Job strain in German novice physical therapists / Psychische Beanspruchung am Arbeitsplatz von Berufsanfängern in der Physiotherapie
Published Online: Jun 11, 2021
Page range: 3 - 19
Received: Aug 31, 2019
Accepted: Mar 10, 2021
DOI: https://doi.org/10.2478/ijhp-2021-0002
Keywords
© 2021 Julia Stadelmaier et al., published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Shortage of skilled workers is a topic of concern within the German healthcare sector, and physical therapy is one of the major bottleneck occupations (Bundesagentur für Arbeit, 2018). Brain drain from this profession has been observed (Hammer & Hebel, 2018) and junior staff is missing in this area. The number of physical therapy graduates is falling. According to the Federal Statistical Office, 6,186 students passed their state examinations at vocational school in 2013, but the number had fallen to 5,562 in 2017 (Statistisches Bundesamt, 2019). In the course of providing healthcare staff to deal with demographic changes and increasing numbers of multimorbid chronically ill patients (Robert Koch-Institut, 2015), job strain is an important topic to address. German DIN Standards define job strain based on the model of stress and strain by Rohmert & Rutenfranz (1975) as ‘direct effects of workplace stress on the individual in relation to current and lasting individual conditions, including individual coping strategies’ (DIN EN ISO 10075-1). High levels of job strain contribute to a variety of poor outcomes. At an individual level, continuing job strain can affect the physical and mental health of working people, and can lead to illness (Angerer et al., 2014), dissatisfaction and resignation (Firth et al., 2004). At a social level, job strain is associated with increased sick leave (Amiri & Behnezhad, 2020) and hence productivity losses, a higher burden on healthy coworkers, and higher turnover (Bridger et al., 2013). Both of these issues result in reduced work performance and decreased availability of skilled workers.
Physical therapists are exposed to a variety of stressors in their daily work. On the one hand, these stressors can be physical in nature due to the many repetitive movements, intensive manual techniques and awkward body positions (Campo et al., 2008; Passier & McPhail, 2011). Work-related musculoskeletal disorders are prevalent in this profession. In particular the lower back, the shoulder-neck area, as well as wrist and finger joints of physical therapists are affected (Bae & Min, 2016; Campo et al., 2008; Truszczynska et al., 2016). On the other hand, physical therapists are confronted with high levels of psychological stress as a result of rising demands and changes towards shorter and more intensive treatment units, time pressure, complex diagnoses and pathologies, multimorbid and frail patients, as well as rising bureaucratic burden (Gröbel, 2008; Li Calzi et al., 2006; Sliwinski et al., 2014).
Although physical therapists are exposed to a variety of demands and high psychological stress in their work, previous studies show that they predominantly classify their work-related stress as being moderate and report a moderate to increased level of job strain (Abaraogu et al. 2017; Brattig et al. 2014; Gröbel, 2008; Pavlakis et al. 2010). It is assumed that therapists benefit from the large amount of resources (e.g. social support, job satisfaction, job control), which can reduce the effects of the stressors (Abaraogu et al., 2017; Brattig et al., 2014; Campo et al., 2009; Gröbel, 2008).
Many studies point to a correlation between length of professional experience and job strain. According to Trucszyska et al. (2016), the number of years a physical therapist has worked in the profession correlates negatively to the level of stress at work. Sliwinski et al. (2014) found greater job satisfaction and lower risk of burnout among experienced therapists. Campo et al. (2009) pointed to an increased risk of turnover intention due to higher levels of job strain, especially among younger and female therapists. In Lindsay et al. (2008), young professionals report a higher number of workplace stressors in comparison to their experienced colleges. In a study by Bae and Min (2016), the highest perceived work-related stress is found in therapists with 5–10 years of work experience and the lowest levels were found in the experienced group (over 15 years). Physical therapists with less than one year of clinical experience, however, were excluded from this study.
This study examines the issue of job strain and workplace stressors of novice physical therapists. Young professionals might be an important subgroup when discussing staff shortages and intention to quit in physical therapy. The first twelve months of employment constitute a phase in which novices gain their initial job experience, develop professional aims and might decide whether to remain in or leave their profession.
This study aims (1) to investigate the level of perceived job strain of German novice physical therapists, (2) to detect the differences in job strain among subgroups (age, sex, rating of professional training), and (3) to investigate the type and frequency of common workplace stressors.
