Health problems and violence experiences of nurses working in acute care hospitals, long-term care facilities, and home-based long-term care in Germany: A systematic review.

BACKGROUND: Working in the nursing sector is accompanied by great physical and mental health burdens. Consequently, it is necessary to develop target-oriented, sustainable profession-specific support and health promotion measures for nurses.
OBJECTIVES: The present review aims to give an overview of existing major health problems and violence experiences of nurses in different settings (acute care hospitals, long-term care facilities, and home-based long-term care) in Germany.
METHODS: A systematic literature search was conducted in PubMed and PubPsych and completed by a manual search upon included studies' references and health insurance reports. Articles were included if they had been published after 2010 and provided data on health problems or violence experiences of nurses in at least one care setting.
RESULTS: A total of 29 studies providing data on nurses health problems and/or violence experience were included. Of these, five studies allowed for direct comparison of nurses in the settings. In addition, 14 studies provided data on nursing working in acute care hospitals, ten on nurses working in long-term care facilities, and four studies on home-based long-term care. The studies either conducted a setting-specific approach or provided subgroup data from setting-unspecific studies. The remaining studies did not allow setting-related differentiation of the results. The available results indicate that mental health problems are the highest for nurses in acute care hospitals. Regarding violence experience, nurses working in long-term care facilities appear to be most frequently affected.
CONCLUSION: The state of research on setting-specific differences of nurses' health problems and violence experiences is insufficient. Setting-specific data are necessesary to develop target-group specific and feasible interventions to support the nurses' health and prevention of violence, as well as dealing with violence experiences of nurses.

Introduction

Despite the international differences in health care systems, professional nursing is generally described as a crucial part of the health care system. It encompasses health promotion, disease prevention, and care of individuals of all ages with physical or mental illness, or with disabilities [1]. In the German care system, nursing care takes place in different settings, such as in hospitals, nursing homes, at home or in community-based institutions. Crucial settings for adult-based nursing care are acute care hospitals, long-term care facilities (LTC), and the patients’ home.

In 2019, more than 19 million medical cases were treated in German acute medical care hospitals and rehabilitation facilities [2]. Beyond, more than 820,000 patients received long-term care (LTC) in LTC facilities. Around 980,000 patients received LTC by professional nurses in home-based settings [3]. With regard to the number of employees, there are currently more than 345,000 nurses working in acute care hospitals [4] and more than 600,000 nurses working in LTC facilities or in home-based LTC [5]. This means that around one million people are currently employed as professional nurses. Demand for this profession steadily rises due to demographic change and the increase of non-communicable diseases [6, 7].

However, about 75% of nurses assume not to be able to work in this profession until retirement under the given conditions [8]. Almost every second nurse thinks about leaving the profession several times a year [8-10]. One reason is that the profession appears to be associated with major health problems [11, 12], which is associated with a comparatively high number of sick days. Nurses in LTC facilities or home-based settings (24.1 days/year), or in hospitals (19.3 days/year) have considerably more sick days than employees in other occupational fields (16.1 days/year) [13]. In addition to health-related burdens, violence experiences are also considered to be a crucial occupational stress factor for nurses. This is reflected in the number of incidents as well as the the severity of the impact [14]. Violence experiences can include physical or verbal violence experiences, patient- or relatives related aggressions, and sexual harassment [15, 16]. Violence experiences can lead not only to physical harm, but also to mental health problems including impaired well-being or even symptoms of post-traumatic stress disorder [17-19]. Additionally, nurses’ feelings of anxiety and anger due to violence experiences also go in line with less job satisfaction [20] and enhanced withdrawal intentions [21]. Studies show that at least 14% of nurses have been victims of violence in the past three months [22].

Despite the importance of nursing as an occupational field, little is known to date about specific health problems of nurses working in acute care hospitals, LTC facilities, or in home-based LTC. Tasks of nurses in these three areas differ considerably. Whereas tasks in the acute care hospital mainly focus on accompanying and supporting patients with acute medical treatment and recovery, the tasks in LTC for the elderly (e.g., in LTC facilities or home-based LTC) are based on the concept of need for LTC according to the Social Code XI (German: “Sozialgesetzbuch XI”) [23]. According to this, tasks mainly support the following sectors: support of mobility (e.g., changing positions in bed, transferring, moving around within the living area), support of cognitive and communicative abilities (e.g., orientation in time and place), reduce behavioral and psychological problems (e.g., self-damaging behavior, aggressive behavior toward other persons, depressive moods), promote activities of daily living (e.g., washing, (un)dressing, using a toilet), coping with illness- or therapy-related requirements and stress (e.g., with regard to medication, wound care), and fostering social contacts [23, 24]. Some tasks occur more frequently in the LTC facilities settings, while others may be more common in the home-based LTC setting. As nurses’ daily working life differs over the settings, it is assumed that health problems and violence experiences might be different, too [25, 26]. This knowledge is an important requirement to develop target group-specific occupational health promotion and support programs for nurses. The research question for this review was: What are the health problems and violence experiences of nurses in acute care hospitals, LTC facilities, and home-based LTC?

Methods

This systematic review was conducted following the international guidelines established by PRISMA (Preferred reporting items for systematic reviews and meta-analysis protocols) [27]. To ensure transparency and reproducibility, the systematic review protocol was registered in the International prospective register of systematic reviews (PROSPERO) (registration number: CRD42021231891).

Search strategy

All potential articles from PubMed and PubPsych were obtained by electronic search. The search for both databases was performed on January 11th, 2021. Search terms used for relevant studies were built of the following keywords and Boolean operators (in cursive): (nurs* OR "professional care" OR "professional caregiver") AND (health OR violence) AND (“cross sectional” OR survey) AND (german*). Original studies in German or English language published between January 01st, 2010 and January 11th, 2021 were taken into account. Results were completed by a manual search upon included studies’ references and health insurance reports.

Inclusion and exclusion criteria

Articles that met the following inclusion criteria were considered for further analysis of (1) cross-sectional data, (2) target group or subgroup analysis: professional nurses in Germany, (3) setting: acute care hospital, LTC facilities and/or home-based LTC, (4) data on physical health, mental health and/or violence experience (physical or verbal violence experiences, patient-related aggressions, sexual harassment). Studies which met at least one of the following criteria were excluded: (1) longitudinal studies or validation studies, (2) qualitative studies, (3) studies outside of Germany. Additionally, we excluded studies addressing health issues of apprentices, supervisors, or managers.

Quality assessment

To evaluate the selected articles and to identify the risk of bias of the included studies, the Joanna Briggs Institute`s checklist for prevalence studies was applied [28]. This checklist includes nine items, which are answered with "yes", "no", "unclear", and “not applicable” respectively. The rating was conducted independently by two authors (MG, TK). Disagreements in the ratings of the nine items were resolved after reconsideration and, if necessary, discussed with a third author (AS). For each study, the percentage of checklist items answered with “yes” was calculated. Studies were considered “low risk of bias” if the study scored ≥50% by fulfilling at least five quality requirements.

Study selection, data extraction and synthesis

After eliminating duplicates, two authors (MG, TK) independently performed the title and abstract screening by using the software tool for systematic reviews “Rayyan” [29]. Subsequently, full-texts of the included studies were again independently assessed for eligibility and reasoned exclusions were recorded. Any disagreements were resolved by discussion and consensus with a third researcher (AS). The selection process was displayed in a PRISMA Flow Chart [27]. Data of the studies were separately extracted by two authors (MG, TK) and crosschecked in each case.

Extracted data included the setting in which the study was conducted (acute care hospital, LTC facilities, home-based LTC, cross-setting), author and publication year, sample size, sample characteristics (age, gender), the health problem and/or violence experience assessed in the study (physical health, mental health, and/or violence experiences) and the findings of the study related to the respective health problem. In the present study, professional nurses were considered to be qualified by graduation from an accredited school of nursing and by passage of a national licensing examination to practice nursing. Our definition of violence is based on the WHO definition of violence against patients or residents. This definition is acknowledged and accepted in the field of nursing and comprises emotional, physical and sexual forms of violence which cause harm or distress to the affected person [30, 31]. Some of the included studies did not contain all the aforementioned variables. In these cases, the available data were reported. Missing data was indicated by the note "not reported".

