A lack of nursing and medical education in hospice and palliative care creates an additional obstacle for providers trying to push back against industry-wide labor shortages. Not only are hospices competing with other health care sectors for new hires, but the vast majority of clinicians entering the workforce are unprepared to provide those services.
Most medical, nursing, pharmacy and social work students receive little exposure to hospice or palliative care during their training. To 2018 study showed that most students in clinical disciplines do not feel prepared to provide family care at the end of life.
Without widespread change, the demand for palliative care will likely outstrip the supply of the clinicians trained to provide it during the next decade.
“Many people in professional schools don’t learn much at all about palliative care, and this has been published in the literature,” Kashelle Lockman, clinical assistant professor at the University of Iowa College of Pharmacy, told Hospice News. “If they don’t know about it, they can’t go into it. That’s why I’m so passionate about teaching palliative care.”
This reality has directly impacted recruitment and retention for some providers.
Case in point: Texas-based Silverstone Hospice reached out to nursing schools near its markets to bring new graduates into its teams. This initiative did not go well.
“One that I thought was an amazing idea ended up being a disaster. That was going to nursing schools and finding graduate nurses and bringing them into hospice,” Silverstone CEO Alfonso Montiel told Hospice News. “To my very unpleasant surprise, nursing schools do not go into hospice in great detail, so the nurses didn’t know what to do.”
In some cases, nurses fresh out of school not only lacked technical skills, but also the emotional resilience necessary to care for the dying on a daily basis, Montiel explained.
The problem is multi-faceted. Not only do providers need clinicians to do the work, but barriers exist on the referral side as well. Many physicians hesitate to refer patients to hospice or palliative care because they don’t fully understand the nature of those services or their benefits. Many also lack the skills necessary to conduct goals-of-care conversations with patients and families.
Educating physicians in other settings on these benefits remains a crucial area of improvement, a recent Trella Health report indicated.
Other research supports these conclusions, including a 2014 study in the journal Palliative & Supportive Care.
“Exploring unfounded and preconceived fears associated with hospice referral needs to be integrated into the curriculum, to prepare future generations of physicians,” the study’s authors wrote. “Medical education should focus on delivering the right amount of end-of-life care training, at the right time, within the medical school and residency curriculum.”
While the problem is extensive, some stakeholders are working to drive change.
For instance, the UI College of Pharmacy is among the few that offer a Palliative Care Certificate program for students. The university’s social work and nursing schools also offer some coursework in palliative care. A long term goal for Lockman and her colleagues is to pursue a coordinated effort across these programs that reflects the interdisciplinary nature of the palliative care model.
Lockman has received an $180,000 grant from the Cambia Health Foundation’s Sojourns Scholar Leadership Program to facilitate development of consensus Entrustable Professional Activities (EPAs) for palliative care specialist and generalist pharmacists.
This project will also design a pilot educational program aligned with the EPAs and create a pilot toolkit to integrate palliative care into PharmD curricula.
Other universities — and some providers themselves — are also taking steps to close the gaps.
Faculty at the University of Arizona Center on Aging last year collaborated with other colleges and health care centers to develop its Interprofessional End-of-Life Care Training Program focused on multicultural and interdisciplinary approaches to end-of-life conversations.
The Medical University of South Carolina (MUSC) has also designed an “externship” program to speed the professional development of advanced practice providers, including skills related to hospice and palliative care.
The medical schools at University of Maryland, Tufts University, the University of Vermont, University of California-San Francisco have likewise introduced more palliative care into their curricula.
The availability of such training could make a significant difference for provider recruitment.
For example, Delayne Glassgow, a student at the UI College of Pharmacy, told Hospice News that her palliative care coursework was “eye-opening” for herself and her peers. It even led her to consider a career in the field.
“I think everybody in my class just kind of stopped and said, ‘Oh my goodness, we had no idea,’” Glassgow said. “These are things that we need to learn now to be able to provide better care later. You don’t realize this until you learn about it, so I think that it’s great that we’re actually getting those integrated into our therapeutics courses.”
Some providers are taking matters into their own hands.
Hospice and home health provider LHC Group (NASDAQ: LHCG) in 2021 announced a $20 million 10-year investment in the University of Louisiana at Lafayette’s College of Nursing and Allied Health Professions to spur home-based care training.
The staffing shortage was part of the impetus for this decision.
“This is a strategic investment in our future, particularly that of our LHC Group family of health care providers – our greatest asset and most important resource,” Keith Myers, LHC Group’s chairman and CEO, said in an announcement. “Advancing employee education is one of the strongest and most strategic differentiators for employee recruitment and retention.”
At Massachusetts-based hospice provider Care Dimensions, Susan Lysaght Hurley, director of research, is working to transform her organization’s nurse residency program into a national model. Hurley also received a $180,000 Sojourns Scholar grant from Cambia to advance this project.
Care Dimensions’ nurse residency program offers training to nurses who are new to hospice and palliative care, though they may be experienced working in other clinical settings.
“Nurse residency has been around for a while in other specialty areas of nursing. However, the vast majority of them are in acute care settings,” Hurley told Hospice News during the project’s launch. “Bringing specialization to the community level is paramount in order to really think about the quality of care going forward.”
These efforts by providers and educators can make a difference, but more needs to be done to boost training on a national scale. Patients who need hospice and palliative care reside in every nook and cranny of the United States, and the handful of stakeholders taking action likely won’t be able to fill that nationwide demand.
Meanwhile, federal legislation designed to bolster the hospice and palliative care workforce has repeatedly stalled despite the best efforts of policymakers and industry advocacy groups.
These include the Provider Training in Palliative Care Act, which would clear the way for members of the National Health Service Corps to defer their service for as long as one year to pursue additional palliative care education.
Another key bill is the Palliative Care and Hospice Education and Training Act (PCHETA), which would finance physician and nurse training, among other interdisciplinary professions such as pharmacy, social work and chaplaincy.
Sen. Tammy Baldwin (D-Wis.) and Rep. Yvette Clarke (DN.Y.) wrote to congressional leaders last September urging action on PCHETA.
“To ensure access to palliative and hospice care for those who need it, we must support an interprofessional, team-based approach to care, and make the needed investments in the palliative care and hospice workforce,” the two Congress members wrote. “These investments must include efforts to address workforce development; health care provider training, including for physicians, nurses, and other health professionals; enhanced research; academic and career incentive awards; and increased education and awareness.”