INTRODUCTION
1. Background
At the end of 2024, South Korea became an ultra-aging society [ 1 ], and one of the key issues was end-of-life care. Modern medicine was not very interested in the treatment of incurable diseases or the care of end-of-life patients as it focused on the cure and prolongation of life, but the interest in improving the quality of life expanded to the quality of death, and the concept of palliative care in the modern sense developed [ 2 ].
Hospice and palliative care are key components of a patient-centered integrated healthcare system that aims to alleviate physical, psychological, and spiritual suffering while maintaining human dignity. This approach extends beyond conventional clinical care to reduce pain and ensure comfort in the final stages of life, and is increasingly recognized as a universal ethical responsibility for humanity [ 3 ]. Hospice and palliative care can be provided in various environments such as hospitals, nursing homes, and patients’ homes, and the operation method varies depending on the cultural characteristics, economic level, medical insurance system, and service provision system of each country [ 4 ]. In the case of Korea, the Ministry of Health and Welfare implemented the ‘Home-based hospice and palliative care pilot project’ in 2016, providing a turning point for hospital-centered end-of-life care to expand to the home. Since the implementation of this system, studies have reported an increased likelihood of patients dying at home, along with positive outcomes such as reduced unnecessary social hospitalization and more efficient use of limited medical resources [ 5 ]. In addition, patients who had at least one home-based hospice service were more likely to choose their home as their preferred treatment site over the hospital [ 6 ], and this trend suggests that the home environment provides patients with psychological stability and continuity of life. However, although the number of inpatient and advisory hospice-specialized institutions has been steadily increasing in recent years, the rate of spread of home-based hospice-specialized institutions remains stagnant, and home-based hospice institutions, which numbered 39 in 2019, have been maintained. Regional gaps and manpower shortages have also intensified [ 6 ]. Accordingly, there is an urgent need to expand institutional support, infrastructure, and professional training.
Home-based hospice care most closely aligns with the philosophy of hospice care and requires a multidisciplinary team approach to deliver holistic care that integrates physical, psychological, social, and spiritual dimensions [ 7 ]. Nurses collaborate with physicians, social workers, and clergy to coordinate the needs of patients and families. From the time of enrollment, they confirm the preferred place of death and make adjustments to facilitate home death whenever possible [ 7 ]. When necessary, home-based hospice services are connected to inpatient hospice care to provide continuous care [ 8 ]. Home-based hospice nurses serve as coordinators and key communicators as the only dedicated personnel in the team. This means that nurses should focus only on home-based hospice care, unlike doctors and social workers, who can concurrently perform other types of hospice tasks [ 6 , 8 ]. Therefore, nurses are key pillars responsible for coordinating communication within teams; linking information between patients, families, and teams; and maintaining continuity of care [ 7 ].
In addition, home-based hospice nurses are the most frequent professionals who visit patient homes and take care of patients and their families closely, providing constant care [ 9 ], including 24-hour telephone counseling and emergency visit services [ 6 ]. In this process, nurses deliver hospice care not in the controlled environment of a hospital but within the complex context of the home as a living space. Thus, they are required to provide contextualized care that considers not only medical needs but also the home environment, family involvement in caregiving, and emotional relationships [ 10 ].
Hospice nurses remain on the patient’s side until the final moments of life, providing systematic end-of-life care to ensure a dignified and peaceful death [ 11 ], reflecting on the meaning of life and death and expanding human understanding [ 12 ]. However, when confronted with a patient whose symptoms are not controlled or who is requesting death due to extreme pain, the nurse inevitably experiences ethical conflict and an emotional burden between professional ethics and human compassion [ 10 ]. These complex experiences highlight the unique nature of home-based hospice nursing and underscore the need to explore end-of-life care experiences in-depth.
Previous studies on end-of-life care have primarily involved quantitative investigations, including research on perceptions of death, end-of-life care stress, and attitudes toward end-of-life care among intensive care unit nurses [ 13 ]; performance of end-of-life care among hospice nurses [ 14 ]; performance and stress related to end-of-life care among nurses in long-term care hospitals [ 15 ]; and death anxiety, stress, and attitudes toward end-of-life care among oncology ward nurses [ 16 ]. Although some studies have explored nurses’ experiences with end-of-life care [ 17 , 18 ], there remains a lack of in-depth research focusing on the end-of-life care experiences of home-based hospice nurses, whose work is characterized by unique constraints distinct from other clinical settings. Accordingly, this study applied Giorgi’s [ 19 ] phenomenological research method to explore the end-of-life care experiences of home-based hospice nurses, analyze their essence and meaning, and apply structural derivation through overall meaning identification, meaning unit classification, conversion into academic terms, and meaning integration.
