Blueprint for a Palliative Advanced Practice Registered Nurse Fellowship

Abstract

Opportunities for advanced practice registered nurses (APRNs) to train for specialty palliative care practice are insufficient to meet workforce needs. Graduate nursing programs in the United States do not have uniform or required curricula in palliative and end-of-life care of the seriously ill. In clinical practice, APRNs acquire palliative care skills by a mix of on-the-job experience, self-study, and continuing education. While physician colleagues can pursue post-residency training in one of 156 accredited hospice and palliative medicine fellowships, there are fewer than a dozen fellowships for APRNs, each training between one and three nurse fellows for specialty palliative care practice. This disparity slows the pipeline of palliative nursing experts and leaders, taxes employers with significant training duties, and results in an APRN workforce without uniform training. There are grass roots initiatives—often by non-nursing educators—to adapt existing physician and interprofessional fellowships for nurse learners, both in palliative care and other specialties. While these efforts help meet staffing needs and promote interprofessionalism, these programs are built upon medical curricula and competencies rather than grounding from a nursing framework. Nursing fellowship directors may not have the same administrative support, protected nonclinical time, funding, or access to nursing mentors and faculty afforded to their medical counterparts. This article provides a blueprint for clinician educators from nursing or non-nursing disciplines, who want to develop or refine training programs for APRNs that adhere to palliative nursing standards and offer a curriculum integrated with supervised practice and mentorship.

Post-Graduate Training for Advanced Practice Registered Nurses

The value and feasibility of widespread post-graduate training for advanced practice registered nurses (APRNs) have been debated for decades.^1,2 New-to-practice APRNs struggle in the gap between their academic preparation and the necessary skills to thrive as independent practitioners.^1,3,4 Regardless of training, evidence shows that new-to-practice APRNs experience a range of emotional and intellectual challenges in their first year, including the anxiety of a new role, navigating a new system, imposter syndrome, and variable confidence with skills acquisition.³ These hurdles are present to a lesser extent for experienced APRNs upon change in practice area. Experienced APRNs who change specialty still need an onboarding that allows a stepwise build of skills and theory-based knowledge over time. Both new and experienced APRNs thrive in an environment of support, mentoring, and flexibility in sizing patient caseload to the APRN's development.^2,5–7

Although the onboarding process typically involves supervised orientation, there is great variation in organization, curriculum, duration, and expected competencies.⁸ Alternatively, structured post-graduate training programs offer intensive training integrated with curricula and mentoring over a longer period of time, such as year-long fellowships.^7,9 While there is no evidence directly comparing fellowship-trained APRNs to those typically trained, there is growing interest among palliative care APRNs for fellowships, and calls to expand post-graduate training nationally.^10,11 Until there is enduring federal, institutional, or philanthropic funding for post-graduate ARPN training, only a small percentage of aspiring palliative APRNs will benefit.²

Less than 5% of palliative care APRNs report they completed fellowship training.¹² Most APRNs report that they learned on-the-job, through self-study and continuing education, and many felt unprepared upon starting palliative care positions. An exemplar of continuing education is the End-of-Life Nursing Education Consortium (ELNEC), a set of education modules to teach palliative care to nurses at all practice levels.¹³ Inclusion of primary palliative care curricula in nursing schools is increasing; however, it is neither standard nor mandatory. The dissemination of ELNEC curricular materials into undergraduate and graduate nursing programs has reached 62,000 nursing students.¹³ While these programs build foundational theoretical knowledge in primary palliative care, they lack integration with experiential learning and mentoring.

In 2011, the Institute of Medicine's (IOM) Future of Nursing report advocated expansion and support for post-graduate nursing training across specialties.¹⁴ Then, the Dying in America report called for more generalist and specialty training of palliative care providers of all disciplines.¹¹ In 2018 and 2019, the House passed the Palliative Care and Hospice Education Training Act (H.R. 647) to improve and support specialty training for all health professionals, including APRNs. H.R. 647 needs Senate confirmation to become law.