A survey was conducted from 28 August to 28 September 2018 using an electronic web-based questionnaire written in German. The questionnaire was created and published on the online platform SoSci Survey (
All the certified physical therapists who had currently been working in this professional field for 12 months or less, with residence in Germany, were invited to participate. Participants who did not provide at least one valid response were excluded.
Subjects were recruited through two paths. Firstly, a link to the web-based questionnaire was posted in four forums for physical therapists. Secondly, 17 German vocational schools for physical therapy agreed to make their mailing lists of graduates (examination years 2018 and 2017) available for the study in order to promote participation. A reminder was sent after two weeks.
The study used a self-administrated questionnaire, which was subdivided into three sections: (A) job strain, (B) workplace stressors and (C) sociodemographic characteristics, including possibly strain-influencing factors such as rating of professional training, psychological resources and external factors. Items were constructed on the basis of a literature search and student consultations. None of the questions were mandatory, and participants could choose to skip answers.
Job Strain: Job strain was measured indirectly evaluating its effects. An overall score of a selection of five groups of effects was compiled. Items were taken from the subscale ‘outcomes’ of the German version of the Copenhagen Psychosocial Questionnaire (COPSOQ). The COPSOQ is an instrument that is widely used in Germany to record psycho-mental workload and job strain (Nübling et al., 2020). Questions about job strain were linked to the following five groups: workplace commitment (3 items), job satisfaction (7 items), general health (1 item), symptoms of burnout (5 items) and intention to turnover (2 items). Each item was on a five-point Likert scale. In order to identify health status, however, a number between 0 (worst) and 10 (best) has to be chosen on a visual rating scale. The results were displayed as percentage values of individual point scores. Items of ‘symptoms of burnout’ and ‘intention to turnover’ were therefore inverted. Values between 0 and 100 were possible.
Workplace stressors: A list of 21 work place stressors was supplied, subdivided into three groups: work environment, work organisation and work task. These were taken from four previous studies evaluating work-related stressors (Brattig et al., 2014; Keller et al., 2010; Lindsay et al., 2008; Lohmann-Haislah, 2012). The selection was based on student prioritisation. Participants were asked to tick those factors that cause job strain for them. In addition, a free-text field was displayed to provide an opportunity to add individual stressors not listed in the given options. All the selected stressors had to be rated regarding their frequency of appearance in everyday work life from 1 = ‘always’ to 5 = ‘hardly ever’.
Characteristics of the sample: Items to describe the sample included gender, age, educational level, residence (federal state), examination grade, clinical experience, type of clinic (outpatient, inpatient) and number of days of sick leave since job entry, as well as type of employment and monthly gross salary. Four self-developed items evaluated the professional training received at vocational school using a five-point Likert scale. Participants were asked whether they (i) rate their training generally positively, (ii) were able to apply what they had learned, (iii) felt well prepared for job entry and (iv) whether they felt able to meet job-related requirements. In order to describe the target group in more detail, participants were also asked to rate the personal resources: own professional expertise and knowledge, social support (friends, family), possibilities for stress reduction (e.g., sport, relaxation) and job control. These four resources had to be rated on a scale between 1 = ‘very negative’ to 5 = ‘very positive’. Furthermore, common stressors (eustress and distress) outside the workplace setting were examined. A list of seven items was provided, on the basis of the results of students’ consultations. Participants were asked whether they (a) frequented advanced training in addition to work, (b) had taken a vacation in the previous 4 weeks, (c) changed job, or (d) changed place of residence since career entry, (e) experienced stressful events in personal life, (f) are responsible for the care of children or relatives, or (g) suffer from a psychological disease.
The complete questionnaire in original language and English translation can be seen in the appendix.
In preparation of the study, a pretest of the questionnaire was carried out with 12 participants, nine of whom were novice physical therapists. The pretest aimed to identify potential problems in the functioning of the test or any difficulties in comprehension, which could lead to biased answers. In addition, the provided list of stressors was evaluated. Free-text fields were displayed on each page of the questionnaire in order to gather comments or remarks. No problems in technical functionality and usability were detected. Remarks on content and wording were discussed and changes were made where appropriate.
Data was analysed using IBM SPSS statistics 2018 software. All the responses were tabulated and descriptive statistics for all the items were obtained. Missing data was not considered in the analysis. To analyse the five different dimensions of job strain, a score of all the items of each dimension was formed and presented as a percentage. Based on the study by Gröbel (2008), five categories were defined for the interpretation of the results: ‘0–19’ as very low, ‘20–39’ as low, ‘40–59’ as moderate, ‘60–79’ as high, ‘80–100’ as very high.
