ft

David Field, David Reid, Sheila Payne, Marilyn Relf

Abstract
Method Postal survey of UK hospices and specialist palliative
care services providing adult bereavement support.
Analysis Descriptive statistics and content analysis of free text
replies.
Results Three hundred services were identified, with 248 valid
responses (83%). Of these, 198(80%) were in England and
180 (73%) were associated with inpatient units. Most had been in
existence for at least 10 years. Paid staff were used by
219 services (88%) and volunteers were involved in 168 services
(68%). A small minority did not provide supervision for their
bereavement staff. A quarter of services had insufficient staff. The
most common activities were individual support, telephone
support, written information, memorialization events and group
support. Ninety five services (43%) formally assessed the need for
individual support. One hundred and fourteen services (51 %) had
no formal mechanisms for bereaved people to provide feedback
about such support. Formal audit and evaiuation of bereavement
services was uncommon.
Conclusions The main elements of bereavement support can be
identified but their combination varies. Assessment of people for
individual support varies and the small size of many services may
inhibit the effective delivery of support. Audit and evaluation of
bereavement support may need to be developed.

David Field is Visiting

Professor, Department of
Health Sciences, University
of Leicester, 22-28 Princess
Road West, Leicester LEI
6TP, UK, David Reid is
Research Fellow and Sheila
Payne is Professor of
Palliative Care, Palliative
and End-of-Life Care
Research Group, University
of Sheffield, Bartolome
House, Winter Street,
Sheffield S3 7ND, UK and
Marilyn Relf is Head of
Education, Sir Michael
Sobell House, Churchill
Hospital, Oxford OX3 7LJ,
UK
Correspondence to.'
Sheila Payne
Email: s.a.payne
sheffield.ac.uk

ntil recently UK health services

have contributed little to bereavement support, with the exception of
spiritual support from hospital chaplains
at the time of death and, in a minority of
cases, psychiatric treatment for those with
complicated grief reactions (Payne, 2004).
In the community, bereavement support
has largely been delivered through religious and other self-help networks and by
voluntary organizations such as Cruse
Bereavement Care (a UK charity specializing in bereavement support). The modern
hospice movement has recognized the
continuing needs of the bereaved relatives
and lay carers of their patients, the majority of whom are in the middle and later
years of life, and most hospices regard the
provision of such support as an integral
part of their services (Payne et al, 1999).

International Journal of Palliative Nursing, 2004, Vol 10, No 12

Most bereavement services are based on

the assumption that loss through death
challenges coping abilities and that supportive interventions may facilitate postdeath adaptation, reduce complicated grief
reactions and promote wellbeing.
In the UK, the National Insititute for
Clinical Excellence (NICE) has recommended that a three-tier model of bereavement support be implemented for all
families and carers of cancer patients in
which all health-care providers should
provide information about local services
to bereaved people (level 1). Those in need
of more comprehensive support should be
offered support from professionals and/or
volunteers (level 2) and a minority of people at high risk of complicated bereavement reactions should be referred to
specialist services (level 3) (NICE, 2004).
Bereavement services have received little
research attention and there is a lack of
evidence to underpin practice developments. Bereavement support in hospices
in the UK appear to be largely at NICE
levels 1 and 2, and may include activities
such as befriending, counselling, information packs, memorial services and support
groups (Kissane, 2004). Support may be
delivered in person or by telephone by
either or both paid staff and volunteers
(Payne, 2001). Two UK studies have indicated the efficacy of using trained volunteers in support bereaved people (Parkes,
1981; Relf, 2000). The diversity of service
models and methods of delivery suggest
little consensus about optimal service
configurations.
A US survey of 260 hospice bereavement services in 2002 (Demmer, 2003),
repeating an earlier survey conducted in
1986 (Lattanzi-Licht, 1989), asked similar
questions to those in the survey reported
here. Almost half of the services had been
in existence for 15 years or more and only
12% had existed for less than 5 years.

569

Servey off UK hospice and speclalistt palMattive care

'This article
reports on the first
phase of a study
aiming to describe
and examine the
nature of adult
bereavement
support provided
in UK hospices.'

