Abstract
The World Health Organization highlights significant disparities in access to palliative care (PC), especially in primary and community care. In France, ASALEE is an innovative national association that brings nurses and general practitioners in primary and community care. Initially created to address the support needs of patients living with chronic diseases, the nurses’ roles have expanded to include PC. However, despite the growing role of such interprofessional models, research on PC nurses’ activities and skills in primary and community care are underdeveloped. To identify, categorize, compare PC models in primary and community care and analyze them through nursing skills and activities, using the ASALEE PC link-nurses’ specific role as a comparator. A narrative literature review on studies published between 2017 and 2024 was performed. PC models were categorized using the Understanding Integrated Care Conceptual Framework. Extracted data on nursing activities and skills in PC were compared with those developed by ASALEE’s PC Support Group. This group is working on the integration of PC for patients in primary and community care. Twenty-one studies were selected. Searching on micro, meso, and macro levels, the review identified six key models of PC in primary and community care: integrative PC, health promotion-, community-, professional skills-, patient-centered, and end-of-life process-focused. These models emphasize inter-professional collaboration, informal caregivers’ involvement, community engagement, and patient partnership in PC support. The review provides insights into PC nurses’ activities and skills in primary and community care, particularly in terms of interpersonal relationships. The review is limited by heterogeneous study designs and contexts, which constrain generalizability, but, while partially transferable to the French healthcare system, these models require adaptations to be fully integrated. This review proposes perspectives for PC integration, future research, and to enhance ASALEE PC link-nurses’ practice and strengthen their collaboration with physicians, informal caregivers, and patients, in France and at the international level. This review identifies PC models, core nursing skills and activities, and collaborative practices that can guide future PC nurses in primary and community care, by proposing changes for their implementation.
Plain language summary
The World Health Organization notes many people lack access to palliative care, especially in community settings. In France, ASALEE is a program where nurses and family doctors work together in local health centers to support patients. While ASALEE nurses now help with palliative care, we need clearer understanding of their specific roles and skills.We reviewed 21 studies (2017-2024) on palliative care nursing models in primary and community care. We found six main approaches, all emphasizing teamwork between healthcare professionals, involving families and communities, and focusing on patients’ individual needs and life goals. These models show how nurses can effectively provide palliative care through activities like symptom management, emotional support, care coordination, and helping patients make informed decisions.While these models offer valuable insights, they need adaptation to fit different healthcare systems like France’s. This research helps identify how programs like ASALEE can better integrate palliative care into everyday community health services by clarifying the essential skills, activities, and collaborative practices nurses need to support patients with serious illnesses near the end of life.
Introduction
Palliative care (PC) improves quality of life for patients with serious illnesses and their families by alleviating suffering through early assessment and treatment of pain and other issues, whether physical, psychosocial, or spiritual. It also includes support for loved ones, particularly during the bereavement process. 1 Globally, 56.8 million people require PC each year, with 78% residing in low- or middle-income countries. 1 In higher-income countries, access disparities persist, particularly in rural areas where healthcare professionals are lacking. 2 The vast majority of healthcare professionals around the world have limited or insufficient knowledge about PC principles and practices.3,4 With growing needs because of aging populations and increasing prevalence of non-communicable diseases, national policies, resources, and tailored training are essential for expanding PC access.5–7 Early implementation of such care can also help reduce unnecessary and undesired hospitalizations. 8
Several local initiatives are promoting access to PC in primary and community care, which are key settings for earlier and more equitable integration of palliative approaches, especially for people with chronic, complex, and socially vulnerable conditions. Primary care refers to the first structured level of the healthcare system (“gate-keeper”), ensuring accessible, continuous, coordinated, and person-centered care, including prevention, health promotion, diagnosis, treatment, and long-term follow-up within a comprehensive and integrated approach.9–11 Community care requires a commitment from each community member (whether geographical or social) with an awareness of their belonging to the same group) in collective reflection on their individual and collective health and involves active participation of various stakeholders, including users, healthcare professionals, policymakers, and health and social organizations, to meet their priority health needs.12,13 Primary care and community care are holistic approaches that involve active participation of local populations in the planning, implementation, and evaluation of healthcare services.10,14 They cover a broad spectrum of activities, including prevention, health promotion, curative care, and PC, with a strong emphasis on equity and accessibility.10,14 Primary care and community care are particularly critical to reduce care access disparities, especially for patients with chronic, complex, or socially vulnerable situations. By relying on first-line, locally embedded services and community participation, primary and community care offer a promising lever to integrate PC earlier and more equitably in patients’ pathways. 