Bereavement care during Covid - the last 6 months
Since May 2020 National Bereavement Care Pathway Scotland has invited the 14 NHS Boards in Scotland to provide regular feedback on the impact of COVID-19 measures on their usual bereavement care following loss in pregnancy or after birth. The feedback form asked about a range of 21 aspects of care such as partner support, sensitive communication, suitable rooms for care, choices about birth options, appropriate follow up and reviews, parents providing care in neonatal units, trained and supported staff. We use 3 measures to understand the impact of Covid.
- The number of boards reporting they are unable to provide their usual care - blue line.
- The number of aspects of care that are harder to deliver from the range of 21 aspects we asked about - red line.
- The total number of aspects of care that are harder to deliver in all units in boards unable to provide their usual care - green line.
The aim was to help NBCP Scotland to build a picture of the impact of Covid measures over time and we share regular reports with Heads of Midwifery in all boards. We can now look back over the last 6 months where we see clear improvements and issues to consider for the future.
May and June
Almost all of the 11 boards responding in May found their usual bereavement care was harder to deliver. It was clear that caring for women separated from partners and families is very challenging for patients and staff. By June the number of boards unable to provide usual care had fallen to half of the boards responding. However Covid measures continued to make a significant impact with the total number of different aspects of care affected across all units and services reducing by only a third. It was possible to identify areas of concern which need to be considered where measures that affect compassionate and sensitive bereavement care will remain in place or have to be reintroduced. These are support for partners, care after discharge (particularly follow up appointments and reviews), sensitive communication, remote care via phone or video, staff training and support (particularly for new starts, redeployees and students).
NBCP Scotland’s Core Group agreed we should work collaboratively to continue to
(a) understand the impact of changes to usual bereavement care and of new ways to deliver care, particularly on Boards’ ability to achieve Bereavement Care Standards particularly Standards 1 – Continuity of care and 6 – Listening to parents.
(b) develop and signpost advice, resources and support for example by publishing further online training and support pages alongside the National Bereavement Care Pathways on the NBCP website.
Boards’ efforts to overcome bereavement care challenges and resume their usual care have resulted in many improvements. This is encouraging because the staged reintroduction of visiting only began from 13th July and the target date for resuming usual bereavement care is 31st August. Two changes to practice are seen as new ways of delivering care long term
- remote care by phone or video, especially for early loss
- staff and patients wearing face masks and other PPE.
Boards are expected to pay close attention to individual parents’ wishes to meet Bereavement Care Standard 6 – ‘All staff listen carefully to bereaved parents, offer them informed choices about their care and the care of their babies, and are guided by their wishes’. Over the last 3 months, the feedback does not suggest that staff were able to offer women and partners choices about remote or in person care, although this may be the case. Whilst comments suggest parents accept the need for and can be reassured by PPE, there is a negative effect on communication before, during and after bereavement. Sands have developed guidance on compassionate communication while wearing PPE.
Boards have largely resumed their usual bereavement care and the position in the 6 weeks between August and mid-September is much the same as that seen in July. The aspects of care that remain harder to deliver in some Boards are beyond the scope of staff providing first line care – arranging or delays with certification or registration, post mortem or test results and providing appropriate follow up appointments or reviews.
These aspects come under Bereavement Care Standard 1 – ‘A parent led approach is taken, providing continuity of care and management of transitions between settings and into any subsequent pregnancies’. Whilst parents may accept disruptions and delays during the pandemic, misleading or contradictory information would cause avoidable distress. Waiting for delayed follow up and review may well add to parents’ trauma. Two expectations in the National Bereavement Care Pathway are relevant: appropriate staff give accurate and realistic information on processes and timescales and all staff keep within the scope of their practice when answering parents’ questions.
A significant majority of boards are now able to provide their usual bereavement care. The number of boards unable to do so has fallen to 3 in the 6 weeks between mid-September and end of October, whereas consistently throughout the summer and up to mid-September 6 boards were unable provide their usual care. We asked respondents to say what has improved most since May. Their responses reflect how important it has been to allow partners and family members to be with women during antenatal care, labour and birth, postnatal care and in neonatal units.
However the feedback for this period shows some marked increases and changes in the aspects of care a few boards are unable to provide. These clearly demonstrate the impact that stretched staff capacity can have on the quality and consistency of bereavement care. For the first time since early summer, key aspects reappear - time to listen to parents and support informed choices; continuity of care in hospital or community healthcare; appropriately trained and supported staff; additional support during next pregnancies e.g. extra scans, longer appointments.
It seems very likely that more boards will experience staffing limitations over the winter with the potential for urgent arrangements to disrupt care and the risk of added distress for parents and staff. The expectations for staff care in the National Bereavement Care Pathways are relevant: aim to provide an emotionally supportive environment for staff where challenges can be discussed openly and individual needs are acknowledged and met.