The educational curriculum for hospice APNs was first introduced in 2004. From 2006 to December 2019, this curriculum has produced 582 hospice APNs. This number accounts for 3.7% of the total number (15,718) of APNs across 13 areas. According to a survey conducted by the Korean Nursing Association in 2014, to which 65% of the licensed APNs responded, only 22% of the licensed APNs were actually working in a field that matched their qualifications [11]. The Hospital Nurses Association’s recent survey on the status of hospital nursing staff placement also revealed that only 683 out of 15,300 licensed APNs were working in hospitals in 2018 [12]. These findings indicate that most APNs are not working in a field that matches their qualifications. The reasons are multi-faceted and complex. From the perspective of an APN, the motivation for obtaining an APN license may be due to future growth or possible opportunities in their career development, rather than reinforcing one’s performance competencies in one’s current department. A lack of job opportunities in the desired field after earning the license could be another reason. The last presumed reason for the number of active APNs not increasing could be that there is no financial compensation nor changes in the given tasks [4].

Since there has not been a detailed investigation into the activities of all the hospice APNs, it is difficult to ascertain where they work and what they are doing. Based on the survey result from the overall APNs, however, if we presume that fewer than 20% of certified hospice APNs are actively working in the field, the number of active hospice APNs would be estimated to be around 120 nationwide. There are currently 179 specialized hospice care facilities providing various service types in South Korea, including 68 inpatient hospice programs, 39 home hospice programs, 33 pilot consultation hospice programs, 11 hospice programs in long-term care hospitals, and 9 pediatric and adolescent palliative care programs. In other words, it is predicted that less than one hospice APN is present per program. Moreover, since the distribution of certified APNs is regionally biased, it is difficult to realistically implement effective hospice APN policies to properly place APNs at facilities in need. Reflecting this imbalance in the supply and demand of hospice APNs, in the home hospice and the consultation hospice pilot project, which started in 2016 and 2017, the criteria for the placement of nurses for home hospices were determined as hospice or family-medicine APNs, and those for consultation hospices were hospice or oncology APNs, or nurses with 2 years or more experience in hospice work. These placement criteria were adopted due to the shortage in the supply of hospice APNs. This decision reflects the difficulty in supplying a sufficient number of APNs to hospice facilities, even after including APNs from other fields [13].

Specialized hospice care facilities are expanding, and HPC has diversified its types to in-patient, consultation-based, and home hospices. However, the usage of hospice for terminal patients has not yet reached 25%; this underscores the need to increase the number of hospice training institutions and human resources that meet the standard of law [14]. In order to ensure the quality of hospice care and patients’ safety, along with the quantitative expansion of HPC, it is desirable to have at least one hospice APN per facility, who has completed the advanced curriculum, has professional knowledge, and is technically competent [15]. From this perspective, the current supply and demand situation of the hospice APN workforce must be improved.

2. The role of hospice APNs in South Korea

Since the first APN was produced in 2005, APNs have steadily broadened their SOP along with medical and social environment changes, such as the specialization of medical fields, medical residency shortages in certain departments, and the expansion of rights of patients as consumers [4]. At the same time, concerns regarding the unclear SOP of APNs and conflicts among different disciplines have grown. With the efforts of professional nursing organizations, in March 2018, it was stipulated in the amended Medical Service Act that the SOP should be determined by the Ordinance of the Ministry of Health and Welfare, and efforts to establish legal grounds for the APN’s SOP have been accelerated thereafter. Unfortunately, however, agreement among disciplines and related organizations on APNs’ SOP has been delayed, and due to the COVID-19 pandemic situation on top of it, the stipulated SOP that should have been enforced on March 28, 2020 is still pending as of January 2021. Now that it has been established that APNs’ SOP is to be stipulated by law, it is expected that the discussions will resume, and an agreement will eventually be reached.