15 In this context, nurses have a continuous presence, working with patients, families, general practitioners (GPs), community services, and their coordinating, educational, and holistic support roles make them key to delivering primary and community PC. Furthermore, nurses play a crucial role in collaboration with GPs in supporting PC patients, particularly in home-based care. In the United States, Canada, the United Kingdom, and Australia, nurse practitioners specialize in PC work in primary care or community care, offering care coordination, medical follow-up, psychosocial support, and education.16–19 Nevertheless, there is limited evidence regarding PC models within primary and community care settings. Few studies provided analyses and comparisons between models, and a few compared these models to real practice, particularly those focusing on nurses’ activities, and skills in primary and community care.20–23
In France, PC demand, especially at home, is increasing due to the aging population and a rise in chronic diseases. 24 The French healthcare system is experiencing a deep structural crisis.25,26 This is further exacerbated by growing inequalities in access to care and end-of-life (EOL) care. 27 This situation impacts both patients and their informal caregivers, whose needs are not fully satisfied. Healthcare providers are facing burnout, compassion fatigue and loss of meaning in their work. 28 The High Council for the Future of Health Insurance 29 has thus issued recommendations to reform local healthcare for greater equity. In this context, a ten-year national strategy to strengthen PC, pain management, and EOL support has been proposed. 30 Care or coordination networks and mobile hospital teams 31 are French services that have been created to meet the needs of populations in PC. These initiatives aim to ensure that PC is integrated into primary care and community care, thereby providing accessible home support to EOL patients and their informal caregivers.
In this context, the “ASALEE” association, 32 was founded in 2000 with a humanistic, patient-centered approach and the core value “The patient is the boss.” ASALEE created a GPs and public health nurses partnership to support patients with chronic conditions in primary and community care. “ASALEE nurses,” or population health nurse delegates, are located in GP surgeries and generally collaborate with five GPs. They offer patients personalized care based on their health needs (prevention, chronic illness, screening) while promoting their participation in the decision-making process. ASALEE became an official cooperation protocol in 2012, accredited by the French High Authority of Health. 33 The ASALEE association is currently restructuring to enable patients to join working groups and take part in the shared governance in 2026.
Since 2018, “ASALEE nurses” and GPs have been exploring PC development in primary care settings with patients and their informal caregivers, but a clear care model is lacking. The expansion of nurses’ roles into PC reflects the evolving needs of patients with chronic diseases. Indeed, patients’ conditions may worsen, and they may develop other progressive illnesses, requiring healthcare professionals to adapt their roles, activities (i.e., specific tasks, responsibilities, and interventions), and skills (i.e., performance and ability to apply knowledge in practice). Thus, the Palliative Care Support Working Group, composed of nurses, nurse practitioners, GPs, and a psychotherapist, was created to highlight inter-professional PC skills and activities. Within ASALEE, PC link-nurses have systematically described and consolidated their activities and skills in a dedicated working group, which provides a structured reference for comparing the nursing roles described in the literature with those developed in ASALEE. The working group conducted an inductive analysis of healthcare professional practices to identify activities and skills of PC link-nurses 34 in primary and community care within ASALEE (Supplemental Appendix 1). This work was based both on the regulatory frameworks governing skills and activities of registered nurses and advanced practice nurses in France35–38 and “ASALEE nurses’” job description (Supplemental Appendix 2). The term “PC link-nurse” was chosen to reflect the nurse’s bridging role between the care team, families, and institutions – without assuming the title of “referent” – inspired by a published study. 39 While this work focuses on nursing practice, a similar reflection is being carried out with GPs. From 2017 to 2024, 460 EOL patients were supported at home by 12 GPs-nurses’ teams from the working group, across France. To formalize and gain recognition for their reflective work on the activities and skills of ASALEE PC link-nurses (Supplemental Appendix 1), and thus help extend and generalize their roles, ASALEE nurses in the PC working group subsequently want to explore existing PC models that are similar to their own working context. In this review, a conceptual or theoretical care model is understood as a structured framework that describes key phenomena in a care context and guides practice, evaluation, and research. 40
In this context, we conducted a narrative literature review to identify PC models in primary and community care, classify them by model orientation, and compare the nursing activities and skills described in these models with those of ASALEE PC link-nurses.