For the overall rating of job strain, mean and standard deviation of all the values of individual point scores were calculated. Five categories were defined for the interpretation: ‘0–19’ as very high, ‘20–39’ as high, ‘40–59’ as moderate, ‘60–79’ as low, ‘80–100’ as very low level of job strain.
Subgroup analyses based on sex, age and rating of professional training were performed. For each analysis, data was divided into two groups: firstly, questionnaires completed by males and females, secondly, those completed by younger (≤ 23 years) and by older physical therapists, and thirdly, those completed by physical therapists who gave a positive rating of their professional training and those with a neutral or negative rating. An independent t-test was used for comparison between the pairs of groups. Correlations between the overall job strain score and age, or rating of professional training were measured using Spearman's correlation coefficient. Results with p < 0.05 were considered to be significant. Workplace stressors were reported according to frequency and percentage of being mentioned, and ranked.
From 502 clicks, 176 questionnaires were edited (35.1%). A total of 23 questionnaires were excluded due to the following reasons: no valid answers (n = 12), clinical experience (> 12 months) (n = 9) type of employment (not currently working as physical therapist) (n = 2). Data of 153 therapists remained for evaluation.
The respondents were aged between 19 and 40 years and had an average length of service of about eight months. Approximately two third of the respondents were women, and the majority were employed full-time in an outpatient medical facility. Characteristics of the sample are listed in Table 1.
Characteristics of the sample.
| female | 103 | 67.3 |
| male | 50 | 32.7 |
| M (SD) | 24.0 (2.9) | |
| Mittlere Reife | 35 | 22.9 |
| Fachabitur | 29 | 19.0 |
| Abitur | 69 | 45.1 |
| University degree | 20 | 13.1 |
| very good (1) | 31 | 20.3 |
| good (2) | 86 | 56.2 |
| satisfactory (3) | 33 | 21.6 |
| sufficient (4) | 3 | 2.0 |
| outpatient sector | 124 | 81.1 |
| inpatient sector | 27 | 17.6 |
| other | 2 | 1.3 |
| M (SD) | 8.2 (3.2) | |
| full-time | 119 | 77.8 |
| part-time | 28 | 18.3 |
| marginally employed | 6 | 3.9 |
| 0 – 5 days | 101 | 66.5 |
| 6 – 10 days | 36 | 23.5 |
| 11 – 15 days | 8 | 5.2 |
| 16 – 20 days | 4 | 2.6 |
| more than 20 days | 3 | 2.0 |
| not specified | 1 | 0.7 |
| < 1.000 € | 17 | 11.1 |
| 1.000 - < 1.500 € | 14 | 9.2 |
| 1.500 - < 2.000 € | 40 | 26.1 |
| 2.000 - < 2.500 € | 66 | 43.1 |
| 2.500 - < 3.000 € | 12 | 7.8 |
| ≥ 3.000 € | 3 | 2.0 |
| not specified | 1 | 0.7 |
| Baden-Wuerttemberg | 37 | 24.2 |
| Bavaria | 24 | 15,7 |
| North Rhine-Westphalia | 24 | 15.7 |
| Rhineland-Palatinate | 17 | 11.1 |
| Brandenburg | 10 | 6.5 |
| Lower Saxony | 8 | 5.2 |
| others | 31 | 21.6 |
| not specified | 2 | 1.3 |
The majority of participants reported their psychological resources positively: 85.0% of all the asked novice physical therapists rated their social support (by friends, family) as positive or very positive. 63.8% positively rated their opportunities for stress reduction, and 63.8% were satisfied with their job control. Regarding their own professional expertise and knowledge, 59.9% ranked this as positive or very positive, 29.6% as moderate and 10.5% as low.
In retrospect, professional training received at vocational school was seen very differently by the respondents (Fig. 1). It was predominantly rated as good. However, 23.7% of the respondents evaluated their education as mediocre and 16.5% as bad or even very bad.
Figure 1
Rating of professional training received at vocational school.
Most of the physical therapists were of the opinion that they had been well prepared for job entry (n = 93, 61.2%), however, 22.4% (n = 34) did not. The majority of respondents felt that they were able to meet job-related requirements (n = 87, 57.2%). But only 44.7% (n = 68) agreed that they could apply what they had learned at vocational school.
