Academic–Clinical Collaborations to Build Undergraduate Nursing Education in Hospice and Palliative Care

Abstract

With the current shortage of hospice/palliative care (HPC) workforce, there is an urgent need to train a generation of nurses with clinical competency in HPC to ensure equitable access and optimal care for patients living with serious illness or at the end of life. The recent demand for HPC teaching in nursing education calls for innovation in establishing clinical placements. Palliative care nursing experts in New York State were surveyed between June and August 2022 about facilitators of academic-clinical partnerships between nursing schools and clinical settings. Inductive content analysis of open-ended responses revealed six major interconnected themes: (a) Increase Awareness of HPC in the Nursing Program, (b) Build a Relationship With Administrators, (c) Look Beyond Acute Care Partnerships, (d) Offer Incentives, (e) Develop Direct Care Experiential Opportunities, and (f) Develop Non-Direct Care Experiential Opportunities. Findings provide rich insights into key considerations for successful collaboration between nursing schools and clinical sites.

The need for palliative care is growing in the United States (Dumanovsky et al., 2016) due, in part, to the growing number of individuals living with serious illness and increasing awareness of the benefits of palliative care to improve quality of life, manage symptoms, and support patients and families (Comart et al., 2013; Kamal et al., 2017; Kelley & Morrison, 2015). Early integration of palliative care, including hospice, requires nurses (the largest group of frontline clinicians) to view their role and contribution to patient care in a new way. Consequently, nursing programs are faced with the corresponding challenge of changing the way nursing students are educated. In 2021, the American Association of Colleges of Nursing (AACN; 2021) adopted Hospice and Palliative Care (HPC) as one of the four core spheres in undergraduate and graduate nursing education. Notably, the new Essentials recommendations include the need for students to engage in direct care learning activities and clinical immersion experiences that provide an opportunity for concentrated clinical synthesis (AACN, 2021).

Developing clinical rotations that incorporate HPC in nursing programs may overwhelm the existing strained infrastructure of limited clinical sites exacerbated by the coronavirus disease 2019 (COVID-19) pandemic (Chan et al., 2021). Enhancing academic–clinical collaboration in planning and conducting robust clinical experiences with a focus on HPC represents a promising approach to successful training of a new generation of entry-level nurses equipped to care for patients living with serious illness and their families. Academic–clinical collaborations have been recommended as essential to maintain sustainable clinical sites for nursing programs and more robust clinical experiences (Hahn-Schroeder et al., 2022; Parekh de Campos et al., 2022). Furthermore, nursing programs and clinical site administrators must establish relationships that bring their unique expertise, knowledge, and skills together, leading to robust clinical experiences for nursing students (Paton et al., 2022). This relationship is particularly important in the field of HPC, which has traditionally been underutilized as a clinical setting in undergraduate nursing programs. However, little guidance has been provided regarding actionable steps to build collaborative partnerships between HPC clinical sites and nursing programs. With the current shortage of HPC workforce, there is an urgent need to train a generation of nurses with clinical competency in HPC to ensure timely, equitable access and optimal care for patients living with serious illness or at the end of life. We surveyed HPC clinicians and health care systems leaders across New York state to elicit their perspectives on academic–clinical collaborations. Our objective was to obtain input and suggestions from HPC experts regarding facilitators of academic–clinical collaboration between undergraduate nursing programs and clinical sites.

METHOD

Data collection occurred June 15 to July 11, 2022, as part of a Delphi survey to develop consensus on essential HPC topics to integrate in undergraduate nursing education. Eligible survey participants were required to be either: (a) a RN or nurse practitioner (NP) with at least 3 years of clinical experience in HPC or a certified hospice and palliative nurse, or (b) have at least 3 years of experience in a senior leadership position (e.g., vice president or chief executive) in HPC in New York state. Participants were recruited from the membership list of the Hospice & Palliative Care Association of New York State and through local HPC committees and groups. Email invitations were sent to complete an anonymous online Qualtrics^® survey comprising open-ended questions about clinical skills and topics in HPC important to integrate in undergraduate nursing education. For the current report, we focused our analysis using qualitative data provided by respondents to one open-ended question collected during the first round of the Delphi survey. Participants were asked to, “Please list up to three to five facilitators or approaches that may improve collaborations between hospice/palliative care settings and nursing programs that seek to expand clinical opportunities in hospice/palliative care for undergraduate students in nursing.” This study was deemed exempt by the Institutional Review Board at Adelphi University.

