Commentary

Throughout the world, nurses are involved across all levels in establishing services and shaping palliative care practice,

including clinical bedside care, clinical leadership, sole practitioner roles, management, education, research and policy development. In all these roles, many models of palliative care nursing exist, with nurses working alone or in teams. While this contribution to palliative care is laudable, we must remember that nursing is not universally respected as its own profession and in many countries, nursing is regarded as lowly, with no status and power and lacking its own autonomous professionalism and accountability.

To comment on the infl uence of palliative care nursing worldwide, I will use the public health framework published in the special edition of Journal of Pain and Symptom Management (Stjernsward et al, 2008). A public health framework describes components for developing palliative care services, which I suggest is applicable in any country, not just developing countries. These components are: ensuring that palliative care has been incorporated into national cancer control programmes and other policies; essential drug availability (but for the purpose of this commentary, symptom management expertise is incorporated); education of health professionals and the public; and implementation of services. Again for the purpose of this commentary, research is inherent in all these activities.

Incorporating palliative care into policyIn ensuring that palliative care is incorporated into national cancer and other policies, we can find many examples of nurses who work at high levels on committees, or in research, to change policy; for example, in Australia, the nurse-led project to develop national guidelines for a palliative approach in residential aged care, has had a far-reaching infl uence on care of the dying in aged care settings (Kristjanson et al, 2005). Nurses work to strategically create both systems and social change and to advocate and lobby for adequate palliative care funding as well as other service delivery

supports. An example of this work is the UK End of Life Care Strategy (Department of Health, 2008). Palliative care nursing leadership is evident in many countries on peak bodies and government committees as well as international organizations, such as the Asia Pacifi c Hospice Palliative Care Network, the International Association for Hospice and Palliative Care (IAHPC) and the Worldwide Palliative Care Alliance (WPCA).

Symptom management expertisePalliative care’s infl uence on symptom management expertise is one shared by all health professionals in the multidisciplinary team. However, the core clinical skill of working with intractable symptoms is an area where specialist palliative care nurses can make a difference to the way a person dies.

The central aspect of nursing work remains care of the body, which often remains invisible as it is perceived as dirty or breaking taboos in some way (Skilbeck and Payne, 2003). Nursing tasks involve being expert in all areas of symptom management, from thorough assessment through to evaluation (Twycross and Wilcock, 2002). Essentially, this also involves nursing leadership of less experienced and generalist nurses. Leadership may also involve advocacy on the part of those for whom nurses are caring, particularly in working for equitable access to medications (Lugton and McIntyre, 2005).

EducationNurses make significant contributions to education, including formal programs, ‘train the trainer’ models and bedside teaching (Reb, 2003). Many countries lack infrastructure within health care in general and palliative care becomes a low priority in places where other basic human needs are dire. Thus education becomes diffi cult, with reliance on donations or overseas aid agencies. There are many examples of nurses who individually give up their free time to assist with educating colleagues in other countries, often using annual leave to support a clinician or service.

Educational opportunities are available from developed countries to developing countries, which

Margaret O’Connor is Vivian Bullwinkel Chair in Palliative Care Nursing, School of Nursing and Midwifery, Monash University, Australia

Correspondence to: Margaret O’ConnorEmail: margaret.oconnor@med.monash.edu.au

Understanding the infl uenceof palliative care nursing:

A global perspectiveMargaret O’Connor

316 International Journal of Palliative Nursing 2009, Vol 15, No 7

Commentary

are again provided through international aid, charities or universities. In resource-poor countries, there are also examples of nurse-led refocusing of western palliative care models to meet local needs. For example, nurses prescribing morphine in Uganda because of a shortage of doctors, and in India, there are wonderful examples of volunteer and community health promotion initiatives to support palliative care services, involving young people being educated into volunteer roles through their school community. These examples of community engagement do not seem to have the same traction within western/affl uent communities.

In relation to formal programmes, undergraduate nursing programmes are traditionally crowded, with little room for specialty areas, including palliative care. Continuing education, whether professional development or specialty postgraduate courses in Australia, attract low numbers.

