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Original Article

Empowering Nurses to Meet Challenges and Lead Palliative Care for Achieving Triple Billion Targets

Department of Obstetrical and Gynaecological Nursing, Velankanni Matha College of Nursing, Kottayam, Kerala, India
Department of Palliative Medicine, Palliative Care Nursing, Mahatma Gandhi Medical College and Research Institute, Pillayarkuppam, Pondicherry, India
Department of Community Health Nursing, SIMET College of Nursing, Palakkad, Kerala, India
Corresponding author: Anu Savio Thelly, Nurse Consultant, Department of Palliative Medicine, Palliative Care Nursing, Mahatma Gandhi Medical College and Research Institute, Pillayarkuppam, Pondicherry, India.
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Mathew JM, Thelly AS, Antony L. Empowering nurses to meet challenges and lead palliative care for achieving triple billion targets. Indian J Palliat Care, doi: 10.25259/IJPC_56_2021



Nurses provide care to patients in all contexts and at all stages of their lives. Their contributions are crucial to meeting global goals like Universal Health Coverage (UHC) and the Sustainable Developmental Goals (SDG) which present challenges and opportunity to improve nursing services including rehabilitation and palliative care. This study identifies challenges for empowering nurses to lead palliative care and achieve triple billion targets’. Determine reasons for challenges to empower nurses. Recommends strategies to overcome challenges in order to empower nurses to lead palliative care and achieve triple billion targets’.

Materials and methods:

Multiple brainstorming sessions were conducted through the Zoom platform among the three authors to ‘identify challenges for empowering nurses to lead palliative care and achieve triple billion targets’ and recommend strategies to overcome those challenges. Narrative literature review was conducted and experts’ opinions were elicited. Identified aspects were discussed in further brainstorming sessions.


Challenges and reasons for empowering nurses to lead palliative care and achieve triple billion targets’ were identified and strategies to overcome those challenges were recommended.


Equitable, competent and compassionate palliative care is a primary tool to relieve serious health-related suffering. There is a pressing necessity to provide available, accessible, acceptable, quality, and cost-effective palliative nursing care. WHO proposed the triple billion targets to improve the health of billions where palliative care is an essential element that can be achieved only with proper identification of challenges and meticulous planning and implementation of strategies to overcome those challenges.


Palliative care nursing
Triple billion targets


As the population ages, there is an increased demand to provide more end-of-life care (EOLC) and respond to the challenges of providing palliative care to people with chronic long-term conditions and multiple comorbidities.[1] Sleeman et al. (2019) projected that the number of people who may die with serious health-related sufferings increases by approximately 87% by 2060,[2] making millions of families impoverished by catastrophic health expenditures as they lack financial risk protection.

Equitable, competent and compassionate palliative care is a primary tool to relieve serious health-related suffering for all people and populations everywhere.[3] The best long-term option is to obtain the services of a nurse in the neighbourhood and encourage them to take training in palliative care. Nurse-led home-care programmes can be started, and, in certain situations, nursing help might be available from a nearby palliative care unit using the nurses’ protocol as a guide for nurse-led home care (WHO, 2016).[4] The triple billion targets proposed to improve the health of billions by 2023 by the WHO (The triple billion targets, 2020).[5] The COVID-19 pandemic and response have had a global impact, causing a slew of healthcare issues, a looming economic downturn and humanitarian concerns. The epidemic has brought the long-standing demand for universal health coverage (UHC) into sharp focus due to changing needs. In the present pandemic, the triple billion targets should stress palliative care, especially for those suffering from COVID-19-related severe infections, who need more care and concern. The WHO proposes achieving the following goals by 2023, which can be reframed by including palliative care as follows:

  • One billion more people getting benefitted from UHC, where palliative care is an essential element

  • One billion more people protected from health emergencies where efforts are needed to integrate palliative care into emergency responses

  • One billion more people enjoy health and well-being where palliative care can support in preventing serious health-related suffering.

