Bereavement the Role of Acute

Bereavement

The Role of Acute Care Nursing in Bereavement

Losing a loved one is one of the most difficult realities of the life cycle. All must experience at some juncture the death and departure of aged family members, sudden tragedies and protracted battles with illness. And all individuals will cope with loss differently. The process of bereavement is the umbrella phase during which individuals will contend with the loss in question. Inherently difficult and rife with variant emotional responses, bereavement is a natural part of the human experience, both culturally and medically. It is this latter context that is of particular concern to the account provided here. Particularly, the research here attempts to better understand the concept of bereavement from a nursing perspective. The medical realities of the end-of-life stages, as well as the human realities facing those left coping with a death are both of central importance to the nursing professional who will provide care in the acute setting.

The regular professional encounter with death and the relationship forged with both the patient and the patient's loved ones are important features in making the nurse a central and guiding figure during bereavement. It is also the case that the skills attributed to a successful nurse will be particularly well-suited to the needs of those who are bereaved. So is this reported in the article by Walsh (2008), which finds that "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, and; The ability to give 'intuitive' support (Anstey and Lewis, 2001)." (Walsh, 33)

These abilities are of direct consequence in helping the bereaved to absorb and confront the immediate impact of one's passing. But these abilities must also be supplemented by a clear comprehension of the different aspects of the bereavement process. One point of use which is provided by the Worden (2001) text is that which helps us to define our terms. Namely, the discourse on coping with death is impacted by a number of terms which are used interchangeably but which in reality have their own particular nuances. This discussion will attempt to respect these nuances by defining and using in their proper place such terms. According to Worden, the text employs the term "grief to indicate the experience of one who has lost a loved one to death. Grief can be a term applied to other losses but this book primarily addresses losses due to death. Mourning is the term applied to the process that one goes through in adapting to the loss of the person. Bereavement defines the loss to which the person is trying to adapt." (Worden, 10) All of these terms emerge as relevant in a discussion on bereavement, but this specific point of focus is important as it characterizes in a broad sense the endeavor of confronting the realities of the passing of a loved one.

From the medical perspective which drives this account, the distinction is crucial. This is because the training of nursing professionals is neither in grief counseling or in proper support for the mourning process. These are aspects of the experience of losing a loved one for which individual will possess particular areas of training and expertise. The nursing professional, by contrast, will take a more important and direct role in aspects of bereavement, where the practical realities of death must be addressed. In spite of the emotional difficulty inherently present in these cases, it is the responsibility to the deceased of the loved ones to execute key aspects of the final stages of one's involvement with the healthcare system. Nursing professionals will take an important role in help to guide the bereaved through this extremely difficult part of the process.

The discussion here considers various aspects of that responsibility, considering bereavement in the broader cultural context of the United States and, subsequently, addressing the various dynamics between patients, loved ones and nursing professionals leading into and during the state of bereavement.

Bereavement and American Culture:

It is normal and healthy to experience grief with the loss of a loved one. But it is also normal and healthy to experience a range of other emotions that may be tied to the personal relationship with the deceased, the degree of emotional preparation availed to one leading up to the death and the living standards and quality of life for the deceased up until the time of death. Often in American culture, the experiences of aging and death are evaded in favor of less confrontational approaches to losing a loved one. The bereavement process requires individuals to dispatch with strategies of emotional avoidance in favor of more constructive coping strategies. Indeed, avoidance tends to reflect feelings of fear and guilt over the passing of a loved one and may be attributed to a difficulty in resolving certain conflicting emotions. Such emotions will include considerations relating to the experience of the loved one, the relationship held with the loved one leading up to the time of death and the relative perception of the suffering of the deceased. Here, Schulz et al. (2003) provide us with a recognition of this complex mix of emotions amongst family members functioning in a primary caregiver capacity. The article reports that "in follow-up surveys after the death, 63% of the caregivers stated the patient suffered frequent pain, 90% felt the death was a relief to the patient, and 72% felt personal relief at the death." (Schulz et al., 1936)

