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


Sample Demographics and Work Experience

We received 596 responses, although we deleted 40 surveys because they were returned blank. Thus, we had a final sample of 556. Table 1 summarizes the demographic characteristics of the sample. Respondents were mostly female (89.7%) and white (87.1%). Almost 60% were 50 years or older, and most (63.0%) had more than 20 years of nursing experience. Table 2 presents the sample's nursing and APRN experience. Although they were very experienced RNs, only 45% had greater than 10 years of experience as an APRN and only 21.2% had more than 10 years of experience as an HPC APRN. The sample represented 92% of the states in the United States.

Graduate Education and National Certifications

Most APRNs in the sample were NPs (86.5%) and worked exclusively with adult or gerontology patients (87.9%) (Table 3). Adult/gerontology primary care was the most common focus of NP graduate education at 46.4%. Family NPs were second at 33.2%, and only 8.1% of NP respondents were acute care prepared (adult gerontology acute and pediatric acute). As far as certification, most NPs were nationally certified in adult/gerontology primary care (53.3%). Many were certified as a family NP (34.9%). Acute care certification (adult and pediatrics) accounted for 9.9% of respondents. To account for dual certification, participants had the option to choose more than 1 national certification.

Only 10% of the sample reported that their role was primarily as a CNS. The focus of graduate education for most CNSs was adult gerontology (adult gerontology, adult, and gerontology) at 69.7%. Most CNSs were also certified in adult/gerontology (55.3%). Almost 6 of 10 participant APRNs (59.8%) reported that they have advanced certification in hospice and palliative nursing (ACHPN); of those who were certified, most (57.8%) had been certified less than 5 years.

Educational Preparation

Table 4 summarizes the educational preparation for the sample. A little more than a third (39.2%) indicated that their education had adequately prepared them for their current HPC APRN position. However, 61.5% reported that they had no palliative care content in their graduate level courses. For those who did have HPC content in their program, topics were equally distributed among pain management, symptom management, communication, cultural care, and care at the end of life. Spiritual care was covered less often than the other topics. Most respondents (88.4%) indicated that they learned about HPC through continuing education sponsored by professional organizations. Advanced practice RNs rarely participated in postgraduate fellowships (4.7%). Many comments indicated that the lack of access to fellowships and postmaster's programs was an issue.

Barriers to Practice

We were interested in uncovering potential barriers to APRN practice in HPC settings, particularly as they relate to educational preparation and regulatory issues. Overall, APRNs reported minimal barriers (Table 5). For example, only 7% reported that they faced barriers to employment based on their educational preparation, and only 10% reported that their employer required additional education for them to be able to practice. However, when asked generally about challenges to their HPC APRN practice, only 22.7% indicated that there were no challenges. Rather, more than one-third of both NPs (37.5%) and CNSs (35.3%) identified the lack of organizational understanding about their APRN role as a challenge to practice. Other common challenges reported by both NP and CNS respondents were limited scope of practice in the state in which they practiced (15.3%) and the inability to bill independently for their services (16.4%).

In general, CNSs were more likely than NPs to report barriers to practice. For example, 25% of the CNSs said that they encountered barriers in becoming credentialed or in obtaining a job in HPC because of educational preparation, compared with 5% of the NPs. In addition, a higher percentage of CNSs reported challenges with having their professional role unrecognized by their state (CNS vs NP, 17.9% vs 1.2%, respectively) or by their employer (CNS vs NP, 14.3% vs 0.4%, respectively). Nearly 29% of CNSs also responded that the inability to bill independently was a barrier, compared with only 14% of NPs. Comments by CNSs identified specific issues including the inability to do recertification visits for hospice patients and lack of recognition for the CNS role (Table 6). Nurse practitioner comments about barriers included limitations in prescribing controlled medicines, the lack of recognition of palliative care certification, the requirement that they have HPC experience to be hired, and the need for acute experience and certification to work in the hospital setting (Table 6).