Experiences of guilt, shame and blame in those affected by burns: A qualitative systematic review

The impact of burn injuries on indigenous populations: A literature review

INTRODUCTION

Ethnic minorities experience disparities in prevention and treatment of burn injury. Research focused on burn injuries in Indigenous populations is limited. This review summarizes literature on burn injuries in Indigenous populations to be considered to inform new research.

METHODS

A search was conducted in CINAHL, Ovid MEDLINE, PSYCinfo and SocINDEX. for "burn OR scars OR scald OR deformity OR disfigurement" and "Aboriginal OR Indigenous OR First Nation OR American Indian OR Maori OR Native OR Torres Strait Islander OR Amerindian OR Inuit OR Metis OR Pacific Islander". Inclusion 1) peer reviewed studies of burns in Indigenous persons 2) in English. Exclusion 1) no data specific to Indigenous burns 2) not peer reviewed 3) not in full text 4) protocol publications.

RESULTS

The search identified 1091 studies with 51 for review. Sixteen were excluded. The 35 included publications were published between 1987 and 2022. Findings indicated higher incidence of injury and poorer outcomes amongst Indigenous people. Indigenous people suffered more flame and inhalation burns, had longer lengths of stay, and more complications including hypertrophic scarring. Australian Indigenous patients struggle with a lack of culturally safe communication and support for aftercare.

CONCLUSION

Racial disparities exist in burn injury incidence and outcome for Indigenous persons. Qualitative research in this area will help providers better understand the experiences of Indigenous burn patients to develop more culturally competent care. We are currently developing a study using qualitative hermeneutic methodology to learn about the experiences of Indigenous burn survivors' injuries, recovery, and social reintegration.

"It's a big trauma for the family": A qualitative insight into the psychological trauma of paediatric burns from the perspective of mothers

BACKGROUND

Despite the medical and surgical improvements of paediatric burn injuries, burn injuries can be a painful and traumatic experience for the child and their family. It is therefore important to explore the experiences of caregivers who support their child throughout the burn journey. Thus, the purpose of this study was to explore the traumatic nature of paediatric burns on the family from a caregiver's perspective.

METHODS

This study used a descriptive qualitative approach to conduct online semi-structured interviews with caregivers (18 years and older) of children (aged four to 17 years) that had previously been admitted with an unintentional acute burn injury to a paediatric burns unit in Western Australia. Interviews explored the child's and caregiver's experiences throughout the burn journey from the perspective of the caregiver and were digitally recorded and transcribed verbatim. Transcripts were analysed using Braun and Clarke's six stages of reflexive thematic analysis.

RESULTS

Eleven mothers participated in the interviews and identified a range of poor psychological and psychosocial outcomes that themselves and their child experienced. Three overarching themes were elaborated from the interviews: Child and caregiver mental health difficulties during and after the burn (including medical trauma, mental health outcomes and caregiver guilt); Lifestyle and physical changes following the burn (including disruptions to routine, appearance concerns and puberty); and factors supporting or inhibiting the recovery journey (including personality factors, coping strategies, family dynamics and support).

FINAL CONSIDERATIONS

This study has presented the difficulties that children, young people, and their family face throughout a paediatric burn injury, which makes the implementation of timely and effective family centred interventions imperative. Meeting the needs and supporting these families with their mental health throughout this traumatic recovery journey, can ensure positive psychosocial outcomes and adaptive coping strategies are adopted early on.

A Qualitative Analysis on the Experiences of Mothers of Children in Burn Intensive Care Unit: "She burned on the outside, me inside..."

