Psychological adjustments made by postburn injury patients: an integrative literature review

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Psychological adjustments made by postburn injury patients: an integrative literature review Kerry Klinge, Diane J. Chamberlain, Maurine Redden & Lindy King Accepted for publication 10 July 2009

Correspondence to D.J. Chamberlain: e-mail: [email protected] Kerry Klinge BBus BN Student BMBS School of Nursing & Midwifery, Faculty of Health Sciences, Flinders University, Adelaide, South Australia Diane J. Chamberlain MNSc MPH RN Senior Lecturer, Co-ordinator Critical Care Studies School of Nursing & Midwifery, Faculty of Health Sciences, Flinders University, Adelaide, South Australia Maurine Redden BN PhD Grad Cert (Critical Care) Research Assistant School of Nursing & Midwifery, Faculty of Health Sciences, Flinders University, Adelaide, South Australia Lindy King BN (Education) PhD RN Senior Lecturer, Associate Dean (Higher Degrees Programs) School of Nursing & Midwifery, Faculty of Health Sciences, Flinders University, Adelaide, South Australia

K L I N G E K . , C H A M B E R L A I N D . J . , R E D D E N M . & K I N G L . ( 2 0 0 9 ) Psychological adjustments made by postburn injury patients: an integrative literature review. Journal of Advanced Nursing 65(11), 2274–2292. doi: 10.1111/j.1365-2648.2009.05138.x

Abstract Title. Psychological adjustments made by postburn injury patients: an integrative literature review. Aim. This paper is a report of a review examining the variables that predispose individuals to significant psychological maladjustment following burn injury. Background. The psychological sequelae of burn injury are well documented; however, the variables that influence individuals’ adjustment following burn injury lack consideration. Data sources. MEDLINE, Cumulative Index of Nursing and Allied Health, and Psychological Abstracts were searched using the keywords burn injury, psychological, psychosocial, rehabilitation, premorbid psychopathology, adjustment, reintegration, body image, post-traumatic stress disorder, depression, coping. Other sources were found from a manual search of nursing, medical and psychological literature and references of identified and related papers. The search strategy was limited to English-language research published between 1997 and 2008. Review methods. An integrative review of the studies was conducted over a 6-month time period during 2007–2008. Results. Burn patients are a heterogeneous group and typically have comorbidities. While preburn personality and coping strategies can influence long-term psychological adjustment, the relationship between postburn adjustment and burn size and severity, and gender are poorly understood. Much of the literature focuses on the prevalence of psychological maladjustment rather than on identifying variables that influence psychological adjustment. Conclusion. The diversity and complexity that characterize burn patients lead to unique adjustment difficulties. Recognizing these difficulties is the first step to offering appropriate intervention and treatment for this unique patient group. Keywords: burn injury, burns patients, integrative literature review, nursing, postburn adjustments

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Introduction Major burn injury is one of the most severe traumas a person can endure, because the skin is the largest organ of the body. In 2002, the estimated annual global incidence of fire-related burn injury was 6,576,000 [World Health Organization (WHO) 2004]. Mortality rates due to burn injuries vary across the world. High socioeconomic status countries have lower rates of burn injuries, which is in stark contrast to the situation in the majority of low and middle socioeconomic status countries (Forjuoh 2007, WHO 2008; Park et al. 2009). Burn injury may occur because of specific social habits and traditions, religious beliefs and activities, social events and festivals, and traditional medical practices (Al-Qattan & Al-Zahrani 2009, Papp 2009). Burn injury by self-immolation, for example, is rare in the developed world, but is responsible for a high proportion of suicide attempts in Africa, the Middle East, the Far East, Egypt, India and Asian countries (Ahmadi et al. 2009, Sanghavi et al. 2009). The occurrence of and reasons for burn injury vary in different countries, and include religious beliefs, socio-economic issues and political protests (Dastgiri et al. 2005). In Australia in the five years to 30 June 2004, 47,000 people were admitted to hospital with a burn-related injury [Australian Institute of Health and Welfare (AIHW) 2006]. After burn injury, the normal protective mechanism of the skin is severely compromised (Young 2002, Bousfield 2003, Herndon 2007). Without immediate medical intervention, the prognosis for extensive burns is poor, with patients experiencing hypovolaemic shock, sepsis, multiorgan failure and consequent high mortality rates (Young 2002, Bousfield 2003, Herndon 2007). Over the past 50 years, mortality rates following major burns have dramatically decreased because of expanding knowledge of the pathophysiology of thermal injury and its systemic consequences, medical technology advances and improved surgical techniques (Young 2002, Bousfield 2003, Herndon 2007). Half a century ago, approximately 50% of victims survived if their burns involved more than 40% total body surface area (TBSA) (Bull & Fisher 1949). Today, burns involving >90% TBSA are sometimes survived by young and healthy people. In the Western world, overall mortality rates following burns have decreased to 5–6% (Ryan et al. 1998, Miller et al. 2006). This can be attributed to the establishment of specialized burn centres, advances in critical care and anaesthetic procedures, vigorous fluid resuscitation (Moore 1970, Diver 2008), excision of burn wounds (Janzekovic 1970, Pereira et al. 2006, Vehmeyer-Heeman et al. 2007), dynamic and aggressive nutritional management (Suri et al. 2006), wound care advances (White & Evans 2008) and use  2009 Blackwell Publishing Ltd

