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Nonpharmacologic adjuncts should be included in the management of burn pain
•
Self-management behaviors have been shown to impact pain outcomes
•
Self-efficacy may be able to be enhanced in the acute care setting
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Burn nurses report greater use of nonpharmacologic adjuncts with a protocol
•
Self-efficacy may increase during prolonged hospitalization
Abstract
Background
Acute burn pain is difficult to manage, and poorly managed pain can lead to deleterious consequences such as post-traumatic stress disorder, prolonged recovery, chronic pain and long-term dependence on opioids. Understanding the role of nursing in promoting self-efficacy and minimizing opioid use is valuable. It is unknown whether strategic efforts aimed at enhancing patient self-efficacy will improve pain managment and lessen opioid requirements in the adult burn population.
Aim
The aim of this study was to examine the effect of a multi-modal, interdisciplinary pain management strategy on coping self-efficacy, pain scores, and opioid use in adult burn patients in the acute care setting.
Method
A quasi-experimental pre-test/post-test design was employed in an American Burn Association (ABA) verified burn center in the Pacific Northwestern United States. Data were collected prospectively for a 6-month period on 44 burn patients. The comparison group received usual care (n = 28), and the intervention received a pain management protocol (n = 16). Coping self-efficacy was measured on admission and at discharge in both groups using the Coping Self-Efficacy Scale. Numeric pain scores and opioid use in morphine milligram equivalents were averaged for each participant. Burn nurse perceptions were gathered via an anonymous electronic survey post data collection in February 2021.
Results
There were no significant differences in measured coping self-efficacy, pain scores, or opioid use between the intervention and comparison groups. A significant positive correlation was found between length of stay, size of burn, and coping self-efficacy and problem focused self-efficacy. Burn nurses reported increased use of nonpharmacologic adjuncts since protocol implementation.
Conclusion
Nonpharmacologic adjuncts are more likely to be used consistently when protocolized. There is also evidence to support that certain aspects of self-efficacy may be enhanced during acute phase of burn care.
Pain resulting from burn injury has proven to be one of the most challenging issues affecting the safe care of burn patients, and there is wide consensus on the risk of morbidities related to under controlled pain or over-prescribed opioid therapy (
American Burn Association guidelines on the management of acute pain in the adult burn patient: A review of the literature, a compilation of expert opinion, and next steps.
Journal of Burn Care & Research.2020; 41: 1129-1151
). Burn care includes serial bedside debridement and dressing changes, surgical excisions and grafting, and challenging sessions with physical and occupational therapy, all of which may evoke anticipatory pain (
American Burn Association guidelines on the management of acute pain in the adult burn patient: A review of the literature, a compilation of expert opinion, and next steps.
Journal of Burn Care & Research.2020; 41: 1129-1151
Efficacy of non-pharmacological interventions for procedural pain relief in adults undergoing burn wound care: A systematic review and meta-analysis of randomized controlled trials.
). Despite the efficacy of opioids in treating acute pain, patients with burn injury are at high risk for adverse effects such as constipation, delayed wound healing, itching, respiratory depression, opioid induced hyperalgesia, opioid tolerance, dependence, addiction, and death related to overdose (
American Burn Association guidelines on the management of acute pain in the adult burn patient: A review of the literature, a compilation of expert opinion, and next steps.
Journal of Burn Care & Research.2020; 41: 1129-1151
Efficacy of non-pharmacological interventions for procedural pain relief in adults undergoing burn wound care: A systematic review and meta-analysis of randomized controlled trials.
discovered a doubling in morphine milligram equivalents (MME) at discharge over a 7-year period at one Midwest Region burn center. This increase in opioid prescriptions, in the setting of a nation-wide opioid crisis, is argued as evidence supporting the need for protocoled approaches to pain management (
American Burn Association guidelines on the management of acute pain in the adult burn patient: A review of the literature, a compilation of expert opinion, and next steps.
Journal of Burn Care & Research.2020; 41: 1129-1151
It is standard practice to incorporate multimodal strategies which include opioids, non-opioids, and nonpharmacologic approaches, in the care of serious burn injuries. In our burn center, as in others, non-opioid pain management may include acetaminophen, non-steroidal anti-inflammatories, gabapentinoids, antidepressants, propranolol, clonidine, dexmedetomidine, nitrous oxide, neuraxial anesthesia, and ketamine. (
American Burn Association guidelines on the management of acute pain in the adult burn patient: A review of the literature, a compilation of expert opinion, and next steps.
