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Literature review of evidence-based family interventions (Grief & Trauma Intervention & Family Bereavement Program that could be used for
this population: Using peer-reviewed journals (attached) & please research 2 more articles to add based on the above 2 mentioned interventions, present research on at least 2
different interventions that could be used to address this issue with a family.
Make sure your articles are no more than 5 years old. A minimum of six
references are required for this section.

Advantages and disadvantages of the interventions: Critically assess the advantages and disadvantages of each of the interventions your group presented in your literature review. Make sure to take diversity and culture into consideration.

Case study: Description of the Family System

Vanessa Abdul is a 14-year-old biracial girl who lacks discipline. Two years ago, Vanessa’s mother passed away due to COVID-19 and has left behind both her and her 3-year-old sister Abby. Up until 3 years ago, Vanessa was an A student who took her schoolwork very seriously. Being the only child at the time, Vanessa was a “daddy’s girl”. She prided herself on the strong transparent relationship she had with her father at the time. Since the passing of Vanessa’s mother, the relationship between her and her father had changed significantly. Vanessa’s father, James Abdul is a 44-year-old African-American man who is a single parent and is struggling to raise both Vanessa and her little sister Abby. James spends a significant amount of time caring for Vanessa’s sister Abby and doesn’t have time to spend with Vanessa. This has taken a mental toll on Vanessa and has caused Vanessa to act out over the last 2 years. James noticed a drastic difference in how Vanessa dresses as she was once a very conservative dresser due to her religious household of a Catholic mother and a Muslim father. James has observed Vanessa leaving the house with short skirts and belly shirts several times a week. When James demands Vanessa to change, she often ignores him and leaves the house anyway. Vanessa is currently failing her classes, sneaking out of the house in the middle of the night, and coming home smelling like weed several times a week. James receives calls from the school that Vanessa is either talking back to her teachers or intimidating her classmates with her confrontational behavior. James sent Vanessa to stay with her grandmother for 2 weeks hoping her behavior would change, but things got worse when he received a call from his mother stating that Vanessa stole her car to go “joyriding” because she was “bored”. James is at his wit’s end and is seeking services to help address Vanessa’s behavior.

Article
Evidence-Informed Primary Bereavement Care:
A Study Protocol of a Knowledge-to-Action Approach for Systems Change
Ariella Lang RN PhD
Nurse Researcher
Victorian Order of Nurses (VON) Canada
Ottawa, Ontario, Canada
Andrea R. Fleiszer RN PhD(c)
Ingram School of Nursing
McGill University
Montreal, Quebec, Canada
Fabie Duhamel RN PhD
Professor
Faculty of Nursing
University of Montreal
Montreal, Quebec, Canada
Megan Aston RN PhD
Associate Professor
School of Nursing
Dalhousie University
Halifax, Nova Scotia, Canada
Tracy Carr RN PhD
Professor
Department of Nursing and Health Sciences
University of New Brunswick
Saint John, New Brunswick, Canada
Sharon Goodwin RN(EC) MN
Vice President Home Care and Private Pay
Central and Western regions and National Vice President Quality and Risk
Victorian Order of Nurses (VON) Canada
Ottawa, Ontario, Canada
© 2015 Lang, Fleiszer, Duhamel, Aston, Carr, and Goodwin. This is an Open Access article distributed under the
terms of the Creative Commons‐Attribution-NonCommercial-ShareAlike License 4.0 International
(http://creativecommons.org/licenses/by-nc-sa/4.0/), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work is properly attributed, not used for commercial purposes, and if
transformed, the resulting work is redistributed under the same or similar license to this one.
121
Abstract
Using a systems change approach to knowledge-to-action, the purpose of this study is to
increase organizational and practitioner uptake of an evidence-informed primary
bereavement care guideline in home and community care through a researcher-knowledgeuser partnership. Guided by the Consolidated Framework for Implementation Research, a
single case study design will be used to examine system change in its natural context. The
project integrates an organizational change initiative and a research study. Multiple data
collection and analysis strategies will be used to explore and map the interactive synergistic
process of interconnected decisions and actions. Iterative cycles of analysis and feedback
will incite knowledge-user reflection and action, shape and substantiate findings, use data in
a timely fashion to inform and guide next steps, and ensure ongoing monitoring and
evaluation of the process.
Keywords: bereavement care, evidence-base guideline, integrated knowledge translation,
nursing, system change, case study
Author Note: This study was supported in part by the Canadian Institutes for Health
Research, as well as the Réseau de recherche portant sur les interventions en
sciences infirmières du Québec (RRISIQ) and the McGill University Ingram
School of Nursing. We would also like to acknowledge Fonds de Recherche
Santé Québec (FRQS) for their support of Dr. Lang as a Checheure-bousière de
Santé et Sociéte. The authors would like to thank all of the VON nurses, VON
national core leadership team and community stakeholders, especially bereaved
family members, who participated in the interviews, focus groups and forums.
A special thanks is also extended to Suzanne D’Entremont, Derrick Babin,
Sandra Hubbard from the VON Tri-County site in Nova Scotia, Canada as well
as to Bertha Brannen. These individuals were instrumental to the realization of
this project as well as the many ensuing system changes around primary
bereavement care. We are grateful to Janet Purivs and Heidi Carr whose
ongoing support and collaboration helped make this initiative a reality. We
would like to thank Lynn Toon for her invaluable comments and edits to the
final manuscript.
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International Journal of Qualitative Methods 2015, 14
Background
Need for Improved Primary Bereavement Care
Bereavement is defined as “the entire experience of family members and friends in the
anticipation, death, and subsequent adjustment to life [surrounding] the death of a loved one”
(Christ, Bonnano, Malkinson & Rubin, 2003, p. 554). Experiences of loss, grief, and bereavement
are unique, dynamic, and wide-ranging in spite of the ubiquitous presence and commonality of
death in our lives (Moules, Simonson, Prins, Angus, & Bell, 2004; Stroebe, 2001; Stroebe, Schut,
& Stroebe, 2007). Although death— both expected and unexpected—is a certainty, the responses
of family members and other loved ones are not (Attig, 2010; Moules, Simonson, Fleiszer, Prins,
& Bob, 2007). Nevertheless, grief occurs in recognizable patterns. Guidelines or guiding
principles for “bereavement care” are scarce despite the need for health-care providers to offer
meaningful support to individuals and families following the death of a loved one (Genevro &
Marshall, 2004). Although it is still unclear which groups of individuals are most vulnerable,
there is agreement that a loved one’s death affects the health and well-being of all who are
bereaved (Stroebe et al., 2007). Empirical studies have revealed increased morbidity and
mortality for the bereaved following the death of a loved one (Christakis & Alison, 2006; Li,
Olsen, Vestergaard, & Obel, 2010; Li, Vestergaard, Obel, Cnattingus, Gissler, & Olsen, 2011;
Moon, Glymour, Vable, Liu, & Subramanian, 2014; Shah, Carey, Harris, DeWilde, Cook, &
Victor, 2013; Shah, Carey, Harris, DeWilde, Victor, & Cook 2013). The bereaved can suffer from
a range of physical, emotional, social, and financial concerns. These include heightened risk of
depression, somatic complaints, medication and substance abuse, and absenteeism and disability
days (Aziz & Steffens, 2013; Christakis & Iwashyna, 2003; Lang, Gottlieb, & Amsel, 1996;
Lang, Goulet, & Amsel, 2004; Liu, 2014; Shah et al., 2013; Stroebe, 2001). These sequellae can
lead to increased use of health services and incur a variety of costs, which are potentially
preventable. Yet, to date, the focus of bereavement care has centered on those who present with
complications, rather than on primary prevention and health promotion (Genevro & Marshall,
2004; Wimpenny et al., 2006). The human and financial costs of providing evidence-informed
primary bereavement care should be set against the likely weightier personal and societal costs of
preventable complications (Wimpenny et al., 2006).
“Primary bereavement care” is defined as capturing and creating opportunities to be with and to
support individuals and families in their experiences of grief and mourning surrounding the death
of a loved one (Lang, Duhamel, Aston, Fleiszer, Gilbert & Sword, 2012, p. 11). This care
includes several levels of upstream preventive and health promoting-type interventions aimed at
supporting bereaved individuals, families, and communities. Across health and social service
settings, primary bereavement care includes the following: actively and openly acknowledging
and validating both the death of the loved one and experiences of bereavement; providing
appropriate and discerning “anticipatory guidance” about grief reactions; ensuring a network for
continuity of care and appropriate resources such as time, staffing, experts/teachers, funds, and
physical space for the bereaved; and developing and implementing bereavement care-centered
initiatives and policies (Attig, 2010; Lang et al., 2012; Robinson, 1996) “A compassionate
approach by all professional and non-professional staff is consistently reported by the bereaved as
having a positive impact on their bereavement” and, conversely, approaches which do not relay
such compassion can impact negatively (Wimpenny et al., 2006, p. 177).
