Exemplary nursing leadership is central to improving care of the dying

Inspire a shared vision

Exemplary nursing leadership within health administration, clinical, education and research underpins the promotion of safe, effective, and appropriate care for patients with palliative care needs (Advancing Expert Care, Hospice and Palliative Nurses Association, Hopsice and Pallliative Nurses Foundation, & Hopsice and Pallliative Credentialling Centre, 2014). Access to specialist palliative care has been demonstrated to improve care, reduce health care costs, and potentially increase survival. However specialist palliative care is not routinely available to all dying patients (Temel et al. 2010). This gap can be largely addressed through the implementation of a palliative approach, also referred to as primary palliative care. A palliative approach is care that is delivered by the patients' usual care team to minimise suffering and distress. Through quiet persuasion, nursing leaders can enlist others in making this vision a reality (Kouzes & Posner 2012). Nurses' ought to envision to their team(s) the steps to be taken to deliver a palliative approach within their care setting(s), taking into consideration: the population(s) to be served; the profile and expertise of the clinical team; and appropriate change strategies. This leadership step enables teams to see how care of the dying can be transformed and creates a vision that the team wants to commit to.

Challenge the process

Now that the value of palliative care has been recognised, nurse leaders play a central role in helping the team move towards a model of care that ensure specialist palliative care services are reserved for those with the most complex care needs (Quill & Abernethy 2013). At the local level this requires the dying patient's care team to: assume primary responsibility to provide a palliative approach; and recognise when referral to specialist palliative care is indicated. Nurse leaders outside of specialist palliative care foster the establishment of a palliative approach to care within their services by searching for opportunities and taking risks to make it happen whilst embracing innovation. These nurses are prepared to reach out to their nearest specialist palliative care team so that their: patients have access to appropriate care and support; and ‘clinical champions’, based within their services are provided with ongoing mentoring, support and palliative care educational opportunities. They recognise that establishing and investing in these strategic relationships makes it easier for the patient's usual care team, including those based in rural areas or aged care, to reach out and seek expert palliative care input and support to help them better manage the complex care needs of their dying patients.

Exemplary leaders actively search for opportunities to breakdown the ‘silos’ to ensure that palliative patients move seamlessly from the community, into acute or aged care and visa-versa. Nurses’ capacity to negotiate these complex care pathways is crucial to improving patients’ access to palliative care. Addressing these access barriers requires nurses to think creatively and to challenge the status quo. Nurse leaders working both within and outside of specialist palliative care recognise that the foundation for more sustainable palliative care models is mobilising communities and helping to build social networks for the dying person. These same nurses are instrumental in helping families navigate the bereavement period and to access the support they require.

Exemplary nurse leaders are vigilant that the treatment and palliative care provided within their service is in accordance with the best available evidence (Tieman et al. 2008). They invest in a range of point-of-care resources and create a culture that demands that patients receive the best palliative care that can be offered. These nurses are courageous, and openly and respectfully challenge care decisions that fall outside of the current evidence base.

Nurses who advocate via their professional organisations to develop palliative approach standards that address clinician-patient communication, advanced symptom management and advance care planning are leaders in their own right. They work to ensure that these standards are reflected in their health care organisations assessments, care plans and form an integral element of reporting health care quality.

Enable others to act

Exemplary nurse leaders in executive, clinical, educational and nursing research roles foster collaboration and strengthening others. Within their individual domains, they ensure that clinical nurses have the prerequisite capabilities to: manage uncomplicated pain, depression, anxiety and other symptoms, respond appropriately to suffering and discuss prognosis, care preferences and resuscitation choices with patients’ and their families (Quill & Abernethy 2013). Nurse leaders achieve this by strategically and systematically investing in palliative care continuing professional development programs. By appraising each individual nurses’ palliative approach capabilities and identifying the areas where they excel and the areas to be strengthened. By tailoring continuing professional development activities to individual learning needs and service priorities, these nurses are able to accelerate the teams’ capacity to provide a palliative approach. In the clinical setting, these nurses also take advantage of existing palliative care learning initiatives and link their clinical nurses into these opportunities. They also identify opportunities to promote the development of the palliative care Nurse Practitioner role and to support members of their nursing teams to move into these new positions. While, academic leaders ensure that the next generation of nurses are adequately prepared to provide a palliative approach by embedding appropriate content across the curricula (Ramjan et al. 2010).

Model the way

Exemplary nurse leaders create more accessible, equitable and sustainable models of palliative care by modelling the way, by clarifying values, setting goals and being an exemplar. By creating excellence they demonstrate that equitable and best evidence based palliative care is within reach for all. They seek opportunities to develop and strengthen palliative care policies at the national and local levels so that all patients have access to the best evidenced based and cost-effective palliative care. They effectively navigate their way through the bureaucracy so that it does not impede progress (Kouzes & Posner 2012). Nurse leaders at the executive level implement quality standards and systems that support the frequent conversations that the inter-professional team are required to have with palliative patients and their families, as well as one another. While clinical nurse leaders support their teams to have these difficult but necessary conversations which help patients avoid unwanted treatment and care. Clinical nurse leaders act as role models for other health professionals, especially junior doctors who during their specialist palliative care rotation often learn the specialties fundamentals through this mentoring. Nurses leaders create opportunities for the team to experience sustained progress and victory.

Encourage the heart

Exemplary nursing leaders at all levels of the health care system play a central role in inspiring others to provide competent and compassionate palliative care. They readily recognise the contribution of others, celebrate victories and applauding the use of values. They understand that the importance of celebrating accomplishments, especially given the huge effort require to achieve great outcomes (Kouzes & Posner 2012).

In essence, exemplary nursing leadership, at all levels of the health care system underpins quality palliative care, helps reduce disparities and improves palliative care outcomes for all. Nurse leaders understand that they will need to take risks, which often involves making mistakes. They turn these setbacks into learning opportunities and look for new ways of transforming end-of-life care. By embracing these leaderships qualities nurses will play a central role in ensuring that the World Health Assembly palliative care visions is actualised.