Effect of quality nursing intervention on wound healing in patients with burns: A meta‐analysis

Abstract

This meta‐analysis aimed to explore the effects of quality nursing intervention on wound healing in patients with burns. A computerised search was conducted for randomised controlled trials (RCTs) on the effect of quality nursing intervention on wound healing in patients with burns in the PubMed, Embase, Google Scholar, Cochrane Library, China National Knowledge Infrastructure and Wanfang databases from the date of database inception to November 2023. Two researchers independently screened the literature, extracted data and performed quality assessment based on the inclusion and exclusion criteria. Stata 17.0 software was used for the data analysis. Twenty‐nine RCTs involving 2637 patients with burns were included. The meta‐analysis revealed that compared with conventional nursing, the implementation of quality nursing intervention in patients with burns significantly shortened the wound healing time (standardised mean difference [SMD] = −2.93, 95% confidence interval [CI]: −3.44 to −2.42, p < 0.001). The incidence of wound infections (odds ratio [OR] = 0.14, 95% CI: 0.07–0.27, p < 0.001) and complications (OR = 0.16, 95% CI: 0.11–0.23, p < 0.001) was also reduced significantly. This meta‐analysis shows that applying quality nursing interventions in patients with burns can significantly shorten the wound healing time and reduce the incidence of wound infection and complications, thus promoting early patient recovery.

1. INTRODUCTION

Burns are injuries to the skin, mucous membranes, tissues and even internal organs that are caused by heat, radiation, electrical current, friction and contact with a strong corrosive substance. They are associated with high mortality and disability rates and are a global public health problem. ¹ , ² Patients with severe burns may experience adverse effects such as acute respiratory distress syndrome, acute kidney injury and even death. ³ Although the rapid improvement in medical treatment has reduced the mortality rate of burns, they are still associated with wound pain, tissue oedema, wound infection, massive fluid exudation, a long and painful healing process and the complications of wound healing. ⁴ , ⁵ , ⁶ , ⁷ Furthermore, the scarring, deformity and dysfunction that occurs after wound healing may cause anxiety, depression and even traumatic stress syndrome, ⁸ , ⁹ , ¹⁰ which can lead to a reduced quality of life, financial pressure and physical pain. ¹¹ , ¹² Therefore, clinical staff should pay special attention to the health and psychological status of patients with burns during hospitalisation, and provide targeted treatment and nursing care to maximise the improvement in the patients' functions and quality of life.

Traditional routine nursing care can no longer meet the clinical needs of patients with burns. Quality care further optimises routine care and is based on a more patient‐centred and personalised approach. ¹³ Quality care is a nursing concept that adheres to the ‘patient‐centred’ principle, and pays more attention to the psychological and spiritual health of patients while maintaining their safety and physical comfort. ¹⁴ The aim of this study was to conduct a meta‐analysis of randomised controlled studies on the effects of quality nursing interventions in patients with burns, in order to provide medical evidence for the clinical application of quality nursing.

2. MATERIALS AND METHODS

2.1. Literature search

Using burns, burn injury, high‐quality nursing, quality nursing care and wound healing as the keywords, a combination of subject terms and free words was used to search the PubMed, Embase, Google Scholar, Cochrane Library, China National Knowledge Infrastructure and Wanfang databases from the date of database inception to November 2023.

2.2. Inclusion and exclusion criteria

2.2.1. Inclusion criteria

(1) Participants: patients clinically diagnosed with burns and requiring treatment; (2) intervention: quality nursing intervention in the experimental group and conventional nursing in the control group; (3) outcomes: wound healing time, wound infection and complications; (4) study design: randomised controlled trials (RCTs).

2.2.2. Exclusion criteria

Duplicate publications; articles that lack the relevant raw data, have incomplete raw data or for which the full‐text data are not available; and reviews, case reports, systematic evaluations, conference articles and animal studies.

