Transformational Leadership: Empowering Palliative Care Nurses to Enhance the Quality of Care for Patients with Complex, Life Threatening Illness and their Families









A. Demographics/Professional Work History

1. Number of years in nursing:

2. Number of years in hospice/palliative care:

3. Do you work in Palliative Care full time:
No (how many hours per week )

4. Which of the following clinical settings do you work in? (check all that apply)
     Public NGO for profit

Outpatient clinic
     Public NGO for profit

     Public NGO for profit

Hospice in patient unit
     Public NGO for profit

     Public NGO for profit

5. Which of the following best describes your responsabilities? (check all that apply)
Bed side nurse
Others (please describe below)

6. Estimate the percentage of time you spend in the following activities per week. Please be careful that all the percentage added together should be 100%:
Providing clinical Palliative Care
Educating nurses and other healthcare providers about Palliative Care
Educating patients about Palliative Care
Educating family members about Palliative Care
Management/administrative responsibilities
Providing grief and bereavement services
Consulting with other healthcare providers about an actual or potential Palliative

Care patient
Participating/leading in Palliative Care rounds
Participating/leading the Palliative Care interdisciplinary meetings
Other (Please describe)

7. How confident are you in the following aspects of Palliative Nursing:

Clinical Area: Circle only one number for each.
0=Not at all Confident; 4= Very Confident
Pain Assessment 0 1 2 3 4
Pain Management 0 1 2 3 4
Symptom Assessment 0 1 2 3 4
Symptom Management 0 1 2 3 4
Nursing techniques 0 1 2 3 4
Care of Patients in the Final Hours 0 1 2 3 4
Communication with Patients/Families 0 1 2 3 4
Communication with other Professionals about Hospice/Palliative Care Patients 0 1 2 3 4
Spiritual Issues in Hospice/Palliative Care 0 1 2 3 4
Ethical Issues in Hospice/Palliative Care 0 1 2 3 4
Grief/Bereavement Support 0 1 2 3 4
Relationships and team dynamics 0 1 2 3 4

8. Please also rate your level of confidence in these areas of leadership in Palliative Care.

Circle only one number for each.
0=Not at all Confident; 4= Very Confident
Change management 0 1 2 3 4
Team Leadership/Interdisciplinary collaboration 0 1 2 3 4
Negociation and feed-back 0 1 2 3 4
Mentorship of/by nursing staff in Palliative Care 0 1 2 3 4
Advocacy for Palliative Care 0 1 2 3 4

9. Please also rate the following questions. Circle only one number for each question.

a) Overall, how important do you believe Palliative Care education is to your nursing practice?
Not Important
Very Important
0 1 2 3 4 5 6 7 8 9 10

b) How effective do you believe the nurses in your clinical setting are in caring for a dying patient?
Not Important
Very Important
0 1 2 3 4 5 6 7 8 9 10

c) How receptive do you believe your staff will be to increased EOL care education?
Not Important
Very Important
0 1 2 3 4 5 6 7 8 9 10

10. In the past 12-months, state the number of times you have:
Attended an international palliative care conference
Attended a national palliative care conference
Attended a local palliative care organization meeting
Participated in journal club
Written an article for publication in a journal
Spent time educating nursing students about palliative care

11. What barriers are most prominent in providing excellent palliative care at your institution? (Check all that apply)
Lack of educated nurses
Lack of educated physicians
Lack of funding to promote/provide palliative care
Lack of marketing of our program
Few referrals
Lack of understanding of patients/families regarding palliative care
Lack of support from administration
Lack of time, as I have so many other responsibilities, other than palliative care
Other barriers

12. What is your current experience in regard to leadership? What are you currently "leading?"

13. The one thing I would wish for to be able to better meet the needs of patients experiencing serious, life-threatening illness is:

14. If selected to attend this grant-funded leadership course, I agree to:
Complete and send in 6 and 12-month post-course evaluations electronically
I agree to attend and participate in 12 monthly SKYPE mentoring conference calls post-course

Project title

For this leadership program you will work for the next 12 months to develop a project.
Please give us information on your project:

1. Goal of the project

2. Objectives

3. Context / Niche of project development

4. Activities involved and time line

5. Resources: human and financial

6. Results (measurable)

7. Changes that will occur after the implementation of the project

8. Evaluation (how will you evaluate your project)

9. Explain how this project will develop you as a leader

Curriculum Vitae:
Recommendation letter: