Korean hospice nursing interventions using the Nursing Interventions Classification system: A comparison with the USA

bs_bs_banner Nursing and Health Sciences (2014), 16, 434 441 Research Article Korean hospice nursing interventions using the Nursing Interventions Classification system: A comparison with the USA Sung-Jung Hong, PhD, RN 1 and Eunjoo Lee, PhD, RN 2 1 Department of Nursing, Semyung University, Jecheon and 2 College of Nursing, Research Institute of Nursing Science, Kyungpook National University, Daegu, Korea Abstract Key words In this study, nursing interventions used by hospice nurses in Korea were identified and compared with core interventions selected by US end-of-life care nurses in order to determine similarities and differences between the two nations regarding such care. Data were collected from the electronic medical records of 353 hospice patients admitted to a tertiary hospital in Korea over a period of two years. First, extracted narrative interventions were mapped onto the Nursing Interventions Classification for comparison with interventions selected by nurses in the USA. A total of 56,712 intervention statements were mapped onto 147 Nursing Interventions Classification interventions. Hospice nurses in Korea performed more nursing interventions in the physiological basic domain, compared to nurses in the USA. The most frequently-used interventions in Korea were related to patient pain management. Among 47 core Nursing Interventions Classification interventions used in the USA, only 18 were used by Korean nurses in this study. This study highlights cultural differences in hospice care nursing interventions between the two countries. end of life care, hospice nurse, hospice nursing practice, Nursing Interventions Classification. INTRODUCTION Although nurses have always been an integral part of the healthcare system, and often provide important direct care, their contributions have largely been invisible, because nursing notes are narrative with an understructured format; therefore, aggregation and analysis are difficult (Bulechek et al., 2008). In addition, important information regarding nursing care has been underrepresented in communicating healthcare data, research, and education. Therefore, there is a pressing need to identify core, essential data and to then perform systematic collection of that data in an easilyretrievable and comparable format that can be incorporated into national databases in the nursing profession (Delaney & Huber, 1996). Standardized nursing languages (SNL) were launched in order to meet this need, and currently, the American Nursing Association recognizes terminologies for a nursing practice information infrastructure (ANA, 2008). One of the SNL, the Nursing Interventions Classification (NIC), is a comprehensive standardized classification of interventions performed Correspondence address: Eunjoo Lee, College of Nursing, Research Institute of Nursing Science, Kyungpook National University, 101 Dongin-dong, Jung-gu, Daegu 700-422, Korea. Email: jewelee@knu.ac.kr Received 12 March 2013; revision received 13 November 2013; accepted 24 November 2013 by nurses; its purpose is to assist in efforts to describe the uniqueness of nurses compared with other healthcare providers, and to articulate their contributions to the health of patients (Bulechek et al., 2008). To date, the NIC has been implemented in nursing information systems at national, as well as international levels in order to describe and capture the interventions performed by nurses (Haugsdal & Scherb, 2003). Recent studies using the NIC in Korea were conducted in diverse nursing practice care settings (Oh et al., 2001; Yong et al., 2001; Kwon & Park, 2002; Lee & Park, 2002; Oh & Park, 2002; Choi et al., 2003; Park & Jung, 2005; Cho & Kim, 2008; Hong et al., 2011). All of these studies reported that the NIC is applicable for use in describing nursing practice in Korea. However, the NIC has not been used by hospice nurses. Cancer, the number one cause of adult death in Korea, imposes an enormous emotional and financial burden on Korean society, and the number of cancer patients is rapidly increasing. Because of this trend, a special law to finance and provide reimbursement for cancer treatments was passed by the Korean legislature in 2006 (Yong et al., 2006). In addition, in response to social pressure to improve the quality of nursing care for hospice patients, a specialized program was developed for hospice nurses at the master level in 2004 (Oh et al., 2007). Thus, hospice and end-of-life care are receiving significant interest and attention in Korea (Kyung et al., 2010). doi: 10.1111/nhs.12120

