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care, whether they feel adept to deliver the care, and if a stand-
to its importance and improved confidence toward its delivery.
ard of provision needs to be established.
KEY WORDS
w bereavement w palliative care w education w interview
Design
Bereavement is a unique and individual experience. In
w qualitative research
order to allow both the participant and researcher to
explore further into the questions (Table1) and create an Data collection
in-depth account of their experiences, the qualitative para- A semi-structured interview style was chosen for data collec-
digm was the chosen methodology. The approach was of tion. This is considered a dominant form of data collection
a phenomenological stance that analyses peoples percep- within a qualitative study (Braun and Clarke, 2013), although
tions or meanings, attitudes, beliefs, feelings, and emotions unstructured interviews are exploratory and set to gain an
(Denscombe, 2014). in-depth point of view from the participant without much
influence from the researcher/interviewer (Ellis, 2013). Semi-
Sample structured interviews provide participants the scope to raise
Purposive sampling was used to identify five nurses with their own questions and explore further into the discussion,
a district or community nursing background. The inclu- while the researcher still maintains control of the interview
sion criteria consisted of significant prior knowledge and (Bowling, 2014; Parahoo, 2014). This method was the most
experience of the subject, which would allow a thorough appropriate to gain a thorough account of the participants
account of their experiences. Age and gender were not experiences, as it also allowed them to feel free to discuss
a factor; however, the participants needed to have over related issues. As the topic of bereavement is of a sensitive and
2years experience of community nursing, as more experi- personal nature, freedom to discuss was paramount to this
enced nurses would have undertaken some palliative nurs- research. The questions focused on the topic and the style
ing. The sample size was deliberately kept small, owing to accommodated any new evidence of forgotten knowledge
the volume of data that would need to be transcribed, and to emerge. An expansion of the participants views on their
because a large sample size within a qualitative study could provision of bereavement care was sought, and any barriers
lead to repetition of data (Parahoo, 2014). According to they may have perceived orencountered.
Denscombe (2014), specific people or events deliberately
selected (purposive sampling) are seen as instances that are Data analysis
likely to produce the most data. The determinant was to Verbatim transcription was carried out to ensure thorough
acknowledge whether district and community nurses had analysis and error from loss of data. Analysis of a phenomeno-
sufficient skills and knowledge to provide effective bereave- logical study is usually thematic in nature and placed together
ment care and explanations for their responses to the pro- to create an essence of the phenomena (Burnard et al, 2008;
posed questions (Table1). Parahoo, 2014). Hence, thematic analysis was used.This involved
identifying patterns/trends within the data and linking them
Ethics as representative of the same phenomena, which can occur
Ethical approval was sought from the University of Chester several times (Gibbs, 2010).Transcription and interpretation of
and the authors previous NHS employment. A complete data were made easy by the use of themes rather than question
description of the research and objectives was sent to each numbers. Not all transcripts stated the same theme, but made
participant, enabling them to make an informed choice. All reference to it; therefore, relationships between themes were
participants signed a consent form to take part in this study identified and categorised accordingly. Looking for missing
and have their interview recorded.Anonymity was maintained data or hidden meanings is another process of thematic analysis,
throughout the research, and no participating nurse will be as what you might expect to be there may be of significance
identified within this article. even if it is not talked about (Gibbs, 2010).
2 Do you feel that you have had enough, if any, training in providing bereavement counselling? (If yes, what? If no, do
you think you should?)