Psychological adjustment postburn injury

of topical antimicrobial agents and systemic antibiotics (Church et al. 2006). Innovative burn care technology has led to the development of multidisciplinary teams which focus on the immediate surgical, medical, and reconstructive phases of treatment, whilst concomitantly attending to the patient’s psychological and psychosocial well-being (Young 2002, Bousfield 2003, Herndon 2007). The focus on psychiatric morbidity and well-being of burn survivors has increased in importance as mortality has decreased. The first year following a burn injury is the vulnerable period during where many patients suffer from anxiety, depression, delirium and psychosis (Patterson 1993; Yu & Dimsdale 1999; Ceranoglu & Stern 2006; Edwards et al. 2007). Most studies highlight that patients suffer longterm psychological complications, with a prevalence rate spanning 10–65% (Williams & Griffiths 1991, Edwards et al. 2007, Thombs et al. 2008). Anxiety and depression are the most frequent long-term symptoms reported by burn patients (Patterson 1993, Edwards et al. 2007, Hulbert-Williams et al. 2008, Thombs et al. 2008). Other studies indicate that psychological maladjustment is associated with premorbid psychopathology, duration of hospitalization and socioeconomic variables (White 1982, Willebrand et al. 2002; Wisely et al. 2007; Mulholland et al. 2008). Similarly, burn patients have a higher incidence of pre-existing psychopathology than the general population (Patterson & Ford 2000, Gilboa 2001, Herndon 2007, Dyster-Aas et al. 2008). For example, high neuroticism and high extraversion predispose to trauma exposure (Breslau et al. 2008), and burn patients exhibit such personality traits more than a normative sample (Fauerbach et al. 2000, 2007, Willebrand et al. 2002). Neuroticism is a vulnerability factor for depression and other comorbid psychiatric disorders (Clarke 1999, Gilboa 2001, Wisely et al. 2007), which in turn contributes to the cause of the burn injury itself (Noyes et al. 1979, Horner et al. 2005). Homelessness, poverty, substance abuse, heightened family disruption and age (young and old) are other major risk factors (Blakeney et al. 2008, Kramer et al. 2008). Individuals with burn injury are more likely to be young adult men (AIHW 2006; Esselman et al. 2006), although women are more likely to experience psychosocial issues such as body image disillusionment secondary to burn injury (Newell 2000, Van Loey & VanSon 2003, Smith et al. 2006, Herndon 2007). Women also report more burn treatment and rehabilitation problems (Park et al. 2008). Importantly, personality traits and coping styles, combined with situational factors, are associated with degree of psychological adjustment following burn injury (Tedstone et al. 1998, Kildal 2003, Fauerbach et al. 2005, Herndon 2275

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2007). For example, employment, marital status, heavy financial burden and inadequate social support, combined with the previously discussed risk factors, are predictors of psychosocial outcome following burn injury (Park et al. 2008). Identifying risk factors is not only possible but essential to identify those at risk of psychological maladjustment following injury to implement preventive and rehabilitative strategies (Patterson & Ford 2000, Lawrence et al. 2004, Fauerbach et al. 2005, 2007). Mapping of the psychological responses in phases generally reflects the patient’s stage of physical recovery. These phases of recovery are admission/acute, chronic and delayed and at each stage the patient may encounter new or continuing complications impeding recovery. Blakeney et al. (2008) discusses a further phase of reintegration occurring on hospital discharge. Smith et al. (2006) describe emerging psychological issues that are ‘dynamic in nature, multifactorial and should be assessed and treated as such’ (p. 105). The influence of psychological and social factors on recovery cannot be overstated (Costa et al. 2008, Menezes et al. 2008, Park et al. 2008). Appropriate screening, assessment and treatment to address the patient’s psychological needs throughout the stages of physical recovery should be the treatment norm (National Burn Care Review 2000; Mulholland et al. 2008). These issues support a case management approach to care, whereby the patient’s specific, whole-ofbody needs are identified to facilitate and best manage the transitions from acute setting to rehabilitation, and then home (Cohen & Cesta 2005, Duff 2007). What the literature presently lacks is identification of the totality of risk factors specific to people with burn injuries. Table 1 shows a summary of common psychosocial issues and the period in which they are likely to emerge (Smith et al. 2006, Herndon 2007). These processes occur concurrently with, and as part of, the body’s physiological response to massive injury. Certain pathophysiological responses to burn injury stimulate the release of inflammatory mediators and stress hormones (Herndon 2007) which, in addition to the physiological response they induce, may provoke a psychological reaction. The reaction presents as heightened levels of anxiety and stress (fight or flight) during the acute phase of injury. Hence, during the acute phase, the body’s physiological mechanisms exacerbate the psychological responses to injury.

The review Aim The aim of this review was to identify factors that place burn patients at risk of significant psychological maladjustment, 2276

and to develop a model of care to highlight to healthcare professionals the sequelae of burn injury.

Design An integrative literature review was carried out. This method seeks to summarize data through the synthesis of existing research information (Taylor et al. 2007). Use of this technique enabled identification of six key variables from the literature.

Search methods The MEDLINE, Cumulative Index of Nursing and Allied Health (CINAHL) and Psychological Abstracts (PsycINFO) databases were searched using the keywords psychological, psychosocial, premorbid psychopathology, reintegration, body image, depression, coping, nursing and literature review. These terms were linked with burn injury. Manual searches of relevant nursing, medical and psychological literature, together with reference lists of identified and related papers followed. The search was limited to Englishlanguage research studies published between January 1997 and December 2008.

Search outcome Using these search criteria, 37 articles were retrieved, of which 20 were excluded from the review for one or more of the following reasons: • The study focus did not discuss premorbid variables considered likely to influence postburn adjustment. • The study focussed on child burn patients, for whom the premorbid variables that influence psychological adjustment postburn injury were considered to vary from those in adolescents or adults. • The focus of the study was to ascertain the relevance of certain outcome measures for burn patients (such as quality of life, body image, depression scales, length of stay and others) and deemed to contain irrelevant subject matter.

Quality appraisal To facilitate critical examination and evaluation, each paper was appraised using an evaluation tool for quantitative research studies (Health Care Practice & Development Unit 2005). This tool contained the following sub-sections: study evaluative overview; study, setting and sample; ethics; group comparability and outcome measurement; policy and practice implications; and other comments.  2009 Blackwell Publishing Ltd

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Table 1 Summary of psychological responses and psychosocial issues Acute (first 3 months)

Chronic (after the first trimester)

Delayed (>6 months)

Drowsiness, confusion, delirium secondary to opioid medications, hypovolaemia, fluid and electrolyte imbalances Psychosis related to drug/alcohol withdrawal, metabolic issues in the ICU environment Pain Depression and anxiety disorders Development of maladaptive behaviours such as aggression and dissociation Phobias Sleep disturbances, nightmares Dread of further surgery Premorbid psychopathology emerges Dysfunctional and disruptive behaviours Issues relating to appearance, function (ROM) Devastation Grief and denial Survivor’s guilt Shame Self-consciousness fi heightened anxiety Poor self-esteem Depression fi acute stress disorder May experience economic crises Prepare for return to work, work rehabilitation Pain Development of maladaptive behaviours such as aggression and dissociation Mood swings, anger Depression, emergence of post-traumatic stress disorder Avoidance behaviours Physical health improves, but psychological issues may continue Decreased quality of life, self-esteem Vocational issues Pain Development of maladaptive behaviours such as aggression and dissociation Family issues, social withdrawal, ‘a social death’

Source: Gilboa (2001); Smith et al. (2006); Herndon (2007). ROM, range of movement.

