The Hospice and Palliative Care Advanced Practice Registered Nurse Workforce

Results of a National Survey

Patricia Pawlow, MSN, ACNP- BC; Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN; Caroline L. Doherty, MSN, AGACNP-BC, AACC; Mary Ersek, PhD, RN, FPCN


Journal of Hospice and Palliative Nursing. 2018;20(4):349-357. 

In This Article

Abstract and Introduction


One barrier to continued growth of palliative care is the shortage of qualified hospice and palliative care clinicians. Advanced practice registered nurses are an important part of the interdisciplinary palliative care team, and strengthening this workforce can help alleviate the shortage of clinicians and improve access to quality palliative care. However, there is a dearth of information about this workforce. The purpose of this study was to describe the current hospice and palliative care advanced practice registered nurse workforce, their educational needs, and barriers to practice. The investigators distributed an online survey between October 2016 and January 2017 and received 556 responses. Sixty-three percent had more than 20 years of experience as a registered nurse yet were newer to practice as a hospice and palliative care advanced practice nurse, with 53.8% having 0 to 5 years of experience in this role. Forty-one percent indicated that their traditional graduate educational preparation was insufficient in preparing them for their specialty role. Most indicated that they did not experience barriers to practice in their current position, but 7.3% identified significant issues. These results can inform future professional, educational, and regulatory efforts to support and develop the palliative care advanced practice registered nurse workforce.


As people live longer with complex medical conditions, health care providers must address the many physical, psychosocial, and spiritual needs of patients living with serious illness and their families. Hospice and palliative care (HPC) has grown quickly in response to these needs and is associated with improved quality of life, better symptom management, increased patient and family satisfaction, and increased survival.[1–3] Advanced practice registered nurses (APRNs) are essential palliative care providers and members of the interdisciplinary palliative care team. Within HPC, nursing care has always been critical. Initially, nursing participation in HPC teams predominantly focused on the registered nurse (RN) role. In 2001, however, an advanced practice nursing summit identified the important role APRNs have in the future of palliative care.[4] Recognizing that APRNs would need more education and training, several recommendations were made including (1) development of continuing education in palliative care competencies for existing APRNs, (2) integration of core palliative care competencies into the education of all APRN students, and (3) development of clinical options for APRN students who plan to specialize in palliative care. In the last 2 decades, the palliative APRN role has evolved, and the education to support this role continues to develop.[4,5]

The Institute of Medicine[6] report, The Future of Nursing: Leading Change, Advancing Health (2010), advocates for nurses to be "full partners" in the evolving health care system and to practice to the full extent of their preparation to ensure access to high-quality care. There are more than 230 000 licensed nurse practitioners (NPs) and approximately 70 000 clinical nurse specialists (CNSs) in the United States.[7,8] The evidence indicates that APRNs provide safe, effective, high-quality care.[9–11] They are well positioned to lead during this time of transformation in health care. Hospice and palliative care is one of many specialties in which there is an identified shortage of clinicians. An American Academy of Hospice and Palliative Medicine task force estimated a need for 6000 to 18 000 hospice and palliative medicine physicians to meet the demand but did not address the role of APRNs.[12] Despite efforts to increase education of physicians trained in PC, the number entering the workforce each year after fellowship is insufficient to meet this demand. Kamal et al[13] conducted a workforce survey in 2013 that involved American Academy of Hospice and Palliative Medicine members. Their findings indicate that the interdisciplinary HPC workforce is older than 50 years (56%) and female (54%) and had 10 years or less experience in palliative care (67%). Their findings, however, may not reflect the APRN workforce, because only 11% of the sample was advanced practice clinicians, APRNs, or physician assistants.[13] Many experts in HPC have acknowledged the importance of the APRN role in the care of patients with life-limiting illnesses.[5,14,15] One barrier to meeting the HPC workforce needs is the lack of data describing the HPC APRN population, including their educational preparation, certifications, roles, and barriers to practice. This information can help policy makers, educators, and nursing leaders to better prepare sufficient numbers of APRNs and support them as they transition into HPC.

In 2011, the Hospice and Palliative Nurses Association (HPNA) created an APRN Taskforce to describe the needs of APRNs working in palliative care and make recommendations. As part of the plan, HPNA called for a study to more clearly define the opportunities and challenges of APRN practice in HPC. The current authors, from the University of Pennsylvania School of Nursing and the HPNA, collaborated on this study to describe the current APRN workforce.