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Nurses’ experiences of caring for severely burned patients
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Nurses’ experiences of caring for severely burned patients Jonathan Bayuo a,b,∗ a b
Department of Nursing, Faculty of Health and Medical Sciences, Presbyterian University College, Ghana Burns Intensive Care Unit, Directorate of Surgery, Komfo Anokye Teaching Hospital, Ghana
a r t i c l e
i n f o
Article history: Received 15 May 2016 Received in revised form 28 February 2017 Accepted 4 March 2017 Available online xxx Keywords: Nurses Severe Burns Caring
a b s t r a c t Background: Nurses form a pivotal part of the burns care team and participate in caring for severely burned patients. Previous studies have identified that severe burn injuries may serve as a form of stress to health professionals and as such they may require support whilst caring for these patients. However, there exists limited exploration of nurses’ experiences regarding caring for severely burned patients. Aim: To explore and describe nurses’ experiences of caring for severely burned patients. Methodology: An exploratory-descriptive approach was utilised to understand nurses’ experiences. Purposive sampling was used to recruit nurses from the Burns Intensive Care Unit (n = 7). Face to face semi-structured interviews were conducted with an interview guide and proceedings audio-recorded. Two follow up interviews were conducted after the initial interviews. Analysis was undertaken using thematic analysis to generate emergent themes. Findings: The themes identified were exhaustion during caring (physical and emotional) and concerns regarding outcomes of care. Conclusion: Nurses face varied issues when caring for severely burned patients and require avenues to express themselves but these are lacking in our current setting. Peer support and other approaches need to be explored as avenues for encouraging nurses to talk about their experiences. Further research is also warranted in understanding how palliative care can be incorporated in burns care. © 2017 Australian College of Nursing Ltd. Published by Elsevier Ltd.
1. Introduction Burn injury is a common type of traumatic injury which leads to significant morbidity and mortality (Brusselaers, Monstrey, Vogelaers, Hoste, & Blot, 2010). Following the occurrence of burn injury, the patient undergoes various phases of care such as resuscitative, acute, rehabilitative and operative phases. Burn care aims to enhance survival outcomes with minimal loss of function (Brusselaers et al., 2010). The initial phase of burns management focuses on fluid resuscitation, pain control, identifying and managing inhalational injury which involves the expertise of various health care professionals. The acute care phase also commences with a period of specialised intensive care when wound management and surgical treatment are carried out in parallel (Herndon, 2007). Though optimal care of the burn injured patient requires a multidisciplinary approach, the bulk of burn care activities have been indicated to involve the expertise of burn care nurses: wound care, monitoring various vital parameters, monitoring urine output,
∗ Correspondence to: Department of Nursing, Faculty of Health and Medical Sciences, Presbyterian University College, Ghana. E-mail address: [email protected]
pain assessment, monitoring the burned patient on ventilatory support among others. Accordingly, Carlson (2013) has specified that burns nursing require astute clinical skills including triage, stabilisation of severely burned patients, fluid balance, pain management, critical care, rehabilitation and trauma recovery. However, this central role of burn care nurses has been observed to be physically exhausting (Coffey, Everett, Miller, & Brown, 2011). Exhaustion associated with the role of burn care nurses has been linked to the prolonged stay of burn patients and the intensive treatment modalities required to prevent complications and restore functional ability (Cronin, 2001). Also, Hettiaratchy and Dziewulski (2004) have specified that the nature of the burn injury is a source of emotional stress for health care professionals. Nurses have been cited to face greater stress as compared to other health professionals (Greenfield, 2010) as they maintain 24-h contact with burned patients (Cronin, 2001). Negble, Agbenorku, Ampomah, and Hoyte-Williams (2014) studied the emotional aspect of nursing severely burned patients using a survey approach and identified that nurses are exposed to human suffering than other health professionals. Severely burned patients may have limited survival chances and palliative care is not well incorporated in burns care (Mosenthal & Murphy, 2003): thus requiring that these patients be subjected to
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Please cite this article in press as: Bayuo, J. Nurses’ experiences of caring for severely burned patients. Collegian (2017), http://dx.doi.org/10.1016/j.colegn.2017.03.002
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aggressive burns management till they die. This could mean that nurses rendering care to severely burned patients may face unique issues for which they may require support. These unique experiences appear under-explored and paucity of research exists in that regard. However, exploring and understanding nurses’ experiences whilst caring for the severely burned patient can provide useful information about specific issues and challenges they may be faced with and this can form the basis of developing strategies to assist and empower them in their roles. 1.1. Objective of the study The aim of this study was to explore and describe the experiences of Ghanaian nurses regarding caring for the severely burned patient. 1.2. Methodology 1.2.1. Design This study utilised qualitative methods to explore and describe nurses’ experiences of caring for severely burned patients. Munhall (2007) has specified that qualitative approaches are useful in exploring and describing human experiences. Also, qualitative methods are helpful in exploring unknown or understudied phenomenon and to promote the development of conceptual and theoretical frameworks as it enables the generation of rich textual descriptions of experiences (Stake, 2010). Ontologically, the qualitative approach is oriented towards constructionism which implies that social phenomena and their meanings are continually accomplished by the social entities involved (Polit & Beck, 2010). Thus in order to understand nurses’ experiences regarding caring for severely burned patients, there is a need to recruit those who have experienced the phenomenon and undertake in-depth discussions so as to capture those experiences unique to the phenomenon. Epistemologically, it is oriented towards interpretivism and inductive approach which leads to theory generation rather than testing theory (Bryman, 2012). The assumption of this stance is that nurses in the Burn Unit have experienced caring for severely burned patients and these experiences are not external facts to them but they possess individual interpretations and live with the experiences. Thus, as this study aimed at exploring and describing these experiences, the qualitative stance was appropriate so as to obtain firsthand information from those who have experienced the phenomenon (Polit & Beck, 2010). Specifically, the study utilised the exploratory-descriptive design in achieving its aim. This approach was selected because the phenomenon of caring for severely burned patients has received minimal attention in our setting and there is a need to map the nature of those experiences (Polit & Beck, 2010). 1.2.2. Setting The Komfo Anokye Teaching Hospital (KATH) in Kumasi is the second-largest hospital in Ghana and a tertiary health institution in the middle belt of the country. It is the main referral hospital for the Ashanti, Brong Ahafo, the Northern, Upper West and Upper East regions of the country. The hospital was built in 1954 and affiliated to the School of Medical Sciences (SMS) of the Kwame Nkrumah University of Science and Technology (KNUST). The hospital currently has 1000 beds, with an annual hospital attendance of about 679,050 patients made up of both out- and in-patients. The hospital has two units dedicated to burns care: Burns Intensive Care Unit and Ward D2C. These units have a six bed capacity each and attend to patients with varying degrees of burn injuries (“Komfo Anokye Teaching Hospital,” 2015). However, patients with severe burns are usually admitted to the Burns Intensive Care Unit (BICU) and as such the study focused on nurses in that unit. The unit has
