Abstract
Palliative care seeks to relieve suffering and promote quality of life for patients and their families regardless of the stage of the disease or the need for other therapies. Although many schools of nursing have initiated advanced training programs in hospice and palliative care, there has been limited research into the type of programs and content for these programs within the Advanced Practice Nursing community. The purpose of this study was to determine Advance Practice Nurses’ perception of the need for an Advanced Practice Education in Hospice Palliative Care program, the preferred method of educational delivery, and the desired program content. One hundred nineteen respondents completed the 20-item online survey. Results show the majority of respondents (90%) perceive the need for a palliative care education program with 36% interested in taking the course now and 44% interested in taking it at a later time. Most respondents preferred the course to be offered online (32%) or as a hybrid course (54%). Findings of the study support the development of an online or hybrid, across the lifespan, palliative care program for advanced practice nurses that includes multidisciplinary content and clinical practicum hours.
Keywords: Palliative Care; Hospice; Practice Nursing; Clinical medicine
Introduction
Palliative care seeks to relieve suffering and improve the quality of life for patients and their families facing life-threatening illnesses, regardless of the stage of the disease or the need for other therapies. It is both a philosophy of care and an organized, highly structured system for delivering care for patients at any stage of their illness [1]. Quality palliative care benefits from advanced education and training in symptom management and communication in setting goals of care in addition to interdisciplinary/team based care and patient/family centered care. Hospice is a form of palliative care involving a teamoriented approach to expert medical care, pain management, and emotional and spiritual support expressly tailored to the needs and wishes of people facing a life-limiting illness or injury at the end of life [2]. It is imperative that all healthcare providers are knowledgeable in aspects of care unique to this population.
Although many schools of nursing have initiated advanced training programs in hospice and palliative care (HPC), there has been limited research into the type of programs and content for these programs within the Advanced Practice Registered Nursing (APRN) community [3-5]. It is unclear if APRNs are aware of the increasing demand for primary care providers (PCPs) in palliative care and the necessity for advanced educational preparation in the field of HPC [6]. The goal of HPC educational programs is to not only train specialists in the field of palliative care, but ultimately to enable all APRNs to integrate palliative care into their primary practice.
Background
In 2000, less than 20% of hospitals had palliative care services. However, in 2013, approximately 70% of hospitals with 50 beds or more had a program in place [6]. In addition to hospital palliative care programs, an aging population will create an even greater demand for outpatient HPC. By the year 2030, nearly 20% of the US population will be over the age of 65 years [7]. As people age, most will develop one or more chronic illnesses requiring medical management and palliative care for several years prior to their death. The proportion of all Americans with two or more chronic conditions increased from 24 percent in 2001 to 28 percent in 2006. In 2009, 145 million Americans were living with a chronic condition. Medical management of chronic illnesses in the elderly is often inadequate due to complex healthcare systems, poor communication, and lack of professional training for healthcare providers. In addition, the Center for Medicare and Medicaid (CMS) announced July 20, 2015 that Medicare Care Choices Model was opening up hospice care to patients receiving palliative and curative care concurrently. Over 140 hospices nationwide were chosen to participate in this innovative program, which may add an additional 150,000 eligible Medicare beneficiaries into the hospice program over the next 3-5 years. Thus, it is imperative that APRNs caring for this population are educated in the assessment and treatment of pain, and other physical and psychosocial problems.
This rapid growth in the number of HPC patient care programs in recent years has led to an increased demand for professionals with this experience that far exceeds the supply of trained clinicians in the field [6,8]. As of December 31, 2014, there were only 6952 subspecialtycertified physicians in hospice and palliative medicine [9-11]. The gap between demand and the number of certified providers is estimated to be between 6,000 to 18,000 physicians. The shortage of physicians depends upon the amount of time each provider devotes in his/her practice to palliative care [7,11].