Mothers closely follow the complex process due to the burning of their children. Caring for and supporting the child can pose various challenges for mothers. With the phenomenological method, this study was conducted to investigate mothers' experiences staying with their children in the pediatric burn intensive care unit. Twelve mothers participated in the study. The semistructured face-to-face interviews obtained data. After each interview, the research team transcribed the interviews verbatim. Interpretive Phenomenological Analysis was used to analyze the data. The experiences of the mothers were classified in four contexts as a result of the interpretative phenomenological analysis; "first reactions to burn trauma" related to the awareness that the child has been burned, "being a mother in the burn intensive care unit" related to caring for the child as a companion in the burn intensive care unit, "coping" related to how they cope with the problems throughout the whole process, and "requirements" regarding the subjects it needs in the process. It was determined that mothers went through a physically and emotionally challenging process from the beginning of the burn trauma and throughout the intensive care unit. During this challenging process, it was observed that mothers could not use effective coping methods and did not receive the necessary professional support. In line with these results, it is recommended that psychological support programs be applied to the mothers and that care focused on the needs of the mothers should be provided.

Psychiatric Illness and Substance Abuse: Unaddressed Factors in Burn Injury

Patients with psychiatric illness and substance use comorbidities have high rates of burn injuries and experience prolonged hospital admissions. This retrospective chart review characterizes this marginalized population's inpatient burn care and examines post-discharge outcomes compared to burn patients without psychiatric or substance use comorbidities treated at our center. Patients admitted to a single burn center from January 1, 2018 to June 1, 2022 were included. Patient demographics, history of psychiatric disorders, treatment course, and post-discharge outcomes were collected. A total of 1660 patients were included in this study, of which 91 (6%) patients were diagnosed for psychiatric comorbidity and/or substance use comorbidity on admission for burn care. In this cohort of 91 patients with psychiatric and/or substance use comorbidities, the majority of patients were undomiciled (66%) and male (67%). In this cohort, 66 (72%) patients reported recent history or had positive urine toxicology results for illicit substances on admission. In this cohort, a total of 25 (28%) patients had psychiatric comorbidity at the time of burn injury or admission and 69 (76%) patients received inpatient psychiatric care, with 31 (46%) patients requiring psychiatric holds. After discharge, the readmission rate within 1 year of patients with psychiatric and/or substance use comorbidity was over four times greater than that of patients without psychiatric and/or substance use comorbidity. The most common causes of readmission were subsequent mental health crisis (40%) and inability to perform burn care (32%). Our study presents strategies to improve burn care for this marginalized and high-risk population.

Environmental scan of mental health supports across Canadian burn centers: A healthcare providers’ perspective

BACKGROUND

Early mental health care and psychosocial support after burn injury provided by a variety of specialists and non-mental health professionals is instrumental in prevention of long-term mental health sequalae such as post-traumatic stress, depressive or substance use disorders. Diversity of mental health supports available to burn survivors vary across geography, resulting in variation of long-term mental health outcomes following burn injury.

METHODS

A mixed-methods study utilizing a semi-structured questionnaire to explore resources available for burn survivors in Canada as an inpatient, outpatient, and more broadly in the aftercare community. Interviews were completed with 17 Canadian burn centers, with a variety of burn care professionals.

RESULTS

In the continuum of burn care, a lack of available mental health professionals in certain regions and in the outpatient and community phases was observed. Emerging themes demonstrated the need for regular screening for mental health concerns among burn survivors and providing up to date discharge resources. In addition, increasing educational opportunities available to burn care staff with respect to burn survivor mental health was emphasized. Lastly, the importance of proactive and prolonged psychological support for burn survivors as they progress through an outpatient, rehabilitation and community setting was underlined.

CONCLUSIONS

Identification of burn care practices and resources across Canada provides the opportunity to compare, unify and improve gaps in care that exist across the Canadian burn network.

Exploring parents' attitudes towards a multicentre cohort study of children with burns injuries: A qualitative interview study

Background

Burn injuries affect more than 60,000 children every year in the UK, with many experiencing scarring as a result. Scarring can be highly variable, and research is required to explore the factors that may influence variability, as well as the psychosocial impact of these injuries on children and their caregivers. A multicentre burns cohort study is being planned to investigate genetic determinants of scarring and long-term psychosocial outcomes. Public involvement (PI) is an essential element of the design and feasibility stages of this planning. As part of this work, this study aimed to gain an in-depth understanding of parents’ attitudes towards participation in burns research, specifically a longitudinal cohort study of children with small burns (<10% total body surface area [TBSA]).

