Referrals for bereavement counselling in primary care: a qualitative study

Complicated grief knowledge and practice: a qualitative study of general practitioners in Ireland

OBJECTIVE

Complicated grief is a debilitating condition that individuals may experience after losing a loved one. General practitioners (GPs) are well positioned to provide patients with support for grief-related issues. Traditionally, Irish GPs play an important role in providing patients with emotional support regarding bereavement. However, GPs have commonly reported not being aptly trained to respond to bereavement-related issues. This study explores GPs' current knowledge of and practice regarding complicated grief.

METHODS

A qualitative study adopting a phenomenological approach to explore the experiences of GPs on this issue. Semi-structured interviews were carried out with a purposive sample of nine GPs (five men and four women) in Ireland. Potential participants were contacted via email and phone. Interviews were audio-recorded, transcribed and analysed using Braun & Clarke's () model of thematic analysis.

RESULTS

GPs had limited awareness of the concept of complicated grief and were unfamiliar with relevant research. They also reported that their training was either non-existent or outdated. GPs formed their own knowledge of grief-related issues based on their intuition and experiences. For these reasons, there was not one agreed method of how to respond to grief-related issues reported by patients, though participants recognised the need for intervention, onward referral and review.

CONCLUSIONS

The research highlighted that GPs felt they required training in complicated grief so that they would be better able to identify and respond to complicated grief.

How can we know what we don't know? An exploration of professionals' engagement with complicated grief

OBJECTIVE

Research has shown that complicated grief has the potential to adversely affect bereaved individuals, and in this context, understanding how mental health professionals engage with it in practice is of relevance. Gaining an understanding of professionals' knowledge, attitudes, skills and training in relation to complicated grief could provide insights that will inform their training and professional development. The aim of this study was to consider professionals' engagement with complicated grief, as represented by self-reported knowledge, attitudes, skills and training.

METHODS

The study used a three-phase mixed methods design (systematic review, qualitative interviews, and a quantitative survey) with empirical data being collected from psychologists, psychiatrists and counselor/psychotherapists.

RESULTS

Analysis yielded 15 integrated findings across the three phases, which were grouped into two clusters: the first highlighted tension between professionals' reported confidence and competence and the second explored the parameters and contribution of research and training in this area.

CONCLUSION

Professionals' perception of their competence to work with complicated grief seems overstated and research and professional practice are not aligned.

PRACTICE IMPLICATIONS

These findings are positioned to inform empirically supported training that addresses identified deficits in professionals' knowledge, attitudes and skills. It is important therefore that training is reflective of the needs of different professional groups.

'Unprepared for the depth of my feelings' - Capturing grief in older people through research poetry

BACKGROUND

Older people are more likely to experience bereavements than any other age group. However, in healthcare and society, their grief experiences and support needs receive limited attention. Through innovative, arts-based research poetry, this study aimed to capture older people's bereavement stories and the effects of grief on their physical and mental health.

METHOD

Semi-structured in-depth interviews with 18 bereaved older adults were analysed using thematic and poetic narrative analysis, following a five-step approach of immersion, creation, critical reflection, ethics and engagement.

RESULTS

Research poems were used to illustrate three themes of bereavement experiences among older adults: feeling unprepared, accumulation of losses and ripple effects of grief. While half of participants reported that the death of their family member was expected, many felt unprepared despite having experienced multiple bereavements throughout their life. Instead, the accumulation of losses had a compounding effect on their health and well-being. While these ripple effects of grief focussed on emotional and mental health consequences, many also reported physical health effects like the onset of a new condition or the worsening of an existing one. In its most extreme form, grief was connected with a perceived increased mortality risk.

CONCLUSIONS

By using poetry to draw attention to the intense and often long-lasting effects of grief on older people's health and well-being, this article offers emotional, engaging and immersive insights into their unique bereavement experiences and thereby challenges the notion that grief has an expiry date.

Supporting bereavement and complicated grief in primary care: a realist review

Background

Bereavement can have significant impacts on physical and mental health, and a minority of people experience complicated and prolonged grief responses. Primary care is ideally situated to offer bereavement care, yet UK provision remains variable and practitioners feel uncertain how best to support bereaved patients.