Low levels of job strain were reported with a mean overall score of 64.8 (SD = 6.3). Of the 153 respondents, 12 physical therapists (7.9%) rated their job strain as high or very high, 39 (25.5%) as moderate, and 102 (66.6%) as low or very low.
Regarding the five different aspects of job strain (Fig. 2), high levels of workplace commitment and general health as well as low levels of turnover were reported. Job satisfaction and burnout symptoms were rated as moderate.
Figure 2
Different aspects of job strain.
Statistical analysis revealed no significant between-group differences in job strain between women (64.9%) and men (65.5%) (p = 0.8), or between therapists younger than 23 years (62.7%) and those older (67.2%) (p = 0.10). However, significant differences in job strain (p < 0.01) were found between the groups reporting positive (71.3%) or negative (56.0%) rating of professional training.
A significant positive correlation (r = 0.5, p < 0.01) between the rating of professional training and the overall job strain score was also noted. Respondents rated their professional training as positive reported lower levels of job strain. No correlation was revealed between age and the overall job strain score (r = −0.1, p = 0.2).
On average, respondents reported 7.1 (SD = 3.7) stressors that contributed to job strain during their first year of profession. Figure 3 shows the complete list of work-related stressors with their frequency selection shown in percentage terms. Inadequate compensation for work (63.4%), high caseload (54.2%), time pressure (52.3%), physical stress (50.3%) and doing work tasks simultaneously (45.8%) were the most common workplace stressors mentioned.
Figure 3
Workplace stressors.
With regard to the frequency of appearance of the selected stressors in everyday work life, inadequate compensation for work, high caseload and time pressure are also dominant. Three-quarters of the respondents who selected these factors indicated that these stressors appeared often or always in everyday work. ‘Physical stress’ appeared predominantly (62.3%) sometimes or often, and high values were measured in work organisation: more than 70% of the participants agreed that understaffing, doing work tasks simultaneously and stressful working hours appear often or very often in everyday work.
On average, novice physical therapists reported two influencing factors outside the workplace setting. 57.5% stated that they frequently attended advanced training in addition to work, 34.0% had taken a vacation in the previous four weeks, 30.7% reported stressful events in private life, and 19.0% reported having changed jobs since career entry. Having changed place of residence or being responsible for the care of children or relatives were less frequently reported (<8%). Six respondents (3.9%) indicated that they suffered from a psychological disease.
This study aimed to investigate job strain in novice physical therapists in Germany during their first year of profession. A sample of 153 physical therapists participated, most aged between 21 and 26 years, and employed full-time in an outpatient medical facility.
In this present study, the surveyed novice physical therapists reported a low level of job strain. These results are in accordance with those of the survey by Gröbel (2008) of German physical therapists with varying amounts of experiences: Participants also described positive outcomes in job strain, although high job demands were reported. A study by Truszyczynska et al. (2016) of young physical therapists in Poland who had been employed in their profession for 6.3 years on average also confirms this observation. The majority of Polish therapists (51.9%) reported a low level of job strain.
However, the impact of job strain in novice physical therapists should not be underestimated. Attention should be paid to the percentage of those who suffer from workplace stress and high job strain. In this study, there were at least 7.9% of the participants who reported high or very high levels of job strain. In Truszyczynska et al. (2016), there were 16.7% young professionals with high to very high levels of job strain.
Regarding the five dimensions of job strain, high levels of general health and workplace commitment and low levels in turnover intention were identified. The symptoms of burnout were considered to be moderate. These results are similar to those for German physical therapists with different length of service (Gröbel, 2008). One possible explanation may be presentism caused by high social pressure under which newcomers to the profession find themselves. This can include perceived obligations to their patients and concerns about the consequences of missed appointments, or concerns about colleagues having to cover their absence by working overtime.
Regarding job satisfaction, only moderate ratings were recorded. This is in contrast to the other German surveys, which point to high levels of job satisfaction among physical therapists (Brattig et al., 2014; Gröbel, 2008), and also among novices with up to three years of experience (Blümke et al., 2019; Dieterich et al., 2019). One explanation might be that this study focused on the first year of profession, and consequently, there is a lack of experience in this group. Previous studies on new graduate nurses showed a positive correlation between length of service and job satisfaction (Cheng et al., 2015; Halfer & Graf, 2006). Sliwinski et al. (2014) also found greater job satisfaction and lower risk of burnout among experienced physical therapists.
