Yearbook on Journal of the Japan Society of Nursing Research 2017

Development of a Nursing Competence for End-of-life Care Scale in Nursing Homes
Mitsuyo Ohmura1) and Kaeko Yamashita2)
Key Words :nursing home
end-of-life carenursing competence
scale

ABSTRACT
Purpose: The aim of this study was to examine the reliability and validity of a scale developed to evaluate
the degree of nursing competence for end-of-life care in nursing homes, and to determine the practicalityof its application. Method: A total of 298 nurses working in nursing homes were evaluated in terms of
their degree of nursing competence for end-of-life care in nursing homes.The data collected were subjected
to confirmatory factor analysis and correlation analysis. Results: The average value of Cronbach’s alphacoefficient for the reliability of the scale was 0.848, which confirmed internal consistency. Goodness of fit
was verified via confirmatory factor analysis, and a significant correlation between the proposed scale andan existing scale was observed. Conclusion: Nursing competence for end-of-life service in nursing homes
was evaluated in terms of 21 items relating to 5 factors identified as having reliability, construct validity,
criterion-related validity and convergent validity. The results of evaluation regarding nursing competence
for end-of-life service in nursing homes suggested general versatility in various facilities for the elderly.

Introduction

whole to ensure quality in end-of-life care at nursing homes,
it is necessary to develop a scale that allows visualization andaccurate assessment of the competence of nurses providing
such care. The scale must incorporate consideration for thesocial significance of nursing homes and the dignity of elderly
people in the end-of-life stage.
In a previous study by the authors, the factor structure ofnursing competence in end-of-life care at nursing homes wasclarified and the construct validity of the proposed scale ofnursing competence in end-of-life care was examined both interms of necessity (i.e., the requirement for particular typesof care) and usage frequency (i.e., how often particular typesof care are administered). The results verified the scale’s
suitability for practical use with appropriate reliability(Ohmura et al., 2015). To put the scale to practical use, it wasnecessary to test its reliability and validity as an evaluationindex in multiple populations. Against such a background,
this study was conducted to assess competence in end-of-lifecare at nursing homes using the scale in order to evaluate its
reliability in practical application.
Considering the diverse educational backgrounds andqualifications of nurses providing end-of-life care at nursing
homes, where related care policies are not yet standardized,
practical application of the scale was expected to support thegrowth of nursing teams as a whole at elderly facilities byhelping to make the competence of end-of-life care nurses
uniform.

Japan is today experiencing the social advancement of
women, an increased number of elderly people living alone,
and more situations in which elderly people are caring foreven more elderly parents. Against such a background,demand is rising for nursing homes where elderly people
with high-level care needs that family members are unable
to meet can spend their final years with peace of mind andreceive living support from medical and welfare specialists.
To improve the quality of end-of-life care in nursing homes,
Japan’s government introduced a long-term care insurance
point addition system in 2006 and made it compulsory fornursing homes to employ full-time nurses to be eligible forsuch addition. Thus, efforts to improve the quality of end-oflife care at nursing homes are essentially left in the hands ofnurses.
Reports on related studies have noted that nursing homenurses exercise their assessment abilities by 1) predicting
the need for end-of-life care based on circumstantial changes
associated with reduced vitality in particular residents,
resident predictions of their own passing, and prediction of
the time of death based on observation of life-threatening
physical issues experienced by residents and symptoms thatindicate proximity to death (Takayama and Mizuno, 2009);
2) maintaining residents’ usual routines during end-of-life
care; and 3) playing a role in the management of specialist
teams to make residents’ remaining time fulfilling (Izawa
and Mizuno, 2009). Based on qualitative analysis, Nagahata
et al. (2012) highlighted the importance of following up
with other residents and reviewing end-of-life care in theprovision of such care to residents. As noted above, endof-life care at nursing homes potentially involves various
ideas and considerations for residents to have the chance
to pass peacefully at the home. However, few studies haveexamined these ideas and considerations as part of nursing
competence. To promote the ability of nursing teams as a

1. AimThe aim of the study was to statistically examine thereliability and validity of the proposed scale in assessing
degrees of competence in end-of-life care at nursing homes
and to determine the practicality of its application.

