Knowledge and Practice of Fluid Resuscitation in Acute Burn Management: A Survey of Nursing and Midwifery Students

ABSTRACT

Aim

To assess the nursing and midwifery students' knowledge and practice regarding fluid resuscitation during the acute phase of burn management.

Design

A cross‐sectional, descriptive design was employed.

Methods

The data were collected using an online‐administered questionnaire at a governmental university among nursing and midwifery students, who were selected purposively. The instrument consisted of three sections. The first section covered participants' characteristics, including age, sex, marital status, academic program, level of study, grade point average (GPA) and residency. The second section is self‐reported and composed of 10 questions to assess the students' knowledge domains, and the third section is also self‐reported and composed of 11 questions to assess participants' practice regarding practice; each question received a binary response based on whether or not students completed a specific practice.

Results

The study of midwifery and nursing students reported that they had an average knowledge (73.58%) of fluid monitoring, with 96% comprehending fluid balance, but only 28.4% being able to calculate fluids using the Parkland formula. In practice, participants demonstrated a high level of compliance (94.89%) with documentation of fluid administration; however, adherence was notably lower (85.7%) for the application of the rule of nines during assessment.

Patient Contribution

Midwives and nurses draw clinical judgements based on their academic and professional experience, as well as scientific facts. Theoretical knowledge can help support and improve health practices. A strong intellectual background is essential for providing appropriate care throughout the acute phase of burn management. Future research could incorporate direct observation methods to validate self‐reported findings and assess the translation of theoretical knowledge into clinical practice.

1. Introduction

Burn is damage to the skin or other organic tissue that is mainly caused by heat, radiation or radioactivity, electricity, friction, or contact with chemicals (Sharma and Garg 2019). Burn is a major cause of mortality and disability in developing countries (Odondi et al. 2020). According to World Health Organisation (WHO) records, approximately 180,000 people die from burns every year (WHO 2018). Globally, 70% of all burn cases occur in the low‐ and middle‐income nations, and over two‐thirds of these cases take place in the African and South‐East Asia areas (James et al. 2020; Stokes and Johnson 2017). Most of these burns are preventable, not fatal and not particularly dangerous (Alistwani et al. 2022). Codner et al. (2021) reported approximately 18,289,496 burn cases and 308,361 deaths occurred in the Middle East region over a period (1990–2017). However, limited attention is addressed to obtaining an epidemiological record regarding burn incidence in Jordan (El‐Maaytah et al. 2019; Hamdan 2018).

Burn injuries are a serious health problem that has significant negative impacts on the population in the community (Mortada et al. 2020). In addition, burns have significant systemic effects that can cause serious complications or even death, depending on the extent, depth, underlying cause, victim's exposure to smoke and other factors (Viana et al. 2020). Among burn patients, serious wound infections, hypovolaemia, hypothermia and respiratory problems are the primary causes of illness and death (Safiya and Annu 2022).

Acute‐phase management of critically burned patients includes together emergency resuscitation and long‐period rehabilitation. Prioritising the airway, breathing and circulation is essential for emergency management, with the long‐term care focus on wound healing, sepsis prevention, control of the hypermetabolic sequences and multiple system disorders (Greenhalgh 2019).

The term fluid balance refers to the equilibrium between the body's fluid intake and output, which is necessary for metabolic processes to function properly (Welch 2010). Critically ill and other hospitalised patients frequently have electrolyte imbalances (Varghese et al. 2018). Certain illnesses or diseases such as burns can directly contribute to fluid and electrolyte imbalances (Peter 2018). According to recent studies, fluid and electrolyte imbalances in critically ill patients are linked to higher morbidity and mortality rates (Peter 2018). In this regard, one of the main issues following severe burns is fluid loss (Atuhaire et al. 2022). About 100–300 mL of fluid is lost every hour on average by burn patients; an extensive burn may result in water loss of up to 350 mL per hour (Grace 2016). Thus, the adequacy of fluid administration should be confirmed (Regan and Hotwagner 2023).

The goal of fluid resuscitation for critically burned patients is to replenish lost extracellular fluid in order to preserve end‐organ perfusion and avoid burn shock. More vigorous fluid resuscitation is needed for these patients because their capillary leak is significantly greater than that of septic or trauma patients (Radzikowska‐Büchner et al. 2023). Also, proper fluid resuscitation directly improves the critically burned patient's outcome (Causbie et al. 2021). However, in accordance with the guidelines of the American Burn Association, fluid resuscitation should be initiated for both adult and paediatric patients whose burns exceed 20% of their entire body surface area by their weight and the area of their body that has been burned (Cartotto et al. 2024).