Methods

In total, 16 parents of children with burns took part in semi-structured interviews regarding their experiences of taking part in research and their attitudes towards the potential future cohort study. Interviews were audio-recorded, transcribed verbatim and analysed using Reflexive Thematic Analysis.

Results

Four themes were identified: ‘Acknowledging trauma’; ‘Aligning research with experience’; ‘Research as a reciprocal relationship’; and ‘Contributing to change’.

Discussion

These four themes represent factors that parents suggested were important for acceptability, relevance, recruitment and retention of participants into a longitudinal multicentre cohort study of children with a burn injury and their caregivers.

Conclusion

The findings of this study will be incorporated into the design of such a study, as well as having wide reaching relevance for research in the field of paediatric burn injuries.

Lay Summary

Background to this subject

More than 60,000 children experience a burn injury every year in the UK and many of these injuries lead to scarring. We know that the extent of this scarring can vary, and we know that some children and their parents/caregivers manage well but others struggle with the challenges they face after having a burn. Researchers would like to carry out research on these topics, including asking participants to take part in research over several years to find out how genetics might influence scarring, as well as their psychological experiences over this time. Before they conduct this study, it is very important that researchers understand parents' attitudes towards this kind of research. The current study aimed to find out parents' opinions and ask what issues were important to them when taking part in burns research.

Details of how the work was conducted

Parents of children who had experienced a scald (a type of burn injury) were asked to take part in a research interview. In total, 16 parents took part in this study. We recorded these interviews and analysed them, looking for patterns and shared experiences in participants' interviews.

What we did and did not learn from this study

We found four themes in the interview data: ‘Acknowledging trauma', ‘Aligning research with experience', ‘Research as a reciprocal relationship', and ‘Contributing to change'. Overall, these themes suggest that parents were mostly supportive of a ‘burns cohort study’, but they have also highlighted some important considerations for this research and other future burns research studies.

Parents' lived experiences of parental needs for support at a burn centre

Purpose: A burn injury to a child is a traumatic event and the parent's emotional reactions and coping strategies affect the child's adaptive outcome. It is therefore important that parents get the right support. The aim was to explore parents' lived experiences of their need for support when having a child admitted to a burn centre. Methods: Semi-structured face-to-face interviews were conducted with 22 parents of children age <12 years hospitalised with an accidental burn injury, 9 to 27 days after the burn accident, from April 2017 to July 2018. A Ricoeur-inspired textual analysis method was used. Results: Four themes emerged from the analysis and describe the parents' needs for support. The parents wanted to be taken care of as a whole family and feel safe in the hands of professionals. This, in turn, depended on being informed about the child's condition and treatment, but also on getting help in dealing with feelings of guilt. Not least, parents wanted opportunities to take care of their own fundamental needs in terms of hygiene, food, adequate rest and activities. Conclusion: As an overall understanding the healthcare providers should focus on the family as a whole in care and treatment.

Experiences of medical tattooing in women following burn injuries: An interpretative phenomenological analysis

INTRODUCTION

Physical changes to appearance caused by burn injuries can have significant psychological consequences. Medical tattooing is an intervention aimed at restoring appearance but little is known about the experiences of patients or the psychological impact of medical tattooing following burns. This study aimed to explore burn patients' psychological experiences of medical tattooing.

METHOD

In-depth interviews were conducted with eight adult women who had experienced a burn injury and subsequently undergone medical tattooing.

RESULTS

Using interpretative phenomenological analysis (IPA) to analyse the verbatim transcripts of interviews, two subordinate themes ('Management of Hope' and 'The Medical Tattooing Process') and one superordinate theme ('Impact of Medical Tattooing: 'Normal-ish is Fantastic'') emerged, which were set within a broader context of another superordinate theme: 'Inner Conflict about Acceptability of Perceived Need'. The findings suggested that medical tattooing is experienced positively, may have positive psychological consequences, and may allow women to regain a sense of normality and an improved sense of being acceptable in society following burn injuries. Findings additionally highlighted a conflicting narrative of a pressure to conform to certain expectations of appearance, alongside a sense that a desire to meet these expectations may also not be viewed as important, acceptable or legitimate.

