A Tribute to the Indispensable RN on the Palliative Care Team

Registered nurses (RNs) are critical members of the palliative care interdisciplinary team caring for patients living with serious illness. They often spend more time with patients and family members than any other part of the team, playing an active role in meeting various needs.

As someone who was an RN for eight years before becoming an advanced practice nurse (APRN), I have a special affinity for palliative care nurses. In fact, one of my greatest professional joys is mentoring them. I strive to help RNs explore what sparks their joy, become leaders in their respective fields, and find ways to break through while encouraging self-advocacy.

This blog serves two purposes. First, I shed light on common sentiments reported to me by palliative care RNs to help those in different disciplines who are wearing different hats understand the role. Then, I shift to mentoring and offer four solutions to help RNs advocate for themselves, focus on professional development, and more.

Every month, I hold virtual office hours for palliative care RNs through the Center to Advance Palliative Care (CAPC). There’s no agenda. I invite attendees to log on, share their feelings, ask questions, listen to others, and chat. Occasionally, an administrator or leader joins us, but they just listen (which is good, so they hear the experiences of those participating on the call). The numbers of attendees vary, but the conversation is always enlightening and engaging.

Collectively, nurses report feeling they have answered a call and are thrilled to be working in palliative care, whether inpatient, in the clinic, or in the community setting. The palliative nursing role can vary from site to site, setting to setting, and even state to state. But regardless of their daily role, most nurses come to palliative care to make a meaningful contribution to patients and their communities, and are not disappointed.

However, a common concern voiced by nurses is feeling like they are being sidelined, which happens in both hospital and community settings. A nurse may say, “The team doesn’t seem to know what to do with me,” or “I’m usually left answering the phone or the pager, and I feel I’m not being utilized. I’m a registered nurse, not a secretary.”

They’re right. Nurses are highly educated professionals with diverse skill sets and much to offer. They want to contribute and use their training and skills. They want to do what they love and are prepared for: clinical work with patients. At the generalist level, they have completed a nursing program and passed the state licensure examination. When RNs who practice in palliative settings provide direct patient and family care, they may take on the role of educators for team or hospital staff, often wearing many hats as case managers and administrators, functioning in a variety of other nursing roles. RNs can provide a variety of services on the team within the realm of patient care, including triaging consults, post-acute care follow-up calls, advance care planning and goals of care discussions, symptom management assessments, and even leading family meetings.

However, as mentioned earlier, some nurses who attend virtual office hours are dismayed because they are not utilized to their full scope of practice. I often hear that palliative care teams that start with providers and other clinicians get in the mindset of “this is how we have always done it” and don’t know what to do with the RN role on a palliative care team. Therefore, the RNs get stuck answering the telephone when there is much more they can do to contribute to quality patient care and high-functioning team dynamics.

I have also had administrators tell me that some providers get territorial when sharing patients. I always remind my team that it is not my patient or their patient; it is a palliative patient, and we collectively care for them as a team. We each bring a unique skill set to the table, and it is important to highlight that and recognize each other for our work.

When nurses confide their frustrations to me either during virtual office hours or through personal mentoring, I encourage them to remember their backgrounds and training and follow-up with some reflection. Given how many nurses are reading this, I’d love to use the remainder of the space in this blog to provide some advice to those who may be feeling similarly.

If you are struggling in a situation where you’re not allowed to work up to the full scope of your practice, envision the role you would like to hold. What would you like to see yourself doing at work? Do you want to be more involved with patient care? Or do you prefer to work more in an administrative capacity? Some nurses feel education is their calling. Is that something you have considered? What are you capable of doing? What professional goals do you have? Do you want to go on to earn an advanced degree? Or is there another path that sounds more appealing to you?

The possibilities are endless. According to the HPNA, the position statement for RNs specific to palliative care includes assessment, diagnosis, outcome identification, planning, implementation, coordination of care, health teaching and health promotion, consultation, and evaluation. As a result, RNs can wear many hats: administrators, nurse navigators, care coordinators, triage nurses, educators, or bedside consultants who assess symptoms.

