Effects of Emergency Nurses’ Life-Sustaining Treatment Withdrawal Knowledge, Role Perception, and Job Stress on Providing End-of-Life Care

Abstract

Purpose

This study aimed to identify predictors of end-of-life (EOL) care provided by emergency nurses in South Korea.

Methods

A cross-sectional survey was conducted using a structured questionnaire. Data were collected using Google Forms between June 21 and 30, 2022. A total of 154 emergency nurses from 10 tertiary hospitals in a metropolitan area were recruited using convenience sampling, and 139 completed surveys were analyzed. Multiple linear regression was employed to examine the effects of nurses’ knowledge of life-sustaining treatment withdrawal (knowledge), their perceptions of their role in the withdrawal process (role perception), and job stress on EOL care.

Results

The mean scores for knowledge, role perception, job stress, and EOL care were 13.09±1.75 (max 6), 4.18±0.44 (max 5), 3.55±0.32 (max 4), and 2.48±0.40 (max 4), respectively. Among the EOL care subdomains, psychological domain scores were the highest. Multiple linear regression analysis indicated that nurses’ role perception significantly predicted EOL care performance, particularly in the psychological (F=3.924, P=0.001) and spiritual (F=2.171, P=0.020) domains.

Conclusion

Despite the challenging environment of the emergency department, nurses who recognize their important role in the process of life-sustaining treatment withdrawal are more likely to provide high-quality EOL care. The perception of nurses’ roles is especially influential on psychological care performance, and alternative approaches may be necessary for spiritual care.

INTRODUCTION

In South Korea, more than 10 million patients visit emergency departments (EDs) annually [1]. ED patients are typically in the acute phase of illness and range in age from infants to older adults. They present with diverse symptoms, varying disease severity, and multiple nursing needs, including medical, surgical, and psychiatric conditions, often arriving unexpectedly and irregularly [2]. Notably, the number of terminally ill patients presenting with acute symptoms, such as pain, respiratory failure, bleeding, and decreased consciousness has been rising [3]. ED overcrowding frequently leads to prolonged stays and delayed admissions, placing psychological and physical strain on patients and increasing nurses’ workloads [4]. Given these environmental constraints, the comprehensive nursing needs of terminally ill patients in the ED are often difficult to meet, and, despite their distinct characteristics compared with other emergency patients, these individuals are often not provided with care tailored to their specific needs [3]. Nonetheless, terminally ill patients who have decided to discontinue life-sustaining treatment (LST) have unique nursing care needs; therefore, attention should be given to end-of-life (EOL) in the ED. However, in practice, implementing the Life-Sustaining Treatment Decision Act remains challenging owing to procedural complexity, insufficient education, and misconceptions regarding the legislation among healthcare providers [5].

EOL care is a holistic approach provided with compassion to patients at the EOL and their families to preserve dignity, maintain quality of life, facilitate a peaceful death, and alleviate bereavement through physical, psychological, and spiritual support [6]. Terminally ill patients exhibit substantial needs across these domains [7]. Accordingly, nurses must ensure that patients understand their clinical situation, assist in establishing clear treatment goals, and support them in articulating their preferences and values [8]. EOL care may be influenced by factors distinct from those affecting acute care. For emergency nurses, whose primary responsibilities involve caring for acutely ill patients, understanding LST withdrawal can be a critical determinant in delivering appropriate care to terminally ill patients.

Role perception refers to the expectations associated with one’s professional responsibilities as well as recognition of the actions and qualities deemed necessary to fulfill them [9]. Nurses play a critical role in LST withdrawal decision–making by safeguarding patients’ physical and psychological well-being, assessing the needs and circumstances of both patients and their families, and facilitating decisions that promote patients’ best interests. Role perception reflects the extent to which emergency nurses acknowledge and accept these responsibilities as integral components of their professional roles.

