Commentary

Understanding the influence

of palliative care nursing:
A global perspective
Margaret OConnor

hroughout 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 influence 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 policy

Margaret OConnor is
Vivian Bullwinkel Chair
in Palliative Care
Nursing, School of
Nursing and Midwifery,
Monash University,
Australia
Correspondence to:
Margaret OConnor
Email: margaret.oconnor@
med.monash.edu.au

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In 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 farreaching influence 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 Pacific Hospice Palliative Care
Network, the International Association for Hospice
and Palliative Care (IAHPC) and the Worldwide
Palliative Care Alliance (WPCA).

Symptom management expertise

Palliative cares influence 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).

Education
Nurses 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 difficult, 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

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/affluent 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 services
In 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 (Duffield 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; Parfitt, 2009).

Research
Underpinning 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

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

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 everyones business.

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

Conclusion
There 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) National Strategy for Palliative Care in Australia. DHA,
Canberra
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of life. HMSO, London
Duffield C, Roche M, OBrien-Pallas L, Catling-Paull C,
King M (2009) Staff satisfaction and retention and the
role of the Nursing Unit Manager. Collegian 16(1): 117
Kristjanson L, Walton J, Toye C (2005) End-of-life challenges in residential aged care facilities: a case for a palliative approach to care. Int J Palliat Nurs 11(3): 1279
Lugton J, McIntyre R (2005) Palliative Care: The nursing
role. Elsevier, Edinburgh
Nelson S, Gordon S (2006) The Complexities of Care: Nursing reconsidered. Cornell University Press, US
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Payne S, Turner M (2008) Research methodologies in palliative
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Reb AM (2003) Palliative and end of life care: policy analysis. Oncol Nurs Forum 30(1): 3550
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Stjernsward J, Foley M, Ferris F (2008) The public health strategy
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