Nursing interventions to promote dignified dying in South Korea

Abstract

Purpose

This descriptive study aimed to assess the appropriateness of the International Classification for Nursing Practice (ICNP) catalogue Palliative Care for Dignified Dying for palliative care nursing interventions in South Korea.

Methods

The study surveyed 213 South Korean nurses who might regularly care for dying patients. Nurses were recruited to complete a survey that included interventions from the ICNP catalogue listed with Likert response sets.

Findings

All of the interventions were scored as being at least ‘slightly important’ on average. The following three nursing interventions were ranked as most important when caring for dying patients: establish trust, establish rapport, and administer pain medication.

Conclusions

The study provides new insights into the palliative care provided in South Korea by documenting nurses’ views of what are the most important palliative care nursing interventions. It also suggests that the palliative care interventions listed in the ICNP catalogue Palliative Care for Dignified Dying are in congruence with the interventions that nurses in South Korea use.

The International Council of Nurses (ICN) envisions the International Classification for Nursing Practice (ICNP) as an integral part of the global information infrastructure, informing health-care practice and policy to improve patient care worldwide. The ICNP is a classification system for nursing diagnoses, interventions, and outcomes. It has established a common nursing language that enables comparison of nursing diagnoses, interventions, and outcomes in the international arena. Nursing interventions are the actions that nurses take to produce a desired outcome (ICN, 2011)—in this study, dignified dying.

Dignified dying has been identified as a nursing phenomenon—an aspect of health that is relevant to nursing practice—and as a desired global nursing outcome. In the Nursing Outcomes Classification, ‘dignified dying’ was renamed ‘dignified life closure’, and the outcome was defined as ‘personal actions to maintain control during approaching end-of-life’ (Moorhead et al, 2004, p259). Dying people and their families deserve competent and compassionate care at this time.

The ICNP catalogue Palliative Care for Dignified Dying was designed to guide nurses as they provide palliative care to promote dignified dying and to support systematic documentation of nursing care (Doorenbos et al, 2009). The catalogue was guided by the dignity-conserving care model (Chochinov, 2002; McClement et al, 2004). This model provides both an organizing framework to examine the phenomenon of dignified dying and guidance for the interventions that nurses use to promote dignified dying. In the model, perceptions of dignity at the end of life are organized into three major categories:

• Illness-related concerns, arising directly from the illness (e.g. the need for symptomatic relief)

• A dignity-conserving repertoire, including those psychological and spiritual resources that enable individuals to maintain a sense of dignity during the illness experience (e.g. hopefulness, a sense of meaning)

• A social dignity inventory, which includes various environmental resources that foster a sense of dignity (e.g. privacy, family support).

Worldwide studies of the interventions identified by the ICNP are ongoing to confirm the relevance and utility of the catalogue (Doorenbos et al, 2011). The current study aims to examine the usefulness of the ICNP catalogue Palliative Care for Dignified Dying in South Korea.

Background

Palliative care in South Korea

As countries make technological advances, promoting a ‘dignified death’ becomes a topic of conversation. Social and economic conditions continue to improve as a result of technology development in South Korea, and issues of dignity and respect for the individual are also being discussed more frequently. Technologies such as mechanical ventilation are increasingly being used, sometimes without the expressed wishes of the patient and their family being known, and hence more undignified deaths are occurring in clinical settings (Jo and Doorenbos, 2009). As palliative care expands in South Korea, tools to guide systemized and standardized nursing interventions are needed to create a comprehensive approach to nursing care for patients facing death.

At present, there is a great deal of interest and attention in South Korea on nursing interventions for patients at the end of life, but generalization of research findings has been difficult, and the development and classification of nursing interventions is just beginning. Current research suggests that there is little agreement among nurses in South Korea on the nursing interventions that are used to promote dignified dying (Lee, 2000; Yi, 2003; Jo and Doorenbos, 2009). Dignified dying includes maintaining the wellbeing of patients in the physical, social, emotional, and spiritual domains. However, the palliative care that is currently provided to patients at the end of life in South Korea is focused mainly on the physical domain, in particular aspects of pain management. The importance of palliative care that includes psychosocial nursing interventions such as emotional support, family support, and spiritual support has not been studied sufficiently (Yong et al, 2001).