Providing EOL care can place considerable stress on nurses due to factors such as negative attitudes toward death, difficulties in allocating sufficient time to terminally ill patients, and interpersonal conflicts with these patients [7]. Elevated stress levels related to EOL care can hinder nurses’ ability to meet patient needs, ultimately compromising care performance [4]. Moreover, nurses’ perceptions of their role in the LST withdrawal decision–making process may influence their level of stress associated with LST care [10,11]. Given that EDs primarily treat acutely ill patients [12], urgent demands for emergency care often consume a substantial portion of nurses’ time and energy, consequently diminishing the priority given to the needs of terminally ill patients and making those needs more difficult to address. Thus, the extent of the EOL care provided by ED nurses is likely to vary depending on their role perception, job stress, and knowledge of LST withdrawal.

In Korea, previous studies on nurses’ perceptions of LST have predominantly focused on general ward nurses as well as those working in intensive care units and hospice ward, with some including ED personnel. Nam et al. [12] investigated factors influencing attitudes toward caring for terminally ill patients among ED nurses and physicians, whereas Cho [13] reported that a positive perception of death was associated with more favorable attitudes toward EOL care among ED nurses. These findings suggest that attitudes toward death significantly influence EOL care provision. However, further research is needed to identify a broader range of factors influencing EOL care in the ED. Considering that many critically ill patients die in the ED, continued investigation into EOL care in this context is warranted. Repeated studies are essential for establishing clear conceptual definitions and practical standards for EOL care delivery in this specialized setting.

This study aimed to assess emergency nurses’ knowledge of LST withdrawal, their perception of their role in decision-making, job-related stress, and the level of EOL care provision. In addition, we examined the impact of these factors on the delivery of EOL care. The findings are expected to provide strategies for improving the quality of EOL care for patients in the ED who have decided to withdraw from LST and are approaching EOL.

METHODS

1. Study design

This descriptive study examined the effects of emergency nurses’ LST withdrawal knowledge, their perception of their role in the LST withdrawal process, and job stress on EOL care.

2. Participants

The study included emergency nurses who had been working in the EDs of tertiary hospitals for more than 1 year, were involved in direct patient care, and had experience caring for patients who had decided to withdraw from LST. Nurse managers or nurse educators who did not provide direct patient care were excluded. The required sample size was calculated using the G*Power program for multiple regression analysis, with a significance level of 0.05, power of 0.80, an effect size of 0.15, and 12 predictor variables, yielding a minimum of 127 participants. A total of 154 online questionnaires were returned, and 139 were included in the final analysis after excluding 15 incomplete responses.

3. Measures

1) Life-sustaining treatment withdrawal knowledge

Knowledge was assessed using a tool developed by Kim [14] comprising 16 items: four on the concepts of the Life-Sustaining Treatment Decision Act, nine on LST procedures, and three on LST plans. Higher scores suggested greater knowledge of LST. Participants responded to each item with “yes,” “no,” or “don’t know.” Correct answers were scored as one point, whereas incorrect or “don’t know” responses were scored as zero. In the study by Kim [14], the KR-20 reliability coefficients were 0.63 for patients and 0.61 for family members, whereas the coefficient in the present study was 0.52.

2) Nurses’ perception of their role in the process of life-sustaining treatment withdrawal

The tool developed by Byun et al. [15] was used to measure emergency nurses’ role perceptions. This instrument comprises 13 items: 12 positively worded statements reflecting the active role of nurses and one negatively worded statement. Participants responded on a 5-point Likert scale ranging from 1 (“Not at all”) to 5 (“Very much”), with higher scores indicating a more positive perception of nurses’ active role in the LST withdrawal process. Cronbach’s alpha was 0.88 in the original study and 0.75 in the present study.

3) Job stress

Yoon’s [4] modified version of a job stress tool was used to measure participants’ job stress level. The original tool comprises 15 domains with 82 items. In this study, 10 items from the “workload” domain were used, with higher scores indicating greater perceived stress. Participants responded on a Likert scale ranging from 1 (“I feel no stress at all”) to 4 (“I feel extreme stress”). The Cronbach’s alpha for the 82-item tool used in Yoon’s [4] study was 0.88, whereas it was 0.75 for the 10 items used in the present study.

