More than 1.49 million patients were served by hospice organizations in the United States in 2014, nearly doubling the number of patients served only 10 years prior (National Hospice and Palliative Care Organization, 2019). Significant growth expected in the aging population will continue to fuel this expansion of hospice services (Ortman et al., 2014). Paramount to the ability of health care teams to meet the demands of the growing hospice and palliative care population is the availability of trained hospice nurses. However, the predicted overall national nursing shortage and 20% annual turnover rates in hospice nursing associated with burnout threatens the ability of hospice providers to meet the expected growth in patients (Keidel, 2002; National Association for Home Care & Hospice, 2015; Zhang et al., 2018).
Critical efforts are underway to increase palliative care content in undergraduate nursing education to prepare all nurses for caring for patients with serious illness; however, gaps remain for those wishing to focus on care for the seriously ill as a career path (O'Connor, 2016). Although palliative care fellowships currently exist for physicians and nurse practitioners, resources are scarce for RNs beginning their nursing careers or changing fields to work in hospice or palliative care (American Academy of Hospice and Palliative Medicine, n.d.; Hospice & Palliative Nurses Association, n.d.; Pittman et al., 2014). The Institute of Medicine's Future of Nursing (2010) recommendations implored health care institutions and regulatory agencies to focus on transition to practice models, particularly upon completion of degree or when moving to a specialty practice.
Nurse residency programs are widely adopted transition-to-practice models bridging the gap between entry-level baccalaureate nursing education and professional nursing roles (LaVigne & Cosme, 2018). National residency accreditation standards dictate that these programs focus on clinical judgment and performance skills, interprofessional collaboration, evidence-based practice expertise, and professionalism. Residencies in nonhospital settings may be most successful when including specialty content, mentoring, preceptorships, and agency administrative support (Spector et al., 2015).
Responding to the need to improve hospice nurse recruitment and retention, we developed a hospice nurse residency based on a collaboration between an academic institution and a clinical hospice agency and piloted the design with two cohorts of RNs who were new to the hospice nurse case management role.
The hospice residency curriculum was developed using a crosswalk of local and national competencies and palliative care content (American Academy of Hospice and Palliative Medicine et al., 2004; American Association of Colleges of Nursing, n.d.; Commission on Collegiate Nursing Education, 2015; Coyle, 2015; Hospice and Palliative Credentialing Center, 2018). The National Consensus Project clinical practice guidelines (American Academy of Hospice and Palliative Medicine et al., 2004) provided the framework for this curriculum. Supporting these guidelines at the state level were the newly revised Massachusetts Nurse of the Future Nursing Core Competencies, included to align with statewide nursing education initiatives (Massachusetts Department of Higher Education Nursing Initiative, 2016). At the national level, the Commission on Collegiate Nursing Education (2015) Standards for Accreditation for Entry-to-Practice Residency Programs was incorporated in hopeful pursuit of accreditation at a future date. At the time this curriculum was implemented, residencies were accredited in acute care facilities only. Palliative care content highlighted the End-of-Life Nursing Education Consortium (ELNEC) curricula and the certified hospice and palliative nurse candidate handbook (American Association of Colleges of Nursing, n.d.).
Blending the crosswalk with our standard orientation resulted in the creation of several new lectures to ensure that content met all the standards noted above. All residents complete the agency new hire orientation and clinical orientation and then have additional residency didactic and educational experiences. Additionally, many new activities were developed, including a book club, debriefing sessions, and simulation exercises focusing on end-of-life communication. In recognition of the importance of specialty certification, nurse residents were purposely prepared for the CHPN® Examination. The examination tests knowledge of symptom management, ethics, and professional practice standards for hospice and palliative care nurses. To take the examination, nurses must practice 500 hours caring for patients with serious illness, so the nurses were eligible after their first year in practice following the residency.
