Osborne__Tyler_-_Final_Honors_Project.docx

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Mitigating Burn Pain through Nursing Care: Are we doing our part? Tyler M. Osborne

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Table of Contents

Acknowledgements...3

Abstract...4

Introduction...5

Current Clinical Practice Guidelines...8

Recommendation 1...9

Recommendation 2...10

Recommendation 3...11

Recommendation 4...11

Recommendation 7...13

Experimental Non-Pharmacological Interventions...14

Virtual Reality...15

Meta-analysis review #1...15

Meta-analysis review #2...17

Other Interventions...19

Hypnosis...19

Postdischarge satisfaction surveys...21

Table 1...22

Methods...23

Table 2...24

Interview...24

Results...26

Discussion...27

Conclusion...28

References...29

Appendix A: Interviewee Information...31

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Acknowledgements

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Abstract

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Mitigating Burn Pain through Nursing Care: Are we doing our part?

Introduction

“The very word ‘patient’ implies, somewhat ironically, that one must endure treatments, varying levels of pain and discomfort, and the passage of time passively and patiently. This implied

passivity raises questions of controlling one’s environment, lack of control, and their implications. Is the level of control a patient feels directly related to his or her fear of treatment

and the perception of pain?” – Dan Ariely

Dan Ariely, a world-renown psychologist, experienced multiple burns as a teenager and spent three years in treatment and rehabilitation. A key observation he made from that

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Burns are one of the most painful types of injuries a person can sustain. The pathology of burn pain is difficult to understand due to the complex mechanism and cascade of events

involved with burn injuries. The exact mechanism(s) surrounding burn pain has yet to be identified, making it difficult to fully account for the burn patient’s experience of pain (Morgan et al., 2017). The patient’s pain also depends, in part, on the type of burn a person sustains. For a time, burns had three classifications: first degree, second degree, and third degree. Due to the lack of detail with these past classifications, they have since been changed to epidermal,

superficial epidermal, mid-dermal, deep dermal, and full thickness (Morgan et al., 2017). Nurses play a pivotal role in the management of burn pain; especially procedural pain, which is the primary focus of this paper. It is the nurse’s responsibility to perform daily dressing changes when managing burn wounds in the hospital. This means they must administer proper medication, at the proper doses, while also providing other adjunctive therapies at the

appropriate times, before and during dressing changes (Greenfield, 2010).

My initial interest in this topic began shortly after I began working as a nursing assistant (NA) in the burn ICU (BICU) at UNC hospitals. The BICU required that NAs have all the basic skills, but also require that NAs become proficient in burn wound care. What separated the BICU from most other ICUs was the extensive baths and dressing changes that most patients experience daily. As an NA, my job was to assist the nurse with the dressing change process that involved dressing removal, cleansing the exposed burn wounds, and then re-dressing the

wounds. I noticed very early on that this was as extremely painful process for the patient, regardless of the amount of pain medications they were given.

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pain management until after I met a float nurse who was sent to work in the BICU for the day. Like usual, I had to assist with a dressing change; however, the patient we were working with seemed to have a lower-than-usual pain tolerance that made it difficult to remove his bandages. Whenever we would begin to remove his bandages, he would plead that we stop because the pain was so intense. After a few attempts, the nurse asked the patient a question that I never heard any of the other nurses ask before. The question was “Do you want to try and take your bandages off yourself?” This was such a basic suggestion, but it instantly made sense to me. I assumed that the nurse was simply trying to give the patient some control over his bandage removal, which could help him anticipate and prepare for the pain.

In my opinion, the idea of allowing the patient to self-remove their dressings not only empowers them in their care but helps them to control their procedural pain. It would appear that giving the patient the option to remove their bandages themselves would not only give them full control over when to expect to feel the pain, but also at which rate they feel the pain and the intensity of the bandage removal (how fast/slow they want to remove the dressings). I thought giving the patient the option to self-remove his bandages was such a brilliant idea because it truly seemed to help with his dressing change process.

While all patients have individual levels and perceptions of pain, it is obvious that most experience a degree of pain. Offering dressing self-removal as a potential intervention to alter the patients’ perception and experience with procedural pain seems an important option to give patients in an effort to decrease said pain. It seemed odd to me that I did not hear about bandage self-removal being offered to patients until I worked with the nurse who was not usually

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patients? What other kinds of non-pharmacologic, nurse-initiated interventions might exist that could be introduced to the unit in the care of our patients? Are nurses leading the way in burn care research to uncover effective methods to ease the burn patient’s experience of trauma during wound care? These are some of the questions I had as I began to explore the role of nursing in mitigating burn pain.