4) End-of-life care

We used Chung’s [7] modified version of the tool originally developed by Park and Choi [16]. This instrument comprises 21 items: eight in the physical domain, eight in the psychological domain, and five in the spiritual domain. Higher scores indicated a higher level of EOL care performance by nurses. Participants responded on a 4-point Likert scale ranging from 1 (“not performed at all”) to 4 (“always performed”). Cronbach’s alpha was 0.90 in Chung’s [7] study and 0.88 in the present study.

4. Data collection

This study was reviewed and approved by the Institutional Review Board of the hospital to which the researcher was affiliated (IRB No. H-2205-159-1328). Data were collected from June 21 to 30, 2022. For convenience in data collection and research procedures, 10 tertiary hospitals in the metropolitan area were selected. The nursing department of each hospital was contacted via telephone to explain the purpose of the study and obtain permission for data collection. After receiving approval, one of the researchers visited each hospital and posted a recruitment notice on the ED bulletin board.

To facilitate data collection and ensure participant anonymity, data were collected online using Google Forms. The recruitment notice included a QR code linking to the online questionnaire, allowing participants to complete the questionnaire via smartphone. Written informed consent could not be obtained as the survey was conducted online. Instead, an explanatory statement was provided on the first page of the questionnaire. The participants were considered to have provided their consent after reading the statement and proceeding to the next page.

The questionnaire comprised six sections. The first section provided a study description outlining the purpose and process, potential benefits and risks of participation, estimated completion time, voluntary participation, assurance of disadvantages for nonparticipation, and the right to withdraw at any time. Sections two through five consisted of self-report questionnaires addressing the four study variables, and the final section collected data on the participants’ general characteristics.

5. Data analysis

The collected data were analyzed using IBM SPSS Statistics version 21.0. The participants’ general characteristics, knowledge, role perception, job stress, and EOL care scores were summarized using frequencies, percentages, and means. Independent t-tests, one-way ANOVA, and Pearson’s correlation coefficients were used to identify differences in knowledge, role perception, job stress, and EOL care according to participants’ characteristics. Multiple linear regression analysis was performed to examine the effects of knowledge, role perception, and job stress on EOL care.

RESULTS

1. General characteristics of the participants

Among the participants, 108 (77.7%) were women. The mean age was 31.13±5.43 years, with the largest group of participants aged 20~29 (n=68, 48.9%). A total of 102 participants (73.4%) were single, and 112 (80.6%) held a bachelor’s degree. Seventy participants (50.4%) reported no religious affiliations. Regarding clinical experience, 47 participants (33.8%) had more than 9 years of clinical tenure, whereas 41 (29.5%) had less than 3 years of ED tenure. Eighty-eight participants (63.3%) had not received any education regarding the Life-Sustaining Treatment Decision Act or LST planning. Additionally, 113 participants (81.3%) had experienced the death of a significant other, such as a family member or relative (Table 1).

Table 1.

Differences in Life-Sustaining Treatment Withdrawal Knowledge, Nurses’ Perception of Their Role in the Process of Life-Sustaining Treatment Withdrawal, Job Stress, and End-of-Life Care by General Characteristics (N=139).