Given their usual involvement around a death and their common presence across levels of health
systems, nurses are strategically positioned to improve services and to better support grieving
individuals and families. Nurses are also ideally situated to lead and motivate other team
members to improve their knowledge, skills, and attitudes around primary bereavement care. Yet,
as with other professionals, nurses often feel ill-prepared and have identified the need to know
how to care more effectively for the bereaved (Granger, George, & Shelly,1995; Lang et al.,
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2012; Tse, Wu, Suen, Ko, & Yung, 2006). However, it is important to recognize that providing
primary bereavement care also requires systems support and is not simply a clinical practice
improvement issue.
There are numerous examples of system-level factors that create either an absence or a
fragmentation of support for the bereaved. First, there is no health-care funding for primary
bereavement care in Canada. The Canada Health Act covers medical care for an end-oflife/palliative client and their family/caregivers over a period of several months (Romanow,
2002). However, when the client dies, the current system ceases to remunerate or support any
further care for the bereaved by health-care organizations and providers—unless the bereaved
present themselves back into the system (e.g., emergency department, mental health clinic,
substance abuse program) with a grief-caused health problem. This funding gap contributes to a
lack of consistent follow-up care for those who are bereaved, even in high risk situations. Second,
primary care for the bereaved is not addressed by nor falls under the mandate of any particular
segment of the health and social system, professional group, or governmental jurisdiction. This
contributes to lack of continuity of care for the bereaved and often leads to disjointed secondary
and tertiary bereavement services in addition to the lack of primary care services altogether. Even
in the domain of end-of-life care, which is centered on the care of the dying, bereavement support
is typically curtailed due to resource restrictions and an absence of national care standards for the
bereaved. These systems problems have further implications related to a broadened patient safety
perspective in health care that considers the safety of more than just patients (Lang, Edwards,
Fleiszer, 2008). Patient safety is increasingly understood as multidimensional and characterized
by physical, emotional, social, and functional aspects intricately linked to family members,
caregivers, and providers (Lang et al., 2008). In addition to safety risks for the bereaved, there are
also increased safety risks for providers as a result of ethical dissonance and burnout that can
come from caring for dying or bereaved individuals and families (Lang, Duhamel, Fleiszer,
Sword, Gilbert, Aston, 2010). These examples and their implications for increased safety risks
point to the need for multiple systems-level interventions, in addition to direct care
improvements.
Development of a Primary Bereavement Care Guideline
A seminal report highlighted “the need for improved linkages between bereavement research and
practice in order to determine and promote the most appropriate and meaningful care for [the]
bereaved” (Genevro & Marshall, 2004). Research suggests that evidence-informed guidelines can
be a valuable part of knowledge translation (KT) and systems change initiatives (Davies,
Edwards, Ploeg, & Virani, 2008; Francke, Smit, De Veer, Mistiaen, 2008; Hakkennes & Dodd,
2008; Thomas et al., 2000). As part of a program of research integrating home care safety,
bereavement care, and KT, a study was conducted to develop an evidence-informed guideline for
primary bereavement care (Lang et al., 2012). The guideline consists of practice, education,
research, and policy/community development recommendations for care providers and their
organizations. The recommendations resulted from a multimethod study that included a
comprehensive review of the literature, an interprofessional expert panel, and a series of focus
groups conducted with community and acute care nurses, healthcare managers, and bereaved
family members. This initial guideline development study was a precursor to the study described
in this protocol. Participants involved in the development of the guideline affirmed that the
guideline presented an appropriate set of competencies that all nurses, as well as other
professionals, health-care workers, and even volunteers, should and could incorporate into
practice. Participants also described significant systemic and organizational barriers such as
inflexible funding structures, inappropriate staffing models, and lack of debriefing and
mentorship initiatives that might ultimately impede the translation of this evidence into practice
(Lang et al., 2012; Lang et al., 2010). This article describes a planned study that aims to explore
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the implementation process of the bereavement care guideline in practice, taking into
consideration the need for a systems-based approach.
Gap in Knowledge about Implementation and Systems Change
Too often, promising planned change initiatives are followed by disparate implementation efforts
producing results that remain disappointing at best (Institute for Healthcare Improvement, 2003).
There are estimates that at least half of attempted changes in health-care systems are not
successfully implemented; those that are often do not yield the results that were anticipated
(Brousselle & Champagne, 2011). Furthermore, there is a gap in the empirical literature regarding
the implementation of evidence-informed practice and system changes. Only a small proportion
of empirical studies reflect the complex interaction between aspects of professionals’ practices,
organizational change processes, and the contexts within which newly implemented innovations
unfold. Moreover, implementation as a crucial phase of the change process as well as the use of
guidelines as vehicles for stimulating change, are still not well understood nor sufficiently
described to guide organizations in making evidence-informed practice and system changes
(Contandriopoulos, Lemire, Denis, & Tremblay, 2010; Damschroder, 2009; Greehalgh, Robert,
Bate, MacFarlane, & Kyriakiou, 2005).
Methodology
Knowledge-to-Action Approach
The Canadian Institutes for Health Research (CIHR), a major health services research funding
organizations, established a “Knowledge-to-Action” (KTA) grant competition. This program was
initiated in recognition of the gap in knowledge about implementation as well as the limited use
of research findings in practice. The KTA initiative funds projects that “bridge a knowledge-toaction gap, and in so doing, increases the understanding of knowledge application through the
process” (CIHR, n.d., para 4). It requires partnering researchers and knowledge users to be fully
engaged and involved throughout project conception to completion and beyond. Given that
practice does not change without leadership support (Gifford et al., 2013; Ploeg, Davies,
Edwards, Gifford, & Miller, 2007), it is important to engage people within the organization who
understand how the system can support practice and where to make changes in order to have an
effect. Strong reciprocal relationships among researchers, practitioners, as well as clinical and
policy decision makers are central to the effective short- and long-term adoption of evidence into
practice. These types of relationships are assumed to be the basis for building capacity for
systems change (Graham et al., 2006; Lindstrom, 2003; Lomas, 1997; National Centre for the
Dissemination of Disability Research, 2006). “Partnership not only moves knowledge to action –
the researcher generates and the knowledge-user acts and both are changed as a result” (CIHR,
n.d., para 8). This approach is a form of “integrated knowledge translation” wherein both research
and change occur.
Study Context
Victorian Order of Nurses (VON) Canada, a nursing-led not-for-profit national home and
community care organization, identified the need to improve the care provided to bereaved
individuals and families in the communities it serves. VON championed the initial project to
develop the primary bereavement care guideline (Lang et al., 2012). The implementation of the
guideline within VON was the planned next step, given the organization’s commitment to
improving primary bereavement care. The following study was developed based on the relevant
and pervasive need to improve primary bereavement care in Canada, narrow the the gap in
research about knowledge-to-action processes, and advance the six-year partnership between the
research team and VON. Hence, this project was conceived and developed collaboratively by the
research team members and the “knowledge users” from VON. The core knowledge-user team
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consists of national leaders who are part of VON’s Practice, Quality, and Risk Team as well as
leaders from the local VON Tri-County site in Nova Scotia (the site that will participate in this
project).
Study Purpose and Research Questions
Using a systems change approach to knowledge-to-action, the purpose of this study is to increase
organizational and practitioner uptake of an evidence-informed primary bereavement care
guideline in home and community care through a researcher-knowledge-user partnership. The
specific research questions included the following:
1. What is the process of translating evidence-informed recommendations from the
guideline into action?
2. How does a researcher-knowledge-user partnership influence the translation of the
guideline?
3. What are the impacts at multiple levels of the system of this knowledge-to-action
approach?
The project integrates an organizational change initiative and a research study. The organizational
change will be supported by several multi-stakeholder meetings as well as two large collaborative
forums. The research study will entail the use of multiple data sources. In addition to observations
and document reviews, a series of individual and group interviews will be conducted over the
course of the two-year project. The organizational change and research study processes are
described below.
Design and Methods
A single case study design (Anthony & Jack, 2009; Stake, 1995; Yin, 2009), will be used to
examine system change in its natural context. Multiple data collection and analysis strategies will
be used to explore and map the “interactive synergistic process of interconnected decisions and
actions” (Graham & Logan 2004). Ethics approval for the project was granted by the ethics
review boards of VON Canada and each of the investigators’ respective universities. Written
informed consent will be obtained from all participants prior to their participation.
