Population aging has led to a rising prevalence of chronic illnesses and an increased number of elderly patients seeking care at Long-Term Care (LTC) hospitals. South Korea experienced a 1.6-fold upsurge in the number of LTC hospitals from 868 in 2010 to 1,428 in 2016, while in-patients at these hospitals increased approximately 1.47-fold from 229,000 in 2012 to 338,000 in 2016[1]. Patients receiving LTC hospital care find themselves in great need of direct care services, such as assistance in everyday activities, safety, and infection management [2], given that their conditions are mostly characterized by reduced cognitive, behavioral problem and physical functions [3]. In addressing these patients' needs, nurses at LTC hospitals are ideally positioned to fulfil a variety of crucial roles, spanning from providing care to elderly patients with their professional knowledge and skills to managing nursing assistants and providing training on infection management, all of which create a high level of expectations for their performance in elderly care [4].

Elderly care performance refers to “nurses activities of assessing the issues unique to patients aged 65 or above and developing and implementing care plans to resolve them with the aim of maintaining the patients' health condition at its best”[5]. This type of nursing care involves injury prevention, dermatological care, assistance with communication, pain management, medication, nutritional care and so on [5]. Understanding factors associated with LTC hospitals nurses' elderly care performance is crucial, since they perform a wide range of tasks from direct care of elderly patients to management of other care professionals. Existing literature on elderly care performance focused on nurses' demographic characteristics of nurses at geriatric hospitals. For example, a survey of nurses at geriatric hospitals reported that older age, longer clinical experience, and higher education level were associated with a more advanced performance in elderly care [6]. There has been limited research to date at Korean LTC hospitals on the factors of elderly care performance among nurses.

Empathy is emerging as an important factor in clinical nursing performance including geriatric care. Different academic disciplines have their own definition of this capacity, but a commonly accepted definition is “understanding, sharing, and creating an internal space to accept the other person, hence helping them to feel understood and not alone”[7]. Adequate provision of geriatric care requires sufficient understanding of this competency. Empathy plays a crucial role in enabling nurses to develop a therapeutic bond with patients and provide high-quality care while simultaneously influencing patients' attitude [8]. A lack of empathy undermines nurses' ability to understand patients or establish a bond with them, thereby precluding the provision of a patient-centered care service [9]. No previous studies have explored the issue of empathy among LTC hospital nurses, but a study of nurses at emergency departments reported that those with a higher performance in compassion care experienced lower levels of work-related burnout [10]. By the same token, an adequate demonstration of empathy may enhance LTC hospital nurses' elderly care performance while reducing burnout and consequently job turnover.

Spirituality constitutes a salient factor determining quality of life and enabling healthy aging [11], and it is also an important concept for healthcare professionals, not least nurses, who manage patients' health-related issues from a holistic perspective [12]. Spirituality is related to important beliefs and belief systems that examine the reality of life, and these provide humans with a sense of meaning in many life experiences, including suffering from disease [12]. Lee and Park [13]'s study found that nurses who recognized the importance of religion, had extensive experience with end-of-life care, completed a basic educational program that emphasized spiritual care, and reported high satisfaction with their job and life demonstrated a particularly high level of spirituality, and nurses with high spirituality showed positive attitudes in end-of-life care settings [13].

End-of-life care is an integral part of elderly care performance and a basic skill expected from LTC hospital nurses, given that the majority of elderly patients and those with chronic illnesses spend the last days of their lives at LTC hospitals [14]. Reinforcing spirituality has thus been proposed as a means to enhance the quality of geriatric care, including end-of-life care. Spirituality in LTC hospital nurses influences dying patients' psychological and spiritual condition [13], and has thus been suggested as a key variable of nursing performance.

Regarding the relationship among empathy, spirituality and care performance, Kim and Choi [15] showed that the empathy affects spiritual care competence in nursing students, and Kim and Kwon [14] reported that empathy affects elderly care performance. They also reported that spirituality has been shown to have a bearing on spiritual and hospice care performance in nurses at general or LTC hospitals [16, 17]. However, there is a paucity of research on the relationship between spirituality and their elderly care performance for LTC hospital nurses' in Korea. Also, most studies only focused on the relationship between only two of the three variables of empathy, spirituality, and elderly care performance not all variables [14, 15, 16, 17] and no research reported the mediating effect of spirituality on the relationship between empathy and elderly care performance.