Role of nurses in achieving triple billion targets

There are 27.9 million nurses worldwide, with 19 million professional nurses who have completed 3–4 years of training and 6 million associate professional nurses who have completed 1–2 years of training.[6] According to the WHO’s Global Strategic Directions for Strengthening Nursing and Midwifery, need for ‘Accessible, affordable, acceptable, quality and cost-effective nursing and midwifery care for everyone, based on population requirements, in support of UHC and Sustainable Development Goals (SDG)’ (WHO: Global Strategic Directions for Strengthening).[7]

Availability of palliative care is still inequitable for many patients with serious chronic illnesses, even in a high-resource system. Despite the development of integrated programmes, trends in referral timeliness may not necessarily point in the direction of maximising palliative care benefits.[8] During COVID-19, both high- and low-resource system, both struggle with repurposing and reorienting their existing palliative care models for an unanticipated crisis. In managing and unfolding and next to the public health crisis, we must investigate how to adapt the skills associated with palliative care training, such as effective communication of patient and family goals, assistance with advance care planning, and tending to spiritual, existential, cultural and psychological needs.[9] This type of training will necessitate recognising nurses’ skills and expertise as palliative care teams that will allow palliative care nurses to refer and prescribe.

Because death can happen anywhere, at any time, it is fundamental that all nursing students, regardless of their future career path, receive EOLC training.[10] Providing palliative care education to both nurses and nursing students is crucial to improving the quality of healthcare along the continuum during COVID-19 and in the face of future health emergencies.[11]

The pressing necessity is to provide available, accessible, acceptable, quality, and cost-effective palliative care nursing care for all in need, wherever needed. There are numerous obstacles and challenges to overcome to reach this goal. This paper identifies a few reasons for these challenges and recommends strategies to overcome those challenges drafted after brainstorming in multiple sessions and by undertaking a literature review.


Multiple brainstorming sessions through the Zoom platform among the three authors were conducted to ‘identify challenges for empowering nurses and leading palliative care to achieve triple billion targets’ and recommend strategies to overcome those challenges. One of the authors, an experienced facilitator in brainstorming, was nominated as the facilitator for the current investigation. During the first session, the problem was discussed by all three authors. It was also decided to do a narrative literature review, seek experts’ opinions and present the findings in subsequent sessions. The facilitator allocated time and led the discussions and jotted down important points. Further, the authors discussed the identified aspects in two brainstorming sessions and summarised them into six challenges, reasons and recommendations below.


Challenge 1

Availability of palliative care services by trained nurses.


  • All nurses are responsible for delivering primary palliative care, but they cannot practice it unless they receive basic formal training in palliative care

  • Even if they receive formal training in palliative care, it would be challenging when added to the responsibilities of professionals who are already overloaded with clinical work. Furthermore, nurses are not overwhelmed to provide palliative care as its importance and need are not very well known or popular

  • Palliative care trained working nurses who are already overworked with day/night shift, and household responsibility may not find additional time to provide palliative care nursing in any other setting

  • Nurses need basic nursing knowledge to give individually tailored palliative care to patients with life-threatening illnesses and relatives. Yet, distinct levels of palliative care provision and corresponding palliative care nursing competencies are rarely defined, even in-service delivery guidelines

  • Lack of description of which core nursing competencies are the most related to each level of palliative care provision

  • There is no consensus on the amount of training needed, and most of the existing educational programmes are in English.


  1. Undertake a workforce planning activity to ensure sufficient nurses is available to meet the growing demand for nursing services in palliative care – estimation of population-based workforce planning in palliative care nursing for community-based palliative care at the local level

  2. An estimation of the availability of willing retired trained nurses/trained nurses who chose to be homemakers due to personal reasons in a community can be given additional training in palliative care. Formation of an organisation/association for retired nurses and empowering them to participate in palliative care services and social prescribing

  3. Global Integration of Palliative Nursing Education addresses serious health-related suffering at different levels, focusing on the primary level (community setting at the local level). Concerted efforts must be made at all levels in nursing schools, with extensive continuing education in palliative care nursing. EOLC could benefit from a programme incorporating hospice and palliative care principles into undergraduate and graduate nursing education (Parker, 2020)

  4. Mapping existing training programmes in palliative care nursing (all levels) to identify core competencies. Nursing competencies in palliative care, especially those more relevant to each level of palliative care provision, should be better outlined to enhance palliative care development, education, and practice[12]