a total of fifteen (15) nurses but two were on study leave and one nurse was on annual leave as at the time of the study. 1.2.3. Participant recruitment Purposive sampling was utilised to recruit Registered Nurses working in BICU. Registered Nurses working in the unit were approached face to face and the study discussed with them. Nurses who were on annual leave and study leave were excluded from the study due to their unavailability. Participants who took part in the study were nurses of varying grades and categories who have worked in the unit for a minimum of one year (a total of 10 nurses were noted to have worked in the unit for a minimum of one year). In all, a total of seven nurses participated in the study. 1.2.4. Data collection A face to face semi structured interview approach was used to collect data. This approach was chosen as it allowed in-depth coverage of caring experiences as well as allowing new themes to emerge (Charmaz, 2006). Data collection was carried out by the primary researcher who is also a Registered Nurse in the Burn Unit. As the primary researcher also works with severely burned patients, the interview was approached with an openness to attend to participants’ experiences. Before each interview, the researcher recorded all personal thoughts about the phenomenon in a diary. As the interview proceeded, the researcher noted any personal thoughts that were aroused by the participants’ description of their experiences. Audio-recordings and field notes enabled an assessment of the quality of the data. Data collection continued till data saturation (Charmaz, 2006). The stage of data saturation was noted at a point where there was no new information. All interviews were audiorecorded with participants’ permission. Interviews were scheduled at periods participants were available and these were conducted in the seminar room of the Burns Intensive Care Unit. The interview took place in the presence of only the primary researcher and each participant separately. Thus, the interviews were void of interruptions except for occasional breaks to allow participants take water. Before commencing each interview, participants were assured that the study aimed to explore their experiences as they provided care and as such there was no need to be apprehensive. Participants were encouraged to view the interviewer as a researcher interested in understanding their experiences. Field notes were also made during the interview process. The initial interviews lasted approximately 50–63 min. Two follow-up interviews were carried out to discuss narratives with each participant and to clarify findings. The follow up interviews lasted approximately 20–30 min. The semi-structured approach allowed new ideas that emerged during the interview to be explored further and that enabled in-depth coverage of the phenomenon (Charmaz, 2006; Polit & Beck, 2010). 1.2.5. Data analysis Audio recordings from interviews were transcribed verbatim in Microsoft Word 2010 version and exported to NVivo version 10. This was followed by thematic analysis which involved identifying, interpreting and reporting patterns within the data (Ritchie, Lewis, Nicholls, & Ormston, 2013). This process required working methodically through the transcribed texts and recognising themes that were progressively integrated into higher-order key themes in relation to the research aim (Joffe, 2012; Lo Biondo-Wood & Haber, 2010). 1.2.6. Trustworthiness of the data and findings The framework of Lincoln and Guba was used to ensure trustworthiness of the data and findings. This framework proposes four criteria: credibility, dependability, confirmability and transferability (Lincoln & Guba, 1985). Credibility was achieved by using purposive sampling technique to recruit nurses who had
Please cite this article in press as: Bayuo, J. Nurses’ experiences of caring for severely burned patients. Collegian (2017), http://dx.doi.org/10.1016/j.colegn.2017.03.002
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J. Bayuo / Collegian xxx (2017) xxx–xxx Table 1 Demographic features of participants (n = 7). Variable
Frequency
Percentage (%)
Age
20–30 years 31–40 years Total
5 2 7
71.40 28.60 100.0
Gender
Male Female Total
3 4 7
42.90 57.10 100.0
Years in burns care
Below 5 years Above 5 years Total
6 1 7
71.40 28.60 100.0
0
0.00
Training in burns care
experienced caring for severely burned patients. Iterative mode of questioning, probes and prompts were utilised throughout the interview process. Also, as the researcher is a registered nurse in the unit, a trust relationship was already in existence. Participants were assured of anonymity and that research findings will only be used as a basis for developing supportive strategies for nurses in the unit without reference to anyone. Confirmability was achieved by carrying out verbatim transcriptions of all audio recordings. As the researcher is a Registered Nurse in the unit, ideas regarding caring for severely burned patients were recorded in a diary. By keeping a diary, the researcher became aware of his thoughts regarding caring for severely burned patients and these were put aside to avoid interfering with participants descriptions. Themes generated from the study were validated by participants as reflecting their experiences. Dependability and transferability were achieved by dense descriptions of nurses’ experiences as well as the methodology used. An audit trail was also developed and maintained for the study. 1.2.7. Ethical clearance Ethical clearance for this study was obtained from KNUST School of Medical Sciences/KATH Committee on Human Research, Publications and Ethics, Kumasi. In addition, each participant was given a thorough description of the study to enable them make a decision as to whether to participate or not. Oral consent was also sought prior to commencement of the interviews. Anonymity and confidentiality were ensured throughout the study. 1.3. Findings From Table 1, majority of the nurses were within the 20–30 year range and most have also practised as burns nurses for less than five years. In terms of training in burns care, none of the nurses included in this sample have received training as burn care nurses. 1.3.1. Emergent themes From the data collected, significant statements were extracted and the following themes were identified: • Exhaustion during caring • Concerns regarding outcome of care 1.3.1.1. Exhaustion during caring. Participants in the study generally described caring for a severely burned patient as exhausting: both physically and emotionally. It was identified that the care requirements of a severely burned patient appeared overwhelming and tiring. This is because the nurse had to provide greater amount of care such as meeting personal care needs and frequent position changes in bed as the severely burned patient was most often confined to bed. Also, the nurse had to check on the patient frequently
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to monitor progress such as checking vital signs, assessing pain and adjusting the ventilator setting especially as the nurses wanted to maintain accurate records of the patients’ progress: “For someone who is severely burned, say like 60% TBSA, it is not like they can do much for themselves. So they depend almost entirely on the nurse to meet their needs. For some of them, they are active within the first two days they are admitted then thereafter they are unable to tolerate any activity. So the nurse does virtually everything for them. When you are on night duty, you have to attend to their personal care needs, assist them to turn in bed and then monitor their physiological status as well” (Female Nurse, 20–30 years) “Because they are usually in bad condition, they have to be monitored every now and then. Some doctors even order that their vitals [vital signs] be checked every 30 minutes. This means standing frequently to monitor them and report appropriately especially if you want to avoid the chart-free style here” (Male Nurse, 20–30 years) Also, for patients on mechanical ventilation, it was identified that they required total care as they were continuously sedated and the frequency of monitoring was even more pronounced: “It is really difficult caring for them because they cannot really help themselves and so we have to do everything for them. You see, they are totally dependent on us. It is even more difficult if the patient is on mechanical ventilation because they are continuously sedated, you have to check up on them almost every time” (Male, 20–30 years) “The patient who has been intubated is just like an unconscious patient and has to be taken care of as such. You see for them, they are put on morphine to control their pain and midazolam to prevent them from extubating or fighting the vent. So you turn them, clean them and still monitor the vital signs plus the vent settings” (Female, 20–30 years) In addition, dressing change was identified as a task that exhausted nurses as they came into contact with the extensive burn wounds, continued monitoring the patient and the need to maintain proper position during the dressing change procedure. Though participants described the care delivery process as tiring, they specified that other professionals did not appreciate the intensity of care they delivered to severely burned patients: “We have six beds here but one patient with burns about 50% or a patient on the ventilator is more than six patients with some medical conditions. But when some people pass by and they are told there is one patient on admission, they think it is just one. They have no idea how tiring it is nursing one client with severe burns” (Female Nurse, 31–40 years) “It does not get any easier; I am usually tired and have to get home for a good rest after caring for them. It really drains my energy reserve. I do not get used to it as well. It appears that each patient comes in with his/her own stress threshold for the nurses” (Male Nurse, 20–30 years) “The wounds are extensive but we still need to change the dressing. It is even more tiring at this time as we need to bend over severally and keep monitoring the patient” (Male Nurse, 20–30 years) For severely burned patients who die, it was noted that the intensity of their care needs appeared to be more pronounced at the end of life period. At that period, aside meeting the patient’s needs, participants indicated that they had to respond to the needs of the family such as responding to questions. Furthermore, participants specified that at the end of life period, patients manifested symptoms such as restlessness, delirium and incoherent speech. Participants’ inability to relieve these symptoms was noted to make