Journal of Burn Care & Research.2020; 41: 1129-1151
). Relaxation and distraction techniques such as music, hypnosis, and virtual reality have been found to be especially useful adjuncts to pharmacologic pain relief (
Efficacy of non-pharmacological interventions for procedural pain relief in adults undergoing burn wound care: A systematic review and meta-analysis of randomized controlled trials.
), and were offered to patients at our center. However, despite wide-spread recognition of the necessity to include such interventions in a pain management program (
American Burn Association guidelines on the management of acute pain in the adult burn patient: A review of the literature, a compilation of expert opinion, and next steps.
Journal of Burn Care & Research.2020; 41: 1129-1151
Efficacy of non-pharmacological interventions for procedural pain relief in adults undergoing burn wound care: A systematic review and meta-analysis of randomized controlled trials.
), our operationalization of nonpharmacologic modalities was limited and inconsistent
The purpose of this study was to examine the effectiveness of an evidence-based pain management protocol, focused on the consistent offering of nonpharmacologic therapies, on affecting the mediating effects of patient self-efficacy on pain scores and opioid use in adult burn patients. By nature of injury, individuals with burn injuries are uniquely vulnerable to the devastating consequences of long, painful recovery and, often, long-term disability, disfigurement and associated pathologies (
). Evidence derived from this study has the potential to guide future practice within the greater burn clinician community to lessen deleterious sequela and optimize burn recovery.
Literature Review
Self-efficacy is defined by Albert Bandura as “the conviction that one can successfully execute the behavior required to produce the [desired] outcomes”. Bandura postulates a person's perceived self-efficacy can be enhanced through behaviors acted out by a participant, called performance accomplishments (
). High levels of perceived self-efficacy (PSE), a measure of self-report, have been linked to increased resilience. Conversely, low levels of PSE correlate with increased levels of anxiety, depression, and ineffective coping (
Benight, C., Shoji, K., James, L., Waldrep, E., Delahanty, D., & Cieslak, R. (2015). Trauma coping self-efficacy: A context specific self-efficacy measure for traumatic stress. Psychological Trauma, 7(6), 591-599.
Self-efficacy is closely related to the concept of self-management, which has been identified by the Institute of Medicine (IOM), the World Health Organization (WHO), and the Robert Wood Johnson Foundation as a crucial area of focus for healthcare providers to ensure best patient outcomes (
). Self-management can be understood as the daily actions and behaviors of patients aimed at managing their disease, role, and emotions. The concept of self-management conveys a sense of agency, on the part of the patient, and deviates from disease-focused, provider-driven medical models to patient-centered care (
). Hallmarks of self-management include problem-solving, decision making, resource utilization, patient-provider partnership, and execution of health-related actions (
). Patient empowerment through self-efficacy enhancing interventions may assist patients to be co-managers in realistic goal setting and symptom management (
). These interventions can be directed toward empowering patients to actively cope with their symptoms through self-management behaviors, which have been shown to enhance self-efficacy (
Does self-efficacy mediate the cross-sectional relationship between perceived quality of health care and self-management of diabetes? Results from Diabetes MILES – Australia.
), and to our knowledge, no studies have examined the relationship between self-efficacy and pain management in people with acute burn injuries.
Nonpharmacologic interventions aimed at treating burn pain, such as hypnosis, virtual reality, gaming, acupuncture, music, and aromatherapy have not been widely studied but do seem to provide varying degrees of relief (
Efficacy of non-pharmacological interventions for procedural pain relief in adults undergoing burn wound care: A systematic review and meta-analysis of randomized controlled trials.
Comparing the effects of aromatherapy massage and inhalation aromatherapy on anxiety and pain in burn patients: A single-blind randomized clinical trial.