The extracted data were presented in four setting-related tables (acute care hospital, LTC facilities, home-based LTC, cross-setting). In this study, “acute care hospital” was considered as a setting where a patient needs immediate treatment and care (e.g., after an accident). Its goal lies on supporting patients with acute medical treatment and recovery. “LTC facilities” in this study were considered as nursing homes or professional nursing facilities. “Home-based LTC” was defined as the provision of nursing and domestic care of older people in need of LTC in their own homes. Both provision of LTC in “LTC facilities” and “home-based LTC” base on support with daily activities for people who experience a decline in self-care on a long-term basis [32]. The tables were used as a basis for a narrative synthesis of the key findings of the included studies.

Results

Selected studies

The initial search yielded 447 articles with 417 remaining after duplicates were removed. After screening titles, abstracts, and full texts, 17 studies were included. Additionally, six studies were identified by cross-reference and another six studies by health insurance reports. This resulted in a total of 29 articles (see Fig 1). Of these, 15 studies were found in PubMed and 8 studies in PubPsych, whereby six duplicates occured.

Fig 1

PRISMA flow chart of the systematic literature search.

Of the 29 studies, ten studies addressed a setting-unspecific or cross-setting approach (Table 1). This implies that the sample could not or could only partially be assigned to the three settings studied. From these ten studies, it was possible to find specific subgroup data for settings in two studies, so that they were also assigned to the respective setting [33, 34]. Fourteen studies provided data on health and/or violence experiences of nurses working in acute care hospitals (Table 2), ten studies of nurses working in LTC facilities (Table 3), and four provided data regarding nurses working in home-based LTC (Table 4). The sample size varied between 20 nurses (LTC facilities) [35] to 355,988 (acute care hospitals) [36]. Overall, the proportion of female nurses in the studies ranged from 69.8% [37] to 93% [38] and the average age ranged between 26.5 years [37] to 45.7±11.4 [39]. The JBI Critical Appraisal Checklist [28] varied between 33% [15] and 100% [40, 41], with an average of 71%.

Table 1

Setting-unspecific/cross-setting—Summary of the studies included in the review.

Setting-unspecific/cross-setting
Author (year)	Sample		Health problem, violence experience and related and outcome	Result
	Sample size (subgroups)	1. Age [years].
		2. Gender (female)
Diehl et al. (2020) [53]	1316 (palliative care)	1.<39: 26.5%; 40–49: 28.4%; >50: 45.1%	Physical health: subjective general health status	Physical healthSelf-rated health [min: 0; max: 100]: M±SD = 72.86±16.94Mental health:Burnout [min: 0; max: 100]: M±SD = 41.43±17.61
		2. 87.3%	Mental health: burnout
Ehegartner et al. (2020) [40]	1381 (27.8% hospital, 41.9% LTC facilities, 30.2% home-based long-term care)	1. M±SD = 40.1±12.0	Physical health: physician-diagnosed disease	Prevalence of physician-diagnosed disease (top 3)Musculoskeletal diseases: 79.7%Cardiovascular diseases: 38.8%Mental impairments: 32.3%
		2. 81%	Mental health: physician-diagnosed disease
Gencer et al. (2019) [33]	167 (65.4% LTC facilities palliative care, 34.6% home-based palliative care)	1. Median = 48 (Range = 23–62)	Physical health: subjective general health status	Physical health:Prevalence of good/very good general health status: 64.2%Mental health:Prevalence of noticeably high strain: 27.6%Prevalence of serious high strain: 27.6%Violence:Subgroup specific results
		2. 89.9%	Mental health: score
Drupp & Meyer (2019) [36]	355,988 (71.7% LTC; 24.9% nurses)	1. Mean = 40.6	Physical and mental health: physician-diagnosed disease	Physical health:Respiratory diseases: 53.9 cases of work incapacity per 100 insured yearsMusculoskeletal diseases: 39.5 cases of work incapacity per 100 insured yearsMental health:Psychological diseases: 19.4 Cases of work incapacity per 100 insured years
		2. 85.5%
Lohmann-Haislah et al. (2019) [34]	318 (Setting-unspecific subgroup of nurses in a study with several professions)	1. 15–34: 21.4%; 34–54: 52.8%; >55: 25.9%	Physical health: Musculoskeletal problems, other health problems	Physical health:Prevalence of musculoskeletal health problems (top 3):Low back pain: 70%Neck-shoulder pain: 64.3%Pain in arms: 35.7%Prevalence of other physical health problems (top 3):Headache: 40.0%Running nose/sneezing: 20.6%Stomach and digestive problems: 18.0%Mental health:Prevalence of psychosomatic health problems (top 3):General fatigue, tiredness, exhaustion: 57.8%Physical exhaustion: 54.5%Nervousness/irritability: 37.7%
		2. 90.4%	Mental health: psychosomatic complaints
Schablon et al. (2012) [16]	1178 (Setting-unspecific subgroup of nurses in a study with several professions, 23.8% head nurses, 76.2% nurses)	not reported for the subgroup of nurses	Violence: verbal, physical	Violence:Prevalence of verbal violence in the past 12 months: 84%Prevalence of physical violence in the past 12 months:: 61%
Schablon et al. (2018) [43]	884 (setting-unspecific subgroup of nurses in a study with several professions, 23.2% nurses with managerial role, 76.8% nurses without managerial role)	not reported for the subgroup of nurses	Violence: verbal, physical	Violence:Prevalence of verbal violence in the past 12 months: 96.6%Prevalence of physical violence in the past 12 months: 76.5%
Schmidt & Diestel (2014) [54]	195 (cross-setting study including: nurses in a hospital and three nursing homes for the elderly)	1. M±SD = 37.29±10.6	Mental health: burnout (emotional exhaustion, depersonalisation), depressive symptoms	Mental health:Emotional exhaustion [min: 1; max: 6]: M±SD = 2.2±0.79Depersonalisation [min: 1; max: 6]: M±SD = 1.92±0.77Depressive symptoms [min: 1; max: 5]: M±SD = 1.02±0.76
		2. 85%
Skoda et al. (2020) [55]	1511 (Setting-unspecific subgroup of nurses in a study with several professions)	1. not reported by the authors	Mental health: anxiety	Mental health:Generalized anxiety disorder: 11.41%
		2. 86.83%
Weidner et al. (2017) [22]	402 (Setting-unspecific subgroup of nurses in a study with several professions)	1. not reported by the author	Violence	Violence:general experience of violence (5-fold likert scale: [min: 1; max: 5] 1: not at all; 5: very often):very often/often: 13.7%
		2. not reported

Table 2

Hospital—Summary of the studies included in the review.

