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

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I am seated at the back of a conference room where 35 hospice and palliative care nurses are gathered to attend a course to promote leadership in their field. These nurses proudly present their accomplishments in developing programs, advocating for better access to opioids, integrating palliative care in nursing curricula, and transforming the care of patients at the time of death. Their presentations are inspirational; they are beaming with pride.


These nurses do not represent resource-rich environments, well-endowed programs, or major academic centers. These nurses are at an international End-of-Life Nursing Education Consortium course that has focused on very resource-poor countries. They come from countries where the roles of women and of nursing are often not respected and they have little voice. They care for impoverished populations of patients with tuberculosis, AIDS, malaria, and cancer. They live and work in communities with no opioids, no blood supply, and hospitals so overburdened that care is beyond our comprehension. And yet these nurses share the universal passion of hospice and palliative care nurses worldwide. They want better care for the seriously ill and dying.


These nurses are pioneers in their countries for palliative care. Some were taught in nursing schools only by physicians, as nurses are not yet recognized as being qualified to teach. They are grateful for this training course, as it is the first time they have been deemed worthy of such an investment of resources. The textbook we give them may be the first they have owned as a nurse.


And yet, I listen as they share their progress. They are eager to learn. A few are pursuing graduate degrees and will be among the first to do so in their countries. They share stories of progress but also setbacks such as unstable governments, economic crises, or epidemics that can wipe out years of progress.


And as I sit in this room watching and listening to these nurses proudly presenting their PowerPoint slides, they display an image on the screen that takes my breath away. It is a black and white photo of a small kitten, fragile and timid, looking into a small pool of water at its own reflection. But the reflection that the kitten sees is of a tiger-bold, large, powerful. The nurses conclude their presentation by encouraging their international colleagues to persist and be strong in their efforts. Above the photographic image they have now added the words "See the Tiger."


For yet another time, I find myself humbled by these nurses. I am once again learning and gaining much more from them than I can possibly give. We are here to teach leadership to a group of nurses who are beyond me on my best day. I can only hope that our presence and support will give them the strength to keep going.


These nurses are not only advancing palliative care, but also they are advancing the place of nursing for men and women in their countries, and they are remarkable agents of social change. They are caring for homosexual patients in countries where such sexual identity is illegal and brutally punished. They often work amid corruption, poverty, and inequality beyond measure. Yet, they also celebrate and thrive in the many good things in their countries-cultural values of family and community, slow but steady progress in nursing education, the opening of a first hospice. They rely on faith-particularly salient in that some of these nurses reside in countries where only recently has it been legal to practice religion.


Dr Mark Lazenby, a nurse researcher and ethicist, recently wrote a book, Toward a Better World: The Social Significance of Nursing, about nurses as moral agents of social change:


If I dwell on these, and other, dissonances of this time, I feel helpless. But I am not helpless. I am a nurse, and nurses are anything but helpless[horizontal ellipsis] Just as we are not helpless in our usual duties, I do not think that we should feel helpless with the dissonances of this, or any, time. Rather, I think that as nurses we have a duty to respond to the social ills of our time.


I look at these nurses standing under the screen, jubilant and proud, full of resolve to do more and I see the tiger.