Raising patients hope in despair: The culture of nursing care of burn pain: An ethnographic study

Abstract

BACKGROUND:

Although many studies have been carried out to address burn patients' pain and suffering, pain relief still remains an immense unsolved challenge with individual, social, and cultural aspects.

MATERIAL AND METHODS:

This study was conducted aiming to investigate and explain nursing care in burn patients. This was a semifocused ethnographic research conducted in burns units in a referral teaching hospital (Mazandaran, Iran). The data were collected through descriptive, focused, and selective participant observations and ethnographic interviews with burns unit nurses selected via a purposeful sampling method. The collected data were analyzed on the basis of James Spradley's approach.

RESULTS:

Three main categories and nine subcategories were obtained from data analysis that are as follows: 1) Bending over backward (tenacity, altruism, dedication, and conscience and constancy), 2) Prevention is worth a pound of cure (unique clinical methods, enhanced frustration tolerance through self-motivation and self-efficacy, raise patient's hope in despair), and 3) undisputed dominance of nursing art (reduced unsettling experiences, burnt and ripped body rehabilitation, patient stress management, and avoidance of false hope).

CONCLUSIONS:

Although burn nurses are under huge physical and mental pressure, they enhance patients' pain tolerance through their art of nursing, which is a collection of empirical knowledge, huge work conscience, unique clinical skills, and various therapeutic communication techniques.

Introduction

Adequate pain control underpins the provision of effective care to burn patients from the initial stages up to their rehabilitation. The same treatments conceived to treat burn injuries are highly likely to cause greater pain than the original injury itself. Thus, the treatment team is required to adopt a multimodal approach to burn pain treatment. Acute pain management should not only focus on the physical but also the emotional, psychosocial, and cultural components of pain.[1] Burn patients receive invasive medical care until death or recovery, and the odds are that palliative burn care may not be as effective for burn patients as possible. Nurses who provide palliative care to burn patients encounter unique problems and experiences that require support. They seem to be explored or even studied inadequately.[2] Exploring and comprehending the experiences of nurses during their palliative care for burn patients paves the way for a host of information about specific issues and challenges they may face. This can underpin the development of strategies to help and empower such nurses and their caring roles.[3] Care of pain as a patients' right is one of the most important components of providing humanistic and ethical care.[4] In pain care, in addition to physical care, spiritual care is also vital.[5] Pain is excruciating not only for burn patients, but it also poses a great challenge for the care team.[6] Caregivers' health is important in order to provide and continue high-quality care in the hospital and after discharge.[7] Most of the investigations in this field have taken into account the nurse–patient interactions or have focused only on pain management for burn patients. Hence, there is a shortage of studies on the nature of palliative care nursing. A robust and consistent culture not only increases individuals' awareness and knowledge of the goals and strategies of the organization but also helps them be committed to its values and norms and be satisfied with their work. Coupled with strong management, it improves their morale, innovative capabilities, and desirable modifications.[6] Researchers believe that a culture that places a value on individuals' status and dignity will strengthen morale and ultimately lead to proper changes. Burn care nurses tend to employ a special and sometimes remarkable behavioral culture for palliative care; they are well aware that a lack of creativity and unique capabilities will often lead to grievous consequences such as dismay, lassitude, and despair for burn patients. Ethnographic studies pave the ground for new insight into pain complexity, expression, and management within the framework of processes, values, and norms. These studies are of utmost significance as they show the ways in which individuals' unique experiences and contexts interact.[8] It is necessary to examine cultural elements such as barriers to care, attitudes, traditions, beliefs, emotions, and creativity in nursing care. This study was conducted aiming to shed some light on care in burn patients.

Qualitative research takes into account natural contexts in which individuals or groups function to provide an in-depth understanding of real-world problems. Qualitative research is sensitive to “context” and is considered one of the key features of this type of studies. Based on this and considering what we found in the review of the literature, we are faced with a lack of studies, especially qualitative studies regarding the culture of nursing care of burn pain. Due to the fact that qualitative studies provide a broader view of the subject under investigation, conducting research in this field seemed appropriate.

