Concept analysis of end-of-life care competency of long-term care hospital nurses: Using a hybrid model

Article information

J Korean Gerontol Nurs. 2024;26(1):19-30
Publication date (electronic) : 2024 February 28
doi :
1Adjunt Lecturer, Department of Nursing, Changwon National University, Changwon, Korea
2Associate Professor, Department of Nursing, Changwon National University, Changwon, Korea
Corresponding author: Mi-Kyeong Jeon Department of Nursing, Changwon National University, 20 Changwondaehak-ro, Uichang-gu, Changwon 51140, Korea TEL: +82-55-213-3573 E-mail:
Received 2023 December 23; Revised 2024 February 13; Accepted 2024 February 15.



This study identified the attributes and indicators of end-of-life care competency in long-term-care hospital nurses and clarified the definition of the concept.


The Competency Outcomes Performance Assessment model was used as a conceptual framework, and conceptual analysis was performed using the hybrid model presented by Schwartz-Barcott and Kim. In the theoretical phase, the attributes of end-of-life care competencies were explored through a literature review. In the fieldwork phase, focus group interview data were analyzed to derive the attributes of nursing competency at the end of life. In the final analysis phase, the attributes and indicators of end-of-life care competency were compared, analyzed, and integrated.


The attributes of end-of-life care competency among nurses in long-term care hospitals included comprehensive symptom management, effective communication, situational response, patient-centered care, information provision and education, resource management, demonstrating leadership, and professional development.


End-of-life care competency in long-term-care hospital nurses can be defined as a comprehensive set of competencies that includes symptom management, situational adaptation, effective communication, resource utilization, leadership, patient-centered care, meeting the needs of patients’ families through adequate information provision and education, and enhancing individual nursing capabilities through professional development. These results can serve as a foundation for developing tools to measure end-of-life care competencies among nurses in long-term care hospitals.


End-of-life care has emerged as an important factor affecting quality of life due to the rapidly aging population, and more people are expected to need end-of-life care in long-term care settings [1]. Accordingly, many countries have prepared strategies to provide quality end-of-life care [2]. Korea announced the 2019 comprehensive plan for hospice and life-sustaining care to ensure dignified and comfortable end-of-life care [3].

The National Institute for Health and Care Excellence [4] defines end-of-life care as care for patients who are likely to die within 12 months and their families. Although it cannot be clearly determined because of the lack of scientific evidence to support the clinical criteria that specify the end-of-life period [5], it has various meanings that reflect the period at which life ends [6]. End-of-life care can be viewed as care provided to support patients and their families in resolving physical, social, emotional, and spiritual problems during the last period of life [6]. The skills, knowledge, experience, and behaviors required to effectively provide end-of-life care are referred to as end-of-life care competency [7].

Nursing competency is a prerequisite for quality nursing care in clinical settings [8], and the knowledge, skills, and attitudes of nurses caring for end-of-life patients have a significant impact on the type of nursing care provided [9]. Griffith [2] mentioned the need to develop competencies to provide quality end-of-life care, as end-of-life care competencies are essential to maintaining and respecting the dignity and value of individuals. The actual level of end-of-life care competency has been reported to have a significant impact on patients facing death and their families [9,10]. Depending on proficiency in end-of-life care, it can influence various aspects of life, potentially leading to a deterioration in the quality of life. Therefore, nurses should possess a sufficient level of competency in end-of-life care, considering various dimensions of life, to enhance the quality of nursing and prevent a decline in the quality of life for both patients and their families. Most patients admitted to long-term care hospitals are older adults with chronic illnesses [11]. Unlike patients admitted to hospital for acute illnesses, who mostly return home following recovery, most patients admitted to long-term care hospitals never return home [12]. In another study, among 1,000 discharged patients, 425 deaths were reported in those aged 65 or older in long-term care hospitals, which is 4~5 times higher than in tertiary general hospitals and general hospitals [13]. Additionally, examining the cases of individuals aged 65 and older who passed away in 2017 revealed that, on average, they spent the last 2 years of their lives in nursing homes or long-term care hospitals [14]. They are unable to maintain independence in their daily lives for a considerable period of time, and requiring care, experiencing physical and mental difficulties until they pass away in medical institutions [15]. End-of-life care competency is considered essential for nurses working in long-term care environments, particularly in institutions where older adults are predominantly admitted [16]. Therefore, a conceptual analysis of care competency at end of life is necessary in a long-term care environment.