Within the hospice setting, the interprofessional team is at the center of hospice care, with the nurse case manager as the team leader. This role can be a steep learning curve for both new graduate nurses and experienced nurses who are changing fields. For this reason, interprofessional team members were integrated into the curriculum from the start. Fieldwork, beginning the second week of the hospice nurse residency, included shadowing of all hospice interprofessional roles: physicians, nurse practitioners, nurses, social workers, chaplains, and home health aides. Interprofessional staff also facilitated some of the classroom activities and didactic lectures. In this way, the nurse residents were taught to recognize the roles of and value other members of the team. Teamwork was emphasized for better patient outcomes but also as a resource for the nurse case manager. The expectation was that by teaching the hospice nurse residents to fully utilize the interprofessional team, nursing frustration, stress, and burn-out would be avoided, leading to improved retention and recruitment.
Interdisciplinary teams were also modeled by including leaders and experienced front-line clinical staff from all disciplines within the agency in delivering curricular content. In addition to residency leadership and nurse education staff, we had four social workers, four chaplains, four physicians, four nurse practitioners, two bereavement counselors, and three members of clinical leadership deliver didactic content. This content ranged from ELNEC modules and symptom management to grief support and professionalism. The curriculum also included a 4-hour simulation provided by academic partner nursing faculty and a 4-hour pediatric training led by agency nurse educators at an off-campus site. The average classroom time for each of the two pilot cohorts was 24 days.
Implementation and Results
The nurse residency curriculum and fieldwork schedules were developed to expand on current hospice orientation and offer enough supervision time for new graduates. Coursework was delivered over 3 months for experienced nurses and 6 months for new graduate nurses, at a large, nonprofit hospice and palliative care agency located in the New England area. There were two sequential cohorts in the initial year of the residency; each group included both experienced nurses and new graduates. To qualify, the nurses had to be RNs. The nurses submitted an application and were interviewed. The new graduate RNs had to have completed their training within the past year; some had a few months of work, but for the remainder the residency was their first nursing job. The experienced nurses had a range of 3 to 6 years of practice in a variety of settings, from acute care to primary care practices. Nine of the nurses were baccalaureate prepared.
The first cohort consisted of five nurses, two experienced nurses and three new graduate nurses. The second cohort, started six months later, consisted of five experienced nurses and three new graduate nurses. The nurses were hired as full-time employees of the hospice agency and given student access to the academic institution libraries and online learning management system.
Classroom activities accounted for 1 to 3 days a week, and included didactic lectures, role-play and simulation exercises, pediatric skills training, a book club, journal writing, and weekly debriefing. The residents began their fieldwork the second week of the residency, which started by shadowing clinical staff. The residents then were paired one-to-one with an experienced nurse preceptor for 8 weeks (experienced RNs) and 12 weeks (new graduate RNs), respectively. Hospice administrators reduced the caseloads of the nurse preceptors by 25% to dedicate their time to teaching and mentoring. Monthly debriefing sessions continued with all hospice nurse residency graduates for 1 year after their hire.
The residency was led by a project director and nurse educator, with curriculum and evaluation assistance from their academic partners. Coursework was taught by the project director and nurse educator, other clinicians at the hospice agency, and faculty at the academic partner site. All classes were hosted at the hospice agency except for a communication simulation laboratory experience hosted by the academic partner. Fieldwork highlighted a variety of disciplines and settings of care, including routine home care in private homes, long-term care facilities, and assisted living facilities and the general inpatient level of care in a freestanding inpatient hospice home. The nurses shadowed a variety of hospice nursing roles (admission nurse, on-call nurse, triage nurse, weekend nurse, and nurse liaison) to deepen their understanding of hospice and palliative care. All nurse residents were expected to assume a hospice nurse case manager role for a minimum of 2 years upon completion of the residency.