Korean hospice nursing practice 435 Given these developments, the identification of NIC interventions for hospice nursing will be valuable. These data will provide empirical evidence to guide practice decisions that will promote high-quality hospice nursing care outcomes and effectiveness (Lunney, 2006). The data will also be helpful to hospice nurses in describing the work they perform, so that the contribution of nursing care can be measured and valued. In addition, the identification of NIC interventions for hospice nursing in Korea to compare with those of other countries, will be helpful in the effort to understand patterns of nursing interventions. This is a step toward the identification of culturally-sensitive care in hospice nursing in Korea. The purposes of the study were: (i) to identify interventions performed by hospice nurses in Korea and then to map them onto NIC interventions; (ii) to compare NIC interventions performed by Korean nurses with NIC interventions selected by members of the American End of Life Care Nursing (AELCN) organization. Through this process, we will be able to identify similarities and differences in nursing interventions between Korean hospice nurses and AELCN nurses. Background NIC The current healthcare system demands data and information on how effectively and economically healthcare professionals contribute to health and quality-of-life of patients. Nurses must demonstrate which interventions in their practice provide the most cost-effective and efficient health care compared to interventions by other healthcare professionals (Simpson, 2003). However, without describing what nurses do and studying ways to make nursing more cost-effective and efficient, that is not possible (Johnson et al., 2005). Being able to describe these nursing interventions in a standardized language is a first step. Prior to the development of the NIC, there was no standardized classification and coding system for describing treatments administered by nurses. The project was initiated in 1987, with the aim to assist in efforts to describe the uniqueness of nurses compared with other healthcare providers (Bulechek et al., 2008). It has been continuously updated and revised with ongoing feedback and review from clinical nurses and researchers in all settings. The sixth edition, published in 2013, includes more than 12,000 activities, which are grouped into a three-level taxonomy for ease of use: seven domains, 30 classes, and 554 interventions. The seven domains are physiological basic, physiological complex, behavior, safety, family, health system, and community (Bulechek et al., 2013). The NIC has been linked with nursing diagnoses and outcomes developed by the North American Nursing Diagnosis Association and Nursing Outcomes Classification, respectively (Moorhead et al., 2008). As a multidisciplinary view, the NIC is mapped onto SNOMED CT, a comprehensive healthcare reference terminology that provides a framework for the integration of concepts and languages from other healthcare disciplines (Campbell et al., 1997; SNOMED CT, 2002). These linkages facilitate the understanding and usage of nursing languages by diverse health professionals, and they enhance interoperability among healthcare professions (Zollo & Huff, 2000; Zeng et al., 2002). The NIC has been adopted by hundreds of healthcare organizations, and used in care plans, competency evaluations, and nursing-education programs. It has been translated into 12 different languages, including Korean, and has been used in many countries, including Brazil, Canada, Denmark, England, France, Germany, Iceland, Japan, Korea, Spain, Switzerland, and the Netherlands (Bulechek et al., 2013). Although using standardized language to identify and compare nursing interventions and their effects on patient outcomes is at an early stage at the international level, it will be studied more actively in the near future. Nursing care quality and SNL Electronic health record (EHR) systems are being implemented worldwide, with the goal being that their use will lead to improved quality and reduced medical costs (Park & Hardiker, 2009). EHR enable nurses to provide virtual documentation of the core nursing elements in the nursing information system and store them in databases. To achieve these goals, standardized classifications with coding systems within the EHR are a key and fundamental factor, because they can facilitate the capture, storage, and retrieval of clinical information in documentation systems and databases (Haugsdal & Scherb, 2003). By collecting data and using databases in information systems, nurses can systemically analyze the treatments they perform and the resulting patient outcomes, and can identify which interventions work best for a given population of patients or set of problems. This will improve nursing care for specific populations, and the nursing profession will gain recognition for its contribution to patient outcomes. Nurses need to use databases for the systemic collection and analysis of patient diagnoses, nursing interventions, and the resulting patient outcomes. Based on this information, they can determine which nursing interventions work best for a given group of diagnoses or a population. By doing this, nursing research will be energized, and can effectively influence the decision-making about nursing-related healthcare policies (Plowfield et al., 2005). The Hospice model in Korea Hospice nursing in Korea was started in 1965 by Catholic nuns, and the first hospice educational program for nurses was started in 1979 (Kang, 2010). Most hospitals in Korea provide hospice care to terminally-ill patients in an effort to help control their pain and symptoms, or for those whose family members are exhausted or in crisis and in need of respite. In the main in Korea, hospice care is delivered using one of the following four models: (i) the hospice unit within a hospital model; (ii) the inpatient scattered-bed consultative model; (iii) the free-standing model; or (iv) the hospice home-care model (Lee et al., 2008).