Given the grim predictions of an insufficient supply of fellowship-trained hospice and palliative care physicians to meet the needs of seriously ill Americans in the coming years, shortages of palliative nursing colleagues are likely substantially larger.^10,15 As palliative care expands into more medical specialties and care settings, there is an urgent need to develop and refine training for all members of the interdisciplinary team, to expand the workforce, to train clinical educators, and to optimize team-based models of care.¹⁰

The earliest post-graduate specialty training fellowship for palliative nurses started at Memorial Sloan-Kettering Cancer Center in 1989 (Fig. 1). Currently, hospice and palliative medicine fellowships graduate nearly 500 new board-certified physicians yearly, yet there are fewer than a dozen fellowships for APRNs, each training between one and three nurse fellows a year.^10,16 In contrast, there are ∼50 residences or fellowships for primary care APRNs.⁸

FIG. 1.

History of advanced practice nurse fellowships. ANCC, American Nurses Credentialing Center; APRN, advanced practice registered nurse.

Conceptual Framework: Novice to Expert

Benner's novice-to-expert framework for nursing career development is ideal to depict role transition and set expectations over the course of APRN fellowship, during onboarding or to set career goals.^17,18 Benner characterized the five stages of a nurse's career development as follows: (1) novice, (2) advanced beginner, (3) competent, (4) proficient, and (5) expert.¹⁷ Novices demonstrate skills inconsistently and require direct preceptor supervision. As the nurse gains mastery, less supervision is required, and they can progress along the continuum to higher levels of mastery.

The Hospice and Palliative Nurses Association's (HPNA) competencies for palliative APRNs delineate core behaviors within each domain that the expert nurse must demonstrate (see Table 1 for list of competencies).⁹ Reville and Foxwell arranged selected core behaviors by domain into Benner's schema to create the Hospice and Palliative APRN Competency Milestone Assessment, a formative competency evaluation and curricular scaffold for palliative APRN fellowships, graduate student training, or APRN career development.^18,19 The Accreditation Council for Graduate Medical Education's (ACGME) Hospice and Palliative Medicine Milestones uses a similar five-level framework for competency evaluation of physician fellows.²⁰ While this article's focus is the nurse practitioner trainee, the HPNA competencies and Benner's model can be applied to other advanced practice nurse roles.²¹

Table 1.

Competencies for Advanced Practice Registered Nurses⁹

Clinical judgment

Advocacy and ethics

Cultural and spiritual competence

Collaboration

Professionalism

Facilitator of learning

Communication

Systems thinking

Evidence-based practice and research

Types of Fellowship

While APRN fellowship design will vary broadly, programs should be rooted in an expressed intention derived from an institution or health system mission, merged with an academic mission, or to serve a professional mission. Through our observation and experience, fellowship types can be broadly grouped by a primary mission supporting educational advancement of APRNs or enhancement of institutional workforce. Table 2 lists unique attributes for each type. For example, in a fellowship with an educational mission, the overarching goal is to train clinician leaders and educators in the field, rather than retain fellows after training. A health system seeking to grow its palliative care presence can build clinical training fellowships to fill new positions. Therefore, these priorities should be manifest through curricula and faculty. The characteristics and challenges listed in Table 2 are based on observation and certainly not absolute.

Table 2.

Types of Advanced Practice Registered Nurse Fellowships: Overview

	Educational mission	Workforce mission
Goal	Train palliative care APRNs to be expert clinicians, educators, and leaders	Train and retain palliative care APRNs to grow workforce or meet needs of a specific patient population
Characteristics	Grant funded by serial grants or philanthropy Traditionally at academic medical centers and follows academic calendar Typically added to existing physician or interprofessional fellowship Post-fellowship job not guaranteed	Secure institutional funding Combined with APP training Includes administrative and faculty structure Variable training duration Part of intensive onboarding program for specific internal role
Challenges	Lack of enduring funding No curricular or evaluation standards	Potential to be discontinued when staffing goals achieved

APP, advanced practice provider; APRN, advanced practice registered nurse.

