Hospice care compliance of nurses working at a hospice ward in Korea

Purpose: The purpose of this study was to investigate the hospice care compliance of nurses working at a hospice ward and provide meaningful data to improve the hospice care compliances. Methods: Participants included 104 nurses working at the hospice ward of the hospital located at P and D cities. Data was collected from February to March 2012. The level of hospice care compliance was measured using Bae (2000)’s questionnaires. Data were analyzed with descriptive statistics, t-test, one-way ANOVA and Scheffè test using SPSS/WIN 18.0 program. Results: The level of hospice care compliance in hospice nurses working at a hospice ward was high (3.25 out of 4). In hospice care compliance, the physical area was highest, followed by the emotional, spiritual, and social areas. Hospice care compliance was significantly different according to age, marital status, education, religion, importance of religion, job position, job satisfaction and life satisfaction. Hospice care compliance was also significantly different according to the nurses’ experience of death, having license or certification related to hospice care and experiences related to clients’ death. Conclusions: The findings of this study showed that the level of hospice care compliance was high and the hospice care compliance in South Korea was primarily focused on physical care. Considering that spiritual needs are important needs in hospice clients, hospice nurses need to focus on those aspects more. To improve the quality of hospice care compliance in the hospice nurses, programs to increase hospice nurses’ job and life satisfaction are needed.


INTRODUCTION
Hospice palliative care is to relieve suffering and improve the quality of living and dying.Hospice palliative care strives to help patients and families: "1) address physical, psychological, social, spiritual and practical issues, and their associated expectations, needs, hopes and fears; 2) prepare for and manage self-determined life closure and the dying process; and 3) cope with loss and grief during the illness and bereavement" [1].In the past, hospice care including end of life care was offered by families or relatives at clients' homes in South Korea.However, the most hospice care is currently provided at hospitals and the current attitude to hospice care at hospitals was changed because of the changes in the family composition in South Korea and the development of modern medical science [2].
In 1995, end of life care was provided to 22.8% of dying clients in hospitals in South Korea, but the number has been increased to 59.9% in 2006 [3].Because of the increase in the need for end of life care in hospitals, nurses working at hospitals have more chance to care for dying clients and their roles are more important than before.To meet the diverse needs of dying clients, nurses need clinical competence and experience to care for dying clients physically, psychosocially, and spiritually but also improve quality of life in clients' families [4].Nurses also need to support dying clients' opinions and respect their dignities [5].
Hospice care is offered by a multi-disciplinary team approach by physicians, nurses, social workers, priests and so on and nurses among them offer direct cares to clients for 24 hours as primary caregivers in South Korea.Hospice nurses also assess clients' health conditions, offer holistic cares, and provide continuous nursing cares [6][7][8].For hospice care, there are four types of hospice care including hospital, scattered, home, and facility types in South Korea.The hospital type as the most common type of hospice care in Korea offers hospice care at an independent hospice ward of the hospital.One of the advantages in the hospital type is providing systemized hospice care with health professionals in the independent ward [9].Since 2011 June, nurses working at a hospice ward are required to have a certified RN license and complete the Standard Curriculum of Hospice and Palliative Care Education with a total of 60 hours including 46 hours of theory and 14 hours of practice for nurses to improve quality of hospice care [10].
In the hospice care, nurses' important roles are to control pain and increase quality of life for hospice patients and to help bereavement management after death [4].Although nurses are eager to provide appropriate end of life care, they have difficulty in doing so because of a shortage of time, lack of knowledge, communication problems, nurse' stress factors, and patients and families unmet care needs [11][12][13].Unless nurses understand the values for dying clients and the important nursing roles, they are anxious or stressed [12,14].Nurses who are married, older, and have more education, higher positions, and more clinical experience and end of life experience generally provide a higher level of hospice care [15][16][17][18].
Many studies regarding the hospice care were reported in South Korea and the studies included patients' needs about hospice care, the effects of hospice care on health problems, hospice nurses' stress and burden, end of life care experiences, ethical/politic issues and so on [19][20][21][22][23].Many studies regarding the hospice care were conducted, but few studies were conducted to investigate the level or degree of hospice care and the studies were focused on home-visit nurses and general nurses working at ICU or cancer center not hospice ward [23,24].
Because the hospice ward is the most common place to provide hospice care in the hospital and all nurses working at the hospice ward offer hospice care for patients, investigating the level of hospice care compliance of nurses working at the hospice ward is required.Thus, there is a need to investigate the level of hospice care compliance for nurses working at the hospice ward.The purpose of this study is to investigate the hospice care compliance of nurses working at the hospice ward and give meaningful suggestions to improve nurses' hospice care compliance and increase patients' quality of life.The specific purposes of this study are as follows: 1) To investigate the levels of hospice care compliance in nurses working at hospice ward.
2) To investigate the levels of hospice care compliance by the nurses' characteristics.

