Prevalence and Predictors of Perceived Stress at Work in Palliative Care Nursing: A Cross-Sectional Study from Poland

Abstract

Background:

Palliative care (PC) nurses are exposed to the pain and suffering of patients and their families while also dealing with their own stress resulting from the nature of their work.

Objectives:

Among palliative care nurses in Poland, understanding the phenomenon of occupational-related stress and its predictors.

Design:

This is an observational study.

Setting/Subjects:

The study was conducted in Poland and the data was collected from palliative care nurses. The survey included 424 nurses, and their responses were utilized to assess the occupational stress level.

Measurements:

The occupational stress level was measured using questionnaires with standardized survey instruments.

Results:

The mean occupational stress level among palliative care nurses was 25.57 (±5.56). Nurses aged 50–59 who lived in rural areas and had 6–15 years of palliative care experience had higher levels of occupational stress (p < 0.05). The mean fatigue level was 20.78 (±5.41), while work engagement was 4.26 (±1.09). Palliative care nurses reported the greatest social support from significant others (20.87 ± 5.6). With regard to the professional quality of life, the highest mean score was obtained in the “Compassion satisfaction” subscale and was 40.59 (±6.67).

Conclusions:

Palliative care nurses experience moderate occupational stress. The number of years of professional experience, the amount of fatigue and burnout felt, as well as degree of secondary traumatic stress endured contribute to higher stress levels. The study has found significant gender differences, with men reporting significantly lower stress levels than women.

Introduction

Palliative care (PC) professional healthcare providers address the physical, psychological, social, and spiritual needs of terminally ill patients and their caregivers or families. They frequently perceive PC as a rewarding experience that gives their lives meaning and allows them to develop personally as a result of caring for patients with terminal diseases.¹ On the contrary, providing palliative care involves receiving negatively loaded emotional reactions and delivering bad news. It also includes challenging personal beliefs, dealing with the impossibility to cure a patient’s disease, immersing in emotional conflicts, as well as playing poorly defined roles in patient well-being. Moreover, providing palliative care necessitates witnessing recurrent loss of life on a daily basis, working in an uncertain environment, and handling patient suffering and secondary trauma.² All the aforementioned can contribute to excessive occupational-related stress. While palliative care nurses play a key role in patient care, providing end-of-life care and addressing the patient’s physical and emotional issues puts them at risk for a substantial burden of mental, spiritual, emotional, and physical suffering.³ However, it should be noted that palliative care nurses can experience occupational stress from a variety of sources. Unfavorable working conditions, such as extremely high workloads, rotating shifts, and a low staffing level per shift result from the increasing demands placed on palliative care nurses.⁴ Further organizational issues, for instance, handling too many non-patient-related tasks, being under time pressure, or caring for too many patients at once, also lead to stress.^5,6 Other studies have also identified emotional challenges, such as dealing with death,⁷ family members of terminal patients having unrealistic expectations regarding end-of-life care, as well as resolving conflicts with such individuals.⁸

A systematic review of the literature on burnout prevalence among palliative care providers showed that 17% of these healthcare professionals experienced burnout.⁹ In other words, nearly one-fifth of palliative care providers may consider leaving their jobs due to occupational-related stress. At the same time, the workload for healthcare professionals is expected to increase further due to a declining working-age population and an increasing demand for palliative care in the upcoming years as a result of an ageing population and the prevalence of more comorbidities.¹⁰ Health systems must adapt to the growing demand for PC by improving integration and development. Additionally, reducing work-related stress among healthcare professionals is essential.¹

In light of the current and future challenges in palliative care, it is of key importance to understand and accurately describe the phenomenon of occupational stress as endured by PC providers. In addition, it is vital to comprehend the physical and emotional needs resulting from the palliative care provision in order to develop effective interventions to reduce occupational-related stress and burnout symptoms in these healthcare professionals. Thus, we decided to conduct a survey of PC nurses, as they are the healthcare professionals who provide the majority of palliative care services to patients in the Polish healthcare system. This study aimed to explore the phenomenon of occupational stress and its predictors among palliative care nurses in Poland.

Material and Methods

Study design and participants

This cross-sectional study covered palliative care nursing and was conducted in accordance with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).¹¹ The STROBE statement checklist for this study is available in Supplementary Table S1. The study data was collected by means of two methods, that is, a paper-and-pen personal interview (PAPI) and a computer-assisted web interview (CAWI) in the period between June and August 2023.

