The Pain and Stress of Wound Treatment in Patients With Burns

8/10/2019 The Pain and Stress of Wound Treatment in Patients With Burns

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The Pain and Stress of Wound Treatment inPatients With Burns

Dominic Upton, PhD, FBPsS, Jessica Morgan, BSc, Abbye Andrews, BSc, MBPsS, David B.Lumenta, MD, Michael Giretzlehner, PhD, Lars P. Kamolz, PhD, MSc

An International Burn Specialist PerspectiveWounds. 2013;25(8):199-204.

Abstract and Introduction

AbstractThis study aimed to explore the views of burn specialists on the importance of reducing stress and

pain during wound treatment.Methods.Burns specialists were invited to complete an online survey, consisting of 10 questionsabout pain and stress in their patients.Results. There were 141 respondents from 39 countries. Most were European (54.9%), and themajority were surgeons (71.8%). Pain-free and stress-free dressing changes were viewed as importantoverall ('very important:' 47.5% and 40.8%, respectively), although, in both cases, 11.3% did notview either to be important. Respondents identified 7 benefits of simple, pain-free dressing removal,although the focus was on clinical advantages rather than being patient-centered. Although mostacknowledged that pain is linked with stress, disagreement levels ranged from 21.9% to 25.3%.Additionally, only 22.5% agreed that stress is related to wound healing.Conclusion. In general, burn specialists recognized that pain can lead to stress and that it isimportant to reduce stress and pain at dressing changes. Most also acknowledged that stress canaffect wound healing. However, these results suggest a need for research to further exploreperceptions about pain and stress, and how these perceptions can impact wound managementregimes.

IntroductionBurn injuries are one of the most devastating forms of individual trauma. However, with

advances in medical treatment techniques, the mortality rate for patients with burns has beenreduced in recent years.[1]Due to such progress, a person with burns over 80% of his total bodysurface area (TBSA) now has a realistic chance of survival.[2]This reduction in patient mortality,though positive, has implications about the challenges these individuals will face in their lives interms of long-term treatment, adjustment to daily life, and rehabilitation.[3] Consequently, burn

wounds have being compared to chronic illness, with a high incidence of physical and psychologicalmorbidity.[1,4]

Severe pain is one of the most significant components in the long-term suffering of burnpatients,[5]with continuous background pain experienced alongside intense pain during woundtreatment procedures. Often patients with burns must endure 1 or more painful procedures daily,for weeks or months,[6] comprising wound cleansing, debridement, dressing changes, surgicaloperations, and physical and occupational therapies.[79]The pain experienced during wound careprocedures has often been reported to be excruciating.[10,11]


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Much research has been conducted within the chronic wound population on thepsychological effects of dressing-related pain, with stress being a common component .[1214]Likewise, anxiety and depression are frequently reported to accompany the pain of burns, oftenhaving a bidirectional relationship.[1516]Due to the emotional and physical trauma that patients withmajor burns experience, high levels of distress and anxiety are common.[17]Additionally, stress and

anxiety are thought to be interlinked with pain, with anxiety increasing due to the anticipation ofpain, and the experience of anxiety also intensifying the perception of pain.[1819]This is cyclical inthat the intense pain often leads to anxiety in anticipation of upcoming pain, such as thatexperienced with dressing change.[20]Due to the amplification of pain, by anxiety and stress levels,for patients with burns, it is important that treatment methods simultaneously target both thephysical and psychological aspects of burn injuries.[1]

The consequences of pain, anxiety, and stress on wound healing provide further incentive toensure treatment protocols incorporate techniques that aim to reduce these experiences for patientswith burns as much as possible. It is known that pain can adversely affect the healing of awound[15,21] and can also have a negative impact on quality of life.[22]A study by McGuire et al[23]found that in gastric bypass surgery patients, reports of postsurgical, high-intensity pain wereassociated with longer healing times. Similarly, Woo and Sibbald[24]found that the mean pain scores

over a 4-week period for patients with leg or foot ulcers was significantly less (P< 0.041) for thosewho achieved wound closure (mean pain score 1.67), than for those who did not (mean pain score3.21).