Variables	n(%) or Mean±SD	LST withdrawal knowledge			Nurses’ perception of their role in the process of LST withdrawal			Job stress			EOL care
		Mean±SD	t or F (P)		Mean±SD	t or F (P)		Mean±SD	t or F (P)		Mean±SD	t or F (P)
Sex
Male	31(22.3)	13.13±1.78	0.15 (0.88)		4.39±0.44	2.64 (0.01)		3.56±0.32	0.22 (0.83)		2.57±0.45	1.36 (0.18)
Female	108 (77.7)	13.07±1.75			4.14±0.46			3.55±0.33			2.46±0.38
Age (yr)	31.13±5.43
20~29	68(48.9)	13.21±1.41	0.70 (0.50)		4.18±0.48	0.23 (0.80)		3.52±0.31	2.26 (0.11)		2.47±0.03	0.25 (0.78)
30~39	60(43.2)	13.03±1.97			4.23±0.43			3.55±0.34			2.46±0.47
≥40	11(7.9)	12.55±2.46			4.18±0.59			3.75±0.27			2.55±0.35
Marital status
Single	102(73.4)	13.01±1.81	–0.86 (0.39)		4.19±0.47	–0.33 (0.74)		3.54±0.32	–0.55 (0.58)		2.50±0.39	0.57 (0.57)
Married	37(26.6)	13.30±1.60			4.22±0.46			3.58±0.35			2.45±0.41
Level of education
Diploma	5(3.6)	13.00±1.23	0.32 (0.73)		3.82±0.28	2.57 (0.08)		3.54±0.24	0.10 (0.90)		2.22±0.18	1.21 (0.30)
Bachelor	112(80.6)	13.14±1.67			4.19±0.49			3.55±0.33			2.49±0.41
≥Master	22(15.8)	12.82±2.24			4.33±0.34			3.58±0.33			2.52±0.34
Religion
Christian	32(23.0)	13.13±1.60	1.17 (0.33)		4.21±0.40	0.34 (0.85)		3.63±0.23	3.78 (0.01)		2.49±0.40	0.47 (0.76)
Catholic	21(15.1)	12.81±1.83			4.30±0.41			3.70±0.27			2.56±0.47
Buddhism	14(10.1)	12.29±2.37			4.15±0.58			3.55±0.31			2.39±0.25
None	70(50.4)	13.31±1.62			4.17±0.49			3.49±0.35			2.48±0.40
Others	2(1.4)	13.00±2.83			4.15±0.65			3.00±0.42			2.33±0.20
Tenure-overall (yr)	90.19±66.27
≤3	30(21.6)	13.10±1.30	0.49 (0.75)		4.24±0.41	0.10 (0.98)		3.62±0.29	1.57 (0.19)		2.44±0.03	1.20 (0.31)
≤5	36(25.9)	13.36±1.25			4.18±0.53			3.44±0.36			2.56±0.36
≤7	11(7.9)	12.73±2.65			4.24±0.44			3.61±0.18			2.36±0.45
≤9	15(10.8)	12.73±2.31			4.18±0.40			3.58±0.30			2.61±0.45
>9	47(33.8)	13.06±1.92			4.18±0.49			3.57±0.34			2.44±0.45
Tenure-ED (yr)	72.78±54.49
≤3	41(29.5)	13.22±1.53	0.44 (0.78)		4.21±0.54	1.40 (0.24)		3.61±0.27	1.47 (0.22)		2.46±0.26	1.16 (0.33)
≤5	37(26.6)	13.16±1.52			4.19±0.42			3.46±0.40			2.58±0.44
≤7	11(7.9)	12.91±2.66			4.15±0.41			3.65±0.18			2.52±0.58
≤9	18(13.0)	12.61±2.06			4.00±0.47			3.52±0.30			2.48±0.32
>9	32(23.0)	13.16±1.78			4.32±0.42			3.58±0.33			2.39±0.43
Participation in LST care education
Yes	51(36.7)	13.22±2.13	–0.60 (0.55)		4.22±0.45	–0.38 (0.70)		3.57±0.34	–0.59 (0.56)		2.53±0.45	–1.00 (0.32)
No	88(63.3)	13.01±1.50			4.19±0.48			3.54±0.32			2.46±0.36
Death of significant others
Yes	113(81.3)	12.96±1.75	1.72 (0.09)		4.21±0.46	–0.47 (0.64)		3.55±0.33	0.41 (0.68)		2.51±0.39	–1.72 (0.09)
No	26(18.7)	13.62±1.68			4.16±0.50			3.58±0.31			2.36±0.42

ED: emergency department, EOL: end-of-life, LST: life-sustaining treatment.