This feeling of relief can be especially difficult for the bereaved to understand and accept. This can be accompanied by feelings of guilt which may ultimately cause a compensatory tendency toward avoidance. A nursing staff which has had contact with the patient during these end-of-life stages should take an active interest in helping individuals to understand that these feelings are natural, offering comfort with verbal assurance. As will be discussed further at a later point in this account, there is a point at which the comfort that a nursing professional can or should provide must end and the attention must shift to those with more direct training in the areas of bereavement management and coping with grief. However, there is a significant cross-section for the nurse in the acute care setting between a sense of duty to the patient and a sense of duty to the bereaved upon said patient's passing. A study by Birtwistle et al. (2002) reports accordingly that among nurses consulted in an acute care setting, "sixty-nine per cent reported having an interest in bereavement support. Logistic regression modelling identified older age of the nurse and district of employment as the best predictors of interest in bereavement, and older age of the nurse, district of employment and higher level of academic qualification (having a diploma or degree) as the best predictors of active follow-up bereavement visiting." (Birtwistle et al., 467).

As will be considered hereafter, some of these qualifications are of particular value in the acute care setting, where nursing professionals will be especially demonstrated by education, training and professional experience in working effectively as transitional figures in the process of bereavement. As denoted in subsequent sections, the degree to which nurses are specifically outfitted with the skills to help families and individuals cope with bereavement will be significantly correlated to the positive reflection of said families on the experience of coping with approaching death and its aftermath.

Acute Care Settings and End Stage Care:

A tendency to appeal to acute care settings such as long-term care and hospice facilities for family members entering the end-stages of life is based on the perception for families that they may lack the time, resources or training to provide proper attention and care themselves. Issues concerning the high level of medical need for such patients, the requirement for the regular visitation of physicians for evaluation of vital signs and a more generalized fear of failure in the face of serious medical needs are just a few of the motives for placing loved ones in such settings.

The cost of in-home care can also levy a serious expense upon a family that it may not be readily prepared to shoulder. To this end, the article by Schulz et al. (2003) indicates that "the in-home care that family members provide for elderly patients with dementia is valued at billions of dollars each year. While these caregivers face a high degree of stress related to the intensity of the demands and the length of time that care is required, we know little about how they respond to and recover from the death of the patient." (Schulz et al., 1936) These uncertainties are based on a somewhat limited nationwide scope of understanding for the in-home caregiver, who functions independently from the broader healthcare system. The research encountered also provides indications that the acute care setting is likely to offer the patient and family both a context for treatment in which the circumstances of bereavement are well-understand and properly addressed through trained and qualified nursing professionals or grief counselors.

In the case of the former of these groups, there is a demand for proper training and experience in helping family members face the practical realities imposed by the death of a loved one. Further, research demonstrates that many acute care settings are lacking in the capacity to manage these particular issues, failing particularly to make some of the most basic steps needs to help the bereaved face this difficult period. According to Murphy et al. (1997), a survey of area hospice facilities revealed that such settings were problematically deficient in the areas of preparation for bereavement. Accordingly, Murphy et al. report that "the facilities completed surveys about on-site services routinely offered by licensed hospice agencies. 55% of the homes sent sympathy cards after the patients death. 99% of the facilities did not provide materials to the family or primary caregiver on the grieving process or bereavement after the death. None of the facilities sent a letter after the patients death informing them of local, community, or on-site bereavement support group meetings." (Murphy et al., 1104) The article continues to indicate that among such facilities, a full 76% lacked any information which could be provided in the event that family members requested psychological counseling for dealing with bereavement.

As the research conducted here denotes, there is a need for nursing professionals who are both trained in the ability to address immediate bereavement needs and perhaps most importantly, to determine where it is appropriate to refer the family members to a bereavement professional. Thus, it is also of critical importance that the nursing professional be able to facilitate contact with such professionals.

Research attained on the subject of end-of-life care suggests that the contentment experienced by the bereaved will depend significantly on the nature of the care setting. Those healthcare contexts which are designed with intent to ease the comfort and experience of patients during the end-of-life stages would received significantly higher marks than those that were simply engaged in the life-function maintenance. According to the study provided by Hanson et al. (1997), those bereaved individuals surveyed about their experiences with the healthcare system during the end-of-life phases of a loved one, found overwhelming positive results in acute care contexts. The study reports that "asked to make positive or negative comments about any aspect of terminal care, 91% of comments on hospice were positive. Nursing home care received the smallest proportion of positive comments (51%). Family members recommendations to improve end of life care emphasized better communication (44%), greater access to physicians' time (17%), and better pain management (10%)." (Hanson et al., 1339)