APRNs have been identified as an essential element for improving healthcare and access by the Institute of Medicine (IOM) [12]. In addition, in multiple studies, APRNs have proven to be effective healthcare providers with satisfaction and outcome surveys equal to or surpassing physicians [13,14]. Nurse practitioners (NPs) offer a safe, cost effective alternative for expanding the number of primary palliative care healthcare providers. As part of a project at Mayo Clinic in Jacksonville, 13 NPs from both public and private cancer clinics throughout the state of Florida were trained in providing endof- life counseling and symptom management to metastatic cancer patients. Patients who received intervention from a nurse practitioner had a significant improvement in their emotional health compared to the control group [14]. Although APRNs are uniquely positioned to fill the need for providers, in 2014, there were only 900 HPC certified APRNs [15] and there is a severe shortage of training programs for APNs interested in the specialty of palliative care [16-21].
Extensive review of the literature on HPC educational programs for APRNs documented courses offered in both university certificate and degree programs [22-37] (Table 1). Although a few HPC courses at universities were suspended at the time of this writing, 10 universities throughout the United States currently offer a postmaster’s certificate program. A master’s programs with a minor or palliative care track in their nurse practitioner programs is also offered at eight universities (Table 2).
School
Degree
Certificate
Setting
Units/Credits
Practicum
NP/CNS
Minor
NP
CNS
Onsite
Online
University of Pennsylvania
x
Boston College
x
Vanderbilt University
x
CSU San Marcos
x
x
x
22units
540hours
Columbia University
x
x
5credits
60hours
University Illinois-Chicago
x
x
x
9credits
2practicum
George Washington University
x
x
x
14/6credits*
---
New York University
x
12credits
500hours
Madonna University
x
7credits**
2practicum
Case Western University***
x
x
6+credits
---
University Colorado-Denver
x
x
6credits
---
Ursuline College
x
x
Not available
Not available
University of South Alabama^^
x
x
Not available
Not available
Note: ^Data available online as of August 31, 2015. *14 credits for the NP certificate, 6 credits for the CNS certificate; **7 didactic credits plus 15 practicum credits; ***MSN Adult Oncology/PC track also; ^^Certificate available in DNP program also.
Table 1: Palliative Care Education Programs^.
School
Intro to PC
Symptom Mgmt
Pain Mgmt
Chronic Illness
Acute PC
Community PC
Dying Loss and Grief
Sociocultural
Ethical Issues
Special Populations
Leadership
& Mgmt
Advanced Concepts
Communication
Inter-
Disciplinary
CSU -
San Marcos
X
X
X
X
X
X
X
X
X
X
Columbia University*
X
Pediatrics
George Washington Univ^
X
X
X
X
X
X
New York
University*
X
X
Lifespan
Madonna
University
X
X
X
X
Case Western University
X
X
University Colorado-Denver
X
X
X
University of Pennsylvania
X
X
X
X
X
X
Boston
College
X
X
X
Vanderbilt University
X
X
X
Ursuline
College
X
University South Alabama
X
X
Univ. California San Francisco
X
X
Univ. Alabama
Birmingham
X
X
X
*Seminars on Palliative Care and End-of-Life Care also. ^Elective also. **Common Health Problems also.
Table 2: Palliative Care Program Content.
Fellowship programs are another option available to a limited number of APRNs interested in HPC. The Harvard Medical School Center for Palliative Care offers Nurse Practitioner Fellowship Programs in both Adult Care and Pediatrics [38]. Consistent with other fellowship programs the NPs and APRNs are paid a stipend salary while completing their training. These programs have a limited capacity and are not traditional university post-master’s educational programs; therefore, college credit is generally not given. Both Memorial Sloan Kettering Cancer Center and Beth Israel in New York, University of Vermont, and The Children’s Hospital of Philadelphia also have limited slots for APRNs, admitting only one to two students each year [39-41]. There is currently a Nurse Practitioner Fellowship program in development at California State University, San Marcos in conjunction with local healthcare agencies [22].