  5. Establish a working group comprised members of the board of nursing and palliative care experts to identify the minimal level of palliative care competencies, knowledge and abilities, as well as years of dedication required to be recognised as a palliative care professional.[13] Development of sample curriculum for basic training (20–40 h) at the primary and community levels, intermediate-level training (60–80 h) at the secondary and tertiary levels, proficiency (specialised) training (3–6 months) to the specialised teams or palliative care units at the secondary and tertiary levels and provide undergraduate training in medical and nursing schools/colleges

  6. Establish community-level training centres to train palliative care volunteers/family caregivers/primary caregivers in each locality where nurses can take lead roles

  7. Ensure honorarium for palliative nursing care nurses working in additional capacity

  8. Cost-effective investment in expanding workforce in palliative care nursing, including required palliative care training, makes primary palliative care accessible to all community settings[14]

  9. Developing a team of palliative care volunteers in each locality to provide an extra layer of support to the primary caregivers/family caregivers, whom palliative care nurses can train

  10. Making palliative care nursing modules available in local languages

  11. Ensuring refresher courses every year for palliative nursing care consultants and palliative care nurses to update their knowledge.

Challenge 2

Access to palliative care assessed by morphine equivalent consumption of strong opioid analgesics.


  • The requirement that opioids can be prescribed only by medical doctors creates another bottleneck to provide palliative care

  • Lack of knowledge about the proper use of pain medication and palliative care, in general, is another significant barrier limiting the appropriate access to pain management in palliative care

  • The lack of nurse specialists, the nurse practitioner in palliative care who can prescribe pain medication is widening the gap.


  1. Empowering palliative care nurses/palliative nursing care consultants to renew doctors’ prescriptions, hold stock for patients or supervise community health workers by validated training

  2. Nurses are critical to any effort to curb opioid abuse and have the opportunity to educate patients about the risks of opioid diversion and provide information on how to safely store and dispose of opioids that are no longer needed.[15] To maximise the benefits of nursing contributions to pain management, nurses must have access to on-going training[16]

  3. Nurse practitioners have a professional responsibility to follow guidelines and be aware of best practices for safe opioid prescribing.[17] Thus, bringing policies and regulations and changing the law to allow nurses who complete special training in palliative medicine to prescribe morphine can be considered in Hospice Uganda to improve service coverage for pain relief.[18]

Challenge 3

Acceptable palliative care: Strategic integration of palliative care to other nursing specialities such as critical care nursing and community health nursing.


  • Incognizance of the benefits of quality palliative care, which can provide through other specialities

  • Conventional medicine is excellent at saving lives, but it may not address the physical, mental, and emotional distress associated with life-limiting diseases

  • Traditional intensive care unit (ICU) quality indicators do not always align with palliative care, even though palliative care is recommended to improve outcomes of dying ICU patients.[19]


  1. Palliative care training for nurses must include understanding significant unavoidable context issues in palliative care, such as specific cultural settings, patient-centred variables and family specificity

  2. Helping nursing students understand the concept of palliative nursing care introduces them to the wider horizons of rendering palliative care nursing services in a community set up, both in urban and rural areas

  3. Integrating palliative care in all nursing (nursing theory sessions and clinical experience) education programmes are crucial for increasing access to impeccable, comprehensive, and continuous palliative care for all. Students should have access to palliative care rotations to gain first-hand experience in a specialist palliative care setting and provide palliative care

  4. Development of context-specific, culturally sensitive training led by palliative care nurses in the regional language for community settings at the local level facilitates training the grassroots health workers and palliative care volunteers

  5. Ensure refresher courses for palliative care nurses/ palliative nursing care

  6. An integrative approach to palliative care in other settings will meet the needs of physical, mental, and emotional by creating a healing environment that supports patients, families, and healthcare professionals

  7. Consensus development and rigorous research in measuring palliative care to evaluate palliative care services in other nursing specialities.

Challenge 4

Reluctance to accept a referral for palliative care nursing services on the part of the patient and family.


  • A misconception that receiving palliative care means going to die soon

  • Ignorance of benefits and improvements in quality of life.


  1. As the benefits of early palliative care have been increasingly recognised, the potential benefits of early integrated palliative care have to be percolated among the general public through judicial use of social media

  2. Organising nurse-led public awareness programmes on palliative care in the local language, preferably with the participation of the general public

  3. Initiatives to associate with social and religious institutions as an agency to create public awareness and advocates of palliative care

  4. Sensitisation programmes on palliative care in different settings such as schools, colleges and public spaces by palliative care nurses, can improve awareness among the general public.

Challenge 5

Cost-effective palliative care.


  • Lack of evidence demonstrates the multiple benefits of nurse-led models/interventions for patients, services, and health systems

  • Nurses are not enabled, resourced, and supported to use their education and experience to their full potential leading to the waste of talent and resources

  • Lack of monitoring and evaluation/setting minimum standards for the WHO’s recommendations on palliative care training with special focus on palliative care nurses training.


  1. Nurse-led palliative care models have been shown to enhance patient outcomes, decrease hospital admissions and minimise healthcare expenditures[20]

  2. Provide funding to develop models that address existing palliative care services’ needs and facilitate dedicated nursing positions across rural/regional settings

  3. To guarantee optimal outcomes, funding to create education programmes and professional development is required to design, implement and evaluate evidence-based nurse-led models/interventions[20]

  4. When initiating a palliative care programme in a low- or middle-income country, nurses should be empowered to provide education and training for all health workers in the target area

  5. Training and empowering of willing retired trained nurses/trained nurses who chose to be homemakers due to personal reasons in palliative care nursing in the community at the local level

  6. Proposing a valuable instrument that identifies good nursing in different areas of palliative care while also establishing quality indicators to guide nursing practice entails recognising autonomy in care.[21]

Challenge 6

Lack of advocacy, policy, and behaviour changes for the recognition of palliative care nursing as a speciality.


  • Without a willing and available supervising physician, access to competent palliative nursing care is denied to patients, especially those located in rural or underserved areas

  • People’s focus is on curing illness rather than promoting health, so they undervalued the coordinated primary care provided through palliative care nursing

  • Economic invisibility – Conventionally, nursing services are treated as an expense rather than an income source on institutional/government balance sheets, perceiving that nurses are not revenue generators. Hence, they are underrepresented or excluded from the decision-making process. This asymmetrical financial treatment shifted the focus from the measurement and valuation of palliative care services

  • Less investment by the government in developing the palliative care nursing workforce, especially in primary levels.


  1. Palliative care nurses should be empowered to represent the patient and communicate on the patient’s behalf. The foundation of advocacy is the nurse-patient relationship

  2. Implement relevant policy, system, and legislative reforms to remove structural barriers that limit the scope of practice for nurses in palliative care, including referring to relevant services and prescribing appropriate treatments to ensure the best outcomes

  3. Fundamental policy shifts at the national and global levels to acknowledge what palliative care nurses can accomplish when given the tools they need

  4. Strategic planning to implement publicly funded, sustainable and palliative care services in international and interdisciplinary collaboration, as well as policy changes and the safe expansion of high-quality palliative care nursing services under UHC

  5. Including palliative care nursing as a component in evaluating palliative care services in healthcare quality indicators.


Worldwide, <20% of palliative care need is now met, mostly in the advanced democracies, although quality and service vary wildly even there. Within and outside of primary care, palliative care is still a growing ‘approach.’ In comparison to pulmonary, renal or cardiac medicine, it is a relatively recent speciality. There is a lack of good programmes on leadership, and mentorship in palliative care nursing which is necessary to build an optimal global health workforce. Governments in developing nations will need to put in a lot of effort and a complete paradigm shift to implement palliative care and strengthen their healthcare systems.[22] The need for a better understanding of palliative care nursing has never been greater than in today’s healthcare climate.


Providing compassionate and quality palliative care nursing that is appropriate and following the patient’s wishes is an essential component of palliative care nursing. As nurses, our ethical responsibility is to have active discussions with patients and family members and consider race, culture and basic understanding and knowledge of advance directives. The power of advocacy removes barriers to achieve the patient’s desired outcomes during palliative care nursing. The goals and targets should also include ending poverty, ensuring gender equality and empowerment, providing decent work, guaranteeing UHC and providing quality education to integrate palliative care nursing to ‘leave no one behind.’

Declaration of patient consent

Patient’s consent not required as there are no patients in this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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