https://doi.org/10.5812/ijp-150107

Loss and Bereavement: In Children

authors:

avatar Kimiya Sabagh ORCID 1 , avatar Mohammad Hosein Abdollahi Nodeh ORCID 2 , avatar Mahin Naderifar ORCID 3 , *

Department of Pediatric Nursing, School of Nursing and Midwifery, Zahedan University of Medical Sciences, Zahedan, Iran
Department of Nursing, Student Research Committee, School of Nursing and Midwifery, Zabol University of Medical Sciences, Zabol, Iran
Department of Medical Surgical Nursing, School of Nursing and Midwifery, Zabol University of Medical Sciences, Zabol, Iran
IJ Pediatrics: Vol.In Press, issue In Press; e150107
published online: February 18, 2025
article type: Review Article
received: June 26, 2024
revised: January 4, 2025
accepted: February 6, 2025

How To Cite? Sabagh K, Abdollahi Nodeh M H, Naderifar M. Loss and Bereavement: In Children. Iran J Pediatr. 2025;In Press(In Press):e150107. https://doi.org/10.5812/ijp-150107.

Abstract

Context:

Mourning following the death of a loved one is a natural and necessary process, but some people lack the skills and abilities to deal with the grief process, which can lead to many psychological problems. Bereaved children are a vulnerable population at risk of social and psychological harm.

Objectives:

The present study aimed to investigate the effects of grief on children and effective interventions to increase adaptation to it.

Evidence Acquisition:

The present study was a review-type design based on the review of the literature on loss and bereavement in children, reactions, and effective interventions. The literature search was conducted in PubMed, Scopus, and Web of Science databases, as well as in the Google Scholar search engine up to December 2024. Relevant keywords and their combinations used for the literature search were as follows: Loss, bereavement, children.

Results:

Supportive interventions in children's traumatic bereavement include cognitive behavioral therapy, developing coping skills, relaxing activities (yoga), and creative counseling techniques (expressing feelings or experiences through poems, drawings, singing, dancing, writing and drawing trauma narratives, epitaphs which are short texts performed in honor of a deceased person, holding a memorial service, holding a holiday program that focuses on helping the child cope with the grief during important family holidays).

Conclusions:

Childhood grief reactions are distinct from those in adults and are affected by developmental and contextual factors such as the age of the child and changes in caregiving environments. Empirically supported interventions can help young people to navigate the many grief-related challenges.

1. Context

A hundred years ago, death was considered a natural and accepted part of family life. However, children currently grow up in a culture that avoids grief and sadness (1). While today, mourning has become a common experience in children, and at some point in their childhood, the vast majority of children will experience the death of a close family member or friend; approximately 1 in 20 children in the United States experiences the death of a parent by the age of 16. To the extent that even in scientific research, the issue of grief in children is considered taboo. Studies of children's perceptions of death began in the 1940s (2). Early definitions and official classifications (ICD and DSM) recognized grief reactions as disorders requiring medical advice. However, this issue has changed in recent versions (3). In DSM-5, “uncomplicated grief” is mentioned as an unclassified condition (4), which should be differentiated from major depression (5). Moreover, DSM-5 has introduced the term prolonged grief disorder and ICD-11 has classified it as long-term grief disorder (2) and defined it as an intense longing for the deceased and the symptoms of grief including extreme sadness, guilt, preoccupation with the deceased loved one, avoiding remembering the loss, aggressiveness, and difficulty in trusting (6). Complicated grief can last longer than usual or expected (7) and may be developed by several factors that interfere with the grief process. These factors can include the type of relationship between the child and the deceased, the circumstances surrounding the death, and the lack of a grief support system (1).