2. Definitions
1) End-of-life care: For the purpose of this study, end-oflife care was defined as “comprehensive care provided to anursing home resident considered by a doctor to have little
chance of recovery and to be close to the end of life, and to
his/her family.”2) Competence in end-of-life care at nursing homes: Basedon the definition of end-of-life care used in this study, the1) School of Nursing, Seirei Christopher University
2) School of Nursing at Narita, International University of Health and Welfare

Corresponding author. Tel.: +81 53 439 1493; Fax.: +81 53 439 1406.
E-mail address: mitsuyo-o@seirei.ac.jp

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Yearbook on Journal of the Japan Society of Nursing Research 2017

construct of competence in end-of-life care at nursing homes
was operationally defined as “the ability of nurses to attainthe goals of nursing care, including support for the resident’s
family; that is, support for residents who have expressed adesire to receive end-of-life care at nursing homes to die apeaceful death without pain.”

the five years since its development.
d. Scale of end-of-life care in general wards
The scale of end-of-life care in general wards (22items) developed by Yoshioka et al. (2009) was used todetermine the convergent validity of the proposed scale. The
questionnaire’s five-option Likert scale spans the range from
“Not implemented at all – 1” to “Implemented very well – 5.”
The scale of end-of-life care in general wards evaluates thecompetence of nurses in such care. The definition of end-oflife care for this scale was “Care provided by nurses to patientswith terminal cancer and their families to support family carebased on consideration of the patient and family as a single
care unit.” While circumstances differ, the scale was selectedon the basis that competency in end-of-life care involving
the patient’s family theoretically has reasonable relevance tocompetence in end-of-life care at nursing homes.

I. Methods

1. Subjects
Approximately 70 percent of the 7,552 nursing homes
currently operating in Japan provide end-of-life care uponrequest from residents or their families (Ministry of Health,Labour and Welfare, 2013). Using the addresses of nursing
homes listed in the Welfare and Medical Service Network
System (WAMNET), a total of 500 facilities were selected(10 to 20 from each prefecture, excluding areas affected by
the 2011 Great East Japan Earthquake), and 1,000 nurses(including assistant nurses; two per facility (one in chargeof nursing care and one staff nurse)) working at the facilities
with experience in end-of-life care were chosen as subjects.
Those in charge of nursing care were included in the study
as providers of end-of-life care because they commonly playroles similar to those of other nursing staff at nursing homes
with a limited staff body.

3. Data collection
Self-recording anonymous questionnaires developed by theauthors were mailed to the subjects. The envelope contained
two further sealed envelopes, each with a letter requesting
participation in the study, a questionnaire and a returnenvelope, and was addressed to the person in charge ofnursing care at the relevant nursing home. The letter to theperson in charge of nursing care outlined the study’s aims
and methods, requested the individual’s participation, andasked for a nursing staff member experienced in end-of-lifecare to also be selected and given the other sealed envelope.
Subjects agreeing to take part in the study were asked to
put the completed anonymous questionnaire in the returnenvelope and mail it without specifying the sender. The period
for data collection was from February to April 2013.