Data abstraction and synthesis

Psychological status prior to burn injury

The final sample included 17 research studies that are shown in Table 2. A review of the studies was conducted during 2007 and 2008. Based on the quantitative evaluation, the studies were further synthesized under the following sections: author and date of publication, study design, aim/objectives of the study, sample and study population, data collection instrument and significance of the findings.

From the studies reviewed, it appears that burn patients have a higher incidence of pre-existing psychopathology than the general population. Furthermore, pre-existing psychiatric disorders, alcohol and substance abuse, and depression play a statistically significant causal role in the aetiology of the injury (Dyster-Aas et al. 2008). Those who sustain a burn may therefore be predisposed to such an injury because of diminished cognitive processes related to substance use, neurosis or disregard for self-preservation leading to risk-taking behaviours. The link between burns and pre-existing psychopathology was supported in a longitudinal, prospective study of post-trauma patients (n = 95) with preburn psychiatric history (Fauerbach et al. 1997). A meta-analysis by Noronha and Faust (2006), comprising 13 papers, confirmed that the presence of pre-existing psychopathology increased the risk of psychological maladjustment following burn injury.

Results Six variables that influence how well burn patients adjust postburn injury were identified: (1) psychological status prior to burn injury, (2) vocational status prior to burn injury, (3) personality and coping style, (4) efficacy of support networks, (5) burn characteristics and 6) gender.  2009 Blackwell Publishing Ltd

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Limits of study/rigour

Significance to issue/ problem/question

Fauerbach et al. (2007)

Wisely et al. (2007)

Small sample size, self- Psychological screening Female gender n = 79, M/F 55:24; Study questionnaires Prospective Understand trajectory of for body image distress report data; small and larger mean age 41Æ7 (SD Satisfaction with longitudinal burn patients body image needs addressing number of patients TBSA burn appearance (SWAP); dissatisfaction; investigate 15Æ5) during hospitalization with very large burns predicted the role of body image in Mean TBSA 16Æ0% Multidimensional Bodyand after discharge (TBSA >50%). increased body Self Relations psychosocial functioning (SD 15Æ5) questionnaire: importance image dissatisfaction; of physical appearance. body image MBSRQ-IA SF-36 Health Survey (measure of quality mediated relationship of life) between preand postburn psychosocial functioning n = 57 M/F 38:19; To address issues of Prospective Did not use diagnostic Model of delivering 63% patients Hospital Anxiety and mean TBSA psychological screening crosspsychological care interviews to clarify required some depression Scale (HADS); 13Æ36% (SD 14Æ7) and intervention within a sectional proposed using a tiered premorbid diagnosis. ‘psychological Impact of Event Scale burns unit format, based on Reports on data care’ beyond (IES); Burns Psychology identified patient needs collected at initial their initial Assessment Tool (BPAT) assessment, screen. A range generalizability of of psychofindings over time logical skills was required to Small sample size, Females under meet the represented psychological care needs of ward patients n = 1232 12 months Brief System Inventory To identify in-hospital Prospective Acute psychological High participant 34% of burn symptoms of burn patients n = 790 6 months longitudinal distress during dropout; preburn patients had (BSI) measures severity of n = 645 12months that may be predictive of multisite hospitalization be used characteristics not psychological distress over significant inn = 433 24 months the previous 7 days long-term psychological cohort measured; preburn and as a marker for poor hospital M/F 980/252 mean Global Severity Index distress overall functional postburn distress. TBSA 18Æ7% (SD outcome postburn psychological distress ‘Alienation’ (GSI) – is BSI’s most injuries measurements and ‘Anxiety’ sensitive index of 6%) different seemed psychological distress particularly predictive of long-term distress

Methods

Thombs et al. (2008)

Sample and study population

Design

Reference

Aim/objectives Question

Table 2 Summary of included studies

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Methods

Major findings

Limits of study/rigour

Significance to issue/ problem/question

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Fauerbach et al. (2005)

Wikehult et al. (2005)

Prospective crosssectional

n = 55 M/F 41/14; To investigate emotional mean age 37 (SD distress and psychosocial resources of burn patients 12Æ1); mean TBSA immediately after injury 22Æ2% (SD 17Æ8) as well as during followup care

Small sample size, self- Illustrated importance Symptom checklist (SCL-K- Demonstrated of routinely screening report subject to bias, significantly 9); Post-traumatic Stress for psychological females higher Disorder Symptom Scale distress to deter future underrepresented, emotional (PSS); HADS; Social onset of debilitating detracts from distress levels Support Questionnaire; psychological issues generalizability of Freiburg Questionnaire of among patients when compared results. Use of valid Coping with Illness; Life and reliable assessment with general Orientation Test (LOT), measures adds to the General Self-Efficacy Scale population. (GSE); Subjective Physical Demonstrated a rigour of the study positive Pain relationship between social support and optimistic selfbeliefs Retrospective To evaluate which factors n = 69 M/F 53/16; Data does not allow for Correlated personality Burn Specific Health Scale Routine mean age at are associated with use of crosstype to outcome assessment of whether screening of (Brief) (BSHS-B); Swedish interview healthcare a long time sectional routine screening personality Universities Scale of 45Æ4 years (SD after severe burn injury would increase quality traits as a Personality (SSP) of care for patients. supplement to 15Æ7); mean time long-term care lapsed 8Æ2 years (SD may help 4Æ7); mean TBSA identify the 30% (SD 18Æ3) patient’s need for care. n = 162 M/F Size of burn does not Prospective Examine influence of Size of burn does Self-report measures, Brief Symptom Inventory; 115:47; mean age necessarily dictate longitudinal baseline physical and subject to response not necessarily Short Form 36 Health 40Æ6 (SD 15Æ0); outcome. psychological burden on biases 12 month dictate Survey: QOL/health serial assessments of follow-up, what effects Multifactorial aspects outcome. mean TBSA 18Æ4% status; Injury Variables; of illness determine health-related QOL persist past this point Cognitive and Limitations in ROM; (SD 15Æ6) outcome (cognitive, among adults with major affective factors Study design adds to Demographics, Medical affective factors, e.g. burns. Examine degree of strength of evidence. may interact and Psychiatric self-perception of impairment and rate of Use of valid and with objective comorbidities injury) recovery among adults reliable assessment aspects of experiencing major burn measures adds to illness to with differing levels of rigour of study worsen the physical and psychological appraisal of burdens physical impairment.

