Palliative care (PC) is a national and global priority for addressing the growing numbers of people of all ages who are living longer with chronic and/or life-threatening illnesses.1 The National Academy of Medicine,2 among others,3 notes that the infrastructure for high-quality end-of-life care remains underdeveloped, with a shortage of PC specialists and insufficient PC knowledge among generalist clinicians (clinicians who are not PC specialists). Most hospital-based PC programs in the United States are secondary-level services, consultative services organized around a specialty-care model of delivery and reaching only a small fraction of patients who could benefit from PC. To address this gap in coverage, PC can be provided by clinicians who are not PC specialists. This care, sometimes called primary PC, requires the entire patient care team to become skilled in basic PC strategies especially pain and symptom management, serious illness communication, and advanced care planning.4 A significant barrier to the adoption of a primary model of PC across the continuum of care is the lack of a workforce educated in primary PC.2,3 Much of the nursing and physician (MD) workforce is aging5; many clinicians were not exposed to PC in their initial education and may not have sought out recent training in serious illness and end-of-life management.2
This initiative addressed a major barrier to PC services—the insufficient knowledge of PC principles among generalist clinicians.2 The reasoning for the development of the workforce infrastructure for primary PC at this medical center was to enhance accessibility and quality of care. To accomplish this, a workforce transformation across our healthcare system was planned utilizing an interdisciplinary PC educational initiative.
This large-scale 2-year initiative was designed to enhance the primary PC infrastructure at an independently operated, 378-bed, nonprofit, Magnet®-designated, regional medical center located near Boston, Massachusetts, and affiliated with Boston's major academic medical centers. The hospital serves 725 000 area residents; provides emergency, medical, surgical, and obstetric services; and has more than 100 providers in associated primary and specialty services. Its home health service ranks 4th largest in the state. Among existing resources is a long-standing academic-practice partnership (APP) between the hospital and a private university's nursing program offering RN-BSN and BSN-MSN programs at the hospital.
The Need for PC
The need for a PC program became apparent in 2010 when the hospital's shared governance research council presented a white paper supporting the establishment of a consultative PC team to nursing leadership. In addition, during the course of a 7-year educational APP, RN students in the RN-BSN curriculum were encouraged to explore the nursing literature and identify areas of exemplary practice to implement at their hospital. Overwhelmingly, RN students continued to identify a need for a consultative PC service. This groundswell of frontline interest in PC coincided with global campaigns to raise awareness of PC services6 and the rollout of the End-of-Life Nursing Education Consortium (ELNEC) curriculum7 to nursing schools in the United States and abroad. Two cohorts of RN students, in separate academic years, created white papers compiling the evidence to support implementing a consultative PC program. During end-of-semester poster sessions, they shared their research with the hospital's executive leadership team. The executive team acknowledged the strength of the evidence but postponed implementation initially because of competing strategic goals.
By spring 2014, heeding the advice of the RN students and a growing internal sentiment among the healthcare workforce, executive leadership launched a small pilot consultative PC program consisting of 1 half-time MD, 1 full-time nurse practitioner (NP), a social worker, and a consulting chaplain. This initiative was highly successful. Utilization rates in the 1st months continuously climbed and were accompanied by anecdotal reports of effectiveness. It quickly became apparent that the need for system-wide PC far outpaced this initial outlay of resources. A year after the PC team launch, an internal needs assessment conducted by the Clinical Professional Development Department found 51.4% (n = 110/214) of nursing respondents identified a need for additional education on how to manage end-of-life pain, and 56.1% (n = 120/214) wanted information on how to have end-of-life conversations. Similarly, 65.8% (n = 27/41) of hospitalist and affiliated MD respondents wanted help managing pain in patients with serious medical illnesses, especially among those at risk of substance use disorder. Moreover, 34.1% of MDs (n = 14/41) requested education on converting from short-acting to long-acting opioids, 56% (n = 23/41) wanted to know about the effective use of PC services across the continuum of care from the emergency department to home to primary care offices, 31.7% (n = 13/41) wanted education on goals-of-care conversation strategies, and 21.9% (n = 9/41) wanted to learn how to reimburse for those conversations. In the past, efforts to address these educational concerns had been siloed within departments. Now, however, a data-driven affirmation of a need for primary PC training from various departments converged and created the opportunity and the atmosphere for interdisciplinary collaboration and a workforce transformation to address this need.