Through this approach, this study aimed to elucidate the emotional and ethical conflicts experienced by home-based hospice nurses and reveal the essential meaning of care in the context of end-of-life nursing. These findings serve as foundational evidence for improving the quality of home-based hospice care and enhancing the effectiveness of end-of-life nursing practices.
2. Purpose of the study
This study aims to understand and describe the meaning of end-of-life care provided by home-based hospice nurses. The research question was: What is the meaning and nature of the end-of-life care experience of home-based hospice nurses?
METHODS
1. Study design
This qualitative study employed Giorgi’s phenomenological approach [ 19 ] to describe the meaning and nature of home-based hospice nurses’ end-of-life care experiences.
2. Study participants
Participants were recruited through purposeful sampling to learn about the end-of-life care experiences of home-based hospice nurses. The participants were 11 home-based hospice nurses with more than six months of work experience. Those who understood the purpose of the study and agreed to participate were selected. A working period of 6 months or longer was judged as the minimum period to take care of the actual patient, perform the role within the team, and fully experience the characteristics and processes of terminal care.
For ethical considerations of research participants, the researcher explained the purpose of the study, data collection methods, anonymity, and confidentiality to all the participants before the interview. Participants were informed that the interviews would be audio recorded, that the recordings would never be used for any purpose other than the study, and that they would retain the right to withdraw from the study at any time without consequences. Written informed consent was obtained from each participant after explanations were provided.
The general characteristics of the participants are presented in Table 1 .
3. Data collection and ethical considerations
This study was approved by the Institutional Review Board of C University before data collection (IRB No. CSIRB-2023017). Participants were selected through purposive sampling and included nurses with experience in providing home-based hospice services, who fully understood the purpose of the study and voluntarily agreed to participate. First, nurses with home-based hospice experience were introduced to explain the purpose and method of the study, and additional participants were recruited by sending official letters of cooperation to home-type hospice institutions nationwide. Nurses who were willing to participate were introduced to the researcher at the institution that agreed to participate, and those who voluntarily agreed were selected as the final participants.
The researcher scheduled interview times and locations by telephone, and individual in-depth interviews were conducted from August to November, 2024. All interviews were audio-recorded with the participants’ consent and key points were documented in field notes.
The interview question started with an open question: “What was the end-of-life care experience of a home-based hospice nurse?” The researcher listened to the participants’ statements while maintaining a neutral attitude. After the 11th interview with the participants, no new content was derived; therefore, it was determined that the data had reached saturation, and the data collection was terminated. Interviews were conducted once or twice per participant and took 60~90 min per session. In addition, considering the possibility of emotional discomfort in the process of recalling the end-of-life nursing experience, if a psychological response occurred during the interview, the interview was immediately stopped; the participant was listened to empathically and helped to stabilize. When necessary, they were guided to receive psychological support in connection with the counseling expert or psychological counseling center of the relevant institution.
4. Data analysis
Giorgi’s phenomenological analysis method was employed to explore the end-of-life care experiences of home-based hospice nurses. First, the researcher repeatedly and carefully read the interview transcripts, field notes, and written memos to grasp the overall sense of the data. In the second step, the researcher focused on phenomena relevant to the study topic and identified meaning units by analyzing each statement provided by the participants. In the third step, meaning units were transformed into academic expressions, with attention directed toward capturing the essence of home-based hospice nurses’ end-of-life care experiences. Finally, the semantic structure was confirmed by synthesizing the semantic units experienced by the participants and integrating them into a general theoretical language.