Hospital
Author (year)	Sample		Health problem, violence experience and related and outcome	Result
	Sample size (respondents)	1. Age [years]
		2. Gender (female)
Aiken et al. (2012) [45]	1508 (Subgroup of an international study)	not reported for the subsample nurses in hospitals	Mental health: burnout	Mental health:Prevalence of burnout: 30%
Fischer et al. (2020) [46]	576	1. <30: 28.6%; 31–40: 18.1%; 41–50: 26.4%; >51: 26.9%	Mental health: burnout	Mental health:Prevalence of burnout symptoms (moderate to high): 50.4%
		2. 74.5%
Grobe & Steinmann (2019) [50]	275,375 (Subgroup of a cross-setting study)	1. not reported for the subsample nurses in hospitals	Physical and mental health: physician-diagnosed disease	Physician-diagnosed disease (top 3):Muscular and skeletal diseases: 446 diagnoses per 100 insured yearsMental disorders: 428 diagnoses per 100 insured yearsRespiratory deseases: 318 diagnoses per 100 insured years
		2. 80%
Kowalski et al. (2010) [41]	959	1. M±SD = 38.0±9.8	Mental health: burnout	Mental health:Prevalence of burnout symptoms (moderate to high): 60%
		2. 87.9%
Lehmann-Willenbrock et al. (2012) [38]	138	1. M±SD = 39.85±9.74	Mental health: stress	Mental health:Stress [min: 1; max: 6]: M±SD = 2.72±1.07
		2. 93%
Lindner et al. (2015) [15]	142	not reported by the authors	Violence: verbal, physical	Violence:Prevalence of verbal aggression in the past six months: 93%Prevalence of physical aggression in the past six months: 46%Prevalence of injuries due to aggression in the past six months: 34%
Lohmann-Haislah et al. (2019) [34]	685 (Subgroup of a cross-setting study)	1. 15–34: 17.5%; 34–54: 63.2%; >55: 19.2%	Physical health: Musculoskeletal problems, other health problems	Prevalence of musculoskeletal health problems (top 3)Neck-shoulder pain: 65.3%Low back pain: 63.8%Pain in legs/feet: 34.6%Prevalence of other physical health problems (top 3)Headache: 43.0%Running nose/sneezing: 27.4%Stomach and digestive problems: 27.1%Prevalence of psychosomatic health problems (top 3)General fatigue, tiredness, exhaustion: 61.4%Physical exhaustion: 53.5%Sleep disorders: 52.3%
		2. 83.5%	Mental health: psychosomatic complaints
Otto et al. (2019) [35]	44 (Subgroup of a cross-setting study)	1. M±SD = 29.45±11.16	Physical health: score incuding physical functioning, role-physical, bodily pain and general health	Physical health:Physical health score [min: 0; max: 100]: M±SD = 53.31±7.07Mental health:Mental health score [min: 0; max: 100]: M±SD = 43.72±9.84Stress [min: 0; max: 48]: M±SD = 22.61 ±10.08
		2. not reported by the authors
			Mental health: score including vitality, social functioning, role-emotional; Stress
Paffenholz et al. (2020) [47]	834	not reported by the authors	Mental health: concern for own health	Concern for own health in the context of the COVID-19 pandemic (5-fold likert scale: [min: 1; max: 5] 1: not at all; 5: very strongly)Strongly: 21.8%Very strongly: 9.5%
Raspe et al. (2020) [37]	205	1. M±SD = 26.5±3.1	Physical health: subjective general health status	Physical health:Subjective general health status [min: 0; max: 100]: M±SD = 56.2±16.9Mental health:Burnout [min: 0; max: 100]: M±SD = 57.1±16.3ViolencePrevalence of verbal aggression (at least 4x/year): 84%Prevalence of physical aggression (at least 4x/year): 74%
		2. 69.8%	Mental health: burnout
			Violence: verbal, physical
Rothgang et al. (2020) [52]	1,896 nurses in hospitals (subgroup of nurses in a study with several professions)	1. Not reported by the authors	Physical health: complaints during/after work, physician-diagnosed disease	Complaints during/after work (top 3):Prevalence of pain in arms/hands: 65%Prevalence of low back pain: 64%Prevalence of physical excaustion: 63%Physician-diagnosed disease (top 3):Muscular and skeletal diseases: 418 diagnoses per 100 insured yearsEndocrine, nutritional and metabolic diseases: 248 diagnoses per 100 insured yearsDiseases of the genitourinary system: 233 diagnoses per 100 insured years
		2. 0.7% (nurses working in LTC);
Vaupel et al. (2020) [51]	123	not reported for the subgroup of nurses in hospitals	Violence: verbal and nonverbal sexual harassment and violence	Violence:Prevalence of nonverbal sexual harassment (at least one time/year): 50.0%Prevalence of verbal sexual harassment and violence (at least one time/year): 76.0%Prevalence of physical sexual harassment and violence (at least one tima/year): 47.0%Mental health:Prevalence of emotional exhaustion (at least one time/month): 69.0%Prevalence of depressiveness (often/very often): 1.6%Prevalence of psychosomatic complaints (every few months to daily): 97.5%Prevalence of well-being (never to rarely): 13.8%
			Mental health: Burnout (emotional exhaustion), depressiveness, psychosomatic complaints, well-being (WHO 5)
Wagner et al. (2019) [48]	567 (Subgroup of a study with several professions)	not reported for the subgroup of nurses	Mental health: burnout	Mental health:Burnout [min: 0; max: 100]: M±SD = 36.5±17.6
Weigl & Schneider (2017) [49]	13 (Subgroup of a study with several professions)	not reported for the subgroup of nurses	Mental health: burnout (emotional exhaustion, irritation)	Mental health:Proportion of nurses reporting irritation: 69.2%Proportion of nurses reporting emotional exhaustion: 53.8%

Table 3

Long-term care (LTC) facilities—Summary of the studies included in the review.

Long-term care (LTC) facilities
Author (year)	Sample		Health problem, violence experience and related and outcome	Result
	Sample size (respondents)	1. Age [years]
		2. Gender (female)
Frey et al. (2018) [42]	155	1. M±SD = 41±13	Physical health: low back pain, subjective general health status	Physical health:Lifetime prevalence of chronic back pain: 45.8% (women: 50.8%, men: 20.0%)Health status bad/ moderate: 38.1%
		2. 83.3%
Gencer et al. (2019) [33]	106 (Subgroup of a cross-setting study)	not reported for the subgroup of nurses in LTC facilities	Violence: patient aggression	ViolencePatient aggression (6-fold likert scale: [min: 0; max: 6] 0: no strain; 5: high strain): M = 2.6Physical healthNo results for subgroup reportedMental healthNo results for subgroup reported
			Physical health: subjective general health status
			Mental health: score
Grobe & Steinmann(2019) [50]	52.016 (Subgroup of a cross-setting study)	1. not reported for the subsample nurses in LTC facilities	Physical and mental health: physician-diagnosed disease	Physician-diagnosed disease (top 3):Muscular and skeletal diseases: 555 diagnoses per 100 insured yearsMental disorders: 549 diagnoses per 100 insured yearsRespiratory diseases: 324 diagnoses per 100 insured years
		2. 80%
Otto et al. (2019) [35]	142 (Subgroup of a cross-setting study)	1. M±SD = 40.70±12.22	Physical health: score incuding physical functioning, role-physical, bodily pain and general health	Physical health:physical health score [min: 0; max: 100]: M±SD = 48.23±9.80Mental health:Mental health score [min: 0; max: 100]: M±SD = 46.36±10.33Stress [min: 0; max: 48]: M±SD = 17.82±10.64
		2. Not reported by the authors	Mental health: score including vitality, social functioning, role-emotional, mental health; Stress
Rothgang et al. (2020) [52]	674 (subgroup of nurses in LTC facilities in a study with several professions)	1. not reported for the subsample nurses in LTC facilities	Physical health: complaints during/after work, physician-diagnosed disease	Complaints during/after work (top 3):Prevalence of low back pain: 64%Prevalence of physical excaustion: 62%Prevalence of pain in arms/hands: 58%Physician-diagnosed disease (top 3):Muscular and skeletal diseases: 476 diagnoses per 100 insured yearsEndocrine, nutritional and metabolic diseases: 284 diagnoses per 100 insured yearsMental disorders: 284 diagnoses per 100 insured years
		2. 80.7% (nurses working in LTC);
Schmidt (2010) [56]	242	1. M±SD = 41.53±8.7	Mental health: burnout (emotional exhaustion, depersonalization), psychosomatic complaints	Mental health:Emotional exhaustion [min: 1; max: 6]: M±SD = 3.78±0.97Depersonalization [min: 1; max: 6]: M±SD = 2.92±1.09Psychosomatic complaints [min: 0; max: 3]: M±SD = 2.17±0.87
		2. 82.6%
Schmidt & Diestel (2011) [57]	379	1. M±SD = 39.25±9.26	Mental health: burnout (emotional exhaustion), psychosomatic complaints	Mental health:Emotional exhaustion [min: 1; max: 6]: M±SD = 2.81±0.96Psychosomatic complaints [min: 0; max: 3]: M±SD = 0.95±0.55
		2. not reported
Vaupel et al. (2021) [44]	292	not reported for the subgroup of nurses in LTC facilities	Violence: verbal and nonverbal sexual harassment and violence	Violence:Prevalence of nonverbal sexual harassment (at least one tima/year): 63.0%Prevalence of verbal sexual harassment and violence (at least one tima/year): 69.0%Prevalence of physical sexual harassment and violence (at least one tima/year): 53.0%Mental health:Prevalence of emotional exhaustion (at least one time/month): 58.4%Prevalence of depressiveness (often/very often): 2.1%Prevalence of psychosomatic complaints (every few months to daily): 94.4%Prevalence of well-being (never to rarely): 13.0%
			Mental health: Burnout (emotional exhaustion), depressiveness, psychosomatic complaints, well-being (WHO 5)
Wirth et al. (2017) [39]	274 (Subgroup of a cross-setting study)	1. M±SD = 44±11.8	Mental health: score (Burnout, cognitive stress symptoms)	Mental health:Burnout [min: 0; max: 100]: M±SD = 55±21Cognitive Stress symptoms [min: 0; max: 100]: M±SD = 38±21Physical health:Health status [min: 0; max: 100]: M±SD = 63±20Violence:Physical Violence: 69%Verbal violence: 80.8%
		2. 83.1%	Physical health: health status
			Violence: physical, verbal
Wollesen et al. (2019) [58]	195	1. M±SD = 40.1±12.2	Physical health: physical well-being	Physical health:Physical well-being [min: 0; max: 100]: M±SD = 43.38±8.68Mental health:Psychological well-being [min: 0; max: 100]: M±SD = 45.92±10.81Stress [min: 0; max: 48]: M±SD = 18.76 ±10.36
		2. 85.64%	Mental health: psychological well-being, stress level