As such, this study aimed to examine the relationship between LTC hospital nurses' empathy, spirituality, and elderly care performance and establish the mediating effect of spirituality between empathy and elderly care in Korea. The findings of this study are anticipated to inform the development of care strategies for LTC hospital nurses as they strive to provide high-quality care services for elderly patients.

In light of the global increasing trend in the number of LTC hospitals, this study explored the mediating effect of spirituality on the relationship between empathy and elderly care performance among LTC hospitals nurses in Korea.

In the present study, LTC hospital nurses' empathy score was 3.26 out of 5, consistent with the results of Jeong [22], who found an average empathy score of 3.31 in general hospital nurses using the same measurement tool. Previous studies reported that more than 39.3% of patients at Korean LTC hospitals in 2012 spent more than 180 days under hospital care [3], with the majority of them presenting symptoms of delirium and depression [3]. This suggests that, besides understanding these patients' physical symptoms accurately to provide adequate care for their condition, nurses need to build their capacity to empathize with their psychological conditions.

Empathy is important in nurses because it helps patients to feel understood and not alone, allowing them to accept themselves as valuable [7, 8]. Nurses' empathy can increase the curative effect of and patients' satisfaction with nursing services by forming a positive trust relationship. Thus, empathy is considered an important part of nursing performances in foreign countries, which provide educational programs with empathy training to improve care performance [23], whereas programs to improve the empathy of nurses in Korea are insufficient. Since empathy is a result of attentive listening, emotional support, and specific related activities [24], there should be education on practical empathetic expressions and supplementary educational programs on behavior correction for nurses in LTC.

In terms of the differences in empathy according to the characteristics of the participants, we observed a higher empathy among female nurses, consistent with the findings of Kliszcz et al.[25] that female nurses and doctors demonstrated a higher capacity to empathize with patients. Currently, the nursing workforce of Korean LTC hospitals consists mostly of women, but the number of male nurses is rising continuously both within Korea and in other countries such as the U.S. Given this, fostering appropriate empathy in the growing number of male nurses at LTC hospitals appears to be an increasingly important concern. Gender differences should be taken into account when developing and implementing programs on building empathy, since male and female nurses may possess different degrees and perception of this capacity [26].

Most patients at LTC hospitals suffer from chronic or degenerative diseases [13, 14]; the ability to empathize with these patients is of particular importance [8], as they require long-term nursing care and nurses need to develop a long-lasting bond with family caregivers as well. In this sense, LTC hospitals nurses need to develop the ability to empathize not only with patients' health problems requiring professional attention but also with various situations that may arise from their conditions.

The mean spirituality score in this study was 3.25 out of the 5, congruent with the scores of 3.4 for doctors and 3.6 for nurses in the study on spirituality of doctors and nurses in general hospitals by Kim [12]. The mean spirituality of the nurses in LTC hospitals found by this study was higher than that of medical doctors or nurses in general hospitals as reported by Kim [12]. As the patients in LTC hospitals undergo long-term hospitalization and tend to be incurable due to chronic diseases, spirituality is important to ensure holistic care [27]. In particular, there are efforts to make spiritual care a mandatory standard for medical services, as spirituality is an important factor in the professional competence of LTC nurses.

In terms of the differences of spirituality according to the characteristics of participants found in this study, nurses having religion had a higher degree of spirituality, congruent with existing research findings that religion and spirituality are associated with each other [12, 13]. Spirituality is indeed closely tied with religion, since spirituality entails religious well-being (in relation to one's relationship with God) and existential well-being (indicating one's satisfaction with life)[12, 13]. However, the current practical approaches to spirituality for nurses leave much room for improvement, as there is no robust continuing education program aimed at promoting a spiritually healthy mindset among nurses, and spiritual health is largely dismissed as nurses' private matters. Our findings indicate that spirituality is associated with elderly care performance in LTC hospital nurses. We thus recommend endeavors toward the efficient management of nurses' spiritual health so that they can better cope in LTC hospital settings. In addition, as the patients in LTC hospitals often reside in the hospitals until they die, it is necessary [13] for nurses to focus on caring not only for their own spirituality but also that of the patients to ensure multi-dimensional nursing comprising physical, mental, and spiritual care.

