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Helping burn patients to look at their injuries: How confident are burn care staff and how often do they help? L. Shepherd a,*, R. Begum b a Nottingham University Hospitals NHS Trust, Burns Unit, City Hospital Campus, Hucknall Road, Nottingham NG5 1PB, United Kingdom b University of Lincoln, Health, Life & Social Sciences, 1st floor, Bridge House, Brayford Pool, Lincoln LN6 7TS, United Kingdom

article info

abstract

Article history:

Patients vary in their feelings about looking at their injuries and burn care staff play an

Accepted 20 February 2014

important role in helping patients. This study explored confidence among burn care staff in helping patients to look at their injuries and how often help was typically offered. Burn care

Keywords:

professionals (n = 33) completed a questionnaire exploring confidence and practice in this

Burns

area. Eighty-five percent (n = 28) believed it was important for patients to look at their

Looking

injuries but a significant proportion lacked confidence in preparing patients for what they

Mirror

might see (18%; n = 6) and having the necessary practical skills required (24%; n = 8). Fifty-

Psychological

five percent (n = 18) worried about upsetting patients and 48% (n = 16) worried about saying/ doing the wrong thing. Practice varied significantly. Only 21% (n = 7) regularly (most or all of

Support

the time) informed patients where mirrors were situated within the ward area. Eighteen percent (n = 6) of staff reported never or only occasionally asking patients if they had seen their injuries, 27% (n = 9) of staff never or only occasionally asked patients if they would like to see their injuries and 30% (n = 10) of staff never or only occasionally asked patients if they wanted any help looking at their injuries. Training in this area may be useful to enhance staff confidence so patients can be offered appropriate support. # 2014 Elsevier Ltd and ISBI. All rights reserved.

1.

Introduction

Burn patients often have to adjust to unexpected and permanent changes in appearance. This can lead to psychological distress related to altered appearance that remains long after physical recovery occurs [1,2]. Psychological distress associated with a changed appearance may be maintained by negative appraisals about the self, ruminating about and

comparing oneself to before the injury, negative predictions or interpretations about other people’s feelings or behaviour towards them, unhelpful avoidance and safety-seeking behaviours (e.g. avoidance of mirrors or social situations; concealing injuries with clothing) as well as negative and prejudicial societal and cultural views surrounding disfigurement and visible differences. Psychological treatment typically involves addressing any unhelpful thought patterns or processes and reducing avoidance and safety-seeking

* Corresponding author. Tel.: +44 115 969 1169. E-mail address: [email protected] (L. Shepherd). http://dx.doi.org/10.1016/j.burns.2014.02.017 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.

Please cite this article in press as: Shepherd L, Begum R. Helping burn patients to look at their injuries: How confident are burn care staff and how often do they help?. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.02.017

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behaviours in a gradual, systematic manner [3–7]. The published research typically focuses on longer-term adjustment and reactions to altered appearance and strategies to reduce associated distress. No published literature could be found that specifically focused on how to help patients to look at their wounds in the acute stage based on psychological models or theories. Indeed, there appears to be an absence in the published literature of what can be defined as best practice with regard to helping patients to look at their wounds during the acute phase. Regardless of location(s) on the body, looking at their burns is likely to be important for patients as a way of starting to adjust to their altered appearance and the accident [8,9]. Indeed, the first experience of looking may be critical [3]. If the area burned is the face, head, neck or back the patient will require a mirror to see their injuries. If injuries are on the front of the body or limbs and would not require a mirror, burns are covered in the acute stage by dressings in order to promote healing and reduce infection. These physical barriers to looking at injuries may be frustrating to those patients who want to look at their injuries but may be welcomed by other patients who prefer to avoid looking at their injuries due to anxiety. In such instances, patients may want (or not) to look at their injuries when dressings are taken off or during wound care. It has been reported that while many patients do not have significant concerns about looking at their injuries for the first time and do so independently during hospitalisation, others may be concerned about this and need support from burn care staff. A significant minority of patients may be extremely anxious about what their injuries might look like or how their appearance may have changed; therefore they avoid looking at their injuries [6]. In order to provide burn patients with support in looking at their injuries it can be presumed that burn care staff will need to be confident in offering such help and have a certain level of knowledge about and skill in using techniques that can make it easier for patients who are distressed. Techniques may include gradually and systematically showing patients their injuries and perhaps initially describing injuries to patients, drawing pictures for patients or showing clinical photographs of the patient’s own or similar injuries in order to prepare patients for what they will see. Staff will also require ability and confidence in handling any emotional distress that may arise in patients when they are looking at their injuries. Furthermore, it may be assumed that staff will also need to have good communication skills in order to (1) inform patients about where mirrors are situated within the ward area, (2) tell patients that they can ask them for help looking at their injuries at any time, and (3) ask patients if they have seen or would like to see their injuries. Importantly, it can be presumed that staff needs to have the confidence in all these different elements. This theoretical perspective for what may constitute best practice, or at least may represent the elements that may be involved, in helping patients to look at their injuries is unpublished and represents the views of the authors. Despite this being an important area of psychological care for burn patients, only two relevant studies could be found about the topic. One study explored nurses’ views [10] and the other investigated patients’ experiences and opinions [11]. The