Material and Methods

Study design and setting

Guided by James Spradley's methods, this research was carried out with a focused and semifocused ethnographic approach from March 201 to June 2022 in Iran. Focused ethnography has wide applications as a research method in medical healthcare studies.[9] Considering that this research aimed at studying nursing care in burn units of the hospital, we employed the focused ethnographic method. The study focused on the status of care in burn units (burns unit, intensive care unit, reconstruction unit) in Zare teaching hospital in the North of Iran (Mazandaran) composed of 84 beds and 80 nurses.

Study participants and sampling

Nurses at burn units made up the key informants of this study composed of 22 individual and 3 group interviews with an average duration of 50 min, all conducted in the resting and the head-Nurse's room. The inclusion criteria were a bachelor's degree in nursing (the least degree), at least one year of full-time employment, and working at burn units during the study period. They were selected from different units and different age groups with different experiences using a purposeful sampling method [Table 1].

Table 1.

Demographic information

Code	Sex	Age	Work experience	Ward	Education level
1	Men	36	14	Plastic	Bachelor
2	Men	32	7	Plastic	Master
3	Men	47	23	Burn	Bachelor
4	Women	46	20	Burn	Bachelor
5	Men	36	12	Plastic	Bachelor
6	Men	34	14	B-ICU	Bachelor
7	Women	28	6	Burn	Diploma
8	Men	38	15	B_ICU	Bachelor
9	Women	28	6	Burn	Bachelor
10	Men	41	18	B-ICU	Bachelor
11	Men	34	11	Burn	Master
12	Women	25	3	Burn	Bachelor
13	Men	36	13	B-ICU	Bachelor
14	Women	61	34	Burn	Bachelor
15	Women	27	4	Burn	Bachelor
16	Men	35	9	B-ICU	Bachelor
17	Women	52	25	B-ICU	Bachelor
18	Men	40	18	plastic	Master
19	Men	34	13	burn	Bachelor
20	Women	38	14	B-ICU	Bachelor
21	Men	28	3	Burn	Bachelor
22	Women	57	26	B-ICU	Master

Data collection tool and technique

Data collection was performed through descriptive, focused, and selective participant observations at different working shifts (morning, noon, night), and situations, along with ethnographic interviews with nurses.

The principal researcher initially conducted direct observations as an outsider, taking account of informants' interactions and behaviors, i.e., their verbal and nonverbal communication, tone of voice, facial expressions, and gestures while communicating with each other. During the study, the researcher's role changed from an ordinary participant to a participant observer. The main researcher not only performed care duties such as delivering patients' medicines, educating patients, and changing dressings but also observed activities and physical aspects in the burn department. During observations, expanded and condensed field notes were recorded.

The descriptive, focused, and selective participant observations lasted from a few minutes to an hour (for a total of 302 h). Interviews made great contributions to the researcher's observations through questions such as “Tell me what you do to relieve your patient's pain?” [Table 2].

Table 2.

Types of questions used in the interviews

Type of questions	Questions
Grand Tour Questions	Could you describe the inside of the Burn Unit for me? Could you describe the main things that happened during the shift? Could you describe a typical shift at Unit?
Mini-Tour Questions	Could you describe a typical day in your work as an in-charge nurse? Could you describe what goes on in bandage? Could you describe what you do when you take a break at shift?
Example Questions	Can you give me an example of bandage? Could you give me an example of someone giving you a hard time?

Data analysis was conducted using Spradley's Developmental Research Sequence method in four stages: domain, taxonomy, component, and theme analysis.[10,11]

The field units of the field observations were regarded as codes; then, the similar codes were classified in an included-terms class based on semantic relationships. Afterward, the obtained classes were dubbed as cover terms (Domain analysis). Taxonomies were developed to establish the relationships between all included terms within each of the identified domains, and the researcher looked for any similarities between “included terms.” Then, larger domains were examined at different levels (Taxonomic analysis), and a comparison was made between terms or semantic components related to cultural classes. At this stage, the data were reclassified in terms of the meaning of a term to the extent that differs from the other. The developed taxonomies were provided to informants to confirm the data obtained from observation and interview (Component analysis). A comparison of domains revealed the connections, and a list of cultural themes was created. Schematic diagrams were devised to examine the association between the data and its relationship with other domains (Cultural theme analysis).