In a way similar to pain, increased stress levels can also delay the healing process.[25,26]Broadbent et al[27]explored the effects of stress levels on wound healing in patients who underwent alaparoscopic cholecystectomy. It was found that those who received a psychological interventionaimed at reducing stress, in addition to standard care, showed lower stress levels and enhancedwound healing postsurgery compared to those who received standard care alone. Similar findingshave been reported in regard to individuals with burns. For example, Wisely et al[28]investigated theeffect of preexisting psychiatric disorders and psychological reactions to stress on the recovery ofburn survivors. It was reported that heightened psychological distress alone, without the presence of

a psychiatric disorder, had a significant delaying effect on the rate of recovery of burn wounds. Thisfinding highlights the importance of identifying and working with difficulties, such as stress andanxiety, in light of the psychosocial and physical impact they may have on recovery.

The effect that both pain and stress have on wound healing makes it important forprofessionals to reduce the pain and stress their patients experience during treatment, especially forthose whose burns require regular wound care procedures.

Despite the importance of pain and anxiety management in burn treatment regimes, Robertet al[29]found it can be omitted during clinical assessments. The authors surveyed nursing directors at64 burns centers. Of the burn teams, 19% (12 teams) did not assess anxiety at all during thetreatment of burn wounds, neither formally nor informally, despite its importance in the painexperience of patients, and the subsequent healing of their wound.

However, it must be noted that many medical professionals are aware of the psychologicalimpacts of wounds upon patients. For example, Upton et al[30]surveyed health care professionals inrelation to patients with acute and chronic wounds. The majority of professionals believed that morethan half of their patients suffered from mood problems related to their condition. These problemswere most likely to include anxiety and feelings of helplessness, with chronic pain and discomfort ofthe wound acting as potential contributory factors. Further research is needed to build upon theknowledge of how important burn specialists perceive pain and stress to be, and how highly theyrate the need for pain- and stress-free management regimes for burn recovery.
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The present study aimed to explore clinicians' views about pain and stress in their patientswith burns. In particular, this research aimed to investigate how clinicians perceive the relationshipbetween pain and stress, and how important they consider reducing pain and stress duringtreatment. Additionally, this research aimed to look at beliefs about how stress affects woundhealing.

MethodsA voluntary, cross-sectional survey was created by the Austria Burn Treatment, Research,

and Prevention Study Group, a scientific, nonprofit medical organization, in conjunction withexperts originating from various other strands of the burn community. The 10 survey questionsrelated to pain of wound treatment, stress of wound treatment, stress-pain relationship, or stressimpairing wound healing. The questions were either open-ended or had a 7-point Likert scaleanswering system, in which a rating of 1 indicated "not important" or "agree totally," and a rating of7 represented "very important" or "disagree totally," depending on the question. Additionally, 4questions were included to gain demographic information on the respondent related to profession,staff grade, country, and city.

An email invitation was sent to 1000 burn specialists worldwide, which included a direct link

to the survey. The list of email contacts was created using the contact information available on theinternet for burn centers, as well as the corresponding email addresses provided in all publicationsfrom 2008 to 2011 of the Burnsjournal (Elsevier Science Ltd for the International Society for BurnInjuries). The personal information of the respondents was not collected, and no incentives tocomplete the survey were offered. In an attempt to guarantee the avoidance of duplicatesubmissions, JQuarks 4 Surveys (IP-TECH, La Marsa, Tunisia) was chosen to host thequestionnaire, as the system does not allow for more than 1 entry from the same participantcomputer IP address.

Throughout the completion of the questionnaire, respondents were able to check andchange any answers previously submitted, with the questionnaire located on a single scrolling webpage. The time taken for completion was not recorded, and once the respondent had submitted their

answers it was automatically logged in a MySQL-Database (Oracle, San Francisco, CA). The websitewas checked on a daily basis for technical difficulties.