first study [10] questioned a sample of nurses working in burns units in the United States of America about helping patients to look at their injuries for the first time. It was found that the nurses used verbal and non-verbal signals from patients to decide when it was appropriate for patients to look at their injuries. The nurses also reported that patients looking at injuries for the first time was not typically a planned event or documented in healthcare records. The second study [11] explored burn patients’ experiences of and concerns about mirrors located on a burns unit in the United Kingdom (UK). Patients most often reported that they decided to look at their injuries for the first time and this was most often when they were alone, with relatives or while nurses were present. The study also explored patients’ recollections regarding the communication about the presence and availability of mirrors by burn care staff during their hospital admission. Only a quarter of patients reported being informed where mirrors were located on the burns unit and only one third of patients reported they were made aware that they could ask for a handheld mirror or were offered a mirror by nurses to look at their injuries. When patients were asked whether they had seen their injuries prior to discharge from the hospital, 10% of patients with facial burns had not. One in twelve patients reported they had not received enough help looking at their injuries and an additional 16% felt unsure about whether they had received enough help. This study concluded that burn care staff may lack confidence in communicating with burn patients about the presence and availability of mirrors on burns units and about looking at their injuries for the first time and providing help with this. It also suggested that a significant minority of burn patients may not be getting the help they need to look at their injuries. A final part of the same study included a survey of all burns services in the UK and it was reported that no protocols or guides existed within any services to support burn care staff in helping patients to look at their injuries (e.g. that offered advice, suggestions or techniques to use if patients were anxious and avoidant of looking at their injuries). This suggested that training on the topic may be required, especially if burn care staff lack confidence in the area as the study suggested [11]. The current study explored levels of confidence among burn care staff in helping burn patients to look at their injuries and how often help at looking at injuries was typically offered to patients in a burns service in the UK. The study was considered important to determine the need for training burn care staff in the area so that burn patients can be offered appropriate levels of support.

2.

Method

2.1.

Participants and setting

Thirty-three burn care staff (32 female) working in the Nottingham burn service, UK, participated in the study. Approximately three quarters of the sample were nurses (n = 25), 12% (n = 4) were occupational therapists, and 12% (n = 4) were physiotherapists. Twenty-four percent (n = 8) of staff were aged 18–29 years, 15% (n = 5) were 30–39 years, 42% (n = 14) were 40–49 years, 15% (n = 5) were 50–59 years and 3%

Please cite this article in press as: Shepherd L, Begum R. Helping burn patients to look at their injuries: How confident are burn care staff and how often do they help?. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.02.017

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(n = 1) was 60–69 years old. The majority classified their ethnicity as White British (94%, n = 31), 3% (n = 1) was of a mixed background, 3% (n = 1) was Asian/British Asian and 3% (n = 1) described themselves as Other. Fifty-two percent (n = 17) had been professionally qualified for more than 10 years, 33% (n = 11) had been qualified for 5–10 years and 15% (n = 5) had been qualified for 2–4 years. In relation to burn care experience, a third (n = 11) had worked in burn care for over ten years, 27% (n = 9) for 5–10 years, 24% (n = 8) for 2–4 years, and 15% (n = 5) for less than two years.

