows the strongest differences depending on the position: the higher the position, the larger the share of the health pattern and the lower the resignation tendency. Most risk patterns become evident among nursing staff with the lowest qualifications. Nursing students temporarily show strong occurrences of resignation and experience patterns as well as a continuous decline in engagement. This trend continues once the vocational training is completed. Only direct, intensive and person-oriented intervention turned out to be suitable in order to achieve pattern changes with respect to promoting health and personality. In the end it turned out that the profession and its related demands and performance conditions is perceived in a pattern-specific way, whereby especially persons with restricted engagement or a trend towards resignation rate essential work features that are said to promote health and personality as less important for themselves and attribute themselves more deficits in their behaviour towards patients.<br><br>The results indicate that above all restrained engagement must be critically examined in the nursing profession. The "burnout" problem, which is often seen as a central problem, is therefore relative. More favourable prerequisites for maintaining and promoting health are especially given wherever there is extended activity and action scope in the actual working environment together with more responsibility. These results coincide with the recognised work psychology models, which emphasise the effect of resources. The results obtained for nursing students indicate that part of the trainees lacks qualification. However, one also has to question the appropriateness of the demands made in nursing schools. With respect to changing the patterns in a way that suits health and motivation, the results showed that behaviour-related measures are not very successful if there are no condition-related interventions at the same time. Concerning the pattern-specific perception of the profession and its related demands and performance conditions, we conclusively have to ascertain that work psychology concepts, which generally attribute personality and health-promoting effects to high or complex demands and extensive degrees of liberty at work, require relativisation through a differential perspective. As a consequence of the encountered interaction of personality and work conditions, behaviour and condition prevention should be seen in an inseparable context.

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Zugl.: Witten, Herdecke, Universiẗat, Diss.

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Hintergrund: Aufgrund des demographischen Wandels nimmt der Anteil der Pflegebedürftigen in Deutschland zu. Aktuelle Erhebungen zeigen, dass der Einzug in stationäre Pflegeeinrichtungen erst in höherem Lebensalter und bei steigenden Komorbiditäten erfolgt, womit ein erhöhter Bedarf an medizinischer und pflegerischer Versorgung einhergeht. Ziele der Studie: Durch die Befragung der Pflegeheimbewohnenden sollten Erkenntnisse über eine bereits erfolgte Vorsorgedokumentation und deren Versorgungswünsche am Lebensende gewonnen werden. Methodik: Es wurde eine multizentrische, explorative Beobachtungsstudie als Vollerhebung in elf bayerischen Pflegeeinrichtungen durchgeführt. Die Datenerhebung erfolgte vor Ort durch den Promovierenden mittels eines standardisierten Fragebogens im Zeitraum von April 2018 bis Mai 2019. Im Zuge der statistischen Auswertung wurden deskriptive Statistiken erstellt, Gruppenunterschiede wurden zweiseitig mittels Fisher-Exakt-Test auf Unabhängigkeit hin überprüft und paarweise Gruppenvergleiche durch binäre logistische Regression durchgeführt. Ergebnisse: Von 1207 wurden 269 (22,3 %) Pflegeheimbewohnende in die Studie eingeschlossen. Von den Studienteilnehmenden hatten sich 55 % bereits intensiver mit dem eigenen Sterben auseinandergesetzt. 50,9 % der Pflegeheimbewohnenden wünschten im Falle einer zum Tode führenden Erkrankung eine alleinige pflegerische und medizinische Versorgung in der Einrichtung. 