Data collection in this research continued until the researcher reached to the data saturation that is an all-around understanding of the cultural scene to the extent that further observations and interviews would lead to no new data. During the study, the researcher recorded her beliefs and wisdom about the culture of nursing care in the form of fieldwork journaling and used them in data analysis. Noted by Morse, validity, reliability, and generalizability are widely utilized as benchmarks for the strength and evaluation of quantitative analysis.[12] Diversity of observation situations in terms of time and place, diversity of informants in terms of gender, age, work experience, and the use of confirmation questions in interviews all ensured the validity of the data. To guarantee data consistency, all the stages of the research, interviews, and data analysis were recorded and documented in detail. To ensure data validation, the research process was accurately recorded and reported.

Ethical considerations

This study was approved by the Ethics Committee of Golestan University of Medical Sciences with the ethics code IR.GOUMS.REC.1399.425. All the ethical considerations such as informed consent, participant anonymity, data confidentiality, participants' freedom to leave at any stage of the research, and their verbal consent were observed and maintained during the research.

Results

A total of 25 nurses include of 15 female and 10 male participants aged 26–61 years, 3–26 years of work experience in burn units, burn intensive care units, and reconstruction units of hospitals were included in the study.

The findings of this research include the three main categories of “Bending over backward, Prevention is worth a pound of cure, and Undisputed dominance of nursing art” and nine cultural subcategories [Table 3]. Direct quotations are provided in “…”.

Table 3.

The main categories and subcategories

Main category	Subcategory
Bending over backward	Tenacity
	Altruism, dedication
	Conscience and constancy
Prevention is worth a pound of cure	Unique clinical methods
	Enhanced frustration tolerance through self-motivation and self-efficacy
	Raise patient’s hope in despair
Undisputed dominance of nursing art	Reduced unsettling experiences
	Burnt and ripped body rehabilitation
	Patient stress management and avoidance of false hope

Bending over backward

It denotes nurses' exerting themselves to the fullest extent initiated when the nurse's body, soul, and mind are involved in alleviating the patient's pain. Considering the challenges in relieving the pain experienced by burn patients, nurses bend over backward to lessen the patients' pain. They make every effort from employing their knowledge, experience, beliefs, and art to the religious, spiritual, and altruistic aspects emanating from the cultural and political arena of the medical system to end the suffering of the patients with a clear conscience.

Nursing tenacity

Who spends more time at the patient's bedside than a nurse?! Whom does the patient view as more readily available than the nurse?! Who understands the effects of the painful burn disaster on the mind, soul, body, and whole life of patients and those around him and then sympathizes better than a nurse?!

“Burn pain is not usually relieved by painkillers… Burn patients tend to become agitated… They scream, shout, swear, and sometimes quarrel with us… We are well aware that they are in great pain… We tell them to be calm and even tell them if they think cursing will help them, continue cursing!… We do not usually give them false hopes… It requires considerable persistence and willpower to persuade patients out of their resistance” (P: 19).

Amazed at the patient's endurance are the nurses, and all are astonished at the nurses' perseverance. Burns injury places a huge burden that falls on the shoulders of all patients, nurses, medical staff, family, and society.

“Burn injuries are intolerable, agonizing, and are incomparable to other kinds of wounds. Burn wounds are excruciating, and grievous, and make patients cry and scream… We are doomed to endure this suffering just like the patients… The clients who see us are amazed by how we bear such appalling conditions”(P: 17).

Nursing altruism, dedication

Nurses are committed and devoted to the extent that they do their best to relieve the burn patients' suffering and pain. As there is no remedy for the excruciating burn pain, the nurses themselves are pain relievers.

“We sedate the patients, and even sometimes ask the physician to prescribe a sedative, we try to divert their attention away from the pain, and encourage attendants to interact with their patients. We provide the care to the patient as soon as possible, raise their morale, and place them in the proper posture to lessen their pain” (P: 22).