436 S-J. Hong and E. Lee Of the hospice care provided for inpatients (i iii), the hospice unit within a hospital and the inpatient scattered-bed consultative models (i and ii) are used for patients who have already been admitted to a hospital and are dying. In hospice units within a hospital, care is usually provided by certified hospice nurses, or nurses who have advanced training in hospice care. Inpatient scattered-bed consultative care is provided by a team of nurses who specialize in hospice care. Admission to one of these units is dependent on bed availability in the hospital. The free-standing hospice model (iii) provides hospice care through an independently-owned hospice center, and might include both home hospice services and an inpatient care facility. The inpatient facility provides hospice care for patients who require medical services not suitable for a home setting. In the hospice home care model (iv), care is provided in a patient s home. The type of hospice care services provided depends on the patient s needs and preferences. Most home care agencies and independentlyowned hospice programs offer home hospice services. Although a nurse provides specialized nursing care for a terminally-ill patient in a home hospice program, the main caregiver is usually a family member of the patient. Some family members are trained by the nurse to provide much of the hands-on care to the patients (Lee et al., 2008). METHODS Research design and participants This study used a descriptive design to identify the nature and types of nursing interventions performed by nurses in a hospital hospice unit. Data were collected from the electronic nursing records of 353 hospice patients who were admitted to a tertiary hospital, and were either discharged or died following end-of-life care between January 2009 and December 2010. Instrument NIC The instrument used in this study was based on the fifth edition of the NIC (Bulechek et al., 2008), which is categorized according to seven domains, 30 classes, and 542 interventions; each intervention has its own definition and unique numeric code. Core intervention list of the AELCN The development of the AELCN core interventions list was performed by the Iowa Interventions Project Team (Bulechek et al., 2008). The AELCN core intervention list was developed and finalized based on input, discussion, and feedback from members of the AELCN, and then carefully reviewed by the project investigators and staff of the Iowa Interventions Project. Members of the AELCN identified 46 interventions as core interventions. Human participants Kyungpook University Hospital institutional review board approval was obtained prior to the collection of the study data. In addition, the purposes and procedures of the study were reviewed by the administrative office, and approved by the hospital where the data were collected. The purpose of the study was also explained to the director of the nursing department of the hospital. The patients had already given their consent, because all patients admitted to the hospital provide informed consent for use of their de-identified demographic, diagnostic, and treatment information recorded in electronic medical records in research. This consent process has been required by medical law for every inpatient throughout Korea since September 2011. Data collection Data were downloaded from the electronic nursing documentation system of the hospice care unit of Kyungpook University Hospital, with encryption of patients personal information, and compiled in an Excel file. Kyungpook University Hospital, a tertiary hospital located in Daegu, South Korea, contains more than 850 beds. This hospice unit, which was established as a hospital-based hospice service in April 2009 as a way to provide the best possible quality of life for terminally-ill patients, serves as a model for tertiary and other hospitals, due to governmental efforts to develop a national hospice system in Korea. All documented nursing statements were extracted and categorized according to nursing assessments, nursing diagnoses, nursing outcomes, and nursing evaluations, and then according to the meaning of each statement within each of these categories. A total of 140,369 nursing statements were extracted, 56,712 of which were related to interventions or activities only. These statements were used in this study. The selection of statements on nursing interventions and activities was performed independently by two researchers who had experience with SNL. After the independent selection of statements on nursing interventions and activities, the statements were compared with one another, and 92% agreement was found between the researchers. The 56,712 statements were then mapped onto the interventions listed in the fifth edition of the NIC, resulting in 147 different NIC interventions. The mapping process was performed by three researchers who had extensive knowledge, as well as research experience, using NIC. For mapping the statements onto NIC interventions, it was necessary to confirm that each extracted statement matched the definition, as well as activities of an NIC intervention. Each researcher independently performed mapping of nursing statements onto NIC labels, and these mappings were compared among the researchers. The original inter-rater reliability was between 80% and 85%. Where discrepancies existed, the context was reviewed, and there was extensive discussion until 100% agreement was reached among the researchers.

