Knowledge to Action:

Implementation of Bereavement

Care Primer at VON Yarmouth

Dr. Megan Aston School of Nursing

Dalhousie University

Dr. Tracy Carr Department of Nursing and Health Sciences

University of New Brunswick, Saint John

Team

Researchers

• Dr. Ariella Lang, RN PhD (VON Canada)

• Dr. Fabie Duhamel, RN PhD (University of Montreal)

• Dr. Megan Aston, RN PhD (Dalhousie University)

• Dr. Tracy Carr, RN PhD (University of New Brunswick, Saint John)

• Dr. Susan Cadell, MSW PhD (Laurier University)

• Dr. Amin Mawani, LL.M PhD (York University)

• Andrea Fleiszer, RN PhD(c) (McGill University)

Knowledge Users (VON Canada)

• Heidi Carr, RN BScN MAdEd

• Suzanne D'Entremont, RN BScN

• Janet Purvis, RN BSc MN CCHN

• Catherine Butler, RN MHA

• Sharon Goodwin, RN(EC) MN

Research Staff (VON Canada)

• Lynn Toon, MSc. RN

• Kristine Iaboni, MA

Acknowledgements

• Victorian Order of Nurses

• Canadian Institute of Health Research

• Fonds de la recherche en santé du Québec

Overview of Research

• Collaboratively implement Bereavement Care “Primer” (suite of systems interventions) using an integrated knowledge translation (iKT) approach to knowledge production and exchange at VON in Yarmouth

• Knowledge to action

• Participatory action research

• Researchers, VON managers, and staff

Study Purpose

• Using a systems change approach to knowledge-to-action, this collaborative researcher-knowledge user team will increase organizational and practitioner uptake and application of a Bereavement Care Primer focused on improving the provision of primary bereavement care for individuals and families at home and in the community around the death of a loved one.

Research Questions

1. How does one site (VON Yarmouth) of a national home/community care organization(VON Canada) initiate change to provide better primary bereavement care in a large urban setting?

2. What is the process of translating evidence-informed recommendations from the primer into practice?

3. What factors most influence translation and application of the primer, and ultimately, system change?

4. How do these factors exert their influence on evidence-informed practice and system change?

5. What are the consequences / process outcomes of evidence-informed practice and system change on home and community care providers?

Knowledge to Action Interventions

• Managers, nurses, home support workers, bereaved clients, and other stakeholders

• Individual interviews

• Focus groups

• Forums

Shared Leadership

• Development of research purpose and questions • Planning meeting in Toronto – researchers and

managers • Organizing and implementing focus group and

individual interviews to explore present practices before implementation of primer – researchers and managers

• Data analysis – researchers – thematic analysis • Sharing findings – researchers present themes at forum • VON managers, nurses, HSW, clients discuss next steps

Preliminary Planning Meeting

• Researchers and VON provincial and national leaders in Toronto, Sept 2011

• Identified unique characteristics of Yarmouth VON setting

• Discussed readiness for VON to implement primer and research

• Strategized plan for focus groups and forum

• Discussed ideas for primer implementation

Data Collection

Focus Groups

Individual Interviews

Nurses (n=6)

Managers (n=3)

Home Support Workers (n=7)

Volunteers (n=5)

Stakeholders (n=5)

Administrators (n=5)

Bereaved clients (n=5)

Findings from Focus Groups and

Interviews

Three overarching themes:

1. Current status of bereavement care

2. Opportunities for improvement

3. Issues surrounding implementation

Current Status of Bereavement Care

• Unanimous agreement that VON provides a very positive work environment

• Strong employee pride

• Strong managerial support for staff

• Staff, in turn, display high degree of compassion and empathy for clients

• Staff and management alike value bereavement care and recognize the need

Current Status of Bereavement Care

• Bereavement care is provided to client and family by VON staff prior to death, but not always consistently

• For VON care-giving staff and families, this can feel like an abrupt end and “another death”

Current Status of Bereavement Care

• All home visits are scheduled centrally which can be problematic for staff and family

• No formal structures in place to support staff and their grief

• No bereavement education programs currently in place for staff

• National Practice Team ▫ Skilled at implementing change across geography and

provider groups ▫ Use evidenced based change and KT strategies ▫ Have process for practice review ▫ Experienced in finding/using evidence such as BPG,

research, primers, texts ▫ Skilled at developing guidelines and tools for nurses ▫ Good relationship with staff at sites (Yarmouth too) ▫ Are all nurses and have good grasp on practice

Current Status of VON Resources

Suggested Opportunities for

Improvement

• Establish consistent after death bereavement visits

• Decentralize scheduling

• Ensure continuity of care

• Use an interdisciplinary approach

• Establish a bereavement program for bereaved individuals who have no family or other supports

Suggested Opportunities for

Improvement

• Fund VON staff time to attend funeral

• Set up a system of follow-up calls to the bereaved

• Provide information to the bereaved

(e.g., community resources, what to expect, etc.)

• Develop ongoing bereavement education programs for staff

• Work with home care funders to increase number of post death visits

Issues Surrounding Implementation

• Care of the dying has a significant impact on all staff

• Dilemma: Emotional attachment to clients and families inevitable but reported as discouraged by whom?

• Personal experiences of death and dying reported as shaping the level of comfort with bereavement care

• Not all staff are comfortable with providing bereavement care

Issues Surrounding Implementation

• Families cannot be expected to know their needs so soon after a death

• Staff report uncertainty in their skills when caring for pediatric clients who are dying and their families

• Challenges of working autonomously in rural communities

• Staff need to feel that their work has been optimal - importance of acknowledgement

Forum #1

Purpose:

• Collaboratively work together

• Share findings from focus groups/interviews

• Develop next step

• Plan how to implement primer

• One and a half days

• 25 people

• Group work

▫ Discussed presented findings and next steps

• Built on strength

▫ What they were doing well

▫ What needed to change

▫ How to begin implementation of the primer

Forum #1

Ideas to Move Forward

• Establish local bereavement committee

• Continue relationship between nurse and bereaved

– Discussed timing , funding and many other issues

• Resources/assessment tools for nurses

• Resource list

• Connect with community

– Spread the word – social media needed

• Education on many levels

• Track process of implementing Primer

– Everyone to write journal notes

Evaluation of Forum

• Very positive

• Effective group work

• Bereaved clients added valuable perspectives

Collaborative work

• Participatory action research supported ownership of research findings (data from focus groups and individual interviews)

• Specific plans were made to implement primer guided by worksheets on: Environmental Scan

Implementation Strategy

Evaluation Strategy

Next steps

• Bereavement committee will meet soon

• Decide how to specifically implement agreed upon parts of the Bereavement Care Primer

• Discuss progress in fall 2012 with researchers, VON managers, nurses and bereaved clients