Sample and study population

Wallis et al. (2006)

Aim/objectives Question

Design

Reference

Table 2 (Continued)

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Major findings

Limits of study/rigour

Significance to issue/ problem/question

Lawrence and Fauerbach (2003)

Prospective crosssectional

Self-perception of injury Only study with more Concluded that n = 361 M/F Examine relationship Demographic and social supports has female (52%) than self-acceptance 174:187; mean age Questionnaire; Burn between burn scarring, positive effect on male participants, and social severity and visibility, and 44Æ1 (SD 13Æ6); Characteristics adjustment good representative comfort are body esteem mean TBSA 47Æ7% Questionnaire; Perceived more important sample. Ave TBSA Stigmatization (SD 24Æ9); mean 47%, limits results than burn Questionnaire; Social time since injury generalizability. severity and Comfort Questionnaire; 18 years Surveys were not burn scar location in Interpersonal Support predicting body specific. Only 20% Evaluation list-12Q respondent rate, limits version; Body esteem Scale image generalizability and for Adolescent and Adults outcomes. representation of burn Interventions Importance of population. Large aimed at Appearance, The Short improving body sample size; Ave. time Mood and Feelings since burn 18Æ5 years, esteem of burn Questionnaire-Adult event recall may be survivors Version-Worry about clouded should include Appearance a component to improve the social comfort of survivors n = 158 M/F Prospective Investigate relationship Premorbid Davidson Trauma Scale (at Best predictor of Limited sample size at 118:40; mean longitudinal between factors psychopathology is 6 months; attrition PTSD 1/12 and 6/12); NEO TBSA 15Æ7% (SD hypothesized to influence rate at 6 months 40%, predictive of greater symptoms at 1 Five-Factor Inventory trauma survivor’s ability postmorbid but comparable to and 6 months (NEO-FFI) five factor 16Æ4) to emotionally resist or other literature; Use of maladjustment was PTSD personality model, Brief recover from effects of valid and reliable symptoms at COPE; Interpersonal trauma. assessment measures hospitalization Support Evaluation List adds to study rigour (ISEL); Chronic Stress Scale (CSS), Stanford Acute Stress Reaction Questionnaire (SASQR)

Sample and study population

Lawrence et al. (2004)

Aim/objectives Question

Design

Reference

Table 2 (Continued)

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Methods

Major findings

Limits of study/rigour

Significance to issue/ problem/question

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Fauerbach et al. (2002)

Dissertation crosssectional prospective

Causal ambiguities and Personality traits and Paper I and II: Burn Specific Health Scale Affirmed a Acquire more knowledge coping strategies affect possible respondent positive n = 248 M/F (BSHS-A and BSHS-R), about long-term health adjustment. Strong bias due to time lapse 199:49; mean age Swedish Scales Personality association status and influencing social support can help since injury. Perceived between 36Æ8 years (SD (SSP), Coping with Burns factors eg personality the patient to health status assessed neuroticismQuestionnaire (CBQ) traits and coping strategies 16Æ1); mean TBSA reintegrate on average 2 years related of patients with severe 23Æ1% (SD 16Æ2) prior to assessment of personality burn injury. Paper III: personality and traits and n = 166 M/F coping, inconsistency psychosocial 132:34; mean age in data collection and physical 38Æ3 years (SD methods Statistical adjustment 14Æ1); TBSA 24Æ6% methods, use of valid after injury (SD 16Æ3) and reliable assessment Paper IV: measures- adds to n = 162M/F study rigour 127:35; mean age 38Æ4 (SD 14Æ2); mean TBSA 24Æ0 (SD 16Æ0) n = 78 M/F (60:18); COPE; satisfaction with Prospective Examine relationship Visibility of burn does Showed variables Relatively small % mean age longitudinal among burn scarring, not predict outcome, TBSA, but majority of appearance (SWAP) did not have severity and visibility, and 41Æ46 years (SD rather social supports burns were to hands strong body esteem and emotional and face, i.e. relationship 13Æ4); mean TBSA adjustment significant level of with social and 15Æ19% (SD 13Æ0) (personality and damage Coping emotional coping patterns) methods only assessed adjustment at baseline variables. Evidence suggests that social skills training can help overcome difficulties in social encounters. Demonstrated the role of coping method in adjustment

Sample and study population

Kildal (2003)

Aim/objectives Question

Design

Reference

Table 2 (Continued)

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Major findings

Limits of study/rigour

Significance to issue/ problem/question

Patterson et al. (2000)

Examine prevalence of pre- n = 770 M/F Prospective 622:148 mean age existing and burn-related longitudinal 36Æ48 years (SD impairments. Describe multi-centre their association with 11Æ8) preburn employment status

Develop, document Large study, prePreinjury Alcohol and Drug CAGE interventions aimed at existing impairments unemployment Questionnaire Scales; reducing burn-related may not be correlated with blood and urine representative of burns complications, their greater preburn toxicology; Brief population as a whole, impact on impairment, Symptom Inventory (BSI), impairments, and obstacles they i.e. ETOH/drug cross-site anomalies Functional Independence relating to detection of place in the way of abuse, Measure (FIM), Injury work, school and pre-existing psychiatric Variables, Limitations in community integration impairments. Use of history and is ROM, Medical and valid and reliable Psychiatric Comorbidities; significant assessment measures determinant of Moberg Hand Function adds to study rigour postinjury Test, Disability vocational Compensation outcomes Longitudinal Examine how distress and n = 295 M/F Satisfaction with Life Scale Findings suggest Larger study Rigour of Physical and 241:54; mean age multi-centre satisfaction with life psychological variables psychosocial the dynamic (SWLS); BSI: on 40Æ03 years (SD among burn survivors interact to influence predictors used were interplay discharge, 6/12 follow-up compares with the general 13Æ00); mean TBSA adjustment and quality not strong. Sample between population. Test whether of life predominantly male biological and 18Æ09% (SD 15Æ91); psychological or medical with TBSA 18%, social factors and physical factors are cannot be generalized need better predictors of consideration in to larger burns or adjustment for burn females estimation of survivors impact of burn injury on distress and life satisfaction