Analysis

Descriptive statistics (e.g., frequencies, mean) were used to describe participants’ characteristics. Conventional inductive content analysis was used to examine written, unstructured comments provided by respondents to one open-ended question (Hsieh & Shannon, 2005). Categories and concepts used to label responses were derived directly from initial reviews of the text data into a codebook. Two coauthors then independently read and coded responses. The team met to discuss results, condense them into categories, and generate themes. Coded text was grouped into 31 sub-categories that were further collapsed into six themes that constitute the findings.

RESULTS

Sample Characteristics

Participants’ characteristics are listed in Table 1. Most of the 28 experts were White (78.6%), female (82.1%), and aged >50 years (71.4%). The most common role was administrative (60.7%). Thirty-five percent practiced as palliative care NPs and the most common work location was home hospice (42.9%). Approximately one half of participants (46.4%) were board certified in hospice and palliative nursing.

TABLE 1.

Participants’ Characteristics (N = 28)

Characteristic	n (%)
Sex
Female	23 (82.1)
Male	5 (17.9)
Race
Asian	2 (7.1)
Black/African American	4 (14.3)
White	22 (78.6)
Age (years)
30 to 39	4 (14.3)
40 to 49	4 (14.3)
50 to 59	10 (35.7)
≥60	10 (35.7)
Years of experience in HPC senior leadership
<2	2 (7.1)
2 to 4	2 (7.1)
5 to 9	6 (21.4)
10 to 19	9 (32.1)
20 to 29	3 (10.7)
30 to 39	3 (14.3)
≥40	2(7.1)
Years of experience as a RN in hospice
<2	2 (7.1)
2 to 4	2 (7.1)
5 to 9	6 (21.4)
10 to 19	9 (32.1)
20 to 29	3 (10.7)
30 to 39	4 (14.3)
≥40	2 (7.1)
Current role in HPC
Administrative/leader	15 (53.6)
Administrative non-clinician	2 (7.1)
Clinical/direct care	8 (28.6)
Educator	3 (10.7)
Board certified in HPC
Yes	13 (46.4)
No	13 (46.4)
NA	2 (7.1)
Current practice setting
Home hospice	12 (42.9)
Hospital palliative care	7(25)
Inpatient hospice	3 (10.7)
Nursing home	3 (10.7)
House calls	1 (3.6)
Home health care	1 (3.6)
Other	1 (3.6)
Highest education attained
Associate degree	1 (3.6)
Bachelor’s degree	6 (21.4)
Master’s degree	12 (42.7)
DNP	4 (14.3)
PhD	3 (10.7)
Other	1 (3.6)
Missing	1 (3.6)
Years of experience in teaching undergraduate nursing students
None	16 (57.1)
1 to 4	5 (17.9)
5 to 9	1 (3.6)
10 to 19	5 (17.9)
NA	1 (3.6)
Practice as a NP in HPC in New York
No	18 (64.3)
Yes	10 (35.7)

Note. HPC = hospice/palliative care; NA = not applicable; DNP = Doctor of Nursing Practice; NP = nurse practitioner.

Themes

Through content analysis, six themes were identified from participants’ responses (Table 2). Each theme offers specific examples of how nursing programs can build active partnerships with HPC settings in the U.S. health care system. The themes included: (1) Increase Awareness of HPC in the Nursing Program, (2) Build a Relationship With Administrators, (3) Look Beyond Acute Care Partnerships, (4) Offer Incentives, (5) Develop Non-Direct Care Experiential Opportunities, and (6) Develop Direct Care Experiential Opportunities.

