THE MANAGEMENT OF BURN WOUNDS BY NURSES Ethel Althea Andrews

486 Pages·2015·6.38 MB·English

by  Andrews, Enver E

THE MANAGEMENT OF BURN WOUNDS BY NURSES

Ethel Althea Andrews

A thesis submitted to the Faculty of Health Sciences, University of the
Witwatersrand, in fulfilment of the requirements for the degree of
Doctor of Philosophy

Johannesburg, 2015
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DEDICATION

I dedicate this thesis to my family both living and departed. I truly stand on the shoulders of giants. A
special feeling of gratitude to my husband, anchor and soulmate Enver, my wonderful and talented
children, Teneale and Taylan and my loving parents, William and Janette, whose words of
encouragement, unfaltering believe in me and love carried me through this journey. I will always
appreciate all the sacrifices made, inconvenience endured and all they have done. You have been my
greatest cheerleaders.
I also dedicate this work to my grandfather, my in-laws, siblings both biological and chosen as well as
my aunts and uncles.

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ABSTRACT

A standardised approach to wound care is vital if a positive outcome is expected. The positive
outcomes of standardisation and evidence based wound care protocols have been well documented,
yet nurses in South Africa do not have a standard that informs burn wound management. The purpose
of this study is to describe the best available evidence for management of burn wounds and to explore
nurses’ current practices in a single burns unit with the aim of developing guidelines to inform
nursing practices.

A QUAN (quantitative dominant) QUAN+ QUAL (quantitative and quantitative concurrently), a
non- experimental explanatory sequential descriptive design was used. The process was divided into
three phases: Phase One involved the search for quality evidence through an integrative review. The
main review question was: “What new knowledge or information related to non-surgical
management of burn wounds has emerged in the literature between 2000 and 2014?” Eleven sub
questions were used to guide the literature search according to the themes of the nursing process of:
Assessment, Diagnosis, Intervention, Outcome and Evaluation. The review process included a
problem identification stage, literature search stage, data evaluation stage, data analysis stage and
presentation stage. The included literature was based on a hierarchy of evidence. The search strategy
included: multiple electronic databases, hand searching, reference lists of relevant articles, comments
of experts, textbook chapters compiled by experts and guidelines. The final sample consisted of n=
354 studies. A qualitative descriptive approach was used to synthesise the research findings. Phase
Two involved the study of current practice through structured observation and semi-structured
interviews.

The purpose of Phase Two was to obtain first-hand information in a naturally occurring situation to
identify the strengths, weaknesses and gaps in current practices. Purposive sampling was undertaken
and included all nurses providing care to patients with superficial to partial thickness burn wounds. A
total of n= 303 dressings were observed and eight interviews were conducted.

Phase Three was the verification of findings from Phases One and Two by experts in the field using
the AGREE II instrument. Conclusions drawn from observations and interviews were integrated and
synthesised with the conclusions from the integrative review. These conclusions were used to develop
guidelines for the management of burn wounds by nurses.

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ACKNOWLEDGEMENTS

I wish to acknowledge firstly my God, the Almighty, the author and finisher of my fate for all the doors opened, the
blessings, the opportunities, wisdom, strength and time. This was my Everest, the climb was never easy, but the view it
promises makes it worth it. “I lift my eyes unto the hills, from whence cometh my help. My help cometh from the Lord,
which made heaven and earth”

My supervisors at various stages of the thesis: Professor Judith Bruce, then Head of the Nursing Department, Doctor Adele
Tjale and Doctor Gayle Langley.

I would also like to acknowledge Doctor Langley, PhD coordinator, for the life lesson she shared on the first day in the first
class with the PhD students. Those words carried me through: “Life is like juggling balls. Some are crystal some are rubber.
Family and health are crystal; you can’t drop them, because if they break the damage is irreplaceable.” Hence taking forever
to complete, but I am glad to say the crystal balls are intact.

The Sunday Scribes was invaluable and without it I would not have completed. My thanks and appreciation to Professor Elly
Grossman for availing herself and seeing the diamond in the ruff.

Members of the Faculty of Health Sciences at the University, for reviewing the proposal and permission to conduct the
study, Post Grad staff Tania, Mpumi and Thando, your support and assistance is appreciated.

