Date Presented 04/200/21
Using narrative responses to the Veterans Affairs Bereaved Family Survey, we have identified practice areas that fall within the OT Practice Framework (3rd ed.). Intervention in the identified OT practice areas could improve the end-of-life health care experience for both patients and providers. Narrative responses can be used to identify areas to improve quality of care and may provide initial support for implementing innovative practices.
Primary Author and Speaker: Matthew Donald McCaa
Additional Authors and Speakers: Megan Bewernitz, LaTonya Summers
BACKGROUND/PURPOSE: Since 2010 the Veterans Affairs (VA) has used the Bereaved Family Survey (BFS) to solicit routine feedback from bereaved family members to assess quality of palliative and end-of-life care. The BFS contains 17 items for rating aspects of care provided to recent descendants and 2 open-ended questions to solicit additional comments and suggestions for improving care. The BFS is a reliable and valid measure of end-of-life quality endorsed by the National Quality Forum. The aim of the current analysis was to identify practice areas in which occupational therapists could intervene to improve the end-of-life experiences for both patients and family members.
DESIGN: Qualitative Descriptive Survey
METHOD: The VA Quality Improvement Resource Center (QuIRC) conducted a primary analysis of 4604 narrative survey responses to the BFS for all VA 2017 inpatient decedents (N = 5964). A descriptive qualitative approach identified major themes. Two QuIRC team members analyzed narrative responses using Atlas t.i. software. Themes and practice areas were identified by the research team which included 2 qualitative methodologists, 2 nurses, a physician, and an occupational therapist. The practices were rated by the multidisciplinary team for intervention feasibility. Actionable practices were categorized as Occupations, Client Factors, and Contexts and Environments as defined in the Occupational Therapy Practice Framework 3 (OPTF3).
RESULTS: Many of the responses that concerned bereaved family members fell within the OTPF3. Occupations: supporting patients' social participation and engagement in leisure activities, minimizing disturbances of rest and sleep, and promoting personal hygiene and grooming. Client factors: identifying cognitive, visual-perceptual, and physical impairments affecting patients' ability to participate in meaningful occupations (adapting equipment to promote self-care, grooming, hygiene; modifying activities to support leisure participation); and working with team members such as chaplains to tailor spiritual support to patient and family members' preferred belief systems and visitation needs. Contexts and environments: modifying the environment to support patients' continued engagement in desired occupations, environmental accommodations to allow family members to stay overnight with loved ones, helping family to become advocates for the needs of both loved ones and themselves, and facilitating clear and timely communication between family and hospice providers regarding changes in patient status and imminence of death. Family members also greatly appreciated ceremonial displays of respect for their deceased Veteran (draping a flag over the body after death, lining the hallways with staff during body removal). Limitation: Highly positive or negative narrative responses may be biased; however, in many examples from the data, these responses mentioned helpful practices or highlighted opportunities for improvement.
CONCLUSIONS: Narrative responses to the VA BFS included specific occupations and client factors that fell directly within the OTPF3. Future research: Analyzing narrative responses to identify areas to improve quality of care may provide support for implementing innovative practices.
IMPACT STATEMENT: Occupational therapists understand the transactional relationship between the person, meaningful occupations, and the context of occupational performance. Occupational therapists are primed to address many of the end-of-life concerns that were raised, and to act on recommendations provided by BFS surveys that can improve the end-of-life health care experience.
References
Occupational Therapy Practice Framework: Domain and Process (3rd Edition). Am J Occup Ther 2017;68(Supplement_1):S1–S48. https://doi.org/10.5014/ajot.2014.682006
Gray, C., Yefimova, M., McCaa, M., Goebel, J. R., Shreve, S., Lorenz, K. A., & Giannitrapani, K. (2020). Developing Unique Insights from Narrative Responses to Bereaved Family Surveys. Journal of Pain and Symptom Management.
Yefimova, M., McCaa, M.,Goebel, J., Kutney-Lee, A., Gray, C., Shreve, S., Giannitrapani, K., & Lorenz, K. A., (2020). Using Narrative Family Reports of Veterans' End -of-Life Care to Identify Practices for Quality Improvement. Manuscript submitted for publication.