3 Do you think it is part of your role? If not, whose role do you think it should be?
5 How long in your opinion should the district nurse provide bereavement counselling for?
10 Do you think having personal bereavement helps with undertaking bereavement care?
Each transcript was analysed and compared to extract any for the nurse to detach from certain families if they have been
form of meaning or common theme. This lengthy process on the caseload for a long period of time; closeness and con-
involved listening to the audio recording throughout the proc- nection invariably develops. When children and young fami-
ess and using any notes made to interpret any occurrences. lies are involved, some participants found it especially difficult
Complete immersion of data was required and all common to not get too involved, as emotions take over and sometimes
themes were generated once data saturation was reached. they get dragged into family disputes. Conversely, it is easier
to be detached if the patient and family have not been known
Findings for a long period, but this can affect the level and support of
Several drafts of themes and sub-themes materialised and bereavement care.
were merged; these were consolidated and contextualised
Palliative care can be up to one year you develop
(Table2). Each sub-theme was incorporated under a main that closeness and continue BC [bereavement care]
theme and related to excerpts from the data.The findings from I suppose its still a connection to their dead
themes1and 2 appeared to merge as they produced similar relative however if youve only known them for
answers, as theme 1 was also dependent on theme 2. a short time its easier not to get attached. [P3,Q5]
Main themes Building up relationships, getting to know the
patient you then have that rapport to automatically
Time management give BC providing the family with that network
All participants experienced bereavement care to be time of support. [P3, Q3]
consuming, requiring lengthy visits, with limited time or
capacity for it to be an ongoing process. All participants high- You have to be careful not to get too involved as it
lighted the relevance of providing bereavement care, but felt could affect you and you could end up grieving for
the need to pass it over to a suitably qualified or experienced every lost patient. [P4, Q10]
professional when they needed more help. The bereavement
care was also done on an individual basis and not all required It doesnt help when you see people at the very end
follow-upvisits. you havent got that connection you have to
You have to know when to stop and pass on to
other services ... bereavement can go on for years, I
Table 2. Final themes and sub-themes derived
wouldnt be able to offer what a bereavement coun- from the interviews
sellor could it becomes out of our capabilities.
[Participant 5, Question 3] Number Main theme Sub-theme
Once the patient dies some [the family] dont want 1 Time management Time consuming/long periods
to know others want you there all the time Capacity/caseload/balance
you may think its not needed, but they do its
about getting the balance right for both . we dont Follow-up call (phone/visit)
have enough time to keep attending we have 2 Case specific/ Relationships/involvement
other patients to see and a large caseload.We dont attachment
have the capacity to continue a high level of sup- Attitudes/approach
port. [P1, Q5]
Individual assessments
Some want you all the time we do 1 post Younger families
bereavement visit, its rare to do anymore after
we dont have the luxury to spend time with the 3 Interprofessional Increased awareness
patient its horrible to feel you are rushing some- working
Guidelines (Department of Health, National
one you know you have other patients to see. Institute for Health and Care Excellence, or
[P3, Q5] NHSTrust)
British Journal of Community Nursing October 2015 Vol 20, No 10 497
PALLIATIVE CARE
know a bit about the patient first in order to provide underqualified and lacked the expertise to provide long-
efficient care cant always work to the best term bereavement care. Acknowledgment of support from
interests of the patient and family. [P2, Q3] other services and policy drivers was made. Communication
between other services, such as Macmillan and GPs, increased
One participant became quite emotional during the inter- awareness toward bereavement care.
view, on recalling the time they got too close to a patient.
When you feel they are getting too reliant you
I became too involved and too close one time when have to know the services in your area you get
a lady asked me directly:Am I going to die?... it info from a death and dying booklet that we should
was a big responsibility, she could then get on and be giving to patients to help prepare them.
organise her life. [P1, Q9] [P1, Q6]
Continuity of care from the same community/district nurses We know who to ring GSF [Gold Standards
attending the patient and family/carers established trust early Framework] meetings we get a lot of info and liaise
on; this helped toward building a professional relationship and with other services improves professional rela-
identifying early complications. Families can also get very tionships shared care team work. [P3, Q7]
attached to the nurse, which is not healthy as it could stop
them from moving on because the nurse can be a constant More structured now lot of interlinking of serv-
reminder of the difficult time they experienced. ices GP, MN [Macmillan Nurse], etc. a lot
of communication and referring work as a team.
