A whole-hospital approach? Some staff views of a hospital bereavement care service.

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A Whole-Hospital Approach? Some Staff Views of a Hospital Bereavement Care Service a

b

a

Trish Walsh , Gaye Breslin , Philip Curry , Maeve a

Foreman & Martin McCormack

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School of Social Work and Social Policy, Trinity College , Dublin , Ireland b

Dublin , Ireland

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Social Work Department , Beaumont Hospital , Whitehall , Dublin , Ireland Accepted author version posted online: 31 Jan 2013.Published online: 13 Mar 2013.

To cite this article: Trish Walsh , Gaye Breslin , Philip Curry , Maeve Foreman & Martin McCormack (2013) A Whole-Hospital Approach? Some Staff Views of a Hospital Bereavement Care Service, Death Studies, 37:6, 552-568, DOI: 10.1080/07481187.2012.673532 To link to this article: http://dx.doi.org/10.1080/07481187.2012.673532

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Death Studies, 37: 552–568, 2013 Copyright # Taylor & Francis Group, LLC ISSN: 0748-1187 print=1091-7683 online DOI: 10.1080/07481187.2012.673532

A WHOLE-HOSPITAL APPROACH? SOME STAFF VIEWS OF A HOSPITAL BEREAVEMENT CARE SERVICE TRISH WALSH


School of Social Work and Social Policy, Trinity College, Dublin, Ireland GAYE BRESLIN Dublin, Ireland PHILIP CURRY and MAEVE FOREMAN School of Social Work and Social Policy, Trinity College, Dublin, Ireland MARTIN MCCORMACK Social Work Department, Beaumont Hospital, Whitehall, Dublin, Ireland

A qualitative study was conducted to address staff’s views of bereavement care in a large hospital setting. Two focus-groups and 1 interview were attended by 21 self-selected staff. The qualitative analysis yielded the following: (a) a staff training program within a structured bereavement care service may give staff a sense of confidence and pride in this aspect of their work; (b) a whole-hospital approach to bereavement care may offer an alternative model to individual clinical services; (c) the question is raised as to whether the presence of a bereavement co-ordinator helps contain staff anxiety and other painful emotions generated by contact with the dying and bereaved; and (d) the potential role of ancillary staff in bereavement care warrants more study.

Introduction Despite considerable advances made in our knowledge base on best practice in end-of-life and bereavement care, an increased literature on factors influencing location of death (Fromme et al., 2006; Yun, Received 31 January 2011; accepted 18 January 2012. This article is dedicated to Siobhan O’Driscoll, RIP, founder- member of Bereavement Services, Social Work Department, Beaumont Hospital, Dublin 9, Ireland. Address correspondence to Trish Walsh, School of Social Work and Social Policy, Trinity College, Dublin 2, Ireland. E-mail: [email protected]

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Lim, Choi, & Rhee, 2006; Wilson et al., 2009), clear indications that most patients would prefer death at home or in hospice care (Higginson & Sen-Gupta, 2000; Weafer & Associates Research with TNS MRBI, 2004), a significant proportion of people continue to die in acute hospitals. In the United Kingdom and Ireland, approximately half of all deaths still occur in acute hospitals (Al-Qurainy, Collis, & Feuer, 2009; Irish Hospice Foundation, 2011). As palliative care provision increases, there is a growing interest in hospital-based bereavement services, yet to date their provision has been found to be patchy and minimal in nature (Bodenbach, 2005). For one Irish hospital, the appointment of a half-time dedicated bereavement coordinator resulted in a more systematic service including a significant staff training component. Senior managers made funds available and approved access for a baseline evaluation study (Walsh, Foreman, & Curry, 2007). Findings from the substantive study, a survey of bereaved next-of-kin, have already been reported (Walsh, Foreman, Curry, O’Driscoll, & McCormack, 2008). In this article, the small-scale qualitative element (focused on some hospital staff views) will be outlined and implications considered in the light of methodological limitations. Literature Review It can be argued that a range of professionals have a role to play in bereavement care but no clear direction from research as to whether one professional group should take a lead role or whether a more flexible multidisciplinary team, or a broader ‘‘whole hospital’’ approach, should be indicated. A whole hospital approach to bereavement care is defined as one in which a range of staff (beyond those specifically charged with bereavement care) identify a role for themselves in supporting the bereaved while carrying out their daily tasks. A Hong Kong study found nurses more likely to take responsibility for managing grief than doctors. In the absence of a structured service, bereaved relatives depended on the most accessible ward staff (often nurses) for support (Tse, Wu, Suen, Ko, & Yung, 2006). Yet, respondents did not feel equipped to deal with this task. Tse et al. recommend the ‘‘provision of structured training in grief management . . . for all acute care staff . . . [It] may enhance their initiative by increasing their understanding of