An APRN-Centered Curriculum

The curriculum for an APRN fellowship is built upon the pillars of mission, values, teaching methods, learner outcomes, and faculty. Although specific curricula are outside the scope of this article, there are many resources for clinical and didactic learning experiences, interprofessional collaboration, course outlines, milestones, and methods for assessing competencies (Table 3).^{18,20,22–26} Traditional didactic seminars include case conference, journal club, and grand rounds presentations. Additional assignments to build leaderships skills include quality improvement projects or teaching presentations. Promotion of self-care, resiliency, and reflective practices include writing, peer professional practice support group and arts-based experiences.^9,25,27,28 Furthermore, health equity, diversity, and inclusion content should be incorporated throughout training to support cultural and advocacy competencies.

Table 3.

Advanced Practice Registered Nurse Palliative Care Curriculum Resources^22–26

HPNA Standards for Clinical Education of Hospice and Palliative Nurses (Dahlin, 2015)

HPNA Core Curriculum for the Advanced Practice Hospice and Palliative Registered Nurse, 3rd edition (Dahlin, Tycon Moreines and Root, 2020)

HPNA Core Curriculum for the Advanced Practice Hospice and Palliative Registered Nurse, 2nd edition (Dahlin and Lynch, 2013)

HPNA Competencies for the Hospice and Palliative Care Advanced Practice Nurse, 2nd edition (Dahlin, 2014)

Clinical Practice Guidelines for Quality Palliative Care, 4th edition, 2018 AAHPM competency milestones

The Hospice and Palliative APRN Professional Practice Guide (Dahlin, 2017).

ELNEC APRN Curriculum https://www.aacnnursing.org/ELNEC/About/ELNEC-Curricula

AAHPM, American Academy Hospice Palliative Medicine; ELNEC, End-of-Life Nursing Education Consortium; HPNA, Hospice and Palliative Nurses Association.

Ideally, APRNs are trained in an interprofessional fellowship with other disciplines on the palliative care team so they are equipped for team-based care practice models.^10,11,24 The interprofessionalism innate to palliative care allows cross-disciplinary sharing of curricula. However, APRN learners are often added onto physician fellowships without consideration of their different skills, training, and experience. To create a level playing field for APRNs training alongside physicians and other disciplines, fellowship directors can design learning experiences to meet nursing competencies and meet learner's goals. These should include mentoring to support nursing role identity within an interprofessional team, teaching palliative nursing research, and providing content mentors for scholarly projects or presentations.^2,5

The HPNA recommends that fellowship directors hold advanced certification in palliative nursing; however, no national standard exists and there are fellowships where leaders are from non-nursing disciplines.⁹ Nursing faculty need to model strong clinical and communication skills, with a background in adult learning-teaching methods and mentoring principles. Fellowship directors need protected time away from clinical duties for fellowship oversight, faculty development, and administrative support. Administrative support offloads the fellowship director during the recruitment cycle of new fellows (marketing, website development, processing applications, and interviewing) and when onboarding new fellows (medical credentialing, nursing department orientation, and arranging clinical rotations).

Case example

The Harvard Interprofessional Palliative Care Fellowship is an example of a physician fellowship that incorporated interprofessional learners from nursing, social work, and pharmacy over its 23-year history. Since 2008, 12 pediatric APRNs and 20 adult APRNs have graduated. As a pioneer in palliative medicine training, the fellowship's mission is to train educators and leaders in the field. Forty-three percent of APRN graduates were hired as palliative care team members and faculty, including two nurse fellowship site directors.

According to Liaw et al., fellowship is a rigorous time of growth for fellows as professionals, interprofessionals, and clinicians.²⁴ Recently, the Harvard faculty embraced interprofessional teaching principles and wove nursing competencies into the curriculum. The nursing faculty created a parallel nursing seminar series to support role transition, highlight palliative nursing research, and support scholarship for its APRNs (Table 4). Fellowship mentors convene for workshops twice yearly to set mentor role expectations and receive faculty support.