The purpose of this paper is to find answers to the questions posed above in order to offer potential solutions and expand the BICU’s approach to the nursing care of patients with severe burns. Through a thorough review of the literature and an interview with the UNC Hospitals Burn Unit’s nurse manager, I hoped to collect key data to inform my efforts.

Current Clinical Practice Guidelines

The International Society for Burn Injury (ISBI) has created practice guidelines addressing how to properly manage burns. The guidelines are informed by the best research available and by expert opinion. To thoroughly explain their goals, the ISBI Practice Guidelines Committee (2018) made this statement:

“The mission of the ISBI Practice Guidelines Committee is to create a set of clinical guidelines to improve the care of burn patients and reduce costs by outlining

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Because of their use of extensive research, the ISBI guidelines seem to represent the best and most recent guidelines created by burn professionals and will be referenced extensively in this paper.

In the ISBI practice guidelines, there is a section in the article titled “Pain Control,” which addresses all the major points that should be considered when managing pain. There are seven recommendations set in place for this section; however, this paper will only address five (1,2,3,4,and 7) of them because they are the recommendations that are most strictly relevant to the management of procedural pain.

Recommendation 1

“Pain related to burns is a complex combination of distress, anxiety, delirium, and situational and emotional factors. Management, monitoring, and treatment of pain are central to optimizing outcomes following burn injury” (ISBI Practice Guidelines Committee, 2018).

Burn injuries not only cause physical pain but cause psychological distress as well. Research data support the notion that proper pain control improves a burn patients’ physical and mental well-being; it also shows that pain control contributes to the patients’ overall satisfaction with their care (ISBI Practice Guidelines Committee, 2018). This fact makes it apparent that proper pain management must be at the heart of nursing care when it comes to working with burn patients. Due to the sheer amount of pain medications that are involved with burn care, a proper balance must be established that maximizes a patients’ pain control without

compromising their health from a medication overdose.

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Guidelines Committee, 2018). Due to the complex mechanisms involved in burn pain, it is important that the patient understand that complete pain relief is not possible, at least given current technologies and current medications (ISBI Practice Guidelines Committee, 2018). Candid discussion between the nurse and patient is necessary to facilitate realistic patient expectations about pain and this is better achieved after the nurse and patient have developed a good rapport.

Recommendation 2

“Monitoring the adequacy of pain control is facilitated by routine use of scoring systems during all phases of care. Scales based on patient self-report are preferred

when possible. Validated pain behavior observation-based scales are useful when the patient is unable to self-report because of mental status impairment or young

age” (ISBI Practice Guidelines Committee, 2018).

The use of pain scales is vital in monitoring and staying on top of a patient’s pain

management. There are several different scales that can be used to assess pain, such as the Face, Legs, Activity, Cry, Consolablity (FLACC) scale for children who are too young to speak, the Faces pain scale revised (FPS-R) scale for children who are of speaking age, and the Numeric Rating Scale (NRS) for adults (ISBI Practice Guidelines Committee, 2018). These are just a few of the many possible scales that can be used for their appropriate age groups. There are also scales available that should be used to address the pain needs of people with disabilities and/or who are intubated (ISBI Practice Guidelines Committee, 2018).

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sometimes intensifies as the procedure continues. Monitoring vital signs, facial expressions, and agitation is important as these can be good indications of when a patient should be assessed and reassessed using a pain scale (ISBI Practice Guidelines Committee, 2018). The primary goal for using a pain scale would be to effectively manage a patient’s pain using minimal doses of medication to help avoid any medication-induced complications (ISBI Practice Guidelines Committee, 2018).

Recommendation 3

“Pain management should address background, breakthrough, procedural, perioperative, and chronic long-term pain” (ISBI Practice Guidelines Committee,

2018).

For the sake of this project the only part of this recommendation that will be focused on is the management of procedural pain. Procedural pain falls under the category of “acute pain.” The ISBI Practice Guidelines Committee (2018) explains that acute pain “has a sudden onset, is severe in intensity, short-lasting, and felt immediately following injury.” As per the definition provided, it is evident that procedural pain is very severe and must be treated carefully. This is because burn wounds must be cleaned by gently irrigating the wound bed directly to help prevent infection. It is the foundation patient recovery and wound healing (ISBI Practice Guidelines Committee, 2016). Wound care, and pain management during wound care, is central to nursing interventions with burn patients.

Recommendation 4

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individualized multimodal approach to burn pain management that utilizes agents from different classes should be considered” (ISBI Practice Guidelines Committee,

2018).

