INTRODUCTION
1. Background
As advances in medical technologies, a high standard of living, improved sanitation, and economic growth led to longer lives, the percentage of people aged 65 or older was 14.3% in 2018 in Korea, entering an aged society. The percentage of the elderly population is projected to be 19.2% in 2024 and 20.3% in 2025, becoming a super-aged society [ 1 ]. Sociodemographic changes from the growth of the nuclear family and increased women’s economic participation have led to the shift in care for older adults with chronic conditions from home to long-term care hospitals [ 2 ]. In most cases, patients remain in long-term care hospitals until death rather than being discharged home [ 3 ]. There were 60,711 deaths in 2015, 63,625 deaths in 2016, and 69,503 deaths in 2017, showing a gradual increase. Given a total of 285,000 deaths in 2017, nearly a quarter of the dead died in long-term care hospitals [ 4 ]. Nurses working in long-term care hospitals should provide holistic care for older adults and help them live comfortably for the rest of their lives. Moreover, they should provide hospice and palliative care and spiritual nursing care to help older adults complete the death process in a dignified and peaceful way.
Since spiritual care was valued as an essential component of holistic nursing that understands and integrates the human dimensions, providing spiritual care is increasingly acknowledged as being a responsibility and duty of nurses [ 5 ]. Spiritual care in nursing practice is to alleviate most spiritual distress and maintain spiritual well-being by recognizing spiritual needs within patients [ 6 ]. Nurses should provide not only physical and psychological nursing care but also well-organized spiritual nursing care for terminally ill patients to reduce suffering from nursing interventions and complete the death process in a peaceful way [ 7 ].
Spiritual care competence is the ability of nurses to provide spiritual care to meet the spiritual needs of patients and an essential and fundamental nursing competency for holistic care. It is a key contributor to an increase in nursing professionalism and improvement of patient care [ 8 ]. Spiritual care competence is a crucial concept in being sensitive to patients’ spiritual needs and handling emotions in the relationship with patients professionally and an essential requirement from nurses [ 9 ]. Nurses should possess knowledge, skills, and attitudes that enable nurses to understand and meet patients’ spiritual needs and provide patient care. Especially, nurses of long-term care hospitals should possess competence in providing spiritual care to improve the quality of holistic care and life by satisfying patients’ spiritual interests and needs.
As knowledge regarding palliative care among nurses of long-term care hospitals is a collection of information that is required for alleviating suffering and discomfort at the end of life in terms of pain and physical, psychological, philosophical, and spiritual problems [ 10 ], the knowledge is a fundamental concept in assessing and responding to patients’ spiritual problems. Knowledge is crucial to nurses providing assessments, plans, interventions, and evaluations continuously, and nurses’ knowledge regarding hospice and palliative care should be the initial basis of not only understanding patients with their last hours, but also identifying spiritual needs among them.
Empathy is the ability to understand the experiences of others and imagine and emotionally feel oneself in someone else’s place [ 11 ], and a key, professional, and crucial quality for nurses to resolve patients’ spiritual problems [ 12 ]. It is necessary for nurses to empathize with sorrow and apprehension associated with impaired capacity to communicate caused by sensory loss, decline in cognitive function, and emotional instability among older adults and take proper responses to emotions. The ability of nurses working at long-term care hospitals to empathize plays a vital role in providing emotional stability and spiritual care for patients and strengthening their spiritual care competency. Especially, nurses with empathy are able to lessen the fear and dread that patients may experience during their impending death and provide spiritual well-being.
Attitude toward end-of-life care refers to the positive or negative perceptions, feelings, and motivations that nurses have in relation to the care of terminally ill patients and is a key determinant of the overall health of dying patients and their families and quality of life [ 13 ]. Therefore, the influence of attitude toward end-of-life care on spiritual care competence should be investigated to enhance the spiritual care competence of nurses who frequently care for dying patients at long-term care hospitals.
