Effects of awareness of person-centered care, knowledge of life-sustaining treatment decisions, and attitudes toward advance directives on end-of-life care competency among nurses in long-term care hospitals: A cross-sectional study
Article information
Abstract
Purpose
This study aimed to investigate the factors influencing end-of-life care competency by examining awareness of person-centered care, knowledge of life-sustaining treatment decisions, and attitudes toward advance directives among nurses in long-term care hospitals.
Methods
Through convenience sampling, nurses with more than 6 months of clinical experience and who were responsible for inpatient care in long-term care hospitals in Jennam-do and Gwangju-metropolitan city were selected to participate in this study. Data were collected using a structured self-administered questionnaire between December 1 and 23, 2023. Data were analyzed through descriptive statistics, independent t-test, one-way ANOVA, Scheffé’s test, Pearson’s correlation coefficient, and multiple regression analysis.
Results
End-of-life care competency had an average of 3.72 out of 5 points. “Collaboration with team members” had the highest average score and “professional development” the lowest. Multiple regression analysis identified that awareness of person-centered care (β=.31, p<.001), attitudes toward advance directives (β=.31, p<.001), and providing end-of-life care 11 times or more in the past year (β=.17, p=.014) significantly influenced end-of-life care competency.
Conclusion
Various educational strategies that promote awareness of person-centered care and foster positive attitudes toward advance directives are needed to enhance nurses’ end-of-life care competency in long-term care hospitals. Additionally, educational programs that provide opportunities for both direct and indirect experience in end-of-life care are needed, as such programs can help establish a system to ensure the delivery of high-quality end-of-life care.
INTRODUCTION
1. Background
With the first generation of baby boomers in South Korea entering older adulthood, the country is rapidly approaching a “super-aged” society. In addition, the substantial gap between life expectancy and healthy life expectancy is expected to accelerate the complex needs of older adults for medical services, long-term care, and caregiving. The Ministry of Health and Welfare has been promoting a revision of the long-term care grading system as a basic model for integrated medical and long-term care assessment and is encouraging the use of long-term care hospitals for patients with extensive medical needs [1]. According to the 2024 population trends survey, over 80% of deaths occurred in medical institutions, which include long-term care hospitals. Among individuals aged 75 years and older, the number of deaths in long-term care hospitals exceeded that in general hospitals by more than four-fold [2]. Moreover, according to severity-adjusted mortality rates, 67.9% of deaths in long-term care hospitals were classified as highly medically complex cases [3]. Therefore, the therapeutic function of long-term care hospitals is expected to expand further, and the number of patients requiring end-of-life care is also anticipated to increase. Consequently, the role of long-term care hospitals in end-of-life care is expected to grow, making nurses’ competencies in providing high-quality end-of-life care increasingly essential.
End-of-life care encompasses nursing practices that support patients nearing death, as well as their families. Beyond providing care during the final hours or days, it broadly aims to relieve the suffering of patients with terminal conditions and help them preserve their dignity and quality of life as they approach their end of life peacefully [4]. End-of-life care competency refers to the integrated skills that nurses need to support patients and their families throughout the end-of-life period. This includes comprehensive symptom management, care planning, person-centered care and communication, resource management, interprofessional collaboration, information provision and education, and professional development [5,6]. Nurses’ end-of-life care competency enhances the overall quality of care for patients nearing their end of life by delivering care that respects the patients’ and families’ values and preferences, while providing emotional support and information [7].
Person-centered care entails respecting patients’ unique values and rights, involving them in decision-making to promote autonomy, and delivering individualized, holistic care based on their needs [8]. Nurses’ perceptions of person-centered care when caring for patients at the end of life are associated with their end-of-life care competence [9].