Research related to end-of-life care competency in Korea includes competency development studies for multidisciplinary hospice and palliative care experts and undergraduate students [12,17], and a study measuring the degree of nurses’ end-of-life care competency targeting intensive care unit nurses [18]. Research has been conducted on long-term care hospital nurses [19,20]. However, no studies have focused on the competencies necessary to provide end-of-life care effectively. Therefore, the phenomenon of end-of-life care competency and its essence and attributes should be identified, and its definition be established.

Concept analysis clarifies ambiguous and confusing concepts and distinguishes similar concepts [21]. Furthermore, among the various concept analysis methods, the hybrid model proposed by Schwartz-Barcott and Kim [22] connects theoretical analysis with empirical observations. This approach allowed for a more accurate observation of the phenomenon, enabling the examination of the importance and appropriateness of the concept in nursing practice. This facilitates the identification of interrelated concepts within a phenomenon [22]. Therefore, in this study, a hybrid model approach was used to conduct a conceptual analysis of end-of-life care competency among nurses in long-term care hospitals.


Ethic statements: This study was approved by the Institutional Review Board (IRB) of Changwon National University (IRB No.7001066-202205-HR-027). Informed consent was obtained from the participants.

This is a concept analysis study on the end-of-life care competency of long-term care hospital nurses using a hybrid model. The research procedure was conducted in the theoretical, fieldwork, and final analysis phases according to the concept analysis procedure of the hybrid model presented by Schwartz-Barcott and Kim [22]. In the theoretical phase, an extensive literature review was conducted focusing on the conceptual definition and attributes of end-of-life care competency. The second phase was the fieldwork phase, in which data were collected and analyzed through focus group interviews (FGI) to empirically validate the concepts analyzed in the theoretical phase through empirical observation. In the third phase, the results of the literature review conducted in the theoretical phase and data analysis results from the fieldwork phase were comprehensively compared and analyzed. This study was described in accordance with the Consolidated criteria for Reporting Quqlitative research (COREQ) reporting guidelines [22].

1. Theoretical Phase

Focusing on the conceptual definition and attributes of end-of-life care competency, we first examined dictionary meanings and extensively reviewed the domestic and international literature. The search was conducted using databases such as the Korea Education and Research Information Service, Korean Information Service System, DBpia, Science On, PubMed, and Cumulative Index to Nursing and Allied Health Literature without limitations on the year of publication. Keywords, including ‘end-of-life care,’ ‘end-of-life care,’ ‘terminal care,’ ‘hospice,’ ‘palliative,’ ‘clinical competence,’ ‘competencies,’ ‘competency,’ ‘nursing,’ were combined, and Boolean operator (AND, OR, NOT) and cut (*) searches were used. Additionally, reports from government agencies and organizations were searched using Google, and more literature was identified using Google Scholar’s ‘cited by’ list. A manual search was conducted to identify relevant studies in the reference lists of the retrieved literature. The selection criteria were as follows: (1) nursing environments targeting adult patients, (2) literature written in Korean or English with the full text available, and (3) literature published in academic journals among degree theses. The exclusion criteria were as follows: (1) studies in which the definition or attributes of end-of-life care competency could not be confirmed, (2) studies targeting only nurses in acute hospitals, and (3) studies targeting only nurses working in community nursing settings. Consequently, 125 domestic documents and 740 international documents were searched. Of these, 64 duplicate domestic and 15 international documents were excluded, and 786 documents were selected. Moreover, 546 papers unrelated to end-of-life care and competency were excluded at the title level. The abstracts (65 excluded) and full texts (160 excluded) were reviewed sequentially, and the final 15 articles were subsequently selected. A literature review was conducted, focusing on the definitions, properties, and indicators of the concepts presented in each final selected paper.