In addition to demonstrating some of the key priorities of those in the support system of a dying loved one, there is an indication that those facilities which are specifically outfitted to prepare for death are also more likely to have healthcare professionals with the interest and training needed to help the family cope with the process of bereavement. This is not as much the case in long-term care contexts, where families have tended to express discontent with the availability of services, counseling and basic compassion. So reports the study by Murphy et al., noting that "the study demonstrated few grief and bereavement services for families of patients residing in longterm care facilities." (Murphy et al., 1104)

Patient, Family and Nursing Dynamics:

Ultimately, the research conducted to this juncture contributes to the overarching argument that the part played by nursing professionals in navigating the bereavement process is both significant and specifically limited. This means that there is an implicitly understood support role to be played by the nurse in providing the family with basic information, immediate support and emotional consultation, but that there is also a point of separation at which juncture, the bereavement support must be moved into the hands of others. This is supported by the report of nursing professionals themselves. According to Birtwistle et al., "ninety five percent of district nurses believed their role should involve visiting bereaved relatives/carers of patients they have nursed, but only 19% believed they should visit bereaved people when the deceased was not their patient." (Birtwistle et al., 467) Beyond this, the Birtwistle text reports that few professionals felt that beyond this visitation, continued contact with the family was necessary.

Research suggests that especially in instances where family members have played a part in caregiving, the relationship with the nursing staff is likely to have been more highly developed. This makes the nursing professional more likely to have an positively effective role in helping family-based caregivers approach a major transition in their lives. Indeed, such nursing professionals will be a first line of contact with a healthcare community that includes numerous resources for helping to navigate the process of bereavement. Evidence also suggests that such family members benefit considerably from access to these resources. According to the study by Schulz et al., "the average caregiver depression scores before the death were relatively high, with 43% of the scores indicating a risk of clinical depression. The depression scores spiked right near the time of the death, but they returned to prebereavement levels within 4 months. By 1 year, the scores showed a significant decline, and the number scoring at risk for clinical depression fell to 30%. Many of the caregivers reported preparing themselves beforehand for the death, and targeted bereavement interventions may benefit them as they care for the patient at the end of life." (Schulz et al., 1936) In addition to helping to provide such intervention, nursing professionals should be armed with information and access to professionals that specialize in such interventions.

As is understood as a basis to this discussion, nursing takes place in an extremely wide array of healthcare areas. As such, confrontation with bereavement is likely to take a wide array of incarnations that will impact how the nurse approaches those in need. As the article by Walsh (2008) remarks, "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." (Walsh, 32) In the case of our discussion, the acute care setting suggests a more regular confrontation with death. A focus on the end-of-life stages of treatment in such settings indicates that counseling and support through the process of bereavement will have begun in the approach of death. The nursing professional will be particularly trained in ways of helping family members and loved ones to prepare for and navigate through the difficult transitional period from end-of-life to death and beyond.

An often overlooked aspect of the bereavement process is that experienced by nurses themselves. Though death is a part of the medical profession, it is certainly not endured without taking its emotional toll on healthcare providers. Indeed, the very best of nursing professionals will help to ease the end-stages of the patient's life by serving in an emotionally invested capacity. Thus, the support which caregivers can offer to one another during the bereavement process is absolutely central. So is this demonstrated in the research by Bunting-Perry (2006), which remarks on the dynamic between nursing support and primary caregivers who spend a greater portion of their professional and personal time with a single patient. The article by Bunting-Perry reports that "the caregiver may be exhausted from providing years of physical and emotional care. Many caregivers have invested so much of themselves in the caregiving role that they are socially isolated and have few support systems to assist them through bereavement." (Bunting-Perry, 106)

This means that an important dynamic through which support should be availed is that between healthcare professionals. The important role that the primary caregiver plays in helping to bring comfort and resolution to the patient in the end-of-life stages must be giving girding by the support of general nurses who come into contact with the patient in the acute care setting. This is especially the case where, as is frequently true, the primary caregiver is also a member of the family of the deceased. Such cases instigate an array of emotional experiences and needs that are complex and widely variable. As discussed above, it is often true that the passing of a loved one who has experienced a protracted illness, who has suffered at length and who has imposed a practical burden on the family will create a sense of relief. This is a natural human experience in which the individual's state of illness has suspended or extended the grieving process, whereas death allows for ultimate confrontation of grief and the beginning of a process of moving on.