Life-sustaining treatment refers to medical interventions that prolong the lives of patients who are dying without providing therapeutic benefit and includes cardiopulmonary resuscitation, hemodialysis, chemotherapy, mechanical ventilation, and other procedures specified by presidential decree [10]. Knowledge of life-sustaining treatment decisions encompasses understanding the terms and concepts related to hospice and palliative care, terminal and dying stages, life-sustaining treatments, advance directives, and life-sustaining treatment plans, as defined by the Act on Decisions on Life-Sustaining Treatment for Patients in Hospice and Palliative Care or at the End of Life (Life-Sustaining Treatment Decision Act), which was enacted in 2018 [11]. Nurses in long-term care hospitals provide end-of-life care in close contact with patients, requiring them to attend to patients’ physical, emotional, and spiritual needs, making them the healthcare professionals that patients rely on the most [12]. Accordingly, these nurses leverage their knowledge of life-sustaining treatment decisions to serve as educators, advocates, and facilitators, roles that are closely connected to their end-of-life care competency [13]. Therefore, a lack of current and accurate knowledge regarding life-sustaining treatment decisions may result in nurses providing patients with distorted or incorrect information [14]. While recent studies have investigated the roles of intensive care unit (ICU) nurses in life-sustaining treatment decision-making and associated factors [15,16], few studies have examined the relationships among life-sustaining treatment decision knowledge, role perception, and end-of-life care competency in nurses in long-term care hospitals. In addition, a positive attitude toward advance directives among nurses in long-term care hospitals has been shown to influence end-of-life care [17], suggesting that it is an important antecedent for improving the quality of end-of-life care. Further, although the relationship between attitudes toward advance directives and end-of-life care competency has been examined among nurses in tertiary hospitals [18], few studies have investigated this relationship among nurses in long-term care hospitals.
Overall, studies on end-of-life care competency and related factors have largely targeted nurses in ICUs and oncology wards of acute care hospitals, whereas research on nurses in long-term care hospitals, where end-of-life care is increasingly significant, remains scarce. Given this scarcity of prior research, the present study’s hypotheses on the relationships between end-of-life care competency, awareness of person-centered care, knowledge of life-sustaining treatment decisions, and attitudes toward advance directives were developed on the basis of findings among acute care nurses and the characteristics of nursing practice in long-term care hospitals. Empirical validation of these relationships is therefore warranted. This study will provide a foundation for a better understanding of end-of-life care competency and for developing strategies to improve this competency among nurses in long-term care hospitals.
2. Purpose
This study aimed to explore the characteristics of end-of-life care competency among nurses in long-term care hospitals and determine the impact of awareness of person-centered care, knowledge of life-sustaining treatment decisions, and attitudes toward advance directives on this competency. The specific objectives are as follows: 1) assess the levels of end-of-life care competency, awareness of person-centered care, knowledge of life-sustaining treatment decisions, and attitudes toward advance directives among long-term care hospital nurses; 2) identify differences in end-of-life care competency based on nurses’ general characteristics; 3) explore the relationships between end-of-life care competency and awareness of person-centered care, knowledge of life-sustaining treatment decisions, and attitudes toward advance directives; and 4) determine the impact of awareness of person-centered care, knowledge of life-sustaining treatment decisions, and attitudes toward advance directives on end-of-life care competency.
METHODS
This study was approved by the Institutional Review Board (IRB) of Mokpo National University (IRB No. MNUIRB-231128-SB-021-01). Informed consent was obtained from the participants.
1. Study Design
This descriptive cross-sectional study aimed to investigate the characteristics of end-of-life care competency among nurses in long-term care hospitals. It also examines the influence of awareness of person-centered care, knowledge of life-sustaining treatment decisions, and attitudes toward advance directives on end-of-life care competency. The study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines (https://www.strobe-statement.org).
2. Participants
Nurses who had provided direct care for at least 6 months in long-term care hospitals in Jennam-do and Gwangju-metropolitan city were recruited using convenience sampling. The required sample size for multiple regression analysis was estimated using G*Power 3.1.9.4, assuming an effect size of 0.15, a significance level of .05, a power of .95, and 16 predictor variables. The minimum required sample size was 204; therefore, accounting for an anticipated 20% attrition rate, a total of 260 questionnaires were distributed. After excluding 29 questionnaires with incomplete responses (11.2% attrition rate), 231 responses were included in the multiple regression analysis. The statistical power for the regression model, based on the seven variables entered in the final step, was .996.
3. Measures
1) General Characteristics
General characteristics included 13 items: gender, age, marital status, religion, highest educational attainment, total clinical experience, long-term care hospital experience, job position, patient load, experience of a family member’s or acquaintance’s death within the past year, provision of end-of-life care in the past year, existence of institutional end-of-life care guidelines, and the completion of end-of-life care training.
2) End-of-Life Care Competency
End-of-life care competency was measured using an instrument developed by Son [6] for nurses in long-term care hospitals. The instrument consists of 30 items: five on comprehensive symptom management, four on end-of-life care planning, six on person-centered care and communication, two on resource management, three on teamwork, six on information provision and education, and four on professional development. Items are rated on a 5-point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”), with higher scores reflecting higher end-of-life care competency. In Son [6], Cronbach’s α for the instrument was .95, whereas in the present study Cronbach’s α was .97.