19,7 % wünschten in diesem Fall eine Klinikeinweisung, aber den Verzicht auf Anwendung invasiver Therapiemaßnahmen. Ein Wunschsterbeort lag bei 65,4 % der Pflegeheimbewohnenden vor. Von diesen wünschten 76,7 % in der Pflegeeinrichtung zu versterben. 71,7 % der Pflegeheimbewohnenden wünschten, nicht allein zu versterben. Über ihre Versorgungswünsche hatten bereits 45,7 % aller Studienteilnehmenden eine andere Person, mehrheitlich die eigenen Angehörigen, informiert. 49,1 % der Pflegeheimbewohnenden wünschten sich eine Erfassung der Versorgungswünsche direkt bei Einzug in die Einrichtung. In 63,6 % der Fälle lag mindestens ein schriftliches Vorsorgedokument vor. Eine Patientenverfügung hatten 45,5 %, eine Vorsorgevollmacht 46,5 % der Pflegeheimbewohnenden verfasst. Schlussfolgerungen: Pflegeheimbewohnende haben mehrheitlich konkrete Vorstellungen für ihre Versorgung am Lebensende. Die vorhandenen Versorgungswünsche sollten auf Wunsch der Pflegeheimbewohnenden erfasst werden, um eine entsprechende Versorgung auch im Falle einer eintretenden Einwilligungsunfähigkeit zu ermöglichen. Der Zeitpunkt der Erfassung der Versorgungswünsche sollte im Hinblick auf das steigende Lebensalter bei Einzug in deutsche Pflegeeinrichtungen und auf die altersbedingt steigende Rate an kognitiven Einschränkungen möglichst frühzeitig gewählt werden. Hierbei stellen Konzepte der vorausschauenden Versorgungsplanung eine Möglichkeit dar, um einen Dialog zwischen den beteiligten Akteuren zu ermöglichen. / Background: Due to demographic change, the proportion of people in need of long-term care in Germany is increasing. Current surveys show that people only move into inpatient care facilities at an older age and with increasing comorbidities, which is accompanied by an increased need for medical and nursing care. Aims of the study: The survey of nursing home residents was intended to gain insights into existing precautionary documentation and their wishes for care at the end of life. Material and Methods: A multicentre explorative observational study was conducted as a full survey in eleven Bavarian care facilities. Data collection was carried out on site by the PhD student using a standardised questionnaire in the period from April 2018 to May 2019. During statistical analysis, descriptive statistics were compiled, group differences were tested two-sided for independence using Fisher’s exact test and pairwise group comparisons were carried out using binary logistic regression. Results: Out of 1207, 269 (22.3%) nursing home residents were included in the study. Of the study participants, 55% had already dealt more intensively with their own dying. 50.9% of the nursing home residents wanted sole nursing and medical care in the facility in the event of an illness leading to death. In this case, 19.7% wanted to be admitted to hospital, but did not want invasive therapy measures to be used. A desired place of death was present in 65.4% of the nursing home residents. Of these, 76.7% wished to die in the nursing home. 71.7% of the nursing home residents did not wish to die alone. 45.7% of all study participants had already informed another person, mostly their own relatives, about their care wishes. 49.1% of the nursing home residents wanted their care wishes to be recorded directly when they moved into the facility. In 63.6% of the cases, at least one written advance directive was available. 45.5% of the nursing home residents had written a living will, 46.5% a health care proxy. Conclusions: The majority of nursing home residents have concrete ideas about their care at the end of life. The existing care wishes should be recorded at the request of the nursing home residents in order to enable appropriate care even in the event of incapacity to consent. The time of recording the care wishes should be chosen as early as possible in view of the increasing age at the time of moving into German nursing homes and the age-related increase in the rate of cognitive impairments. Here, concepts of advance care planning are a possibility to enable a dialogue between the actors involved.