Research in South Korea has addressed palliative care primarily with end-stage cancer patients (Yang and Lee, 2000; Choi and Kang, 2007). In one such study, levels of patient satisfaction regarding pain control were very low for patients experiencing moderate to severe pain, even though the patients were receiving pain medication (Lee, 2000). Effective pain management is an important patient outcome in the physical domain, although pain at the end of life comprises multiple concepts, including physical, social, emotional, and spiritual elements (Lee 2000). In Lee's research (2000) addressing hospice patients, pain was not classified simply as a physical symptom—it was also classified in relation to symptoms in the emotional and spiritual domains, such as anxiety, melancholy, and anger. Pain management is often complex, and previous research suggests that knowledge about pain assessment and management is important to nursing care for patients at the end of life (Suh, 1997; Lee, 2000).

However, research focused on palliative care should not be limited to cancer patients (Kang and Oh, 2000; Ro et al, 2001). Bae's research in South Korea (2001) identified the most important aspects of nursing care as listening to patients’ reports of symptoms, protecting patient privacy, having a kind attitude towards patients and their families, candidly explaining the patient's status, controlling pain, and using positive thinking, hope, and encouragement. Bae's findings echoed the results of Kim's (1997) research—that in hospital-based hospices in South Korea nursing care is focused on physical symptoms, and that interventions include measuring and monitoring symptoms of a patient's physical condition.

Methods

Design, sample, and setting

The international nursing research team used a cross-sectional descriptive study design. This approach was selected because the aim was to identify the importance that nurses in South Korea currently assign to different palliative care nursing interventions. The data was collected via a survey in Korean. A convenience sample of nurses who provide end-of-life care at general hospitals and public health centres in Daegu City and Kyungbuk Province in South Korea was recruited. The final sample of 213 participants included 167 clinical nurses from 5 different hospitals and 46 community nurses from 7 different public health centres.

Procedure and ethical approval

Human subjects approval was obtained at the University of Washington and from the 12 institutions (5 general hospitals and 7 public health centres) in South Korea. Written informed consent was obtained from each participant before the surveys were distributed. The consent form included the contact information for the research team, in case any nurse had questions about the study. The written introduction to the survey also included statements describing the confidentiality and privacy procedures and the right to refuse participation.

In the general hospitals, nurses working in the wards were approached by the nursing superintendents and given the survey packets. In the public health clinics, the nurse department heads approached the staff nurses and provided the survey packets. Along with the survey packets, all potential participants were given a token of appreciation valued at approximately 5,000 won (roughly $5 USD) for considering completing the survey. Nurses who chose to participate were able to complete the questionnaire in a quiet room at their own institution.

The survey packet included a copy of the interventions listed in the ICNP catalogue Palliative Care for Dignified Dying. The catalogue consists of 105 palliative care interventions. Participants were asked to rate each intervention on a four-point Likert response set. The survey also included seven demographic items, including educational level and number of years in nursing practice. The entire survey packet was written in English and translated into Korean by certified translators. The text was then back-translated and checked for accuracy. A nurse who is bilingual in Korean and English assisted in verifying the accuracy of the Korean version of the survey and the appropriateness of interpretation.

The time required to complete the survey was approximately 40–50 minutes. Surveys were placed in the envelopes that were provided and were then placed by the nurses in a drop box. Having drop boxes decreased the potential for coercion resulting from having supervisors distribute the surveys to the nurses, as supervisors and colleagues had no way to identify who had or had not participated.

Data analysis

There were 213 survey respondents. All of these provided demographic information that was analysed using descriptive statistics. The nursing intervention items had a non-response rate of <1%. The interventions were rated as follows: 4=very important, 3=moderately important, 2=slightly important, 1=not at all important. An average rating for each item was calculated. The interventions were then ranked by average rating to determine which were the most and least important. Average ratings and rankings for subgroups of nurses were also calculated. All analyses were performed using SAS v. 9.1 (Cary, NC).

Results

The average length of time that the study participants had been employed in nursing was 10.7 years, and their average age was 34.7 years. The majority of the participants (62.7%) indicated that their highest degree in nursing was an associate's degree. Most were employed full-time (82.6%) and worked at a hospital (78.4%). The majority of participants cared for dying patients: 58.7% reported providing palliative care sometimes and a further 26.8% reported providing palliative care often or very often. Table 1 displays the descriptive statistics for the study participants.

Table 1.