Previous studies on spiritual care competence of nurses reported that self-esteem [ 14 ], communication [ 14 ], existential well-being [ 14 ], spiritual well-being [ 15 ], empathy [ 16 ], and interpersonal competency [ 16 ] are associated with spiritual care competence. Also, factors related to spiritual care competence included marital status [ 15 ], perception of the necessity of spiritual care [ 16 ], experiences in spiritual care [ 14 ], education level [ 15 ], and position [ 14 ] among the characteristics of nurses. However, research that investigated the association of spiritual care competence with knowledge of hospice and palliative care, empathy, and end-of-life care is sparsely conducted. Moreover, although spiritual care competence is essential to nurses in long-term hospitals due to the increased number of older adults with care needs and frequent provision of end-of-life care, the competence among nurses in long-term care hospitals is understudied. Since the quality of spiritual care depends on the knowledge, skills, and attitudes of nurses who directly care for patients in long-term care hospitals, it is necessary to identify and understand factors influencing spiritual care competence among nurses in long-term care hospitals. Therefore, the present study aims to identify the influence of knowledge about hospice and palliative care, empathy, and attitude toward end-of-life care on spiritual care competence among nurses in long-term care hospitals and provide fundamental data used for developing an education program that enhance spiritual care competence among nurses in long-term care hospitals.
2. Purpose
The present study was conducted to identify the influence of knowledge about hospice and palliative care, empathy, and attitude toward end-of-life care on spiritual care competence among nurses in long-term care hospitals and provide fundamental data used for developing an education program that enhance spiritual care competence among nurses in long-term care hospitals. The present study aims to:
1) Determine the level of knowledge about hospice and palliative care, empathy, attitude toward end-of-life care, and spiritual care competence among participants.
2) Determine a difference in spiritual care competence by participants’ general characteristics.
3) Analyze the correlation between knowledge of hospice and palliative care, empathy, attitude toward end-of-life care, and spiritual care competence in participants.
4) Analyze factors that affect spiritual care competence among participants.
METHODS
1. Study design
This is a descriptive study, aiming to identify the influence of knowledge of hospice and palliative care, empathy, and attitude toward end-of-life care on spiritual care competence among nurses in long-term hospitals.
2. Participants and data collection
Nurses who were working in 14 long-term care hospitals located in C province were selected through random sampling at the time of study. Nurses with at least one year of clinical experience and an experience of caring for at least one dying patient in the long-term care hospital were included in the study. The participants informed that they understood the study purposes and signed a consent from indicating their voluntary study participation.
G*Power software (ver. 3.1) was used to calculate the appropriate sample size required for multiple regression analysis. The minimum sample size was 162 by considering an effect size of 0.15, significance level (α) of 0.05, power (1-β) of 0.90, and 13 predictable variables. Given the dropout rate of 20%, questionnaires were distributed to 202 participants. Of total, 178 questionnaires were returned, and four questionnaires with many missing data were excluded. Finally, data from 174 questionnaires were analyzed.
The study was reviewed and approved by the Institutional Review Board of Korea National University of Transportation (KNUT IRB 2023-17) and collected data from 17 September to 15 October, 2023. The researcher of the present study visited the long-term care hospitals in C province and met the president of the long-term care hospital and the director of nursing to explain the purposes and objectives of this study and asked for their cooperation in conducting the study. The researcher met the participants face-to-face and distributed the questionnaire directly and obtained consent on the attached consent form after describing the study purposes, process, and confidentiality. The questionnaires were completed by the study participants by themselves. The respondents were instructed to put the completed questionnaires in an envelope and seal it by themselves and directly handed to the researcher.
3. Study tools
1) General characteristics
General characteristics consist of 10 items, including sex, age, marital status, religion, education level, total clinical experience in months, form of work, experience of losing family members, relatives, or friends within a year, subjective health status, and job satisfaction.
2) Knowledge about hospice and palliative care
To measure nurses’ knowledge of hospice and palliative care, a tool developed by Ross et al. [ 17 ] and translated by Kim et al. [ 18 ] was used with the permission of researcher. To determine the validity of each item, the content validity index (CVI) of quiz was calculated and tested by five experts consisting of two nursing professors, two hospice nurses, and one nurse working at a convalescent hospital. The CVI for all items was 1.0 for all experts, resulting in good content validity. The questionnaire consists of 20 items each of which should be answered as Yes, No, or Don’t know. Each correct answer gave 1 point and incorrect answer and answer with don’t know gave 0 points. Higher scores indicate a greater level of knowledge of hospice and palliative care.