1.1. Children’s Perception of Death

Children gradually acquire five concepts for understanding and coping with death: Irreversibility (permanence of death), individuals’ death (death comes even to the individual himself/herself), universality (death is unavoidable), inoperability (cutting off all life functions), and causality (understanding the causes of death) (8, 9). Causality refers to knowing the cause of death. The development of the understanding of the cause of death occurs during the following stages: In stage one (2 - 3 years), children often have many questions about cemeteries, caskets, and funerals. However, for them, death is still considered a temporary phenomenon. The second stage (5 - 9 years) is when children pass from Piaget's pre-operational stage to the concrete operational stage (10) to recognize that death is an irreversible phenomenon (2). At this age, due to the presence of magical thinking, the child may think that their thinking and actions caused the death of their loved one, making them feel guilty (11). The third stage (+9 years) is when an individual perceives death as a personal, final, inevitable, and universal phenomenon (2). However, the individual still thinks that only very old and weak people die. At the age of adolescence, death is accepted as a natural process, but it is perceived as too far away, and it is not easy to accept that any accident may lead to death; this is why high-risk behaviors are often observed in adolescents (11). An accurate understanding of death usually develops at 9 to 11 years of age, although brain maturation and higher-order cognitive functioning continue to develop during adolescence and early adulthood (9). Finally, with the child's further development, his/her coping mechanisms become more effective and operational (12). Nevertheless, since grief occurs during development, there is always a part of the grieving process that may need to be resolved in the future (10). Black summarizes children's levels of perception of death and the symptoms of complicated grief as shown in Table 1 (1).

Table 1.

Black's Stages of Childhood Grief

Age (y)Meaning of DeathSymptoms of Complicated Grief
3 - 5Does not understand the permanence of death; repeatedly asks for the deceased person.Anxiety, and regressive behaviors more than 6 months after the death
6 - 8Understands death is permanent; assumes blame, and guilt for death.School refusal; physical symptoms; suicidal thoughts; regressive behavior
9 - 11Demands detailed information; increased expression of anger.Shuning friends; increased moodiness 3 - 6 months after the death
12 - 14Acts callous, indifferent, and egocentric; describes conversations with deceased.School refusal; persistent depression, drug or alcohol use; associates with delinquents; precocious sexual behavior
15 - 17Expresses thoughtfulness and empathy; feels overwhelmed by survivors’ emotional dependence and grief.Mood swings; withdrawal from friends and group activities; poor school performance; high-risk behaviors, such as drug use

1.2. Children's Reactions to Grief and Loss

Children do not "overcome" their grief but rather learn to live with the loss of their loved ones and adapt to it (13). The grief process of a child is not different from that of an adult. Children also go through the stages of denial, anger, and depression to accept the loss and grief, but there are minor differences in terms of behavior (14). For example, grief in children is considered intermittent (15), oscillating between short stages of extreme sadness and stages of apparently normal behavior. This stems from children's limited capacity to endure intense emotions for long periods and their inability to verbalize these experiences appropriately (9). Additionally, since children's speech ability is not yet fully developed, they have difficulty expressing their grief verbally (16) and prefer to express their feelings indirectly, mainly through games and drawings (17).

In general, a child's reaction to grief depends on several variables: Their relationship with the person who was lost, the reaction of other family members, the presence or absence of preparation for the event, the child's personality, mental resilience, and developmental stage or age (6). Behavioral disorders are also likely to occur in grieving children (18). Thus, a child known to be calm may exhibit delinquent and aggressive behaviors (19). Over time, childhood grief increases the child's sensitivity to problems with the law, school issues, and depression (20). Common and natural reactions of a grieving child include moodiness, crying or laughing without reason, destructive tendencies, isolation, developing phobias, behavioral regression, reduced school performance (21), and physical symptoms such as sleep problems, nocturia, loss of appetite, and anorexia (9).

Studies have shown that grieving children up to 2 years after the death of their parents have higher levels of disorders and emotional symptoms than non-grieving children (22). If grief counseling is not available during the formative years leading to adulthood, grieving children are more likely to develop psychophysical and socioeconomic consequences (9). Some reasons for not providing services to children include unrealistic public expectations, disagreements among mental health professionals about the need for services for grieving children, and the lack of information about the grief process in children (1).