, explored the positive effect of expressing vulnerability, connecting with loved ones, and empowerment through self-care on the early stages of burn recovery. Cognitive and behavioral interventions such as guided imagery and relaxation activities have been shown to reduce burn-related pain and anxiety (
). An Iranian study found connection with one's religious faith, and a supportive, trusting relationship with the burn nurse, resulted in a significant reduction in pain during wound care (
). Widely, nurse-led nonpharmacologic interventions to treat pain and other symptoms of acute or chronic illness are often utilized consistently and effectively (
An American Burn Association (ABA)-verified burn center located in the Pacific Northwestern United States conducted informal staff surveys and interviews, followed by a comprehensive literature review, to identify existing strengths and determine potential barriers to effective pain management. Usual care included rational non-opioid and opioid polypharmacy, access to behavioral health support, daily team rounding, and consistent, practical expressions of compassion. The team was less consistent with offering nonpharmacologic intervention, coordinating wound care to minimize open-time, and having direct conversations related to changes in medication management, particularly as it related to opioid tapers. Burn center clinicians identified lack of standardization in pain management strategy and poor patient coping with injury-associated pain and stress to be reflective of gaps in clinical practice amenable to improvement.
Based on the evidence in support of patient empowerment and self-management, we developed a pain management protocol, Pathways to Pain Management (PPM), aimed at: (1) defining a culture of collaboration between clinicians and patients; (2) using consistent language to educate; (3) assisting patients in realistic goal setting; and (4) empowering patients to choose nonpharmacologic interventions.
Design
A quasi-experimental pre-test/post-test design, with a nonequivalent comparison group and an intervention group, was employed to conduct this study with 44 patients from July 1, 2020, to January 31, 2021. This study evaluated the effect of PPM on the outcome variables of self-efficacy, pain, and opioid use, which are known to be negatively affected secondary to burn injury (
), through the research questions: (1) RQ1, Will perceived self-efficacy and secondary outcomes improve in patients receiving a standardized approach to education and pain management (protocol) over those who receive usual care?; (2) RQ2, Will increases in perceived self-efficacy be associated with improvements in pain self-management behaviors, better pain control, and less opioids use?; (3) RQ3, Will burn nurses perceive improvements in overall pain management and utilization of resources with the PPM protocol compared with usual care?
Protocol
For the intervention group, burn center staff (RNs, MDs, certified nursing assistants (CNAs), psychologist, occupational therapists [OTs], physicial therapists [PTs]) practiced and reinforced evidence-based pain management by:
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Targeting the first dressing change as an opportunity to lessen the fear and anxiety associated with traumatic pain
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Supporting a culture of patient empowerment by verbally recognizing the patient as co-manager in their care
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Consistently using correct pain management terminology with patients (background, breakthrough, procedural, post-op, opioid, non-opioid, non-medical, non-pharmacologic, etc.)
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Consistently encouraging and making available the use of nonpharmacologic intervention
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Coordinating dressing changes to limit open wound time
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Endeavoring to be compassionate, transparent, and direct in conversations about pain management with patients
Newly admitted patients were oriented to the PPM protocol within the first 72 hours of admission by burn nurses or the unit psychologist using the two-sided Pain Management Partnership/My Toolbox sheet (Fig. 1, Fig. 2) and patient education video. By design, this orientation was conducted after the first dressing change, due to the traumatic nature of a burn injury and the immediate medical care that follows. Patients were given a chance to acclimate to the burn unit and their broader plan of care, and were then encouraged daily to choose nonpharmacologic adjuncts from the toolbox to help manage their pain.
The partnership/toolbox was designed by the burn center medical director, assistant nurse manager, CNS/DNP student, and clinical psychologist. The partnership was reflective of concepts associated with empowerment and self-management (
). The toolbox incorporated nonpharmacologic interventions that were reasonable to incorporate into the plan of care and found in the literature to be safe and effective.
Interventions such as IVR, self-hypnosis, and music were already being offered, albeit inconsistently. Aromatherapy was new to the burn center and required the development of a separate policy and staff education initiative prior to PPM initiation. Concepts and skills related to guided imagery, breath work, progressive relaxation, meditation, and motivational interviewing were covered in two 1-hour skills day sessions over a 1-year period. A mobile resource cart was built which contained a binder of PPM protocol steps and resources, as well as IVR equipment, suggestions for guided imagery, aromatherapy supplies, and notebooks for patients to use in their positive thinking and meditation practices. A 2-week pilot was conducted, which identified education gaps and inconsistencies in initiating the protocol among staff. This led to the assistant manager, clinical psychologist, and CNS/DNP student to provide one-on-one education and modeling to staff nurses and burn surgeons during day and night shift rounding.