Theoretical Framework
A systems perspective suggests that “issues, events, forces, and incidents should not be viewed as
isolated phenomena but seen as inter-connected, inter-dependent components of a complex
entity” (Iles & Sutherland, 2001, p. 17). This perspective reflects the interdependent systems of
organizations; the need for shared values, purposes, and practices within and between
organizations; and the requirement for multiple interventions to integrate the perspectives of a
range of stakeholders across a wide system (Edwards, Rowan, Marck, & Grinspun, 2011;
Greenhalgh et al., 2005; Iles & Sutherland, 2001; Sterman, 2006). The focus extends beyond how
to diffuse an innovation throughout a system, to how systems adaptively respond to planned and
unplanned change in ways that enable them to effectively evolve, adapt, and renew over time
(Sterman, 2006). Introducing new practice changes such as the recommendations from the
guideline into busy practice environments with numerous competing demands is challenging and
often met with resistance (Bero, Grilli, Grimshaw, Harvey, Oxman, & Thomson, 1998; Davies,
Edwards, Ploeg, Virani, 2008; Davies, Edwards, Ploeg, Virani, Skelly, & Dobbins, 2006;
Edwards, Marck, Virani, Davies, & Rowan, 2007). Implementation of a new guideline can be
particularly challenging in home care where providers do not work within a common physical
space, but rather are spread out across different homes, neighborhoods, and communities.
Furthermore, as we have identified, primary bereavement care requires interventions at multiple
levels of the health and social systems. Successful adoption of research into practice is also
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largely a function of the interactions between the evidence, the contexts, and the facilitation
processes utilized (Kitson, Harvey, & McComack, 1998; Kitson et al., 2008; Rycroft-Malone et
al., 2002; Rycroft-Malone et al., 2004). Thus, effectively managing system change involves
targeting multiple system levels with multiple change strategies.
This study is guided by the Consolidated Framework for Implementation Research (CFIR)
(Damschroder, 2009). The authors of this framework synthesized Greenhalgh and colleagues’
(2005) seminal work on implementation of innovations in health service delivery organizations
with the work of 18 other models, theories, or frameworks used to translate research findings into
health services practice (e.g., Ottawa Model of Research Use, PARiHS framework) (Graham &
Logan, 2004; Kitson, 1997; Rycroft-Malone et al., 2002). The CFIR presents strong conceptual
and empirical support to guide implementation and to structure this knowledge-to-action study.
The framework comprehensively addresses the innovation, process, context and players, and is
flexible to the change strategy preferences of our user partners at VON Canada.
CFIR has five major domains: (a) the characteristics of the intervention (e.g., evidence strength,
quality, complexity) must be adaptable to the setting without loss of integrity; (b) the dynamic
interface between outer setting (e.g., patient needs and resources) and inner setting (e.g., the
organization’s structural characteristics and readiness for implementation) influences the
translation process; (c) individuals are active players who can facilitate or impede the
intervention; (d) players’ characteristics, both individual (e.g., knowledge, beliefs, and selfefficacy) and social (e.g., professional and organizational norms), influence the success of change
interventions; and (e) the implementation process (e.g., planning, engaging, executing) requires
multiple, nonsequential levels of active change. This framework informs the study design and
methods. The distinction between the two main components of the project, namely, the
implementation of the guideline within the setting and the research study activities, are portrayed
in Table 1 and are described in greater detail below.
Table 1
Knowledge-to-Action Organizational Change and Research Study
Organizational change
Research study
Implementation of guideline
Data collection, analyses, and translation
This is a collaborative process between VON and
research team, with VON leading this aspect of the
project.
This is a collaborative process between VON
and research team, with the research team
leading this aspect of the project.
Pre-forum activities (0-3 months)
Baseline (at 0 months)
Goal: to conduct planning meetings with VON
core leadership team, other employees, and
research team; to establish goals and determine
responsibilities for Forum #1
Forum #1
Individual interviews
Goal: to glean an understanding of status of
bereavement care at VON, from the leadership
perspective; to anticipate the challenges of
guideline implementation
Participants: 5 members of VON “core
leadership team”
Guideline implementation “kick off” (at 3 months)
Goal: to gather ideas and solidify plans for
guideline implementation
Focus groups
Goal: to provide a baseline of different
perspectives of the current status of
bereavement care at VON
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Organizational change
Research study
Participants: VON core team, research team, and
20 others (e.g., VON nurses, managers,
administrators, volunteers; bereaved; external
stakeholders)
* sources of research data: research team member
field notes; worksheets and flip charts from small
and large group work
Participants: 5 homogeneous groups (nurses,
personal support workers, managers,
volunteers, bereaved)
Forum #2
Guideline implementation “follow-up” (at 15
months)
Goal: to assess if and how the implementation has
begun to impact practice change and the care
provided
Participants: same as Forum #1, if possible
* sources of research data: research team member
field notes; brainstorming/planning flip charts
from small group work
Post-forum activities (16+ months)
Goal: to plan for next steps; to work on
sustaining/spreading changes
Mid-Process (at 8-9 months)
Focus groups
Goal: to share experiences of the change
amongst different stakeholders; to address
challenges to improving bereavement care
Participants: 2 heterogeneous groups (nurses,
personal support workers, managers,
volunteers, bereaved)
Project conclusion (at 17-18 months)
Individual interviews
Goal: to uncover the impacts of the
knowledge-to-action process and the resultant
changes in bereavement care, from the
leadership perspective
Participants: same 5 members of VON “core
team”
Focus groups
Goal: to examine the impacts of the
knowledge-to-action process and the resultant
changes in bereavement care
Participants: 5 homogeneous groups (nurses,
personal support workers, managers,
volunteers, bereaved)
Setting
VON leaders proposed the Tri-County site in Nova Scotia, Canada, as the ideal setting within
which to begin this initiative. This site serves three counties in a large, predominantly rural area at
the southwestern end of Nova Scotia. This site is fitting because of its provincial contract for
providing home and community care services involving 75 nurses, as well as for its active
palliative and supportive care program that provides over 2000 palliative care visits per month.
Furthermore, stakeholders from this site were involved in the development of the guideline and
the site leadership team remains highly passionate and committed to improving bereavement care
in their community.
Data Collection
As part of the research component of the project, interviews will be a main source of study data.
Semistructured interview guides (Tables 2 and 3) are informed by the study objectives and the
CFIR. All interviews will be digitally recorded and transcribed verbatim.
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Table 2
Focus Group Interview Guide
Focus Group Interview Guide
At the beginning of each focus group, there will be an introduction by the facilitator(s). This introduction
will include a preliminary discussion of terms (i.e., meaning of bereavement—encompasses experiences
before, during, and after the death of a loved one) that may be used in proceeding questions, the format
of the focus groups, and a review of the consent form. The facilitator(s) will also give participants a
chance to ask any questions prior to commencement of the focus groups.
ï‚·
ï‚·
ï‚·
ï‚·
ï‚·
ï‚·
ï‚·
ï‚·
ï‚·
Give out name tags.
Introduce facilitators.
Review purpose of study and purpose of focus group.
Explain goal to tap into their experience and opinions about bereavement care.
Review and sign of consent forms. Emphasize that there will be no names or identifying
information in the final report and that comments shared are confidential.
Explain that after a question is asked, we will go around the circle, so everyone has a chance to
share their thoughts. If more time is needed to think or to pass on the question that is fine.
Assure that there are no right or wrong answers.
Describe how notes may be taken during the discussion to guide follow up on issues.
Remind participants to feel free to get up for refreshments.
ï‚·
Staff warm-up question: Please tell us your name, how long you have been working at VON,
and something interesting about yourself.
ï‚·
Bereaved warm-up question: Please tell us your name, where you are from, and something else
that is interesting about yourself.
Before implementation (0 months)
In five minutes or less:
ï‚·
ï‚·
ï‚·
ï‚·
ï‚·
ï‚·
ï‚·
ï‚·
ï‚·
(Bereaved only) Tell us about one or more meaningful experiences you had during the care that
VON provided to you and your loved one (before, during, after).
(Bereaved) What helped you in your bereavement? What, if anything, was not helpful? Are
there any changes you would like to see in how bereavement care is provided through the
VON?
(Staff only) Tell us about one or more meaningful experiences you had providing bereavement
care since your time with the VON.
(Admin) Tell us about what you know of bereavement care provided through the VON.
(Admin) Tell us about your involvement/engagement with bereavement care.
(Staff only) What works well in your bereavement care practices now? What is challenging?
How would you want to change it?
(Admin)Tell us about how institutional practices support or create challenges for your
bereavement care practices.
(Staff) Tell us about how your workplace supports or creates challenges for your bereavement
care practices.
(All) Is there anything you came here wanting to say but didn’t get a chance?
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ï‚·
ï‚·
Have we missed anything?
Any closing thoughts/comments/questions?
After implementation (Last 2 focus groups)
ï‚·
ï‚·
ï‚·
ï‚·
ï‚·
ï‚·
(Bereaved only) Tell us about your experiences with bereavement care.
