A survey of current specialty palliative care education in the United States

Current landscape of interprofessional specialty palliative care (SPC) education

Introduction

Palliative care (PC) is individualized, developmentally appropriate, comprehensive, holistic care that can be integrated into any care setting (1). An interprofessional PC team is necessary to meet the physical, psychosocial, social, cultural, and spiritual needs of patients experiencing serious illness and their families (1). The interprofessional team (IPT) is most often composed of Advanced Practice Providers (APPs) including Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), and Physician Associates/Assistants (PAs), Chaplains, Registered Nurses (RNs), Doctors of Medicine and Doctors of Osteopathic Medicine (MDs/DOs), Registered Pharmacists (RPhs), Social Workers (SWs) and other professions depending on site of care, the age of the patient and the illness. Other professionals are included in the team based on the needs of the patient and caregivers to enhance holistic care (1). All IPT members provide primary palliative care (PPC) which entails basic pain and symptom management, foundational communication skills, and knowledge of community resources for patients with serious illness (1-3). Generalists, who provide PPC, have an important role in identifying common patient and caregiver needs, initiating common palliative interventions for pain and symptoms, understanding their resources, and referring to PC specialists when needed. PC specialists provide more in-depth PC and have advanced education and experience in the “management of complex and refractory symptoms, advanced skills in communication and conflict resolution, and navigation of the evolving care needs across the trajectory of life” [(3), page 4] (Table 1). There is national agreement that specialty PC providers have appropriate education and certification within the specialty (1); although this has not been specifically delineated within the field.

SPC is most needed by patients who have chronic disease that affects their daily quality of life and serious illnesses (1,6,7). Estimates of the incidence of chronic disease indicate that up to 57% of adults have chronic illnesses worldwide (8,9) and this is expected to rise in coming years (10). At the same time, there is a growing workforce shortage of the SPC professionals (11,12). SPC education builds on foundational PC skills that should be consistent within the academic preparation and clinical training of all healthcare professionals (1,3), including pain and symptom management, communication, psychosocial, cultural, and spiritual care. SPC education is essential for professionals transitioning from primary to SPC roles. Yet, those seeking information on SPC programs may struggle to identify programs that meet their needs due to inconsistency in language used to describe programs, variability in length of programs, and disuniformity of content within programs. Although a thorough review of post graduate SPC programs was described in 2023 (3), a comprehensive survey of PC education programs for the wider IPT has not been previously compiled. This article provides more detail regarding the current landscape of education for each IPT member. Thus, the purpose of this article is to summarize the availability of SPC education programs in the US to enable informed decisions about educational options.

Methods

Data collection involved systematic Google web searches conducted in 2022 and 2023 using the key terms “palliative care certificate”, “palliative care education”, “graduate programs in palliative care”, “specialty palliative care education”, “palliative care programs”, and “specialty specific professions (i.e., nurse, physician, social worker, chaplain, pharmacist, physician associate/assistant, rehabilitation therapists) palliative care” (see Figure 1). Search results yielded websites for PC educational programs and each website was then examined for the type of program offered.

Figure 1 Data flow chart.

Only programs designed for SPC education were included; courses incorporated into undergraduate programs were excluded as they represent preparation for PPC provision rather than SPC education. SPC program information was organized in an Excel spreadsheet arranged according to core courses offered, format of program (online, in person, or hybrid), length of program, cost, and the nature of the program (interprofessional or profession-specific). Once data collection was completed and no new programs were identified, the results were verified with program directors using a Google Form Survey. Only verified results are included in this report.

Results

The results were categorized according to the main characteristics of the SPC programs: content offered in coursework, delivery format, length of program, cost, and nature of the program (interprofessional or profession-specific). General results for all programs will be reviewed in this section followed by a breakdown of each program according to its interprofessional nature or profession specific (APPs, Chaplains, RNs, RPhs, MDs/DOs, SWs, and extended members of the IPT). In general, three types of SPC programs are available: certificate, residencies, and fellowships (see Table 2).

Certificate programs in PC are becoming more common. They are generally defined as a specialized PC education programs occurring over a designated time to develop or strengthen skills in PC (3). Upon completion of the required content for the program, a certificate is awarded. Most certificate programs are offered online (about 89%), roughly 10% are offered in hybrid format, and less than 1% are offered in a face-to-face format.