Administration and funding considerations of the grant include initial funding support, resident salary support, residency leadership, and preceptor release time. The residency was initially developed with grant funding, which covered any additional curriculum development needed, leadership time, and preceptor release time. Salary costs for the nurse residents were covered by the agency as a new hire employee. Of the first two cohorts, 12 of 13 nurse residents were retained at 1 year (92.3%). Upon completing the mandatory 500 clinical hours, 90% passed the CHPN Examination on their first attempt. Five nurses have since left the agency, resulting in a 50% 3-year retention rate. These nurses left for various reasons (health issues, distance, change of practice area, and pursuit of further education) and the majority left the hospice specialty at least initially.
To measure outcomes beyond just completion of the residency, an evaluation plan was put into place. The evaluation plan included (a) resident assessment of the overall program; (b) resident evaluation of their skills and confidence over time; and (c) solicitation of feedback from agency staff involved with training the residents.
Resident Assessment of Overall Program
Data evaluating the overall program were gathered using a tool specifically developed for this project. The intent of this evaluation tool was to capture aspects of the program that the residents enjoyed and found valuable to their growth as hospice nurses. It also helped to highlight some important aspects of training to be modified for future cohorts. A course evaluation tool used at the academic institution to evaluate didactic and clinical courses was adapted for evaluating the hospice residency program. The tool included both quantitative and qualitative questions. Examples of questions include “In which ways has this program made you a more competent, knowledgeable, and skillful nurse?” and “To what extent did you find the following aspects of the residency effective?” The tool was administered to all nurse residents at the end of the program. Answers to the qualitative, open-ended questions were summarized and the summary validated by the study team.
Residents described experiences in the didactic and clinical settings as generally positive. Two major components of the residency emerged as most critical in the residents' own reflection of their experience. The first was that content covered in the lectures and debriefing sessions was crucial to the residents' learning. Seventy-seven percent of the residents reported that the lecture content was completely or moderately relevant to their practice and helped them in their growth as a hospice nurse. Additionally, 10 residents thought that the group debriefs from clinical time were necessary and recommended that there be more of them throughout the entire residency. Residents commented:
- All of the classroom time was extremely beneficial. All of the knowledge and insight gained from lectures and others' experiences left me more prepared than I even realized! I enjoyed the book readings/discussion and being able to debrief with everyone.
- Lectures were helpful to gain knowledge about clinical practice. Debriefing is helpful to validate experiences and allow us to review what we did with patients and ask questions.
The second most highly valued component was the residents' time with a dedicated preceptor. This precepting time was invaluable to their attainment of residency learning objectives. Some of the resident comments about their preceptors included:
- Her [preceptor] experience and knowledge was the best tool I had and she was extremely approachable with any questions I had.... She made [me] more confident in myself as a nurse.
- The best part of this preceptor experience is feeling like there will always be someone who has my back and who I can reach out for help if needed. I feel very supported by not only [my preceptor], but by all of the nurses, social workers, and managers.
Although everyone reported that they would recommend the residency program to peers, many of the residents would have liked for the dedicated preceptor training to start earlier.
Resident Self-Evaluation of Skills and Confidence
The Casey-Fink Graduate Nurse Experience Survey (Casey et al., 2004) was used to assess the growth of residents throughout the curriculum intervention. The Casey-Fink tool is a self-assessment survey used to measure skill, professional growth and relationships, confidence, and overall quality of life for nurses as they transition to practice. The tool was modified slightly with permission from the authors (K. Casey & R. Fink, personal communication, June 16, 2015) to have language that reflected care of patients in a community-based hospice setting. Some of the statements residents were asked to self-rate included:
- I am comfortable knowing what to do for a dying patient.
- I feel prepared to complete my job responsibilities.
- I am having difficulty prioritizing patient care.
Each of the 24 statements was rated on a 4-point Likert scale with the following responses: 1 = strongly disagree, 2 = disagree, 3 = agree, and 4 = strongly agree. The survey was administered to the residents at the beginning of the residency, at the end of the residency, and at the 1-year mark following completion of the residency.