3) Awareness of Person-Centered Care
Awareness of person-centered care was assessed using the Korean version of the Individualized Care Scale (nurse version) translated and adapted by Lee [19], which assesses nurses’ perceptions of providing patient-centered care through nursing activities. The scale comprises 17 items in three domains: clinical situations (7 items), personal life (4 items), and decision-making (6 items). Items are scored on a 5-point Likert scale from 1 (“strongly disagree”) to 5 (“strongly agree”), with higher scores indicating higher levels of awareness of person-centered care. The original study by Lee [19] reported a Cronbach’s α of .85, and the current study reported a Cronbach’s α of .91.
4) Knowledge of Life-Sustaining Treatment Decisions
Knowledge of life-sustaining treatment decisions was assessed with the End-of-Life Care Decision Inventory developed by Kim et al. [11]. The instrument comprises 21 items across five domains: hospice and palliative care (3 items), terminal/end-of-life stage (2 items), life-sustaining treatment (2 items), advance directives (7 items), and life-sustaining treatment plans (7 items). Items are scored 1 for a correct answer and 0 for an incorrect or “don’t know” response, with total scores ranging from 0 to 21 and higher scores indicating greater knowledge of life-sustaining treatment decisions. In Kim et al. [11], the instrument demonstrated a Kuder–Richardson 20 coefficient (KR-20) of 0.81, whereas in the present study KR-20 was 0.44.
5) Attitudes Toward Advance Directives
Attitudes toward advance directives were assessed using the Korean version of the Advance Directives Attitude Scale for Nurses, which was developed by Kim and Park [20]. The scale comprises 14 items in three domains: patient rights (7 items), nurses’ roles (4 items), and ethical judgment (3 items). Items are scored on a 4-point Likert scale ranging from 1 (“strongly disagree”) to 4 (“strongly agree”), with higher scores reflecting more positive attitudes toward advance directives. The original study by Kim and Park [20] reported a Cronbach’s α of .76 for the scale, and in the current study Cronbach’s α was .72.
4. Data Collection and Ethical Considerations
Data were collected using a structured questionnaire from December 1 to 23, 2023, after obtaining approval from the Institutional Review Board of Mokpo National University (No. MNUIRB-231128-SB-021-01). Participants were provided with an information sheet explaining the study’s purpose, procedures, and confidentiality measures, and were informed that they could withdraw from the study at any time. It was also explained that the collected data would be used solely for research purposes and securely stored for 3 years before being destroyed. Questionnaires were distributed after obtaining written informed consent from participants who voluntarily agreed to participate. Completed questionnaires were sealed in envelopes, and any personal information collected for case purposes was deleted immediately after use.
5. Data Analysis
Data were analyzed using the SPSS/WIN Statistics 27.0 program (IBM Corp.). Participants’ general characteristics, end-of-life care competency, awareness of person-centered care, knowledge of life-sustaining treatment decisions, and attitudes toward advance directives were analyzed by frequency, percentage, mean, and standard deviation. Differences in end-of-life care competency according to general characteristics were also analyzed using independent t-tests and one-way ANOVA, with Scheffé’s test applied for post hoc comparisons. Correlations between end-of-life care competency and the independent variables were analyzed using Pearson’s correlation coefficient. Multiple regression analysis was conducted to identify factors affecting end-of-life care competency.
RESULTS
1. General Characteristics
Among the 231 participants, 89.6% were women, and the mean age was 44.6±10.1 years. Of the participants, 77.5% were married, and 58.0% had no religious affiliation. Regarding educational attainment, 53.2% of participants held a bachelor’s degree, and 6.5% had a master’s degree or higher. The mean clinical experience was 12.6±8.3 years, and the mean experience in long-term care hospitals was 6.0±4.5 years. Staff nurses accounted for 74.5% of the participants, with an average patient load of 58.0±22.0 per shift. Overall, 46.3% of participants had provided end-of-life care 6~10 times in the past year, and 24.2% had done so 11 times or more. Further, 36.4% reported that their units had end-of-life care guidelines, and 55.4% indicated having received education related to end-of-life care (Table 1).