Currently, the typical opioid/benzodiazepine is the most widely used medication combination to optimize pain control. However, there are newer options that are starting to be used. One of these newer drugs is ketamine, a dissociative drug that can help manage pain during procedural pain (ISBI Practice Guidelines Committee, 2018). Dissociative drugs are a class of hallucinogen that can alter a person’s perception of sight, sound, pain, and can cause feelings of detachment to one’s self (National Institute on Drug Abuse). Another drug that is showing promise to be affective in managing procedural pain (while also helping to reduce opioid needs) is a sedative called dexmedetomidine. Currently, propofol is the primary sedative that is used in certain instances of wound care. However, patients will experience less

respiratory depression and will be more arousable on dexmedetomidine compared to propofol (ISBI Practice Guidelines Committee, 2018). Lastly, other non-opioid analgesics, such as nonsteroidal anti-inflammatory agents (NSAIDS) should be used adjunctively during dressing changes (ISBI Practice Guidelines Committee, 2018).

While it is currently not possible to come up with a single treatment modality when it comes to pain management, the ISBI Practice Guidelines Committee (2018) has come up with three specific guidelines that can be used for every patient:

 “All burn centers should have an organized approach to the treatment of burn pain that considers background, procedural, and breakthrough pain.”

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The ultimate goal this recommendation is trying to achieve is to be able to manage procedural pain by not just depending solely on the opioid/benzodiazepine combination, but rather use multiple modalities to help reduce the potential for medication complications and tolerance/dependence to any single drug (ISBI Practice Guidelines Committee, 2018). Recommendation 7

“Nonpharmacologic techniques should be considered as important additional elements of a comprehensive post-burn pain management plan” (ISBI Practice Guidelines Committee, 2018).

While all the recommendations mentioned are crucial to consider for managing procedural pain, this recommendation is the most relevant for the purpose of this paper. The primary focus of this paper is to look at non-pharmacological ways to help manage procedural pain adjunctively to pharmacological measures. While nurses work with physicians to monitor patient pain relief and inform medication management, they do not prescribe medications. They can, however, implement interventions that could enhance a patient’s level of comfort with nursing procedures. Examples of non-pharmacological measures include: patient education, distraction, enhanced patient control, relaxation techniques, music therapy, hypnosis, activity-based play therapy, somatosensory approach of motor imagery, guided imagery, acupuncture, meditation, and parental participation (ISBI Practice Guidelines Committee, 2018). However, out of all the interventions listed, recent research has so far concluded that distraction techniques have proven to be the most useful.

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implemented when the patient is comfortable and calm. If these interventions are implemented while the patient is experiencing pain or high anxiety it will most likely not be as beneficial (ISBI Practice Guidelines Committee, 2018). Also, it is also important to note that these

interventions will most likely produce the greatest efficacy once pain is optimally managed with a pharmacological approach (ISBI Practice Guidelines Committee, 2018).

Non-pharmacological interventions also need to be taken with an individual approach because different interventions may work better for others. Important questions that the ISBI Practice Guidelines (2018) recommend asking patients before implementing any

non-pharmacological interventions would be things such as:  Is the intervention easy to learn?

 How much time does it take to use and how much effort is required by the patient/ health care provider?

 Is the intervention appropriate for this patient’s age group?

 How much will the intervention cost when considering training and/or equipment?

Experimental Non-Pharmacological Interventions

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Virtual Reality

Meta-analysis review #1. In the article “Efficacy of non-pharmacological interventions for procedural pain relief in adults undergoing burn wound care: A systematic review and meta-analysis of randomized controlled trials,” VR is discussed and concluded to have potential of being an effective non-pharmacologic adjunctive treatment during burn wound care. VR falls under the category of a type of distraction intervention. Distraction interventions are described as “diverting attention towards a non-painful stimulus to lessen the intensity of perceived pain by providing additional stimuli to the environment” (Scheffler et al., 2018). VR fits perfectly into this category because it involves using a three-dimensional, computer-created environment that the patient can see and interact with (Scheffler et al., 2018). The idea here is to help take some of the focus off the procedural pain by giving the patient something else to visualize, rather than seeing the dressing changes occur.

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non-pharmacological interventions (some including VR) to the control group (Scheffler et al., 2018). For more detail related to the studies used, please refer to the original article. When it comes to bias, there was insufficient reporting for there to be any conclusion to be made about selection and reporting bias; however, there is a risk of performance bias because most studies did not warrant that the studies were blinded (Scheffler et al., 2018).

All the studies used compared some form of intervention such as distraction, hypnosis, relaxation, or the combination of relaxation and distraction. After all the studies were reviewed and the data was analyzed, it was found that all the studies which included VR had significant positive results (Scheffler et al., 2018). Furthermore, the summary of the meta-analysis also explains that right now it is assumed that a person’s pain experience is something that is cognitively controlled (Scheffler et al., 2018). The primary idea for the use of VR is that

immersing burn patients into a world of illusion will help them to spend more time focusing their attention to that environment rather than the processing the pain (Scheffler et al., 2018).