Aim

To identify what works, how, and for whom, in the management of complicated grief (CG) in primary care.

Design & setting

A review of evidence on the management of CG and bereavement in UK primary care settings.

Method

A realist approach was taken that aims to provide causal explanations through the generation and articulation of contexts, mechanisms, and outcomes.

Results

Forty-two articles were included. Evidence on the primary care management of complicated or prolonged grief was limited. GPs and nurses view bereavement support as part of their role, yet experience uncertainty over the appropriate extent of their involvement. Patients and clinicians often have differing views on the role of primary care in bereavement. Training in bereavement, local systems for reporting deaths, practitioner time, and resources can assist or hinder bereavement care provision. Practitioners find bereavement care can be emotionally challenging. Understanding patients’ needs can encourage a proactive response and help identify appropriate support.

Conclusion

Bereavement care in primary care remains variable and practitioners feel unprepared to provide appropriate bereavement care. Patients at higher risk of complicated or prolonged grief may fail to receive the support they need from primary care. Further research is required to address the potential unmet needs of bereaved patients.

Complicated grief knowledge, attitudes, skills, and training among mental health professionals: A qualitative exploration

The knowledge, attitudes, skills, and training of professionals regarding complicated grief influence their practice. We conducted 30 semi-structured interviews with psychiatrists, psychologists, and counselor/psychotherapists; the preliminary findings were contextualized via interviews with three experts in complicated grief research/practice. Findings suggest that professionals did not substantially rely on research evidence, favoring instead personal and professional knowledge. They expressed concern regarding the possible pathologization of normal grief that might arise from having a diagnosis of complicated grief. Deficits in professional training were evident. A need for an improved culture of collaboration between researchers and practitioners was identified.

Psychiatrists', psychologists' and counselors' attitudes regarding complicated grief

BACKGROUND

Complicated grief encompasses various presentations where aspects of grief do not become integrated into the bereaved person's life. Professionals' attitudes to complicated grief may impact how they engage with bereaved patients/clients. The aim of this study was to empirically examine the attitudes of mental health professionals, specifically psychologists, psychiatrists and counselor/psychotherapists, regarding complicated grief and to investigate any between profession-differences.

METHOD

Psychiatrists, counselor/psychotherapists and psychologists were recruited using publicly available databases managed by professional bodies. A total of 185 professionals (71.8% female), returned a questionnaire containing usable data (23.8% response rate).

RESULTS

Over two-thirds of the professionals (68.5%) supported the inclusion of complicated grief in diagnostic manuals while only a quarter (25.1%) thought that recognition of complicated grief might lead to the pathologization of 'normal' grief. The majority of respondents (83.0%) thought that diagnosing complicated grief would increase the likelihood of clients accessing support and there was no significant difference between the groups.

LIMITATIONS

Although the response rate compares favorably with other studies it is nonetheless somewhat lower than optimum, and it is possible that those who responded were more interested in bereavement and consequently, that the attitudes held by participants are different from those who did not participate.

CONCLUSION

The attitude to a diagnosis of complicated grief was more positive than the specialist literature suggests, with the benefits of having a diagnosis of complicated grief outweighing the risks of pathologization.

Developing a practice-based research agenda for grief and bereavement care

We aimed to identify practitioners' perspectives on current research priorities in grief and bereavement care. Grief and bereavement care providers were invited to participate in a three-phase Delphi study to create expert consensus on the top priorities for grief and bereavement research. A total of 140 participants completed Phase 1, 84 completed Phase 2, and 70 completed Phase 3. These top 10 research priorities form the basis of a practice-based research agenda for grief and bereavement care to enable researchers to respond to key issues in grief and bereavement care that will ultimately improve the lives of bereaved people.

Complicated grief: Knowledge, attitudes, skills and training of mental health professionals: A systematic review

OBJECTIVE

A systematic review and qualitative synthesis was undertaken to deduce the knowledge, attitudes, skills and training of mental health professionals regarding complicated grief (CG).

METHODS

PsychInfo, Embase, Medline, CINAHL, PBSC, Web of Science and ERIC databases were used to identify relevant literature. Searches were executed from inception to September 2014.