Table 4

Home-based long-term care—Summary of the studies included in the review.

Home-based long-term care
Author (year)	Sample		Health problem, violence experience and related and outcome	Results
	Sample size	1. Age [years]
	(respondents)	2. Gender (female)
Gencer et al. (2019) [33]	56 (Subgroup of a cross-setting study)	not reported for the subgroup of nurses in home-based long-term care	Violence: patient aggression	ViolencePatient aggression (6-fold likert scale [min: 0; max: 5]: 0: no strain; 5: high strain): M = 1.9Physical healthNo results for subgroup reportedMental healthNo results for subgroup reported
			Physical health: subjective general health status
			Mental health: score
Otto et al. (2019) [35]	20 (Subgroup of a cross-setting study)	1. M±SD = 30.20±11.17	Physical health: score incuding physical functioning, role-physical, bodily pain and general health	Physical health:Physical health score [min: 0; max: 100]: M±SD = 54.77±5.76Mental health:Mental health score [min: 0; max: 100]: M±SD = 44.40±12.21Stress: [min: 0; max: 48]: M±SD = 26.10±12.86
		2. not reported	Mental health: score including vitality, social functioning, role-emotional, mental health; Stress
Wirth et al. (2017) [39]	92 (Subgroup of a cross-setting study)	1. M±SD = 45.7±11.4	Mental health: score (Burnout, cognitive stress symptoms)	Mental health:Burnout [min: 0; max: 100]: M±SD = 46±24Cognitive Stress symptoms [min: 0; max: 100]: M±SD = 27±22Physical health:Health status [min: 0; max: 100]: M±SD = 66±19Violence: Physical Violence: 20.7%Verbal violence: 70.3%
		2. 90.1%	Physical health: health status
			Violence: physical, verbal
Vaupel et al. (2021) [44]	107	not reported for the subgroup of nurses in home-based long-term care	Violence: verbal and nonverbal sexual harassment and violence	Violence:Prevalence of nonverbal sexual harassment (at least one tima/year): 48.1%Prevalence of verbal sexual harassment and violence (at least one tima/year): 71.0%Prevalence of physical sexual harassment and violence (at least one tima/year): 51.0%Mental health:Prevalence of emotional exhaustion (at least one time/month): 50.0%Prevalence of depressiveness (often/very often): 1,9%. Prevalence of psychosomatic complaints (every few months to daily): 98.1%Prevalence of well-being (never to rarely): 7.5%
			Mental health: Burnout (emotional exhaustion), depressiveness, psychosomatic complaints, well-being (WHO 5)

Regarding the health problems assessed, 23 of the 29 studies assessed mental health, twelve physical health, and nine violence experiences (multiple outcomes possible). Thereby, mental health was most frequently ascertained in the form of the latent construct burnout. Regarding physical health, the most frequently assessed aspects were musculoskeletal complaints [34, 40, 42]. Violence experiences were asked in four studies in terms of both physical and verbal violence [15, 16, 37, 43], and in terms of patient-related aggression [33], general experience of violence [22], or sexual harassment [44].

From a setting-specific perspective, the most frequently studied health problem in the acute care hospital setting was mental health (13 studies) [34, 35, 37, 38, 41, 45–51], whereas physical health was assessed in five studies, and violence problems in four studies. Seven of the ten studies with data on TLC facilities reported on mental or physical health, and three studies on violence experiences. Regarding home-based LTC, three subgroup data available assessed violence experiences, four studies mental,and three studies physical health. Mental health topics were also the most frequently addressed in the cross-setting and non-setting-specific studies.

Five studies pursued a setting-comparative approach, of which data of two studies compared all three settings [35]. The two publications of Vaupel et al. [44, 51] enable a comparison between nurses working in acute care hospitals, LTC facilities, and home-based LTC, because they are based on the same primary data and structured analogously to each other. Both, the results of Otto et al. [35] as well as Vaupel et al. [44, 51] indicate that there are rarely differences in regard to physical health or well-being. However, nurses working in hospitals showed higher stress levels [35] and emotional exhaustion [35]. In contrast, exposure to violence experience was higher in nurses working in LTC facilities, followed by those working in home-based LTC [44, 51].

Two further studies compared health problems and/or violence experience of nurses working in LTC facilities or in home-based LTC [33, 35]. These data confirm that nurses working in LTC facilities seem to be more affected to violence experiences than nurses in home-based LTC. In contrast, nurses working in home-based LTC seem to be more frequently affected by burnout and cognitive stress symptoms than nurses working in LTC facilities [39, 50]. Comparing nurses working in acute care hospitals and in LTC facilities, findings indicate more physical and mental health complaints among nurses working in LTC facilities [50, 52].

Discussion

To our knowledge, this is the first review that focused on summarizing and comparing major health problems and violence experiences of nurses working in acute care hospitals, LTC facilities, and home-based LTC in Germany. We must state that there are currently hardly any cross-setting primary studies providing a well-founded empirical data basis to compare major health problems and violence experiences. The available results indicate that mental health problems might be highest for nurses in acute care hospitals, whereas no setting-specific differences were identified with regard to physical health problems. Comparing nurses working in LTC facilities with those in home-based LTC, mental and physical health problems in those working in LTC facilities appear to be higher. With regard to experiences of violence, nurses working in LTC facilities appear to be more frequently affected compared to those working in acute hospitals and home-based LTC.

Both the lack of comparative studies and the lack of setting-based studies, especially in home-based LTC, is surprising given the known remarkably differences in the working contexts of the settings. In addition to common characteristics in the working conditions of the settings (e.g., time pressure, the availability or appropriate use of ergonomic equipment) further occupational exposure factors emerge. The daily work routine in LTC facilities and hospitals is typically characterized by work interruptions what, for example, points out the need for a coordinated cooperation with other professional groups. In contrast, nurses working in home-based LTC are very much on their own in terms of performing nursing activities and in some cases are also responsible for planning the work tours [59-61]. Although this might appear to be an advantage at first glance, this can easily become a stress factor, for example, if, despite legal requirements, no adequate breaks are taken or possible due to the necessary travel times and possible traffic problems [59-61]. In contrast, hospitals often have a strong hierarchical organizational structure resulting in comparably low participation opportunities for nurses [59, 60, 62]. The consideration of these different working conditions provides one reason for the necessity of setting-specific differentiation in research on the health status and health behavior of nurses. On the other hand, this perspective offers starting points for putting the above-mentioned results of our review into context.