2. Questionnairea. Subject attributes
The five subject attributes considered were age, qualifications,educational background, clinical experience at medical
institutions (in years) and experience of care provision atelderly facilities (in years).
b. Scale of competence in end-of-life care at nursing homes
In the development of the scale, a pool of 60 nursing
competence items associated with end-of-life care was createdbased on preceding studies, and the validity of the items wasconsidered by observing participation in and examining
records of end-of-life nursing care at nursing homes wheresuch care is provided to residents in accordance with theirwishes. Using these 60 items as a basis for questions, thestructure of competence in end-of-life care at nursing homes
was statistically analyzed. Then, using five factors and 21
items extracted as scale considerations, the proposed scale
was developed (Ohmura et al., 2015; referred to here as “theproposed scale”). The 21 considerations were categorized as
Medical management in line with resident wishes (five items),
Collaboration toward peaceful passing (four items), Predictionbased management (five items), Personally tailored terminal
care (three items) and Review following resident passing (fouritems). Initial statistical analysis confirmed the reliability andconstruct validity of these items. The questionnaire’s fouroption Likert scale spanned the range from “Not applicable – 1”
to “Wholly applicable – 4.”c. Clinical Nursing Competence Self-assessment Scale (CNCSS)
The Clinical Nursing Competence Self-assessment Scale(CNCSS) (64 items) developed by Nakayama et al. (2010) wasused determine the criterion-related validity of the proposed
scale. The questionnaire’s four-option Likert scale spans therange from “Not confident – 1” to “Fully confident – 4.” The
CNCSS was developed as a tool to measure the competenceof nursing school graduates working in the field. The authors
consider this a highly stable scale and chose it because its
reliability and validity have been continuously verified over

4. Analysis method
SPSS ver. 19.0 for Windows and Amos ver. 20 were used forstatistical analysis.
a. Reliability
To evaluate the internal consistency of the proposed scale,
Cronback’s α was calculated for each factor using the averageof the lower items of each scale as a factor point. In addition,
to evaluate the reliability of existing scales in the study,
Cronback’s α was also calculated for each factor of the CNCSS(Nakayama, 2010) and the scale of nursing competence inend-of-life care in general wards (Yoshioka, 2009).
b. Construct validity
The response data obtained were applied to the five-factor
model for competency in end-of-life care at nursing homes,
and their goodness of fit was examined via explanatory factor
analysis and covariance structure analysis. As fit indices, χ2 /df, GFI, AGFI, IFI, CFI and RMSEA were used.
c. Criterion-related validity and convergent validity
Spearman rank correlation coefficients were calculated via
correlation analysis using the CNCSS (Nakayama, 2010) andthe scale of competency in end-of-life care in general wards(Yoshioka, 2009).

5. Ethical considerations
The study was conducted with approval from the Seirei
Christopher University Ethics Committee (approval no.
12041). A letter was sent to the individuals in charge ofnursing care at nursing homes requesting participation in the
study and selection of a nursing staff member experienced
in end-of-life care. In the letter, the individual in charge of
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This paper was published at “the Japan Society of Nursing Research” Vol.39 No.1 in 2016.

Yearbook on Journal of the Japan Society of Nursing Research 2017

nursing care was informed that the study subjects included
the person himself/herself and asked that another nursing
staff member be made free of pressure from superiors toenable contribution to the study. The letter specified theanonymity of the questionnaire, the voluntary nature of
the study, strict observance of anonymity, and details of thestringent management and eventual destruction of the datacollected. Return of the questionnaire was taken as agreement
to take part in the study.

at 13.1%. In terms of qualifications, 73.5% were nurses and88.6% had graduated from technical school. A total of 67.5%
had had eight years or more of clinical experience at medical
institutions, and 21.5% had had four to seven years. A totalof 54.4% had had eight years or more of experience at elderly
facilities, and 45.6% had had seven years or less. In terms ofindividual attributes, there were no great differences in the
response rate between people in charge of nursing care andnursing staff.

II. Results

2. Reliability (Table 2)
The value of Cronbach’s α calculated for the entire scaleof nursing competence in end-of-life care at nursing homes
was .848, with the coefficient for individual factors ranging
from .781 to .948. The value for the entire CNCSS (Nakayama
et al., 2010) was .787, with the coefficient for individual
factors ranging from .628 to .879, and that for the entire
scale of nursing competence in end-of-life care in generalwards (Yoshioka et al., 2009) was .798, with the coefficientfor individual factors ranging from .692 to .857.

