Recommendations for nursing diagnoses for burn victims undergoing prolonged field care in China: a Delphi study

Abstract

Aim

To construct a nursing diagnosis index system for burn patients under prolonged field care (PFC).

Design

A modified Delphi study.

Setting

13 class A tertiary hospitals and 2 universities.

Participants

Nine experts were selected for expert interview: (1) bachelor’s degree or higher; (2) ≥10 years’ experience in burn care, nursing quality management or health service management, including participation in ≥3 PFC operations; (3) intermediate or higher professional title; (4) willingness to participate. 22 experts were selected for expert consultation: (1) bachelor’s degree or higher; (2) ≥3 years’ nurse management experience with theoretical expertise in burn nursing diagnosis; participation in ≥3 major non-combat military operations; (3) intermediate or higher professional title; (4) commitment to complete consultations.

Interventions

Including a two-stage process: (1) system construction: developed a preliminary index system using The North American Nursing Diagnosis Association international’s framework, guided by US military ‘10 PFC Core Competencies’ and UK military SHEEP VOMIT standards, via literature analysis and expert interviews. (2) Delphi refinement: conducted three Delphi rounds with 22 experts. Finalised indicators using Analytical Hierarchy Process to assign weights.

Results

The burn PFC nursing diagnosis index system established in this study comprises 7 primary indicators, 18 secondary indicators and 44 tertiary indicators. The valid questionnaire response rate for the expert consultation reached 100%, with an expert authority coefficient of 0.85. After three rounds of the Delphi expert consultation, Kendall’s coefficient of concordance (Kendall’s W) for indicators at all levels ranged from 0.104 to 0.305 (p<0.001), indicating a convergence of expert opinions. Regarding weight distribution, the top three weighted primary indicators were Safety/Protection, Nutrition and Elimination/Exchange. The top three weighted secondary indicators were Risk of Physical Injury, Thermoregulation and Coping Responses. The top three weighted tertiary indicators were Risk for Electrolyte Imbalance, Impaired Gas Exchange and Hyperthermia.

Conclusion

This systematic, scientific and rational index system provides a foundation for standardising burn PFC nursing plans, potentially enhancing care quality and efficiency in PFC settings.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Research innovation: this study pioneers the integration of the civilian North American Nursing Diagnosis Association international nursing diagnosis system with military prolonged field care (PFC) framework, establishing the first standardised burn PFC nursing diagnosis index system with methodological originality.

• Methodological strength: the enhanced quantitative-driven Delphi approach effectively mitigates inherent constraints of field-based research paradigms.

• Sampling limitation: while Delphi participants (N=22) were selected for their authoritative expertise and geographical representation, the restricted sample size and incomplete disciplinary/regional coverage necessitate cautious interpretation of results due to potential cognitive/professional biases.

• Anonymity constraint: preserved anonymity limited discursive depth during consensus-building, and iterative feedback rounds may have marginalised dissenting perspectives.

• Validation gap: despite achieving three-round Delphi consensus, clinical validation remains pending to confirm operational utility.

Introduction

Burns represent one of the most common injuries in contemporary and projected conflict scenarios, frequently presenting with complex comorbidities including blast injuries, inhalation injuries, carbon monoxide poisoning, smoke intoxication and heavy metal poisoning. These multidimensional trauma profiles result in exceptionally severe clinical presentations.¹ During Operation Iraqi Freedom and Operation Enduring Freedom, burns accounted for approximately 5% of all military casualties.² Historical combat data confirms persistently high mortality rates associated with wartime burns.^{3 4} Comparative analyses demonstrated that combat-related burns exhibit significantly higher Injury Severity Scores, greater incidence of inhalation injuries, deeper burn depths, elevated mortality rates relative to civilian burns.^{5 6} A retrospective review of burn admissions to the US Army Burn Center ICU (intensive care unit) (January 2001 to September 2018) revealed that severe burn cases required mean ICU hospitalisation of 12–29 days, and mechanical ventilation duration of 6–14 days.² These complex care requirements substantially impede both on-site resuscitation and evacuation of burn casualties in combat settings.