As far as limitations are concerned regarding the meta-analysis, there were a few. Some of the primary limitations were populations of patients, the type of settings, the interventions that were applied, and the varying outcome definitions that were used across the individual studies (Scheffler et al., 2018). The internal validity could possibly be limited due to the risk of performance bias in 10 of the 21 studies and the quality of reporting was an issue regarding the assessment of the risk of selection bias (Scheffler et al., 2018).

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high-validity standards need to be done to help further support the use of VR as a sound non-pharmacological intervention. (Scheffler et al., 2018)

Meta-analysis review #2. Unlike the first meta-analysis reviewed, the article “Adjunctive virtual reality for procedural pain management of burn patients during dressing change or physical therapy: A systematic review and meta analysis of randomized controlled ‐

trials” focuses solely on the efficacy of VR when used adjunctively with pharmacologic

analgesics. While the rational for VR is similar in both articles, the authors of this meta-analysis more specifically explain the rational for VR being effective is due to the gate-control theory (Luo, Cao, Zhong, Chen, & Cen, 2018).

The gate-control theory explains that brain’s process of painful stimuli can be altered/interrupted by non-painful stimuli (Luo et al., 2018). In other words, a person’s psychology, cognition, emotions, and environment can all affect a person’s perception of nociceptive pain by either increasing it or decreasing it (Luo et al., 2018). In this case, VR would help to diminish the perceived nociceptive pain by using the patient’s visual, tactile, and auditory inputs (Luo et al., 2018). This multi-factorial approach helps the patient to immerse themselves into the VR and take more attention away from the pain being felt from the dressing changes.

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found to have a p-value less than 0.0001 (Luo et al., 2018). Time spent thinking about pain was measured in the same 7 of the 9 studies and found to have a p-value less than 0.00001 (Luo et al., 2018). Fun was measured in 4 of the 9 studies and found to have a p-value equal to p = 0.02 (Luo et al., 2018). All these statistics were found using a random effect model and all display statistical significance (Luo et al., 2018). It is also important to note that the results for the dressing changes are the only thing that will be shared on this paper, not the results related to physical therapy. This is because dressing changes are related more closely with the nursing aspect of care.

Based on these results provided, the authors concluded that these results show promise that VR used alongside medication analgesics helps to provide more control over a patient’s pain, along with other benefits that were discussed in the paragraph above. What is even more interesting is that some of the patients reported to have pain reduction from their VR experience lasting up to 7 days (Luo et al., 2018). However, there is still some hesitance to the idea of using VR not only because of the lack of research, but because of its practicality (Luo et al., 2018). The upside to this dilemma is that with rapid technological advances affordable, high-quality, and simplified VR models are not far from reach (Luo et al., 2018). In fact, high-quality VR will be important in the future because it is thought to provide better pain reduction due to the

immersion factor; the better the graphics contributes to the more real it feels and ultimately helps distract the patient more from the procedural pain (Luo et al., 2018).

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baths/dressing changes with VR compared to the control group was not thoroughly studied and needs further research (Luo et al., 2018).

As far as side effects are concerned, the only thing noted was that some patients

experienced nausea; however, it is difficult to know if the nausea came from the VR or from the opioid analgesics (Luo et al., 2018). Other things that were not reported but can be associated with using VR is eye straining, disorientation, and headaches (Luo et al., 2018). Further research will need to be done to explore all possible side effects.

Other Interventions

Hypnosis. Provençal, Bond, Rizkallah, and El-Baalbaki (2018) describe hypnosis as: “A technique that includes a hypnotic induction meant to attain a state of relaxed and focused attention followed by suggestions oriented toward a goal, in this case pain and anxiety reduction. Indeed, hypnosis is a technique that has been shown in many medical procedures not only to reduce pain and emotional distress, but also to improve recovery, reduce procedural time, and stabilize physiological parameters.”

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sensory pain felt but was not included in the statistics mentioned in the other 5 RCT’s due to lacking data (Provençal et al., 2018).

Effects on anxiety. After using the random effect model using a pooled effect of the data, Provençal et al. (2018) discovered that there was statistical evidence supporting that hypnosis could reduce the amount of anxiety endured (MD = −21.78, 95% CI −35.64, −7.93) with no statistically significant heterogeneity (I2 = 61%, p = 0.11) Only 4 of the 6 articles addressed anxiety with only two of them being included into the pooled data (Provençal et al., 2018). The two RCT’s included in the data both used the Visual Analogue Scale (VAS), however, one of them only measured positive effects on anxiety reduction before and during the treatment, not after (Provençal et al., 2018). The second study also used the VAS to measure their results; however, the study was specifically interested with the effects of using lorazepam along with hypnosis (Provençal et al., 2018).