Those coordinating bereavement services

were most likely to be social workers
(44%) or from 'mixed disciplines' (15%);
only 10% had a nursing background
(down from 25% in 1986). A third of the
services had a full-time paid coordinator
and nearly all the remainder (64%) had a
part-time coordinator. In most services
(62%) one staff member provided the services, 26% employed two to three staff
and 12% had more than three staff. Most
services used volunteers: 56% had less
than 5 volunteers, 30% had 5-15 and 14%
had more than 15 volunteers. In most hospices (83%) bereavement staff received
specialised bereavement training.
The survey found that the number of
both paid and voluntary bereavement staff
had declined since 1986. The lack of sufficient staff time and funding pressures were
indicated as the greatest obstacles to delivering the bereavement service by 58% of
respondents, followed by lack of personnel (31%). Bereaved people were most
likely to receive 'letters or notices about
meetings or groups' (87%), phone calls
from bereavement staff (83%) and written
information about grief (81%). There was
a significant reduction in bereavement visits from 1986 (83%) to 2002 (55%). Most
of the hospices (92%) used a 'bereavement
assessment process', usually an 'in-house
form' (87%) to identify 'high risk' individuals. Aspects of these US bereavement services will be compared with the findings
the current survey.
This article reports on the first phase of a
study aiming to describe and examine the
nature of adult bereavement support provided in UK hospices. It provides a brief
description of the organization and delivery of adult bereavement support in UK
hospices and specialist palliative care services as reported in a national postal survey
conducted in 2003 (Field et al, 2003).

Methods
A national postal survey of all adult
bereavement support services provided by
UK hospices and specialist palliative care
services was conducted in the early
months of 2003 using a questionnaire
derived in part from one used in an earlier
survey of risk assessment in hospice
bereavement services (Payne and Relf,
1994). The questionnaire consisted of
structured and open-ended questions.
Some of the structured questions addressed similar topics as the US survey
(Demmer, 2003). Approval to conduct the

570

Ibereavemeinill services
survey was obtained from the Trent
Multi-centre Research Ethics Committee.
Questionnaires were mailed to the
bereavement coordinators or lead personnel at the 322 adult bereavement services
in the UK identified in the Directory of
Hospice and Palliative Care Services
(Hospice Information, 2002). Children's
services and single Macmillan nurse services were omitted as it was judged that
the bereavement support provided by
these individuals did not constitute a
'bereavement service'. Replies that stated
no adult bereavement service existed at
their organization (8), questionnaires
where there was insufficient evidence that
a bereavement service existed (6) and multiply listed services (8) were excluded.
There were 248 valid returns from the
300 adult bereavement services identified,
a response rate of 83%.
Descriptive statistics were used to analyse
the numerical data, using SPSS 11.5.
Missing data were coded as such and are
acknowledged in the descriptive statistics
presented in this article. After preliminary
discussion within the research team, DF
scrutinized the answers to the two openended questions at the end of the questionnaire and comments made elsewhere and
developed the categories to organize this
material. MR checked the use of these
categories and discussed any anomalies
with DF. There was near-unanimous agreement between DF and MR, although a
formal count of their agreement level was
not made.

Results
Organizational context
The majority of the services were located
in England (198, 80%). It was most common for them to be associated with a combination of specialist palliative care
services rather than with just one kind of
service {Table 1). Three-quarters of the
services were associated with an inpatient
hospice or specialist palliative care organization. These are referred to as 'inpatient'
services and, where relevant, compared
with the 64 'other' services that were not
associated with an inpatient hospice or
specialist palliative care service. For four
services it was not possible to establish
to which of these categories they should
be assigned.
The 248 services had been in existence
from a few months to 50 years, with a
median length of operation of 10 years
{Figure 1). Over half of the bereavement
International Journal of Palliative Nursing, 2004, Vol 10, No 12