Lewenberg and Goldring listed age-appropriate activities for dealing with grief:

- Children at the ages of 2 to 5 develop self-centered ways and magical thinking and are afraid to go to sleep when they are told that someone who has died has fallen asleep.

- Children from 6 to 9 years of age consider death to be a visit to heaven. Supportive activities include listing changes they can or cannot control, writing down how they see themselves and how others see them, and writing down their feelings.

- Restrictions should be placed on scary or disturbing games for children between the ages of 6 and 11. Parents should also consider taking time to read a book or pay attention to the child's feelings through games.

- Children between the ages of 12 and 18 can be encouraged to engage in discussions, express their frustrations through art, music, gardening, and sports, or handle their feelings of guilt, shame, embarrassment, or revenge as normal emotions (2).

The cause of death can have different effects on bereaved people. Those who lost someone to a sudden death reported more intense grief experiences, more complex grief symptoms, and less social acceptance of their experiences than those who lost someone to a "non-sudden" death, regardless of the type of death experienced. Specifically, unexpected death was associated with higher levels of abandonment, seeking an explanation for the loss, feelings of guilt and responsibility for the death, engaging in destructive behaviors, and shame. Sudden deaths interfere with the capabilities of the bereaved person (23, 24). Sudden and violent deaths usually include deaths from accidents, suicide, or murder. Any sudden loss makes it difficult for the relatives to understand the reality of the death of a close family member and prevents the bereaved relatives from saying their final goodbyes and performing the last services for that loved one. Furthermore, violent deaths can occur in gruesome ways, and relatives are helpless witnesses. After a sudden and violent death, the body may be severely mutilated or disfigured, which can prevent the body from being seen (24, 25).

While culture is recognized as an essential element of one's life, its impact is never more evident than when one is going through the grieving process. A family's culture can dictate established traditions for mourning. Some researchers argue that grief is not the same across cultures and that different groups experience different levels of emotional intensity (26, 27). People in some cultures tend to grieve more intensely and for longer (or less in some cultures) than many Europeans and Americans. Balinese people almost never look sad or upset in mourning and try to present a happy and smooth emotional appearance. In the United States, where there are thousands of cultures, there are significant cultural differences in mourning. For example, a large number of African Americans believe that whites grieve with much less intensity or display of emotion than Africans in the early stages of grief. European Americans often suppress mourning (28, 29).

2. Evidence Acquisition

The present study was a review-type design based on the review of the literature on Loss and bereavement in children, reactions and Effective interventions.

2.1. Search Strategy and Data Collection

The literature search was conducted in PubMed, Scopus, and Web of Science databases, as well as in the Google Scholar search engine, up to December 2024. Relevant keywords and their combinations used for the literature search were as follows: Loss, bereavement, children.

2.2. Inclusion Criteria and Data Extraction

We included studies that examined grief and loss in children, children's reactions to grief, and effective interventions. A total of 820 articles were selected for further evaluation. After reviewing the titles and abstracts of the remaining articles and excluding irrelevant studies, 120 studies were selected for screening of titles and full-text review. Finally, 41 studies were included in the final review. The following data were extracted from eligible studies: Name of the first author, year of publication, study site, study population, number of participants in study groups, and interventions (Figure 1).

Study selection process
Study selection process
Figure 1.