Coursework differs according to the program, however topics generally covered include communication, cultural considerations in serious illness, ethical considerations, grief and loss, psychosocial care, spiritual care, symptom management, billing, and coding, research, quality improvement, and interprofessional collaboration (see Table 3). Depending on the number of courses required, some certificate programs can be completed in as little as 30 hours. Others require 9–12 graduate credits that are earned over the course of 9 months to 1 year. The cost of certificate programs offering graduate credits ranged from $5,000–$10,000. Those offering continuing education credits were less expensive, typically between $1,000–$5,000.

Residencies and fellowships are offered in person, typically in a clinical setting but many also integrate didactic education, journal clubs, and/or grand rounds. Not every profession offers either residencies or fellowships and the definitions for each vary among profession (3). Course offerings within residency and fellowship programs center on the application of adult and pediatric SPC concepts in various care settings such as inpatient acute care, long-term care settings, outpatient clinics, and home care (see Table 3). Coursework is offered on topics such as ethics, communication, billing and coding, and research. Residencies and fellowships are rigidly structured, typically requiring 3 months to 1 year for completion. Residencies and fellowships offer salaries to support professionals as they transition into the role of PC specialists.

Some SPC programs are designed to mimic the interprofessional nature of the PC IPT and are open to PC professionals from the various professions. Other SPC programs offer profession-specific educational opportunities, focusing on disciplinary knowledge, skills, and attitudes. In the following sections, interprofessional and profession-specific programs will be discussed. Since SPC generally involves certification, options for demonstrating expertise through certification will be reviewed along with SPC educational opportunities (see Table 4).

Interprofessional programs

According to the World Health Organization (16), interprofessional education involves two or more health professionals who are learning with and from each other with the mutual goal of improving patient health outcomes. Interprofessional education supports strong collaboration in clinical practice, challenges disciplinary biases, and may strengthen healthcare provision worldwide (16,17). Interprofessional education programs are defined by the admission of individuals from various professional backgrounds. In PC programs, traditional members of the IPT are generally eligible, including Advanced Practice Registered Nurses (APRNs), Certified Nursing Assistants (CNAs), Chaplains, RNs, MDs/DOs, PAs, SWs, and others (1,17). Although most interprofessional programs are geared toward allied health professionals, some programs are more inclusive, offering admission to individuals from a variety of disciplinary backgrounds if they have completed a baccalaureate degree.

Currently, eight interprofessional certificate PC programs are available in the U.S. No interprofessional residencies or fellowships were identified. Six of the SPC certificate programs require the completion of 12–15 graduate credits over 9–12 months. The graduate credits can be applied to the completion of a master’s degree, and many programs that offer PC certificates also offer master’s degrees in PC, one offers a Doctor of Philosophy in PC. For those who are not interested in graduate programs, two programs offer continuing education credits for the completion of a PC certificate and can be completed in approximately 30 hours. Topics common to all interprofessional SPC programs include communication, symptom management, psychosocial, cultural, and spiritual care, loss and grief, and ethical aspects of PC.

Advantages of interprofessional SPC programs include the ability to collaborate with members of the IPT and to learn about experiences of those outside of one’s own disciplinary silo. Further, interprofessional PC education increases knowledge and confidence and improves learner satisfaction (17,18). The distance education platform of most programs may also provide cross-cultural experiences and exposure to new ways of thinking about global healthcare systems. Nonetheless, professional-specific SPC programs offer focused, specialized education that enhances understanding of the distinct knowledge, attitudes, and skills required for individuals’ respective professions.

APPs

As defined in the National Consensus Project (1), APPs include PAs and APRNs. APRNs include NPs, CNSs, Certified Nurse Midwives (CNMs), and Certified Registered Nurse Anesthetists (CRNAs) (19). Currently, only NPs and CNSs are eligible for certification by the Hospice and Palliative Credentialing Center as an Advanced Certified Hospice and Palliative Nurses (ACHPN) (20). However, it should be noted that CNMs and CRNAs do care for individuals with serious illness. SPC certification is also available for PAs through the National Commission of Certification of Physician Assistants in which PAs earn a Certificate of Added Qualifications (CAQ) in Palliative Medicine and Hospice Care (21). Eligibility requires demonstration of knowledge that exceeds PPC concepts.