Measures
In addition to demographic data, variables measured included CSE, pain, and opioid use. CSE was measured twice with each participant, at admission and again at discharge, using the Coping Self-Efficacy Scale (CSES), a 26-item patient-report survey quantifying self-confidence in one's ability to execute coping behaviors in the setting of significant health challenges. Specifically, the CSES asks participants to rate on a scale from 0 to 10, “When things aren't going well for you, or when you're having problems, how confident or certain are you that you can do the following:” This is followed by 26 items that describe coping behaviors, such as: “Stop yourself form being upset by unpleasant thoughts,” or “Make a plan of action and following it when confronted with a problem.” The scores on the CSES are summed to create an overall score. Higher scores are reflective of higher levels of perceived self-efficacy, with a scale mean of 137.4 (
). Three sub-scales may be scored using subsets of survey items: problem-focused (PF) coping, social-support (SS) focused coping, and emotion-focused (EF) coping. PF coping reflects self-efficacy in thinking through a problem and reducing larger problems into smaller parts. SS coping represents the ability to reach out to friends and family for help, and EF coping reflects the ability to redirect one's negative thoughts (
Reliability and validity of the CSES was evaluated via two clinical trials evaluating the effects of a coping self-efficacy enhancing intervention on the perceived coping self-efficacy of HIV+ men who have sex with men. Reliability was assessed by Cronbach's alpha (.80-.91) and test-retest analysis (.40-.80). Validity was tested by comparing the CSES to similar validated measures via Pearson's correlation and support the CSES as a measure of coping self-efficacy. Multiple regression analysis was also applied to the CSES to support validity of the tool to predict reduction of stress and increase in mental wellness (
Microsoft Power BI reports were created to mine daily averages of morphine milligram equivalents (MME), methadone dosages, and numeric pain scores based on a 0 to 10 scale, for each participant. Methadone MME conversion is complicated and differs from other opioids, thus total MME scores including methadone were calculated algorithmically in Power BI based on Centers for Disease Control (CDC) suggested conversion factors for opioids and methadone (
). Patient demographics of percentage of total body surface area injured (%TBSA), length of stay (LOS), number of surgeries, pain scores, and opioid use in MMEs were gathered from the electronic medical record (EMR) and recorded on a password-protected Microsoft Excel spreadsheet.
To measure burn nurse experience with the PPM protocol, a researcher-created 4-item survey was electronically administered to burn center nurses at the end of the data collection period. Higher scores reflect higher nurse confidence in the protocol. The survey was not able to be tested for reliability, however it was vetted by experienced burn RNs, a critical care CNS, burn surgeon, and an academic faculty advisor who supported the face validity of this measure.
Sample
Inclusion criteria were patients 18 years and older, English, or Spanish speaking, admitted to the burn center for a burn injury requiring at least two dressings before discharge, who were able to participate in their own care. Exclusion criteria included patients who were disoriented to person, place, or situation due to dementia, psychiatric illness, substance use, or delirium. Patients who were intubated or otherwise unable/unwilling to consent to participation or who were treated for burn wounds on an outpatient basis prior to hospitalization were excluded. Sample size was limited by the census of qualifying patients during an allotted 7-month period. Data from the comparison group (n = 28), which received usual care, were gathered over the first 3 months. Staff were then educated on the PPM protocol followed by a 2-week pilot before data was gathered on the intervention group (n = 16). This study was approved through the Legacy Health institutional review board (IRB) and by the Old Dominion University Institutional Review Board. All participants were recruited according to written informed consent and informed of voluntary participation.
Analysis
Descriptive statistics were used to evaluate demographic data. The research questions were evaluated using inferential statistics. To analyze RQ1, a between-groups comparison utilized the CSES and was analyzed via comparison of means, Mann-Whitney U, and Wilcoxon signed ranks tests with a p value set at .05. A within-group (n = 44) comparison using the Spearman rho and Pearson correlation was utilized to evaluate RQ2 and examine relationships between demographic variables, coping self-efficacy and pain scores, and MMEs. RQ3 was evaluated through descriptive statistics applied to a four-question staff survey delivered via Qualtrics. All statistical testing was run through IBM SPSS 26.