Sample and study population

Fauerbach et al. (2001)

Aim/objectives Question

Design

Reference

Table 2 (Continued)

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Gilboa et al. (1999)

Elicit information on type n = 71 M/F 52:19; Prospective mean age of injury experienced and crosslevel of psychological help 37Æ8 years (SD sectional required by burn injured multi-centre 17Æ3) adults. Obtain insight into factors which may predict such a need and types of interventions requested of a psychological service. Retrospective Examine why different burn n = 61 M/F 61:0; mean age patients cope differently crosswith burn trauma. Aim to 32Æ4 years (SD sectional develop screening method 11Æ3); mean TBSA to identify patients at risk 30% for poor adjustment. Tailor interventions according to patients preexisting personality traits

Kleve and Robinson (1999)

n = 86 M/F 67:19; mean age 42Æ39 years (SD 14Æ6); mean TBSA 17Æ02%

Retrospective Examine influence of PTD/ mild PTSD on QOL crossfollowing severe burn sectional injury multi-centre

Sample and study population

Fauerbach et al. (1999)

Aim/objectives Question

Design

Reference

Table 2 (Continued) Major findings

Limits of study/rigour

Significance to issue/ problem/question

Male only sample, small Healthcare providers Personality SWLS; General Health size sample use of self- should access specific factors mediate Questionnaire, Symptoms traits that enhance report questionnaires adjustment. Checklist 90-Revised patients’ relationship Patients scoring skew findings; results (contains 90 items) with their generalizable; need to high on environment, their replicate study to personality expectations of determine whether traits of positive outcomes, and findings applicable to extroversion their efforts at selfother traumatic events optimism, selfmastery mastery and hope demonstrated better adjustment to coping and rehabilitation

Personality traits may Relies on self-report, PTSD Davidson Trauma Scale contribute to symptom subject to response significantly (DTS), Beck Depression reports of biases. Small sample related to Inventory (BDI), psychopathology (e.g. size, attrition 16% impairments in Satisfaction with sample over follow-up. PTSD) physical and Appearance Scale Use of valid and psycho-social (SAWP), Life Orientation reliable assessment Test (LOT), SF-36 Health adjustment of instruments may Survey (measure of quality adults with negate some severe burns of life) limitations and lend regardless of credence to results pre trauma adjustment level Time does not Questionnaires Results indicate Participants given questionnaires, but did necessarily alleviate administered not specified no correlation the distress not specify which between time experienced since injury and ones. Self-report therefore subject to degree of bias emotional difficulty experienced

Methods

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Prospective Examine the relative longitudinal risk of developing PTSD in patients with a history of preburn anxiety disorder, or affective disorder, compared with those with no preburn history

Fauerbach et al. (1997)

Methods

Major findings

Limits of study/rigour

Significance to issue/ problem/question

n = 45 M/F 33:12, mean age 38Æ5 years (SD 11Æ9)

Structured clinical interview for DSM-IIIR; HADS; IES;, Penn Inventory (PENN): measures symptoms of PTSD

Small sample size; use of Identifying those at risk Early use of difficult due to valid and reliable acceptance complex and dynamic assessment measures coping is nature of injury and adds to study rigour protective factor psychosocial sequelae. in preventing Teaching patients to future anxiety respond in a nonand PTSD, helpless way could be positive outlook useful on future soon after injury may protect against subsequent depression and PTSD n = 95 M/F 76:19; Targeting psychosocial High attrition rate Results support Structured clinical mean age services to patients (50%) at follow-up findings of interview for DSM-IIIR; 35Æ05 years (SD interview. Use of valid with this demonstrated previous studies. BDI; NEO Personality and reliable assessment preburn vulnerability 11Æ74); mean TBSA Inventory, Quality of Life Specifically that measures adds to study may offset the negative aspects of 20Æ74% (SD 18Æ23) (Burn Specific Health impact affective, alcohol, rigour of the study. Scale), Psychopathology and substance use Generalizability to (SCID-NP) other samples limited may increase risk of burn injury. There is an increased risk of postburn psychiatric disorder in those with a preburn psychiatric disorder

Sample and study population

TBSA, total body surface area; BMS, burn model systems; PTSD, post-traumatic stress disorder; ASD, acute stress disorder; BSI, Brief Symptom Inventory; ROM, range of motion; GSI, Global Severity Index (of the BSI); OR, odds ratio; RCI, Reliable Change Index; SD , standard deviation; CI, confidence interval; ETOH, ethanol (i.e. alcohol); NEO, NeuroticismExtroversion-Openness; DSM-IIIR, Diagnostic and Statistical Manual of Mental Disorders 3rd edition revision; BSHS-A, Burn Specific Health Scale – Abbreviated; BSHS-R, Burn Specific Health Scale – Revised; CAGE, cut-annoyed-guilty-eye acronym; SWLS, satisfaction with life questionnaire; SCID-NP, non-patient version of the Structured Clinical Interview for DSMIII-R; BDI, Beck Depression Inventory; HADS, Hospital Anxiety and Depression Scale; IES, Impact of Event Scale; ROM, Range of movement: COPE, questionnaire for coping strategies; M/F, Male/Female; SCL-K9, symptom checklist 9 item scale.