Standards for Clinical Education of Hospice and Palliative Nurses are readily available from Hospice and Palliative Nurses Association (HPNA) 2015 [42], yet consensus on curriculum is seriously lacking. Although there are a few courses, such as pain and symptom management, which are offered in most HPC educational programs, overall program course content varied greatly. Programs also varied greatly in the number of required semester units or course credits, ranging from 5 credits [29] to 31credits [28], as well as the number of practicum hours ranging from no clinical hours to 540 hours (Table 1). Although research has shown the importance of Pediatric Palliative care [43-47], it is of interest that only three programs, CSU San Marcos, Madonna University and New York University, included education throughout the lifespan with exposure and content to include the neonatal and pediatric populations as well as geriatrics with life-limiting illnesses [22,27,28]. Although all programs include an introduction to palliative care course, specific content was unavailable.
The purpose of this survey was to assess APRNs perceived need for an advanced practice nurse’s post-master’s certificate training program in HPC. The preferred method for receiving such education and the desired content for a program from the clinician’s point of view was also explored.
Methods
Design
The survey of APRNs for a post master’s certification program in palliative care was conducted from the School of Nursing at San Francisco State University (SFSU) as part of a proposed expansion of the graduate nursing program. After review of the literature and existing hospice and palliative care programs, a 20-item survey was developed by the authors to assess the APRNs perceptions of the need for an Advanced Practice Education in HPC Program, the preferred method of educational delivery, and the desired content for such a program. In addition, demographic characteristics including highest degree earned, primary practice location and type of setting, and comments and suggestions were obtained.
The survey was distributed through Qualtrics (Provo, Utah), an online survey program supported by SFSU. This study was determined to be exempt by the university institutional review board prior to data collection. Participants were recruited through notices posted on the California Association for Nurse Practitioners (CANP) and HPNA websites and through snowball sampling at local hospitals and universities. Participants were informed of the anonymity and confidentiality of the data. Consent was implied by completion of the online survey. Two surveys were not included in the data analyses due to significant missing data resulting in 121 surveys in the final dataset.
Data analysis
Data from survey responses were imported from Qualtrics directly into SPSS Version 22.0 (IBM Corp, Armont, NY) for statistical analysis. Descriptive analysis of the demographic data was conducted to determine sample characteristics. A chi-square test was performed to examine the relationship between the perceived need for a palliative care program for APRNs and demographic characteristics. Comments and suggestions were reviewed for additional insight into participants’ perceptions of the need for and preferred content of palliative care programs for APRNs.
Results
Sample characteristics
The respondents were primarily female (86%) ranging in age from 24 to 66 years (M-42, SD-10.889). More than half of the respondents (56%) were nurse practitioners and 55% of respondents reported working in an acute care setting. The majority of respondents work full time (70%) and earn more than $100,000.00 annually (74%) (Table 3).
Categories
Mean (SD)
%
Gender
Male
Female
14
86
Age
42 (10.89)
Degree
Bachelors
Masters
Doctoral
Certification*
16
77
7
9
Practice Setting
Primary Care
Community
Acute Care
Long-term Care
Hospice
Other**
20
12
55
5
3
22
Practice Type
NP
CNS
CNL
Educator
Administrator
Student
Other (PA, BSN)
56
12
2
3
4
7
17
Salary
< $50,000
$50,000-$100,000
>$100,000
5
21
74
Employment
Full time
Part time
Not working
Retired
70
24
5
2
Part-Time Employment
< $50,000
$50,000-$100,000
>$100,000
9
48
43
Full-Time Employment
< $50,000
$50,000-$100,000
>$100,000
0
14
86
*N=9, CAN/HHA; APN; FNP; ACNP/ANP-BC; AHPN; AGACNP BC/CCRN; Gero NP; CNS/CCRN. **University health, Occupational health, Operating room, Specialty clinic, Outpatient oncology. ^Physician Assistants, Certified Nurse Midwives, Certified Nurse Anesthetists.
Table 3: Sample Characteristics.
