Nurses’ Knowledge About End-of-Life Care:
Where Are We?
Mona Choi, PhD, RN, JuHee Lee, PhD, APRN, RN, So-sun Kim, PhD, APRN, RN, Doori Kim,
MSN, RN, and Hogon Kim, BSN, RN
abstract
Background: During the end-of-life stage, patients
suffer from multiple symptoms or impairments of altered
body systems. This study examined nurses’ knowledge
of end-of-life care and also the relationship between the
nurses’ knowledge and their characteristics.
Methods: This was a descriptive, correlational study
using a convenience sample of 368 Korean registered
nurses working on cancer units, general wards, and in-
tensive care units of a university health system. Twenty
questions of the Palliative Care Quiz for Nursing (PCQN)
were used to examine nurses’ knowledge of end-of-life
care.
Results: The mean score on the PCQN was 8.95 of
a possible 20. Participants who had the end-of-life care
education (M = 9.57, SD = 2.19) tended to score higher
than those without this education (M = 8.47, SD = 2.34),
and the difference was statistically significant.
Conclusion: Comprehensive continuing education
programs on end-of-life care should be provided to fill
the gap in knowledge and skill of staff nurses.
J Contin Educ Nurs 2012;43(X):xxx-xxx.
Q uality of health care at the end of life has been em-
phasized in nursing in the last two decades because
of the increase in the number of patients with chronic
illnesses who are dying in hospitals or long-term care
facilities. At the end-of-life stage, patients often have
symptoms or impairments resulting from the underly-
ing altered body systems (National Institutes of Health,
2004) that require complex nursing care interventions.
Multiple symptoms include dehydration, respiratory
The Journal of Continuing Education in Nursing · Vol 43, No X, 2012
congestion, loss of independent function, uncontrolled
pain, cognitive decline, and difficulties in communica-
tion. Family members also are required to make deci-
sions about treatments that might prolong life (Della
Santina & Bernstein, 2004; Hallenbeck, 2003; Shugar-
man, Lorenz, & Lynn, 2005). Therefore, nurses who
provide end-of-life care to patients and their family
members need to be aware of ways to relieve physical
and psychological stress. Previous studies reported that
dying patients and family caregivers received poor end-
of-life care, such as inadequate pain control, symptom
management, and lack of communication with health
care providers (Goodridge, Bond, Cameron, & McKean,
2005; Gross, 2006; Lautrette, Ciroldi, Ksibi, & Azoulay,
2006; McClung, 2007; White, Coyne, & Patel, 2001).
Current palliative practice highlights the continuum
of care, which includes disease-modifying treatment,
palliative care, hospice care, and bereavement. In other
words, end-of-life care covers the time from the be-
ginning of the disease curative process and continues
through therapeutic treatment (Hallenbeck, 2003; Kue-
bler, Heidrich, & Esper, 2007). The goal of end-of-life
care is to provide optimum care while ensuring the pa-
tient’s dignity and comfort. However, end-of-life care is
complex and has multiple related factors. Della Santina
Dr. Choi is Assistant Professor, Dr. Lee is Assistant Professor, Dr.
S. Kim is Professor, Ms. D. Kim is graduate student, and Ms. H. Kim
is graduate student, College of Nursing, Nursing Policy and Research
Institute, Yonsei University, Seoul, South Korea.
The authors have disclosed no potential conflicts of interest, financial
or otherwise.
Address correspondence to JuHee Lee, PhD, APRN, RN, Assistant
Professor, College of Nursing, Nursing Policy and Research Institute,
Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, South Korea
120-752. E-mail: jhl@yuhs.ac.
Received: September 25, 2011; Accepted: 2012; Posted:
doi:10.3928/00220124-2011
1
and Bernstein (2004) described the quality of end-of-life
care as the “whole-patient assessment” that facilitates so-
cial or practical needs, spiritual care, physical and emo-
tional symptoms, and therapeutic communication.