Participant demographics (n=213)

Description	Statistics	Missing responses
Years in nursing: mean (range)	10.7 (0.6–29)	4
Degree in nursing: N (%)		4
Associate's	131 (62.7)
Bachelor's	59 (28.2)
Master's	19 (9.1)
Non-nursing degree: N (%)		N/A
No response	103 (48.3)
Associate's	75 (35.2)
Bachelor's	27 (12.7)
Master's	8 (3.8)
Employment status: N (%)		6
Full-time	171 (82.6)
Part-time	34 (16.4)
Retired	1 (0.5)
Unemployed	1 (0.5)
Work setting: N (%)		0
Community	43 (20.2)
Hospital	167 (78.4)
Clinic	1 (0.5)
Other	2 (0.9)
Age: mean (range)	34.7 (22–58)	1
Frequency of care for dying: N (%)		0
Very often	14 (6.6)
Often	43 (20.2)
Sometimes	125 (58.7)
Rarely	31 (14.5)

All 105 of the interventions listed in the ICNP catalogue received an average rating of at least 2 on the four-point scale. The total sample identified the three most important nursing interventions when caring for dying patients as establish trust, establish rapport, and administer pain medication (Table 2). The three interventions rated least important were refer for legal assistance, refer to occupational therapist, and support use of traditional therapies.

Table 2.

Most important nursing interventions ranked by average importance ratings

Intervention	Number of rankings	Minimum score	Maximum score	Mean score	Standard deviation
Establish trust	212	2	4	3.88	0.40
Establish rapport	212	2	4	3.88	0.38
Administer pain medication	213	2	4	3.77	0.60
Manage pain	212	1	4	3.77	0.52
Consult for pain management	213	2	4	3.74	0.54
Encourage emotional expression	213	2	4	3.73	0.57
Collaborate in initiating patient-controlled analgesia	213	2	4	3.67	0.58
Encourage positive affirmations	213	2	4	3.67	0.61
Collaborate with physician	213	2	4	3.66	0.62
Teach about managing pain	213	2	4	3.66	0.60
Maintain dignity and privacy	212	2	4	3.66	0.61
Manage dyspnoea	212	1	4	3.65	0.59
Provide emotional support	213	2	4	3.64	0.59
Promote self-esteem	213	2	4	3.64	0.59
Encourage patient to express spiritual concerns	213	1	4	3.59	0.66
Ensure continuity of care	212	2	4	3.58	0.63
Provide privacy	213	2	4	3.57	0.60
Monitor respiratory status	212	2	4	3.56	0.63
Teach about managing dyspnoea	213	2	4	3.55	0.65

The ranking of palliative care nursing interventions differed slightly by the nurses’ educational level. Table 3 shows the top ten ranked nursing interventions by nursing educational level. For participants with an associate's degree as their highest degree, the nursing intervention identified as most important when caring for dying patients was establish trust. For participants with a bachelor's degree as their highest degree it was administer pain medication, and for participants with a master's degree as their highest degree it was establish rapport.

Table 3.

Highest-ranked nursing interventions among nurses with associate's, bachelor's, and master's degrees

Rank	Associate's degree	Bachelor's degree	Master's degree
1	Establish trust	Administer pain medication	Establish rapport
2	Establish rapport	Establish rapport	Establish trust
3	Manage pain	Establish trust	Provide emotional support
4	Encourage emotional expression	Consult for pain management	Administer pain medication
5	Administer pain medication	Manage pain	Collaborate in initiating patient-controlled analgesia
6	Consult for pain management	Collaborate in initiating patient-controlled analgesia	Manage pain
7	Collaborate with physician	Encourage emotional expression	Promote self-esteem
8	Maintain dignity and privacy	Encourage positive affirmations	Consult for pain management
9	Encourage positive affirmations	Teach about managing pain	Encourage emotional expression
10	Promote self esteem	Collaborate with physician	Manage dyspnoea

*Rank order of mean importance rating

Discussion

Participants’ demographic characteristics

The majority of the study participants (62.7%) had associate's degrees, which reflects the two-tiered basic nursing educational system in South Korea (i.e. a 3-year junior college course versus a 4-year Bachelor's degree course). As 76% of each year's nursing graduates are from 3-year junior colleges (Choi, 2004), the sample closely matches the South Korean nursing workforce.

The majority of the study participants were full-time employees working in hospitals, and more than three-quarters reported providing palliative care sometimes, often or very often. Many nurses who practice in South Korean hospital wards provide palliative care as a large part of their clinical activities. Accordingly, palliative care interventions are important for promoting dignified dying in hospitals.

Nursing interventions to promote dignified dying in South Korea

Cancer is the number one cause of death in South Korea (Korea National Statistical Office, 2007), and the number of end-stage cancer patients is continuously increasing. Palliative care nursing interventions that can improve dignified dying and quality of life at the end of life for cancer patients are essential. However, palliative care is not only for cancer patients, but rather for all patients diagnosed with a life-threatening illness. This study identified South Korean nurses’ views on the most important palliative care nursing interventions used to promote dignified dying and provides support for the relevance and usefulness of the ICNP catalogue for all patients in South Korea.