For each of the cohorts, including both new graduate RNs and experienced nurses, the overall findings support that the residency program helped to increase their level of confidence in their role as hospice nurse, confidence in communicating, caring for dying patients, and case management. A third of the residents at the beginning of the program reported a general sense of discomfort when needing to speak with physicians and other nurses about their patients. After completion of the program, all residents agreed they were comfortable communicating with other clinicians.
The survey also revealed improvement in residents' comfort level of caring for a dying patient, with half feeling uncomfortable at the beginning of the program and all residents feeling comfortable at the end of the program. Improvement was noted in delegation of tasks and issues to the rest of the hospice team, as well as managing families. Aspects of knowledge and confidence as a hospice nurse also increased from the start to end of the program, as evidenced by the Casey-Fink question responses. This included a 20% increase in being able to prioritize patient care needs, as well as an 80% increase in comfort making suggestions for changes to the nursing plan of care. All residents were satisfied in their positions and felt supported by colleagues in the organization.
Importantly, we also found that 40% of the residents continued to feel overwhelmed with their caseloads and thought they had not practiced specific hospice skills as much as they wanted (i.e., port access, intravenous catheter starts, and tracheostomy care) even at the end of the residency. To address these issues for subsequent residencies, strategies around managing caseloads and delegation were integrated into the debriefing sessions. Also, the time that the residents spent at the hospice house during their field experience was increased to provide them with greater opportunities to practice some of the more acute nursing skills utilized in hospice care.
Clinical and Administrative Feedback
An open-ended qualitative tool was used to elicit feedback from all clinical and administrative staff that interacted with the nurse residents. The anonymous survey was conducted through SurveyMonkey™. A link to the survey was sent via email immediately following the conclusion of the second cohort of the residency. Questions included:
- What did you find most helpful, useful, or great about the nurse residency program?
- Would you recommend this program to a new graduate or experienced nurse looking to switch to hospice care?
- What did you find less helpful or disappointing about the nurse residency program?
- What suggestions do you have for future residencies?
Responses to the survey were summarized and validated, and findings are being used to make program improvements for current and future cohorts.
Twenty-four people responded to the survey sent to all clinical and administrative staff who had direct contact with the nurse residents. Staff reported that the most positive aspects of the residency were providing support to new nurses, more team interaction with the whole interprofessional team, and having well-prepared new staff. One comment from a staff member was, “Once the nurses started to have their own caseloads, they seemed confident in their role as hospice nurses, knowledgeable about the care they were providing and the resources of the clinical team.” Negative aspects of the residency included not always having a preceptor on the team where the nurse was assigned, feeling upset that a resident did leave the program, and concern for disruption in the clinical setting to go back for classes later in the program. One staff member was concerned that preceptors needed more structured guidance. When asked if they would recommend the hospice nurse residency to a nurse interested in hospice, 17 of 24 indicated they would “highly recommend” the training, five would “recommend” the program, one was “neutral,” and one “would not recommend” the program. Suggestions for future residencies included expanding to other disciplines, spending more time studying case management skills, and ensuring a preceptor from each team was trained.
The preceptors also completed midprogram and final evaluations of their residents. The preceptors evaluated the residents in seven areas: patient-centered care, professionalism, system-based practice, informatics/technology, communication, teamwork/collaboration, and safety. The evaluations also had space for preceptor comments. The ratings for the midprogram evaluation were “progressing satisfactorily,” “needs improvement,” and “unsatisfactory.” If there were any areas where a resident needed improvement or where they were unsatisfactory, the areas were identified and addressed by the residency project director and nurse educator, along with the resident's clinical manager and preceptor. The ratings for the final evaluation were “satisfactory” and “unsatisfactory.” All 12 of the residents who completed the residency received a “satisfactory” rating from their preceptor.