2. Degree of life-sustaining treatment withdrawal knowledge, nurses’ perception of their role in the process of life-sustaining-treatment withdrawal, job stress and end-of-life care

The mean knowledge score was 13.09±1.75 out of 16 (Table 2), with correct answer rates for individual items ranging from 73.4% to 99.3%. The item “Painkillers can be administered to patients who have decided to withdraw life-sustaining treatment” received the highest percentage of accurate answers (99.3%). The items with the lowest correct answer rates (23.7% each) were “Patients who have decided to withdraw life-sustaining treatment can be subjected to surgery requiring general anesthesia” and “Family members can decide to withdraw life-sustaining treatment and complete the required forms.” The mean score for nurses’ role perception was 4.18±0.44 (maximum=5). The highest item score was for “Nurses should provide necessary information from an objective and professional standpoint and respect their judgment” (4.70±0.49), whereas the lowest was for “Patients’ and their families’ decisions about withdrawal of life-sustaining treatment may be influenced by nurses’ beliefs” (3.00±1.46). The mean job stress score was 3.55±0.32 (maximum=4). The highest stress factor was “When working under circumstances with a shortage of nursing staff” (3.90±0.33), whereas the lowest was “When many patients died during the duty” (3.04±0.79). The mean score for EOL care was 2.48±0.40 (maximum=4). The mean scores for the physical, psychological, and spiritual domains were 2.63±0.45, 2.90±0.46, and 1.58±0.62, respectively. In the physical domain, the highest item score was for “Assisted patients upon request when using the toilet” (3.52±0.62), and the lowest was for “Assisted patients to take a high-caloric, high-vitamin diet” (1.70±0.71). In the psychological domain, the highest rating was for “Nursing care was provided with courtesy and the utmost professional competence” (3.28±0.59), and the lowest was for “Promoted the patient’s sense of self-worth through recognition of their strengths” (2.37±0.89). In the spiritual domain, the highest score was for “Provided an environment conducive to prayer, meditation, and comfort” (1.77±0.86), and the lowest score was for “Sang religious music (e.g., hymns) or played recordings” (1.35±0.68).

Table 2.

Degree of Life-Sustaining Treatment Withdrawal Knowledge, Nurses’ Perception of Their Role in the Process of Life-Sustaining Treatment Withdrawal, Job Stress, and End-of-Life Care (N=139).

Variable	Scale	Min~Max	Mean±SD
LST withdrawal knowledge	16	7.00~16.00	13.09±1.75
Nurses’ perception of their role in the process of LST withdrawal	5	2.92~5.00	4.18±0.44
Job stress	4	2.70~4.00	3.55±0.32
EOL care	4	1.48~3.95	2.48±0.40
Physical domain	-	1.50~4.00	2.63±0.45
Psychological domain	-	1.38~4.00	2.90±0.46
Spiritual domain	-	1.00~4.00	1.58±0.62

LST: life-sustaining treatment, EOL: end-of-life.

3. Differences in the degree of life-sustaining treatment withdrawal knowledge, nurses’ perception of their role in the process of life-sustaining treatment withdrawal, job stress, and end-of-life care according to the general characteristics of the participants

No significant differences were observed in the level of knowledge of EOL care based on the participants’ general characteristics. Regarding nurses’ role perception, male participants scored significantly higher than female participants (t=2.64, P=0.01). Job stress differed significantly according to religion (F=3.78, P=0.01); however, post-hoc analysis revealed no significant differences between specific groups (Table 1).

4. The correlation among the degree of life-sustaining treatment withdrawal knowledge, nurses’ perception of their role in the process of life-sustaining treatment withdrawal, job stress, and end-of-life care

A correlation analysis among participants’ knowledge, role perception, job stress, and EOL care revealed that role perception was positively correlated with EOL care (r=0.25, P<0.001) (Table 3).

Table 3.