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bereaved people’’ (p. 11). Any profession taking up an exclusively individualized approach (such as the provision of grief counselling alone) may risk creating ‘‘competition among professions for similar roles’’ (p. 519) and ignoring the potential of a whole systems approach to bereavement and loss (Payne, 2009). A broader, social development approach is advocated to develop interventions to ‘‘achieve increased capacity in social networks and professions in dealing effectively with dying and loss’’ (p. 521). The ambivalence of hospital staff as to whether it is their role, or ‘‘the hospital’s’’ to deal with the bereaved has been suggested (Ellinson & Ptacek, 2002). Caring for dying children is a particularly difficult task, evoking feelings of helplessness sometimes resulting in communication difficulties with patients and their families (Papadatou, Martinson, & Chung, 2001; Papadatou, Papazoglou, Bellali, & Petraki, 2002). Staff experience as particularly difficult the sudden death of a young person, or a patient initially improving after an acute illness or operation, or the slow death of chronically ill or brain dead patients (Williams, Harris, Randall, Nichols, & Brown, 2003). Deaths as a result of accidents, cardiac arrests, or trauma can be very distressing for staff, as is giving bad news to relatives where there had been no time to establish rapport prior to death (Browne, O’Mahony, & MacEochaidh, 2005). Junior medical staff report regular exposure to patient deaths and significant uncertainty regarding their role (Ferris, Hallward, Ronan, & Billings, 1998). Many nurses and doctors lack confidence in dealing with the bereaved in a hospital setting (Tse et al., 2006). Healthcare professionals in both pediatric and geriatric services emphasize the importance of the emotional impact of dealing with death (Ulla et al., 2003). Black (2007) suggested that health care professionals who demonstrate avoidant strategies such as ‘‘fright, evasion, or dodging issues that involve death and dying’’ are less likely to collaborate with other professionals (p. 569). A range of studies make similar recommendations: bereavement care coordination in acute hospitals (Bodenbach, 2005), peer support (Papadatou et al., 2002), assistance to sustain staff through multiple losses (Ferris et al., 1998; Holman, 2008), educational programs for hospital staff, particularly those with most direct contact with the dying and bereaved (Papadatou et al., 2001; Ferris et al., 1998; Tse et al., 2006; Ulla et al., 2003), and bereavement debriefing sessions, especially for less experienced



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staff (Rushton et al., 2006). Generally, palliative and oncology healthcare professionals are of the view that contact should be made with bereaved relatives following death but that impediments to such practices existed such as time constraints, institutional factors, and personal barriers (Collins-Tracey et al., 2009). Elements of hospital care for improvement included communication with relatives, training for staff in related areas, improved physical settings, and counselling and support provision from within the hospital (Tse et al., 2006). Family caregivers cite information, privacy, better communication with doctors and nurses, and better symptom control as areas for improvement (Formiga et al., 2007). Communication issues emerge repeatedly both as a source of dissatisfaction for patients and bereaved relatives (Formiga et al., 2007; Payne, Burton, Addington-Hall, & Jones, 2010; Trice & Prigerson, 2009), and as issues between professionals within hospitals (Fineberg & Miller, 2008; Tse et al., 2006; Papadatou et al., 2001; Al-Qurainy et al., 2009). Communication training for healthcare professionals is one specific recommendation for improving end-of-life care in acute hospitals (Al-Qurainy et al., 2009, Wittenberg-Lyles, Goldsmith, & Ragan, 2010). A link is suggested between health professionals’ own experiences of and attitudes toward loss and proactivity in managing advance directives and communication with the dying and bereaved (Black, 2007). Death and loss also has a significant organizational impact (McKeown et al., 2010). Healthcare systems invest heavily in their workforce and increasingly staff care has legal and financial as well as ethical dimensions. Despite the potential for staff to be affected by their exposure to death and dying, the provision of education and supports is not commonplace and where it does exist is often informal, rather than hospital policy (McKeown et al., 2010; Wimpenny et al., 2006). Education and training not only increase levels of comfort in dealing with death (Nucleus Group, 2004; Rushton et al., 2006), but may also protect against the risk of burn-out (Holland & Neimeyer, 2005). The provision of bereavement services may benefit staff as ‘‘knowing that the bereaved are attended to’’ can free staff ‘‘to focus on the immediate needs of others still under their care’’ (Fauri, Ettner, & Kovacs, 1998, p. 62). Most studies surveyed focused on nursing and medical professionals with some reference to the role of social workers,