A total of 336 people responded (response rate: 33.6%),
and the number of valid responses was 298 (valid response
rate: 97.3%). Among the respondents, 156 were in charge ofnursing care and 142 were nursing staff.
1. Subject backgrounds (Table 1)
Subjects in their forties and fifties accounted for 76.2%
of all respondents, followed by respondents in their thirties

Table 1. Basic subject attributes

AgeTotal number of subjects(individuals; %)

20s
30s
40s
50s
60s
Other

Qualification
Educational background

Nurse
Assistant nurse
Unknown

Technical school
Junior college
University
Other

Years of clinical experience at 1 – 3
medical institutions
4–7
8 – 1010+

Years of clinical experience at 1 – 3elderly facilities
4–7
8 – 10
10+

2.7
13.1
34.9
41.3
7.4
0.7

219
78
   1

73.5
26.2

33
64
39
162

11.1
21.5
13.1
54.4

264
18
   2
14

Nursing care supervisors(Individuals)

Nursing staff(Individuals)

117
39

102
39

88.6
6.0
0.7
4.7

42
94
53
109

Total



   8
39
104
123
22
   2

14.1
31.5
17.8
36.6

298

(n = 298)

   4
17
59
66
   9
   1

139
10
   1
   6
18
31
18
89

20
48
29
59

156

   4
22
45
57
13
   1

125
   8
   1
   8

15
33
21
73

22
46
24
50

142

Table 2. Descriptive statistics and confidence coefficient for competence based on the CNCSS
Factor

CNCSS

Scale of end-of-life care in general wards

Basic responsibilities
Ethical practices
Supportive relationships
Clinical judgment
Systematic development of nursing care
Assessment of care
Health promotion
Risk management
Care coordination
Nursing management
Improvement of specialization
Improvement of quality
Continued learning

Care facilitating passage without regrets
Spiritual care
Assurance of palliative care
Support for decisions based on appropriate information
Arrangement of available care

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This paper was published at “the Japan Society of Nursing Research” Vol.39 No.1 in 2016.

α

.788
.754
.820
.858
.879
.831
.852
.708
.628
.811
.777
.725
.804

.810
.828
.857
.802
.692

(n = 298)

Yearbook on Journal of the Japan Society of Nursing Research 2017

3. Scale validity
a. Construct validity (Fig. 1)
The data obtained were applied to the five-factor structureof nursing competence in end-of-life care at nursing homes
to examine their goodness of fit. The analysis of covariancestructure for the five-factor model was converged with thegoodness of fit χ2/df = 3.012, GFI = .848, AGFI = .803, IFI =.917, CFI = .917, RMSEA = .081 (p = .000). The path coefficient
between individual factors ranged from .57 to .89, and that forlower items ranged from .54 to .96.
b. Criterion-related validity (Table 3)
Correlation analysis for the proposed scale and the CNCSS(Nakayama et al., 2010) revealed intermediate (.40 < r < .65)
correlations among all factors (p < .001). Factors withwhich “Medical management in line with resident wishes”
had a relatively high correlation coefficient of .60 or higher
were “Supportive relationships,” “Systematic developmentof nursing care,” “Health promotion” and “Improvement ofquality.” “Prediction-based management” was also found to
be correlated with “Clinical judgment.”c. Convergent validity (Table 4)
Correlation analysis for the scale of competence in end-oflife care at nursing homes and the scale of end-of-life carein general wards showed an intermediate (.47 < r < .65)
correlation among all factors (p < 0.001). The factors withwhich “Medical management in line with resident wishes” hada relatively high correlation coefficient of .60 or higher were“Care facilitating passage without regrets,” “Spiritual care” and“Support for decisions based on appropriate information.”
Likewise, “Prediction-based management” was found to becorrelated with “Assurance of palliative care,” and “Personally
tailored terminal care” was found to be correlated with “Carefor comfort and the spirit,” “Support for decisions based on
appropriate information” and “Arrangement of available care”(p < .001).
III. Discussion