Usually the same face/DN [district nurse] going [P5, Q7]
in to build up that rapport patients can get too
attached to you which is not healthy cant get
on with everyone reassurance from the same DN
as they will be able to notice a difference. [P4, Q5] Role/scope
All participants considered bereavement care to be part of
Depends upon the individual of when to stop their role and concomitant with palliative care.The provision
discussion between the DN and family some- can become challenging, exhaustive, and draining, especially
times they request you not to go in as you are a if it is over a long period of time.
reminder. [P1, Q5] I wouldnt say its not our role we do bereave-
ment support however, bereavement can go on for
As long as they need it however too much can years I wouldnt be able to offer what a counsel-
be detrimental to the family if they become too lor could out of our capabilities. [P5, Q3]
attached you know they need more professional
help. [P5, Q5] It is our role but we may need support ourselves
cant be there all the time to know when we
Providing bereavement care is determined on individ- are out of our depth and to stop! [P4,Q3]
ual need; at times, how much to provide and commencing
and ceasing the support can become problematic. Also, the We are counsellors of such but you have to know
approach and attitude toward the dying patient and family can quite a bit about them, if you dont it cant always
have a detrimental effect. work efficiently just going in and caring is start
of counselling. [P2, Q3]
BC should start as soon as someone has a terminal
illness/going to die. [P3, Q4]
A lot of training through the years I have beneficial for community nurses as well as the family, as the
enough skills and experience to continue care community nurse may also experience bereavement, espe-
attended study days it doesnt make you an cially if the palliative phase has been over a long period and
expert. [P5, Q1 and Q2] relationships developed. Closure is then needed. In contrast,
Lyttle (2005) stated that getting too attached or involved could
I have enough knowledge to recognise signs of become problematic and cause the district nurse to experi-
bereavement training gives you basics of what ence burnout.
to recognise doesnt always prepare you for every Participants also expressed that knowing the family and
eventuality. [P2, Q2] building a rapport with them would help in the identifica-
tion of any problems should they arise. If the palliative phase is
Yes, but you have to be detached, otherwise you
short, then the connection is not made and complications may
may find yourself experiencing bereavement in some
not always be recognised. When the family gets used to the
way not good as you have to be professional.
same nurse visiting, for reassurance they become more recep-
[P3, Q10]
tive; relatives can also get too attached, which is not healthy.
Having a personal bereavement makes you more The family also needs to recognise that the nurse is there for
empathetic, you have compassion instinctively. the dying patient, and not just for relatives and carers (Mallon,
[P2,Q10] 2008). According to some participants, sometimes relatives
have to be left to their own devices or referred on, especially
Definitely you empathise more and understand if both parties are getting too involved; otherwise, they would
what they are going through. [P1, Q10] end up grieving for every lost patient.
Increased awareness of other roles and specialities involved
in palliative and bereavement care came from experience and
Discussion awareness of whats available within their area of work. The
This study explored the perceptions of five community/dis- knowledge of other services and supporters were known to
trict nurses providing bereavement care. The purpose of this all participants, but it was evident that the district nurse was
study was not to generalise the findings, but to increase aware- the one who was mainly involved, as other services, such as
ness to other district nursing groups. In particular, reflect- Macmillan nurses and GPs, tended to step back once the
ing the findings of previous research (Wimpenny et al, 2006; community/district became involved. All the participants
Smith and Porock, 2009) highlighting the importance of pre- stated they did not feel qualified or have the expertise to
bereavement care and how it can improve recovery and reduce carry out long-term bereavement care; hence, they would
the need for follow-up support after death. refer the families/carers on to a support group or special-
All participants considered bereavement care to be time ist counsellor, as soon as possible, thus reducing pressure
consuming and stressful when undertaken as follow-up visits andstressors.