Korean hospice nursing practice 437 Table 1. Classification of narrative nursing statements in the electronic nursing record Total narrative nursing statements Nursing-assessment statements Nursing-planning statements Nursing-intervention statements Statements mapped onto the Nursing Interventions Classification Nursing-evaluation statements 140,369 9244 10,624 57,629 56,712 62,872 Data analysis Data were analyzed using SPSS (version 18.0; SPSS, Chicago, IL, USA). Descriptive statistics, such as frequencies and percentages, were used to identify the demographic characteristics of the hospice patients. NIC utilization rates were calculated using frequency and percentages. Frequencies and percentages were used for comparison with core NIC interventions identified by the AELCN. In order to make the data comparison easier to understand, the interventions selected in both countries were displayed and categorized according to the classes and domains of the NIC taxonomy structure. RESULTS Classification of nursing records The nursing records of 353 patients consisted of assessments, diagnoses, planning, interventions, and evaluations. The total number of statements was 140,369. There were 10,624 nursing-assessment statements, 10,624 nursing-planning statements, 57,629 nursing-intervention statements, and 62,872 nursing-evaluation statements. Documented intervention classification according to the NIC taxonomic structure The results of an analysis showed that only 56,712 of 57,629 nursing statements were mapped onto 147 NIC interventions (Table 1). Thus, 917 nursing-intervention statements were not mapped with NIC interventions. All of these 56,712 statements were categorized according to the NIC taxonomic structure, resulting in six domains and 24 classes. Approximately 35% of the nursing-intervention statements belonged to the physiological basic domain, followed by the physiological complex (26.7%), safety (19%), behavioral (15.63%), health system (3.58%), and family (0.43%) domains. The NIC community domain was not selected (Table 2). The most often used classes of intervention statements were risk management (19%) and physical comfort promotion (18.98%), followed by drug management (15.18%), patient teaching (11.89%), and immobility management (9.36%). the other classes included less than 5% of the nursing-intervention statements. Comparison of core interventions between Korea and the USA A comparison between the interventions most frequently selected by Korean hospice nurses and core nursing interventions identified by members of AELCN is shown in Table 3. In order to compare the data of Korean hospice nurses with those of US nurses, the same number of interventions was selected from Korean data. Eighteen interventions (32%) were selected by nurses from both countries. Among the similarities and differences in the use of nursing interventions observed between the two countries, Korean nurses selected four interventions related to medication and six related to teaching, while no interventions related to medication or teaching were selected by nurses in the USA. Comparison of core interventions between the two countries using NIC taxonomy The core interventions of the two countries were then categorized according to the classes and domains of the NIC taxonomic structure (Table 4). The interventions selected by Korean nurses belonged to 21 classes and six domains, whereas the interventions selected by members of the AELCN in belonged to 17 classes and six domains. The class most frequently selected by Korean nurses was patient education (6 interventions, 13%), followed by drug management (5 interventions, 10.9%). the most frequently-selected class in the USA was coping assistance (14 interventions, 34.4%), followed by health system mediation (5 interventions, 10.9%). Korean nurses performed more interventions in the physiological basic, and physiological complex, and safety domains than nurses in the USA. However, the behavioral, family, and health system domains were more often selected by nurses in the USA than by Korean nurses. DISCUSSION SNL contributes to the accumulation of evidence-based hospice nursing practice using data retrieved from ENR systems; therefore, the utilization of SNL, such as the NIC, by hospice nurses is very important. This study identified actual nursing interventions performed for terminally-ill patients by hospice nurses in Korea. Comparisons were then made with the core interventions selected by the AELCN. Thus, this study broadens the possibilities for the utilization of SNL for the quantification of hospice care. In addition, the study provides an important transcultural reflection of hospice nursing practice. This process could be the first step to the identification of similarities and differences in hospice nursing practice between the two countries. In the future, it could provide an important opportunity to improve the quality of hospice care in both countries.