Correlation among Life-Sustaining Treatment Withdrawal Knowledge, Nurses’ Perception of Their Role in the Process of Life-Sustaining Treatment Withdrawal, Job Stress, and End-of-Life Care (N=139).

Variable	LST withdrawal knowledge	Nurses’ perception of their role in the process of LST withdrawal	Job stress
		r (P)
Nurses’ perception of their role in the process of LST withdrawal	0.02 (0.82)	-	-
Job stress	−0.05 (0.57)	0.13 (0.14)	-
EOL care	−0.07 (0.42)	0.25 (0.00)	0.17 (0.05)

EOL: end-of-life, LST: life-sustaining treatment.

5. Factors affecting end-of-life care

To identify the factors influencing EOL care, multiple linear regression analysis was conducted using general characteristics, knowledge, role perception, and job stress as independent variables (Table 4). Although no general characteristic variables showed significant differences in EOL care, and aside from role perception no variables were significantly correlated with EOL care in the correlation analysis, all variables were included in the regression model to examine their explanatory power while controlling for potential confounders. Nurses’ role perception was significantly and positively correlated with EOL care (r=0.25, P=0.003). The correlation coefficients among knowledge, role perception, job stress, and EOL care were all below 0.80, satisfying assumptions for multiple regression analysis. In general, multicollinearity can be considered absent if the tolerance exceeds 0.10, and the variance inflation factor (VIF) is less than 10. In the initial analysis, the tolerance of the clinical work experience variable was 0.09, and the VIF was 11.083, indicating multicollinearity. After reanalysis, excluding this variable, the Durbin–Watson statistic for testing the independence of residuals was 1.964, indicating no autocorrelation. Furthermore, all remaining variables had tolerance values greater than 0.10, and the VIFs were below 10, satisfying the criteria for the absence of multicollinearity.

Table 4.

Influencing Factors on End-of-Life Care (N=139).

Variables	Dependent variable: end-of-life care						Dependent variable: physical domain of end-of-life care						Dependent variable: psychological domain of end-of-life care						Dependent variable: spiritual domain of end-of-life care
	B	SE	β	t	P		B	SE	β	t	P		B	SE	β	t	P		B	SE	β	t	P
Sex*	0.00	0.08	0.00	−0.05	0.961		0.10	0.10	0.10	1.03	0.305		0.10	0.10	0.10	1.03	0.305		0.05	0.13	0.04	0.40	0.689
Age	0.02	0.01	0.21	1.71	0.089		0.01	0.01	0.15	1.17	0.246		0.01	0.01	0.15	1.17	0.246		0.01	0.01	0.10	0.78	0.440
Marital status†	−0.12	0.08	−0.14	−1.52	0.131		−0.02	0.10	−0.02	−0.21	0.835		−0.02	0.10	−0.02	−0.21	0.835		−0.26	0.13	−0.19	−1.99	0.048
Level of education‡	0.05	0.08	0.05	0.55	0.583		0.10	0.10	0.10	1.01	0.317		0.10	0.10	0.10	1.01	0.317		−0.07	0.13	−0.05	−0.51	0.609
Religion§	−0.01	0.03	−0.03	−0.32	0.752		0.03	0.03	0.09	1.01	0.313		0.03	0.03	0.09	1.01	0.313		−0.08	0.04	−0.17	−2.05	0.042
Tenure-ED	0.00	0.00	−0.21	−1.75	0.083		0.00	0.00	−0.23	−1.79	0.075		0.00	0.00	−0.23	−1.79	0.075		0.00	0.00	0.02	0.18	0.856
Participation in LST care education∥	0.06	0.07	0.07	0.85	0.395		−0.05	0.08	−0.05	−0.56	0.577		−0.05	0.08	−0.05	−0.56	0.577		0.20	0.11	0.16	1.87	0.064
Death of significant others¶	0.11	0.08	0.11	1.34	0.183		0.14	0.10	0.12	1.39	0.167		0.14	0.10	0.12	1.39	0.167		0.14	0.13	0.09	1.06	0.292
LST withdrawal knowledge	0.01	0.02	–0.06	–0.70	0.484		–0.01	0.02	–0.02	–0.22	0.830		–0.01	0.02	–0.02	–0.22	0.830		–0.03	0.03	–0.10	–1.14	0.255
Nurses’ perception of their role in the process of LST withdrawal	0.24	0.07	0.29	3.37	0.001		0.22	0.09	0.22	2.38	0.019		0.22	0.09	0.22	2.38	0.019		0.23	0.12	0.17	1.86	0.066
Job stress	0.11	0.10	0.09	1.08	0.281		−0.06	0.12	−0.04	−0.04	0.657		−0.06	0.12	−0.04	−0.04	0.657		0.20	0.16	0.11	1.24	0.218
	R2=0.176, Adjusted R2=0.104, F=2.441, P=0.009						R2=0.091, Adjusted R2=0.011, F=1.140, P=0.336						R2=0.255, Adjusted R2=0.190, F=3.924, p<0.001						R2=0.159, Adjusted R2=0.086, F=2.171, P=0.020

