Welcome and Housekeeping

2. H&S No Smoking Loos Mobile Phones Breaks & refreshments Welcome and Housekeeping

3. Programme for the day Informal & interactive Range of teaching methods Some small group work Regular breaks throughout the day BYO lunch Evaluation End by 4.15 pm!

4. Ground Rules Shared learning experience – respecting each other’s opinions Confidentiality Listening / ‘One at a time’ Time keeping Looking after yourself Ok to have fun!

5. Learning Objectives & Outcomes By the end of this session you will: Understand how grief and loss impacts on people’s lives Understand & feel more confident about the role you can take in providing appropriate & timely levels of support and information to family and friends Be aware of the range and types of bereavement support services and information available locally and nationally Understand the impact and importance of looking after yourself when involved in end of life care

6. Individual introductions and expectations of the day Your name Your role at work One thing you’re hoping to get out of the day

7. Facts & Figures 54% of all complaints in the NHS relate to end of life care and bereavement (Healthcare commission 2007). Approximately 6,000 deaths occur in Gloucestershire each year (Cruse, 2008). 2-8 people will be affected by each death. Bereavement support needs vary significantly. With support and information most people(80-90%) cope well following the death of someone significant in their life (NICE, 2004). In addition to the support provided by family and friends bereaved people benefit from the support and information provided by health and social care practitioners.

8. Jargon? Slang? Euphemisms? Humour? Language & Terminology

9. Language & Terminology Bereavement Grief Mourning

10. BEREAVEMENT The state of having suffered a loss; either physical (e.g. through death) or psychological (e.g. loss of status)

11. GRIEF A universal, natural response to loss typically manifested and expressed through thoughts, feelings and behaviours.

12. MOURNING The social, public and culturally influenced experience of sharing grief through the process of rituals and customs such as attending funerals & memorials, wearing mourning clothes, reading scriptures & praying

13. Who, Where & When we meet bereaved adults at work? Who? Family & Friends of deceased Fellow Residents / Patients /Clients Staff /Colleagues You

14. Who, Where & When we meet bereaved adults? Where? At home Hospital wards Care Homes Nursing Homes GP Surgery / receptions Hospices / receptions Funerals Local community

15. Who, Where & When we meet bereaved adults? When? First few hours First few days First few weeks First few months First few years Many years later…..

16. Types of support? Information Practical Emotional Cultural Spiritual Specialist

17. Personal reflections & attitudes Small group work

18. Take a break Time for coffee!

19. Common reactions to death & loss Small group work

20. Theories & Models of Grief Theories & models of grief attempt to explain how, when & why grief happens and provide a framework from which helping strategies can be developed

21. Worden’s Tasks of Mourning (1989) To accept the reality of loss To experience and work through the pain of grief To adjust to an environment in which the dead person is missing To withdraw emotional energy and reinvest in new relationships

22. Factors influencing grief Quality & type of relationship with person who has died How, when & where death occurred (e.g. sudden or unexpected, traumatic or peaceful) Age, gender & level of understanding Previous experience of loss

23. Factors influencing grief (cont) Cultural and religious beliefs & influences Involvement in mourning rituals (e.g. attending or not attending the funeral) Support network & coping strategies Other concurrent stressors

24. Talking to the bereaved:Barriers to offering support? Four key barriers to communication/support: You – e.g. role and responsibility, your own personal issues, fear of showing own emotions, saying the wrong thing & confidence in dealing with emotional/difficult responses. The bereaved person - e.g. fear of breaking down in front of a health or care professional and/or not believing staff will have the time to listen. Environment - e.g. workplace culture, role & responsibility, time and place. Cultural – e.g. inadequate command of each other’s language and lack of understanding of cultural differences

25. Talking to the bereaved Helpful & Unhelpful Comments?

26. Unhelpful comments… ‘I know exactly how you’re feeling’ ‘Time’s a great healer’ ‘It’s a blessing in disguise’ ‘At least he/she got to live to be that age’ ‘Oh well, you’re young enough to have another child’

27. Other unhelpful responses… Other unhelpful responses can include: People not mentioning / acknowledging what has happened People crossing the road to avoid speaking People overwhelming you with their experiences of loss Being told not to cry Being told to get on with life Being told to cheer up Being expected to be back to normal after a couple of months

28. More helpful comments and responses… ‘I’m sorry to hear about the death of your mother’. ‘I can’t imagine how you are feeling’. Allowing someone the space and time to be listened to Just being alongside / silence when appropriate