Study selection process

3. Results

3.1. The Role of Nurses in Dealing with Grieving Children

The main key and one of the most effective treatments in grief interventions is to talk about the deceased's death and related feelings (30, 31). Given the high emotional load of grief, children may feel uncomfortable expressing their suffering. Thus, it is necessary to use verbal skills and counseling services along with other strategies and enjoyable and appropriate activities such as storytelling, games, collage making, diaries, drama, role-playing, book therapy, and all kinds of non-verbal activities that can help children express their feelings and thoughts about the death of their loved ones (6). Other supportive interventions in children's traumatic bereavement include cognitive behavioral therapy, developing coping skills, relaxing activities (yoga), and creative counseling techniques (expressing feelings or experiences through poems, drawings, singing, dancing, writing and drawing trauma narratives, epitaphs which are short texts performed in honor of a deceased person, holding a memorial service, holding a holiday program that focuses on helping the child cope with the grief during important family holidays) (26, 32-34). Finally, it is necessary to help children understand that seeking professional help does not indicate their weakness or mental illness, but rather it is a sign of their strength in recognizing pain and courage to move forward in life (6).

Depending on how the person copes with the death, grief consequences can be both positive and negative. Possible positive effects include personal growth, maturity, and a positive impact on the child's compassion. Negative consequences include temporary cognitive and emotional problems such as confusion, inability to focus on schoolwork, sleep disorders, and disturbing dreams, which may have serious consequences on school performance and career aspirations (20). It is very important to recognize the trauma experienced by grieving children (1). Thus, nurses can play an effective role in meeting the needs of the grieving child through the early implementation of a comprehensive assessment, management education about the benefits of grief support, initiating appropriate referrals, and providing grief support (1). Acknowledging the loss, active listening, and allowing family caregivers to express their feelings and tell their story are important ways that nurses can use (35).

There is a lack of evidence-based strategies to guide health professionals in providing optimal support during caregiver care and after a patient's death. There is evidence that the implementation of clinical guidelines, protocols, and tools facilitates improved care.

Part 1: Setting up the family caregiver support guide.

Part 2: Assessing the needs and creating a care guidance plan, conducting a needs assessment with family caregiver(s).

Part 3: Preparing dying instructions (if applicable, help family caregivers learn how to recognize signs of impending death and potential implications for the patient's care needs) (36).

Other recommendations for improving existing support for bereaved people include: Training and capacity building for current mental health workers, resource allocation and task sharing, prioritizing staff psychosocial well-being, increasing the provision and adaptation of services, including providing more resources and expanding national supports as well as regional services in areas with long waiting lists, and attention to the characteristics of interventions and support programs (37-39).

Unfortunately, it seems that nurses cannot spend as much time as grieving children need. Most baccalaureate nursing curricula have limited programs on pediatric grief. In addition, the lack of evidence-based guidelines has left nurses with inadequate tools and expertise to care for grieving children (20). Teaching nursing students about loss, grief, and bereavement should also be an interactive process to stimulate critical thinking and address the emotional domain of learning. Modules, case studies, and simulated scenarios using role-playing, speech, and sharing personal and professional experiences of loss improve psychomotor skills and knowledge. Structured simulated experience can provide skills and knowledge for the nurse's role when providing care of loss (40, 41). Therefore, nursing educators should include the assessment and management of complex grief at all levels of the nursing curriculum and conduct educational research to measure the effectiveness of adding content related to this topic (35).

4. Conclusions

Childhood grief reactions are distinct from those in adults and are affected by developmental and contextual factors such as the age of the child and changes in caregiving environments. Empirically supported interventions can help young people navigate the many grief-related challenges.

References

  • 1.

    Auman MJ. Bereavement support for children. J Sch Nurs. 2007;23(1):34-9. [PubMed ID: 17253893]. https://doi.org/10.1177/10598405070230010601.

  • 2.

    Kentor RA, Kaplow JB. Supporting children and adolescents following parental bereavement: guidance for health-care professionals. Lancet Child Adolescent Health. 2020;4(12):889-98. https://doi.org/10.1542/peds.2016-2147.

  • 3.

    Killikelly C, Merzhvynska M, Zhou N, Stelzer EM, Hyland P, Rocha J, et al. Examination of the New ICD-11 Prolonged Grief Disorder Guidelines Across Five International Samples. Clin Psychol Eur. 2021;3(1). e4159. [PubMed ID: 36397782]. [PubMed Central ID: PMC9667123]. https://doi.org/10.32872/cpe.4159.