2. Fieldwork Phase

The fieldwork phase was conducted to determine whether the attributes, indicators, and definitions derived for end-of-life care competencies are consistently observed in the practical nursing field, and identify any new attributes. During the field phase of the hybrid model, it was recommended to set up the site, negotiate, select cases, and collect data through participant observation [18]. However, participant observation was not possible due to concerns regarding the spread of COVID-19; hence, the FGI approach was used.

The data collection period was from August 4 to August 29, 2022. The study participants were eight nurses working in four different long-term care hospitals in Daejeon and Gyeongsangnam-do, and seven advanced practice nurses in five hospice palliative care institutions in Seoul, Daejeon, Daegu, and Gyeongbuk, selected using convenience and snowball sampling. There were a total of 15 participants. The selection criteria were that they had to have at least 3 years of total clinical experience, at least 1 year of work experience at a long-term care hospital or hospice palliative care institutions, participated in direct nursing, had experience with end-of-life care, and understand the study and agree to participate. In particular, nursing staff from long-term care hospitals were nurses who could demonstrate a good understanding of the characteristics of end-of-life patients in long-term care hospitals, and articulate their experiences candidly and actively regarding their end-of-life care competencies. The number of participants per FGI group ranged from two to four, and the interview was terminated after confirming that the data was saturated as no new topics emerged in the fifth FGI. The interviews lasted between 1 to 2 hours each. The interview schedule and location were discussed with the participants, and a location was selected where they could talk freely and comfortably according to their desired schedule, and where the confidentiality of the interview contents and the privacy of the participants could be guaranteed. The participants were also informed that they could withdraw from the study at any time without facing any consequences, the interview content would not be used for any purpose other than the purpose of the study, personal information would be kept secure, and that after a certain period of time elapsed after the data analysis, the data would be destroyed. In addition, the interview was conducted after explaining that the interview would be recorded and obtaining consent.

The interviews were conducted in an open-ended manner, starting with semi-structured questions that allowed the participant to describe their experiences of end-of-life care competency, including general characteristics. The interview questions were ‘Please tell me about your experiences related to end-of-life care.’; ‘What do you think end-of-life care is?’; ‘What do nurses need to have when providing end-of-life care?’; ‘What are some things you need to know when providing end-of-life care?’; ‘What are the difficulties in providing end-of-life care?’; ‘What do patients and their families need at the end of life?’; ‘What do you think is the most important thing when providing end-of-life care?’ During the interviews, the main content stated by the participants was noted, statements were reconfirmed based on the notes, and the researcher’s understanding and interpretation were verified by the participants. The recorded data were directly transcribed verbatim by the researcher the same day after the interview was completed. The transcribed data were shared by the two researchers and analyzed using the qualitative content analysis method proposed by Elo and Kyngäs [24]. After a meeting, the analyzed content was presented as terms used in the hybrid model, with subcategories as indicators and categories as attributes.

3. Final Analysis Phase

The attributes and indicators derived from each phase were compared and analyzed to integrate the results of the theoretical and fieldwork phases. The attributes and indicators of the care competency concept at the end-of-life for long-term care hospital nurses were confirmed, and the final results were derived.

4. Ethical Considerations

This study was approved by the Institutional Review Board (IRB) of Changwon National University University (IRB No. 7001066-202205-HR-027). Informed consent was obtained from the participants.


1. Theoretical Phase

1) Dictionary Meaning of End-of-Life Care Competency

In the National Institute of Korean Language Standard Korean Dictionary [25], “life” is defined as “the period of one’s lifetime as long as one is alive,” “end” is defined as “the end or concluding phase of a certain period,” “nursing” is defined as “taking care of and nursing patients or older adults who are injured or ill,” and “competency” is defined as “the ability to accomplish a task or work.” In the Oxford English Dictionary [26], “competency” is defined as “the ability to do something well and the skills required for a specific profession or particular task.” The Cancer Terms Dictionary [27] defines “End of Life care” as “treatment for individuals approaching the end of their life who have discontinued treatment aimed at curing or controlling the disease.” It involves managing pain and other symptoms to ensure patient comfort, and includes physical, emotional, social, and spiritual support for both patients and their families.

