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Original Article
Factors influencing Korean nurses’ attitudes towards hospice care K.S. Park1
RN, MS
& H.A. Yeom2
RN, PhD, ANP-C
1 Staff Nurse, Keumho Nursing Home, 2 Assistant Professor, Research Institute for Hospice/Palliative Care, College of Nursing, The Catholic University of Korea, Seoul, Korea
PARK K.S. & YEOM H.A. (2014) Factors influencing Korean nurses’ attitudes towards hospice care. International Nursing Review Background: While the need for hospice care is increasing in Korea, there is limited research describing the way hospice care is understood by hospital ward nurses who may have relatively limited opportunities for hospice education in their workplace. Aim: This study aimed to describe Korean nurses’ attitudes towards hospice care and to examine the relationships between nurses’ attitudes towards hospice care and their demographic and work-related characteristics. Methods: This was a cross-sectional descriptive study. A total of 348 registered nurses recruited from six general hospitals were surveyed using a structured questionnaire. Measurements included general and work-related characteristics and the Frommelt Attitude Toward Care of the Dying Scale. Results: The mean score for nurses’ attitudes towards hospice care was 2.52 out of a maximum of 3.0. More positive attitudes towards hospice care were associated with older age, married status, a higher level of education, working at a hospice unit, a higher job position, more years of work experience, having previous experience caring for dying patients and having received education in hospice care. Factors predicting nurses’ attitudes towards hospice care included the number of years of work experience and working at a hospice unit in a hospital, with an explanatory power of 22%. Limitations: The study was conducted in tertiary care hospitals in Seoul metropolitan area; results may therefore differ in other geographical regions. Conclusion: Education on hospice care should be targeted to less experienced, younger staff nurses who have no previous education on hospice care or have not worked in a hospice unit. Implication for Nursing and Health Policy: Tertiary hospitals need to provide more opportunities for their nurses to obtain continuing education on hospice care or increase the number of courses available at the institutional level in order to enhance their nurses’ attitudes towards hospice care. Keywords: Attitudes, End-of-life Care, Hospice Care, Hospice Education, Korea, Nurses, Palliative Care
Correspondence address: Hye-A Yeom, Research Institute for Hospice/Palliative Care, College of Nursing, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Korea. Tel: +82-2-2258-7402; Fax: +82-2-2258-7772; E-mail: [email protected].
Source of funding: This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (2013R1A1A3005236). Conflicts of interest: No conflict of interest has been declared by the authors.
© 2014 International Council of Nurses
1
2
K. S. Park & H. A. Yeom
Introduction The goal of hospice care is to provide holistic care to terminally ill patients and their families by supporting their physical, emotional and spiritual well-being. Hospice care is based upon a team approach, in which physicians, nurses, social workers and other relevant professionals collaborate in order to provide quality end-of-life care. The compassionate design of hospice care is known to increase patients’ and families’ satisfaction with end-of-life care because it reduces physical, psychological and spiritual suffering, and increases patient comfort (National Hospice and Palliative Care Organization 2013). Due to the positive impact of hospice care on the quality of life of dying patients, the number of patients and families receiving hospice care has been gradually increasing internationally. Korea is not an exception; interest in hospice care in Korea has increased remarkably, particularly interest in hospice care policy and the costs of care. The number of patients dying in hospitals has increased from 13.8% in 1990, to 28.3% in 1998 and to 67.5% in 2010 (Jung et al. 2013). Korea has approximately 253 hospice institutions, and onethird of all hospice care cases are bed-bound in-patients (Hong 2008). While the total number of dying patients has been increasing, utilization of hospice care is still not widespread. In Korea, only 6% of terminal patients receiving palliative care use hospice care services (Yun 2009). The underutilization of hospice and palliative care services is an international healthcare issue and is known to be due to several reasons, including disparities of use of hospice care, late referrals to hospice care services due to the difficulty physicians face in accurately predicting survival and negative attitudes towards hospice care among healthcare professionals (Litauska et al. 2014; O’Mahony et al. 2008). Specifically regarding attitudes, healthcare professionals often tend to consider a patient’s death as a professional failure and to focus more on quantitative aspects than on qualitative aspects of the patient’s life (Gazelle 2007). Often, nurses are the largest workforce in the healthcare field; they provide care for patients at all stages of their illness and play an important role in communicating with patients and their families. Nurses often coordinate care plans, facilitate discussions with patients and advocate for dying patients (Kim 2008). It is logical to assume that the positive attitudes of a nurse towards hospice care have an impact on the quality of care the nurse provides to dying patients. Nurses who have positive attitudes towards hospice care may be aware of the importance of hospice care for dying patients and thus may make more effort to provide high-quality hospice care to them. This attitudinal aspect is particularly important for nurses working at general hospitals, who take care of dying patients receiving