438 S-J. Hong and E. Lee Table 2. Domains and classes of interventions mapped onto the Nursing Interventions Classification Domains n % Classes n (%) Physiological basic 19,657 34.66 Activity and exercise management 108 (0.19) Elimination management 751 (1.32) Immobility management 5,307 (9.36) Nutrition support 1,207 (2.13) Physical comfort promotion 10,763 (18.98) Self-care facilitation 1,521 (2.68) Physiological complex 15,140 26.70 Drug management 8,608 (15.18) Electrolyte and acid-base management 701 (1.24) Neurological management 646 (1.14) Perioperative care 10 (0.02) Respiratory management 1,764 (3.11) Skin/wound care 2,209 (3.90) Thermoregulation 549 (0.97) Tissue perfusion management 653 (1.15) Behavioral 8,866 15.63 Behavioral therapy 322 (0.57) Communication enhancement 2 (0) Coping assistance 1,530 (2.70) Patient education 6,742 (11.89) Psychological comfort promotion 270 (0.48) Safety 10,774 19.0 Risk management 10,774 (19.00) Family 244 0.43 Lifespan care 244 (0.43) Health system 2,031 3.58 Health system management 313 (0.55) Health system mediation 1,370 (2.42) Information management 348 (0.61) Total 56,712 100 56,712 (100) In this study, 56,712 nursing-intervention statements were mapped with the NIC; these 56,712 nursing statements fit into the 147 NIC interventions and belonged to 21 classes and six domains. In an analysis of paper charts of discharged patients with end-stage cancer who were admitted to a hospice unit and to general units, respectively, in a tertiary hospital, Ro et al. (2002) found 121 and 103 different NIC interventions. Choi and Jang (2005) found that 190 different NIC interventions were used in a paper chart for terminal-stage cancer patients admitted to a tertiary hospital. Therefore, the numbers of NIC interventions used for hospice patients ranged between approximately 100 and 200. This could reflect how hospice nurses need to be equipped with knowledge and skills for the performance of a variety of interventions in order to provide quality nursing care to terminally-ill patients. In this study, hospice nurses in Korea selected most of the interventions in the physiological basic domain, followed by the physiological complex domain. However, among the seven domains in the NIC taxonomic structure, interventions from five domains were rarely selected. Similarly, Choi and Jang (2005) reported that interventions from the physiological basic domain were most frequently performed by nurses for terminal cancer patients, followed the physiological complex domain; whereas, in the research reported by Ro et al. (2002), nurses performed interventions for terminal cancer patients from the physiological complex domain, followed by the physiological basic domain. The findings from all three of these studies indicated that Korean nurses focus more on providing physiological care, rather than other aspects of care, to terminally-ill patients. In accordance with the results described, in this study, the top 10 most commonly-performed interventions for hospice patients were pain management, analgesic administration, medication administration: intravenous, bed rest care, vital signs monitoring, teaching: procedure/treatment, environment management: comfort, medication administration: oral, teaching: prescribed medication, and emotional support. In the study reported by Ro et al. (2002), more than 90% of hospice nurses reported that they performed interventions, such as medication administration (95.5% of the nurses), fluid management (95.5%), fluid monitoring (95.1%), urinary elimination management (93.3%), nutritional monitoring (93.4%), and nutrition therapy (93%). Choi and Jang (2005) reported that vomiting management, pain management, surveillance, respiratory monitoring, and fluid monitoring were the most commonly-documented interventions for terminally-ill patients. All of these studies showed that hospice nurses in Korea were focused on providing more interventions for the relief of physical symptoms than on those related to emotional and psychosocial aspects of terminally-ill patients. Why do Korean nurses perform more interventions from the physiological domain compared to nurses in the USA? One of the reasons might be due to the shortage of nurses in Korea. The staffing ratio in Korea is much lower: the number of registered nurses per 1000 patients in the USA is 10.8; however, that in Korea was 4.5, less than that of the USA, and