2) End-of-Life Care Competency in Adjacent Disciplines

It was confirmed that research is being conducted focusing on interdisciplinary core competencies in adjacent disciplines, such as medicine (health care) and social welfare. Kang et al. [16] conducted a study of the minimum essential competencies required by interdisciplinary professionals in South Korea and identified 12 core competencies, specifically for nurses, considering the appropriate competencies for each occupation. Buness et al. [28] emphasized that all healthcare professionals involved in end-of-life care can support individuals in various situations and environments to live their remaining lives by possessing end-of-life care competencies. They also mentioned that by preparing for death, professionals could assist individuals in dying with dignity. Furthermore, they highlighted that professional practices can promote and provide patient-centered nursing through the process and communication of end-of-life care.

In social work, research has been conducted on the development and validation of end-of-life care competency assessment tools. These studies aimed to investigate differences in end-of-life care competencies based on various fields, work environments, and individual characteristics by validating assessment tools [29].

3) End-of-Life Care Competency in Nursing

In nursing, research on end-of-life care competencies has been conducted using various methods such as surveys, reviews, qualitative studies, and systematic literature reviews. White et al. [30] state that competency is required to effectively provide end-of-life care to patients. Robinson [31] states that because end-of-life care can occur in a variety of environments, nurses must have the necessary attitudes, knowledge, and skills to provide care for dying patients. Casey et al. [32] assert that making individuals as happy and comfortable as possible is the focus of end-of-life care. They highlighted the importance of knowing the individual and forming intimate relationships, which they identified as crucial factors determining the quality of end-of-life care. To provide such high-quality end-of-life care, skills of cooperation, coordination, and teamwork are required through communication and exchange among all relevant medical providers, and end-of-life care provided near the end of life and after death was considered an important competency [2,6,33].

In a domestic study, the competencies required to provide terminal patient care to improve the quality of life of terminally ill patients were divided into the areas of hospice palliative care principles, communication, individual nursing, self-management, and ethical practice, and were described as terminal patient nursing competencies [17]. Nurses in long-term care hospitals need integrated nursing competencies, including emotional and spiritual support for end-of-life patients and their families, management of physical symptoms, continuity of care, and skills in decision-making and communication, which are not limited to imminent end-of-life situations [19].

4) Attributes of End-of-Life Care Competency

By analyzing 15 documents related to end-of-life care competency, eight attributes were identified (Table 1) based on the Competency Outcomes Performance Assessment (COPA) model presented by Lenburg [34]. The first attribute was ‘assessment and intervention,’ aiming to understand and address various issues that arise during end-of-life. These attributes include management of physical symptoms including pain, integrated assessment of psychosocial, emotional, and spiritual problems, holistic individual nursing, identifying signs of imminent death, care for the dying, advance treatment plan, nursing care planning and evaluation, palliative care, bereavement care, and indicators of nursing continuity. ‘Communication’ has been identified as a fundamental attribute for providing quality end-of-life care. It includes indicators such as talking with patients and their families about dying, effective communication, communication and interaction, and appropriate documentation of communication. The attribute of ‘critical thinking’ includes indicators such as decision-making and prioritization. The attribute of ‘human care and relationships’ includes indicators such as providing ethical principles and legal standards, cultural and religious care, interpersonal relationships, and support for patients and their families. The attribute of ‘management’ includes indicators such as the physical environment and support, teamwork, and support and education for staff. ‘Leadership’ has also been identified as an attribute, with indicators such as coordination, collaboration, self-reflection and self-management, and understanding one’s role. The attribute of ‘teaching’ includes indicators such as preparing and equipping families to cope with death, educating and supporting staff, and providing information. Lastly, the attribute of ‘knowledge integration’ included integration of hospice and palliative care principles, education and research, professional knowledge, and ethical and legal issues.

Attributes and Indicators of Theoretical, Fieldwork, and Integration Phases

2. Fieldwork Phase

During the fieldwork phase, the below nine attributes were derived, which are shown in Table 1.

‘Symptom management for comfort’ involves a nursing process that assesses the diverse needs of patients and implements interventions to address and alleviate them, and it included indicators such as assessment of the patients and their families’ comprehension of the patient’s illness severity, evaluation and assessment of spiritual components, and holistic personalized nursing.