3) Empathy
The Toronto Empathy Questionnaire (TEQ) developed by Spreng et al. [ 19 ] is used to measure empathy. The present study used the Korean version of the TEQ that was translated and validated by Kim and Han [ 20 ] with the permission of researcher. The questionnaire consists of 16 items, and each item is rated on a 5-point Likert scale ranging from 0 (never) to 4 (always). Higher scores indicate greater empathy. The Cronbach’s alpha for the questionnaire was 0.87 [ 20 ] in the original study, and it was 0.81 in the present study.
4) Attitude toward end-of-life care
To measure attitudes toward end-of-life care, Attitudes toward Nursing Care of the Dying Scale developed by Frommelt [ 21 ] and translated, modified, and revised by Cho and Kim [ 22 ] was used with the permission of researcher. The scale is composed of 30 items, and each item is rated on a 4-Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). Higher scores indicate a more positive attitude toward end-of-life care. The Cronbach’s alpha for the scale was 0.94 [ 22 ] in the original study, and it was 0.82 in the present study.
5) Spiritual care competence
The Spiritual Care Competence Scale developed by van Leeuwen et al. [ 8 ] and translated into Korean by Kang et al. [ 23 ] was used with the permission of researcher. The scale is composed of 27 items, and each item is rated on a 5-Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Higher scores indicate a high level of spiritual care competence. The Cronbach’s alpha for the scale was 0.94 [ 23 ] in the original study, and it was 0.96 in the present study.
4. Data analysis
The collected data were analyzed using SPSS (Statistical Package for the Social Science) WIN 29.0, and specific methods for data analysis are as below.
1) Participants’ general characteristics were analyzed using percentages, means, and standard deviations.
2) An independent t-test, a one-way ANOVA, and the Kruskal-Wallis test, a non-parametric test of three or more groups, were used to compare differences in spiritual care competence by participants’ general characteristics, and the Scheffe test was used as a post-hoc test.
3) Pearson correlation coefficient was used to analyze the correlation between participants’ knowledge of hospice and palliative care, empathy, attitude toward end-of-life care, and spiritual care competence.
4) Stepwise multiple regression analysis was used to determine factors influencing spiritual care competence among the participants.
RESULTS
1. Participants’ general characteristics
Of the participants, 158 were females (90.8%). The mean age was 44.8±11.7 years old, and 129 (74.1%) were married. There were 99 (56.9%) participants who had religion and 88 (50.6%) participants who were four-year college graduates. The mean duration of clinical experience was 169.5±105.5 months. With regard to form of work, there were 54 (31.0%) with schedules for three-shift work and 54 (31.0%) working in a day or evening. Of the participants, 116 (66.7%) had no experience of death of family members, relatives, or friends over the last year, 82 (47.1%) had average subjective health status, and 92 (52.9%) were satisfied with their job ( Table 1 ).
Table 1
Difference of Spiritual Care Competence according to General Characteristics of Participants (N=174).
| Variables | Categories | n (%) | M±SD | Spiritual care competence | |
| M±SD or Median [IQR] | t, Z or F(P), Scheffe | ||||
| Gender | Male Female | 16 (9.2) 158 (90.8) | 3.31±0.57 3.41±0.63 | –0.58 (0.566) | |
| Age (yr) | 20~29 30~39 40~49 50~59 ≥60 | 18 (10.3) 45 (25.9) 41 (23.6) 48 (27.6) 22 (12.6) | 44.8±11.7 | 3.46±0.69 3.36±0.63 3.29±0.54 3.42±0.65 3.61±0.64 | 1.06 (0.378) |
| Marital status | Single Married | 45 (25.9) 129 (74.1) | 3.33±0.54 3.43±0.65 | –0.93 (0.353) | |
| Religion | Yes No | 99 (56.9) 75 (43.1) | 3.47±0.54 5.31±0.67 | 1.62 (0.108) | |
| Education | Junior collegea Universityb Graduate schoolc | 78 (44.8) 88 (50.6) 8 (4.6) | 3.33 [0.83] 3.46 [0.81] 4.00 [0.65] | 12.24† (0.002) (a,b<c) | |
