Psychometric Evaluation of the Veterans Affairs Bereaved Family Survey in Community Nursing Homes

  • Daniel Kinder
    Address correspondence to: Daniel Kinder, MPH, Corporal Michael J. Crescenz VAMC, 3900 Woodland Avenue, Building 4100, Philadelphia, PA 19104, USA.
    Veteran Experience Center (D.K.,D.S.,A.K-L.), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
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  • Joshua Thorpe
    Center for Health Equity Research and Promotion (J.T,), Pittsburgh VA Medical Center, Pittsburgh, Pennsylyania, USA

    UNC Eshelman School of Pharmacy (J.T.), Chapel Hill, North Carolina, USA
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  • Dawn Smith
    Veteran Experience Center (D.K.,D.S.,A.K-L.), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
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  • Melissa Wachterman
    Veterans Affairs Boston Healthcare System (M.W.), Boston, Massachusetts, USA

    Division of General Internal Medicine and Primary Care, Department of Medicine (M.W.), Brigham and Women's Hospital, Boston, Massachusetts, USA

    Department of Psychosocial Oncology and Palliative Care (M.W.), Dana Farber Cancer Institute, Boston, Massachusetts, USA
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  • Ann Kutney-Lee
    Veteran Experience Center (D.K.,D.S.,A.K-L.), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA

    University of Pennsylvania School of Nursing (A.K-L.), Philadelphia, Pennsylyania, USA
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      For over a decade, the Department of Veterans Affairs (VA) has used the Bereaved Family Survey (BFS) to measure the quality of end-of-life (EOL) care in VA inpatient settings. In 2019, VA developed a revised version of the BFS to evaluate the quality of EOL care for Veterans who received hospice services in VA-contracted community nursing homes (CNHs).


      The purpose of this analysis was to evaluate the psychometric properties and factor structure of the BFS-CNH.


      The BFS-CNH was administered to the next-of-kin of Veterans who died in a VA-contracted CNH with hospice care between October 2019 and April 2020. Exploratory factor analysis (EFA) was used with the 10 core items of the BFS-CNH that were derived from the inpatient BFS to evaluate whether the BFS-CNH exhibited a similar factor structure to the inpatient version. Cronbach's alpha was used to assess internal consistency/reliability of the identified factors and linear regression models were used to evaluate construct validity of the identified BFS-CNH factor scores and individual items.


      The EFA revealed a three-dimension solution that corresponded to factors on the inpatient BFS, including Care and Communication, Emotional and Spiritual Support and Death Benefits. Cronbach's alpha coefficients for all three factors indicated acceptable internal consistency.


      Our findings provide support for use of the BFS-CNH to evaluate the quality of EOL care provided to Veterans in CNHs and lay the foundation for future comparisons of BFS ratings between VA inpatient and CNH settings.

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        • US Government Accountability Office
        VA Nursing Home Care: VA Has Opportunities to Enhance Its Oversight and Provide More Comprehensive Information on Its Website.
        US Government Accountability Office, Washington, DC2019 (GAO-19-428) Available at (Accessed February 2, 2022)
      1. Internal communication with GEC program office and GEC data analysis center, 2022

        • Atkins D
        • Kilbourne AM
        • Shulkin D.
        Moving from discovery to system-wide change: the role of research in a learning health care system: experience from three decades of health systems research in the veterans health administration.
        Annu Rev Public Health. 2017; 38: 467-487
        • O'Hanlon C
        • Huang C
        • Sloss E
        • et al.
        Comparing VA and non-VA quality of care: a systematic review.
        J Gen Intern Med. 2017; 32: 105-121
        • Thorpe JM
        • Smith D
        • Kuzla N
        • Scott L
        • Ersek M.
        Does mode of survey administration matter? Using measurement invariance to validate the mail and telephone versions of the bereaved family survey.
        J Pain Symptom Manage. 2016; 51: 546-556
        • Royston P.
        Multiple imputation of missing values: update.
        The Stata J. 2005; 5: 188-201
        • Pett MA
        • Lackey NR
        • Sullivan JJ.
        Making sense of factor analysis: The use of factor analysis for instrument development in health care research.
        Sage Publications, Inc., Thousand Oaks, CA2003
        • DeVellis RF
        Scale development: theory and applications.
        SAGE Publications, Thousand Oaks, CA2016
        • Comrey AL
        • Lee HB
        A first course in factor analysis.
        2nd. Psychology Press, New York, NY1992
        • Nunnally JC
        • Bernstein I.H.
        The assessment of reliability.
        Psychometric Theory. 1994; 3: 248-292
        • Nunnally JC
        Psychometric theory 3E.
        Tata McGraw-Hill Education, New York, NY1994
        • Kross EK
        • Engelberg RA
        • Shannon SE
        • Curtis JR.
        Potential for response bias in family surveys about end-of-life care in the ICU.
        Chest. 2009; 136: 1496-1502
        • Starks H
        • Diehr P
        • Curtis JR.
        The challenge of selection bias and confounding in palliative care research.
        J Palliat Med. 2009; 12: 181-187
        • Smith D
        • Kuzla N
        • Thorpe J
        • Scott L
        • Ersek M.
        Exploring nonresponse Bias in the department of veterans affairs' bereaved family survey.
        J Palliat Med. 2015; 18: 858-864
        • Tabachnick BG
        • Fidell LS
        Using multivariate statistics.
        Allyn and Bacon, Boston, MA2001