The need for hospice services continues to grow in the U.S. According to National Hospice and Palliative Care Organization (NHPCO) data, there were 5,358 hospices certified by Medicare operating in 2021, an increase from 2020. Around 1.71 million Medicare recipients received hospice care the same year.
As the need for hospice grows, so does the need for nurses who specialize in this specialty.
Julie McFadden, RN, BSN, had been working in the intensive care unit for about eight years when she started questioning whether nursing was right for her.
“I was really, really burned out,” McFadden said.
McFadden felt as though she had to “hurry up and care” and found the fast pace of ICU nursing difficult to endure.
“In the ICU, we did all these wonderful things, but we lacked the ability to really talk with patients and families about what was really happening,” she said. “I felt like if people are going to die, there has to be a better way to do it.”
Determined to explore a little more about nursing before leaving the profession, McFadden started agency and travel nursing to experience different assignment types.
Hospice nursing intrigued McFadden, and despite not having any experience at hospice care, she took the plunge.
Years into her career as a per diem hospice nurse, McFadden said she has found her calling and a reason to stay in the profession.
Hospice nursing: What it is and isn’t
Many nurses without hospice experience don’t know what hospice is about, according to Mindy Poretsky, RN, MBA, Associate Executive Director of Clinical Operations of Northwell Health’s Hospice Care Network in New York.
Common hospice myths include that a person must be a do not resuscitate (DNR) to get hospice care. They don’t, according to Poretsky.
“You can come on and be a full code,” Poretsky said.
Many also believe that hospice is only offered in a single setting. But hospice providers work in multiple environments, including people’s homes.
Hospice, according to the NHPCO, is focused on caring, not curing. Hospice patients have life-limiting illnesses, and hospice care provides those patients with individually tailored medical care, pain management, and emotional and spiritual support.
“In most cases, care is provided in the patient’s private residence, but may also be provided in freestanding hospice facilities, hospitals, nursing homes, assisted living facilities, or other long-term care facilities,” according to NHPCO’s Facts and Figures report.
The NHPCO also highlights how hospice teams are interdisciplinary, which can include the following professionals:
- Personal physicians
- Hospice physician or medical director
- Nurses
- Hospice aides, including certified nursing assistants and home health aides
- Social workers
- Grief counselors
- Religious or spiritual care providers
- Trained volunteers
And hospice has four levels of care, according to Poretsky: standard home care, ongoing care, inpatient care, and respite.
Education, training, and skills
Northwell Health requires that new hires have a year of acute care experience to help ensure they have skills to manage often independent work in the field, said Poretsky.
At Northwell, hospice nurses that don’t have a Bachelor of Science in nursing (BSN) are required to enroll in a BSN program within two years of their hire date and complete the program within five years of that date.
“BSN nurses are well prepared to manage our patients and this population,” she said.
New hires must also have an RN or LPN license, without sanctions, in the state of New York and/or one with reciprocity.
To fill potential knowledge gaps, Northwell’s new hospice nurses go through what Poretsky called a preceptor program, including didactic training in pain and symptom management and how to assess caregivers for risk-burden, to make sure caregivers are ready, able, and willing to help care for patients.
The training includes knowledge about regulations, as well as the psychosocial aspects of hospice care. Nurses need to also understand medication reconciliation and how to use the employer’s electronic medical record (EMR).
Regulatory knowledge includes creating orders for nurses’ work and understanding such things as how, why, and when to change a patient’s level of care, she said.
How to become certified in hospice nursing
At Norwell Health, being certified by the Hospice and Palliative Credentialing Center (HPCC) is a bonus but not a requirement. And this may be the case for other employers, but this can vary by state.
McFadden is not certified in hospice nursing, and it’s not required in California where she works.
But certification has its benefits.
The HPCC states that while licensure guarantees basic competence in a field, certification demonstrates a mastery. This organization offers six different hospice and palliative certification exams for the following nurses and healthcare professionals:
- Advanced practice nurses
- Registered nurses (RNs)
- Pediatric hospice and palliative nurses
- Licensed practical nurses/licensed vocational nurses (LPNs/LVNs)
- Nursing assistants
- Social workers
Nearly 14,500 healthcare professionals hold HPCC credentials, according to the credentialing center. Requirements for this certification can vary, especially for advanced practice nurses and social workers.
However, RNs, LPNs/LVNs, and nursing assistants applying for this certification are required to hold a current, unrestricted license and have completed either 500 hours of clinical hospice and palliative nursing experience within the last year or 1,000 hours in the last two years.
Nurse.com offers a certification review course for HPCC’s Certified Hospice and Palliative Nurse (CHPN) exam. The course covers patient care, pain management, practical issues, and professional development. The content helps prepare hospice nurses to discuss end-of-life issues, advocacy, and life-limiting conditions.
Learning soft skills is universal
Northwell Health’s hospice nurse preceptor program focuses on team building because hospice members work in interdisciplinary teams. Hospice care teams include physicians or nurse practitioners as well as nurses, social workers, home health aides, pastoral care coordinators, and others.
Hospice is not just about a nurse being in a room with a patient. Its family centered, and focused caregiving is a big part of what hospice nurses do, Poretsky said.
Nurses caring for hospice patients are active listeners — a skill some must hone, she added.
“A lot of people know how to talk, but do they know how to listen?” Poretsky asked. “We talk a lot about the impact of the care that [nurses] provide as they journey with the patient and family through end of life.”
McFadden added that she feared she would lose critical thinking skills during her transition from the ICU to hospice, but that hasn’t been the case.
“Not every case is cut and dry. You have to think critically to try to help manage people’s symptoms,” McFadden said, adding that the ultimate goal is comfort.
Building strong connections
Hospice’s slower pace is different from the ICU. It’s more about connecting to people, listening, and having the time to hear what they need and want, McFadden said.
“I’ve gained skills in the sense of really understanding how the body dies and what happens physiologically,” she said.
Hospice nursing feels right, according to McFadden, who uses social media to educate people on hospice care.
McFadden said, “To see the look of relief on people’s faces when you start educating them and explaining to them about a really scary time in their lives [because] they don’t know what’s going to happen or what to expect. And to be the person that can ease those fears in real time, it feels so good.”
“Anyone who has been a nurse for a while knows that death is not always the worst outcome,” she said. “Suffering is.”
Whether you're actively seeking a new role or assessing your next steps, explore Nurse.com's talent marketplace to help match your experience and skills to the best-fitting role.
