Hospice leaders may have a narrow view around the hidden daily challenges experienced by nurses — both at the bedside and operationally. More providers are peeling back the layers of the largest nursing workforce obstacles to strengthen their retention strategies.

Rising demand and widespread staffing shortages have given way to a difficult state of the hospice nursing workforce. Hospice nurses face unique challenges compared to others across the care continuum, according to Danny Cox, a registered nurse. Cox is also senior vice president of clinical operations at Crossroads Hospice & Palliative Care, which serves Ohio, Pennsylvania and Tennessee.

Employers need meaningful avenues of support to sustain and grow future generations of nursing workforces, Cox said. Hospice leaders need to recognize and address the diverse and complex needs that go beyond financial and practical considerations, he indicated.

“We want to throw money at the issue sometimes, but people don’t typically get into hospice for the dollar,” Cox told Hospice News. “You can always go somewhere else and make more money. It’s figuring out some kind of holistic program beyond the things [leaders] may think about. If you focus on that holistic support, that could be huge.”

Hidden nursing challenges

More than 1.5 million hospice registered nurses are employed nationwide, reported the career firm Zippia, which aggregates data from the U.S. Bureau of Labor Statistics and other sources. A large portion of this workforce, 89.8%, are women, the report found. Female hospice registered nurses earned 95% of what males earned in 2022, according to the research.

Demographics are driving demand for nurses. An estimated 82.13 million Americans will be 65 and older by 2050, a rise from nearly 57.8 million in this age cohort during 2022, reported the U.S. Census Bureau.

Hospices have taken varied routes to improve nurse recruitment and retention including increased compensation, expanded benefits, flexible scheduling and investing in technology to build workflow efficiency, among others.

Employee appreciation efforts have also included various events, awards and recognitions in observance of National Nurses Week. Annually observed from May 6–12 in the United States, the week is intended to honor the contributions of this workforce across the health care continuum.

Among the under-recognized issues affecting satisfaction and turnover among nurses is the tremendous compliance burdens of today’s hospice regulatory climate, according to Cox. A great deal of time, effort and education goes into understanding clinical documentation requirements and hospice regulations, he indicated.

Nurses receive ongoing training around the compliance standards and ways to ensure solid documentation. Nurses’ documentation and administrative burdens have heightened amid rising auditing activity and increased enforcement as regulators address quality and program integrity issues in the hospice space, Cox indicated.

“What we’re noticing right now is documentation and regulatory burden,” Cox told Hospice News. “The documentation requirements for Medicare compliance can be extensive, especially in the days of all the [audits] going on right now across most organizations. For the nurses at the bedside, it’s charting and being able to facilitate care without spending hours [on documentation]. Leaders might not be thinking about that, but we’re finding this as a big time issue right now.”

Providing goal-concordant care to terminally ill individuals is both taxing and rewarding work for hospice nurses, according to Cindy Bergeron, senior director of home care at Granite VNA. The New Hampshire-based home health and hospice provider serves 72 towns statewide, predominantly across rural regions.

Nurses need strong training not only in clinical best practices, but also around communication and holding effective goals-of-care conversations, Bergeron stated. Even with solid education and leadership support, providing end-of-life care at the bedside can come with unforeseen and challenging situations, she said.

“Some of the lesser-known challenges we face that we can’t fully prepare for are incidents such as ethical dilemmas,” Bergeron told Hospice News. “[It’s] the difficult decision-making for our staff related to finding a balance between the patient’s wishes, family expectations and the services we can offer. That is a lesser-known challenge, is trying to find that balance and creating that plan of care for those patients.”

Unlocking keys to address nursing challenges

Equipping a nursing workforce for sustainability involves taking a creative approach to retention, according to Bergeron. Greater opportunities exist for more peer-based coaching, respite, meaningful recognition and overlapping areas of career development, she indicated.

“This is a really sensitive nursing field, and we [need to] take a look from a different point of view,” she said. “In hospice, it’s a very different plan of care with that high emotion and compassion fatigue. How do we better address it to give that reprieve?”

Granite VNA has increasingly provided more cross-training opportunities for its home health and hospice nurses. The “robust education” allows greater exposure to the different regulations and care delivery approaches in hospice that other nurses might not otherwise receive, Bergeron said. The strategy has also “built bridges” for career development and allowed hospice nurses to see patients further upstream, which can help ease some of the emotional tolls on this workforce, she added.

The cross-training initiative has also fostered greater continuity of care, which has become a sticking point in nursing retention across the organization, said Granite VNA Vice President Angela Arria. Nurses are able to continue providing care to patients who are referred to hospice and play an integral role in their end-of-life journey, Arria said.

Having nurses trained in both home health and hospice has also increased clinical capacity and helped reduce burnout, she indicated.

“We train our home care nurses with compliments of hospice [and] it has been wildly successful,” Arria told Hospice News. “It is personally gratifying for our nurses to provide this continuity of care to patients that they have had for a while, and it provides us more bandwidth to be able to provide hospice in all settings. It’s pretty impactful. We’re trying to be as flexible with our staff as possible, with all of our nurses trained to care for patients in either setting.”

Staff engagement and mentorship can help build a supportive culture that deepens nursing retention, said Karen Bergenholtz, vice president of implementation and education at Enclara Pharmacia, a Humana (NYSE: HUM) company. Bergenholtz has also served as a pediatric nurse practitioner.

Having more experienced nurses pass on their knowledge and perspective to others can foster stronger retention, she indicated.

Nurses need leaders with the capacity to listen to their concerns and advocate for improved strategies, Bergenholtz said. Encouraging regular peer check-ins can curb burnout while also increasing visibility into the potential career pathways across a hospice organization. This strategy can lead to increased satisfaction and confidence, as well as greater collaboration, she stated.

“Hospice is a highly self-directed specialty, often requiring nurses to manage complex care on the go with limited time to reference materials or seek guidance,” Bergenholtz told Hospice News in an email. “Traditional training models often don’t account for this shift, so many new nurses enter the field without a strong foundation in hospice-specific care, requiring them to seek specialization and credentialing on their own. With fewer daily touch points with peers, they miss opportunities for informal learning, mentorship, and emotional support. This isolation can lead to burnout and affect confidence.”