ResultsRespondents

A total of 141 respondents (response rate of 14.2%) from 39 countries completed the onlinequestionnaire over a 6-week period. Out of the total sample, 72.3% were surgeons (n = 102), 5.7%were anesthetists/intensivists (n = 8), and 14.2% were nursing staff (n = 20), with 7.8% falling intothe 'other' category (n = 11) of emergency physicians, physical therapists, or unknown. Respondentswere from a variety of countries, including Europe (57.5%), Australia and New Zealand (17.7%),North America (12.8%), Asia (9.2%), South America (1.4%), and Africa (0.7%), with 0.7% not

specifying country of origin.

Importance of Pain-free, Stress-free Dressing ChangesMedical professionals were asked to rate the importance of pain-free dressing changes using

one of 3 options: essential, desirable, or neutral. Of the 141 respondents, 53.9% expressed that pain-free dressing changes were "essential," and 44% felt they were "desirable." Only 1.4% ofrespondents indicated a "neutral" opinion, and 0.7% did not answer. When the same question wasasked slightly differently, using a scale from "very important" to "not important," 47.5% ofrespondents expressed it was "very important" that dressing changes are pain-free. However, 11.3%


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considered it "not important." Similar findings were obtained for the question of how important it isthat dressing changes are stress-free, with 40.8% of respondents rating this as "very important," and11.3% considering it "not important."

Potential Effects of Easy-to-Use, Painless Dressing Removal Products

When asked to identify the changes that could be brought about by an easy-to-use, pain-freedressing removal product, respondents referred to 7 main areas. These included less pain relief,effective treatment and quicker dressing change, reduced healing time and movement from inpatientto outpatient, reduced pain, reduced stress, increased patient compliance, and cost implications(Table 1).

Effects of Pain and StressOverall, 71.8% of respondents generally agreed that pain from patients' wounds caused the

patient stress, with 48.6% of respondents "totally agreeing." However, an overall 23.2% generallydisagreed, with 10.6% "totally disagreeing."

Similarly, when asked if higher wound pain correlated with higher levels of stress in patients,72.5% generally agreed, with 47.9% "agreeing totally." In disagreement were 22.5% of respondents,

with 12% "disagreeing totally."When asked if pain associated specifically with wound dressing caused patients stress, 67.5%

generally agreed, 40.8% of whom "agreed totally." Although this still represents the majority, theagreement levels were reduced compared to responses to the previous 2 questions. Additionally,25.3% disagreed with this, with 9.9% "totally disagreeing." Thus, more people disagreed with thestatement that pain at wound dressing caused stress than with the idea that pain in general wasrelated to stress.

Similar results were found for the question of whether or not pain associated with a woundmanagement regime caused stress, with 40.1% "totally agreeing" that it did.

Finally, when respondents were asked their opinions on whether or not stress impairswound healing, an overall 66.9% generally agreed that it does, with 22.5% "agreeing totally."

However, 20.3% generally disagreed, with 4.9% "disagreeing totally." An additional 10.6% ofrespondents selected the middle value on the Likert scale, neither agreeing nor disagreeing with thestatement.

DiscussionThe majority of the health care professionals surveyed (97.9%) indicated that pain-free

dressing changes were either "essential" (53.9%) or "desirable" (44%). However, when asked a verysimilar question about the importance of pain-free dressing changes using a different scale, only77.7% expressed that it was important (with 47.5% responding "very important"). Considering that97.9% of respondents selected "essential" or "desirable" to the first question, it is surprising that20.4% then went on to select low importance levels in this subsequent question, with 11.3%

expressing that pain-free dressing change is "not important." Almost identical figures were found inrelation to the importance of stress-free dressing changes, with the majority expressing this wasimportant, but a proportion of professionals expressing low or no importance.

Nevertheless, most specialists who responded to the survey believed dressing changesshould be painless and stress-free, although it is possible that some consider this to be the "ideal"rather than an important factor. Additionally, they may rate the importance of pain-free dressing interms of a "comfort factor," and not in relation to the effect on the outcome and well-being of thepatient.