Another explanation may be related to some of the dominating factors, which influence job satisfaction. With regard to the individual items describing job satisfaction in this study, therapists voiced dissatisfaction with their salary and indecision about their career prospects in particular. In the study by Brattig et al. (2014), a third of German physical therapists also mentioned higher wages as an important factor to promote job satisfaction. It can be assumed that the importance of remuneration for entrant workers is decisive, especially against the background of the financial costs of their professional education. At the same time, the wage can be seen as a sign of appreciation for work done. A possible explanation for the indecisiveness of career perspectives is the current discussion in politics and the media regarding the role of the physical therapists. The effect of the shortage of skilled workers has become evident. Physical therapy is also currently in a phase of upheaval: model projects are being initiated, and academisation is progressing. At present, however, it is unclear how these issues will affect the profession and the perspectives of therapists.
The novice physical therapists in this study experience many stressors at work. Nevertheless, the resultant strain is perceived to be low. The presence of high coping capacities and psychological resources may serve to counteract the stressors. In this study, there were a number of psychological resources that were held in high regard by the respondents: workplace commitment, social support, and job control. According to the Job Demands-Resources model of Demerouti et al. (2001), it may be these resources that serve as protective factors and have a pronounced mitigating effect on the burdens experienced by novice physical therapists. The high rating of job control also suggests a classification in the active job category of Karasek's demand-control model in which both the demands and the perceived control are high, resulting in little strain (Karasek, 1979).
This study indicates that the professional training received at vocational school is a significant influencing factor. 22.4% of the surveyed novices did not feel well prepared for job entry and did not feel able to meet job-related requirements. Almost every third subject stated that they could not implement what they had learned at vocational school. This also applies vice versa: a positive perception of the training received was accompanied by a lower level of job strain. This result is in line with the studies on medical graduates. Brennan et al. (2010) showed that a lack of clinical experience and competences as well as subjective perceptions of insufficient preparation through medical studies contribute to an increased experience of strain. Therefore, a good and highly professional practice-oriented training may be an important protective factor curbing job strain, and can be a possible starting point to ameliorate transition to practice for novice physical therapists.
In this study, job strain is recorded using a subjective analysis procedure. This could be a possible source of bias, as the self-assessment can be influenced by the subject's characteristics and expectations as well as his/her current life situation (Böckelmann & Seibt, 2011). By collecting data at a single point in time, currently dominant strain factors or positive events can have a greater impact on an individual assessment and distort the perceptions of the subject. In this context, it should be pointed out that the survey took place during a holiday period. At least 34.0% of all the novice physical therapists asked reported that they had taken a vacation in the previous four weeks. It can be assumed that the physical therapists would have been more relaxed due to the summer holidays and that the number of patients being treated would be lower.
A self-administered questionnaire was used in this survey, which has not been evaluated as a measuring instrument. This poses a risk of bias. However, for validation purposes a pretest was carried out during the development of the questionnaire and changes were adapted accordingly.
The survey addresses physical therapists throughout Germany. By sharing the link via online portals, wide access to the survey was made possible. However, the results regarding the place of residence indicate that some federal states are underrepresented and the majority of the participants reside in the southwest of the country. One reason for this could be the sharing of the link via vocational schools. Most schools who agreed to forward the link to their graduates were situated in the southwest of Germany.
A further important limitation is the under-representation of physical therapists employed in the inpatient sector (hospitals and clinics), with only 17.6% of all the participants practicing in this sector. As a result, the results of the study are dominated by the situation of newcomers to the profession who are employed in outpatient facilities (81.1%). This may also be a source of bias because lower levels of job strain can be assumed for those working in hospitals—due to the higher salaries (collective labour agreements), reduced level of bureaucratic burdens and fewer patients per hour.
In this study, novice physical therapists in Germany reported low levels of job strain. They identified various workplace stressors, but at the same time showed high levels of workplace commitment, general health and psychological resources, which might be strongly protective factors. However, many workplace stressors, in particular inadequate compensation for work, high caseload, time pressure, physical stress and requirements to perform work tasks simultaneously, as well as moderate levels of job satisfaction and burnout symptoms were reported.
These results present potentials to improve the situation of novice physical therapists in order to maintain job satisfaction and health. In particular, this includes the introduction of health promotion programs within workplaces and improvement of professional training at vocational school for better integration of learned skills into practice.