1. Reliability and validity of the proposed scale
The value of Cronbach’s α calculated for the entire scaleof competence in end-of-life care at nursing homes was.848, with values of .7 or higher indicating high reliability(Oda, 2010, pp. 210 – 212), thereby indicating the internalconsistency of the scale. The value was higher for all factors
than that calculated for necessity and practice frequency ina preceding study (Ohmura et al., 2015), thereby indicating
the reliability of the scale for evaluating competency in endof-life care. The value for the entire CNCSS (Nakayama et al.,2010) was .787, and that for the entire scale of end-of-life carein general wards (Yoshioka et al., 2009) was .798, thereby
indicating reliability in this study of the two existing scales
selected for examination of the proposed scale’s validity.
In explanatory factor analysis for the proposed scale,goodness of fit statistics converged within acceptable ranges
and correlation was observed among factors in the five-factor
model, thereby indicating the construct validity of the scale.
Goodness of fit values and path coefficients among variables
were also similar to those for the necessity model and thepractice frequency model examined in a preceding study(Ohmura et al., 2015). These results suggested the suitabilityof the proposed scale for evaluation of competence in enablingelderly residents of nursing homes to die a painless andpeaceful death.
Analysis revealed a significant positive correlation between

A

E

B

C

D

CMIN/DF
3.012

A: Review following resident passing
B: Medical management in line with resident wishes
C: Collaboration toward peaceful passing
D: Prediction-based management
E: Personally tailored terminal care

GFI

.848

AGFI

CFI

.803

.917

IFI

.917

RMSEA
.081

Fig. 1. Results of covariance structure analysis for the five factors of nursing competence in end-of-life care at nursing homes32This paper was published at “the Japan Society of Nursing Research” Vol.39 No.1 in 2016.

Yearbook on Journal of the Japan Society of Nursing Research 2017

Table 3. Descriptive statistics for competence in end-of-life care at nursing homes


Review following
resident passing

Medical management
in line with resident
wishesCollaboration toward
peaceful passing
Prediction-based
management

Personally tailoredterminal care

3.11
3.01
2.97

0.68

Average

1. Recall and assessment of whether resident passing was painless and natural
2. Recall and assessment regarding the effects of care administered and the statusof the resident’s body
3. Recall of exchanges with family and their reactions, and assessment on theappropriateness of support provided
4. Recall and assessment on whether end-of-life care in line with resident wishes
was provided
5. Provision of care prioritizing resident wishes as much as possible
6. Development of relationships supporting free expression among residents
prior to the terminal stage
7. Provision of opportunities for residents and family to express wishes regarding
end-of-life care
8. Administration of pain control in collaboration with a doctor
9. Review of unnecessary treatment and testing once the terminal stage has beenreached10. Observation and assessment of symptoms and pain characteristics to the endof-life stage
11. Prediction of entry to the terminal stage
12. Close collaboration with care workers specializing in life support
13. Standardization of end-of-life care policies in consideration of the opinions ofother professionals
14. Prediction of sudden nighttime changes based on daytime wellbeing amongresidents
15. Prediction of potential symptoms and advance medical consultation
16. Provision of information to care workers on the next night shift regarding thepossibility of sudden changes in resident conditions
17. Provision of information to residents and family on medical services available
at the facility
18. Checking of resident/family wishes regarding life-prolonging procedures
19. Consideration of requests relating to residents’ religious customs and beliefs
20. Reflection of resident interests, preferences, life history, etc., in end-of-life careplans
21. Inference and application of resident wishes based on individual characteristics
in cases where direct communication is impractical(n = 298)

Standard
deviation
0.66
0.71

2.98
3.14
2.96
2.94
3.03
3.05
2.97
3.16
3.15
3.20
3.21
3.14
3.36
3.39
3.36
2.91
2.97
3.00

0.69
0.59
0.66

α

.948

.781

0.63
0.68
0.68
0.51

.810

0.56

.878

0.47
0.55
0.56
0.63
0.54
0.61
0.62
0.72
0.69

.823

0.64

Table 4. Correlation between the competence factors in end-of-life care at nursing homes and existing scales



CNCSS

Scale of endof-life care in
general wards

Basic responsibilities
Ethical practices
Supportive relationships
Clinical judgment
Systematic development of
nursing care
Assessment of care
Health promotion
Risk management
Care coordination
Nursing management
Improvement of specialization
Improvement of quality
Continued learning
Care facilitating passage
without regrets
Spiritual care
Assurance of palliative care
Support for decisions based on
appropriate information
Arrangement of available care