Nursing conscience and constancy

Nurses working in burn units are usually deprived of the joy and pleasure of their job owing to various reasons induced by their work in burn units. They witness patients' pain and suffering, the empty beds after all they have been through to save patients, the draining, and burdensome burn wound curing, along with the burn scar left on the patients' bodies and souls. They tolerate patients' verbal and physical violence and those of their attendants. Not only have that, but they even have to deal with illiterate individuals, both desperate patients, and their companions.

“I remember when a burn patient unconsciously hit a nurse on the face when the nurse was trying to change the patient's position. When you are insulted during providing care to patients, you cannot claim that not break down mentally, even if you ignore such insults, they are still irritating, making you restless and anxious. Despite all the adversities, we continue our work as we are aware that the patient is not to blame; they are incapacitated by the severe pain” (P: 13).

Nurses do not try to respond to intolerance, irritability, and aggressiveness on the part of patients and their attendants. They always assert that unbearable burn pain entitles patients to behave like that. This kind of attitude toward all the insults and anxieties caused by their patients emanates from nurses' conscience and constancy.

“If patients ask a nurse a question ten times, they will answer every ten times. Patients' and their attendants' degree of literacy determines their level of mutual understanding. There are times when the attendants themselves are the problem and they themselves need to be accompanied and cared for as they lack the ability to do their own tasks” (P: 17).

Prevention is worth a pound of cure

Excruciating pain is caused by burn injuries, and pain relief interventions are usually temporary. After short-lived pain relief, the pain roars again with scathing harshness, putting an end to the patient's endurance. The nurses believe that the patient's cooperation is needed for pain relief, so they do to the best of their ability to build up their motivation and increase the patient's self-efficacy to boost their tolerance.

Unique clinical methods

Nurses utilize a variety of nursing art, intuition, and scientific evidence to remedy patients' wounds and relieve their pain.

“I usually speak in Mazandarani dialect with patients who are old. We tell jokes to them and then they state the pain did not hurt me today at all as we laughed! They sing poems or tell old proverbs in Mazandarani” (P: 4).

Working based on personal experience and medical progress has lessened patients' pain compared to the past.

“Now we utilize sterile, silver dressings on the patient's wound, and as a result, they suffer less pain as such gauze dressings are lighter. In the past, we used to employ silver dressings on burn wounds using gloves. Yet, nowadays, the silver remains on the dressings keep them moistened, hence their easier removal and patients' much less pain.” (P: 18).

Enhanced frustration tolerance through self-motivation and self-efficacy

When burn patients see the wounds and burn injuries on their bodies, along with the resultant extreme pain and suffering, they seem to be sunk into an inescapable quagmire. Nurses instill confidence and positive thinking into patients, trying to remind them of their natural body strength in rehabilitation and recovery.

“Higher life expectancy releases a series of wound-healing substances in patients' bodies. Patients are encouraged to keep telling themselves that they will rehabilitate and meet their family soon.

The effect of nutrition, mobility, and hope on patients' recovery is far greater than that of physicians, nurses, ointments, and dressings” (P: 13).

Raising patient's hope in despair

Patients' unawareness of burn wounds, extended hospitalization, and the gradual healing process leads to increased patient anxiety and stress, making the pain even more unbearable.

“We inform them that the burn wounds healing process has a natural procedure, show them photos of their wounds at an earlier time and assure them how improved they are after healing. In doing so, we keep the light of hope in their hearts alive, thereby facilitating their pain tolerance.” (P: 17).

Undisputed dominance of nursing art

Employing an artistic approach, the nurses pave the way for the patient's recovery in different dimensions and make efforts to decrease their pain and suffering.

Reducing unsettling experiences

The patients undergo such unimaginable pain and suffering that make them restless and easily agitated. Close encounters with patients who have grievous and crushing wounds that cause frustrating groans have made nurses employ their art of care to lessen the pain and alleviate the transfer of such bitterness to other patients.