Simrvey off UK hospnce amd specEallstt pallaattive care aduiM toereavememtt services
services (133, 54%) had been operating for
10 years or less, with three quarters (190,
n/o) operating for 15 years or less.
Inpatient services were likely to have been
in operation for longer than other services:
all but four other services had been in existence for no longer than 15 years. It is
worth noting the high number of missing
cases (21, 8%), which suggests that some
respondents found it difficult to date their
bereavement service, possibly because it
was unclear when bereavement support
was identified as a discrete element of
service provision.
Personnel involved in delivering
bereavement services
The questionnaire was most likely to have
been completed by someone with 'bereavement' in their job title (70, 28%), by a
nurse (66, 27%) or a social worker (36,
15%). The most common professional

Organization

Number

Per cent

Inpatient services
inpatient hospice or palliative care unit only
inpatient hospice or palliative care unit and other
forms of care

26
154

10
62

AHinpatient

180

73

All other services

19
II
8
6
20
64

8
4
3
2
8
26

Missing
Total

4
248

2
100

services

Other services
Home care only
Day care only
Day care and home care
Hospital support service only
Other

All percentages are rounded

35-1
302520151050

0-5

>5-IO

>IO-I5

>I5-2O

Years

Figure 1. Age of adult bereavement services.

International Journal of Palliative Nursing, 2004, Vol 10, No 12

>20-35

>35
(n=248)

qualification of respondents was in nursing

(88, 35%). Many respondents reported
having a counselling qualification of some
description (96, 39%) and just over a quarter had a social work qualification (58,
23%). A fifth of the respondents reported
having both a counselling qualification and
either a nursing (28) or social work (22)
qualification. The majority of respondents
were female (216, 87%).
All respondents were asked about the
number of people currently working in
their bereavement service. The great
majority of services used paid staff (219,
88%) and the rest used voluntary staff
only. It was not possible to establish the
number of hours paid workers spent on
bereavement support activities, although
some services indicated that some or all of
their paid staff worked part time in
bereavement support. The paid professionals most frequently identified as being
actively involved in bereavement services
were nurses (140, 56%). Counsellors and
social workers were equally likely to be
actively involved (both 113, 46%). Other
actively involved paid staff were chaplains
or clergy (43, 17%), doctors (41, 17%),
psychologists (23, 9%) administrative and
clerical staff (12, 5%), therapists (11, 4%)
and psychiatrists (6, 2%).
Volunteers were reported to be involved
in over two thirds of the services (168,
68%). The number of voluntary workers
ranged from one to 62. Two thirds of the
volunteers were under the age of 60 years.
Voluntary and paid staff were reported to
work together at nearly two thirds of the
services (157, 63%), paid staff alone at a
quarter of the services (62, 25%) and volunteers alone at 11 services (4%). Typically
bereavement services employed 2-3 paid
staff assisted by 11-12 voluntary staff.
Table 2 shows that although both paid
and voluntary staff were engaged in delivering all elements of bereavement support,
volunteers were unlikely to be the sole
providers of these activities. Paid staff
were especially likely to be the sole
providers of written information and
advice, one-to-one and drop-in support
and referral to other agencies. The types of
activities that were most likely to be
provided by a combination of paid and
voluntary staff were one-to-one support,
memorial, remembrance or anniversary
services and support groups. The important contribution made by volunteers to
the provision of bereavement support was
commented on by several respondents.

571

SuBirvey off UK hospice amdl specnalistt palMallive care adellt beireavemeinilt services
Preparation and supervision
The preparation and supervision of staff
providing bereavement support plays
an important role in the quality of this
support and the wellbeing of the staff
providing it. Among the 168 services with
volunteers, 143 (85%) provided an induction programme for their new voluntary
workers, 17 (10%) did not and the rest
did not provide this information. It was
most common for induction programmes
to last 6-15 hours (55 services), although
their duration ranged from 1-5 hours
(37 services) to over 65 hours (4 services).
Services not associated with inpatient
units were less likely to provide information about the length of their induction
programmes.
Most organizations provided training
for the people working for their bereavement service (172, 69%), but 16% (39) did
not and another 15% (37) did not answer
this question. Among the services providing such information (120, 48%), the
length of training programmes for new
volunteers varied from 1-10 hours (23 services) to over 60 hours (8 services), with a
median duration of 24 hours. Bereavement
services associated with an inpatient unit
were more likely to provide training for
their staff than other services.

