As we begin 2023, we must remain resolute in achieving one of the founding ambitions of palliative care, which is to enhance people’s quality of life (QOL) as they die. Nothing must sway us from achieving this goal, may it be the rising costs of living, global events such as climate change, the ongoing COVID-19 crisis, or the current reckless war on Ukraine. We must do all we can, as a professional people, to enhance patients’ QOL.
Harnessing potential
One of the many dimensions of community nursing is to provide end-of-life care at home. While this aspiration follows from the NHS strategy of empowering people to be cared for and to die in their place of choosing, it also creates challenges for community nurses (CNs) on the field. The challenges of providing such care, as highlighted by the Royal College of Nursing (RCN) in 2013 are still present today (RCN, 2013). To reiterate, ‘Harnessing the potential’ (RCN, 2013) reports that the percentage of CNs has remained almost static between 2001–2011 and yet, the clinical demands have increased each year. What was most worrying from this report was the claim that in 2012, only five students across London universities studied for the specialist practitioner district nursing course at undergraduate and postgraduate levels. While these numbers are only representative of London, it most likely reflects the entire country, and the impact this might have or is already having on care provision. The dangers of such education lapses is even more evident when we expect community nursing to provide palliative and end-of-life care. This link is important to remind each and everyone involved in community care, as death does not wait for a perfect time when resources are abundant; or when all nurses are educated and skilled; or when we have sufficient staff numbers to care for all patients. The challenge for CNs is that patients, and those deemed important to them, expect good care (despite all the difficulties) and afford enhanced QOL that ensures a unique and dignified death.
While the NHS works on the premise of empowering patients to be cared for at home, critics see another motivation; that of cost saving (as the money does not always follow the patient), and the evidence is overwhelming (RCN, 2013)—district nursing reduces long-term health-related costs and provides appropriate care that is driven by the needs of the patients.
The RCN has highlighted not only such clinical demands on CNs, but also the nature of difficulties encountered with problems of staff retention, sickness through stress and poor recruitment, and now threats of strikes, which negatively affect nursing objectives and targets of care.
With people living longer, there is an increase in long-term conditions and co-morbidities that require complex or expert nursing care being provided in their own homes in order to prevent unwanted hospital admissions. This serves two purposes: supporting the government’s NHS empowerment project of caring for people at home, while ensuring that end-of-life care is delivered at home. Therefore, there is an increasing and urgent need for community nursing expertise and confidence to provide such care consistently and effectively.
Quality of life
Although most of us in palliative care may claim to have a conception of QOL, in reality, it is elusive to clearly pin down. Yet, we make it one of the key outcomes of care for people at the end of life. This comment is too short to enter into a philosophical discussion, but it is important to highlight some of the characteristics CNs are expected to achieve for their patients to enhance QOL. The common unwritten rule is that QOL is subjective and encompasses some of the following:
- Being at peace with yourself
- Having the courage to accept the things that we cannot change
- Achieving a harmony from multidimensional aspects of physical, psychological, social and spiritual dimensions
- Satisfying cultural perspectives, own values, goals and personal expectations of what we want from this life
- Allowing our own interpretation of the same events (like death) that may be different from others
- Being accepted as we are without feeling the need to conform.
It is clear from the RCN’s position that CNs work under enormous pressures from many challenging issues; the government can help by making sure they are well supported, educated and trained. CNs play a pivotal role in achieving the wishes of the NHS; that is, to care for more people at home, including those at the end of life. CNs and their teams must not only be acknowledged and trained, but they must also be better rewarded.