Disclosures: Economou reports no relevant financial disclosures.
November 25, 2020
3 min read

Educating APPs to provide primary palliative care improves integration into practice

Disclosures: Economou reports no relevant financial disclosures.
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Palliative care is an important piece of cancer care that improves the quality of life for patients with cancer.

Denice Economou, PhD, CNS, CHPN
Denice Economou

As a follow-up to our previous article — published in the Sept. 25, 2019, issue of HemOnc Today — that described the importance of primary palliative care education to help meet the “tremendous need,” this update describes the success of an NCI-funded R25 project (5R25CA217270-02) of the End-of-Life Nursing Education Consortium, or ELNEC, under the direction of Betty Ferrell, PhD, RN, MA, CHPN, FPCN, FAAN, and the first two training courses.

Course design

Managing complex symptoms in a coordinated and comprehensive way provides quality cancer care, manages costs and improves patient satisfaction.

The National Consensus Project’s 2018 guidelines, Clinical Practice Guidelines for Quality Palliative Care, define eight domains of quality care. These include structure and processes of care; physical aspects of care; psychological and psychiatric aspects of care; social aspects of care; spiritual, religious and existential aspects of care; cultural aspects of care; care of the patient nearing the end of life; and ethical and legal aspects of care.

Using these eight domains to develop a curriculum and evaluate its impact on changing advanced practice registered nurse (APRN) practice, the guidelines provided an evidence-based framework for measuring success.

Ferrell and colleagues described the program details in March in Oncology Nursing Forum, demonstrating that the program can influence practice change and improve care for patients.

We trained 165 oncology-specific APRNs in the first two courses. The program included a pre-course evaluation that asked participants to describe their use of each of the domains in their practice, results of which revealed deficiencies in current practice, with few participants reporting that patients receive palliative care as part of their oncology care.

In longitudinal follow-up at 6 months and 12 months after the course, participants identified barriers and facilitators to implementing palliative care skills in their practice. Additionally, course participants observed a palliative care team over 12 months following the course. Documentation of the outcomes focused on improving implementation of each domain into practice.


The clinical activities that participants described demonstrated improved palliative care skills within their individual practices.

Participants rated the eight domains on a scale of 1 through 5, with 1 being “least effective” and 5 being “very effective.” Evaluating the improved averages for “effective” and “very effective,” each domain showed an increase in effectiveness. Averages for both courses per domain ranged from 17% to 59% at baseline to 55% to 83% at 6 months and 59% to 91% at 12 months.

Between the baseline pre-course to 12 months after the course, the most improved domains included psychological and psychiatric, social, spiritual/existential and cultural aspects of care. These aspects of care included interdisciplinary teamwork and skills related to assessment and management of specific areas, including global aspects, screening and assessment, treatment, and ongoing care needs specific to each domain.

Examples of palliative care activities described by the participants at 6- and 12-month follow-up included:

  • providing “lunch and learn” sessions to their nurse colleagues on symptom management;
  • formalizing the internal program with chaplaincy and social services for palliative care support;
  • developing a template for palliative care consults during clinic visits;
  • expanding their role from gastrointestinal oncology to inpatient general oncology to provide palliative care consults;/li>
  • developing confidence by observing palliative care teams;
  • starting an integrative review of literature for supportive/palliative care of patients with cancer and heart failure;
  • working with patient experience teams to discuss “legacy building;”
  • developing insight into the conflict between APRNs, physicians and bedside nurses about palliative care knowledge needs;
  • recognizing the need to develop an oncology home-care program to meet patient needs;
  • using appropriate verbiage and learning to wait and understand the patient’s and family’s responses to difficult news;
  • developing a “quick facts” resource on symptom management for the inpatient oncology unit;
  • advocating for young patients to help their parents recognize patient’s wishes;
  • starting a new palliative care nursing class at the school of nursing; and
  • starting a class for primary care providers to educate them about palliative care and the value to their patients

These palliative care activities and principles that course participants are integrating into their practices are having an impact on patient care and palliative practice.

Observing palliative care practice has improved participant confidence and competence in palliative care. Oncology APRNs described feeling increased independence and confidence in their roles and in discussing goals of care with their patient populations.

Providing this essential education to APRNs is improving palliative care, helping APRNs meet the complex needs of patients with cancer and helping to improve the quality of life for patients and their families.


Ferrell B, et al. Oncol Nurs Forum. 2020;doi:10.1188/20.ONF.222-227.

National Consensus Project. 2018. Clinical practice guidelines for quality palliative care, 4th ed. Available at: Accessed Nov. 2, 2020.

Oncology Nursing Society. 2017. Position statement: Palliative care for people with cancer. Available at: Accessed Nov. 2, 2020.

Wholihan D and Tilley C. 2017. Fundamental skills and education for the palliative advanced practice registered nurse. In: C. Dahlin PJ, et al. Advanced Practice Palliative Nursing. New York, NY: Oxford University Press.

For more information:

Denice Economou, PhD, CNS, CHPN, is a senior research scientist in the department of nursing research and education at City of Hope. She can be reached at