The global nursing workforce: realising universal palliative care
Authors: William E Rosa, Eric L Krakauer, Paul E Farmer, Viola Karanja, Sheila Davis, Nigel Crisp, M R Rajagopal
Journal: The Lancet Global Health (2020)

Researchers estimate the number of people who will die with serious health-related suffering is projected to increase by approximately 87% by the year 2060.1Sleeman KE de Brito M Etkind S et al.The escalating global burden of serious health-related suffering: projections to 2060 by world regions, age groups, and health conditions.Lancet Glob Health. 2019; 7: e883-e892Summary Full Text Full Text PDF PubMed Scopus (123) Google Scholar Palliative care is the discipline devoted entirely to preventing and relieving serious health-related suffering. WHO has called for the universal accessibility of palliative care at all levels of health care and in the home because palliative care is an indispensable component of universal health coverage.2WHOStrengthening of palliative care as a component of comprehensive care throughout the life course.http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_R19-en.pdfDate: 2014Date accessed: January 21, 2020Google Scholar The report of the Lancet Commission on Palliative Care3Knaul FM Farmer PE Krakauer EL et al.Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report.Lancet. 2018; 391: 1391-1454Summary Full Text Full Text PDF PubMed Scopus (328) Google Scholar emphasised the need for cost-effective investment in expanding the capacity of palliative care, including required palliative care training for specialist and primary care clinicians, and task shifting to help make basic palliative care accessible in community settings. The purpose herein is to identify how global health-care systems can encourage the nursing workforce to implement the recommendations of the Lancet Commission and WHO guidance on palliative care.4WHOIntegrating palliative care and symptom relief into primary health care: a WHO guide for planners, implementers and managers.http://apps.who.int/medicinedocs/documents/s23558en/s23558en.pdfDate: 2018Date accessed: January 21, 2020Google Scholar Specifically, the skill set, experience, and perspectives of nurses are crucial to optimum palliative care policy development, strategic planning, service implementation, and research. The vision of WHO's Global Strategic Directions for Strengthening Nursing and Midwifery is "accessible, available, acceptable, quality and cost-effective nursing and midwifery care for all, based on population needs, in support of universal health coverage and the Sustainable Development Goals".5WHOGlobal strategic directions for strengthening nursing and midwifery 2016–2020.https://www.who.int/hrh/nursing_midwifery/global-strategic-midwifery2016-2020.pdf?ua=1Date: 2016Date accessed: January 21, 2020Google Scholar This vision indicates the indispensability of nursing to palliative care, especially in low-income and middle-income countries where this care is less accessible. WHO's declaration of the International Year of the Nurse and Midwife makes 2020 the ideal time to promote nursing contributions to palliative care policy, training, and services in low-income and middle-income countries. First, governmental and health ministry support of nurse optimisation initiatives, such as Nursing Now (based on the Triple Impact report6All-Party Parliamentary Group on Global HealthTriple impact: how developing nursing will improve health, promote gender equality and support economic growth.https://www.who.int/hrh/com-heeg/digital-APPG_triple-impact.pdf?ua=1Date: 2016Date accessed: December 16, 2019Google Scholar), is a crucial step. A programme of the Burdett Trust developed in collaboration with WHO and the International Council of Nurses, Nursing Now is a 3-year (2018–20) international campaign that aims to improve the health of the population by raising the profile and status of nursing globally.7WHONursing Now campaign.https://www.who.int/hrh/news/2018/nursing_now_campaign/en/Date: 2019Date accessed: December 16, 2019Google Scholar Campaign advocates call for increased contributions from nurses to policy making, greater investment in workforce development, recruitment of more nurses to positions of leadership, additional research that measures the effect of nursing in certain areas, and sharing of best practices across the profession. As the ability of nurses to influence care delivery increases, so does their opportunity to ensure the development and implementation of palliative care programmes throughout the illness trajectory. Second, there are models of education for palliative care nursing that can be readily adapted to the cultural, resource, and practical needs of varied international settings.8Ferrell B Buller H Paice J Anderson W Donesky D End-of-life nursing and education consortium communication curriculum for interdisciplinary palliative care teams.J Palliat Med. 2019; 22: 1082-1091Crossref PubMed Scopus (11) Google Scholar In Uganda, enabling nurses with 6 months of advanced training in pain relief and palliative care to prescribe morphine extended the reach of palliative care in the community throughout the country.3Knaul FM Farmer PE Krakauer EL et al.Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report.Lancet. 2018; 391: 1391-1454Summary Full Text Full Text PDF PubMed Scopus (328) Google Scholar Additionally, nurses briefly trained in palliative care in a major general hospital are able to identify patients with palliative care needs and request palliative care consultation, thereby improving access for hospitalised patients.9Downing J Batuli M Kivumbi G et al.A palliative care link nurse programme in Mulago Hospital, Uganda: an evaluation using mixed methods.BMC Palliat Care. 2016; 15: 40Crossref PubMed Scopus (21) Google Scholar In Vietnam, basic training in palliative care will soon be a required part of the undergraduate curriculum of a leading nursing school.10Krakauer EL Thinh DHQ Khanh QT et al.Palliative care in Vietnam: long-term partnerships yield increasing access.J Pain Symptom Manage. 2018; 55: S92-S95Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar Third, nurses in high-income countries must partner with colleagues in low-income and middle-income countries to exchange knowledge using respectful, inclusive, mutually beneficial, and sustainable mechanisms. These models have been established in Rwanda and Liberia through health-care capacity building initiatives and ventures with non-governmental organisations, such as Partners In Health.11Rosa WE Male MA Uwimana P et al.The advancement of palliative care in Rwanda: transnational partnerships and educational innovation.J Hosp Palliat Nurs. 2018; 20: 304-312Crossref PubMed Scopus (5) Google Scholar, 12Rosa WE Karanja V Kpoeh JDN Liberia's steps towards alleviating serious health-related suffering.Lancet Glob Health. 2019; 7e1489Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Long-term partnerships that meet the host country nurses' learning and practice needs are key to ensuring pragmatic solutions to palliative care delivery gaps locally and globally. Finally, nurses should be engaged as full interdisciplinary team members in the planning and delivery of patient-centred and family-centred palliative care. In addition, nurses can be valuable in advocacy for palliative care and the generation of much needed research. Nurses and midwives account for more than 50% of the health-care workforce in many countries and if universal palliative care access is to be realised, policy makers, ministries of health, and health system leadership must strategise nurses' intelligent deployment accordingly.3Knaul FM Farmer PE Krakauer EL et al.Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report.Lancet. 2018; 391: 1391-1454Summary Full Text Full Text PDF PubMed Scopus (328) Google Scholar Including nurses to an equivalent degree as other disciplines at all levels of palliative care implementation is foundational to palliative care philosophy and effectiveness. The international health-care system must prepare for a substantially increased prevalence of serious health-related suffering among all patients, particularly the poorest, the oldest, and those affected by dementia and dying from cancer.1Sleeman KE de Brito M Etkind S et al.The escalating global burden of serious health-related suffering: projections to 2060 by world regions, age groups, and health conditions.Lancet Glob Health. 2019; 7: e883-e892Summary Full Text Full Text PDF PubMed Scopus (123) Google Scholar Competent, equitable, and compassionate palliative care is a primary mechanism to relieve serious health-related suffering for all people and populations everywhere. The nursing workforce is a prime stakeholder in making high-quality palliative care accessible, especially for the rural poor, and an invaluable contributor to universal health coverage. We declare no competing interests.