| Career (mo) | ≤120 120~239 ≥240 | 57 (32.8) 65 (37.3) 52 (29.9) | 169.5±105.5 | 3.41±0.67 3.34±0.56 3.47±0.65 | 0.58 (0.561) |
| Form of work | Three-shift Day/evening keep Night keep Full-time job | 54 (31.0) 54 (31.0) 27 (15.6) 39 (22.4) | 3.36±0.58 3.35±0.68 3.38±0.62 3.53±0.61 | 0.73 (0.536) | |
| Experience of death of family members, relatives or friends within 1 year | Yes No | 58 (33.3) 116 (66.7) | 3.44±0.63 3.38±0.62 | 0.60 (0.552) | |
| Subjective health status | Poor Average Good | 14 (8.0) 82 (47.1) 78 (44.9) | 3.30±0.69 3.35±0.58 3.47±0.66 | 1.03 (0.360) | |
| Job satisfaction | Very dissatisfactiona Dissatisfactionb Averagedc Satisfactiond Very satisfactione | 2 (1.1) 5 (2.9) 62 (35.6) 92 (52.9) 13 (7.5) | 3.07 3.85 [0.96] 3.31 [0.84] 3.41 [0.88] 4.07 [0.96] | 12.24† (0.002) (c,d<e) |
2. Level of knowledge about hospice and palliative care, empathy, attitude toward end-of-life care, and spiritual care competence
The mean score for knowledge about hospice and palliative care was 8.56±2.24 out of 20, and the mean score for empathy was 2.64±0.46. The mean score for attitude toward end-of-life care was 3.05±0.32 out of 4. The mean score for sub-categories of attitude toward end-of-life care was 3.12±0.34 and 3.12±0.39 for attitude to end-stage patients and attitude to family members, respectively. The mean score for spiritual care competence was 3.10±0.62 out of 5. The highest score on spiritual care competence was for communication (4.10±0.69), followed by attitude towards patient spirituality (4.03±0.67), personal support and patient counseling (3.30±0.76), assessment and implementation of spiritual care (3.29±0.73), referral to professionals (3.12±0.83), and professionalization and improving the quality of spiritual care (3.11±0.80) ( Table 2 ).
Table 2
Level of Hospice-Palliative Nursing Knowledge, Empathy, Attitude toward End-of-Life Care and Spiritual Care Competence (N=174).
| Variables | M±SD | Range | Min~Max |
| Hospice-palliative nursing knowledge | 8.56±2.24 | 0~20 | 0~15 |
| Empathy | 2.64±0.46 | 0~4 | 1.38~3.63 |
| Attitude toward end-of-life care | 3.05±0.32 | 1~4 | 2.30~3.80 |
| Attitude of end-stage patients | 3.12±0.34 | 1~4 | 2.15~3.80 |
| Attitude to family members | 3.12±0.39 | 1~4 | 2.10~3.90 |
| Spiritual care competence | 3.10±0.62 | 1~5 | 1.85~5.00 |
| Assessment and implementation of spiritual care | 3.29±0.73 | 1~5 | 1.50~5.00 |
| Professionalization and improving the quality of spiritual care | 3.11±0.80 | 1~5 | 1.13~5.00 |
| Personal support and patient counseling | 3.30±0.76 | 1~5 | 1.17~5.00 |
| Referral to professionals | 3.12±0.83 | 1~5 | 1.00~4.00 |
| Attitude towards patient spirituality | 4.03±0.67 | 1~5 | 1.75~4.00 |
| Communication | 4.10±0.69 | 1~5 | 2.00~5.00 |
3. Difference in spiritual care competence depending on participants’ general characteristics
Statistically significant differences were observed in the scores of spiritual care competence regarding the level of education (Z=12.24, P=0.002) and job satisfaction (Z=12.24, P=0.002). The post-hoc test shows that nurses with a master’s degree had a higher level of spiritual care competence than those with associate degree and bachelor degree. Also, those who were very satisfied with the job had a higher level of spiritual care competence than those who were satisfied and moderately satisfied ( Table 1 ).
4. Correlation among knowledge of hospice and palliative care, empathy, attitude toward end-of-life care, and spiritual care competence of the participants
The correlation between knowledge of hospice and palliative care, empathy, attitude toward end-of-life care and spiritual care competence was analyzed, showing a statistically significant positive correlation between attitude toward end-of-life care and knowledge of hospice-palliative care (r=0.27, P<0.001) and empathy (r=0.43, P<0.001). Also, there was a statistically significant positive correlation between spiritual care competence and empathy (r=0.43, P<0.001) and attitude toward end-of-life care (r=0.43, P<0.001) ( Table 3 ).