(Staff only) Tell us about your bereavement care practices now since the guideline was
introduced. Are you practicing differently because of the guideline? Why or why not?
(Staff only) Tell us about your practices with clients.
(Staff only) Tell us about how institutional practices support or create challenges for your
bereavement care practices.
In your opinion, what changes, if any, have been made to improve bereavement care?
Can you provide any specific examples of the guideline implementation and how you felt it was
or was not successful?
Focus group interviews (Table 2) will provide an interactive venue for eliciting a variety of
stakeholder perspectives about implementation. The interaction will prompt exchanges and
insights between all participants and interviewers that would not have been possible through
individual interviews (Krueger & Casey, 2000; Ulin, Robinson, & Tolley, 2005). Using purposive
and snowball sampling to identify potential participants, homogenous focus groups will be
conducted with nurses, personal support workers, managers, volunteers, and bereaved family
members respectively. Each group will consist of approximately 6 to 8 participants (Krueger &
Casey, 2000) and will be held before the first large stakeholder meeting (Forum #1; see Table 1).
Data from the focus groups will provide a baseline about the current status of bereavement care,
identify facilitators and barriers to providing evidence-informed bereavement care, and elicit
potential strategies for implementing system changes. A second set of these homogeneous focus
groups will be held after the final forum (Forum #2; see Table 1). These will examine the
knowledge-to-action process, the resulting changes, and the remaining opportunities and
challenges to continued improvement.
Five heterogeneous focus groups will be held between Forums #1 and #2. Participants will
include representatives from each of the five original groups (i.e., nurses, personal support
workers, managers, volunteers, bereaved family members). The purpose of the heterogeneous
focus groups will be for stakeholders to share their perspectives with each other and to monitor
the progress of the initiative. Although homogeneity of participants in focus groups is a common
method used in research (Krueger & Casey, 2000), this mixed approach will be used to extend
knowledge-to-action through interactions between different categories of participants.
Participants will be able to broaden their appreciation for the perspectives of the other
stakeholders and subsequently consider these within their respective contexts as the initiative
unfolds. The researchers are skilled focus group facilitators, with previous in-depth knowledge of
the study content and context.
In addition to the focus groups, members of the VON national core leadership team, who are
considered organizational leaders of change in their executive and senior management positions,
will participate in two sets of individual interviews (Table 3). The first set will be conducted at
the beginning of the study, where the goal will be to glean an understanding of the status of
bereavement care at VON from the leadership perspective, and to anticipate the challenges and
levers for implementing the guideline. The second set of individual interviews will be conducted
toward the end of the study, where the goal will be to uncover the impacts of the knowledge-toaction process and the resultant changes in bereavement care, from this leadership perspective.
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Table 3
Individual Interview Guide
Individual Interview Guide
Before implementation (0 months)
ï‚·
ï‚·
ï‚·
ï‚·
ï‚·
Tell us about your bereavement care practices now. What works well? What is challenging?
What, if anything, would you want to change about the current bereavement care practices?
How would you want to change it?
Who do you feel needs to be involved in changing bereavement care practices?
Tell us about how institutional practices support or create challenges for your bereavement care
practices.
What similar changes have you been involved with at VON and what lessons learned can be
applied or built on for this project?
After implementation (12-13 months)
ï‚·
ï‚·
ï‚·
ï‚·
Tell us about your bereavement care practices now since the guideline was introduced. Are you
practicing differently because of the guideline? Why or why not?
Tell us about how institutional practices support or create challenges for your bereavement care
practices.
Can you identify how the change and implementation process might be applied more broadly
across VON?
Are there any other recommendations you would make to help move the guideline into the
bereavement care system?
In addition to interviews, additional sources of data will be collected. During team meetings and
forums (described further below), digital recorders will be used to capture discussions focused on
the guideline and the implementation process. During forums, work sheets and flip charts will be
used to record brainstorming and discussions. Organizational and project documents (e.g.,
agendas, presentations, preliminary findings reports) will be collected in order to trace the history
around and the context for the knowledge-to-action process. Research team members will keep
descriptive and reflective notes documenting observations and impressions about the process.
Building on the collaborative relationship with the knowledge users throughout the development
of this initiative, the research team will meet regularly throughout the course of the project. For
example, a face-to-face planning meeting with the VON core team will be held to establish goals
and determine responsibilities for Forum #1. A series of teleconferences will also be held to
exchange emerging findings, identify opportunities and challenges, and plan contextuallysensitive implementation and system change activities. At the end of the project, a meeting will
be held to plan for next steps, particularly around sustaining and spreading changes for the
improvement of primary bereavement care.
A critical element of this integrated KT effort will be to hold two knowledge exchange forums.
These will be held 18 months apart and are intended to serve as an important opportunity for
exchange between VON employees, community stakeholders, and research team members.
VON’s core leadership knowledge-user team, along with the variety of other stakeholders, will
participate at the forum. VON will lead this aspect of the project. Forums will include a variety of
individuals (VON nurses, managers, administrators, volunteers; bereaved individuals; and some
external stakeholders, such as funeral home directors, social workers, physicians, bereavement
coordinators, health-system funders, and spiritual/religious professionals). We estimate 40
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attendees per forum. The inclusion of participants from all levels of VON is expected to promote
a supportive, synergistic environment in which the most context-sensitive bereavement-related
KT activities can be planned and initiated. Furthermore, including the experience of stakeholders
from external settings such as funeral directors, spiritual leaders, and family support group
members is anticipated to contribute additional innovative and strategic avenues toward
knowledge-to-action that will help to link the VON initiatives with potential changes within the
larger system.
The purpose of the forums will be to (a) critically discuss the components of the proposed
guideline and adapt recommendations to fit the local context, (b) identify and support key
champions/opinion-leaders, (c) select multidimensional KT implementation strategies, and (d)
identify and document facilitators and barriers related to implementation. Forum agendas will be
developed jointly by the core VON leadership group and the research team prior to each meeting.
Forums will be formally evaluated (formative and summative) by all participants. Feedback will
be used to modify the approaches used.
The philosophy underpinning the forums is to serve as the foundation of “a learning
collaborative” in which participants will learn from each other, create innovative strategies for the
implementation of the guideline, and together, ultimately, improve bereavement care. “Learning
collaborative” is a multistakeholder structure within an organization aimed at improving quality
of care and often producing dramatic results (Bodheimer, 2007; Institute for Healthcare
Improvement, 2003). An evidence-based guideline implementation toolkit (Registered Nurses’
Association of Ontario, 2012) will be used to guide the work of the forums. The first forum will
gather ideas and plan for implementation; the second will assess how the implementation has
impacted system changes and the care provided. The forums will facilitate small and large group
discussions about issues related to the guideline and its implementation, as well as opportunities
for sharing of experiences, feedback, and problem solving strategies. The diversity of participants
is expected to cultivate strategic and complementary alliances for knowledge-to-action around
primary bereavement care.
Researchers will contribute to the translation process by (a) providing timely feedback of findings
from forums, interviews, and focus groups; (b) problem-solving with implementation groups
during exchange periods; (c) contributing financially to the release of a project facilitator and
staff participants from their usual work within VON; and (d) assisting in the development of a
support structure, a learning collaborative, as an outcome of the integrated knowledge-to-action
methods proposed. The researchers will promote stakeholder collaboration from the beginning
and will aim to support the synergy of researcher-user interaction throughout the project toward
evidence-informed bereavement care.
Data Analysis
Data analysis will begin as data are collected. Preliminary and increasingly finalized findings will
be conveyed back in subsequent researcher-knowledge-user interactions including
teleconferences, meetings, focus groups, and the final forum. The purpose of these iterative
cycles of analysis and feedback will be to incite knowledge-user reflection and action, shape and
validate findings, use data in a timely fashion to inform and guide next steps, and ensure ongoing
monitoring and evaluation of the process. This collaborative and participatory approach
represents a departure from more traditional designs in that researchers and knowledge-users,
together will co-construct interpretations rather than the initiative remaining exclusively driven
by the researchers.
An interpretive descriptive method of analysis will be used. Interpretive description is an
approach developed to generate disciplinary knowledge capable of informing clinical practice
(Thorne, 2008) and is therefore appropriate to this integrated KT study. Study data will be
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organized and managed with NVivo qualitative software. Drawing on the main components of the
study framework as a guide (Thorne, 2008), constant comparison techniques will be employed to
cluster the data into sufficiently distinct and comprehensive categories. The intent will be to
highlight both complementary and divergent perspectives about the knowledge-to-action process
and multiple changes across the system.
Discussion
Although this single case will provide the opportunity to investigate in an in-depth fashion one
initiative within one organization, the transferability of the findings could be strengthened
through comparisons with other initiatives or organizations. Multiple data sources, a theoretical
framework, and collaborative multistakeholder process will be used to confirm and challenge the
interpretation of key findings.
