Care planning for grieving significant others is as important as the care of the dying person. To be strong and to succeed in going on with one’s life requires the individual to affirm his or her self-image, self-determination, social relationships, symptom control, synthesis and summation, and surrender. The 6S model, therefore, was found to be a well-functioning tool for analyzing grief among significant others.
The findings of the present study indicate that the bereavement groups, in some sense, contributed to strengthening the significant others’ self-images and gave them a better understanding of themselves. The groups gave participants opportunities to process the story of the death and to make sense of it and of their upcoming lives without their loved one. This aligns with international grief therapy as described by Neimeyer (30).
However, not all significant others used the bereavement groups as a catalyst to affirm their self-image.
Whether these significant others had come to terms with the imminent death is unknown. Holland, Futterman, Thompson, Moran, and Gallagher-Thompson (31) suggested that non-acceptance of the upcoming loss when the patient is still alive is a predictor for negative grief experiences later. Identifying those individuals who are likely to benefit from bereavement services should be part of the palliative-care process before the death of their loved one. Other findings have shown, for example, that psycho-educational group interventions for significant others before death can increase competence for caregiving and preparedness for the loved one’s end of life (32). Nurses and physicians in palliative care should pay close attention to expressions of grief in the early aftermath of loss. However, participation in groups is related to the date of death and can lose its effectiveness in the long term. Findings confirm that, over time, significant others are hesitant about whether the bereavement groups offer any support at all (31, 32). However, Blackburn, McGrath, and Bulsara (33) found that significant others can struggle with difficulties for longer periods than formal support services are aware of. Follow-up support to some significant others may need to be continued for a longer time. Blackburn et al.’s suggestion is that the community should provide that kind of bereavement support.
To reveal one’s inner feelings in a group can be difficult and may require self-determination. In bereavement groups, significant others had the opportunity to decide whether they wanted to discuss their grief and share their inner feelings. Hefren and Thyer (34) recommended guided bereavement support, which may be helpful for relieving participants’ negative emotions and avoidance behaviours. Guided support can be valuable for identifying grief and enhancing bereavement even in complicated grief.
Feelings of loneliness and isolation are common, and many times, the bereaved struggle with these feelings. Many among the bereaved participants had been half of a couple (Table 1), and the loss of a spouse or partner can be a risk factor for prolonged grief disruption. Participation in bereavement groups can improve relational functioning in the post-treatment phase and well-being at follow-up (18). Social support is a source of finding a meaning and can ease the risk of prolonged grief (35). Being a member of a bereavement group is a form of social support. Research shows that being an ageing couple can imply that friendships outside the relationship are lacking. The spouse and family members are the only social network (36). However, this study’s findings illustrate that the bereavement groups had a positive influence on social relationships close to the death of the deceased. Significant others experienced that participation as providing a sense of coherence and understanding that they could share with others in the same situation in connection to their loved one’s death, as confirmed by Blackburn and Bulsara (19). Findings from this study show that social relationships benefitted by meeting other persons in the same situation in bereavement groups. Participation can give valuable meaning in life. The loss of a spouse or partner has been shown to be significantly negatively correlated with having meaning in life (-.25, -.29: n=171) and with prolonged grief disorder (.36: n=171) (35).
The findings of Oliver et al. (37) showed that using technology in bereavement can be beneficial. On Facebook, bereaved significant others shared confidential posts in private groups with a social worker as the facilitator. Members’ relationships with the deceased influenced the group’s responses; in Oliver et al.’s study, spouses offered significantly more support to each other. In addition, newly bereaved significant others received posts from significant others who suffered bereavement earlier (ibid). Sharing bereavement through social media can be a way to offer persons living far away from bereavement groups an opportunity to manage to go through the death of a loved one.
Symptom control is also a key term in palliative care for both patients and significant others and is habitually seen as physical needs (5, 11). However, the findings in this study did not seem to indicate that the symptoms of physical needs were alleviated. Rather, the benefit seemed to be psychological. This aligns with Bergman et al.’s review (14) about bereaved children who showed no physical distress in grief.
Findings from the present study demonstrate that bereavement groups were a source of a feeling of synthesis in the retrospect of the loved ones’ death. However, significant others also gave valuable advice about how to assemble the groups. Not all were comfortable in a blended group or with the time at which the bereavement process was offered. Developing groups can be challenging in rural areas as the number of bereaved is small, and thus, the number of those in need of bereavement groups is even smaller. Findings from rural Australia also confirm this. In rural areas, all significant others were offered the same bereavement support, while, in urban areas, bereavement support could be offered, for example, solely for those who were grieving the loss of a loved one from leukaemia; this distinction was appreciated by participants (23). The earlier study by Näppä et al. (17) revealed that living a large geographic distance from the groups could be a reason for not participating in bereavement groups. In the Internet age, a way to manage time and distances might be the use of online services for bereavement. This already exists but is, in general, directed to specific groups, for example, bereaved parents after the loss of a child (33, 34) or bereaved children, for example, as through CanTeen (38), a website that has a page for children with parents suffering from cancer.
This study shows that bereavement groups gave significant others the tools to accept the loss they had suffered and recognize that life must go on. Group membership has been found to provide therapeutic benefits. Small, time-limited groups can lead to intimacy and cohesiveness and promote mutual aid and support. Members in the groups benefit from opportunities to give, not just receive, assistance in the form of support, understanding, comfort, and suggestions about how to go on in life. In the long run, this empowers the bereaved and enhances their feelings of self-efficacy and ability to cope in bereavement (36, 39). However, earlier research has shown that bereavement interventions provide therapeutic outcomes close to the post-intervention time but fail to last in follow-up (18).
The findings from this study also demonstrate that the role of the palliative-care team was unexpected. Significant others experienced the support from the palliative-care team as more valuable than that from the bereavement group. The relationship that developed earlier seemed to be more valuable, yet they participated in the bereavement groups. Other research has confirmed that the close, pre-existing relationships that develop between palliative-care teams and nurses working in home-care and the family members of the patients are highly valuable. The interactions create relationships characterized by mutual sharing of understanding and trust, almost like a family (19, 40). Aoun, Rumbold, Howting, Bolleter, and Breen (41) found that about half of the significant others who had received support from a palliative-care team (n=298) felt they were given as much help as they needed from the team. Of these, only 10% participated in bereavement groups.
However, support provided by palliative-care teams is strongly related to available resources and opportunities. Caring for bereaved significant others for a long period will take resources away from the primary task of such teams – providing palliative care for living patients. Therefore, it is important to be clear regarding the set-up of work by the team while the care is on-going.
Implementing some kind of program, for example, the one described by Holm et al. (32) with three sessions by health professionals involving significant others in palliative caregiving, can be a way to support the lives of significant others following the death of a loved one.
Using the 6S for analysis may be controversial since it was developed with the goal of having a good death. Our belief is that, if the significant others experienced that their loved ones had had a good death, their own experience of grief could be connected to the 6S’s. Using this model provided a systematic structure to the analysis that was easily repeated. Studying the effectiveness of bereavement support should align with the actual settings to the greatest extent possible (42). The aim of the bereavement groups studied in this research was to provide a sense of the loved one having had a good death.
Written comments without the possibility of asking follow-up questions are always a one-way type of communication, the interviewer would have had opportunities to further develop the questions and gain more-complete responses. As it was, written comments gave the significant others opportunities to describe their experiences in regard to the influence of bereavement groups and their thoughts about the value of these groups. The time it took for participants to sit down with pen and paper gave them a chance to reflect and then record their thoughts and inner feelings without the stress an interviewer’s presence may have caused them.