With over half a million deaths occurring in the UK each year, it is inevitable that all professionals working in healthcare will at some time care for those who are bereaved.
- This article has been double-blind peer reviewed
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1. Explain nurses’ role in helping bereaved people.
2. Identify skills required to help bereaved relatives.
Helen C. Walsh, DBA, MSc, RM, RGN, RHV, is tutor in nursing, Swansea University.
Walsh, H.C. (2008) Caring for bereaved people 2: nursing management. Nursing Times; 104: 1, 32–33.
This two-part unit examines caring for bereaved people. Part 1 discussed the manifestations of grief and explored bereavement models. Part 2 examines nurses’ role in helping bereaved relatives.
With over half a million deaths occurring in the UK each year, it is inevitable that all professionals working in healthcare will at some time care for those who are bereaved. These professionals can offer support at the time of and/or subsequent to the death. They include bereavement counsellors, social workers, chaplains and community faith leaders/clergy, as well as nurses.
Nurses’ experiences of dealing with the grief that follows bereavement will vary depending on the clinical area in which they work. For example, nurses working in A&E may witness relatives experiencing acute grief as they face the sudden and unexpected death of a loved one. For community nurses, it is likely to be different since they will probably have visited the patient before death and may well continue to support the family in the early post-bereavement period.
For the most part, nurses are likely to be involved with relatives in the immediate and acute stage of their grief (Russell, 2007). Whenever and wherever nurses encounter bereaved people, they need to recognise when more specialist help may be needed and know how to refer people to services that can help, such as Cruse Bereavement Care or other local support services.
RESPONSE TO BEREAVEMENT
Each individual is unique and their response to bereavement will depend on numerous factors, such as:
- Nature of the relationship with the deceased person;
- Levels of social support;
- Nature of death (Kinghorn and Duncan, 2005).
Individual responses and the effect of bereavement can span the entire spectrum of human emotions, behaviours and physical and psychological responses (Anstey and Lewis, 2001). These responses, grouped into four main categories, are detailed in full in Portfolio Pages on nursingtimes.net for part 1 of this unit.
If responses to bereavement are so diverse and are unique to the individual, how can nurses help? Nurses have many transferable skills that are vital when helping bereaved people. These include:
- The ability to establish and maintain relationships, which in some circumstances needs to be done very quickly;
- Interpersonal skills;
- Skills in communicating and giving information;
- The ability to give ‘intuitive’ support (Anstey and Lewis, 2001).
Within a multicultural society, it is important that nurses have some understanding of spiritual and religious differences that may exist. This is particularly relevant when caring for bereaved relatives. When there is time for nurses to build a relationship with those involved before the death occurs, it is possible to explore specific needs or issues.
Following sudden death, however, nurses may have to rely on a more general knowledge of different faiths, cultures and rituals, treading sensitively, ever mindful of the potential for individual differences.
Whenever possible, practitioners should ask the family if there are any particular customs or practices that should be observed, rather than make assumptions based on ‘book’ knowledge. The Liverpool Care Pathway (Ellershaw and Wilkinson, 2003) makes it clear that nurses should check the religious/spiritual as well as cultural needs families may have.
The needs of bereaved people differ depending on the stage of their bereavement. Whether nurses are caring for bereaved relatives immediately following or some time after the death, there are key principles that can help to deliver effective care. These principles are explored first, before those at the time of death and further on into the bereavement are examined.
The most valuable thing nurses can give bereaved relatives is time. While this is a precious commodity, the value of just being there can never be underestimated (Kinghorn and Duncan, 2005).
Perhaps the most important principle is allowing the bereaved person to take control, letting them set the tone, pace and content of any discussion or interaction. Nurses need to display active listening skills, that is, listening with all the senses. Nurses must hear what is being said, accept it and adopt a non-judgemental attitude. Practitioners need to hear what the person really has to say and, through the use of effective communication skills, demonstrate empathy and understanding.
As nurses spend time with bereaved people, they must learn to tolerate and stay with silence. In the rapid pace of life today people often find silence uncomfortable but staying with bereaved people in their silence conveys to them that we have time (Kinghorn and Duncan, 2005).
Anger is a natural response to bereavement (Kubler Ross, 1969) and professionals must learn not to take any expressions of it personally (Russell, 2007).
As people express their grief, nurses need to consider diversity/cultural differences and allow for different coping strategies, providing reassurance as appropriate (Field and Payne, 2003).