The Understanding integrated care conceptual framework was used to classify the model’s orientation and to distinguish integration at the clinical (micro), professional and organizational (meso), and system (macro) levels. 41 This framework was selected because it explicitly links primary care with different levels of integration (clinical, professional/organizational, and system-level), providing a coherent structure to map heterogeneous PC models and to situate nursing activities and skills within micro, meso, and macro dynamics of care delivery. This review may thus inform the development of evidence-based models for integrating PC link-nurses’ skills and activities into primary and community care. It could also provide first outcomes to help healthcare professionals and policymakers develop practical recommendations in this area.
Methods
Research questions
The PICO research questions were: What are the PC models in primary care and community care (Intervention) for the support of patients (Population)? In these models, what are nurses’ activities and skills (Outcomes) compared to those defined by ASALEE PC Support Group (Comparison)?
Search strategy
A narrative review was used since it allows flexible, in-depth synthesis and interpretation of complex findings. Two reviewers (L.C. and J.C.) conducted electronic searches on Embase, PubMed, and CINAHL databases. The search equation (specified in Supplemental Appendix 2) was defined by L.S., J.C., N.M., and the librarian of the National Center for Palliative and End-of-Life Care. Studies published between December 2017 and December 2023 were included, with an update in April 2024. As PC models in primary care and community care are a recent topic, few papers have been published before 2017. A pearl-growing search and a key author search have also been conducted to be as exhaustive as possible.
Screening and eligibility criteria
Articles, gray literature (national and international reports, posters, editorials, and conference presentations on the HAL and WHO websites, French Ministry of Health documents, international and French learned societies’ websites, were included if they were: published between 2017 and 2024; in English or French; accessible in open source or via university library. They were excluded if they were: written in a language other than French or English; not available in full text; described or analyzed only healthcare organization or management model.
Two reviewers (L.S. and J.C.) screened titles and abstracts independently. If the paper met the inclusion criteria, the full paper was obtained and analyzed by them and N.M. for inclusion. In case of disagreement, at each stage, reviewers discussed until reaching a consensus.
Data extraction, summary, and analysis
One reviewer (L.S.) extracted data and the second one (J.C.) verified them. For each included paper, the following data were extracted: authors, title, year of publication, population, theoretical model, framework or concept background, and the description of nurses’ activities and skills in the model. An inductive categorization with Understanding integrated care’s conceptual framework 41 was done with each model’s full description as a unit of analysis. L.S. and J.C. independently coded relevant text segments describing models’ elements, nurses’ activities, and skills from which models’ orientation categorization was derived. Findings were compiled in a summary table on Excel®, and disagreements about coding or categorization were resolved through discussion with L.S., J.C., and N.M.
Qualitative studies’ methodological rigor was appraised using Mixed Methods Appraisal Tool (MMAT) criteria. For systematic, narrative, and integrative reviews, we conducted a narrative critique focusing on the studies’ rigor. Although we did not apply a standardized checklist such as the JBI appraisal tools, our narrative critique was based on similar domains (rigor of methods, transparency, and relevance to practice). For descriptive and conceptual studies, we narratively assessed their contribution to PC in primary and community care practice, considering conceptual clarity, internal coherence, grounding in the existing literature, and explicitness of implications for practice and policy.
Search outcomes and analysis
This narrative review aimed to identify PC models in primary and community care, with a specific focus on nurses’ activities and skills compared with those defined by ASALEE PC Support Group. Thus, for each article, L.S. and J.C. compared the highlighted nursing activities and skills with those defined by ASALEE PC Support Group. Comparison (common points and differences) of nurses’ activities and skills is presented in Table 1.
Comparison of nurses’ skills and activities between the literature and ASALEE.
Authors didn’t explain nurses’ skills and activities in their study, so the comparison is not applicable.
PC: palliative care.
Results
Articles selection process
Figure 1 shows the literature review flow chart with the different selection steps. In total, 970 articles were identified. After removing duplicates, 23 were screened based on titles and abstracts. Seven were retained for full-text analysis. 14 articles were added to the selection by pearl-growing search (screening bibliographic references of the articles and their associated references), and key author search. Finally, 21 articles were included.
Literature review flow chart.
Articles’ characteristics and quality
Table 1 provides an overview of the included studies, their characteristics, and a comprehensive description. It includes two systematic reviews,39,42 three integrative reviews,43–45 seven qualitative studies,20,46–51 one narrative review, 52 seven descriptions of conceptual framework or theoretical framework or model,53–59 and one scoping review. 60 Studies were conducted across 39 countries (Table 1).