Program design
The majority of respondents (90%) perceived the need for a palliative care program and 74% were interested in taking a palliative course either now (31%) or at some later time (42%). The chi-square test did not show any significant relationship between sample characteristics and the perceived need for a post-graduate hospice and palliative care educational program other than the type of practice, X2 = 31.84, p = .01, with NPs showing a higher perceived need for the program than APRNs in other types of practices, such as clinical nurse leaders. An online or hybrid course was the preferred delivery method for the majority of participants (32% and 54% respectively). The cost of taking a palliative course was noted to be of concern for 93% of the respondents, with the need for financial aid or scholarships reported by 33%. Although nearly one-third of the respondents would be able to study either full- or part-time, 61% of respondents were only interested in part-time study. Some type of acknowledgement of program completion was of interest to the majority of the respondents with 69% interested in a national certification, 23% interested in a certificate of completion, and 50% interested in the program providing continuing education units (Table 4).
(%)
Perceived Need (N=121)
Yes
No
Not sure
90
2
7
Interest in (N=120)
Yes, interested
Not now, but later
No
26
42
32
Type of program preferred
(N=117)
Online
Onsite
Hybrid
32
14
54
Concerns with program cost
(N=115)
No
Low cost preferred/required
Low cost required
Aid required
7
57
35
33
Study (N=117)
Full time
Part time
Either
3
61
36
Credentials (N=115)
National certification
Certificate of completion
Continuing Education Units
No
Other
69
23
50
9
3
Setting to include in content (N=113)
Primary Care
Community based
Acute care
Long term care
Hospice
Other
51
48
60
46
48
7
Program Focus (N=115)
Nursing
Gerontology
Social Work
Medicine
Physical Therapy
Occupational Therapy
Public Health
Pharmacy
Chaplaincy
Other
81
57
50
64
30
23
25
47
31
6
Program Content (N=117)
Chronic Health
Pharmacology
Symptom Management
Pain assessment/management
Ethical Issues
Case Management
Pediatrics
Adults
Geriatrics
Hospice
Interdisciplinary
Communication
Other
79
83
87
78
74
42
28
50
52
50
50
53
5
Program Population (N=114)
Family
Pediatrics
Adult
Geriatrics
Other
45
14
69
61
1
Clinical Experience (N=114)
Primary Care
Community based
Acute Care
Long Term Care
Hospice
Other
46
35
57
38
39
7
Table 4: Survey Program Results.
Program content
Respondents reported interest in a palliative care program based on primary care (51%), community-based PC (48%), acute care (60%), long-term PC (46%), and hospice (48%). Although 81% of respondents reported interest in the palliative care program focusing on nursing, respondents also reported interest in additional interdisciplinary areas such as medicine (64%) and gerontology (57%). Respondents reported interest in inclusion of ethical issues (74%) and communication (53%) in the palliative care program content in addition to symptom management (87%). The program population focus of highest interest was adults (69%), although participants also reported an interest in inclusion of family (45%), pediatrics (14%), and geriatrics (61%). Respondents reported an interest in the palliative care program including clinical practice in multiple settings such as acute care (57%) and primary care (46%) (Table 4).
Discussion
Findings of the study support development of a palliative care program for advanced practice nurses. Ninety percent of respondents saw the need for a palliative care program and more than 2/3 of respondents were interested in a program now or sometime in the future. The need for palliative care programs was expressed in comments including: “This should be included and required in all NP programs now, because of the daily issues I deal with.” “A course of this nature would fill a tremendous need. NPs could contribute an enormous amount in this role.” The 32% of respondents not interested in enrolling in a palliative care program were working in areas where palliative care may not be applicable to their specialty, such as the operating room.
The vast majority of respondents expressed interest in an online or hybrid educational program with only 14% requesting an onsite program. This flexibility may be necessary for working APRNs and physician assistants (PAs) and is consistent with many current and past palliative care programs. An online program for advanced practice nursing education is supported by the literature as a successful method for delivering graduate education [48]. It can also be a cost effective method, which was a major concern for 93% of respondents interested in a palliative care program. Development of a part time, low-cost online/ hybrid program would meet the needs of most APRNs interested in an education in palliative care.
Although the highest perceived need was for an Adult/Geriatric palliative care program, almost half (45%) of respondents were interested in an across-the-lifespan focus. This focus provides flexibility for changing population needs. Respondents expressed interest in a curriculum with a diverse interdisciplinary team approach to include social work, chaplaincy, physical therapy, medicine, and pharmacy. This is consistent with the HPC’s philosophy of meeting the physical, psychosocial, and spiritual needs of patients and their families. Respondents' inclusion of symptom management, pharmacology, chronic disease management, pain assessment and management, and ethics in the palliative care program content addresses the challenging and complex environment associated with life-threatening illnesses.