CONCLUSIONS

Medical tattooing may be a potentially valuable intervention psychologically, although support and information seem important and further research is required.

Prevalence and course of posttraumatic stress disorder symptoms in partners of burn survivors

Background: Partners of burn survivors may develop posttraumatic stress disorder (PTSD) symptoms in response to the potential life threatening nature of the burn event and the burn survivor's medical treatment. Objective: This longitudinal study examined the prevalence, course and potential predictors of partners' PTSD symptoms up to 18 months post-burn. Methods: Participants were 111 partners of adult burn survivors. In a multi-centre study, PTSD symptoms were assessed with the Impact of Event Scale-Revised during the acute phase and subsequently at 3, 6, 12 and 18 months post-burn. Partners' appraisal of life threat, anger, guilt and level of rumination were assessed as potential predictors of PTSD symptoms in an exploratory piecewise latent growth model. Results: Acute PTSD symptoms in the clinical range were reported by 30% of the partners, which decreased to 4% at 18 months post-burn. Higher acute PTSD symptoms were related to perceived life threat and higher levels of anger, guilt, and rumination. Over time, mean symptom levels decreased, especially in partners with high levels of acute PTSD symptoms, perceived life threat and rumination. From three months onward, PTSD symptoms decreased less in partners of more severely burned survivors. At 18 months post-burn, higher levels of PTSD symptoms were related to higher acute PTSD symptoms and more severe burns. Conclusions: One in three partners reported clinical levels of acute PTSD symptoms, of which the majority recovered over time. Perceived life threat, feelings of anger and guilt, and rumination may indicate the presence of acute PTSD symptoms, whereas more severe burns predict long-term PTSD symptom levels. The results highlight the need to screen for acute PTSD symptoms and offer psychological help to partners to alleviate acute elevated stress levels if indicated.

Parent and Clinician Communication During Paediatric Burn Wound Care: A Qualitative Study

PURPOSE

To thematically describe parent-clinician communication during a child's first burn dressing change following emergency department presentation.

DESIGN AND METHODS

An observational study of parent-clinician communication during the first burn dressing change at a tertiary children's hospital. Verbal communication between those present at the dressing change for 87 families, was audio recorded. The recordings were transcribed verbatim and transcripts were analysed within NVivo11 qualitative data analysis software using qualitative content analysis.

FINDINGS

Three themes, underpinned by parent-clinician rapport-building, were identified. Firstly, knowledge sharing was demonstrated: Clinicians frequently informed the parent about the state of the child's wound, what the procedure will involve, and need for future treatment. Comparatively, parents informed the clinician about their child's temperament and coping since the accident. Secondly, child procedural distress management was discussed: Clinicians and parents had expectations about the likelihood of procedural distress, which was also related to communication about how to prevent and interpret procedural distress (i.e., pain/fear). Finally, parents communicated to clinicians about their own distress, worry and uncertainty, from the accident and wound care. Parents also communicated guilt and blame in relation to injury responsibility.

CONCLUSIONS

This study provides a description of parent-clinician communication during paediatric burn wound care.

PRACTICAL IMPLICATIONS

The results can assist healthcare professionals to be prepared for a range of conversations with parents during potentially distressing paediatric medical procedures.

Factors associated with adherence to follow-up care after burn injuries

INTRODUCTION

In South Africa, burns result in excessive morbidity which can be mitigated via follow-up treatments. This study evaluated factors associated with care retention for after burn injuries.

METHODS

A retrospective chart review was performed for twelve months of care at the public burn facility in Kwazulu-Natal, South Africa. All inpatients were eligible, although those who were transferred or died during care were excluded. The primary outcome was return for initial appointment one-week after discharge. The population was analyzed descriptively, and multivariable logistic regression was employed to yield adjusted odds ratios (aOR) with associated 95% confidence intervals (CIs).