Although the differences in health problems appear to be small on the basis of the current data or have not yet been sufficiently systematically analyzed, it is widely acknowledged that the nursing profession differs significantly from other professions in terms of mental and physical health problems, as well as days of sick leave [36, 50, 52, 59]. In this respect, the available studies of our review are in line with current research showing high prevalences of burnout risk [39, 44, 46, 51, 53, 63] and musculoskeletal disorders [34, 40, 42, 52], independently from the setting nurses work in. This indicates that nurses do not only show an increased risk of long-term absence from work, but also are at risk in terms of occupational disability [13, 58, 64] and early retirement [8]. Thus, it is not surprising that in Germany almost every second employee in this field thinks about leaving the profession several times a year [9].

As a basis for a systematic analysis of the health problems of nurses in Germany, most data are available in the field of mental health, with most of the data on burnout, stress and psychosomatic complaints. Despite different operationalizations, the included studies reveal moderate to high burnout levels or a high burnout prevalence, respectively [39, 44, 46, 51, 53]. This is usually explained by the circumstances of the nursing profession, e.g., unfavorable working hours, routinely coping with obligatory rotating shifts, work overload because of understaffing, time pressure, interfacing problems with other occupational groups and high social responsibility [36, 59, 65–67]. Our results therefore are in line with current research and political demands on developing interventions or therapies helping to prevent or attenuate the above symptoms. Nevertheless, more setting-specific data are needed to help nurses manage their job-related tasks in a health-conscious manner. This also relates to the high proportion of musculoskeletal diseases. Our results show that especially musculoskeletal problems in the shoulder-neck area and low back pain take a high priority [34]. In principle, these problems are attributed to frequent and heavy lifting, as well as patient transfer and positioning [36, 59]. However, due to the different working conditions, setting-specific data would also be highly relevant in this regard for improving the working situation of nursing employees.

In our review, the topic of violence and the lack of studies on it were particularly striking. Compared to mental and physical health topics, violence was by far the least investigated. In total, only seven studies addressed violence experienced by nurses. Setting-specific information on this can only be derived from publications each. Going in line with other research [22], the available data indicate a high level of problems related to verbal and physical experiences of violence, as well as sexual harassment. The high prevalence of experiences of violence is also confirmed by international findings on this topic in acute medical care hospitals [68]. For a well-founded setting-specific comparison, however, the data available in Germany is still very scarce and international comparisons are very limited due to the different health care systems. Therefore, a significant research gap in order to contribute to an improvement in working conditions for nurses is considered. Assuming that violence experience represents a high psychological burden for nurses, the topic of violence prevention and dealing with experiences of violence must be attributed a central role in workplace health promotion measures. At present, it can be assumed that a systematic reappraisal rarely takes place in this regard [22].

Due to the high health burdens and the well-known social and political relevance of the nursing profession, which since the pandemic has been counted among the so-called “system-relevant professions”, the Nursing Personnel Strengthening Act [69], as well as the Concerted Action on Nursing [70] intend to support an improvement in working conditions in nursing. The aim is, amongst other things, to promote support options for professional nursing staff who are exposed to physical or mental stress and to increase the attractiveness of the nursing profession. This, however, requires a systematic and setting-related analysis of the health situation of professional nurses. In this respect, our results indicate that the field of home-based LTC is by far the least studied compared to LTC facilities for the elderly and acute hospitals.

Strengths and limitations of the review

The results of our review provide a setting-specific and cross-setting insight into the current evidence about health problems and violence experiences of nurses in Germany. Thereby, it highlights knowledge gaps that need to be addressed to improve the setting-specific working conditions for nurses. Nevertheless, some limitations occur. The conclusions of this review are limited due to the lack of comparable setting-specific data. Thereby, it needs to be considered that the number of studies with setting-specific data differs substantially. While most studies are available for the setting “acute care hospital”, there are hardly any data for the setting “home-based LTC”. In addition, our research was limited to adult care and our definition of settings had to be specified (e.g., exclusion of community-based LTC settings). Current evidence about health problems of nurses working in those settings should be addressed in future studies. Furthermore, the results obtained are subject to variability in study design and/or measurement instruments used. Additionally, the very different and in some cases extremely small sample sizes or subsample sizes of the different studies also significantly limited the comparability of the included studies. Due to the limited data available, no further specification about nurses (e.g., according to nursing degrees), different care areas within the setting (e.g., palliative care units, intensive care units), or patients (e.g., level of care, musculoskeletal disorders) was possible. Beyond, our research might be affected by a publication bias, since it was limited to scientific publications and health insurance reports which were considered as grey literature. Occupational and health science projects that could not be found in one of the scientific databases were not taken into account what indicates a risk of publication bias. Furthermore, misinterpretation by authors of available data cannot be completely avoided [71].

Conclusion

This review provides an overview of the current state of research on setting-specific data on health problems and violence experiences of nurses in Germany. Considering the socio-economic and political relevance of this profession, we argue that it is crucial to get insight in setting-specific differences of nurses’ health problems and violence experiences. The aim of our review was to examine regular health issues affecting nurses in Germany, including physical and mental health. Since violence experiences are apparent in nurses’ everyday working life and are strongly related to physical and mental health, the previously neglected topic of violence experiences was also explicitly taken up.Hence, the state of research on this topic is characterized by a lack of studies explicitly comparing the three settings. Beyond, it is characterized by heterogeneity of health problems assessed, operationalization and sample size. This makes it difficult to compare studies within a setting and across settings. Due to the high relevance in practice, the clear underrepresentation of data and studies on the topic of violence experiences of nurses is also worth considering. We hope that our review will help to underline the need for target-group specific occupational health interventions for nurses in different settings. Furthermore, we emphasize the importance of a sound empirical basis for this, taking into account setting-specific aspects and violence experiences. On this basis, occupational health interventions could be developed or it could be examined whether interventions applied in practice adequately address the needs of nurses.

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20 Sep 2021

PONE-D-21-22976Health problems and violence experiences of nurses working in acute care hospitals, long-term care facilities or home-based long-term care: a systematic review.PLOS ONE

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Reviewer #1: Page 3, line 60: I suggest you specify that these data refer to the German nation.

Page 3, lines 73-79: it is very important to expand the literature supporting these statements to an international context and not just a German one, the only non-German article cited is dated (2000). Some studies are suggested below, in a non-exhaustive way:

Jiali Liu, Jing Zheng, Ke Liu, Xu Liu, Yan Wu, Jun Wang, Liming You. Workplace violence against nurses, job satisfaction, burnout, and patient safety in Chinese hospitals. Nurs Outlook. 2019;67(5):558-566. doi: 10.1016/j.outlook.2019.04.006;

Shi-Hong Zhao, Yu Shi, Zhi-Nan Sun, Feng-Zhe Xie, Jing-Hui Wang, Shu-E Zhang, Tian-Yu Gou, Xuan-Ye Han, Tao Sun, Li-Hua Fan. Impact of workplace violence against nurses' thriving at work, job satisfaction and turnover intention: A cross-sectional study. J Clin Nurs. 2018;27(13-14):2620-2632. doi: 10.1111/jocn.14311.

Page 4, lines 94-95: it is advisable to add a supporting bibliography, for example:

Ferri Paola, Stifani Serena, Accoto Angela, Bonetti Loris, Rubbi Ivan, Di Lorenzo Rosaria. Violence Against Nurses in the Triage Area: A Mixed-Methods Study. J Emerg Nurs. 2020;46(3):384-397. doi: 10.1016/j.jen.2020.02.013;

Li Lu, Ka-In Lok, Ling Zhang, Ailing Hu, Gabor S Ungvari, Daniel T Bressington, Teris Cheung, Feng-Rong An, Yu-Tao Xiang. Prevalence of verbal and physical workplace violence against nurses in psychiatric hospitals in China. Arch Psychiatr Nurs. 2019;33(5):68-72. doi: 10.1016/j.apnu.2019.07.002.