Please cite this article in press as: Bayuo, J. Nurses’ experiences of caring for severely burned patients. Collegian (2017), http://dx.doi.org/10.1016/j.colegn.2017.03.002
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them feel powerless at that period of care delivery. Thus, participants were not only physically exhausted but felt emotional exhaustion as they provided care to severely burned patients: “Some of the patients who come here with severe burns end up dying no matter what we do to them. When they finally get to their final stages, they just cannot tolerate any activity even if they are conscious. Sometimes too their speech changes and they are restless such that we have to tie them to the bed. Everything has to be done for them but these symptoms just do not go away. Sometimes, you just have to stand by them without having an idea of what to do” (Male Nurse, 20–30 years) “The family is equally difficult to deal with when the patient is at the end of life period. The questions they ask are sometimes difficult to respond to” (Female Nurse, 31–40 years) Also, visible suffering of the burn injured patient (those who survived and those who died) appeared to contribute to emotional exhaustion experienced by participants. This was associated with features such as concerns regarding pain control, extent and depth of burn wounds, coming into continuous contact with the burn patient and symptoms at the end of life. Despite the exhaustion participants described, they still felt the need to display compassion and empathy as they delivered care. Occasionally, participants wished they worked in other setting as burns care was described as extremely challenging. However during such periods, words of encouragement from colleagues kept them going. Also, participants hoped that the number of nurses assigned to the unit would increase so as to enhance the staffing levels. Through this, participants hoped that they will get less exhausted: “Can you imagine nursing someone with most of the skin gone and some will keep asking when their skin will be restored. The wounds are large and the patient will undergo dressing change and other procedures. The pain is. . .. . .. . .. . .umm. . . I can’t just describe it. I cannot really stand this sometimes” (Male Nurse, 20–30 years) “These patients suffer from pain during wound care and for those who are conscious; you can hear them scream with their little energy reserve. It is sad to see them this way but you cannot just leave them like that, you still need to continue caring for them” (Male Nurse, 20–30 years) “When they get to their final stage, their speech is distorted and cannot seem to remember anything. They are bed ridden and it is quite sad seeing them in this state at the end stage” (Female Nurse, 31–40 years) “We are not many here but the patient on the ventilator needs more hands to provide care. For afternoon schedules, we are usually two on duty and if a severely burned client comes around at that time, I know I will definitely get home very tired. Sometimes, I wished I was even working at the OPD instead of here but when you feel like giving up, someone passes an encouraging text around.”(Female Nurse, 20–30 years)
1.3.1.2. Concerns regarding outcome of care. Participants noted that the outcome for patients with severe burns was usually death even when they felt they offered their best assistance. Thus, participants felt frustrated and raised concerns regarding the aggressive burns care severely burned patients are subjected to. However, they were unsure when exactly the patient moved into the end of life stage as they continued to render the usual care. They expressed hope even when they noted that a patient was not going to survive: “You know you are doing your best but it is not even likely the patient will make it. The chances that a patient with about 70% TBSA making it is very low but we still subject them to aggressive
treatment. Well. . .. . .. . . a miracle may happen though I am yet to see one”(Female Nurse, 20–30 years) “Most of the people who come with severe burns end up dying. Personally, I cannot recall any client with burns above 60% surviving in my three year practice. No matter how hard we try, they end up dying but we treat them just like any other burn patient. I think we need to know when to stop pushing these antibiotics into their system so that they can die peacefully” (Male Nurse, 20–30 years) “We do our best but most, if not all severely burned clients die. As soon as we hear a new client is coming in with TBSA of 60% and above, the likelihood they will die is high though we are not God”(Female Nurse, 31–40 years) “Personally, I do my best no matter the TBSA of the client. Even if from a clinician’s viewpoint chances of survival are thin, you can never tell what will happen the next minute whether the client will survive or not” (Male Nurse, 20–30 years) Participants also indicated that they felt uncertain about the progress of care and the patient’s condition. This period was described as an emotionally intense period in the unit as they were unsure when and how the patient might die. During this period, some participants noted that they prayed with the patient and expressed faith in a Supreme Being: “For those who are likely to die, we are unsure when they will pass on. Sometimes, I will complete my night schedule and off duties and still come and meet a severely burned client on admission. Some of the nurses will even call to ask if the patient has died or not and when they are told the patient died, they heave a big sigh of relief” (Male Nurse, 20–30 years) “It is usually difficult to answer when family members ask whether the client will survive or not because I am unsure what will happen. God has his own ways and we cannot tell if a particular client will survive or not so you just pray with them and hope for the best” (Male Nurse, 20–30 years) Participants also specified that even if the patient survived the injury, they were worried about functional abilities that the patient may face: “Even if the patient survives, most of their joints will not be able to work well and will need surgery to correct it. Some have extensive keloids all over and it is worrying to see them that way” (Female Nurse, 31–40 years) Consequently when a patient died, participants felt the need to have an avenue for release of emotions and feelings regarding the death of the patient. However, this was absent as work continued as usual with no time to sit and talk about the loss. Participants indicated that they were rather asked for details of the events leading to the death of the patient and not the how they felt about the loss. Thus, some participants noted that they kept thinking about the loss even after close of work and it appeared as a form of burden for them: “When you are on duty and death occurs other people will only want to know how you managed the client at the period but not how you are also dealing with the loss. We also need to be allowed to talk about how the loss has affected us because it feels like you are carrying a load with no one to lift it off your shoulders” (Male Nurse, 20–30 years) “No one really cares about how the nurse feels about the death. It is painful to lose a client but nurses are trained not to shed tears. But you see, sometimes, we give our all to a client and in the end they die. It makes you feel like there was still more you could have done but there is no one to really talk to about these things and you just have to keep it to yourself” (Female Nurse, 20–30 years)