Table 4.

Advanced Practice Registered Nurse-Specific Track in the Harvard Interprofessional Fellowship

Topic	Teaching method	APRN competency22
Career advancement	Seminar and workshop on resume and job negotiation Fellowship mentor relationship	Professionalism
Preparing a podium presentation	Seminar on professional presentations Workshop to refine topic for grand rounds presentation Fellow works with content expert/mentor	Professionalism Evidence-based practice and research Facilitator of learning Communication
ACHPN certification	Workshop and practice session for ACHPN certification examination	Professionalism
Evidence-based practice and research in palliative nursing	Didactic; review of grand rounds; mentorship focused on concept development and academic writing	Evidence-based practice and research
Role transition	Seminar on imposter syndrome and sharing of nurse fellows' experience in new roles	Professionalism collaboration

ACHPN, Advanced Certified Hospice Palliative Nurse.

Ultimately, what distinguishes a palliative APRN fellowship is the educational community that the institution offers, the talents and engagement of its faculty, and its graduates' career success. Nurse fellows will thrive in an environment that supports both maturation of a nursing identity and inclusion in an interprofessional learning community.

Competency Measurement

Fellowship faculty can establish and measure progress toward competency during the fellowship trajectory using the Hospice and Palliative APRN Competency Milestone Assessment (Table 5).^18,19 At the start of fellowship, most incoming fellows self-assess as novice or advanced beginners in most of the HPNA's nine domains of advanced practice. Nursing faculty can choose benchmarks for minimal achievement level of key competencies required for graduation. For example, Harvard fellows are expected to achieve “competent” level (Table 5) in clinical judgment, professionalism, collaboration, facilitator of learning, and communication. Faculty may set different benchmarks, for example, advanced beginner, in other areas based on curricular priorities and type of fellowship. In another example of matching expected milestones with type of fellowship, a fellowship prioritizing a workforce mission may set the benchmark for evidence-based practice and research competency at “advanced beginner” level, yet require “competent” level or higher in the clinical judgment domain.

Table 5.

Hospice and Palliative Advanced Practice Registered Nurse Competency Milestones^18,19

	Novice	Advanced beginner	Competent	Proficient	Expert
APRN entering fellowship	X
New-to-practice APRN completing on-the-job orientation	X	X
APRN at completion of one-year palliative care fellowship			X

X indicates expected stage of development at APRN career milestones.

Scoring the competency milestones tool is a collaborative, formative process, not a personnel procedure. The fellow, fellowship director, preceptor(s), and members of the interdisciplinary faculty share input about growth and suggest specific core behaviors needing attention. While “expert”-level practice at the completion of fellowship is unrealistic, awareness of the core behaviors necessary for advancement will help fellows and educators co-construct realistic goals for career development during and after fellowship.¹⁸

Evaluation and Determining Impact

Just as no standard or required curriculum exists, evaluating the effectiveness and impact of APRN fellowships is highly variable.²⁹ Thus far, we have compiled experiences, literature, and observations of palliative APRN fellowships to provide readers with a blueprint and self-assessment when considering building or remodeling a fellowship (Table 6). During the design phase, it is crucial to consider how to measure success for fellows, the health system, and ultimately, patients and families affected by serious illness.

Table 6.