“I believe it’s important to be able to evaluate and assess different symptoms, also caring for terminally ill patients requires both theoretical knowledge about their condition and a set of skills to provide customized nursing care that meets individual patient needs…” (Participant 9)

‘Communication in individual nursing’ requires skills to elicit patients’ and their families’ emotions and comprehend their thoughts. Additionally, flexibility in word selection and intonation based on the patient’s situation or characteristics is crucial for effective communication. In unexpected situations, therapeutic communication techniques appropriate for the situation and subject can be employed. Developing effective communication skills with patients and their families is crucial to achieve end-of-life care goals. This involves getting to know the recipient, understanding their wishes, and building trust. In doing so, nurses can provide better care and support during this important stage of life.

“It is crucial to actively seek and understand the perspectives of the other person. Understanding an individual enables you to discern their needs, recognize desires, and formulate interventions or plans tailored to them. These skills serve as a compass for touching the person’s heart. Central to this is communication, encompassing physical, psychological, social, and spiritual dimensions, in order to learn more closely.” (Participant 4)

‘Communication between team members for continuity of nursing’ has been demonstrated as an essential competency for ensuring continuity of nursing. This proficiency plays a pivotal role in facilitating the delivery of high-quality end-of-life care that benefits patients and their families. The indicators included team member communication, information sharing, and thorough documentation.

“When a patient issue arises, it’s critical that team members share information quickly and accurately to ensure positive outcomes…” (Participant 14)

‘Determining priorities according to the situation’ involves determining the focus and systematically delivering nursing care in alignment with the diverse needs of patients and their families. It emphasizes decision-making, situation-appropriate judgment, and effective problem-solving.

“Prioritization plays a crucial role in end-of-life care due to the limited time available for the patient’s needs. It is necessary to determine what is urgent and what can be sacrificed or postponed in order to fulfill the patient’s requirements within that restricted span. Therefore, it is important to prioritize certain aspects to ensure optimal care. I believe that prioritizing these aspects should be the primary concern even towards the end of life.” (Participant 9)

‘Care that accompanies daily life’ entails encouraging and supporting patients to live as independently as possible while providing emotional support and attention to ensure that patients feel respected as they go through their daily routines. Consequently, sharing the details of daily lives of patients with their families and involving them in the care process are essential. Additionally, the nurses’ role in ensuring patient comfort included supporting the family’s decision-making and alleviating any difficulties they might face in deciding the course of treatment for the patient.

“Explanation, attention, and compassion are essential elements of genuine end-of-life care. Even if nobody is interested in preparing for the end while residing in the hospital, or if one is bedridden and unable to respond or comprehend, it is important to at least hold their hand and engage in conversation during rounds instead of abandoning them. In this process, a connection is gradually established, and you open up to us during both difficult and joyful moments. As trust develops, you feel comfortable sharing concerns, pains, and loneliness, allowing us to make preparations for the last moment.” (Participant 10)

Utilizing resources at the appropriate time and location improves efficiency through the division of labor and necessitates the linking and proper utilization of both human and material resources to meet the diverse needs of the target audience.

“By fulfilling our role in connecting individuals with the relevant resources, we can significantly alleviate the pain experienced by patients and their families (omitted) Among that, our proficiency in social services and economic matters, as well as making connections, is not particularly strong. However, the social worker excels in these areas, particularly in establishing connections with entities like the city office…” (Participant 3)

Exercising leadership aligned with the situation necessitates the ability to provide expert counseling, collaborate with colleagues or other departments, manage and reconcile disparate opinions, and engage in self-reflection and self-management.

“In the midst of a crisis faced by patients and their families nearing the end of life, it is crucial to possess the ability to remain centered and provide unwavering guidance until the conclusion of their journey. In addition, it is important to possess spiritual maturity, self-awareness, and the ability to prioritize self-care.” (Participant 6)

‘Providing education and information regarding uncertain situations’ involves instructing caregivers on individualized nursing, offering a precise description of the condition to help families prepare for and handle death, providing problem-solving strategies and information on predictable changes, furnishing the necessary information for decision-making, and supporting relationships as helpers.