Although fifty percent of respondents wanted to have CEUs awarded for participation in the program, 69% preferred national certification. This is understandable as more nurses are obtaining certification in specialty areas [49,50] as formal recognition of their specialized knowledge and quality patient care [51]. HPNA provides certification for APRNs. The requirements for certification testing are a current nursing license to practice within the US, a master’s degree as CNS or NP, and 500 hours of advanced practice in palliative care over the previous 12 months or 1000 hours within the previous 24 months. Attending a program which includes clinical practicum hours consistent with the HPNA certification requirements should be a priority for those wishing to apply for the certification exam. Clinical experience as an essential component for any certification program was expressed by several of the survey respondents, “post graduate programs for specialty training of APPs (PAs and APNs) are fantastic, however, they should be clinical.”
This study has several limitations. The small sample size with the majority of respondents residing in one area of Northern California limits generalizability to perceived palliative care educational needs in other areas of the United States. More than half (56%) of respondents were acute care NPs making it difficult to determine if the perceived need for a palliative care program is merely reflective of the unique view of NPs. Few respondents reported a population-based certification. This may reflect lack of population-focused certification among the respondents, but is more likely due to poor wording of the survey question resulting in lack of participant reporting. Further research should also explore the desirability of APRNs’ having HPC education by physicians in their hiring practices and hospice/ palliative care settings.
Conclusion
The present study shows a perceived need for and interest in educational training programs in palliative care for APRNs in Northern California. Implementation of an HPC educational program for APRNs will assist in meeting the increasing need for palliative care educated providers and provide patients of all ages with an improved quality of life when facing a life-threatening illness. Future research should explore the quality and effectiveness of training across different APRN practice populations, settings, and educational levels. Clinical practice is a key issue for educational programs. Future programs should consider offering 500 practicum hours of advanced practice nursing in palliative care so students are eligible to sit for the certification exam through HPNA. Ultimately, programs should be available to provide APRNs with the education necessary to provide quality palliative care to their patients.
References
- National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care, 3rd Ed. Pittsburgh, PA. 2013.
- National Hospice and Palliative Care Organization. NHPCO facts and figures: Hospice care in America.
- Hospice and Palliative Nurses Association. Graduate Program Listing. 2013.
- Hospice and Palliative Nurses Association. Competencies for advanced practice hospice and palliative. 2002.
- Hospice and Palliative Nurses Association. Standards for clinical practicum in palliative nursing for practicing professional nurses. 2016.
- Punke H. Workforce shortage threatens future of palliative care. 2013.
- National Palliative Care Research Center. 2015.
- American Academy of Hospice and Palliative Medicine: ABMS/AOA CAQ subspecialty-certified physicians in hospice and palliative medicine. 2015.
- Lupu D. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage. 2010; 40: 899-911.
- Zuraw L. As palliative care need grows, specialists are scarce. 2013.
- Herman B. Palliative care: Why it has become a growing specialty within hospitals. 2013.
- Institute of Medicine (IOM). The Future of Nursing: Leading Change, Advancing Health. Committee of the Robert Wood Johnson Foundation. Initiative on the Future of Nursing, at the Institute of Medicine. Washington, DC: The National Academies Press. 2010.
- Taylor LG. A study of patient satisfaction in rural Texas. Adv Nurse Pract. 2007; 15: 53-60.
- Dyar S, Lesperance M, Shannon R, Sloan J, and Colon-Otero G. A Nurse Practitioner Directed Intervention Improves the Quality of Life of Patients with Metastatic Cancer: Results of a Randomized Pilot Study. J Palliat Med. 2012; 15: 890-895.
- Hospice and Palliative Credentialing Center (HPCC). 2015.
- Jeffrey D. Education in palliative care: A qualitative evaluation of the present state and the needs of general practitioners and community nurses. Eur J Cancer Care. 1994; 3: 67-74.