General Characteristics (N=231)
2. End-of-Life Care Competency, Awareness of Person-Centered Care, Knowledge of Life-Sustaining Treatment Decisions, and Attitudes Toward Advance Directives
The mean score for end-of-life care competency was 3.72±0.48 out of 5 points. The subdomain scores were as follows: collaboration with team members, 3.82±0.59; comprehensive symptom management, 3.80±0.53; person-centered care and communication, 3.76±0.56; information provision and education, 3.75±0.56; resource management, 3.68±0.61 end-of-life care planning, 3.63±0.63; and professional development, 3.58±0.66. Awareness of person-centered care had a mean score of 3.75±0.47 out of 5 points, knowledge of life-sustaining treatment decisions averaged 0.74±0.11 out of 1 point, and attitudes toward advance directives had 2.99±0.27 out of 4 points (Table 2).
EOL Care Competency, Awareness of Person-Centered Care, Knowledge of Life-Sustaining Treatment Decisions and Attitudes Toward Advance Directives (N=231)
3. Differences in End-of-Life Care Competency According to General Characteristics
Significant differences in end-of-life care competency were observed according to participants’ job position, frequency of providing end-of-life care in the past year, and prior end-of-life care education experience. Post hoc analysis revealed that participants who provided end-of-life care 11 times or more in the past year had higher competency compared with those with 6~10 or fewer than five instances (F=8.11, p<.001). End-of-life care competency was also higher among nurses in charge or with higher positions compared with staff nurses (t=-2.50, p=.013) and among those with prior end-of-life care education experience versus those without (t=2.03, p=.043) (Table 3).
Differences in EOL Care Competency to General Characteristics (N=231)
4. Correlations Between End-of-Life Care Competency and the Independent Variables
End-of-life care competency was significantly positively correlated with awareness of person-centered care (r=0.40, p<.001) and with attitudes toward advance directives (r=0.41, p<.001) (Table 4).
Correlation Among EOL Care Competency and Independent Variables (N=231)
5. Factors Influencing End-of-Life Care Competency
Dummy variables for awareness of person-centered care, attitudes toward advance directives, frequency of providing end-of-life care in the past year, position, and prior end-of-life care education experience were included in the analysis. The Durbin-Watson statistic was 2.019 in the multiple regression analysis. Tolerance values ranged from 0.67 to 0.96, exceeding the 0.1 threshold, and variance inflation factors ranged from 1.04 to 1.50, which is below the cutoff of 10. No cases exceeded a Cook’s D value of 1.0. Residual analysis, including scatterplots, confirmed linearity and homoscedasticity, and a P-P plot verified the normality of the error terms. Among nurses in long-term care hospitals, end-of-life care competency was significantly influenced by awareness of person-centered care (β=.31, p<.001), attitudes toward advance directives (β=.31, p<.001), and having provided end-of-life care 11 times or more in the past year (β=.17, p=.014). The regression model was statistically significant (F=14.43, p<.001) and accounted for 31.0% of the variance in end-of-life care competency (Table 5).
Factors Affecting EOL Care Competency (N=231)
DISCUSSION
The participants’ end-of-life care competency averaged 3.72 out of 5 points, comparable to that of nurses in long-term care hospitals measured with the same instrument [6] and higher than competency levels reported using instruments assessing knowledge, attitudes, and behaviors [21,22]. Additionally, end-of-life care competency was higher among nurses in managerial positions than among staff nurses, among those who had provided end-of-life care 11 times or more in the past year compared with 10 or fewer times, and among nurses with prior end-of-life care education compared with those without. These results were consistent with those of previous studies, independent of the measurement instruments employed [21,22]. This suggests that end-of-life care competency among nurses in long-term care hospitals can be enhanced not only through the quality and quantity of end-of-life care experience in clinical practice but also through participation in end-of-life care education. Of the subdomains of end-of-life care competency, “collaboration with team members” scored the highest, likely reflecting nurses’ awareness of the significance of their managerial role, given that end-of-life care is delivered through collaboration with diverse healthcare personnel, including the supervision of nursing assistants as a part of their professional competence. Further, the “comprehensive symptom management” subdomain, encompassing assessment of pain and physical symptoms as well as non-pharmacological and pharmacological interventions, had the second-highest average score. This indicates that nurses perceive pain and symptom management as a key priority when providing end-of-life care [23]. Conversely, “professional development” had the lowest mean score of 3.58, with the item “ability to apply standard guidelines for pain and physical symptom management” rating the lowest among all items. The proportion of participants reporting the presence of any form of in-hospital end-of-life care guidelines was also very low, which aligns with findings reported by Son [6]. Nurses may face the burden of care provision without a clear understanding of their roles and responsibilities in end-of-life care when standardized guidelines are lacking in long-term care hospitals or when