Despite longstanding recognition that prompt effective intervention substantially reduces wartime burn mortality and disability, operationalisation remains challenging. This paradox stems from the fundamental conflict between immediate intervention necessity and wartime resource acquisition constraints.⁷ Military medical personnel must deliver specialised burn care at point of injury—stabilising casualties (particularly severe burns) using available resources—rather than prioritising evacuation.⁷ However, frontline medics often lack such capabilities due to (1) insufficient prolonged field care (PFC) training; (2) skill attrition during extended deployments; (3) resource shortages impeding basic 24–48 hours fluid resuscitation.⁸ The most critical challenges in PFC settings include: unstandardised care protocols for combat medics, ambiguous nursing diagnoses during extended burn patient evacuations and absent nursing planning in battlefield chaos. Establishing burn-specific nursing diagnoses and targeted care plans for PFC operations would provide military paramedics with a standardised training framework adaptable to prolonged evacuation scenarios. This approach would significantly enhance casualty care capabilities during patient transport through structured clinical guidance.

Background

PFC refers to medical interventions exceeding standard evacuation windows, delivered in remote, resource-constrained environments. Its primary objective is stabilising critically injured casualties until definitive medical treatment becomes available.⁹ The concept of PFC was originated from US Special Operations Forces’ operational necessity to evacuate casualties from remote, austere environments. Given constraints imposed by battlefield conditions, geographical isolation and transport limitations, most military forces globally cannot deliver optimal care within the critical ‘golden hour’ time frame.10,12 A significant proportion of combat casualties require PFC due to evacuation constraints in austere environments.¹³

The core challenge of PFC lies in delivering advanced life support to critically injured casualties under resource-constrained combat settings. Forward medical personnel in conflict zones often operate without clinical supervision, adequate support or established medical infrastructure.⁹ Therefore, enhancing frontline medical personnel’s PFC proficiency—particularly in managing critical casualties—is imperative to optimise survival duration and outcomes. Nursing constitutes the cornerstone of effective PFC clinical management.¹⁴ Nursing responsibilities in PFC encompass continuous patient monitoring, nutritional interventions, wound management, medication administration and daily care provision. These functions form the critical foundation for effective PFC delivery to critical casualties. However, unlike conventional hierarchical medical systems, PFC nursing operates with limited resources and requires autonomous clinical decision-making in austere environments.^{12 14 15} PFC situations present greater challenges due to limited resources and staff shortages. Given these constraints, it is imperative to enhance the efficiency and quality of nursing interventions as much as possible. However, previous research on PFC has not adequately addressed critical aspects.¹⁶ Furthermore, the development of standardised nursing protocols during PFC remains an area that has not been thoroughly investigated. The US Army Institute of Surgical Research Burn Center published its ‘Burn Wound Management in PFC (CPG ID: 57)’ guideline in 2017, focusing on airway control and evaluation of burn extent assessment within burn care. This guideline details management in nine key areas: airway management, fluid resuscitation, burn size assessment, monitoring, extremity burns, infection, pain management, telemedicine consultation and urine output. It also provides treatment protocols categorised as ‘best’, ‘better’ and ‘minimum’.⁹ Nevertheless, the guideline fails to provide recommendations based on nursing diagnoses and lacks a comprehensive explanation of standardised language.¹⁶ Furthermore, the 2018 guidelines on burn care in combat omitted standardised nursing procedures.¹

Standardised nursing languages (SNLs) primarily encompass three essential components of nursing practice: nursing diagnoses, outcomes and interventions.^{17 18} Due to their uniformity and systematisation, SNLs have been widely embraced by nursing staff,¹⁹ effectively facilitating advancements in both clinical nursing practice and research.²⁰ Nursing diagnosis, a crucial component of SNLs, accurately identifies the nursing problems and needs of patients, enabling timely interventions. This process ensures nursing care is cost-effective, safe, efficient and of high quality.²¹ The North American Nursing Diagnosis Association International (NANDA-I) classification system is the most widely acknowledged for nursing diagnoses worldwide. NANDA-I includes diagnoses only when substantial research and literature support them.²² Research demonstrates significant compatibility between NANDA-I, the Nursing Outcomes Classification (NOC) and the Nursing Interventions Classification (NIC) regarding nursing diagnoses, outcomes and interventions. Typically, the nursing process uses NNN linkages (NANDA-I, NOC, NIC) to create standardised nursing plans through the steps of assessment, diagnosis (NANDA-I), planning (NOC), implementation (NIC) and evaluation.²³ This approach effectively enhances the standardisation and efficiency of nursing while also facilitating communication among professionals.²⁴