TABLE 2.

Themes and Responses

Theme	Sample Responses/Recommendations
Increase Awareness of Hospice and Palliative Care (HPC) in the Nursing Program	Invite hospice RN and palliative care NP as guest lecturers Host panel discussions with HPC representation across the curriculum Invite hospice clinicians to programs on campus so students can ask questions (i.e., interactive discussion)
Build a Relationship With Administrators	Meet the needs of potential partners—ask organizations “What are your priorities?” Volunteer as a group to participate in or have a fundraiser for the hospice Get administrators’ buy-in about CEUs Collaborate with clinical partners to establish HPC nurse residency programs
Look Beyond Acute Care Partnerships	Have more focus on other providers besides acute care (e.g., collaborate with nursing homes, home health, and other long-term care settings or outpatient geriatric practices with HPC [NP or MD]) Collaborate with faculty in practice at clinical sites
Offer Incentives	Offer to assess medical records for institutions Have students perform quality improvement projects (e.g., participation in JCAHO preparation) Have research faculty offer services to sites for projects Offer incentives for faculty who are in practices that take students Payment of clinical preceptors Offer CEUs
Non-Direct Care Experiential Opportunities	More relevant, up-to-date, and comprehensive experiences One-on-one interview with hospice nurse Capstone experience in residential care/home hospice Help students understand community perception of hospice Promote cross-cultural understanding Offer students to attend interdisciplinary group or observe team meeting/mock team meeting Participate in bereavement support groups
Direct Care Experiential Opportunities	Flexibility to the clinical site; extended clinical rotation in home or facility Students should be available to work variable shifts, including evening, night, and weekends, and be flexible to travel long geographic distances Home visits to both palliative type cases in the homecare environment and hospice Work with child-life/chaplaincy in pediatric hospitals Student nurses should do a clinical rotation in a hospice setting Clinical experience or palliative rounds in residential care/home hospice Send students to nursing homes with a palliative care program Mandatory 1-week rotation for students in HPC

Note. NP = nurse practitioner; CEUs = continuing education units; JCAHO = Joint Commission on Accreditation of Healthcare Organization.

DISCUSSION

Abundant literature in nursing has highlighted the importance of academic–clinical collaborations to create opportunities for clinical experiences for nursing students, especially amid the COVID-19 pandemic (Hahn-Schroeder et al., 2022; Zerwic et al., 2021), yet little is known about practical stakeholder-informed strategies for advancing this goal, particularly in HPC. Open-ended responses to this survey captured a snapshot of HPC RNs’, NPs’, and administrators’ perspectives about how to develop academic–clinical collaborations to support clinical learning experiences in undergraduate nursing programs. Content analysis resulted in six categories: increase awareness of HPC in nursing programs, build relationships with administrators, look beyond hospitals, offer incentives, and provide non-direct care and direct care experiential opportunities.

The AACN–American Organization of Nurse Executives Task Force on Academic–Practice Partnerships highlights that successful academic–practice partnerships necessitate a shared commitment to establish collaborative arrangements based on common goals, mutual respect, and shared knowledge (Beal et al., 2012). Recommendations from our participants elucidate strategies to ensure that clinical partners and nursing programs mutually benefit from collaborations to build HPC clinical experiences for nursing students. Some recommendations were consistent with literature across nursing education: relationship building with health care systems administrators (Baptiste et al., 2022) and the need to focus clinical experiences in undergraduate nursing on non-acute care settings as areas for ongoing attention in developing clinical experiences in nursing (Mazanec et al., 2020). The current study highlights various factors that need to be considered in developing and structuring these placements.

Additional categories uncovered in the current study extend previous research by illuminating new areas of needed attention. For example, participants’ recommendations called for increasing awareness of HPC in nursing programs. Lack of awareness of the role and benefits of HPC has been associated with clinician difficulty in referring patients for palliative and hospice services (Parekh de Campos et al., 2022). Awareness of the role of HPC clinicians in caring for the growing population of older adults living with serious illnesses warrants attention in academic settings.