Building the Infrastructure for Primary PC
The core of the initiative was a multicomponent, interdisciplinary, 2-year-long, educational intervention that leveraged existing organizational and regional resources. The plan focused on evidence-based curricula centered on the 3 main subject areas identified by the needs assessment data: serious illness communications, advanced care planning, and pain and symptom management.7-9
The First Steps
A small steering committee was formed to identify available expertise, resources, and strategies within the hospital and beyond. This group included the nurse research scientist who had expertise in grant writing and was also the APP liaison. She was joined by an MD and an NP from the recently launched PC team, who offered content expertise and by the hospital's vice president of Clinical, Outpatient, and Home Care, who was well placed to obtain institutional resources. The steering committee took a broad view as it strategized the workforce transformation in 3 areas: address the learning needs, establish an atmosphere of interdisciplinary collaboration, and build a broad base of institutional support for this system-wide educational initiative.
The Educational Initiative
The committee selected preexisting nationally recognized, evidence-based curricula that addressed the 3 core areas identified by the clinician needs assessment. The APP was utilized to optimize available educational resources already in the building, and a train-the-trainer (TtT) model was deployed whenever possible, thereby multiplying the training effects. The TtT model of education is recognized as a mechanism that engenders stakeholder buy-in and enhances the sustainability of the efforts.10 As part of the initiative, the ELNEC curriculum7 for nurses was chosen because it offered on-site instruction in 8 modules for serious illness care including the topics identified in the needs assessment. The nationally recognized Harvard Center for Palliative Care's workshops11 were selected for their interdisciplinary format and close proximity to this health system. Each of these initiatives focused on specific healthcare clinician groups from varied disciplines and is described in Table 1. Teaching strategies in the educational offerings included short didactic sessions, video segments, role playing, case studies, active learning exercises, and small-group discussions. Attendees at select daylong or multiday workshops received a comprehensive binder and disc containing educational resources and strategies to teach this content to others. To broaden the base of institutional support and further expand the reach of this primary PC educational initiative, grant monies funded an institutional membership to the Center to Advance Palliative Care (CAPC).8 Membership provided online, asynchronous learning and free continuing medical education (CME) to all institutional staff. As a final step in securing institutional support, the steering committee convened 2 advisory boards. The nursing advisory board consisted of practicing direct care nurses from inpatient and home care divisions who offered their perspective on the problem from the practice environment. Also, 2 nurse educators were recruited as program planners for American Nurses Credentialing Center® nursing credits and as mentors in the TtT model. A nurse manager joined who could rally administrative support for the endeavor. This board met during the planning phase to review needs assessments, continued to meet after the initial launch to recommend changes as the project rolled out, and reviewed evaluations for the educational sessions. A medical advisory board convened consisting of a PC MD, a hospitalist, social worker, and pharmacist, all of whom demonstrated interest in the PC agenda. They designed an orientation program on PC for new hospitalists and coordinated a 2-year program of CME events focusing on PC.
This committee identified a state funding source, the Commonwealth Corporation,12 which called for proposals “to enhance infrastructure for palliative care.” The committee used the 6 months of work on the educational initiative to develop a workforce transformation grant submission and was awarded a $250 000 award to facilitate the initiative. The nurse research scientist became the project manager, interfacing with the funding agency to provide quarterly reports and measure program outcomes.
Program Implementation and Enlisting Participants
A 2-year timeline of educational events was designed, specifically front-loading the bulk of the education in the 1st year, especially those offerings with TtT elements. The expected benefit of this approach was that a large cadre of healthcare providers could receive the training at the same time in a more concentrated effort to build the movement toward primary PC. The hospital's PC team was selected as the 1st group to attend national PC conferences to ensure they had the latest research and evidence to support practice changes; attendance was later opened for a more interdisciplinary team to ensure adoption across the healthcare workforce. The steering committee charged the nursing advisory board to implement the ELNEC curriculum.7 Acute care and home care nurses, managers, case managers, and educators were invited to apply for a 2-day workshop to become trainers for either the core or the critical care curriculum. Selected applicants demonstrated formal or informal leadership, had some prior skill as educators, identified a plan to implement future trainings, and obtained nurse manager commitment to be released from direct care for the 2-day-long workshops. Forty-five nurses applied for 30 core slots, and 25 nurses applied for the 15 critical care slots. These new trainers were then tasked with offering workshops with no application required to all nurses and allied health staff. To ensure clinicians could be relieved of their care responsibilities to attend these workshops, replacement wages were provided with grant funding.