Page 4: I would suggest to clarify the rationale of the systematic review, in particular because it was chosen to compare different care settings and limit it only to the German context.

Page 20, lines 229-231 “With regard to experiences of violence, nurses working in LTC facilities appear to be more frequently affected compared to those working in acute hospitals and home-based LTC”: It would be really important to compare these results to international studies.

Page 20, lines 252-254: “In this respect, the available studies of our review are in line with current research showing high prevalences of burnout risk” It is suggested to broaden the comparison with international studies that have investigated burnout in nurses, such as, for example, not exhaustive:

Chiara Dall'Ora, Jane Ball Maria Reinius, Peter Griffiths. Burnout in nursing: a theoretical review. Hum Resour Health. 2020;18(1):41. doi: 10.1186/s12960-020-00469-9.

Ferri P, Guerra E, Marcheselli L, Cunico L, Di Lorenzo R. Empathy and burnout: an analytic cross-sectional study among nurses and nursing students. Acta Biomed. 2015;86 Suppl 2:104-15.

Page 21, lines 257-258: “It is therefore not surprising that almost every second employee in this field thinks about leaving the profession several times a year [9]” :

A Nantsupawat, W Kunaviktikul, R Nantsupawat, O-A Wichaikhum, H Thienthong, L Poghosyan. Effects of nurse work environment on job dissatisfaction, burnout, intention to leave. Int Nurs Rev. 2017;64(1):91-98. doi: 10.1111/inr.12342.

Page 25, line 391 “Rippon TJ. Aggression and violence in health care professions. J Adv Nurs. 2000; 31:452–

392 60. doi: 10.1046/j.1365-2648.2000.01284.x PMID: 10672105” it is not necessary, in addition to the doi, to report the PMID.

Finally, a revision of the English translation is suggested.

Reviewer #2: Please note the attachment. This Systematic review requires major revision as I enclosed in the attached document. Please revise the methods section and follow the recommended checklist to ensure that a high quality of your study achieved.

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Submitted filename: PLOS ONE paper review 5.docx

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15 Oct 2021

Thank you very much for pointing out the potential of our manuscript and the opportunity to revise it based on your comments. Your comments helped us a lot to substantially improve the quality of our manuscript. Please find below our point-by-point answers. Marked passages highlight the changes in the revised manuscript.

Editor comments:

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

• Thanks for the advice. We have taken the guidelines into account

2. Please confirm that you have included all items recommended in the PRISMA checklist including:

- the full electronic search strategy used to identify studies with all search terms and limits for at least one database.

- an explanation for why the search inclusion dates began in 2009

- a Supplemental file of the results of the individual components of the quality assessment, not just the overall score, for each study included.

• The full electronic search strategy for the PubMed database is submitted in a supplemental file with the revision

• Please apologize our mistake in the abstract. As stated in the methods section of the original version, “Original studies in German or English language published between January 01st, 2010 and January 11th, 2021 were taken into account (p. 4, lines 117 – 118). We have narrowed our search to the last 10 years, as an even longer period would not be adequate regarding the health policy framework conditions in Germany. we have corrected the year in the abstract:

o “Articles were included if they had been published after 2010 and provided data on health problems or violence experiences of nurses in at least one care setting.” (p. 2, lines 32-34)

• We have enclosed a supplemental file containing the quality assessment for each study included.

3. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide

• Please excuse the incorrect information. All relevant data are within the paper and its Supporting Information files.

Reviewers' comments:

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes; Reviewer #2: No

• We have revised the manuscript according to the feedback from Reviewer 2 (see below in the detailed comments)

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A; Reviewer #2: No

• We have revised the manuscript according to the feedback from Reviewer 2 (see below in the detailed comments)

3. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes; Reviewer #2: Yes

4. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes; Reviewer #2: No

• The manuscript was again revised regarding language. Changed parts are highlighted within the manuscript.

5. Review Comments to the Author

Reviewer #1:

#1.1: Page 3, line 60: I suggest you specify that these data refer to the German nation.

• We added the following information:

“In 2019, more than 19 million medical cases were treated in German hospitals, including acute medical care hospitals and rehabilitation facilities [2].” (p. 3, lines 61-62)

#1.2: Page 3, lines 73-79: it is very important to expand the literature supporting these statements to an international context and not just a German one, the only non-German article cited is dated (2000). Some studies are suggested below, in a non-exhaustive way:

• Many thanks for this advice and the references. We have expanded the section as follows:

“Violence experiences can include physical or verbal violence experiences, patient- or relatives related aggressions and sexual harassment [15,16]. Violence experiences can lead not only to physical harm but also to mental health problems including impaired well-being or even symptoms of post-traumatic stress disorder [17-19]. Additionally, nurses’ feelings of anxiety and anger due to violence experiences also go in line with less job satisfaction [20] and enhanced withdrawal intentions [21].” (p. 3, lines 77-83)

• Newly considered international literature sources:

o 17. Franz S, Zeh A, Schablon A, Kuhnert S, Nienhaus A. Aggression and violence against health care workers in Germany--a cross sectional retrospective survey. BMC Health Serv Res. 2010; 10:51. Epub 2010/02/25. doi: 10.1186/1472-6963-10-51 PMID: 20184718.

o 18. Willness CR, Steel P, Lee K. A Meta-Analysis of the Antecedents and Consequences of workplace sexual harassment. Personnel Psychology. 2007; 60:127–62. doi: 10.1111/j.1744-6570.2007.00067.x.

o 19. Bowling NA, Beehr TA. Workplace harassment from the victim's perspective: a theoretical model and meta-analysis. J Appl Psychol. 2006; 91:998–1012. doi: 10.1037/0021-9010.91.5.998. PMID: 16953764.

o 20. Liu J, Zheng J, Liu K, Liu X, Wu Y, Wang J, et al. Workplace violence against nurses, job satisfaction, burnout, and patient safety in Chinese hospitals. Nurs Outlook. 2019; 67:558–66. Epub 2019/05/02. doi: 10.1016/j.outlook.2019.04.006 PMID: 31202444.

o 21. Barling J, Rogers AG, Kelloway EK. Behind closed doors: in-home workers' experience of sexual harassment and workplace violence. J Occup Health Psychol. 2001; 6:255–69.

#1.3: Page 4, lines 94-95: it is advisable to add a supporting bibliography, for example:

o We added the following references: to the sentence:

“As nurses’ daily working life differs over the settings, it is assumed that health problems and violence experiences might be different, too [25,26].” (p. 4, line 100)

� 25. Galdikien N, Asikainen P, Balčiūnas S, Suominen T. Do nurses feel stressed? A perspective from primary health care. Nursing & Health Sciences. 2014; 16:327–34. doi: 10.1111/nhs.12108 PMID: 25389543.

� 26. Ferri P, Silvestri M, Artoni C, Di Lorenzo R. Workplace violence in different settings and among various health professionals in an Italian general hospital: a cross-sectional study. Psychol Res Behav Manag. 2016; 9:263–75. Epub 2016/09/23. doi: 10.2147/PRBM.S114870 PMID: 27729818.

#1.4: Page 4: I would suggest to clarify the rationale of the systematic review, in particular because it was chosen to compare different care settings and limit it only to the German context.