“A few days ago, we were treating a moribund patient. I showed him several appreciation letters delivered to the treatment staff from patients who struggled with death but survived. Upon seeing the photos, suddenly the eruption of overwhelming emotions within him subsided. He said quietly and with a smile what a useless preoccupation he had. Then, he thanked me” (P: 8).

Burnt and ripped body rehabilitation

The nurses take care of burn wounds in a skillful and artistic manner as if they are mending this fully ripped and broken china of burnt body, transforming it into a usable whole. A middle-aged man electrocuted during welding work in a building and lost his left leg to amputation. After four months of receiving treatment and care and at the time of discharge from the hospital, he felt a deep appreciation for the nurses for the value they put on his ripped body. Now, it is his responsibility to love his body and himself.

Patient stress management and avoidance of false hope

The nurses tend to communicate the painful news of the patients' changed body shape and appearance due to burning injuries through a certain process. They usually avoid giving false hope. Conveying the hot truths about their burnt body to patients seems like walking on a razor's edge, an art fully recognized by patients.

“When a patient asks me if his/her burnt body parts will recover or not I try to make the patient obtain an understanding of his/her status over time and within a few weeks that there's only a fifty-fifty chance that you get a scarred face” (P: 11).

Discussion

Bending over backward, prevention is worth a pound of cure and undisputed dominance of nursing art were the main themes that represented the culture of nursing burn injury pain. Highly tenacious and devoted burn unit nurses performed to their fullest to reach a thorough and profound understanding of their patients and made great contributions to the care process with the aim of removing cultural barriers such as false beliefs and traditions. Pain experienced by burn patients was excruciating and even sometimes intolerable as if they had no more vigor and strength left in their body.

The desperate burn patients are away from their homes for weeks and months, are deprived of the warmth of family hugs, and are distanced from the love of their mothers and wives. All these repressed desires make them void of any feelings, emotions, and charms in their eyes and faces. Their hope is buried under the thick layer of despair. The immense burden of alleviating the physical and mental pains plaguing burn patients drains nurses' patience and strength and severely impacts their personal lives.

Costa et al., (2003) also came to the conclusion that burns unit nurses share common suffering, yet they work arduously and provide care to their patients with compassion and devotion.[13] Nurses' uncomplaining attending to the burn patients' wistful sighs and groans that tremble the doors and walls in the burns unit, their understanding of the patient's agitation and unease emanating from the suffering of their burnt and ripped bodies and faces, their reticence and huge tolerance, and satisfying the needs of their patients have only one meaning: “that the patient is always right.” It shows the zenith of the nurses' conscience and commitment. They may suffer deep inside, yet they never fail to fulfill their obligation.

The findings of Tetteh et al (2021). revealed that nurses have the ability to assess the severity of a patient's pain through their mental and perceptional skills. They endured patient screams, sighs, moans, frowns, loss of sense of humor, and body language to better understand the depth and intensity of their pain. Then, they employed these perceived behaviors to optimally manage their pain and suffering.[14]

Nurses tended to anticipate the patient's state before the excruciating and agonizing pain extremely plagued them, thereby preventing more dire conditions and incidents. Their verbal and nonverbal communication with patients and their tolerance of patients' complaints about the nursing service provided the patients with the opportunity to clearly see their pain experience. In doing so, they would draw the nurse's attention to listen to, answer their questions, and explain all care steps.[15] The tender hands of burns unit nurses would alleviate the unendurable pain and suffering caused by burn wounds. The benevolence and affection, which is typical of nurses, are derived from the culture and experience of coexistence with patients. Furthermore, an application of new scientific methods through intuition and evidence-based knowledge enables nurses to heal the wound and pain based on each patient's specific condition.

Burns unit nurses formed an effective and useful communication with patients through pleasures, jokes, and joys present in patients' traditions and cultures of the patients. They would recall good memories by sharing poems and proverbs in the patients' local language. In doing so, the nurses raised patients' motivation and built up their hopes, tolerance, and self-efficacy.

The last tactic employed to alleviate and ease the pain and suffering of burn patients was nurses' eloquence and prowess in the use of charming language, which amazed all the attendants. By communicating the pleasing and exciting experiences of discharged burn patients, the nurses would build up patients' hopes for the future in the form of soothing language and words.