Selected studies demonstrate generally high methodological quality (Table 2; Supplemental Appendix 3). Qualitative studies20,46–51 are explicitly described as rigorous according to MMAT 61 criteria, ensuring the credibility and transferability of results in PC research. Systematic, narrative, and integrative reviews39,42–45,52,60 stand out for the structure of their protocol, transparency of selection criteria, and thorough synthesis of the field, but the systematic formalization of critical appraisal, as highlighted by Sawyer et al., can be lacking in two of them.43,52 Descriptive and conceptual studies53–59 make strong theoretical contributions that provide an international context and aim to advance the community approach and reflection in the field of PC. In some cases, however, the diversity of models and heterogeneity of practices limit the generalization of the conclusions.
In summary, while most of the works cited are rigorous and can be widely used as references to strengthen practice and reflection, caution is warranted regarding the strength of evidence on models’ effectiveness and the lack of systematic critical appraisal in two reviews and descriptive studies.
Several included articles did not provide explicit descriptions of nurses’ activities and skills (“not specified” in Table 1). These studies were nevertheless retained because they contributed essential elements to the conceptualization and contextualization of community and health-promotion models (e.g., compassionate communities, compassionate cities, social capital), which form the macro-level environment within which primary palliative nursing practice develops. In the analysis, such studies informed the classification and description of models, whereas only studies detailing nursing roles were used for the direct comparison of nurses’ activities and skills with ASALEE PC link-nurses.
Topics identified
Of the 21 studies, 6 topics were identified (Table 1) and classified with the Understanding Integrated Care Framework 41 before comparison: For each topic, we first describe the PC models and then summarize the nurses’ activities and skills when they are specified in the sources. The detailed comparison between these activities and skills and those of ASALEE PC link-nurses is presented in Table 1 and further interpreted in the section “Discussion.”
All levels: one study is an integrated PC across all of the health system levels 39 and allowed to classify topics according to these levels.
Macro level: three studies are health promotion centered,20,43,44 nine studies are community centered.20,42,44,45,48,54,56,59,60
Meso level: two studies are professionals’ skills-centered.46,52
Micro level: six studies are patient-centered.47,49–51,53,55 Finally, two studies are focused on EOL process: death, “good death” 48 or “peaceful death” 58 involving healthcare professionals and nurses’ skills.
Integrative palliative care
This model (Table 1), initially developed in the Understanding Integrated Care Conceptual Framework by Valentijn, 41 is applied by Court and Oliver 39 in PC integration at all healthcare system levels: macro (system integration), meso (organizational and professional integration), and micro (clinical integration). It ensures that patients with life-threatening illnesses receive comprehensive care that meets their needs and integrates both patient-centered and population-centered PC. Integrated PC model involves collaboration between various healthcare providers (physicians, nurses, community health workers) and services (in the community, in the hospital), ensuring continuity of care, from diagnosis to EOL, including bereavement support for families. The goal is to provide coordinated patient-centered care to improve the quality of life of patients and their families.
Nurses’ skills and activities
In primary care, specifically trained “link-nurses” provide generalist PC to patients with life-threatening and complex needs, support other staff through training in a palliative approach, and serve as reference professionals for patients and services. They also identify situations requiring specialist PC and refer patients to specialist PC teams when needed. 39
Health promotion palliative care models
Health promotion palliative care models (HPPC; Table 1) are a theoretical framework encouraging individuals and communities to adopt health-promoting behaviors and care for their well-being.20,43,44 It emphasizes health prevention and promotion rather than simply treatment. Rooted in the 1986 Ottawa Charter, 62 it highlights the need for community action, personal skill development, and supportive environments. 43 Evidence later showed that community involvement improves health, which led Kellehear, in 1999, to promote a public health approach to PC, recognizing the central role of close relations in supporting people at the EOL or in bereavement.43,44
Nurses’ skills and activities
Across HPPC models, Leclerc-Loiselle et al. describe home PC care nurses’ activities and how nurses play a central role in holistic support, combining empowerment and health promotion with relational skills (listening, trust partnership), emotional support, education and communication about illness at EOL, advocacy, and interprofessional-community collaboration. 44 In their conceptual work, 20 they emphasize nurses’ reflexive and creative practice in caring for dying individuals, being attentive to patients’ values, viewing them as both capable and vulnerable. Sawyer et al., although situated within a health promotion perspective, do not specify nursing roles or activities in their study. 43
Communities models
These holistic approaches include social, spiritual, emotional, and economic dimensions, especially for underserved populations.42,45,54,56,57,59,60
Neighbourhood Network in Palliative Care (NNPC), launched in Kerala, illustrates how strong community mobilization and trained volunteers’ active participation can deliver free home-based PC, with chronic disease framed as a social issue involving both medical and community responses. 59
In the 2000s, Compassionate Communities extended Kellehear’s HPPC model 44 and later adapted this into the Compassionate Cities model, 56 expanding these principles and arguing that quality of life at EOL depends not just on clinical support but on social relationships, civic involvement, practical caregiving, and shared knowledge. The integration of volunteers, local leaders, and families forms networks for emotional, practical, and bereavement support, and fosters public dialogue on death and dying. The Compassionate Cities model further emphasizes collective responsibility, encouraging schools, municipalities, and local organizations to become active agents in normalizing and responding to issues of death and grief. Kellehear 56 describes this as changing the cultural paradigm from medicalized to socially and existentially informed experiences. Systematic reviews42,60 note the lack of robust program evaluation and call for more data on impacts. However, they do highlight that the leadership and hidden coordination often provided by healthcare professionals, including nurses, drive these initiatives.
