1. Background

Terminal cancer patients receiving hospice and palliative care need care for various physical symptoms, including pain, as well as psychosocial and spiritual care for fear of death, depression, and concerns about their families [1,2]. Hospice nurses interact most frequently and closely with terminal cancer patients and their families and play a pivotal role in integrated and holistic hospice care [3]. In holistic hospice care, compassion is essential for understanding and responding properly to patients’ pain and care needs in their specific environment and situation [4]. Compassion refers to the ability to understand others’ feelings and emotions, to feel like another person’s situation is one’s own, and to take action to help [4-6]. For nurses to demonstrate compassion in hospice care, it is essential to intuitively identify patients’ internal needs by considering their situations and environmental characteristics beyond the level of understanding of their pain or simply empathizing [4,5]. In hospice care, nurses’ compassion competence can be a basis for catching clues regarding various and complex needs that patients express verbally and non-verbally and performing holistic care with consideration of the strengths and limitations of individual patients’ internal and external resources [6,7].

According to previous studies, the compassion competence of nurses caring for severely or chronically ill patients, including critical patients and patients with dementia, is associated with intrinsic characteristics, such as professional self-concept, happiness, and personal relations [8,9], as well as aspects of the extrinsic environment, such as the work environment, support from colleagues, and professional achievement [10,11]. However, there is an insufficient understanding of the characteristics associated with compassion competence among hospice nurses who provide integrated care, including physical, psychosocial, and spiritual aspects, to terminal cancer patients and their families.

Spirituality is not limited to simply religious beliefs. Instead, it is a philosophical characteristic that transcends reality; makes harmonious relationships with the Absolute, oneself, one’s neighbors, and one’s environment; grants meaning and value to life; and guides attitudes and behaviors in one’s life [12-14]. Moreover, spirituality is an intrinsic resource that integrates humans’ physical, mental, and social characteristics and a source for manifesting an individual’s value of humanity and wholeness [14,15]. In a crisis where hospice patients and their families face multifaceted physical and psychosocial distress, they need supportive care to maintain spiritual well-being by recognizing meaning in life and existential value [12]. The spirituality of hospice nurses can act as an inner power to facilitate professional care by understanding the distress of patients and their families and maintaining detachment rather than being overwhelmed with their negative situations and grief [12,15]. Spirituality also serves as a source of spiritual care that helps patients and their families derive the meaning and value of life by understanding the spiritual conflicts they experience in life crises [12,13,15]. Since compassion competence is an essential capability for human-centered holistic care [16], it is necessary to examine whether the spirituality of hospice nurses influences compassion competence for holistic care.

Hospice nurses are responsible for a broad range of tasks, including assessing pain and needs, establishing and performing care plans, educating families and volunteers, and serving as counselors, coordinators, and quality managers for multidisciplinary teamwork and managers of environment, administration, and finance [3]. In addition, nurses carry out unique roles requiring compassion competence for the spiritual care of patients and their families, encompassing before death, during the dying process, and managing bereaved families after death [3,17,18]. As such, hospice nurses’ satisfaction with their distinctive tasks, different from those of other care units, is related to confidence in their role, professionalism, and performance and can influence the quality of hospice care [19]. Furthermore, a previous study reported that nurses’ job satisfaction in various clinical fields is associated with compassion competence, and the quality of medical services [20]. Therefore, the job satisfaction of hospice nurses must be considered a critical characteristic affecting compassion competence for holistic care.

Compassion competence is essential for hospice nurses, who must closely communicate and interact with patients for holistic care. However, little research has focused on compassion competence and associated characteristics among hospice nurses. Hence, this study aimed to examine whether the spirituality of hospice nurses, as an intrapersonal characteristic, and job satisfaction, as an extrinsic factor, affect their compassion competence.

2. Purpose

This study aimed to identify the extent to which hospice nurses have spirituality, job satisfaction, and compassion competence, assess the relationships among these variables, and examine the influence of spirituality and job satisfaction on compassion competence. Through this, this study aimed to present essential evidence that contributes to improving the quality of care provided to end-of-life patients.

