Honing clinical scheduling and onboarding models is key to sustaining the hospice nurse workforce as demand for these clinicians rises and wages lag compared to those in other settings.

Future generations of health care clinicians may be woefully unprepared to address both the quantity and and the complexity of emotional, physical and spiritual needs among a swelling aging population nearing the end of life. A main issue is that many students do not receive adequate exposure to hospice and palliative care during their medical education, including training in the full scope of these interdisciplinary services.

Nurses entering the workforce need a wider scope of hospice and palliative care education and awareness to help fill these knowledge gaps and prepare them for growing demand, according to Michelle White, director of home and transitional care and homecare providers at North Carolina-based Cone Health.

“I’ve been in this industry for the past 25 years and have had a lot of background in seeing why people come into the industry of home health, home care or hospice, and why they leave,” White told Hospice News. “Much of that was because new nursing students who come into the industry are often ill-equipped to understand the big picture. If we look at the sequencing of core [education] components [it’s] about understanding the roles of various disciplines within the organization.”

Building sustainable models

Effective and empathetic communication is among the key skills for hospice nurses to possess, White indicated. Goals-of-care conversations are an important “building block” in training future nursing workforces, she stated.

But these communication skills may be lacking among many clinicians. For instance, nurses and nursing students frequently reported difficulties in communicating with patients about their life-limiting prognoses in a 2020 study published in Behavioral Sciences.

Medical educators and hospice providers alike are working to improve clinical training models to better integrate a wider breadth of interdisciplinary skills. These efforts come alongside a growing need for sufficiently trained nursing staff amid widespread clinical shortages.

A research project was recently launched to explore the common breakdowns in medical training, onboarding and clinical rotation exacerbating nursing shortages. Implemented by the Hospice and Home Care Foundation of North Carolina, the project was evaluated with input from the East Carolina University in North Carolina

A large goal was to establish more standardized education tools that can be integrated across various organizations throughout the care continuum, according to Susan Harmuth, the project’s director.

“We were interested in developing a clinical rotation model and an onboarding model that would provide real-life exposure opportunities for nursing students in home health and hospice, as well as a tool that agencies could use to successfully integrate newly hired graduated registered nurses into their organizations,” Harmuth said.

The findings, published in Home Healthcare Now, helped illustrate the greatest unmet needs among new nurses providing home-based care in rural-based regions of North Carolina. The project followed clinical orientation and onboarding models for newly graduated home health and hospice registered nurses across North Carolina organizations.

A key finding among the nurses who participated in home health and hospice education was that they often indicated they wanted more of these opportunities, even if it would reduce other clinical rotation areas, Harmuth stated. Several nurse participants expressed interest in receiving more simulated patient visit training and bedside “ride alongs” to gain greater exposure around care delivery nuances in the home health and hospice realms, she added.

More hands-on training and exposure to home health and hospice earlier on in medical education trajectories could lead to improved recruitment and retention in these fields, according to White.

“One of the greatest outcomes is that we do see people that maybe have had this wonderful, robust exposure coming back into this industry,” White said. “One of the outcomes [was] that we recruit people into the industry – and that may not happen right away, but maybe months or years later. It’s about how we equip someone with the understanding where they feel comfortable and competent in the ranges of infection control, personal safety and lots of things in between.”

A common misconception detering nursing students from entering the hospice workforce sooner in their careers is that they will lose out on important experiences in the acute care landscape, according to Nancy Dias, associate professor East Carolina University in North Carolina’s College of Nursing. Introducing end-of-life care sooner in their education could “make a dent” busting this myth, Dias stated.

“Death is an important component that we need to stress in our curriculum and onboarding models, because buying into that concept will help with retention and engagement and better understanding of quality metrics in terms of what aspects are needed to take care of in a patient, their family and this whole bigger picture of understanding palliative and hospice care as well,” Dias told Hospice News.

Compensation, demographic trends

Alongside complex interdisciplinary educational needs, nurses are also facing challenges related to their earnings potential, recent research has found.

Registered hospice and palliative nurses reported on average earning slightly less compared to those in other settings in a national survey from AMGA Consulting and global consulting firm Korn Ferry. The AMGA 2024 Nursing Specialty Compensation and Pay Practices Survey polled more than 127,000 nurses across 16 health settings from 39 organizations.

Registered hospice and palliative care nurses reported an average of $42.48 in hourly wages, which fell slightly below average rates among hospital nursing workforce at $42.55 per hour. Hospital-based nurses in surgical settings earned the highest hourly rates compared to others. Average compensation for inpatient mental health nurses was second highest.

Nursing compensation trends have largely been driven by retention strategies coming out of the pandemic, according to Marc Hallee, senior client partner at Korn Ferry.

“Retention incentives really spiked during the pandemic, and that became a strategy a lot of health systems and organizations used to keep their workforces intact,” Hallee said. “They trailed off some, but this data suggests that they’re still prevalent in hospice and palliative care.”

The survey findings provide hospices with a wider picture of the clinical compensation outlook, according to Mike Coppola, chief operating officer at AMGA Consulting.

The nursing workforce in general has seen increased wage rates during the past three years, a trend not anticipated to abate anytime soon, Coppola said. But settings such as home health, hospice and palliative care may offer nurses improved work-life balance, a significant sticking point in retention, he stated.

“There has been an overall inflationary increase in wages that is not going to reverse itself,” Coppola told Hospice News. “What sticks out in the data is that the clinic and ambulatory care side [rates] are lower than home health, hospice and palliative care, which is generally what we see historically as a trend. It’s not a significant difference to look at the median compensation … but that’s an easy trade-off for an RN moving to [another] setting for a little less compensation for more work-life balance.”

Hospices in particular face greater demographic pressures compared to other settings, according to Coppola.

The demographic trends among hospice clinicians are similar to those of the swelling aging population in need of their services.

For instance, the hospice and home health nursing workforce has the highest percentage of individuals 60 and older, the AMGA data found. The majority of hospice and palliative nurses were 40 and older, compared to the average age of 25-to-39 years old among those in intensive and critical care unit settings.

“One thing to notice in the data is the age cohorts of those RNs in hospice and palliative care,” Coppola said. “If you compare that to some of the other specialties, there’s a much younger population in the critical care speciality world than there is in the hospice and palliative care world. You’ll see some pretty significant changes in that age range.”