The primary nursing challenges during the PFC phase stem from the uncertainty surrounding nursing diagnoses for combat casualties, particularly burn victims, during prolonged evacuation, coupled with the absence of standardised nursing plans in wartime settings. Shortages of medical personnel and challenging environmental conditions persist during combat operations or extended evacuations. Therefore, based on the NANDA-I framework, it is proposed to develop a standardised nursing plan for burn casualties in PFC. This standardisation could enhance the scientific rigour of nursing practices during prolonged evacuation, potentially improving frontline casualty care efficiency, patient outcomes and the quality of the tiered medical response system. However, no relevant studies addressing this specific need have been identified to date.

Research on nursing diagnosis, grounded in standardised nursing language methodologies, frequently employs the mapping approach and the Delphi method. The mapping approach involves gathering, analysing and extracting concepts from clinical nursing records, followed by aligning these concepts based on ideas, semantics and other factors.²⁵ The Delphi method relies on expert consensus as the primary basis for evaluating the suitability of terminology.²⁶ Given the nature of this study—aiming to develop an implementable wartime burn nursing protocol—access to genuine clinical scenarios and hands-on practical experience in real-world settings is limited. To enhance the thorough investigation of pertinent factors, this study used the Delphi method with proficient burn care and nursing professionals. Consequently, a standardised PFC nursing diagnosis checklist for wartime burn patients was developed to serve as a foundational resource for scholars conducting research in this field.

This study aims to develop a structured framework of nursing diagnoses for PFC in disaster or combat settings. By systematically organising and classifying potential nursing diagnoses for burn patients under PFC conditions, this framework will enable healthcare providers to rapidly identify core care priorities and optimise intervention strategies in similar austere environments. The research objectives are twofold: (1) to develop an adaptive nursing diagnostic index system applicable to extreme operational environments (combat zones/disasters). (2) To promote the translation of military PFC knowledge for civilian applications. These efforts establish a robust foundation for implementing a comprehensive ‘assessment-diagnosis-intervention-feedback’ cycle for burn care during PFC operations.

Methods

The modified Delphi study conducted by the research team consisted of three distinct methodological phases: (1) a systematic literature review, (2) in-depth expert interviews and (3) iterative Delphi consultation rounds.

Literature review

The US Prolonged Field Care Working Group identified 10 core capabilities for medical care in austere environments in 2014.²⁷ Continuously expanded, these capabilities include: injury monitoring, airway management, ventilation, advanced resuscitation, diagnostics, field surgery, sedation/analgesia, prolonged casualty care, telemedicine and evacuation preparation.⁹ Frameworks like HITMAN, developed by the British military,²⁸ and SHEEP VOMIT, developed by the College of Remote and Offshore Medicine (CoROM),^{29 30} were created to operationalise these capabilities.³¹ The acronym HITMAN stands for: (1) H: Head-to-toe check, Hydration, Hygiene, Heat; (2) I : Infection Control; (3) T: Tubes; (4) M: Medication; (5) A: Analgesia; (6) N: Nutrition, Nursing, Notes. Specifically, SHEEP VOMIT extends HITMAN’s Nursing (N) component to aid nurses in core duties,³¹ serving to aid nurses in recalling fundamental duties in nursing practice and ensuring their proper execution. This acronym symbolises several fundamental duties in PFC, encompassing: (1) S: Skin care (cleaning, moisturising and protecting); (2) H: Thermoregulation (preventing excessive heat or cold exposure); (3) E: Raising the head (upper body); (4) E: Physical activity (active or passive joint movement); (5) P: Mat/pressure point; (6）V: Monitoring and vital indicators recording; (7) O: Maintaining cleanliness and health of the mouth and nose; (8) M: Massage (to avoid deep vein thrombosis); (9) I: Ingesting/consuming food or beverages; (10) T: Rotating, expectorating or inhaling deeply. This study employs the factors for PFC framework of the US military and the SHEEP VOMIT assessment tool within the NANDA-I taxonomy.²⁸ Through a combination of literature review and expert interviews, the research comprehensively investigates and categorises potential PFC risk factors in burn patients.