1. Study design

This study used a descriptive design to identify the influence of spirituality and job satisfaction on the compassion competence of hospice nurses.

2. Participants

The participants of this study were 118 nurses responsible for direct care for 6 months or longer at hospice-specialized institutions in Daejeon, Chungcheong Province, and Jeolla Province and provided written consent for participation after understanding the purpose and procedure of this study.

The sample size for this study was calculated using G*Power version 3.1.9.4. Using a medium effect size of 0.15 for multiple regression analysis, as suggested by Cohen [21], a significance level of 0.05, a power of 0.80, and 10 predictors, the minimal number of samples required for the study was 118. Considering the data collection through a non-face-to-face self-reported questionnaire, we added 20% of the samples to account for potential unreturned questionnaires and insincere responses. The questionnaire was distributed to 147 individuals, and eventually, 29 questionnaires with incomplete responses were excluded. The final sample size analyzed for this study was 118.

3. Study tools

Spirituality was assessed using the Spirituality Scale for Koreans developed by Lee et al. [14]. The tool includes six sub-domains: transcendence, meaning and purpose of life, compassion, inner resources, awareness, and connectedness. Each domain consists of 5 items with responses on a 5-point scale (1 point for “strongly disagree” to 5 points for “strongly agree”), and a higher score represents a higher level of spirituality. The reliability of the tool was shown by Cronbach’s α values of 0.93 in the original study [14] and 0.94 in this study.

Job satisfaction was assessed using the Index of Work Satisfaction, modified and supplemented by Han and Choe [17]. The tool consists of 30 items in six sub-domains: the task itself (6 items), pay (4 items), interaction (5 items), professional status (6 items), autonomy (3 items), and administrative aspects (6 items). Each item is answered on a 5-point scale (1 point for “strongly disagree” to 5 points for “strongly agree”), and a higher score represents higher job satisfaction. The reliability of the tool was shown by Cronbach’s α values of 0.88 in the study of Han and Choe [17] and 0.90 in this study.

Compassion competence was assessed using the Compassion Competence Scale for nurses developed by Lee and Seomun [6]. The tool consisted of 17 items on communication (8 items), sensitivity (5 items), and insight (4 items). Each item was answered on a 5-point scale (1 point for “strongly disagree” to 5 points for “strongly agree”) and a higher score represents higher compassion competence. The reliability of the tool was shown by Cronbach’s α values of 0.91 in the original study [17] and 0.87 in this study.

The sociodemographic characteristics (e.g., gender, age, marital status, religion, education, and monthly salary) of the participants were investigated. We also gathered information on their characteristics regarding personal experience of hospice care for someone close, total clinical career, clinical career in hospice care unit, type of work schedule, and the number of participations in a burnout prevention program, which were reported to be associated with compassion competence by Kim and Lim [22].

4. Data collection and ethical considerations

The purpose and procedure of this study were approved by the C University Institutional Review Board (No. 202007-SB-095-01). In order to prevent the spread of coronavirus disease 2019, the data were collected in a non-face-to-face way via mail. The questionnaire package, including an explanation, consent form, questionnaire, and collection envelope for participants, was mailed to hospitals’ hospice and palliative care wards where data collection was allowed. Before mailing, the data collection process and participation method were explained to the ward managers via phone. Participants were informed about the protection of personal information, the potential benefits, and risks of participation. The rights to autonomy of participation and withdrawal guaranteed to participants were also explained. If participants fully understood the explanations and were willing to participate in the study voluntarily, they were asked to complete a written consent form and respond to the questionnaire. The written consent forms and completed questionnaires were placed in an anonymous envelope, sealed, and kept in the wards. The researchers then visited the wards and collected them after 1 week after the date of mailing. The data were collected from October 19 to 30, 2020.