RESULTS

The electronic search yielded 305 results. Forty-one papers were selected for full text review, 20 were included for analysis. 6 examined primary data, the remaining 14 being reviews, opinion or guideline pieces.

CONCLUSIONS

Despite the lack of consensus on terminology, criteria and diagnosis, it appears that there is more than sufficient agreement within the CG research community regarding the knowledge and skills required to assist someone presenting with CG. A palpable fear of medicalising grief exists, but this would seem to be based on a conflation of normal grief and CG. This review highlights the mainly unidirectional nature of current research, the voice of the practitioner being largely unheard. A need for and an interest in training in CG was expressed.

PRACTICE IMPLICATIONS

There is an urgent need to translate research findings into clinical practice. Training must take account of attitudinal barriers to implementation, balancing evidence and stories.

The Fundamental Paradox in the Grief Literature: A Critical Reflection

A key theme in the bereavement literature is the recognition that every grief experience is unique and dependent on many variables, such as the circumstances of the death, characteristics of the bereaved individual, their relationship with the deceased, the provision and availability of support, and a myriad of sociocultural factors. Concurrently, there are corresponding efforts to define “normal” grief and delineate it from “complicated” grief experiences. The discord between these two potentially opposing statements remains a paradox evident within the three major tensions within the thanatological literature—the dominance of grief theories, the medicalization of grief, and the efficacy of grief interventions. Three recommendations for moving beyond the paradox are discussed—the provision of improved grief education for service providers, the bereaved, and the wider community; the conduct of research that emphasizes the context of grief and is relevant to service provision; and the examination of current grief interventions.

General Practitioners' experiences of bereavement care and their educational support needs: a qualitative study

BACKGROUND

General Practitioners (GPs) are well-positioned to provide grief support to patients. Most GPs view the provision of bereavement care as an important aspect of their role and the GP is the health professional that many people turn to when they need support. We aimed to explore GPs' understandings of bereavement care and their education and professional development needs in relation to bereavement care.

METHODS

An in-depth qualitative design was adopted using a social constructionist approach as our aims were exploratory and applied. Nineteen GPs (12 women and 7 men) living in Western Australia were interviewed; 14 were based in metropolitan Perth and 5 in rural areas. GPs were invited, via a letter, to participate in a semi-structured interview. The interviews occurred within each GP's workplace or, for the rural GPs, via telephone, and all interviews were digitally audio-recorded and transcribed.

RESULTS

Analysis was based upon constant comparison and began as soon as possible after each interview. The data revealed four tensions or opposing views concerning bereavement and bereavement care. These were (1) whether grief is a standardised versus an individual process, (2) the role of the GP in intervening versus promoting resilience, (3) the GP as a broker of services versus a service provider, and (4) the need for formal education and professional development versus 'on-the-job' experiential learning.

CONCLUSIONS

GPs have a critical role in exploring distress, including grief. However, changes need to be made to ensure GPs have up-to-date knowledge of contemporary theories and approaches. GPs urgently need education both at the undergraduate and postgraduate degree levels, and in continuing professional development. Otherwise GPs will rely on out-dated theories and constructions of grief, which may be detrimental to patient care.

The preparation of graduate health professionals for working with bereaved clients: an Australian perspective

Students enrolled in health profession courses require grief education so that, upon graduation, they are able to meet the needs of clients living with loss and grief. We investigated grief and loss education in six Australian university programs--medicine, nursing, counseling, psychology, social work, and occupational therapy--drawing from course documents and face-to-face interviews with key staff and final-year students. Only the counseling course included a dedicated grief and loss unit. The nursing, medicine, and occupational therapy courses emphasized end-of-life issues rather than a breadth of bereavement experiences. The social work course taught grief as a socially-constructed practice and the psychology course focused on grief and loss in addiction. Several factors influenced the delivery of grief education, including staffing, time, placement opportunities, student feedback, and needs of each profession. The study provides an indication as to how future health professionals are prepared for grief and loss issues in their practice.