One of the factors contributing to confusion in the discussion of APNs’ SOP is that the duties of registered nurses and those of APNs are not clearly differentiated. Both APNs and registered nurses (a) perform nursing through the same process of assessment, diagnosis, planning, and evaluation; (b) educate and counsel patients and their families; (c) participate in quality improvement activity, and (d) collaborate with other medical team members. What distinguishes APNs from registered nurses is that APNs provide an advanced level of nursing with experience and qualifications beyond the level of registered nurses. In addition to clinical practice, education, administration, research, and communication skills are reinforced in APNs. The International Council of Nurses (ICN) clarifies this point in their APN competency framework proposed in 2008 [16]. For instance, when assessing subjects, registered nurses should collect both subjective and objective data accurately through a systematic health assessment. APNs receive additional education and training to enhance their clinical reasoning capabilities. Thus, in addition to registered nurse duties, they perform additional tasks (e.g., prescribing relevant diagnostic tests) within the scope permitted by regulations. More specifically, in a HPC setting, general nurses conduct risk assessments for all bereaved families, whereas APNs should select high-risk bereaved families and establish nursing plans accordingly.

Based on the framework regarding APNs’ roles and competencies suggested by the ICN, the KABONE suggested the following roles for Korean APNs: advanced nursing practice providers, educators, counsellors, researchers, leaders, and coordinators/collaborators [9]. The KABONE further proposed a task guideline for APNs in 13 specialties, including nine types of duties, tasks for each duty, and task elements that construct each task [9]. According to the list of tasks for hospice APNs, their nine duties are data collection, clinical decision-making, treatment and intervention, emergency symptom management, education and counseling, environment and resource management, participation in professional development, coordination, and collaboration, which are identical to those of other APN fields. The task elements include several specific characteristics of HPC, such as risk assessment of bereaved families, pain management, and end-of-life nursing. This guideline has been used as the basis for APN curriculum and licensing examination criteria. However, this guideline does not accurately reflect all the roles of APNs in other specialized fields such as public health, infection control, health science, and anesthesiology. In addition, the guideline does not describe APNs’ actual tasks in specific terms. Thus, there is a limitation in including APNs’ nursing practice in the reimbursement system.

The placement criteria of hospice APNs are specified in the enforcement regulation for home and consultation hospices, yet no regulations exist regarding hospice APNs’ SOP. In order to prepare a regulation (draft) for the SOP of APNs to be included in the Ordinance of the Ministry of Health and Welfare, the KNA [17] surveyed a panel of 17 hospice APNs to investigate the tasks they are conducting or need to conduct. The KNA collected and analyzed 462 statements, and test validity was evaluated using the Delphi method. The results showed that hospice APNs perform 88 roles in total, which can be categorized into four main types (education, leadership, advanced nursing practice, collaboration and coordination of care) and 23 sub-categories (Table 2). The study conducted by the KNA is valuable since it empirically confirmed hospice APNs perform tasks (e.g., spiritual nursing, end-of-life nursing, and managing patient in transition to hospice care) that are markedly distinct from those of APNs in other fields. Since the other identified roles (e.g., developing and operating family education programs, calculating and analyzing statistics on HPC quality indicators, establishing the goals of care and care plan of patients and their families) from this study are very specific and detailed, the findings provide guidance on what competencies should be trained and evaluated in the future hospice APN curriculum and the licensing examination.

Table 2 . The Roles of Hospice APNs..