Among health care professionals, nurses play a ma-
jor role in end-of-life care, acting as an advocate, liai-
son, and translator between physician and patient/family
members for the decision-making process (Hopkinson,
Hallett, & Luker, 2005). To provide the knowledge and
skills needed for end-of-life care for nurses, the end-of-
life Nursing Education Consortium (ELNEC) was es-
tablished to train nurses and unlicensed staff members in
health care settings in the United States (Sherman, Mat-
zo, Rogers, McLaughlin, & Virani, 2002). The content
of this program includes modules of ethical issues, cul-
turally sensitive care, bereavement, and communication
skills as well as physical management. To achieve nursing
competencies, nurses and nurses’ aides should meet the
goal of each module during the end-of-life care program.
In Korea, the Korea Hospice and Palliative Care Asso-
ciation and the ELNEC Project-Korea team launched
the ELNEC program to provide end-of-life care educa-
tion to nurses in Korea (Kim et al., 2011) with the same
content as the English version.
Although several conferences and programs on end-
of-life care were held for health care providers with ac-
ademic or government support (Kang et al., 2010), the
opportunity to receive basic or continuing nursing edu-
cation in end-of-life care might be insufficient in Korea.
Current nursing education programs in end-of-life care
are partially provided in the Fundamentals of Nursing
course at the undergraduate level or as an elective course
at the graduate level. For instance, only 4 continuing ed-
ucation courses about spiritual care or hospice out of 400
continuing courses are planned for 2012 (Korean Nurses
Association, 2012).
There are limited reports about clinical nurses’
knowledge of end-of-life care in Korea. This study was
conducted to examine nurses’ knowledge of end-of-life
care and the relationship between knowledge and nurse
characteristics. The study findings could be helpful in
developing an educational program based on the knowl-
edge needs of Korean nurses in end-of-life care.
METHODS
Participants and Setting
This descriptive, correlational study examined nurses’
current knowledge of end-of-life care and its relation-
ship to nurses’ characteristics. The study included a
sample of 368 registered nurses working on cancer units,
general wards, and intensive care units (ICUs) at a uni-
versity health system in Seoul, Korea.
2 Copyright © SLACK Incorporated
Instruments
To identify the nurses’ knowledge of end-of-life
care, the Palliative Care Quiz for Nursing (PCQN)
(Ross, McDonald, & McGuinness, 1996) was used,
which consists of 20 questions with three possible re-
sponses (true, false, or don’t know). The PCQN covers
the following three categories in end-of-life care (Ross
et al., 1996): philosophy and principles of palliative
care (4 items), psychosocial aspects of care (3 items),
and management and control of pain and other symp-
toms (13 items). The original version of the PCQN was
back-translated into Korean by Kim et al. (2011). Sev-
eral studies were conducted with the PCQN in differ-
ent countries (Brajtman, Fothergill-Bourbonnais, Fiset,
& Alain, 2009; Carroll, Brisson, Ross, & Labbe, 2005;
Knapp et al., 2009; Raudonis, Kyba, & Kinsey, 2002).
The original English version of the PCQN reported
acceptable reliability and validity when being devel-
oped (Ross et al., 1996). Internal consistency for the
Kuder Richardson 20 (KR-20), a formula for dichoto-
mous true/false items on knowledge tests, was 0.78 in
the original version. The KR-20 for the Korean ver-
sion was 0.65 in this study, showing a minimally ac-
ceptable level of internal consistency (DeVellis, 2003).
This result might be related to the measurement of
multi-constructs in the PCQN, which can be a threat
to reliability. Kim et al. (2011) reported content valid-
ity of 0.85 but did not report the KR-20. Scores for
the PCQN were calculated using the items with cor-
rect answers, and the “don’t know” responses were
counted as incorrect. The mean percentage of correct
responses was calculated for scoring. The total mean
score out of 20 items, with a possible range of 0 to
20, was also obtained for comparison with previously
published studies. There was also a demographic data
collection sheet.
Data Collection Procedure and Ethical
Consideration
In this study, data collection was undertaken at two
hospitals at a university health system in November and
December 2010. A convenience sample of nurses work-
ing on 3 cancer units, 14 general wards, and 7 ICUs were
chosen. With the supervisors’ assistance, questionnaires
were distributed to a convenience sample of 400 nurses.