Number

Table 3 shows the availability of supervision for those working in bereavement

services. Although the majority of
bereavement workers received supervision from their bereavement service, 12%
of paid staff and 7% of voluntary staff
were not receiving supervision from their
organization (counsellors, either paid or
voluntary, may receive external supervision). Further, a fifth of the respondents
from services with paid staff provided no
information about the supervision of
these staff.
Bereavement support activities
Respondents were asked to report what
services they offered from a range of specified activities {Table 2). Nearly all organizations (238, 96%) offered individual
one-to-one support to bereaved people, in
their own home (207, 83%), at the organization (199, 80%) or elsewhere (92, 37%).
Individual support was more likely to be
offered by inpatient services (169/180,
94%) than by other services (54/64, 84%).
Nearly as common as this were some form
of telephone support (223, 90%) and the
practice of referring bereaved people on to
other agencies (220, 89%). For the latter,
the agencies most frequently mentioned
were Cruse (48, 19%), counselling services

Service activity

(%)

Paid staff
only

Voluntary
staff only

Both paid and

voluntary staff

One-to-one support
Telephone support
Referral on to other agencies
Memorial, remembrance or
anniversary service
Written information and advice
Support group
Drop-in support

237 (96)
223 (90)
220 (89)
178(72)

82 (33)
115(46)
163(66)
51 (21)

13(5)
15(6)
4(2)
6(2)

132(53)
95 (38)
35(14)
132(53)

181 (73)
151 (61)
107(43)

138 (56)
42(17)
63 (25)

5(2)
6(2)
9(4)

43(17)
103 (42)
36(15)

n = 248, all percentages have been rounded.

" '

- -----

- -

'

-'zeX'"',-

Voluntary staff

Paid staff

UK
Inpatient
Rest
Inpatient
Rest
UK
number (%) number (%) number (%) number (%) number(%) number (%)
Provided
148* (68)
Not provided 27 (12)
Missing
44t(20)
Total
219(100)

120 (73)
15 (9)
30 (18)
165(100)

28
12
II
51

(55)
(23)
(22)
(100

148 (88)
II (7)
9 (5)
168(100)

126 (89)
8 (6)
7 (5)
141 (100)

21 (81)
3 (12)
2 (8)
26(100)

* One of these services could not be identified as either 'inpatient' or 'other'

t Three of these services could not be identified as either 'inpatient' or 'other'
All percentages are rounded

572

International Journal of Palliative Nursing, 2004, Vol 10, No 12

Sunirvey IF USC hospice aed specialistt paMiattive care aduiMtoeireavemeimttservices

'Respondents were
asked whether
their services had
any formal
processes in place
to encourage
hereaved people
to provide
feedback ahout
their experiences
of one-to-one
services.'

(28, 11%), GPs (23, 9%) and social

services (17, 7%).
Well over half of the services provided
written information and advice, memorial,
remembrance or anniversary services, and
support groups. The median number of
activities offered by each service was six,
the range being from two to eight activities. Respondents were also asked to rank
what they felt to be the three most commonly used aspects of their service.
Overall, the most commonly reported
activity was individual one-to-one support
(164, 66%) followed by telephone support
(107, 43%) and then some form of group
support (89, 36%).
Duration of bereavement support
In 25 services (10%) support for bereaved
people was typically offered for the first
12 months. It was unusual for bereaved
people to have one-off contact with services (8, 3%) or to have contact that
lasted for only the first 3 or 6 months (14,
6%). Over half (133, 54%) reported that
their service users were in contact with
the service for as long as required. For
inpatient services the adults using their
bereavement services were primarily
those who had already been in contact
with the organization.
Other services were less likely to restrict
their bereavement support solely to those
who had previous contact with their organization. Overall, nearly half of the
bereavement services (114, 46%) restricted
access to those with previous contact to
the organization and nearly half (116,
47%) also accepted referrals from elsewhere. Fifteen services said they received
external referrals only. A fifth of respondents (55, 22%) reported that those using
their service could be people who were
neither in contact with inpatient services
nor referred by other agencies (self-referrals (20), 'any bereaved people in the locality' (15), unspecified (20)). Fifteen
respondents reported that referrals were
sometimes taken from local services for
children or young people.
One-to-one support
Over 90% (226) of the services provided
one-to-one support to bereaved people.
Three of these services could not be classified as either 'inpatient' or 'other' services
so this section is based on 223 services
(inpatient 169, other 54). The median
number of annual new referrals was 98,
but the number of new referrals varied