Table 3
Correlation among Hospice-Palliative Nursing Knowledge, Empathy, Attitude toward End-of-Life Care and Spiritual Care Competence (N=174).
| Variables | Hospice-palliative nursing knowledge | Empathy | Attitude toward end-of-life care |
| r(P) | |||
| Empathy | 0.14 (0.068) | - | - |
| Attitude toward end-of-life care | 0.27 (<0.001) | 0.43 (<0.001) | - |
| Spiritual care competence | 0.14 (0.058) | 0.43 (<0.001) | 0.43 (<0.001) |
5. Factors influencing spiritual care competence
Stepwise multiple regression was used to identify factors influencing spiritual care competence of participants. The assumption for regression analysis was tested. Since the value of the Durbin-Watson statistic was 2.11, indicating non-autocorrelation for dependent variable, the residuals were independent of each other. A value of variance inflation factor was 1.07~1.33 (less than 10), which was indicative that multicollinearity problems were non-existent. Therefore, the assumptions were met to conduct the multiple regression analysis. The analysis of residuals showed no abnormal values and met the normality or homoscedasticity of the model, indicating that the regression model is appropriate. During the first phase, the general characteristics, education level and job satisfaction, showing significant differences in spiritual care competence, were selected as dummy variables and kept in the stepwise selection. The variables explained 13.8% of spiritual care competence (F=14.90, P<0.001), and job satisfaction (B=0.68, P<0.001) and education level (B=0.57, P=0.009) were factors influencing spiritual care competence. During the second phase, independent variables, including knowledge of hospice and palliative care, empathy, and attitude toward end-of-life care, were used and explained 36.9% of spiritual care competence. Job satisfaction (very satisfaction) (B=0.39, P=0.014), education level (graduate school) (B=0.38, P=0.045), empathy (B=0.27, P=0.005), attitude toward end-of-life care (B=0.76, P<0.001) were identified as factors significantly affecting spiritual care competence. Of the factors, attitude toward end-of-life care (β=0.39) was the most influential factor for spiritual care competence, followed by empathy (β=0.20), job satisfaction (very satisfaction) (β=0.16), and education level (graduate school) (β=0.13) ( Table 4 ).
Table 4
Factors Influencing Spiritual Care Competence (N=174).
| Variables | Model 1 | Model 2 | |||||||||
| B | SE | β | t | P | B | SE | β | t | P | ||
| Constant | 3.32 | 0.05 | - | 71.94 | <0.001 | 0.31 | 0.38 | - | 0.82 | 0.415 | |
| Job satisfaction | 0.68 | 0.17 | 0.29 | 3.96 | <0.001 | 0.39 | 0.16 | 0.16 | 2.48 | 0.014 | |
| Education | 0.57 | 0.22 | 0.19 | 2.64 | 0.009 | 0.38 | 0.19 | 0.13 | 2.02 | 0.045 | |
| Empathy | - | - | - | - | - | 0.27 | 0.10 | 0.20 | 2.85 | 0.005 | |
| Attitude toward end-of-life care | - | - | - | - | - | 0.76 | 0.13 | 0.39 | 5.76 | <0.001 | |
| F(P) | 14.90 (<0.001) | - | - | - | - | 26.24 (<0.001) | - | - | - | - | |
| Adjusted R 2 | 0.138 | - | - | - | - | 0.369 | - | - | - | - | |
| ∆adjusted R 2 (P) | - | - | - | - | - | 0.231 (0.001) | - | - | - | - |
DISCUSSION
The present study was conducted to identify the influence of knowledge of hospice and palliative care, empathy, and attitude toward end-of-life care on spiritual care competence among nurses in long-term hospitals.
The total mean score for knowledge about hospice and palliative care was 8.56 out of 20 in the present study and 7.96 and 8.92 in a study by Seol [ 24 ] and a study by Wi [ 25 ], respectively, using the same instrument. Despite the same instrument that the studies used, the conflicting outcomes might result from differences in general characteristics, including education level, duration of working experience, and type and location of hospitals where they were working. The average clinical experience was 169.5±105.5 months in the present study, 49.60±38.80 months in a study by Seol [ 24 ], and 66.17±60.12 months in a study by Wi [ 25 ]. Also, 50.6% of the participants in the present study had a four-year degree, while 72.7% in a study by Wi [ 25 ] had a four-year degree. We believe that the difference in curriculum and duration of studies between 3-year colleges and 4-year colleges might affect opportunities to learn about hospice and palliative care. Moreover, the mean age of the participants was 44.8±11.7 years old, while the mean age was 27.39±3.53 in a study of nurses in an adult intensive care unit [ 24 ] and 29.29±4.77 years in a study of nurses in a neonatal intensive care unit [ 25 ]. Most nurses working in long-term care hospitals usually return to work after taking a break for a certain period of time due to family responsibilities, such as marriage, childbirth, and childcare [ 26 ].