Expert interviews

This study employed a purposive sampling to recruit experts specialising in military nursing, burn specialty and health services, focusing on nursing diagnoses for combat burn care in PFC settings. Using the NANDA-I framework, open-ended interviews were conducted. Inclusion criteria comprised: (1) a bachelor’s degree or higher; (2) ≥10 years of experience in burn care, quality control or health management, with participation in ≥3 PFC operations; (3) intermediate-level or higher professional certification; (4) voluntary interview participation. Expert panel size was determined by data saturation (consensus achieved when new participants yielded no novel information).^{32 33} Nine experts were enrolled (three burn care specialists, six military nursing experts), including four doctoral and five master’s degree holders. A preliminary PFC nursing diagnosis system was developed, comprising 7 primary domains, 18 secondary categories and 43 tertiary indicators.

Delphi technique

The Delphi expert consultation questionnaire was developed by consolidating the aforementioned indicator system into four sections: (1) guidelines outlining the study’s background, objectives, significance and Delphi methodology; (2) consultation form evaluating item significance via a 5-point Likert scale (highly significant to insignificant), with space for feedback; (3) expert demographic survey capturing professional field, age, experience, education and credentials; (4) form assessing expert decision-making basis and familiarity level. Technical specifications are provided in online supplemental appendix 1.

The Delphi expert panel was selected via purposive stratified sampling from military nursing, healthcare management and burn specialty nursing. Inclusion criteria comprised: (1) bachelor’s degree or higher; (2) competence in ≥3 major military operations with >3 years of nursing management experience and demonstrated expertise in burn nursing diagnosis; (3) intermediate or higher professional rank; (4) willingness to complete all consultation rounds. All 22 experts completed three Delphi rounds, with increasingly convergent opinions establishing the final index system (table 1).

Table 1. Profile characteristics of the experts (n=22).

Characteristics		N (%)
Age (year)	>50	6 (27.27)
	41–50	10 (45.45)
	≤40	6 (27.27)
Years worked in nursing management	>30	6 (27.27)
	21–30	7 (31.82)
	10–20	9 (40.91)
Expert location	Chongqing	7 (31.82)
	Shanghai	3 (13.64)
	Changsha	1 (4.55)
	Guangzhou	1 (4.55)
	Wuhan	2 (9.09)
	Xi'an	1 (4.55)
	Zhumadian	1 (4.55)
	Shenyang	1 (4.55)
	Chengdu	1 (4.55)
	Nanjing	2 (9.09)
	Beijing	1 (4.55)
	Urumqi	1 (4.55)
Educational background	Doctor	3 (13.64)
	Master	7 (31.82)
	Bachelor	12 (54.55)
Professional title	Professor	6 (27.27)
	Associate professor	10 (45.45)
	Nurse in charge	6 (27.27)
Subject category	Burn nursing	13 (59.09)
	Emergency nursing	5 (22.73)
	Field nursing	2 (9.09)
	Basic nursing	2 (9.09)

Delphi consultations were conducted via email and face-to-face interviews between July 2022 and April 2023. Each round incorporated personalised telephone interviews to clarify expert feedback and enhance data extraction. The research team systematically analysed responses and facilitated structured discussions.

The Analytical Hierarchy Process (AHP) was applied to determine weight coefficients for nursing diagnoses and assess indicator relevance within combat burn care systems during PFC scenarios. The methodological flow is presented in figure 1.

Figure 1. The Delphi survey rounds and design. The figure outlines the methodological steps involved in developing and refining a nursing diagnosis index system, including literature search, expert interviews, group discussions and three rounds of Delphi expert consultation. Key modifications to the indicator system at each stage are highlighted, culminating in a final system comprising 7 primary indicators, 18 secondary indicators and 44 tertiary indicators. The analytical hierarchy process was subsequently applied to evaluate the weights of all indicators. PFC, prolonged field care.