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One participant who recently took a module in palliative care noted positive feelings when the client has been given all possible care: “I think in a way the palliative care programme I recently took has helped me a lot. Previously, I used to think a lot when a patient died but now if I know all possible care was given to a client with severe burns and the client dies, I feel happy with myself and I believe my skills have been helpful at least to some extent”(Male Nurse, 20–30 years) 1.4. Discussion Nursing practice demands appropriate utilisation of technical skills, physical and mental strength. Hettiaratchy and Dziewulski (2004) have argued that burn injuredpatients present serious challenges to health professionals. As nurses are at the centre of the multidisciplinary team, they probably experience greater levels of these challenges (Greenfield, 2010). In the current study, nurses expressed both physical and emotional exhaustion whilst caring for severely burned patients. The exhaustion arose from various aspects of care rendered, the extent of the burn injury and the symptoms presented by the patient in the acute or end of life phase of care. This finding corroborates the observation by Coffey et al. (2011) that the central role played by nurses in burns care is extremely exhausting. In the current study, it was identified that severely burned patients required frequent monitoring and assistance in meeting personal care needs and these were more pronounced in patients on mechanical ventilation. This finding is in line with the assertion by Herndon (2007) as he noted that the care requirements of severely burned patients comprising of wound care, nutritional support, ventilatory support and constant monitoring is enormous which contribute to physical exhaustion. Kornhaber (2009) has observed that nurses felt traumatised after major dressing change and this was also identified in this current study as participants indicated that coming face to face with extensive wounds made them visualise human suffering and this contributed to emotional exhaustion. Even if the patient survived, the continuous contact with the extensive wounds and concerns regarding functional limitations made participants experience exhaustion. This finding is in line with those of Negble et al. (2014) as they identified that caring for severely burned patients was associated with significant physical and emotional tiredness. This may mean that caregiving to the severely burned patient requires both emotional and physical strength as care requirements appear to be high. The current study also identified that care needs intensify at the end of life period when the patient was totally dependent on the nurses for care and this further heightened the experience of physical and emotional exhaustion. Hauser and Kramer (2004) have argued that end of life care is a combination of physical and emotional care and this could increase the level of physical and emotional exhaustion experienced by health professionals. Hebert and Schulz (2006) further describe these features as intensifying over the course of the illness. This affirms the finding noted in this study that nurses experience heightened physical and emotional exhaustion whilst caring for severely burned patients at the end of life. Heightened exhaustion at this period was associated with responding to family concerns, inability to resolve patient symptoms and unclear guidelines regarding when a patient entered into the end of life phase. Furthermore, the apparent suffering such as inadequate pain control that severely burned patients undergo also contributed to the experience of exhaustion. In addition, participants in this study specified that symptoms that the patient manifested at the end of life such as incoherent speech made them
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feel powerless as they could not provide a solution to it. As indicated by Negble et al. (2014), nurses are exposed to human suffering more than other health professionals. Bayuo and Agbenorku (2015) have noted that challenges of pain management exists in the burn units of KATH and that could also be apparent in the visible suffering that participants indicated as existing among severely burned patients. This may specify the need to identify more appropriate and innovative approaches to manage pain in the burned patient (Bayuo, Agbenorku, & Amankwa, 2016). Also, there may a need to undertake further research to understand exactly when a burned patient entered the end of life phase so as to enable nurses know when this has occurred (Mosenthal & Murphy, 2003). In addition to exhaustion, nurses expressed their concerns regarding outcomes of care associated with nursing severely burned patients. Brusselaers et al. (2010) have identified that mortality in burns is associated with increasing Total Surface Area Burned (TBSA). Thus, for the severely burned patient with associated inhalational injury, the likelihood of dying may be high (Brusselaers et al., 2010). In relation, nurses noted that survival rates were low among this category of burn injured patients and despite giving off their best, the patients died. This made participants require an avenue for release but this was apparently absent in the unit. However, one nurse who had recently undertaken training in palliative care expressed positive feelings of satisfaction regarding the occurrence of death. Henderson (cited in Alligood & Tomey, 2006) in her definition of nursing has specified that nursing aims to assist a patient to recovery or to a peaceful death. However, palliative care is not well incorporated in burn or trauma care (Cronin, 2001) and as such aggressive burns treatment may continue till the patient died. Mosenthal and Murphy (2003) have argued that palliative care has not been considered as a key part of trauma care and practitioners in trauma have little training and experience in end of life care issues. They noted that the principles of palliative care encompass excellent communication, pain and symptom management, goals of care, bereavement, and spiritual support. However, it appears as though burns care only aims to achieve survival when in reality a substantial number of severely burned patients die in Ghanaian health facilities or experience distress symptoms that might respond to palliative care. There is the need for nurses in the burn unit to come to the realisation that achieving a peaceful death is a goal of nursing that they need to work towards. However, this may mean that there is a need to clearly delineate when a severely burned patient entered the end of life stage and this calls for further research. As one participant who had undergone palliative care training expressed positive feelings regarding care, it may mean that the tenets of palliative care may be useful in burns care (Mosenthal & Murphy, 2003). Another issue worth noting is the need expressed by nurses for an avenue of release. As noted by Negble et al. (2014), nurses are witnesses to human suffering than other health professionals and this clearly creates the need to allow nurses communicate their feelings regarding caring for severely burned patients. Coffey et al. (2011) also concluded from a case study report of a burn injured patient with over 65% TBSA that nurses were faced with several emotional challenges as the patient’s condition worsened. This happened to the extent that nurses had to request not to care for the patient more than a day at a time until the patient died. This observation emphasises the need to create avenues for release for nurses in the burn unit as Coffey et al. (2011) suggest the need to communicate about death and dying issues among nurses within the burns team. Peer support may be beneficial to allow nurses express themselves about caring for severely burned patients as some participants in this study indicated that words of encouragement kept them going in the face of exhaustion. This may require further research to assess the effectiveness of peer support in attenuating the exhaustion that burn care nurses faced. Also, further research is
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warranted in determining other avenues of release that could assist nurses in their burn care role. 1.5. Conclusion Nurses play vital role in the care of burn injured patients. This pivotal role is usually accompanied with several issues that need consideration. Through an exploratory-descriptive approach, nurses’ experiences in caring for severely burned patients have been brought to the fore. Caring for the severely burned patient is associated with exhaustion which is usually heightened at the end of life phase. For patients who survive the injury, nurses had concerns regarding functional abilities. However, as participants indicated that most patients with severe burns die, there is a need for further research to establish the place of palliative care in burns management. Further research is also warranted in identifying avenues for release for nurses in the burns care team. Peer support in the burns team also needs further research consideration so as to assess its effects on burn care nurses. The findings of this study are however limited in some aspects. Firstly, the study was undertaken among nurses who have worked for a minimum of one year in the Burns Intensive Care Unit of KATH and as such findings may be unique and limited to that setting and participants. Furthermore, the close relationship and familiarity between the researcher and the unit as well as participants may have affected the study in some aspects though the researcher attempted to distance himself from the phenomenon so as to describe it as experienced by participants. Moreover, though the number of participants recruited for the study represented those who were available and have experienced the phenomenon of caring for severely burned patients, it appears small. Thus, the findings may be unique to the setting in which the study was undertaken even though it can provide insights into further research and practice considerations. References Alligood, R., & Tomey, M. (2006). Nursing theory: Utilization & application (3rd ed.). USA: Mosby. Bayuo, J., Agbenorku, P., & Amankwa, R. (2016). Study on acute burn injury survivors and the associated issues. Journal of Acute Disease, 5(3), 206–209.