Several strategies are planned to address some potential threats to the success of this project. One
potential obstacle to this study is the possibility that this initiative will become a burden for this
large busy organization, which is constantly negotiating many competing demands on
administrators, staff, and clients. Furthermore, the nature of home care is that everyone is spread
out geographically, making it challenging to bring people together. In addition, in the guideline
development process and planning stages for this project, stakeholders outlined a range of
systemic and organizational barriers to providing primary bereavement care. These included
insufficient and inflexible remuneration, inappropriate staffing models, lack of debriefing and
mentorship, as well as time constraints and multiple competing priorities. Nonetheless, the strong
support experienced to date from VON’s President/CEO right through to the directors, managers,
and frontline staff is an indication that such potential challenges may be mediated. Flexibility and
adaptation will be of key importance in this collaborative study given the often unpredictable
events and situations that inevitably arise in the life of an organization. To help address some of
these impediments, project funding will be provided to support a facilitator for this project and to
liberate staff. The forums and focus groups will be conducted at a convenient time and place for
participants, perhaps piggybacking on to preplanned organizational activities to minimize time
and cost expenditures. The development of a learning collaborative and the fostering of
relationships between multiple stakeholders are anticipated to assist with longer-term support and
mentorship around the provision of bereavement care.
VON Canada is the largest national not-for-profit charitable home and community care
organization, with most of its sites engaged in palliative and end-of-life care. VON Canada
considers therapeutic relationships and supporting families (core competencies to bereavement
care) to be a foundation for their “Care and Service Model” (Victorian Order of Nurses Canada,
n.d.). VON Canada has identified improving the delivery of quality services for bereaved
individuals and families as a high priority. This is fitting for this home care organization for
several reasons: (a) it is at the interface between acute care and the community and therefore well
placed to identify the conduits for ensuring continuity of care across sectors; (b) its clinical and
program emphasis on the elderly, palliative care, and chronic care management; (c) regardless of
where or in what setting they lose their loved one, bereaved individuals and families ultimately
grieve at home; (d) VON is recognized as a pioneer and champion in the field of caregiver/family
information, support, and education; (e) VON is characterized by a learning culture which aims
for excellence, innovation, and integration; research and evidence is used to inform practice and
organizational decision-making and to proactively influence policy at the organizational and
health system level; and (f) as a nongovernmental organization with extensive experience in the
policy arena, VON can champion this innovation for bereaved Canadians.
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VON Canada has been an active partner in the Principal Investigator’s program of research for
over a decade. The Principal Investigator’s position as an embedded researcher in this national
home and community care organization has been important in the development of research and
implementation of evidence-based practice change. VON’s commitment to having a nurse
researcher as part of its organizational structure highlights the dedication to ensuring that research
evidence will inform home care practice and, in turn, that practice will inform research. There has
been an underlying assumption in the KT literature that users and producers traditionally reside in
two separate communities (Phelps, 2005; Phelps & Hase, 2002). The colocation within an
organization of research producers and knowledge users is an under-studied aspect of KT to
which this study can also contribute.
The knowledge-user partners range in positions across all system levels. For example, this project
includes the President/CEO, National Directors and Vice Presidents, managers and front line
staff, in addition to other key stakeholder across the system locally, regionally, and nationally.
This breadth of involvement provides the potential for scaling up and spreading of this initiative.
VON Canada’s long-term goal for this system innovation is to be a champion of the process to
reach a national consensus for a standard of care for primary bereavement care across the nation.
This standard of primary bereavement care will be based on a philosophy of prevention and
health promotion. Given the evidence for potential negative health impacts following the death of
a loved one, and the documented need for support (Bonanno & Kaltman, 2001; Christakis &
Alison, 2006; Christakis & Iwashna, 2003; Lang et al., 1996; Lang et al., 2004; Lilard & Waite,
1995; Schulz, Boemer, Shear, Zhang, & Gitlin, 2006; Wimpenny et al., 2006), it is clear that
bereavement care must be integral to health-care agendas and services. It requires a large system
change through effective KT strategies, with key stakeholders across sectors and provinces. The
knowledge user partners are strategically positioned and committed to realizing the study
objectives and to undertaking future initiatives. They also have the potential to disseminate the
outcomes and evidence on a broad and influential scale.
In order to improve the care to bereaved Canadians in a sustainable fashion, there is a need to
reach out to and partner with resources outside of the health-care system including funeral homes
and to the bereaved themselves. It is anticipated that implementation of the primary bereavement
care guideline will have benefits for the health-care workforce as well as for the bereaved. Some
benefits to providers include a reduced level of stress, lower incidences of anxiety and depression,
reduced substance abuse, lower employment turnover, and fewer sick days. Some benefits to the
bereaved include reduced use of medical and other health and social services, reduced leaves of
absence from work, as well as improved health and quality of life.
Results from this study will be published in a health services and policy peer-reviewed journal.
The notion of primary bereavement care will be introduced to the public health community
through conference presentations. This diverse team will transfer the knowledge from this project
to other health and social issues for which large system change is sought. It is also anticipated that
the project findings will have significant impact by augmenting the practice recommendations
that are part of the guideline with more specific and significant organizational and policy change
recommendations. As part of this project, VON is positioned to be a model community of
practice for primary bereavement care, wherein local research-user interaction is maximized. This
project is anticipated to yield empirical and theoretical evidence about the process of researcherknowledge user partnerships as well as the process initiating systems transformations related to
primary bereavement care in the community.
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Yin, R. (2009). Case Study Research (4th ed.). Thousand Oaks, CA: Sage.
139
International Journal of Qualitative Methods 2015, 14
Appendix A: Individual Consent
Evidence-Informed Primary Bereavement Care:
A Knowledge-to-Action Approach
Interview Consent Form
STUDY PRINCIPAL INVESTIGATOR:
Ariella Lang, RN PhD
Research Scientist, VON Canada
Assistant Professor, School of Nursing McGill University
Professeure associée, Faculté des sciences infirmières Université de Montréal
RESEARCH TEAM:
Andrea Fleiszer, RN BSc BN PhD(c), McGill University
Amin Mawani, PhD, FCMA, York University
Megan Aston, RN PhD, Dalhousie University
Susan Cadell, PhD, Wilfrid Laurier University
Catherine Butler, RN, BA, BScN, MHA, VON Canada
You are being invited to participate in a research study led by Dr. Ariella Lang about improving
bereavement care. Prior to agreeing to participate and before signing this consent form, please take
the time to read and understand the information that follows.
STUDY PURPOSE
The main purpose of this research study is to increase organizational and practitioner uptake and
application of a Primary Bereavement Care Guideline 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. The knowledge gained through this research project will be used to inform
future practice and policy development. In addition, it aims to have a significant impact on
providers’ knowledge, skills and attitudes about caring for the bereaved, while also seeking benefits
for the bereaved.
PARTICIPATION
Your participation in this study is voluntary and confidential. It will consist of your participation
in two 30-60 minute audio-recorded semi-structured interviews (the first at the beginning and the
second at the end of the study). The goal of the first baseline interview will be to gain an
understanding of the bereavement care status at VON, particularly from the leadership perspective,
and to anticipate the levers for and challenges of implementing the Primary Bereavement Care
Guideline. The goal of the second or end of project interview will be to: uncover the impacts of the
knowledge-to-action process; discuss the resultant changes in bereavement care; and, identify how
the change and implementation process might be applied more broadly across VON. At the time of
your interview, you will also be asked to complete a brief demographics form.
The most important thing about your participation is that we hear what you have to say. There are
no right or wrong answers. Your participation is completely voluntary, and you may refuse to
answer any questions during the interview and/or withdraw from the study at any time. You may
also request that the data that is collected from you be excluded from the study findings.
Participating in, or withdrawing from the study will not affect your employment at VON in any
way.
140
International Journal of Qualitative Methods 2015, 14
CONFIDENTIALITY
The information gathered from you will be used only for the purposes of this research. Only the
researchers and research staff involved in this study will see the transcripts and study records. All
information will be kept confidential. Your name will not be recorded alongside your responses. A
unique identification number will be assigned to your interview data. Your individual results will
not be shared with anyone outside of the research team. Only group results will be presented or
published publicly. Your words may be quoted in reports of this research; however, you will not
be identified by name. It is possible that you may be identifiable by virtue of your unique position
in this organization. If so, you will be offered the option of reviewing portions of your interview
transcript and of excluding any text that you do not wish quoted. The Research Ethics Boards
overseeing this study may request and inspect information from the study to make sure that it is
being conducted properly. In this case, the members of these ethics committees will also adhere to
strict confidentiality policies.