[Note] ***: p < .001

.416***.493***.503***.515***.520***

Medicalmanagement inline with resident
wishes.454***.588***.628***.587***.642***

Collaboration
towardpeaceful
passing.454***.536***.508***.579***.580***.532***.519***.540***.603***.596***.629***.539***.579***.533***

Review following
resident passing.494***.427***.491***.435***.476***.494***.480***.404***.487***.595***.613***.544***.569***.546***.575***.605***.517***.631***.472***.548***(n = 298)

PersonallyPrediction-based
tailoredmanagement
terminal care
.513***.571***.450***.616***.575***.424***.513***.542***.494***.594***.471***.457***.541***.480***.589***.504***.539***.442***.542***.467***.400***.518***.435***.553***.429***.517***.406***.524***.505***.474***.531***.515***.491***.534***.519***.466***.565***.523***.525***.612***.470***.606***.576***.622***.516***.603***

The correlation with the scale of end-of-life care in generalwards, which was selected as a theoretically highly correlated
concept, supported the conceptual definition of end-of-lifecare used in the scale and indicated its appropriateness inthe assessment of overall care for terminally ill patients andtheir families.

the proposed scale and the CNCSS at the 0.1% level, thereby
indicating the criterion-related validity of the scale. Thishighlighted the scale’s appropriateness as a measurement
tool conforming to external criteria for self-assessment ofbasic nursing competence. Analysis with the scale of endof-life care in general wards (Yoshioka et al., 2009) also
showed a significant positive correlation at the 0.1% level,
thereby confirming the convergent validity of the scale.
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Yearbook on Journal of the Japan Society of Nursing Research 2017

2. Characteristics of competence in end-of-life care at nursing
homes
The correlation observed between the CNCSS (Nakayama
et al., 2010) and the proposed scale indicated that nursing
competence in end-of-life care at nursing homes could be
improved via the establishment of supportive relationships
with residents, systematic nursing care, emphasis on theautonomy and wishes of residents, and awareness of thecapacity for quality improvement. In particular, interpretationof the strong correlation between “Medical management inline with resident wishes” in the proposed scale and the“Health promotion” part of the CNCSS (Nakayama et al., 2010)
suggests that the concept of health promotion in nursing care
implicitly exists in competence for end-of-life care at nursing
homes. That is, such competence implicitly involves nursing
recognition with focus on respect for the wishes of residents,
allowing them to live out their remaining time, however short
it may be, autonomously. These results support the findingsof a preceding study by Iwamoto et al. (2007) supporting
the promotion of terminal care nursing advocacy at nursing
homes based on the importance of clarifying residents’ wishes
and making efforts to support their decisions.
Meanwhile, the correlation with existing scales was weakerfor “Collaboration toward peaceful passing” and “Review
following resident passing.” Such collaboration involves thecapacity for coordination with care workers, who in mostcases do not work in general wards of medical institutions.
Care workers, or specialists in life support, tend to exhibit
strong anxiety and fear regarding death, and their smoothcollaboration with nurses in end-of-life care is enabled by thelatter’s provision of psychological support to such workers(Ohmura, 2013). Nurses are able to provide such support
due to the staff organization associated with elderly facilities,
which is part of competence in end-of-life care at nursing
homes.
“Review following resident passing” involves post-mortem
review of the care provided, and is a characteristic of end-oflife care at nursing homes. Such review is a primary factor
with loading higher than that of other factors as extracted
via exploratory factor analysis in preceding studies, and is the
only factor with a Cronbach’s α value of .9 or higher based on
judgment of necessity and application frequency in precedingstudies from competence assessment in this study. This
result indicates that the subjects of this study, who provide
end-of-life care to numerous people, consider this factor asvery important. Behind the history of such nurses’ provisionof highly personalized end-of-life care in the absence ofguidelines at nursing homes, where the medical care system
is not as comprehensive as that at hospitals, is a professional
ability enabling them to implement critical self-assessment inwhich all end-of-life care is reviewed earnestly (e.g., Was theresident’s passing painless and natural? Were the resident’s
wishes respected and was support provided to the family
appropriate? Was the body of the deceased clean? (i.e., Was
the care provided sufficiently effective?)) and use the resultsin subsequent end-of-life care along with incorporation
into their views on life/death and nursing. In relation to thenecessity of review following each case of end-of-life care,
Shimada (2012) discussed the importance of considering not
how residents died but whether they lived in a manner thatsuited them. Accordingly, it can be said that “Review following
resident passing” involves the ability to assess quality of life
for elderly people approaching their final days at nursing