Bayuo, J., & Agbenorku, P. (2015). Nurses’ perceptions and experiences regarding morphine usage in burn pain management. Burns, 41(4), 86471. Brusselaers, N., Monstrey, S., Vogelaers, D., Hoste, E., & Blot, S. (2010). Severe burn injury in Europe: A systematic review of the incidence, etiology, morbidity, and mortality. Critical Care, 14(5), R188. Bryman, A. (2012). Social research methods (4th ed.). Oxford: Oxford University Press. Carlson, K. (2013). Burn care nursing: Interview with Alison Gavin, RN. Healing the physical and emotional wound.. Available at: http://www.workingnurse.com. articles Accessed 08.12.15 Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. London: Sage. Cronin, N. (2001). How do nurses deal with their emotions on a burns unit? Hermeneutic study. International Journal of Nursing Practice, 342–348. Coffey, R., Everett, S., Miller, S., & Brown, J. (2011). End of life in the burns unit/trauma unit. A nursing perspective. International Journal of Critical Illness and Injury Science. Greenfield, E. (2010). The pivotal role of nursing personnel in burn care. Indian Journal of Plastic Surgery, 43(3), 94. Hauser, J. M., & Kramer, B. J. (2004). Family caregivers in palliative care. Clinics in Geriatric Medicine, 20, 671–688. PMID: 15541619 Herndon, D. N. (2007). Total burn care. Elsevier Health Sciences. Hettiaratchy, S., & Dziewulski, P. (2004). Pathophysiology and types of burns. British Medical Journal, 328(7453), 1427–1429. Hebert, R. S., & Schulz, R. (2006). Caregiving at the end of life. Journal of Palliative Medicine, 9, 1174–1187. PMID: 17040156 Joffe, H. (2012). . pp. 210–223. Thematic analysis: Qualitative research methods in mental health and psychotherapy. A guide for students and Practitioners (Vol. 1). Komfo Anokye Teaching Hospital. Kumasi: Komfo Anokye Teaching Hospital. Available from: http://www.kathhsp.org/index.html Accessed 08.12.15. Kornhaber, R. (2009). The Lived Experiences of Nursing Severe Burn Injury Patients. A phenomenological Inquiry.. Available at: http://www.gigital.library.adelaide.ed. au/dspace/bistream Accessed 01.12.15 Lincoln, Y. S., & Guba, E. G. (1985). Establishing trustworthiness. Naturalistic Inquiry, 289, 331. Lo Biondo-Wood, G., & Haber, J. (2010). Nursing research: Methods and critical appraisal for evidence-based practice (7th ed.). St. Louis: Mosby Elsevier. Mosenthal, A. C., & Murphy, P. A. (2003). Trauma care and palliative care: Time to integrate the two? Journal of the American College of Surgeons, 197(3), 509–516. Munhall, P. L. (2007). Nursing research: A qualitative perspective (4th ed.). Sudbury: Jones and Bartlett Publishers. Negble, M., Agbenorku, P., Ampomah, E. A., & Hoyte-Williams, P. E. (2014). Nursing severe burn injury patients: Emotional impact on nurses. International Journal of Medicine and Medical Sciences, 47(1), 1430. Polit, D. F., & Beck, C. T. (2010). Essentials of nursing research: Appraising evidence for nursing practice (7th ed.). Philadelphia: Lippincott Williams and Wilkins. Ritchie, J., Lewis, J., Nicholls, C. M., & Ormston, R. (2013). Qualitative research practice: A guide for social science students and researchers. London: Sage. Stake, R. E. (2010). Qualitative research: Studying how things work. New York: Guildford Press.
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Contents lists available at ScienceDirect
Collegian journal homepage: www.elsevier.com/locate/coll
Nurses’ experiences of caring for severely burned patients Jonathan Bayuo a,b,∗ a b
Department of Nursing, Faculty of Health and Medical Sciences, Presbyterian University College, Ghana Burns Intensive Care Unit, Directorate of Surgery, Komfo Anokye Teaching Hospital, Ghana
a r t i c l e
i n f o
Article history: Received 15 May 2016 Received in revised form 28 February 2017 Accepted 4 March 2017 Available online xxx Keywords: Nurses Severe Burns Caring
a b s t r a c t Background: Nurses form a pivotal part of the burns care team and participate in caring for severely burned patients. Previous studies have identified that severe burn injuries may serve as a form of stress to health professionals and as such they may require support whilst caring for these patients. However, there exists limited exploration of nurses’ experiences regarding caring for severely burned patients. Aim: To explore and describe nurses’ experiences of caring for severely burned patients. Methodology: An exploratory-descriptive approach was utilised to understand nurses’ experiences. Purposive sampling was used to recruit nurses from the Burns Intensive Care Unit (n = 7). Face to face semi-structured interviews were conducted with an interview guide and proceedings audio-recorded. Two follow up interviews were conducted after the initial interviews. Analysis was undertaken using thematic analysis to generate emergent themes. Findings: The themes identified were exhaustion during caring (physical and emotional) and concerns regarding outcomes of care. Conclusion: Nurses face varied issues when caring for severely burned patients and require avenues to express themselves but these are lacking in our current setting. Peer support and other approaches need to be explored as avenues for encouraging nurses to talk about their experiences. Further research is also warranted in understanding how palliative care can be incorporated in burns care. © 2017 Australian College of Nursing Ltd. Published by Elsevier Ltd.
1. Introduction Burn injury is a common type of traumatic injury which leads to significant morbidity and mortality (Brusselaers, Monstrey, Vogelaers, Hoste, & Blot, 2010). Following the occurrence of burn injury, the patient undergoes various phases of care such as resuscitative, acute, rehabilitative and operative phases. Burn care aims to enhance survival outcomes with minimal loss of function (Brusselaers et al., 2010). The initial phase of burns management focuses on fluid resuscitation, pain control, identifying and managing inhalational injury which involves the expertise of various health care professionals. The acute care phase also commences with a period of specialised intensive care when wound management and surgical treatment are carried out in parallel (Herndon, 2007). Though optimal care of the burn injured patient requires a multidisciplinary approach, the bulk of burn care activities have been indicated to involve the expertise of burn care nurses: wound care, monitoring various vital parameters, monitoring urine output,
∗ Correspondence to: Department of Nursing, Faculty of Health and Medical Sciences, Presbyterian University College, Ghana. E-mail address: [email protected]
pain assessment, monitoring the burned patient on ventilatory support among others. Accordingly, Carlson (2013) has specified that burns nursing require astute clinical skills including triage, stabilisation of severely burned patients, fluid balance, pain management, critical care, rehabilitation and trauma recovery. However, this central role of burn care nurses has been observed to be physically exhausting (Coffey, Everett, Miller, & Brown, 2011). Exhaustion associated with the role of burn care nurses has been linked to the prolonged stay of burn patients and the intensive treatment modalities required to prevent complications and restore functional ability (Cronin, 2001). Also, Hettiaratchy and Dziewulski (2004) have specified that the nature of the burn injury is a source of emotional stress for health care professionals. Nurses have been cited to face greater stress as compared to other health professionals (Greenfield, 2010) as they maintain 24-h contact with burned patients (Cronin, 2001). Negble, Agbenorku, Ampomah, and Hoyte-Williams (2014) studied the emotional aspect of nursing severely burned patients using a survey approach and identified that nurses are exposed to human suffering than other health professionals. Severely burned patients may have limited survival chances and palliative care is not well incorporated in burns care (Mosenthal & Murphy, 2003): thus requiring that these patients be subjected to
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aggressive burns management till they die. This could mean that nurses rendering care to severely burned patients may face unique issues for which they may require support. These unique experiences appear under-explored and paucity of research exists in that regard. However, exploring and understanding nurses’ experiences whilst caring for the severely burned patient can provide useful information about specific issues and challenges they may be faced with and this can form the basis of developing strategies to assist and empower them in their roles. 1.1. Objective of the study The aim of this study was to explore and describe the experiences of Ghanaian nurses regarding caring for the severely burned patient. 1.2. Methodology 1.2.1. Design This study utilised qualitative methods to explore and describe nurses’ experiences of caring for severely burned patients. Munhall (2007) has specified that qualitative approaches are useful in exploring and describing human experiences. Also, qualitative methods are helpful in exploring unknown or understudied phenomenon and to promote the development of conceptual and theoretical frameworks as it enables the generation of rich textual descriptions of experiences (Stake, 2010). Ontologically, the qualitative approach is oriented towards constructionism which implies that social phenomena and their meanings are continually accomplished by the social entities involved (Polit & Beck, 2010). Thus in order to understand nurses’ experiences regarding caring for severely burned patients, there is a need to recruit those who have experienced the phenomenon and undertake in-depth discussions so as to capture those experiences unique to the phenomenon. Epistemologically, it is oriented towards interpretivism and inductive approach which leads to theory generation rather than testing theory (Bryman, 2012). The assumption of this stance is that nurses in the Burn Unit have experienced caring for severely burned patients and these experiences are not external facts to them but they possess individual interpretations and live with the experiences. Thus, as this study aimed at exploring and describing these experiences, the qualitative stance was appropriate so as to obtain firsthand information from those who have experienced the phenomenon (Polit & Beck, 2010). Specifically, the study utilised the exploratory-descriptive design in achieving its aim. This approach was selected because the phenomenon of caring for severely burned patients has received minimal attention in our setting and there is a need to map the nature of those experiences (Polit & Beck, 2010). 