Design
The study is a descriptive study to investigate the level of hospice care compliances of nurses working at a hospice ward.

Sample Selection
The PI contacted the nursing directors of 11 hospitals having a hospice ward in D-city, B-city, and K-province within three hours' drive from the PI's working place.A total of 104 nurses working at the 11 hospice wards completed the study.Based on the G*Power 3 Program analysis with moderate effect 0.25, power 0.80, and alpha value 0.05, a minimum sample size was 104.Allowing for a 10% of dropout rate, 116 subjects initially participated in the study, but 104 subjects' data were included for final data analysis because 12 subjects' data were not completed appropriately.The inclusion criteria of this study were as follows: 1) A nurse working in a hospice ward of the hospital; 2) A full-time regular nurse; 3) A nurse who understands the purpose and process of this study and agrees to participate in this study.

Procedure
The data collection was conducted from February to March 2012.The PI had visited the directors of nursing in 11 hospitals at D-city, B-city, and K-province to introduce this study and presented the purpose and meaning of this study to the directors of nursing, head nurses, and nurses.When the nurses understood the purpose of this study and agreed to participate, the PI obtained a formal consent from each of the nurses.After the consent was obtained, while the hospice nurses at D-city completed the questionnaires and the PI picked them up by herself, the nurses in the other cities answered the questionnaires and sent them back to the PI by mail because of their hospital conditions.

1) Hospice care compliance
The level of hospice care compliance was measured using Bae (2001)'s questionnaire [25].The questionnaire includes 49 questions with 4 areas (physical area with 11 questions, emotional 15, spiritual 14, and social 9).A Likert scale from "never carry out" 1 point to "always fulfill" 4 points was used, ranging from 1 to 4 possible points.A higher score in the questionnaire means higher levels of hospice nursing compliance.The Cronbach's alpha value of the questionnaire was initially 0.97 (physical area 0.89, emotional 0.93, spiritual 0.94, and social 0.93).In this study, the Cronbach's alpha value was 0.96 (physical area 0.79, emotional, 0.90, spiritual 0.92, and social 0.83).

Ethical Approval
The study was approved by K university D hospital IRB committee members (12)(13)(14)(15)(16)(17)(18) and the data collection was started after the approval.The PI had provided sufficient explanations to the all participants regarding the purpose of this study and the contents.They were allowed that they could withdraw from the study whenever they want if they did not want to continue the participation.The personal information of the participants was kept confidentially in the PI's office room.

Analysis
Data analysis was conducted using SPSS/WIN 18.0 Program (SPSS, Inc., an IBM Company, Chicago, Illinois, USA).Descriptive statistics were used to describe subjects' characteristics and levels of hospice care compliance.T-test, One-way ANOVA, and Scheffe test were used to answer the levels of hospice care compliance by the subjects' characteristics.

Subjects' Characteristics
The findings of sample characteristics are presented in Table 1.Most participants were female (99%), unmarried (64.4%), diploma graduated (48.1%), and Christian (40.4%).Most participants were religious for more than 15years (29.8%), thought that religion is important (66.4%), had income more than 2,000,000 won/month (65.4%), working experiences at general hospitals (63.5%), clinical experiences less than 3 years (39.4%), and working experiences in a hospice ward less than 3 years (62.5%).Most participants were staff nurses (84.6%), almost half of them were satisfied with the job (49.1%), and satisfied with life (48.1%).Regarding education related to hospice care, most participants had education about the topic of dying (81.7%), had no license or certification of hospice care (58.7%), and had certificates of hospice standard education (28.8%).Most participants had experience of more than 20 cases of patients' dying (66.3%).