© 2014 International Council of Nurses
24-h care and consistently interact with them as they adjust to life with a terminal illness. Although nurses believe that it is important to develop professional and humanistic attitudes with regard to palliative care (Boyd et al. 2011; Zhou et al. 2010), nurses in clinical settings are often not prepared for end-of-life care; in fact, they report difficulty in providing high-quality care to dying patients and their families due to busy work conditions and duty-oriented care environment (Zamanzadeh et al. 2014). To date, most studies on attitudes towards hospice care have focused on physicians (Ache et al. 2011; Csikos et al. 2010; Litauska et al. 2014) or nursing home settings (Leclerc et al. 2014; Wowchuk et al. 2007). There has also been relevant research describing nurses’ attitudes towards hospice care in diverse cultures, including Iran (Iranmanesh et al. 2014), Jordan (Abu Hasheesh et al. 2013) and Turkey (Cevik & Kav 2013). However, there is little research describing the way hospice care is understood by Korean hospital ward nurses who may have relatively limited opportunities for hospice education in their workplace. Reflecting the growing number of terminally ill patients in acute care settings in Korea and the lack of preparedness of nurses for end-of-life care, the present study was designed to assess Korean nurses’ attitudes towards hospice care and to examine the relationships between this variable and their demographic and work-related characteristics.
Methods Design and sample
A cross-sectional descriptive study design was used. Participants were 380 registered female nurses recruited from six general hospitals in the metropolitan area of Seoul, Korea. This sample size was estimated using G*Power (Heinrich-Heine-Universität Dusseldorf, Düsseldorf, Germany), for a significance level of 0.05, a power of 0.80 and an effect size of 0.15. This effect size was determined based upon the correlation index between the attitude variable and other affective factors related to end-of-life care reported in a previous study (Lange et al. 2008). A convenience sampling method was used. Participants were eligible for enrolment if they were registered nurses (RNs) working at one of the participating general hospitals and if they agreed to participate in the study voluntarily. Measurements
Study variables included socio-demographic characteristics, work-related characteristics, personal experience in hospice care and attitudes towards hospice care. Socio-demographic variables included age, marital status, religion and level of education. Work-related characteristics included current work
Nurses’ attitudes towards hospice care
department, years practising as an RN, years employed at the hospital and current job position. Variables related to personal experience included previous nursing experience for terminally ill patients, previous bereavement experience regarding close family members and previous education on hospice care. Attitudes towards hospice care refer to nurses’ positive or negative feelings and motivations regarding care for terminally ill patients. Attitudes towards hospice care were measured using the Frommelt Attitudes Toward Care of the Dying Scale (FATCOD), which was originally developed by Frommelt (1991) and translated by Lee and Lee (2001) into Korean. This scale uses a three-point scale, from 1 (disagree) to 3 (agree). A higher score indicates a more positive attitude towards hospice care. The validity of the FATCOD has been established (Braun et al. 2010; Chi & Kim 2005; Lange et al. 2008). The Cronbach’s alpha reliability coefficient was 0.80 in this study. Data collection procedure
Upon approval by the Institutional Review Board for the Protection of Human Subjects (MC12QAS10169), participants were recruited from the nursing departments of six general hospitals in Seoul, Korea. The research team presented the study verbally in the hospitals’ nursing units, describing the purpose and the data collection procedures to potential subjects. The data were collected by one of the investigators, a graduate nursing student trained in research methodology, a specialty in hospice care and more than 5 years of clinical experience as an RN. The data were collected from December 2012 to January 2013. Survey questionnaires were distributed to those who were interested in participating in the study and who signed the informed consent form. Participants spent about 20–30 min completing the survey and were compensated with the equivalent of US$5.