ED: emergency department, LST: life-sustaining treatment. *male, ^†single, ^‡diploma, ^§Christian, ^∥No, ^¶No.

The regression model with EOL nursing performance as the dependent variable was significant (F=2.441, P=0.009), with an overall explanatory power of 10.4%. The only statistically significant influencing factor was role perception (β=0.29, P<0.001). Additionally, regression analyses were conducted using each subdomain of EOL care—physical, psychological, and spiritual—as dependent variables. However, the regression model for the physical domain was not statistically significant. In contrast, the models for the psychological (F=3.924, P=0.001) and spiritual (F=2.171, P=0.020) domains were significant, with explanatory powers of 19% and 8.6%, respectively. Role perception was a significant predictor in the psychological domain (β=0.35, P<0.001); however, none of the three factors were statistically significant in the spiritual domain.

DISCUSSION

Although only 36% of ED nurses had received LST training, their knowledge scores regarding LST withdrawal were relatively high compared with those reported in previous studies [8,17]. Many patients presenting to the ED are critically ill and expected to die [12], and discussions regarding LST are frequent [18]. In this context, emergency nurses often prepare documentation related to LST directives and facilitate communication and coordination among physicians, patients, and guardians [19]. Although emergency nurses may acquire relevant knowledge through frequent exposure to the decision-making process for LST withdrawal, this study could not confirm the relationship between such experience and related knowledge. Therefore, caution is warranted in overinterpreting the results, and further research is needed. Moreover, despite their frequent involvement in the LST withdrawal process, the proportion of emergency nurses who received formal training was very low, indicating the need for additional educational opportunities. In particular, novice nurses who are currently adapting to the demands of acute care, which is a priority in the ED, may lack the ability to identify the nursing needs of terminally ill patients owing to their limited clinical experience; thus, tailored training for this group should be considered.

The role perception score in this study was higher than those reported by Lee [10] (3.94) and Lee and Kim [11] (3.94), suggesting that the emergency nurses who participated in this study recognized the need to actively engage in the decision-making process for LST withdrawal.

The average job stress score was 3.55 (maximum=4), which is comparable to that reported by Song and Lee [20] (3.62) using the same tool. This high level of stress is likely attributable to the characteristics of 24-hour operations in EDs, the absence of restrictions on patient volume, and the frequent occurrence of emergency situations.

Among the subdomains of EOL care, the spiritual domain received the lowest score, which is consistent with the findings of a study of intensive care unit nurses [21]. Terminally ill patients approaching death have high spiritual needs [22], and providing spiritual care can promote spiritual well-being and reduce depression [23]. Therefore, to deliver high-quality care to terminally ill patients in EDs, it is essential to address their physical and psychological needs and their spiritual needs. However, EDs often do not provide patients and families with sufficient time to prepare for death, make it difficult to ensure privacy, and lack facilities such as death rooms or family rooms, rendering them unsuitable for a peaceful death [24]. Despite these limitations, many patients die in EDs [12], underscoring the need to improve the ED environment to better meet their nursing needs.