So, I encourage you to think about what brings you joy. We all went into nursing because it was a calling. No one goes into palliative care for a change of scenery. We felt compelled to become palliative nurses for a reason, and we must make the most of it—for ourselves, our patients, and their families. If this work teaches us anything, it is that life is too short to be doing anything other than what we love. So ensure that you are doing what sparks joy, is fulfilling, and at the end of the day you are proud of the contribution you have made.

Once you have a vision for yourself, it’s time to put that plan into practice, which starts by being a great self-advocate.

Ask to meet with your manager. You might start the conversation by stating that you want to work to the full scope of your license. Express your concerns, listen, and then ask to take on a few responsibilities that can help you achieve your goal. (Make sure to identify the responsibilities you think would be most helpful for your team prior to your meeting.) Be careful to frame your pitch as something that will not only help you but will benefit the team. Even if your manager only agrees to one or two responsibilities, that’s a start. You can take small steps, collect data, monitor outcomes, and come back at a later date, ready to take on more.

Unfortunately, nursing has a high burnout rate. You are already a valuable member of the team, and your manager will not want to lose you. Don’t be afraid to let them know what fulfills you. One of the great things about palliative care is that the field is still evolving, and you can say, “This is what I want to do, and this is how I can contribute to our team and to patient care.”

Though you may not have experienced this personally, it’s important to take action if you encounter other team members being territorial about patients. Palliative care, by definition, is multidisciplinary. Everyone has a stake in each patient. This is high-stress work; we must work together and have faith in each other. If you encounter territorialism, consider asking your colleague if you can participate in a joint visit. This will allow you to build rapport with this person, so they see you as a team player trying to do your job.

Even though I have been practicing as an APRN for 11 years, I personally love having someone join me for patient visits because I can learn a different approach and see how they perform certain tasks and interact with patients. I often pick up new techniques and incorporate them into my own practice, and I can ask for feedback from them on the encounter.

In order to truly meet our patients’ needs, we must always learn and sharpen our skills. I regularly remind nurses of Florence Nightingale’s famous quote, “Let us never consider ourselves finished nurses… we must be learning all of our lives.” With that goal in mind, nurses can attend workshops and meetings, participate in continuing education opportunities, and pursue certification through the Hospice and Palliative Credentialing Center (HPCC).

It’s important for nurses to take CAPC’s courses to further their clinical skills and earn Designation status. There’s a specific learning pathway created for RNs with its own CAPC Designation available, and many more courses that would be helpful for any RN in the field (and where continuing education credits can be earned). Besides your own professional development, having this experience is great to note during annual appraisals with your manager because it shows that you want to learn and grow.

I also encourage all palliative RNs to attend the End of Life Nursing Education Consortium (ELNEC) Train the Trainer courses. This is a fantastic way to show your commitment and dedication to the field. ELNEC was created by nurses for nurses, and since its conception, over 47,000 nurses and health care professionals have been trained in the modules of pain, symptom management, end-of-life, cultural and ethical issues, and communication. You can also take the modules back to your respective institutions as the expert and teach other health care professionals.

This can empower you and help you grow as a palliative care nurse.

The palliative care nurse is a true leader on the interprofessional team and is in an ideal position to establish practice standards, enhance education, and promote quality care. It is imperative for palliative care RNs to envision what they would like their role to be, find out what would bring the most job satisfaction, advocate for themselves, and help shape their job description. Within our evolving specialty, the possibilities of the nurse leader as an integral role on the team are endless. RNs belong at the heart of the palliative care team.

In addition to the advice outlined in this blog, CAPC has various additional resources for RNs:

• Registered Nursing Serious Illness Designation: Foundational Skills, a learning pathway that provides comprehensive online education in nursing practices to improve the quality of life for patients living with serious illnesses. Nurses can use Serious Illness Designation to demonstrate expertise in working with this patient population.
• Other learning pathways useful for RNs, which include a curated list of additional CAPC courses for RNs.
• The Evolving Role of the Palliative Registered Nurse, an upcoming webinar scheduled for April 4, 2024. It will also be available on demand.
• The Role of the Nurse of the Palliative Care Team, the monthly virtual office hours opportunity that I mentioned earlier. Join the next one on April 29, 2024.

Edited by Melissa Baron. Clinical review by Andrew Esch, MD, MBA.