The value of implementation science in bridging the evidence gap in bereavement care

Contextual determinants of guideline-based family support during end-of-life cancer care and subsequent bereavement care: A cross-sectional survey of registered nurses

PURPOSE

In end-of-life cancer care, 10-20% of bereaved family members experience adverse mental health effects, including prolonged grief disorder. Despite great efforts, evidence-based recommendations to support their grieving process and well-being are often not successfully adopted into routine clinical care. This study identified facilitators and barriers using implementation science methodology.

METHODS

81 registered nurses working in cancer care from four hospitals and three home care services in Switzerland assessed their current family support practices in end-of-life care and bereavement care. They then assessed organisational attributes of their institution and their own individual characteristics and skills regarding literature-based factors of potential relevance. Facilitators and barriers to guideline-based family support were determined using fractional logistic regression.

RESULTS

Service specialisation in palliative care, a culture that supports change, the availability of family support guidelines, billing/reimbursement of bereavement support services, and individual knowledge of family support and skill were systematically associated with higher adoption of guideline-based family support practices. Lack of privacy with families and insufficient training acted as significant barriers.

CONCLUSIONS

While several potentially relevant factors have emerged in the literature, certain organisational and individual determinants actually empirically predict guideline-based family support according to nurses in end-of-life cancer care, with some determinants having much stronger implications than others. This provides crucial guidance for focussing quality improvement and implementation efforts through tailored strategies, especially with scarce resources. Furthermore, adoption is lower in bereavement care than in end-of-life care, suggesting a particular need for supportive organisational cultures including specific training and billing/reimbursement options.

The European Grief Conference, Copenhagen 2022: An effort to unite the field of bereavement care in Europe

Bereavement care in Europe varies in quality and availability. Through greater collaboration across Europe, there could potentially be an opportunity to improve care. This article discusses the inaugural European Grief Conference held in Denmark in 2022: "Bereavement and Grief in Europe - Emerging Perspectives & Collaborations". The conference was structured around a 4-tiered public health model of bereavement care needs. It included practice, research, policy, and educational perspectives. A total of 250 people from 27 different countries participated. To determine if the conference had appealed to a broad European audience of grief professionals and to assess how the conference was received by participants, we examined registration/submission data, the results of a one-word real-time feedback exercise, and the answers to an online satisfaction survey. The results indicated wide interest in greater information sharing and collaboration across Europe among bereavement care, research, and education professionals.

End-of-life and bereavement support to families in cancer care: a cross-sectional survey with bereaved family members

BACKGROUND

Losing a close other to cancer is an incisive experience that occurs after a long course of illness and intense family caregiving. Despite an evident need for family engagement and support and guidance on this, patients and family members may not receive the attention and support they need when a family unit is experiencing a disruption by death. A clear understanding of the quality of care that is currently provided and its ability to address family needs is necessary to improve end-of-life and bereavement support to families affected by cancer. The purpose of this study is to investigate the quality of support of end-of-life and bereavement care to families, their (un)met needs, grief experiences, and self-perceived health outcomes.

METHODS

A multi-center, cross-sectional observational survey study with family members (n = 35) whose close other died of cancer in a health institution or their own home in German-speaking Switzerland.

RESULTS

Bereaved family members were mostly satisfied with end-of-life care. Information on the grief process and services, and acknowledgment of their grief was experienced as helpful. Most coped with their grief drawing on family resources and exhibited resilience, but they reported unmet needs in relation to family togetherness and caregiving.

CONCLUSION

This study with a small number of family members indicates that support provided to families across settings and illness trajectories is perceived as helpful, with specific needs related to family support. The findings suggest that improvements should focus on ensuring care that addresses the family as a unit and enables togetherness, mutual reflection, meaningful relationships, preparedness for death, resilience, and benefit-finding.

PROTOCOL REGISTRATION

https://osf.io/j4kfh .

Adoption of evidence-based end-of-life and bereavement support to families in cancer care: A contextual analysis study with health professionals

AIMS

To investigate the level of adoption of evidence-based family engagement and support during end-of-life cancer care and subsequent bereavement and its contextual facilitators and barriers from health professionals' perspectives, and to explore differences between professional groups.