Data collection and analysis

Data were analysed using IBM SPSS Statistics V.23.0 to compute coefficients of variation (CV) and Kendall’s W, while YAAHP V.12.6 calculated hierarchical indicator weights. Expert consultation forms were distributed via email or in person. Ethical compliance ensured participant anonymity and mutual unawareness of others’ involvement. Confidentiality was maintained across all communication modes. Participants provided informed consent with withdrawal rights.

Expert engagement was measured by response rate (≥50% acceptable, ≥60% intermediate, ≥70% high). Authority coefficient (Cr=(Ca+Cs)/2) quantified reliability (Cr≥0.7 required), where Ca was judgement coefficient (table 2) and Cs familiarity coefficient. Post-consultation modifications were determined through data analysis, expert feedback and team discussions. Indicators were deleted if meeting any criterion: (1) mean score <4; (2) CV>0.3; (3) consensus rate (proportion scoring ≥4) <70%; (4) full-score rate (K)<20%. New indicators required endorsement by ≥2 experts. Revised questionnaires presented prior-round scores and modifications iteratively until consensus metrics were met. The level of expertise consensus is detailed in online supplemental appendix 1.

Table 2. Value assignment of Ca coefficient.

Criteria used by experts to make decisions	Mostly dependent	Moderately dependent	Lightly dependent
Empirical knowledge	0.5	0.4	0.3
Rational analysis	0.3	0.2	0.1
Referencing academic literatures	0.1	0.1	0.1
Intuition	0.1	0.1	0.1

The final AHP-weighted system required consistency ratio ≤0.1 for validity.

Research bias control and quality assurance

To mitigate Delphi study bias, quality control measures included: (1) recruiting multidisciplinary military healthcare experts (medicine, nursing, management) from diverse regions to counteract homogeneity bias; (2) applying stringent selection criteria ensuring expert competency³⁴; (3) validating questionnaires through iterative phrasing refinement and pilot testing; (4) maintaining anonymous consultations³⁵ with iterative feedback and flexible timelines until result stability; (5) implementing mixed-methods analysis with data integrity verification and expert consultation for anomalies.

Results

Assessment of scientific rigour and reliability

Three rounds of Delphi consultations were conducted, with all 22 distributed questionnaires collected per round (100% response rate). The expert authority coefficient Cr, calculated as (Cs=0.773+Ca=0.936)/2=0.85 (>0.7 threshold), confirms result reliability. Kendall’s W coefficients ranged 0.104–0.305 (p<0.001), demonstrating significant consensus (table 3).

Table 3. Results of Kendall consistency test for each round.

Scoring criteria	Data
	W value	Χ2	df	P value
Round 1
Primary indicator	0.213	18.16	6	<0.001
Secondary indicator	0.263	98.5	17	<0.001
Tertiary indicator	0.305	281.638	42	<0.001
Round 2
Primary indicator	0.104	13.765	6	0.032
Secondary indicator	0.117	67.314	18	<0.001
Tertiary indicator	0.160	186.65	53	<0.001
Round 3
Primary indicator	0.271	35.793	6	<0.001
Secondary indicator	0.172	64.301	17	<0.001
Tertiary indicator	0.173	163.72	43	<0.001

Modifications to indicators during the Delphi process

During Round 1, expert feedback highlighted the need to differentiate nursing management across battlefield, disaster and ward settings while comprehensively evaluating burn patients’ conditions, environments and equipment. Incorporating data analysis and 32 revision suggestions from 7 experts, the indicator system was restructured into 7 primary, 19 secondary and 54 tertiary indicators.

Round 2 integrated 50 suggestions from 8 specialists, emphasising deeper integration of PFC principles with burn-specific characteristics. Key modifications addressed differential care based on evacuation timelines and transportation factors in remote/high-altitude regions. This yielded 7 primary, 18 secondary and 44 tertiary indicators.

Round 3 retained all indicators meeting predefined criteria (significance scores >4, 100% consensus, CV 0.00–0.19). Finalised through Delphi completion, the burn PFC nursing diagnostic system comprises 7 primary, 18 secondary and 44 tertiary indicators (table 4; expert comments in online supplemental file 2).

Table 4. Burn PFC nursing diagnosis index system and key parameters.

