The GPs described four tensions concerning their understandings of grief, when to intervene, intervention role, and education needs. These tensions demonstrate a lack of clarity and consistency and a ‘piecemeal’ approach to the provision of bereavement care amongst GPs.
The view of grief as a standardised process contrasts with contemporary models of grief as unique and multi-dimensional, and a process that oscillates between loss and restoration
[13, 31]. These beliefs indicate a lack of knowledge of current models and theories of grief and do not allow for the range of grief experiences and different types of losses. The findings reflect those of Wiles et al.
, who reported that GPs focussed on grief as a very concrete experience with distinct phases and stages. An expectation that there is a ‘natural’ time to move on could also place stress on people to conform and result in people feeling isolated and stigmatised in a time of vulnerability
. The unique, multifaceted nature of grief needs to be emphasised in GP education at all levels so that this conceptualisation of grief becomes the norm rather than the stage-based, time-bound model.
The second tension related to whether the GP sees him/herself as a provider of support or a broker of support involving referral to mental health professionals. This is an interesting paradox in that bereavement, for most people, is a natural event that they will accommodate with minimal support
. However, a significant minority will need extra support
. The GP is ideally placed to listen and use empathy as they tend to have an ongoing relationship with the patient established over a number of years. They can also ask questions to see if the patient is coping, prescribe pharmacological treatments if deemed necessary, and refer if appropriate (see Lobb et al.
 for a checklist for GPs to use). However, education is needed to emphasise that the GP does not have to resolve all the issues and that the use of specialised strategies such as cognitive behavioural therapy and counselling require a high level education and training, and timely and appropriate referral to specialist mental health professionals for these approaches may be appropriate
Effective communication is essential for both the ‘provider’ and ‘broker’ roles and, again, training would be useful. Community pharmacists face similar issues concerning how to speak to grieving clients when people bring back medications for disposal or want to talk about the death of their family member who may have been using the same community pharmacy for years
. It is also important to note that many people may not ask for help or bring up distress without being prompted. Hence, there is a role for education on asking questions
[6, 36] and eliciting emotional cues
Findings on referral reflect those of Siegal et al.
 who found that, for general psychological issues, GPs would refer when they felt they had reached the limit of their skills, did not have time to spend with the patient and when they deemed the patient suitable and ready. One barrier to referral these authors identified was that GPs disliked the lack of feedback from mental health professionals. In the current study barriers to referral, such as bureaucracy, liaison with other health care professionals and the time needed for referral, need to be challenged at the systemic level. However, some barriers, such as knowing who to refer to and where to obtain resources, such as lists of appropriate contacts or web pages, could be remedied and improved by education and continuing professional development, and also by simple solutions such as a calendar with key web addresses and telephone numbers. Lobb et al.
 published a list of key resources in Australia for GPs, which could be updated regularly.
In terms of assessing grief support needs of patients, it is important that GPs acknowledge the circumstances of the death and previous experience with death, and recognise that these factors may affect grief. However, each GP could have a different idea about what is the ‘worst’ type of loss and these conceptualisations could be affected greatly by personal experiences. Complicated or prolonged grief reactions may be more related to background factors such as relationship with the person who has died or attachment style
[39, 40]. Without adequate education, GPs may overlook these factors and place undue emphasis on situational factors such as type of death or age of the person who died.
The idea of resilience reflects the public health model of grief, which emphasises that most people do not need any extra support other than family or friends, some people need community supports, and a significant minority need access to a mental health professional
. Grief education needs to alert GPs to the range of responses. The promotion of resiliance is an ideal approach for the majority of people but education is needed to highlight that, at times, additional support is needed e.g. information on support groups or helplines and, for a minority of people; referral is appropriate
There is a distinct lack of education at the undergraduate degree level for grief and bereavement, and a gap in ongoing professional development in the area. This was mentioned by participants with years of experience as a GP as well as those with less experience. Analyses of American, British, and Australian medical courses demonstrate that most presented some information on grief but the information was inadequate and lacked depth or detail (e.g.
[14–18]). This gap needs to be rectified if GPs are to play an active role in supporting bereaved patients and making appropriate and timely referrals.
Some GPs advocated the need to learn from experience and some felt that personal experience of loss was necessary in responding to and supporting others in a sensitive or empathetic way. This latter point contradicts findings from research with palliative care patients, which indicates the need for professional distance and that GPs’ identification with patients may be problematic and have an emotional impact
. Limited education in death, dying and grief not only affects the provision of sensitive, timely and appropriate support for bereaved patients; it also affects GPs. Reliance on personal experience could lead to over identification with patients, stress, and ultimately burnout. Education acts as a protective factor when dealing with death and dying
. The use of clinical review and case studies could be useful for GPs who prefer experiential learning while protecting them from secondary trauma and burnout
Limitations and future research
The use of interviews and their systematic analysis provided a contextual and data-driven account of bereavement practice of GPs in Western Australia; this is important as it is the first such study in Australia. However, the findings might not be transferable to GPs working in other contexts. Additionally, we did not collect information concerning each participant’s background, such as ethnic identity or religious affiliation, and these demographics could potentially impact the data and their interpretations. GPs are generalists and busy people and, as a consequence, some interviews were quite short. A convenience sample was used, which means the results may reflect a partial overview. As such, a survey design, based on the findings from the current study, could capture further information from a larger and more representative sample.