The Pain and Stress of Wound Treatment in Patients With Burns: An International Burn Specialist Perspective

This study aimed to explore the views of burn specialists on the importance of reducing stress and pain during wound treatment. Methods. Burns specialists were invited to complete an online survey, consisting of 10 questions about pain and stress in their patients. Results. There were 141 respondents from 39 countries. Most were European (54.9%), and the majority were surgeons (71.8%). Pain-free and stress-free dressing changes were viewed as important overall (‘very important:’ 47.5% and 40.8%, respectively), although, in both cases, 11.3% did not view either to be important. Respondents identified 7 benefits of simple, pain-free dressing removal, although the focus was on clinical advantages rather than being patient-centered. Although most acknowledged that pain is linked with stress, disagreement levels ranged from 21.9% to 25.3%. Additionally, only 22.5% agreed that stress is related to wound healing. Conclusion. In general, burn specialists recognized that pain can lead to stress and that it is important to reduce stress and pain at dressing changes. Most also acknowledged that stress can affect wound healing. However, these results suggest a need for research to further explore perceptions about pain and stress, and how these perceptions can impact wound management regimes.

Burn injuries are one of the most devastating forms of individual trauma. However, with advances in medical treatment techniques, the mortality rate for patients with burns has been reduced in recent years.¹ Due to such progress, a person with burns over 80% of his total body surface area (TBSA) now has a realistic chance of survival.² This reduction in patient mortality, though positive, has implications about the challenges these individuals will face in their lives in terms of long-term treatment, adjustment to daily life, and rehabilitation.³ Consequently, burn wounds have being compared to chronic illness, with a high incidence of physical and psychological morbidity.^1,4   Severe pain is one of the most significant components in the long-term suffering of burn patients,⁵ with continuous background pain experienced alongside intense pain during wound treatment procedures. Often patients with burns must endure 1 or more painful procedures daily, for weeks or months,⁶ comprising wound cleansing, debridement, dressing changes, surgical operations, and physical and occupational therapies.^7-9 The pain experienced during wound care procedures has often been reported to be excruciating.^10,11   Much research has been conducted within the chronic wound population on the psychological effects of dressing-related pain, with stress being a common component.^12-14 Likewise, anxiety and depression are frequently reported to accompany the pain of burns, often having a bidirectional relationship.^15-16 Due to the emotional and physical trauma that patients with major burns experience, high levels of distress and anxiety are common.¹⁷ Additionally, stress and anxiety are thought to be interlinked with pain, with anxiety increasing due to the anticipation of pain, and the experience of anxiety also intensifying the perception of pain.^18-19 This is cyclical in that the intense pain often leads to anxiety in anticipation of upcoming pain, such as that experienced with dressing change.²⁰ Due to the amplification of pain, by anxiety and stress levels, for patients with burns, it is important that treatment methods simultaneously target both the physical and psychological aspects of burn injuries.¹   The consequences of pain, anxiety, and stress on wound healing provide further incentive to ensure treatment protocols incorporate techniques that aim to reduce these experiences for patients with burns as much as possible. It is known that pain can adversely affect the healing of a wound^15,21 and can also have a negative impact on quality of life.²² A study by McGuire et al²³ found that in gastric bypass surgery patients, reports of postsurgical, high-intensity pain were associated with longer healing times. Similarly, Woo and Sibbald²⁴ found that the mean pain scores over a 4-week period for patients with leg or foot ulcers was significantly less (P < 0.041) for those who achieved wound closure (mean pain score 1.67), than for those who did not (mean pain score 3.21).   In a way similar to pain, increased stress levels can also delay the healing process.^25,26 Broadbent et al²⁷ explored the effects of stress levels on wound healing in patients who underwent a laparoscopic cholecystectomy. It was found that those who received a psychological intervention aimed at reducing stress, in addition to standard care, showed lower stress levels and enhanced wound healing postsurgery compared to those who received standard care alone. Similar findings have been reported in regard to individuals with burns. For example, Wisely et al²⁸ investigated the effect of preexisting psychiatric disorders and psychological reactions to stress on the recovery of burn survivors. It was reported that heightened psychological distress alone, without the presence of a psychiatric disorder, had a significant delaying effect on the rate of recovery of burn wounds. This finding highlights the importance of identifying and working with difficulties, such as stress and anxiety, in light of the psychosocial and physical impact they may have on recovery. The effect that both pain and stress have on wound healing makes it important for professionals to reduce the pain and stress their patients experience during treatment, especially for those whose burns require regular wound care procedures.   Despite the importance of pain and anxiety management in burn treatment regimes, Robert et al²⁹ found it can be omitted during clinical assessments. The authors surveyed nursing directors at 64 burns centers. Of the burn teams, 19% (12 teams) did not assess anxiety at all during the treatment of burn wounds, neither formally nor informally, despite its importance in the pain experience of patients, and the subsequent healing of their wound.   However, it must be noted that many medical professionals are aware of the psychological impacts of wounds upon patients. For example, Upton et al³⁰ surveyed health care professionals in relation to patients with acute and chronic wounds. The majority of professionals believed that more than half of their patients suffered from mood problems related to their condition. These problems were most likely to include anxiety and feelings of helplessness, with chronic pain and discomfort of the wound acting as potential contributory factors. Further research is needed to build upon the knowledge of how important burn specialists perceive pain and stress to be, and how highly they rate the need for pain- and stress-free management regimes for burn recovery.   The present study aimed to explore clinicians’ views about pain and stress in their patients with burns. In particular, this research aimed to investigate how clinicians perceive the relationship between pain and stress, and how important they consider reducing pain and stress during treatment. Additionally, this research aimed to look at beliefs about how stress affects wound healing.