International Journal of Palliative Nursing, 2004, Vol 10, No 12

from 1 to 1055. Inpatient services were

more likely to have provided this information (140, 83%) than other services (39,
72%). About half of the 179 services completing the question (96) reported
1-100 new referrals for one-to-one support annually, with a further fifth (37)
reporting 100-200 new referrals. Half of
other services (26, 48%) reported
1-100 new referrals annually.
Bereaved people were reported to access
one-to-one services in a variety of ways,
often through a combination of agencies.
Less than a fifth of referrals (42) came
from within the organization alone and a
similar proportion came through a combination of self-referral and internal referral
from the organization (40). Most commonly, a combination of internal referral,
self-referral and referral from external
agencies was reported (98, 44%). Overall,
more than half of the services (126, 56.5%)
reported accepting referrals from other
agencies, mainly primary care (86). Other
sources of referral were nurses (25), social
care (22), mental health services (17), hospitals (16), agencies working with children
(16) and chaplains (7). Only three respondents reported referrals from other local
bereavement services. Self-referral only
(11) and referral from external agencies
only (4) were uncommon.
Respondents were asked whether they
assessed the needs of bereaved people
who were eligible for one-to-one support.
Half of those who replied (110) reported
that only informal assessment was used.
This was more common for other services
(33, 61%) than for inpatient services {77,
46%). More than a third of the services
were reported to be using a formal risk
assessment tool (95, 43%). Formal assessment was more likely to be used by inpatient services, often in combination with
informal assessment (81, 48%), and was
most frequently undertaken by nurses
(41) or by groups of professionals (38). In
the open-ended question about changes
that were planned, 19 respondents indicated that their service was either considering or planning to introduce formal
risk assessment.
Respondents were asked whether their
services had any formal processes in place
to encourage bereaved people to provide
feedback about their experiences of oneto-one services. Just over half of these
(114, 51%) did not have formal feedback
processes. The most frequently reported
feedback tools were satisfaction surveys or

573

Sniirvey off UK hospice aed speclallstt palMallive care admllt Ibeireavemeiiiitt services
questionnaires (24), unspecified forms (18)
and audit tools (12). Twelve services were
reported to be developing formal feedback
processes.
Constraints and changes
Most respondents (197, 79%) provided
information about the changes they were
planning or would like to make to their
bereavement services. Many of them also
indicated the sorts of constraints within
which their service operated.
Constraints
The most commonly identified constraint
was the need for more paid (44, 18%) or
voluntary (21, 8%) staff (three respondents wanted both more paid and voluntary staff). Twenty-one respondents (8%)
wanted the appointment of a paid coordinator for their bereavement service and
23 wanted to recruit other professional,
administrative or clerical staff.
Changes
Many respondents reported on changes
that were being planned or considered:

45 planned or wanted to introduce or

increase group support, both formal
and informal
29 wanted or planned to extend their
bereavement services to children and
6 wanted to include young people (over
70% (178) of the adult bereavement services already offered some bereavement
support to children)
24 were planning to review or improve
the evaluation of their service
16 were planning to improve the training of their bereavement workers
11 wanted to introduce or increase
counselling
11 planned to provide more information to bereaved people and/or to
improve upon the information that was
already being provided to them.
6 planned or wanted to introduce
drop-in support
6 planned or wanted to introduce the
use of 'anniversary' or condolence cards
6 planned or wanted to introduce
memorial services
3 planned or wanted to introduce
support for people bereaved through
traumatic or sudden death.