3
for more than one-third of the total variables, which was considered a systemic error rather than a random one. General characteristics of subjects
All participants were women. Approximately half of the respondents (56.3%) were aged between 25 and 34 years. The majority of participants were single (72.1%) and living with family (65.5%). Roman Catholicism was the most prevalent religion (38.8%). In terms of education, 42.5% of participants were baccalaureate degree graduates and 41.7% were associate degree graduates. Participants had been practising as RNs for an average of 6.8 years. More than 80% were working as staff nurses, with 47.7% working in internal medicine units. Approximately 98% of participants (N = 341) reported that they had heard about hospice care, mostly through published literature (books, journals, etc.) or related education programmes (64.7%). More than 90% of participants had experience caring for dying patients. Of the participants, 38.3% reported having experienced the loss of a family member. Two hundred ten nurses (60.5%) reported that they had previously received education on hospice care (Table 1). Attitudes towards hospice care
The average score on the FATCOD was 2.52 out of a maximum of 3.0. FATCOD scores were significantly higher among participants aged 35 years or older (P = 0.001) and those with a master’s degree or higher (P = 0.001). Higher FATCOD scores were also significantly associated with working in a hospice unit (P = 0.001) and working in a unit management position (P = 0.001). Those who had more than 11 years of experience in nursing showed significantly higher FATCOD scores than other groups (P = 0.001). Those who had received hospice education showed higher FATCOD scores than those who had no experience of such education (P = 0.003) (Table 1).
Data analysis
The data were analysed using SPSS 12.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to summarize demographic characteristics and attitudes towards hospice care. Associations between attitudes towards hospice care and general characteristics were examined using t-tests and analyses of variance (ANOVAs), with Schéffe post-hoc tests. Significant bivariate correlates of the dependent variable were entered as potential predictors in the regression model using multiple stepwise regression techniques.
Results The final data analysed included the responses of 348 participants, after excluding 32 incomplete questionnaires. An incomplete questionnaire was defined as one that had missing values
© 2014 International Council of Nurses
Predictors of attitudes towards hospice care
The regression model predicting attitudes towards hospice care was statistically significant (F = 49.33, P < 0.001) with 22% of explanatory power. The significant predictors of attitudes towards hospice care were the number of years working as an RN (β = 0.41) and working in a hospice unit (β = 0.17) (Table 2).
Discussion This study described Korean nurses’ attitudes towards hospice care and examined the relationship between their attitudes and demographic and work-related characteristics. In the present study, attitudes of hospital nurses working in general wards, primarily internal medicine and surgery departments, were fairly
4
K. S. Park & H. A. Yeom
Table 1 Demographic and hospice-related characteristics in relation to nurses’ attitudes towards hospice care (N = 348) Variable
Age (years)
Marital status Religion
Education (degree)
Work department
Job position
Years as RN
Having heard of hospice care Previous nursing experience for dying patients Previous bereavement experience for family Previous experience of education on hospice
Category
Original Article
Factors influencing Korean nurses’ attitudes towards hospice care K.S. Park1
RN, MS
& H.A. Yeom2
RN, PhD, ANP-C
1 Staff Nurse, Keumho Nursing Home, 2 Assistant Professor, Research Institute for Hospice/Palliative Care, College of Nursing, The Catholic University of Korea, Seoul, Korea
PARK K.S. & YEOM H.A. (2014) Factors influencing Korean nurses’ attitudes towards hospice care. International Nursing Review Background: While the need for hospice care is increasing in Korea, there is limited research describing the way hospice care is understood by hospital ward nurses who may have relatively limited opportunities for hospice education in their workplace. Aim: This study aimed to describe Korean nurses’ attitudes towards hospice care and to examine the relationships between nurses’ attitudes towards hospice care and their demographic and work-related characteristics. Methods: This was a cross-sectional descriptive study. A total of 348 registered nurses recruited from six general hospitals were surveyed using a structured questionnaire. Measurements included general and work-related characteristics and the Frommelt Attitude Toward Care of the Dying Scale. Results: The mean score for nurses’ attitudes towards hospice care was 2.52 out of a maximum of 3.0. More positive attitudes towards hospice care were associated with older age, married status, a higher level of education, working at a hospice unit, a higher job position, more years of work experience, having previous experience caring for dying patients and having received education in hospice care. Factors predicting nurses’ attitudes towards hospice care included the number of years of work experience and working at a hospice unit in a hospital, with an explanatory power of 22%. Limitations: The study was conducted in tertiary care hospitals in Seoul metropolitan area; results may therefore differ in other geographical regions. Conclusion: Education on hospice care should be targeted to less experienced, younger staff nurses who have no previous education on hospice care or have not worked in a hospice unit. Implication for Nursing and Health Policy: Tertiary hospitals need to provide more opportunities for their nurses to obtain continuing education on hospice care or increase the number of courses available at the institutional level in order to enhance their nurses’ attitudes towards hospice care. Keywords: Attitudes, End-of-life Care, Hospice Care, Hospice Education, Korea, Nurses, Palliative Care
Correspondence address: Hye-A Yeom, Research Institute for Hospice/Palliative Care, College of Nursing, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Korea. Tel: +82-2-2258-7402; Fax: +82-2-2258-7772; E-mail: [email protected].