Concern has been expressed in the literature about the loss of palliative care nursing knowledge as a consequence of role changes (Reb, 2003). Mainstreaming of specialist services requires a delicate balance of maintaining specialist knowledge while developing the knowledge of generalist nurses. This issue makes for a rich source of debate across many countries (Reb, 2003; Nelson and Gordon, 2006) and is an area which should never be too far away from the core of palliative care research agendas.

Implementing servicesIn implementing services, nurses in Australia have increasingly taken lead roles over recent years. Literature notes the key role that the nurse leader plays in relation to staff satisfaction and the development of their knowledge and skills that enable them to provide quality care (Duffi eld et al, 2009). In many countries (poor as well as more developed), there are shifts away from the traditional focus on acute care to extended roles in primary health care models. This is no less important in palliative care, where primary health care models are ensuring that the skills are extended to nurses and other health workers to provide care for dying people wherever they are. Primary health care models requires the community to become a partner in the care of the dying (Stjernsward et al, 2008; Parfi tt, 2009).

ResearchUnderpinning these aspects of the framework is research, which should always be about improving care of the dying. This may be through undertaking clinical studies on symptom management, being part of randomized controlled trials on medications, or undertaking service system research. National

strategies in many countries have overtly supported research in palliative care nursing, by funding research projects or capacity-building exercises, like providing funding for PhD and postdoctoral fellowships (Department of Health and Ageing [Australia], 2000). Literature notes an increase in published palliative care research, with a major focus on nursing over other disciplines (Payne and Turner, 2008). However, greater attention is needed to develop scholarship in palliative care that is more global, and a number of recent initiatives, such as the WPCA and the IAHPC, offer an opportunity for the development of researchers and research methods adapted to resource-poor settings (Payne and Turner, 2008).

Well-funded research that extends its reach into internationally-comparative frameworks will assist the development of palliative care throughout the world. A health promotion model of palliative care nursing is one that ultimately ensures that dying is everyone’s business.

ConclusionThere are a number of opportunities for palliative care nurses to ensure that the public health framework continues to inform the development of palliative care worldwide. Essential aspects of this work are the advocacy for drug availability and for funding to establish and develop services. Nurses will continue their core role in pain and symptom management and there is a contemporary opportunity to be creative with developing specialist roles, such as the nurse practitioner. ✉IJPN

Department of Health and Ageing (Australia) (2000) Na-tional Strategy for Palliative Care in Australia. DHA, Canberra

Department of Health (UK) (2008) End of Life Care Strat-egy: Promoting high quality care for all adults at the end of life. HMSO, London

Duffi eld C, Roche M, O’Brien-Pallas L, Catling-Paull C, King M (2009) Staff satisfaction and retention and the role of the Nursing Unit Manager. Collegian 16(1): 11–7

Kristjanson L, Walton J, Toye C (2005) End-of-life chal-lenges in residential aged care facilities: a case for a pallia-tive approach to care. Int J Palliat Nurs 11(3): 127–9

Lugton J, McIntyre R (2005) Palliative Care: The nursing role. Elsevier, Edinburgh

Nelson S, Gordon S (2006) The Complexities of Care: Nurs-ing reconsidered. Cornell University Press, US

Parfi tt B (2009) Health reform: the human resource chal-lenges for Central Asian Commonwealth of Independent States (CIS) countries. Collegian 16(1): 35–40

Payne S, Turner M (2008) Research methodologies in palliative care: a bibliometric analysis. Palliat Med 22(4): 336–42

Reb AM (2003) Palliative and end of life care: policy analy-sis. Oncol Nurs Forum 30(1): 35–50

Skilbeck J, Payne S (2003) Emotional support and the role of Clinical Nurse Specialists in palliative care. J Adv Nurs 43(5): 521–30

Stjernsward J, Foley M, Ferris F (2008) The public health strategy for palliative care. J Pain Symptom Manage 33(5): 486–93

Twycross R, Wilcock A (2002) Symptom Management in Advanced Cancer. Radcliffe Medical, Oxford

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‘Concern has been expressed in the literature about the loss of palliative care nursing knowledge as a consequence of role changes’