and scheduling them into their workload, but not so when Regular meetings, multidisciplinary teams, and implement-
performed in conjunction with the palliative care visit. This ing the Gold Standards Framework (GSF) in the authors and
was congruent with previous research findings about the participants workplace created greater awareness of pallia-
added pressures and stresses district and comminity nurses face tive patients,. This encouraged joint working practices and
when providing palliative care (Walshe and Luker, 2010).Time increased support for patients and relatives. Identification of
constraints and workload pressures influenced attitudes toward any problems were thus shared between services. Burt et al
palliative care in the home, owing to extra time having to be (2005) found that strong communication skills between serv-
spent against the time with a more generalist caseload (Smith ices led to improved quality of care and effective coordination
and Porock, 2009;Walshe and Luker, 2010). It also strained the of work. Following a distance-learning, practice-based training
transition from palliative care to routine areas of care (Burt et programme called Going for Gold into the foundation level
al, 2005); moreover, having a heavy workload can impinge on of GSF, seven GP practices demonstrated success in several
a second visit (Brownhill et al, 2013). areas, including improved carer assessment and bereavement
Getting the balance right was another concern raised. It care (Office for National Statistics, 2012). The training pro-
is very challenging, but it has to be right for both the nurse gramme also included practice updates and helped the GP
and patient/relative, and it becomes a huge responsibility as practices meet national policy targets.
the relative can see you as a constant reminder of the patient. All participants considered bereavement care to be part
Brownhill et al (2013) also found that families forever associate of their role, but felt that it was out of their capability and
the nurse with their deceased relative. expertise when it was over a long period of time. All had
This study found that it was rare to do more than one some degree of trainingstudy days and on-the-job expe-
2015 MA Healthcare Ltd
bereavement visit; sometimes only a phone call is required, rience in bereavement care. One participant assumed that
as the relatives request you not to go in. However, some stages of bereavement are experienced after the death; there-
participants found it difficult when young family members fore, the community/district nurse would not witness any of
are involved, and they could not help but get too attached. it. However, according to Mallon (2008) and Kbler-Ross
Emotions then took over, and subsequent visits occurred. (2014), the stages of bereavement can be experienced pre-
Chang et al (2012) found that follow-up visits can be both death as well as during the dying phase. This participants
British Journal of Community Nursing October 2015 Vol 20, No 10 499
PALLIATIVE CARE
assumption could be down to a lack of experience in pallia- period with an alternate phrase of questioning, this shortcom-
tive care and the theoretical underpinnings. ing may be avoided.
What was apparent from the findings is that bereavement This research was guided by the literature review and
theory, that is, knowing the stages and types, helps with the undertaken because of a lack of previous study into this area;
background of bereavement care and frameworks help with therefore, the comparisons were limited.The sample size was
the delivery of effective care. This can determine what the small and contained within one geographical area, which was
bereft need, whom they need support from, and to what also the researchers place of work. This could have poten-
degree. Training was stated to be ongoing, as it constantly tially influenced the transcribing and findings.The author has
changes in addition to new experiences; therefore, the nurse attempted to be clear on the professional relationship they had
must adapt and access the resources to obtain new knowledge. with the participants and exclusion of any personal views, in
It is not the case for all community/district nurses to receive order for the reader to be aware of any potential inherent bias.
training in bereavement care, as Momen et al (2012) found
that both GPs and community/district nurses received educa- Conclusion
tion and training in end-of-life care, but with the exception Bereavement care is an important aspect of palliative care;
of bereavement care. however, it is not as great as other parts of the community/
Having empathy and an interest in bereavement care district nursing role. This was evident in the limited time the
helps with the support given. Participants who experi- participants stated they spent on its provision. Breavement
enced a personal bereavement stated it does help toward care can be unpredictable and complex for the district nurse,
the care, as it makes you more empathetic; however, you be it a swift or long process, resulting in continuous adjust-
have to be careful not to make it about yourself and should ment of the caseload to compensate for changes. It would be
remain detached. Lyttle (2006) concurs it can be seen as beneficial to have clarity into the scope for the community/
an advantage when delivering bereavement care. However, district nurse with regard to bereavement care provision.The
experiencing a personal loss can be problematic for com- author accepts that this clarity in itself is difficult, as each situ-
munity/district nurses as they may find they have little ation has an inherent level of ambiguity with regard to when
time for themselves and others, as a result of becoming too bereavement care not so much begins, but when it should end.