The medical advisory board was charged with choosing registrants for the regional and national conferences. A hospital oncologist and a social worker, known to be champions of PC, well regarded by MD groups, and experienced in teaching continuing medical education events, attended the Serious Illness Communication Plan (SICP) TtT workshop. They then offered their training services to primary and specialty care practices. To support this training, the grant funded the purchase of 200 pocket-sized Serious Illness Conversation Guide laminated cards to be distributed to those attending these educational sessions.9 The medical advisory board also reviewed the orientation program for new hospitalists and infused PC principles into the program. The board proposed a list of nationally renowned speakers for internal CME events. The steering committee chose those who could address the stated educational needs and were working or teaching in the New England area and available on the dates and times desired. All MDs, nurses, and allied health providers were invited to the CME events via email, newsletter announcements, flyers in mailboxes, and posting in the medical staff lounge. These events were offered around meal times to increase attendance.
It became evident that the demand for these educational events far exceeded the original goal, and 11 more sessions (6 ELNEC workshops, 2 CME events and 3 new hospitalist trainings) were added on site. The availability of CAPC membership was also advertised, which included online educational opportunities to accommodate different work schedules and learning styles. The CAPC membership was found to be underutilized, and explicit efforts to promote this resource were begun. For example, after alerting the outpatient pain clinic that a certificate of completion in pain assessment and management was available, the unit-based nurses' council adopted the certificate of completion as a goal for pain clinic nurses.
By a variety of measures, this primary PC initiative generated meaningful results, not only in terms of organizational infrastructure, but also in terms of culture around PC. The initiative committed to offering 16 educational events to reach 350 members of the workforce, while increasing the number of ELNEC TtT from a baseline of 4 nurses to 15 and the number of SICP TtT from 0 to 3. Over the course of the 2-year curriculum, more than 1000 people attended at least 1 of the 27 program offerings. Included in this number were 48 nurse ELNEC TtT, who subsequently educated 564 colleagues. An oncologist, a PC MD, an NP, and a social worker became SICP TtTs, who then educated 104 colleagues, including hospitalists and the facility's affiliated medical practice groups (Table 1). A commitment was made to improve nursing knowledge and attitudes by 10%. Overall knowledge levels increased beyond these stated goals as measured by a previously validated 50-item ELNEC PC knowledge examination13 administered before, after, and more than 6 months after ELNEC training. Baseline PC knowledge scores varied greatly, ranging from 22% to 100% between individuals. Mean knowledge scores increased 4% to 6% overall from baseline; however, the proportion of attendees who attained a competency level of 80% of items correct increased by 14 percentage points. Core attendees improved from a baseline of 70.8% competency pretraining to 84.9% afterward, whereas critical care attendees improved from a baseline of 62.1% competency to 82.8% posteducation.
Attitudinal changes were noted as well. An internally developed 10-item instrument (see Instrument, Supplemental Digital Content 1, http://links.lww.com/NNA/A11, which lists each item and corresponding responses in the Palliative Care Confidence Scale) was determined to have adequate face and content validity by PC content experts and research scientists and was used to monitor changes in self-reported levels of confidence among clinical providers. Responses ranged from not confident to extremely confident. At the start of the ELNEC program, only 18.9% of attendees rated themselves as highly confident in being able to describe the difference between palliative and hospice care, and similarly low levels of self-reported confidence were found in all other domains of PC at baseline, as shown in Table 2. The ELNEC education generated between 2- and 5-fold increases in nurses' confidence in providing PC across the domains, as depicted in Table 2.