1.2.2. Setting The Komfo Anokye Teaching Hospital (KATH) in Kumasi is the second-largest hospital in Ghana and a tertiary health institution in the middle belt of the country. It is the main referral hospital for the Ashanti, Brong Ahafo, the Northern, Upper West and Upper East regions of the country. The hospital was built in 1954 and affiliated to the School of Medical Sciences (SMS) of the Kwame Nkrumah University of Science and Technology (KNUST). The hospital currently has 1000 beds, with an annual hospital attendance of about 679,050 patients made up of both out- and in-patients. The hospital has two units dedicated to burns care: Burns Intensive Care Unit and Ward D2C. These units have a six bed capacity each and attend to patients with varying degrees of burn injuries (“Komfo Anokye Teaching Hospital,” 2015). However, patients with severe burns are usually admitted to the Burns Intensive Care Unit (BICU) and as such the study focused on nurses in that unit. The unit has
a total of fifteen (15) nurses but two were on study leave and one nurse was on annual leave as at the time of the study. 1.2.3. Participant recruitment Purposive sampling was utilised to recruit Registered Nurses working in BICU. Registered Nurses working in the unit were approached face to face and the study discussed with them. Nurses who were on annual leave and study leave were excluded from the study due to their unavailability. Participants who took part in the study were nurses of varying grades and categories who have worked in the unit for a minimum of one year (a total of 10 nurses were noted to have worked in the unit for a minimum of one year). In all, a total of seven nurses participated in the study. 1.2.4. Data collection A face to face semi structured interview approach was used to collect data. This approach was chosen as it allowed in-depth coverage of caring experiences as well as allowing new themes to emerge (Charmaz, 2006). Data collection was carried out by the primary researcher who is also a Registered Nurse in the Burn Unit. As the primary researcher also works with severely burned patients, the interview was approached with an openness to attend to participants’ experiences. Before each interview, the researcher recorded all personal thoughts about the phenomenon in a diary. As the interview proceeded, the researcher noted any personal thoughts that were aroused by the participants’ description of their experiences. Audio-recordings and field notes enabled an assessment of the quality of the data. Data collection continued till data saturation (Charmaz, 2006). The stage of data saturation was noted at a point where there was no new information. All interviews were audiorecorded with participants’ permission. Interviews were scheduled at periods participants were available and these were conducted in the seminar room of the Burns Intensive Care Unit. The interview took place in the presence of only the primary researcher and each participant separately. Thus, the interviews were void of interruptions except for occasional breaks to allow participants take water. Before commencing each interview, participants were assured that the study aimed to explore their experiences as they provided care and as such there was no need to be apprehensive. Participants were encouraged to view the interviewer as a researcher interested in understanding their experiences. Field notes were also made during the interview process. The initial interviews lasted approximately 50–63 min. Two follow-up interviews were carried out to discuss narratives with each participant and to clarify findings. The follow up interviews lasted approximately 20–30 min. The semi-structured approach allowed new ideas that emerged during the interview to be explored further and that enabled in-depth coverage of the phenomenon (Charmaz, 2006; Polit & Beck, 2010). 1.2.5. Data analysis Audio recordings from interviews were transcribed verbatim in Microsoft Word 2010 version and exported to NVivo version 10. This was followed by thematic analysis which involved identifying, interpreting and reporting patterns within the data (Ritchie, Lewis, Nicholls, & Ormston, 2013). This process required working methodically through the transcribed texts and recognising themes that were progressively integrated into higher-order key themes in relation to the research aim (Joffe, 2012; Lo Biondo-Wood & Haber, 2010). 1.2.6. Trustworthiness of the data and findings The framework of Lincoln and Guba was used to ensure trustworthiness of the data and findings. This framework proposes four criteria: credibility, dependability, confirmability and transferability (Lincoln & Guba, 1985). Credibility was achieved by using purposive sampling technique to recruit nurses who had
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J. Bayuo / Collegian xxx (2017) xxx–xxx Table 1 Demographic features of participants (n = 7). Variable
Frequency
Percentage (%)
Age
20–30 years 31–40 years Total
5 2 7
71.40 28.60 100.0
Gender
Male Female Total
3 4 7
42.90 57.10 100.0
Years in burns care
Below 5 years Above 5 years Total
6 1 7
71.40 28.60 100.0
0
0.00
Training in burns care
experienced caring for severely burned patients. Iterative mode of questioning, probes and prompts were utilised throughout the interview process. Also, as the researcher is a registered nurse in the unit, a trust relationship was already in existence. Participants were assured of anonymity and that research findings will only be used as a basis for developing supportive strategies for nurses in the unit without reference to anyone. Confirmability was achieved by carrying out verbatim transcriptions of all audio recordings. As the researcher is a Registered Nurse in the unit, ideas regarding caring for severely burned patients were recorded in a diary. By keeping a diary, the researcher became aware of his thoughts regarding caring for severely burned patients and these were put aside to avoid interfering with participants descriptions. Themes generated from the study were validated by participants as reflecting their experiences. Dependability and transferability were achieved by dense descriptions of nurses’ experiences as well as the methodology used. An audit trail was also developed and maintained for the study. 1.2.7. Ethical clearance Ethical clearance for this study was obtained from KNUST School of Medical Sciences/KATH Committee on Human Research, Publications and Ethics, Kumasi. In addition, each participant was given a thorough description of the study to enable them make a decision as to whether to participate or not. Oral consent was also sought prior to commencement of the interviews. Anonymity and confidentiality were ensured throughout the study. 1.3. Findings From Table 1, majority of the nurses were within the 20–30 year range and most have also practised as burns nurses for less than five years. In terms of training in burns care, none of the nurses included in this sample have received training as burn care nurses. 1.3.1. Emergent themes From the data collected, significant statements were extracted and the following themes were identified: • Exhaustion during caring • Concerns regarding outcome of care 1.3.1.1. Exhaustion during caring. Participants in the study generally described caring for a severely burned patient as exhausting: both physically and emotionally. It was identified that the care requirements of a severely burned patient appeared overwhelming and tiring. This is because the nurse had to provide greater amount of care such as meeting personal care needs and frequent position changes in bed as the severely burned patient was most often confined to bed. Also, the nurse had to check on the patient frequently
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to monitor progress such as checking vital signs, assessing pain and adjusting the ventilator setting especially as the nurses wanted to maintain accurate records of the patients’ progress: “For someone who is severely burned, say like 60% TBSA, it is not like they can do much for themselves. So they depend almost entirely on the nurse to meet their needs. For some of them, they are active within the first two days they are admitted then thereafter they are unable to tolerate any activity. So the nurse does virtually everything for them. When you are on night duty, you have to attend to their personal care needs, assist them to turn in bed and then monitor their physiological status as well” (Female Nurse, 20–30 years) “Because they are usually in bad condition, they have to be monitored every now and then. Some doctors even order that their vitals [vital signs] be checked every 30 minutes. This means standing frequently to monitor them and report appropriately especially if you want to avoid the chart-free style here” (Male Nurse, 20–30 years) Also, for patients on mechanical ventilation, it was identified that they required total care as they were continuously sedated and the frequency of monitoring was even more pronounced: “It is really difficult caring for them because they cannot really help themselves and so we have to do everything for them. You see, they are totally dependent on us. It is even more difficult if the patient is on mechanical ventilation because they are continuously sedated, you have to check up on them almost every time” (Male, 20–30 years) “The patient who has been intubated is just