  • 4.

    Horwitz AV. The medicalization of grief. In: Jacobsen MH, Petersen A, editors. Exploring Grief: Towards a Sociology of Sorrow. Abingdon, Oxfordshire: Routledge; 2019. p. 171-87.

  • 5.

    Moayedoddin B, Markowitz JC. Abnormal Grief: Should We Consider a More Patient-Centered Approach? Am J Psychother. 2015;69(4):361-78. [PubMed ID: 26802420]. https://doi.org/10.1176/appi.psychotherapy.2015.69.4.361.

  • 6.

    Jamshidi Sianaki M, Mazaheri MA, Zadeh Mohammadi A. [Grief intervention for helping bereaved children]. Rooyesh-e-Ravanshenasi J. 2016;5(1):129-64. FA.

  • 7.

    Iglewicz A, Shear MK, Reynolds C3, Simon N, Lebowitz B, Zisook S. Complicated grief therapy for clinicians: An evidence-based protocol for mental health practice. Depress Anxiety. 2020;37(1):90-8. [PubMed ID: 31622522]. https://doi.org/10.1002/da.22965.

  • 8.

    Keshavaraz N, Firouzkouhi M, Abdollahimohammad A, Naderifar M, Jahantigh M. Effect of telenursing on stress, anxiety and depression in patients with myocardial infarction. Neuropsychiatria i Neuropsychologia. 2021;16(1-2):76-81. https://doi.org/10.5114/nan.2021.108036.

  • 9.

    Ridley A, Frache S. Bereavement care interventions for children under the age of 18 following the death of a sibling: a systematic review. Palliat Med. 2020;34(10):1340-50. [PubMed ID: 32807009]. https://doi.org/10.1177/0269216320947951.

  • 10.

    Kanwal W, Mehmood K, Perveen R. Development of skills at the preoperational stage; A comparative study on Cognitive development of Urban and rural children. JECCE. 2023;7(1).

  • 11.

    Aramesh Z, Berimani P. [Bereavement in children and acceptance of death]. 17th International Conference on Psychology, Counseling and Educational Sciences. 2023. FA.

  • 12.

    Frydenberg E, Deans J, Liang R. Developing Coping Skills in the Early Years: A Positive Educational Approach. In: Kern ML, Wehmeyer ML, editors. The Palgrave Handbook of Positive Education. Cham: Springer; 2021. p. 369-93.

  • 13.

    Cohen JA, Mannarino AP. Supporting children with traumatic grief: What educators need to know. Sch Psychol Int. 2011;32(2):117-31. https://doi.org/10.1177/0143034311400827.

  • 14.

    Morais C. Face à un enfant endeuillé en structure d'accueil, quel accompagnement peut apporter l'éducatrice de l'enfance?. 2015. Available from: https://folia.unifr.ch/global/documents/317721.

  • 15.

    Chachar AS, Younus S, Ali W. Developmental Understanding of Death and Grief Among Children During COVID-19 Pandemic: Application of Bronfenbrenner's Bioecological Model. Front Psychiatry. 2021;12:654584. [PubMed ID: 34658940]. [PubMed Central ID: PMC8511419]. https://doi.org/10.3389/fpsyt.2021.654584.

  • 16.

    Schweich T, Luxen T, Bell C, Federspiel J. Grief in Children and Adolescents. In: Böhmer M, Steffgen G, editors. Grief in Schools: Basic Knowledge and Advice on Dealing with Dying and Death. Berlin, Heidelberg: Springer Berlin Heidelberg; 2022. p. 29-68. https://doi.org/10.1007/978-3-662-64297-9_3.

  • 17.