RESULTS

From 354 patients 310 were analyzed. Of these, 177 (57.47%) were children (<12 years). One third (33.12%) of patients were non-adherent to follow-up (n = 102). In multivariable analysis, children ≤12 years of age were more likely to follow up (aOR = 1.87; 95% CI: 1.07-3.25, p = 0.028), as were those who underwent an operation (aOR = 2.69; 95% CI: 1.47-4.91, p = 0.001). Residing ≥50 km from the health center was associated with lower likelihood of follow up (aOR = 0.52; 95% CI: 0.29-0.93, p = 0.027).

CONCLUSION

High follow up attrition suggests the need for enhanced engagement in the high-risk burn population studied, and the identified factors could be leveraged in such programming.

Issues and concerns of family members of burn patients: A scoping review

INTRODUCTION

The issues and concerns that emerge in the families of burn patients have received minimal attention.

OBJECTIVE

To map out what is known about the challenges facing the family members of burn patients.

METHODS

The review followed the PRISMA Extension guidelines for scoping reviews and the review approach by Arksey and O'Malley to synthesize the available evidence. Twenty-six (26) papers from various database searches were identified and included in the review. The citation retrieval and retention methods are reported in a PRISMA statement.

RESULTS

Although most of the studies included parents (n=21), the evidence suggests that the shared concerns of family members include taking on new roles, and psychosocial and financial issues. Uniquely, parents had to endure blame, shame and guilt; partners/spouses were faced with difficulties in re-establishing an emotional connection with the patient; siblings simultaneously expressed jealousy and feelings of being outsiders; and children with a burn parent had to deal with feelings of exclusion from the care delivery process. Aside from these individuals, friends, neighbours and in-laws may also assume a caregiving role, with grandparents playing a supporting role. Family members are unprepared for their roles, as they are forced into them suddenly. Although distress may occur among family members, its determinants, severity, pattern and recovery process remain unclear.

CONCLUSION

A burn is a family injury that creates the need for family-centred care. Future studies need to explore the nature of psychological distress, family members' recovery pathways, and how family members can prepare for their roles in the period after discharge.

Drivers and consequences of self-immolation in parts of Iran, Iraq and Uzbekistan: A systematic review of qualitative evidence

OBJECTIVES

The prevalence of self-immolation is significantly higher in some Middle Eastern and Central Asian Islamic countries than in Western countries. Self-immolation typically occurs among females and can be either an attempt at suicide or an act of protest. This systematic review examined the drivers and consequences of self-immolation in Asian Islamic countries from the perspective of those affected by it, including survivors, family and health care staff in order to understand its higher prevalence in these countries.

METHOD

A systematic review of qualitative studies was conducted in June 2018, using five electronic databases: PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), EMBASE, Scopus and PsycINFO. Of the 236 papers identified, seven met the inclusion criteria. Authors independently rated the reporting of included qualitative studies and thematic analysis was used to analyse the data.

RESULTS

The drivers of self-immolation included marital and familial conflict, male-dominated culture, mental health disorders and economic and social factors. Survivors chose self-immolation in order to express their sense of a lack of control and mostly utilised this method due to its accessibility. The consequences of self-immolation were social isolation, regret, and physical and psychological impacts.

CONCLUSIONS

The reasons for self-immolation, its prevalence and the demographics of those who choose this means vary significantly between Asian Islamic and Western countries. This review confirmed the impact of culture, tradition, and societal structures and relationships on people's decisions to self-immolate. Education about the consequences of self-immolation may reduce the use of this method.

Challenges Facing Women Survivors of Self-Immolation in the Kurdish Regions of Iran: A Qualitative Study

OBJECTIVES

Women confront many problems after self-immolation, so the purpose of this study was to explore the challenges facing women survivors of self-immolation in the Kurdish Regions of Iran.