Another striking finding from our study was the theme of incentives. Most notable was the subcategory for incentives to encourage nurse preceptors to support teaching clinicals in HPC. This recommendation highlights the current shortage of preceptors and clinical sites further exacerbated by the COVID-19 pandemic (Alexander, 2020). Preceptors play a critical role in the education of entry-level nurses. Yet, the use of incentives to foster academic–clinical collaborations has received little attention in the nursing literature. Limited research examining incentives has explored the topic of precepting NP students and shows that the most highly rated incentives were credit toward professional recertification, access to clinical references, and remuneration (Webb et al., 2015). Similar to our theme that classifies continuing education units as potential incentives, recent studies show that the establishment of academic–clinical partnerships offer the advantage of developing continuing education programs and resources for clinical partners (Baptiste et al., 2022). The need for incentives to bolster the supply of clinical preceptors is clearly reflected in the AACN (2022) report, which outlines several states that offer tax incentives for nurses serving as preceptors.

Participants also cited a need to look beyond the acute care system and develop relationships with post-acute care providers (e.g., nursing homes, home health care). As palliative care continues to expand into community-based settings, nursing students should be trained to understand the unmet needs of patients in these settings. Nurse leaders and researchers have advocated for nursing programs to expand beyond the current high focus on acute care in nursing programs and have suggested practice–community partnerships are requisite to achieving this goal (Parekh de Campos et al., 2022). As the U.S. long-term care system rapidly expands to home and community-based care (Grabowski, 2021), clinical training opportunities should evolve to reflect the spectrum of care settings in the United States.

There is much discussion in the HPC nursing arena surrounding the need to collaborate with clinical partners to establish hospice and palliative nurse residency programs (Parekh de Campos et al., 2022). The nurse residency is an important training opportunity for preparing entry-level nurses to provide primary palliative care for patients with serious illness and their families. Nurse residency programs also offer the dual benefit of developing nurse faculty from the clinical site and providing a platform for ongoing clinicals for undergraduate students (Mazanec et al., 2020; Salmond et al., 2017). Collaboration between nursing programs and health care systems is key to resource sharing. Health care system clinicians can participate in clinical training and nursing programs can provide high-fidelity simulation labs that are also important for skills training (Liaw et al., 2015; Smith et al., 2018). In particular, high-fidelity simulation resources may be limited in home- and community-based settings and provide a critical opportunity for clinical skills refresher courses for experienced nurses. The new AACN Essentials guidelines call for all schools to incorporate HPC content in undergraduate and graduate nursing education. However, efforts to formalize HPC in the curriculum are stalled by saturated nursing curricula and a shortage of faculty with expertise in palliative care content (Ferrell et al., 2018).

LIMITATIONS

We believe our study is one of the first to elucidate, from the perspectives of expert nurses and administrators in HPC, a path forward to develop these partnerships with a focus on HPC in undergraduate nursing programs. Nevertheless, our study limitations include that data were collected as part of a broader Delphi study, with no opportunity to further probe responses, and were collected at one time point and are not consensus-based. Furthermore, participants were only from New York state. Thus, findings may not be representative of stakeholders’ views outside of New York. A strength of this study is that it was conducted during the COVID-19 pandemic, so findings are reflective of the perspectives of health care systems leaders and clinicians currently practicing in HPC.

CONCLUSION

Transforming nursing education to integrate a focus on HPC is not a small task and requires a structured partnership with health care leaders and stakeholders in HPC. Such collaborations are key to train a generation of nurses who are prepared to understand and prioritize the palliative care needs of patients in a health care environment already struggling with a critical nursing workforce shortage. Our findings offer insight on important steps nursing schools may take to build and sustain relationships with health care systems that support clinical learning experiences in HPC for undergraduate nursing programs.