“As medical professionals, when a patient’s condition worsens, we may recognize signs of imminent death. However, family members often struggle to accept this reality, even when it’s apparent to them, leading to difficulties and awkward situations. It is imperative to offer comprehensive education to bridge this understanding gap, as it appears to be a crucial necessity. Ultimately, the patient’s comfort is dependent on the preparedness of their family. So in the end, to make the patient comfortable, the family must be prepared as well.” (Participant 3)

‘Professional development to strengthen competency’ involves acquiring knowledge about hospice palliative care and related laws and end-of-life care which helps in decision-making.

“To ensure the family’s comprehension, it is essential to explain that a phenomenon present in this situation necessitates a specific intervention. Such knowledge is very important. Because you can’t just explain it to your family out of the blue. Because understanding theoretical knowledge of various symptoms is also essential.” (Participant 4)

3. Final Analysis Phase

In the final analysis phase, the data obtained during the theoretical and fieldwork phases were thoroughly compared and analyzed. Communication between team members for the continuity of nursing, newly developed in the fieldwork phase, was incorporated into effective communication. During the integration of the additional indicators identified in the field phase, a list of attributes was created to comprehensively depict competency in end-of-life care. The final analysis results showed the derivation of eight attributes and 50 indicators, including comprehensive symptom management, effective communication, situational response, patient-centered care, information provision and education, resource management, demonstration leadership, and professional development (Table 1).

Based on the results obtained from the final analysis phase, the end-of-life care competency of long-term care hospital nurses is as follows: implementing comprehensive symptom management and responsive interventions is crucial in long-term care hospitals to facilitate end-of-life care, which allows patients to live independently with human dignity in their final moments; demonstrating leadership by employing effective communication and optimal resource utilization; providing comprehensive information and education that addresses the needs of both patients and their families by actively engaging in patients’ daily lives; and ensuring professional development to strengthen individual nurses’ competency.

From a social perspective, the increase in the older population and attention to end-of-life care are significant. From the subject’s perspective, as the disease worsens, individual needs increase, dependence increases, and quality of life decreases. From the patient’s standpoint, the focus is on well-being, enhanced quality of life, and a dignified, comfortable, and serene death. From the nurses’ perspective, a positive attitude towards death can strengthen self-competency.


The study identified the attributes of end-of-life care competency as comprehensive symptom management, effective communication, situational response, patient-centered care, resource management, demonstrating leadership, information provision and education, and professional development. The results of this study were similar to those of the research conducted by Korean Hospice Palliative Nursing Research Network et al. [17] on the palliative care competencies required of undergraduate nursing students in Korea. However, more specific attributes were identified in this study; it was observed that performing bereavement nursing, including aspects such as loss and mourning, is challenging due to work environment factors. The main disease groups among inpatients in long-term care hospitals include dementia, cerebrovascular diseases, malignant neoplasms, paralysis, and musculoskeletal disorders. Except for cancer, most of these conditions do not follow a clear progression of the disease, making it challenging to accurately predict disease deterioration or the end-of-life stage [35]. Long-term care hospital nurses are responsible for providing comprehensive care by classifying pathological changes in patients from a professional perspective and closely observing emergency situations [36]. According to Lee [37], when a patient’s condition worsens in a situation where there is no doctor on duty, nurses often have to accurately and quickly judge the patient’s condition and respond appropriately, resulting in difficulties in end-of-life care. In this study as well, the study participants reported facing such difficulties. The participants reported situations in which patients suffer due to their guardians’ sudden decision-making changes and meaningless life extension. Furthermore, their ability to cope with such situations is also important. Therefore, we would like to discuss each derived end-of-life care competency attribute as follows.

Comprehensive symptom management refers to an approach including pain and physical symptoms and mental, social, emotional, and spiritual aspects of the patient’s comfort. In studies by White et al. [30], pain management is the core of end-of-life care and is the top priority for people experiencing severe pain. However, it is an aspect of end-of-life care and requires the ability to manage pain, including physical, emotional, psychosocial, and spiritual dimensions. This finding is consistent with the results of the present study. To achieve comprehensive symptom management, nurses require the ability to accurately assess whether patients and their families have a precise awareness of the patient’s current condition. Additionally, the ability to set nursing goals based on the needs of individuals and to provide individualized nursing care in a cyclical manner up to the evaluation stage is essential. Additionally, continuity of care can facilitate high-quality end-of-life care [38], and sensitive and immediate responses are required to identify patients at the imminent end of life.