The hospital management, heads of the Department, nursing service managers, nurses, patients, panel of experts:
Professor Jacques Goosen, Professor Elias Ndobe, Doctor Adelin Muganza, Sister Katinka Rheeder, Sister Eva
Lekwaba, Sister Phindi Lehabe and Sister Karen Swart for their participation in the study and their invaluable
contribution.

My friends and colleagues for their love and support and dedication to the nursing profession.

Mrs Jenny Hesk for editing and being great about it in record time.

The various statisticians I drove mad looking for figures.

Xolani Mtembu for assisting with the formatting and all the copies.

My parents in-law for giving birth and raising me a godly man.

My parents for babysitting, their prayers, support, patience, advice, and raising me to believe I can.

My children for blossoming into the most beautiful children despite the thesis taking up so much of my time.

My husband for postponing his studies, taking care of the kids, encouraging and drying the many tears shed. For being
patient with me when the stress levels and the emotions were running high and tolerating my moods in the way only he
can. For supporting me, loving me and sacrificing. I could not have done it without you. A man to God’s own heart.

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TABLE OF CONTENTS
DECLARATION ii
DEDICATION iii
ABSTRACT iv
ACKOWLEDGEMENTS v
TABLE OF CONTENTS vi
LIST OF FIGURES xii
LIST OF TABLES xiii
LIST OF APPENDICES xv
LIST OF REFERENCES 330

CHAPTER ONE LAYOUT
CHAPTER ONE: ORIENTATION TO THE STUDY
1.0 INTRODUCTION 1
1.1 BACKGROUND 1
1.1.1 Management of burn wounds by nurses 1
1.2 RESEARCH PROBLEM 5
1.3 RESEARCH QUESTIONS 5
1.4 PURPOSE OF THE RESEARCH 6
1.5 RESEARCH OBJECTIVES 6
1.6 RATIONALE FOR THE STUDY 7
1.7 CENTRAL THEORETICAL STATEMENT 9
1.8 ASSUMPTIONS OF THE RESEARCHER 9
1.8.1 Meta-theoretical assumptions 9
1.8.2 Theoretical assumptions 10
1.8.2.1 Definitions 10
1.8.3 Methodological assumptions 11
1.8.3.1 Evidence based research 12
1.8.3.2 Scientific method 12
1.8.3.3 Ethical research 13
1.9 CONTEXT 13
1.9.1 Admission criteria to burns unit 13
1.9.2 Nursing personnel 14
1.9.3 Infrastructure 14
1.10 RESEARCH DESIGN AND METHOD 15
1.10.1 Research method 15
1.10.2 Study design 15
1.10.3 Study population 17
1.10.3.1 Population 17
1.10.4 Sample and Sampling 17
1.10.4.1 Sample 17
1.10.4.2 Sampling 18
1.10.4.3 Sample size estimation 18
1.11 METHODS OF DATA COLLECTION 18
1.11.1 Data collection instrument 18
1.11.2 Administration of data collection instrument 19
1.12 METHODS TO ENSURE VALIDITY AND RELIABILITY 19
1.12.1 Validity 19
1.12.2 Reliability 20
1.13 DATA ANALYSIS 20
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1.14 PILOT STUDY 21
1.15 SIGNIFICANCE OF THE STUDY 21
1.16 ETHICAL CONSIDERATIONS 22
1.17 THESIS STRUCTURE 22
1.18 SUMMARY 24