The inclusion criteria for the survey required participants to be practicing nurses working in a palliative and hospice care facility (home hospice, inpatient hospice, or palliative care unit). The study participants were recruited using two methods: a paper-based survey (PAPI) and an online survey (CAWI). Questionnaires were sent by postal mail to 228 healthcare facilities that had contracts with the National Health Fund for palliative and hospice care services. Each facility received two copies of the questionnaire, specifically addressed to nurses working in palliative care. In total, 456 questionnaires were distributed, of which 197 were correctly completed and returned (response rate: 43.2%).

Additionally, recruitment was conducted via Facebook, where administrators of the seven largest nursing-related groups shared links to the survey. This method resulted in 227 correctly completed questionnaires.

We acknowledge that the CAWI method may have introduced certain sampling biases. In the discussion section, we thoroughly analyzed such impact on the study results and assessed the potential risk of duplicate responses. To minimize the aforementioned risk, the online survey restricted multiple submissions from the same IP address.

Eligibility

The inclusion criteria for the study were as follows: having the right to practice as a nurse in Poland, providing health services within palliative care, and giving informed consent to participate in the study. The postal questionnaire was preceded by a letter explaining the study’s aim and requesting responses only from individuals who met the inclusion criteria. The online questionnaire, in turn, was preceded by an information page that explained the study’s aim and eligibility requirements. To continue with the questionnaire, the participant had to confirm that he or she met the requirements. After providing an affirmative response to the following questions: “Do you meet the above criteria?” (with possible answers “Yes” or “No”), the respondent could then complete the questionnaire. In accordance with the STROBE checklist guidelines, reporting observational studies in epidemiology does not require sample size calculations.

Ethics

The study was approved by Witold Chodźko Institute of Rural Health in Lublin (no. 7/2023) and was conducted in accordance with the Declaration of Helsinki. All participants gave their informed consent to participate in the study.

Measures

Outcome variable

The Perceived Stress at Work (PSaW) Scale by Chirkowska-Smolak and Grobelny,¹² based on the Perceived Stress Scale (PSS) by Cohen et al.,¹³ is one of the most widely used instruments for measuring stress perception in terms of transactions. The PSaW Scale is made up of ten questions that measure work stress and serve as an assessment of an employee’s adaptation to the work environment. The responses are given using a 5-point scale, from 0 = never to 4 = very often. The psychometric properties of the PSaW Scale were examined in two studies involving 537 professionally active people. The scale was determined to have a homogeneous structure, confirmed theoretical accuracy, and satisfactory reliability (Cronbach’s α = 0.84–0.87). The Cronbach’s α reliability coefficient for the PSaW Scale in the analyses presented in this article was α = 0.77. The full version of the PSaW Scale is shown in Supplementary Table S3.

The scale is reliable and accurate¹² and in the current study, the Cronbach’s alpha value was 0.77.

Independent variables

Sociodemographic variables were assessed using standard questions. Our statistical models included data such as gender, age, place of residence, marital status, and education. The attitude towards the Catholic faith was assessed by the following question: “What is your attitude towards the Catholic faith?” and answers could be as follows: “believer”, “agnostic”, “I am of a different faith” and “I don’t want to answer this question”. In addition, we employed information about the respondent’s years of nursing experience, palliative care experience, and the number of current workplaces.

The Fatigue Assessment Scale (FAS)¹⁴ evaluates feelings of total fatigue experienced. It consists of 10 items, which include physical fatigue (5 items) and mental fatigue (5 items). Each item is measured on a 5-point Likert scale ranging between 1 and 5 as follows: “never”, “sometimes”, “often”, “quite often”, “always”. The scale’s summary scores range between 10 and 50, where higher scores indicate greater fatigue. The Cronbach’s α coefficient was 0.87 in this study, as compared to 0.86 in studies adapting the scale to Polish.¹⁵

The Utrecht Work Engagement Scale (UWES)¹⁶ assesses impressions of work engagement, which is defined as “a positive, fulfilling, affective-motivational state of work-related well-being that can be seen as the antipode of job burnout.¹⁷” The scale consists of 17 items that are measured on a 7-point Likert scale ranging between 1 and 7 as follows: “never,” “almost never,” “rarely,” “sometimes,” “often,” “very often” and “always.” The instrument provides three partial scores and a total score. The partial scores are obtained by adding the items corresponding to each subscale (vigor: Items 1, 2, 5; dedication: Items 3, 4, 7; absorption: Items 6, 8, 9) and dividing the result by the number of items that compose it. The total score ranges from 0 to 6 points. In this study, the Cronbach’s α coefficient was 0.939.