5. Data analysis

The data were analyzed using SPSS for Windows version 26.0 (IBM Corp., Armonk, NY, USA). The general characteristics, spirituality, job satisfaction, and compassion competence were presented as frequency, percentage, mean, and standard deviation. Differences in compassion competence according to the participants’ characteristics were analyzed using the t-test and Pearson’s correlation coefficients. The correlations of spirituality, job satisfaction, and compassion competence were evaluated using Pearson correlation coefficients. The influence of spirituality and job satisfaction on compassion competence was examined using hierarchical multiple regression analysis.

1. Characteristics of the participants

The mean age of the participants was 41.99 years old, 112 (94.9%) were women, and 70 (59.3%) were married. In addition, most participants (98 nurses, 78.8%) had a bachelor’s degree, and the monthly salary of 67 nurses (56.8%) was less than 3,000,000 KRW.

The average length of clinical career of the participants was 14.35 years. The mean clinical career in the hospice care unit was 3.64 years, and the most frequent work schedule (78 nurses, 66.1%) was shift work. Sixty-four (54.2%) participants had completed burnout prevention programs fewer than 3 times, and 37 (31.4%) had personal experiences of hospice care for someone close (Table 1).

Table 1 . Characteristics of the Participants (N=118)..

Characteristics	n (%)	Mean±SD (min~max)
Age (yr)		41.99±12.05 (24~68)
Gender
Women	112 (94.9)
Men	6 (5.1)
Marital status
Married or others	70 (59.3)
Single	48 (40.7)
Religion
Yes	70 (59.3)
No	48 (40.7)
Education
≤Bachelor’s degree	93 (78.8)
≥Master’s degree	25 (21.2)
Monthly salary (10,000 Korean won)
<300	67 (56.8)
≥300	51 (43.2)
Clinical career (yr)		14.35±10.73 (0.92~45)
Clinical career in hospice care unit (yr)		3.64±3.83 (0.92~22)
Types of work schedule
Shift work	78 (66.1)
Fixed work schedule	40 (33.9)
Participation in burnout prevention programs (number)
<3	64 (54.2)
≥3	54 (45.8)
Personal experience of hospice care for someone close
Yes	37 (31.4)
No	81 (68.6)

2. Spirituality, job satisfaction, and compassion competence of the participants

The characteristics of participants’ spirituality, job satisfaction, compassion competence, and the characteristics of each sub-variable are presented in Table 2. The mean score of participants’ spirituality was 3.66 out of 5 points, with the lowest score (3.28 points) for transcendence, followed by inner resources (3.43 points), compassion (3.73 points), connectedness (3.75 points), awareness (3.85 points), and meaning and purpose of life (3.94 points) in ascending order.

Table 2 . Spirituality, Job Satisfaction and Compassionate Competence of Hospice Nurses (N=118)..

Variables	Mean±SD
Spirituality	3.66±0.48
Transcendence	3.28±0.92
Meaning and purpose of life	3.94±0.59
Compassion	3.73±0.50
Inner resources	3.43±0.61
Awareness	3.85±0.48
Connectedness	3.75±0.62
Job satisfaction	3.57±0.40
Task itself	3.62±0.38
Pay	2.72±0.70
Interaction	3.87±0.60
Professional status	3.99±0.64
Autonomous	3.37±0.56
Administrative aspects	3.49±0.47
Compassion competence	3.91±0.43
Communication	3.88±0.49
Sensitivity	4.15±0.43
Insight	3.75±0.59

The mean score of job satisfaction was 3.57 out of 5 points, with the lowest score for pay (2.72 points), followed by autonomy (3.37 points), administrative aspects (3.62 points), interaction (3.87 points), and professional status (3.99 points) in ascending order.

The mean score of compassion competence was 3.91 out of 5 points, with the lowest score for insight (3.75 points), followed by communication (3.88 points) and sensitivity (4.15 points) in ascending order.

Spirituality was positively correlated with job satisfaction (r=0.44, P<0.001) and compassion competence (r=0.66, P<0.001). There was also a positive correlation between job satisfaction and compassion competence (r=0.52, P<0.001) (Table 3).

Table 3 . Reciprocal Relationships between Spirituality, Job Satisfaction, and Compassion Competence (N=118)..