Source of funding: This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (2013R1A1A3005236). Conflicts of interest: No conflict of interest has been declared by the authors.
© 2014 International Council of Nurses
1
2
K. S. Park & H. A. Yeom
Introduction The goal of hospice care is to provide holistic care to terminally ill patients and their families by supporting their physical, emotional and spiritual well-being. Hospice care is based upon a team approach, in which physicians, nurses, social workers and other relevant professionals collaborate in order to provide quality end-of-life care. The compassionate design of hospice care is known to increase patients’ and families’ satisfaction with end-of-life care because it reduces physical, psychological and spiritual suffering, and increases patient comfort (National Hospice and Palliative Care Organization 2013). Due to the positive impact of hospice care on the quality of life of dying patients, the number of patients and families receiving hospice care has been gradually increasing internationally. Korea is not an exception; interest in hospice care in Korea has increased remarkably, particularly interest in hospice care policy and the costs of care. The number of patients dying in hospitals has increased from 13.8% in 1990, to 28.3% in 1998 and to 67.5% in 2010 (Jung et al. 2013). Korea has approximately 253 hospice institutions, and onethird of all hospice care cases are bed-bound in-patients (Hong 2008). While the total number of dying patients has been increasing, utilization of hospice care is still not widespread. In Korea, only 6% of terminal patients receiving palliative care use hospice care services (Yun 2009). The underutilization of hospice and palliative care services is an international healthcare issue and is known to be due to several reasons, including disparities of use of hospice care, late referrals to hospice care services due to the difficulty physicians face in accurately predicting survival and negative attitudes towards hospice care among healthcare professionals (Litauska et al. 2014; O’Mahony et al. 2008). Specifically regarding attitudes, healthcare professionals often tend to consider a patient’s death as a professional failure and to focus more on quantitative aspects than on qualitative aspects of the patient’s life (Gazelle 2007). Often, nurses are the largest workforce in the healthcare field; they provide care for patients at all stages of their illness and play an important role in communicating with patients and their families. Nurses often coordinate care plans, facilitate discussions with patients and advocate for dying patients (Kim 2008). It is logical to assume that the positive attitudes of a nurse towards hospice care have an impact on the quality of care the nurse provides to dying patients. Nurses who have positive attitudes towards hospice care may be aware of the importance of hospice care for dying patients and thus may make more effort to provide high-quality hospice care to them. This attitudinal aspect is particularly important for nurses working at general hospitals, who take care of dying patients receiving
© 2014 International Council of Nurses
24-h care and consistently interact with them as they adjust to life with a terminal illness. Although nurses believe that it is important to develop professional and humanistic attitudes with regard to palliative care (Boyd et al. 2011; Zhou et al. 2010), nurses in clinical settings are often not prepared for end-of-life care; in fact, they report difficulty in providing high-quality care to dying patients and their families due to busy work conditions and duty-oriented care environment (Zamanzadeh et al. 2014). To date, most studies on attitudes towards hospice care have focused on physicians (Ache et al. 2011; Csikos et al. 2010; Litauska et al. 2014) or nursing home settings (Leclerc et al. 2014; Wowchuk et al. 2007). There has also been relevant research describing nurses’ attitudes towards hospice care in diverse cultures, including Iran (Iranmanesh et al. 2014), Jordan (Abu Hasheesh et al. 2013) and Turkey (Cevik & Kav 2013). However, there is little research describing the way hospice care is understood by Korean hospital ward nurses who may have relatively limited opportunities for hospice education in their workplace. Reflecting the growing number of terminally ill patients in acute care settings in Korea and the lack of preparedness of nurses for end-of-life care, the present study was designed to assess Korean nurses’ attitudes towards hospice care and to examine the relationships between this variable and their demographic and work-related characteristics.