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chaplains, and psychologists. Only one included ancillary staff such as administrative, telephony, portering, catering, and mortuary staff (Browne et al., 2005) as such staff can be ‘‘ frequently the first point of contact in emergency situations and regularly deal with dying and death-related queries and processes’’ (p. 12) and they report that despite no training or support framework they regularly encountered issues around death and dying. Telephone operators, receptionists, and volunteers are viewed as potential supports as they are likely to have contact with the bereaved at the time of, or after, a loss (Fauri et al., 1998). In this article, we aim to supplement the sparse existing literature by providing initial qualitative data on how the presence of a dedicated bereavement service within an acute hospital appears to impact on staff across clinical and ancillary services. Contextual Factors Beaumont Hospital is a large teaching hospital in inner-city Dublin. It provides national specialisms in neurosurgery, neurology, and renal transplants. With 820 beds (750 at the time of the study), it also has a busy emergency room. The staff complement currently consists of 3,500 workers (Walsh, Winston, & O’Connor, 2010). In a 12-month period, the census of deaths extracted from centralized hospital records showed 934 recorded. The average length of stay was 22.8 days—the shortest was a day and the longest was 601 days; 63.6% of people had spent 15 days or less in hospital and 234 people (25.1%) died within one day of admission. This high percentage (25.1%) is partly due to the presence of a national neurosurgery=brain injury center and a large emergency room. Although actual cause of death was not possible to establish in this limited census, the location of death gives some indication. The majority took place on general wards (564; 60.4%); the emergency room (168; 18%), general and neurosurgical intensive care units (just under 10% each), and the coronary care unit (less than 3%) made up the rest. A total of 75 (12.9%) occurred in the 9–50 year age range; 283 (30.3%) in the range 51–70 years and 493 (over 50%) between 71–90 years. Five hundred thirty-five (57.3%) were men; 399 (42.7%) were women. The average age for men (67.6 years) was significantly lower than that for women (70.8 years). This corresponds with national trends.



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In Ireland, postmortems occur in all cases where death is unexpected, or cause of death unclear. A total of 223 deaths (23.9%) warranted postmortems. For both hospital staff and bereaved kin, circumstances are often more traumatic, cause of death difficult to establish, and funeral arrangements delayed, leading to risk of heightened emotions and distress and a more complicated grief reaction (Clements, DeRanieri, Vigil, & Benasutti, 2004; Currier, Holland, & Neimeyer, 2006; Doka, 1996). Such deaths also create more demands on a range of ancillary hospital staff from administrators, mortuary and patient services, as well as healthcare professionals. A palliative care team was established in this hospital in the 1990s and an appointment of a half-time bereavement care coordinator made in 2001. A conceptual bereavement care model was developed, comprising a tiered pyramid approach straddled information, training, and support for the bereaved, staff, and the wider community (Walsh, Foreman, & Curry, 2007; Walsh, Foreman, Curry, et al., 2008). The annual training program comprises workshops for student social workers and doctors; four half-day workshops for all hospital staff; a one-day training event for nursing staff in the emergency room with inputs from a range of professionals. In addition, employees are encouraged to attend public lectures and memorial services (McCormack, Beaumont Hospital Social Work Department manager, personal communication, 2008). Informed by a strengths-based philosophy, the model is both preventative and holistic. In essence, it aims to cultivate and implement a corporate responsibility and a whole hospital approach to bereavement care which goes beyond the domain of any one occupational group or role-bearer. Method As the main study was primarily focused on feedback from the bereaved in the context of the census of deaths, data from this qualitative element relating to staff views and needs must be considered secondary and partial. An open invitation to participate in focus groups was issued to all hospital staff and one semistructured interview with a key informant involved with patient complaints conducted. Twenty staff opted in, comprising a range of 8 healthcare professionals (nursing, palliative care, chaplaincy) and 12 ancillary=administrative grades (transplant coordinators; patient


