1. Ferrell, Betty PhD, MA, FAAN, FPCN, CHPN

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The Power of Ten

Sigma Theta Tau, the international nursing honor society, recently published the 2nd edition of a book, The Power of Ten.1 Edited by Drs. Susan Hassmiller and Jennifer Mensik, the text presents their compilation of the top ten priorities in nursing. This list of priorities was created based on interviews of 50 national and international nursing leaders, inclusive of both very experienced nursing leaders as well as emerging leaders newer to the profession.


This is an excellent book and I would recommend it for anyone interested in the future of nursing in our complex, overburdened health system and diverse society. The issues raised by these authors are consistent with the Institute of Medicine's recommendations for the future of nursing.2


Following is a brief synopsis of the top ten priorities with some of my questions for you, the readers of JHPN (and members of HPNA), on the application to hospice and palliative nursing.


1. Educational Reform. This section suggests that nursing education must be retooled to educate nurses to be culturally competent; be prepared to participate on boards and serve in leadership positions; promote team leadership and participation skills; and create a community of life-long learners. Nurse leader Marilyn Chow points out that technology must be employed so that education is available in multiple on-demand formats to long-distance learners, online, with open courseware utilizing the expertise of scholars anywhere in the world and able to readily incorporate new research as it becomes available. Curriculums must be co-designed with students' consensus on what content is essential for baccalaureate and graduate nursing programs. Finally, education must stress human-centered, health-first care in partnership with the communities being served, with an eye towards the future including 24/7 virtual care, and telehealth. (pp. 4-8)



What are the greatest needs for educational reform in palliative nursing?


2. Academic Progression. Academic progression, a key recommendation in the 2010 IOM report on the future of nursing,2 is a term used to achieve a better educated nursing workforce. With a grant from the Robert Wood Johnson Foundation, the Tri-Council of Nursing tested four models of academic progression but none will be able to achieve the IOM goal that 80% of nurses achieve a bachelor's degree (BSN) by 2020. Nurse leader Pamela Thompson states that a fifth model that involves dual enrollment in community college and university (ADN and BSN) is showing greater promise but in order for it to succeed, supportive infrastructures with dedicated staff, sustainability plans, strong partnerships among the academic and practice communities, tuition benefits, schedule flexibility, supportive policies, and practice leaders will be critical. Academic institutions must be dedicated to assisting and ensuring smooth transitions for the nurse trying to attain a baccalaureate or higher degree. (pp. 29-35)



How can we as palliative care leaders, managers, and administrators support nurses in academic progression?


3. Diversity. Diversity is a key issue within the nursing population. The nursing workforce does not represent the diversity of our population and "healthcare disparities continue to affect the quality of health and care among populations with racial, ethnic, socioeconomic, sexual, and gender diversity." (p.44) Mission statements, support systems such an internal and community committees, dedicated and long-term budgets, leadership, more research to guide nurse leaders, long-term goals, and constant evaluation can help organizations ensure that their "rhetoric[horizontal ellipsis][their] words" match "the reality, [their] behavior" in how they render care to diverse populations. (Beverly Malone, p. 46-51) Nurse leader Adriana Perez states that ethnic minority faculty within educational institutions and in leadership positions and dedicated programs to recruit minority students are vital to increasing the number of minority nurses in practice today. (p.55)



How can we make the community of palliative care more diverse? How can we increase the diversity of those we serve?


4. Interprofessional Collaboration. The goal is to prepare nurses to render team-based care that is "coordinated and patient-directed-and then lead in fostering an environment that would not even imagine practicing without an interprofessional team" (p.62), creating and supporting clinical care models as the standard of care. Nurse leader Brenda Zierler states that although the nursing profession may embrace this model, the goal is to "successfully operationalize the concept." (p.67) Zierler adds that to do that education systems and training models that emphasize only technical knowledge and skills have to shift towards the science of team science and on different professionals working within a team to produce better outcomes. (p. 70) Additionally, Zierler states that barriers that prevent nurse team participation include time, confidence, and communication skills-"we need to educate and train nurses in team science across the learning continuum"-but we must first learn to "practice interprofessional collaboration[horizontal ellipsis] across education, practice, research, and policy[horizontal ellipsis]" (p.74).



We are fortunate in palliative care to work in a field that embraces interdisciplinary care. What models best support interprofessional palliative care?


5. Systems Thinking. Nurse leader Mary Naylor explains that "Systems thinking enables leaders to reframe their goals and responses to increasingly complex health issues." (p.85) Elements in this discussion include payment and economic models of healthcare in the US and understanding the politics in working internationally, the politics of systems, and the politics of advocating at the national level on behalf of the profession. Nurses must be educated in health policy and trained in advocacy, specifically leadership, authority, power, and competition. Nurse leader Suzanne Miyamoto states that only then can nurses "advocate for what is necessary to improve the state of health and healthcare nationally and globally." (p.81) "[horizontal ellipsis][N]urses should consider how the services they provide relate to the healthcare system-the efficiency and coordination of the care delivery system; the perspective of payers who finance care delivery; the type, amount, quality, and cost of services that they are providing; and whether the services are provided to all people. Not paying attention to these components of the healthcare system is akin to failing to pay attention to the person as a whole and only focusing on the disease." (Peter Buerbaus, p.84) Nurses are particularly well suited for the task of advancing a systems approach to healthcare-nurse scholars emphasize a holistic model to comprehensively address health challenges, creating nurse-led interventions that target individuals, family caregivers, and communities which are multidimensional in nature and focused on longer-term outcomes. (Mary Naylor, p.85)



How can nurses best impact health policy in what will likely be a time of changing national health care?