2.2.

Number of nursing staff approached to participate (n=32)

Number of occupational therapy staff approached to participate (n=4)

Number of physiotherapy staff approached to participate (n=4)

Number of nursing staff who participated (n=25)

Number of occupational therapy staff who participated (n=4)

Number of physiotherapy staff who participated (n=4)

Materials

In the absence of any published or standardised measures that would have been suitable for use in the study, a questionnaire was designed by the researchers and other psychosocial colleagues specialising in burns. The questionnaire captured demographic information and mainly contained Likert-scaled items asking for levels of agreement (from one to five, with one representing ‘Strongly agree’ and five representing ‘Strongly disagree’) to explore degrees of confidence and other beliefs associated with helping burn patients to look at their injuries (e.g. ‘‘I am confident asking patients whether they have seen their burns’’ and ‘‘I am confident in dealing with patients’ distress as a consequence of them seeing their burns’’). Likert-scaled items to explore how frequently staff helped patients to look at their injuries in their routine practice (from one to five, with one representing ‘Never’ and five representing ‘Always’) were also incorporated (e.g. ‘‘I ask patients if they would like to see their burns’’ and ‘‘I tell patients where mirrors are situated within the ward area’’). The internal reliability of the measure was high (Cronbach’s alpha = 0.813). Five open-ended questions were also included to explore issues surrounding helping patients to look at their injuries in more detail (e.g. ‘‘How you do feel about helping patients to look at their burns? Please explain your answer’’). The content of the questionnaire was designed around an unpublished theoretical perspective of the elements that may be involved in helping patients look at their injuries, as previously described.

2.3.

Total approached to participate (n= 40)

Procedure

This study was approved as a clinical audit by the affiliated hospital trust. Scientific review of the study was completed by the second author’s affiliated university. The questionnaire was piloted with the ward manager and subsequently given to all nurses, occupational therapists, and physiotherapists working in the burns service because it was believed that these professionals would generally have the most opportunity in terms of time and scope of their role to discuss and help patients to look at their injuries. Informed consent was gained and participants were requested to respond within a threeweek period in May 2012. Participants were prompted to complete the questionnaire alone and refrain from sharing responses with others. The 33 responses represented 83% of the nursing and therapy staff working in the burns service, indicating a high response rate. Fig. 1 represents the response rate in relation to the overall sample and different professional groups.

Total number of staff who participated (n= 33)

Fig. 1 – CONSORT diagram representing the response rate of the overall sample and different professional groups.

3.

Results

Data were inspected for skewness and kurtosis using visual inspection and Z-scores. The data were not normally distributed; therefore non-parametric analyses were used in addition to descriptive analyses.

3.1. Levels of confidence and practice in helping burn patients to look at their injuries Table 1 displays levels of confidence and beliefs among burn care staff in helping patients to look at their injuries. The data suggest that 88% (n = 29) of burn care staff reported feeling confident asking patients whether they have looked at their injuries and 82% (n = 27) reported feeling confident asking patients if they needed any help to look at their injuries. Furthermore, 85% (n = 28) believed that it was important for patients to look at their injuries. However, 18% (n = 6) reported not feeling confident about talking to patients to emotionally prepare them for what they might see, and an additional 12% (n = 4) felt unsure about this. Sixty-four percent (n = 21) of staff felt confident dealing with patients’ distress. However, 21% (n = 7) were unsure and an additional 15% (n = 8) did not feel confident about this. Furthermore, 24% (n = 8) of staff did not feel they had the skills to practically support patients in looking at their injuries and an additional 30% (n = 10) were unsure. Sixty-three percent (n = 21) of staff worried about patients’ reactions to seeing their injuries and 48% (n = 16) worried about saying or doing something wrong. In addition, 55% (n = 18) worried about upsetting patients by helping them look at their injuries and 82% (n = 28) of staff felt they needed further training about the subject. Table 2 summarises the variation in staff practice in helping patients to look at their injuries. The data indicate that only 21% (n = 7) of staff regularly (most or all of the time) informed patients where mirrors were situated within the ward area. Informing patients that hand-held mirrors were available or offering patients these mirrors was also not routine practice (doing it half the time or less). Eighteen