DESIGN

Contextual analysis using an online cross-sectional survey.

METHODS

This study was conducted in four Swiss hospitals and three home care oncology and palliative care services. Non-parametric testing was used to investigate the level of adoption and differences between nurses, physicians, occupational- and physiotherapists and psychosocial professionals (chaplains, onco-psychologists and social workers). The STROBE checklist for cross-sectional studies was followed.

RESULTS

The majority of the 111 participating health professionals were nurses. Adoption was statistically significantly higher during end-of-life care than bereavement, with nurses and physicians reporting higher levels than the other professional groups. Guidance on end-of-life family care was available in about half of the cases, in contrast to a quarter for bereavement care. Self-perceived knowledge, skills and attitudes were moderate to high, with nurses and physicians reporting higher levels than others, except for general skills in working with families. Organisational structures were experienced as rather supportive, with the psychosocial group appraising the organisational context as significantly less conducive to fully implementing end-of-life and bereavement care than others, particularly during the end-of-life phase.

CONCLUSION

Evidence-based family engagement and support were better adopted during end-of-life care than bereavement. Overall, nurses and physicians felt better enabled to care for families compared to other professional groups.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

PROTOCOL REGISTRATION

https://osf.io/j4kfh.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Implementation and quality improvement efforts should focus particularly on the bereavement phase and be tailored to professional groups.

IMPACT

The findings show that evidence-based family engagement and support practices during end-of-life were rather well adopted in contrast to subsequent bereavement care, with nurses and physicians better enabled than other professionals to provide care. A better understanding of health professionals' contributions and roles in family care is important to build interprofessional capacity for evidence-based end-of-life and bereavement support.

REPORTING METHOD

The STROBE checklist for reports of cross-sectional studies was followed (von Elm et al., 2007).

[When the diagnosis came in … Bereavement care in Germany in 2020/2021: Where do we stand?]

BACKGROUND

In Germany, numerous health care providers work in the field of bereavement care. An epidemiological study of the field immediately after the introduction of the ICD-11 diagnosis "Prolonged Grief Disorder" (PGD) is pending.

METHODS

The second survey of the trend study, which is designed over a total of three measurement points at intervals of one decade each, explores whether and to what extent the field of bereavement care has evolved after the introduction of the grief-specific diagnosis PGD. For this purpose, providers of bereavement care at various organizational levels were asked to participate in an online survey. The survey was conducted from October 2020 to January 2021.

RESULTS

456 questionnaires were included in the study. Data analysis was descriptive. 80.5% of the participants have an additional grief-specific qualification, 59.4% base their work on a grief-specific concept. In view of the PGD diagnosis, only a few respondents have participated in a PGD-related advanced training. Most are afraid that the topic of grief will increasingly be subsumed in the medical-psychological-therapeutic field. An increase in bereavement research and the number and quality of continuing education is also expected.

DISCUSSION

Some positive trends in German bereavement care can be identified. However, there is a need for further development in the areas "designation of the activity", "diagnostics", and "intervention". Also, there is a need for training with regard to PGD.

CONCLUSION

After the introduction of PGD, the field of bereavement care in Germany turns out to be slightly different. The diagnosis is viewed skeptically.

Innovation in Bereavement Care: Research Circles as a Framework for Translation of Research-Based Knowledge

This article aims to contribute to the research-practice gap in bereavement care by exploring Research Circles as a collaborative approach to implementation of research-based knowledge into bereavement care. Particularly the article discusses key dimensions for translating research concerning bereaved after drug-related deaths into practice-relevant knowledge, as a first step of implementation. This co-created knowledge translation took place in the first phase of a Research Circle including bereaved mothers, practitioners and researchers. Data were collected via semi-structured interviews with Research Circle participants and field notes. Data were analyzed using reflexive thematic analysis. Results showed two key dimensions with the Research Circle approach influencing the translation process: (1) multiple and long-lasting arenas for translation: (2) multiple stakeholders and perspectives. Research Circles appear to be a promising framework for translating research-based knowledge in bereavement care, but there are some barriers to fully realizing the democratic ideal that underlines the Research Circle framework.