Primary indicator	M±SD	Weight	CV	Secondary indicator	M±SD	Weight	CV	Tertiary indicator	M±SD	Weight	CV
I-1 Nutrition	5.00±0.00	0.1856	0.00	II-1 Ingestion	4.82±0.59	0.0463	0.12	III-1 Impaired swallowing	4.73±0.55	0.0227	0.12
								III-2 Imbalanced nutrition: less than body requirements	4.91±0.29	0.0236	0.06
				II-2 Metabolism	4.86±0.47	0.0684	0.10	III-3 Risk for unstable blood glucose level	4.77±0.53	0.0229	0.11
								III-4 Risk for impaired liver function	4.64±0.58	0.0222	0.13
								III-5 Risk for impaired kidney function	4.86±0.35	0.0233	0.07
				II-3 Hydration	5.00±0.00	0.0709	0.00	III-6 Risk for electrolyte imbalance	5.00±0.00	0.0240	0.00
								III-7 Deficient effective circulating blood volume	4.95±0.21	0.0238	0.04
								III-8 Risk for deficient effective circulating blood volume	4.82±0.39	0.0231	0.08
I-2 Elimination and exchange	4.95±0.21	0.1627	0.04	II-4 Urinary function	4.86±0.35	0.0233	0.07	III-9 Abnormal urination	4.86±0.35	0.0233	0.07
				II-5 Gastrointestinal function	4.86±0.47	0.0455	0.10	III-10 Dysfunctional gastrointestinal motility	4.86±0.47	0.0233	0.10
								III-11 Risk for dysfunctional gastrointestinal motility	4.64±0.58	0.0222	0.13
				II-6 Respiratory function	4.96±0.21	0.0939	0.04	III-12 Impaired gas exchange	5.00±0.00	0.0240	0.00
								III-13 Impaired spontaneous ventilation	4.77±0.61	0.0230	0.13
								III-14 Ineffective breathing pattern	4.82±0.50	0.0231	0.10
								III-15 Ineffective airway clearance	4.96±0.21	0.0238	0.04
I-3 Activity/rest	4.73±0.46	0.0650	0.10	II-7 Sleep/rest	4.73±0.46	0.0227	0.10	III-16 Disturbed sleep pattern	4.73±0.46	0.0227	0.10
				II-8 Activity/exercise	4.55±0.60	0.0423	0.13	III-17 Impaired bed mobility	4.27±0.70	0.0205	0.16
								III-18 Impaired movement capability	4.55±0.60	0.0218	0.13
I-4 Perception/ cognition	4.59±0.50	0.0667	0.11	II-9 Cognition	4.59±0.67	0.0445	0.15	III-19 Labile emotional control	4.86±0.35	0.0233	0.07
								III-20 Deficient knowledge	4.41±0.67	0.0212	0.15
				II-10 Communication	4.73±0.55	0.0222	0.12	III-21 Impaired communication	4.64±0.49	0.0222	0.11
I-5 Coping/ stress tolerance	4.82±0.39	0.1561	0.08	II-11 Post-trauma responses	4.68±0.48	0.0451	0.10	III-22 Post-trauma syndrome	4.86±0.35	0.0233	0.07
								III-23 Risk for post-trauma syndrome	4.55±0.67	0.0218	0.15
				II-12 Coping responses	4.64±0.49	0.1110	0.11	III-24 Anxiety	4.64±0.58	0.0222	0.13
								III-25 Defensive coping	4.55±0.67	0.0218	0.15
								III-26 Fear	4.68±0.48	0.0225	0.10
								III-27 Death anxiety	4.55±0.60	0.0218	0.13
								III-28 Ineffective coping	4.73±0.55	0.0227	0.12
I-6 Safety/ protection	4.86±0.35	0.2069	0.07	II-13 Infection	4.86±0.47	0.0231	0.10	III-29 Risk for infection	4.82±0.50	0.0231	0.10
				II-14 Physical injury	4.96±0.21	0.1151	0.04	III-30 Risk for shock	4.86±0.47	0.0233	0.10
								III-31 Impaired skin/tissue integrity	4.82±0.39	0.0231	0.08
								III-32 Risk for impaired skin integrity	4.55±0.67	0.0218	0.15
								III-33 Risk for suffocation	4.91±0.29	0.0236	0.06
								III-34 Risk for deep vein thrombosis	4.86±0.35	0.0233	0.07
				II-15 Cardiovascular	4.73±0.46	0.0687	0.10	III-35 Risk for decreased cardiac output	4.77±0.43	0.0229	0.09
								III-36 Risk for unstable blood pressure	4.73±0.55	0.0227	0.12
								III-37 Risk for ineffective tissue perfusion	4.82±0.50	0.0231	0.10
I-7 Comfort	4.50±0.51	0.1571	0.11	II-16 Thermoregulation	4.91±0.29	0.1130	0.06	III-38 Hyperthermia	5.00±0.00	0.0240	0.00
								III-39 Hypothermia	4.91±0.43	0.0236	0.09
								III-40 Risk for hyperthermia	4.59±0.59	0.0220	0.13
								III-41 Risk for hypothermia	4.46±0.80	0.0214	0.18
								III-42 Ineffective thermoregulation	4.59±0.73	0.0220	0.16
				II-17 Physical comfort	4.68±0.48	0.0236	0.10	III-43 Acute pain	4.91±0.29	0.0236	0.06
				II-18 Environmental comfort	4.32±0.72	0.0205	0.17	III-44 Impaired comfort	4.27±0.83	0.0205	0.19