A hospice nurse residency pilot program was successfully implemented in one large nonprofit hospice adding 12 new nurse case managers to a growing community-based hospice. Retention rates of the nurse residents was 92% at 1 year and 50% at 3 years. The 1-year retention rate is in line with other nurse residency programs across the United States, whereas the 3-year retention rate is lower than other programs have reported (Asber, 2019; Van Camp & Chappy, 2017). Data about nurse residency programs in hospice are limited and thus difficult to compare, but the nurses who left at 3 years pursued roles outside of hospice. Future studies are needed to elucidate factors of generalized new graduate turnover compared with the emotional toll of working in hospice as a new graduate.
This pilot study also uncovered a need for more guidance for preceptors. Support for enhanced preparation and training for preceptors is a common theme in new graduate transition to practice models (Dahlke et al., 2016; Smith & Sweet, 2019). Although a preceptor training program was a component of this residency pilot, more structured weekly support has been offered in residency cohorts moving forward.
The hospice residency had some limitations. The program took place within one hospice setting, and the small sample size may affect the replicability and generalizability of the results. Additionally, the nurse residents agreed to a 2-year contract at the start of the residency, which may affect analysis of the retention rate. Funding and sustainability are also potential challenges. This project was funded by a Health Care Workforce Transformation Fund grant through the Commonwealth of Massachusetts, Executive Office of Labor and Workforce Development. The Commonwealth Corporation administered the grant program. The grant funding supported the development of the residency curriculum and first year of implementation. However, given the success of the residency pilot program, the hospice agency has committed to continue funding the program.
New strategies are needed to better prepare nurses to provide hospice and palliative care. This hospice residency pilot program is one potential strategy to prepare both new graduate and experienced nurses to transition-to-practice within the hospice and palliative care field. Given the success of the residency pilot program, the hospice agency committed to continue funding the residency program on a yearly basis. This conclusion was based on the overall agency goals of enabling a transition to practice option for new graduates to increase the pool of potential nurse applicants and the cost savings from nurse retention offset costs of annual program operation (versus overall curriculum development, which was funded by the grant). However, implementation of residency programs in community-based settings needs further evaluation. Future research should focus on specific hospice and palliative care clinical and learning outcomes, hospice nurse retention, and agency cost–benefit analyses for continued sustainability.
- American Academy of Hospice and Palliative Medicine. (n.d.). Clinical training: Hospice and palliative medicine fellowship training. http://aahpm.org/career/clinical-training
- American Academy of Hospice and Palliative MedicineThe Center to Advance Palliative CareThe Hospice and Palliative Nurses Association, & the Last Acts PartnershipThe National Hospice and Palliative Care Organization. (2004). National Consensus Project for Quality Palliative Care: Clinical practice guidelines for quality palliative care, executive summary. [Policy document]. Journal of Palliative Medicine, 7(5), 611–627 doi:10.1089/jpm.2004.7.611 [CrossRef] PMID:15588352
- American Association of Colleges of Nursing. (n.d.). End-of-life care: ELNEC. Retrieved from http://www.aacnnursing.org/ELNEC
- Asber, S. R. (2019). Retention outcomes of new graduate nurse residency programs: An integrative review. The Journal of Nursing Administration, 49(9), 430–435 doi:10.1097/NNA.0000000000000780 [CrossRef] PMID:31436741