Please cite this article in press as: Shepherd L, Begum R. Helping burn patients to look at their injuries: How confident are burn care staff and how often do they help?. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.02.017

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Table 1 – Levels of confidence and beliefs about helping burn patients to look at their injuries. Questionnaire item

Strongly disagree

Disagree

Unsure

Agree

Strongly agree

I am confident asking patients whether they have seen their burns I am confident asking patients if they need psychosocial help to look at their burns I am confident talking to patients to help them feel prepared for what they might see I worry about patients’ reactions to seeing their burns

0% n=0 0% n=0 3% n=1 3% n=1 3% n=1 6% n=2 0% n=0 0% n=0

6% n=2 3% n=1 15% n=5 21% n=7 12% n=7 18% n=6 6% n=2 33% n = 11

6% n=2 15% n=5 12% n=4 12% n=4 21% n=7 30% n = 10 12% n=4 18% n=6

18% n=6 27% n=9 33% n = 11 39% n = 13 52% n = 17 36% n = 12 49% n = 16 36% n = 12

70% n = 23 55% n = 18 36% n = 12 24% n=8 12% n=4 9% n=3 33% n = 11 12% n=4

I worry about upsetting patients by exposing them to their burns

3% n=1

33% n = 11

9% n=3

46% n = 15

9% n=3

It is important for patients to look at their burns

0% n=0

3% n=1

12% n=4

27% n=9

58% n = 19

There are adequate mirrors available on the ward for patients to look at their burns There is not enough time to support patients in looking at their burns

0% n=0 6% n=2

9% n=3 30% n = 10

30% n = 10 24% n=8

39% n = 13 24% n=8

21% n = 17 15% n=5

I am confident in dealing with patients’ distress as a consequence of them seeing their burns I have the skills to practically support patients in seeing their burns I feel I need further training in supporting patients in looking at their burns I worry about saying or doing something wrong

Qualitative data from the questionnaire were analysed using a model of thematic analysis [12]. Five themes were extracted representing how burn care staff felt about helping patients to look at their injuries. These are presented in Table 3. Table 3 suggests that staff generally reported feeling uneasy and low in confidence in helping patients to look at their injuries but felt they had interpersonal skills that would

percent (n = 6) of staff reported never or only occasionally asking patients if they had seen their injuries, 27% (n = 9) of staff never or only occasionally asked patients if they would like to see their injuries, and 30% (n = 10) of staff never or only occasionally asked patients if they wanted any help looking at their injuries. Finally, 30% (n = 10) of staff never or only occasionally ensured that patients had seen their injuries prior to discharge from the hospital.

Table 2 – How often staff help burn patients to look at their injuries. Questionnaire item

Never

Occasionally

Half the time

Most of the time

Always

Tell patients where mirrors are situated within the ward area

21% n=7 22% n=9

46% n = 15 22% n=9

12% n=4 12% n=4

18% n=6 21% n=7

3% n=1 24% n=8

21% n=7

30% n = 10

15% n=5

21% n=7

12% n=4

27% n=9

21% n=7

18% n=6

24% n=8

6% n=2

27% n=9 0% n=0 3% n=1 3% n=1 18% n=6

27% n=9 18% n=6 24% n=8 27% n=9 12% n=4

15% n=5 21% n=7 21% n=7 15% n=5 3% n=1

21% n=7 33% n = 11 27% n=9 21% n=7 39% n = 13

6% n=2 27% n=9 24% n=8 33% n = 11 27% n=9

Tell patients with face, neck and back burns that hand-held mirrors are available if they would like to see their burns using these Tell patients with burns to other areas of the body that hand-held mirrors are available if they would like to see their burns using these Explicitly offer patients with face, neck and back burns hand-held mirrors so they can look at their burns Explicitly offer patients with burns to other areas of the body hand-held mirrors so they can look at their burns Ask patients if they have looked at their burns Ask patients if they would like to see their burns Ask patients if they would like help looking at their burns Ensure patients have seen their burns prior to discharge