Care delivered to burn patients should feature adequate communication, the devotion of time and response to their regular requests, and thorough support such that patients are able to voluntarily and willingly express their feelings and concerns.[16]

This study was an attempt to reveal attention to the covert and nuanced aspects of caring for burn patients using the purest human attributes and unique clinical skills. It is indicative of the undisputed dominance of nursing art. In two-four-bed rooms, burn patients are readily impacted by each other such that if a patient is moaning in pain, others tend to undergo the same condition. Nurses with greater amounts of experience reduce burn patients' pain and anxiety through a shred of objective evidence and enhance awareness of the patients, thereby preventing the transmission of unpleasant experiences to other patients. In actuality, nurses position themselves among patients to provide them with emotional support and rid patients of mutual, negative influence from each other. The nurses endeavor to the best of their potential through explanation and clarification to make patients understand that each disease has its own healing process, and each individual has their own distinctive defense system and physiological ability. They keep reminding their patients that the severity and degree of burn injuries are also different, thereby requiring a unique and specific treatment and care response.

Pain management in burn injuries is exceedingly demanding and demands not only great knowledge and experience but also special attention and concentration. Nurses can provide high-quality care through the employment of their experience and in accordance with patients' individual needs and cultural, economic, and social conditions. It makes a prominent contribution to speeding up the treatment and particularly reducing the duration of hospitalization.[17]

The fright that burns pain and suffering generate will permeate the patient's mind not only during hospitalization but also for years, thereafter lasting sometimes even for the rest of their life. On the one hand, creating a balance between the avoidance of delivering false hope to the patient and avoidance of statements that disappoint the patient poses a huge challenge to nurses.

Psychologically, patients encounter unbearable amounts of pain. Thus, they expect the care treatment team to have an accurate understanding of the realities of the patients' suffering, and in turn, to adopt appropriate pain control mechanisms.[18]

The culture of nursing care in burns units comprises a combination of scientific guidelines and rules emanating from the traditions and beliefs of each patient, along with particular nursing experiences. Certain experiences in the cultural context offer both the undesirable and pleasant ones in the past that are now viewed as a guiding care model. Although the caregiving process has its adversity and problems and will lead to significant decreases in nurses' physical and emotional strength in the long run, what happens at the moment is an inner call that hones the ears and arouses the hearts. Beyond all administrative rules and instructions lies the extraordinary power of nurses' conscience, instilled into burnt patients and refining their bodies and mind.

Strengths and limitations

The limitation: This study was conducted during the covid-19 pandemic; therefore, patients who had burns and covid-19 were hospitalized in certain departments, and therefore it was not possible to access them. One of the strengths of this study is the variety of burn departments studied (reconstruction department, women's, men's, children's burn department, special care burn department). The main researcher had experience working in the burn departments, and one of the researchers was expert in ethnography.

Conclusion

This study has reverberated the passionate calling and inner howl of burn unit nurses who are the epitome of an Iranian nurse. This study also showed the most covert and hidden aspects of oppression and repression that have been inflicted on this distinguished and revered class of society over the years. Such incidents have led to nurses' reduced physical and emotional caring processes. Beyond all administrative rules and instructions lies the extraordinary power of nurses' conscience, instilled into burnt patients and refining their bodies and mind. The pain caused by burn injuries is an excruciating experience. The wearing hospitalization days that patients spend with discontentment and disappointment incur a much more immense burden on the shoulders of nurses as they attentively listen to the painful stories of patients to turn the illusion of pain relief into a soothing reality. Despite the high physical and mental pressure, burn unit nurses employ their art of nursing to keep the candle of hope lit during the dark moments of pain and suffering. Likewise, the nurses' power of intuition and their exact understanding of their patients' minds and souls permeate hearts as if they are a cool and calm breeze caressing the burn patients' suffering. The results of the present study can be an introduction to further research: a) investigating the art of nursing in burn ward from the perspective of patients, b) development of an instrument for perceived suffering among nurses using a mixed method study, and c) conducting ethnography research among other ethnicity groups.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.