Bereavement care in general practice: a cluster-randomized clinical trial

BACKGROUND

The loss of a loved person may lead to complicated grief (CG). General practitioners (GPs) consider bereavement care to be important but find training for this task to be insufficient. We hypothesized that improvement in skills that facilitate early identification of CG and enhance GPs' clinical care may reduce adverse health outcomes. Aim. To test whether implementation of a bereavement management program in general practice could improve the GPs' ability to identify CG and provide clinical care.

DESIGN

A cluster-randomized controlled trial allocating GPs and their listed patients suffering from bereavement to either a intervention or a control group.

SETTING

Close relatives of patients who had died from cancer in Denmark were recruited (N = 402).

METHOD

The primary outcomes were defined as the bereaved relatives' score on the Beck's Depression Inventory II and the Inventory of Complicated Grief-Revised (ICG-R), the GP's clinical assessment of the relative's grief reaction and the relative's number of contacts with general practice.

RESULTS

Larger improvements in ICG-R scores were found in the intervention group than in the control group. In the intervention group, patients exhibiting CG symptoms were more likely to receive supportive care and to be referred to mental health practitioners, whereas GP's in the control group more often prescribed psychotropic drugs for patients with symptoms of CG. The GP's ability to identify CG at 13 months did not seem to be better in the intervention group than in the control group.

CONCLUSION

While only statistically near significant, we found some indications of an effect of the intervention compared with usual care. Our results underscore the need for improving GPs' clinical skills in identifying patients with CG.

A qualitative evaluation of the provision of bereavement care accessed by service users living in a Health and Social Care Trust area in Northern Ireland

Within the health and social care sector in the United Kingdom, the management of death and bereavement has become increasingly challenging. This service evaluation sought to explore the bereavement care offered to individuals living in one Health and Social Care Trust catchment area of Northern Ireland. Qualitative interviews were conducted with key government and voluntary agency staff. The findings indicated that much of the bereavement provision is based on the interest and initiative of individual staff members, with few processes to assess the level of bereavement care needed and those best skilled to provide it. Recommendations are made for a bereavement care strategy that outlines a bereavement needs assessment process, identifying the scope of interventions and protocols for practice.

Professionals' experiences of grief counseling: implications for bridging the gap between research and practice

Despite the escalating interest in grief interventions, there is a clear misalignment between contemporary grief research and grief counseling practices, and this disparity may limit intervention effectiveness. Semi-structured interviews with 19 grief counselors revealed their current practices of grief counseling. The counselors' descriptions of grief and their grief counseling practices were diverse and many were influenced by classic grief theories and the grief work hypothesis. The grief counselors described negotiating several issues and dilemmas in their work and provided recommendations for achieving greater exchange between research and practice. The findings have the potential to inform the delivery, efficacy, and relevance of grief counseling in Western Australia.

Bereavement care in primary care: a systematic literature review and narrative synthesis

BACKGROUND

Over half a million people die in Britain each year and, on average, a GP will have 20 patients die annually. Bereavement is associated with significant morbidity and mortality, but the research evidence on which GPs and district nurses can base their practice is limited.

AIM

To review the existing literature concerning how GPs and district nurses think they should care for patients who are bereaved and how they do care for them. design systematic literature review.

METHOD

Searches of AMED, BNI, CINAHL, EMBASE, Medline and PsychInfo databases were undertaken, with citation searches of key papers and hand searches of two journals. Inclusion criteria were studies containing empirical data relating to adult bereavement care provided by GPs and district nurses. Information from data extraction forms were analysed using NVivo software, with a narrative synthesis of emergent themes.

RESULTS

Eleven papers relating to GPs and two relating to district nurses were included. Both groups viewed bereavement care as an important and satisfying part of their work, for which they had received little training. They were anxious not to 'medicalise' normal grief. Home visits, telephone consultations, and condolence letters were all used in their support of bereaved people.

CONCLUSION

A small number of studies were identified, most of which were > 10 years old, from single GP practices, or small in size and of limited quality. Although GPs and district nurses stated a preference to care for those who were bereaved in a proactive fashion, little is known of the extent to which this takes place in current practice, or the content of such care.