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services [complaints]; telephony, mortuary, clerical, and administrative staff). Two frontline groups are conspicuously absent: physicians and social workers. In the case of the former, none were available to attend. In the case of social workers, they were excluded due to their role in service delivery. In retrospect, dedicated focus groups for both groups would have greatly enhanced the study. The fieldwork was conducted by two experienced researchers— academics from a local university—taped and transcribed. Care was taken to ensure all participants had an opportunity to make their own contributions and a neutrality maintained regarding positive and negative feedback. Analysis of the transcripts used axial coding (Krueger, 1998) to highlight recurring ideas and themes, supplemented by observational and debriefing notes. Two researchers analyzed independently and then amalgamated common themes. Results Perceived Improvements and Deficits in Care Most participants thought services had improved tremendously over the previous decade. Various opinions were expressed as to whether this was attributable to external drivers (specified as changed public expectations, public debates about the care of the dying, increased publicity about and promotion of hospice and palliative care services, organ retention scandals, and the work of patient advocacy groups) or internal drivers (specified as the establishment of the palliative team, management-led initiatives to change practices such as ‘‘belongings bags,’’ an increase in patient satisfaction research, and the creation of new organ retention and transplant services). The work of the palliative team was singled out as the most important driver for change yet limitations were also expressed regarding the unique challenges posed by sudden or unexpected death. Palliative care was seen to work for expected deaths, whereas ‘‘an acute death like that- it doesn’t matter where it happened whether in hospital or at home, at mass or in the shopping centre but an acute death like that, that’s always going to be shocking and distressing . . . afterwards, that’s where [bereavement care] is important (manager).’’ Improved practices were contrasted by a couple of staff (who were in positions to hold


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an overview throughout the hospital) with continued negative practices on some wards:


I’ve probably worked on about 10 or 12 different wards. It [care of the dying] depends sometimes on who is in charge of the ward . . . .I’ve seen wards where it is not so sensitively handled, where the dying person is simply curtained off and life goes on around them, there’s no privacy. It depends on who is in charge.’’ (administrator)

Services such as oncology, neurosurgery, and neuropediatrics were perceived to have adapted practices most and to have successfully created dedicated facilities such as relatives’ rooms. Emergency room personnel were seen to have developed an expertise in dealing with traumatic deaths and distressed next-ofkin. Against this, general surgical and medical wards were thought by focus-group participants to be less familiar with the dying patient and hence less practiced in their approach. Interestingly, this perception is not borne out by the census figures, which identified general wards as being by far the most common location of death with 60.4% of deaths in one year. Yet the absence of any nursing staff from general wards at the focus groups meant that this remained an unexplored topic and an area for detailed exploration in future studies. Identified service improvements include facilitation offered by patient services out of office hours, the resolution of difficulties in tandem with the bereavement coordinator or other social workers, improved procedures and communication with families around organ retention and coroner’s cases, improved facilities in the mortuary and mortuary care, and follow-through from surveys of satisfaction (e.g., the implementation of a policy of family-centered care for patients in the neurosurgery intensive care unit). In contrast, in our survey of bereaved next-of-kin (Walsh, Foreman, & Curry, 2007), some 52% (168) of respondents thought care received had been excellent with no necessary improvements cited, and a further 28.2% (91) though it was good but could be improved. The four most frequently cited areas for improvement in hospital care were (a) information=communication (25.2% of respondents; 56), (b) privacy for patient and family at time of death (20.7%; 46), (c) difficulties in Emergency Room conditions (15.8%; 35), and (d) problems with staff, both individual and collective


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(13.1%; 29). In the staff focus groups, the physical problems most cited were lack of privacy for the bereaved following a death, unavailability of refreshments out of hours, and punitive car parking charges. Car parking availability and charges were especially an issue around the mortuary and for the patient complaints section: ‘‘We’ve had a number of complaints [about car parking availability and charges]’’ (patient services). Interestingly, although a number of next-of-kin complained about the lack of privacy and poor physical facilities, only a handful specified car-parking charges as a specific issue. Rather, families focused more on relational and communication issues. Staff in the focus-groups also repeatedly returned to communication. When asked to name the most important things that a hospital could do for bereaved relatives, one replied: ‘‘We should provide them with gentle support. A means to get information around care which is not always forthcoming . . . A lack of information leads to huge distress, especially a lack of information from the medical staff—they need to be trained in understanding the needs of bereaved relatives’’ (manager). There were concerns that the bereaved were still on occasions given wrong information: I’d get patients’ families who have samples in pathology . . . they’d be looking for results from an autopsy to get a death cert. And they . . . were told to contact us and we wouldn’t be able to release [information] if it was a coroner’s case until after the autopsy. As soon as you mention that you are not able to release it, they become very panicked . . . Generally it is just incorrect information that has been passed along. And I think that is an area that really should be changed. (administrative staff)