Although immersion, certificate programs, and fellowships are not typically intended to prepare APPs for certification in palliative and hospice care, the programs available build on foundational skills and prepare APPs for SPC practice. Currently, there are total of 23 SPC programs available for APPs; 3 immersion programs, 6 certificate programs, and 14 fellowships. The first type of program—immersion programs offer specialized PC knowledge within a circumscribed timeframe of between 5 days to 3 months. The three immersion programs identified through this review offer didactic content and two offer a clinical component; all programs are offered in person.

PC certificate programs for APPs are offered in online or hybrid format and require between 12 weeks and 1 year to complete, shorter programs offer 175 continuing education credits and longer programs offer 9–12 graduate credits. Topics common to all APP certificate programs include communication, pain and symptom management, psychosocial, cultural care, spiritual care, loss and grief, and billing and coding. Some APRN graduate programs offer PC specialization within another master-level track (such as family NP), while others require completion of a master’s degree prior to admission.

Post-master’s fellowships require licensure as an APP and clinical experience in PC, some programs require national certification in palliative and hospice care. Fellows are usually matched with a mentor, completing didactic education and clinical rotations in inpatient (hospice, skilled nursing, rehabilitation), outpatient (pain management, PC, and chronic disease clinics), and in the community (home care hospice and/or PC). Due to the mentor-mentee relationships involved in fellowships, the programs are in-person and require between 10 months and 1 year to complete. Advantages of fellowships over certificate programs include the one-on-one education model, clinical practice hours, and collaborative problem solving in the clinical area. Fellowships improve clinical competence, promote confidence in decision-making skills, and ease providers’ transition into specialized practice (22,23).

Chaplains

Chaplains specializing in PC facilitate connections between individuals and their faith communities, build relationships among patients, families, and IPT members, facilitate religious rituals, engage in goals of care conversations, and take part in managing distressing symptoms, especially existential and spiritual suffering (1,24). Advanced Palliative Care and Hospice Certification for Chaplains is available through the Board of Chaplaincy Certification Inc. (25). Partial requirements for advanced certification include a master’s degree in theology, philosophy, or psychology, as well as 2,000 hours of practice following completion of the required clinical pastoral education. Chaplains who wish to gain specialized education in the role of the PC and hospice chaplain may attend one of two online certificate programs, earning 25–64 continuing education credits. Topics such as grief, spiritual support, cultural care, and physical suffering are covered in the 6–8-week programs.

RNs

RNs provide direct patient care, engage in patient advocacy, and coordinate patient care (1). Many RNs working in hospice settings serve as case managers, assessing patients’ needs, planning interventions, and evaluating the patient’s and family’s response to team interventions (24,26). Specialty certification in hospice and palliative nursing is available for RNs in adult and pediatric care through the Hospice and Palliative Credentialing Center (27,28). Initial certification requires licensure and 500–1,000 practice hours in the specialty. Professional educational activities can support recertification. Two post-baccalaureate programs in palliative and hospice nursing were identified in this review, both requiring 12 undergraduate credits for completion. The programs are offered in online or hybrid format, require 1 year to complete and involve education on communication, grief, psychosocial suffering, and symptom management. Some undergraduate nursing programs offer courses in PC or end-of-life nursing. However, such courses were not included in this review because the focus is SPC rather than preparation of professionals for PPC practice.

RNs choosing to transition from PPC to SPC in the year after completion of their academic preparation may consider a residency program, which requires 3–12 months, depending on the nurses’ experience level. Residency programs offer the opportunity to work with a designated preceptor in hospitals, outpatient settings, and/or in patient homes to develop specialized skills in PC. Some residency programs offer both didactic and clinical education and nurses in some settings may earn continuing education credits for participation.

Pharmacists

Certification in pain management, which will also include an element of PC, has recently been approved by the Board of Pharmacy Specialties which is indication of the integral role RPhs play on the PC IPT. PC RPhs optimize pharmaceutical therapies by performing medication review, identifying needed pharmaceutical interventions, calculating medication dosages, identifying potential drug interactions and toxicities, and making recommendations for appropriate deprescribing (1). RPhs who choose to specialize in PC can participate in any of the interprofessional programs that have been mentioned. Additionally, 30 post-graduate residency programs have been identified for pharmacists across the U.S., with at least two fellowships in PC. A directory of available residency programs is accessible through the American Society of Health-System Pharmacists (29).