2.3. Data extraction and quality assessment

The retrieved literature was imported into Endnote X9 literature management software to remove the duplicates, followed by screening by two researchers who independently read the titles, abstracts and full text to decide whether to include the articles based on the inclusion and exclusion criteria. If there was a disagreement between the two researchers during the screening process, the issue was resolved through a joint discussion or with the assistance of a third researcher. Excel software was used for data extraction, including first author, year of publication, sample size, sex and age, and outcome indicators (wound healing time, wound infection and complications). The quality of RCTs was assessed using the risk of bias tool recommended by the Cochrane Collaboration, which assesses the risk of bias in six main areas: selection bias, implementation bias, measurement bias, follow‐up bias, reporting bias and other biases.

2.4. Statistical analyses

Stata 17.0 software was used for data analysis. Dichotomous variables were expressed as odds ratios (ORs) and their 95% confidence intervals (CI), and continuous variables were expressed as standardised mean difference (SMD) and their 95% CI. Heterogeneity was determined using the χ ² test and I ² value; when I ² < 50% and p > 0.1, it indicates no significant heterogeneity and a fixed‐effects model was applied; otherwise, a random‐effects model was used. The robustness of the findings was assessed by sensitivity analysis. As the number of included articles exceeded 10, publication bias was assessed using funnel plots.

3. RESULTS

3.1. Basic characteristics

The literature screening process is shown in Figure 1. A total of 239 articles were initially retrieved; 137 duplicates were removed manually and by software; and 49 articles were removed after reading the titles and abstracts according to the screening criteria. The remaining 53 articles were read in their entirety, and 29 RCTs were finally included in the study, ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ , ⁴² , ⁴³ amounting to a total of 2637 patients with burns, with 1325 in the quality nursing group and 1312 in the conventional nursing group. The basic characteristics of the included literature are shown in Table 1. The process of literature risk assessment is shown in Figure 2.

FIGURE 1.

Literature screening flowchart.

TABLE 1.

Characteristics of the included studies.

Author	Year	Number of patients		Age (years)		Sex (male/female)
		Intervention	Control	Intervention	Control	Intervention	Control
Huang	2020	30	30	34.3 ± 6.0	35.47 ± 5.24	16/14	14/16
Hu	2020	44	41	40.1 ± 10.3	40.3 ± 10.5	25/19	23/18
Hu	2017	56	56	37.54 ± 5.32	38.24 ± 5.73	31/25	32/24
He	2022	40	40	35.34 ± 11.89	36.12 ± 11.43	22/18	19/21
Han	2014	29	29	35.6 ± 15.8		38/20
Gu	2019	36	36	35.34 ± 11.89	36.12 ± 11.43	20/16	17/19
Feng	2023	30	30	45.07 ± 4.90	45.31 ± 4.28	17/13	19/11
Deng	2020	40	40	41.72 ± 2.59	42.01 ± 2.14	19/21	22/18
Zeng	2019	45	43	6.15 ± 1.04	6.17 ± 1.01	29/16	28/15
Huang	2022	49	49	33.05 ± 10.11	32.71 ± 9.84	25/24	29/20
Liu	2015	43	43	6.7 ± 1.0	6.5 ± 1.1	28/15	25/18
Liao	2019	30	30	7.5 ± 0.5	7.0 ± 0.3	17/13	16/14
Li	2018	25	25	39.3 ± 4.6	38.9 ± 4.8	13/12	14/11
Li	2020	25	25	51.71 ± 4.73	51.85 ± 4.67	14/11	13/12
Peng	2019	90	90	36.48 ± 10.18	37.24 ± 10.49	54/36	52/38
Wang	2022a	40	40	26.68 ± 2.36	26.07 ± 2.21	31/9	30/10
Wang	2023	40	40	48.29 ± 8.67	48.54 ± 8.62	21/19	22/18
Wang	2022b	23	23	37.82 ± 4.20	37.37 ± 4.14	15/8	16/7
Tao	2017	37	37	3.9 ± 1.4	4.3 ± 1.5	20/17	19/18
Tang	2023	66	66	9.98 ± 2.36	9.24 ± 2.52	34/32	35/31
Sun	2020	71	71	7.53 ± 0.48	7.69 ± 0.51	45/26	46/25
Sun	2022	25	25	39.52 ± 4.38	39.40 ± 4.25	17/8	16/9
Wang	2021	80	72	29.87 ± 3.64	29.76 ± 3.69	47/33	38/34
Zhou	2023	100	100	38.06 ± 3.65	41.95 ± 4.23	50/50	50/50
Zhang	2020	15	15	35.53 ± 9.27	42.51 ± 11.97	10/5	8/7
Zhang	2017	37	37	3.9 ± 1.4	4.3 ± 1.5	20/17	19/18
Zhang	2019	50	50	5.0 ± 1.0	5.3 ± 1.1	33/17	35/15
Yi	2020	65	65	5.54 ± 1.32	5.52 ± 1.03	37/28	30/35
Xiao	2016	64	64	42.74 ± 1.57	42.13 ± 1.21	43/21	42/22