Assess affects of Prospective non-psychological longitudinal and psychological cohort factors on their subsequent mental health

Tedstone et al. (1998)

Aim/objectives Question

Design

Reference

Table 2 (Continued)

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Fauerbach et al. (2005) investigated the relationship between pre-existing psychological and social issues and postburn outcome in a prospective, longitudinal study of patients (n = 162). They examined the degree of impairment and rate of recovery among individuals who experienced a major burn injury with differing levels of physical and psychological burden. Interventions to reduce in-hospital distress and psychological well-being were found to be as efficacious as surgical intervention (Fauerbach et al. 2005). Two structural components of in-hospital distress, alienation and anxiety, were identified by burn patients (n = 1232) as predictive of long-term distress (Fauerbach et al. 2007). Similarly, Edwards et al.’s (2007) research established a prospective link between emotional symptoms (anxiety and depression) and pain-related outcomes following burn injury. Their 2-year cohort study (n = 526) showed that anxiety (but not depression) predicted elevation in fatigue, while depression (but not anxiety) predicted greater pain sensation and reduced physical functioning. A cyclic effect ensued, because severe pain and fatigue then predicted increased anxiety and depression. These researchers suggested that treating emotional and physical symptoms concurrently may improve the broad range of long-term outcomes following burn injury (Edwards et al. 2007). Another study, aimed at identifying psychological morbidity among inpatients (n = 72) in a burns unit (Wisely et al. 2007), showed that 35% of the patients had pre-existing mental health disorders. The study also revealed that 63% of patients required some form of ongoing psychological care to assist with anxiety, depression, as well as requiring basic supportive counselling (Wisely et al. 2007). What was highlighted in the present review was the importance of early psychological intervention to recognize and treat pre-existing impairments that can complicate longterm adjustment. This was despite small sample sizes in 15 of the 16 studies reviewed and an under-representation of females.

Vocational status prior to burn injury The literature also shows a relationship between pre-existing impairments and preburn employment status. One study showed that those (n = 95) with a complex psychiatric history were more likely to be unemployed at the time of injury than those without such a history (Fauerbach et al. 1997). A large (n = 770), prospective, longitudinal, multi-centre study examining the prevalence of pre-existing and burnrelated impairments and their association with preburn employment status was carried out by Fauerbach et al. (2001). This supported previous findings (Fauerbach et al.  2009 Blackwell Publishing Ltd

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1997, Patterson et al. 2000), that being unemployed at the time of injury, coupled with pre-existing factors such as alcohol dependence, illegal substance use and/or irrespective of psychiatric treatment in the previous year, was associated with poorer psychological outcomes postburn injury. The researchers suggested that pre-existing impairments were barriers to employment, noting the compounding effects of burn-related impairments on adjustment (Fauerbach et al. 2001). In case of self-inflicted burn injuries, employment status prior to hospital admission was a predictor (Baker et al. 2007). Of the burn patients (n = 1239) admitted to hospital over a six-year period, 44 (3Æ5%) sustained self-inflicted burns. About half of these self-inflicted burn patients (47Æ7%) were unemployed at the time of hospital admission, compared with 5Æ3% of the general burn patient group. These studies highlight the need for early identification of impairments and the importance of vocational rehabilitation as part of standard of care to address the barriers to employment experienced by many burn patients (Fauerbach et al. 2001).

Personality and coping style Much of the reviewed literature focussed on the relationship between personality type and coping strategies, and adjustment following burn injury. A common theme was that individuals with specific personality traits experienced greater adjustment difficulties. Neuroticism, the main trait identified, is characterized by pessimism, negative affect and introversion, and the use of avoidance coping strategies. A retrospective study of male burn patients (n = 61) identified the need for healthcare providers to assess for specific personality traits that may predispose to dysfunctional coping and maladjustment (Gilboa et al. 1999). Denial as a coping style was identified by Elijah et al. (2008) as used more by women without readily identifiable social support, and it possibly contributed to their delay in seeking medical attention for burn injuries. Proactive action to address these issues, such as social skills training and goal-setting, could equip patients with tools to cope with the crisis of burn injury. Gilboa et al. (1999) found that individuals displaying optimism, extroversion, belief in their ability to influence the outcome (termed ‘self-mastery’ in the study) and a sense of hope, adjusted better over time. Conversely, those showing neurotic and introverted personality traits displayed greater adjustment difficulties (Gilboa et al. 1999) and were predisposed to post-traumatic stress disorder (PTSD) following burn injury (Fauerbach et al. 1997). Despite the relatively small samples in these studies, the findings were replicated in larger, more recent studies (Fauerbach et al. 2000, Kildal 2285

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2003, Lawrence & Fauerbach 2003, Noronha & Faust 2006). These studies supported the correlation between neuroticism-related personality traits and psychosocial and physical maladjustment after injury, including symptoms of PTSD. Furthermore, certain personality traits can have an impact on physical and psychological recovery after a traumatic event.

Efficacy of support networks Until recently, physical symptoms were considered the primary determinants of psychological outcome. A large multi-centre study by Patterson et al. (2000), however, demonstrated an interaction between physical, psychological and social factors and the effect on adjustment and quality of life. In isolation, these factors have limited predictive application. However, the pervasiveness of burn injury for the individual, and the interplay between the body and psyche post-trauma, support the complex biosocial models of recovery in which outcome correlates with the summation of these factors (Patterson et al. 2000). Moreover, the positive effects of a stable social relationship correlate with better adjustment after burn injury (Patterson et al. 2000, Kildal 2003, Wallis et al. 2006). These findings suggest that the biosocial interventions in which physical and psychological variables interact to influence adjustment and quality of life (Patterson et al. 2000). Wallis et al. (2006) suggested that variables such as personality traits, coping style and perceived social support could influence the process of psychological and psychosocial adjustment following burn injury. This extrapolation from their findings is supported in other studies linking a stable, supportive social network (and being employed at the time of burn injury) with better outcome (Costa et al. 2008, Elijah et al.2008). This suggests that the quality of the relationship generates positive experiences for a burn survivor, increasing self-esteem and the confidence to approach social situations with strangers (Kildal 2003, Noronha & Faust 2006). Multiple social resources and networks, acceptance by family and friends and reciprocity can influence time of hospital admission, improved recovery outcomes and earlier discharge from hospital following burn injury, according to Elijah et al. (2008). The study of male and female burn patients (n = 290) suggested that women who sustained burn injuries were less likely to work outside the home, less likely to be partnered, less likely to live in single family housing and more likely to have children at home. The authors speculated that women who sustain burns are more likely to live in stressful situation than are men with similar burn injuries. They found that discharge planning 2286

that includes the patient’s disposition could improve the process of recovery.