Post-graduate residencies for RPhs are designed for those who have completed a general pharmacy residency and choose to specialize in PC. Topics covered in 1-year residencies depend on the program but generally include education on opioid stewardship, opioid use disorder, medication supply chain issues, and management of acute and chronic pain and other symptoms. Rotations take place in numerous care settings such as inpatient and outpatient palliative and hospice care clinics, pediatrics, oncology, women’s health, intensive care, and emergency departments, among others.

Physicians

Physician certification in hospice and palliative medicine is available through the American Board of Medical Specialties and the American Osteopathic Association for both MDs and DOs. Eligibility for both exams require completion of a fellowship in the specialty. Numerous fellowship opportunities are available for physicians through the American Association of Medical Colleges’ Electronic Residency Application Service (30). At the time of this publication, there are some 171 participating programs available with some 300 slots available. Fellowships require at least a one-year commitment within a health system. Fellows are paired with mentors and complete rotations in various healthcare settings where PC is practiced, such as hospitals, home care, pediatrics, long-term care, oncology, and pain clinics. Advantages of the paid, intensive fellowships include focused, mentored education and practice. Disadvantages include the limited number of fellows in any one program, which may necessitate a lengthy commute or a move to complete the educational program.

SWs

Advanced certification in palliative and hospice care is available for SWs through two different certifying bodies. The National Association of Social Workers (31) offers a portfolio-based certification pathway; partial eligibility criteria for the certification include a master’s degree, 2 years of practice, and at least 20 continuing education credits in hospice care and PC. The Hospice & Palliative Credentialing Center (32) offers an examination-based certification for SWs with a baccalaureate or master’s degree, a prescribed number of practice hours, and state licensure. Recertification requirements can be partially met through continuing education in hospice care and PC.

Three 8–12-month online continuing education-based (45–70 credits) certificate programs are available for SWs. Online certificate programs in PC are the most convenient and inexpensive option. Another option for SWs who choose to specialize in PC is an academic specialization within Master of Social Work degree programs. Specialization generally requires completion of 9–12 graduate credits in PC, hospice care, and/or end-of-life care in addition to the requirements for degree completion.

Following completion of the master’s degree, SWs may opt for a 1–2-year fellowship in PC. Fellowships provide mentored opportunities to work with the interdisciplinary team in various settings where PC is practiced, including inpatient centers, outpatient clinics, pediatric sites, and hospices. Fellowships require the greatest commitment and although they are paid positions, only a few exist and may require moving to another location. Topics covered in certificate, graduate, and fellowship programs for SWs include ethics, grief and bereavement, interdisciplinary collaboration, leadership, symptom management, public policy, and spiritual issues.

Extended members of the IPT

The National Consensus Project (NCP) Clinical Practice Guidelines for Quality Care, which guide PC delivery in the United States, recognizes that the intense and diverse nature of PC practice requires the skills of members of the IDT who have pertinent expertise and experience and can be relied upon, as needed, to perform and/or recommend interventions. Some examples include registered dieticians, mental health professionals, child life specialists, therapists, and others (1). Only three programs were identified for extended members of the IPT. One program is designed for physical therapists and requires completion of 18 continuing education credits. The program is 3 hours in length and can be completed online. Topics covered in the program include hospice care, clinical practice, and self-care.

End of life doulas, sometimes referred to as death doulas, provide support and companionship to dying patients and their families. There are two certificate programs available to them. Key skills include communication, relationship building, and advocacy. End of life doulas may also provide emotional and spiritual support, assist with care coordination and navigation, provide family respite, take on light housekeeping, and render after-death care. However, end of life doulas typically do not provide medical or physical care (33,34). Some end-of-life doulas work within structured palliative or hospice programs while others are paid privately or volunteer their time (34). Currently, no federal or state regulations have been established for practice as an end-of-life doula. However, The International End of Life Doula Association (35) offers a certification that is based on experience and application of “foundational doula principles” (para 1) and maintains an online registry of certified end of life doulas.

Strengths and limitations

The review of SPC educational programs offers in-depth information for those seeking to transition to specialty PC practice and those practicing in secondary PC who wish to update their skills. The review was conducted systematically over the course of a full year with ample time given to checking and rechecking program information. Verification of program information was sought from program directors across the country as a failsafe in case websites had not been updated. This attention to the validity of the results ensures that accurate, up-to-date information is included in this review at the time of publication. However, a few program directors chose not to respond to the survey (12%) and their information was not included. This partially limits the veracity of the results because we relied only on information published on public websites, which may not have been updated. Another methodological limitation is that we defined fellowships as post-graduate opportunities for the purposes of consistency. However, some programs (i.e., Social Work programs) begin residencies during graduate education programs. By not including residencies that began or ended within master’s degree programs, we may have excluded a few opportunities for specific professionals from our analysis.