Acts of resistance: breaking the silence of grief following traffic crash fatalities

Theoretical arguments and empirical evidence demonstrate the limited utility of a narrow construction of "normal" grief. Sudden and violent death, the young age of the deceased, and perceptions of death preventability are associated with grief reactions that extend beyond an expected grief response. Interviews were conducted with 21 adults bereaved through the death of a family member in a traffic crash. We present their attempts to resist notions of "working through" grief and "recovery" from it and consider how the participants' constructions of an alternative discourse, or normative narrative, possess the potential to challenge a prevailing grief discourse.

Dying, death and bereavement: a qualitative study of the views of carers of people with heart failure in the UK

Background

This paper explores carers' views of dying, death and bereavement for family members who had recently died with heart failure adding to a growing literature on end of life experiences for people with conditions other than cancer.

Methods

Twenty interviews were conducted with bereaved carers of older people with heart failure (HF) who had been participating in a longitudinal study. Carers were approached in writing 3 months after the death. Interviews were transcribed verbatim and analysed thematically with the assistance of NUD*IST.

Results

Findings were grouped into three time periods: prior to death; the death itself and bereavement. Most carers found discussions about end of life with their family member prior to death difficult. Dissatisfaction with the manner of the death was focused around hospital care, particularly what they believed to be futile treatments. In contrast deaths in the home were considered 'good'. Carers adopted a range of coping strategies to deal with grief including 'using their faith' and 'busying themselves' with practicalities. There was some satisfaction with services accessed during the bereavement period although only a small number had taken up counselling.

Discussion

Our findings suggest that an absence of discussion about end of life care wishes with family members or health professionals is a barrier to advance care planning. Carers' perceptions about prioritising making the dying person comfortable can be in conflict with doctors' decisions to treat. Whilst carers report a range of strategies adopted in response to bereavement there is a need for continued support for vulnerable carers after the death of the person with HF.

Some issues in the provision of adult bereavement support by UK hospices

This paper considers some issues in the provision of adult bereavement support in UK hospices. The paper is based on the findings of a multi-method study conducted in two phases over 30 months (2003-2005) to examine the nature and quality of adult bereavement support in UK hospices from the perspectives of bereaved people and professional and volunteer bereavement workers [Field, Reid, Payne, & Relf (2005). Adult Bereavement Support in Five Hospices in England. Sheffield, UK: Palliative and End-of-Life Care Research Group, University of Sheffield. (Available from Professor Payne)]. It discusses the importance of continuity between pre-bereavement and bereavement support, the integration of bereavement services within hospices and the involvement of volunteers in bereavement support. It then discusses the engagement of UK hospices in the broader development of bereavement support. Although hospices have developed expertise in supporting bereaved people, our research suggests that they have not had a major impact on other health service providers, such as general practitioners and distinct nurses and staff in acute hospital trusts, in this area.

Does ethnicity matter? Bereavement outcomes in two ethnic groups living in the United Kingdom

Background: Sociologists, anthropologists, and psychologists agree that grief is a universal phenomenon. Reactions to it are, however, socially constructed and patterned.

Objective: To compare the outcomes of bereavement among family or close friends of deceased first-generation black Caribbean and white native-born patients living in the United Kingdom.

Design: Comparative cross-sectional questionnaire survey in three inner London health authorities administered 10 months after the patient's death.

Participants: Family and close friends of 50 deceased first-generation black Caribbean and 50 native-born white patients with advanced disease.

Main outcome measures: 28-item General Health Questionnaire (GHQ-28), Core Bereavement Items scale, a 17-item measure of grief.

Results: The intensity of grief, measured using the Core Bereavement Items was similar between the two groups. Seventy-two respondents had visited their family doctor subsequent to bereavement, and of these, black Caribbean respondents reported more psychological problems. Depression and anxiety measured by the GHQ-28 were significantly higher among black Caribbean respondents (28.00 vs. 21.2) (t-test = −2.28,p= 0.025). Multiple regression analysis revealed this difference was best accounted for by bereavement concerns such as legal and housing problems.

Conclusions: This study has observed higher psychological morbidity among the bereaved Caribbean individuals. Family doctors are a source of support for three-quarters of respondents, and they may need to focus on the needs of black and minority ethnic minorities.