Why assessment tools?
Services and their staff offering bereavement care need to demonstrate ‘best practice’ by:
- Working towards agreed practice standards set out in ‘Bereavement Care Service Standards’ 2014;
- Recognising the need to provide appropriately varied provision for the varied needs of bereaved clients. Increasing use is being made of the NICE guidance on appropriate levels of intervention;
- Ensuring that intervention standards are being reached through monitoring processes and recording outcomes;
- Addressing the requirement of commissioning bodies for evidence of appropriate and effective interventions.
Implementing the AAG – an organisational process:
i) Starting point: a) an understanding by service managers about the rationale for assessment tools, b) motivation to explore the administrative and clinical implications of adopting a particular measure, c) agreement by senior staff to initiate an assessment procedure.
ii) Initiation: a) organisation-wide discussion about the measure and the implication for practice, b) induction/training on the measure, focusing on providing appropriate knowledge and skills, c) organisational strategy for its implementation i.e. clinical and administrative procedures, including recording systems, put in place.
iii) Implementation: a) ‘ownership’ of the approach to assessment and practice by mangers/team leaders, administrative staff and practitioners, b) piloting the process, c) adjustment of the practice strategies in the light of the piloting, d) full implementation, e) audit and review of the measure in practice, f) accumulation of statistical data to inform practice, justify funding and where appropriate for wider dissemination.
Practice use of the AAG
Within bereavement and palliative care settings interest and enthusiasm for using the Adult Attitude to Grief scale (AAG) has grown considerably and with it the need for clear guidance about its use in practice. This website is designed to help managers make informed strategic choices about assessment determined interventions within services and practitioners make appropriate and effective use of the AAG, and/or any of the authorised but yet to be validated modified versions (AHC, CAG, ALL) in their support of grieving people.
A step by step approach sets out the process of working with the AAG. Whilst it is meant to provide simplicity and clarity, the application of the scale should always be undertaken within the frame of wider professional judgment and expertise if it is to be a flexible and sensitive tool for practice.
The AAG is free to download from the resource page of this site but users are required to agree to use it without modification and in the way set out (see protocol below) by the copyright holder, Linda Machin. (See contact page)
To Download the AAG Practice Record Sheet go to the Resource page.
A protocol for using the Adult Attitude to Grief scale (AAG) in practice
These procedures also inform the range of practice competencies required for working with the AAG i.e. clear information giving about the uses and purpose of the AAG; ensuring client consent; introducing and using the AAG appropriately; ability to appraise the quantitative narrative and qualitative scores; ability to interpret responses in a way which can lead to appropriate interventions; use of the AAG for learning within supervision. All of these elements need to be contextualised within the clinical competence and judgement of the practitioner.
The AAG can be used as a standard form of assessment within a bereavement service or used selectively i.e. where it is seen to be appropriate for an individual client /service user.
Timing – when to use the AAG? While benefit can be derived from the conversation which the AAG prompts at any point on the grief journey its function in assessment is best completed at least two months post bereavement. At this point the natural vulnerability which is likely to be evident in most people who have suffered a significant loss is likely to have lessened and the core grief reactions are beginning to be addressed by a focus on coping.
When a service adopts the AAG as an assessment tool it is likely to be used in one of several ways: a) as a preliminary process, undertaken by someone designated to assess client need, ahead of allocation to an individual practitioner; b) at a first session with an allocated practitioner; c) at second session if, for example, the client/service user was very distressed at the initial session. Repeat use of the AAG will occur for monitoring and review at appropriate times in the help process.
A. Introducing the AAG to clients/service users
- Explain how the AAG scale is used:
i) explain the purpose of the scale – to help client / service user and practitioner have a clear picture of how grief is being experienced and expressed.
ii) explain how the AAG is used in the service and by the practitioner – to help decide the most appropriate form of support or intervention.
iii) give a copy of the scale to the client/service user; explain the 5 choices associated with each item on the scale (from strong agreement to strong disagreement).
iv) assure the client / service user that there are no right or wrong answers.
2. Gain informed consent/agreement to use the AAG:
Having given the explanations above (1), provide information on your organisation’s policy on record keeping, confidentiality and use of collected data e.g. for audit, research or funding purposes (this is likely to form part of a general contracting process, including GDPR compliance information/permission).
Where a client /service user is hesitant, reassurance can be given about their right to withdraw from proceeding with the AAG’s use at any point.
- Use of the scale:
i) decide how the scale will be used i.e. who will read out the statements and agree the practitioner will record the responses.
ii) encourage the client / service user to say more about each of the 9 statements in the scale in order to:
- clarify any aspects/specific words in the scale which are unclear to them. This may involve finding an alternative word/phrase but bear in mind it is important to retain the RRL concepts which lie behind the words i.e. 2,5,7 – the dominance of overwhelmed emotion; 4,6,8 – the dominance of emotional control; 1,3,9 the evidence of effective/resilient coping.
- encourage them to say more about the thoughts and feelings which each statement in the scale brings up for them.
- use the statements to prompt a wider exploration of the their circumstances e.g. social support, cultural factors, existential perspectives.
This AAG provides a practice framework within which qualitative responses by the client/service user provide an opportunity for fuller exploration of the experience and expressions of grief. This use of the AAG enhances clinical engagement at the time of assessment and can be used throughout the helping process to prompt reflective conversation.
B. On completion, discuss the responses to the scale with the client/service user:
i) ask how they felt using the scale.
ii) ask whether there were particular items and themes in the scale which stood out as being significant or troubling to them.
iii) reflect back any of the most obvious dominant issues e.g. predominantly emotion focused, predominantly avoiding emotion, emerging from the responses to the scale.
