Nurses' Knowledge About End-of-Life Care: Where Are We?
Nurses' Knowledge About End-of-Life Care: Where Are We?
Nurses' Knowledge About End-of-Life Care: Where Are We?
Q uality of health care at the end of life has been em- S. Kim is Professor, Ms. D. Kim is graduate student, and Ms. H. Kim
is graduate student, College of Nursing, Nursing Policy and Research
phasized in nursing in the last two decades because Institute, Yonsei University, Seoul, South Korea.
of the increase in the number of patients with chronic The authors have disclosed no potential conflicts of interest, financial
illnesses who are dying in hospitals or long-term care or otherwise.
facilities. At the end-of-life stage, patients often have Address correspondence to JuHee Lee, PhD, APRN, RN, Assistant
symptoms or impairments resulting from the underly- Professor, College of Nursing, Nursing Policy and Research Institute,
Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, South Korea
ing altered body systems (National Institutes of Health, 120-752. E-mail: jhl@yuhs.ac.
2004) that require complex nursing care interventions. Received: September 25, 2011; Accepted: 2012; Posted:
Multiple symptoms include dehydration, respiratory doi:10.3928/00220124-2011
Clinical setting
Cancer unit 43 11.7
General ward 174 47.3 RESULTS
Intensive care unit 150 40.8 Characteristics of the Study Participants
Characteristics of participants in this study are shown
Years of total clinical experienceb
in Table 1. Mean participant age was 29.8 years, with a
<5 179 48.6
range of 22 to 58 years. Two-thirds of the participants
5 to 10 105 28.5 were 30 years or younger. Most participants (88.1%)
> 10 84 22.8 worked on a general ward or the ICU. Mean years of
Years of experience in current clinical total clinical experience was 6.9, and mean years of expe-
settingc rience in the current clinical setting was 4.1. Fewer than
<5 262 71.2 half of the participants (43.8%, n = 161) had previous
5 to 10 78 21.2 education about end-of-life care.
> 10 28 7.6
a b c
Nurses’ Knowledge of End-of-Life Care
Note. M = 29.84, SD = 5.84. M = 6.92, SD = 5.97. M = 4.10, SD =
3.74. The questionnaire about the nurses’ knowledge had
20 total questions. The mean scores and percentages of
correct responses in the three categories are shown in
Table 2. The mean score on the PCQN was 8.94 (SD =
box separately. Therefore, researchers were not able to 2.34) of a possible 20. The items that received the highest
link their identifier to the questionnaire. Among the 398 percentage of correct responses included comparison of
questionnaires returned, 30 were excluded because the chronic and acute pain and bowel regimen for patients
respondents were not staff nurses or had missed demo- on opioids. Items receiving the lowest percentage of
graphic characteristics (e.g., education level); therefore, correct responses included those on family members re-
368 questionnaires were analyzed. The returned ques- maining at the bedside, burnout in palliative care nurses,
tionnaires were stored in a locked drawer, and a coded and use of placebos.
data file was password protected. The study was ap-
proved by the university institutional review board. Difference in Nurses’ Knowledge Scores by
General Characteristics
Data Analysis The PCQN score was statistically significant for
Descriptive statistics, the t test, Pearson correlation, clinical setting and end-of-life care education (Table 3).
and analysis of variance were used to describe the items Nurses working on cancer units had higher scores (M =
of the PCQN and examine the differences in total score 10.63, SD = 1.93) than those working on general wards
of the PCQN according to participant characteristics. or ICUs (F (2, 364) = 15.669, p < .001), according to the
Data were coded and analyzed using SPSS for Windows, findings of Scheffé’s test. According to Pearson correla-
version 18.0. tion analysis, the PCQN score was correlated with nurse
age (r = .11, p = .037) but not with years of total experi- the meaning of the original version of this item, whether
ence or experience in the current clinical setting. Partici- it is related to the moment of dying or a certain period
pants who received end-of-life care education showed of end-of-life caregiving. Another plausible explanation
higher scores than those who did not receive this educa- is that the item may have been interpreted as an absolute
tion (t = 4.591, p < .001). meaning that family members should be at the bedside
constantly, rather than being provided the opportunity
DISCUSSION to be at the bedside. Second, Korean people traditionally
The study was conducted to assess nurses’ end-of-life view remaining at the bedside of a dying patient as the
care knowledge and examine the relationship between right thing to do. Therefore, this item should be inter-
this knowledge and the nurses’ characteristics. The re- preted carefully and with cultural sensitivity.