Results
Sample demographics in Table 1 reveal the comparison and intervention groups were largely comprised of white, English-speaking males with burns of less than 15% total surface body area (TBSA). For RQ1, the comparison and intervention groups had very similar mean scores on the admission CSES of 177.62 and 177.5 respectively (Table 2). At discharge, the CSES mean score for the comparison group was 180.57 and 187.69 for the intervention group. Though the protocol group reported higher coping self-efficacy scores at discharge than the comparison group, the difference was not significant (Z = -.659, p = .51). Mean pain scores between the two groups were almost identical at 5.41 and 5.38. We felt it would be helpful to evaluate how the use of methadone inflates the mean daily MME. The MME, without methadone, in the protocol group was slightly lower at 84.2 compared with 88.8 in the usual care group, however this difference is not significant (Z = -.61, p= .542). The addition of methadone increased the daily MME in the protocol group to 117.87, and to 115.98 in the usual care group, however, this difference is also not significant (Z = −.756, p=.449). A Wilcoxon signed ranks test revealed no significant differences in either group between CSES/subscale admission and discharge scores.
Table 1Descriptive Statistics on Study Control and Intervention Groups.
p < .05. CSES = Coping Self-Efficacy Scale; EF = emotion focused coping; MME = morphine milligram equivalents; PF = problem focused coping; SS = social support coping .
CSES total score
Admission
177.60 (15)
177.52 (27)
-.013 (.990)
Discharge
187.69 (13)
180.57 (23)
-.659 (.510)
Wilcoxon signed ranks Z (p)
-.070 (.944)
-.471 (.638)
PF subscale
Admission
41.40 (15)
40.04 (27)
-.763 (.445)
Discharge
44.92 (13)
41.26 (23)
-1.385 (.166)
Wilcoxon signed ranks Z (p)
-.455 (.656)
-1.011 (.312)
SS subscale
Admission
19.87 (15)
21.85 (27)
-.606 (.544)
Discharge
20.46 (13)
22.26 (23)
-.611 (.541)
Wilcoxon signed ranks
Z (p)
-.462 (.644)
-.503 (.615)
EF subscale
Admission
26.60 (15)
26.96 (27)
-.145 (.885)
Discharge
27.31 (13)
27.57 (23)
-.082 (.934)
Wilcoxon signed ranks Z (p)
-.669 (.504)
-.942 (.346)
Pain scores
5.38 (16)
5.41 (28)
-.122 (.903)
MME daily average
84.20 (16)
88.76 (28)
-.610 (.542)
MME w/ methadone daily average
117.87 (16)
115.98 (28)
-.765 (.449)
a mean.
b number of subjects.
c p < .05.CSES = Coping Self-Efficacy Scale; EF = emotion focused coping; MME = morphine milligram equivalents; PF = problem focused coping; SS = social support coping .
The Spearman Rho correlational analysis revealed a significant positive correlation between race and total admit CSES score (rs = .383, p = .012), with non-whites scoring higher. Similarly, non-whites scored higher in the subscale of PF coping at both admit (rs = .384, p = .012) and discharge (rs = .338, p = .044), as well as in SS coping at admit (rs = .352, p = .022) and discharge (rs = .427, p = .009). Irrespective of race, overall CSES (rs = -.387, p = .020) and PF coping (rs = -.334, p = .046) at discharge were weakly inversely correlated with comorbidity requiring medical management. At discharge, positive correlations were noted between PF coping, length of stay (rs = .390, p = .019), and TBSA% (rs = .392, p = .018). The Pearson correlation revealed no significant relationships between groups between CSES total scores, subscale scores, pain scores, or opioid use in the evaluation of RQ2.