Categories	Sub-categories	Job
Education	Training hospice professionals	• Developing and operating hospice palliative care training programs such as seminar, clinical practice, field trips etc.
	Educating inter-disciplinary hospice team members	• Educating hospice volunteers • Supervising hospice nurses • Training new members of the interdisciplinary team • Providing in-service education for interdisciplinary team members
	Educating terminal patients and their family	• Educating patients and their family regarding following topics; - Pain management - Symptom management during end-of-life care - Imminent death symptoms and comfort care - How to care for people who are dying • Developing and operating family education program • Evaluating and feedback on family education program
Leadership	Managing national hospice projects	• Managing the national hospice project in accordance with guidelines
	Facilitating the hospice team	• Enhancing information sharing and communication among hospice team members • Coordinating conflicts among hospice team members • Mediating conflicts among clients and hospice team members • Supporting and coordinating the hospice team members and their work • Monitoring burnout of hospice team members • Planning and carrying out burnout prevention activities for hospice team members • Counseling hospice team members about ethical dilemmas in end of life care
	Quality improvement	• Collaborating in the development and reform of electronic data processing and standardizing of medical recording in hospice palliative care • Developing and renewal hospice palliative care guidelines • Conducting hospice palliative research • Managing in response to quality evaluation by external agencies • Evaluating patient outcomes by cases • Auditing hospice palliative care medical records • Developing hospice palliative care quality indicators • Analyzing statistics on hospice palliative care quality indicators
	Administration	• Managing the workforce of hospice palliative care team • Operating inpatient, home, and consultation hospice palliative programs
	Promotion	• Promoting hospice palliative care to patients, family, hospital staff, and the public
	Policy development	• Participating in the development of hospice palliative care policies • Participating in committees on hospice palliative care
Advanced nursing practice	Comprehensive assessment	• Performing hospice initial assessment including following areas of patients and their family; - Complete history taking - Systematic physical examination - Values and preferences in end-of-life care - Holistic care needs - Emergency symptoms • Recording the results of comprehensive assessments
	Patient-centered care: case management	• Coordinating resources needed for the patient in an efficient manner • Supporting the shared decision-making process for patients and their family • Establishing the goal of care and a care plan consistent with patient’ values and preferences • Planning admission and discharge • Communicatingwith patients and their families about the changes in treatment • Evaluating and adjusting the hospice care plan • Establishing an emergency symptom management plan • Evaluating achievement of goals of care for the patient • Consulting on an advance directives with patients and their families
	Bereavement care	• Screening high-risk individuals for bereavement • Assessing needs of bereaved family • Setting individualized goals for bereaved family • Developing and operating bereavement programs • Evaluating outcomes of bereavement programs
	Counseling	• Providing supportive counseling to dying patients • Providing supportive counseling to family members of dying patients • Evaluating needs for family meetings • Hosting family meetings
	Spiritual care	• Assessing spiritual needs • Providing spiritual counseling • Referring spiritual care specialists
	Clinical judgement	• Adjusting oxygen therapy and wound care plan according to guidelines or standing orders • Arranging room allocation based on patients’ condition
	Comfort care in imminent death	• Acknowledging impending death • Assessing the comprehensive needs of dying patients and their family • Managing physical symptoms of dying patients • Supporting ethical decision-making during dying process • Provide supportive counseling to family of dying patients
	Care in transition to hospice palliative care	• Providing initial and discharge counselling • Counseling for home hospice registration • Assessing discharge suitability • Following up patients after discharge • Sharing patient care plan and collaborating with other health care teams
	Treatment skills	• Inserting naso-gastric tube
	Program management	• Developing and managing programs to improve quality of life of patients and their family
Collaboration and coordination of care	Collaboration	• Establishing a collaboration system for hospice palliative care within the community
	Consultation	• Providing consultation regarding the process of withholding and withdrawing life sustaining treatment • Providing information about hospice palliative care • Providing consultation regarding symptom management in end of life care • Advising nurses on care for difficult cases
	Referral	• Discussing care plan with professionals in other specialties • Facilitating consultation on withholding and withdrawing life sustaining treatment • Collaborating with the referral hospice agency • Referral to social work team, therapists, clinical pastors according to clients’ needs
	Collaborative case management	• Providing care to patients and their families through consultation- and/or home-based hospice palliative care

APNs: advanced practice nurses..

Source: Korean Nurses Association. A study to prepare regulations for the scope of practice of advanced practice nurses. Seoul:Korean Nurses Association;2018..

Table was reproduced with permission from Korean Nurses Association and the representative author (Soon-Rim Suh)..

In November 2019, based on many suggestions from various organizations for the SOP regulation of APNs, the Board of Directors of the Korean Society for Hospice and Palliative Care agreed upon the following roles of hospice APNs:

• Providing a multi-dimensional and comprehensive assessment including values and preferences for terminal patients with life-threatening diseases and their families

• Establishing the goals of holistic care and a care plan, and evaluating and coordinating the care plan for terminal patients and their families

• Supporting ethical decision-making for terminal patients and their families

• Selecting and managing high-risk bereaved families

• Assessing spiritual needs and providing spiritual counseling for terminal patients and their families

• Managing patients in the transition to HPC

• Providing end-of-life assessment and care

• Providing palliative nursing care to relieve pain and physical symptoms

• Selecting medicine and controlling doses to relieve pain and physical symptoms for the purpose of palliative nursing (under the supervision of physicians)

Among the duties for terminal patients and their families, the following require participation and agreement not only on the part of the interdisciplinary medical team, but also the patients and their families: establishing the goal of holistic care and a care plan, evaluating, and coordinating care. This is because from the perspective of HPC, the goal and care plan of holistic care goes beyond medical treatment and physical care, further including psychosocial care, and spiritual care plans. During this process, hospice APNs (under the supervision of a physician) need to conduct preliminary counseling of patients and their families, perform a holistic assessment, conduct and coordinate weekly interdisciplinary team conferences, and perform effective and efficient communication among team members.