The key components for fluid resuscitation for burn patients are based on body surface area (BSA). Body weight and the percentage of BSA burned are the two primary factors used in all current resuscitation formulas and techniques for burn patients (Ouda Awad et al. 2020). Nowadays, one of the most commonly used formulas for fluid resuscitation for burn patients is the Parkland formula, which was developed in 1968 by Baxter and Shires (Baxter and Shires 1968). According to the recommendations of the American Burn Association's Advanced Burn Life Support program, this formula now calls for 2–4 mL of Ringer's lactate (RL) solution per kilogram of body weight per % of burned body surface area in adults (Guilabert et al. 2016).

On the other hand, fluid administration for burn patients remains a challenge. Inadequate fluid balance monitoring, particularly in critically ill patients, can worsen patients' health (Mohamed Ahmed Hassan et al. 2021). Large amounts of resuscitative fluids are given to burn patients to prevent hypovolemic shock, and inadequate perfusion can lead to fluid overload, which is associated with pulmonary oedema, poor wound healing, and compartment syndrome (Shah et al. 2020). Therefore, to establish physiological stability, proper fluid balance monitoring is required to guide medical and nursing interventions (Ouda Awad et al. 2020). Also, nursing students who administer intravenous fluids must have up‐to‐date knowledge and skills in the administration of fluids and electrolytes for safe nursing practice and to provide high‐quality nursing care.

Given that nursing and midwifery students are future healthcare providers, minimal information exists about nursing and midwifery students' comprehension of proper fluid resuscitation. Therefore, it is crucial to increase our understanding in this area. Additionally, this study would help to ascertain which burn nursing care topics require more attention while creating improved teaching initiatives. Furthermore, it enhances nursing and midwifery students' understanding, perceptions and practice around the fluid and electrolyte needs for the acute phase of burn management during the first 24 h. Therefore, the present research intends to assess the nursing and midwifery students' knowledge and practice regarding fluid resuscitation during the acute phase of burn management.

2. Methodology

2.1. Design and Setting

A cross‐sectional, descriptive design was used in this investigation to assess knowledge and practice of nursing and midwifery students regarding fluid resuscitation in acute‐phase burn management. It was conducted at a government university among nursing and midwifery students.

2.2. Participants

A purposive sampling method was utilised to recruit the study participants. Inclusion criteria included students in midwifery and nursing program who were willing to engage in the study, aged between 18 and 22 years, male and female, had access to the internet, being able to read and understand the Arabic language and students who never enrolled in a clinical placement in burn units. However, students who previously participated in the same research project and were unwilling to provide electronic informed consent were excluded from this study.

Nursing and midwifery students from the contacted university were invited to participate. In the study once the inclusion criteria have been met. The total number of students in the nursing and midwifery departments is approximately 850 students. On a confidence interval of 0.95, 0.05 margin of error and an estimated population size of 850 (population proportion assumed to be 50%), the estimated sample size is 265 responses.

$$\mathrm{n}=\left[{\mathrm{z}}^2*\mathrm{p}*\left(1-p\right)/e^2\right]\text{divided}\mathrm{by}\left[1+\left(\mathrm{z}2*\mathrm{p}*\left(1-p\right)/\left({\mathrm{e}}^2*\mathrm{N}\right)\right)\right]$$

where: z = 1.96 for a 95% confidence level (α), proportion (expressed as a decimal), population size (N) and margin of error (e).

$$\begin{array}{cc}\mathrm{n}=\hfill & \left[1.962*0.5*\left(1-0.5\right)/0.052\right]/\left[1+\left(1.962*0.5*\left(1-0.5\right)/\left(0.052*850\right)\right)\right]\hfill \\ \hfill & n=384.16/1.452=264.582\mathrm{n}\approx 265\hfill \end{array}$$

Oversampling was intended to address participants' withdrawal and incomplete responses by adding 20% to the total calculated sample size. Therefore, the required sample size in this study is 318 participants.

2.3. Measures

The study instrument included a questionnaire that participants self‐administered. The questionnaire was hosted through Google Forms, and it consisted of three parts. The first section of the instrument was the demographic data (age, sex, marital status, academic program, academic level, grade point average [GPA] and residency). The second section consisted of 10 questions and the third section was composed of 11 questions. This tool was developed by Awad and colleagues (Ouda Awad et al. 2020) and modified by Atuhaire and colleagues (Atuhaire et al. 2022). A panel of experts examined the questionnaire's content validity and determined that all of the items accurately measured the construct expected to assess, and adequately assess the study domains (Atuhaire et al. 2022).