- Le Grand SB, Walsh D, Nelson KA, & Davis MP. A syllabus for fellowship education in palliative care. Am J Hosp Palliat Care. 2003; 20: 279-289.
- Coyne PJ. The evolution of the advanced practice nurse within palliative care. J Palliat Med. 2003; 6: 769-770.
- Meier DE & Beresford L. Advanced practice nurses in palliative care: A pivotal role and perspective. J Palliat Med. 2006; 9: 624-627.
- Promoting Excellence in End of Life Care Program. Advanced practice nurses role in palliative care: A position statement from American nursing leaders. 2002.
- Quaglietti S, Blum L, & Ellis V. The role of the adult nurse practitioner in palliative care. J Hosp Palliat Nurs. 2004; 6: 209-214.
- California State University Institute for Palliative Care. Post-MSN certificate in palliative care: For advanced practice nurses interested in providing expert palliative nursing care for those with serious or chronic illness. 2013.
- Columbia University School of Nursing. Palliative and end of life care. 2011.
- University of Illinois at Chicago College of Nursing. Advanced practice palliative care nursing certificate. 2010.
- The George Washington University. Post-master’s palliative care nurse practitioner. 2013.
- University of Colorado College of Nursing. Palliative care certificate. 2013.
- New York University. Post-MS advanced certificate program: Advanced practice nursing: Palliative care. 2011.
- Madonna University. Post-master’s adult advanced practice hospice & palliative care nurse specialty. 2013.
- Frances Payne Bolton School of Nursing. Adult-gerontology oncology and palliative care nurse practitioner. 2012.
- Case Western Reserve University. $1.76 million federal grant to support palliative care program at CWRU nursing school. 2013. [Press release].
- University of Pennsylvania School of Nursing. Nursing 304: Concepts in pain management. 2008. [Syllabus].
- The Pennsylvania State University School of Nursing. Nursing 464: Dying and death. 2009. [Syllabus].
- Boston College Connell School of Nursing. Palliative care nursing post-master’s specialty certificate program. 2013.
- Vanderbilt University School of Nursing. Adult-gerontology primary care nurse practitioner (AGPCNP). 2013.
- Ursuline College. Tracks and academic components. 2013.
- University of South Alabama College of Nursing. Palliative care subspecialty. 2013.
- University of California, San Francisco. Palliative care minor. 2014.
- Massachusetts General Hospital. MGH palliative care nurse practitioner fellowship. 2013.
- Mount Sinai Beth Israel. Palliative Medicine Fellowship Program. 2015.
- Memorial Sloan Kettering Cancer Center. Palliative Medicine Fellowship. 2015.
- The Children’s Hospital of Philadelphia. Pediatric palliative care fellowship curriculum. 2013.
- HPNA Standards for Clinical Education of Hospice and Palliative Nurses. Hospice and Palliative Nurses Association. 2015.
- American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health. The pediatrician and childhood bereavement. Pediatrics. 2000; 105: 445-447.
- Kolarik RC, Walker G, Arnold RM. Pediatric resident education in palliative care: a needs assessment. Pediatrics. 2006; 117: 1949-1954.
- Benini F, Spizzichino M, Trapanotto M, Ferrante A. Pediatric palliative care. Italian Journal of Pediatrics. 2008; 34: 4.
- Center to Advance Palliative Care. Pediatric palliative care. 2013.
- Rushton CH, Reder E, Hall B, Comello K, Sellers DE, Hutton N. Interdisciplinary interventions to improve pediatric palliative care and reduce health care professional suffering. J Palliat Med. 2006; 9: 922-933.
- Huckstadt A, Hayes K. Evaluation of Interactive Online Courses for Advanced Practice Nurses. J Am Acad Nurse Prac. 2005; 17: 85-89.
- American Board of Nursing Specialties (ABNS). 2016.
- American Nurses Credentialing Center (ANCC). 2014 ANCC Certification Data.
- Miller PA, Boyle DK. Nursing specialty certification: A measure of expertise. Nursing Management. 2008; 39: 10-16.
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