Effects on medication needs. After using the random effect model using a pooled effect of the data, Provençal et al. (2018) discovered that there was no statistical evidence supporting that hypnosis could reduce the amount of medication needed to control pain (MD = −0.07, 95% CI −0.32, 0.17) with no significant heterogeneity (I2 = 0%, p = 0.81). This data was drawn from only using 2 of the 6 studies (Provençal et al., 2018).

Future research still needed. While this meta-analysis did show promise that hypnosis could be a useful non-pharmacologic therapy for treating burn pain, Provençal et al. (2018) mention several aspects of upcoming studies that need to be addressed:

 Utilization of several research teams in various settings to replicate study findings,

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 discovering a way to prove whether or not a trance state has been achieved before assuming the independent variable is accurately manipulated and,

 addressing the misconceptions of what hypnosis actually is.

Postdischarge satisfaction surveys. According to research, little is known about burn care satisfaction and the personal patient experience of inpatient care; however, it is known that “patients who are satisfied with their care are more likely to adhere to treatment guidelines, are more involved with their care, and thus are more likely to follow-up, and achieve better clinical outcomes” (Dai et al., 2018). Knowing and addressing the patients’ experience through

quantitative and qualitative measures is a vital part of improving the quality of care provided for burn survivors in the future.

Dai et al. (2018) set out to discover themes regarding the patients’ perception of their care through the use of a Hospital Consumer Assessment of Healthcare Providers and Systems

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Table 1

The Three Themes and Their Respective Subsets

Staff Communication Hospital Environment Discharge and Transitional Care

Respect and professionalism Cleanliness Overall discharge experience

Coordination and handoff Quietness Clinic follow-up

Explanations and understanding

Sleep

Room issues

Wound care supplies and medications upon discharge

Listening Ambience Wound care instructions

Confidence in provider Privacy Postdischarge coordination of

care

Note: The information in Table 1 came from the article “Burn Patients’ Perceptions of Their Care: What Can We Learn From Postdischarge Satisfaction Surveys?” by Dai et al. (2018).

The HCAHPS survey tool included a total of 32 questions that could be ranked on a scale of 1 to 10 (Dai et al., 2018). These surveys were given to a random sample of adults between 48 hours and 6 weeks postdischarge (Dai et al., 2018).

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apparent that the three main themes mentioned in the table above were the primary areas that needed to be addressed (Dai et al., 2018). Through more in-depth review of the themes, it was found that discharge teaching was ranked highest for patient satisfaction and MD communication was ranked the lowest (Dai et al., 2018).

The authors concluded that the HCAHPS survey, along with the patients’ personal narratives, helped to discover areas that needed improvement for overall patient satisfaction of care (Dai et al., 2018). The primary limitation of this study was the fact that the data collected only included data from one specific burn center. This means that if the same survey was used in another burn center, the areas that provide the most satisfaction or need the most improvement could be completely different (Dai et al., 2018). Individual burn centers would need to

implement their own survey to develop an improvement plan and optimize patient satisfaction specific to their unit.

Methods

There were two methods used to address the central questions of this project. The first was a thorough literature review to ascertain current thinking on pain control during burn wound care, particularly any article that addressed the nurses’ role in managing and mitigating patient pain during that care was sought. The goal was to try and keep all the literature used no more than five years old; however, due to the scarcity of information regarding the topic some articles were older.

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The literature review was conducted using the search engine “Google Scholar” and the academic nursing database “CINAHL.” Below is a table showing what combinations of words/phrases that were used to find the literature.

Table 2

Databases and Searching Strategies Used for Research

Database Search Strategy

CINAHL

(“burns” OR “burn injury” OR “burn injuries”) AND (“pain management” OR “pain relief” OR “pain control”

OR “pain reduction”) AND (“systematic review” OR “meta-analysis”)

(“pain management” OR “pain relief” OR “pain control” OR “pain reduction” OR “pain prevention”) AND (“dressing change” OR “bandage removal” OR

“self-removal”)

Google Scholar

(“practice guidelines for burn wound care”)

Interview

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care effort on a nationally recognized burn intensive care unit. More information about the interviewee is in Appendix A and the interview transcript is in Appendix B.

The interview was conducted on March 4th, 2020 with Chris Turner, MHL, BSN, RN, PCCN, the Patient Services Manager III, from the Burn ICU in UNC hospitals. While the actual interview transcript can be found in Appendix A, a summary of that interview is as follows:

Mr. Turner explained that the burn ICU (BICU) did not currently have any specific protocols set in place regarding patient bandage self-removal for pain management. However, he did state that the patient involvement aspect is something that should already be a part of best practice in general. If the UNC BICU were to adopt a specific protocol for patient bandage self-removal the two main challenges would be hesitation from the nurses changing the way they are used to doing bandage removal and making sure key members of the multidisciplinary team were informed about, and would support, this new approach. Fortunately, Mr. Turner

believes that newer nurses would show the least amount of resistance to adopting such a protocol because they seem to be the most interested in learning new approaches and are more open to new ideas. This is particularly important because many of the best-practice guidelines are created through nurse-driven wound care in the burn ICU setting (C. Turner, personal communication, March 4, 2020).