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In terms of the possible effects of using easy-to-use, pain-free dressing removal products,the health care professionals identified 7 areas. Clinical and practical benefits were highly cited, suchas reduced need for pain relief, efficiency of treatment with quicker dressing change, reduced healingtime, and quicker progress from inpatient to outpatient. In contrast, more patient-centered benefits,such as reduced pain and stress, were referred to less frequently. This suggests that medical

professionals face a challenge in juggling departmental demands with patient needs, which mayaffect which issues they prioritize as important. Since almost half of respondents expressed thatpain- and stress- free dressing changes are "very important," it may seem surprising that patient-centered benefits were not referred to frequently. However, it is important to note that the questionasked about changes in care practices, and different findings may have been reported if the questionasked about the general benefits of easy-to-use, pain-free dressing removal products.

In a similar study, Selig et al[31]explored the views of 121 clinicians from 39 countries, aboutthe 'ideal' properties of wound dressings. The clinicians referred to nonadhesion, absorbency, andantimicrobial activity as key factors which would contribute to the ideal dressing. They also reportedthat it would be beneficial if the dressing was easy to remove, leading to reduced pain at dressingchange. This shows some consideration of minimizing pain in ideal practice, although no dressingswere known to exist at the time of the study that incorporated all of those factors.

Another area explored in this research was that of medical professionals' views on the role ofpain and stress and their patients' experiences of these. It is known that there is a cyclicalrelationship between pain and stress andanxiety,with pain causing anticipatory anxiety, and anxietylowering the pain threshold.[1820]Taking this relationship into consideration, it is surprising thatoverall disagreement responses ranged from 21.9%-25.3% for statements relating to wound pain,wound dressing, dressing removal, and wound-management regime causing patient stress. However,the majority of respondents did agree that stress could be caused from wound pain, wound dressing,dressing removal, and wound-management regime, and that wound pain and stress levels arepositively correlated with one another (72.5% overall). This demonstrates that most burn specialistsacknowledge the effect pain can have on patient stress levels, although some may not fully recognizehow pain and stress are linked.

While the majority of the medical professionals thought it was important that dressingchanges did not cause stress for their patients (73.9%), only 22.5% totally agreed that stress impairswound healing, with 4.9% totally disagreeing, and 10.6% selecting the middle value. The number ofrespondents who disagreed with the statement, or who were unsure, is surprising, considering thatstress is reported to be directly associated with the healing of wounds .[2527]An important message tocome from this research is that some burn specialists believe pain and stress do not influence woundhealing. Whilst most acknowledge that patients experience stress in relation to pain, they may notfully understand the implications of this stress. This highlights the need for further education ofspecialists in relation to pain, stress, and wound healing in the burn population.

Conclusion

The findings of this study indicate that, in general, burn specialists acknowledge theimportance of pain- and stress- free dressing changes, agree that pain associated with wounds andwound treatment does cause stress, and believe that stress impairs wound healing. Despite thisgeneral agreement however, there were relatively high percentages of respondents who 'disagreedtotally', or believed that pain- and stress-free dressing changes were "not important." Additionally,when considering the benefits of using an easy and pain-free dressing removal product, clinical andpractical implications were referred to most frequently, with patient-centered outcomes consideredless often. These findings suggest a need for additional research and education about the role of painand stress for patients with burns.
http://emedicine.medscape.com/article/286227-overview?src=wgt_edit_news_lsm&lc=int_mb_1001http://emedicine.medscape.com/article/286227-overview?src=wgt_edit_news_lsm&lc=int_mb_1001


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Research needs to further explore the views of burn specialists in relation to the importance of pain-and stress-free wound treatments, and the consequences that both stress and pain can have on thepatient. In particular, research needs to investigate how these opinions affect wound managementregimes for people with burns.

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The Pain and Stress of Wound Treatment in Patients With Burns