CV, coefficients of variation; M, mean; PFC, prolonged field care; SD, standard deviation.

Discussion

The necessity of establishing nursing diagnosis indicators for burn care in PFC

Military wartime rescue tactics frequently provide efficient strategy models for civilian trauma rescue. PFC during evacuation has garnered increasing attention, driven by accumulated practical experience in combat casualty management and extensive analysis of related challenges. Continuous monitoring and resuscitation are crucial determinants of patient prognosis, particularly for severe burn victim. Consequently, implementing effective PFC remains an urgent priority requiring immediate resolution.³⁶ Different environments significantly impact burn nursing during PFC.³⁷ For example, tropical island’ high humidity promotes skin diseases and accelerates bacterial growth in combat settings, increasing risks of severe wound infections and delayed healing.³⁸ Conversely, desert conditions with extreme diurnal temperature variations predispose casualties to electrolyte imbalances, causing excessively dry wounds and complex wound management challenges.³⁹ These environmental factors substantially compromise PFC nursing quality. While existing studies address burn evaluations, diagnoses, interventions and issues like poor healing, end-of-life care, disfigurement, psychological distress and social withdrawal,¹ PFC-specific scenario analysis remains lacking.

To efficiently address any prolongation in the evacuation of casualties in the future, it is imperative to proactively establish a comprehensive and evidence-based training programme for military paramedics. This training should be regularly updated to ensure that military paramedics maintain their proficiency at an elevated standard. While there have been previous studies and debates on this subject in different nations, this study is the first to specifically examine nursing diagnoses and nursing difficulties.

Scientific basis for PFC burn nursing diagnosis indicators

This study addressed research gaps by constructing the indicator system based on PFC’s 10 core capabilities and the SHEEP VOMIT framework. These frameworks guide paramedics in critical tasks—injury monitoring, airway management, ventilation, resuscitation, field surgery and evacuation—while highlighting the centrality of nursing in PFC. The resulting system standardises care for severe burns during field care and serves as a benchmark for military nursing training.