Hospice Care Compliance
The levels of hospice care compliance in subjects are presented in Table 2.The mean level of hospice care compliance was 3.25 out of 4. The mean of nursing care compliance in the physical area was the highest (3.37) followed by the emotional area (3.35), spiritual area (3.13), and social area (3.09).
In the physical area of the nursing care compliance, "Check a client's BP, PR, RR, BT exactly" was the highest (3.80) following "Encourage a client to express his/her discomfort under the pain, document change of pain, medication status, and medication intervals after administrating, and observe the level of pain" (3.69), "Observe a client's symptoms frequently and notify to Dr if needed" (3.67), and "Change a client's position regularly and apply mattress to prevent bed sore" (3.59).The lowest part of the nursing hospice compliance in the physical area was "Help with high calorie, vitamin and protein intake" (2.86) following "Clean a client's discharge and help client going to the bathroom" (3.17), and "Change a client's clothes and sheet frequently when he/she is sweating" (3.18).
In the emotional area of the nursing care compliance, the highest items were "Genuine attitude to a client and his/her families" (3.66) and "Respect a client's privacy" (3.61).On the other hand, "Consider families not to be exhausted" (3.09) and "Talk to a client about his/her health status frankly" (3.10) were the lowest in that area.
In the spiritual area of the nursing care compliance, "Respect a client's beliefs, values, and existence" was the highest (3.35) following "Encourage a client's positive thinking and hope" (3.32), "Help a client understand the current status and keep his/her peace of mind" (3.28), and "Do not force a client's spiritual problems and respect his/her thinking as it is" (3.28).The lowest items were "Pray with a client and read/provide a religious book" (2.52) following "Help a client to participate in religious observances and keep a quiet environment" (3.03), "Consult a client's spiritual leader" (3.04), and "Use myself as a therapeutic tool" (3.06).
The level of social area in the nursing care compliance was low compared to other areas and the highest level on that area (educate families to be ready for a client's dying) was 3.49.The lowest item of the social area included "Offer a chance to meet other families who had lost their families" (2.83), "Offer a room to talk about client's will or legacy when needed" (2.93), "Counsel about social support to help families" (3.04), and "Request bereavement care to relieve families' grief after the client's dying" (3.05).

Hospice Care Compliance According to the Subjects' Characteristics
The hospice care compliance according to the subjects' characteristics is presented in Table 3.There were significant differences in age (F = 4.17, p = 0.008), marriage (t = −2.17,p = 0.032), education (F = 4.88, p =