like an unconscious patient and has to be taken care of as such. You see for them, they are put on morphine to control their pain and midazolam to prevent them from extubating or fighting the vent. So you turn them, clean them and still monitor the vital signs plus the vent settings” (Female, 20–30 years) In addition, dressing change was identified as a task that exhausted nurses as they came into contact with the extensive burn wounds, continued monitoring the patient and the need to maintain proper position during the dressing change procedure. Though participants described the care delivery process as tiring, they specified that other professionals did not appreciate the intensity of care they delivered to severely burned patients: “We have six beds here but one patient with burns about 50% or a patient on the ventilator is more than six patients with some medical conditions. But when some people pass by and they are told there is one patient on admission, they think it is just one. They have no idea how tiring it is nursing one client with severe burns” (Female Nurse, 31–40 years) “It does not get any easier; I am usually tired and have to get home for a good rest after caring for them. It really drains my energy reserve. I do not get used to it as well. It appears that each patient comes in with his/her own stress threshold for the nurses” (Male Nurse, 20–30 years) “The wounds are extensive but we still need to change the dressing. It is even more tiring at this time as we need to bend over severally and keep monitoring the patient” (Male Nurse, 20–30 years) For severely burned patients who die, it was noted that the intensity of their care needs appeared to be more pronounced at the end of life period. At that period, aside meeting the patient’s needs, participants indicated that they had to respond to the needs of the family such as responding to questions. Furthermore, participants specified that at the end of life period, patients manifested symptoms such as restlessness, delirium and incoherent speech. Participants’ inability to relieve these symptoms was noted to make
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them feel powerless at that period of care delivery. Thus, participants were not only physically exhausted but felt emotional exhaustion as they provided care to severely burned patients: “Some of the patients who come here with severe burns end up dying no matter what we do to them. When they finally get to their final stages, they just cannot tolerate any activity even if they are conscious. Sometimes too their speech changes and they are restless such that we have to tie them to the bed. Everything has to be done for them but these symptoms just do not go away. Sometimes, you just have to stand by them without having an idea of what to do” (Male Nurse, 20–30 years) “The family is equally difficult to deal with when the patient is at the end of life period. The questions they ask are sometimes difficult to respond to” (Female Nurse, 31–40 years) Also, visible suffering of the burn injured patient (those who survived and those who died) appeared to contribute to emotional exhaustion experienced by participants. This was associated with features such as concerns regarding pain control, extent and depth of burn wounds, coming into continuous contact with the burn patient and symptoms at the end of life. Despite the exhaustion participants described, they still felt the need to display compassion and empathy as they delivered care. Occasionally, participants wished they worked in other setting as burns care was described as extremely challenging. However during such periods, words of encouragement from colleagues kept them going. Also, participants hoped that the number of nurses assigned to the unit would increase so as to enhance the staffing levels. Through this, participants hoped that they will get less exhausted: “Can you imagine nursing someone with most of the skin gone and some will keep asking when their skin will be restored. The wounds are large and the patient will undergo dressing change and other procedures. The pain is. . .. . .. . .. . .umm. . . I can’t just describe it. I cannot really stand this sometimes” (Male Nurse, 20–30 years) “These patients suffer from pain during wound care and for those who are conscious; you can hear them scream with their little energy reserve. It is sad to see them this way but you cannot just leave them like that, you still need to continue caring for them” (Male Nurse, 20–30 years) “When they get to their final stage, their speech is distorted and cannot seem to remember anything. They are bed ridden and it is quite sad seeing them in this state at the end stage” (Female Nurse, 31–40 years) “We are not many here but the patient on the ventilator needs more hands to provide care. For afternoon schedules, we are usually two on duty and if a severely burned client comes around at that time, I know I will definitely get home very tired. Sometimes, I wished I was even working at the OPD instead of here but when you feel like giving up, someone passes an encouraging text around.”(Female Nurse, 20–30 years)
1.3.1.2. Concerns regarding outcome of care. Participants noted that the outcome for patients with severe burns was usually death even when they felt they offered their best assistance. Thus, participants felt frustrated and raised concerns regarding the aggressive burns care severely burned patients are subjected to. However, they were unsure when exactly the patient moved into the end of life stage as they continued to render the usual care. They expressed hope even when they noted that a patient was not going to survive: “You know you are doing your best but it is not even likely the patient will make it. The chances that a patient with about 70% TBSA making it is very low but we still subject them to aggressive
treatment. Well. . .. . .. . . a miracle may happen though I am yet to see one”(Female Nurse, 20–30 years) “Most of the people who come with severe burns end up dying. Personally, I cannot recall any client with burns above 60% surviving in my three year practice. No matter how hard we try, they end up dying but we treat them just like any other burn patient. I think we need to know when to stop pushing these antibiotics into their system so that they can die peacefully” (Male Nurse, 20–30 years) “We do our best but most, if not all severely burned clients die. As soon as we hear a new client is coming in with TBSA of 60% and above, the likelihood they will die is high though we are not God”(Female Nurse, 31–40 years) “Personally, I do my best no matter the TBSA of the client. Even if from a clinician’s viewpoint chances of survival are thin, you can never tell what will happen the next minute whether the client will survive or not” (Male Nurse, 20–30 years) Participants also indicated that they felt uncertain about the progress of care and the patient’s condition. This period was described as an emotionally intense period in the unit as they were unsure when and how the patient might die. During this period, some participants noted that they prayed with the patient and expressed faith in a Supreme Being: “For those who are likely to die, we are unsure when they will pass on. Sometimes, I will complete my night schedule and off duties and still come and meet a severely burned client on admission. Some of the nurses will even call to ask if the patient has died or not and when they are told the patient died, they heave a big sigh of relief” (Male Nurse, 20–30 years) “It is usually difficult to answer when family members ask whether the client will survive or not because I am unsure what will happen. God has his own ways and we cannot tell if a particular client will survive or not so you just pray with them and hope for the best” (Male Nurse, 20–30 years) Participants also specified that even if the patient survived the injury, they were worried about functional abilities that the patient may face: “Even if the patient survives, most of their joints will not be able to work well and will need surgery to correct it. Some have extensive keloids all over and it is worrying to see them that way” (Female Nurse, 31–40 years) Consequently when a patient died, participants felt the need to have an avenue for release of emotions and feelings regarding the death of the patient. However, this was absent as work continued as usual with no time to sit and talk about the loss. Participants indicated that they were rather asked for details of the events leading to the death of the patient and not the how they felt about the loss. Thus, some participants noted that they kept thinking about the loss even after close of work and it appeared as a form of burden for them: “When you are on duty and death occurs other people will only want to know how you managed the client at the period but not how you are also dealing with the loss. We also need to be allowed to talk about how the loss has affected us because it feels like you are carrying a load with no one to lift it off your shoulders” (Male Nurse, 20–30 years) “No one really cares about how the nurse feels about the death. It is painful to lose a client but nurses are trained not to shed tears. But you see, sometimes, we give our all to a client and in the end they die. It makes you feel like there was still more you could have done but there is no one to really talk to about these things and you just have to keep it to yourself” (Female Nurse, 20–30 years)