Scores were determined based on student responses using a scoring system that was customised along with the questionnaire (Atuhaire et al. 2022). Knowledge questions had a binary response for each question (zero or one). Scores of > 75% were measured as good; scores below 50% were considered poor, while those between 50% and 75% were considered average. Regarding practice, each practice item was scored using a binary response scale indicating whether the student performed the specified practice, that is (1) = Complete, although (zero) = Not complete. If a practice overall score was ≥ 75% it was considered satisfactory, while it was considered unsatisfactory if a practice overall score was < 75% (Atuhaire et al. 2022).

The questionnaire used in the current study was translated into Arabic and then back‐translated by two professionals to ensure that its content was appropriate and relevant to the study setting and culture. Initially, two proficient translators rendered the 21‐item English questionnaire, encompassing two distinct domains, into Arabic. The back‐translation was then performed by two more experienced translators. The final Arabic version of the questionnaire was thoroughly examined to ensure it conformed to the original structure and content. The Arabic version of the knowledge and practice questionnaire had no problems with language or semantics. An initial check was conducted to measure the reliability of the translating tool. The pilot sample had 45 participants who were excluded from the final analysis. The Cronbach's alpha coefficient for the tool was 0.86, which is considered satisfactory.

2.4. Data Collection Procedure

Upon obtaining participants' consent to take part in the study and their completion of the online consent form, demographic information was collected, and the knowledge and practice questionnaire was administered. The data collection process was facilitated through Google Forms, and subsequently, the collected data were exported into an Excel file. Subjects who matched the inclusion parameters were invited to share via a Google Form link distributed within the Microsoft Teams class. Notably, the application of an online Google Forms link ensured the complete anonymity of all submitted responses, with no collection of personally identifiable information. To safeguard participant confidentiality, the data obtained from the questionnaires were coded, and access was restricted solely to the research team. Finally, the collected data were stored in a password‐protected computer.

2.5. Data Analysis

The data were analysed using SPSS (Version 27) on Windows. Descriptive statistics, including percentages, means, frequencies and standard deviations, were used to describe participants' characteristics and to assess the levels of knowledge and self‐reported practice among the participating students, according to the level of measurement.

3. Results

3.1. Demographic Characteristics

The questionnaire was distributed to 400 students, of whom 356 participated in the study, yielding a response rate of 91.25%. The mean age of the participants was 20.48 years (M = 20.48, SD = 1.52), and the mean GPA was 72.39 (M = 72.39, SD = 7.25) (Table 1). Most participants were female (n = 284, 79.8%), single (n = 349, 98%), enrolled in nursing (n = 284, 79.8%), and in their second year of study (n = 165, 46.3%).

TABLE 1.

Subjects biographical profiles (n = 356).

Variable	F (%)	M	SD
Age		20.48	1.52
Sex
Male	72 (20.2)
Female	284 (79.8)
Marriage status
Single	349 (98)
Married	7 (2)
Academic program
Nursing	284 (79.8)
Midwifery	72 (20.2)
Academic year
First year	135 (37.9)
Second year	165 (46.3)
Third year	56 (15.7)
Cumulative average (GPA)		72.39	7.25
Residency
City	130 (36.5)
Rural	226 (63.5)
Have you received practical training in surgery or burn ICU?
Yes	126 (35.4)
No	230 (64.6)
Have you received fluid resuscitation training and IV fluid follow‐up during the acute phase for burn patients?
Yes	108 (30.3)
No	248 (69.7)

Abbreviations: F, frequency; M, mean; SD, standard deviation.

More than half of the participants were from rural areas (n = 226, 63.5%), had not received practical training in surgery or burn departments (n = 230, 64.6%), and had not received training in intravenous (IV) fluid administration or monitoring for burn patients (n = 248, 69.7%).

3.2. Students' Knowledge of Fluid Monitoring in Burn Cases

Participants demonstrated a moderate level of knowledge regarding fluid monitoring for burn patients (73.58%). The proportion of students who correctly identified the fluid balance in the body was greater (n = 345, 96%) than the proportion of students who were able to calculate the appropriate fluid requirements using the Parkland formula (n = 101, 28.4%) (Table 2).

TABLE 2.

Participants' knowledge regarding fluid monitoring for burns patients (n = 356).