Burn characteristics Until recently, the severity of a person’s disfigurement was thought to influence the extent to which they adapted, although little evidence to support this notion was available (Kleve & Robinson 1999). In Blumfield and Reddish (1987, p. 142) coined the term ‘small burn, big problem’, to signify that preinjury factors may have a greater impact on the person’s psychological adjustment than the extent or location of the injury. A number of empirical studies have demonstrated that compounding psychological problems can follow relatively minor burn injury (Kleve & Robinson 1999, Patterson et al. 2000, Wallis et al. 2006). A few studies provide firm support for this concept. One prospective, longitudinal study (n = 162) identified no statistically significant association between physical burden, defined by TBSA, and the extent of psychosocial dysfunction (Fauerbach et al. 2005). Consistent with these findings, Fauerbach et al. (2002) and Wallis et al. (2006) demonstrated no statistically significant relationship between severity of injury and degree of psychological distress. In contrast, Noronha and Faust (2006) found that the location and visibility of scarring correlated most strongly with psychological adjustment. However, they cautioned that the result might be positively skewed because of the association with decreased functionality and pain. Thombs et al. (2008)study focussed on body image dissatisfaction in burn patients (n = 79) in the 12 months following the burn injury. Their results concur with those of Noronha and Faust, because they strongly indicate that the extent of burn injury, female gender and subjective importance of appearance are risk factors for developing body image dissatisfaction after burn injury. The finding of a strong correlation between the burn injury variable (burn severity) and psychological adjustment by Noronha and Faust (2006) and Thombs et al. (2008) contradicts previous reports (Kleve & Robinson 1999, Fauerbach et al. 2002, Lawrence et al. 2004, Wallis et al. 2006). A strong association may therefore be an artefact of grouping several burn injury-related variables in one impact variable category. Kildal (2003) attributed some of the inconsistencies concerning burn severity and degree of adjustment to variations in reporting measures. Thus, the importance of using more comprehensive and specific burn severity measures is important to gain a more accurate and detailed understanding of the link between burn severity and level of adaptation.  2009 Blackwell Publishing Ltd

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Gender Society values beauty, and those bearing visible scars are frequently socially stigmatized and marginalized or undervalued (Newell 2000, Gilboa 2001, Lawrence et al. 2004). Whilst the literature supports the notion that premorbid factors have a greater influence on postburn psychological adjustment than does the extent or location of the injury (Gilboa 2001, Fauerbach et al. 2002), there is evidence that extent or location of injury may nevertheless be important. Studies by Fauerbach et al. (1999), Kleve and Robinson (1999), Kildal (2003) and Thombs et al. (2008) suggest that, depending upon the location and visibility of the scarring, females suffered greater and more prolonged psychological maladjustment related to altered body image and sexual

dysfunction than their male counterparts. A deviation from the accepted ‘norm’ through burn injury can initiate psychological complications for those at risk because of factors such as poor coping skills, poor family support and low selfesteem (Newell 2000, Elijah et al. 2008). This in turn, may lead to increased anxiety and avoidance behaviour, culminating in ‘social death’ as the individual withdraws entirely from society (Gilboa 2001). In contrast, the only study reviewed where more than half the participants (n = 341) were female (52%) showed that burn characteristics were less important determinants of body esteem than social and emotional variables (Lawrence et al. 2004). The researchers concluded that self-acceptance and social comfort are more important than burn severity and scar location in predicting body image outcomes (Lawrence

Psychological assessment of burn patients (Refer to Table 3 for appropriate assessment tool/s)

Identification of risk factors – Premorbid psychopathology – Affective mood disorder – Alcohol/drug dependence – Unemployment – Female gender

No

Follow routine in–patient Intervention protocol

Yes

Provision and revision of appropriate interventions

Psychiatric – Pharmacotherapy – Specialised mental health or addictive services Ongoing routine outpatient psychological assessment, support, counselling; If onset of symptoms of PTSD, anxiety, &/or depression develop

Behavioural – Cognitive behavioural treatment – Coping strategies – Pain & stress management – Reduce PTSD/BID

Social – Social skills training – Work hardening

Figure 1 Proposed model of care: physical assessment after burn injury (PTSD, post-traumatic stress disorder; BID, burns injury distress).  2009 Blackwell Publishing Ltd

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et al. 2004). These results contradict those in other studies that female gender, in particular, predisposes to greater body image dissatisfaction and associated sexual dysfunction, lower self-esteem and heightened anxiety (Fauerbach et al. 1999, Kleve & Robinson 1999, Kildal 2003, Thombs et al. 2008). This discrepancy may be attributed to the length of time between initial injury and data collection (an average of 18 years) in Lawrence et al.’s (2004) study. Whilst some empirical studies (Fauerbach et al. 1999, Kleve & Robinson 1999, Kildal 2003) demonstrated a strong correlation between female gender and poorer psychological outcomes related to body image dissatisfaction and sexual dysfunction, further investigation of the effect of visibility and location of scarring on adjustment is required. The disparity in the literature highlights the complexity and heterogeneity of burn patients as a group, and the difficulty of predicting adjustment outcomes in this population.

Discussion The literature overall was limited, and this requires comment in several ways. First, there were small sample sizes and underrepresentation of females. In addition, lack of information about those who declined to participate, and the high attrition rate of participants, raises questions about response bias and generalizability of the findings to the broader burn population. The potential generalizability of the evidence is also limited by the focus mainly on developed countries, while the incidence and prevalence of burn injury is high in lower socioeconomic countries, where it may be challenging to implement the proposed care pathway. Notwithstanding these limitations, a number of conclusions can be drawn about the variables that influence psychological adjustment postburn injury. The review highlighted that heterogeneity and comorbidity are key characteristics of this patient group, and that this diversity offers unique challenges for nurses. Furthermore, the diverse reactions to injury and compounding psychological problems that affect adjustment make it difficult to predict how an individual will react (Wallis et al. 2006). Proactive and comprehensive models that ‘incorporate person, injury and treatment variables’ (Patterson et al. 2000, p. 496) are important to consider in the care of burn patients. The need for a tiered approach to treatment, with a spectrum of care and psychological skill to address the disparate needs of each patient (Wisely et al. 2007), is reinforced by this review. To facilitate this process, patients can be categorized based on predetermined risk factors, and an appropriate level of care initiated. Whilst the presence of pre-existing psychopathology, mood disorder or a history of alcohol and/or drug dependence places individuals at high 2288

risk following burn injury, being unemployed or female are also risk factors and signal the need for preventive and supportive intervention. At the same time, ‘normalizing’ trauma symptoms and the psychological reactions to injury must be emphasized to avoid attaching stigma to psychological intervention (Colling 2004, Wisely et al. 2007).