DISCUSSION
The purpose of this study was to investigate the hospice care compliance of nurses working at a hospice ward and to provide basic data of improving the hospice care compliance.In this study, the level of hospice care compliance of the nurses working at hospice ward was high, 3.25 out of 4, compared to other clinical nurses working at general wards (2.81 out of 4) or ICU nurses (2.76 out of 4) [16,25].The reasons for the high level of hospice care compliance in nurses working at hospice ward compared to the other nurses are thought to be that the ratio of nurses and hospice clients is higher than others, so that the nurses working at hospice ward could offer high quality of care.
In the sub-category of the hospice care compliance, the level of physical area in the hospice care compliance was the highest.Because there was no study reported investigating the hospice care compliance using the same instrument, so that it was difficult to compare the findings of the study with others, but the finding of this study was consistent with the finding of No's study that the physical area in the hospice care compliance was the highest [17].In this study, the level of spiritual area was low and the finding was consistent with other studies [15,16,18].Nurses working at hospice ward in this study focused on physical care more than the spiritual care even though hospice clients still have higher levels of spiritual needs at the end of life compare to other moments and the spiritual care is one of the most important roles in nurses working at hospice ward [26].Hospice nurses are good at pain management and symptom management but they have difficulties in the area of the spiritual care and psychosocial care in the hospice care [4].Thus, developing a culturally sensitive and objective tool first to assess the spiritual needs of hospice clients and trying to meet client's spiritual needs specifically are needed.
In the physical area of the hospice care compliance, nurses at hospice ward perform 'vital sign check' and 'pain management' frequently, but level of 'clean clients' discharge' and 'encouraging nutritional intake' was low.On the other hand, in Kim's study [21], nurses working at ICU perform 'removing client's discharge' frequently.The inconsistent finding is because clients' family members at hospice ward rather than nurses usually 'remove clients' discharges' and nurses at ICU do rather than the families.In the hospice ward, clients usually stay with their families so that nurses are inclined to shift cleaning clients' discharge on families.For the better quality of care, nurses need to involve direct care such as cleansing clients' discharge.
In the emotional area, the level of respecting client's privacy with sincere attitude in hospice nurses was high, but the communication level such as talking to a client about his/her health status or talking to express his/her feelings was low.In Anthony and Scarcelli's study, one of the important cost-effective approaches to corporate compliance for hospice and home health providers is communication.Communicating compliance standards, policies, and procedures among organization, employees, agents, and clients is emphasized in the study.Based on the findings, nurses working at hospice ward need to have more time to communicate clients and families but also understand clients' feelings and families' exhaustions.
In the spiritual area, the level of respecting hospice clients' beliefs or values and encouraging a client's positive thinking was high, but the level of helping clients' religious activities such as consulting a client's spiritual leader, helping a client to participate in religious observances, and praying with a client was low.In Wang and Chen's study [28], terminal cancer patients in an ICU exhibited spiritual disturbance and the spiritual disturbance including the fear of death was overcame by encouraging a joint of nurses, hospice care team, and religious chaplain.In Korea, spiritual care is currently encouraged with hospice care, but in this study helping the clients to participate in religious activities was not active.To increase the spirituality of hospice clients, nurses need to design the regular time to pray with hospice clients and help them to participate in the religious activities with the spiritual leaders.
In the social area, the level of educating families to be ready for a client's dying or encouraging friends or relatives' visits was high, but the level of offering a room to talk about clients' will or legacy when needed or offering a chance to meet other families who had lost their families was low.Many studies reported that talking about clients' living will and offering the bereavement program with hospice clients are important to increase patient access to hospice care [29,30].In Korea, talking about clients' living will is not that culturally easy issue even with hospice clients, but offering a private room to talk about client's living will is needed.Anttonen, Nikkonen, and Tarja suggested that privacy, time spent together, being present at the time of death created a feeling of caring environment and more time for farewells after death is important for the quality of hospice care [31].Based on the findings, being present with the client but also providing privacy is needed.
The current study reported that nurses who were highly educated (graduate college) showed the higher level of hospice care compliance than others (diploma or college) and the nurses who were believers showed the higher level of hospice care compliance than non-believers.The findings were consistent with the other studies which were conducted for ICU nurses or general nurses [15][16][17]32].Based on the findings of this study, nurses working at hospice ward are encouraged to take more education programs related to hospice care and participate in the religious activities with hospice clients.In addition, nurses who have clinical experiences more than 10 years and have better job and life satisfaction showed high level of hospice care compliance compared to the others [15,17].Thus, counseling and mentoring to improve nurses' job and life satisfaction at the hospice ward is suggested to increase the hospice care compliance.
The previous studies reported that hospice clients have more emotional needs than physical and spiritual needs [33][34][35].In this study, nurses working at hospice ward showed high level of hospice care compliance in the physical area more than the other areas such as emotional, spiritual, and social area.Even though the hospice clients have more emotional needs, nurses working at hospice ward showed high level of hospice care compliance in the physical area.The findings show that the priority of hospice clients' needs differs from the priority of hospice care compliance in nurses.Thus, trials to assess hospice clients' needs and to plan hospice care according to the priority of the clients' needs are needed.
There are a couple of limitations in this study.This study was conducted at 11 hospitals having the hospice ward in a few cities so that the findings of this study are limited to generalize to the other cities.Hospice care compliance in this study was answered by the nurses working at hospice ward not hospice nurses licensed.Because the roles of hospice nurses licensed are important in the hospice ward, investigating the level of hospice care compliance for only hospice nurses licensed is needed.Also, there is a need to compare the level of hospice care compliance between the general nurses working at hospice ward and hospice nurses licensed.In this study, Bae's [25] questionnaires developed by Korean was used to measure hospice care compliance so that the findings of this study could not be compared with the international studies because the different instruments were used in the studies.For the further studies, by using the international instruments to measure hospice care compliance, comparing the level of hospice care compliance among countries is suggested.

CONCLUSION
The purpose of this study was to investigate the level of hospice care compliance in nurses working at hospice ward and provide meaningful data to improve the hospice care compliance.The level of the hospice care compliance in nurses working at hospice wards was high compared to the nurses working at general wards or ICU.The hospice care compliances of nurses working at hospice ward were high in physical area following the emotional, spiritual, and social areas.The hospice care com-pliances in nurses who are aged, married, highly educated, and having religion and high position were high compared to the others.In addition, nurses who are satisfied with their jobs and lives showed high level of hospice care compliance.Thus, to meet the hospice clients' emotional and spiritual needs, the education programs to remind the importance of emotional and spiritual care for hospice clients are required because the nurses are inclined to focus on the hospice clients' physical needs.

Table 2 .
Hospice care compliance of nurses working at hospice ward.(N = 104).
fied with job and life reported high levels of hospice care compliance.Nurses who have education experiences regarding clients' dying and have license or certification about hospice care showed higher levels of hospice care compliance than others.

Table 3 .
Differences in hospice nursing compliance according to subjects' characteristics (N = 104).