CHAPTER TWO LAYOUT 25
CHAPTER TWO: RESEARCH DESIGN AND METHODOLOGY
2.0 INTRODUCTION 26
2.1 PURPOSE AND OBJECTIVES OF THE STUDY 29
2.2 RESEARCH DESIGN 30
2.2.1 Rationale for the research design 32
2.2.1.1 Mixed method research design 32
2.2.1.2 Quantitative research 41
2.2.1.3 Qualitative research 43
2.2.1.4 Non-experimental 46
2.2.1.5 Explanatory Sequential 47
2.2.1.6 Descriptive 48
2.2.1.7 Reasoning strategies 48
2.3 RESEARCH METHODS 52
2.3.1 PHASE ONE: INTEGRATIVE REVIEW 54
2.3.1.1 Purpose of the Integrative Review 55
2.3.1.2 Step One: Problem Identification Stage 56
2.3.1.3 Step Two: Review Question 57
2.3.1.4 Step Three: Literature search stage 58
2.3.1.5 Step Four: Data evaluation stage 66
2.3.1.6 Step Five: Data analysis stage 67
2.3.1.7 Step Six: Presentation stage 70
2.3.1.8 Validity and Reliability 71
2.3.1.9 Findings of the integrative review 71
2.3.2 PHASE TWO (a): STRUCTURED OBSERVATION 72
2.3.2.1 Observation 72
2.3.2.2 The purpose of observation 74
2.3.2.3 Research Method 74
2.3.2.4 Findings from structured observation 83
2.3.3 PHASE TWO (b): SEMI- STRUCTURED INTERVIEWS 83
2.3.3.1 Interview 83
2.3.3.2 The purpose of the semi-structured interviews 85
2.3.3.3 Research Method 85
2.3.3.4 Findings of the semi- structured interviews 96
2.3.4 PHASE THREE: VERIFICATION OF FINDINGS 96
2.3.4.1 Verification process 96
2.3.4.2 Purpose of verification 101
2.3.4.3 Research method 101
2.3.4.4 Verification instrument 104
2.4 ETHICAL CONSIDERATIONS 109
2.5 SUMMARY 110
2.6 CONCLUSION 112

CHAPTER THREE LAYOUT 113
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CHAPTER THREE: NURSING PROCESS AS FOUNDATION OF STUDY
3.0 INTRODUCTION 114
3.1 PHASES OF NURSING PROCESS 115
3.1.1 Assessment 115
3.1.2 Diagnosis 116
3.1.3 Interventions / Implementation 120
3.1.4 Outcomes and Evaluation 122
3.1.5 Accuracy 124
3.1.6 Quality 125
3.1.7 Standardization 126
3.2 CONCLUSIONS 126

CHAPTER FOUR LAYOUT 127
CHAPTER FOUR: INTEGRATIVE REVIEW
4.0 INTRODUCTION 129
4.1 INTEGRATIVE REVIEW BACKGROUND 131
4.2 METHODOLOGY 132
4.2.1 Step One: Problem Identification Stage 132
4.2.2 Step Two: Review Question 132
4.2.3 Step Three: Literature search stage 133
4.2.4 Inclusion/Exclusion Criteria 135
4.2.5 Step Four: Data evaluation stage 135
4.2.6 Updating literature searches and current awareness 136
4.2.7 Step Five: Data analysis stage 136
4.2.8 Step Six: Presentation stage 139
4.2.9 Validity and Reliability 139
4.3 FRAMEWORK FROM THE LITERATURE 140
4.3.1 Quality 140
4.3.2 Study population 140
4.3.3 Outcome measure 140
4.4FINDINGS FROM THE LITERATURE/RESULTS 141
4.4.1 Assessment 141
4.4.1.1Guiding question 1: How should burn wounds be assessed at macro- level? 141
4.4.1.2 Guiding question 2: How should burn wounds be assessed at micro level? 148
4.4.2 Diagnosis 160
4.4.2.1 Guiding question 3: What is the correct terminology for burn wounds? 161
4.4.3 Interventions / Implementation 162
4.4.3.1 Guiding question 4: What is the best technique for burn wound 163
management?
4.4.3.2 Guiding question 5: What are the ideal wound surrounding temperatures? 175
4.4.3.3 Guiding question 6: What are the differences between dressings? 178
4.4.3.4 Guiding question 7: Open vs. closed method of dressing? 193
4.4.3.5 Guiding question 8: Ointment vs. dressing? 197
4.4.4 Outcomes and Evaluation 199
4.4.4.1 Guiding question 9: How is wound healing measured? 200
4.4.4.2 Guiding question 10: How should pain in burns be managed? 200
4.4.4.3 Guiding question 11: How should the management of burn wounds be 213
recorded?
4.5 GAPS IN THE LITERATURE 214
4.6 CONCLUSIONS 214
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CHAPTER FIVE LAYOUT 215
CHAPTER FIVE: STRUCTURED OBSERVATION
5.0 INTRODUCTION 216
5.1 RESEARCH DESIGN AND METHOD 216
5.2 DRESSING PREPARATION 220
5.3 ASSESSMENT AND DIAGNOSIS 221
5.4 DRESSING EXECUTION (INTERVENTION) 223
5.5 OUTCOME AND EVALUATION 225
5.6 DISCUSSION 227
5.6.1 Dressing Preparation 227
5.6.1.1 Introduction of him or herself to the patient and explanation of proposed 227
procedure.
5.6.1.2 Preparation of proposed material 228
5.6.1.3 Temperature of cleaning solution 229
5.6.1.4 Hand washing 229
5.6.1.5 Integrity of the patient 230
5.6.2 Assessment and Diagnosis 231
5.6.2.1 Assessment done on the wound 231
5.6.2.2 Classification and location of the wound described or considered 232
5.6.2.3 Description of the wound bed utilizing the TIME model and the 232
identification and management of elements of TIME
5.6.2.4 Size of the wound described 233
5.6.2.5 Pain control and considering the subjective pain complaints of the patient 233
5.6.3 Dressing execution 234
5.6.3.1 Preparation of environment 234
5.6.3.2 Packaging opened aseptically and expiry dates checked 235
5.6.3.3 “Dirty” material kept separately from the clean field and aseptic technique 236
maintained
5.6.3.4 Prescribed solution for wound dressing 237
5.6.3.5 Logical sequence throughout the procedure 237
5.6.4 Outcome and Evaluation 238
5.6.4.1 Nursing process and the TIME framework reflected in cardex 238
(documentation)
5.6.4.2 Referral to multi-disciplinary team 239
5.7 SUMMARY 240
5.8 CONCLUSION 240