When asked his opinion on the use of baths versus hand-held shower hoses and if the benefit of fully submerging a wound in a bath would make dressing removal easier, Mr. Turner explained that the type of bathing method utilized was determined more by the situation and/or patient preference. He reinforced the idea that the primary goal, regardless of bathing method, was making sure that the dressings were saturated completely before removal (C. Turner,

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their own bandages would truly be an effective intervention for reducing procedural pain he responded yes. He explained that he has had injuries before where dressing changes were painful but being able to have that sense of control helped. He further explained that his wife had sustained an actual burn injury in the past and having her involved in her dressing changes not only allowed her to control the speed at which the bandages were removed, but also helped decrease the fear and anxiety that came along with dressing changes (C. Turner, personal communication, March 4, 2020).

Lastly, Mr. Turner was briefly asked if other interventions such as VR and/or

mindfulness apps with headphones have been utilized on the unit as a means of distraction/pain relief. He explained that they have not been due to the lack of research; however, he did say that preliminary research on use of VR on children/adolescents has recently began at UNC. He did state that distraction methods such as music therapy and ceiling tile paintings are two methods that are currently being used in the BICU (C. Turner, personal communication, March 4, 2020).

Results

I wanted the emphasis to be on this idea of patient dressing self-removal, but I also wanted to look at interventions that could be at the forefront of future nursing procedural pain management. A literature review revealed that virtual reality interventions are currently showing great promise in being an effective non-pharmacological intervention to help aid in the relief of procedural pain; however, these interventions are not yet readily available for use at most care centers.

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the burn wound management setting. However, I was able to find articles regarding the benefits of incorporating patients into their care and how it can be beneficial to their recovery.

Discussion

The project began with an observation from a clinical encounter: during burn wound care when a patient was given an opportunity to remove their own dressings, they seemed to

experience less pain yet, in my experience, nurses rarely offer bandage self-removal to patients as a means of decreasing pain and increasing a patient’s sense of agency. Why not? What keeps nurses from offering this option to patients? Is it their lack of knowledge about the practice? Or is there a lack of a strong evidence-base to promote such a practice? What does the literature reveal about the practice of bandage self-removal? It seems that there is not much in the literature about the practice.

There has been some exploration into some non-pharmacologic methods of pain mitigation, like virtual reality, but these measures are costly, cumbersome and difficult to implement in an area where infection control and patient-positioning impede their use. Yet a simple measure, like bandage self-removal, has not been studied. This is exactly the kind of research that nurses need to pursue. Without attention to development of our own interventions how can we provide the best possible care to patients. My interview with the nurse manager revealed a willingness to consider using bandage self-removal on the unit but a concern about nurses being willing to change practice, especially if doing so might include soaking in a tub. Both interventions together could require more time to orchestrate and complete the treatment.

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of burns, a study could measure self-reported pain scores and use of pain medication across the two conditions to see if bandage self-removal had an impact.

Conclusion

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References Ariely, D. (2008). Painful Lessons.

Ariely, D. (2015). Irrationally Yours: On Missing Socks, Pickup Lines and Other Existential Puzzles. New York, NY: HarperCollins Publishers.

Dai, A., Moore, M., Polyakovsky, A., Gooding, T., Lerew, T., Carrougher, G. J., … Pham, T. N. (2018). Burn Patients’ Perceptions of Their Care: What Can We Learn From

Postdischarge Satisfaction Surveys? Journal of Burn Care & Research, 40(2), 202–210. doi: 10.1093/jbcr/iry018

Greenfield, E. (2010). The pivotal role of nursing personnel in burn care. Indian Journal of Plastic Surgery, 43(3), 94. doi: 10.4103/0970-0358.70728

ISBI Practice Guidelines Committee (2016). ISBI Practice Guidelines for Burn Care. Burns, 42(5), 953–1021. doi: 10.1016/j.burns.2016.06.020

ISBI Practice Guidelines Committee (2018). ISBI Practice Guidelines for Burn Care, Part 2. Burns, 44(7), 1617–1706. doi: https://doi.org/10.1016/j.burns.2018.09.012

Luo, H., Cao, C., Zhong, J., Chen, J., & Cen, Y. (2018). Adjunctive virtual reality for procedural pain management of burn patients during dressing change or physical therapy: A

systematic review and meta-analysis of randomized controlled trials. Wound Repair and Regeneration, 27(1), 90–101. doi: 10.1111/wrr.1