5. Ensuring the rigor, reliability, and validity of the study
This study attempted to ensure reliability and validity according to the rigorous evaluation criteria of Lincoln and Guba [ 20 ]. First, to increase credibility, the interview data were repeatedly reviewed, the analyzed contents were described, and the results were presented to some participants to verify that the researcher’s interpretation was consistent with their actual experiences. In addition, to ensure the applicability of the study, a peer review was conducted to present the analysis process and results to one nursing professor and fellow researchers with extensive qualitative research experience and to discuss the validity of the interpretation. To ensure the consistency and confirmability of the study, the entire process was systematically recorded, and the processes of data collection, analysis, subject derivation, interpretation, and conclusion were made transparent in writing to maintain an audit trail. These procedures minimized researcher bias and ensured the reliability and replicability of the study findings.
RESULTS
As a result of analyzing the end-of-life care experiences of home-based hospice nurses through in-depth interviews with 11 participants, four categories and 11 components were derived. The nursing experience at the end-of-life of home-based hospice nurses was ‘practicing emotional care,‘ ‘burden and burnout of professional life,‘ ‘rediscovering the meaning of existence,’ and ‘awareness of sustainable care systems.’ ( Table 2 )
1. Practicing emotional care
Participants emphasized that the suffering of patients at the end-of-life should not be limited to physical dimensions but must be understood and addressed with sensitivity to emotional and psychological aspects. They reported that, for patients preparing for the final stage of life, emotions such as anxiety, fear, loneliness, lingering attachments, and regret were sometimes experienced as more distressing than physical symptoms.
1) Emotional support for preparing for death
Interview participants reported that they played an important role in providing emotional support and guidance to help patients and their families prepare for death and accept it peacefully, thereby alleviating their fear and anxiety. Through this process, they supported patients and their families in approaching the final stage of life in a calm and stable state of mind.
“When the patient expressed anxiety while preparing for death, I sat beside them, listened quietly, and calmly explained the changes that could occur during the dying process. As I watched the patient gradually regain emotional stability, I realized how important my role could be.” (Participant 1)
2) Providing psychological stability
The participants provided psychological comfort to ease the fear and anxiety of the patients and their families, offering steady emotional support to help them face the final stages of life with peace. Through this process, the interviewees supported the patients and their families in preparing for death, with a sense of emotional stability.
“While caring for patients and families overwhelmed by anxiety, I felt deeply that I could offer even a small sense of emotional comfort. Watching them gradually find peace of mind made me recognize once again the importance of my work.” (Participant 6)
3) Forming emotional bonds
Interview participants played an important role in helping patients and families form emotional bonds as they faced the final moments together, and in creating an environment that allowed them to say goodbye peacefully. Through this process, they experienced supporting the development of deep emotional connections between patients and their families.
“I believe it is important to support patients and families so they can feel emotionally connected and prepare for their final moments together in peace. Watching them lean on one another and find a sense of stability made me realize the significance of this role.” (Participant 7)
2. Burden and burnout of professional life
During the process of end-of-life care, they repeatedly faced pain from patients and their families and experienced complex burnout that overlaps with emotional, ethical, and relational burdens. In addition, performing multiple roles simultaneously was found to aggravate physical and emotional fatigue and deepen burnout.
1) Complex burden of end-of-life care
Participants faced the suffering of patients and their families in close proximity and experienced a complex burden in which emotional, ethical, and relational conflicts were intertwined. The responsibility of simultaneously performing multiple roles while preparing for death created ongoing tension and contributed to persistent burnout among nurses.
“It was never easy to be beside families as they faced the pain of letting go of someone they loved. Although I empathized deeply with their emotions, repeatedly encountering the same situations every day left me emotionally exhausted.” (Participant 2)
2) Burnout due to multiple roles
The participants experienced accumulated emotional burnout and empathy fatigue in the process of repeatedly facing the sadness of patients and their families. In the process of repeated end-of-life care, the situation in which the patient’s pain had to be closely monitored and the family’s anxiety and sadness had to be addressed was a factor that further increased burnout.
“Helping patients and their families at the same time is not just about nursing them, but also about educators explaining their condition, counselors who comfort and support emotionally disturbed families, and coordinators who must coordinate opinions and needs among patients, families and medical staff. When I try to perform multiple roles at the same time, I have to make a quick judgment every moment, and I have to get the feelings of the patient and family together, so I often get physically and emotionally tired.” (Participant 5)
3. Rediscovering the meaning of existence
Participants reported that their involvement in end-of-life care extended beyond routine tasks and led them to engage in deep self-reflection and reinterpret the meaning of their existence. The participants realized the finiteness of life in the repetitive accompaniment of death and had the opportunity to look back on the lives they are currently living.