Discussion

Clinicians who wish to specialize in PC delivery are expected to possess advanced knowledge and skills, which can be gained through advanced PC education. Review of SPC educational offerings revealed numerous strengths of available SPC programs such as the variety of opportunities, the proliferation of interprofessional programs, and the inclusion of extended members of the IPT to meet the multidimensional needs of individuals with serious illness and their families. Several areas were found through this review that deserve further attention and discussion. Specifically, the cost variation in SPC programs, the program delivery methods, and the lack of a standardized SPC curriculum should be more closely examined. Moreover, it is hoped that interprofessional competencies can be created to then disseminate through each profession.

Cost

The wide variation in cost of SPC programs is startling. Tuition for SPC educational programs ranges from under $1,000 to more than $10,000. Due to salary disparities and variable employer-supported educational benefits, professionals may be forced to choose lower-cost programs, forgoing more rigid, immersive learning experiences as lower cost programs tend to be of shorter duration and primarily offered asynchronously online.

Delivery methods

Benefits of online education include the opportunity to connect with a global and diverse learning community, provide greater access to ideas and resources, and foster self-discipline and accountability (36). In the post-COVID-19 era, most learners are accustomed to online learning, and it is a very effective delivery mode for healthcare professionals (37). Nonetheless, some adult learners prefer in-person instruction, noting the importance of real-time interactions, socialization, and dedicated meeting times (38,39). For those seeking face-to-face interpersonal interactions, residencies and fellowships may be the best option. Such clinically based training opportunities require a significant amount of devoted time within a practice setting to develop clinical expertise. Supervised skill demonstration with real-time instructor feedback is key to clinical skills development (40,41).

Need for standardization

In recent years, an increased focus on total quality management in education has led to pressure to increase quality, and accountability for educational outcomes (42). Currently, there is no curricular standardization among SPC programs, meaning that there is no way to benchmark outcomes or compare the quality of education offered or program outcomes. Standardization of SPC curricula is an important step in ensuring consistency, uniformity, and equity in the knowledge base of SPC professionals. For this to happen, it will necessitate an interprofessional panel to engage in the process according to the principles of the Interprofessional Educational Collaborative (3,18).

Uniform requirements for SPC programs would promote transferability of credits, address educational gaps across programs, allow for tracking of student progress in meeting SPC educational outcomes, and help ensure program quality (43). Standardization can begin with a review of the topics already covered in SPC programs across the U.S. The results of this review uncovered that all SPC programs require coursework in symptom management and grief, and most incorporate principles of psychosocial care. Such courses could serve as a common core curriculum for all SPC programs. Coursework on ethics, spiritual care, cultural care, collaboration, and billing/coding are currently offered in many SPC programs and can be tailored for the needs of the students. Other content such as cultural care, provider well-being, and interprofessional tensions should also be included in SPC programs (44). Without a common curriculum for SPC programs, it is not possible for professionals to evaluate the return on investment of SPC programs in any comparative way or to determine the benefits such programs will have on their clinical performance.

Conclusions

The provision of SPC involves the promotion of expert, holistic, comprehensive management throughout serious illness attending to all domains of care (1). The needs of individuals facing serious illness are so complex that no single healthcare professional can address them alone. In fact, the mobilization of an interdisciplinary team is the cornerstone of quality SPC. Quality SPC can be provided only by well-educated, experienced, and skilled professionals with advanced knowledge in the specialty. Educational programs designed to help build expertise in SPC are available throughout the U.S. However, choosing a program may be challenging due to the disparate nature of the programs, variable cost, and time required to complete the program. Thus, the purpose of this review was to unify the available information regarding SPC programs, providing a succinct, yet thorough, overview of the SPC educational landscape. The results indicate that a wide variety of online and in-person certificate, residency, and fellowship programs exist for those seeking further education in SPC. The choice of program may be influenced by cost, delivery methods, and ability to estimate the return on investment due to lack of curricular standardization. Future research should address curricular uniformity, program outcome oversight, cost-quality analysis, and the effects of SPC education on patient outcomes.

Acknowledgments

Funding: None.

Footnote

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-23-582/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-23-582/coif). The authors have no conflicts of interest to disclose.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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