The British military has developed the abbreviations HITMAN²⁸ while CoROM has established SHEEP VOMIT. These abbreviations have significantly advanced the comprehension of nursing protocols during PFC. Through rigorous analysis of both frameworks, scholars prioritised crucial nursing requirements to reduce mortality and disability rates. Consequently, they constructed a burn PFC nursing diagnosis index system focused on pivotal concerns. During PFC, burn patients present primary nursing demands encompassing the following aspects: first, burn patients undergoing PFC often experience significant exudate loss, leading to critical complications including hypovolaemic shock, hypoalbuminaemia, hypercoagulability, stress-induced renal injury and gastrointestinal damage. Establishing an efficient emergency response system is therefore imperative. To enhance fluid-electrolyte elimination capacity, immediate interventions must include securing intravenous access, initiating time-sensitive fluid resuscitation, implementing optimised nutritional support and protecting gastrointestinal mucosa and renal function. Second, wound pain in burn patients can trigger pain-induced hypertension, vital sign instability and heightened anxiety—particularly during PFC. Consequently, strengthening continuous vital sign monitoring, implementing effective pain control protocols and enhancing patients’ stress tolerance through cognitive restructuring are critical priorities. In addition, hypothermia secondary to burn-induced thermoregulatory failure requires urgent intervention. Given the critical impact of core temperature on cardiovascular stability, implementing active rewarming protocols is essential to preserve physiological integrity. Furthermore, systemic absorption of burn toxins combined with bacterial proliferation significantly increases sepsis risk, necessitating vigilant monitoring for infection signs, tissue damage mitigation and targeted cardiovascular support.

Significance of constructing a burn nursing diagnosis indicator system for PFC

The development of this evidence-based nursing diagnosis indicator system fundamentally addresses critical gaps in PFC for burn casualties. By integrating the NANDA-I taxonomy with comprehensive literature analysis and structured expert interviews, we systematically identified and categorised potential PFC nursing diagnoses. Through three iterative Delphi rounds, we refined a diagnostic framework comprising seven core domains—Nutrition, Elimination and Exchange, Activity/Rest, Perception/Cognition, Coping-Stress Tolerance, Safety/Protection and Comfort—encompassing 44 nursing diagnoses. This system uniquely translates complex burn management priorities into actionable interventions within resource-constrained PFC environments. Its phased implementation strategy prioritises foundational indicators for initial training while progressively integrating advanced elements based on resource availability.

This study advances PFC standardisation, triage efficiency and casualty outcomes through three innovations: (1) an evidence-based diagnostic framework standardising clinical nursing decisions for core challenges (eg, hypovolaemic shock, pain-induced hypertension, hypothermia); (2) operational efficiency via integrating SHEEP VOMIT/HITMAN to pre-identify nursing diagnoses, reducing triage errors and increasing throughput; (3) trauma-informed care using a comprehensive diagnostic index refining plans to mitigate psychological trauma and improve outcomes. Although multinational studies have previously examined aspects of this field, this research constitutes the first explicit investigation into nursing diagnoses and associated challenges within PFC contexts.

Limitations of the research methodology

The study’s limitations might encompass five key dimensions: (1) expertise-dependent bias: individual experts’ cognitive limitations, professional predispositions and groupthink tendencies may introduce systematic biases—for instance, military practitioners might overgeneralise combat-specific protocols to civilian contexts. (2) Methodological constraints: while Delphi anonymity reduces interpersonal pressure, it limits discursive depth and iterative rounds risk marginalising dissenting perspectives, thereby suppressing innovation. (3) Sampling limitations: although the 22-expert panel meets methodological thresholds, incomplete disciplinary diversity and geographical representation may compromise extrapolation validity. (4) Validation deficits: despite achieving tri-round statistical consensus, the lack of clinical field trials leaves the operational efficacy of diagnostic indicators unvalidated. (5) Framework applicability: the indicator system, built on the US military’s 10 core PFC competencies and the UK’s SHEEP VOMIT may encounter implementation barriers in resource-constrained environments.

Conclusion

This research synthesise current PFC literature by integrating the HITMAN and the SHEEP VOMIT framework, employing a rigorously enhanced Delphi methodology to construct a specialised nursing diagnosis indicator system for burn casualties. The system holds significant reference value for mass casualty rescue in burn disasters, particularly during prolonged evacuation scenarios. This evidence-based foundation enables the development of innovative, applicable prehospital burn care training programmes. Subsequent research phases will: (1) conduct predictive validation studies using case data to establish a nursing diagnosis risk stratification system; (2) generate predictive insights through empirical data integration; (3) calculate individualised PFC nursing risk scores for burn patients using multidimensional variables; and (4) provide actionable feedback to healthcare administrations. By predictably identifying burn PFC capability gaps, this study delivers practical value for health service planning while optimising combat medic training programmes to enhance proficiency in complex and conflict environments.

Data availability statement

Data are available upon reasonable request.