Summary and discussion

Aspect

U K 2003

US 2002*

Typical length of operation

10+ years

15+ years

2-3
35%

1
<5
10%

23%

44%

39%

13%

20%

15%

Staffing

Typical number of paid staff

Typical number of volunteers
Respondents with a nursing
qualification/background
Respondents with a social work
qualification/background
Respondents with a counselling
qualification/background
Respondents with 'mixed
backgrounds'
Types of support
Written information and advice
Phone calls
Home visits
One-to-one support at hospice
Memorial services
Group support
Range of support activities

11-12

73% of
90% of
83% of
80% of
72% of
63% of
2-8

services
services
services
services
services
services

81% of services
83% of services
55% of services
Not applicable
46% of services
23% of services
Not reported

Risk assessment

Formal process of assessment

used

43%

92%

not askedt
21% of services
not asked

58% of services
31% of services
58% of services

Constraints

Insufficient staff time

Lack of personnel
Funding

*US data taken from Demmer (2003). Some of the US categories are expressed
sligiitly differently from the categories used in the UK survey tAlthough not asked
directly, 62 respondents (25%) said they had insufficient staff

574

The findings of this cross-sectional postal

survey must be interpreted cautiously,
although an 83% response rate suggests
that it is representative of all adult
bereavement services provided by UK
hospice and specialist palliative care services in 2003. In particular, the survey
only reflects the views of service
providers, as reported by one person
(phase 2 of the study is collecting the
views of bereaved people). However, there
are a number of points that are worthy
of comment, and comparison can made
between the findings of this survey
and the similar survey conducted in US
hospices {Table 4).
UK:US comparisons
Maturity and staffing of services
From Table 4 it can be seen that that US
bereavement support services have been
established longer than those in the UK.
Demmer reports that 'bereavement services were well established in responding
hospices' (2003). However, in both countries they are relatively small, in the UK
typically involving no more than two to
three paid staff, not all of whom are necessarily working full time for the service. In
the US, 64% of the services coordinators
International Journal of Palliative Nursing, 2004, Vol 10, No 12

survey off UK hospnce amd specialist palliattive care adniM bereavememil; services
'In both the UK
and the US
insufficient staff
time and lack of
personnel are seen
as obstacles to
delivering
bereavement
support.'

worked part time. The most common professional staff background in the US is
social work. In the UK nurses are major
providers of bereavement support, and
may have the coordinating role in such
services. In both countries a significant
minority of paid staff have more than one
professional qualification. In both countries, most services had volunteers working in the bereavement service, usually in
conjunction with professional staff.
In both the UK and the US insufficient
staff time and lack of personnel are seen as
obstacles to delivering bereavement support. The comments made by respondents
in the current survey suggest that the lack
of sufficient paid and voluntary staff may
inhibit the effective delivery of existing
services, the development of other types of
support, and the expansion of bereavement support to other potential clients. In
particular, as in the US, several respondents felt that their service would be
improved by the appointment of a person
to manage and coordinate bereavement
support activities. Both the small number
of paid staff and the predominance of staff
who were not centrally involved in clinical
decision making suggests that, despite the
rhetoric that bereavement support is integral to hospice and specialist palliative care
services, in practice adult bereavement
support remains marginal to the core
activities of patient care:
'This area of palliative care is the poor
sister to clinical medical care and often
over-stretched with low resource levels'
{Respondent 24)

A similar situation has been reported

for US hospice bereavement services
(Lattanzi-Licht, 1989).
Types of bereavement support
The core elements of bereavement support - one-to-one support, phone support, group support, memorial services,
and the provision of informational literature - are common in both the UK and
US. However, this survey suggests that
the ways that they are combined in the
UK bereavement support services is
highly variable.
The most commonly provided type of
bereavement support in the UK was individual one-to-one support, although the
questionnaire design meant that it was not
possible to identify precisely what this
entailed. That individual support is much
more common in the UK than in the US
International Journal of Palliative Nursing, 2004, Vol 10, No 12

