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


This article describes the first known national survey specific to APRNs practicing in HPC. The workforce includes very experienced APRNs who are new to specialty HPC practice. Many respondents reported that their graduate education did not provide adequate preparation for their HPC role, and they have sought additional education most commonly through professional organizations. Most of these APRNs did not report barriers to becoming credentialed, obtaining a job in HPC, or state licensing for practice in their HPC role. Clinical nurse specialists were proportionately more likely to report barriers. The most common challenges for both CNSs and NPs relate to the lack of understanding of the HPC role and regulatory/legislative restrictions on scope of APRN practice. Our findings indicate that the HPC APRN workforce is similar to the general APRN workforce. Previous APRN workforce surveys have reported very similar demographics to this APRN specialty group. For example, the 2016 American Association of Nurse Practitioners National AANP Sample Survey found that the average age of respondents was 49 years and most were female (92.4%) and white (86.5%).[7] According to the 2014 National Association of Clinical Nurse Specialists Census, the demographics for CNSs are quite similar to NPs with a predominantly white, female workforce.[8] Our results also suggest that the demographics of the HPC APRN workforce are similar to those of HPC physicians, that is, predominantly female and older and having 10 or fewer years of experience in the field.[13] These demographics can inform future recruitment efforts to focus on diversification of providers including African American, Hispanic, and Native American populations as well as men.

The need for improved palliative care education of health care professionals has been previously identified.[16–18] This deficit in preparation has been noted in undergraduate and graduate nursing programs.[17] This survey confirms that this gap in graduate education has a negative impact on transition to specialty HPC APRN practice. Most respondents (67.4%) reported a lack of HPC content and/or coursework in their graduate programs. What is not clear is whether education has caught up to the calls for increased HPC content and skills in nursing curricula. Although most of this sample (54.3%) has been APRNs for 10 years or less, it is unclear whether HPC educational opportunities were not available or whether the specialty courses were not of interest to the APRN students during their initial graduate preparation. However, currently, the HPNA Web site lists only 15 graduate programs that have HPC minors or tracks.[19] Although inclusion in the listing is voluntary and thus some programs are likely missing, it appears that there are few nursing programs that offer high-quality HPC coursework.

The recent ANA HPNA Call for Action: Nurses Lead and Transform Palliative Care recommended that all RN and APRN educational programs adopt End-of-Life Nursing Education Consortium as a standard.[20] For APRNs, this would be APRN End-of-Life Nursing Education Consortium. Other models of palliative care education have been proposed to address this recommendation, including the integration of interdisciplinary simulation programs, weeklong intensives to prepare APRNs to provide primary palliative care, and postmaster's certification and fellowship programs.[15,18]

Regulations and legislation remain barriers to APRN practice in many states, despite ongoing efforts to remove these barriers and expand APRN scope of practice.[21,22] As of March 2017, 24 states allow NPs full practice authority without physician oversight.[23] In January of 2017, the Veterans Administration granted full practice authority to certified NPs, certified CNSs, and certified nurse midwives across the Veterans Administration. Despite these advances, restrictive regulatory conditions continue to prevent implementation of full APRN scope of practice. Although the percentage of respondents reporting regulatory barriers was small, the challenges these barriers pose to practice are concerning. Limitations to HPC APRN practice described in this survey include lack of prescriptive authority, billing restrictions, and physician oversight requirements. These limitations are not unique to HPC and need to be addressed in ongoing efforts.[22] However, the hospice-related restrictions such as the ability to recertify for hospice and qualifications to serve as "attending of record" to bill need to be addressed through advocacy and legislative efforts within the Centers for Medicare and Medicaid Services. Such state and national level efforts could greatly impact the availability of qualified specialty APRN HPC providers.

Recent changes to promote consistency in Licensure, Accreditation, Credentialing, and Education among APRNs (related to the National Council of State Boards of Nursing Consensus Model)[24] eliminated palliative care as a primary national certification for APRN practice. As a result, graduate nursing programs that awarded a master's in palliative nursing shifted to a model of offering a minor or a certificate. To align their practice, APRNs need to make sure their educational preparation and certification match the primary population they work with. Only a small minority of respondents indicated that they have acute care education (8.1%) or certification (9.9%), although many PC teams operate largely in inpatient settings. The future impact of the Licensure, Accreditation, Credentialing, and Education Model on specialty HPC practice and preparation is not clear. Graduate nursing students may need to be thoughtful in deciding between acute and primary care programs depending on state and employer requirements.

This study has important limitations. Although we recruited respondents through several methods, we cannot be sure that our sample is representative of the HPC APRN workforce. Using an electronic survey format distributed through emails to a professional organization may yield a sample bias. New-to-practice APRNs may not yet qualify for certification and may not be associated with a professional organization so this group may be underrepresented; to address this issue, we asked the HPNA Graduate Nursing Faculty Council to share the survey link with alumni of graduate level palliative care programs. Another strategy to minimize this sample bias was the use of a snowball sampling technique, which encouraged forwarding of email to other potential participants, with the goal of reaching beyond APRNs directly associated with HPNA. This survey was limited to NPs and CNSs because they are the only APRN roles that are currently recognized as qualified for specialty certification through the ACHPN certification examination. It is possible that APRNs in other specialty areas may have been missed. Thus, despite efforts to recruit broadly, we do not know how representative our sample is. Part of the problem is that there is uncertainty about the total number of the APRNs currently practicing in HPC. If we use the members of the HPNA Advanced Practice Nurse SIG listserv (≈1700 members) as the denominator, we estimate a response rate between 30% and 35%. Although this response rate is similar to other HPC workforce surveys,[6] our results may not generalize to the actual population of HPC APRNs.