FIGURE 2.

The risk of bias graph of the included studies.

3.2. Wound healing time

Wound healing time was reported in 29 RCTs, including 1325 patients in the quality nursing group and 1312 in the conventional nursing group. There was significant heterogeneity among the studies (I ² = 95.8%, p < 0.001); therefore, a random‐effects model was applied. The analysis revealed that the quality nursing group had a significantly shorter wound healing time than the conventional nursing group (SMD = −2.93, 95% CI: −3.44 to −2.42, p < 0.001), as shown in Figure 3.

FIGURE 3.

The forest plots of wound healing time.

3.3. Wound infection

Thirteen RCTs reported wound infections. There were 613 patients in the quality nursing group, of which 10 had infections, and 611 patients in the conventional nursing group, of which 64 experienced infections. No significant heterogeneity was found (I ² = 0.0%, p = 0.949), and a fixed‐effects model was applied. It was found that the incidence of wound infection in the quality nursing group was significantly lower than that in the conventional nursing group (OR = 0.14, 95% CI: 0.07–0.27, p < 0.001), as shown in Figure 4.

FIGURE 4.

The forest plots of wound infection.

3.4. Complications

Fifteen RCTs reported the occurrence of complications. There were 702 patients in the quality nursing group, of which 39 developed complications, and 700 patients in the conventional nursing group, of which 180 had complications. As no significant heterogeneity was detected (I ² = 0.0%, p = 0.998), a fixed‐effects model was applied. The incidence of complications in the quality nursing group was significantly lower than that in the conventional nursing group (OR = 0.16, 95% CI: 0.11–0.23, p < 0.001), as shown in Figure 5.

FIGURE 5.

The forest plots of complications.

3.5. Sensitivity analyses and publication bias

Sensitivity analyses were conducted by excluding the individual studies one by one. It revealed that the results of the study were robust (Figure 6). The funnel plot is shown in Figure 7. The two sides of the funnel plot for the outcome indicators of wound infection and complications were basically symmetrical, suggesting that the possibility of publication bias was small; however, the two sides of the funnel plot for wound healing time were asymmetrical, indicating that the possibility of publication bias existed.

FIGURE 6.

Sensitivity analysis. (A) Wound healing time. (B) Wound infection. (C) Complications.

FIGURE 7.

Funnel plots. (A) Wound healing time. (B) Wound infection. (C) Complications.