Issues of miscommunication were the primary source of complaints to the hospital: ‘‘Normally, communication [is the main source of complaint]. Very often the complaints are about misunderstanding or upsetting—they just cannot hear what is happening because they are so overwhelmed’’ (patient services). Despite some negative allusions to physicians as the primary culprits in matters of miscommunication, communication was also viewed as a team responsibility: Teamwork is huge, I think that’s where we’re coming from . . . you might have the best of chaplaincy service, the best palliative care, the best


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nursing staff, and then because of lack of knowledge, a lack of communication, we don’t get the Garda identification done in a Coroner’s case, and all of a sudden, all that good work is just wiped because people will have a bad taste in their mouths. They will remember the bad things that were traumatic. Personally I think teamwork, and that includes getting the family involved in the team as well, everybody openly communicating, and if they don’t know something ringing around to find out. (organ transplant coordinator)


Perceived Impact of Bereavement Care Coordination Although the consensus was that the coordinator was effective in both raising staff awareness around bereavement issues and in developing a whole hospital commitment through training and information dissemination, some participants were not aware of the extent of bereavement services offered or how to access them. Those with least correct information and awareness were in administrative posts. There was some confusion regarding the extent and timing of various interventions, with some staff (working at some distance from the wards) of the view that contact was made 6 months after death (and not 10 weeks). From those based on the wards, examples were given of how supportive they found the presence of the service: I didn’t know how to go about it, but I got a phone call from a guy whose wife died last autumn, she was . . . very young. He [did an event] to fundraise . . . and raised a vast sum . . . He kept saying that he was fine [after her death]. He arrived at my desk one day, sweating, distressed, I thought he was going to have a heart attack, and I phoned the social worker and she came and saw him and got him sorted. His wife was dead 10 or 11 weeks at that stage. Within 24 hours of his arriving, he was seen. (nurse specialist)

More explicitly experienced:

articulated

was

a

sense

of

containment

The difference is that it is now more formalised, that I know who to go to. I can pick up the phone and . . . say: Look, somebody needs to see [the bereavement co-ordinator]. And because we know now that there are set services, that there are set groups, we can say that to the client . . . If you are dealing with somebody who is going through a trauma and they are really angry and upset, you might say to them that they really need to mind themselves, and we’ll do that today. But

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tomorrow you need to have to look after yourself, and I know in my head that there is a lot of support there. That’s great for me as well. That I’m not kind of [worrying] about—what am I going to do with her? (patient services)


The Perceived Role for Staff in Bereavement Support Three participants had recent (within 2 years) personal bereavement experiences, two of which related to deaths within this specific hospital. These experiences appeared important in shaping their sensitivity toward the bereaved (and may indeed have been a factor in their choice to attend the focus-group). In the transcripts it became evident that in relation to specific issues such as conditions within the mortuary and the return of personal belongings, they explicitly relayed salient personal experiences. The need for support around the impact of traumatic or sudden death was described. Some had experience of critical incident debriefing after particularly traumatic cases (such as multiple murders), but this was not widespread. The general consensus was that staff did receive adequate support when suffering personal bereavements with a staff counselor available, as well as the general bereavement service. In general, this self-selected group had a sense of participation and pride in the hospital’s bereavement care services: Beaumont in general is very well established when it comes to the care of the dying patient . . . Once the decision has been made that the patient is dying . . . everybody comes on board and they really do their utmost to look after the family and the patient and it’s not always ideal but hospital is not an ideal place to die anyhow. (nurse, emphasis in original)

For ancillary staff, one example demonstrates what this meant in practice: On the switch we would get quite a lot of calls in, they’d be crying and ringing just to say thank you. I remember two years ago, a woman rang in [whose child had died in the hospital] and she asked me if I would go down and get the words [of a poem on a memorial in the hospital], and I took her number and phoned her back later that day with it. It meant so much to her, she said, because she had spent so much time when her child was dying going past that memorial’ (telephony).


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This example resonates with existing literature on the potential role of ancillary staff (Browne et al., 2005; Fauri et al., 2000).