When helping bereaved relatives, practitioners need to be self-aware so they can recognise their own feelings and responses to what is happening. It is possible that their feelings may reflect those of the bereaved person and it may be helpful to voice those emotions (Russell, 2007). Anstey and Lewis (2001) suggest that nurses should also be aware of future care and support that the person may need.
Nurses enter the profession because they want to make things better. It is important to accept the fact that, for bereaved people, we cannot make things better (Russell, 2007). The only thing that would make it better is for them not to be bereaved.
TIME OF DEATH
At the time of death, the focus of care is on the needs of the family (Anstey and Lewis, 2001). Nurses must expect to encounter the relatives’ overwhelming sense of shock, numbness, disorientation and, in some circumstances, overt distress and anguish (Field and Payne, 2003).
Whenever possible, the family should be given as much time as they want to say their goodbyes (Kinghorn and Duncan, 2005). This is easier in some areas than others and practitioners should give relatives the option of spending time alone with patients.
Caring for the body in a respectful and appropriate way is crucial, as is supporting individuals in their particular rituals and mourning customs (Anstey and Lewis, 2001). Legal and medical interventions, for example postmortems, may be necessary. Giving information to relatives about such matters needs to be handled sensitively.
Giving and receiving information at this time is very important and it is vital that nurses have accurate, up-to-date knowledge to give (Anstey and Lewis, 2001). For example, this could include giving details of when to collect the death certificate or how and when to register the death. While nurses cannot take away the pain, providing factual information may make it easier for bereaved people to complete the practical and legal tasks that must be undertaken. Providing written information for relatives to take away may be helpful as, in their grief, they may be unable to absorb verbal information (Kinghorn and Duncan, 2005); information can also be referred to at a future date.
LATER IN THE BEREAVEMENT
Some nurses may have a role in supporting bereaved people after the initial period following death, as they begin to acclimatise to life without the deceased person (Egan and Arnold, 2003). It is important that practitioners normalise grief, assuring relatives that what they are experiencing is normal and that there is no right way to grieve (Russell, 2007; Egan and Arnold, 2003). Nurses need to encourage them to identify and express their feelings. Sometimes bereaved people need encouragement to talk about the person who has died (Field and Payne, 2003).
Professionals may need to encourage the person to be patient with themselves, as they underestimate the enormity of the task they face and how much time they need (Egan and Arnold, 2003). Words are not always necessary; gentle touch and silence can often convey understanding when words cannot (Egan and Arnold, 2003).
NURSES’ OWN NEEDS
While bereavement care involves looking after other people, nurses need to look after themselves. Being with people who are acutely distressed is upsetting and witnessing such distress may make nurses cry. Shared tears, however, can demonstrate genuine care and relatives may find this comforting (Kinghorn and Duncan, 2005).
Nurses need to recognise their skills and emotional/spiritual capacity to care for others (Kinghorn and Duncan, 2005) and clinical supervision may well have a role in ensuring their well-being. Supporting bereaved people can reopen unresolved grief for the caregiver. If this occurs, nurses may then need to seek help outside the work situation.
The frequency, type and amount of care nurses provide to bereaved people depends largely on the setting in which they work. All nurses should expect to encounter bereaved relatives at some time and, consequently, they need to develop the necessary skills and knowledge to ensure they provide high standards of care.
Portfolio Pages can be filed in your professional portfolio as evidence of your learning and professional development. They contain learning activities that correspond to the learning objectives in this unit, presented in a convenient format for you to print out or work through on screen.
Anstey, S., Lewis, M. (2001) Bereavement, grief and mourning. In: Kinghorn, S., Gamlin, R. Palliative Care: Bringing Comfort and Hope. London: Bailli貥 Tindall.
Egan, K.A., Arnold, R.L. (2003) Grief and bereavement care. American Journal of Nursing; 103: 9, 42–52.
Field, D., Payne, S. (2003) Social aspects of bereavement. Cancer Nursing Practice; 2: 8, 21–25.
Kinghorn, S., Duncan, F. (2005) Living with loss. In: Lugton, J., McIntyre, R. (eds) Palliative Care: the Nursing Role. Edinburgh: Elsevier Churchill Livingstone.
Russell, P. (2007) Dying, death and spirituality. In: Hogston, R., Marjoram, B.A. (eds) Foundations of Nursing Practice: Leading the Way. Basingstoke: Palgrave Macmillan.