Methods Design and sample
A cross-sectional descriptive study design was used. Participants were 380 registered female nurses recruited from six general hospitals in the metropolitan area of Seoul, Korea. This sample size was estimated using G*Power (Heinrich-Heine-Universität Dusseldorf, Düsseldorf, Germany), for a significance level of 0.05, a power of 0.80 and an effect size of 0.15. This effect size was determined based upon the correlation index between the attitude variable and other affective factors related to end-of-life care reported in a previous study (Lange et al. 2008). A convenience sampling method was used. Participants were eligible for enrolment if they were registered nurses (RNs) working at one of the participating general hospitals and if they agreed to participate in the study voluntarily. Measurements
Study variables included socio-demographic characteristics, work-related characteristics, personal experience in hospice care and attitudes towards hospice care. Socio-demographic variables included age, marital status, religion and level of education. Work-related characteristics included current work
Nurses’ attitudes towards hospice care
department, years practising as an RN, years employed at the hospital and current job position. Variables related to personal experience included previous nursing experience for terminally ill patients, previous bereavement experience regarding close family members and previous education on hospice care. Attitudes towards hospice care refer to nurses’ positive or negative feelings and motivations regarding care for terminally ill patients. Attitudes towards hospice care were measured using the Frommelt Attitudes Toward Care of the Dying Scale (FATCOD), which was originally developed by Frommelt (1991) and translated by Lee and Lee (2001) into Korean. This scale uses a three-point scale, from 1 (disagree) to 3 (agree). A higher score indicates a more positive attitude towards hospice care. The validity of the FATCOD has been established (Braun et al. 2010; Chi & Kim 2005; Lange et al. 2008). The Cronbach’s alpha reliability coefficient was 0.80 in this study. Data collection procedure
Upon approval by the Institutional Review Board for the Protection of Human Subjects (MC12QAS10169), participants were recruited from the nursing departments of six general hospitals in Seoul, Korea. The research team presented the study verbally in the hospitals’ nursing units, describing the purpose and the data collection procedures to potential subjects. The data were collected by one of the investigators, a graduate nursing student trained in research methodology, a specialty in hospice care and more than 5 years of clinical experience as an RN. The data were collected from December 2012 to January 2013. Survey questionnaires were distributed to those who were interested in participating in the study and who signed the informed consent form. Participants spent about 20–30 min completing the survey and were compensated with the equivalent of US$5.
3
for more than one-third of the total variables, which was considered a systemic error rather than a random one. General characteristics of subjects
All participants were women. Approximately half of the respondents (56.3%) were aged between 25 and 34 years. The majority of participants were single (72.1%) and living with family (65.5%). Roman Catholicism was the most prevalent religion (38.8%). In terms of education, 42.5% of participants were baccalaureate degree graduates and 41.7% were associate degree graduates. Participants had been practising as RNs for an average of 6.8 years. More than 80% were working as staff nurses, with 47.7% working in internal medicine units. Approximately 98% of participants (N = 341) reported that they had heard about hospice care, mostly through published literature (books, journals, etc.) or related education programmes (64.7%). More than 90% of participants had experience caring for dying patients. Of the participants, 38.3% reported having experienced the loss of a family member. Two hundred ten nurses (60.5%) reported that they had previously received education on hospice care (Table 1). Attitudes towards hospice care
The average score on the FATCOD was 2.52 out of a maximum of 3.0. FATCOD scores were significantly higher among participants aged 35 years or older (P = 0.001) and those with a master’s degree or higher (P = 0.001). Higher FATCOD scores were also significantly associated with working in a hospice unit (P = 0.001) and working in a unit management position (P = 0.001). Those who had more than 11 years of experience in nursing showed significantly higher FATCOD scores than other groups (P = 0.001). Those who had received hospice education showed higher FATCOD scores than those who had no experience of such education (P = 0.003) (Table 1).
Data analysis
The data were analysed using SPSS 12.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to summarize demographic characteristics and attitudes towards hospice care. Associations between attitudes towards hospice care and general characteristics were examined using t-tests and analyses of variance (ANOVAs), with Schéffe post-hoc tests. Significant bivariate correlates of the dependent variable were entered as potential predictors in the regression model using multiple stepwise regression techniques.
Results The final data analysed included the responses of 348 participants, after excluding 32 incomplete questionnaires. An incomplete questionnaire was defined as one that had missing values
© 2014 International Council of Nurses
Predictors of attitudes towards hospice care
The regression model predicting attitudes towards hospice care was statistically significant (F = 49.33, P < 0.001) with 22% of explanatory power. The significant predictors of attitudes towards hospice care were the number of years working as an RN (β = 0.41) and working in a hospice unit (β = 0.17) (Table 2).
Discussion This study described Korean nurses’ attitudes towards hospice care and examined the relationship between their attitudes and demographic and work-related characteristics. In the present study, attitudes of hospital nurses working in general wards, primarily internal medicine and surgery departments, were fairly
4
K. S. Park & H. A. Yeom
Table 1 Demographic and hospice-related characteristics in relation to nurses’ attitudes towards hospice care (N = 348) Variable
Age (years)
Marital status Religion
Education (degree)
Work department
Job position
Years as RN
Having heard of hospice care Previous nursing experience for dying patients Previous bereavement experience for family Previous experience of education on hospice
Category