Men demonstrated higher role perception scores than women, which is consistent with the findings of Lee [10]. In contrast, Lee and Kim [11] reported higher role perception among women; however, neither study found statistically significant differences. Given these inconsistent findings, the observed sex differences in role perception are likely attributable to variations in sample characteristics, and further studies are warranted to determine their academic or practical significance.

Additionally, although differences in job stress were observed across religious groups, post-hoc analyses revealed no significant differences between them. Similarly, Yoon [4] reported no differences in job stress according to religion, and Chung [7] found no differences in EOL care–related stress according to religion, supporting the findings of the present study.

The perception of nurses’ roles was identified as a significant factor influencing the provision of EOL care. This suggests that when emergency nurses perceive their role as important in deciding whether to continue or withdraw LST from terminally ill patients, they tend to provide more active EOL care. The perception of nurses’ roles in LST withdrawal can be regarded as a component of EOL care, and the role perception tool used in this study reflected nurses’ attitudes toward EOL care. For example, it includes items such as “Nurses should do their best to provide care until the end, even if life-sustaining treatment is withdrawn” and “Nurses should help patients experience a comfortable end of life.”

According to the theory of planned behavior, human behavior is determined by intention, which is influenced by attitudes toward the behavior [25]. Therefore, it is plausible that nurses’ role perception in the decision-making process for LST withdrawal, which reflects their attitudes toward EOL care, positively influences their EOL care performance. In this study, nurses’ role perception was a significant influencing factor in the psychological domain of EOL care. Moreover, the model’s explanatory power for the psychological domain was higher than that for overall EOL care. These results may reflect the characteristics of the ED, where the physical environment prioritizes acute treatment and poses challenges in providing EOL care. For example, in the EOL care tool used in this study, items such as “being interested in the patient and being kind with a smile” represent aspects of care that emergency nurses can provide relatively frequently, as they require minimal time and effort. In contrast, in the spiritual domain, marital status and religion were significant influencing factors. The findings of Park and Choi [16], which showed differences in spiritual care performance according to nurses’ marital status and religion, may partially support our results. These findings suggest that the EOL care delivered by nurses differs across domains. Specific and specialized approaches tailored to each domain should be considered to enhance both the frequency and quality of EOL care.

Based on the above results and discussion, the following limitations and directions for future research are noted:

First, this study used a convenience sample of tertiary hospitals in certain regions; therefore, caution is needed when generalizing the findings to all emergency nurses. Future studies should be conducted with emergency nurses from a broader range of regions to provide a more comprehensive understanding of the EOL care they deliver. Second, although the tool used to measure nurses’ role perceptions incorporated the concept of attitudes toward EOL care, it did not directly assess such attitudes, which limited the interpretation of the results. Future research should employ instruments that encompass the broader concept of LST and directly measure nurses’ attitudes toward EOL care, thereby enabling a deeper understanding of the manner in which emergency nurses provide EOL care. Third, the reliability of the knowledge tool for LST withdrawal was low, reflecting the participants’ characteristics. Although discussions regarding LST are frequently held in EDs, the primary focus is on patient recovery after acute deterioration. In some cases, even when terminally ill patients visit the ED owing to an acute exacerbation, treatment may be initiated before medical staff become aware that the patient does not wish to receive LST. Even when this preference is known, the patient’s family members may still request LST provision. Consequently, the participants’ knowledge of LST may have been inconsistent, as decisions to withdraw or maintain LST for acutely ill patients are often made after treatment has started.

Despite these limitations, this study is meaningful as a foundational investigation that extends the scope of emergency nursing from acute care to include EOL care by identifying factors influencing EOL care provided by emergency nurses in EDs, where many patients die.

SUPPLEMENTARY MATERIALS

Supplementary materials can be found via https://doi.org/10.14475/jhpc.2025.28.3.89.