Researching Compassionate Communities: Identifying theoretical frameworks to evaluate the complex processes behind public health palliative care initiatives

BACKGROUND

Compassionate Communities have been put forward as a new model for community-based palliative care to positively impact the health and wellbeing of those experiencing challenges of serious illness, death, dying, and loss. Despite the growing international movement to develop these public health initiatives to end-of-life care, only a handful of initiatives have undergone some form of evaluation.

AIM

To provide guidance on designing evaluation research by identifying theoretical frameworks to understand the development, implementation, and underlying mechanisms of Compassionate Communities.

METHODS

To identify suitable theoretical frameworks for the study of Compassionate Communities, we applied two steps. The first step examined the characteristics of Compassionate Communities and translated them into assessment criteria for the selection of theoretical frameworks. The second step consisted of applying the identified assessment criteria to a list of widely used and highly cited theoretical frameworks.

RESULTS

Three well-established theoretical frameworks were identified as being most suitable to study the development, implementation, and underlying mechanisms of Compassionate Communities: The Consolidated Framework for Implementation Research (CFIR), the integrated-Promoting Action on Research Implementation in Health Services framework (i-PARIHS), and the Extended Normalization Process Theory (ENPT).

CONCLUSIONS

The article supports and encourages the use of theoretical frameworks to evaluate the complex processes behind public health palliative care initiatives. The complementary use of two determinant frameworks and an implementation theory provides theoretical grounding to gain rich insights into the emergent and shifting interplays between agency, social processes, and contextual factors that shape the development and implementation of Compassionate Communities.

Revising ruling discourses: The griefwork evidence-to-practice gap and the mental health workforce

Elisabeth Kübler-Ross' pioneering work focused on dying, yet some clinicians persist in prescribing it as a path through grief. We surveyed 964 mental health clinicians who completed a five-section mixed methods survey: two sections assessed knowledge with multiple choice questions and a case study to assess clinicians' knowledge-base and approach to grief/loss in practice. Analysis of four items related to Kübler-Ross' model and 66/962 case studies indicates ongoing use of "stages" and Kübler-Ross' model. Only 330 (34.2%) of the clinicians were deemed knowledgeable; 462 (47.9%) were questionable; and 172 (17.9%) were misinformed, continuing to use Kübler-Ross' stage theory for grief.

Effectiveness and Feasibility of Internet-Based Interventions for Grief After Bereavement: Systematic Review and Meta-analysis

BACKGROUND

Although grief and its symptoms constitute a normal reaction to experiences of loss, some of those affected still report elevated levels of distress after an extended period, often termed complicated grief. Beneficial treatment effects of face-to-face therapies, for example, grief counseling or cognitive behavioral therapy against complicated grief, have been reported. Evaluations of internet- and mobile-based interventions targeting symptoms of grief in bereaved individuals with regard to objective quality criteria are currently lacking.

OBJECTIVE

We aim to conduct a systematic review and meta-analysis on the effectiveness and feasibility of internet- and mobile-based interventions against symptoms of grief after bereavement.

METHODS

We conducted systematic literature searches of randomized controlled trials or feasibility studies published before January 9, 2020, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, in PubMed, PsycINFO, Web of Science Core Collection, and the Cochrane Library. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations system. We further assessed aspects of feasibility and rated quality of interventions using criteria suggested by an expert panel on mental health care (German Association for Psychiatry, Psychotherapy, and Psychosomatics). A random-effects meta-analysis was conducted to assess between-group effect sizes.