The most important palliative care nursing interventions, in rank order, were establish trust, establish rapport, administer pain medication, manage pain, consult for pain management, and encourage emotional expression. Establishing trust and establishing rapport are both important initial activities in establishing a therapeutic relationship with patients. Establishing rapport is a method of talking with patients and drawing them out to facilitate an open dialogue, and is important in establishing trust. Trust differs from rapport in that it is considered a stronger therapeutic relationship. Administering pain medication and managing pain also have potential overlap as nursing interventions: pain medication is often administered to manage pain, but intervening to manage pain encompasses more nursing activities than just the administration of medication.

These results coincide with those of Yi (2003), who emphasized the importance of psychological and emotional domains in delivering palliative care. However, they contrast with those of Bae (2001), who emphasized the importance of the physical domain. Whereas Bae found that the most important intervention provided by South Korean nurses was observation of patients’ symptoms, the present study indicates that establishing trust and establishing rapport are the most important nursing interventions, followed by pain control. These differences may be related to the study sample selection processes, as participants in Bae's study worked only in hospitals, whereas the sample of the present study was comprised of nurses working in both hospitals and community centres.

The results of this study suggest that establishing trust and establishing rapport are very important parts of helping palliative care patients achieve dignified dying. We can infer that in South Korean culture, establishing trust and establishing rapport are highly valued parts of developing interpersonal relationships. South Korea is a traditional society based in Confucianism, which holds harmony as a primary virtue (Kim and Im, 2005). Nurses’ establishment of trust and rapport would support harmony in the nurse–patient relationship.

The next most important palliative care interventions were administer pain medication and manage pain. This coincides with existing research that describes the highest expectation of hospice patients as pain management and symptom relief (Lee, 2000).

The ranked importance of palliative care interventions differed somewhat according to the nurses’ level of education. Administer pain medication was rated as the top intervention by nurses with a bachelor's degree as their highest level of qualification but not by nurses with a master's or diploma degree. This finding may be related to the fact that palliative care has recently been added to the requirements in undergraduate curricula in South Korea (Sung and Jo, 2008; Jo et al, 2009). Nurses who have recently received bachelor's degrees would have increased knowledge of pain management.

Research in South Korea suggests that there is a high level of pain among South Korean patients, in particular end-stage cancer patients (Ro et al, 2001). This may be because effective pain-management protocols have not been available to nurses and physicians (Suh, 1997). More education on standardized pain-management interventions for end-stage cancer patients and all of those at the end of life may be needed.

In the present study, the nursing intervention collaborate with physicians emerged as one of the ten most important interventions for promoting dignified dying. Teamwork between nurses and physicians not only reduces medical costs but also improves the quality of health care and the efficiency of teams (Hojat et al, 2000). Also, in any culture, levels of satisfaction among health professionals are improved with good interprofessional communication (Rosenstein, 2002). Therefore, interprofessional education that provides not only sharing of experiences but also a mutual understanding of the nurse and physician roles is recommended.

Given that the findings endorse the ICNP interventions in the South Korean health-care context, the ICNP catalogue Palliative Care for Dignified Dying might be used as a collaborative tool to encourage discussion across professional disciplines involved in palliative care. According to research that compared the attitudes of nurses and physicians in the United States, Israel, Italy, and Mexico regarding physician–nurse cooperation (Hojat et al, 2003), the participants suggested that there is a need for physician–nurse cooperation and for the development of interdisciplinary education.

Limitations

The study was limited by the use of convenience sampling and the focus on one province in South Korea. Thus, generalizations of the study findings are weakened. However, this study is an important start for understanding what interventions are considered important in delivering palliative care in South Korea.

Conclusion

Until recently there has been little reported research focusing on nursing care for patients at the end of life in South Korea. As palliative care expands in South Korea, standardized palliative care nursing interventions are needed to create a comprehensive approach to nursing care plans for patients facing death. This research is the first to use a standardized nursing classification system to reveal what nursing interventions are considered important by South Korean nurses. These findings provide new insights into the palliative care provided in South Korea by documenting the most important palliative care interventions used by nurses. The study also suggests that the ICNP palliative care interventions are in congruence with the interventions that nurses in South Korea use. Use of the ICNP catalogue Palliative Care for Dignified Dying to classify nursing interventions worldwide will have a positive impact on the ability of nurses to communicate with other nurses regarding the nursing care that is delivered in their country.