Nurses’ skills and activities
While many models42,54,56,57,60 do not specify nurses’ professional scope, several studies44,45,60 highlight their potential contributions in care coordination, volunteer training, community engagement, advocacy, and relational trust. Cross 45 highlights nurses’ involvement in community-based participatory PC research, while in the NNPC model, Sallnow et al. 59 describe nurses providing home-based care according to patient needs and working directly with neighborhood networks. These roles remain largely underrepresented but are increasingly recognized as essential in these frameworks.
Professional’s skills-centered models
Models such as those developed by Curtis et al. 46 and Sanders et al., 52 provide a structured framework listing the essential skills for high-quality EOL and PC. In identifying key domains, they include effective communication with patients and families, emotional support, continuity and accessibility of care, clinical skills, respect for patient values, interprofessional coordination, therapeutic education, personalization of care, symptom management, family inclusion, and support in decision-making. They emphasize the importance of adapting care to each individual, building trust, and fostering collaboration among healthcare professionals to holistically address the needs of the patients and their loved ones at EOL.
Nurses’ skills and activities
In professionals’ skills-centered models, Sanders et al. 52 focus on communication and Curtis et al. 46 on physicians’ skills for high-quality EOL care. Primary and community PC nursing skills and activities were not described in these studies.
Patient-centered models
Amartya Sen’s capabilities approach, 55 Nolan and Mock’s integrity of the human person framework, 53 Sinclair’s patient compassion model, 47 Hemberg and Bergdahl’s staircase model, 50 Chan’s social capital theory, 49 and Aworinde’s EMBED-Care model, 51 all emphasize a care approach that places the experience, values, and unique individual’s needs at the center of EOL and PC pathways.
Nurses’ skills and activities
Nolan and Mock’s framework 53 proposes a holistic approach to EOL care, integrating spiritual, psychological, physical, and functional dimensions, with nurses playing a key role in facilitating dialogue regarding their values and preserving decision-making autonomy until the EOL. Hemberg and Bergdahl 50 highlight the importance of co-creation in the PC relationship, enabling joint navigation of ethical and existential challenges, through attentive presence, active listening, mediation, and emotional support to encourage patient autonomy. Amartya Sen’s capabilities approach, 55 conceptualizes complex nursing action as transforming available resources into genuine freedoms, so that the cared-for person may “be and do” what they have reason to value, through engagement, contextual adaptation, and the creation of enabling environments. Nurses are involved in public health policies and collaborative health approaches with patients in a unique relationship, and they facilitate the conversion of resources into capability. Sinclair’s model 47 adds a dimension of relational virtue: deep understanding of the person, authentic communication, and personalized responses to patients’ suffering are central and supported by nursing compassion through a close, reciprocal relationship. Nursing skills include emotional intelligence, relational adaptability, subtle patients’ cues, and proactive action.
Chan et al. 49 and Aworinde et al. 51 did not specify nurses’ skills and activities in their studies. Social capital theory 49 reframes PC as a relational and community-based process, where trust, reciprocity, and close relationships help counter isolation and foster collaboration between families and professional teams. Professionals must draw on advanced relational skills, nuanced communication, and adaptability, all within an empowerment approach. The EMBED-Care model 51 promotes a holistic and collaborative approach to enhance shared-decision-making in PC and introduces collaborative tools for needs assessment and decision support, including sensitive communication and cultural adaptation for people living with dementia, thus reinforcing assessment, mediation, supporting dialogue, and ensuring that care is aligned with the patient’s and relatives’ priorities.
