VOL: 98, ISSUE: 42, PAGE NO: 36
Mary Douglas, MSc, BSc, RGN, is professional development leader and research and development lead (nursing), based at Salford Royal Hospitals NHS Trust, Hope Hospital, Salford
Susan Pemberton, DipN, RGN, is ward sister;Barbara Hewitt, DipN, RGN, is ward sister, ICU; all based at Salford Royal Hospitals NHS Trust, Hope Hospital, SalfordThe sudden death of a close relative can be an extremely distressing experience (Bowlby, 1981). The recently bereaved may go through a roller coaster of emotions so that interactions with health care professionals may be fraught and difficult.
The sudden death of a close relative can be an extremely distressing experience (Bowlby, 1981). The recently bereaved may go through a roller coaster of emotions so that interactions with health care professionals may be fraught and difficult.
In acute care, nurses are regularly required to help people cope with the trauma of sudden death. They can do this by offering support and by creating an environment that allows the bereaved person to deal effectively with the crisis. However, if nurses do not have the necessary skills and knowledge they are unlikely to be able to provide the level of support needed and may end up feeling overwhelmed.
Greater understanding of their own emotional responses and those of the bereaved can help to make these situations more manageable for nurses, so that their contributions are more effective. The nature of bereaved people's responses means that carers need to be flexible, nonjudgemental and adaptable to chaos and disorder (Wright, 1999).
An inability to demonstrate these qualities could lead to frustration, helplessness and, ultimately, burnout. Education, mentorship and ongoing support are therefore essential so that nurses can understand people's responses to bereavement and react in an effective way.
At Salford Royal Hospitals NHS Trust we acknowledged the importance of bereavement education for staff in acute care and decided to undertake a project to improve this in the trust. Funds were provided by the Greater Manchester (West) Education and Training Consortium.
The aim of any bereavement educational programme for nurses should be to give them the opportunity to identify their own needs, re-examine what they know, and share this knowledge and experience with others. The subject of bereavement may arouse strong feelings and emotional distress. It is important that course participants can express feelings that come up in a safe environment.
Wright (1999) suggests that such programmes should be provided for groups of 10-12 people over two to three days. Programme facilitators must be appropriately qualified and have the skills and knowledge to support staff dealing with personal issues that may be raised.
The initial work centred on identifying an approach that would ensure we met the objectives of the programme. The outline plan was as follows:
- Identify key staff working on bereavement issues in the trust;
- Clarify the purpose of the project and agree core elements with the focus group;
- Arrange formal workshops;
- Arrange a follow-up in-house study involving a high level of participation by specialist nursing and chaplaincy staff.
It was agreed that after the education programme, participants should discuss personal development plans with their facilitators so that they could continue to develop their knowledge and understanding of this area of care. The facilitators would be on hand to support ex-participants in developing their personal portfolios of evidence and, where applicable, offer support in the workplace.
Two trust nurses were seconded as trainer/support coordinators on a job-share basis. However, these nurses did not have the expertise to facilitate the necessary in-depth and specialist workshops for this project.
As a result, an external specialist in bereavement support was brought in to facilitate six two-day workshops on bereavement issues, while the two project coordinators facilitated the follow-up day.
The objectives of the programme were:
- To enable ward nurses to reflect on their experiences of meeting death on their ward/unit and the care offered to relatives/friends during this stressful time;
- To give nurses opportunities to share experiences and focus on concerns about their practice in this nursing area.
Additional study days were organised to address associated topics such as memorial services and cultural awareness when caring for the bereaved.
The first two-day workshop took place in November 1999. In the following 18 months, 102 staff attended the workshops and study days, representing all the main units across the trust. Participants received support from the project coordinators in developing their skills and expertise and in developing their portfolio of evidence.
Participants were asked to complete a post-workshop evaluation form, as well as a pre-programme and post-programme questionnaire to assess whether it had met their needs. Evaluation feedback (Figs 1-3) demonstrates that the bereavement project has had a demonstrable impact on the nurses in the trust: 95% of respondents rated the content of the days as either 'extremely satisfactory' or 'very satisfactory'.
Factors identified as being most useful included 'using silences and listening skills', and 'being allowed to actually listen and not to feel that you should be saying something'.
Staff were also asked to identify how they felt the study days would help them in their practice. Responses included:
- 'It gave me more confidence in dealing with issues, and to feel more self-aware' (four responses);
- 'It extended my knowledge, which I can pass on to other members of staff' (two responses);
- 'I am more confident dealing with relatives, advising on support and the grieving process' (13 responses).
The workshops revealed areas of particular concern. These included a lack of understanding of the roles of those involved in the bereavement process, such as morticians, coroners and patient affairs staff.
In response, the project coordinators carried out a series of visits to gain accurate up-to-date information on these roles. This was fed into a post-bereavement information flow chart for use in clinical environments. The chart is accessible on the hospital intranet bereavement site, and has been circulated for display in each department and ward.
Up-to-date post-bereavement information is accessible at all times to all trust staff and students on the trust's bereavement intranet site, and also to other NHS staff.
Discussion and recommendations
The overall aims and agreed milestones of the project have been accomplished (Box 1). Employing two nurses in a job-share capacity has benefited the trust, as it allows them to discuss, plan and implement the programme, and enables them to enhance their communication skills.
Evaluation of the project has shown that the information and knowledge nurses have gained will improve services. The aim for the future is that staff will continue to build on their portfolios, which it is hoped will help their personal development and continue to improve bereavement care.
Lack of cultural awareness was raised as an important issue for many nurses. As this project concludes, discussions are ongoing with the chaplains to look at developing a flow chart to provide cultural information for nurses to prevent problems occurring at the time of death and after.
Personal reflection from project coordinators
Working as project coordinators has allowed us to develop personally and professionally. We have collaborated with the key people in the trust who deal with bereavement care, and have involved them in the delivery of information on our follow-up day. As part of the consortium we have visited other trusts to see how different organisations work.
We set out to improve care for the bereaved. We listened carefully to what the nurses in our trust wanted in terms of bereavement care and were directed by their learning needs and the gaps in care delivery that they identified. From this information we met the outcomes set by the consortium.
However, we also exceeded these outcomes by developing a flow chart containing clear and simple information in response to nurses' questions for use in every ward and department. We believe this will improve bereavement care, and we intend to audit its use to monitor its effectiveness.
On a personal level, our confidence has grown through the experience of communicating with professionals from various disciplines and at all levels within the trust. We have also gained experience in teaching and presenting skills.
This project has helped nurses to improve the basics of care. It fits in with the aims of The NHS Plan, which asks nurses to put patients at the centre of care. The project has given nurses working with individuals who experience sudden death the knowledge that their work is worthwhile even when they themselves may experience difficulties.
It has also given them the training, mentorship and support that is essential for all staff charged with managing such highly charged situations.