The Multidimensional Scale of Perceived Social Support (MSPSS)¹⁸ appraises three key sources of perceived social support: “significant other”, “family” and “friends.” The aforementioned scale consists of 12 items that are answered using a 7-point Likert scale: 1-“Strongly disagree”, 2-“Disagree”, 3-“Somewhat disagree,” 4-“Neither agree nor disagree,” 5-“Somewhat agree”, 6-“Agree,” 7-“Strongly agree.” The scale summary ranges between 12 and 84 for the entire scale and between 4 and 28 for the subscales. Higher scores indicate that the respondent feels more social support in his or her environment. In this study, the Cronbach’s α coefficient for the entire scale was 0.96, while it was between 0.92 and 0.96 for the individual subscales. In turn, the Cronbach’s α coefficient in Polish adaptation studies was 0.86.¹⁹

The Professional Quality of Life Scale Version 5 (ProQOL 5)^20,21 measures burnout, secondary traumatic stress, and compassion satisfaction and is useful for examining the opinions expressed by a broad range of healthcare professional providers, including those who provide emotional support, as well as those who have been exposed to a traumatic situation. The scale is made up of 30 items (10 for each subscale), and the respondent rates the frequency of each symptom in the previous 30 days on a scale of one to five (“never,” “rarely,” “sometimes,” “often,” “very often”). The scale’s summary scores range between 0 and 50, where higher scores indicate greater burnout, secondary traumatic stress, and compassion satisfaction. In the study group, the Cronbach’s α for individual scales ranged between 0.749 and 0.896.

Statistical analysis

Continuous variables were presented as means (M) with standard deviation (SD). The Shapiro-Wilk test was used to assess conformity with a normal distribution. Categorical variables were reported as absolute numbers and percentages. Differences between groups were determined via Mann–Whitney test or Kruskal–Wallis test with post hoc test. Pearson correlation was used to investigate the relationships between numerical variables. In addition to the aforementioned, multivariable linear regression with backward elimination (p < 0.1) was employed to find significant predictors of occupational stress level. The results of linear regression were presented as beta coefficient (b) with standard error (SE). The coefficient of determination (R²) was applied to describe goodness-of-fit for performed linear regression models. Statistical analyses were performed by way of IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp. P-values <0.05 were accepted as statistically significant.

Results

Participants’ characteristics

Supplementary Table S2 summarizes characteristics of the study participant. The study included 424 palliative care nurses with a mean age of 50.65 years (±9.99). In this study, the youngest nurse was 23 years old and the oldest was 76 years old. The majority of respondents (94.34%) were females who lived in an urban area (64.4%), were married (68.4%), and held a master’s degree in nursing with specialization (36.79%). The study group’s mean length of service as nurses was 25.45 years (±12.32), where the majority of respondents worked between 30 and 39 years (38.68%). The study group’s mean length of service in palliative care was 11.89 years (±8.34), where the majority worked in palliative care for up to five years (29.48%). With regard to the attitude toward the catholic faith, the majority of respondents (85.61%) described themselves as believers.

Distribution of the outcome variable and independent variables assessed with standardized scales

Table 1 presents the results of the respondents on the scales used in the study. The average occupational stress score among palliative care nursing respondents was 25.57 (±5.56). In turn, the mean total fatigue score was 20.78 (±5.41), while the mean work engagement score was 4.26 (±1.09). The mean social support score was 66.97 (±14.89), while palliative care nursing respondents received the highest support score from significant others (20.87 ± 5.6). With regard to the professional quality of life, the highest mean score was obtained in the “Compassion satisfaction” subscale and was 40.59 (±6.67).

Table 1.