EOL process-focused models
Both the “Good Death” conceptual model, by Veillette, 48 and the Peaceful End of Life Theory, applied by Minanton 58 in the Indonesian Muslim context, propose a holistic approach to EOL care, encompassing physical, spiritual, social, and emotional dimensions. They highlight the importance of maintaining quality of life, dignity, comfort, inner peace, and being surrounded by loved ones.
Nurses’ skills and activities
While professional skills are not explicitly detailed, the models reflect key practices in community-based palliative nursing, such as attentive listening, continuity of care, respect for personal beliefs, and adaptation to cultural values, emphasizing the need for contextual sensitivity and comprehensive support at the EOL.
Discussion
This narrative literature review identifies, categorizes, and compares several PC models in primary and community care, and analyzes them through nursing skills, using ASALEE PC link-nurses’ specific role as a comparator. The diversity of integrative, health promotion-centered, community-centered, professional skills-centered, patient-centered, and EOL process-focused models reflects the complexity and richness of primary and community PC. This provides a useful basis for understanding nursing practice in these settings.
Interpretation of findings in ASALEE context
These models are complementary but not exclusive: their integration supports a coherent PC offer across all levels of the healthcare system, as proposed in the integrative PC model. 39 This model provides a transversal framework for embedding PC throughout systems and improving ASALEE PC link-nurses’ skills in primary care. Central components, such as “generalist PC” and the “link-nurses” role, mirror ASALEE PC link-nurses’ core activities and skills, such as coordinating patient referrals, supporting peers’ upskilling through supervision and mentorship, and systematically integrating PC principles into routine practice. Furthermore, system-wide collaboration and continuity of care, as emphasized by this model, offer structured mission design and comprehensive skill frameworks for ASALEE PC link-nurses, strengthening their contribution to integrated care pathways. 39
A first complementary axis emerges at the macro level in the articulation between systemic vision and local adaptability. HPPC20,43,44 and community-centered models42,45,54,56,57,59,60 embed PC within health system structures while recognizing that meaningful implementation depends on local dynamics, especially when supported by community engagement.45,54,59 This requires that nurses mobilize not only clinical skills but also adaptability, contextual analysis, and mediation between policy, organizations, and individual lives. For ASALEE, these models offer concrete strategies to expand its action, encouraging nurses to adopt broader roles: facilitating health education, promoting patient autonomy, strengthening family and community networks, and engaging with local stakeholders around EOL issues. Integrating these approaches into ASALEE practice can enhance the PC link-nurses’ capacity to support patients’ well-being, coordinate home-based care with community resources, develop a culturally adapted support system, while fostering a proactive, health-promoting approach to PC.20,44 This may improve the accessibility, equity, and quality of support for patients and their relatives throughout the PC pathway.
Professional’s skills-centered models52,46 describe a set of PC skills for GPs and healthcare professionals at the meso level. It offers perspectives for developing and assessing ASALEE PC link-nurses and GPs’ skills involved in primary PC. They serve to formalize training requirements, guide ongoing improvement, and reinforce the ASALEE team’s role as coordinators and key contacts for clinical and relational care.
At the micro level, patient-centered models and EOL process-focused models demand nuanced, responsive, and individualized practice, emphasizing ethical deliberation, communication about values and goals, and support for families throughout the EOL trajectory. Together, these models invite considerate skills and activities as a dynamic adaptation: ASALEE link-nurses are expected to move between roles of expert clinician, facilitator, advocate, educator and, at times, community leader. That appears essential to high-quality PC in primary and community care. By integrating these patient-centered principles into their practice, ASALEE link-nurses can reinforce personalization, ethical rigor, and relational quality for holistic support in primary and community PC. Across all models, relational and communication skills46,47,50,52,53,55 emerge as transversal and arguably foundational skills. Whether supporting autonomy,53,55 managing existential distress,48,50 normalizing EOL discussions or fostering inter-professional and community collaboration,45,47,48,52 nurses’ ability to build trust, listen, to show compassion, co-create care, and advocate for patients and families is pivotal. In ASALEE, this translates into advanced relational work, navigating between direct care, patient/family empowerment, and facilitating shared decision-making.20,47,51 This relational expertise allows adaptation to the singularity of each patient’s needs, values, and context, an aspect strongly developed in patient-centered and EOL process models.47,48,53,55,58
Leadership and community facilitation, often implicit, deserve renewed attention. Nurses are repeatedly positioned as potential leaders not only of clinical interventions but also of volunteer coordination, community education, systemic integration, and the participatory research’s initiation.39,43,45,59,60 Their innovative capacity, such as adapting “link-nurse” functions 39 or integrating social capital approaches, 49 makes them central to effective model articulation in practice. Professional skills models52,46 further call for leadership through interprofessional coordination and the stewardship of dynamic, personalized care trajectories.