A voluntary, cross-sectional survey was created by the Austria Burn Treatment, Research, and Prevention Study Group, a scientific, nonprofit medical organization, in conjunction with experts originating from various other strands of the burn community. The 10 survey questions related to pain of wound treatment, stress of wound treatment, stress-pain relationship, or stress impairing wound healing. The questions were either open-ended or had a 7-point Likert scale answering system, in which a rating of 1 indicated “not important” or “agree totally,” and a rating of 7 represented “very important” or “disagree totally,” depending on the question. Additionally, 4 questions were included to gain demographic information on the respondent related to profession, staff grade, country, and city.   An email invitation was sent to 1000 burn specialists worldwide, which included a direct link to the survey. The list of email contacts was created using the contact information available on the internet for burn centers, as well as the corresponding email addresses provided in all publications from 2008 to 2011 of the Burns journal (Elsevier Science Ltd for the International Society for Burn Injuries). The personal information of the respondents was not collected, and no incentives to complete the survey were offered. In an attempt to guarantee the avoidance of duplicate submissions, JQuarks 4 Surveys (IP-TECH, La Marsa, Tunisia) was chosen to host the questionnaire, as the system does not allow for more than 1 entry from the same participant computer IP address. Throughout the completion of the questionnaire, respondents were able to check and change any answers previously submitted, with the questionnaire located on a single scrolling web page. The time taken for completion was not recorded, and once the respondent had submitted their answers it was automatically logged in a MySQL-Database (Oracle, San Francisco, CA). The website was checked on a daily basis for technical difficulties.