Burn nurse perceptions of protocol efficacy were largely favorable as shown in Fig. 3. To survey Question 1, “The Pathways to Pain Management Protocol (PPM) has improved overall pain management at the [burn center]”: (1) 14.3% of respondents strongly agreed; (2) 52.4% somewhat agreed; (3) 19.1% were neutral; (4) 9.5% somewhat disagreed; and (5) 4.8% strongly disagreed. Survey Question 2 asked, “The PPM protocol has helped nurses support patient engagement in pain management”, to which: (1) 33.3% of respondents strongly agreed; (2) 42.9% somewhat agreed; (3) 9.5% were neutral; and (4) the remaining 14.3% somewhat disagreed. Survey Question 3 stated “We are using nonpharmacologic pain management adjuncts (ie., music, virtual reality, breathing, etc.) with more consistency since implementing PPM”, and: (1) 33.3% strongly agreed; (2) 38.1% somewhat agreed; (3) 19.1% were neutral; and (4) the remaining 9.5% somewhat disagreed. Six respondents answered the fourth survey item, a free text opportunity for burn nurses to share insights regarding current pain management practices and future improvements. These responses called out frustrations with the protocol adding extra work to already increased burn-nurse workloads during the COVID-19 pandemic. Several respondents expressed the need for burn team nurses to be more consistent with patient education and in utilizing the PPM toolbox and nonpharmacologic adjuncts.
The study protocol was a product of teamwork and reflective of evidence-based, interdisciplinary endorsed pain management strategies. While the analysis suggests coping self-efficacy did not significantly affect pain reporting, opioid use among the study's sample, or significantly increase in patients exposed to the protocol; the researchers did observe high efficacy of several nonpharmacologic adjuncts when they were employed. Anecdotal evidence based on direct observation and conversations between burn nurses, research team members, and patients found aromatherapy, therapeutic breathing, guided imagery, and progressive relaxation to be among the most frequently chosen adjuncts from the toolbox. These were observed to aid in relaxation and sleep in the setting of breakthrough pain, in some instances bypassing the need for additional IV pain medication. Despite varied demographics, the two groups were very similar in CSES scores, pain reporting, and opioid use.
Correlational analysis suggests a positive relationship between race and PF coping and SS coping, subscales of the CSES. Though not the focus of this study, this correlation may be one of the more significant findings and deserves further exploration as health care providers and organizations seek to understand and bridge racial equity gaps in care and within systems. During the height of pandemic, hospital policy restricted visitors to only allow for end-of-life visitation for adult patients. While this was certainly a universal challenge, findings from this study suggest non-English speaking and non-white patients may have experienced some of the most deleterious effects from being separated from their social supports.
While individuals should not be viewed monolithically, having better understanding of coping tendencies among diverse populations could guide clinicians to ensure access to the most beneficial strategies. For example, a generous visitation policy and inclusion of family in PPM may enhance outcomes for patients with higher SS scores.
Additionally, there were also clinically significant unexpected positive associations found between PF coping, length of stay and %TBSA. This is an important finding in that it suggests severity of injury and time spent in acute care may provide opportunity for patients to develop problem solving skills needed for self-management in recovery. This finding epitomizes the axiom attributed to Friedrich Nietzsche, “What doesn't kill you makes you stronger”, and serves to underscore the PPM Pain Management Partnership assertion; patients can do hard things (
Nurse perception of additions to an already overfull workload was a barrier to the consistent implementation of the PPM protocol requiring adjustments in protocol initiation and follow up. The protocol was implemented, and outcomes measured, in a clinical setting during the COVID-19 pandemic, during which burn center census remained uncharacteristically high. A system-wide hiring freeze was initiated, and travel nurses were hired to supplement the burn team. Burn unit stability requires staff resiliency. However, in these unprecedented times, the fears, stressors, and uncertainties related to health, social, and political threats have greatly challenged acute care staff in ways that have led to burn out.
Burn center nurse responses to the post-implementation survey were mostly favorable to the protocol's efficacy. However, nurses expressed concerns about over-burdening RN workload in an already stressed healthcare system. These concerns highlight the importance of allowing longer time frames for making incremental changes as part of large-scale practice improvements, such as PPM. Doing so would also provide opportunity for staff to improve consistency in implementation on different protocol elements. A major learning from this project is that large-scale changes cannot be made too quickly.