4. DISCUSSION

Globally, about 11 million people are estimated to be affected by burns each year. The incidence and mortality rate of burns are decreasing each year owing to the advances in burn treatment and the introduction and implementation of measures to prevent burns. ² , ⁴⁴ , ⁴⁵ However, due to the severe damage caused by burns, even after the wound heals and the patient is discharged from the hospital, scar proliferation, contracture or deformity, wound infection, disfigurement, physical disability, activity disorders, and mental and psychological problems may occur. ⁴⁶ , ⁴⁷ Additionally, burns are associated with a heavy economic burden, ⁴⁸ especially in developing countries. ⁴⁹ Consequently, burns have become an important public health challenge worldwide. ⁵⁰ During burn treatment, attention should not only be given to wound healing and life‐saving, but also burn rehabilitation should be given equal importance. ⁵¹ Therefore, it is the duty of the nursing staff to provide systematic and high‐quality nursing care to patients and their families, to enable patients to return to social life as soon as possible, reduce the impact of the burn symptoms on daily life, save unnecessary medical expenses, improve the satisfaction of patients and their families, and enhance the quality of life of patients. ⁵²

The healing of burns is a complex process involving multiple factors, and prolonged healing can have a seriously negative impact on the patients' physical and mental health and quality of life. ⁵³ Difficult‐to‐heal wounds are usually associated with infection, impaired microcirculation in and around the wound, aging of the granulation tissue and formation of fibrous plates and biofilms, leading to a further reduction in the expression of various growth factors and slower wound healing, which creates a vicious cycle. ⁵⁴ , ⁵⁵ Our results showed that compared with the conventional nursing group, quality nursing intervention can significantly shorten the wound healing time. This is because quality nursing focuses on the management of the dressing change process, paying attention to the neglected aspects of traditional nursing, such as reasonably adjusting the dressing change method according to the area and depth of the wound, and strictly following an aseptic protocol to complete all work. This ensures the high quality of dressing change, reduction in the patient's pain and enhancement of the efficiency of wound healing. ⁴¹ At the same time, attention is paid to nurse–patient communication through psychological interventions to address the emotional problems of the patients. This ensures that the patients maintain a positive and optimistic attitude during dressing change and wound healing, and cooperate with the nursing staff to ensure that the dressing change is carried out smoothly, which is conducive to accelerated healing of burn wounds. ⁵⁶

Wound infection is one of the common complications in patients with burns and can lead to prolonged wound healing, uncontrolled local infection and serious systemic infection that may be life‐threatening. ⁵⁷ Our results showed that the incidence of postoperative wound infection was significantly lower in patients with burns who experienced quality nursing compared with those who underwent conventional nursing. This is because quality nursing care requires the nursing staff to formulate personalised care for the patients, which includes applying antibiotics for infection prevention in accordance with the doctor's orders before surgery, strictly implementing the concept of asepsis during surgery, changing the dressing regularly after surgery and ensuring the wounds are dry and clean, thus reducing the incidence of infections. ⁵⁸ , ⁵⁹

Postoperative complications lead to high mortality rates, longer hospital stays and high hospitalisation costs and are considered as clinical indicators for assessing the prognosis of patients with burns. ⁶⁰ Patients with burns are more prone to complications such as wound infection, wound fluid and bacteraemia, which increase pain, aggravate the underlying condition, prolong the disease course and endanger lives. ⁶¹ , ⁶² According to our results, the incidence of postoperative complications in the quality nursing group was significantly lower than that in the conventional nursing group. Therefore, quality nursing can reduce the rate of complications in patients with burns and promote their recovery.

This meta‐analysis used strict inclusion and exclusion criteria for the literature search and screening, while heterogeneity and sensitivity analyses were conducted for each of the included studies, making the results more credible and reliable. However, certain limitations still exist. Firstly, all the included studies were from China, leading to certain geographical limitations; secondly, the sample sizes of the included studies were small, resulting in the lack of sufficient clinical data.

5. CONCLUSIONS

In conclusion, quality nursing intervention has a significant effect in patients with burns, as quality nursing intervention can promote wound healing, reduce the occurrence of wound infection and complications, effectively improve the patient's prognosis and promote rapid postoperative recovery, which makes it worth promoting.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Liu L, Liu Z‐F, Zhu H‐Y, Xu H‐Q. Effect of quality nursing intervention on wound healing in patients with burns: A meta‐analysis. Int Wound J. 2024;21(3):e14717. doi: 10.1111/iwj.14717

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.