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One participant who recently took a module in palliative care noted positive feelings when the client has been given all possible care: “I think in a way the palliative care programme I recently took has helped me a lot. Previously, I used to think a lot when a patient died but now if I know all possible care was given to a client with severe burns and the client dies, I feel happy with myself and I believe my skills have been helpful at least to some extent”(Male Nurse, 20–30 years) 1.4. Discussion Nursing practice demands appropriate utilisation of technical skills, physical and mental strength. Hettiaratchy and Dziewulski (2004) have argued that burn injuredpatients present serious challenges to health professionals. As nurses are at the centre of the multidisciplinary team, they probably experience greater levels of these challenges (Greenfield, 2010). In the current study, nurses expressed both physical and emotional exhaustion whilst caring for severely burned patients. The exhaustion arose from various aspects of care rendered, the extent of the burn injury and the symptoms presented by the patient in the acute or end of life phase of care. This finding corroborates the observation by Coffey et al. (2011) that the central role played by nurses in burns care is extremely exhausting. In the current study, it was identified that severely burned patients required frequent monitoring and assistance in meeting personal care needs and these were more pronounced in patients on mechanical ventilation. This finding is in line with the assertion by Herndon (2007) as he noted that the care requirements of severely burned patients comprising of wound care, nutritional support, ventilatory support and constant monitoring is enormous which contribute to physical exhaustion. Kornhaber (2009) has observed that nurses felt traumatised after major dressing change and this was also identified in this current study as participants indicated that coming face to face with extensive wounds made them visualise human suffering and this contributed to emotional exhaustion. Even if the patient survived, the continuous contact with the extensive wounds and concerns regarding functional limitations made participants experience exhaustion. This finding is in line with those of Negble et al. (2014) as they identified that caring for severely burned patients was associated with significant physical and emotional tiredness. This may mean that caregiving to the severely burned patient requires both emotional and physical strength as care requirements appear to be high. The current study also identified that care needs intensify at the end of life period when the patient was totally dependent on the nurses for care and this further heightened the experience of physical and emotional exhaustion. Hauser and Kramer (2004) have argued that end of life care is a combination of physical and emotional care and this could increase the level of physical and emotional exhaustion experienced by health professionals. Hebert and Schulz (2006) further describe these features as intensifying over the course of the illness. This affirms the finding noted in this study that nurses experience heightened physical and emotional exhaustion whilst caring for severely burned patients at the end of life. Heightened exhaustion at this period was associated with responding to family concerns, inability to resolve patient symptoms and unclear guidelines regarding when a patient entered into the end of life phase. Furthermore, the apparent suffering such as inadequate pain control that severely burned patients undergo also contributed to the experience of exhaustion. In addition, participants in this study specified that symptoms that the patient manifested at the end of life such as incoherent speech made them
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feel powerless as they could not provide a solution to it. As indicated by Negble et al. (2014), nurses are exposed to human suffering more than other health professionals. Bayuo and Agbenorku (2015) have noted that challenges of pain management exists in the burn units of KATH and that could also be apparent in the visible suffering that participants indicated as existing among severely burned patients. This may specify the need to identify more appropriate and innovative approaches to manage pain in the burned patient (Bayuo, Agbenorku, & Amankwa, 2016). Also, there may a need to undertake further research to understand exactly when a burned patient entered the end of life phase so as to enable nurses know when this has occurred (Mosenthal & Murphy, 2003). In addition to exhaustion, nurses expressed their concerns regarding outcomes of care associated with nursing severely burned patients. Brusselaers et al. (2010) have identified that mortality in burns is associated with increasing Total Surface Area Burned (TBSA). Thus, for the severely burned patient with associated inhalational injury, the likelihood of dying may be high (Brusselaers et al., 2010). In relation, nurses noted that survival rates were low among this category of burn injured patients and despite giving off their best, the patients died. This made participants require an avenue for release but this was apparently absent in the unit. However, one nurse who had recently undertaken training in palliative care expressed positive feelings of satisfaction regarding the occurrence of death. Henderson (cited in Alligood & Tomey, 2006) in her definition of nursing has specified that nursing aims to assist a patient to recovery or to a peaceful death. However, palliative care is not well incorporated in burn or trauma care (Cronin, 2001) and as such aggressive burns treatment may continue till the patient died. Mosenthal and Murphy (2003) have argued that palliative care has not been considered as a key part of trauma care and practitioners in trauma have little training and experience in end of life care issues. They noted that the principles of palliative care encompass excellent communication, pain and symptom management, goals of care, bereavement, and spiritual support. However, it appears as though burns care only aims to achieve survival when in reality a substantial number of severely burned patients die in Ghanaian health facilities or experience distress symptoms that might respond to palliative care. There is the need for nurses in the burn unit to come to the realisation that achieving a peaceful death is a goal of nursing that they need to work towards. However, this may mean that there is a need to clearly delineate when a severely burned patient entered the end of life stage and this calls for further research. As one participant who had undergone palliative care training expressed positive feelings regarding care, it may mean that the tenets of palliative care may be useful in burns care (Mosenthal & Murphy, 2003). Another issue worth noting is the need expressed by nurses for an avenue of release. As noted by Negble et al. (2014), nurses are witnesses to human suffering than other health professionals and this clearly creates the need to allow nurses communicate their feelings regarding caring for severely burned patients. Coffey et al. (2011) also concluded from a case study report of a burn injured patient with over 65% TBSA that nurses were faced with several emotional challenges as the patient’s condition worsened. This happened to the extent that nurses had to request not to care for the patient more than a day at a time until the patient died. This observation emphasises the need to create avenues for release for nurses in the burn unit as Coffey et al. (2011) suggest the need to communicate about death and dying issues among nurses within the burns team. Peer support may be beneficial to allow nurses express themselves about caring for severely burned patients as some participants in this study indicated that words of encouragement kept them going in the face of exhaustion. This may require further research to assess the effectiveness of peer support in attenuating the exhaustion that burn care nurses faced. Also, further research is
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warranted in determining other avenues of release that could assist nurses in their burn care role. 1.5. Conclusion Nurses play vital role in the care of burn injured patients. This pivotal role is usually accompanied with several issues that need consideration. Through an exploratory-descriptive approach, nurses’ experiences in caring for severely burned patients have been brought to the fore. Caring for the severely burned patient is associated with exhaustion which is usually heightened at the end of life phase. For patients who survive the injury, nurses had concerns regarding functional abilities. However, as participants indicated that most patients with severe burns die, there is a need for further research to establish the place of palliative care in burns management. Further research is also warranted in identifying avenues for release for nurses in the burns care team. Peer support in the burns team also needs further research consideration so as to assess its effects on burn care nurses. The findings of this study are however limited in some aspects. Firstly, the study was undertaken among nurses who have worked for a minimum of one year in the Burns Intensive Care Unit of KATH and as such findings may be unique and limited to that setting and participants. Furthermore, the close relationship and familiarity between the researcher and the unit as well as participants may have affected the study in some aspects though the researcher attempted to distance himself from the phenomenon so as to describe it as experienced by participants. Moreover, though the number of participants recruited for the study represented those who were available and have experienced the phenomenon of caring for severely burned patients, it appears small. Thus, the findings may be unique to the setting in which the study was undertaken even though it can provide insights into further research and practice considerations. References Alligood, R., & Tomey, M. (2006). Nursing theory: Utilization & application (3rd ed.). USA: Mosby. Bayuo, J., Agbenorku, P., & Amankwa, R. (2016). Study on acute burn injury survivors and the associated issues. Journal of Acute Disease, 5(3), 206–209.
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Please cite this article in press as: Bayuo, J. Nurses’ experiences of caring for severely burned patients. Collegian (2017), http://dx.doi.org/10.1016/j.colegn.2017.03.002