RESULTS

In total, 9 trials (N=1349) were included. Of these, 7 studies were analyzed meta-analytically. Significant effects were found for symptoms of grief (g=0.54, 95% CI 0.32-0.77), depression (g=0.44, 95% CI 0.20-0.68), and posttraumatic stress (g=0.82, 95% CI 0.63-1.01). Heterogeneity was moderate for grief and depression (I2=48.75% and 55.19%, respectively) and low for posttraumatic stress symptoms (I2=0%). The overall quality of evidence was graded low (grief and depression) to moderate (posttraumatic stress). User satisfaction with the interventions was high, as was the quality of the interventions assessed using objective quality criteria.

CONCLUSIONS

Internet- or mobile-based interventions might constitute an effective treatment approach against symptoms of grief in bereaved adults. However, the small sample sizes and limited number of studies included in the review warrant further investigation.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) CRD42012002100; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=131428.

Grief and bereavement beliefs among U. S. mental health professionals and the general public

The present study examined beliefs about grief and bereavement in a sample of mental health professionals and the general public in the United States. In part 1 of this study, we developed a 12-item questionnaire based on extant thanatology literature and expert review. In part 2, 210 participants rated their beliefs about grief and bereavement using this questionnaire. Participants rated most items accurately, and mental health professionals were more likely to answer items accurately compared to the general public. These findings provide support for increasing grief literacy in professional and public domains.

The Utility of the Pandemic Grief Scale in Identifying Functional Impairment from COVID-19 Bereavement

Background: Meeting the needs of people bereaved by COVID-19 poses a substantial challenge to palliative care. The Pandemic Grief Scale (PGS) is a 5-item mental health screener to identify probable cases of dysfunctional grief during the pandemic. Objective: The PGS has strong psychometric and diagnostic features. The objective was to examine the incremental validity of the PGS in identifying mourners at risk of harmful outcomes. Design: A cross-sectional survey design involving sociodemographic questions and self-report measures of pandemic grief, generalized anxiety, depression, post-traumatic stress, separation distress, functional impairment, meaning-making difficulties, and substance use coping. Setting/Subjects: A sample of people bereaved through COVID-19 (N = 1065) in the United States. Results: Fully 56.6% of participants scored above the cut score of ≥7 on the PGS for clinically dysfunctional pandemic grief and 69.7% coped with their loss using drugs or alcohol for at least several days in past two weeks. PGS scores were not associated with time since loss. Hierarchical multiple regression models demonstrated that the PGS uniquely explained variance in functional impairment, meaning-making difficulties, and substance use coping, over relevant background factors, bereavement-related psychopathology, and separation distress. In the final model, the standardized regression coefficients for the PGS were 2-15 times larger than for the other competing measures in explaining each of the three outcomes. Conclusions: The findings underscore the clinical utility of this short and easy-to-use measure in identifying risk of deleterious outcomes across a range of functional and behavioral domains.

Treatment gap in bereavement care: (Online) bereavement support needs and use after traumatic loss

People bereaved through road traffic accidents (RTAs) are at risk for severe and disabling grief (i.e., pathological grief). Knowledge about needs and use of bereavement care, including psychotherapy, pharmacotherapy, and support groups, is limited. This study charted (correlates of) the needs and use of bereavement care in RTA bereaved people. Furthermore, although online grief treatment seems effective, it is unknown whether it is perceived as acceptable. Accordingly, we examined the acceptability of online treatment. Dutch RTA bereaved adults (N = 273) completed self‐report measures about needs and use of bereavement care, acceptability of online grief treatment, and pathological grief. Regression analyses were used to identify correlates of care needs and use and acceptability of online treatment. The majority (63%) had received help from psychotherapy, pharmacotherapy, and/or support groups. One in five participants had not used bereavement care services, despite reporting elevated pathological grief levels and/or expressing a need for care, pointing to a treatment gap. Use of psychological support before the loss was the strongest predictor of bereavement care needs and use following the loss. A minority (35%) reported being inclined to use online grief treatment if in need of support. More openness towards online services was related to greater acceptability of online treatment. In conclusion, 20% of RTA bereaved people with pathological grief or care needs had not received care. This treatment gap may be reduced by improving accessibility of online treatments. However, as only 35% was open to using online treatments, increasing the acceptability of (online) treatments appears important.