Assessment for Building an Advanced Practice Registered Nurse Fellowship

Domain	Action	Considerations
Why?	Define mission, values, and goals of fellowship.	Articulate the fellowship mission: Educational or workforce (Table 2)
		Define population served (adult/pediatrics), setting(s) of care and overarching goals.
		Commit to guiding values, for example, interprofessionalism, education, resilience training, diversity, and equity.
		Propose mission statement for feedback to key stakeholders as listed in the next step.
Who?	Assess commitment from potential stakeholders and partner with shared goals.	Leadership: palliative care team, institutional and Nursing leadership.
		Colleagues: palliative care interdisciplinary team members, consulting providers
		Educational: HPM Fellowship Director, other APRN Fellowship Director(s), School of Nursing Faculty
		Other: potential funders, philanthropy, counterparts at nearby institutions, etc.
		During this assessment, assemble key faculty members in fellowship education.
What?	Take a critical self-assessment of both institution and self as potential fellowship director.	Institution as host to fellowships: What are the strengths of the institution? E.g.: established HPM fellowship curriculum What are the weaknesses? E.g.: no budget What are the opportunities for growth? E.g.: partnering with ambulatory clinic  What are potential threats at a systems level? E.g.: pending hospital merger	Self as fellowship director: What are your strengths? E.g.: ACHPN certification, passion and experience in teaching role within team What are you challenges in this role? E.g.: new to leadership, limited protected time What are the opportunities for growth? E.g.: available leadership training, mentors What are potential threats to role? E.g.: funding; measuring success
		Brainstorm possible solutions for challenges and threats.
How? So what?	Consider the value proposition of an APRN fellowship at your institution.	Describe how a successful palliative APRN fellowship will provide value to your institution.
		Increase specialty palliative care provider population pool,
		Enhance reputation as top academic institution with interdisciplinary post-graduate training, and/or
		Intense training will increase APRN retention in the health system and improve patient outcomes.
		Present final proposal to key stakeholders for approval and commitment.

HPM, hospice and palliative medicine.

Evaluation is an iterative process that should contribute to the improvement of the fellowship itself. In terms of curricula, clinical experiences and didactics need to be adapted based on real-time feedback. Faculty and mentors need to be evaluated by mentees and fellows on their effectiveness. In addition to these nuts and bolts, the overall impact of the fellowship requires thoughtful evaluation to ensure system support.

For workforce fellowships, the most straightforward way to measure impact is to track retention of fellows within the health system. These data can be used to demonstrate cost benefit to institutional stakeholders. Fellowships with an educational mission may track retention, that is, numbers of fellows who remain in the field of palliative care, or who obtain leadership roles in palliative nursing, as described in the case above. Furthermore, impact on the field by former fellows whether by publications, conference presentations or research output, are worth tracking. These data may be presented to stakeholders both as quantitative (retention rates) and qualitative (vignettes of a clinical impact or scholarly engagement). Finally, the impact of APRN fellowship can be seen in the ongoing networking that occurs among current and past fellows, whether on collaborative projects or at interprofessional meetings.

Limitations

This overview of palliative nursing fellowships with case description, assessment, and blueprint recommendations should be interpreted in the context of the following limitations: first, there is sparse literature on APRN fellowships in general, and even less in specialty palliative APRN literature because it is difficult to test the effectiveness of fellowship, given the small numbers of programs and graduates.²⁹ Furthermore, for the programs that have run successfully, there is wide heterogeneity in makeup, curriculum, evaluation, and leadership. In this discussion, we have attempted to provide the blueprint of the palliative APRN fellowship based on experience and observation.

Conclusions

Palliative APRN fellowships have the potential to have dramatic clinical, educational, and research implication in the very near future. There is a critical need to train and retain competent palliative APRNs to care for the growing population of seriously ill patients and their families. Ideally, APRNs are trained in an interprofessional fellowship so they are equipped for team-based care practice and to model a strong nursing identity.^10,11,24 However, accounts of palliative APRN fellowships are sparse and to date, research has never explored their effectiveness in preparing trainees for practice, onboarding time and costs, or patient outcomes. There is a national call to fund, build, and expand palliative APRN fellowship programs^.10,11,14 This article aimed to summarize observations and experience and continue the conversation with educators committed to preparing the next generation of palliative care clinicians.

Authors' Contributions

B.R. researched and wrote much of the article and completed final review and editing. A.M.F. researched and wrote sections of the article and created the tables and figure in this article.

Funding Information

Acknowledgment of research support: A.M.F. is supported by the National Institute of Nursing Research Ruth L. Kirschstein National Research Service Award training program Individualized Care for at Risk Older Adults (T32NR009356) as a predoctoral fellow.

Author Disclosure Statement

No competing financial interests exist.