Clinical decision-making is affected by the severity of a patient’s health problems and the context of the patient’s actual life [8]. Situational response was revealed as an attribute that allowed the patient to make a quick judgment according to their situation and respond according to decision-making and priorities in the event of a rapidly worsening patient’s condition or a sudden unexpected situation. Soikkeli-Jalonen et al. [39] stated that it is necessary to respond according to physical conditions or various circumstances and to provide advocacy and guidance for patients so that decisions can be made when ethical issues are related to treatment.

Effective communication can strengthen trust and cooperation between patients, their families, and team members; facilitate end-of-life care; reduce the emotional pain of patients and the burden on families; and influence the quality of care [28,38]. Participants stated that failure to communicate properly could have a negative impact on the patients’ and their families’ ability to decide how to live the rest of their lives. Similarly, this study identified effective communication as one of the attributes that nurses providing end-of-life care must have, as it has been reported that dissatisfaction with end-of-life care may occur in the absence of clear communication [16,30].

Nursing consists of several areas, including direct nursing, focusing on “what to do” or “can you do,” while caring behavior focuses on “how to do” and “how to convey” nursing practice [40]. Patient-centered care can be effectively achieved depending on the trusting relationships formed with the patient, family, and team members; knowing the person and forming a close relationship are key factors in determining the quality of end-of-life care [32]. In most cases, patients in long-term care hospitals die after living together for a long period of time rather than suddenly dying. Applying ethical principles and legal standards from a religious and cultural perspective to support patients and families, supporting patients to live their daily lives as much as possible, and providing comfort to patients by cooperating with each other in caring are important indicators of successful end-of-life care [16].

The attributes of resource management refer to the ability to link and utilize human and material resources so that the needs of the target audience can be addressed in various ways and the ability to efficiently exercise teamwork through an appropriate division of work. Participants said that patients often experienced financial difficulties due to prolonged hospitalization or relied on religion during the dying process; therefore, it is necessary to connect them with appropriate resources to alleviate their difficulties.

Demonstrating leadership means managing oneself and patients, families, and all staff involved in end-of-life care. Long-term care hospital nurses play a pivotal role in providing end-of-life care because they have the closest relationships with patients and their families and spend more time with them than with other medical professionals [33]. Collaboration between team members and other professions is one way for effective interventions to be carried out, and all professionals must work in harmony to promote quality end-of-life care [8,16,28]. Most long-term care hospital patients remain in hospital for long periods; therefore, they need the ability to manage personal emotions and stress that arise from their relationships with patients [41]. Additionally, the desire to provide quality nursing depends on an individual; therefore, changing attitudes and beliefs about caring for end-of-life patients through self-reflection and self-management are regarded as the key to lasting behavioral change [42]. Through their experience of end-of-life care, the research participants confirmed that they naturally accepted death as a life process and strengthened their capabilities through self-reflection.

Information provision and education can improve quality of life for the remainder of one’s life by providing appropriate education at the right time, to patients and their guardians, and those who provide care. Education and counseling for patients and their families can provide an opportunity to prepare for bereavement [33,39]. Additionally, it was confirmed that, when there is a problem in the relationship between a patient and their family or close acquaintances, the competency of the nurse as a facilitator is needed to maintain the patient’s psychological comfort through relationship recovery. Particularly, nurses in long-term care hospitals not only provide direct and indirect nursing care but also engage in educational activities related to auxiliary staff [43]. Therefore, educational competency for nursing assistants and caregivers is necessary to effectively provide end-of-life care. Nurses in long-term care hospitals are involved in caring for the daily lives of individuals and require educational competence, which aligns with previous research findings [39] emphasizing the need for such competence.