Morgan, M., Deuis, J. R., Frøsig-Jørgensen, M., Lewis, R. J., Cabot, P. J., Gray, P. D., & Vetter, I. (2017). Burn Pain: A Systematic and Critical Review of Epidemiology,

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National Institute on Drug Abuse. (n.d.). What Are the Effects of Common Dissociative Drugs on the Brain and Body? Retrieved from

https://www.drugabuse.gov/publications/research-reports/hallucinogens-dissociative-drugs/what-are-effects-common-dissociative-drugs-brain-body

Provençal, S.-C., Bond, S., Rizkallah, E., & El-Baalbaki, G. (2018). Hypnosis for burn wound care pain and anxiety: A systematic review and meta-analysis. Burns, 44(8), 1870–1881. doi: 10.1016/j.burns.2018.04.017

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Appendix A

Interviewee Information

To give the reader more background information about Christ Turner, I asked him to give a brief job description and explain his responsibilities. Mr. Turner explained that he was the “The Patient Services Manager III” and that he “leads and facilitates a large team who has a strong skill set in leadership, quality improvement and budget. In addition, the ability to motivate, problem solve and communicate effectively is paramount to the success of the team. Description of duties to include patient care, human resource management, budget management, accreditation, quality improvement, education and customer satisfaction, amongst others” (C. Turner, personal communication, March 4, 2020).

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Appendix B

Interview Transcript Tyler:

“Does the UNC burn unit have any protocols addressing the

involvement of patients with their wound care? Does it

state anything specific about allowing patients to remove

their own bandages to aid in procedural pain control?”

Chris:

“We do not have a protocol.”

Tyler:

“Have you heard of any burn units or have seen any

research encouraging patients to remove their own

dressings during a dressing change?”

Chris:

“Not a protocol per se, but that is, I mean, that is a

part of best practice is involving. So, the whole… you’ll

hear those adages as a new grad. That you hear it, um you

know, discharge starts the day of admission and you

encourage them to participate as much as possible, but when

they are appropriately ready. Especially families who’s

going to help take care of said burn patient, but there’s

not a protocol that I know of and probably not much

(33)

Tyler:

“If patient bandage self-removal was considered an

effective intervention through the research, um do you

think there would be any significant drawbacks? Such as

longer bath times, increased infection rates, etcetera?”

Chris:

“Initially yes, but I think as we… it’s just like any new

learning opportunity. You’re going to have some resistance

on all parts, but as we show overtime and you do a

potential research trial or whatever it may be, I think

long term one: It’s going to save a lot of time, right,

you’re just gonna… but you’re gonna have increased comfort

of the patient and the family early, um, infections I don’t

think so as long as we’re teaching them appropriate hand

washing techniques and appropriate PPE use and etcetera, but

short term yes long term no.”

Tyler:

“From a cultural standpoint, is this intervention

something you think nurses would be willing to offer to

their patients from the beginning of a dressing change, um,

(34)

Chris:

“Long term yes, short term no. I mean that’s just not

nursing I think that’s you know, you too right? I mean you

know this is your best practice, this is what you wanna do.

You’re used to doing it your way. It adds a little bit more

time initially and that’s the hesitancy because it’s like ‘I

could have done it better if I just did it myself’, um, but

over time it eases your use. You know, you take the time

initially to do anything. It’s just, you know whatever it

may be and then long term you’ll see the effects of it.”

Tyler:

“If you were interested in implementing patient bandage

self-removal into the unit protocol, is it something you

believe could be implemented into the unit quickly

considering it requires no resources of any kind? What

would that process look like?”

Chris:

“Um, quickly yes, the implementation…very easy, you just

have to, you know, encourage people to do it etcetera. The

piece that’s gonna take longer is meeting with all the

other entities because it’s not just nursing. You have

providers. You have PT. You have OT… who kind of help with

that. We’re gonna have to ensure that they’re all on

(35)

is that it’s interdisciplinary. The bad thing… it’s

interdisciplinary. Right? So, you have to get everybody’s

approval most of the time. Especially when it comes to

wound care. Um, so the implementation, there’s really not

much to teach other than ‘Hey we’re gonna start day one’ or

whatever it may be, encourage them, give them direction,

but there’s still gonna have to be some oversight to ensure

that they’re doing it correctly… but before the patient is

discharged, family has to show teaching. Or the patient

has to show teaching… or not teaching but understanding of

the teaching before they leave, but involving them earlier

from day one… I think it’s great.

Tyler:

“So in general, not just, um, specifically to the patient

bandage self-removal. Do you think nurses on this unit are

curious and/or engaged in exploring new ways to better

address patient’s pain or other needs? Um, or do they leave

patient care research more so to the physicians?”

