Future-proofing the palliative care workforce: Why wait for the future?

How can we best future-proof the palliative care workforce to overcome foreseeable challenges on the horizon? Clearly, this is a complex question that warrants consideration of multiple factors and input from many stakeholders, including palliative care volunteers.¹ Whilst providing a definitive answer is beyond the scope of this paper, here we discuss but a few pieces in contribution to the larger workforce-puzzle of discourse in the field of palliative care. Broader discussion to advocate for strategic workforce policy is essential and waiting passively for an uncertain future is simply not an option.

Careful consideration of workforce issues is not new to palliative care. Indeed, calls for workforce development and future workforce planning to address shortages have been evident within the international literature for quite some time.^2,3 However, there now appears to be a growing sense of urgency. More recently, studies conducted by the American Academy of Hospice and Palliative Medicine's Workforce Task Force^4,5 have pointed towards an impending crisis in the form of a ‘workforce valley’ associated with factors such as burnout, intention to leave palliative care, retirement age demographics, and limitations in specialist training.

Future workforce challenges for palliative care are thus foreseeable not only from increased demand associated with population growth and ageing, but also a decrease in supply as a significant proportion of the palliative care workforce retire or otherwise leave this specialty area of practice, with insufficient numbers being trained to cover the shortfall.

This is reflected in a projected ratio of one palliative care physician per 26,000 American patients eligible for palliative care in 2030, if significant action is not taken soon.⁴

Importantly, these concerns are not isolated to the USA or palliative medicine specialists. Kamal and colleagues⁴ conclude that ‘potential solutions should address the substantial prevalence of burnout in the field, support increased delivery of foundational palliative care services by non-specialty clinicians, and grow the workforce of trained palliative care clinicians through traditional and alternative mechanisms’. We now speak to these briefly, in turn.

As an occupational phenomenon formally recognised in the World Health Organization's International Classification of Diseases,⁶ burnout represents a growing concern. Initiatives to address the prevalence of burnout in the palliative care workforce should not only focus on building resilience to adversity; there is also a need to address organisational barriers to compassion for self and others. Retention of the current workforce could be supported by increased staff support and education about effective self-care to promote compassion literacy, building self-compassion and emotional intelligence.^7–9

An increased delivery of general and specialist palliative care services could be supported, in part, by leveraging the relative size of the palliative care nursing workforce. While much of the workforce data has focused on physicians, nurses form the largest component of the palliative care workforce. A systematic review of the international literature suggests that innovations in advanced practice and nurse-led models of palliative care can effectively bridge gaps in health care service delivery and improve the patient experience through early palliative care intervention.¹⁰ However, the implementation of nurse-led models of care should not be misconstrued as substitution of physicians by advanced practice nurses or nurse practitioners.

Growing the workforce of trained palliative care clinicians is vital. How, then, can we promote palliative care as a specialty of choice for health professionals – and how can we best welcome and nurture their growth? This endeavour will require positive alternatives to traditional approaches used previously to educate and train junior nurses and doctors. For example, discourse on nurses ‘eating their young’, and doctors ‘teaching by humiliation’ have punctuated general nursing and medical education. While positive cases of nurses nurturing their young, and physicians mentoring junior doctors can be found in palliative care, we suggest that pathways into palliative care may, at times, be chequered by resistance to early career clinicians working in palliative care.

Although a specific number of years may not appear in official recruitment processes, anecdotal evidence suggests a tacit culture of shielding away junior clinicians who are inspired and already know they want to specialise in palliative care. Indeed, our common experience after becoming registered nurses – in different practice jurisdictions and many years apart – was that of having to reconcile other palliative care nurses’ calls to spend several years in other clinical areas prior to even thinking about working in palliative care as a viable option, with knowing that the reality of doing so would likely result in our being lost to palliative care in the long term. Although well-intended, cognisance of potential implications for the workforce is increasingly important.

Could it be, that those of us working in palliative care feel a need to shield newer clinicians from death and dying? Or, might it also be a case of trying to protect those living with life-limiting illness from junior clinicians perceived to lack competence, based on limited experience working in palliative care? In either instance there may be an underlying paternalism to be reframed, as health care professionals are exposed to death and dying across nearly all clinical settings, and cumulative years of clinical experience do not necessarily equate directly to higher levels of clinical competency. That is not to suggest that years of clinical experience in other areas are not beneficial; it is, however, a caution that we may do palliative care a disservice if we perpetuate only those traditional pathways to palliative care that many of us may have followed, not early, but later in our clinical careers.

We argue that beyond the requisite baseline of competence required for entry-level clinical practice, an appropriate understanding of and passion for palliative care should be considered favourably when considering someone's suitability to work in palliative care, over an arbitrary number of years’ experience in other clinical areas. Consistent with this, recent innovations in the way that graduate nurses transition to professional practice represent an alternative strategy with potential to fast-track pathways into the specialty of palliative care nursing.

In Australia, university trained graduate nurses traditionally undertake a 12-month transition to professional practice programme encompassing rotations through different clinical practice areas. While most programmes consist of general acute care oriented medical-surgical rotations, specialty graduate nurse programmes have been developed to promote workforce capacity in specialties such as mental health and more recently, primary health care.¹¹ In 2018, a 12-month transition to professional practice programme was completed in the palliative care unit at The Prince Charles Hospital, a major teaching hospital in Queensland, Australia. To our knowledge, this innovative programme was the first of its kind in Australia, and given its success, we believe this approach can serve as a case study to help grow the palliative care workforce.¹²

Palliative care must be promoted as a speciality of choice. But those who come knocking on the door must also be welcomed. We fear that if the door remains closed, based upon an arbitrary accumulation of years in other clinical areas, the current palliative care workforce may be turning away its potential leaders of the future. In addition to welcoming those who may come to palliative care with years of experience from other clinical areas, we must also begin to plant seeds in fertile soil and grow our own future workforce through early exposure, encouragement and ongoing nurturance.

In many respects, the quality and extent of palliative care provision over the coming decades will be shaped by the issues we currently choose to prioritise. We cannot afford to be short-sighted; workforce and succession planning must be key priorities. The time is now, for strategic planning and action towards the growth of a more sustainable palliative care workforce. In the context of palliative care as a human right, the human cost of inaction will be far greater than any fiscal cost of investment towards a future in which there is healthy workforce capacity to provide palliative care whenever and wherever it is needed.

ORCID

Jason Mills http://orcid.org/0000-0002-5584-5225