CONSERVATION OF STUDY DATA
All participant information, demographics forms, as well as recordings and transcripts of your
interview(s) will be kept in the research team members’ locked offices. Electronic versions of your
data will be stored on the research team members’ password-protected computers. The raw data
from this study will be kept for a minimum of 10 years from the time of collection. Secondary
analysis of the data collected may be performed as part of future studies conducted at VON related
to the Primary Bereavement Care Guideline program.
RISKS & BENEFITS
Other than the time it takes to participate, it is unlikely that you will experience any discomfort or
inconvenience as a result of your participation. Your participation in this study will not necessarily
benefit you directly. However, your participation will help to develop knowledge that may help
improve bereavement services and help families locally and across Canada.
ETHICAL CONSIDERATIONS
If you have any questions concerning the study, you may contact Dr. Lang at the telephone number
or email address below. If you have any concerns about how the study is being conducted you may
contact the VON Canada Research Ethics Committee Chair directly at
(phone number).
If you are interested in participating in this study, please contact the Research Project Coordinator
at (phone number) or at (email). She will further explain the study and answer any questions that
you may have.
141
International Journal of Qualitative Methods 2015, 14
CONSENT FORM
Title of Project:
Evidence-Informed Primary Bereavement Care: A Knowledge-To-Action Approach
Consent questions (to be completed by the research participant):
Yes No
 
I have had the opportunity to ask questions and discuss this study:
I understand that I am free to withdraw from the study at any time,
without having to give a reason and without affecting my employment:
I am willing to participate in an audio-taped interview:
I agree to the secondary analysis of the data collected from me as part
of future related studies conducted by members of the research team:
 
 
 
________________
________________________
________/______/____
Signature of Participant
Name (Printed)
Year/Month/Day
________________
________________________
________/______/____
Signature of Witness
Name (Printed)
Year/Month/Day
I, __________________________________, would / would not [please circle one] like to be
contacted when the results of the study are available.
Please contact me at:
NAME: ____________________________________________
ADDRESS:
_____________________________________________
EMAIL:
_____________________________________________
142
International Journal of Qualitative Methods 2015, 14
Appendix B: Focus Group Consent
Evidence-Informed Primary Bereavement Care:
A Knowledge-to-Action Approach
Focus Group Consent Form
STUDY PRINCIPAL INVESTIGATOR:
Ariella Lang, RN PhD
Research Scientist, VON Canada
Assistant Professor, School of Nursing McGill University
Professeure associée, Faculté des sciences infirmières Université de Montréal
RESEARCH TEAM:
Fabie Duhamel, RN PhD, University of Montreal
Andrea Fleiszer, RN BSc BN PhD(c), McGill University
Amin Mawani, PhD FCMA, York University
Megan Aston, RN PhD, Dalhousie University
Tracy Carr, RN PhD, University of New Brunswick Saint John
Susan Cadell, MSW PhD, Wilfred Laurier University
Catherine Butler, RN BA BScN MHA, VON Canada
You are being invited to participate in a research study led by Dr. Ariella Lang about improving
primary bereavement care. Before agreeing to participate and before signing this consent form,
please take the time to read and understand the information that follows.
You are being invited to participate in this study because:
1) You are > 18 years of age,
2) You are a volunteer / community member who works with bereaved individuals, OR are
employed at VON and work with the bereaved, OR have experienced the death of family
member, OR are employed by Nova Scotia Health and your work in some way involves the
bereaved, AND
3) You are able to participate in an English focus group.
STUDY PURPOSE
The main purpose of this research study is to increase the use of a developed Primary Bereavement
Care Guideline (PBCG) at an organizational and practitioner level. This guideline is aimed at
improving bereavement care for individuals and families at home and in the community around the
death of a loved one. The knowledge gained through this research project will be used to inform
future practice and policy development. In addition, it aims to have a major impact on providers’
knowledge, skills and attitudes about caring for the bereaved, while also seeking benefits for the
bereaved.
PARTICIPATION
Your participation in this study is voluntary and confidential. It will consist of your participation
in a 1.5 to 2 hour face-to-face audio-recorded focus group with you and others involved in some
way with bereavement care. During the focus group you will be asked to participate in a discussion
about your perception of bereavement care at VON. We want to hear what you have to say. There
is no right or wrong answer.
143
International Journal of Qualitative Methods 2015, 14
Your participation is completely voluntary, and you may refuse to answer any questions during the
focus groups and/or withdraw from the study at any time. You may also request that the data that
is collected from you be excluded from the study findings. Participating in or withdrawing from
the study will not affect your employment or relationship with VON in any way.
CONFIDENTIALITY & ANONYMITY
For the purposes of this research related to the Primary Bereavement Care program, only the
researchers and research staff involved in this study will see the transcripts and study records. All
information will be kept confidential. Your name will not be recorded alongside your responses.
Only group results will be presented or published publicly. Your words may be quoted in reports
of this research; however, you will not be identified by name. The Research Ethics Boards
overseeing this study may request and inspect information from the study to make sure that it is
being conducted properly. In this case, the members of these ethics committees will also adhere to
strict confidentiality policies.
Anonymity will not be possible among the members of the focus groups. The researcher will ask
other members of the focus group to keep what you say confidential, but please note that the
researcher cannot guarantee they will do so.
CONSERVATION OF STUDY DATA
All participant information, demographics forms, as well as recordings and transcripts of the focus
groups will be kept in the research team members’ locked offices. Electronic versions of your data
will be stored on the research team members’ password-protected computers. The raw data from
this study will be kept for a minimum of 10 years from the time of collection. The data collected
might be used in future related studies conducted at VON and related to the Primary Bereavement
Care program.
RISKS & BENEFITS
During the focus group, you will be asked to speak about your feelings, thoughts, and experiences
related to bereavement and bereavement care. Discussing these things may cause you to feel
emotional discomfort. The focus groups will be conducted by facilitators who are experienced in
facilitating such discussions. These group moderators will be attentive to the need to mediate any
potentially harmful interactions between participants. The moderator will establish “ground rules”
for the focus groups and remind all participants of these rules if respectful communication is
breached. You may refuse to answer any question at any time during the focus group. In case of
harm or serious discomfort during the focus groups, contact information for professional counseling
will be offered to you.
Your participation in this study will not necessarily benefit you directly. However, your
participation will help to develop knowledge that may help improve bereavement services and help
families locally and across Canada.
ETHICAL CONSIDERATIONS
If you have any questions concerning the study, you may contact Dr. Lang at the telephone number
or email address below. If you have any concerns about how the study is being conducted you may
contact the VON Canada Research Ethics Committee Chair directly at
(phone number).
If you are interested in participating in this study, Research Project Coordinator at (phone number)
or at (email). She will further explain the study and answer any questions that you may have.
144
International Journal of Qualitative Methods 2015, 14
CONSENT FORM
Title of Project:
Evidence-Informed Primary Bereavement Care: A Knowledge-To-Action Approach
Consent questions (to be completed by the research participant):
I have had the opportunity to ask questions and discuss this study:
I understand that I am free to withdraw from the study at any time,
without having to give a reason:
I am willing to participate in an audio-taped focus group:
I agree the data collected from me might be used in future related studies
conducted by members of the research team
I am interested in participating in another mixed focus group with nurses,
managers, home support workers, family members and volunteers:
Yes No
 
 
 
 


________________
________________________
________/______/____
Signature of Participant
Name (Printed)
Year/Month/Day
________________
________________________
________/______/____
Signature of Witness
Name (Printed)
Year/Month/Day
I, __________________________________, would / would not [please circle one] like to be
contacted when the results of the study are available.
Please contact me at:
NAME: ____________________________________________
ADDRESS:
_____________________________________________
EMAIL:
_____________________________________________
145
Copyright 2001 by the Educational Publishing Foundation
1089-2699/01/S5.00 DOI: 10.1037//1089-2699.5.4.291
Group Dynamics: Tlieory, Research, and Practice
2001, Vol. 5, No. 4, 291-303
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Trauma- and Grief-Focused Intervention for Adolescents Exposed to
Community Violence: Results of a School-Based Screening and
Group Treatment Protocol
William R. Saltzman
Robert S. Pynoos
University of California, Los Angeles,
and California State University, Long Beach
University of California, Los Angeles
Christopher M. Layne
Alan M. Steinberg and Eugene Aisenberg
University of California, Los Angeles, and Brigham
Young University
University of California, Los Angeles
This study assessed the prevalence of trauma exposure among middle school students
and evaluated the effectiveness of a school-based, trauma- and grief-focused group
psychotherapy protocol in treating a subset of students with severe exposure, posttraumatic stress disorder (PTSD), and functional impairment. Using a stratified screening
procedure, 812 students completed a screening survey; 58 students (7.1% of those
surveyed) met criteria for group treatment, and 26 students participated in the group.