- Casey, K., Fink, R., Krugman, M. & Propst, J. (2004). The graduate nurse experience. The Journal of Nursing Administration, 34(6), 303–311 doi:10.1097/00005110-200406000-00010 [CrossRef] PMID:15190226
- Commission on Collegiate Nursing Education. (2015). Standards for accreditation for entry-to-practice residency programs: Amended 2015. http://www.aacnnursing.org/Portals/42/CCNE/PDF/CCNE-Entry-to-Practice-Residency-Standards-2015.pdf
- Coyle, N. (2015). Introduction to palliative nursing care. In Ferrell, B. R., Coyle, N. & Paice, J. A. (Eds.), Oxford Textbook of Palliative Nursing (4th ed., pp. 3–10). Oxford University Press. doi:10.1093/med/9780199332342.003.0001 [CrossRef]
- Dahlke, S., O'Connor, M., Hannesson, T. & Cheetham, K. (2016). Understanding clinical nursing education: An exploratory study. Nurse Education in Practice, 17, 145–152 doi:10.1016/j.nepr.2015.12.004 [CrossRef] PMID:26775165
- Hospice and Palliative Credentialing Center. (2018). CHPN candidate handbook: Certified hospice and palliative nurse computer based examination. http://documents.goamp.com/Publications/candidateHandbooks/HPCC-CHPN-Handbook.pdf
- Hospice & Palliative Nurses Association. (n.d.). Palliative care APRN fellowships. https://advancingexpertcare.org/HPNAweb/Palliative_Care_APRN_Fellowship.aspx
- Institute of Medicine of the National Academies. (2010). The future of nursing: Leading change, advancing health: Report recommendations. http://nationalacademies.org/hmd/∼/media/Files/Report%20Files/2010/The-Future-of-Nursing/Future%20of%20Nursing%202010%20Recommendations.pdf
- Keidel, G. C. (2002). Burnout and compassion fatigue among hospice caregivers. The American Journal of Hospice & Palliative Care, 19(3), 200–205 doi:10.1177/104990910201900312 [CrossRef] PMID:12026044
- LaVigne, R. & Cosme, S. (2018). Nurse residency accreditation: An approach for organizational engagement. Nurse Leader, 16(1), 29–33 doi:10.1016/j.mnl.2017.10.007 [CrossRef]
- Massachusetts Department of Higher Education Nursing Initiative. (2016). Massachusetts nurse of the future nursing core competencies: Registered nurse. http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf
- National Association for Home Care & Hospice. (2015). Hospice 2015–2016 salary & benefits report now available. https://report.nahc.org/hospice-2015-2016-salary-benefits-report-now-available/
- National Hospice and Palliative Care Organization. (2019). NHPCO facts and figures. https://www.nhpco.org/wp-content/uploads/2019/07/2018_NHPCO_Facts_Figures.pdf
- Ortman, J. M., Velkof, V. A. & Howard, H. (2014). An aging nation: The older population in the United States. United States Census Bureau website: https://www.census.gov/prod/2014pubs/p25-1140.pdf
- O'Connor, B. (2016). CARES: Competencies and recommendations for educating undergraduate nursing students preparing nurses to care for the seriously ill and their families. Journal of Professional Nursing, 32(2), 78–84 doi:10.1016/j.profnurs.2016.02.008 [CrossRef]
- Pittman, P., Horton, K., Terry, M. & Bass, E. (2014). Residency programs for home health and hospice nurses: Prevalence, barriers, and potential policy responses. Home Health Care Management & Practice, 26(2), 86–91 doi:10.1177/1084822313511457 [CrossRef]
- Smith, J. H. & Sweet, L. (2019). Becoming a nurse preceptor, the challenges and rewards of novice registered nurses in high acuity hospital environments. Nurse Education in Practice, 36, 101–107 doi:10.1016/j.nepr.2019.03.001 [CrossRef] PMID:30901723
- Spector, N., Blegen, M. A., Silvestre, J., Barnsteiner, J., Lynn, M. R. & Ulrich, B. (2015). Transition to practice in nonhospital settings. Journal of Nursing Regulation, 6(1), 4–13 doi:10.1016/S2155-8256(15)30003-X [CrossRef]
- Van Camp, J. & Chappy, S. (2017, August). The effectiveness of nurse residency programs on retention: A systematic review. AORN Journal, 106, 128–144 doi:10.1016/j.aorn.2017.06.003 [CrossRef] PMID:28755665
- Zhang, X., Tai, D., Pforsich, H. & Lin, V. W. (2018). United States registered nurse workforce report card and shortage forecast: A revisit. American Journal of Medical Quality, 33(3), 229–236 doi:10.1177/1062860617738328 [CrossRef] PMID:29183169