Korean hospice nursing practice 439 Table 3. Comparison of core nursing interventions between Korean and US nurses Korean nurses Activity therapy Admission care Analgesic administration Anxiety reduction Bed rest care Bleeding precautions Bowel management Coping enhancement Dying care Emotional support Environmental management: comfort Examination assistance Family involvement promotion Fever treatment Fluid/electrolyte management Incident reporting Massage Medication administration Medication administration: intravenous Medication administration: oral Medication reconciliation Nausea management Neurological monitoring Nutrition management Nutrition therapy Oxygen therapy Pain management Pass facilitation Positioning Pressure management Respiratory monitoring Skin care: topical treatments Skin surveillance Sleep enhancement Support system enhancement Surveillance Surveillance: safety Teaching: disease process Teaching: individual Teaching: prescribed activity/exercise Teaching: prescribed diet Teaching: prescribed medication Teaching: procedure/treatment Total parental nutrition administration Vital signs monitoring Wound care: closed drainage US nurses Active listening Analgesic administration Anticipatory guidance Anxiety reduction Bed rest care Bowel management Caregiver support Case management Constipation/impaction management Coping enhancement Decision-making support Delirium management Dying care Emotional support Energy management Environmental management Family integrity promotion Family involvement promotion Financial resource assistance Fluid/electrolyte management Forgiveness facilitation Grief work facilitation Healthcare information exchange Health system guidance Multidisciplinary care conference Neurological monitoring Nutrition management Pain management Patient rights protection Positioning Presence Pressure management Religious ritual enhancement Reminiscence therapy Respiratory monitoring Respite care Self-care assistance Skin surveillance Sleep enhancement Spiritual support Support system enhancement Telephone consultation Touch Urinary elimination management Values clarification Visitation facilitation Note: US data are from the Iowa Interventions Project Team (Bulechek et al., 2008). Table 4. Comparisons of core interventions between Korean and US nurses by Nursing Interventions Classification domains and classes Korean nurses US nurses n (%) n (%) Class Activity and exercise management 0 1 (2.2) Elimination management 1 (2.2) 3 (6.5) Immobility management 2 (4.3) 3 (6.5) Nutrition support 2 (4.3) 0 Physical comfort promotion 4 (8.7) 1 (2.2) Self-care facilitation 1 (2.2) 2 (4.3) Electrolyte and acid-base 1 (2.2) 1 (2.2) management Drug management 5 (10.9) 1 (2.2) Neurological management 1 (2.2) 1 (2.2) Respiratory management 2 (4.3) 1 (2.2) Skin/wound management 4 (8.7) 2 (4.3) Thermoregulation 1 (2.2) 0 Tissue perfusion management 1 (2.2) 0 Behavioral therapy 1 (2.2) 0 Communication enhancement 0 1 (2.2) Coping assistance 4 (8.7) 14 (30.4) Patient education 6 (13.0) 0 Psychological comfort promotion 1 (2.2) 1 (2.2) Crisis management 0 0 Risk management 3 (6.5) 2 (4.3) Lifespan care 1 (2.2) 4 (8.7) Health system mediation 2 (4.3) 5 (10.9) Health system management 1 (4.3) 0 Information management 2 (4.3) 4 (8.7) Total 46 (100) 46 (100) Domains Physiological basic 11 (23.9) 10 (21.7) Physiological complex 15 (32.6) 6 (13.0) Behavioral 12 (26.1) 16 (34.8) Safety 3 (6.5) 2 (4.3) Family 1 (2.2) 4 (8.7) Health system 4 (8.7) 8 (17.4) Total 46 (100) 46 (100) below the average number of registered nurses (8.4) in the Organization for Economic Cooperation and Development countries (OECD Factbook, 2011). Task-oriented work assignments prescribed by physicians, and those providing basic physiological nursing care, have taken priority over interventions based on psychosocial aspects, resulting in relatively less time to provide the psychosocial aspects of nursing care. This study also compared the use of interventions between Korean and US hospice nurses. The data suggest clear similarities and differences in nursing practices between the two countries. Eighteen interventions were the same ones selected in both countries. US nurses selected interventions that are more focused on psychosocial aspects than physical aspects. For example, anticipatory guidance, decision making support, forgiveness facilitation, grief work facilitation, presence, religious ritual enhancement, spiritual support, and

440 S-J. Hong and E. Lee values clarification were selected by the AELCN, while Korean nurses in this study selected only coping enhancement, dying care, emotional support, and support system enhancement as psychosocial interventions. In addition, Korean nurses focused more on interventions related to patient education, such as teaching: prescribed medication, teaching: procedure/treatment, and teaching: prescribed diet. However, there are no teaching-related interventions on the US core intervention list. Why do Korean nurses provide more interventions for patient teaching than their counterparts? In Korea, one family member always stays with the patient. Therefore, due to the shortage of nurses, some interventions are delegated to, and performed by, family members of patients. This kind of informal caregiver is very popular in Korean hospitals, with the exception of the intensive care unit. Some interventions are delegated to informal caregivers; therefore, interventions related to teaching might be needed. A list