nurses are unaware of or unable to implement them [24]. Therefore, to enhance the professional development of end-of-life care competency, long-term care hospitals should establish standardized guidelines, such as the National Institute for Health and Care Excellence guidelines [5], and concentrate on strategies or educational programs that can facilitate their dissemination and practical application [25]. The next lowest-rated subdomain was “end-of-life care planning,” which is related to the psychological, emotional, social, and spiritual care of patients at the end of life. This is consistent with reports from South Korea [6,22], but contrasts with findings from the United States, where it was rated the highest among nurses in university hospitals [26]. In this study, the average patient load per nurse per shift was 58.0, indicating that the impact of workload and other work environment factors cannot be ruled out. For competency in quality end-of-life care, considerations of organizational culture and structure that includes an appropriate workload, alongside practical experience, education, and training, should also be addressed [7]. Thus, it is important to consider concrete, multifaceted programs such as the Hong Kong Project, which incorporated long-term participation across diverse sessions using a variety of methods such as topic-specific lectures, small-group discussions, case sharing, role-playing scenarios, and experiential exercises [27].
Awareness of person-centered care was found to have the greatest influence on end-of-life care competency among long-term care hospital nurses. Patients admitted to long-term care hospitals often have chronic and complex health issues, requiring care that reflects their diverse needs while remaining individualized. Nurses in these facilities play a crucial role in accompanying patients through the final stages of life, supporting them in maintaining the highest possible quality of life until the end. Although no prior studies exist for direct comparison, higher levels of awareness of person-centered care among long-term care hospital nurses appear to reduce job stress and enhance care quality, suggesting a key role in buffering end-of-life care stress and promoting high-quality care [9,28]. In this study, Awareness of person-centered care had a score of 3.75 out of 5 points, which is slightly higher than that in previous studies [9,29]. The “clinical situation” subdomain had the highest score, whereas the “personal life” subdomain had the lowest, consistent with prior research [19,29]. A core attribute of person-centered care is respecting the values and autonomy of patients. However, in long-term care hospital settings, nursing is often carried out according to provider-centered routines and standard procedures, with other nursing tasks prioritized over person-centered care, limiting the provision of personalized care. It is thus essential to shift the care perspective from an institutional-centered approach to one that focuses on the patient and incorporates their values, preferences, and needs to enhance nursing home nurses’ awareness of person-centered care. This requires the formation and sharing of strategies aimed at fostering such a shift in perception.
A positive attitude toward advance directives was also identified as a factor influencing long-term care hospital nurses’ competency in end-of-life care. This was similar to findings from a previous study, wherein long-term care hospital nurses’ attitudes toward advance directives were found to influence their performance in end-of-life care [17]. Additionally, participants with a graduate-level education or those who had provided end-of-life care more frequently in the past year showed a more positive attitude toward advance directives. This suggests that the combination of practical experience and advanced education enhances both professionalism and practical competence, leading to an increased provision of end-of-life care. As a result, attitudes toward advance directives also appear to become more positive. In the subdomains of attitudes toward advance directives, positivity was lower in the areas of “patient rights” and “nurses’ roles” compared with “ethical judgment.” It is particularly important to note that the item “not providing treatment-related information when necessary,” in the “patient rights” domain received the lowest score among all items. This may reflect the belief that withholding information is sometimes necessary depending on the patient’s condition. Many family members may request this, fearing that informing the patient could lead to disappointment or loss of hope. However, it cannot be overlooked that, for long-term care patients to exercise their right to self-determination and die with dignity, they also have the right to be fully informed about their health status. Therefore, education addressing the ultimate purpose and significance of advance directives is needed for both patients and their families. Nurse training is also necessary to enable them to discuss and make decisions with patients and their families.
The frequency of providing end-of-life care in the past year was found to influence end-of-life care competency, which aligns with previous findings [18,30]. This shows that end-of-life care competency partly depends on the individual nurse’s experience and that providing end-of-life care enhances understanding of patients while fostering empathy, ultimately improving practical competency. In this case, simulation training programs designed to allow nurses to fully engage in hypothetical end-of-life care scenarios could be beneficial.