Please cite this article in press as: Shepherd L, Begum R. Helping burn patients to look at their injuries: How confident are burn care staff and how often do they help?. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.02.017

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Table 3 – Themes identified from comments by staff about helping burn patients look at their injuries. Theme Uneasy feelings

Having appropriate interpersonal skills to help

Guidance and other support wanted

Knowing more about how to handle patients’ emotional reactions, communicate and strategies to help

Challenging populations or situations

Example quotes ‘‘Would feel anxious asking patients about their injuries for the first time’’ ‘‘Inadequate’’ ‘‘Lack confidence in doing this’’ ‘‘Scared I’ll say something wrong. . .’’ ‘‘Patience, empathy, kindness’’ ‘‘I am empathic and honest’’ ‘‘Compassion, knowledge and experience’’ ‘‘Communication skills’’ ‘‘Leaflets and face to face training. I think it would be useful to discuss in MDT’’ ‘‘Availability for help/discussion’’ ‘‘Joint working and psychology staff may be valuable’’ ‘‘Before/after photos’’ ‘‘Documentation’’ ‘‘Questions to ask, how to deal with different reactions’’ ‘‘Help with phrasing/terminology’’ ‘‘More information of the nursing aspect of burn care and how to deal with the emotional side of this’’ ‘‘When is it best to start talking about scaring’’ ‘‘Strategies to help patients build up to looking at their injuries’’ ‘‘More extensive injuries and traumatic injuries’’ ‘‘Suicidal patients, potential self-harming’’ ‘‘Facial burns, young people’’ ‘‘Women’’

be useful. Guidance and strategies to assist staff in helping patients in looking at their injuries appeared to be desired. Specifically, staff reported wanting further information about how to manage patients’ emotional reactions, ways of communicating and help with what to say and strategies that may be useful to try when helping patients to look at their injuries. There were certain populations and situations that staff believed would be more challenging to help look at their injuries such as those with more extensive injuries, facial burns, women and those with psychiatric presentations.

3.2. Factors associated with helping patients to look at their burns The different behaviours implicated in helping patients to look at their injuries, as presented in Table 2, were collapsed into a single variable, a total help behaviour score. The internal reliability of this sub-scale was high (Cronbach’s alpha = 0.902). In order to explore factors associated with helping patients to look at their injuries, this total help behaviour score was correlated with self-reported confidence and beliefs, as presented in Table 1, using Spearman’s Rho correlation analyses. More frequently helping patients to look at their injuries was related to increased confidence asking patients whether they have seen their injuries (r = 0.50, n = 33, p < 0.01), increased confidence talking to patients to help them feel prepared for what they might see (r = 0.56, n = 33, p < 0.001), increased confidence in dealing with patients’ distress as a consequence of them seeing their injuries (r = 0.73, n = 33, p < 0.001) and a stronger belief that they have the skills to practically support patients in seeing their injuries (r = 0.59, n = 33, p < 0.001). Helping patients less frequently was related to a stronger belief that they needed further training on the topic (r = 0.49, n = 33, p < 0.01) and a

weaker belief that there were sufficient mirrors available on the ward (r = 0.41, n = 33, p < 0.05).

3.3.

Individual differences in confidence and practice

Mann–Whitney U analyses suggested that staff who had more than five years experience working in burn care perceived themselves to be more confident in dealing with patients’ distress as a consequence of them seeing their injuries (U(1) = 70.5, Z = 2.38, p < 0.05) and having the skills to practically support patients in looking at their injuries (U(1) = 69, Z = 2.35, p < 0.05) compared to staff with less than five years experience working in burn care. There was also a trend for these more experienced staff to perceive themselves as having more confidence in talking to patients to help them feel prepared for what they might see (U(1) = 82.0, Z = 1.85, p = 0.06). In relation to practice, staff who had more than five years experience of working in burn care more frequently told patients where mirrors were located on the unit (U(1) = 76.5, Z = 2.09, p < 0.05), more frequently informed patients with face, head and back burns that hand-held mirrors are available (U(1) = 50.5, Z = 2.3, p < 0.05) and more frequently informed patients with burns to other areas of the body that hand-held mirrors are available (U(1) = 62.5, Z = 2.55, p < 0.05) compared to staff who had worked in burn care for less than five years. However, there were no other statistically significant differences in relation to practice according to experience.