HPC involves holistic care provided by an interdisciplinary team to improve the quality of life of patients with life-threatening diseases and their families. Therefore, all stages of care should involve physicians, nurses, social workers, and spiritual caregivers from the beginning of the goal-setting and planning stage. Among these members, hospice APNs are professionals who help patients to maintain the best quality of life in the midst of progressing disease through patient-centered care, pain and symptom management, and sympathetic end-of-life nursing care [18]. Just like pouring water into a bowl that contains large and small pebbles, hospice APNs with their new professional identity fill the gaps among disciplines and services within the interdisciplinary team [19]. Although the standards of HPC presented in the National Quality Forum in the United States reflect the goal of an interdisciplinary team, these standards are consistent with the goal of comprehensive and holistic nursing care, and therefore they are particularly suitable for nurses. In 2006, to ensure that high-quality HPC can be provided in all nursing fields, the Hospice Palliative Nurse Association in the US issued a statement that HPC education should be included in the curriculum for APNs in all fields, and that hospice APNs should serve as mentors of these nurses [20]. It is noteworthy that the KNA [17] included fostering the hospice workforce and providing advising as part of hospice APNs’ roles because it allows hospice APNs to contribute to expanding human resources capable of providing HPC in all nursing fields. It is also encouraging that the KSHPC, where all interdisciplinary team members recognized and supported the roles and duties of hospice APNs.

3. Prospects

The amended Article 78, paragraph 3 of Medical Service Act states that APNs “shall conduct the duty of nursing in the relevant area for which his/her qualification is accredited pursuant to paragraph 2.” Article 78, paragraph 4 states that “the classification of qualifications, standards for qualification, qualification examinations, certificates of qualification, and scope of duties of specialized nurses, and other necessary matters shall be prescribed by Ordinance of the Ministry of Health and Welfare.” However, the statutes regarding APN qualification certification do not clearly include APNs’ SOP as of January 2021. The absence of legal ground for APNs’ role may cause confusion in performing APNs’ duties [21]. On June 4, 2019, the Ministry of Health and Welfare hosted the first Consultative Body to Discuss the SOP of the Medical Workforce, and the Korean Medical Association (2 medical specialists), KNA (2 nurses), Korean Hospital Association (2 medical specialists), Korean Intern Resident Association (2 residents), Korean Academy of Medical Sciences (2 medical specialists), and HNA (2 nurses) have started discussing the issues related to SOP. These discussions are still in progress. The Korean Association of Advanced Practice Nurses was also established in 2015 as the central association for APNs. This organization is striving to establish the SOP that effectively reflects the APNs’ actual duties that ensure the right to health of the people in the medical field and efficiently fill medical gaps [22]. Through these efforts, these organizations with different opinions are expected to reach an agreement shortly and propose enforcement regulations with detailed description of APNs’ duties in each field as suggested by the KNA [17].

Since the interdisciplinary team approach is a distinctive characteristic of HPC, the role of hospice APNs is important when collaborating with various medical specialists. Moreover, particular recognition should be given to the work of consultation and home hospice APNs, as they are responsible for educating and counseling patients in transition and their families. When hospice APNs are working in a special situation such as in patients’ homes, where immediate collaboration with other medical professionals is not easy, hospice APNs need to have more autonomy in making clinical decisions based on their training, so that they can promptly control pain or symptoms or satisfy dying patients’ physical or psychological needs. For example, legal safeguards should be provided to enable prompt responses through protocols or standard prescriptions for specific situations. In several countries such as the United States, the United Kingdom, and Canada, APNs are authorized to make autonomous decisions regarding treatment and prescriptions [23]. According to the Medical Service Act in Korea, nurses can administer medicine to patients under the prescription of physicians, oriental medical doctors, or dentists, as this is categorized as medical assistance. However, under the Occupational Safety and Health Act [24], as public health managers, nurses can independently administer medicine to prevent disease exacerbation of workers in a workplace. Public civil servants serving as community health practitioners, pursuant to the Act on Special Measures for Health and Medical Services in Agricultural and Fishing Villages, may engage in minor medical practices prescribed by a presidential decree in the medically underserved areas designated as their work areas [25].