	Spirituality		Job satisfaction
	r (P)		r (P)
Job satisfaction	0.44 (<0.001)		-
Compassion competence	0.66 (<0.001)		0.52 (<0.001)

3. Differences in compassion competence according to the participants’ characteristics

The level of compassion competence was significantly lower among participants with a bachelor’s degree (t=-3.81, P<0.001) and participants whose monthly salary was less than 3,000,000 KRW (t=-2.10, P=0.038) than in their counterparts. The entire clinical career (r=0.28, P=0.003) and clinical career in the hospice care unit (r=0.25, P=0.006) showed significant positive correlations with compassion competence, with a trend for more extended career experience to be associated with higher compassion competence. Compassion competence was significantly lower among nurses who carried out shift work (t=-3.02, P=0.003), participated in burnout prevention programs fewer than 3 times (t=-2.14, P=0.034), and did not have personal experience of hospice care for someone close (t=2.98, P=0.003) (Table 4).

Table 4 . Differences in Compassion Competence according to the Participants’ General Characteristics (N=118)..

Characteristics	Compassion competence
	Mean±SD	r or t (P)
Age (yr)	41.99±12.05	0.12 (0.198)
Gender
Women	3.91±0.43	-0.46 (0.647)
Men	3.83±0.34
Marital status
Married	3.92±0.42	0.43 (0.670)
Single or others	3.89±0.43
Religion
Yes	3.95±0.41	1.38 (0.170)
No	3.84±0.43
Education
≤Bachelor’s degree	3.83±0.41	-3.81 (<0.001)
≥Master’s degree	4.18±0.37
Monthly salary (10,000 Korean won)
<300	3.84±0.43	-2.10 (0.038)
≥300	4.00±0.40
Clinical career (yr)	14.35±10.73	0.28 (0.003)
Clinical career in hospice care unit (yr)	3.64±3.83	0.25 (0.006)
Types of work schedule
Shift work	3.82±0.40	-3.02 (0.003)
Fixed work schedule	4.07±0.42
Participation in burnout prevention programs (number)
<3	3.83±0.46	-2.14 (0.034)
≥3	4.00±0.36
Personal experience of hospice care for someone close
Yes	4.07±0.33	2.98 (0.003)
No	3.83±0.44

4. Influence of spirituality and job satisfaction on compassion competence

Testing the multicollinearity of the independent variables for the multiple linear regression model showed that the tolerance limit was 0.565~0.91 (i.e., higher than 0.1), and the variance inflation factor was 1.089~1.769 (i.e., lower than 10). Therefore, there was no collinearity among the independent variables. Furthermore, the Durbin-Watson statistic (d) was 2.493, close to 2, indicating a low risk of autocorrelation among residuals and satisfaction of the independence assumption.

Table 5 presents the step-by-step results of hierarchical multiple linear regression analysis. In model 1, the covariates (i.e., education, monthly salary, total clinical career, clinical career in hospice care unit, type of work schedule, participation in burnout prevention programs, and personal experience of hospice care for someone close) were entered due to their significant associations with compassion competence. Education (β=0.230 P=0.036) and personal experience of hospice care for someone close (β=-0.204, P=0.032) were significant predictors of compassion competence, and the explanatory power was 13.9% (F=3.700, P<0.001).

Table 5 . The Effects of Spirituality and Job Satisfaction on Compassion Competence (N=118)..