C. Understanding and interpreting the AAG responses
There are five steps to evaluating the information provided by the AAG:
i) The Vulnerability Indicator score is to help the practitioner have an overview of the level of intensity of the client’s / service user’s grief and the level of support this signals. (Vulnerability indicator scale: 0-36 where >24 is severe vulnerability, 21-23 is high vulnerability and <20 is low vulnerability).It will be supplemented by other clinical judgement about the client’s vulnerability and needs.
It is important NOT to use a score / numbers sheet with clients as this can convey a sense of being tested and may prevent honest responses.
Always remember that if you are using the scores to look at individual categories, especially changes taking place over time, that the ‘resilient’ score, having been reversed, is in fact giving you a measure of vulnerability.
Table 1. AAG score to aid the exploration of the quantitative responses to the scale.
Exploring the AAG scores
ii) Look for evidence of a bias towards one or other of the three categories in the scale, by examining the quantitative and qualitative responses to; items 2, 5 and 7 (overwhelmed), items 4, 6 and 8 (controlled) and items 1, 3 and 9 (resilient).
In practice there may not be a clear bias but rather a mix of agreement across the categories requiring more careful interpretation (see iii, iv and v below).
iii) Examine the relationship between the O, C and R:
- Heightened vulnerability will result where there is equally (strong) agreement with both the overwhelmed and controlled items i. e. a tension between aspirations for control and unbidden strong feelings of grief.
- Where there is disagreement with the resilient items, the characteristics which underpin positive coping with loss, and some degree of agreement with the overwhelmed and controlled* items, vulnerability is likely to be evident.
- Conversely, where there is agreement with the resilient items the overwhelmed and controlled reactions will be moderated and this will lead to an increased capacity for effective coping.
*It is important to remember that ‘control’, in addition to being a reflexive reaction to loss, can also be a potentially effective coping mechanism. Where there is agreement with the controlled and resilient items the client/service user is likely to be coping effectively i.e. defensiveness or avoidance are not preventing appropriate management of grief and its consequences.
iv) Focus on each item in the AAG which the client/service user has identified as significant or troubling and any which you as practitioner feel are significant. Invite further qualitative amplification to help identify ways in which the grief is especially distressing and creating difficulties in coping.
v) Qualitative comments. Exploring the grief narrative will give a deeper level of understanding about those areas where help/support most needs to be focused.
AAG – Focus on the qualitative responses:
(Here the interest is in the level of agreement/disagreement with each item on the scale and not the score)
- Feeling reactions evident in items 1,5,6.
- Functioning reactions evident in items 2,3,4.
- Consequences and coping evident in items 7,8,9.
You will note that these are different groupings to those in the RRL i.e. overwhelmed, controlled, resilient categories, but rather help to focus on how those elements interrelate. These interrelationships can be explored by using the resilient responses as a reference point and choosing the emphasis that is needed with each client/service user e.g.
- What do you find most challenging about facing the pain of loss?– being overwhelmed by feeling of grief ; trying not to lose control of feelings; balancing feelings with managing day to day life.
- What get in the way/stops you, from recognising your inner strength? – persistent thinking about the person who has died; believing that being brave is a way of showing inner strength; difficulty in reconciling these thoughts and beliefs.
- Is a sense of hopefulness, about coming through grief, hampered by……….? – a struggle to make sense of the experience; trying not to focus on what has been lost; trying to reconcile a search for meaning while avoiding the consequences of loss.
The qualitative engagement, which the AAG generates, may continue as part of the on-going therapeutic dialogue.
D. Recognise the contextual factors which influence attitudes to grief and how they are likely to be experienced and expressed, and reflected in the AAG responses:
i) culture, ethnicity, religion / beliefs.
ii) family, education, employment.
iii) current circumstances – relationships, roles, responsibilities, finance, housing etc.
iv) collectively these factors – i) ii) iii) are likely to effect the nature of social support and its availability to the client.
Practitioners need to be alert to these factors, listening for them as they emerge in the qualitative comments and where necessary prompting a more explicit exploration of these dimensions of a client / service user’s life-experience, past and present, as they impact on their attitude to bereavement.
E. Use the evidence from the AAG responses
i) at an initial assessment to determine what kind of support service is most appropriate for the client. Increasing use is made of the three components in NICE guidance used to distinguish levels of intervention based on levels of need (See Fig,1)
Fig.1. Three levels of need as indicators of varied levels of intervention
ii) use the AAG responses as a focus for the practitioner and the client to jointly set goals for support or intervention. Where grief is complicated and counselling as a third level of intervention is indicated, a pluralistic approach is recommended and set out in Chapter 7 of ‘Working with Loss and Grief’ (Machin 2014).
iii) re-use the AAG as part of the help process, to review the client’s changing grief reactions and responses.
iv) use the AAG as a tool in supervision, as a basis for the reflections on appropriate and effective therapeutic support strategies.
v) use the AAG to evaluate the outcome of the client’s/ service user’s grief at the end of support or intervention.
(See – ‘An approach to intervention’ for more detailed information)
Bereavement Care Standards (2014) – developed by Bereavement Services Association and Cruse Bereavement Care.
National Institute of Clinical Excellence (NICE) (2004). Improving Supportive and Palliative Care for Adults with Cancer. London.
Machin, L. (2014) Working with Loss and Grief. London: Sage (2nd edition)