There is longstanding causal relationship between cigarette smoking and lung cancer. Smoke-free policies and anti-smoking campaigns have been linked to the decline in smoking acceptance and contribute to the unintended consequence of stigmatizing smokers. Lung cancer is viewed as a self-inflicted disease and patients’ feel judged in a manner different from other cancers affecting social interactions between family, friends, and healthcare professionals. Lung cancer stigma contributes to depression, anxiety, poor self-esteem, guilt, shame, blame, threatens a person’s social identity, and limits social support that deeply affects patients and their support persons. This dissertation contains a review of the literature related to smoking and stigma, an evaluation of the psychometric properties of an investigator-developed instrument, “Lung Cancer Stigma Scale” (LuCaSS) and the main findings from a cross-sectional observational study of 104 lung cancer patients assessing factors associated with lung cancer stigma. The Model of Stigma Induced Identity Threat provides the framework to examine stigma and the relationship between social constraints, self-esteem, and smoking and to test whether social support mediates the relationship between stigma, and depression/anxiety. The LuCaSS was a reliable and valid instrument measuring lung cancer stigma (alpha = 0.89). The principle components analysis determined three subscales measuring internalized stigma: social rejections/judgment, blame/guilt, and shame. Social constraints, self-esteem, smoking each significantly contributed to the prediction of stigma controlling for SES. Lung cancer patients with greater social constraints and lower self-esteem and who were smokers scored higher on stigma. Social support was a mediator for the relationship between stigma and depression but not for anxiety. The findings are consistent with Stigma Induced Identity Threat Model. A stigmatized identity can lead to stress-related health outcomes such as depression. A lung cancer diagnosis has numerous negative psychosocial effects on patients. Integrating stigma tools (i.e. LuCaSS) in practice settings may assist with determining potential stigma related distress among lung cancer patients. Emphasizing the need for social support and implementing more advocacy efforts may also help minimize the effects of stigma and depression. Future studies are necessary to further examine the role of social support in minimizing stigma and psychosocial distress.

Heart failure (HF) is a major public health problem throughout the world. It accounts for one death certificate among nine in the United States. Heart failure and sudden death combined are responsible for the largest number of deaths in America. The total costs of HF in the United States are estimated to be $37 billion each year. Despite substantial medical and surgical advances related to treatment of HF, it remains a very costly condition with high mortality and morbidity rates. Although biological factors contribute to high morbidity and mortality in HF, there are many unexplored psychosocial factors that also likely contribute to these rates. Thus, the purpose of this dissertation was to examine the association between some of the psychosocial factors (i.e. depression, anxiety, comorbid depression and anxiety, stress, cognitive appraisal, and coping) and health outcomes as defined by rehospitalisation and mortality among HF patients. The first paper is a report of longitudinal study of 1,260 patients with HF. The purpose of the study was to determine whether co-morbid symptoms of depression and anxiety are associated with all-cause mortality or rehospitalization for cardiac causes in patients with HF. Anxiety and depression were treated first as continuous level variables, then as categorical variables using standard published cut points. Patients were then divided into four groups based on the presence of symptoms of anxiety and depression. When depression and anxiety were treated as continuous level variables, both comorbid depression and anxiety, and depression alone were significant predictors of all-cause mortality. However, when depression and anxiety were treated as categorical variables, comorbid depression and anxiety was a predictor of all-cause mortality, while anxiety and depressive symptoms considered alone were not independent predictors of the same outcome. None of those variables were significant predictors of cardiac rehospitalization outcome, regardless of whether entered as continuous or categorical level variables. The second paper is a report of a study that was conducted to (1) examine the association of stress with 6-month cardiac event-free survival; (2) examine the relationship of stress with salivary cortisol; and (3) examine the association of salivary cortisol level with 6-month cardiac event-free survival. The study sample was 81 HF patients. A prospective design was used in which patients were followed for 6 months to determine occurrence of 6-month cardiac event-free survival, defined as time to the combined endpoint of cardiac rehospitalization or all-cause death. Stress was not a significant predictor of event-free survival in HF, salivary cortisol was a significant predictor of event-free survival in the unadjusted model, but not in the adjusted model, and stress was not a significant predictor of salivary cortisol level. The final paper is a report of prospective design study that aimed to describe self-reported stress level, cognitive appraisal and coping among patients with HF, and to examine the association of cognitive appraisal and coping strategies with event-free survival based on a proposed model of HF patients’ response to stressors that been suggested according to literature to date. The study sample consisted of 88 HF patients who been followed for 6 months to determine occurrence of the combined endpoint of rehospitalization for cardiac causes or all-cause death. The study showed that stress level was associated with harm and loss cognitive appraisal. Harm/loss and threat cognitive appraisals were associated with avoidant emotional coping. Furthermore, harm/loss cognitive appraisal was a significant predictor of avoidant emotional coping and event free survival. Finally avoidant emotional coping was a significant predictor of event free survival among HF patients in the unadjusted model, but not in the adjusted model. The findings from this dissertation provided further evidence of the importance of psychosocial factors to health outcomes in HF patients. It also filled important gaps in the body of knowledge related to health outcomes among those with HF by demonstrating the need for cognitive and behavioral therapy among HF patients who negatively appraise their health condition.