Participants knowledge	Answer correct		Answer incorrect
	F	%	F	%
The typical range (%) of bodily fluids in adulthood and pathophysiology of the burn immediately and first 24 h post‐burn injury	296	83.1	60	16.9
The meaning and importance of fluid balance in the body	345	96.9	11	3.1
Monitor organs to ensure accurate fluid balance and inhalation injury signs	328	92.1	28	7.9
The duty of a nurse in evaluating the urinary tract of acute burn patient	321	90.2	35	9.8
The nurse's responsibility in monitoring the haemodynamic and haematologic consequences of acute burn patient	253	71.1	103	28.9
The meaning of fluid resuscitation	290	81.5	66	18.5
The basic steps of management during the acute‐phase and formula type of the fluid titration process	211	59.3	145	40.7
Importance of fluid replacement in acute and initial phases of burn management in patients	212	59.6	144	40.4
For a 30‐kg patient in the resuscitative phase with 28% TBSA, use the Parkland formula to calculate the appropriate amount of fluid to administer	101	28.4	255	71.6
Overall		73.58		26.42

Abbreviation: F, frequency.

3.3. Students' Practice About Monitoring Fluid for Patients With Burns Trauma

Participants reported a satisfactory level of practice regarding fluid monitoring for burn patients (94.89%). Most students indicated that they recorded their signature and date after fluid administration (n = 349, 98%). In contrast, a lower proportion reported assessing patients using the rule of nines (n = 305, 85.7%) (Table 3).

TABLE 3.

Students' practice about monitoring fluid for patients with burns trauma (n = 356).

Students' practice	Done		Not done
	F	%	F	%
Performing hand hygiene	343	96.3	13	3.7
Checking and monitoring IV‐line flows freely	341	95.8	15	4.2
Estimation burn percentage by using a rule of nines	305	85.7	51	14.3
Calculating fluids using the Parklands formula	328	92.1	28	7.9
Check the infusion rate/date	333	93.5	23	6.5
Record the Fluid as instructed on the patient's chart	347	97.5	9	2.5
Check whether inflammation signs show	339	95.2	17	4.8
Report the fluid administration time	345	96.9	11	3.1
The document describes the amount of fluid pumped as well as the additives employed	348	97.8	8	2.2
After providing fluids, record the signature and date	349	98	7	2
Overall		94.89		5.11

Abbreviation: F, frequency.

4. Discussion

Fluid resuscitation therapy is a cornerstone in preserving life, but the intervention actually may lead to a negative impact on patients' condition. Intensive resuscitation can cause pneumonia, acute respiratory syndrome, distress fluid creep, gastrointestinal tract disorders, a rise in orbital pressure, limb or abdominal compartment syndrome, cerebral oedema or multiorgan disorders (Ball et al. 2020). This paradox has created several clinical practice challenges and inquiries for ICU healthcare personnel about how to resuscitate and monitor burn patients during the acute phase. To achieve a balance between under‐ and over‐provision of fluids during resuscitation, important factors to consider include formula selection, nurse response and titration, fluid composition and measures to prevent increased vascular permeability and subsequent loss of circulating fluids volume. Although resuscitation burn formulas simply guide initial fluid infusion rates, selecting the right formula might be crucial (Cartotto et al. 2024).

The present investigation is designed to explore nursing and midwifery undergraduates' knowledge and practices related to the application of fluid resuscitation therapy during the acute phase of burn management within the ICU as they play a significant area in the care that is provided. They must have a comprehensive awareness of the many procedures that are accessible and may be utilized to logically manage any given issue. A holistic care and assessment of the traumatic burn patients and their relatives enrolled in the management strategies to enhance patient outcomes as reported by Ouda Awad et al. (2020).

Regarding participants' characteristics, the present study's findings indicated that 356 students (91.25%) belong to the mean age of 20.48 and more than 50% of the students resided in rural regions. This finding is in line with the results of Kareem (2024), who stated that 90% of the population under study was between the ages of 20% and 28% and 66% from a rural zone. Current results show that the majority of participants are female (79.8%), while males account for 22.2%. This finding is consistent with that of Dyulgerova et al. (2023), whose study on nursing students' knowledge of burn care reported that a large portion of the sample was female (94.6%) compared with male (5.4%).

In the field of education, the findings indicate that a significant percentage of participants are in their second year of nursing studies. Additionally, 98.3% of the surveyed students were single. This result is consistent with that of Atuhaire et al. (2022), who conducted a study on nursing students' knowledge and practice and found that the majority were in their second year of study (64.9%), with most of them being single.