    Alvis L, Zhang N, Sandler IN, Kaplow JB. Developmental Manifestations of Grief in Children and Adolescents: Caregivers as Key Grief Facilitators. J Child Adolesc Trauma. 2023;16(2):447-57. [PubMed ID: 35106114]. [PubMed Central ID: PMC8794619]. https://doi.org/10.1007/s40653-021-00435-0.

  • 18.

    Watts-Figueroa C, McCallum AR. Military and veteran communities' experiences with grief. In: Turner RB, Stauffer SD, editors. Disenfranchised Grief: Examining Social, Cultural, and Relational Impacts. New York, Iran: Routledge; 2023.

  • 19.

    Institute of Medicine (US) Committee. CHAPTER 5, Bereavement During Childhood and Adolescence. In: Osterweis M, Solomon F, Green M, editors. Bereavement: Reactions, Consequences, and Care. Washington (DC): National Academies Press; 1984. https://doi.org/10.17226/8.

  • 20.

    Lohan JA. School nurses' support for bereaved students: a pilot study. J Sch Nurs. 2006;22(1):48-52. [PubMed ID: 16435930]. https://doi.org/10.1177/10598405060220010801.

  • 21.

    Morell-Velasco C, Fernandez-Alcantara M, Hueso-Montoro C, Montoya-Juarez R. Teachers' Perception of Grief in Primary and Secondary School Students in Spain: Children's Responses and Elements which Facilitate or Hinder the Grieving Process. J Pediatr Nurs. 2020;51:e100-7. [PubMed ID: 31928803]. https://doi.org/10.1016/j.pedn.2019.12.016.

  • 22.

    Robinson SK. Healing stories: Bibliotherapy and art therapy as tools to support bereaved children, a literature review[thesis]. Lesley University; 2022.

  • 23.

    Krychiw JK, James R, Ward-Ciesielski EF. Suddenness of death as a determinant of differential grief experiences. Bereavement Care. 2018;37(3):92-100. https://doi.org/10.1080/02682621.2018.1539312.

  • 24.

    Domino JL, Whiteman SE, Davis MT, Witte TK, Weathers FW. Sudden unexpected death as a traumatic stressor: The impact of the DSM–5 revision of Criterion A for posttraumatic stress disorder. Traumatology. 2021;27(2):168-76. https://doi.org/10.1037/trm0000272.

  • 25.

    Kristensen P, Weisaeth L, Heir T. Bereavement and mental health after sudden and violent losses: a review. Psychiatry. 2012;75(1):76-97. [PubMed ID: 22397543]. https://doi.org/10.1521/psyc.2012.75.1.76.

  • 26.

    Thanasiu PL, Pizza N. Constructing Culturally Sensitive Creative Interventions for Use with Grieving Children and Adolescents. J Creativity Mental Health. 2019;14(3):270-9. https://doi.org/10.1080/15401383.2019.1589402.

  • 27.

    Silverman GS, Baroiller A, Hemer SR. Culture and grief: Ethnographic perspectives on ritual, relationships and remembering. Death Stud. 2021;45(1):1-8. [PubMed ID: 33272138]. https://doi.org/10.1080/07481187.2020.1851885.

  • 28.

    Rosenblatt PC. Family grief in cross-cultural perspective. Fam Sci. 2013;4(1):12-9. https://doi.org/10.1080/19424620.2013.819226.

  • 29.

    Ayebare E, Lavender T, Mweteise J, Nabisere A, Nendela A, Mukhwana R, et al. The impact of cultural beliefs and practices on parents' experiences of bereavement following stillbirth: a qualitative study in Uganda and Kenya. BMC Pregnancy Childbirth. 2021;21(1):443. [PubMed ID: 34172018]. [PubMed Central ID: PMC8228937]. https://doi.org/10.1186/s12884-021-03912-4.

  • 30.

    Sormanti M, Ballan MS. Strengthening grief support for children with developmental disabilities. Sch Psychol Int. 2011;32(2):179-93. https://doi.org/10.1177/0143034311400831.