probably reflects cultural preferences

Counselling appeared to be widely used
and a number of services were planning to
introduce counselling into their provision
of adult bereavement support. However,
what this counselling involved might vary
quite widely as this term has a variety of
meanings (Payne et al, 1999). The extent to
which befriending is used as a means of
supporting bereaved people is unclear. The
second phase of the study, which is examining different 'packages' of bereavement
support in five hospices, should provide
more information about these and other
types of support.
Bereavement risk assessment
According to Davies and Higginson
(2004), 'Assessing the need for support
and counselling after bereavement is
regarded as an important part of palliative
care'. Targeting bereavement services by
systematically identifying people at risk of
complicated grief is a central theme in the
literature (Relf, 2004). In US hospices formalized methods of risk assessment are
usual (Demmer, 2003) and in Australia
risk assessment is a performance indicator
and guidelines are available (Aranda and
Milne, 2000).
In this survey less than half of the organizations (42%) used some formal
method of needs assessment to identify
the people most in need of bereavement
support. This is an increase from an earlier survey which found that standardized
assessment to target one-to-one support
was undertaken in 25% of UK hospices
(Payne and Relf, 1994). Associated with
this increase in bereavement needs assessment seems be a demand for an effective
risk assessment tool for use by the services, although a few respondents indicated that they were opposed to the use of
such tools. One of the results of the
NICE guidance may be to increase the
demand for the effective assessment of the
potential for complicated grief reactions,
even though, as Davies and Higginson,
(2004) state: 'There is relatively little evidence... for the predictive power of
assessments, the targeting of individuals
or the benefits of individual therapy'.
Policy and practice
NICE guidance
This survey suggests that level 1 and 2 of
the NICE guidance (2004) are widely
available to bereaved adults in contact
with hospice and specialist palliative care

575

Sunrvey off UliC Ihosplce amd speciaMstt palMallve care admlft toereavememtt services
services. Some level 3 support is also
offered but, given the nature of the questionnaire (which was developed before
this guidance), the extent and processes
of referral to other specialist services
is unclear.
Staff preparation and support

The majority of services provide induction, training and supervision for their
paid and voluntary staff. However, a small
but significant minority of services do not
provide supervision for their paid bereavement workers or for voluntary staff. The
lack of supervision for staff working with
people who are bereaved is of concern, as
adequate supervision is an important
ingredient in assuring the quality of
bereavement support services and the
wellbeing of the staff providing them. This
must be addressed. As noted above, a
number of services were planning to
improve the training and supervision of
their staff.
Evaluation of services

A third of the UK respondents (82)

reported that they either had in place or
were developing formal processes that
allowed bereaved people receiving individual one-to-one support to provide feedback about their experience of using this
form of bereavement support. Within the
developing culture of audit and userinvolvement in the UK this may come to
be seen as an area of weakness that
bereavement support services will have to
address. Despite the charitable status of
most hospices, they typically receive substantial state funding and thus it is highly
likely that their bereavement support services will need to develop audit and evaluation procedures that can demonstrate the
effectiveness of this support.

Conclusions
This survey has identified a number of
issues that should be addressed at a
national level. Although the main elements of adult bereavement support can
be identified, the way these are combined

and delivered varies between organizations. The assessment of bereaved people

for individual support also varies. The
small size of many services may inhibit
the effective delivery of bereavement support. Finally, procedures to audit and
evaluate the effectiveness of bereavement
support may need to be developed. The
establishment in 2005 of a bereavement
support programme by Help the
Hospices {Box 1) may provide the forum
for this discussion.
This survey was funded by The Health Foundation.
The authors thank all of the respondents for their
participation in the survey.
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521-38

Box I. Further information

Further information about
Help the Hospices Bereavement Support
Programme, funded by HBOS pic, can be
obtained from Jennie McDowall
Tel: (+44) (0)20 7520 8220
Email: j.mcdowall@helpthehospices.org.uk

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Key words
Adult bereavement

Hospice

Evaluation of services
Palliative care

International Journal of Palliative Nursing, 2004, Vol 10, No 12