Variables	Model 1				Model 2				Model 3
	β	SE	t (P)		β	SE	t (P)		β	SE	t (P)
Constant		0.208	18.089 (<0.001)			0.329	4.621 (<0.001)			0.361	2.345 (0.021)
Education†1	0.230	0.112	2.129 (0.036)		0.151	0.091	1.730 (0.087)		0.160	0.086	1.942 (0.055)
Monthly salary†2	-0.003	0.094	-0.025 (0.980)		-0.003	0.075	-0.040 (0.968)		-0.024	0.071	-0.288 (0.774)
Clinical career (yr)	0.021	0.005	0.165 (0.869)		-0.037	0.004	-0.363 (0.717)		-0.040	0.004	-0.412 (0.681)
Clinical practice in hospice care unit (yr)	0.101	0.011	1.042 (0.300)		0.043	0.009	0.557 (0.579)		0.064	0.008	0.865 (0.389)
Type of work schedule†3	0.108	0.100	0.975 (0.331)		0.125	0.080	1.407 (0.162)		0.085	0.076	0.996 (0.322)
Participation in burnout prevention programs (number)†4	-0.053	0.007	-0.601 (0.549)		0.002	0.006	0.030 (0.976)		-0.018	0.005	-0.266 (0.790)
Personal experience of hospice care for someone close†5	-0.204	0.086	-2.167 (0.032)		0.023	0.074	0.286 (0.776)		0.047	0.070	0.612 (0.542)
Spirituality					0.621	0.070	7.932 (<0.001)		0.513	0.071	6.431 (<0.001)
Job satisfaction									0.273	0.080	3.679 (<0.001)
R2 (Adjusted R2)	0.191 (0.139)				0.487 (0.449)				0.544 (0.506)
F (P)	3.700 (<0.001)				12.924 (<0.001)				14.314 (<0.001)

†Dummy variable: ¹Reference: ≤Bachelor’s degree, ²Reference: <300 (10,000 Korean won/month), ³Reference: Shift work, ⁴Reference: <3, ⁵Reference: No..

The explanatory power of model 2, which included spirituality, was 44.9% (F=12.924, P<0.001), which increased by 31.0%p compared to model 1. In addition, spirituality was a significant predictor of compassion competence (β=0.621, P<0.001) after adjusting for the covariates entered in model 1.

The explanatory power of model 3, which included job satisfaction, was 50.6%, indicating an additional increase of 5.7%p compared to model 2 (F=14.314, P<0.001). Furthermore, job satisfaction was a significant predictor of compassion competence (β=0.273, P<0.001), after controlling for the covariates and spirituality, and the influence of spirituality remained significant (β=0.513, P<0.001) (Table 5).

This study aimed to furnish primary evidence that contributes to improving the quality of care provided to end-of-life patients by identifying the influence of spirituality and job satisfaction on the compassion competence of hospice nurses.

In this study, the mean score of the spirituality of hospice nurses was 3.66 points, which was slightly higher than those of nurses in long-term facilities (3.40 points) [23] and ward nurses caring for dying patients (3.36 points) [22] measured using the same tool. This study identified spirituality as a phenomenon related to life’s meaning and purpose, awareness, connectedness, compassion, inner sources, and transcendence. Comparably, a previous study [24] identified spirituality, with regard to vertical features (e.g., self-acceptance, transcendence, interrelationships) and a horizontal feature (e.g., the meaning of life, community) [24]. As such, there is a limitation in generalizing the spiritual attributes of hospice nurses; therefore, further research is necessary to understand the spirituality of hospice nurses and elucidate the characteristics of detailed attributes in the future. Meanwhile, the mean score of job satisfaction of hospice nurses was 3.57 points, which was higher than those of nurses in general hospitals (3.03 points) [25], fixed-work nurses (3.42 points) [26], and shift-work nurses (3.52 points) [26]. Hospice nurses perform tasks based on multidisciplinary teamwork to provide integrated care to terminal cancer patients and their families, implying that the characteristics of their job satisfaction may differ from those of nurses in other care units. In this study, the mean score of compassion competence of hospice nurses was 3.91 points, which was higher than those of 3.61 points and 3.68 points of nurses in internal medicine and surgical wards and special wards (e.g., intensive care units, operating rooms), measured using the same tool [8,27]. As a result, it was confirmed that the spirituality, job satisfaction, and compassion competence of hospice nurses were higher than those of nurses in other nursing units, such as special and general wards. The findings may be due to task-related characteristics; in particular, hospice nurses provide holistic and integrated care by responding sensitively to patients’ needs and communicating with them, corresponding to the hospice philosophy. Nonetheless, empirical evidence on spirituality, job satisfaction, and compassion competence of hospice nurses is insufficient; therefore, replication studies on hospice nurses and comparative studies with nurses in various care units are required in the future.