METHOD

This study used a qualitative approach and conventional content analysis. Data were collected through semi-structured interviews with 19 Kurdish women who attempted self-immolation in Iran. They were sampled through purposeful sampling and snowball sampling. The Lincoln and Guba criteria were used to strengthen the research.

RESULTS

The results of data analysis were categorized into five main categories: 1-psychological problems, 2-lack of social and legal supportive structures, 3-incomplete treatment, 4-poor self-care, and 5-social problems. These categories consist of 19 subcategories.

CONCLUSION

Having been rescued from self-immolation, the women confront many challenges returning to normal life. Reducing these women's problems and paving the way for their return to life requires multi-dimensional and community-based interventions. Therefore, all social organizations and institutes can cooperate and each of them paves part of the way.

Staff Members’ Experience of Providing Parental Support in a National Burn Centre

Background

Paediatric burn injuries affect not only the child but the whole family, especially the parents. Knowledge of how parents are affected psychologically has increased, but there is an ongoing dearth of literature on parental support while hospitalised. There is also very little documentation of the ways in which burn staff members support parents.

Objectives

To explore staff members’ lived experiences of supporting parents with children hospitalised at a burn centre due to a burn injury.

Methods

Four focus group interviews were conducted in 2017 with a total of 21 staff members at the National Burn Centre in Norway. Seven different burn staff professions participated. Data were analysed using a Ricoeur-inspired method for text analysis and managed using NVivo 12Plus.

Results

Four themes were identified in the treatment trajectory: creating a safe, secure and trusting environment from the moment parents enter the burn centre; helping parents deal with feelings of guilt; helping parents navigate in their daily routines while continuing to be a mother or father; and gradually involving parents in wound treatment as preparation for discharge.

Conclusion

Staff must carefully consider their verbal and non-verbal (body) language and how to approach parents from the very moment they enter the burn ward. Most parents are affected by feelings of guilt and these feelings must be addressed and processed. During the treatment trajectory, parents are guided to participate in the daily care of their child and are gradually assisted in taking over the wound treatment prior to discharge.

Bringing research to the bedside: Knowledge translation in the mental health care of burns patients

Advances in surgical techniques and wound management have improved outcomes for burn patients; however, the psychological impacts on burn survivors have had less attention. There is a higher rate of mental health disorders amongst burns victims, with those with pre-existing mental health conditions likely to have worse outcomes. To implement effective burns care and rehabilitation, knowledge and understanding of mental health issues is required. This position paper discusses the extent to which clinicians currently translate knowledge around mental health and burns into practice to identify enables and inhibitors. Successful knowledge translation requires dissemination and accessibility of information with the capacity and readiness for change. Clinicians and researchers need to identify how translating research to practice can meet the needs of burn survivors. There is a gap in the utilization of evidence concerning mental health and the needs of burns survivors, and we need to understand what we know as compared to what we do. Clinicians are well placed to determine how and why knowledge does not necessarily translate to practice and how they can better accommodate the needs of burn survivors.

Qualitative research investigating the mental health care service gap in Chinese burn injury patients

BACKGROUND

Psychological disturbances are prevalent in people with burn injuries; however, psychological services are rarely accessiblepost-burn injury in China. The objective of this qualitative study was to explore and conceptualize the obstacles to delivering mental health care in burn injury patients.

METHODS

The researchers used a grounded theory research approach to interview sixteen burn injury patients, five nurses, four rehabilitation therapists, five medical doctors, and eight caregivers regarding their experiences with current health care services and barriers.

RESULTS

An explorative model was generated from the data, and the relationships among the categories were identified. People's beliefs, knowledge, socioeconomic status, cultural understanding of mental health, and social stigma appear to play key roles in the public health approach to post-burn health promotion and post-burn psychosocial interventions.

CONCLUSION

The model proposed in our research highlights the need to focus on the underlying social, economic, and cultural determinants of mental health care. The underlying social determinants of the mental health care gap that is responsible for the ill-prepared health care must be addressed.