4.

Discussion

The current study explored confidence levels and beliefs among burn care staff in relation to helping patients to look at their injuries. It also investigated how frequently staff

Please cite this article in press as: Shepherd L, Begum R. Helping burn patients to look at their injuries: How confident are burn care staff and how often do they help?. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.02.017

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typically helped patients to look at their injuries. The main findings suggested that the majority of staff believed it was important for patients to look at their injuries but a significant proportion lacked confidence in helping patients. How often staff helped patients to look at their injuries varied. Staff who had worked in burn care for more than five years reported increased confidence and practice in helping patients to look at their injuries compared to staff who had worked in burn care for less than five years. Given that it is considered to be important for burn patients to look at their injuries to begin the adjustment process, in addition to assertions that a significant minority of patients will be distressed and avoidant about looking at their injuries [5,6,8,9], it follows that burn care staff require confidence in helping patients look at their burns and offer support routinely in line with individual patients’ needs. The current findings suggest that for a significant proportion of burn care staff this may not be the case. The current results are consistent with findings from an earlier study [11] that explored patient’s experiences about mirrors on a burns unit and suggested that communication from burn care staff about the presence and availability of mirrors that could be used to look at their injuries was not common practice and that a significant proportion of patients reported feeling that they had not received enough help looking at their injuries while in the hospital. The study [11] concluded that burn care staff may lack confidence in helping patients to look at their injuries and the current findings support this conclusion for a significant proportion of staff. It also suggested that a significant minority of burn patients may not be getting the help they need to look at their injuries. Again, the current findings support this given the reported variation in help offered to patients. Because some injuries on the body cannot be viewed without mirrors, it may be useful to discuss the current results in light of the fact that the presence of mirrors in healthcare settings generally is often limited and health care staff may hold unhelpful myths such as ‘‘People who are sick or dying do not want to look in mirrors’’ and ‘‘Patients who want to look in a mirror will ask for a mirror’’ [13]. Indeed, the presence of mirrors on burns units is often minimal, creating an artificial environment, which may give patients the implicit message that they should not look at their injuries [11]. In addition to the current findings, which suggest that a significant proportion of staff lack confidence in helping patients to look at their injuries, mutually reinforcing avoidance behaviour may occur. Patients who are anxious about looking at their injuries may avoid looking at them, which may serve to suppress their anxiety in the short-term. However, this avoidance may be maintained due to the artificial environment and staff who are anxious about helping patients and therefore do not offer help. Such staff members’ anxiety about helping patients to look at their injuries may then also be maintained because they do not develop positive experiences of helping patients in this way and skills in helping patients to look at their burns are not developed and/or practiced. The results also suggest that if staff believe there are insufficient mirrors on the ward they help patients to look at their injuries less often, which highlights the need for mirrors to be available on burns units.

The qualitative data provided richer data and suggested that staff had uneasy feelings about helping patients to look at their injuries. However, they perceived themselves as having interpersonal skills that could be transferable. Guidance and other support around the topic of helping patients to look at their injuries were desired. In particular, skills and techniques in handling patients’ emotional reactions and communicate about the topic as well as specific strategies to help patients to look at their injuries was wanted by staff. Information about how to help women, those with facial burns and those with psychiatric presentations was also required. This data enabled the researchers to develop training and guidance for staff, specifically focusing on these issues. National burn care standards for the UK [14] suggest a tiered approach to the provision of psychosocial care in burn services. Furthermore, all staff should receive appropriate psychosocial training so that all members of the burn care team can provide lower-level support to patients. The current findings suggest that efforts may need to be dedicated to enhancing specific areas of confidence and psychosocial skills among burn care staff so that patients can routinely be offered help at looking at their injuries. This may be aided by the development of a theoretical framework for helping patients to look at their injuries that can be drawn upon. Currently, the authors believe that no such published framework exists which leads to a lack of guidance about what may constitute best practice. The introductory section provides an unpublished theoretical perspective representing elements that may be involved in helping patients to look at their injuries. However, this has not been examined or tested.