There were also measurable behavioral changes. The electronic medical record (EMR) was used to monitor progress. Although the initial goal was to increase PC referrals by 50%, increase documentation of healthcare proxy (HCP) by 30% and medical orders for life-sustaining treatment (MOLST) by 30%, these targets were exceeded, as described in Table 3.
Unanticipated benefits of the program were also noted. These included anecdotal reports of internal job promotions to leadership positions in PC and hospice settings. Those promoted attributed their success to their new training and to the commitment to PC workforce development, which led to diffusion of efforts across the organization. These efforts reached broadly to other committees and divisions in the hospital, as increasing attention came to be focused on improving patient experience at end of life. For example, the pastoral care services developed a new bereavement program in the acute care setting, and the ethics advisory committee spearheaded “DNR Is Not a Plan,” an effort to align Massachusetts MOLST with EMR documentation of code status orders. The hospital's community benefits program, moreover, procured outside grant funding to host a showing of the Frontline documentary based on Atul Gawande's book Being Mortal for a large senior-living community served by the healthcare system. The grant funded 500 copies of the “Five Wishes” document14 to encourage attendees to have goals-of-care conversations with their MDs.
The APP benefited as well, as the initiative prompted a gap analysis of the university nursing curriculum. Results led to curriculum revisions that included enhancing the teaching of PC principles throughout both the undergraduate and graduate nursing programs. For this work, the university was recognized by the American Association of Colleges of Nurses® as a 2017 ELNEC Hall of Fame Award Winner for wide adoption of the online ELNEC curriculum. The university continues its efforts to promote primary PC by expanding ELNEC TtT workshops to other Boston-area medical centers.
This initiative succeeded in addressing 1 of the most compelling barriers to PC noted in the Dying in America report: “inadequate numbers of palliative care specialists and too little palliative care knowledge among other clinicians who care for individuals with serious advanced illness.”2(p2) We accomplished this by attending to principles of workforce transformation, including understanding the specific needs of the workforce, choosing the appropriate educational tools to address those needs, establishing achievable goals, engaging a critical mass of interested stakeholders, allowing sufficient time for changes to take hold, and securing sufficient leadership support to sustain/strengthen/nurture the effort.15 Diverse offerings and teaching strategies engaged interdisciplinary stakeholders and achieved impressive increases in PC knowledge, skills, and behaviors. The workforce transformation initiative was recognized by the City of Hope as a 2016 ELNEC Award Winner for professional development.
Several lessons became apparent during the management of the intervention. Unexpectedly, despite being able to fund replacement wages to remove clinicians from direct patient care to attend the ELNEC training, nurse managers simply could not find replacements for a 2-day absence. Thus, the content was delivered in a single 9-hour day, which is pedagogically undesirable but was necessary in order to comply with ELNEC curriculum requirements while meeting institutional workforce demands. Alternative approaches to deliver this content to busy clinicians should be considered and might include online or blended options or sequential, 1-hour modules that could be combined for a completion certificate. A cost-benefit analysis of this initiative would have been beneficial had we included that in the original design. Engaging a healthcare economist on the team when planning future educational initiatives is recommended.
Although the ELNEC curriculum provides an assessment tool specific to its nursing content, validated tools for other health professionals were not freely available. Such tools could assess each profession's knowledge deficits, thus enabling the tailoring of the education even more specifically and yielding a more holistic assessment of the institution's educational needs.
Finally, it was very effective to front-load the bulk of the educational offering early and to utilize the TtT model. This is clearly evidenced by the 48 early nurse trainers who then trained 564 colleagues. However, attention must be paid to the needs of novice educators, and any such initiative would benefit from a program to build support for that group from more seasoned faculty mentors.
A multiyear, state-funded project to create and sustain an interdisciplinary workforce transformation that would build primary PC knowledge and skills was developed and successfully implemented in a large 378-bed hospital in the Boston area. The project generated wide-ranging impact on organizational culture and climate related to PC and was nationally recognized by 2 separate bodies. The initiative demonstrated that not only can a concerted, coordinated, well-executed educational initiative meet its established goal, but may also propagate across the system to create unexpected benefits such as job promotions, interdisciplinary collaborations, and community outreach.