29. Starting conversations Small group work

30. Take a break Time for Lunch!

31. Dealing with emotional responses: Small group work

32. Recognising Complicated Grief Complicated grief is a form of grief characterised by intense longing and yearning for the person who has died, with recurrent intrusive & distressing thoughts & feelings that make it difficult to move beyond the acute state of mourning and inability to form other relationships or engage in potentially rewarding activities (Boener & Schulz 2009)

33. Case study : 6months after bereavement Inability to function at work /everyday life Emotionally detached from significant others/concerns about parenting Excessive bitterness & anger Expression of hopelessness Feeling overwhelmed but no tears Increased dependence on anti-depressants

34. Case Study: History In care from 2 yrs of age /adopted at 7 yrs Ambivalent relationship with adoptive parents Yearning to find birth parents early age Death of adopted sibling (aged12) Difficult adolescence: depression & attempted suicide Long term use of anti-depressants Ambivalent relationship with significant others miscarriage / birth of twin daughters (now 11yrs) Death of adoptive father (sorrow & guilt) Finding birth mother (aged 41), birth mother killed in RTA 12 months later.

35. Take a break Time for coffee!

36.  Bereavement services & resources: Signposting & referring on

37. Underlying principles of bereavement care Respect for the individual Confidentiality Recognising & acknowledging the loss Providing timely information and appropriate support Conducting conversations and meetings in an appropriate environment Assessing the need for ongoing support (where appropriate) Knowing where and when to signpost and/or refer on to another service (Gloucestershire NHS Bereavement Policy,2010)

38. Services & Resources:what’s available? Written information Help-lines and websites Local bereavement support groups & services Local specialist support National resources/organisations

39. Local written resources Gloucestershire NHS Bereavement Policy (May 2010) Liverpool Care Pathway Resource Pack & Guidance sheet ‘What to do after death’ leaflet (available from Department of Work & Pensions) ‘After a death – grieving the loss of someone’ (available from Guide & Pals) Directory of bereavement services in Gloucestershire ( BIGG)

40. Local services providing bereavement support Includes: Cruse GP & other community counselling services Hospice Bereavement & Counselling services (i.e. Cotswold Care, Great Oaks, Sue Ryder) Psychological services Winston’s Wish (support for children) For further information see the Directory for Bereavement Support in Gloucestershire

41. National Resources NHS Direct: 08454647 Cruse: www.crusebereavementcare.org.uk WAY Foundation: www.wayfoundation.or.uk Child Death Helpline: 0800282986 LGBT ( Lesbian, Gay, Bisexual & Transgender) Bereavement Helpline: 02074035969 British association for counselling and psychotherapy ( 01455 883300 / www.bacp.co.uk)

42. Looking after yourself My personal ‘First Aid Kit’ At home At work Other support networks & activities

43. Personal reflections of learning: from classroom to workplace One thing I’ve learnt about myself today The most useful/important thing I’ve learnt today? One thing I’ll do differently at work as a result of attending this workshop

44. References Cruse Gloucestershire (2008) Boerner K, & Schulz, R, (2009) Care giving, bereavement and complicated grief , Bereavement Care, Vol 28 Dent, A. (2005), Supporting the bereaved : theory and practice , Counselling at Work, Autumn edition Department of Health (2008), End of Life Care Strategy – promoting high quality care for all adults at the end of life Freud, S (1917), Mourning and Melancholia. Standard Edition, Vol. 14 Gloucestershire NHS, Gloucestershire NHS Bereavement Policy (2010) Klass, D., Silverman. S, Nickman, S (Eds.),( 1996) Continuing Bonds: new understandings of grief, Taylor and Francis, Washington Machin, L (2001), Exploring a framework for understanding the range of response to loss; a study of clients receiving bereavement counselling, Keel University, unpublished, for more information see Relf, M, Machin, L & Archer, N (2008) Guidance for bereavement needs assessment in palliative care (2008), Help the Hospices National Extension College (1990) Nice Institute for Clinical Excellence (NICE) ( 2004) - Guidance on Cancer Services, Improving Supportive Care for Adults with Cancer Stroebe, M & Schut, H, (1999) The Dual Process Model of Coping with Bereavement: rationale and description, Death Studies, Vol 23 pp 197 -224 Worden, W.J, (1989) Grief Counselling and Grief Therapy, London , Routledge