Group participation was associated with improvements in posttraumatic stress and
complicated grief symptoms and in academic performance. Results suggest that students who are exposed to severe levels of community violence often may not be
identified or treated. The findings also suggest that severe PTSD in adolescence may be
associated with impaired school functioning, and that a reduction in PTSD symptoms
may be related to academic remediation.
Although overall rates of violent crime in the
United States have diminished in recent years,
levels of exposure to violence among adolescents continue to be high. Juveniles are two
times more likely than adults to be victims of
serious violent crime and three times more
William R. Saltzman, Trauma Psychiatry Service, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, and Department of Educational Psychology, Administration, and Counseling, California State University, Long Beach; Robert S. Pynoos,
Alan M. Steinberg, and Eugene Aisenberg, Trauma Psychiatry Service, Department of Psychiatry and Biobehavioral
Sciences, University of California, Los Angeles; Christopher M. Layne, Trauma Psychiatry Service, Department of
Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, and Department of Psychology,
Brigham Young University.
This woik was supported by California State Office of
Criminal Justice Planning Grant CU97011637, the Bing
Fund, and the Irene Foundation for Mental Health.
Correspondence concerning this article should be addressed to William R. Saltzman, Department of Educational
Psychology, Administration, and Counseling, California
State University, Long Beach, 1250 Bellflower Boulevard,
Long Beach, California 90840-2201. Electronic mail may
be sent to wsaltzman@att.net.
likely to be victims of simple assault (Sickmund, Snyder, & Poe-Yamagata, 1997; Snyder,
1998). A national survey of adolescents found
that 23% reported having been both a victim of
assault and a witness to violence and that over
20% met lifetime criteria for posttraumatic
stress disorder (PTSD; Kilpatrick, Saunders,
Resnick, & Smith, 1995).
Of particular concern to educators and health
professionals is the considerable evidence indicating that adolescents exposed to violence are
at increased risk for a spectrum of adverse psychosocial difficulties and functional impairments. These difficulties include reduced academic achievement; aggressive, delinquent, or
high-risk sexual behaviors; and substance abuse
and dependence (Cavaiola & Schiff, 1988; Collins & Bailey, 1989; Farrell & Bruce, 1997;
Kilpatrick, Aciermo, Saunders, Resnick, &
Best, 2000; Saigh, Mroueh, & Bremner, 1997).
Trauma in adolescence has been linked with
long-term developmental disturbances, including disrupted moral development, missed developmental opportunities, delayed preparation for
professional and family life, and disruptions in
close relationships (Goenjian et al., 1999;
291
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
292
SALTZMAN, PYNOOS, LAYNE, STEINBERG, AND AISENBERG
Layne, Pynoos, & Cardenas, 2001; MalinkoskyRummell & Hansen, 1993; Pynoos, Steinberg,
& Piacentini, 1999; Pynoos, Steinberg, &
Wraith, 1995).
Moreover, the high rates of traumatic deaths
found in inner U.S. cities associated with gang
violence, domestic violence, fatal accidents, and
other traumatic losses create additional risks for
those adolescents who suffer the violent death
of a family member or friend. Such traumatic
losses impose a dual burden of posttraumatic
stress reactions and bereavement, the interplay
of which may complicate grief reactions (Pynoos, 1992). In particular, intrusive, distressing
memories and emotions linked to the violent
circumstances of the death, avoidance of cues
linked to the death or to the deceased, and
numbing of responsiveness may disrupt critical
adaptive grieving processes. These processes
include reminiscing, participating in grief rituals, processing painful emotions associated with
accepting and adapting to the loss, and making
meaning of the death (Jacobs, 1999; Pynoos,
1992; Pynoos, Steinberg, & Goenjian, 1996;
Rando, 1993; Saigh, Mroueh, & Bremner,
1997).
These findings point to a need to provide
trauma-exposed adolescents with access to specialized mental health services, especially given
the recent trend toward developing trauma-focused and empirically validated treatment protocols (see Foa, Keane, & Friedman, 2000).
Growing evidence supports the effectiveness of
group-based therapeutic approaches for the
treatment of traumatized individuals because of
the benefits that this modality confers (Foa et
al., 2000; see also Foa & Meadows, 1997; Goenjian et al., 1997; Murphy, Pynoos, & James,
1997; March, Amay-Jackson, Murray, &
Schulte, 1998). Group approaches for adolescents may have special advantages. They make
use of the adolescent peer group to help with
appraisal and response to danger, motivational
explanations of behavior, misattributions about
severity of response and course of recovery,
sensitivity to peer approval, self and other judgments about normality, emotional support and
affect regulation, problem solving current difficulties, and promotion of developmental recovery (Pynoos & Nader, 1992; Layne, Pynoos, &
Cardenas, 2001; Yule & Canterbury, 1994).
The challenge to providing appropriate services to adolescents exposed to community vi-
olence has two major aspects. The first involves
the need for a systematic, accurate, and efficient
means of identifying youths with histories of
severe trauma or loss who currently experience
distress and functional impairment. Traumatized youths do not generally seek professional
assistance, and recruiting school personnel to
refer trauma-exposed students to school counselors can also leave many of these students
unidentified (Layne, 1996). Many studies have
used self-report instruments to estimate the
prevalence of trauma exposure and PTSD
among youths (Bell & Jenkins, 1993; Kilpatrick, Saunders, Resnick, & Smith, 1995; Osofsky, Wewers, Hann, & Fick, 1993). These
findings suggest that a more comprehensive assessment of exposure parameters, associated
distress, and impairment in function is needed
to make informed treatment decisions, especially given the possibility of inaccuracies in
child and adolescent reports of the degree of
exposure (Richters & Martinez, 1993) and the
great variability in responses to similar traumatic events observed among survivors (Asarnow et al., 1999; Garmezy, 1993).
The second aspect to providing appropriate
services to adolescents exposed to community
violence is to recruit and retain traumatized
youths in appropriate treatment. Services must
be easily accessible, engage the adolescent, and
minimize attrition. According to school counselors and community mental health providers,
as many as one half of the students referred by
schools for mental health services in the community do not present for treatment, and those
who do present frequently terminate prematurely (Saltzman, 2001). These results are consistent with the general psychotherapy outcome
literature, which indicates that most clients do
not receive a sufficient number of psychotherapy sessions to produce clinically significant
change (Hansen, Lambert, & Forman, in press).
This article describes the results of a schoolbased trauma- and grief-focused group psychotherapy program designed to address these two
challenges. The primary tools used by this program included (a) a methodology for systematically screening for trauma exposure and distress among large groups of public school students and (b) a specialized school-based
trauma- and grief-focused treatment protocol
designed to reduce distress in targeted traumarelated outcomes, promote retention, and im-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
SPECIAL ISSUE: SCHOOL-BASED INTERVENTION FOR COMMUNITY VIOLENCE
293
tive features of the referent traumatic experience, a hierarchy of trauma and loss experiences, identification of key negative emotions
(e.g., guilt, shame, rage, revenge), an inventory
of trauma reminders, and a description of developmental disturbances and current psychosocial adversities. The interview provides psychoeducation about traumatic stress and complicated bereavement, initiates the construction
of a shared vocabulary about the trauma or loss,
and prepares the adolescent for group participation (Layne, Pynoos, & Cardenas, 2001).
The fourth component consists of a manualized trauma- and grief-focused group psychotherapy protocol that is based on five treatment
foci developed by Pynoos and his colleagues
(Pynoos et al., 1995; see Layne et al., 2001, for
a more detailed review of the treatment foci and
manual). The five foci include traumatic experiences, reminders of trauma and loss, the interplay of trauma and grief, posttrauma adversities,
Trauma- and Grief-Focused
and developmental progression. The group psyTreatment Protocol
chotherapy protocol consists of 20 semistrucThe program described herein was adapted tured sessions, which are divided into four modfrom intervention programs developed by mem- ules. These modules are designed to succesbers of the University of California, Los Ange- sively build a foundation of group cohesion and
les (UCLA) Trauma Psychiatry Service and coping skills, process traumatic experiences,
used in Armenia following the 1988 earthquake promote adaptive grieving, and promote normal
(Goenjian et al., 1997), in Southern California developmental progression, respectively. The
with adolescents traumatized by community vi- format for all sessions consists of a check-in
olence (Layne et al., 2001), and in post-war activity, review of the practice exercise asBosnia with severely war-exposed secondary signed the previous week, presentations of inschool students (see Layne, Pynoos, Saltzman, formation and skills coupled with a group acet al., 2001). The program consists of four pri- tivity, assignment of a practice exercise, and a
mary components. The first and second compo- check-out exercise. Module I is dedicated to
nents constitute a multistep screening approach building group cohesion, providing psychoeduto enhance identification and accurate charac- cation regarding trauma and loss, normalizing
terization of exposure, distress, and adaptation. members’ distress reactions, and developing
The first is a triage self-report survey of com- specific skills to cope with trauma-related dismunity violence exposure and posttraumatic tress. Module II focuses on the therapeutic processing of selected traumatic experiences,
stress, depression, and grief symptoms.