Chris:

“No, I think if, um, so if I had to estimate, I would say

fifty percent of staff are engaged to learn something new.

It’s generally the younger generation because you’re coming

in with open new ideas and etcetera, and you’re learning

(36)

don’t want to learn anything new. Because they are a

little bit more mature in life and that’s just anything.

That’s, um, but I do think especially in a burn center

where we don’t have a lot of evidence-based practice,

because we create the evidence-based, and it takes that

much more time. There’re only a hundred burn centers

(nationally). So, it’s very siloed approach for most of it. There’s best practice but it depends on attending

preference, but more so nursing would want to drive it

versus physicians. If you look at best-practice in burn

centers, nurse-driven wound care is the most successful

because there’s more, there’s more than just an attending

or two. Right? They have enough other things to kind of

worry about, and that’s where the direction that we have

headed, that we direct it.”

Tyler:

“Why are tub baths not something really used on the unit?

Um, using the rational that a fully submerged and saturated

bandage would come off easier. Um, Is the reason the

showers are preferred to primarily help with the infection

control? If so, how significant is that research? If the

significance is low, would it be reasonable to question if

(37)

could make removing bandages easier and significantly

reduce the procedural pain?

Chris:

“Yeah no, I think tub use overall has decreased

significantly in burn centers and just in general because

it depends. There’s, you know, you have the dependent

patient who you get them in the tub, it’s going to be

physically draining. Then you have the independent. Most

independent patients don’t want to take a bath. So, you

have this middle ground, but as long as you are truly

soaking the bandage… that’s the most important part about

removal. If we’re not, and we’re trying to rip and you

know, it’s just not use. We’ve changed some of our

practice when it comes to some of our bandage removal for

patients who are being discharged sooner rather than later

out of the hospital, and we’ve asked them to either

submerge their dressing before removal and/or soak it and

leave it on for thirty minutes. Which is hard for them,

like ‘I’m soaked’, but because it’s easier for removal, the

pain is decreased, less adherence, and so on and so forth.

A tub would work, but it’s generally a preference. You

know, you have to have… there’s a middle ground of finding

(38)

easier to get them in a tub, but ease of use and nurse

preference is always generally the, um, uh, stretcher (that

used in the shower). There’s no reason why we can’t use the tub.”

Tyler:

“What is your professional opinion on the idea of

allowing patients to remove their own bandages during a

dressing change? Would you consider it to be a logical

intervention to implement or not something that would

really make much of a difference regarding the perceived

pain and care satisfaction?”

Chris:

“No, I think I’m one hundred percent supportive, because,

you know I’ve had injuries, sports injuries, and when I

participated in my care, I controlled my pain. It still

hurt. Um, its generally a slower process versus just, you

know, rip the band aid off kind of thing. Um, but you

know, as long we’re working together in it, and if you

involve the patient. I know myself; I have never been

burned, but my wife was burned, and I made her participate

because that’s just who I am, but her participating in it…

You know, she was able to control the speed, she was able

to control her pain some, she was able to apply her

(39)

of that because only she knows her pain. You know we have

to interpret sometimes with the pain is but if by involving

them early, not just the patient but the family too. It’s

generally a little bit easier process and their fear and

their anxiety is down because they’re a part of it. You

know I think that’s with anything, but with wound care

especially.”

Tyler:

“And then lastly, um, have you ever considered having

patients undergoing a dressing change use headphones and a

mindfulness app to help with guided relaxation?”

Chris:

“We have not here, um, there’s very little research in the

burn world to do so; however, I liken it almost to like a

dentist office, right? I mean it’s painful when you’re

sitting in there and you know, but any distraction methods…

We did add music therapy, in terms of the Alexa in there

(The tank room – the place where patients are bathed) as a way for

distraction. Also, a way for staff to be able to enjoy

themselves when they’re in there for hours at a time. Um,

we use ceiling tiles as a distraction piece as well so when

they’re looking up and etcetera. We haven’t gone as far as

using VR or um, headphones and etcetera, but I think that’s

(40)

preliminary research in the VR world, um, or using some sort

of distraction in that sense. Our burn center is actually

doing some of that, they’re doing it with teenagers and

kids. Not necessarily in the adult world yet. Um, but I

think, I do think here it just depends on where the burns

are. You don’t want to put it (the VR) over (their face) when

they have a, you know (facial burn), so that’s the hard part in

keeping them (the VR’s) clean. Um, but the music at

least, allowing the patient to determine what they want to

listen to. Um, and you know, having some distraction as

they’re looking up (at the painted ceiling tiles), just like the

dentist office kind of thing. Kind of tenfold though, but…

Great thought, great process man I like it. I like your

thought process.”

Tyler:

Figure

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References

  1. hypnotic
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