1) Re-recognition of the value of life
Participants noted that encountering patients’ lives and deaths in close proximity led them to reflect deeply on the essence of life and meaning of existence. In particular, as we shared the last journeys of patients and families, we felt that human life was finite, and this experience served as an opportunity for nurses to reexamine the importance of living at this moment and the meaning of daily life.
“As I continue to experience death up close, how finite life is... And now, I feel so much that this moment is so precious to me. That ’ s why I cherish my life more, and I take care of my family and people around me more.” (Participant 5)
2) Self-growth opportunities
Through the end-of-life nursing process, participants experienced deep reflection on and growth of their inner self and existence beyond simply providing care. By accompanying patients through their final stages of life, nurses witness both human vulnerability in the face of death and the strength with which individuals strive to maintain dignity until the end-of-life, providing them with meaningful opportunities for self-reflection.
“At first, I was scared and afraid. I was not used to seeing death up close. But as time went by, I became more in awe of life, and I feel like I have become deeper in myself. I have changed my way of dealing with people than before.” (Participant 3)
3) Confirming the value of nurses’ existence
By caring for patients and their families at the end-of-life, participants realized that their role extended beyond providing nursing care to embody that of a companion and supporter who accompanies individuals through the final moments of life. Participants came to recognize that supporting a peaceful death for patients and providing emotional support to surviving family members were not merely professional duties but meaningful acts that substantively contributed to one of the most dignified moments in human life.
“I’m so grateful that there is something I can do in the face of someone’s death. That’s what I mean by being myself. It’s hard, but it makes me feel more alive.” (Participant 8)
4. Awareness of sustainable care systems
The participants recognized that institutional improvements and support were essential for enhancing the quality of care and providing effective assistance. In particular, they experienced emotional exhaustion due to a lack of manpower and resources and desperately felt the need for policy support, financial support, and sufficient manpower support to improve the care environment.
1) Shortage of personnel and excessive workloads
In the process of providing care for end-of-life patients, the participants were directly experiencing limitations in the sustainability of care in an infrastructure that was not systematically supported and an unstable institutional foundation. Although nurses possess a strong sense of mission and professional pride regarding the necessity and value of hospice services, they continually face difficulties in providing high-quality and stable care due to staff shortages, excessive workloads, inadequate financial compensation, and insufficient policy support.
“The workload keeps piling up, and I even have to take care of administrative tasks myself… Even if I want to focus on nursing, I have so many other things to do. By the time I finish writing documents, preparing reports, and handling various administrative tasks, the actual time I can spend at the patient’s bedside becomes extremely limited. Sometimes I even find myself wondering whether I am an administrative worker or a nurse.” (Participant 10)
2) Institutional and policy limitations
The participants felt that the continuity and quality of on-site nursing were threatened by institutional and policy limitations in the process of performing end-of-life nursing. In particular, compared to the social necessity and nursing expertise of home-based hospice services, it was recognized that the policy stability and administrative support system to support them were insufficient. Such institutional instability manifested in frequent changes to guidelines, ambiguous standards, and excessive administrative work, ultimately creating conditions in which nurses found it difficult to focus adequately on direct patient care.
“Because the guidelines keep changing, I often find myself confused. What I was told to do yesterday is different again today… The standards are unclear, and at times I am not even sure what is allowed and what is not. This makes me more cautious, and everything takes much longer.” (Participant 2)
3) Request for institutional improvement
Participants reported that in the process of delivering continuous care in home-based hospice settings, they directly experienced the limited effectiveness and poor applicability of current policies in real-world practice, which led them to feel an urgent need for institutional improvements.
“The actual situation is different from the system. In the field, it’s often difficult to apply them all by that standard. The patient’s condition is different, and things change in a hurry. So we need guidance that’s applicable to real world practice. It’s not just what it is in the document, it’s the standard that we can actually apply.” (Participant 6)
DISCUSSION
This study attempted to deeply investigate the nature and meaning of end-of-life care at home by exploring the nursing experiences of home-based hospice nurses using Giorgi’s phenomenological approach. As a result, four categories and 11 components were derived: ‘practice emotional care,’ ‘burden and burnout of professional life,’ ‘rediscovering the meaning of existence,’ and ‘awareness of sustainable care systems.’ These results provide an empirical basis for structuring and understanding the reality of nurses who practice holistic care in the daily space of the home and illuminate the professionalism of end-of-life care and the meaning of human dignity.