which entails selecting a focal traumatic expeStudents who endorse significant exposure rience, conducting trauma narrative exposure
and concurrent distress are then invited to par- work, exploring the worst moments to increase
ticipate in the second component, which con- tolerance, and identifying and restructuring
sists of an individual screening interview. This maladaptive cognitions associated with extreme
interview is designed to verify the survey re- negative emotions. The primary goal of Module
sults; to explore functional impairments at HI is the therapeutic management of the interschool, home, and with peers; and to assist in play between trauma, loss, and complicated bedetermining appropriateness for individual or reavement. Activities include psychoeducation
group psychotherapy.
about grief symptoms and loss reminders, the
A pregroup clinical interview is a critical processing of angry reactions to losses, and the
third component. This interview provides in- reconstruction of a nontraumatic image of the
depth information about objective and subjec-
prove academic performance. The site selected
for program implementation consisted of a secondary school cluster (a senior high school and
two feeder junior high schools) located within a
community characterized by chronic economic
disadvantage and violent gang activity. Twentysix percent of the households in the community
are below the poverty level, and 18% receive
public assistance (Pasadena City Police, 1996).
A prior large-scale survey of violent victimization among ninth graders from the community
revealed that 22% reported having been shot at,
8% reported having been stabbed, 20% reported
having been badly beaten, 9% reported having
been sexually assaulted, 48% reported that they
had a friend who was injured or killed by gunshot, and 28% reported that they had a relative
who was injured or killed by gunshot (Rohrbach, Mansergh, Fishkin, & Johnson, 1997).
294
SALTZMAN, PYNOOS, LAYNE, STEINBERG, AND AISENBERG
deceased to promote healthy grieving. Module
IV is devoted to problem solving current adversities, identifying and challenging maladaptive
core life beliefs, and taking steps to restore or
initiate normal developmental progression.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Study Questions
This study addressed basic questions related
to the identification and treatment of students
with histories of community violence exposure
and associated distress. The first question explored the extent to which trauma and traumatic
loss constitute a clinically significant problem
among the general population of students attending the schools: What are the prevalence
rates of different forms of trauma and traumatic
loss exposure reported by students who participated in the screening survey? Related questions explored the magnitude of the mental
health problem associated with community violence exposure (What percentage of the students surveyed were considered appropriate
candidates for specialized trauma- and grieffocused psychological services?) and the extent
of mental health service coverage among those
judged to need it (How many students appeared
to be in need of specialized mental health services but did not access it?). The last question
addressed the degree to which the mental health
services provided were effective in achieving
their targeted outcomes: Was participation in
trauma- and grief-focused group psychotherapy
associated with significant improvements in
posttraumatic stress, depression, complicated
grief symptoms, and academic performance?
Method
Participants
Participants consisted of 812 students who
were surveyed for trauma exposure and distress
and 26 students who participated in the traumaand grief-focused group psychotherapy program. Group participants consisted of 61% boys
and 39% girls, ranging from 11 to 14 years of
age (M = 12.58, SD = .99). The ethnic composition of the group members was 68% Hispanic, 28% African American, and 4%
Caucasian.
Measures
Community Violence Exposure Survey
(CVES; Saltzman, Layne, & Steinberg, 1998).
The CVES is a 25-item self-report inventory of
community violence exposure adapted from the
widely used Survey of Exposure to Community
Violence (Richters & Saltzman, 1989). CVES
items assess exposure to a range of violent
events within the community through the channels of direct exposure, witnessing, and verbal
mediation. Violent events include serious accidents, homicides, being threatened with a
weapon, shootings, kidnappings, beatings, and
attempted or completed suicide. The instrument
is scored by identifying endorsements of one or
more forms of trauma exposure, with particular
emphasis given to events involving physical
injury, direct life threat, and life loss.
UCLA PTSD Reaction Index—Adolescent
Version (RI-R; Rodriguez, Steinberg, & Pynoos, 1999). The RI-R is a revised version of
the widely used UCLA Reaction Index (Pynoos
et al., 1987), which is based on the Diagnostic
and Statistical Manual of Mental Disorders
(3rd ed.; DSM-HI; American Psychiatric Association, 1980). The RI-R is a 22-item self-report
measure of the frequency with which posttraumatic stress symptoms have been experienced
during the past 4 weeks. Symptoms are rated on
a 5-point Likert scale ranging from 0 (none of
the time) to 4 (most all the time). Twenty of
the 22 items assess core DSM-IV (4th ed. of the
DSM; American Psychiatric Association, 1994)
PTSD symptoms; two additional questions assess associated features, including fear of recurrence and trauma-related guilt. Kutlac et al.
(2000) reported a Cronbach’s alpha of .92 and
evidence of good convergent validity. Cutoff
scores of 30-39, and 40 and above, respectively, are associated with “moderate” and “severe to very severe” levels of PTSD symptomatology (Pynoos, 1992).
Reynolds Adolescent Depression Scale
(RADS; Reynolds, 1987). The RADS is a 30item self-report measure of depressive symptoms among adolescents. Items are scored on a
scale ranging from 0 (almost never) to 3 (most
of the time). The instrument uses cutoff scores
to categorize severity levels of clinical depression and has excellent validity and reliability
with diverse adolescent populations. Internal
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SPECIAL ISSUE: SCHOOL-BASED INTERVENTION FOR COMMUNITY VIOLENCE
consistency coefficients range from .91 to .94,
and test-retest coefficients range between .79
and .80.
Grief Screening Scale (GSS; Layne, Steinberg, Savjak, & Pynoos, 1998). The GSS is a
10-item self-report screening inventory of grief
symptoms in adolescents and adults. The scale
is a revised version of the UCLA Grief Inventory (Pynoos, Nader, Frederick, & Gonda,
1987) and is composed of two factor-analytically derived subscales containing five items
each: One subscale measures symptoms of normal grief, and the other measures symptoms of
complicated grief. Symptoms experienced during the past 4 weeks are measured on a 5-point
scale ranging from 0 (none of the time) to 4
(most of the time). Layne et al. (2000) reported
a full-scale Cronbach’s alpha of .86 and good
convergent validity.
The UCLA Trauma-Grief Screening Interview (Layne, Saltzman, & Woods, 1999). This
semistructured individual interview is designed
for administration by a trained clinician. The
interviewing clinician reviews the student’s survey responses and asks for clarifications and
examples of endorsed traumatic experiences
and symptoms to verify the presence of clinically significant trauma exposure and current
psychological distress. Additional questions
then assess the interviewee’s current level of
psychosocial functioning with respect to school
performance, family relationships, and peer relationships. The last portion of the interview
consists of a criterion-based scoring and decision-making protocol that assists the interviewer in determining the type or degree of
services that the student should receive (instrument is available on request).
Grade point average (GPA). GPA was used
to assess school performance. At the participating schools, grades for each class are reported at
the end of every 20 weeks of instruction. GPA
is the average of overall class grades based on
the following weights: A = 4, B = 3, C = 2,
D = 1, F = 0. Pre- versus posttreatment GPA
was calculated by calculating each student’s
overall GPA obtained during the 20-week period immediately prior to the intervention and
his or her overall GPA obtained during the
20-week period during which the group treatment was implemented.
295
Procedure
Letters were sent home to all parents describing the program and requesting active written
consent for (a) the student’s participation in the
screening survey and (b) if appropriate, a follow-up screening interview. Students with parental consent then completed the screening
measures in groups of approximately 30 under
the direction of trained clinicians following a
written protocol. To ensure test comprehension,
the group leaders read all printed directions and
individual items. Groups of Hispanic students
with limited English proficiency were administered a backward- and forward-translated translated version of all measures; all directions and
items were read by a bilingual group leader. A
second method of identifying appropriate candidates for treatment consisted of referrals from
students, school staff, and parents.
Students were selected for an individual
screening interview if they met either of two
criteria: (a) reporting one or more forms of
significant exposure to trauma, violence, or loss
as a victim, witness, or friend or family member
of a victim and scoring 30 or higher on the
RI-R; or (b) reporting the death of a close friend
or family member and scoring 45 or higher on
the RADS and/or scoring 8 or higher on the
Complicated Grief subscale of the GSS. Students meeting these criteria were then invited to
participate in an individual screening interview.
In accordance with the individual screening
interview protocol, the interviewing clinician
referred students to the treatment program who
met the following four criteria: (a) one or more
significant trauma or loss-related experiences
(e.g., accidental injury; assault, dea…
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