However, implementation barriers persist: community-centered approaches require robust volunteer infrastructure,42,59,63,64 which are not always available in France 30 ; concepts (i.e., “good death” 48 ) may conflict with individual patient narratives 20 ; Peaceful End of Life Theory, 58 developed in and for Muslim contexts, would require adaptation in more secular or pluralistic environments and system integration efforts hinge on institutional readiness and ongoing professional development.
In summary, in other contexts such as ASALEE, articulating these models requires judicious combination by leveraging system-level frameworks while foregrounding skills like patient partnership, leadership, contextual adaptation, and relational skills, while continually reassessing role adaptation to local needs and resources. This synthesis supports a primary and community PC model that is integrative and sustainable, in a critical and reflective approach.
Implications for nurses’ roles
In PC models within primary and community healthcare, interprofessional collaboration is a fundamental principle, promoting comprehensive and coordinated care for patients and their families. While nurses are mentioned in several models,39,45,47,48,57–59 their activities and nursing skills are rarely central to the models analyzed, with the exception of those by Leclerc-Loiselle, 55 Hemberg and Bergdahl, 50 and Nolan and Mock. 53 This relative invisibility can be attributed to an interprofessional approach of PC in primary and community settings, where roles tend to be presented collectively, thereby obscuring the specificity of nursing practice. However, this trend raises a challenge for the nursing discipline, as it risks undermining the recognition and appreciation of its unique skills.
The comparative analysis of the models nonetheless highlights several common skills with ASALEE link-nurses, notably:
Advanced relational skills: models emphasize the nurses’ ability to establish deep and trusting relationships with patients and their families, referred to as: “deep co-creative relationships,” “deep trustful caring relationship,” “close relationship,” 50 “meaningful relationship,” 55 “close or intimate relationship,” 58 “deliberative model” for relationship, 53 and “compassion model.” 47
Clinical skills in symptom management vary according to the nurse’s level of training.44,53,58
Coordination skills: nurses play a pivotal role in coordinating care pathways, particularly in integrative PC models 39 and HPPC. 44
Health education and advocacy skills: nurses are involved in educating patients and families, as well as advocating for their rights and needs, as illustrated in the HPPC 44 or Amartya Sen’s capabilities. 55
These various nursing skills have already been described in the international literature on PC in primary and community settings.65–71 Such studies could therefore contribute to the development of activities and skills for ASALEE PC link-nurses.
Finally, ASALEE PC link-nurses play a crucial role in integrating PC at various levels of the healthcare system 39 :
- Micro level: direct support for patients and their loved ones, daily coordination of care.
- Meso level: facilitating and coordinating multi-professional teams, developing local networks, organizing interprofessional training, and conducting analyses of professional practices.
- Macro level: contributing to the development of a new PC service in primary care in France within the ASALEE framework, in collaboration with GPs, and developing advanced research on this theme.
Exploring these levels highlights the importance of nursing leadership, demonstrating the nurse’s ability to initiate and coordinate collective dynamics, represent the voice of patients and teams, and promote innovation in care organization. 72 Within ASALEE PC, further developing their political leadership could enable the PC link-nurses to contribute to health policies’ development, participate in institutional working groups, and integrate PC into primary and community care within national strategies.
However, this leadership and the associated skills remain under-documented in the literature, even though they are essential to address current challenges for PC’s integration.
Strengths and limitations
This is one of the first reviews that aims to identify PC models with a focus on nursing activities and skills in primary and community care. The outcomes highlighted six models of PC in primary or community settings.
One limitation is that we restricted publication dates for the review, knowing that this is a recent research field. Nevertheless, previous and princeps articles were included through citations and author tracking. We manually searched additional studies cited in the list of references of selected articles.
Despite the methodological rigor in the selection and analysis of studies, certain limitations remain. The absence of a systematic critical appraisal for two included articles43,52 and six descriptive reviews,53–59 limits the overall robustness of the conclusions. Moreover, models’ heterogeneity and study contexts, as well as the variability in the level of evidence, make it difficult to generalize the findings to other contexts, necessitating cautious interpretation and underscoring the need for more robust comparative studies in the field.
