Nursingmanagementin palliative care * Jessica Corner Nurses, have from the very beginning, played a key role in the delivery of palliative care. In all settings of care; home, hospital, or hospice/ specialist palliative care units, nurses lead or participate in the care of patients with far- advanced illness. Two levels of specialist nurses exist, the first are nurses who have undergone post-qualification training in palliative care and who work in a variety of settings using skills gained from this. The second is a distinct role, that of ‘the nurse specialist’. The role of ‘the nurse specialist’ in palliative care developed in the UK from the early 1980’s, and was designed to make expert palliative care more widely available. The goal for specialist nurses was to pass on good practice in the control of symptoms such as pain, and to increase the proportion of patients realising the wish to die at home. Since these early beginnings there has been a rapid expansion in the number of nurse specialists and in specialist palliative care services. For example, in the UK there are now some 2000 specialist nurses funded by the charity Macmillan Cancer Relief, and the gov- ernment has made funding available to establish nurse specialists for patients with the most common cancers such as lung, breast and color- ectal cancer. The rapid expansion of nurse specialists in the UK has been excellent in allowing the provision of high quality services. Roles have largely been developed according to local needs and prio- rities, and in a somewhat ad hoc manner; there are, as a result, problems of role confusion, role overlap between similar posts, and the need for education, training and research into best practice. There is also a need for evidence from the range of existing service models about the particular contribution of nurses and evidence about outcomes for patients. My intention here is not to review all the literature pertinent to the role of nurses in palliative care, rather, to selectively explore how nurses’ input into patient management. Both levels of palliative care nursing are dis- cussed, at times interchangeably and at other times I will refer more specifically to the work of ‘the nurse specialist’. Nursing management in palliative care is explored under 2 themes: 1. The work of palliative care nurses. 2. The concept of nursing therapy and the contribution of nursing to the management of difficult symptoms. THE WORKOF NURSES IN PALLIATIVE CARE Care of patients with far advanced illness such as cancer, and dealing with death and dying is an in-escapable part of nurses’ work in all settings. The degree to which nurses have skills in palliative and terminal care varies, as does nurses’ confidence in dealing with issues such as talking openly about illness and dying, or in symptom management. Managing issues around death and dying is one of the most frequently cited sources of stress and difficulty for nurses and doctors in both acute and community settings. Recognition of the difficulties in caring for people who are dying led to the establishment of specialist palliative care nurses. Palliative care as a speciality has evolved rapidly over the last 40 years. There are now an array of services and facilities that exist across the range of health care settings: -- specialist in-patient facilities, -- services in acute hospitals, -- services to support people in their own homes, -- intermediate care, such as day and respite care. The two levels of specialist nursing can be ob- served in all of these settings. Most nurses who work in specialist palliative care facilities have undertaken post qualification training. There also exist in all these settings more advanced and independent ‘specialist nurses’. ‘The nurse specialist’ is an expert clinician who works with a caseload of patients and their families, offering consultancy over the management of patients’ problems, educating and supporting other staff involved in care of patients with advanced disease, and conducting research, or more importantly, implementing the findings from research. Often specialist nurses work solely with patients who have cancer since palliative care originated through the hospice movement which has primarily focused on meeting the needs of *This article is a reprint of ‘Nursing management in Palliative Care’ (Jessica Corner), European Journal of Cancer, Vol. 37, Suppl. 7 (2001):S289--S296.Rep- rinted with permission of the author and of the Federation of European Cancer Societies. Jessica Corner, The Royal Marsden NHS Trust, School of Nursing & Midwifery,University of Southampton,UK European Journal of Oncology Nursing (2003)7(2),83^90 & 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S1462-3889(02)00052-2