The research packet included a questionnaire; a cover
letter that explained the aims of the study and provided
assurance regarding anonymity; confidentiality, volun-
tary participation, and consent forms; and a small gift.
Research assistants put the return boxes on each nursing
unit. When nurses completed the questionnaires, they
placed the questionnaire and the consent form in the
 TABLE 1 TABLE 2
CHARACTERISTICS OF STUDY PARTICIPANTS NURSES’ KNOWLEDGE OF END-OF-LIFE CARE
(N = 368) (N = 368)
Variable n % Mean Scores
of Correct % of Correct
Age (years)a
Category of PCQN Responses Responses
< 25 95 25.8
Philosophy and principles of 1.81 45.3
26 to 30 154 41.8 palliative care (4 items)
31 to 35 53 14.4 Psychosocial aspects of care 0.60 20.2
(3 items)
> 36 66 17.9
Management and control of 6.54 50.3
Education
pain and other symptoms
Associate’s degree (3 years) 81 22.0 (13 items)
Bachelor’s degree 267 72.6 Total score on the PCQN 8.95 44.9
Master’s degree 20 5.4 Note. PCQN = Palliative Care Quiz for Nursing.

Clinical setting
Cancer unit 43 11.7
General ward 174 47.3 RESULTS
Intensive care unit 150 40.8 Characteristics of the Study Participants
Characteristics of participants in this study are shown
Years of total clinical experienceb
in Table 1. Mean participant age was 29.8 years, with a
<5 179 48.6
range of 22 to 58 years. Two-thirds of the participants
5 to 10 105 28.5 were 30 years or younger. Most participants (88.1%)
> 10 84 22.8 worked on a general ward or the ICU. Mean years of
Years of experience in current clinical total clinical experience was 6.9, and mean years of expe-
settingc rience in the current clinical setting was 4.1. Fewer than
<5 262 71.2 half of the participants (43.8%, n = 161) had previous
5 to 10 78 21.2 education about end-of-life care.
> 10 28 7.6
a b c
Nurses’ Knowledge of End-of-Life Care
Note. M = 29.84, SD = 5.84. M = 6.92, SD = 5.97. M = 4.10, SD =
3.74. The questionnaire about the nurses’ knowledge had
20 total questions. The mean scores and percentages of
correct responses in the three categories are shown in
Table 2. The mean score on the PCQN was 8.94 (SD =
box separately. Therefore, researchers were not able to 2.34) of a possible 20. The items that received the highest
link their identifier to the questionnaire. Among the 398 percentage of correct responses included comparison of
questionnaires returned, 30 were excluded because the chronic and acute pain and bowel regimen for patients
respondents were not staff nurses or had missed demo- on opioids. Items receiving the lowest percentage of
graphic characteristics (e.g., education level); therefore, correct responses included those on family members re-
368 questionnaires were analyzed. The returned ques- maining at the bedside, burnout in palliative care nurses,
tionnaires were stored in a locked drawer, and a coded and use of placebos.
data file was password protected. The study was ap-
proved by the university institutional review board. Difference in Nurses’ Knowledge Scores by
General Characteristics
Data Analysis The PCQN score was statistically significant for
Descriptive statistics, the t test, Pearson correlation, clinical setting and end-of-life care education (Table 3).
and analysis of variance were used to describe the items Nurses working on cancer units had higher scores (M =
of the PCQN and examine the differences in total score 10.63, SD = 1.93) than those working on general wards
of the PCQN according to participant characteristics. or ICUs (F (2, 364) = 15.669, p < .001), according to the
Data were coded and analyzed using SPSS for Windows, findings of Scheffé’s test. According to Pearson correla-
version 18.0. tion analysis, the PCQN score was correlated with nurse

The Journal of Continuing Education in Nursing · Vol 43, No X, 2012 3

 TABLE 3
DIFFERENCE IN NURSES’ SCORES OF KNOWLEDGE OF END-OF-LIFE CARE BY CHARACTERISTICS (N = 368)
Variable n M
Education
Associate’s degree (3 years) 81
Bachelor’s degree 267
Master’s degree 20
Clinical settinga
Cancer unitb 43
General ward c
174
Intensive care unitd 150
End-of-life care education
Yes 161
No 204
Note. aScheffé’s test was performed.
age (r = .11, p = .037) but not with years of total experi-
ence or experience in the current clinical setting. Partici-
pants who received end-of-life care education showed
higher scores than those who did not receive this educa-
tion (t = 4.591, p < .001).