Any nursing facilities that conduct infection prevention and control activities by hiring at least one infection control APN or a designated nurse who has completed a 1-year training program are granted reimbursements, and they are calculated once per day of patient’s admission to the hospital. To meet the reimbursement requirement, infection control APNs are hired at most medical institutions [21]. Similarly, to realize universal HPC, a legal ground should be established to assign hospice APNs to work as HPC coordinators at every medical institution. Establishing criteria for hiring hospice APNs as evaluation indices for the accreditation of medical institutions could also secure APN placement. Based on whether a hospice APN is hired by a hospice specialized facility, 3 points are added to the maximum of 50 points of operating performance [26]. However, the new evaluation criteria need to encompass not only the hiring status of APNs, but also on whether they are actually performing the duties of hospice APNs.

Reviewing the statutes focusing on nurses, midwives, APNs, assistant nurses, Kim et al. [21] indicated that the interpretations are not consistent due to the sporadic statutes, and this inconsistency may lead to confusion in the actual performance of nursing duties; therefore, the enactment of a nursing law integrating the scattered nursing-related statutes should be considered to improve the consistency of laws related to duties of nursing. If the nursing law promoted by KNA is enacted, the legal basis for the duties of APNs will also become clearer in the future.

APNs are working in 13 areas in Korea, and their SOP is not clearly distinguished, causing many overlapping areas in their educational curriculum and core competencies. It was also found that the compensation of APNs is unsatisfactory, while the academic workload is greater than that of other master’s degree programs, which decreases the motivation to apply to APN programs. Accordingly, several practical efforts to revise the curriculum seem necessary, including: (a) reducing the excessive academic burden by integrating subjects; (b) reducing training hours to a realistic level; and (c) benchmarking residency trainings and licensing examinations, so that the training content and the licensing examination can be better adjusted to match practice in clinical settings.

In the United States, advanced practice registered nurses (APRNs) are required to have a masters’ degree or above and are divided into four different categories: certified registered nurse anesthetist (CRNA), certified nurse midwife (CNM), clinical nurse specialist (CNS), and certified nurse practitioner (CNP). The certification is given to masters’ degree holders based on their years of experience in the clinical field [27]. Although the APRN license is broadly divided into four categories reflecting the characteristics of the clinical practice fields that are more subdivided and specialized, each subfield is specified to reflect the expertise in each field. Along with this trend, the KNA [17] also suggested that 13 APN areas should be reduced to four areas integrating similar duties: special field nursing, public health, acute critical care, and chronic or terminal care. In other words, the system should be reorganized to deploy APN professionals effectively.

Registered nurses are obligated to report their licensing and employment status every 3 years, and it is handled by the KNA entrusted by the Ministry of Health and Welfare. However, APNs are not required to report their licensing or employment status, and there is no regulation on continuing education; they only need to provide information about their licensing status and complete 8 hours or more of continuing education every year as a registered nurse. Since they are not legally required to report their licensing or employment status, it makes it difficult to identify APNs’ current working status [21]. In Canada, there are APNs for families, adult health, and pediatric health, and they are provided with continuing education and support to be able to continue providing HPC in their field [28]. Categorizing and providing APNs’ continuing education based on their core competencies according to each experience level would enable more specialized patient management. In other words, in order to improve the quality of life of terminal patients and their families and to develop specialized hospice nursing practice, developing a clear continuing education program is necessary.

APNs demonstrate excellent patient outcomes and are potentially cost-effective [29,30]. Under the National Health Insurance System in South Korea, however, hospice nursing fees are only compensated indirectly through the differential payment of nursing management fees, and APNs’ practice is not recognized independently. The nursing fees of family medicine APNs are paid by health insurance under their own legally recognized fee system. As education fees for cancer patients have been established, oncology APNs have been integrated relatively early into clinical practice compared to those in other fields, and the number of oncology APNs has been increasing every year. Unfortunately, this is not the case for hospice APNs. Specific efforts should be made to develop an appropriate insurance reimbursement system, such as establishing a separate fee for APNs’ nursing practices or establishing a fee system that adds a certain percentage to existing hospitalization fees, observation fees, or management fees. To make this systematic change possible, it is necessary to regularly provide evidence of the achievements of hospice APNs’ nursing practices, such as reduction of pain and symptoms of terminal patients, reduction of family care burdens, and improvement of quality of life and care satisfaction.