Professional development refers to the ability to integrate the necessary knowledge to effectively provide end-of-life care through education and participation in research, thereby providing the basis for the end-of-life care needed by patients and their families. It was reported that nurses felt well prepared and gained competency in their role in caring for dying patients through education, and that end-of-life patient care improved after education [2]. Therefore, support at the organizational level, and individual efforts are needed to acquire professional knowledge and qualifications related to end-of-life care.

Based on the COPA model, this study redefined the definition of end-of-life care competency by confirming the attributes and indicators of end-of-life care competency recognized by nurses in clinical settings and conducting a literature review. However, this investigation has limitations in generalizing the results, because it reviewed verifiable literature in English and Korean at the theoretical stage, and conducted convenience sampling of participants at the field stage.


This conceptual analysis study used a hybrid model. The results showed that long-term care hospitals require integrated nursing competencies to provide end-of-life care. By establishing a conceptual definition through this study, it will be possible to provide basic data for the development of a tool to measure the end-of-life care competency of hospital nurses and contribute to the development of educational programs to secure their competency.


Authors' contribution

Study conception and design acquisition - SS and MKJ; Data collection - SS; Data analysis and interpretation - SS and MKJ; Drafting and critical revision of the manuscript - SS and MKJ

Conflict of interest

No existing or potential conflict of interest relevant to this article was reported.


This research was funded by convergence research financial program for instructors, graduate students and professors in 2023.

Data availability

Please contact the corresponding author for data availability.


This study is an excerpt of a part of the first author’s doctoral thesis.


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Table 1.

Attributes and Indicators of Theoretical, Fieldwork, and Integration Phases

Theoretical phase Fieldwork phase Integration phase
Assessment and intervention Symptom management for comfort Comprehensive symptom management ⦁ Assessment of patient and their family’s comprehension of the patient’s illness severity
⦁ Assessing and evaluating pain involves considering its physical, psychosocial, emotional, and spiritual aspects
⦁ Sensitive and immediate reaction to changes in status
⦁ Identifying signs of imminent death
⦁ Palliative care
⦁ Evaluation of nursing care plans and goals
⦁ Holistic individual nursing
⦁ Continuity of nursing
⦁ Advance treatment plan
⦁ Care of the dying
Communication Communication for individual nursing Effective communication ⦁ Eliciting the mind
⦁ Understanding the mind
⦁ Suitable intonation and vocabulary selection, flexibility
⦁ Utilization of therapeutic communication techniques
⦁ Build trusting relationships with patients and families
⦁ Communication and information sharing among team members
Communication between team members for continuity of nursing ⦁ Proper documentation
Critical thinking Determining priorities according to the situation Situational response ⦁ Decision making (choices and decisions)
⦁ Appropriate judgment for the situation
⦁ Priorities for problem resolution
Human caring/relationship Care that accompanies daily life Patient-centered care ⦁ Emotional support
⦁ Supporting the decisions of patients and their families
⦁ Encouragement and support for independent daily living
⦁ Support for patient and family (emotional, psychosocial, spiritual)
⦁ Interest, warm heart
⦁ Religious and cultural care
⦁ Family participation in care
⦁ Share daily life
Teaching Providing information and education on uncertain situations Information provision and education • Accurate condition description
⦁ Preparing for and coping with death
⦁ Providing information for decision making
⦁ Provide information to solve decision problems
⦁ Providing information about predictable changes
⦁ A facilitator for nurturing positive relationships.
⦁ Caregiver training for personalized nursing care.
Management Optimal resource utilization Resource management ⦁ Utilization of human and material resources
⦁ Teamwork
⦁ Employee support and training
Leadership Exercise leadership aligned with the situation Demonstrate leadership ⦁ Advice from an expert
⦁ Collaboration with team members or other departments
⦁ Coordination and orchestration on opinions
⦁ Self-reflection and self-management
⦁ Understanding one’s own role
Knowledge integration Professional development to strengthen competency Professional development Knowledge of hospice palliative care and related laws
⦁ Knowledge of end-of-life care
⦁ Providing basis for decision making
⦁ Integration of hospice and palliative care principles.
⦁ Education and research
⦁ Expertise
⦁ Ethical and legal issues