This study found that spirituality, job satisfaction, and compassion competence were positively related. The relationship between spirituality and job satisfaction was consistent with previous studies reporting that higher spirituality among nurses in internal medicine and surgical wards was associated with higher job satisfaction [28]. In addition, consistent with a finding about nurses in cancer wards [20], higher job satisfaction was associated with higher compassion competence. As such, the current study confirms that spirituality and job satisfaction are closely related. Therefore, paying attention to these as crucial factors affecting hospice nurses’ compassion competence is necessary.

This study demonstrated the essential impacts of spirituality and job satisfaction of hospice nurses on compassion competence through a step-by-step analytic investigation that compares their relative impacts. As the initial step, we investigated the effects of general attributes of hospice nurses (i.e., education, monthly salary, clinical career, type of work schedule, participation in a burnout prevention program, and personal experience of hospice care for someone close) on compassion competence. Notably, nurses’ compassion competence was different according to their education, clinical career, and type of work schedule, similar to those reported by Park and Ahn [20] as characteristics of nurses in cancer wards. As a result of the next step, after considering these influences, both spirituality and job satisfaction were factors affecting compassion competence. Furthermore, compared to job satisfaction, spirituality had a more significant impact on compassion competence. Spirituality is the whole of human’s inner resources that are the center of life, and it can influence the holistic aspects of a person’s overall thoughts, beliefs, and behaviors [13]. Although the relative impact of spirituality and job satisfaction on compassion competence is inconclusive, our findings are consistent with empirical evidence in nurses in general and special wards [8,23], which reported that spirituality influenced compassion competence. Therefore, to strengthen the compassion competence of hospice nurses and improve their quality of care, nurses should recognize the awareness of their spirituality—that is, the relationship between themselves, others, and the environment—and reflect and explore the meaning, value, and purpose of life. A previous study [29] reported that education and participatory support programs could affect nurses’ spirituality. Based on this, in order to strengthen the compassion competence of hospice nurses, it is necessary to enhance spirituality to maintain the internal and external balance of humans through acquiring didactic knowledge, exploring one’s self through meditation, and communicating and sharing among team members.

Moreover, job satisfaction influenced compassion competence, even after controlling for the impact of spirituality. The finding supports previous studies [9,20] reporting the relationship between job satisfaction and compassion competence among nurses in general hospitals. This study focused on job satisfaction related to job performance, interaction, autonomy, and administrative aspects. Our finding is similar to that of the study of Singh et al. [30], which reported that satisfaction with the job system, relationships with colleagues, and organizational culture perceived by healthcare providers performing hospice care influenced compassion. Therefore, this study confirmed that job satisfaction needs to be strengthened through efforts to organize and supplement the overall work environment, including clinical practice and the administrative system, in order to enhance the compassion competence of hospice nurses. In particular, for hospice nurses to perform integrated care based on multidisciplinary teamwork, it is vital to respect nurses’ professionalism and autonomy at work and create work environments that encourage supportive interactions with team members.

This study used data collected from hospice nurses working in Daejeon, Chungcheong Province, and Jeolla Province through convenience sampling. Therefore, caution is needed in interpreting the findings of this study as representative characteristics of hospice nurses in general. Furthermore, since few studies have focused on the spiritual aspect and compassion competence of hospice nurses, replication studies including nurses from a broader range of regions and institutions are necessary for the future. Despite these limitations, this study is meaningful in that the findings furnish empirical evidence of the importance of providing hospice nurses opportunities to explore their spirituality and build supportive work environments related to job satisfaction in order to strengthen their compassion competence.

Supplementary materials can be found via https://doi.org/10.14475/jhpc.2022.25.4.169.

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

Conception or design of the work: all authors. Data collection: SJL. Data analysis and interpretation: all authors. Drafting the article: SJL. Critical revision of the article: HEY. Final approval of the version to be published: all authors.