Distribution of the Outcome Variable and Independent Variables Assessed with Standardized Scales

Scales	M ± SD	Scope of the assessment
PSaW—Total score	25.57 ± 5.6	0–40
FAS—Total score	20.78 ± 5.41	10–50
UWES—Total score	4.26 ± 1.09	1–6
MSPSS—Total score	66.97 ± 14.89	12–84
MSPSS—Family	21.99 ± 5.69	4–28
MSPSS—Friends	22.11 ± 5.67	4–28
MSPSS—Others	22.87 ± 5.6	4–28
ProQOL—Compassion satisfaction	40.59 ± 6.67	10–50
ProQOL—Burnout	21.14 ± 5.56	10–50
ProQOL—Secondary traumatic stress	23.66 ± 5.66	10–50

M, mean; SD, standard deviation; PSaW, Perceived Stress at Work Scale; FAS, Fatigue Assessment Scale; UWES, Ultrecht Work Engagement Scale; MSPSS, Multidimensional Scale of Perceived Social Support; ProQOL, Professional Quality of Life 5.

Relationship between occupational stress level and independent variables in univariate analysis

Table 2 shows the relationships between occupational-related stress levels and sociodemographic variables. The respondents aged 39 and under had lower levels of stress, as compared to respondents aged 50 to 59 years (p = 0.006). Rural residents are also more stressed than urban residents (p = 0.021). Moreover, nurses with 11–15 and 6–10 years of palliative care experience reported significantly higher levels of occupational stress, as compared to nurses with up to 5 years, 16–20 years, and 21 years or more of palliative care experience (p = 0.038). The study additionally showed that professional healthcare providers who worked under a contract other than a full-time job, as well as those working in three or more workplaces, had significantly lower levels of occupational stress as compared to respondents working in two workplaces or one workplace. Moreover, we found that individuals describing themselves as non-believers had the highest levels of occupational stress (p = 0.001).

Table 2.

Relationships Between Occupational-Related Stress Levels and Sociodemographic Variables

Variable	PSaW	p
Variable	M ± SD	p
Gender
Female	25.56 ± 5.48	0.708^a
Male	25.73 ± 7.27	0.708^a
Age
39 years old and under	24.22 ± 5.51	0.006^b
40 to 49 years old	25.55 ± 5.70
50 to 59 years old	26.47 ± 5.43
60 to 69 years old	24.30 ± 5.71
70 years old and over	24.50 ± 2.12
Place of residence
Village	26.19 ± 6.32	0.021^a
City	25.29 ± 5.23	0.021^a
Marital status
Married	25.53 ± 5.27	0.439^b
Single	27.02 ± 5.60
Divorced	25.41 ± 6.18
Widow/widower	24.67 ± 5.79
Cohabitation/in formal relationship	23.58 ± 9.35
Education
Certified nurse	25.94 ± 4.95	0.106^b
Certified nurse with a specialization	26.64 ± 4.40
Bachelor of science in nursing	24.28 ± 6.88
Bachelor of science in nursing with specialization	24.68 ± 6.52
Master of science in nursing	24.15 ± 5.27
Master of science in nursing with specialization	25.81 ± 5.32
Doctor of health sciences/doctor of medicine	31.80 ± 6.02
Other	22.00 ± 8.64
Years of experience
9 years and under	24.32 ± 5.23	0.146^b
10 to 19 years	25.44 ± 5.26
20 to 29 years	25.77 ± 5.77
30 to 39 years	26.18 ± 5.64
40 years and over	23.83 ± 5.87
Years of experience in palliative care
5 years and under	24.73 ± 5.63	0.038^b
6 to 10 years	26.40 ± 4.88
11 to 15 years	26.80 ± 4.96
16 to 20 years	25.32 ± 5.31
21 years and over	24.26 ± 6.72
Number of workplaces
One	25.75 ± 5.63	0.005^b
Two	26.37 ± 5.03
Three and more	25.12 ± 5.01
I work under a contract other than a full-time job	22.23 ± 6.84
Attitude towards the Catholic faith
Believer	25.87 ± 5.37	0.001^b
Agnostic	29.40 ± 5.58
I am of a different faith	24.20 ± 2.95
I don’t want to answer this question	22.43 ± 6.49

Statistical significance tested with.

Mann–Whitney test, or.

Kruskal–Wallis test.

M, mean; SD, standard deviation; PSaW, Perceived Stress at Work Scale.

Table 3 shows the relationships between occupational-related stress levels and independent variables as assessed by way of standardized scales. A significantly positive relationship was found between perceived occupational stress and fatigue, burnout, and secondary traumatic stress. On the other hand, a significantly negative relationship was found between perceived occupational-related stress and work engagement, as well as general social support from family, friends, and significant others. Moreover, a significantly negative relationship was discovered between occupational stress and compassion satisfaction.

Table 3.