Limitations
Reliability and validity of the CSES cannot be generalized beyond the population it was tested in. Though other self-efficacy scales have been derived from the CSES for persons suffering various forms of trauma, including burns (
Benight, C., Shoji, K., James, L., Waldrep, E., Delahanty, D., & Cieslak, R. (2015). Trauma coping self-efficacy: A context specific self-efficacy measure for traumatic stress. Psychological Trauma, 7(6), 591-599.
), these were not accessible for our study. This highlights the importance of dissemination and collaboration within the greater scientific community in working toward improved outcomes for specific populations.
Additional study limitations include: (1) the study's narrow inclusion criteria juxtaposed with an unpredictable census, a small fraction of the burn population met the inclusion criteria; (2) loss of enrolled participants for a variety of reasons including change in condition, or against medical advice (AMA) discharge; (3) the time-limited structure of this project, the study relied on the census in a set 6-month period resulting in a small N and unequal sample groups; and (4) the single-center study design reflective of the pacific northwest region, limiting generalizability to a larger burn population.
Conclusion
Self-efficacy enhancing strategies have been shown to support pain and symptom self-management, though the research is limited regarding their effect on burn recovery in the acute care phase (
). There is agreement among burn clinicians regarding the importance of multimodal pain management, however clinical practice guidelines lack specific guidance for the inclusion of nonpharmacologic adjuncts in multimodal pain management for burn patients (
American Burn Association guidelines on the management of acute pain in the adult burn patient: A review of the literature, a compilation of expert opinion, and next steps.
Journal of Burn Care & Research.2020; 41: 1129-1151
), Many nonpharmacologic approaches accessible to patients do not require special skills or credentialing and have been shown to work synergistically with pharmacologic pain management (
American Burn Association guidelines on the management of acute pain in the adult burn patient: A review of the literature, a compilation of expert opinion, and next steps.
Journal of Burn Care & Research.2020; 41: 1129-1151
). While our findings did not identify overall improvements in CSE, they did indicate potential for improvements in PF coping with longer LOS, such as is expected with severe burn injury. Nurses are well-positioned to provide patients with education and access to these complementary strategies but require the resources of time, staffing support, and education for implementation. Further research is needed to examine if self-efficacy enhancing interventions may work toward optimizing outcomes and reducing harms such as chronic opioid dependency, hyperalgesia, persistent pain states, PTSD, or other adverse psychological sequela associated with prolonged major illness. The Pathways to Pain Management protocol and study can be adapted to other acute care settings and may serve as a pilot for broader implementation and outcomes measurement via a multi-center study.
Clinical Implications
The burn team has an opportunity and responsibility to enhance self-efficacy in patients who have suffered a traumatic injury and prolonged hospitalization.
Declaration of interests
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgments
We want to thank burn center manager, Emily Helmold, who provided support and feedback to the research team from study conception to dissemination. Informaticists Dr. Josh Jones and Adam Beauchamp created Power Bi reports for pain scores and MMEs. Derek Shields produced and edited the patient education video. Chris Schulman provided feedback on study design. Dr. Thomas Schrattenholzer and the Legacy Pain Management Center team provided the time necessary for getting this work ready for publication. Finally, we thank our dedicated nurse, physician, and therapy colleagues at the Oregon Burn Center, who embodied this work and delivered evidence-based, compassionate care to our patients during one of the most globally challenging times in history.
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Benight, C., Shoji, K., James, L., Waldrep, E., Delahanty, D., & Cieslak, R. (2015). Trauma coping self-efficacy: A context specific self-efficacy measure for traumatic stress. Psychological Trauma, 7(6), 591-599.
American Burn Association guidelines on the management of acute pain in the adult burn patient: A review of the literature, a compilation of expert opinion, and next steps.
Journal of Burn Care & Research.2020; 41: 1129-1151
Efficacy of non-pharmacological interventions for procedural pain relief in adults undergoing burn wound care: A systematic review and meta-analysis of randomized controlled trials.
Comparing the effects of aromatherapy massage and inhalation aromatherapy on anxiety and pain in burn patients: A single-blind randomized clinical trial.
Does self-efficacy mediate the cross-sectional relationship between perceived quality of health care and self-management of diabetes? Results from Diabetes MILES – Australia.
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