DISCUSSION
The study was conducted to assess nurses’ end-of-life
care knowledge and examine the relationship between
this knowledge and the nurses’ characteristics. The re-
sults showed that nurses scored higher than 50% on 10
of the 20 items, whereas nurses in the study of Ross et
al. (1996) scored higher than 50% on 18 items on the
PCQN. The highest scored item was 4, “Adjuvant ther-
apies are important in managing pain,” with 91.6% of
participants providing the correct answer. This was simi-
lar to findings of Knapp et al. (2009) and Brajtman et al.
(2009), with 87% and 96% of respondents providing the
correct answer, respectively. The lowest scored item was
5, “It is crucial for family members to remain at the bed-
side until death occurs,” which was answered correctly
by 1.4% of nurses. This finding is similar to another Ko-
rean study (Kim et al., 2011) that reported a 0% correct
answer rate and contrasts with other studies in Western
culture (Brajtman et al., 2009; Knapp et al., 2009; Loftus
& Thompson, 2002). Although the authors who devel-
oped the PCQN provided the rationale for item 5, pos-
iting that it is important to prevent exhaustion in fam-
ily members keeping a vigil at the bedside (Ross et al.,
1996), several explanations can be considered for why
Korean nurses scored this item as true. First, this item
in the translated Korean version may not exactly reflect
4 Copyright © SLACK Incorporated
SD t or F p
8.62 2.29 2.189 .113
8.99 2.35
9.80 2.31
10.63 1.93 15.669 < .001
8.98 2.12 b > c, d
8.45 2.48
9.57 2.19 4.591 < .001
8.47 2.34
the meaning of the original version of this item, whether
it is related to the moment of dying or a certain period
of end-of-life caregiving. Another plausible explanation
is that the item may have been interpreted as an absolute
meaning that family members should be at the bedside
constantly, rather than being provided the opportunity
to be at the bedside. Second, Korean people traditionally
view remaining at the bedside of a dying patient as the
right thing to do. Therefore, this item should be inter-
preted carefully and with cultural sensitivity.
The mean score from study participants was some-
what low (M = 8.95, SD = 2.34) compared with pre-
vious studies (Brajtman et al., 2009; Kim et al., 2011;
Knapp et al., 2009; Raudonis et al., 2002; Ronaldson,
Hayes, Carey, & Aggar, 2008). Knapp et al. (2009) re-
ported an average score of 10.9 in 279 pediatric care
nurses, and Brajtman et al. (2009) reported a score of
12.8 in 52 nursing faculty members. The PCQN score
of nurses working at residential long-term care facili-
ties was 11.7 (Ronaldson et al., 2008). Among Korean
nurses who participated in the ELNEC program train-
ing, the pretest result was 12.5 (Kim et al., 2011); how-
ever, those nurses (approximately 40%) were certified
nurses working in hospice and palliative care areas. In
this study, only half of participants reported that they
had received any education on end-of-life care. This
might explain the lower score on the PCQN compared
with findings from previous studies. Our study results
indicate the need for end-of-life continuing education
for nurses if they will be expected to provide optimum
care. With limited end-of-life care experience and little
educational exposure, nurses’ knowledge and skill in
decision making and communicating with patients and
family members might be inadequate.
The findings also showed that nurses who worked
on cancer units and who had previous end-of-life care
education had higher scores on knowledge of end-of-life
care. This is similar to the findings of a previous study
(Knapp et al., 2009) that also reported higher scores in
nurses who received training and who worked in a hos-
pice setting. Additionally, Kim et al. (2011) confirmed
that nurses certified in hospice and palliative care scored
high if they had received previous end-of-life education.