Respondents. A total of 141 respondents (response rate of 14.2%) from 39 countries completed the online questionnaire over a 6-week period. Out of the total sample, 72.3% were surgeons (n = 102), 5.7% were anesthetists/intensivists (n = 8), and 14.2% were nursing staff (n = 20), with 7.8% falling into the ‘other’ category (n = 11) of emergency physicians, physical therapists, or unknown. Respondents were from a variety of countries, including Europe (57.5%), Australia and New Zealand (17.7%), North America (12.8%), Asia (9.2%), South America (1.4%), and Africa (0.7%), with 0.7% not specifying country of origin.   Importance of pain-free, stress-free dressing changes. Medical professionals were asked to rate the importance of pain-free dressing changes using one of 3 options: essential, desirable, or neutral. Of the 141 respondents, 53.9% expressed that pain-free dressing changes were “essential,” and 44% felt they were “desirable.” Only 1.4% of respondents indicated a “neutral” opinion, and 0.7% did not answer. When the same question was asked slightly differently, using a scale from “very important” to “not important,” 47.5% of respondents expressed it was “very important” that dressing changes are pain-free. However, 11.3% considered it “not important.” Similar findings were obtained for the question of how important it is that dressing changes are stress-free, with 40.8% of respondents rating this as “very important,” and 11.3% considering it “not important.”   Potential effects of easy-to-use, painless dressing removal products. When asked to identify the changes that could be brought about by an easy-to-use, pain-free dressing removal product, respondents referred to 7 main areas. These included less pain relief, effective treatment and quicker dressing change, reduced healing time and movement from inpatient to outpatient, reduced pain, reduced stress, increased patient compliance, and cost implications (Table 1).   Effects of pain and stress. Overall, 71.8% of respondents generally agreed that pain from patients’ wounds caused the patient stress, with 48.6% of respondents “totally agreeing.” However, an overall 23.2% generally disagreed, with 10.6% “totally disagreeing.”   Similarly, when asked if higher wound pain correlated with higher levels of stress in patients, 72.5% generally agreed, with 47.9% “agreeing totally.” In disagreement were 22.5% of respondents, with 12% “disagreeing totally.”   When asked if pain associated specifically with wound dressing caused patients stress, 67.5% generally agreed, 40.8% of whom “agreed totally.” Although this still represents the majority, the agreement levels were reduced compared to responses to the previous 2 questions. Additionally, 25.3% disagreed with this, with 9.9% “totally disagreeing.” Thus, more people disagreed with the statement that pain at wound dressing caused stress than with the idea that pain in general was related to stress. Similar results were found for the question of whether or not pain associated with a wound management regime caused stress, with 40.1% “totally agreeing” that it did.   Finally, when respondents were asked their opinions on whether or not stress impairs wound healing, an overall 66.9% generally agreed that it does, with 22.5% “agreeing totally.” However, 20.3% generally disagreed, with 4.9% “disagreeing totally.” An additional 10.6% of respondents selected the middle value on the Likert scale, neither agreeing nor disagreeing with the statement.