• We hope to bring out the rationale or background more clearly with the following additions and additional references in the background:

o “Despite the international differences in health care systems, professional nursing is generally described as a crucial part of the health care system. It encompasses health promotion, disease prevention, and care of individuals of all ages with physical or mental illness, or with disabilities [1]. In the German care system, nursing care takes place in different settings, such as in hospitals, nursing homes, at home or in community-based institutions. Crucial settings for adult-based nursing care are acute care hospitals, long-term care facilities (LTC) and the patients’ home.” (p. 3, lines 54 – 60)

o “Violence experiences can lead not only to physical harm but also to mental health problems including impaired well-being or even symptoms of post-traumatic stress disorder [17-19].” (p.3, lines 79 – 83).

o “As nurses’ daily working life differs over the settings, it is assumed that health problems and violence experiences might be different, too [25,26].” (p. 4, lines 99 – 100)

#1.5: Page 20, lines 229-231 “With regard to experiences of violence, nurses working in LTC facilities appear to be more frequently affected compared to those working in acute hospitals and home-based LTC”: It would be really important to compare these results to international studies.

• Thank you for the comment. We have added the following international review, in order to place the results in the international context:

o 68. Liu J, Gan Y, Jiang H, Li L, Dwyer R, Lu K, et al. Prevalence of workplace violence against healthcare workers: a systematic review and meta-analysis. Occup Environ Med. 2019; 76:927–37. Epub 2019/10/13. doi: 10.1136/oemed-2019-105849 PMID: 31611310.

o “Going in line with other research [22], the available data indicate a high level of problems related to verbal and physical experiences of violence, as well as sexual harassment. The high prevalence of experiences of violence is also confirmed by international findings on this topic in acute medical care hospitals [68]. For a well-founded setting-specific comparison, however, the data available in Germany is still very scarce and international comparisons are very limited due to the different health care systems. Therefore, a significant research gap in order to contribute to an improvement in working conditions for nurses is considered.” (p. 21, lines 292 – 299)

#1.6: Page 20, lines 252-254: “In this respect, the available studies of our review are in line with current research showing high prevalences of burnout risk” It is suggested to broaden the comparison with international studies that have investigated burnout in nurses, such as, for example, not exhaustive:

• We added this reference in the discussion:

o “In this respect, the available studies of our review are in line with current research showing high prevalences of burnout risk [39,44,46,51,53,63] and musculoskeletal disorders [34,40,42,52], independently from the setting nurses work in.” (p. 20, lines 266 – 269)

o 63 Dall'Ora D, Jane Ball Maria Reinius, Peter Griffiths. Burnout in nursing: a theoretical review. Hum Resour Health. 2020;18(1):41. doi: 10.1186/s12960-020-00469-9.

#1.7: Page 21, lines 257-258: “It is therefore not surprising that almost every second employee in this field thinks about leaving the profession several times a year [9]”:

• Since our results are limited to the German health care system, we prefer to limit ourselves to a German reference for this statement because of the international differences in health care systems. We have highlighted this as follows:

“Thus, it is not surprising that in Germany almost every second employee in this field thinks about leaving the profession several times a year [9].” (p. 21, lines 271–272)

#1.8: Page 25, line 391: it is not necessary, in addition to the doi, to report the PMID.

• Thank you for pointing this out. We have followed the journal guidelines and will consult with the editorial team if the article is to be published.

#1.9: Finally, a revision of the English translation is suggested.

• We had a colleague revise the language of the manuscript.

Reviewer #2:

2.1: I almost felt that these was two systematic reviews in one. It could be “Health problems of nurses” and “Violence Experiences among nurses” I am not sure what is the relation between both? Why to include both under one systematic review?

• Thank you very much for this important comment. We hope to bring this out more clearly with the following additions and additional references in the background:

o “Violence experiences can lead not only to physical harm, but also to mental health problems including impaired well-being or even symptoms of post-traumatic stress disorder [17-19]. Additionally, nurses’ feelings of anxiety and anger due to violence experiences also go in line with less job satisfaction [20] and enhanced withdrawal intentions [21]..” (p.3, 79 – 83).

o “As nurses’ daily working life differs over the settings, it is assumed that health problems and violence experiences might be different, too [25,26].” (p. 4, 99 – 100)

• Beyond, we expanded the conclusion as follows: “

o “The aim of our review was to examine regular health issues affecting nurses in Germany, including physical and mental health. Since violence experiences are apparent in nurses’ everyday working life and are strongly related to physical and mental health, the previously neglected topic of violence experiences was also explicitly taken up.” (p.23, lines 342 – 346)

#2.2: Title: the word “or” should be “and” as both settings were reviewed by the authors. Also add “in Germany” under the title as the authors excluded studies outside Germany.

• We have revised the title as follows:

Health problems and violence experiences of nurses working in acute care hospitals, long-term care facilities, and home-based long-term care in Germany: A systematic review.

#2.3: Introduction: should be rewritten and it will benefit from details explanation on the impact of workplace violence and its risk factors and why to include this topic under systematic review? What is the gap in the current literature in this regard? What is the aim of this systematic review?

• As explained under comment 2.1, we hope to bring this out more clearly with the following additions and additional references in the background:

o “Violence experiences can lead not only to physical harm but also to mental health problems including impaired well-being or even symptoms of post-traumatic stress disorder [17-19].” (p.3, lines 79 – 83).

o “As nurses’ daily working life differs over the settings, it is assumed that health problems and violence experiences might be different, too [25,26].” (p. 4, lines 99 – 100)

#2.4: Under introduction Line 60: the statement “In 2018, 19.4 million patients were treated in hospitals” Which hospitals?

• Thank you for this advice. We have revised the sentence as follows:

“In 2019, more than 19 million medical cases were treated in German acute medical care hospitals and rehabilitation facilities [2].” (p. 3, lines 61-62)

#2.5: Under introduction Line 77: “Theycan” should read “They can”

• Thank you very much, we have followed the suggestion by rewording the content as follows:

“Violence experiences can include physical or verbal violence experiences, patient- or relatives related aggressions, and sexual harassment [15,16].” (p. 3, lines 77 – 79)

Methods:

#2.6: Search strategy: Why only used PubMed and PubPsych? How about other database such as Medline, CINAHL, Web of sciences database?

• Since the PRISMA guidelines do not specify the number of databases, we agreed on two different databases. In addition, MEDLINE was integrated into PUBMed search. We excluded CINAHL as a fee-based database.

#2.7: Explain in details Keywords and MESH. What are the Boolean operators used in this study?

• We pointed out the keywords and operators more clearly in the text:

“Search terms used for relevant studies were built of the following keywords and Boolean operators (in cursive): (nurs* OR "professional care" OR "professional caregiver") AND (health OR violence) AND (“cross sectional” OR survey) AND (german*).” (p. 4, lines 115 – 118)

• We did not consider MeSH. After reviewing the terms listed in MeSH, this would have inappropriately extended our very specific search strategy without any gain in relevant studies.

#2.8: What are the participants used in the search? Did they include nurse practitioners, supervisors, and managers of nursing, ….etc?

• Our participants were professional nurses in Germany. Apprentices, supervisors and managers were excluded. We pointed this out more clearly:

• “Studies which met at least one of the following criteria were excluded: (1) longitudinal studies or validation studies, (2) qualitative studies, (3) studies outside of Germany. Additionally, we excluded studies addressing health issues of apprentices, supervisors, or managers” (p.5, lines 130 – 131)

#2.9: Authors should not used health insurance reports as these unreliable from scientific point of view. Only published studies can be used in Systematic Reviews.

• We have followed the PRISMA, which do not prescribe any quality standards with regard to study selection. Thereby, the consideration of grey literature, such as reports, is considered desirable. We added this aspect in the limitations:

“Beyond, our research might be affected by a publication bias, since it was limited to scientific publications and health insurance reports which were considered as grey literature.” (p. 22, lines 332 – 334)

#2.10: Inclusion and Exclusion criteria: should be explained in detail. Why to include only cross-sectional studies? These subjected to bias. What are skilled nurses in Germany? Why they excluded longitudinal studies and studies outside of Germany?

• The aim of our review was to get an overview about the current health problems and violence experiences of nurses in different care settings in Germany. To answer this question, we consider the focus on cross-sectional data to be justifiable. We would like to remark at this point that we did not intend to conduct a Cochrane Review of intervention studies.

• Studies outside Germany were excluded due to international differences in the health care systems.