  • 31.

    Zhou N, Smith KV, Stelzer E, Maercker A, Xi J, Killikelly C. How the bereaved behave: a cross-cultural study of emotional display behaviours and rules. Cogn Emot. 2023;37(5):1023-39. [PubMed ID: 37357869]. https://doi.org/10.1080/02699931.2023.2219046.

  • 32.

    Weber Falk M, Alvariza A, Kreicbergs U, Sveen J. The grief and communication family support intervention: Intervention fidelity, participant experiences, and potential outcomes. Death Stud. 2022;46(1):233-44. [PubMed ID: 32072870]. https://doi.org/10.1080/07481187.2020.1728429.

  • 33.

    Edgar-Bailey M, Kress V. Resolving Child and Adolescent Traumatic Grief: Creative Techniques and Interventions. J Creativity Mental Health. 2010;5(2):158-76. https://doi.org/10.1080/15401383.2010.485090.

  • 34.

    Kirwin KM, Hamrin V. Decreasing the risk of complicated bereavement and future psychiatric disorders in children. J Child Adolesc Psychiatr Nurs. 2005;18(2):62-78. [PubMed ID: 15966949]. https://doi.org/10.1111/j.1744-6171.2005.00002.x.

  • 35.

    Tofthagen CS, Kip K, Witt A, McMillan SC. Complicated Grief: Risk Factors, Interventions, and Resources for Oncology Nurses. Clin J Oncol Nurs. 2017;21(3):331-7. [PubMed ID: 28524889]. https://doi.org/10.1188/17.CJON.331-337.

  • 36.

    Hudson P, Remedios C, Zordan R, Thomas K, Clifton D, Crewdson M, et al. Guidelines for the psychosocial and bereavement support of family caregivers of palliative care patients. J Palliat Med. 2012;15(6):696-702. [PubMed ID: 22385026]. [PubMed Central ID: PMC3362953]. https://doi.org/10.1089/jpm.2011.0466.

  • 37.

    Kane JC, Adaku A, Nakku J, Odokonyero R, Okello J, Musisi S, et al. Challenges for the implementation of World Health Organization guidelines for acute stress, PTSD, and bereavement: a qualitative study in Uganda. Implement Sci. 2016;11:36. [PubMed ID: 26979944]. [PubMed Central ID: PMC4793547]. https://doi.org/10.1186/s13012-016-0400-z.

  • 38.

    Harrop E, Goss S, Farnell D, Longo M, Byrne A, Barawi K, et al. Support needs and barriers to accessing support: Baseline results of a mixed-methods national survey of people bereaved during the COVID-19 pandemic. Palliat Med. 2021;35(10):1985-97. [PubMed ID: 34676792]. [PubMed Central ID: PMC8637353]. https://doi.org/10.1177/02692163211043372.

  • 39.

    Inhestern L, Haller AC, Wlodarczyk O, Bergelt C. Psychosocial Interventions for Families with Parental Cancer and Barriers and Facilitators to Implementation and Use - A Systematic Review. PLoS One. 2016;11(6). e0156967. [PubMed ID: 27276079]. [PubMed Central ID: PMC4898703]. https://doi.org/10.1371/journal.pone.0156967.

  • 40.

    O'Shea ER, Campbell SH, Engler AJ, Beauregard R, Chamberlin EC, Currie LM. Effectiveness of a perinatal and pediatric End-of-Life Nursing Education Consortium (ELNEC) curricula integration. Nurse Educ Today. 2015;35(6):765-70. [PubMed ID: 25771263]. https://doi.org/10.1016/j.nedt.2015.02.015.

  • 41.

    Cole MA, Foito K. Pediatric End-of-life Simulation: Preparing the Future Nurse to Care for the Needs of the Child and Family. J Pediatr Nurs. 2019;44:e9-e12. [PubMed ID: 30266527]. https://doi.org/10.1016/j.pedn.2018.09.005.