involved (Lyttle, 2005). One participant discussed experi- No definitive answer surfaced to a standardised approach
encing a personal recent bereavement as being a factor to or the number of post-bereavement visits/phone calls needed
not undertake any palliative care on returning to work. from the community/district nurse, as its based on individual
Performing bereavement care could become overwhelm- need and assessment. Bereavement care could be ongoing, or
ing and hinder them from doing the job effectively, as they not commence at all, as it can start as soon as the palliative
would be constantly reminded of their own bereavement. phase begins or according to the patients/relatives receptive-
They could return to this role when they feel ready and ness toward it.
have a good support network. Education at both pre- and Training and knowledge into the theory of bereavement
post-registration would help identify any personal issues of care were thought to be helpful in recognising the signs and
grief (Nagraj and Barclay, 2011). types of bereavement, in order to determine the approach to
effective care delivery. It could also assist in reducing the risks
Limitations associated with bereavement, prompting the district nurse to
The use of a single method of data collection and one seek assistance or refer to appropriate specialist services.
researcher meant there was no triangulation, and the data All the identified themes were interlinked, as experience
were subjective in nature.The interpretation was exclusively teaches you to become detached and how to deal with dif-
the researchers, although every effort was made to reduce ficult situations. It enhances capabilities and knowledge of
bias.The style and wording of the questions may have inad- other specialities. Confidence and exposure increases aware-
vertently suggested the themes as they could be interpreted ness and improves delivery of care and develops professional
as leading the participants to answer in a pre-determined relationships with patients and members of the multidisci-
manner. There is a risk that this research could have been plinary team. BJCN
lead in a direction associated with the researchers personal
view. However, this method and questioning was intentional, Accepted for publication: 22 September 2015
to address any gaps in knowledge identified in the literature
review carried out by Johnson (2015). A comparable analysis Declaration of interest: The author has no conflicts of interest
was thus easier to conduct. In addition, as certain themes may todeclare.
have been pre-suggestive, a grounded theory approach using
inductive and deductive reasoning may have produced more Note:A literature review on the subject of bereavement care and sup-
2015 MA Healthcare Ltd
substantial results, thus allowing a multidimensional view of port, written by the same author and published earlier this year, can be
the phenomena (Parahoo, 2014). found here: http://dx.doi.org/10.12968/bjcn.2015.20.6.272.
Questions 1 and 2 (Table1) produced similar answers.They
were therefore combined within the findings. This may have Bereavement Services Association and National End of Life Care Programme
(2011) When a person dies: guidance for professionals on developing
suppressed additional themes from emerging from the data. bereavement services. http://bsauk.org/uploads/834766631.pdf (accessed
However, if a similar study was to be conducted over a longer 22 September 2015)
Fundamental Aspects of
Palliative Care Nursing 2nd edition About the book
All nurses are intimately involved
student nurses it is widely recogni
towards their particular needs
in caring for the dying and bereave
sed as one of the most challeng
d at some point in their career
ing aspects of their role. This book
and for
Fundamental Aspects of
and the difficulties that student is centred
nurses face when confronted
2nd edition
the reader
Clinical anecdotes to illustrat
Links to appropriate clauses
Reflective activities and points
e the reality of practice
for professional development
Links to appropriate clauses
It contains important material on a wide Internet resources of the NMC Code of
of the current 2008 NMC Code
of Professional Conduct
Self assessment tests at the Robert Becker
range of initiatives that are impacting A palliative care quiz to test ProfessionalConduct
end of each chapter to consoli
your knowledge
date learning
ISBN 1-85642-394-8
9 781856 423946
Fundamental Aspects of Nurs
www.quaybooks.co.uk
ing series
Order your copies by visiting or call our Hotline
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British Journal of Community Nursing October 2015 Vol 20, No 10 501
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