A ‘‘Whole-Hospital’’ Approach? A hospital philosophy of care centered around the dual concepts of respect and dignity was referred to by several participants. The role of management in taking a proactive role in developing bereavement care services was identified as different (from other hospitals) by those who had worked in several locations. Related to this, several talked of how work behind the scenes coordinating and communicating across the hospital was an important part of making sure the whole system worked: Because the system has been ironed out and now we have a clear line of how we follow things . . . we are protecting families from the upset they used to go through. And I think that has to be highlighted, it’s very important. It’s not just how a person talks to them [bereaved] on the ward. It’s everything that happens behind the scenes as well to make everything easier. Because if it works well behind the scenes, then the nurse or the doctor that’s talking to the family directly aren’t getting the backlash for something over which they have no control. (nurse)

The benefit of a whole hospital approach to bereavement care was described thus: If they [staff] deal with a situation in a way that you are more positive and feel more comfortable about the bereavement side—then the patient benefits . . . And there is that knock-on [benefit] for staff as well . . . very often if I can say [in a bereavement situation], they are bereaved—they didn’t hear what you said, they were upset at the time etc . . . if you can get them to understand just a little bit more how these people are feeling. We’re not all rational human beings when some terrible tragedy happens. (patient services)

Discussion Limitations of the Study The findings reported here derive from a small-scale qualitative element of a larger-scale evaluation study. It involves feedback from a total of 21 staff members who self-selected into the

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focus-groups. It is reasonable to presume that those that were motivated to take part in the focus-groups were more likely to have a particular interest in this area of work and this may result in a positive response set bias. Therefore the findings cannot be considered to be representative of the hospital staff as a whole. Rather the issues raised and discussed are illustrative of themes arising in bereavement care in acute hospitals, staff support and training in bereavement work, and the role of a bereavement care coordinator in supporting staff as well as the bereaved. Summary These focus groups feature a range of ancillary staff whose views and experiences are underreported to date. The annual program of staff training within a structured bereavement service and improvements in infrastructure such as mortuary services appeared to give these (self-selecting) participants a sense of confidence and pride in this aspect of their work. There is a suggestion from the data that the existence of a structured service and bereavement coordinator may help contain anxiety generated by contact with the dying and bereaved, for some staff. This possibility warrants further study. Overall, although it cannot be claimed to represent staff as a whole, this preliminary study suggests that a whole-hospital philosophy of bereavement care (straddling staff across different levels and grades) is not an unrealistic goal. Firstly, staff across a range of disciplines and sites in a hospital can feel a great commitment to this area of work and consider it within their remit to do what they can to help the bereaved if they feel supported in doing so. This finding is also replicated in a subsequent national audit of 1,000 deaths in Irish hospitals (McKeown et al., 2010), which concluded that hospital staff can be ‘‘supported through training and development to ensure they are competent and compassionate in carrying out their roles in end-of-life care’’ (p. 25). The potential role of ancillary staff in bereavement care needs further research related to a more in-depth needs assessment. Secondly, staff who attended these focus-groups displayed a strong congruity with bereaved next-ofkin in their identification of shortcomings and areas for improvement within the hospital system. Both groups highlighted issues of communication as central followed by the importance of the



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physical environment in either compromising or facilitating privacy at the time of death, basic care facilities such as the availability of refreshments, and the particular challenges posed by sudden or unexpected deaths, as well as the circumstances of death in emergency rooms. Thirdly, the process of bereavement service development was achieved without resort to professional silos; in other words, although the social work department took a lead role in service development, they were not seen to have an exclusive role. This aspect is tremendously important if a whole hospital approach to bereavement care is to be promoted. Coordination may be the key term here as it denotes a bringing together of disparate parts of a service rather than a claim of specialism and possible exclusion that terms such as specialist bereavement worker (or clinical specialist) can denote. Conclusions That a range of staff in this hospital feel a responsibility for being aware of, and catering to, the needs of the bereaved is in itself positive. Staff in the focus groups generally portrayed a high level of confidence in their ability to relate to the bereaved but they may be atypical of the whole staff group. They spontaneously identified many of the same issues of concern as did bereaved respondents. This degree of congruence is heartening as it suggests that hospital staff can be accurately perceptive to the needs of the bereaved and have a role to play in identifying and correcting problem areas and practices. A pragmatic tone was expressed by many relating to the core functions of an acute hospital and the need for end-oflife care to be balanced with the continuing needs of ill patients and their families. This study suggests that some staff positively rate annual programs of training activities, memorial services, and public lectures. The role that ancillary staff may have in a whole-hospital approach to bereavement care, the impact of exposure to death on such staff and a more detailed assessment of their training and support needs appears warranted. Finally, we wonder if the actual presence of a dedicated bereavement co-ordinator bolsters other hospital staff’s (beyond that of healthcare professional grades) level of comfort in interactions with the dying and bereaved, and helps contain what might otherwise be experienced as stressful psychological anxiety?

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