• Please excuse the ambiguity: by skilled nurses we understand professional nurses, qualified by graduation from an accredited school of nursing and by passage of a national licensing examination to practice nursing. We have replaced the term “skilled nurses” by “professional nurses” in the manuscript and added the previous definition in the methods section:

o “In the present study, professional nurses were considered to be qualified by graduation from an accredited school of nursing and by passage of a national licensing examination to practice nursing.” (p. 5, lines 155-157)

#2.11: Quality assessment: JBI checklist of prevalence studies is not appropriate to use in this review. The two independent reviewers should assess the included studies using the Critical Appraisal Skills Program (CASP) checklist (Critical Appraisal Skills Program (CASP) Checklist, 2016) in two phases. During the first phase, each reviewer read the title and abstract of all the citations retrieved and entered this information into a custom-designed database. In the second phase, full-text articles that met the inclusion criteria should be retrieved and reviewed. Pertinent information related to health problems and violence experiences among nurses should be collected and stored in the database. The CASP used to evaluate the methodological rigor of each of the studies. Also use the Cochrane Collaboration ‘Risk of bias’ assessment tool across six domains of bias including selection, performance, detection, attrition, presorting and other (Higgins, Altman, & Sterne, 2011). Furthermore, the inter-rater reliability should be assessed by Kappa statistical test. Then authors should report the Kappa level?

• Thank you for this remark. We decided to keep the JBI checktlist, which we would like to explain below:

o Again, we would like to remark at this point that we did not intend to conduct a Cochrane Review of intervention studies. The Critical Appraisal Skills Program (CASP) checklists are not applicable to the included study designs. As we have only considered cross-sectional data to represent the prevalence of health problems, we consider the JBI checklist for prevalence studies as appropriate. It is tailored to cross-sectional studies and was applied with a four-eyes-principle.

o We think that the same applies to the risk of bias assessment tool of the Cochrane Collaboration, which is designed for intervention studies. Five of the six bias dimensions mentioned are therefore not applicable to our primary studies (selection, performance, detection, attrition, and presorting bias).

o We have addressed the sixth bias dimension (“other sources of bias”) in the limitations:

“Additionally, the very different and in some cases extremely small sample sizes or subsample sizes of the different studies also significantly limited the comparability of the included studies. Due to the limited data available, no further specification about nurses (e.g., according to nursing degrees), different care areas within the setting (e.g., palliative care units, intensive care units), or patients (e.g., level of care, musculoskeletal disorders) was possible. Beyond, our research might be affected by a publication bias, since it was limited to scientific publications and health insurance reports which were considered as grey literature. Occupational and health science projects that could not be found in one of the scientific databases were not taken into account what indicates a risk of publication bias. Furthermore, misinterpretation by authors of available data cannot be completely avoided [71].” (p. 22, lines 327-336)

#2.12: Study selection: What is the definition of violence included in this Systematic Review (SR)? Type of violence? Did the authors explored whether the reporting of 29 studies associated with being Cochrane review?

• Thank you for this remark. We included the types of violence in the inclusion criteria and added a definition of violence:

o (4) data on physical health, mental health, and/or violence experience (physical or verbal violence experiences, patient-related aggressions, sexual harassment) (p 5, lines 126-1289).

o “Our definition of violence is based on the WHO definition of violence against patients or residents. This definition is acknowledged and accepted in the field of nursing and comprises emotional, physical and sexual forms of violence which cause harm or distress to the affected person [30,31]..” (p. 5 – 6, lines 157-160)

Data extraction

#2.13: Authors should perform data extraction on a random sample of the included systematic Review (SR) which were selected using the random number generator. Sampling should be stratified so that the proportion of Cochrane reviews in the selected sample equaled that in the total sample

To minimize errors in the remaining sample of SR, one author verifies the data for these items in all SR. Also, one author reviewed the free text responses of all items with an “Other (please specify)” option. Responses should be modified if it was judged that one of the forced-choice options was a more appropriate selection.

• As we did not conduct a Cochrane Review (see 2.10 and 2.11) we have followed the Prisma guidelines for data extraction. This procedure was reported as follows:

“Extracted data included the setting in which the study was conducted (acute care hospital, LTC facilities, home-based LTC, cross-setting), author and publication year, sample size, sample characteristics (age, gender), the health problem and/or violence experience assessed in the study (physical health, mental health, and/or violence experiences) and the findings of the study related to the respective health problem. In the present study, professional nurses were considered to be qualified by graduation from an accredited school of nursing and by passage of a national licensing examination to practice nursing. Our definition of violence is based on the WHO definition of violence against patients or residents. This definition is acknowledged and accepted in the field of nursing and comprises emotional, physical and sexual forms of violence which cause harm or distress to the affected person [30,31]. Some of the included studies did not contain all the aforementioned variables. In these cases, the available data were reported. Missing data was indicated by the note "not reported". (p.5 - 6, lines 151-162):

Data synthesis

#2.14: Data synthesis should involve a mixture of descriptive summaries of the included methodological research papers. Data extracted from research articles that described a summary of measures (odds ratios, the difference in means, incident rate ratios) should be grouped and analyzed by study design. From this analysis, you should prepare a descriptive analysis of the included studies. Authors did not explain their data synthesis.

• Based on our research question and the different outcomes and measurement instruments in the primary studies, a synthesis of the quantitative data is not possible. As described in the methods section, we therefore intentionally limit ourselves to a narrative report of the results in addition to the tables:

“The tables were used as a basis for a narrative synthesis of the key findings of the included studies.” (p.6, lines 171 – 172)

Results:

#2.15: Figure 1 PRISMA Flow chart has many errors, and it is very confusing. For example, full text article in figure 1 were excluded with reasons 20….etc., these did not add up into n=37. Also 8 studies are missing to come down from 37 to 29. The total studies included under manual search were 22 and if these included in the final 29 we left with only 7 and how many of these either from Pubmed or PubPsych? Please clarify.

• We apologize for our mistake. The studies identified through manual search was 12. We corrected this number in the figure.

• In addition, we added the number of studies identified in each database:

“Of these, 15 studies were found in PubMed and 8 studies in PubPsych, whereby six duplicates occured.” (p.6., lines 179 – 180)

#2.16: Why to include studies with setting unspecific as reported under Table 1. These should be excluded from this SR as it contradicts with the aim of the study and the title of this SR.

• Thank you for this advice. From our point of view, however, setting-unspecific or cross-setting studies do not contradict our research aim. In fact, more setting-specific studies would be desirable from our point of view, as this would allow an appropriate comparison of the health problems and violence experiences of professional nurses, provided that the subgroups are identified in detail and the results are reported accordingly.

#2.17: Tables should be revised as per the above comments

• Since we are unfortunately unable to take most of the feedback on the presentation of results into account, we have decided not to revise the tables.

#2.18: Discussion: the statement “this is the first review” is very strong and authors unaware of unpublished work. I suggest deleting it

• Thanks for the advice. Please consider that we introduced our statement with “To our knowledge” (p. 20, line 235). In our opinion, this indicates that there may be unpublished works, for example, which we then cannot know about, of course.

#2.19: Limitations of the study: should explain in details and logical ways. Personal, misinterpretation, publication biases are possibilities in this SR.

• Thank you for pointing this out. We have extended the limitations as follows:

“Beyond, our research might be affected by a publication bias, since it was limited to scientific publications and health insurance reports which were considered as grey literature. Occupational and health science projects that could not be found in one of the scientific databases were not taken into account what indicates a risk of publication bias. Furthermore, misinterpretation by authors of available data cannot be completely completely avoided [71].” (p. 22, 332 – 336)

Submitted filename: Response to Reviewers.docx

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2 Nov 2021

Health problems and violence experiences of nurses working in acute care hospitals, long-term care facilities, and home-based long-term care in Germany: A systematic review.

PONE-D-21-22976R1

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8 Nov 2021

PONE-D-21-22976R1

Health problems and violence experiences of nurses working in acute care hospitals, long-term care facilities, and home-based long-term care in Germany: A systematic review.

Dear Dr. Schaller:

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