This study found an elderly care performance score of 3.80 out of 5, greater than the score of 3.07 found by Kim [5] for nurses in general hospitals. This is an expected outcome, since LTC hospitals nurses almost exclusively deal with elderly patients and thus have a high awareness of elderly care as well as a high level of performance in this care setting [28], whereas nurses at general hospitals attend to various types of patients, from younger adults to elderly people, and may therefore have less awareness of elderly care and a lower level of elderly care performance. In examining the differences in elderly care performance by the characteristics of the participants, nurses aged 50 or older and with a title of charge staff nurse or higher demonstrated higher performance of elderly care in this study, while Kim [5] found that married nurses showed higher elderly care performance than did unmarried nurses. The measuring tool of elderly care performance in this study addresses various nursing tasks required in geriatric care settings, including injury prevention, communication, and medication of which communication may not be easy to be adequately performed by younger or less experienced nurses. This partly explains the association between higher elderly care performance and age in this study. Because existing education programs for nurses at LTC hospitals in Korea include only geriatric assessment, nutrition, use of restraints, fall prevention, and urinary incontinence [29], professional education including effective communication skills and safe nursing practices for elderly care performance is needed, particularly for young nurses or those with a short nursing career.

We demonstrated that spirituality has a full mediating effect on the relationship between empathy and elderly care performance. In other words, when empathy increases, spirituality also increases and indirectly influences elderly care performance. Accordingly, because spirituality plays a strong mediating role in the relationship between empathy and elderly care performance, nursing education programs that can improve nurses' empathy with a focus on spirituality are needed to support a high level of elderly care performance. Also, since there have been few studies of the correlations among empathy, spirituality, and elderly care performance, it is hard to directly compare the results of this study with others. However, Seo and Sung [16] reported that spirituality and deathbed experiences affect the nursing performance of hospice nurses, and Sung [17] reported that spiritual well-being and clinical career affect the nursing performance of nurses working at general hospitals, showing that spirituality is a significant influencing factor on nursing performance, similar to the results of this study. Since spirituality affects nursing performance, it is important to assist nurses to recognize its full mediating effect and also provide training for empathy skills which affects spirituality.

However, this study is significant as it additionally confirmed a mediating effect of spirituality, and in particular identified the elderly care performance of the nurses working at the LTC hospitals. Recently, many recent studies report empathy as an important nursing skill and a key concept that should be implemented in clinical environments [8]. Through the process of introspection – which involves self-recognition, understanding, and empathy – one's spirituality can also be improved. Empathy is necessary to improve one's spirituality, but self-empathy – which is to embrace one's imperfection and to open one's heart – needs to precede it to improve one's empathy [30]. With improved self-empathy, nurses can exhibit improved communication skills with the patients, eventually leading to a better clinical environment and more efficient nursing service. Thus, nurses who have both empathy and spirituality can improve their elderly care performance. Since empathy and spirituality are necessary to improve nursing performance, systematic efforts to provide meditation time for the nurses to introspect and operate spiritual programs based on spiritual recognition are necessary.

This study has a few limitations. Our findings are difficult to generalize, since we only included nurses at LTC hospitals within a limited geographical area. Additionally, because a self-report questionnaire was used to measure the research variables, there is the possibility of common method variance according to individual characteristics; because an exploratory cross-sectional correlational survey design was used, the study's results cannot make causal implications. Future research must explore the causal relationships of empathy and spirituality on increase and decrease in elderly care performance using a longitudinal design. Finally, we also could not control for all the exogenous variables that affect elderly care performance.

Nonetheless, this study represents a significant contribution to community nursing research as the first endeavor to explore the relationship of empathy and spirituality, two key nurse qualities with increasing importance in recent years, with nurses' performance in geriatric care settings in Korea.

Going forward, in light of the present findings, we call for efforts to train LTC hospitals nurses' empathy and develop their spirituality to improve their elderly care performance. We also look forward to future research aiming to identify other factors of elderly care performance, including work environment and management at hospitals, along with empathy and spirituality.

The current study identified that the spirituality plays a strong mediating role in the relationship between empathy and elderly care performance. There is a need to provide nursing education programs that can improve nurses' empathy with a focus on spirituality to ensure a high level of elderly care performance. To improve nursing performance, programs to enhance both spirituality and empathy of the nurses – including introspection, improving the relationship with others, and understanding the meaning of life – need to be established.