Regarding previous training in burn management, fluid therapy and IV fluid resuscitation for burn patients, more than two‐thirds of the students had not received any prior training. This finding is consistent with that of (Ouda Awad et al. 2020), whose study entitled ‘Effect of an Educational Program on Nurses' Practice Regarding Monitoring Fluid and Electrolyte Replacement for Burned Patients’ showed that most nurses had never participated in fluid balance monitoring training. These results highlight the need for educational programs, as the majority of students had not attended sufficient training courses.

This current study showed that nursing and midwifery students exhibited an inadequate understanding of fluid requirement monitoring and had poor proficiency in measuring burn percentages using the rule of nines for adult burn patients. This study is the first to examine the practices and knowledge of midwifery and nursing undergraduates concurrently concerning proper fluid resuscitation for the acute care of adult burn patients in Jordan. The participants in the current study were students with minimal expertise and contact with patients in clinical environments. This gap must be addressed, since students lacking sufficient information may result in significant injury or suboptimal patient outcomes.

The results of the current research are in the same line with those of Atuhaire et al. (2022) who carried out a survey on nursing students' understanding and habits of keeping track of burn patients' fluid needs. The study found little expertise and poor management in monitoring fluid replenishment for burn patients. Similar was the case in previous studies (Ouda Awad et al. 2020; Olszewski et al. 2017), where nurses reported a deficit in knowledge regarding fluid resuscitation monitoring for burn patients prior to the educational intervention.

From the researcher's perspective, both academic lecturers and students continue to face professional and academic challenges. Moreover, the integration of theoretical knowledge with practical skills has yielded satisfactory outcomes, particularly in relation to midwifery and nursing undergraduates, which is relevant to the current study. Students who had the opportunity to perform procedures related to fluid resuscitation and acute phase of burn management were nearly four times more likely to possess appropriate knowledge and experience in this area. However, a limitation of this study is that the findings are based on self‐reported questionnaires, which may be subject to recall bias or social desirability bias and therefore might not fully reflect actual practice or competence.

The current findings indicate that the highest proportion of students demonstrated good knowledge regarding the explanation of fluid balance in adults. This result supports the work of Sheta and Mahmoud (2018), who reported substantial improvements in nurses' understanding of body fluid balance evaluation before and after program implementation. Similarly, Asfour (2016) emphasised the importance of fluid balance for nurses managing critically ill patients. In the current study, these findings suggest that the academic phase plays a vital role in shaping students' knowledge, as they acquire increasing information about the acute phase of burn management during their college years. Regular assessment of students' clinical skills is essential for teaching institutions to ensure compliance with standards, while effective management of serious burns remains critical for improving patient outcomes.

5. Conclusion

Midwives and nurses draw clinical judgements based on their academic and professional experience, as well as scientific facts. Theoretical knowledge can help support and improve health practices. A strong intellectual background is essential for providing appropriate care throughout the acute phase of burn management.

6. Limitations and Recommendations

This study acknowledges the limitation of relying on self‐reported questionnaires to assess clinical practice, as such measures may be influenced by social desirability and recall bias, potentially overestimating actual competence. To address these gaps, future research should incorporate direct observation methods, objective structured clinical examinations (OSCEs), or chart reviews to validate findings and better capture the translation of theoretical knowledge into practice. Supplementary educational programs are recommended to strengthen midwifery and nursing students' clinical skills in fluid replacement and balance monitoring. Moreover, a randomised controlled trial with a robust experimental and control group design is suggested to quantitatively evaluate the impact of educational interventions on students' performance. Policymakers and educational institutions should also integrate structured, recurring training and assessment modules on fluid resuscitation into nursing and midwifery curricula to ensure competence is achieved during education and sustained throughout professional practice.

Funding

The authors have nothing to report.

Ethics Statement

Al‐Balqa Applied University's Institutional Review Board (IRB) granted ethics approval number (26/3/2/2086) for data collection. Informed permission was acquired from research participants online using Google Forms. Every participant in the study was guaranteed that their participation was completely voluntary, and no incentives were offered for participation in this study. Participants received comprehensive information on the study's aim and objectives, the time required to complete the questionnaire and the possible benefits and drawbacks of their involvement. The confidentiality and identity of participants were preserved throughout the investigation, encompassing data collection and analysis. Participants were assured that they were free to leave at any moment and were not required to respond to any questions they did not want to answer. The researchers included their email addresses on the informed consent form to address any queries or requests from participants and to share study findings upon request.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.