Finally, the keywords in the MeSH were chosen to perform an exhaustive search across databases, but this may have potentially limited the results.
These limitations may affect the generalizability and transferability of the proposed interpretation to other primary and community care contexts and underline the need for further empirical testing.
Perspectives
The models analyzed in this review, although originating from different contexts, offer conceptual and practical frameworks for developing integrated PC in primary and community care settings in France and internationally.
First, strengthening interprofessional collaboration and nursing practice emerges as a central perspective for primary PC: beyond specialist PC teams, primary care professionals (nurses, GPs, and other providers) need structured frameworks to coordinate care, share decisions, and link hospital and community services across trajectories of advanced illness. Developing training programs that support emotional skills, communication about EOL, and teamwork skills could help primary care nurses take on expanded roles in assessment, coordination, and support, building on international experiences with advanced practice nursing in PC.
Second, patient empowerment models, such as Amartya Sen’s capabilities approach, provide a promising lens to analyze and strengthen how nurses promote autonomy, dignity, and well-being for people at the EOL in primary and community care. Future research could examine how these models are operationalized in practice, their effects on patients’ sense of control and quality of life, and how they can inform public policies aimed at reducing social and territorial inequalities in access to PC.
Finally, this review shows that several nursing models identified in primary and community PC share core activities and skills (emotional labor, caregiver support, community engagement, cross-level coordination), which can serve as a basis for designing integrated PC models adapted to different national contexts. Mapping these shared skills could support the development of targeted training for PC link-nurses or advanced practice nurses in diverse settings (e.g., population health programs, multidisciplinary primary care centers, community networks), while taking into account the legal and organizational frameworks specific to each country. In France, practices developed within population-health-oriented programs such as ASALEE provide a concrete testing ground for such models, while also offering insights that may inspire the adaptation of integrated PC in other health systems facing similar organizational and social challenges.
Conclusion
This narrative review shows that six types of PC models in primary and community care and nursing skills and activities, including relational work, care coordination, health promotion, advocacy, and leadership. By linking these international models to the specific role of ASALEE PC link-nurses at micro, meso, and macro levels, the review offers perspectives on how integrated primary and community PC can be organized in practice. Although the synthesis is constrained by heterogeneous study designs, contexts, and levels of evidence, it provides a basis for developing and testing context-adapted interventions that support nurses’ professional development, strengthen interprofessional and community partnerships, and involve patients and families throughout the PC process. Beyond France, the core skills and collaborative activities identified here may inform the adaptation and empirical evaluation of integrated PC models across diverse health systems and cultural settings, to promote more accessible, person-centered PC on an international scale.
Supplemental Material
sj-docx-1-pcr-10.1177_26323524261447387 – Supplemental material for Narrative review comparing palliative care models in primary and community care settings: For a better integration of nurses’ activities and skills
Supplemental material, sj-docx-1-pcr-10.1177_26323524261447387 for Narrative review comparing palliative care models in primary and community care settings: For a better integration of nurses’ activities and skills by Lucille Saillard, Julien Carretier and Nora Moumjid in Palliative Care and Social Practice
Supplemental Material
sj-docx-2-pcr-10.1177_26323524261447387 – Supplemental material for Narrative review comparing palliative care models in primary and community care settings: For a better integration of nurses’ activities and skills
Supplemental material, sj-docx-2-pcr-10.1177_26323524261447387 for Narrative review comparing palliative care models in primary and community care settings: For a better integration of nurses’ activities and skills by Lucille Saillard, Julien Carretier and Nora Moumjid in Palliative Care and Social Practice
Supplemental Material
sj-docx-3-pcr-10.1177_26323524261447387 – Supplemental material for Narrative review comparing palliative care models in primary and community care settings: For a better integration of nurses’ activities and skills
Supplemental material, sj-docx-3-pcr-10.1177_26323524261447387 for Narrative review comparing palliative care models in primary and community care settings: For a better integration of nurses’ activities and skills by Lucille Saillard, Julien Carretier and Nora Moumjid in Palliative Care and Social Practice
Footnotes
Acknowledgements
We thank Sophie Ferron, librarian at the National Center for Palliative Care and End-of-Life Care, for her bibliographic assistance. We thank a native English speaker, Debbie Loughran, for reviewing and editing the manuscript.
Author contributions
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was conducted as part of Lucille Saillard’s doctoral studies, for which she receives funding from the ASALEE association.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data availability statement
Not applicable.
Supplemental material
Supplemental material for this article is available online.
References
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