Previous research described the value farmers place on their ability to work. The impact of obesity on workers is an increasing concern in occupational health research; yet, knowledge regarding the impact of obesity on the performance of farm work is limited. Identifying the impact of obesity on farmer’s work ability can guide healthcare workers in promoting and motivating farmers to implement lifestyle changes to improve health and sustain longevity in their ability to work. The purpose of this dissertation was to examine the impact of obesity on the work ability of U.S. farmers. Specific aims were to 1) examine the current state of the science regarding obesity in farmers; 2) to evaluate the psychometric properties of the Work Ability Index; 3) identify the relationship between obesity and work ability; and 4) compare central versus general obesity as predictors of decreased work ability in U.S. farmers. Key findings of this research support obesity as an increasing concern among U.S. farmers which can result in a decline in work ability. Psychometric evaluation of the Work Ability Index also supports the use of this tool for research and clinical assessment in this population. Implications for clinical practice and nursing research are also discussed.

Injury is a global health problem and in the United States is the leading cause of death for persons aged 1 – 44 years. The primary causes of trauma related death are head injury and hemorrhage; hemorrhagic shock is difficult to recognize in the first hours after trauma. Identification of specific and optimal criteria upon which to base effective triage decisions for trauma patients has been an elusive goal for decades. The purpose of this dissertation was to identify measures available in the prehospital phase of care and in the Emergency Department that should be included for a more comprehensive definition of the trauma patient who will require trauma center care to better allocate trauma care and resources available. The first paper is a critical review of early physiologic markers of occult tissue hypoperfuson in which we examine markers of cardiovascular function and markers of tissue perfusion. In this review, we found surrogate measures of tissue perfusion include shock index as a measure of hemodynamic stability and acid-base indicators as measures of tissue oxygenation. This review guides the variable selection for the research study. The second paper is a report of a study conducted to examine shock index calculated from the first available prehospital vital signs and first available emergency department vital signs as a predictor of mortality within 48-hours in trauma compared to the Injury Severity Score. Shock index can be calculated in real-time during the course of treatment and provides continuous input into the ever changing condition of the patient. Injury severity score is calculated once, at the time of hospital discharge and is used primarily as a marker for comparison of injury severity in research and quality measures of trauma care. The study consisted of 516,156 trauma patient data reported to the National Trauma Data Bank (NTDB) in 2009. The results revealed SI as calculated in both the pre-hospital phase of care by Emergency Medical Services and in the Emergency Department to be significant independent predictors of mortality within forty-eight hours from trauma injuries. The third paper is a report of a study conducted to examine potential markers of occult tissue hypoperfusion within forty-eight hours of injury. The variables included four major variable categories, physiologic measures, anatomic measures, injury severity and presence of reported comorbid illness. The variable most predictive of death from trauma related injuries within forty-eight hours was the need for intubation. The findings from this dissertation provide further evidence of the value of multiple physiologic markers in early recognition of occult tissue hypoperfusion. Data from neither the review of the literature nor the two data-based studies are sufficient to identify a brief, accurate, easily used clinical instrument. Further work is needed to develop a clinically useful instrument to identify the occult tissue hypoperfusion in the trauma patient.