CHAPTER SIX LAYOUT 241
CHAPTER SIX: SEMI STRUCTURED INTERVIEWS
6.0 INTRODUCTION 242
6.1 DRESSING PREPARATION 248
6.1.1 Preparation of the patient 248
6.1.2 Preparation of self 249
6.1.3. Preparation of the environment 250
6.1.4 Preparation of supplies 251
6.1.5 Introduction of self to patient 252
6.1.6 Explanation of the procedure 253
6.1.7 Temperature of cleaning solution 254
6.1.8 Hand washing 255
6.1.9 Integrity 255
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6.2 ASSESSMENT 256
6.2.1 Roles and responsibilities 257
6.2.2 Description of the wound 258
6.2.3 TIME framework 258
6.3 DRESSING EXECUTION (INTERVENTION) 263
6.3.1 Process of dressing change 264
6.3.2 Information overload 264
6.4 OUTCOME AND EVALUATION 265
6.4.1 Documentation 266
6.4.2 Referral 266
6.4.3 Work overload 267
6.4.4 Needs of nurses 268
6.5 CONCLUSION 269

CHAPTER SEVEN LAYOUT 270
CHAPTER SEVEN: VERIFICATION OF GUIDELINES
7.0 INTRODUCTION 271
7.1 VERIFICATION PROCESS 273
7.2 METHODOLOGY FOR VERIFICATION 276
7.2.1 Planning the nominal group 276
7.2.2 Selecting participants 276
7.2.3 Conducting the group 278
7.3 VERIFICATION INSTRUMENT 279
7.3.1 AGREE II instrument 286
7.4 VERIFICATION OF THE BEST PRACTICE GUIDELINES 287
7.4.1 Scope and Purpose 287
7.4.2 Stakeholder Involvement 288
7.4.3 Rigour of Development 289
7.4.4 Clarity of Presentation 290
7.4.5 Applicability 291
7.4.6 Editorial Independence 292
7.4.7 Overall Assessment 293
7.5 INTEGRATION AND SYNTHESIS OF CONCLUSIONS AND 295
DEVELOPMENT OF BEST PRACTICE GUIDELINES
7.6 SUMMARY 311
7.7 CONCLUSIONS 311

CHAPTER EIGHT LAYOUT 312
CHAPTER EIGHT: EVALUATION OF THE STUDY,
RECOMMENDATIONS AND LIMITATIONS
8.0 INTRODUCTION 313
8.1 EVALUATION OF THE STUDY 313
8.1.1 Step one: Evaluation of quantitative research 313
8.1.1.1 Comprehension 313
8.1.1.2 Comparison 315
8.1.1.3 Analysis phase 316
8.1.1.4 Evaluation phase 316
8.1.2 Step two: Evaluation of qualitative research 317
8.1.2.1 Descriptive vividness 317
8.1.2.2 Methodological congruence 318
8.1.2.3 Analytical and interpretative preciseness 327
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