The majority of the health care professionals surveyed (97.9%) indicated that pain-free dressing changes were either “essential” (53.9%) or “desirable” (44%). However, when asked a very similar question about the importance of pain-free dressing changes using a different scale, only 77.7% expressed that it was important (with 47.5% responding “very important”). Considering that 97.9% of respondents selected “essential” or “desirable” to the first question, it is surprising that 20.4% then went on to select low importance levels in this subsequent question, with 11.3% expressing that pain-free dressing change is “not important.” Almost identical figures were found in relation to the importance of stress-free dressing changes, with the majority expressing this was important, but a proportion of professionals expressing low or no importance.   Nevertheless, most specialists who responded to the survey believed dressing changes should be painless and stress-free, although it is possible that some consider this to be the “ideal” rather than an important factor. Additionally, they may rate the importance of pain-free dressing in terms of a “comfort factor,” and not in relation to the effect on the outcome and well-being of the patient.   In terms of the possible effects of using easy-to-use, pain-free dressing removal products, the health care professionals identified 7 areas. Clinical and practical benefits were highly cited, such as reduced need for pain relief, efficiency of treatment with quicker dressing change, reduced healing time, and quicker progress from inpatient to outpatient. In contrast, more patient-centered benefits, such as reduced pain and stress, were referred to less frequently. This suggests that medical professionals face a challenge in juggling departmental demands with patient needs, which may affect which issues they prioritize as important. Since almost half of respondents expressed that pain- and stress- free dressing changes are “very important,” it may seem surprising that patient-centered benefits were not referred to frequently. However, it is important to note that the question asked about changes in care practices, and different findings may have been reported if the question asked about the general benefits of easy-to-use, pain-free dressing removal products.   In a similar study, Selig et al³¹ explored the views of 121 clinicians from 39 countries, about the ‘ideal’ properties of wound dressings. The clinicians referred to nonadhesion, absorbency, and antimicrobial activity as key factors which would contribute to the ideal dressing. They also reported that it would be beneficial if the dressing was easy to remove, leading to reduced pain at dressing change. This shows some consideration of minimizing pain in ideal practice, although no dressings were known to exist at the time of the study that incorporated all of those factors.   Another area explored in this research was that of medical professionals’ views on the role of pain and stress and their patients’ experiences of these. It is known that there is a cyclical relationship between pain and stress and anxiety, with pain causing anticipatory anxiety, and anxiety lowering the pain threshold.^18-20 Taking this relationship into consideration, it is surprising that overall disagreement responses ranged from 21.9%-25.3% for statements relating to wound pain, wound dressing, dressing removal, and wound-management regime causing patient stress. However, the majority of respondents did agree that stress could be caused from wound pain, wound dressing, dressing removal, and wound-management regime, and that wound pain and stress levels are positively correlated with one another (72.5% overall). This demonstrates that most burn specialists acknowledge the effect pain can have on patient stress levels, although some may not fully recognize how pain and stress are linked.   While the majority of the medical professionals thought it was important that dressing changes did not cause stress for their patients (73.9%), only 22.5% totally agreed that stress impairs wound healing, with 4.9% totally disagreeing, and 10.6% selecting the middle value. The number of respondents who disagreed with the statement, or who were unsure, is surprising, considering that stress is reported to be directly associated with the healing of wounds.^25-27 An important message to come from this research is that some burn specialists believe pain and stress do not influence wound healing. Whilst most acknowledge that patients experience stress in relation to pain, they may not fully understand the implications of this stress. This highlights the need for further education of specialists in relation to pain, stress, and wound healing in the burn population.

The findings of this study indicate that, in general, burn specialists acknowledge the importance of pain- and stress- free dressing changes, agree that pain associated with wounds and wound treatment does cause stress, and believe that stress impairs wound healing. Despite this general agreement however, there were relatively high percentages of respondents who ‘disagreed totally’, or believed that pain- and stress-free dressing changes were “not important.” Additionally, when considering the benefits of using an easy and pain-free dressing removal product, clinical and practical implications were referred to most frequently, with patient-centered outcomes considered less often. These findings suggest a need for additional research and education about the role of pain and stress for patients with burns.   Research needs to further explore the views of burn specialists in relation to the importance of pain- and stress-free wound treatments, and the consequences that both stress and pain can have on the patient. In particular, research needs to investigate how these opinions affect wound management regimes for people with burns.

Dominic Upton, PhD, FBPsS; Jessica Morgan, BSc; and Abbye Andrews, BSc, MBPsS are from the Institute of Health and Society, University of Worcester, Worcester, UK. David B. Lumenta, MD is from the Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria. Michael Giretzlehner, PhD is from Research Unit for Medical-Informatics, RISC Software GmbH, Johannes Kepler University Linz, Linz, Austria. Lars P. Kamolz, PhD, MSc is from the Section of Plastic, Aesthetic, and Reconstructive Surgery, Department of Surgery, State Hospital Wiener Neustadt, Austria.

Address correspondence to: Dominic Upton, PhD, FBPsS Institute of Health and Society University of Worcester Henwick Grove WR2 6AJ d.upton@worc.ac.uk

Disclosure: The authors disclose no financial or other conflicts of interest.