The first category derived from this study, ‘practice of emotional care,’ emphasizes the role of nurses who respond sensitively to emotions such as anxiety, fear, and loneliness experienced by terminally ill patients and their families, accepting and supporting them. Home-based hospice nurses promoted emotional stability for patients and their families through a strategy of ‘listening-accompanied-explaining,’ which is consistent with previous studies that emphasized that hospice nurses relieve psychological and social pain and function as emotional supporters [ 21 ]. Providing care within the familiar environment of the home offers patients psychological tranquility and gives families meaningful opportunities to accompany the dying process. This is consistent with domestic findings that patients who receive home-based hospice services are more likely to die at home [ 22 ]. However, such emotional care requires repeated emotional labor from nurses, and intensified emotional suppression can lead to emotional exhaustion [ 23 ]. Umubyeyi et al. [ 24 ] reported that palliative care nurses experienced psychological isolation and fatigue when they suppressed their emotions while accommodating the emotions of patients and their family caregivers. The participants in this study also described having to suppress their emotions while calmly explaining situations to family caregivers, revealing the tension involved in emotional restraint. Korea’s home-based hospice system, a structure in which one nurse is in charge of both 24-hour phone counseling and home visits, has the characteristics of high frequency and intensity of emotional care. Accordingly, organizational awareness of emotional labor and institutional support for psychological recovery must be provided in parallel. Regular supervision and debriefing systems are required to ensure that nurses’ empathetic capacity translates into positive caregiving outcomes.
The second category, ‘burden and burnout of professional life,’ shows the emotional labor and accumulation of fatigue experienced by nurses as they share in the suffering of patients and families facing anticipated death, engage in emotional interactions with family caregivers, and carry out caregiving responsibilities alone. Participants continuously experienced the tension of having to suppress their emotions externally, even as they deeply empathized with the suffering of patients approaching death or the despair of family caregivers. Such emotional suppression and regulation led to the depletion of nurses’ psychological resources, aligning with the findings of Chung and Han [ 25 ], which reported that high emotional labor increases burnout and turnover intention. Among the study participants, he stated, “I wanted to cry, but I endured it for my family,” and “I could only cry in the car after taking care of it,” referring to the conflict between emotional expression and suppression. This means that if the emotion regulation strategy is insufficient, emotional labor can weaken an individual’s resilience and hinder job continuity. A study on long-term care hospital nurses also pointed out that end-of-life nursing is accompanied by ethical tensions and practical limitations, and emotional exhaustion is a difficult problem to overcome with individual competence alone [ 26 ]. Therefore, care providers need a culture that allows emotional support and emotional expression at the organizational level, which is a key condition for maintaining the quality of care and job continuity of nurses. What is meaningful is that the participating nurses experienced burnout and felt a kind of psychological reward through the expression of gratitude of patients and caregivers. Despite the accumulation of emotional fatigue, the expression of gratitude by patients and their families acted as an internal motive for strengthening nurses’ job identity and continuing care, suggesting that it functions as an emotional resource to alleviate job burnout. This finding supports the notion that ‘attributing meaning to care’ positively influences nurses’ resilience [ 27 ]. Ultimately, nursing in home-based hospice care is not merely a technical activity, but a highly demanding professional practice that simultaneously requires emotional regulation, human relational engagement, and ethical judgment. Therefore, to prevent burnout among nurses and realize sustainable care, concrete measures, such as the introduction of a debriefing program, an institutional device that can buffer the emotional burden, establishing an appropriate compensation system for emotional labor, and deploying personnel to support administrative work, are essential.
The third category, ‘rediscovering the meaning of existence,’ revealed that accompanying patients through the end-of-life process led home-based hospice nurses to reflect on the finitude of life and the essence of human existence, thereby prompting them to restructure their professional and personal meaning systems. home-based hospice nurses, through their repeated involvement in end-of-life care, came to newly recognize “the preciousness of the present moment” and “the value of relationships with others and family,” and experientially confirmed that their role imparted substantive meaning to the patient’s final journey.