sults showed that nurses scored higher than 50% on 10 The mean score from study participants was some-
of the 20 items, whereas nurses in the study of Ross et what low (M = 8.95, SD = 2.34) compared with pre-
al. (1996) scored higher than 50% on 18 items on the vious studies (Brajtman et al., 2009; Kim et al., 2011;
PCQN. The highest scored item was 4, “Adjuvant ther- Knapp et al., 2009; Raudonis et al., 2002; Ronaldson,
apies are important in managing pain,” with 91.6% of Hayes, Carey, & Aggar, 2008). Knapp et al. (2009) re-
participants providing the correct answer. This was simi- ported an average score of 10.9 in 279 pediatric care
lar to findings of Knapp et al. (2009) and Brajtman et al. nurses, and Brajtman et al. (2009) reported a score of
(2009), with 87% and 96% of respondents providing the 12.8 in 52 nursing faculty members. The PCQN score
correct answer, respectively. The lowest scored item was of nurses working at residential long-term care facili-
5, “It is crucial for family members to remain at the bed- ties was 11.7 (Ronaldson et al., 2008). Among Korean
side until death occurs,” which was answered correctly nurses who participated in the ELNEC program train-
by 1.4% of nurses. This finding is similar to another Ko- ing, the pretest result was 12.5 (Kim et al., 2011); how-
rean study (Kim et al., 2011) that reported a 0% correct ever, those nurses (approximately 40%) were certified
answer rate and contrasts with other studies in Western nurses working in hospice and palliative care areas. In
culture (Brajtman et al., 2009; Knapp et al., 2009; Loftus this study, only half of participants reported that they
& Thompson, 2002). Although the authors who devel- had received any education on end-of-life care. This
oped the PCQN provided the rationale for item 5, pos- might explain the lower score on the PCQN compared
iting that it is important to prevent exhaustion in fam- with findings from previous studies. Our study results
ily members keeping a vigil at the bedside (Ross et al., indicate the need for end-of-life continuing education
1996), several explanations can be considered for why for nurses if they will be expected to provide optimum
Korean nurses scored this item as true. First, this item care. With limited end-of-life care experience and little
in the translated Korean version may not exactly reflect educational exposure, nurses’ knowledge and skill in
1
nurses who received training and who worked in a hos- Among the Korean nurses studied, nurses generally have little
pice setting. Additionally, Kim et al. (2011) confirmed knowledge of end-of-life care and half of nurses have not
that nurses certified in hospice and palliative care scored received end-of-life care education in this study.
high if they had received previous end-of-life education.
This evidence might indicate that oncology nurses have
more opportunities to manage cancer-related pain and
symptoms.
2 Nurses taking end-of-life care education had higher score on
knowledge of end-of-life care than those who did not experi-
ence an education.
The PCQN covers three categories in end-of-life care
(i.e., philosophy and principles of palliative care, psy-
chosocial aspects of care, and management and control 3 For staff development, continuing education will be the most ef-
fective way to fill staff nurses’ knowledge gap and advance their
competencies in end-of-life care.
of pain and other symptoms). In the current study, low-
scoring items were distributed in all three categories. In
particular, there were low-scoring categories in the phi-
losophy and principles of palliative care and the psycho-
social aspects of care. This finding must be interpreted were statistically significant. However, these findings
cautiously because these categories have only three and should be interpreted with caution because of the sample
four items, respectively. Therefore, a comprehensive size.
education program should be developed to increase In Korea, end-of-life care education for nurses has
end-of-life care competencies for nurses. First, this type mostly focused on the area of oncology. Therefore, end-
of program is needed to strengthen nurses’ knowledge of-life care for other patient groups, such as patients
of philosophical aspects of end-of-life care, principles with chronic illness or those in the ICU, might have
of end-of-life care, the dying process, and the role of been relatively overlooked, resulting in a lack of end-
health care professionals or case managers. Second, as of-life care training. Nurses in all areas of patient care
part of psychosocial and spiritual care, nurses need to should be included in future education because of the
be instructed in how to communicate bad news effec- needs of this aged society, with its growing population
tively. Additionally, nurses who provide end-of-life care and increasing incidence of chronic, complex diseases re-
should thoroughly understand the bereavement pro- quiring extended care.
cess. Finally, education in nursing care of patients who
are near death should include management of pain and CONCLUSION
symptoms, such as dyspnea, delirium, depression, and This study provided an insight into end-of-life care
constipation. This education should cover the identifica- by examining knowledge of end-of-life care in nurses
tion and timely use of appropriate medication, includ- who work in broader clinical settings than did those in
ing side effects and placebo ineffectiveness. To achieve previous studies conducted in Korea. Nurses play a criti-
this education goal, the underlying causes of symptoms cal role in providing 24-hour end-of-life care to patients.
should be sought. Furthermore, nurses’ knowledge of Continuing education programs that provide compre-
related medication should also be updated periodically hensive end-of-life care should be widely provided not
through continuing education. only for nurses working in palliative, hospice, or on-
The participants of this study were drawn from con- cology care areas, but also for all nurses in general. For
venience sampling at a tertiary care health system in Ko- the vast majority of staff nurses in the clinical setting,
rea. Study subjects were limited to nurses who cared for the only way to fill this gap in knowledge and skill is
adult/geriatric patients only. The limited focus of using through continuing education in end-of-life care. Pro-
only the PCQN may not cover all of the knowledge that viding continuing education programs in end-of-life care
might be required for nurses providing end-of-life care. at an organizational or professional nursing society level
In addition, the mean differences by setting and end-of- will equip nurses with the knowledge base and skill set
life care education and correlation coefficient with age in end-of-life care.