Regarding knowledge of hospice and palliative care in the participants, the mean proportion of questions answered correctly was 47.3%, which is lower than 50%. Among the 20 items, only six items received greater than 50% of correct responses, indicating a low level of overall knowledge. Similarly, a study by Seol [ 24 ] also reported that six items received greater than 50% of correct responses. In the study, the proportion of those with experiences of education on hospice and palliative care was 7.1%, demonstrating an association between the level of knowledge of hospice and palliative care and education. In a previous study, education experience regarding hospice care was reported in 77.5% of nurses working in hospice and palliative care wards [ 27 ] and 39.1% of nurses in long-term care hospitals [ 28 ]. Nurses in long-term care hospitals had less experience in education related to hospice and palliative care than those in hospice and palliative care wards. This implies that nurses in long-term care hospitals have fewer opportunities to learn more specialized knowledge about or experience hospice and palliative care relatively than those in hospice and palliative care specialized hospitals. Although the present study did not investigate the education experience of hospice and palliative care among nurses in long-term care hospitals, in-depth studies should be conducted regarding the experience of education on hospice and palliative care and education content in the future. Furthermore, since nurses in long-term care hospitals should provide hospice care and spiritual care for older adults, it is necessary to develop and apply a program for improving knowledge about hospice and palliative care among nurses in long-term care hospitals so that they can determine spiritual problems of patients and provide spiritual care.
The mean score for empathy was 2.64 out of 4, above average. Similarly, the mean score for empathy was 2.71 in a previous study by Lee [ 16 ] using the same instrument. As empathy is the ability to understand what other people feel and appropriately respond using empathic communication skills [ 19 ], nurses’ ability to empathize is essential to meet the spiritual needs of patients. Especially, nurses play a role in empathizing and supporting patients with an interest in their stories and behaviors when providing psychological stability and care as most patients in hospice are older adults with dementia or psychological problems. It is necessary to develop and apply a program that can enhance the empathy of hospice nurses.
The mean score for attitude toward end-of-life care was 3.05, above average. The similar mean score (2.99) was reported in a previous study by Ahn [ 29 ] that used the same instrument. Since nurses in long-term care hospitals have more chances to provide end-of-life care and witness the end of one’s life, they better understand patients and caregivers regarding death and provide psychological comfort and emotional support. This may contribute to above average score of attitude toward end-of-life care. The mean score for sub-items, attitude of individuals and attitude to family members was 3.12, respectively. This implies that in terms of the provision of end-of-life care, nurses in long-term care hospitals should provide care in consideration with not only patients but also their families. Accordingly, a systematic education program should be developed to improve nurses’ attitudes toward end-of-life care so that patients can retain their dignity at the end of life.