This evidence might indicate that oncology nurses have
more opportunities to manage cancer-related pain and
symptoms.
The PCQN covers three categories in end-of-life care
(i.e., philosophy and principles of palliative care, psy-
chosocial aspects of care, and management and control
of pain and other symptoms). In the current study, low-
scoring items were distributed in all three categories. In
particular, there were low-scoring categories in the phi-
losophy and principles of palliative care and the psycho-
social aspects of care. This finding must be interpreted
cautiously because these categories have only three and
four items, respectively. Therefore, a comprehensive
education program should be developed to increase
end-of-life care competencies for nurses. First, this type
of program is needed to strengthen nurses’ knowledge
of philosophical aspects of end-of-life care, principles
of end-of-life care, the dying process, and the role of
health care professionals or case managers. Second, as
part of psychosocial and spiritual care, nurses need to
be instructed in how to communicate bad news effec-
tively. Additionally, nurses who provide end-of-life care
should thoroughly understand the bereavement pro-
cess. Finally, education in nursing care of patients who
are near death should include management of pain and
symptoms, such as dyspnea, delirium, depression, and
constipation. This education should cover the identifica-
tion and timely use of appropriate medication, includ-
ing side effects and placebo ineffectiveness. To achieve
this education goal, the underlying causes of symptoms
should be sought. Furthermore, nurses’ knowledge of
related medication should also be updated periodically
through continuing education.
The participants of this study were drawn from con-
venience sampling at a tertiary care health system in Ko-
rea. Study subjects were limited to nurses who cared for
adult/geriatric patients only. The limited focus of using
only the PCQN may not cover all of the knowledge that
might be required for nurses providing end-of-life care.
In addition, the mean differences by setting and end-of-
life care education and correlation coefficient with age
The Journal of Continuing Education in Nursing · Vol 43, No X, 2012
key points
End-of-Life Care
Choi, M., Lee, J., Kim, S., Kim, D., Kim, H. (2012). Nurses’ End-of-
Life Care Knowledge: Where Are We? The Journal of Continuing
Education in Nursing, 43(X), xxx-xxx.
1
Among the Korean nurses studied, nurses generally have little
knowledge of end-of-life care and half of nurses have not
received end-of-life care education in this study.
2 Nurses taking end-of-life care education had higher score on
knowledge of end-of-life care than those who did not experi-
ence an education.
3 For staff development, continuing education will be the most ef-
fective way to fill staff nurses’ knowledge gap and advance their
competencies in end-of-life care.
were statistically significant. However, these findings
should be interpreted with caution because of the sample
size.
In Korea, end-of-life care education for nurses has
mostly focused on the area of oncology. Therefore, end-
of-life care for other patient groups, such as patients
with chronic illness or those in the ICU, might have
been relatively overlooked, resulting in a lack of end-
of-life care training. Nurses in all areas of patient care
should be included in future education because of the
needs of this aged society, with its growing population
and increasing incidence of chronic, complex diseases re-
quiring extended care.
CONCLUSION
This study provided an insight into end-of-life care
by examining knowledge of end-of-life care in nurses
who work in broader clinical settings than did those in
previous studies conducted in Korea. Nurses play a criti-
cal role in providing 24-hour end-of-life care to patients.
Continuing education programs that provide compre-
hensive end-of-life care should be widely provided not
only for nurses working in palliative, hospice, or on-
cology care areas, but also for all nurses in general. For
the vast majority of staff nurses in the clinical setting,
the only way to fill this gap in knowledge and skill is
through continuing education in end-of-life care. Pro-
viding continuing education programs in end-of-life care
at an organizational or professional nursing society level
will equip nurses with the knowledge base and skill set
in end-of-life care.
5
 The implication of the role of administrators, educa-
tors, and researchers is also essential. For example, hos-
pital administrators could provide organizational sup-
port for staff members to attend continuing education
programs for end-of-life care. There is a policy require-
ment for institutional structure as well as a standardized
protocol to guide the decision-making process for health
care providers. Educators could identify gaps in knowl-
edge and develop programs for staff nurses. Finally,
there is a need for future studies with a larger sample size
from multiple organizations.
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