Table 3 Psychological assessment tools collated from the studies in this review Psychological assessment tools Acute Stress Reaction Questionnaire (SASQR) Alcohol and Drug CAGE Questionnaire Scales Beck Depression Inventory (BDI) Body Esteem Scale for Adolescent and Adults Importance of Appearance Brief Symptom Inventory Burn Characteristics Questionnaire Burns Psychology Assessment Tool (BPAT) Burn Specific Health Scale (Brief) (BSHS-B) Burn Specific Health Scale (BSHS-A and BSHS-R) Coping with Burns Questionnaire (CBQ) Chronic Stress Scale (CSS) COPE and Brief COPE Davidson Trauma Scale (DTS) Freiburg Questionnaire of Coping with Illness Functional Independence Measure (FIM) General Self-Efficacy Scale (GSE) General Health Questionnaire Symptoms Checklist 90-R Hospital Anxiety and Depression Scale (HADS) Impact of event scale (IES) Interpersonal Support Evaluation List (ISEL) Interpersonal Support Evaluation List-12Q version Life Orientation Test (LOT) Multidimensional Body-Self Relations Questionnaire (MBSRQ-IA) NEO Personality Inventory NEO Five-Factor Inventory (NEO-FFI) model Penn Inventory (PENN) (measures symptoms of PTSD) Perceived Stigmatization Questionnaire Post-traumatic Stress Disorder Symptom Scale (PSS); Psychopathology (SCID-NP) Quality of life (Burn Specific Health Scale) Satisfaction with appearance (SWAP) Satisfaction with Life Scale (SWLS) Short Form 36 Health Survey (SF-36) – measure of quality of life Stanford Life Orientation Test (LOT) Social Comfort Questionnaire Social Support Questionnaire Structured clinical interview for DSM-IIIR Swedish Universities Scale of Personality (SSP) PTSD, post-traumatic stress disorder; NEO, neuroticism–extroversion–openness; DSM-IIIR, Diagnostic and Statistical Manual of Mental Disorders 3rd edition revision; BSHS-A, Burn Specific Health Scale – abbreviated; BSHS-R, Burn-Specific Health Scale – Revised; CAGE, cut-annoyed-guilty-eye acronym; SCID-NP, Structured clinical interview for diagnostic and statistical manual of mental disorders - non-patient edition.  2009 Blackwell Publishing Ltd

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What is already known about this topic • Preburn personality and coping strategies can influence long-term psychological adjustment. • Heterogeneity and comorbid conditions are key characteristics of this patient group, and pose unique challenges for nurses.

What this paper adds • The complex factors that influence postburn psychological adjustment are not confounding, nor are they contradictory; rather they are just not fully known and are consequently poorly understood. • The diverse reactions to injury and the psychological problems that affect adjustment make it difficult to predict how an individual will respond.

Implications for practice and/or policy • The first step is to recognize the challenges posed by the diversity and complexity of this group and then offer tailored interventions and treatment. • A multidisciplinary, tiered approach to treatment potentially offers a spectrum of care and psychological skill to address each patient’s needs optimally. Treatment programmes should also be proactive and preventive, and this can be achieved by targeting specific risk factors to activate and strengthen resources relevant to the desired outcome (Wallis et al. 2006). The following recommendations are presented diagrammatically in a proposed model of care in Figure 1. First, routine preassessment and psychological screening should be an element of care for every patient, and should include screening of personality traits and level of psychological distress at initial consultation. Assessment tools collated from the studies in this review are listed in Table 3. This will facilitate early identification of patients ‘at risk’ and initiation of specialized early intervention, such as inpatient psychiatric care, and/or behavioural or social interventions. Those identified as at high risk should receive specialized care to treat the co-morbidities that are likely to amplify the normal psychological responses to burn injury. The level of intervention should be based on the perceived or identified needs of the patient. The structure of the model, with its ongoing counselling and support, will facilitate healthcare professionals to recognize when a patient requires a higher tier of support and intervention to address more complex needs.  2009 Blackwell Publishing Ltd

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Setting-specific goals of rehabilitation should be undertaken collaboratively by the patient, their support network and the case manager (Cohen & Cesta 2005). The role of the case manager is to guide the rehabilitation process, to ensure that the patient has realistic expectations of treatment, and to facilitate the transition from acute care to home (Cohen & Cesta 2005). If psychological symptoms are identified early, understood in the context of the experience, and managed effectively, they are unlikely to become chronic and incapacitating (Rusch 1998, Herndon 2007). Nurses can assist with the rehabilitation process by promoting and encouraging social reintegration and the resumption of preburn activities with minimal disruption, and by implementing appropriate supportive measures.

Conclusion The model of delivering psychological care proposed in this paper requires evaluation for validity and economic viability. Timely recognition, knowledge and management of risk factors for psychological maladjustment are crucial in the management of the burn patients. These factors remain a cornerstone of care during the acute phase of treatment to ensure patients progress to full physical recovery and positive long-term psychosocial adjustment.

Acknowledgement Kerry Klinge would like to acknowledge the support of the Flinders University Scholarships Office during the completion of this paper.

Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest No conflict of interest has been declared by the authors.

Author contributions KK, DC and LK were responsible for the study conception and design; performed the data analysis. KK and MR performed the data collection. KK and DC were responsible for the drafting of the manuscript. DC and MR made critical revisions to the paper for important intellectual content; provided administrative, technical or material support. DC 2289

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and LK supervised the study. LK provided other contributions.

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