Relationships Between Occupational-Related Stress Levels and Independent Variables Assessed with Standardized Scales

Variable	PSaW
FAS—Total score	r = 0.56; p < 0.001
UWES—Total score	r = −0.43; p < 0.001
MSPSS—Total score	r = −0.21; p < 0.001
MSPSS—Family	r = −0.18; p < 0.001
MSPSS—Friends	r = −0.19; p < 0.001
MSPSS—Others	r = −0.19; p < 0.001
ProQOL—Compassion satisfaction	r = −0.42; p < 0.001
ProQOL—Burnout	r = 0.59; p < 0.001
ProQOL—Secondary traumatic stress	r = 0.40; p < 0.001

PSaW, Perceived Stress at Work Scale; FAS, Fatigue Assessment Scale; UWES, Ultrecht Work Engagement Scale; MSPSS, Multidimensional Scale of Perceived Social Support; ProQOL, Professional Quality of Life; r, correlation coefficient.

Relationship between occupational stress level and independent variables in multivariable analysis

Table 4 shows the significant predictors of occupational stress level obtained by applying linear regression. The data we received indicates that men had significantly lower mean occupational stress levels than women. What is more, the number of years of nursing experience was found to have a significantly positive relationship with fatigue, burnout, secondary traumatic stress, and occupational stress levels. On the other hand, there was a significantly negative relationship between age, years of palliative care experience, work engagement, and occupational stress levels.

Table 4.

Relationship Between Occupational Stress Level and Independent Variables in Multivariable Analysis

Variable	b	SE	p	R ²
Gender (reference category: female)				41%
Male	−0.13	0.04	0.002
Age	−0.12	0.06	0.048
Years of experience	0.18	0.04	0.003
Years of experience in palliative care	−0.13	0.04	0.003
FAS—Total score	0.32	0.05	<0.001
UWES—Total score	−0.10	0.05	0.049
ProQOL—Burnout	0.24	0.06	<0.001
ProQOL—Secondary traumatic stress	0.12	0.05	0.022

b, regression coefficient; p, p-value; R², Coefficient of Determination; SE, Standard Error.

Discussion

This study aimed to explore the phenomenon of occupational stress and its predictors among palliative care nurses in Poland. To the best of the authors’ knowledge, this is the first study to involve such a large study group of PC nurses in Poland. Overall, we found that our study group’s occupational stress level was medium (more than 25 in the range between 0 and 50). It should be noted that it was significantly affected by a number of the variables we examined in both the univariate and multivariable analysis. Interestingly, we were surprised by the occupational stress level obtained in this study, as we expected it to be higher given the burdening working conditions in the palliative care settings. Costeira et al.²² found that PC nurses experienced higher levels of occupational stress, but the sample size was only 32 respondents.

Our study results regarding the level of occupational stress experienced by the PC nurse group can be attributed to a number of factors. First, the majority of the surveyed nurses were more educated, which might have given them the ability to provide palliative care and manage the associated emotional burden more effectively than less educated nurses. The above is supported by a Portuguese study,²³ which found that PC staff with postgraduate training in PC had fewer burnout symptoms as compared to those without such training. Second, the majority of respondents also had vast professional and palliative care experience. This reality appears to be a protective factor. This is supported by research in the United States, which discovered that more experienced professionals were less likely to experience job burnout.²⁴ Additionally, the respondents had more than twice the average length of service in nursing as compared to palliative care. This suggests that the majority gained experience in other settings before joining palliative care, which may have made them more stress-resistant. Moreover, age was negatively correlated with occupational stress levels in multivariable analyses, possibly as a result of older nurses’ greater empathy and acceptance of the challenging situation faced by the patient and his or her family.²⁵ Third, the majority of respondents identified themselves as believers, and studies indicate that religiosity and spirituality can be important internal resources for enhancing a person’s resilience mechanisms and, consequently, reducing stress.²⁶

In univariate analyses, we found positive correlations with fatigue, burnout, secondary traumatic stress, and occupational stress levels, but negative correlations with work engagement, social support, and compassion satisfaction. In the multivariable analysis, fatigue, burnout, and secondary traumatic stress were found to be positively related to occupational stress levels, whereas work engagement was negatively related. Even though our study assessed fatigue in a broad sense, other authors’ research has shown that compassion fatigue in palliative care nurses is linked to both work-related stress²⁷ and the stress of providing care for terminally ill patients.²⁵ Additionally, our study confirmed that occupational burnout syndrome and secondary traumatic stress²⁸ may be caused by exposure to stress in the workplace and its chronic nature.