5.

Implications

First, results suggest that a significant proportion of burn care staff may lack confidence in helping patients to look at their injuries which may lead to avoidance of offering help. Second, it may imply that some burn patients are not receiving the help they need to look at their injuries while in the hospital. Indeed, burns services may find it useful to evaluate confidence and practice of their staff in helping patients to look at their injuries and provide training as appropriate. This may involve providing staff with written or verbal guidance, face-to-face training or ongoing clinical supervision from more senior burn care staff or psychosocial professionals in teams. Any training should be subject to evaluation and ran or supervised by the lead psychosocial professional to ensure quality and effectiveness. Training or clinical supervision may be particularly useful for staff with less experience in burn care. A limitation of the current study is that categorised rather than actual time values were captured by the questionnaire in relation to how many years each staff member had worked in burn care. This prevents more detailed analysis of the stage at which confidence in helping patients look at their injuries may start to increase and when it may plateau. This should be a focus of previous research to determine whether training at specific time points is indicated. Based on the results of the study, written guidance was developed for burn care staff to use to support them in helping patients to look at their injuries as discussed above. This is

Please cite this article in press as: Shepherd L, Begum R. Helping burn patients to look at their injuries: How confident are burn care staff and how often do they help?. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.02.017

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now being used locally and includes advice about raising the issue of patients looking at their injuries, considering whether patients are ready to look at their injuries, practical techniques based on psychological theories of exposure and anxiety management, ways to manage emotional reactions in patients and provide support and guidance about when to seek further support from psychosocial professionals. Electronic copies of this guide can be requested through the corresponding author for use in other services. Furthermore, the findings suggest that mirrors are needed on burns units because this may prompt staff to offer help more often. Finally, if patients are significantly distressed by the appearance of their injuries and have concerns about how they will cope after they leave the burns unit environment and return home they should be referred to relevant psychosocial professionals within the burns service. Further research on the topic is warranted as helping patients to look at their injuries is an important aspect of burn care. This may include qualitative studies exploring staff members’ confidence and practice to gather richer and more in-depth data, further examination of the relationship between confidence and practice in this area and experience in burn care, or replications of the current study in other burns services within and outside the UK using the questionnaire developed by the authors.

6.

Limitations

The study has limitations. In particular, the study consisted of a relatively small sample size and it relies on subjective selfreport ratings of burn care staff, which may be subject to bias. Furthermore, it may not be representative of all burns services within the UK or in other countries. Finally, in the absence of any suitable published or standardised measure, the questionnaire used was developed specifically for the study and has not been subject to rigorous psychometric examination. However, the internal reliability of the questionnaire was found to be high. Furthermore, it fills a previous gap in the research literature in this area and it has important clinical implications as previously detailed.

7.

Conclusions

In conclusion, helping patients to look at their injuries may not be routine practice for a significant proportion of burn care staff and this may be related to a lack of confidence in particular aspects and implications of offering help for these staff members. Training burn care staff in this area may be useful to enhance staff confidence so that patients can be offered the appropriate level of support they need. A guide for

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staff has been developed locally to support staff in helping patients to look at their injuries.

Conflict of interest The authors have no conflict of interest to declare.

Acknowledgements We kindly acknowledge the staff members who participated in the study. We would also like to thank Dr Liz Coombes and Dr Sam Williams from the Birmingham burns service, UK, who assisted us with the design of the project and the development of the questionnaire used in the study.

references

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Please cite this article in press as: Shepherd L, Begum R. Helping burn patients to look at their injuries: How confident are burn care staff and how often do they help?. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.02.017

Helping burn patients to look at their injuries: how confident are burn care staff and how often do they help?

Patients vary in their feelings about looking at their injuries and burn care staff play an important role in helping patients. This study explored co...
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