The mean score for spiritual care competence was 3.10. In a study by Song and Park [ 15 ] and a study by Sim et al. [ 14 ], the mean score was 2.99 and 2.83, respectively. Among the sub-items of spiritual care competence, the highest score was for communication with 4.10, whereas the lowest score was for professionalization and improving the quality of spiritual care with 3.11. The finding was similar to a previous study by Song and Park [ 15 ], which reported that the highest score was for communication and the lowest score was for professionalization and improving the quality of spiritual care. This implies that nurses in long-term care hospitals have a high level of competence in communicating when providing spiritual care. A study by Sim et al. [ 14 ] reported that since a high level of communication in clinical nurses gives stability to patients and forms therapeutic relationships that enable recognition of spiritual needs and support, it is a professional trait required for spiritual care. However, the low level of competence in professionalization and improving the quality of spiritual care might be caused by the fact that nursing activity targeting the quality of spiritual care was not actively performed and learning about relevant professionalization in colleges does not continue to clinical setting systemically. Moreover, spiritual care competence can be developed through education, and nursing care providers themselves should have clear spiritual beliefs and values to efficiently perform spiritual care [ 9 ]. It is necessary to provide systematic training for professionalization and improving the quality of spiritual care to enhance spiritual care competence. Also, among the sub-categories, the second lowest score was referral to professionals, which was 3.12, immediately higher than professionalization and improving the quality of spiritual care. Long-term care hospitals have a lack of environmental support, including organization of hospice team or development of facility that provides spiritual care, compared to hospitals providing hospice care for patients with cancer and terminal illness. Long-term care hospitals, which provide professionalized spiritual care, should have a team composed of multidisciplinary professionals who can meet patients’ spiritual needs and provide spiritual care. Significant differences were observed in the scores of spiritual care competence regarding the level of education and job satisfaction. A higher level of education showed greater spiritual care competence. In the same context, previous studies [ 14 , 15 ] reported that those with higher levels of education showed greater spiritual care competence. Since individuals with a master’s degree receive more professionalized and specialized education on spiritual nursing care, the level of spiritual care competence increased as the level of knowledge increased. Accordingly, environmental development and support are necessary for nurses to increase their level of education. Moreover, a political measure is necessary to provide a systematic training program related to hospice and palliative care and spiritual care for nurses in long-term care hospitals.
Nurses’ attitudes toward end-of-life care had a significant positive correlation with knowledge of hospice and palliative care, and a higher level of knowledge about hospice and palliative care indicates a more positive attitude toward end-of-life care. An educational program that increases knowledge about hospice and palliative care among nurses who care for patients in their last days should be developed and provided to nurses to help them have positive attitudes toward end-of-life care.
In the present study, job satisfaction, education level, empathy, and attitude toward end-of-life care significantly affected spiritual care competence among nurses in long-term care hospitals, and the most influencing factor was attitude toward end-of-life care that explained 36.9% of spiritual care competence. In other words, a higher level of job satisfaction, education and empathy and a more positive attitude toward end-of-life care increases the level of spiritual care competence. Since nurses work more closely with patients than other medical team members and frequently face dying patients, they should have a correct understanding of death and a positive attitude toward end-of-life care to help the patients prepare for death with peace of mind [ 30 ]. Accordingly, nurses with positive attitudes toward end-of-life care are more likely to have a higher spiritual care competence, resulting in the provision of high-quality end-of-life care and better spiritual care. Since the relationship between attitudes toward end-of-life care and spiritual care competence has not been studied in previous research, future studies are needed. Also, a study by Lee [ 16 ] identified the necessity of spiritual nursing care, religious well-being, and empathy as factors influencing spiritual care competence, and the factors explained 25.4%. Similarly, the present study identified empathy as a factor influencing spiritual care competence. Therefore, empathy is considered to play a vital role in providing spiritual nursing care to patients and enhancing the spiritual care competence of nurses. Job satisfaction is nurses’ perception of given duties, organizational system, communication, autonomy, free time, and wages. Nurses with higher satisfaction are more likely to be more interested in and empathize with the conversation, behaviors, and emotional expression of patients. Accordingly, hospitals should be interested in the working environment and improve working conditions to improve job satisfaction among nurses, and a legal and systematic basis should be prepared.
In order to enhance the spiritual care competence of nurses in long-term care hospitals, it is important to increase job satisfaction, develop empathy, prepare for support for continuing education, and provide a systematical educational program enhancing positive attitude toward end-of-life care.
We suggest the development of a program that can enhance the spiritual care competence of nurses in long-term care hospitals and validation of its effectiveness by using influencing factors identified in the present study. Since this study included only one long-term care hospital, the findings cannot be generalized. The study needs to be repeated by including other facilities with various sizes in different regions. Furthermore, a future study is suggested by including previous educational experience related to hospice and palliative care and end-of-life care and educational content to determine the correlation among participants’ knowledge about hospice and palliative care, empathy, attitude toward end-of-life care, and spiritual care competence and influencing factors.
SUPPLEMENTARY MATERIALS
Supplementary materials can be found via https://doi.org/10.14475/jhpc.2025.28.2.71 .
Footnotes
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
AUTHOR’S CONTRIBUTIONS
Conception or design of the work: HJL. Data collection: HJL. Data analysis and interpretation: HJL. Drafting the article: HJL. Critical revision of the article: MSP. Final approval of the version to be published: MSP.
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