These experiences align with recent studies emphasizing that hospice nurses function not merely as providers of technical procedures but as “existential partners” who accompany patients through the final phase of life [ 28 ]. In a phenomenological study of Chinese hospice nurses, Wang et al. [ 28 ] reported that reflection on life and death fostered inner growth and strengthened professional competence, whereas Kim and Lee [ 27 ] found that a sense of meaning in life enhanced job satisfaction by mediating resilience. This study likewise identified this pattern, suggesting that the incorporation of reflection-based educational programs such as reflective practice curricula or storytelling workshops into formal training may help nurses reestablish their sense of existential meaning and strengthen their motivation to sustain caregiving. Jameson [ 12 ] reported that structured debriefing and spiritual reflection programs enhanced the inner growth of hospice team members and reduced burnout, indicating the need for future research on the design and application of systematic reflection programs in domestic clinical settings.
The fourth category, ‘awareness of sustainable care systems,’ suggests that the sustainability of home-based hospice services is being undermined by structural constraints such as chronic staff shortages, frequent revisions of guidelines, and excessive administrative workload. Nurses reported that the quality of care diminished because the staffing and patient ratios in the field far exceeded the recommended levels, and a substantial amount of administrative documentation encroached on the time available for direct nursing care. These statements align with findings from a nationwide survey of long-term care facility workers, in which more than 70% identified the expansion of hospice education and the establishment of administrative support systems as urgent priorities [ 29 ]. A cross-sectional study of community hospice-based nurses [ 30 ] also identified a pathway in which excessive responsibility and emotional burden influenced turnover intention through job burnout and highlighted organizational emotional support and workforce reinforcement as key factors in mitigating exhaustion. Recent government statistics indicate that as of 2025, there are only 39 home-based hospice specialty institutions nationwide, demonstrating that the number of such facilities has remained stagnant for several years since 2019 [ 6 ]. To solve this problem, efforts are needed to closely connect the policy direction of the second hospice and life-saving medical comprehensive plan (2024 to 2028) with actual care field experience [ 4 ]. Stepwise policy implementation is required to establish a solid institutional foundation through revisions to reimbursement systems and legal frameworks and to enhance accessibility by developing region-centered delivery systems and diversifying service types [ 4 ]. In addition, a multilayered policy design including sustainable education and emotional support for nurses, strengthening psychological and emotional counseling functions for patients and families, and raising public awareness of end-of-life care should be implemented in parallel [ 4 ]. To ensure the sustainability of home-based hospice care delivery systems, structural support, including appropriate reimbursement, workforce expansion, and the separation of administrative responsibilities, is required. Clear, concise, and flexible guidelines that can be applied in practice are essential to minimize confusion in care, and both infrastructure and care models should be designed to reflect the regional characteristics and diversity of patients’ lives.
Based on these results, the following suggestions are made: First, it is suggested that regular debriefing and supervision programs be institutionally implemented to help home-based hospice nurses minimize emotional exhaustion despite their repeated involvement in end-of-life care. Second, to enhance the efficiency of the nursing workload, it is recommended to expand administrative support personnel and separate non-nursing tasks so that nurses can focus on their primary caregiving roles. Third, flexible practice guidelines and field-based standard protocols should be developed to reflect real-world conditions, including patient clinical status, home environment, and family caregiving capacity. Finally, future studies should expand integrated research, including members of multidisciplinary teams such as doctors, social workers, and spiritual counselors, to identify the structural characteristics and interaction mechanisms of home-based hospice care.
This study clearly demonstrated that the care provided by home-based hospice nurses is not merely a medical intervention but an existential practice that accompanies patients through the final journey of life with dignity. These findings may serve as a basis for institutional improvements in home-based hospice care, the strengthening of educational systems, and the development of emotional support policies for nurses. Furthermore, this study is expected to provide foundational data for enhancing job satisfaction and the sustainability of caregiving among clinical nursing practitioners.
SUPPLEMENTARY MATERIALS
Supplementary materials can be found via https://doi.org/10.14475/jhpc.2025.28.4.169 .
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
AUTHOR’S CONTRIBUTIONS
Conception or design of the work: MB, HY. Data collection: MB, IK. Data analysis and interpretation: HY. Drafting the article: MB, IK. Critical revision of the article: MB, HY, IK. Final approval of the version to be published: MB, HY.
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