However, the relationship between knowledge of life-sustaining treatment decisions and end-of-life care competency has not been verified, and relevant prior literature was also difficult to find. A closer look reveals that the lack of familiarity with terms related to life-sustaining treatment decisions, limited understanding, and low awareness of specific aspects of these decisions may be the reason for this gap. Knowledge of life-sustaining treatment decisions had a score of 74 out of 100 points, which was slightly higher than that scored by nurses in general hospitals [11]. In terms of the subdomains, “hospice and palliative care” and “end-of-life/terminal stage” had exceptionally high scores, whereas “advance directives” and “life-sustaining treatment plans” had scores in the 60s. Specifically, the items “professional assistance from a physician or nurse is required to complete an advance directive” and “designation of a proxy when completing an advance directive” had scores of 39 and 19 points, respectively. Likewise, the items “the life-sustaining treatment plan is prepared by a physician” and “use of alternative forms (e.g., do-not-resuscitate order) instead of a life-sustaining treatment plan” had scores of 39 and 31 points, respectively, showing the lowest scores. These findings were also similar to those reported among nurses at tertiary hospitals [11]. Despite the Life-Sustaining Treatment Decision Act being in effect since 2018, long-term care hospital providers appear to lack understanding of advance directives and life-sustaining treatment plans, as they cannot differentiate between them or identify the relevant criteria and responsible parties. A tailored continuing education program that accurately reflects the entire life-sustaining treatment decision process and focuses on the areas and items with low correct response rates is therefore needed for long-term care hospital providers.
This study is significant because it empirically tested the relationships between end-of-life care competency, awareness of person-centered care, knowledge of life-sustaining treatment decisions, and attitudes toward advance directives among long-term care hospital nurses, filling a gap in prior research and also highlighting the need for further studies. It also confirmed the need for tailored standardized guidelines for nurses in these facilities to enhance end-of-life care competency. In particular, there is an urgent need to develop strategies that offer a more concrete approach to enhancing knowledge and shaping attitudes toward advance directives and decisions on life-sustaining treatment.
CONCLUSION
The level of end-of-life care competency among nurses in long-term care hospitals in the present study was approximately 75%. Among the subdomains of end-of-life care competency, “collaboration with team members” and “comprehensive symptom management” were relatively strong, whereas “end-of-life care planning” and “professional development” were comparatively weak. Awareness of person-centered care, attitudes toward advance directives, and experience in providing end-of-life care were shown to influence end-of-life care competency among nurses in long-term care hospitals. This study thus provided an understanding of the characteristics of end-of-life care competency and its related factors among nurses in long-term care hospitals, and offered foundational evidence on the need for and direction of multifaceted strategies to enhance end-of-life care competency. Since awareness of person-centered care had the greatest impact on end-of-life care competency among long-term care hospital nurses, strategies that move beyond knowledge-focused training and instead use diverse approaches to foster the capacity for individualized care that respects the value of each person’s life are needed. There is also a need for educational programs that reflect the characteristics of nursing practice in long-term care hospitals, not only fostering positive attitudes toward advance directives but also allowing for the accumulation of practical experience in accurately distinguishing between and making judgments about advance directives and life-sustaining treatment plans.
The participants in this study were limited to nurses from a few long-term care hospitals in certain regions and were selected through convenience sampling; therefore, the findings should be interpreted cautiously. Additionally, because the reliability of the life-sustaining treatment decision knowledge instrument was low, caution is needed when interpreting the results. Moreover, since decisions regarding life-sustaining treatment fall within a specialized area of knowledge, this study reaffirmed the need for active, targeted education for nurses in long-term care hospitals that covers the specific details of life-sustaining treatment decision-making. Simultaneously, since the original instrument’s reliability was tested on clinical nurses in secondary and tertiary hospitals with Institutional Review Boards, further validation through repeated studies among nurses in long-term care hospitals is warranted.
Notes
Authors' contribution
Conceptualization - SOJ and SR; Formal analysis - SOJ and SR; Investigation - SOJ; Methodology - SOJ and SR; Writing–original draft - SOJ and SR; Writing – review & editing: SR
Conflict of interest
No existing or potential conflict of interest relevant to this article was reported.
Funding
None.
Data availability
Please contact the corresponding author for data availability.
Acknowledgements
This article is based on a part of the first author’s master’s thesis from Mokpo National University.