6. Voice of Nursing. "The voice of nursing must be spoken in a cohesive manner, regardless of the country in which a nurse practices." (p.92). Nurse leaders have the power to speak up and make decisions to affect health and the quality of life and specifically, quality healthcare. They also have the power to "encourage patients to undertake advocacy themselves and become agents of change." (p.101) Nurse leader Linda Burnes Bolton said: "If the doors to quality healthcare can't be opened, knock the doors down! Stand up and lead colleagues!" (p.99) Nurse leader Frances Hughes points out that in order to improve healthcare, nurses must understand how policy is made, participate in shaping policy, while always being aware of the "broader environment"- the "key players" (politicians and government officials); networks; and local, national, and international developments. (p.100) Hughes added that "Once the right people have been identified, the right message needs to be delivered". (p.101) "Nurses possess the bedside expertise, epidemiological knowledge, and problem-solving skills that legislators and local officials need to make informed decisions." (Jesse Kennedy, p.106) Good communication and interpersonal skills, arguments based on scientific issue-related knowledge, clear policy positions, supportive resources, "well-researched and well-placed articles," a political commitment and political skills to influence decisions, and strategic organizational alliances are all tools that will ensure the success of nurses' voices. (Frances Hughes, pp. 102-103).



How can you best use your voice to advocate for the seriously ill?


7. Global Stewardship. Nurse leader Judith Shamian points out that "stewardship" is defined by as "The responsible overseeing and protection of something considered worth caring for and preserving." (p. 120), while global stewardship is defined as "social responsibility and social justice, awareness of the natural environment surrounding us, interpersonal and intercultural understanding, and empathy for human suffering." (Elizabeth Holguin, p.118) How nurses can become involved in the global community? The answer is echoed in the topics above-nurses have to be involved in public policy, health policy, and public health. (Holguin, p.118). They need to be "allowed" and "encouraged" to speak up on "system issues" and become active in the making of public policy.



What are the most important issues of social justice in our field?


8. Practice Authority. This section deals with removing barriers that hinder APRN practice authority including practice law restrictions, reimbursement obstacles, and license portability across state lines, while suggesting other changes to enable APRN access to modern healthcare approached including telehealth. Laure Marino, Director of The Primary Care Center called the over-regulation of nurses a travesty: "It's a travesty that highly educated health professionals with rigorous training could be regulated to such a degree that they are actually prohibited from using their skills and knowledge." (p132) Marino suggests that nurses must become more active in the legislative process and advance the supporting data that APRN practice is a "safe, cost-effective model of care". (p.132)



Have you advocated for greater practice authority for palliative care?


9. Delivery of Care. Healthcare will look radically different by 2025. We must plan for the changes in nursing care and be ready to adapt care delivery methods. This will involve developing new nursing models that look beyond physician-led care that use technology, a focus on community care rather than acute care, retooling the nursing workforce, and supporting nurse leaders who advocate for a primary role in palliative care, end-of-life care, community health, and wellness care. Nurse leader Kathleen Sanford stated: "In the longer term, our success should be judged not by what we do to preserve current practices or elevate our profession, but by what we do to support and build the health of individuals, communities, and the world. That is, after all, the true definition of care delivery." (p.147) Andrea Tanner states that a Robert Wood Johnson Foundation-funded search for delivery of care models "found that 23 of the 24 most promising models 'elevated' the role of nurse from simply caregiver to 'integrator' of care (Joynt & Kimball, 2008)." (Tanner, p.150)



What would your vision be for palliative care in the year 2020? 2030?


10. Professional Handoff. This section discusses the need for mentorship, leaving a legacy and preparing our colleagues for professional leadership. As baby boomers retire, much nursing knowledge will be lost. It is critical, therefore, that all nurses mentor and seek to be mentored to share the knowledge gained in the course of their professional careers. Mentorship has been described as a "beautiful dance in which sometimes you lead and sometimes you follow," (Diana Ruiz, p.160) "inspiring and challenging[horizontal ellipsis][other nurses] to let go of the past and move forward with a greater, system-wide vision." (Ruiz, p.161) Ruiz continues: "Invest in others" and "be the spark that ignites others to be more, do more, and serve more." (p.160) The future of nursing depends on this passage of knowledge. Nurse leader Terrie Sterling counsels: "As nurses, we must place value on what we do from the bedside to the boardroom. Nurses are the keeper of the keys related to the public perception of this sacred profession, and we must challenge ourselves to share what is going well in our profession." (p.163) Finally, "As a member of the most trusted profession in America, each of us is responsible for the perception we leave behind[horizontal ellipsis]Whether in a clinical setting, classroom, or boardroom, the future of nursing rests with us. It is incumbent upon us to answer the call to serve as a catalyst for a positive nursing future[horizontal ellipsis]" (Sterling, p.165)



Who do you mentor? Who is your mentor?



This list of priorities for nursing published by Sigma Theta Tau is a very thoughtful summary of the challenges for the nursing profession. Each of these 10 priorities can be a springboard for conversations within our own palliative care community. What are your priorities?



Betty Ferrell, PhD, MA, FAAN, FPCN, CHPN






1. Institute of Medicine. (2011) The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. Retrieved from Accessed February 15, 2017. [Context Link]


2. Hassmiller S, Mensik J. The Power of Ten. (2017) Sigma Theta Tau International. [Context Link]