According to a meta-analysis of six studies on the prevalence of burnout among palliative care nurses, these healthcare professionals are significantly affected by occupational burnout syndrome, and the prevalence of emotional exhaustion, depersonalization, and low personal achievement in palliative care nurses ranged between 24% and 30%. The primary factors linked to burnout levels in PC nurses are professional (workload, work commitment, work environment, relationships with patients, and family) and psychological (extraversion, neuroticism, empowerment, sense of life, and negative affect).²⁹ In turn, personal factors can provide “psychological capital.”

Work engagement, social support, and compassion satisfaction were among the protective factors found to be negatively correlated with occupational stress. According to Ford-Gilboe and Cohan,³⁰ psychological reinforcement-based stress coping mechanisms involve changing a stressful life event or shifting one’s mindset to a more optimistic one. Subsequently, following a thorough review of the literature on the stress among PC nurses, Vachon³¹ formulated a hypothesis that early identification of potential stress sources in palliative care results in the development of suitable coping mechanisms to address stressors on an organizational and individual level. Previous research has shown that personal resources like resilience,³² humor,^33,34 hobbies,³⁵ physical activity,³⁶ spirituality,³⁵ empathy,³⁷ personality traits³⁸ and sociodemographic factors³¹ can help PC nurses manage work-related stress and improve their mental health. According to our study results, the personal resources listed above should be supplemented with social support, compassion satisfaction, and work commitment.

Several study limitations should be acknowledged. Since the study is cross-sectional, the relationship between specific variables affecting occupational stress levels should be interpreted as associative rather than causal. As the relationship between stress and personal resources is dynamic and long-term, a study planned over time may capture the dynamics of their evolution. Understanding the cause-and-effect relationship could help develop preventive programs to reduce occupational stress among PC nurses. Second, the research data were collected during the holiday season, which might have led to an underestimation of stress at work. Third, the study’s results may not be applicable to men due to the unequal gender distribution of its participants, which was dominated by women. However, it is well known that the nursing profession is highly feminized. Fourth, the Perceived Stress at Work was employed to assess occupational stress levels. The Perceived Stress at Work Scale is a valid and reliable instrument for measuring stress (defined as an evaluation of the perceived relationship between the work environment and the individual) but is available in Polish. As a result, the lack of an English-language version of the tool prevents comparisons in international groups. This instrument measures general work-related stress levels but does not measure particular types of stress, for instance, mental strain or compassionate stress. Understanding these levels and predictors may also be of key importance when developing interventions to support nurses’ mental health.

Despite the above-listed limitations, we believe that this study contributes significantly to the understanding of occupational stress and its predictors among PC nurses. Based upon the results of our own research and that of other authors such as Clayton et al.² or Peters et al.,³⁹ it is essential to highlight the critical need for educational programs dedicated to PC nurses to reduce occupational stress, which will help them improve their mental health, stay in the nursing position, and deliver higher-quality care.

Conclusions

According to our study’s findings, palliative care nurses experience moderate levels of occupational stress. We found that occupational stress increased with years of nursing experience, fatigue, job burnout, and secondary traumatic stress experienced. It should be noted that men had significantly lower levels of occupational stress. On the other hand, our study has shown that occupational stress decreases with age, number of years of palliative care experience, and feelings of greater work commitment.

Footnotes

Acknowledgment

The authors are thankful to all participants in the study.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Ethics Statement

The standards stipulated in the Declaration of Helsinki were followed during each step of the study. Ethical approval was obtained from the Bioethics Committee of Witold Chodźko Institute of Rural Health in Lublin (No. 7/2023).

Authors’ Contributions

Conception and design: K.C. and B.Ś. Design: K.C. and B.Ś. Data collection and processing: K.C. and B.Ś. Analysis and interpretation: K.C., B.Ś., M.G., and G.N. Writing—original draft preparation: K.C. and B.Ś. Supervision: M.G. and G.N. Writing, reviewing and editing: K.C., B.Ś., M.G., and G.N. Research concept, research methodology, collecting material: K.C. and B.Ś. Statistical analysis, interpretation of results: K.C., G.N., M.G., and B.S.

Author Disclosure Statement

No potential conflict of interest was reported by the authors.

Funding Information

This research received no grant from any funding agency in public, commercial, or not-for-profit sectors.

Supplementary Material

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