of nursing interventions specific to hospice nursing in Korea was identified in this study.this list can be used for the education and training of newly-hired nurses in hospice units, and in the competency examination for the career ladder system. This process can also be used to define the roles of hospice nurses, and increase the autonomy of nurses working in hospice units. By identifying the core interventions according to each specialty, we were able to determine which interventions were more cost-effective and provide better outcomes for patients with fewer resources. This process ultimately benefits patients by use of research-based data, as well as nurses, by visualizing the contribution of nurses to patient outcomes. However, among 57,629 nursing-intervention statements, 56,712 (98.4%) were mapped into the NIC, thus, 917 (1.6%) nursing-intervention statements were not mapped with the NIC. The very high mapped rate of nursing interventions in the study with the NIC might suggest that the NIC can be used to describe nursing interventions for terminally-ill patients in Korea. However, 917 nursing statements might be unique or culturally-sensitive interventions specific to hospice care settings in Korea. This requires further investigation. Thus, a comparison of nursing interventions internationally is valuable, because nurses should understand cultural diversity in order to offer their services in the 21st century global society. Limitations of the study related to the data-collection methods; Korean data were collected from the ENR system, while US data were selected by members of the AELCN.This threatens the external validity of the results, and a more consistent data-collection method will be needed for future studies. Comprehensive and complete documentation by nurses in hospitals using a nursing process model is a compulsory requirement for hospitals in order to obtain hospital accreditation in Korea.Thus, nurses in Korea, especially those working in tertiary hospitals, receive education and training in the importance of regular documentation. However, there is a possible gap between actual nursing interventions performed for hospice patients and interventions documented in the ENR by nurses. In addition, with the ease of documentation due to use of the ENR, there is always a chance of overdocumenting interventions performed by nurses. For all of these reasons, careful consideration is needed when interpreting the results of this study. Conclusion The data in this study contribute to knowledge regarding nursing interventions related to hospice care, especially core nursing interventions for patients at the end of their lives. The use of a standardized language, such as NIC, provides a tool for comparison of Korean and American hospice nursing interventions. This type of information is expected to be useful in understanding how to improve hospice care, determination of costs for hospice nursing, and the standardization of nursing interventions. This study provides a direct comparison between end-of-life nursing practices in Korea and the USA, and suggests future transcultural comparisons of nursing practice patterns. The identification of nursing interventions using a standard terminology, such as the NIC, rather than with a narrative description for each specialty, is a fundamental and essential step toward facilitating the exchange of data. The results of this study can be used in the development of more userfriendly ENR systems in Korea. This aggregation of data is one way to ensure the visibility of the contribution of hospice nurses to health outcomes for patients. In addition, it will be helpful in building nursing knowledge and delineating the unique roles of hospice nurses as a profession. For these reasons, continuous dissemination of the NIC will be necessary, and leaders, researchers, and educators should make an effort to incorporate this terminology into practice in Korea. In addition, this study demonstrated the applicability of the NIC to hospice nursing in Korea. The identified core interventions list can be utilized in the clinical practice of nurses by providing valuable information for use in the development of hospice nurse-orientation programs, education, and training, and maintaining competencies of hospice nurses. ACKNOWLEDGMENTS This work was supported by the National Research Foundation of Korea Grant funded by the Korean Government (NRF- 2013S1A5A2A03044389). CONTRIBUTIONS Study Design: EL, SJH. Data Collection and Analysis: SJH. Manuscript Writing: EL. REFERENCES American Nurses Association. Scope and Standards of Nursing Informatics Practice. Washington, DC: American Nurses Publishing, 2008. Bakken S, Cashen MS, Mendonca EA, O Brien A, Zieniewicz J. Representing nursing activities within a concept-oriented terminological system: evaluation of a type definition. J. Am. Med. Inform. Assoc. 2000; 7: 81 90.

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