Towards improved psychological outcomes for survivors of burn injuries

This collection of articles^1–5 highlights important work carried out by psychologists within burns services in the UK, as well as some of the challenges in providing psychosocial care. Together, these five papers^1–5 provide an insight into the research and clinical issues faced by psychologists and multidisciplinary teams working within UK burn care with the aim of improving psychosocial outcomes of patients with burn injuries and their families. In recent years, the advances in the medical treatment of burn injuries has led to increased survival rates and better outcomes for patients.^6,7 However, surviving and experiencing a burn injury, regardless of its size, location or depth, can be traumatic and may result in psychological difficulties such as post-traumatic stress disorder, anxiety, depression, difficulty adjusting to an altered appearance/scarring, sleep disturbance, difficulties associated with intimate or sexual relationships, and/or an exacerbation of previous psychological problems.^8–10 The psychosocial impact on both the patient and their family members can be extensive and enduring.¹¹ Furthermore, a significant minority of patients utilising burn services have injuries as a consequence of self-harm, either as an attempt to end their lives or to cope with emotional distress.^12,13 As such, there has been a growing focus within burn care on the prevention and amelioration of the emotional, psychological and social challenges experienced by burns patients of any age and their families.^14–16

A key role of psychologists within burns services is to develop and manage ways of identifying when a patient or caregiver requires psychological input. Indeed, psychosocial assessment (or ‘screening’) is part of routine care and features as a National Burn Care Standard.^17,18 Understanding how pre-burn (vulnerability) factors impact upon recovery and engaging patients proactively enables interventions to be offered earlier, rather than when difficulties have escalated or become entrenched.¹⁹ Some services use established, standardised psychometric measures in order to screen for psychosocial distress among their patients. However, these are often generalised measures (i.e. not burn-specific), can be long and unwieldy, and are often only standardised for outpatient populations. In response to the need for inpatient screening tools with good face validity, which can be completed easily and relatively quickly, Williams et al.¹ developed their own tool for use in their service, based on their extensive clinical experience. In this paper, they report data collected using this tool soon after injury and provide an indication of the profile of patients who may have higher levels of distress and who may consequently warrant some level of supportive intervention. Although there are complexities associated with using new measures that have not been psychometrically tested, this paper provides an interesting initial evaluation. It presents an insight into the use of alternatives to the well-tested measures that are not burn-specific. Further research is still needed to develop effective and efficient burn-specific screening measures and to test their predictive value in identifying those who will require psychological interventions.

One example of a psychological concern commonly witnessed among burn patients is pain-related distress or procedural anxiety associated with painful treatments. Indeed, in addition to the trauma of suffering a burn, the ensuing medical procedures can also be traumatising, sometimes resulting in fear and helplessness.²⁰ Dressing changes can be particularly traumatic for injured children and their parents.²¹ In the second paper, Green et al.² explore health professionals’ experiences of using iPads to facilitate distraction during paediatric burn dressing changes. Despite this exploratory study having a small sample from a single site, their paper highlights the importance of combining training in the delivery of effective distraction techniques with good multidisciplinary team communication and working. This approach has the potential to facilitate a reduction in anxiety and perceived pain, ensuring that the child’s psychological wellbeing is prioritised and reducing the possibility of further traumatising the child, in addition to secondary benefits such as easing caregiver anxiety and stress. While Green et al.² examine this form of distraction from the health professionals’ perspective, further research is still needed to explore it from the point of view of patients and their families. Trials testing the effectiveness of iPads at reducing pain and distress are also warranted.

It is known that many patients seen within burns services have pre-existing physical and mental health problems.²² While most of the burns we treat are accidental, some patients present with injuries caused by self-harm. Those presenting with self-inflicted burns may have a history of a pre-existing psychiatric disorders or be struggling to cope with stressors such as health and social problems.¹² In the third paper, Heyward-Chaplin et al.³ consider the attitudes of burns and plastic surgery healthcare professionals towards self-harm and reflect on adherence to national guidance.²³ The paper highlights that although the majority of participants held positive attitudes towards patients who self-harm, a significant minority held negative views. The findings also suggest that this patient group may be offered surgical treatments for smaller non-life-threatening burns less frequently than those who have sustained injuries accidentally, which is contrary to national guidance. Further research is needed to explore why this may be the case and a limitation of the study is that causal links were not explored. For example, unhelpful or inaccurate beliefs held by health professionals about why individuals might self-harm, or concern about patients tampering with wounds could influence the treatment they receive, despite a lack of research to support or contradict these views. Heyward-Chaplin et al.³ conclude that there is a lack of awareness about national guidance in the acute management of self-harm and a clear need for education for burns and plastic surgery healthcare professionals to ensure that best practice is delivered to all patients. In order to address this issue, the British Burns Association Psychosocial Special Interest Group (SIG) runs a biennial study day focused on self-harm with delegates attending from a range of professional backgrounds within burns care.

The fourth paper further provides insights from a small number of psychosocial professionals working in different regions of the UK and suggests a number of ways in which psychosocial care in NHS burns services could be developed to ensure that patients achieve adequate physical and mental health. Guest et al.⁴ found that burns patients and staff are not always aware of the psychosocial support that is available and can tend to prioritise outpatient appointments for medical treatment over those for psychosocial support. The authors also describe how individual differences regarding the time at which patients are amenable to psychosocial support means that some find it difficult to re-engage with services at the point at which they may benefit from it the most. Further multidisciplinary research would be beneficial to establish specific treatment pathways for individuals with pre-existing mental health problems, assisting them in accessing the most appropriate support and potentially reducing their time in hospital.

Supporting the families of those affected by burn injuries is imperative. A paper by Heath et al.⁵ reports their qualitative investigation into the experiences of a small sample of parents of burn-injured children treated in different services throughout the UK, and how appropriate and effective psychosocial support for this group might be facilitated. Presentation of the initial findings from this research was awarded an oral presentation prize by the British Burns Association in 2017.²⁴ In this paper, Heath et al.⁵ describe how parents can feel isolated following their child’s injury and how these feelings can be exacerbated by real world and psychological barriers that may prevent them accessing psychosocial support. Following further quantitative research,²⁵ the next step in this work is the development of an online resource that could provide accessible psychoeducation and advice to parents, which can be informed and promoted by professionals working within burns care.

This collection of papers provides useful practice-based evidence. While they highlight some of the work being carried out by psychologists in UK burn services, there is still much to be done. With ongoing commitment to research and patient involvement, further progress should be possible towards the development of the highest standards of both psychological and medical care for patients and their families. The robust development of reliable outcome measures and evaluation of psychological interventions should now be a priority. We encourage others within the field to consider the issues raised in these papers and to formulate well-designed studies to address the questions that could positively influence future clinical practice.