homes, and that this perspective on end-of-life care at nursing
homes differs from that provided at hospitals. That is, thistype of review represents the core of nursing competence
in end-of-life care as well as being an ethical principle thatshould be followed by care workers and anybody else involvedin the provision of such care.
3. Practicality of the scale
The study indicated that the scale of competency in endof-life care at nursing homes could be used to evaluate thedegree of overall nursing competence required to enableelderly people at nursing homes to die a painless and peacefuldeath. Nurses in their forties and fifties with eight or more
years of clinical experience at medical institutions or elderly
facilities (i.e., proficient experts based on Benner’s nursing
theory) accounted for over half of all subjects.
Taking this into consideration, it can be said thatcompetence in end-of-life care at nursing homes is a unique
skill developed via trial and error using existing nursing
competence to realize the peaceful death of residents.
Accordingly, all nurses providing end-of-life care, regardlessof their basic attributes, can be assessed using the scale. The
five-factor structure allows its use to calculate scores forindividual factors, thereby helping to identify specific abilities
in nursing care that require improvement or supplementationand supporting efficient improvement of nursing competence.
Chiba et al. (2009) highlighted that nurses providing
terminal care at group homes are expected to help improvethe medical system and the quality of staff at their facilities
as well as to create a pleasant environment for residents, andthese elements are similar to the factors of the proposed scale
identified in this study. That is, the scale can be consideredapplicable to end-of-life care at elderly facilities such as grouphomes, in addition to nursing homes, as long as conditions
such as elderly residents living out their final days, various
professionals collaborating and nurses being able to exercise
leadership in medical care are met.
IV. Conclusions

1. The scale of competency in end-of-life care at nursing
homes can be used to evaluate the overall nursing competence
required to allow elderly people to die a painless and peacefuldeath at residential facilities.
2. The scale consists of 5 factors and 21 items: Medical management in line with resident wishes (five items), Collaboration
toward a peaceful death (four items), Prediction-based management (five items), Personally tailored terminal care (three
items) and Review following resident passing (four items).
3. The scale is characterized by reliability, construct validity,
criterion-related validity and convergent validity.
V. Study limitations and future issues

A limitation of the study was its use of nurses experienced
in end-of-life care as subjects with no comparison of
possible response trends relating to clinical experienceand qualifications. Institutional policies relating to theadministration of end-of-life care at nursing homes are
currently diverse, and competence in such care is considered
to be influenced by factors including facility principles andscales, the duration of end-of-life care and the presence ofpartner hospitals. It is therefore necessary to investigate
34

This paper was published at “the Japan Society of Nursing Research” Vol.39 No.1 in 2016.

Yearbook on Journal of the Japan Society of Nursing Research 2017

influencing factors and to compare the effects of nursing
experience and ability.
Nevertheless, the study involved a larger population than
the authors’ preceding study, and certain levels of reliability
and validity for the scale were identified. In future work, theauthors plan to expand the scope of the scale beyond nursing
homes based on testing of its applicability at elderly facilities
nationwide, including group homes and fee-charging homes
for elderly people.

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Acknowledgements

The authors are grateful to the nursing home staff who
contributed to the study and to the Seirei Christopher
University staff who provided valuable guidance.
This paper is based on part of a doctoral thesis submitted
to the Graduate School of Nursing at Seirei Christopher
University.
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Received: March 1, 2015
Accepted: August 25, 2015

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This paper was published at “the Japan Society of Nursing Research” Vol.39 No.1 in 2016.